Federal employee preventive health services

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Material Information

Title:
Federal employee preventive health services
Physical Description:
iii, 46 p. : ; 24 cm.
Language:
English
Creator:
United States -- Congress. -- House. -- Committee on Post Office and Civil Service. -- Subcommittee on Retirement and Employee Benefits
Publisher:
U.S. Govt. Print. Off.
Place of Publication:
Washington
Publication Date:

Subjects

Subjects / Keywords:
Preventive health services -- United States   ( lcsh )
Officials and employees -- Health and hygiene -- United States   ( lcsh )
Genre:
federal government publication   ( marcgt )
bibliography   ( marcgt )
non-fiction   ( marcgt )

Notes

Bibliography:
Includes bibliographical references.
Statement of Responsibility:
Subcommittee on Retirement and Employee Benefits of the Committee on Post Office and Civil Service, House of Representatives, Ninety-fourth Congress, second session.
General Note:
Reuse of record except for individual research requires license from Congressional Information Service, Inc.
General Note:
At head of title: 94th Congress, 2d session. Committee print no. 94-22.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 024430565
oclc - 03167618
lccn - 77600810
Classification:
lcc - KF49
System ID:
AA00024778:00001

Full Text



S94th Congress COMMITTEE PRINT fCo MITTE
2d Session C IP NPRINT NO. 94-22






FEDERAL EMPLOYEE PREVENTIVE
HEALTH SERVICES




SUBCOMMITTEE ON RETIREMENT AND

EMPLOYEE BENEFITS OF THE

COMMITTEE ON POST OFFICE AND
CIVIL SERVICE
HOUSE OF REPRESENTATIVES
NINETY-FOURTH CONGRESS SECOND SESSION








DECEMBER 16, 1976 PI>-//




Printed for the use of the Committee on Post Office and Civil Service

U.S. GOVERNMENT PRINTING OFFICE
78--927 WASHINGTON : 1976




















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STJBCONIMITTEE ON RETIREMENT AND ENIPLOYLE RICHARD C%\VJKTETvxnq, Clainnan DMIKICK V.DAMFL N' jcr l;FNI-: TAYLOR, Mi ouri
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CONTENTS

Page
Introduction_ 1
Legislative history -------------------------------------------------4
The preventive health services offered to Federal employees-------------- 12
(1) Government-wide program_--12
(2) General Accounting Office review of the Government-wide
program ----------------------------------------------- 1
(3) Summary of section- --- 20
Costs-- 21
(1) Costs of the Government program ----------------------------21
(2) Preventive health services available from non-Government institutions for approximately S30---(A) The University of Florida program---24 (B) The Kaiser-Permanente program--24
(a) Cost analysis per examination -----------------25
(b) Cost analysis per positive case 2 )
(3) Summary of sectionI -) Cost'benefit analysis of preventive health services- 31
(1) Positions supporting periodic examinations------------------ 32
(A) Department of Health, Education, and Welfare ----------)2 (B) General Accounting Office_-3(
(C) Results of the Kaiser-Permanente study------------(2) Positions opposing periodic examinations0-9
(A) Statement of Dr. W. Keith C. Morgan 39
(B) Statement of Dr. Richard Spark-__- 40
(3) Summary of section--41 Findings and conclusions --------------------------------------------42
Recommendations ------------------------------------------------- 45
Bibliography------46 (TITi



















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INTRODUCTION
The Federal Government has long held an active interest in promoting and providing for the general well-being of its employees while at the same time maintaining an active vigorous work force. In order to promote and maintain Federal employees physical and mental fitness, the Con ess enacted legislation authorizing, the heads of Federal departments, agencies, and corporations to establish employee health service programs; when enacted more than three decades ago, increased employee efficiency, decreased sick leave, disability, and improved employee health and morale were among the benefits anticipated. It was believed that "practical, measurable gains" would be achieved under this program.
The oversight hearings on the Government's preventive health program conducted throughout the month of August 1976 came about after an intensive investigation into the program by this subcommittee. The investigation was prompted by complaint.,-,, of inequities within the program whereby not all Federal employees had access to or were eligible for the same services. Additional impetus was added by the fact that since its inception in 1946 there has been no comprehensive review of the program, its costs, and its benefits.
As enacted, the legislation authorized, but did not require, the establishment of employee health services. Although agency headquarters have issued health program guidelines, the agency head was usually delegated responsibility for program development and operations to lower level headquarters and local officials. Consequently, an employee can receive either a complete physical examination, a limited number of screening tests, or no preventive health services at all. For example, according to a GAO report issued on June 14, 1976, the Social Security Administration at its Baltimore headquarters offers a yearly examination to employees over the age of 50; employees between the ages of 40 and 50 are eligible for an examination every 2 year,-;; and those under 40, every 3 years. By contrast, all 1,498 employees located in 46 Los Angeles County Social Security offices were offered no preventive health services. The fact that inequalities exist-providing non-job-related preventive health services to some Federal employees but not to others of equal age and grade-is undisputed and even defended in testimony before this subcommittee, by the Office of Management and Budget and by the Civil Service 'Commission. This point of view is unacceptable and will not be tolerated. The subcommittee strongly believes that equal treatment of Federal employees of equal grade and age should be a prime concern of the Federal Government. The subcommittee has written a legacy dedicated to this principle punctuated by its record number of hearings, meetings, and public laws designed to improve the well-being of all employees.
Bringing the costs of this program into focus, the Subcommittee is distressed to report that this very important consideration has received no more attention and scrutiny than the equal treatment of
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pro(utivitY; therefore, if illi b Cllle b~'v~te ll)eeit' sV i CIJWcri to both parties involved. The lo~2l W, 5 VN cciZ ira~ll. Cl a- i11licit ly inclicated earlier in t hs pa,-,z)(e( ; d at' is, tat i1e tunio-imorre thn),in :'I' vto a>I., ag(o ma-I"n Wa s (lestrove(I b !et- olltsj*le The l~~iaibody that entere(l via Ow heiit h, floS, and I hro,,t 1; 1)i'(e1k I'iv~em 1-tih prnIct ir I ?lt tllem 1elVes; eXCODtiO atty well to the (irt-ctionll and e-arly cure of
teety~pes_ of lt~e. oeei e value of earlyA (l fIectio iofl1di5(eti5(e5 that (',(,,troy by bi-eakintlo mlenlo~ I-, is ncreasim 1Tv Iell C
questioned by a ,--ignificant minority of physician-, ill contemporaryv inetil circles.
For example, Dr. Riussell Roth, aI lou,,-rfime Erie. Pa., ur-ologist and former president of the Amiericafn M\edic,,it Ass ociltlon, fias staite1 thalt even, the most elabonata chieckuips do not detect early and trealtaible
disesesWith any recriaritv. Even if diseases could be dletectedl in checkups patientsls are probably better ofi not kniowinog they are going to die of Huntington's chorea or mutltiple, sclerosis 1.5 or- 201ver fromt n1ow'' Said Di'. William Keith )vlorg-an of West Vil-ginia Uniiversity's; SchIool of -Medicine in testimon- before this subcol-miit tee. By contrast the Kaiser-Permanente medical care pi'oc-ram has be-en conduc1(ting a, long termi controlled, studlv of the value of multiphasic hielth checkups on adults anti has found periodlic health checkups to be associated with sig-nificanitly lower (lea th rates from potentially post ponable causes for adults aged. .35 to 54, and to be cost-e'-ffective for mniddle-agyed men as, measured by deceased disability and increased earning capacity. The subcommritte e hias also noted. the "Forw ard Plan for Health 1978-S2", a study done by the Depairtment of health, Education, and Welfare which concludes that the best, hope of achieving any siganifie-Iant extention. of life expectancy lies in the area of disease prevention. However, it is indeed recognliz.(1 by the suibcommittee that the present health system is geared1 prim-arily to handle the effects of disease rather than to attack d-isease by pre-entive m'leafsurICs.
In conclusion, let US summarize the task undertaken b~v thilsucommittee in reviewing the Feder-al Government's lpreventive health program. We have endleavored to stu-dy the s.-ope of tim programn, its, costs, its benefits. These three areas were briki fly touch-ed upoi) in thi-, introduiction: they will be dealt with in more (etail in the body of this report as will the legislative history of the program; the findings, and reco-mmendtiions for future program Ll~eo~etaestfrha h
end of this report. Finally, it is our sinicere hiope that the reauler 17i-11 Ltake the time and put forth the effort required to ciiu'efullysy anld dig est +.he contents of this report and not p')ceol dijreejily from here to the findings and recommenda-tions i: so oft en happens, with ( oinnliU tee prints of this t-ype for this' report has bearing'( )o t only v cn a pirogrami longr lost in the bireauc-trai bog- but also onl 1two m esthat aire very close to US all: our lii'ith anid omr e( onon)ic w1-e~ l~iI[~iI)C. WHITE,















LEGISLATIVE IlSTOiR Y

To promote and maintain Federal employee physical and mental fitness, the Congress enacted Public Law 79-658 (5 USC 7901),
approved on August 8, 1946, which authorizes, but does not require, the heads of Federal departments, agencies, and corporations to establish employee health service programs.
[Public Law 79-658 follows:]
[PItri Ric L ,w 6" -79,ri Coxiss]
[CHiAPTER 865-23 SE-ssioN]
[1l.R. 2716]
AN ACT
To provide for health programs for Government employees.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That, for the purpose of promoting and maintaining the physical and mental fitness of employees of the Federal Government, the heads of departments and agencies, including Government-owned and controlled corporations are authorized, within the limits of appropriations made available therefor, to establish by contract or otherwise, health service programs which will provide health services for employees under their respective jurisdictions: Provided, That such health service programs shall be established only after consultation with the Public Health Service and consideration of its recommendations, and only in localities where there are a sufficient number of Federal employees to warrant the provision of such services, and shall be limited to (1) treatments of on-the-job illness and dental conditions requiring emergency attention; (2) preemploynment and other examinations; (3) referral of employees to private physicians and dentists; and (4) preventive programs relating to health: Provided further, That the health program now being conducted by the Tennessee Valley Authority and by the Panama Canal and Panama Railroad Company shall not be affected by the provisions of this Act: And provided further, That such health, programs as are now being conducted for other Federal employees may be continued until June 30, 1947. The Public HIealth Service, when requested to do so shall review the health service programs being conducted by any department or agency under authority of this Act and shall submit appropriate comment and recommendations. Wherever the professional services of physicians are authorized to be utilized under this Act, the definition of "physician" contained in the Act of September 7, 1916, as amended (U.S.C., 1940 edition, title 5, sec. 790), shall be applicable.
Approved August 8, 1946.
In the hearings conducted by the subcommittees of both the House and Senate Committees on Civil Service, testimony was presented by the heads of various Federal agencies, by the representatives of a number of business concerns which operated comprehensive industrial health programs, by representatives of the major government unions, and by representatives of the American Legion and the American Medical Association. All witnesses testified in support of the legislation. At this time increased employee efficiency, decreased sick leave and disability, and improved employee health and morale were among the benefits anticipated. Testimony indicated that practical, measurable gains would be achieved under the program. In testimony on the
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5

proposed legislation Arthur S. Fleming, Commissioner, U.S. Civil Service Commission, stated that adequate health and medical programs in the various departments and agencies of the Government would help to cut down turnover and also make it possible for the Government to be carried on in some instances with fewer people. In further testimony Mr. Fleming noted that in 1942, employees were charged with an average of 7 days' sick leave per person per year. If the average of 7 days per employee was reduced to 6, with 2,900,000 persons then on the Federal payroll, there would be a savings of over 5,500,000 man-days per year, or the equivalent of dbout 20,000 full time workers. %Ir. Fleming's statements were representative of the testimony presented during the course of the hearings and was restated in both committee reports accompanying the legislation as strong rationale for adoption. Before progressing, one small note: the fact that employees still average 7 sick days per year will be addressed in detail later on.
As enacted the law limits preventive health programs to: (1) treatment of on-the-job illness and dental conditions requiring emergency attention, (2) preemployment and other examinations, (3) referral to private physicians and dentists, and (4) preventive programs relating to health.
Th.,. law also provides that programs be established only after consultation with the Public Health Service and only in locations with enough employees. On request the Public Health Service is to review programs conducted under this law. However, the law does not require agencies-which include departments, installations, and Government corporations-to adopt its recommendations.
On June 18, 1965, the Office of Management and Budget issued circular A-72 entitled "Federal Employees Occupational Health Service Programs. "
[A reproduction of circular No. A-72 follows:]




















718-92T-76-2







6


EXECUT vE OFFICE OF THE PRESIDENT BUREAU OF THiE BUDGET
WAIHINGTOn DC 20503

JuC 1 CULA NO. A-72


TO I iAD6 OF EXECUTIVE DART& T AND ESTA3ISV-S

JBJEC: Federal employees Occupational Health Service Progrms


1. Purse. Deprtments and agencies are authorized by the Act of Auust 3, 1 946, as amended (5 U.S.C. 150), to provide health service program in order to promote and maintain the physical and mental fitness of employees under their respective jurisdictions. Departments and agencies have provided such health service programs subject to the "Policy Statement Covering the Establishment and Operation of Federal Employees Health Programs" approved by the President on January 9, 1950.

Feicral employees who sustain personal injuries or disease while in the performance of duty are provided medical and other services, appliances, supplies, and vocational rehabilitation in permanent disability cases, under regulations of the Secretary of Labor. Departments and agencies undertake programs to eliminate health risks under the Federal Employees' Compensation Act, as amended (5 U.S.C. 751).

This Circular replaces the 1950 Policy Statement. It establishes criteria to be followed by the heads of executive branch departments and
agencies in providing programs of health services under the 19'6 Act, and in relating them to programs established to provide medical and other services and to eliminate health risks under the Federal EZployees' Compensation Act.

2. Policy. The health fitness of Federal employees for efficient performance of their assigned work is an important element in a progressive personnel management system and in effective administration of Federal programs. Te head of each department and agency, therefore, will review existing programs and is authorized and encouraged to establish an occupational health program to deal constructively with the health of the employees of his department or agency in relation to their work.

Such programs will ultIihately provide employee health services of the scope specified in this Circular for all employees who work in groups of 300 or more, counting employees of all departments or agencies who are scheduled to be on duty at one time in the same locality.



(No. A-72)










2

Such proFg-c&-s may aJ. a provt 3rl.3 or :-De C., ~ se~v 2. the scope specified in tni2. c'ircu~lar fo:r iz~;e wowr:n groups of less than 300 where the employii5 :rr or dgecv errnes
that working co. itio..s irvoivirg 'ce's r>s ar-oso
provision.

In localities wi4h cign-;i-ca,t ccnce-. rt~.:*cn f e, act+ivfties and employees, health sf=rvicej ru c! oie su a "-_t:rtn~ service" when appropri-Aate drth Doies .i r c.es prescribed in Budget Circular A-60, kuz-eI AuSt 23,i~4

Treatment and medical care in ri n Compensation Act.'

3. Estab .tsj-h, End1 or-~T~hd~rietad agency head, after consulting' '~-1~ nt _11-1c -1. Za Iece as +0 occupational mnedi.cal. stn=n 6c oi, d c~It wit'l Department of Labor standards an e.hcis P ro s ~c service in
perforrmance-of -dut injury c&3ses ara" fora-> ii-~h~ risks r.3
authorized under the Federal &C4o ,e1 Open,6at.z..a is authorized.
to establish, within the limi-ts off i%-%aable a~prcpriatio ns, an occupational health program with haa,.Ltha sei->icez to be pr ovfd-ed as h_, teems necessary:

a. By utilizing professional staff' or facilities existin- in his department or agency at locations whe-re ae;:t oi-,

b. Where an agency's staff or facilities are not adeute, by
entering into an appropriate agreement with anotherr d'eral depart-ent or agency at locations where tt department or agryhas av&aba'le adequate professional staff or facilities; cr,

c. Where neither the agency n.-. another, federal depa-rtment or
agency has adequate staff or facilities available, by' establishing the department's or agency's oirn professional staff or facilities or by entering into an appropriate agreement with cq.alifi ed! p21%ate or public sources for professional services, including consultfag zervi'ces, or facilities.

The General Services Administ'-ratton, the Post Office De~partmient, or any other agency that provides a-ni maintains Federal. space occupied with other agencies where adequate heeilth facilities are not provided by a tenant agency are authorized_- to proviJe occupational health services under this Circular for -,he employees of all such agenc-4es working in groups off over 300 in the same localty, az provided for "central supporting services" under the policies and procedures off 'Budget Circular A-68 dated August 26, 196.



(No. A-72)






S


3

'.ere the ert : r encie cn ern ,ointy determine that the health service .~.ch ar~e necessary Xe to nork6in conditions involving healh ris for fever than 300 e loyees in the same loality canot be adege:tely or e onomcally s applied from qualife: private or public soces vy ontrac:, thy wil be provided by means of a health s rvice eni operated in Federal space.

L. Scoe of occup ional health seri FederQ employee health
services are 2thorice1 to be provided fVr 2il employees, consistent with the staa.i presiel in pragraph 3, and will be limited to the o:cupational health. services acined celow.

Te extent of there services o be provided at each work location will be determined by the head of the department or agency according to the working conditions and number of p oyees at that work location:

a. Emergency diagnosis and first treatment of injury or illness that become neces: .y during working hours and that are within the competence of the rafesionral staff and facilities of the health service unit, whether or not such inj-ury was sustained by the employee while ir the perfo'runce of duty or whether or not such illness was caused by his employment. In cases where the necessary first treatment is outside the competence of the health service staff and faciliies, conveyance of the employee to a nearby physician or suitable co=unity medical facility may be provided at the request of, or on behalf of, the employee.

b. Pre-employment examinations of persons selected for appointment.

c. Such in-service examinations of employees as the department or agency head determines to be necessary (in addition to fitness-for-duty examinations which are performed under existing authority).

d. Administration, in the discretion of the responsible health service unit physician, of treatments and medications (1) furnished by the employee and prescribed in writing by his personal physician as reasonably necessary to maintain the employee at work, and (2) prescribed by a physician providing medical care in performance-of-duty injury or illness cases under the Federal Employees' Compensation Act.

e. Preventive services within the competence of the professional staff (1) to appraise and report work environment health hazards to departmental management as an aid in preventing and controlling health risks; (2) to provide health education to encourage employees to maintain personal health; and (3) to provide specific disease screening examinations and immunizations, as the department or agency head determines to be necessary.



(No. A-72)










4


f. In additicn to he above, employees my be referred, upon
their request, to privat-e physicians, dentists, and other community health resources.

5. Health service er-onn0, facili tes d Sce. Health services
of the scope defined i & I will be jrv~ under the direction of a licensed phsician, and nursing services will be provided by registered professior. nurses. To the maxlmn extent feasible such physicians and nurses 2_ll be qalified in ocupational medicine and nursing. Thie number of health service pr and the types and
extent of facilit es rove at each work Ioat~i~ where health services are furnished v 2_I be determined by the hed of the department or agency according to the working conditions and the number of empreloyees at that wo location.

Diagnostic and laboratory cui~pment, other than hand instruraents, of such cost &nd recuirir.ng &uch technical staff maintenance &s an E K, a fluoroscope, a diagnostic X-ray, or laboratory equipment used to analyze body fluids, may be mainntained only in those large installations, particularly of an industrial nature, where cost analysis and experience data show that maintainir, such equipment in the health
service unit will be more economical than securing services from nearby community facilities.

Where the agency head determines it to be necessary to maintain such equipment, he will obtain it, wherever possible, from available Government excess property. The Administrator of General Services will advise departments and agencies; upon their request, concerning availability of excess Federal property suitable to their health service equipment needs.

Pursuant to the Public Buildings Act, as amended (40 U.S.C. 601 et seq.) and the Federal Property and Ad4rinistrative Services Act, as amended (40 U.S.C. 471 et seq.)., the Administrator of General Services in space planning, construction, and leasing activities, and in delegations of such activities to other agencies, will makIe adequate space provision for occupational health services under this Circular in accordance with space standards to be determined by the A-dministrator of General Services. Heads of departments and agencies excluded from the provisions of the Federal Property and Administrative Services Act or operating under delegated authority from the Administrator of General Services will also make adequate space provision.

6. Records.

a. Medical records of persons selected for appointment and of.
individual employees, and professional evaluations, will be maintained under control of and for use only by the responsible professional



(No. A-72)







10

5

eror::Dl. When requested by the employee, his full medical record will be made available by the physician in charZge to a licensed physician deslgated by the employee.

b. The basis for an~y deternTinations made by departments and agencies as to (1) the need for and means of providing health services for employees working in groups of less than 300, (2) the need for in-service examinations, screening examinations and immunization, and (3) the need for and comparative costs of maintaining special diagnostic or laboratory equipment will be recorded.

7. Coordination and eval-t ion. The Chairman of the Civil Service Commission will assist the departments and agencies to develop adequate occupatioral health programs with services provided at work locations in the States, the District of Columbia, the Territories and possessions and Puerto Rico. He vill elso set guidelines for cooperative provision of such health services by two or more departments or agencies having employees in the same or nearby buildin.gs where they find that joint action will result in providing mere effective health services.

As authorized under the Act of August 8, 1946, the Public Health Service will advise departments ind agencies, upon request, concerning their health service programs by providing agencies with occupational health standards to guide the provision of the occupational health services herein authorized, and by evaluating agency health service programs in relation to such standards. As authorized under the Federal Employees' Compensation Act, the Department of Labor will advise departments and agencies concerning the provision of medical services in performanceof-duty cases and the appraisal of work environment health risks.

The Chairman of the Civil Service Commission, after obtaining information from the departments and agencies concerning the extent, staffing,
facilities, and operating results of their occupational health programs, after consulting with the Public Health Service and with the Department of Labor in their respective areas of responsibility, and after such consultation with non-Federal occupational health program specialists as may be desirable, will report annually to the President the extent, costs, and results of departmental occupational health programs, together with an evaluation of such departmental programs and with appropriate recommendations.




CEAILES L. -CHULTZE
Director




(No. A-72)

The ircilar state s that the health fitness of Federdal employees for ettir iet 1e fo)rminee i+ :t imlport ant element of a progressive personnel

lI l WI'ge(1 eient (J apartments and agencies to estl)isi CIl)loyC'e
1021t f 1 })f Ii~l< 1I ,lf I0 -rai~ I 11 il IIf I01 t OpIfI I I ,,tS
OlIl 1 r I 1 1d11 )nll Ii t II(O I 1 t 11I 1 (11c0 lIfi Y c 1 21 I 1 11 118 0011Iealtbp 1ruIii. The cIr'uZIr slated th1t an geIwcv coId opIerate its ow )Ie8 Ih1i. t 1Iact to usel another ag,(,cv's lhealth 11itt-, conti'8('t H 11h (il liiled l)1ivaite or )Ulir 5o111'c(, oi om0111)ie the methods. )I })ela t.d to tl h (C vil '-rvice (' nmiis-ion Wvts thle (ponahsibility for






11

(1) helping agencies -levelop adequate occupational health proran: at work locations and (2) annually reporting t o the Prri(lenit lie extent, costs, and results of the total IFederal ep!oyeev(e occupalio al'a health programs. (iircular A-72 a(lditionallv specifie-; t}hat the Public Health Service should provide agencies with health sta dar'd uind
evaluate their health service programs cordingg to thee tan diard(l. As a result the Divicion of Federal Employee Health was etabliheod within the Public Health Service. This division wa chiare,,'I with the following function> and responsibilitie<:
(1) To help any Federal agency requelstng advice on organiizing
and establishing employee health service programs;
(2) To provide standards and criteria for these progrr.s:
(3) To assist any Federal agency ,eq ', ti an evaluation of its
services; and
(4) To organize, administer, and operate, on a reimbursable
basis, Federal employee health units for participating agencies.
Pursuant to its organization and responsibilities the Division has issued guidelines for planning and operating health units for Federal employees. In these guidelines it is recommended that an employee health program consist of at least a periodic medical examination program, periodic tests-commonly referred to as screening tests throughout this report-to detect chronic diseases at an early stage, immunizations, emergency treatment, referral to a private phy-ician or dentist, health guidance and counseling, access to emergency ambulance service, physician requested treatments, mental and emotional evaluations, and preemployment and other examinations. The guidelines state that the philosophy of prevention should be the guiding influence in every activity carried out in the health unit. They also state that "preventive programs relating to health" means that occupational health units should provide screening programs, immunizations, health counseling, and complete physical examinations.
The Division of Federal Employee Health recommends that management prepare a list of eligible employees for a voluntary complete physical examination. First priority should be to those whose work involves risks to health regardless of age. Second priority should be to employees aged 40 and over.
The examination should include a complete medical history, glaucoma test, pelvic examination and pap smear for a woman, chest X-ray, electrocardiogram, serology-blood test for svphillis--urinalysis, blood count, and other tests as warranted. The guidelines state that numerous screening tests may be conducted for early detection of disease. The guidelines recommend screening tests to detect glaucoma, visual defects, diabetes, hearing defects, uterine cancer, and breast cancer. Although not enumerated in the guideline, testi for hypertension-high blood pressure-is also recommended by the officials. It is pointed out that these test-; should be offered on a voluntary basis to all employees. The guidelines provide d(letailed instructions for conducting screening programi-, i ding di;tribution of information to employees, conducting tests, a:d interpreting laboratory reports.
One final note in passing is that in 1970 the law whi h created the Postal Service also removed the Service for the Civil Service Commission' s control. The Postal Service is responsible for developing its own occupational health program. IHowever. the ('emmision does render hel) in developing occupational health ): 1-ams.












1I(LENTIVE lEALTIl SERVI('ES OFFERED FEDERAL
E11 PLO Y EES
SCOPE OF GOVERNMEr PaOGRAM
The Division of Federal Employees Hlealth had its genesis in Public Law 79 -65,, August 8, 1946, now codified under 5 U.S.C. 7901. Under the nact, the Public Iealth Service is assigned responsibility to (1) operate health units on a reimbursement basis; (2) provide standards; and (3) )provide, when requested, technical assistance in determining staffing needs and evaluating agency programs.
I the guidelines issued by DFEII for planning and operating health units it is recommended that an employee health program consist of the following: (1) a )periodic medical examination program;
(2) screening tests to d(letect chronic diseases or disorders at an early stage; (3) immunizations; (4) emergency treatment; (5) referral to a private physician or dentist; (6) health guidance and counseling;
(7) access to an emergency ambulance service; (8) physician-requested treatments; (9) mental and emotional evaluations; and (10) preemployment and other examinations.
With the passage of this law the Bureau of Medical Services expanded developmental efforts to design typical health programs for Federal worksites. The first division of Federal Employees Health was organized in 1947.
On June 18, 1965, the issuance of OMB Circular A-72 established a Federal policy toward occupational health programs for Federal employees. The General Services Administration was required to expand its role in providing space and facilities in GSA managed buildings for Federal employee health units. The General Service Administration coordinates with the Division of Federal Employees Health for consultation services for design of health unit physical facilities, in making recommendations for equipment, and in the establishment of Public Health Service operated programs in multiagency locations. A formal agreement clarifying the cooperative activities of the General Services Administration and Public Health Service was concluded in 1967. Since the issuance of Circular A-72 the role of the Division of Federal Employees Health has expanded approximately three-fold with respect to the number of consultations and requests for reimbursable occupational health programs to serve Federal agencies. The development of health units has primarily taken place outside of the Washington, D.C. metropolitan area principally at Federal work sites involving multiagency settings. Currently DFElI operates a total of approximately 125 health units; 47 of these units are in the Washington, D.C. area and the remainder scattered throughout the United States.
The 0MB Circular and Public Law 79-658 provide that health service programs for Federal employees shall be established only
(12)






13

after consultation with the Public Health Service and after "consideration" of its recommendations. The Division may receive requests for consultation from any Federal agency.
Since 1965, DFEH has responded to approximately 120 consultation requests per year in 15 to 25 cities covering all of the 10 Federal regioas. Typically, such consultations will involve 15 to 25 health unit design layouts and tables of medical equipment and furnishings recommended for health unit operation. As stated in testimony before the subcommittee, as many as five of these consul tatiois wil also involve an indepth evaluation of an agency's physical facility, program, and staffing, for its health progratn. The number of' requests for advise and consultation has been steadily increasing from year to -year.
TIhe facilities avaih6ble to a e-deral employee depend upon the number of such employees concentrated in a given area. For (xa.mle, health services for Federal employees are autliorized and en:o(iraged for Federal activities working in groups of 300 or more in the same locality. Units serving this category have been operati-g on a reimnbursable basis for some 25 years. They must be under the supervision of a physician and staffed by professional nurses. Thje kind of physician-full time, part time, or intermittent contract-and the number of professional nurses and other support personnel are determined by the size of the employee population to be served and in some cases by the nature of the specialized work, processes, or materials involved in the occupational setting. For these programs, a full-time physician is employed in health units serving 3,50 or more eloyees. For employee health units serving less than 3,500 employees, a contract with a practicing physician in the community is arranged for on the basis of one 2-hour visit per week for each 500 employees served. The number of professional nurses employed is established at a ratio of 1 nurse per 1,000 employees served; the number of nurses assigned is reappraised in relation to the work caseload.
The services provided at a typical health unit include (1) on-thejob emergency first aid health services; (2) preemployment and other examinations; (3) referral to private physicians, dentists, and other private health resources; and (4) preventive programs relating to health.
Early in the 1960's DFEH began to provide screening programs in testing for visual acuity, glaucoma, and diabetes. In more recent years screening programs have been developed for the detection of uterine and breast cancer in female employees, hearing defects, and hypertension. In addition, special pilot programs have been developed to seek a reliable method for evaluation of coronary risk factors and to design a screening program specifically for women employees. Currently, it is recommended that management nominate employees for comprehensive physical examination-called employee health maintenance examinations-on a voluntary basis in accordance with priorities as follows: First priority to be given to employees, regardless of age, whose work involves some stress or hazard to health; second priority is given to employees over the age of 40. The number of examinations available to a Federal manager in a DFEH program is limited by economic considerations which translates into the number of visits a physician makes to a health unit in any given program year.


78-927-76-3






14

The preceding has been a sitnary of program guidelines set forth by the I)ivi ion of Fe(deral Employees Iealth in testimony before this subcommittees, August 24, 1976. Prior to the August hearingsfnl13Y complaint concerning inequal cities iln the proflul promip.d the sulbconinittee to re(lquest that the General Acoultiilig Ofice conduct an investigation into the complaints. In its program review the
General Accounting Office reported on the preventive health services offered to employees at five agencies. 'This is ldocumented by the following letter sent to the President of the Senate and the Speaker of the House.
COMPTROLIER ENERAL OF THE UNITED STATES, Washington, D.C.
B-164031(3).
To the Presided of the Senate anld the Speaker of the Ilouse of Represelatives:
We have reviewed preventive health services offered to Federal employees at five agencies and found that inequalities exist in the availability of ueth services. This report includes recommendations and matters for congressional consideration aimed at eliminating these inequalities and strengthening program management.
We made our review pursuant to the Budget and Accounting Act, 1921 (31 U.S.C. 53), and the Accounting and Auditing Act of 1950 (31 U. S.C. 67).
We are sending copies of this report to the Director, Office of Management and Budget, Counrssioner, Civil Service Commission; Postmaster General; Administrator, Niational Aeronautics and Space Administration; Administrator of Veterans Affairs:; and Secretaries of the Treasury, Defense, and Health, Education, and Welfare.
ELMER B. STAATS,
Comptroller General of the United Stales.
The review by the General Accounting Office concentrated on the physical examination and screening-test aspects of the preventive health programs in the five agencies. The preventive health programs offered by the following five agencies at their headquarters and their field offices in Los Angeles County, Calif., and the Greater Cincinnati metropolitan area, Ohio, were selected for review: (1) Defense Supply Agency, Defense Contract Administration, Department of Defenie;
(2) Social Security Administration, Department of Health, Education, and Welfare; (3) Internal Revenue Service, Department of the Treasury; (4) U.S. Postal Service; and (5) Veterans' Administration (excluding hospitals).
In this undertaking, GAO visited headquarters personnel responsible for each agency's employee health program and each health unit serving headquarters. The field offices examined varied with the agency's organization. For example, for the Postal Service in Los Angeles, GAO consulted with the district personnel responsible for the 285 Service locations and on Service-operated health unit serving 63 of those locations, while for the Defense Contract Administration Services in Los Angeles, the regional personnel responsible for the eight health units were consulted. In addition management control by headquarters was examined at three locations. They were the National Aeronautics and Space Administration, Lewis Research (C'enter, Cleveland, Ohio, the Department of Defense's Long Beach Naval Shipyard, Long Beach, Calif., and the Department of Defense's Wright-Patterson Air Force Base in Dayton, Ohio. Finally, the review also included the manner in which the Office of Management, the (Civil Service Commission, and the Division of Federal Employees I health dischargedl their Government-wide program responsibilities.






15

GAO REVIEW OF GOVERNMENT-VIDE PROGRAM
As of 1974, the Federal Government employed about 2.8 million civilians, of which about 1 million were employed by the Departmeinjt of Defense. As of January 1975, no current programwide statisticwere available on the total number of health units or employees with access to health units. However a 1970 study by the Civil Servic Commission counted about 800 physician-su)ervised Federal health facilities offering health services to civilian employees. These faciliti-Z included 80 health unit. operated by DFEHI. According, to the study. services in the 800 facilities ranged from emergency first aid only to comprehensive prograns which included emergency care, screening tests, and physician-supervised examinations. This study, however, did not include those units without the services of a physician: at- of July 1974, DFEH was operating 103 health units servicing is0o,0) employees.
As stated in the introduction, the fact that inequalities exist--providing nonjob related preventive health services to some Federal employees but not to others of equal age and grade-is undi-puted and even defended in testimony before this subcommittee, by the Office of MIanagement and Budget and by the Civil Service 'ormmission. This fact is amplified by the General Accounting Office's review.
Public Law 79-568 allows each Federal agency to formulate its own employee health program, resulting in substantial inequalities in the scope and accessibility of preventive services, both among agencie and among each agency's locations, stated the GAO report. All agencies reviewed offered some preventive health services, but not at all locations. Often the services offered did not meet the minimum program requirements recommended by DFEH. Depending on work location, an employee can receive either a complete physical examination, a limited number of screening tests, or no preventive health services at all. The following table shows the scope of preventive health services available in fiscal year 1975 to employees at the locations reviewed.











16











4, 4
I~~~ S- a f r ~ o






AnAi

4 3 Y-i ;~n V 5 1 4y A~ 4%~aAA Ii I





a1 1 4, 23 4 years old:~ rta~

'.n tr 2 A2 d3, C !o








p~ ~ 31 HC or, in in





c',tuberculosis,
and Sc--celj ariernia





t,31 4







r 4 ~ y-cc r Glic~ On n~v~







V' 1 s 4


8 Ir Q k


ir 17 94 GS 14fi

4 ,41







-~~~o less F, 2<



r4o m w~ w; ii %or9) is rrr' ~i T foor175




A n i4 n, r. 14 .* d i5, I n






17

Each of the fiv,,e agency headquarters provides some type of preventive services. However, employees working at; field offices sometimes did not have access to preventive programs. Of the 365 locations without access to preventive services, 317 were Postal S "er vice f,-.ili ies with a total of 16,922 employees. These facilities varied in size froryl 3 employees at someI Los Angeles substations to 3,17 7G e mpl oees at the Los AngelJes main terminal. The following chr so.0red as doc umentation of these GAO findings.

Locations Employces
Preventive services Number Percent Number Percent
Available---------------------------------------- 31 8 65, 47 71
Unavailable-------------------------------------- 355 92 26, 633 29
Total-------------------------------------- 396 100 91,680 100

Among the 30 locations which provided physical examination, different employee groups were eligible because of locally imposed eligibility restraints. Four locations restricted physical examination eligibility to GS-12's and above regardless of age. Of the 26 locations which offered both physicals and screening tests, 11 offered. both services to all 23,668 employees; the remaining 15 offered screening tests to all 37,068 employees, but phys-ical examinations only to employees who met selection criteria. The selection criteria for physical examinations varied. For example, at the central Veter,,ans' Administration headquarters location, with 2,600 employees, phyATsicals were restricted to GS-14's and above over age 40. By comparison, at the Defense Supply Agency's Defense Contract Administration Services headquarters, with 2,505 employees, all employees over age, 40 were eligible. Of the 23,000 employees at Social Security Administration headquarters all who had been employed at least IS inonths were offered both physical examinations and screening tests. Al1though not all personnel received physicals every year, they could participate in each screening program offered. In contrast, none of the 2,291 employees at Postal Service headquarters were offered) physical examinations.
With one excep tion, where screening programs were provided, they were available to all employees. Again, however, the tests offered varied. Of the 27 locations providing screening programs 24 serving 40,255 employees tested for several disorders. The Veterans' Administration in Los Angeles, for example, offered hearing, vision, glaucoma, tuberculosis, and sickle cell anemia tests. On the other hand at seven Los Angeles locations, the Internal Revenue Service offered 66S employees a multiphasic testing program consisting of the DFEHrecommended tests, plus tests of color vision and pulmonary function. The National Aeronautics and Space Administration's Lewis Research Center tested for blood disorders, blood pressure, and weight abnormalities.
The remaining three locations with 22,792 employees tested for only one disoider in their screening programs. Only glaucoma screening tests were offered to employees at Defense Contract Admninistration Services and Postal Service headquarters. At Wright-






is

Air F()rcr, oidv c()i-()iinn- dif,:!-t, -1-f- offered
'111(l (),,it\- to einplov, vs 2tcre 40, limvever, (dlllclok; there ivere d'w i'l1)l1lT)L 11 (101111)rcheri- Iv( T1111 ltlplm ;ic procri-nin for till enlplo\-v(
t -1) 1 () t 11 1- p(milt f he I rit fl,.l (Z"T IcY I rie(JIMI it W.,4 di.- c ii<. Pd III t he GAO I*OP IVI 11,IVe eV I i, 1'! 1:11 IOP __N *1 11 it ", hi, \vcell 4 1 Ild 50 could rec( *IVO 1111 CXZ1111111:1t, ion
cvcrN, ") vuzlr- J11 C111611111167 till v (Ali(Ts 1VOIT I.&I"Vit'd bV 11
j. ie '! "'e
I I I I I i I I I L I i d I ( riploy,,es i\ offervo-1 I )FE11's
w il1)1-11(h'd pcrlm ll(l 1_(T(1PI 1111). -ontrn,,t 4:) vinploVVVS ilW ;J11.41 III ZI fl tll '11.1"1 01 1"t, V (Jifl'ered no lie:iltli si ,rviees.
I 49, cm ph) locit( (t in 46 Los Aii(,clcs Countv social
oflic(-:- oller(, I no prev,.,utive licalth S ICCS.
ldf lilllled nll(i doclitilelited the fact th"It 111('(111,11itios exist vll'llll t110 pro-,r"[111, the ( ('Ilerzil Accountiucr Office's report went on to id(,I1,L1fv th" 111,11,01, F lil- oa for this. Tlie report leaves no doubt as to Nvk, re th", I i irs rests when it
for the present stzite of affit'
-tz,,!,,s th"'t of the einployee healt1i prograin is generally
W(I"!k nt ,III lovel.,7).
Althou4,1 with the agency
"Ll I)rmitrY intliiigement responsibility reqts
lwi(k, thev (,( iicrallv dote(rate program, decisionniziking to their local
t __ I I,- zn
olll(,(,_ to such tin extent that headquarters officials are ustially not f,tinillarwitli the extent, cost orscopeof tbeiremployeeheidt.1i prograins AN-hicli, is confrirN- to the original congressional intent. Consequently, largely dependent on local pbilosopl.iles and re requesti,-1d, in deQigning programs, determining staff lieeds for liealth unit<, tind evaluating agency programs and (2) provi(ling pro-rraiii t,,i Tidzirds and criteria. The. Civil Service (_/'oinin;1_1)Si0TI's responsibility, fl__ a,-zSi_11II(d by Circular A-72 is to evaluate, the overall procynan and to report to Oic Presi(lent annii.,illy on progress,, while its regional healtil nre for proniotin(_), the erliployce health
j)I'W_)T,1TTl- Vill,111V, t1le Office of Mtm igoijieiit, tind Budget liasi the
*I;tv to pro-mini acliievement under Reorganization
Pl )tl -No. 2 of 19"1"0.
in the GAO report. concerning the re. J)OTJ ,jj)'Jity, or 1-Irk ',!iereof, 'llid the 1) re es having
of 1,rrencv hea(l(IlIzArlor, 0 Wyellcl
or Lick ther( ojf, Nvill nom- bo pre-;ented.
IT
C,_l for its
I acrency r(,.-;I.oi 1 it
Allho,10,11 *I"INICN, have issued
t le jCr(qj(.,Nr h i(l Ims ii, u illy (Ielgated lie:thh proormn e,
IL C JI
dity for proniin developitiont, irid ol)0nitiolis to lower lo(.,11 Bec,Aus! of OIL-; deleg"Ition, some
hv( -i,1(vutrt--,r-; sizdrs do not recei or financ*al
do not kn.wx tottil proklmini costs, lv" !I o, It I I ("I It 11 j)1'0(rrt1 a Tid the, r,, -;tilts of services provided.






19

In fact, in the opinion of GAO, official-, of all eight agencies surveyed did not have sufficient information to adequately monitor local program content and results. For example, National Aeronautics and Space Administration personnel do not review fI eld operations and make recommendations for improvement. This is also the case in Postal Service headquarters. In the remaining six agencies, headquarters officials made periodic gnrlreviews o ledpersou-nel operations including the employee health programs. fhowev-r, the employee health prog-ram segment of these reviews-somc times:- c al led Inspector General's reviews or personnel nmnago-ment surveys, depending on the agency involved-was too general to provide head quarters officials sufficient information to adequately monitor local health program content and results, concluded the GAO. For example, three Veterans' Administration personnel management t survey reports were stud ied In each report only one paragraph was devoted to the employee hcaih program. Regarding voluntary preventive health services, each rc-,-ort included only one sentence stating whether or not such services wr available. INo specific comments were made about what types of preventive health. services should be provided or how frequently they should be offered.
The Civil Service Commission's duties in reporting program costs have been discussed at length in the section on costs; at this point it serves our purpose to examine the Commission's responsibility in evaluating, the overall program and its annual report to the Presidlent assessing program development. In 1973, the Civil Service Commission began developing a Government-wide management information stem based on an annual questionnaire completed by each agency concerning services, staffing, costs, and facilities. The Commission plans to use this system to help in reviewing the employee health program's progress, reporting to the President, and selecting priority locations for improvement. It is believed that the data gathered will also help to assist Federal agencies in developing more effective programs. Since a number of agencies opposed the new system as being too expensive, the Commission has obtained clearance from 0MB and the General Services Administration to collect the data until December 1976, after which it must provide an analysis of data collection to 0MB and General Services. On May 16, 1975, each agency was asked for cost, staffing, service, and facilities data, by location, on their employee health programs. The questionnaire did not ask for data on the programs' operating results. However the agencies have indicated that they could not provide this information from their current record maintenance system. This typifies the fundamental problem in the entire program: "Lack of Information."
Earlier in this section the scope of the program as set forth by the Division of Federal Employees Health in testimony before this subcommittee was presented. In its review GAO found that in 197-4 DFEH conducted over 100 consultations for Federal agencies, executive boards, and associations. A consultation can range from a phone call regarding a single question to a formal visit to evaluate an agency's program. An official of DFEH told GAO that, nine formal site visit consultations were madec in 19'74, and all involved indepth evaluations of physical facilities, programs, and staffing. Each year, numerous consultations involve health unit layouts and recommended equipment, however, DFEH officials stated they do not follow up on






20

consultation recommendations because agencies are not obligated to aCceIt their a( ldvie. Al-o, since agencies are required by law to consult with DFEI only when establihing a health program- and DFEIlt is not required to review et ablishel health unit modlificat ions, officials do not know the current status of alil agencies' health programs. This typifies the fundamental p)roblemI in the entire program: "Lack of Infl(rmatin."
The re-ponsibilitv, or Ick thereof, of the Office of Management and Bubdt will now be discussed in teris of the GAO review. In Reorganization Plan 2, effective July 1, 1970, which changed the designation of the Bureau of the udget to ()MB,. the President stated that the "... creation of the Office of Management and Budget represents far more than a mere change of name of the Bureau of the Budget. It represents a basic chance in concept and emphasis, reflecting the broader mianaeunt needs of the Office of the President." In addition to budget functions, 0MB was to place much greater emphasis on (1) evaluation of program performance and (2) assessing program achiveinent. According to the report on an 0MB official said that the Office has not established procedures to assure compliance with Circular A-72, June 18, 1965. There can be no reason for this other than gross neglect. The official went on to say that the normal budget review proess acts as a control on the program and would identify any problems. This however is difficult to digest in view of the fact that many agencies do not compute employee health program costs as discussed in the cost section. The Office of Management and Budget cannot control the program through the normal budget review process; again the fundamental problem in the entire program is clear: "Lack of Information."
SUMMARY
Although officials in the agencies studied by the General Accounting Office generally stated that they believed preventive services benefit the Government, their management of preventive health programs generally does not evidence this belief. Agency heads have not emphasized their preventive health programs and management at all levels is generally weak. Agency heads usually delegate to local officials the authority to develop and operate health programs. Most agency headquarters keep no records of the status of preventive health programs at field locations. Consequently, inequalities exist in the preventive health services both within and among agencies. Depending on an employee's work location, he or she could receive either a complete physical, a limited number of screening tests, or no preventive services at all. Although employees work for different agencies, they are all part of the Federal Government and should receive comparable services.












COSTS FOR GOVERNMENT PROGRAM
In both the House and Senate reports accompanying Public Law 79-658 it was stated that: "Each agency would be required to work out a statement of its needs and the cost of handling those needs, and submit the statement to the House and Senate Appropriations Committees, following review by the Bureau of the Budget" (now the Office of Management and Budget). Following this procedure the program would have to demonstrate its value from year to year as the requests of the agencies for funds are presented to the Office of Management and Budget and to the Appropriations Committees of the Congress. Unfortunately, this intent of the Congress has never been realized. In 19651 OMB assigned the Civil Service Commi sion the responsibility of assisting agencies evaluate Government-wide services and annually reporting findings to the President. In 1966, the Commission issued the first in a series of reports to the President, showing the status of employee health programs. In its 1967 report, it was noted that many locations were without services and offered to help these locations establish services if economically feasible. In 1970, the Commission reported on the costs, range, and accessibility of health services to employees. The report surveyed the 1970 Federal work force of 2.5 million employees in 57 agencies. In part, it was concluded that 552,000 employees had no access to health services; agencies needed to improve information gathering; and many preventive medical services needed expansion.
Of the employees without access, 172,000 were in groups of 300 or more at about 230 locations, while 90 of the 784 locations with service offered little more than emergency services. The 90 locations mentioned above were designated as primary targets for improvement,.
Reports in subsequent years described program status without analyzing needed improvements. For fiscal year 1972, the report on the health program was reduced from a separate comprehensive report to five paragraphs in the Civil Service Commission's annual overall report to the President. The Commission has stated its intent to continue this method of reporting.
As stated in the introduction and alluded to in the above, f funding for this program is hidden in an agency's budget request; program costs are never a line item as originally intended. The Air Force and Veterans' Administration are typical examples of this practice. As documented in a GAO report, the Air Force identifies its total health program cost but not the cost of civilian employee health services. In the same vein, the Veterans' Administration included health program cost in the "Personnel" line item of its costs reports but did not separately identify them. The conclusion to be drawn from these policies is obvious: In most instances top-level agency management as minimal information showing employee preventive health program costs. This conclusion is substantiated by the GAO report, in that the headquarters staffs of only three of the eight agencies contacted were able to supply costs of employee health programs.
(21)
78-.927-76 4






22

top ij):111 1(rellliqlt ofhcial ,
lm-zd level, va ',110r M, Icf- held bV 0I- 1*
l-,-1,;.-,!II1,, t1he vIkle 11,d primity 4 prevolktive 110111th (T \ I V0 "! t, I kw :l I I I (IM I t (q)-t ,111 (1, hol"ce, the (,()St.
I I 1():1 t Ili- poll"t it I- cvld, 11 I 11"it ()Iile loco I oflc'als'
Ilw k ,Wlit of pi-evelill"-V 1walth Ill occlipatiolial settilills
NV li I o 1"I I (. 1.11 r t)" 1,1 d c I- e! I I I ()y ef, I I c a I (TVIC(11-1 11 11 jigh1)kl(wii v 1):,(, (11111110 1*1c po-itm li- MT ext"111plified by the
follmvili oxalliplo-;. Rolitillf" pieveTitive al'o liot, provide'd
lit ;,rvlce Illlit, P1 Lw Allryeli- bec:m- (, tho medical officer., nt
h()f!1 hwzltlofl- holiove emplo yeo- ( iin ohtwn ,nch ,ervUes, through ollt- ido A1 -IG Aljfrf.le- ( mllitv ,-;ocial Secllrltv offices, no
n"Wdic"d -(.rvic(-- Ilre proN-Idod becati-o oflicial,4 feel that pre,,,-ing pul)lic (le;'I'llid", f0l, W 1,011C I I I I
vl'Vic(,- ili conpiuct on w th I'mite(I resources 110t 11'.11( fol. dev-11oplTilf (11111)loyee li(,ldth "I"he
Lo!,:,-). Al elich N'ard NN-itil '- .100 employees--fi,500 industritil
W01*1_ office preventive, health services
A(111_ ll"Ild I 6M workoi-- --feok thitt
MT V,1111"Ablo blit, not ("Stabli-died thern lwcaii- e of other priorities. lit (.olltnl- t, seven of eight 10(,nial Revenue Service offices in. Los Ali offer periodic 111(11til)118- IC t,"Stillcr thrOllgh contract with a
Private screenincr clinic. Employev- M the remaining Internal Revenue Servile office are located in a building served by a Department of Federfil iinit. and receive all of tile DFEH recommended serviceS. Official-; have sai(l tliat i)rvventive serviceeq would reduce employ v e a l)-,outteeism.
Froin the pr(TC10ing, it is clear that differences. in local nianagernent support trank-late into flio co.,ts ageiici(- inctir for 'health programs. The co-- t, can range froin nothing in the case of the Los Angeles County Socittl Security offices to $160 per employee at the National Aeronautics and Space Administraflon'- Pasadena, Calif., office where officitil-- believe verT stron(rly in offorlli(y preventive health service,4. However, on the averacre, I-M'TICk" ( Ilel-zlllv von idor lilt alintial cost of $30 per eiliploveo to li(I D-11111-10il-lilde :Iccor(lillg to tile Civil Service Conlrrii<,4on and the D.P.H.
Tn. or(ler to Provi(le tile reader with ftn idea of the Service and resultant cost ineludod in one Government outpatient clinic, the folloNving ( orrv,,pondonce Nvas rocolve(l in com,,ection with the Sub(10111111ittecs in, pecfion of tile PtIblic 1 fealth Service 011t patient Clinicy Wa-,,hincrton, D.C.
DEPARTMENT OF HEALTH) EDUCATION, AND WELFARE
HEALT11 SE.RN-icEs ADMINISTRATION
111711FAU OF !MEDICAL SERVICES,
Washinqton, D.C., August 18, 1976.
Mr. ROVALD P. "NTCCLUSKEY1
Staff Director and Couiesel,
SO)cononitter on Retirement and Entployer Benefias, "'ashzit.qton, D.C.
DKAR 'MR. AMvCrxsm.,Y: Tho following i< w)Tnitted in response to i1our requ(-,,t durim, vt)nr recent visit t0 the PHS Outpatient (,'hnie, Washington, D.C.
As we discus ,;ed this facility 1,, not a Federal einployee heAth program, however, we do provide a substantial nunilwr of I.Aiysical examinations and laboratory procediire, for the ( employeee health 1)rograni of Fe(leral agencies. These services are pro%,id(,d on a r(,iinf)ursablc ha.- i under authorit.N of the 1 economyy Act.
Outlined below are tli(, ustial services and reirnhur-eTlient rates:
1. Physical examinations:
a. Exat-nination by physician.






23

b. Vision screening.
c. Hearing screening.
d. Recording of height, weight, temperature, blood pressure.
e. Electrocardiogram (EKG) if over 40 years of age.
f. Chest x-ray.
g. Pap smear for females.
h. Laboratory tests:
1. Serology
2. Blood sugar
3. Blood urea nitrogen
4. Uric acid
5. Cholesterol
6. Urine
7. Complete blood count (white blood count, hematocrit, hemoglobin, differential)
8. Others, if indicated (serum)
Cost, $35.
II. Laboratory studies and other tests usually provided Federal employee health
units when services of physician are not required:
a. Chest x-ray.
b. Electrocardiogram (EKG).
c. Laboratory tests:
(Same as listed above.)
Cost, $25.
I hope this information is sufficient for your purposes. If I can be of additional help, please let me know.
Sincerely yours,
WILLIAM M. CORNISH, Director.
This correspondence is evidence that the minimum services recommended by DFEH can be implemented for $35 with a physician in attendance or for $25 in his absence. This cost range is certainly within the "reasonable" limit as stated by the Civil Service ( ommission. Finally it should be noted that these tests are not performed with automated testing equipment which provide economies of scale in tests of this nature.

PREVENTIVE HEALTH SERVICES AVAILABLE FRO\i NON-GOVERNMENT
INSTITurTIONS FOR APPROXIMATELY 0O
Using the Civil Service Commission's assumption-$30 per employee is a reasonable expenditure-it would serve the subcommittee's purpose in examining the existing program to tu n to non-government institutions and determine what services can be purchased for approximately $30 per person. In this analy4s we wish to consider the two methods of providing screening tests: Traditional health evaluations provided by physicians and/or qualified technical p)ersonnel mid multiphasic testing. The traditional health checku) as practiced in this country usually consists of a medical history from the patient, doing a physical examination, and then arranging for supplemental diagnostic tests and procedures which, in the physician's judgment, are essential to comlete the health evaluation. On the other hand automated multiphasic testing can be viewed as a planned course or series of events or procedures, programed in advance and utilizing allied health personnel and automated instrumentation, through which various categories of persons, who inay or mnay not be patients under medical care, are processed in order to accomplish some medical or health-related purpose such as providing preventive health services for employees.
While the traditional approach has been practiced for over 100 years, multiphasic screening became popular after World War II as






24

an extension of the use of single screening tests for programs of cormmuniicable disease control, such as the serologic test for syphilis. When more than one test or modality began to be included in the survev, the term 'multiphasic screening" came into use. As the conduct of the testing took on aspects of a planned and organized sequence of events, accomplished by automated equipment and analyzed by computer, the process began to be called automated multiphasic screening.
UNIVERSITY OF FLORIDA PROGRAM
One advantage of group nmultiphasic screening is that the tests can be performed at a lower total cost than the same tests on an individual baeis. An article in Perspective, 3074, examines a multi phasic screeing program developed by the University of Florida for its athletes, nursing students, and medical students. The procedure ineludes a battery of 11 tests. (osts $13.03 per person, and takes an individual just over an hour to complete. The tests are not automated although the plasma and serum samples go to a commercial automated laboratory for biochemical analyais. Unit costs by exmination station for this screening include:
-20.3 cents for reception and medical history.
-.$1 for glucola (for blood sugar).
-38.1 cents for spirometry (lung capacity).
-14.5 cents for vision testing.
-36 cents for EKG (electrocardiogram).
-12.4 cents for anthropometry (body size, weight, and
proportions).
-$1.58 for physical examination (visual inspection of eyes, nose,
and throat, audio inspection of heart and lungs, abdominal palpation, and inspection of skin, general body posture and development, including examination for hernia in men and optional
Pap smear for women).
-$1.17 for hematology (blood hematocrit and white cell count.
-41 cents for urinalysis (color, specific gravity, pH presence of
ketones, occult blood, protein and reducing substances, and presence of cells, casts and other deposits in a centrifuged
sample).
-66 cents for urine culture (women only).
-$7 for biochemistry (plasma and serum analysis for alkaline
phosphatase, cholesterol, bilirubin, total lipids, serum glutamic oxalacetic transaminase (SGOT), latic dehydrogenase, creatine,
glucose, blood-urea-nitrogen (B.U.N.) and uric acid).
In concluding our discussion of this program it should be pointed out that, in ord(r to hold down expenses, trained high school seniors are used to take EKG readings, test vision, anthropometry and blood pressure. This practice serves to contain costs because salaries and wages are the largest items of direct cost ($4.16 for each battery of tests). Finally, it is very important to note that the same tests provided in this program, if ordered individually by a physician, would cost $86.50; the savings, by comparison to this program, are very substantial, $73.47.

KAISER-PERMANENTE PROGRAM
No serious analsis of multiphasic or automated multiphasic testing can be complete without examining the work done in this area by the






25

Kaiser-Permanente medical centers in California. As early a 1951, Kaiser-Permanente employed multiphasic screening as part of a periodic health examination within an organized group-practice program. Since 1964, the Department of Medical Methods Research of the Kaiser-Permanente medical care program has been co nducti by a controlled long-term study to evaluate the efficacy of periodic health examinations that utilize automated miultiphasic techniques. At this point only the services offered for preventive health and the acconmpanying costs will be discussed; the results, when viewed from the standpoint of benefits will be dealt with in a later secteon.
In the beginning a group of 46,000 Kaiser health plan members was identified as a source of subjects for the study. This initial patient, pool consisted of men and women, born in 1910-1929 (ages 34-5 at entry), residing in northern California, and having at least 2 ,ears continuous membership in the plan. From the initial patient pool a study group and a definitive long-term control group were selected. The study group was to be urged to have an annual mnultiphasic health checkup and the control group would not be so urged. A sampling method was devised to select over 5,000 members for each group. Shortly after the project began in late 1964, members of the study group were invited by letter to undergo a multiphasic checkup. By the end of 1965, it became evident that more effort would be required to induce a substantial proportion of the study group to be examined annually. This item is important in that not every employee would exercise his right to an annual examination even if uniformly available to every civil servant. Kaiser's experience has been that 80 percent of the control group has not taken advantage of the yearly examinations offered by the plan, while 40 percent of the study group, for which computerized recordkeeping has been developed to facilitate telephoning before all appointments and examinations, has not taken advantage of the yearly examinations.
The systemized examinations given at the medical center; take about 2 hours and include self-administered questionnaires, electrocardiography, sphygmomanometry, spirometry, anthropometry, chest roentgenography, mammography (for females aged 48 years or older), visual acuity, tonometry, audiometry, serum chemistries (including alkaline phosphatase, total bilirubin, urea nitrogen, calcium, cholesterol, creatinine, glucose, lactic dehydrogenase, SGO-transaminase, potassium, sodium, uric acid), hematology (including hemoglobin, hematocrit, red cell indices, white cell count, red cell count), serology (VDRL), and urinalysis (including urine glucose, blood, specific gravity, protein, pH, and urine culture in women). In addition, before the patient left the laboratory supplemental tests were ordered by computer if needed before the patient saw the physician.
Having defined the basic examination available to all subscribers of the Plan let us focus attention on the cost of providing these services. The procedures will be examined from two points of view: (1) cost analysis per examination and (2) cost analysis per positive test. Cost analysis per examination
Table 1 details the distribution of the 6,285 examinees in the Kaiser-Permanente study by age, sex, and health status group (HSG) for each of the three health evaluation methods: traditional (TMD), multiphasic (MHC), and the new medical care delivery system utilizing nurse practitioners (MCDS since 1971).











26




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28

Table 2 sItows the co ts to Kaiser Foundation Iealth Plan for each
of the o1ut) ati ent services scheduled and actually provided by the
Permane te M1(11ed Group to these patients, w o() were a ll members
of the plan. Essentially these were then the preI)aid costs by these
Members for their health examinations. These costs do not represent fees or charges which would have been paid by nonnember or private patients; such private fees are usually about twice the cost to health plan Inembers. For example, the automated multiphasic health
tetiIIg cost to the health plan for a member was $17.46 as shown in table 2(b), but the usual charge to a private patient for the examination was $30 to $40.

TABLE 2.-UNIT COSTS FOR SERVICES USED IN HEALTH EVALUATION
(A) PHYSICIAN SERVICES

Direct costs
Salaries and wages including
benefits
Physi- Support Sub- Non- Indirect Total
cian I personnel total payroll Total costs2 unit cost

Medical appointment:
New and new return (30 min) ..... $12. 43 $7.00 $19.43 $.71 $20.14 $8.38 $28.52
Return (15 min) ................ 6.22 3.98 10.20 .36 10.56 4.19 14.75
AMHT followup (15 min)-----------........... 6.22 3.98 10.20 .36 10.56 4.19 14.75
Sigmoidoscopy (10 min)............ ------------4.14 2.98 7.12 .24 7.36 2.79 10.15
MCDSfollowup(15 min)-----------........... 6.22 3.97 10.19 .36 10.55 4.19 14.74
Medical: Nonappointment(10 min)...... 3.03 2.03 5.06 .22 5.28 2.79 8.07
Gynecology: Appointment (15 min)...... ------ 6.41 3.36 9.77 .60 10.37 4.19 14.56
Surgery: Appointment (15 min)---------......... 6.72 4.22 10.94 .57 11.51 4.19 15.70
Eye:Appointment(17.57 min)......--------- 4.23 5.01 9.24 .48 9.72 4.91 14.63
DermatIogy:Appointment(15min) ... 6.28 2.16 8.44 .33 8.77 4.19 12.96
Orthopedics:Appointment (20 min)..... 8.97 5.00 13.97 .71 14.68 5.59 20.27
Allothers: Appointment (15 min)------....... 6.47 8.12 14.59 2.07 16.66 4.19 20.85

'In:ludes retirement benefits and incentive payments by health plan to physicians.
2 Overhead and plant operation.
SComposite of ophthalmologist and optometrist visits.
(B) NONPHYSICIAN SERVICES

Total
unit
cost

(1) Nurse practitioner health evaluation (30 min)-------------------------------------------......................................................... $8. 22
(2) Nurse practitioner and/or paramedic (38 min)-------------------------------------------........................................................ 10. 46
(3) Multiphasic testing (AMHT)-------------------------------------------------------......................................................................... 17. 46
(4) Clinicallaboratory tests ----------------------------------------------------------.......................................................................... 1.66
(5) Radiology diagnostic films---------------------------------------------------------........................................................................-. 4.10
() Special diagnostic procadures..........------------------------------------------------------.......................................................-. 5.66

The physician services cost data in table 2 show all expenses to the
health plan, including "incentive" payments to doctors which constitute a profit-sharing plan for partner physicians and costs of their
retirement benefits. The costs listed for nonphysician services include for each item all direct costs-personnel, fringe benefits, amortized
equipment, and supplies-and indirect costs-overhead, plant maintenance, regional administration, et cetera. The nurse practitioners who provided the physical examinations to the MCDS group were
scheduled for an average of 30 minutes at a cost of $8.22 which includes all direct and indirect costs. Those specialized paramedical personnel (nurse practitioners and clinical assistants) who provided some evaluation followup services were also scheduled for an average of 38 minutes per visit, at an average cost of $10.46.






29

The multiphasic laboratory cost was $17.46 per examination and includes from three to seven more tests than given by the University of Florida.
Cost analysis per positive case
Table 3 presents the costs incurred to identify a clinically significant positive test for the most important components of a multiphasic screening program and indicates which tests would be most cost effective when planning for a specified population such as Federal employees. As before, data is taken from the Kaiser-Permanente
study.
From analyzing the data it can be determined that mammography was provided to women age 48 years and older at a cost of 45 per examinee. In 1 percent of women age 50 years or older in the cries the mammogram was reported by the radiologi, t as "su picios" for cancer; the cost per positive mamnimogram was therefore 0.01 or
$500. However, since only 1 in every 10 of these women with a positive mammogram was confirmed subsequently by surgical biopsy to have cancer of the breast the cost per "true" positive was approximately $5.000. Along the same lines, urine cultures for bacteriuria screening can be provided by collecting and incubating midstream "clean-catch" specimens, and then identifying patients with more than 100,000 bacilli per cubic milliliter in the urine at a cost of about $0.60 per test. In women, about 3 percent have been found consistently to have a positive urine culture at a cost of $20 per positive case. In men, the frequency of positive urine cultures is approximately one-tenth that of women, so the cost per positive in men was about $200.
In conclusion, the researchers say that in the program it costs about $25 to test an adult and that the cost effectiveness of screening depends upon the efficiency of the care process and the prevalence of the abnormality in the target population.
TABLE 3.-COSTS OF AUTOMATED MULTIPHASIC TESTING
Percent/ Cost'
Unit plus plus
Test cost tests test
Electrocardicagraphy-- - .-.....--.- -.........-...........$1.50 15.0 $10.00
Chest X-ray (70 mm) - - 1.00 7.0 14.00
Blood pressure......... .--------------------------------------------- .40 5.0 8.00
Respirometry--------------- ...... -.50 2.0 25.00
Visual acuity ----------------------------------------------- .50 15.0 3.50
Tonometry ------------------------------------------------ .60 .5 120.00
Hemoglobin (women) ----------------------------------------- .50 10.0 5.00
Serum glucose I -------------------------------------------------- .80 4.0 20. 00
Serum uric acid --------------------------------------------- .30 4.0 7.50
Serum cholesterol ...........------------------------------------------- .30 2.0 15.00
Serum calcium --------------------------------------------- .30 1.0 30.00
VDRL __ -_ ...... . . . . . ... . ... ..25 1.0 25.00
Urine dipstick__ - - --- .50 10.0 5.00
Urire culture (women only)- .- ---- .60 3.0 20.00
1Mammography - - - ..................-.. 5.00 1.0 500.00
Medical history_.- --.-.-- -- -- -- -- (3) 90.0 (3)
Total examination-.- --------- ----. -25.00 50.0 50.00
1 1- or 2-hr test after glucose challenge dose for diabetes.
2 2 X-ray views for women greater than 50 years only.
a Depends upon methods used; greater than 90 percent will have some "yes" responses (plus test),






30


Ila- endorsed the concept of preN-eritIN-e health in tile ]),I-t. \N-1th pz), a(-re of Public Lziw 79-65' and more recently witli t1w
Of tlie Public Health SerN-Ice Act Arnendment' of 19,175 (Public, Liw )-l -Wi), winch authorizes (rr*int-; for micrrant lwalth centerA Rnd C0TIIl1111r1ltN- 11C.11th conter-4 riii, act requin-4 both typeo of health centers to provide pr(-N-(TItIN-(, healtil sem,lce-- In addition the Health MailItNIIMCO 01-.-,1TIMltlon Act of 1973 Puhllc Inw 93-22) ako
health malliteliance or(Tarlizations to provide preventive health

Altfiou-(rh the act, doe- not contain a 114 of the-ze >er\'icf- the llotl- ('. committee, I*eport (93-451) accompam-incr thi, t loll state ; tilfit
preventive 1walth ervlces 4ioiild include ari (-rN-Ice which crin be hown to prevent or promptlN detect Gli\-eii the endor.- lenient
()f ('0n.crr(,.-;-:, the Goverliment, has proceeded to peiid va-4 sum,; of
to $65 million in fi-cal N-ezir 1977, nccording- to Dan L. McGurk from the Office of Manacrement and Budget in testimony before thi z -;4ubcommittee-on employee health unit-;- It should be noted th 'It thl.- firrim, I,; an aggrecrate amount, entzillincr both occupationat zl, well a, z preventive he"I -- ervice-'.
No attempt ha- been made to comply with thC 11CCOUTItillrg principie-; set forth in the oricrimd lziw, Public I.,iw 79-65, s, which tates that each 11(y(III(IN, Would he 1-t-quired to work out i statement of it -; need,, and the cost of 11,11idlimy tllo,-:(, lwcd-- and tfien cuhmlt Hie -,tatvment to the llou.- o and Senate Approprlatlon- Committees, following review by flie Office of Management and Bud et. And final1v if de,. ,ired, sufficient data exlst- and Im-, been pre.,ente(rto support the concept that all of the Department of Federil Employees' Health recommended service-, cim he made available to every FMeral employee oil a volitntary ba '-Ft for $.")0 or . I espiciz-11IN III VI(1w of t1le st'Itistics oil utiliz.8tion of these service-- from the 1\' ,iisei--Permaneute -Atidy.












COST/BENEFIT ANALYSIS OF PREVENTIVE HEALTH SERVICES
The introduction pointed out the fundamental premise in preventive medicine: physicians have the capacity to detect any of a variety of potentially "health threatening" abnormalities in well individuals and then can initiate treatment that will ward off impending disease, disability, or death. This section will attempt to shed some light upon the costs and benefits of this premise.
When enacted into law originally, the Congress expected benefits" increased employee efficiency, health, and morale as well as decreased disability and sick leave. Today supporters of periodic health examinations maintain that it is indispensable to good health care while critics of the annual physical examination call it a ritual and a fiasco. The answer to the key question-Is a periodic health examination associated with improved health status?-is one which must coe from research by the medical community. The real question that the subcommittee must address is whether there is validity to the premise that the periodic health examination, as specified by the Division of Federal Employees Health, yields tangible benefits that outweigh its costs. The World Health Organization has developed criteria for the validation of screening procedures that should be applied to the periodic health examination. As summarized the important points are the following:
Screening must lead to an improvement in end results among
those whom early diagnosis is achieved.
The therapy for the condition must favorably alter its natural
history, not simply by advancing the point in time at which
diagnosis occurs, but by improving survival, function, or both.
Available health services must ensure diagnostic confirmation
and provide long-term care.
Compliance among asymptomatic patients in whom an early
diagnosis has been achieved must be at a level to be effective in
altering the natural history of the disease.
The long-term beneficial effects must outweigh the long-term
detrimental effects.
The effectiveness of potential components of multiphasic
screening should be shown individually prior to their combination.
If the benefits of screening accrue to the community at large,
the community benefit must withstand scientific scrutiny.
The cost-benefit and cost-effectiveness characteristics of mass
screening and long-term therapy must be known.
The burden of disability for the condition in question must
warrant action.
The cost, sensitivity, specificity, and acceptability of the screening test must be known.
The criteria set forth by the World Health Organization are both sensible and very demanding. There are very reaf problems with the
(31)







32

perolic health examination when one tests it in the context of what is still a(lnlittedlv an inadequate set of data. Therefore, at this time the opposing points of view will be presented. Considered first will be those favoring )periodic exam nations.

POSITIONS SUPPORTING PERIODIC EiXAMINATIONS

1 :-tP to be eaniued is a 3-month study conducted by the DepartW:t of lailnth, lEducation, ald Welfare onI the "(st and Bewnefit to tiltal G ', (,t
Li' IL'leIrl (Thver:ment, as an Employer, in Providing Health
>trv~c ws inC an (),Cilat jonal SetTo )g." To detc jne the extent of the 1)enlets to the F(:di-,l GoI'dexiinlt ii this study it was neessar to Swint would be lst if the health services were not available.
Tie following account of iis souIy is taken from the hEW report:
DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
To achieve the desired results it was necessary to identify any increased sick leave and/or disabilities< likely to occur as a result of the absence of the service. Tx indicate what benefits would be lost if these health services were not provided, the following information was solicited:
-what health ,services are currently being requested by Federal employees.
-what action would be taken by a Federal employee if health services were
niot being provided.
This information was collected by asking each participating health unit to distribute a questionnaire to all employees using the unit during the weeks of June 28 and July 5.
The following items were covered in the questionnaire:
-the number of times the employee used the health unit in the last three
months.
-the type of health professional providing the health services.
-the type of medical treatment received by the employee.
-the reason for using the health unit.
-the extent to which the employee would seek the same health services
elsewhere if the services were not provided in the health unit.
-grade (GS level or Wage Board grade).
-amount of time needed by the employee to go to his/her usual source of
care from place of employment.
Categorization of services
To calculate the approximate amount of time saved (through unused sick leave and reduced disability), the health services were categorized as follows:
Category 1.-Health services which the employee must receive whether or not they are provided in an occupational setting.
Category 2.-Health services that the agency requires of an employee as a condition of employment.
Category 3.-fHealth services which are not mandated by either the agency or the eInployee.
In determining how a specific unit of service should be classified, the following factors were taken into consideration:
-the frequency an employee receives a particular health service.
-the type of health service provided.
-employee options to the Federal health unit.
--rationale behind the health services encounter.
The frequency of receiving a specific health service was particularly important in c! lasifying shots/immunizations, blood pressure (hypertension monitoring), and bed rest. Individuals receiving three or more services fr shots immunizations I bhlod pressure monitoring (hypertension) during the reporting period (last 3 m,)nth<) and those who indicated that they would receive their health services el-ewhere were placed in category one.
Individuals receiving fewer than 3 of these services, regardless of their intention to receive care elsewhere, were placed in category three. Individuals requesting bed rest were included in category I only if they indicated that it was required by their physician.







33

Any health service identified by the employee as a medical emergency was classified under category 1. If an employee felt that the health care was an emergencycy' it was assumed that he/she would immediately obtain the necessary care.
Some Federal agencies require that their employees receive specific services as a condition for maintaining their employment. The most frequent health service of this type is the physical examination. Hearing and eye examinations and immunizations are also required by some agencies for specific jobs. All such services reported as required by the agency were classified in category 2.
Category 3 contains the following screening program: eye examination (glaucoma), diabetes, pap smears and breast examinations. Depending on the frequency or reason given for receiving specific services, certain other health services are also classified under category 3.
After classifying all health services requested into one of three categories, it was then possible to approximate the "benefit" to the Federal Government in providing health services in an occupational setting. However, because of the methodological problems (coupled with time constraints) involved in measuring benefits that accrue over time, the analysis that follows deals with category 1 services only.
In order to estimate the benefits to the Federal Government, the amount of unused sick leave and the reduction in disabilities were used as measures. It is assumed that by reducing sick leave, time on the job is increased. The employee's hourly wage is being used as a measure of that person's contribution to the efficient administration of Federal programs, even though such an approach is not necessarily an accurate indicator in all cases.
For all health services classified in category one, the study assumes that the employee would seek that care elsewhere if it were no longer provided in the health unit (excluding bed rest). This assumption is based on the fact that the employee has taken the following actions. First, employees who have been receiving allergy shots or hypertension monitoring have had to have their private physician request that service. In most cases this has required at least one visit to their private physician prior to requesting the services being provided by the health unit. In addition, these employees provided evidence that they had sought this care-this classification would not apply unless the employee had received the service three or more times during the reporting period (last 3 months).
While some Federal employees might seek care during nonworking hours, it is unlikely that the majority of the employees would use this option. Since these services are requested on a fairly routine basis, the assumption is that the employee would take only the sick leave necessary to receive the health care. The dollar value of the amount of sick leave that would not be used by providing these health services would be a product of the average amount of travel time needed to receive health care from their usual source of health care multiplied by the average hourly wage.'
It is more difficult to measure the potential benefit to the Federal Government in offering to its employees bed rest services. As was explained above, only those employees who requested this care through their physician were included in category one. If it were not available, the employee may continue to work but presumably at a less than normal pace. In other cases, employees would not come to work if the service were not available, which would result in a work loss. To provide some rough measure of this element, the study assumed that all employees seeking bed rest of more than 10 units during the reporting period would be absent from their job for some period of time. After reviewing a selected number of the questionnaires, it appeared that employees requesting more than 10 units of bed rest are employees who recently either had an operation or severe heart problem. These employees are returning to work on the condition that bed rest is available.
For all other employees seeking bed rest in category 1, it is a,.,,sumed that they are at work for the full 40 hours but are not as productive: To provide an indication of productivity loss, it is also assumed that if this service were not available, at least 1 hour would be lost per request for bed rest.

I Any services which the employee classified as emergency service. In some cases, these services would not classified by a health professional as emergency services. We are concerned with what the employee perceives to be the case and what that employee would do If this service were not provided.
2 Information collected through our limited survey was used in our calculations. Average hourly wage was based on average salary.







34

-41 r%,[(,, -.
tw t i- i c: I r( \I, I It I I d Sce K
VI 1A t III I I I I I t I I I I t I I ri 1 11 111 1 If I I i ot -rg
m i t wk li-] I, IT I i!i I :m iw i nt if t im e
I t Ili, c irt, III it -,Tit I ill v ri -I I I ict -- I I it :I I I, it i I I I I of ,w k It,, tv ot- t a L. c n ()r
III, :it I I It I i I I -,( k 1, w c I I I vcc Nvm I I d l< ttj,i:d Ii, tit., tilted tr tv,,-l tim i, rt,(juirio-d tt, r, :w h :iItcrw ttIv(- sw .in CS Of care I Ili, I 111H, lltCt- .- trv fIr nc, IvIn,_r th:it c:ir,,. 'I'll(, hrriefl"S ti) ( 1w%*(-rnnwnt III
W,- I hl- WI)III(I Own ho till- pro'(11wt I)f Ow killmilit ,f tilm- liecdt--d to
t it(, (,:il*(, I 1w
x i'.r iwa!lh ii
I J'( :tt',tn of th, k -ti(lit tit th- ( ()vt,rm n(-Yit Ili providin- honith W ( it c1lil oil )[1:1 1 -(,t t lyig, :i. Ilw Ittd 1111it- \V:I- 11 lId,-rt:ikcn. Thi- to ()htnm in
NO Ii t 1w: t I t Ii rit, 1, wi I 114 r(,qut-t ( d I v F(-der.-il ( mp1()yevs9
Wh:lt wtI,,)n miglit tilt, tAc If Hic,'c ,(-r\ ico,,:- 1W Imiger avail-I 1 )1(''!
Ill 't (if i it I( )It t n it-:i urill t It(. t 1, t:,t in 1wt provide ng specific services, it is,
tit (1,1tj (III Ow :imouht ()f t1mo the empl()yoc w(mId need to get to
Ili.- 1wr tIt(,rrimvc ()f earey and a nwa-- tire of the cml)hi.vec's productivity,
i.(,., tilt, -rndt, lev('4.
'I'll(, Ix milt- crved F(,df-ral employcc, Nv,)rking primarily in administrative
()r While certItill do require ,mm, ()f their emtit ilav( ()Ilw cVIltoIITI:ItjC)IIS 'lIIIIUIll V, IIOTIV (J th(, units selected and
(Ir ni:m:t(-m,,nt WhiNm- in-magement While certain agirnc
tot hztvo ".,1w :11IIIIIAllyy JIWW Of tit(, unlt- selected and
dm itil h(-:tItIl. wilt duriii.- t1w wcck of June 2S ()r July 5,1 number of cinpl(Iyees having r:,,in(_, c()-t, and per cinpl()y( e operating cost. Pit: number of vi -ltlm,) the lic"Ilth unit i,., all 11(1*11-4( d fi,,urc t.iking into e(msideration Jul v -1 Approxinintel v ON percent of Federal empl()yces Nv()rking were oil
,'tlIlIIl:t1 lc tv,, (411r,11(y t fi, lii- iwriod. All the in Oil, e()1unin -were adju-4ed to
(I 111to C"lI" id(-rttIwi till.-; almorzimlIv high 1('.LV(, r.itc. 'I'll(, Civil Servicc
G)lIHIII-I()ll, in it- urve v ()f :i!l Federally ()jwrnted health units provided the
il if, orillm I, Ol 1 )1'1 1111 Ill I wr I )f cl 11 ph havIll(T to th(, health, wfit.i and their

T"hic t1w 11111111w]. (if seching s1welfic lw.dth services, totfil
Of ,ci-%Wc:- pr()v1d(-d by rcI ()Il for' visit, clI'lI)1(,y(,c 11tilMitioll rates, alld tit(, i) !-ccl&luc (of ('111plove('1< having acc( .-- to 11c.,11th ulllt-- hv tvpe ()f he'llth ":wl-vices 1'(1(0i,,>t"d. Till, main for % i -itjng the licalth unit.-; to i-eccive Inimullih1m)d pt- -mc moiiI1(;!-M-, b( d rc zt, or for medic.il cinei-eneies. Fw<1IMS '111d him)(1 pr(,siur(, thir., utilizati(m rate I-"
it(, El,lity-twi) i)-i cent of tlws( ciaph)y(v, seeking immunization
'llid GG p-l'co,,iTit (of tho-(1, iv(pikstEig blood pro.- -sure exaninatiorts are receiving

Tilt, to the mvei-imient ill providing t1i(-(, (-r-vice:, per employee i ; the
1)roorluct, I)f ( l ilme multiplicd it v tiw (mipityee hwirly \%ngc multiplied hy the
it. c t(tt;il imontial s:i% ing, for providing vach
t Ji/,,iti( n nitc jwr (-mpb)v( (,. 'I'll I I
:_N(TVIC(I ]I-.t,-(i 1- I pr(Iduet ()f sielz jwr (,mplt)N c( mult.11)Iled hy the number of
,jwcinc crvwo (lurln'-,, thc s(,(-()zid (juni-ttir. T:ihIc .1 ,hows 1)(4entill f( r (!.tt(,gu(iry I wrvlces. Th(-, jmto,-ittl kl avlll"_,_ 11 i (2xPr(,,-;s(,d In reduced sick


IT) :t(imini fl!t, (j:,o;tj()wm1rv. st-iff of tit(, lienio imitt4 wero llol(l timt the em-11111t;ln lIII(I tl,;it Hw ilikirmatiii wouill he hanIllvd it, lk
I'>I[imalt'd by Hw slaff or' the ,ix hoalill lillit"
11, iji- Ilw IwAth milt., (,it1wr tilt, wcf-k of Jimo 2, or Till\- -, constitilted mir ":,.I il';w h 1.111phl \ci 11 ,kcd l(i, Iff-I)Xifif. (III their lw alih w ili-/atim ,
'I. 11 v (If A pril. M aY 11111d lim e (m r iorii)(i
1p irvi.v iiiiiiiij to henith 1111;1-4 n(Iiiiiii.O rntive and vIerical staff- No
I-! ro,11A I"'d 1 2 ,ervj('V, '111V jT1 productivitY iti nol jin)v1(Iiiw calegor) 2
ilw ri, :I.- 1.-! 1;1.1(, ;1%% .1 eo
irtim Ow i(o, IIiii :t] the t-st of 11;lvill Ill( vIIIII'm iov I,! 1.\\









35


hots/immunizations, blood prcssiure monitoring, and h('di(,:id eifergeclc i aIre
the services offering the greatest poteAtial for reducing the ied to us k leave.
The availability of bedrest facilities during the day does afford a number of employees the opportunity to return to work earlier than might be possible after a serious illness. The savings in reduced sick leave, though modest CoJiipared to the other services in this category, are certainly more than the cost of providing this service.6
The cost of operating the six health units for the second quarter of this yea:r was approximately $104,000.7 By offering the serviee. listed ill categorV o1e,
approximately 88 percent of the cost of operating the units might be offset Iv)5 the savings resulting from a reduction in sick leave utilization.
TABLE 1.-EMPLOYEES UTILIZING HEALTH UNITS DURING DATA COLLECTION PERIOD, TOTAL NU,1BER OF EMPLOYEES HAVING ACCESS TO HEALTH UNITS, ANNUAL OPERATING COST AND PER EMPLOYEE OPERATING COST

Employees Annual
Employees visiting having access Annual per employee
Health unit health unit 2 to health unit; operating cost 3 operating cost

1-----------------------------------247 5,000 $88,548 $17.71
2 ---------------------------------- 20 2,700 60, 248 22.31
3 ---------------------------------- 129 1, 430 52, 512 37.51
4 ---------------------------------- 215 1,650 41,824 2o. 35
5 ---------------------------------- 129 2,015 40,032 19.87
6 ---------------------------------- 190 3,766 134, 812 35.80
1,030 16,531 417,976 25.28

I Department of Interior, 18th and C Sts., Washington, D.C.; Internal Revenue Service, North Atlantic Region Headquarters; Federal Energy Administration, 12th and Pennsylvania Ave., Washington, D.C.; National Science Foundation, 18th and G Sts. NW., Washington, D.C.; General Services Administration, 7 and D Sts. SW., Washington, D.C.; Internal Revenue Service, 1100 Constitution Ave., Washington, D.C.
2 The weeks of June 28 and July 5 showed a rate of annual leave substantially above normal due to July 4. Using as a measure of annual leave taken through the Federal Government, the hours taken by Health Services Administration employees in the Parklawn Bidg.-approximately 30 percent weie on annual leave-the utilization rates were adjusted to reflect this factor.
3 Information supplied by the Civil Service Commission.
TABLE2.-NUMBER OF EMPLOYEES USING HEALTH UNITS, BY REASON FOR ViSIT, TOTAL NUMBER OF ENCOUNTERS
BY REASON FOR VISIT, UTILIZATION RATE BY REASONS FOR VISIT, AND PERCENTAGE OF EMPLOYEES HAVING ACCESS USING SERVICE DURING APRIL, MAY, AND JUNE 1976
[Using health units by reason for visit]

Number
Number of encounters Utilization
of employees during April rate for April,
seeking specific May, and June May, and June Percent, employees Reason for visit health services by reason for visit by reason for visit access to services

Complete physical- ------------------- 178 214 1.2 1.0
Immunization/shots ----------------- 302 2,205 7.3 1.8
Eye test (vision) -------------------- 89 95 1.0 .5
Eye test (glaucoma) ----------------- 59 1.0 .3
Hearing- ----------------------------59 59 1.0 .3
Pap smear --------_ ---------------- 64 64 1.0 .4
Blood pressure (hypertension) -------- 342 1,607 4.7 2.!
Lab X-ray -------------------------- 60 75 1.25 .4
Medical treatment (emergency) ------- 280 672 2.4 1.7
Diabetes screening ------------------ 65 72 1. 1 .3
Bed rest --------------------------- 145 532 3.8 .8
Other ------------------------------ 141 564 4.0 .8
Total ------------------------ 1,784 G,218 3.5 10.7

6 For those employees requesting bed rest less than 10 times during the reportinl- tori', It is assumed that their efficiency would decrease but that they would stay at work if this service were not available. One hour per request is being ased as a measure of tie reu(uned efficiency. For those employees requesting more than 10 iniis o1f led rest, iT is n sinilt that they would be absent from work for some period of time if this service were not available. (Fourteen employees requested bed rest for an average of 24 times per employee.) Using a conservative approach, it is assumed that if these services were not available, at least 1 week of sick leave would be taken per employee.
7 Based on the information supplied by Civil Service Commission, this figure includes all salaries and operating expense for the six health units. This is one quarter of the total annual operating cost for these six units as reported by their agencies. This figure represenis only the six units reviewed. It does not cover the agencies' total operating cost for all their health units.








36

TAtbLE 3 -CATEGORY 1-PERCENTAGE OF EMPLOYEES HAVING ACCESS UTILIZING CATEGORY 1 SERVICES. AVERACE UTILIZATION RATE FOR 2D QUARTER OF 1976, AVERAGE HOURLY WAGE, AVERAGE ROUNDIRIP IRAVELTIME TO ALTERNATIVE SOURCES OF CAR, 2D QUARTER SICK LEAVE SAVINGS PER EMPLOYEE AN'D TOTAL SICK LEAVE SAVING FOR SECOND QUARTER

Per
centage
of Number
er- of Sick
ployees em- leave
having ployees saved
access utizing Utili- per Total
using the zation employee sick
health health rate using leave
units by units by for clinic saving
reason reason 2d Average Travel during for
for for quarter hourly time 2d 2d
Reason for vist vst' visit I7G wage (houi) quarter quarter 3

Shots immunizations......... ........ 1.5 252 8.5 $8. 78 *2 $1.19. 26 $37, 613
Blood pressure ......................... 1.5 252 6.3 8.20 22 103.32 26,037
Bed rest:
(A) Regular utizer .................... 8 131 3.8 6. 65 ........ 25.27 3, 310
(B)High utisze rs..... .... 04 14 24.0 7.24 ........ 173.76 2,433
Medical treatment (emTergency) ....... 1.7 280 2.4 8.20 64 78.72 22, 042
Total............................. ....................................................-------------------------------------------------------------------. 91, 435

I Total number of employees having access to the 6 health un ts-16,531. S(Average wage times sick leave used for travel) times (utilization per quarter) minus sick leave saved by having employee us ng health un ts per quarter.
4 (Total number of employees using unit in quarter) times (sick leave) minus saving per employee.
4 Amount of leavetime necessary to travel. The actual traveltime was less than 2 hr but for recordkeeping it would be recorded as 2 hr.
This figure was arrived at through the following process: average hourly wage per employee ($8.78) times traveltime (2 hr) minus $17.56. The utility rate per employee receiving this care (8.5) times the amount of time used to receive this care ($17.56) minus $149.26. This represents the savings per employee. Total benefits for providing these services in the b health units is the benefits per 1 employee ($14926) times the number of employees utilizing the services (252) minus total benefits providing these services ($37,613).
e Includes traveltime plus time necessary to receive medical care.

The conclusions reached by the Department are as follows:
(1) According to this limited study of selected health services
delivered in six health units, there is some indication of a benefit
to the Federal Government in providing these services,
(2) 10.7 percent of the employees having access to a health
unit received care from that unit during either April, May, or
June 1976, and
(3) Approximately 1,250 days of sick leave are estimated to
have been saved in a 3-month period. This represents approxiMmately 88 percent of the total operating cost for these units
during that period.

GENERAL ACCOUNTING OFFICE

At this time the findings of the General Accounting Office in their
rel)ort, "Inequalities in the Preventive Health Services Offered to
Federal Employees" will be considered. It is important to note that this report was published prior to the study by the Department of
Health, Education, and Welfare. According to GAO, agency officials
believed that it would be difficult to determine whether preventive
health programs have achieved the benefits expected by the Congress. Except for sick leave usage and number of disability claims awarded
no data showing changes in employee well-being and performance
was available. According to an official from the Civil Service Commission, stated the report, data on Federal employee sick leave and
disability is insufficient to evaluate benefits of the program. For
example, a Federal eni)loyee averaged 7 days of sick leave during






3 7

1942; for 1974, tle average was still about 7 days. Disabiit anute on the other hand have increased in recent years--. In 1965, new annuities per 100,000 Federal employees numrbered 767; in 1974 this figure increased to 1,112. Th~le Commission went on to say that no informiation about differences in sick leave and disabiity rates between emiployees who had and had not received preventive service-i was available. It was stated that such information could not be obtained without a scientifically controlled study.
Although agencies had not evaluated program benefits, officials generally believed that preventive services have increased productivit-v and decreased disability and death benefits payments. Also, they believed that employees are the program's primary beneficiaries, through improved health and free medical service. However, statements about preventive service benefits varied from agency to agency. The Veterans' Administration personnel policy manual, for example, states that
...while the program benefits employees, its greatest advantages accrue to management by maintaining its personnel at their productive best.
Allthoughl the Defense Supply Agency's regulations state that the employee is primarily responsible for is or her health, headquarters officials considered preventive services essential because an employee's physical and mental well-being is important to the Government. The Postal Service personnel handbook also states that an employee's health is primarily his or her repsonsihility; however, headquarters officials believe the Service could benefit from physical examinations of top executives.
The GAO report also stated that treatment of disorders recoimmended by the Division of Federal Employees Health for testing can reduce disease and death. For example, DFEH recommends that female employees be tested for breast and uterine cancer. Cancer of the breast, kills more American women than myv other form of cancer. The American Cancer Societyv estimated that 90,000 new ca -es. would develop and 33,000 deaths from this disease would occur in 1974. With
earv iacnois treatment th oit eports an 85- to 90-percent 5-year survival rate. Once the disease has spread to the lymph nodes the 5-year survival rate drops to 40 to 45 percent.
There is no overall data available on the number of women within the Federal work force who have breast cancer, however, the society has estimated that 6 percent of American women will develop breast cancer during their lives. At this rate about 50,000 women in the Federal work force have or will develop) breast cancer. Again using data from the American Cancer Society, the General Accounting Office has estimated that about 30,000 women in the Federal work force have or will develop uterine cancer. As of April 30, 1974, 829,784 women were employed by Federal agencies, about .30 percent of the work force. Of the 27 locations included in the GAO review, six that conducted screening programs did not test for breast or uterine cancer.
To further illustrate the point that has just been made, DFETI also recommends testing for diabetes among Federal employees.
The American Diabetes Association reported in 1974 that diabetes ranked as the fifth most common cause of death by disease in the United States. The association reported that untreated diabetes is the leading, cause of blindness and a common factor in kidney failure, heart disease, stroke, gangrene, and other tragic disorders related to










tO iet el it1 (111 e I I Jile If fo d I ai I Io~h t~n 1,; -~
(lubte rt ~pllil-iii hv t li P1ibi 11 Ia ii>rieIeIu
1'eetld~ U~IZI~e ("~AO ~it e h ib 4j)(0) Federal
C~~ -u I i VrC ti I I I i i, l1k iii h i-\ 'oI. I e I w 2r -0 iibet I 111t
Iii ~uiinuarxI li ( ;'IWI~LI Auiiit iig ( lhie coludT tha reeliv hel h eriee hve ctei n 11:0 \di~ ~ 1c~.Thev i'Aed27 Vea ii rvii 1n 1.( wn~ 11 11i~ v 1fw hwre -iv 1 b I F I II
c~~~flhi~~r l-e I~ I OkIC (Idiw 1'l j I I7 hers eetdaaaalbe

at khe I ea > I u I' v 1 ~ I )V L I vlI ui 1~ 1n vt 7 Iternalt 1


DFEH locations, locations
1e~ 0 virders Tests Disorders
P --:c-r performed de;Lected perormed detected

------e-- 2 49 302 91Ri6
GIaUcoM a -- - - - - - - - - - -681 9 327 28
Visi n -- -- -- -- -- -- -7 39 68



v1( ) w 1oi~. 1, -,lfill tu h I n 11 to t Nt k i Ier-Per nn (,! te sttud~v describedd iil dl tll cjsexvl\ i'e iii. this I'u(w1t. At ths )ilit t'le be eit )f K ie
lo~n~-terin priodic ll I exwaiftionus xvIII be (oniIdei'Cd. Results;
If'i-!le q ie' J1ti(J l" 1 surveN'ysI I o eath "tt Its, c )11(l11 t ed biennI. iallyv
ia..) rChe io 0 1 daili Ig t' lie st grI te Ige4
tO (t eit 't o I te prIet eii Ioi~U'5i wi Ii thi (7lt I' r
con r~It..Also( aImng' t Ie'e illidd Ie agecd I1C I i51 II e iim pld1tilizz'ti~ll
~ MIIQ\ bt lwe i te tldy group (Il'llg the years': 190-S-7 1 Amoll(ng t 1e Ioe V111 th Ione I Imaz 1 1 )t holier hand, !( consis.'-t ent 11d /,I '~ZI~ rlfe I s of a sila :atuIre were niot seL(1maio 0oj i1OI't atlit'v ill the( f I I.st 17 (ear rveaI(I th i n.II the tt(l groupI as a'i NV11\ hole, theVc'rall deat:a1Lailihl lwta ht obs-ervedl for
thte 1, (d ol gru.Frag'upo lsa C Iet Iyo hes ized (before
t he 1'dl Ws weeMoxU to be I t Ial~ posv t )oI Iah oI(r IrevenIt abIe b\- allilel i lekIthe iiioi't alitv l"1 rat was- -1igniicait Iv lower
(p 1'~stinit 05)iiithest rou. iJor alt v(IifleI'liees atlmng the
111415. ae7)45 15 1 t e1i11'v (.()Ii itrh tedl muclh to the- overzill ,tid.(1--conItroI group II initahtx IIvffen1ce.
Sii (C 1 C 8 )1)1'(Itliefil- () oftie gi'reate fT xp)5t1' to) 1eriodliC

4 1)5 1 at entIry i it the stud in 196.4 t he hecalth1-relatcd ex pelises- inl tbis gi'ou ;p \W ("FO X~lte1 tiflie peiodM COVOre(l jijeltidcd the yeaIrs 7 Is71 1 (1edical,1 ca Ire u itiI izaion()P\ was l1("Iwasure( In t he s'tudy~ and (itI'ii)l ~~ J)s Abi-'hitY rates were mesrdIn ,ubjects; who reIplan aIII"nd 1.":p a1,ltn I q ues-t Iionires. As of
l 1o t I'( tio of srIvorswi Ii prIa dIsi I In ti std
gioIj xz.12 1 whIieI I t I-) I'or t ioi ,for I th11e con Itrol,)I ,( grou was 0.164.






39

In the filial aliaty-,is 1, ai- el- foun(l. Pro(rr'1.!1 Op
71
aged men to take "1111,111al 11,1111tiplla,- ie hec 111, net savings of more tliat T) p)r iii,,tii vo-,r ,,t 11,4,
men urged to tako the checiCt1ps z 14 to ille'), 11''
-. cc-ii) tro
This difference principally flie
rates observed for the men wlio wero t () recoiN-e
However, JNlii. er ,tlso note(I t-hiat similar demonstrated 1'01- wolliell or vwunfrer 11-1011.
Tl e PermaT101111-0 'Me(lical Group doctorss (-Io ii!itlion of
the checkup-; de,- crfl)ed earlier. Throi-igh. t'hi. i-,- ,, i,cli Inive -ct
the follo- ,;-ing for receiviii, i perlotiA I ickilp (Vlveli L-1
the pen on is healtbc from the of (Ia-k.,
aetivitv and endi.trallCO.
(1) For a cliool child rel--t
intervall-, of or iii-oll e.-t!r(,.1\in twell,*
2) Foi- rol- L I
ezin wzilt ,i7,jL *i)terv,A of 21 vean or JA1011'.
(3) For voutl'g i- -l their ti-liptletbolll- 9(4) For C Cir fol t* ITN
IS month,-, o 2 i(5) if you tirc,, ill your f1ftie:7;, or older, yoiiiteil -ou ilml.- oftell t") if t -\A,- a 1-1 o r 7 1 "k. IL e
tinie ali(I feel and full, of ze,- t, t'O, ,i,,inuz, J
recol-l-imended.
An excefAlwa to the "'1150ve i- for W0311011 ill tillo 0'
age or older. (-ictive womp--La 4iouhl have lo4Ai li6titd
p I
01 peivic ext", 11 UP- il tioll s
doctor a- -;ure vou th-,,t, -ou lon yer betw,2"Il.
The. fir- t part of fl-d--, eCtioll li-is exzlni.-ziecl oime of. thel
reported by supporter-; of periodic phy-dull held by tho- e who doubt the vtdue of -Iiis service will i-)e this th-tile.

POSITIONS OPPOSI---"'G PE11IODIC
Dr. 11'. Kei!h C. -AloIgau
One of fl-le strolqlrest voices ill Oppo' itioli. to t"ho
examination belongs to Dr. IV. Keith C. p-,,*of(- (),X- w
Di,,,,i ion of Pu1il-on.-Itrv Depiirtincitt of'
Virginia Ui.-livenity. -ill testimmy pre- entLU to tlhli, Dr. -'\Vlorcrim lla,, ; -,tated that the trt.ditloiial. t1ii'It
medical science respon-ible for the ;AIL I!expectancy -,md of health iii. the U.S. pul)lji- w -(,I* t1w
pas.t 100 years is w). over -implific,-,Ition. The accept,,u),ce ("l, thl- tria-litionalviOw has pro(luced a -.dtilatio-li ill which (111-ekA oil
health are chatmeled lato care, laborato-1-y t:,-t- aiid di u"S.
lie went ou to say that the pner(-11 public aii(I
bodies believe tlmt i ::dltiontd funllelilng of fli18,11cit"I re- ollrce-- into
these salne will further improve the hezildi ol the z venige
Americtail. wheu, ill Lkcl, there little evidt'-- J-e to upport tllil -V i e w
point. Ill rezility, lie said, there it 11*41-i'l,', (Joubt th-A ti f,,,:- (-rcat -,r iii-






40

p1roveillnt ill the health of thie average American could be obtained through a modification of behavioral pattern- namely, by improving the environment and by reducing s elf-imposed risks such as cigarette smoking, traffic acidenI ts, and excessive alcohol consumption. The average phyV ical can (11 ) a thousal( times more for the health of his patients by persuading them to stop smoking, to lose weight, and to take a moderate amount of exerC,( se than he can by performing routine annual phyvsical. "It will doubtless be said that my views [Dr. Morgan's] are in error, that many well-informed and sincere physicians endorse the annual physical, and that I am a nihilist. Most of such statements will come from those who have a vested interest in the ritual of the annual physical. With all due deference, I would suggest that the time has come for Congress to look into where and how it d(Iecides to spend the health dollarr" In 1973, the United States spent a greater percentage (7.3 percent) of its gross national product on health than lid any other country.
Sine the United States gross national product is the largest in the world, the enormity of the financial outlay becomes apparent. Yet, in regard to life expectancy and infant mortality, the United States lags behind many European countries, New Zealand, and Canada. For example in tmhe United States, $1 billion a year is spent on respiratory therapy, a mode of therapy that has been shown not only to be useless, but indeed often harmful.
In conclusion Dr. MIorgan stated ". . you might well ask me why so many physicians endorse the annual physical. The answer, I am afraid, is that many of my colleagues suffer from an all-pervasive enthusiasm that sometime overwhelms their scientific objectivity." Dr. IRichard Spark
The position opposing regular physicals is furthered by Dr. Richard Spark. Writing in the New York Times Magazine, Dr. Spark points out that there is no consistent agreement concerning the component parts that are essential for an effective health screen. The general concept is that the more tests one does, the more certain one can be that the patient will remain healthy. Despite the very best intentions and extensive examination provided by Kaiser to its members, the periodic health exam is best with problems according to this analysis. The reasons are complex. Some of the elements of the health screen are just not sensitive enough to detect disease processes early enough to allow for effective treatment of a patient who does not yet have the actual symptoms of that disease.
For example, in an effort to detect lung cancer the Medical College of Pennsylvania screened 6,138 males over the age of 45 with chest Xrays every 6 months for 10 years. Initially none of the men had any symptoms of lung cancer. Over the course of the program, lung cancer was discovered in 121 of them. These men were given immediate and sustained treatment but only 8 percent survived 5 years. This figure is id(lentical to the survival rate observed when cancer of the lung is detected in people who do have symptoms of that disease. The conelusion must be that even when performed as frequently as every 6 months the chest X-ray is inadequate as a device for detecting lung cancer early enough to facilitate effective treatment. Sometimes the problem is not with the test but with the patient's inability to alter a deeply rootedl behavior pattern to his own benefit.






41

The health screen may detect an abnormality before svmptoms appear, and the doctor may know that correcting the abnormality will improve the development of disease and disability, but the patient will not or cannot comply with the physician's recommendations. For instance, a high content of cholesterol in the blood which is readily detected is believed to increase the risk of coronary heart disease, an i a proper diet can reduce the cholesterol count.
However, on an outpatient basis such a diet is not so readily acceptable. Dr. Spark also points to the work of Dr. E. G. Knox of the Health Services Research Center in Birmingham, England, who concludes that the multiphasic health screen appears to have succeeded in achieving the unfortunate double-barreled combination of low efficiency at high cost. Dr. Knox reluctantly agrees with the statement of the National Health and Medical Research Council of Australia that "multiphasic health screening procedures appear to be of little value in medical practice at present, particularly in respect to individuals who are apparently well." This sentiment appears to be shared by the rest of the world for aside from a few isolated experimental projects, the multiphasic health screen has been a uniquely American
phenomenon.
Dr. Spark concludes that there may be some value in encouraging people to have a single limited phsical examination as a means of establishing contact with a physician. After that, further repetitive annual exams of healthy individuals seem to be profitable only for the physician. Perhaps future developments will allow us to be more optimistic. For the present, it must be concluded that the annual physical examination has proved to be little more than an elaborate and expensive ritual that has not fulfilled its promise.
SUMMARY
It would be a disservice to Federal employees everywhere for this subcommittee to engage in evangelical advocacy of any of the po-" .si O policy alternatives about the periodic health examination. We have attempted instead to focus on the only certainty about the whole subject: there are compelling reasons-our economic and physical well being-to inquire into these matters with the highest attamable professional standards. The studies and opinions cited here represent our present knowledge pertaining to an unexplored frontier; by the same token, they also show how lengthy and arduous a road remains to be covered.












FT'VDING'S AND C(-)NCLT' IONS
'I'llo (If llil__ F(lim i-t .1, A ,11"'I irl 0)(' illtrodliction w a-, to proV'dt, 1 (d, tilt, IWOCITM11 (AferillEr, preventive health
to Feder'll zi, 'ilitimTIzed underi)uhlic Law 79-65S.
At 1h1*_ tiln", the 111wollill',litec'- cmIchi,-Ion,,-; -will be presented.
ITIVOlv(ld L-elIl,1.,IlIY stated thit tll(,.v believed (IM-01,11111(lilt, their 11),11121Crellient of IVO -(TV 1 11
)D'VL'Ilti\C ll("Iltll protuzull- lclier'llk- (Im- llot Support till', belief. A(Yellcv lle;ld-. 11 (Ive not l,!1lpIlI--Jzed their preventive heidth programs, 'tIld at '111 lev( I- Nvezlk. Tll,-; beczlm. (" acrellex llemk
oczi I ()T( the zmtliority to dolvelop and operate, WI pro(Y1rI1lI-- Nlo- t :oyency Il('ZIdq1lzIrt('r- keep no records of the
(4 prcvellLive lu Ildl ti('I(l locatloll-- Consequently,
ilwqlt llltle- em ,L In tilt' i)l, 1\-(-"1'ive lienith servicess both within and ,1'11M1,_z The tli it lilequahtie- exi-4 -prov iding liolljob
prove"ItIve heidth 10 OF (1(111,11 and -is imdi pittedd and even defended III
tf- l i[;,o11\- b0fol'C t11i,-; SlIbCORIMIL40P bN- HIC Offi(T Of M.111agellient and 1111d('et, an(I im- the 061, Comm;_,-;,zIon. Dependilla Oil all eillW01-k I(W'ItiOTI1 li( or sTw could recei\-(, either a complete physi(-d, I limlte(l number of ,(-reeiiincr tt,,sts, or llo Preventive service-, at, ,1! bcolmyl I t1lat e(jiltll treatillent of
of equal 7rade zm(l ap, 11".11,01 procri-am NN-a- intended to imprm-e the efficiency of t-ho '(,.Jerzil work force by rt-ducuis (1111PION-ce absence and AltlimioJi the prwn-tim ha-- i,,Ieutified employ.-(- with health problem's,
it i.-; also triu-, the Genend Aclroiintlll ,r Offic"- Ilas eAlmilted that
1)J I 1 50.090 NVOMOT1 iTI Ole Federal -work force hav', or will develop t"':) C'illc('T 1!1(1 tliit oN-er 20 percent of the loc.itlon- selected for I t rjj,(, v, I I I.-;
-111dy (1,1(11 11("t te-t for tll*- ( i !111d hv i:1 inforinzitiol-I and
'he 110\v (Io(- not pro -Ide Information oil the utliI Mi1, :1 1;i the prf N-entive lie:dth When till".."
F*i,,tIk1- t.he Divi- *wi of Federal F.,mployI iii, iltj;i h:t< : !-o i f (,,'I io fo-- [( r coii A'a I I. I I" t1ler" Ll he Uttle hope of co
ii i i y i- to liccopt or reject. tho I1(1(10_L0 111011d ,It lolls of

i- lIt"I c'rciil.ir A-72 i M 1)1('l1WlIt il l r Public Lnv 658 M 1:11 tlr ho )i[P-k- ()r M X I,11_ ('L1W 1It 111(t B it(]Lret 'f -- t ent I v I'll, 1 11 111fol-1111 v a 1)1)1 y tile
C P1, I la r. %_11 St, r v I I I I I I I I ()t I a I Id t ke D 1 \'1.1410 11
(42)






43

of Federal Employees Health wvere a[~e {S)(MVi1)iI kQ I b tile
circular te Office of M anagernent m n~t B uJ ~et 1is VImt 01 eVtI ki oversight role-a role it has, failed to cirey oi,,.
Finally, it i-ust be concluded. that at the prsei i i hre -i no conclusive evidence supporting the notion tllat aii aj1,1iul l1)~v-WJ1 examin ation is desirable from a cost /benetlit point olt'Nview for e~i~e of all agre groups. The evidence does tend to slij)p~ort the desirabili'1t 'V of an annual physical for all over the age of 40) but ev-en the rsl and effectiveness of early disease detection in this groul iiildipted.












R E (). EN D)ATIONS
In the face of such d(ivergence of professional medical opinion at all levels, as well as in many countries, concerning the effectiveness and/or noneffectiveness of preventive health screening programs, and recognizing the limited but strong evidence which exists sustaniung viewp)oints of both sides, the sub'conunittee cannot and will not profess one view over the other, but nevertheless makes the following recoimmen(lations in light of all tihe evidence received and( researched.
First. The subconiuit tee reconmmen(s that the provisions of Public Law 79-658 be strictlY a(lhered to and administered over the next 7 years through 19S3, at which time the complete program is to be reexamined( ini light of all statistical evidence given to and gathered by the appropriate committee or conmmnittees, by all agencies:
(a) To carry out the above recommendation, the Office of
Management and Bud(lget must be responsible for insuring that the agencies consistently and uniforminly apply its circular A-72,
issued in 1965;
(b) The Civil Service Conmmnission must, in addition to analytic
(lata require(l in its present form, direct all agencies establishing or having in existence a preventive health program, that the total cost and utilization figures must be given annually and that these should be directed to the appropriate conmmnittees, as directed by Public Law 79-658, and that the funds utilized for such services
should be a line item in their annual budget requests; and
(c) The (Civil Service Comnission and( the Office of Managementt and Budget should revise their regulations for the implementation of Public Law 79-658, whereby all agencies having or desiring to implement a preventive health program must be required( to consult tihe Division of Federal Employee HealthD)FE!ll-in writing outlining their proposal and moneys available, and the recommendation then offered )by DFEl should be followed as closely as possible, unless justification can be established for not (loing so, and whenever moneys are drastically reduced or increased(l for such programs, DFEII should be consuited again for advice based on the new budget.
Second. To foster conlsistencvI, it is recommerled that all agencies (direct their departments that if it establishes or has a preventive health program it must offer its services at least uniformly and( on a priority basis to: (a) those involved in hazardous or severe stress situation, and (b) age 40, 45, 50, or older. The subcommittee fin(lds inherent discrinination in only using a general schedule or wage grade level as a basis of priority.
Third. It is reconmnlend(l that the Dep)artment of IIealth, E(ducation, and Welfare-IIEW--innediately set forth on the task of establishing a basic miniun u of effective screening test which must
estabishin a bam n ~(i14)






45

be offered if an agency is to go beyond edltcational programs to an3y screening test-that is, blood pressure, diabetes, blood, urine, eye and ear, et cetera.
Fourth. The subcommittee finds undisputable the fact that an individual's daily habits of eating, drinking, exercising, and sleeping are as important in preventive health care, if not more so, than preventive screening tests; therefore, HEW and the Civil Service Commission should work toward the establishment of an educational program to be constantly updated and given or made available to all employees of all agencies on a regular basis.
















U I MAO(, 1"A P11 y
Sp Itz, r, AV Ilt r 1-(,(l (),I, -ti-n- Akoit thc Pi r1mlic 11t,.ilth Eviminat I ,i. A m i I Ti rn I,-( 1 7- 2(;",, 1
r lic I I :i rd T I i, t A i -t I I k u I I I L r I '1I New Y( rk Times MLigazinc,
2
I- I.V I )''I I CI I I i )j I M it Ext(,iid )ur Liv(-? Is it a Wistc of Scarce
1 11 ir-? Tt It I c A cI i W v,, I? 1)(,r- I )(-(,i 1\-(, :R )7-1.
L I P 1111- .
J, A In-( it, I I :trr\- .1 I if I v I W ith FINOCIlt i%-( I 10,11th EX,1111in it'

(',,lh M-rrl- 1'. 1 )1 11.tr P,,r P(-It Iv(, Tt-1 F( .)r Aut,)matcd 'Multipliasic
d 1, --W3, ](1170.
I T h, P, rl()(11(, I I calt 1i I 'xi iii imation for t lic A(iult : Wa ;tc or
_N( 2, Jutic 11)76.
1't r Autonmtc(l Al tilt lph.i ('011, 1, 1 T"r I~ I". C, of azid Screening. ('iroup
IL :Ath I ti-I it'll (., );111(, 2-', 2-1, 197--). ( ;r(oip I length A< Vd. 21, -" '( 71')'.
G I I I i _Nh rrl- 1'. : of Thrf,(, lfcalth Fv:diiLit1(,n AT()(1c.- Department
f A 1, d I (,:,L I I (.t 11, d- (-c:trcl1, R a I.< cr Foun (L it 1 )n I Z( -- (,.trc I I. I ii t It ut( and
I )t -ri, 1 i iw iit '\1 (-d I( i I ',r( ,,I p .
11ctriii,_- t Siihc()riinltt( t ()f the Cwmimtt(,( (),,I the Civil -crvice, Hoil.,(, of
pr-t-litA 's t f I I i (-y ,, -re Sec()nd U.S. Government Printing
0111c,,,
M-Lith 1) r, ,-, r. t I I i 1'or 6ov(mmout. Empb)ye(- : "eiiat,,, Committee on Civil
P, N, 74,"), 719th G)111(rr(- .- I ir- t -November 15, 1945.
R dl i Pr, L r: i i I,, I ', )r jv(T!1II1eIIt F1 111h Y(- I I nio )111 mittv(. wi CIvIt
S,.rv c-, 1't-p-,rt N,,. 79th Cougrcss, I'li-t (111, .1y 4, 19-15.
'U.S. twr:t I A cu, n iii Ii I,-, ( )ilicc : Report to Thc Corign-,, Ille(junlitic,; III the
Pr(-viiitI,,t, 11(- ,Ith -;,-rvIc(-,-, Offered to Fc(i(,rA E'iiiploycc<, -NINN D-76-62,
.1 14. Pj76.
t-.S. D( p:triiiwni ,f 11 ,nlfli, Education, 1'71 Tid Welfare: A Stu(ly of 11calth ServicesPri)vId-d 1:i I (,d(,r:d Activitl(- OMol6er 25, 197G.
I I c I ) I I I I I [i T 1 1 t I r( I I i (- I I t : i I I d ET n pl o-\ (I B(,iwfits: Ilearing-s on The III('(j1I:LlItI('- III th'' HcnIth (,rvicc:-; oircred to Ecdcral Employees.
Au,_,u-,L :'I, Pt 21. P'76 : :id S ptfmllwr 1, 1976.
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