We are taught that information is a light, a way to see the path forward, but in the specific, grinding reality of a medical practice, information is usually a ghost. It is a report of an event that finished happening a thousand miles and ago.
By the time it reaches your kitchen table on a Sunday afternoon, it is no longer a diagnostic tool. It is an invitation to blame the person sitting across from you for a crime neither of you committed.
The Eleven-Year Tension
Dr. Okafor and Dr. Bhatt have been partners for . They have seen each other through two office moves, three EHR transitions, and a pandemic that nearly shuttered their cardiology suite. They are friends. Or they were friends until ten minutes ago when the printed remittance summary landed between them next to a half-empty carafe of lukewarm coffee.
The numbers on the page are lower than they expected. The Medicare payments are coming in with a negative adjustment. It is a haircut, a small percentage taken off the top of every claim. In a high-volume practice, that small percentage is the difference between a new ultrasound machine and another year of making do with the one that hums like a dying refrigerator.
-9%
Adjustment
The “haircut” that turns a Sunday morning coffee into a clinical post-mortem of errors made years in the past.
Okafor is certain he knows why. He points a finger at the summary. He says it is the scheduling change they made last autumn. He says the front desk is letting too many gaps open in the day, or maybe they are coding the intake forms wrong. He has been complaining about the front desk for six months. To him, the data is a confirmation of his existing frustration.
Bhatt shakes his head. He does not agree. He thinks it is the new clearinghouse. He thinks the software is stripping out modifiers or failing to sync with the billing office in the way they were promised. He has hated the clearinghouse since the day they signed the contract. To him, the data is a weapon to be used against the vendor he never wanted.
Neither of them is right. Neither of them has mentioned the year .
A Machine That Already Finished Running
They are troubleshooting a machine that already finished running. The adjustment they are looking at-the one currently eating their margins-was earned during a performance year that took place two calendars ago. In , they had a different office manager. They had a different workflow for capturing social determinants of health.
They were reporting a different set of quality measures because the CMS requirements had shifted. The staff that made the errors Okafor wants to fix are mostly gone. The software settings Bhatt wants to rewrite didn’t even exist when these numbers were being baked into the Medicare formula.
Jamie A.J., Therapy Animal Trainer
I tried to go to bed early last night. I turned out the lights at nine, but my brain stayed behind in , much like these partners. I kept thinking about a dog I worked with last month.
I spent three weeks with a Golden Retriever named Barnaby who had a habit of chewing on the corners of mahogany desks. If I walked into a room and found a chewed desk corner from three hours ago and yelled at Barnaby, he wouldn’t learn anything about furniture.
He would only learn that I am a person who yells for no reason. He would become anxious. He would stop trusting my cues.
By the time the punishment arrives, the dog has already forgotten the shoe and is wondering why the person he loves is suddenly acting like a stranger. This is the measurement defect that ruins partnerships.
The two-year gap between action and consequence is not just a timing annoyance. It is a fundamental breakdown in human logic. When cause and effect are separated by , the human brain fills the gap with whatever is most convenient. We attribute the result to the nearest visible object. If the coffee is cold, we blame the pot. If the revenue is down, we blame the person we argued with this morning.
A Confession of Operational Errors
I was wrong about this for a long time. I spent years thinking that if I just had more granular data, I could solve any operational problem in the clinic. I once spent an entire quarter obsessing over the “Promoting Interoperability” category of MIPS because I was convinced our low scores were the result of a specific physician’s refusal to use the patient portal.
I made his life miserable. I tracked his clicks. I sent him weekly reprimands. It wasn’t until a year later that I realized the low score had nothing to do with him; it was a backend configuration error in the registry interface that had been fixed months before I even started looking at the reports. I had spent months “training” a doctor who wasn’t doing anything wrong, all because I was looking at a result from a period that had already closed.
The Anatomy of a Sunday Afternoon
The partners sit at the table.
The paper lies on the wood.
Okafor points at the line.
Bhatt looks at the line.
The line shows a negative number.
The number represents a year.
The year is long gone.
Staff members left the practice.
This is the psychological tax of the MIPS system. It’s not just the administrative burden of reporting; it’s the way the delayed feedback erodes the trust between clinicians. When you are operating in the dark, every bump in the road feels like a betrayal. You start to see your partner’s habits not as quirks, but as liabilities.
“If you are reporting through Prime Well Med Solutions and only receive the bad news two years after the fact, you are effectively flying a plane by looking at a map of where you were an hour ago.”
– Clinical Performance Logic
You will eventually hit a mountain, and when you do, you will blame the co-pilot for a turn he made ten miles back. The frustration is compounded by the complexity of the categories. Most practices are still trying to figure out the “Cost” category, which is perhaps the most opaque of all.
The Mystery of Cost Calculations
Medicare calculates your cost score based on claims data you never even see in real-time. They look at what your patients spent at the hospital, at the pharmacy, and at other specialists. Then, , they tell you that you were “inefficient.”
How can a cardiologist in a private practice account for the cost of a patient’s hip surgery performed by a different surgeon at a different hospital? They can’t. But when the adjustment comes back negative, Okafor looks at Bhatt and wonders if Bhatt is seeing too many high-risk patients. Bhatt looks at Okafor and wonders if Okafor is ordering too many diagnostic tests. They start to second-guess the very clinical judgment that made them successful in the first place.
Proactive Monitoring vs. Reactive Troubleshooting
The only way out of this trap is to stop treating the remittance as a news report. It isn’t news. It’s history. To fix the future, you have to look at the “machine” while it is currently running. This requires a shift from reactive troubleshooting to proactive monitoring.
You need a way to see your Quality measures, your Improvement Activities, and your Promoting Interoperability scores in a dashboard that updates every week, not every two years. Prime Well Med Solutions spends a lot of time talking about this specific gap. They know that if a clinic isn’t seeing their performance data in real-time, that clinic is basically guessing.
And guessing is expensive. It’s expensive in terms of Medicare dollars, but it’s even more expensive in terms of the emotional energy it drains from the partners.
2024 Performance Dashboard
Live Update: This Tuesday
Mapping cardiology specialty sets to MIPS Value Pathways (MVPs) in real-time.
Closing the Loop
When you have a Qualified Registry that can map your current specialty set-whether you’re in cardiology or neurology or radiation oncology-to the specific MIPS Value Pathways (MVPs) that matter right now, the mystery disappears. You stop arguing about the front desk turnover of because you can see exactly how the front desk of is performing this Tuesday.
We have to stop trying to put out the old fires. We have to look at the trees that are standing right now. Dr. Okafor needs to realize that his obsession with the scheduling change is just a way to handle the anxiety of not knowing. Dr. Bhatt needs to realize that his hatred of the clearinghouse is just a placeholder for a system he feels he can’t control.
They need to close the loop.
When I train a dog, I make sure the treat arrives within of the desired behavior. . That is the window for learning. In the world of Medicare reimbursements, the window is . It is an impossible gap for the human brain to bridge without help.
If you don’t have a system that provides that “one-second” feedback-or at least a “one-month” feedback-you will continue to misattribute your failures and your successes. You will fire the wrong people. You will buy the wrong software. You will lose sleep on Sunday afternoons, staring at a piece of paper that tells you everything about who you used to be and nothing about who you are.
The partners eventually finish their coffee. The paper is folded and put into a briefcase. They will go into the office tomorrow and they will be polite to each other, but the seed of doubt has been planted. Okafor will watch the front desk with a narrowed eye. Bhatt will keep a tally of every glitch in the clearinghouse.
They are both fixing things that aren’t broken, guided by a ghost that has no interest in their future. The real work isn’t in the argument. The real work is in finding a mirror that actually shows you your own face in the present moment, rather than a portrait of a stranger from two years ago. Until that happens, the data will always be a weapon, and the kitchen table will always be a battlefield.
I’m going to try to go to bed early again tonight. Maybe this time, I’ll stop thinking about Barnaby and the mahogany desks. Maybe I’ll just think about the silence of a practice that finally knows exactly where its money is going, right as it leaves the door.
