You sit at the kitchen counter and the clock says it is in the evening. The house is quiet and the dishwasher hums in the corner and you have a laptop open on the granite. There is a PDF on the left side of the screen and a spreadsheet on the right side of the screen.
The PDF is the final rule from the federal government and it is hundreds of pages long and the text is very small. You are looking for the new weights for the performance categories and you find them but they do not match the weights from last year. You look at your internal tracker and you see the columns you built with care and now two of those columns are useless.
The measure you tracked for is gone and a new measure has taken its place and the baseline has moved. You feel a small sharp anger and you realize it is because your favorite mug broke this morning. It was a good mug with a heavy handle and now it is in the trash in four pieces and you are drinking tea from a cup that feels too light.
Heavy, reliable, stable handle.
Light, fragile, lacking history.
The Constant of the Gear
The measurement of a thing should stay the same or the measurement is not a measurement. Muhammad L.M. knows this because he spends his days with a loupe pressed to his eye and he assembles watch movements. He handles balance wheels and hairsprings and he knows that if the length of a second changed every year he could never finish his work.
“A watch is a machine that captures a constant and it relies on the teeth of the gears being the same size today as they were yesterday.”
– Muhammad L.M., Watchmaker
But you are not a watchmaker and you are trying to measure the quality of a medical practice and the gears are changing size while the watch is still running. You look at the spreadsheet and you try to find a trend but the trend is a lie because the denominator is different and the exclusion criteria have shifted and the point values have been re-baselined.
You have spent trying to improve the way your clinic handles patient engagement but the category has a new name now. Last year the weight for Quality was one number and this year it is another number and the Cost category has swallowed a larger portion of the total score.
You want to know if the doctors are doing better work but the instrument is too busy being responsive to tell you the truth. The regulators say the changes are necessary and they say the changes reflect the modern state of medicine but the cost of the change is your history.
You are building a tower on sand and every November the sand moves and the tower leans and you have to start the foundation again.
The Choice Between Maps
The shift toward the MIPS Value Pathways is the new direction and it is supposed to make things simpler for the specialties. You look at the requirements for cardiology and you look at the requirements for neurology and they are different but they are both new.
You have to decide if you will move to the new pathway or stay in the traditional framework and the decision is hard because you cannot compare the outcomes. If you choose the new path you lose the ability to look back at the last of data and if you stay on the old path you are fighting a system that wants to be replaced. It is a choice between a map that is expiring and a map that has no landmarks yet.
You work with a mips registry and they try to help you bridge the gap but the gap is wide. They provide the channel for the data and they keep the connection to the government open and they tell you what the new rules mean but even they cannot find a trend where none exists.
A registry is a witness to the reporting and they see the same frustration in every clinic from radiation oncology to ophthalmology. The doctors want to see a graph that goes up or a graph that stays steady but the graph is broken into segments and the segments do not touch each other. You look at the numbers for the performance year and you try to lay them over the numbers and they do not fit and it feels like trying to put a square peg into a round hole that is also moving.
The Price of Relevancy
The industry defends the annual revision as a way to stay relevant and they are right that medicine changes fast. But when you rewrite the instrument every year you charge a tax that nobody records on a balance sheet. You lose the argument for patient investments and you lose the ability to prove that a three-year project was worth the money.
If a practice spends $42,600 on a workflow but the measure is retired in year two, the investment has no proof of success.
The practice responds by only caring about the current and they stop looking at the horizon. They optimize for the snapshot and they forget the movie.
The tea in your light cup is cold now and you set it down on a coaster. You think about Muhammad and his watch movements and how he would feel if the millimeter was redefined while he was holding his tweezers. He would probably set the tweezers down and walk out of the shop and he would be right to do it.
But you cannot walk out because the claims need to be paid and the reporting needs to be done and the revenue cycle does not stop for a moving baseline. You have sixteen specialties to worry about and each one has its own measure set and each one has a different set of anxieties. The neurologists are worried about the new cognitive assessment measures and the ophthalmologists are worried about the changes to surgical follow-up tracking.
The Burden of Continuity
You look at the internal tracker again and you realize you have to rebuild it. You cannot stop keeping a tracker because then you would have nothing at all and having a broken history is better than having no history. You start a new tab in the spreadsheet and you label it with the new year and you begin to copy the data that still applies.
It is slow work and it is frustrating work and it is the kind of work that makes you miss your old mug even more. The old mug was heavy and it was reliable and it did not change its shape just because the season changed.
The data for the Promoting Interoperability category is sitting there and it requires a high level of technical precision but the thresholds have moved again. You have to tell the IT department that the goalposts are further back and you have to tell the billing department that the credentialing needs to be updated for the new reporting year.
It is a cycle of administrative churn and it consumes the energy that should be spent on the patients. The regulators want to improve the health of the nation but they are doing it by making the people who provide the health care spend their nights at kitchen counters looking at small font on a laptop screen.
The Compass and the Ship
You wonder if anyone at the top realizes that a lack of continuity is a form of friction. If you want a ship to sail in a straight line you have to keep the compass pointed at the same North but the North in this industry moves a few degrees every winter.
You spend your time adjusting the sails instead of moving forward and you end up in the same patch of ocean year after year. You are working harder than ever but you are not going anywhere because the destination is being renamed as you approach it.
The spreadsheet keeps the count and the rule changes the number and the doctor cannot see the shape of the years.
You close the laptop and the screen goes dark and the room is very quiet. The dishwasher has finished its cycle and the only sound is the wind against the window. You will wake up tomorrow and you will go to the office and you will explain the new rules to the partners and they will ask if the clinic is doing better than last year.
You will look at them and you will be honest and you will tell them that the question no longer has a stable form. You will tell them that you are measuring a different thing now and that the comparison is a ghost. They will not like the answer but it is the only true answer you have.
You pick up the light cup and you carry it to the sink and you wish you had your favorite mug back. Precision is a fragile thing and it is easy to break and it is very hard to replace.