Pay for the “A”

Medicine is simple and straightforward; except when it’s complex and nuanced.

Medical diagnosis is a simple matter of taking a history, performing an examination, and reviewing the results of ancillary testing; except when it’s a complicated case of eliciting subtle nuances from the patient in both the interview and the exam, and interpreting multiple pieces of conflicting data.

Medical treatment is a straightforward affair of providing appropriate treatment; except when there are multiple treatment options with unclear risks and benefits, technically challenging surgical or other procedures to perform, not to mention fully informing the patient and family about all of those treatment options, risks, and benefits, plus eliciting and answering all their questions.

Nothing to it.

Notice, though, that the key ingredient here is DIAGNOSIS. Performing a flawless appendectomy won’t do a thing for an ovarian cyst, nor will a PPI prescription do much for an acute coronary syndrome. Performance measures that look at treatment without addressing diagnosis are somewhere between misguided and ludicrous.

Why does American medicine have this so bass-ackwards? Follow the money. Thanks to the specialty-heavy RUC, the commission that sets fees for various procedures, doing something — anything — is paid far more handsomely than thinking (even thinking about what to do).

But wait, I hear you clamor: what about the so-called Evaluation and Management codes, those that presume to compensate “cognitive services”, ie, thinking. Sorry; they fail too. Again, follow the money.

In order to get paid, we have to document what we do. In the mid-1990s, Medicare promulgated two separate sets of ridiculously reductionist guidelines that tried to define documentation requirements as precisely as possible. What resulted are lists of elements of the history (the “subjective” part of the old-fashioned “SOAP” note) and bullet pointed exam components (“objective”) easily generated by computerized medical record systems, that communicate nothing of use to those actually taking care of patients.

Here’s my radical new proposal: Pay for the “A”. The Assessment part of the medical encounter, also called “Impression” by some, is where the astute clinician synthesizes all the data, producing a “differential diagnosis” (a variably exhaustive list of the various potential diagnoses), and a plan for further diagnostic workup, if necessary, and/or treatment.

I say ditch the endless, meaningless bullet points of redundant family, surgical, and social histories that litter every hospital and office note (the “S” and the “O”) and restore the emphasis to where it belongs: the patient assessment. Diagnose the patient accurately before worrying about measuring the quality of the treatment.

Let the medical record reflect what it should: the physician’s thought processes involved in medical diagnosis and treatment. Documentation would be far more useful if it included lists of possible diagnoses, annotated with pros and cons gleaned from the history, exam, and studies, instead of reams of irrelevant data from the initial encounter (when an exhaustively documented past history is appropriate) duplicated ad nauseum.

Join me in my new quest to convince Medicare and other carriers to “Pay for the A”.

Dinosaur MD (aka, Lucy E. Hornstein, MD) is a solo-practitioner in Family Medicine. She is also a book author (Declarations of a Dinosaur) and posts frequently at her blog, Musings of a Dinosaur, where this post first appeared.

5 replies »

  1. My experience with my mother was that she made such a rapid and unexpected decline that she was written off by the experts. They used words like “Dementia” which I found hard to listen to.
    To my shame I agreed with them. I didn’t really think and I couldn’t see my mother through her “disease”.
    The thing is that she had, for a long time, confused her medications. The more she mixed them up the worse she got and the more she mixed them up!
    Fortunately I witnessed this and was able to control it for her. She soon improved to the point where I actually had my Mom back!
    The way I managed it from there was to get an electronic pill dispenser for her. This ensured she got the right dose at the right time.
    I would recommend one to anyone who has a loved one on medications.

    Don’t leave it too late.

    Sadly, my Mom has now passed away, but I am going to promote the use of electronic pill dispensers so others might help eliminate the cause of a common problem.


  2. The coding guidelines try to standardize what is very hard to standardize. I agree that one could go from a rather dysfunctional, (pseudo) objective system to an individualized system: the provider needs to state the time spent for the patient, let’s say up to 10 min, up to 20 min, 40 min, 60 and 80 minutes. The note than would need to reflect somehow how much time was spent. If you do a great discussion in the A part, that should suffice. If you need to do repetitive counseling (i.e. pt asks the same questions over and over), you should be able to bill based on time as is already possible now. If you do a long interview and/or chart review (which easily gets you into 80 minute + territory), the content of the interview and chart review should be summarized in the note. The 3rd party/parties would then likely not issue any guidelines/rules, but when providers bill 60 min and they write a 10 line note, it would not pass … and providers that do 40 min counseling for an unusually high percentage but never document what they discuss should not be surprised if they are suspected to scrutiny. I would say, give it a try.

  3. Have the day off today, so in catching up with my readings, read the USA Today from March 15 and in the back of the first section came across two op-ed pieces that I think have some applicability to this post, the first moreso, but you the readers take the time to peruse and reflect:




    I’ll just leave the readers with a paragraph from each to get the gist I am leaning to here; the first from the J S Taylor piece: An even greater reliance on one size fits all research to make treatment decisions will reduce patient autonomy and could result in mistreatment or even the denial of life saving care. Patients are individuals, not statistics–and it is as individuals that they should be treated.

    and from T C Fishman’s piece: Still, there is much we simply cannot do for ourselves. People require all kinds of support when they are older, especially when they are isolated frail, or have begun a slide into dementia. As public and private support dwindles, our default position will be to shift more burdens back to the family. But what family? The one that is shrinking? Non existent? The family in which a retired child of 70 cares for a helpless parent who is 95?

    My use of the second article re Challenge for our ripe old age is simply this comment as the Social Darwinist: what species other than our own is obligated and overcares for the elderly of the pack? We as humans are wrongly rewriting the rules of survival and evolution, and the consequences will not be limited to our own DNA pool. And I am not advocating for eugenics nor euthanizing our elders. Just reminding people that living beyond 70 with a host of chronic illnesses does not obligate the rest of the village to sacrifice their own needs to prop up failing parts!