Posted by: notdeaddinosaur | April 3, 2012

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”.





  1. Great idea! Now how, exactly, to we convince the insurance companies?

  2. Have you read the Weeds’ “Medicine in Denial”?

    See, e.g.,

    Paying for the “A.” Indeed. Isn’t that how attorneys do it?

  3. Wow, excellent analysis and so amazing that there isn’t much if any compensation for this. I do wish doctors were compensated for this crucial part of your jobs. It’s very uncomfortable to be a complex patient under the current approach – reading this helps me to understand there are some quite strong, institutionalized incentives for following the test-test-test approach (and punishments for taking the think-test-think approach). Is there anything that patients can do to help, either broadly or in their one on one encounters with their doctors?

  4. This is exactly the struggle that the profession of pharmacy is going through. We are paid for prescriptions (doing something), and not so well for the thinking interventions we can do (MTM – medication therapy management).

  5. It’s all about proceduralizing (made up word?) medicine. THAT is what pays. I can’t tell you how many times I see CKD or ARF patients whisked to the cath lab for a minor troponin bump, which if anyone had a farking brain would know is expected in these patients. And it’s almost unheard of to find a GI doctor willing to treat anyone w/o having them undergo an EGD or colonoscopy first, regardless of the risks of invasive procedures.

    Seriously, I despise going to doctors these days. No one wants to diagnose based on an exam and clinical expertise. He/she either wants umpteen blood tests/x-rays/ultrasounds/CT scans and/or referrals to specialists to get care that a PCP should be doing in the first place. It’s no wonder people flock to the ER. Who has time (and the gas) to run around from place to place to place for a simple RX?

    I so wish I lived near you. You would be our doctor in a heartbeat.

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