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January 25, 1995

Health System Reform: Will Controlling Cost Require Rationing Services?-Reply

Author Affiliations

Duke University Durham, NC

JAMA. 1995;273(4):286. doi:10.1001/jama.1995.03520280028027

In Reply.  —Dr Carlton's presentation of the case for PSA screening appears to confirm that there is no solid evidence of benefit, which was how I defined "uncertain waste." For the case against PSA, and for further discussion of the uncertainty about this test, see two recent articles in JAMA.1,2 I agree with Carlton that many other common practices are equally uncertain and could be added to the category of "uncertain waste."Before addressing Dr Engoren's points, I should emphasize that the purpose of examining the causes of increases in health care costs is not to blame anyone for anything—it is to help identify the most promising solutions. Also, we need to be aware that medical price inflation was the smaller of the two main sources of "unacceptable" increases in costs (the other being the "volume and intensity of services"), and that physician services—the subject of Engoren's letter—are only

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