The Fourteen Day Rule Sage: An Experiment in AI
The “Fourteen Day Rule” is an obscure corner of Medicare
policy that governs payment for laboratory tests in the hospital inpatient outpatient
setting.
I gave Chat GPT 5 several tasks, and published them on my
health policy blog.
From August 20, here is PART ONE, which tells the
actual history of the 14 day rule. How it
emerged from several CMS publications over several years.
https://www.discoveriesinhealthpolicy.com/2025/08/medicares-14-day-rule-where-did-it-come.html
From August 20, here is PART TWO, the 14 Day Rule as
a “dramatic novel” that recreates exciting historical events.
https://www.discoveriesinhealthpolicy.com/2025/08/14-day-rule-part-two-dramatic-novel-ai.html
BELOW: From August 23, PART THREE.
In which we ask Chat GPT to write an article in the style of THE NEW
YORKER, about Mary Sullivan, the CMS leader in charge of the 14 day rule (Mary,
now retired, is entirely fictional).
# # #
NEW YORKER – SHORT VERSION
The Woman Who Invented Fourteen Days
By [Your Name]
On a warm afternoon in New Orleans, Mary
Sullivan—sixty-eight, small-boned, still sharp as a needle—sits on the balcony
of a shotgun house in the French Quarter, sipping chicory coffee. The shutters
are open to the street below, where a brass band rehearses for a wedding
procession. “People think the 14 Day Rule was born in a conference room,” she
tells me. “But it was really born in a thousand sighs. Mine, mostly.”
She laughs, though the laugh sounds more rueful than amused.
Sullivan was the head of the Hospital and Ambulatory Payment Group at CMS
in 2006 and 2007, a job that carried with it the bureaucratic equivalent of an
impossible math problem: ensuring that the sprawling Medicare program paid
fairly for hospital services while preventing what insiders call
“unbundling”—the siphoning off of billable items into ever smaller, more
lucrative pieces. “It sounds dull,” she admits. “But dull things are often
where the real blood is shed.”
I. The Apparent Banality
At first glance, the 14 Day Rule was a regulation about a
phrase—date of service. This phrase should have been boring. An
administrative clarification, tucked into the back pages of the Federal
Register. It was the kind of definition you could imagine scrawled on a
napkin between two bored lawyers.
But the impact was anything but clerical. For the
fast-growing molecular diagnostics industry—then still in its adolescence—the
rule effectively meant that any test performed on a specimen collected during a
hospital stay was “bundled” into the hospital’s payment if ordered within 14
days of discharge. Pathologists soon discovered that genomic tests guiding
cancer therapy could not be billed to Medicare unless physicians waited, almost
theatrically, for two Sundays to pass.
“Fourteen days was a compromise number,” Sullivan recalls.
“It wasn’t based on oncology, or genomics, or anything in medicine at all. It
was based on how long we thought it would take for the hospital episode to be
seen as definitively ‘over.’ Fourteen days sounded neutral. Reasonable.
Everyone hated it, so I figured it might stick.”
II. The Atmosphere of Contention
The period was contentious in ways hard to convey to
outsiders. Hospitals accused independent labs of trying to cherry-pick
lucrative tests out of DRGs. Labs accused hospitals of hoarding specimens.
Congressional staffers, tasked with explaining it all to their bosses,
despaired. “A staffer once told me,” Sullivan says, “that if he had to explain
the 14 Day Rule one more time, he’d defect to the Agriculture Committee.”
Senior officials at HHS were no better. “The Secretary would
get these letters from cancer advocacy groups saying, My husband’s test was
denied because of the 14 Day Rule,” she recalls. “And then, inevitably,
someone from upstairs would call me and say, ‘Mary, what is this?’ And I’d say:
It’s exactly what you told us to write last December.”
She pauses, savoring the absurdity. “Bureaucracy has this
way of creating comedy out of tragedy. Or maybe it’s tragedy out of comedy. I’m
still not sure which.”
III. The Confusion as Legacy
What made the episode so memorable, Sullivan reflects, is
not the policy itself but the confusion it sowed. “The 14 Day Rule became a
kind of Rorschach test,” she says. “Hospitals thought it was about protecting
them. Labs thought it was about killing them. Patients thought it was about
denying care. And inside CMS, we thought it was just about making the claims
system work.”
The awareness of its repercussions, she says, emerged
slowly, like ink spreading across blotter paper. “At first, only a few labs
understood how serious it was. Then oncologists started calling. Then Congress
got letters. By the time we realized it was a political problem, the thing was
already enshrined in regulation.”
IV. The French Quarter Aftermath
In retirement, Sullivan occupies a world far from the
fluorescent-lit cubicles of Baltimore. Her neighbors are painters and jazz
musicians. Her mornings are punctuated by the sound of streetcars and the
clatter of dishes in corner cafés. “It’s almost funny,” she says, “to think
that something so dry—the date of service—became my legacy. In New
Orleans, people ask me what I did, and when I tell them, they just look at me
blankly. Which is a relief.”
And yet, among lab professionals, she is infamous. The 14
Day Rule is still cited in presentations and white papers, often with a groan.
Some laugh at its arbitrariness; others curse its endurance. “I’ve been called
the Mother of Fourteen Days,” Sullivan says, mock-solemn. “If they ever build a
statue, I hope it’s at least in bronze.”
V. Tongue-in-Cheek Epilogue
The truth is that Sullivan’s rule, like so many Medicare
oddities, is both ridiculous and consequential. Its arbitrariness makes it a
punchline at conferences, while its real-world impact shaped the economics of
molecular oncology for a decade. “The irony,” Sullivan concludes, “is that it
was never meant to be permanent. We assumed the industry would evolve, Congress
would revisit it, something would change. But in Washington, nothing is so
permanent as the temporary.”
She looks down at the street, where the brass band has
resumed its march. “Fourteen days,” she muses, “that’s not even half a month.
And yet, in policy years, it turned out to be forever.”
# # #
Chat GPT offered to write a longer 5000 word article but in
sections of about 1000 words each. As
below.
# # #
ONE
Excellent. Here is Section I: “Arrival in the Quarter”
— about 1,000 words — written in the style of a Janet Malcolm profile in The
New Yorker.
The Woman Who Invented Fourteen Days
I. Arrival in the Quarter
On a narrow street in the French Quarter of New Orleans,
where balconies lean like tipsy spectators over the slow-moving tourists below,
Mary Sullivan lives in what she calls her “bureaucrat’s retirement fantasy.” It
is a faded but carefully maintained Creole townhouse, with the shuttered
windows painted a shade of green that looks more Parisian than Southern. From
her balcony you can hear a brass band rehearsing somewhere down Dauphine
Street. On days when the wind is right, the smell of beignets and frying oil
from Café du Monde drifts inside.
Sullivan is sixty-eight now, with short-cropped white hair
and a way of tilting her head, slightly birdlike, when she listens. She is not
a woman you would immediately recognize as having changed the economics of
cancer testing in the United States, though she has. “When I tell people here
what I did, they nod politely and ask if I’d like more chicory coffee,” she
says. “No one in New Orleans has ever heard of the 14 Day Rule. Which is a
relief. It means I can buy groceries without anyone hissing.”
The 14 Day Rule—officially, an amendment to Section 414.510
of the Code of Federal Regulations, published in December 2006—is one of those
obscure Medicare regulations that looks like a footnote but behaves like a
landmine. It defines, in dry bureaucratic terms, the “date of service” for a
laboratory test performed on a hospital-collected specimen. The phrase
alone—date of service—suggests something innocuous, even clerical. But in
practice, the rule has haunted molecular diagnostics for nearly two decades.
The regulation, in plainest terms, said that if a physician
ordered a molecular test within two weeks of a hospital discharge, payment for
the test would be bundled into the hospital’s global payment. Only if the
physician waited until day fifteen or later could the laboratory bill Medicare
directly. This seemingly small change produced a cascade of strange effects:
labs waiting, sometimes absurdly, to run tests; oncologists timing their orders
like chess moves; hospitals and labs fighting over control of specimens.
Sullivan, in her balcony chair, looks back on it with a
mixture of amusement and fatigue. “It was a definition,” she says. “That’s all.
A definition that happened to carry billions of dollars on its back.”
In conversation, Sullivan has the even, careful diction of
someone who has spent her life surrounded by lawyers. Every clause is
qualified, every assertion hedged, though occasionally she will let out a sharp
laugh at her own expense. She spent thirty years in government service, the
last ten as head of the Hospital and Ambulatory Payment Group at the
Centers for Medicare & Medicaid Services. “It sounds important,” she says,
“but really it meant that I sat in a lot of windowless conference rooms trying
to keep hospitals, doctors, and labs from killing each other.”
When she moved to New Orleans after retirement, she was
determined to leave that world behind. She threw out most of her briefing
binders, keeping only a single black notebook that she sometimes flips through
when old colleagues call. The rest—stacks of Federal Register clippings,
annotated with yellow sticky notes—she donated to a library in Baltimore that,
she suspects, promptly recycled them. “It felt like an exorcism,” she says.
And yet she knows that in her corner of the world—among
policy analysts, lab executives, and hospital finance officers—her name is
permanently linked to one number. Fourteen. “If I’m remembered at all,” she
says, “it’s as the mother of fourteen days.” She says this with a trace of
irony, but not without pride.
The strangeness of the 14 Day Rule lies partly in how slowly
its significance dawned on the people it governed. At first, it appeared to be
an administrative housekeeping measure. But as molecular oncology blossomed in
the late 2000s, the rule revealed itself as a choke point. Reference labs, who
were building businesses around the analysis of DNA and RNA extracted from
hospital tissue blocks, discovered that the rule placed their most lucrative
claims inside the hospital’s payment window. Hospitals, never eager to share
revenue, embraced this as a kind of windfall. “You’d have congressional
staffers staring at us in hearings,” Sullivan recalls, “and you could see them
thinking, How did a billing rule turn into a cancer care crisis?”
She laughs, remembering. “They were right. It was
ridiculous.”
One of the charms of interviewing Sullivan is her refusal to
indulge in the kind of piety that often accompanies retrospectives of
government service. She does not speak of “serving the American people” or of
her time in office as a noble sacrifice. Instead she describes it as
“work”—work she did competently, doggedly, often thanklessly. “You have to
understand,” she says, “bureaucracy isn’t about heroism. It’s about inertia.
It’s about keeping the wheels turning. The art is in making tiny adjustments so
the wheels don’t fly off. The 14 Day Rule was one of those adjustments.”
Yet, like many such adjustments, it outlived its context. In
New Orleans, Sullivan often runs into tourists who have come for medical
conferences—oncologists in polo shirts, pathologists with rolling carry-ons.
“Every now and then,” she says, “one of them will ask me if I’m that
Mary Sullivan. And I’ll say, yes, but only after you buy me a Sazerac.”
The French Quarter is a strange place to discuss Medicare
payment policy. On the afternoon I visit, a jazz funeral clatters by, the
mourners dancing behind a brass band playing “When the Saints Go Marching In.”
Sullivan watches from her balcony, clapping softly to the beat. “This,” she
says, “is the opposite of Baltimore.”
In Baltimore, in the years she presided over the Hospital
and Ambulatory Payment Group, her days began at 6:00 a.m. with coffee in a
government-issue Styrofoam cup and ended at 9:00 p.m. in a conference room that
smelled of dry-erase markers. In New Orleans, her mornings begin with a walk to
the French Market, her evenings with oysters on the half-shell at Antoine’s.
“You could say I’ve been unbundled,” she jokes.
The irony, of course, is that Sullivan’s escape from
Washington is never complete. The 14 Day Rule continues to follow her.
Colleagues still call when Medicare proposes changes. Younger staffers still
ask what the “original intent” was. Journalists (like me) still arrive with
notebooks, eager to reconstruct the bureaucratic archaeology of a regulation
that was meant to clarify, but ended by confusing.
“It’s the curse of definitions,” Sullivan says, gazing down
at the tourists below. “They look so clean on the page. But once they enter the
world, they become lives. And lives are never clean.”
TWO
The Woman Who Invented Fourteen Days
II. The Bureaucrat’s Apprenticeship
Mary Sullivan’s biography does not resemble the linear
progress of a Washington résumé. She was raised in Worcester, Massachusetts,
the daughter of a postal worker and a school secretary. Her father carried mail
on foot; her mother typed attendance lists for the Catholic high school where
Mary and her three siblings were educated. “We were a family of
rule-followers,” she tells me. “Rules weren’t oppressive. They were how you
made sense of the day. My father believed in the sanctity of the mail schedule.
My mother believed in the sanctity of report cards. I suppose I was doomed.”
As a teenager she was a good but not dazzling student—an
English major’s gift for composition mixed with a mathematician’s fondness for
neatness. She enrolled at Boston College, studying economics at a time when
women were still a curiosity in the lecture hall. “I liked the elegance of it,”
she recalls. “The charts, the equations. But more than anything, I liked that
it gave names to things you already felt were true.” She pauses. “It was a way
of turning common sense into rules.”
She came to Washington in 1979, in the Carter years, hired
as a GS-9 analyst at what was then the Health Care Financing Administration
(HCFA). Her assignment was to help track the early implementation of the prospective
payment system, a project that turned the reimbursement world upside down.
Until then, hospitals billed Medicare by tallying up their charges; suddenly
they were being paid by fixed bundles called DRGs, diagnosis-related groups.
“Everyone was panicking,” she says. “Hospitals thought they would collapse.
Doctors thought they would revolt. Patients thought they would die in the
hallway. And the truth was—it kind of worked. Badly, at first. But it worked.”
The chaos appealed to her. “I realized I was good at being
the person in the middle,” she says. “Doctors yelled at me, hospitals yelled at
me, members of Congress yelled at me. And I found it oddly calming.” She
smiles, and for a moment she looks like a conductor recalling the early days of
an orchestra.
The culture of HCFA—later renamed CMS—was one of procedural
obsession. Analysts argued over commas in regulations, not out of pedantry but
because commas determined money. “If you said ‘services furnished incident to
physician services’ instead of ‘services furnished, incident to physician
services,’ millions of dollars moved,” Sullivan recalls. “We learned quickly
that punctuation was policy.”
In the late 1990s she rose into management, a path she did
not seek but did not resist. “I was never ambitious in the sense of wanting a
title,” she insists. “But I was ambitious about clarity. If something didn’t
make sense, I wanted to be in the room where it got hammered out.” She became
deputy director of hospital payment systems in 2001, just as molecular
diagnostics were starting to appear in journals and in the faint murmurings of
billing disputes.
By 2005 she was the head of the Hospital and Ambulatory
Payment Group, a position that came with a permanent seat at the long oak
conference table where coverage rules were written. Her staff—sixty economists,
analysts, and clinicians—worked out of a drab office tower in Baltimore. “We
weren’t glamorous,” she says. “If NIH was a cathedral of science, CMS was a
warehouse of receipts.”
But to Sullivan, the warehouse had its own beauty. She
describes the annual cycle of policymaking the way a farmer might describe the
rhythm of the seasons: proposed rule in August, final rule in November,
implementation in January. “It was eternal recurrence,” she says. “You couldn’t
get attached to a decision because it would come around again next year. Like
Lent.”
When I ask her what qualities made her successful at CMS,
she thinks for a long moment. “You had to be willing to be hated,” she says
finally. “Every decision created losers. If you bundled a service, hospitals
thanked you and labs cursed you. If you unbundled, it was the reverse. People
called you cruel, stupid, dishonest. You had to be able to read those letters
and still go home and cook dinner.”
She tells me a story from 2004, when CMS was debating
whether to cover PET scans for cancer staging. At a stakeholder meeting, a
prominent oncologist pounded the table and called her a murderer. “I went back
to my office and shut the door,” she says. “And then I laughed for ten minutes
straight. Not because it was funny, but because it was absurd. I was an
economist with a government badge. I didn’t hold anyone’s life in my hands. And
yet, in that moment, to him, I did.”
This was the paradox of bureaucratic life: you were both
invisible and omnipotent, ignored and reviled. “People think the real decisions
happen in Congress,” Sullivan says. “But the truth is, Congress passes a vague
law, and then someone like me has to decide what ‘reasonable and necessary’
means on page 437 of a manual. That’s where reality is made.”
Her apprenticeship at CMS also taught her the theater of
regulation. Public comment periods, listening sessions, stakeholder
roundtables—these were rituals in which every actor played a role. “Hospitals
would say they couldn’t survive another cut. Labs would say they couldn’t
survive another bundling. Doctors would say patients would die. Patients would
come with heartbreaking stories. And we would nod, take notes, and then retreat
to a room where the real discussion was: How will this edit run on the
claims system?”
She insists that she respected the passion of the
stakeholders. “But we knew that everyone had money in the game. You couldn’t
let yourself be swept away by sincerity. The trick was to hear the story and
then translate it into a line of code.”
By 2006, Sullivan had acquired a reputation inside CMS as a
steady hand. “Mary could calm a room,” recalls a former colleague. “She had
this way of listening without giving anything away. She’d let people rage at
her for thirty minutes, and then she’d say, ‘Thank you, that’s helpful,’ and
they’d leave thinking she was on their side. She wasn’t on anyone’s side. She
was on the side of the rulebook.”
This temperament—equable, slightly ironic, allergic to
drama—was about to be tested by a problem that seemed trivial until it
exploded: the definition of the “date of service.” It was a problem inherited
from the 1997 Balanced Budget Act, which had forced CMS into negotiated
rulemaking with labs to harmonize national coverage policies. In the course of
that process, CMS had defined the date of service as the date the specimen was
collected. That seemed reasonable enough—until it wasn’t.
Archived specimens—paraffin blocks stored for months or
years—did not fit neatly into this definition. If the date of service was
locked to the collection date, labs could not bill Medicare for tests run long
after the original hospitalization. CMS improvised a fix: if the specimen was
stored for more than thirty days, the date of service became the date the
specimen was retrieved. It was an inelegant solution, but it worked—until new
molecular assays began to be performed on fresh surgical specimens. Suddenly,
hospitals and labs were colliding over claims that no one had anticipated in
1997.
This was the problem that landed on Sullivan’s desk in the
spring of 2006. “It looked like housekeeping,” she says. “Just a small
clarification. But I could feel immediately it was going to turn into a
battle.”
As she tells me this, the brass band outside has finished
its rehearsal, and the Quarter is filling with the dusk clatter of dinner
service. Sullivan leans back, her coffee long gone cold. “It’s funny,” she
says. “I spent my youth thinking I’d be a teacher. I imagined myself correcting
essays, writing neat red comments in the margins. And instead I spent my life
correcting statutes, writing neat blue comments in the margins of the CFR. In a
way, I got exactly what I wanted.”
THREE
The Woman Who Invented Fourteen Days
III. The Problem of the Date of Service
Among the hundreds of definitions tucked into the Medicare
manuals, date of service might have seemed the safest from controversy.
It was, after all, only a date: the day something happened. But in Medicare, as
Mary Sullivan likes to remind you, dates are money.
When the Balanced Budget Act of 1997 mandated “negotiated
rulemaking” for laboratory services, CMS was forced into a peculiar,
months-long parley with the clinical lab industry. The aim was to eliminate the
notorious patchwork of local coverage decisions. “Quest would get paid in
Boston for something it wouldn’t get paid for in Dallas,” Sullivan explains.
“Labs were spending more time deciphering carrier policies than doing science.
Congress told us to fix it.”
The fix was a set of 23 National Coverage Determinations,
published in 2001. They covered common tests—prothrombin time, thyroid assays,
urine cultures—and were meant to be definitive. Alongside these, CMS quietly
issued a definition: the date of service for a lab test was the date the
specimen was collected. To anyone not steeped in Medicare arcana, this seemed
like a sentence unworthy of comment. But to Sullivan, even then a deputy
division director, it had the scent of trouble.
“Specimens don’t all behave alike,” she says. “Blood is
ephemeral—you draw it and test it. But tissue blocks can sit in paraffin for
years. What happens when you go back later?”
Her worry was prescient. In 2001, the problem was
theoretical. By 2005, it was tangible. Labs were retrieving old blocks for new
immunohistochemistry stains; then for HER2 assays; and soon, for the molecular
tests that were starting to enter oncology practice. If the date of service
was frozen at the original collection date, labs could not bill Medicare for
tests run months or years later. No one could submit a claim from 2003 in the
year 2005.
The initial workaround was the “30-day archive rule.” If the
specimen had been stored for more than thirty days, the date of service shifted
to the day it was retrieved. The language was clumsy—what constituted
“archive”? Did a shelf count? A drawer? A fridge?—but it kept claims flowing.
“We thought of it as a patch,” Sullivan says. “Like duct tape on a pipe. Ugly,
but it held.”
The deeper problem emerged from the other side of the
equation: hospitals. Under Medicare’s inpatient payment system, virtually all
services provided during a hospital stay were “bundled” into the DRG payment.
If a surgeon removed a tumor and sent the tissue to pathology, any associated
tests were assumed to be part of the hospital’s global bill. But what if, two
weeks later, the oncologist wanted a genomic panel on that same tissue? Was it
part of the hospital’s episode, or a new service?
Hospitals argued the former. Labs, increasingly independent
and national, argued the latter. The result was a bureaucratic no-man’s-land.
Claims ping-ponged between carriers. Some were denied outright. Others were
paid inconsistently. Patients were left in limbo. “Everyone wanted clarity,”
Sullivan recalls. “No one wanted the clarity we were about to give them.”
What complicated matters was the timing of molecular
oncology’s rise. By 2006, genomic assays were no longer curiosities in academic
journals; they were creeping into clinical guidelines. Tests for KRAS mutations
in colorectal cancer, EGFR in lung cancer, BCR-ABL monitoring in leukemia—all
were beginning to dictate therapy. “It was the moment when DNA went from being
a research tool to being a prescription pad,” Sullivan says.
But Medicare’s payment systems were still built for an
earlier era. They assumed that tests were routine, cheap, and contemporaneous
with the hospital encounter. The notion that a specimen could generate claims
weeks later, at prices in the thousands, seemed to violate the metaphysics of
DRGs. “Hospitals felt blindsided,” Sullivan says. “They believed they had
bought the cow. And suddenly the labs were selling them the milk separately.”
In May 2006, a series of test cases reached Sullivan’s desk:
inpatient colectomies where oncologists had ordered KRAS testing ten days after
discharge, only to find the claims denied. The hospitals refused to pay. The
labs appealed. The patients complained to their senators. “That’s when I knew,”
she says, “this wasn’t duct tape anymore. The pipe was bursting.”
The atmosphere inside CMS was one of exasperated
bewilderment. Senior officials at HHS, when briefed, asked the obvious but
impossible question: why couldn’t the labs just bill Medicare like they did for
everything else? “Because of bundling,” Sullivan told them. “Because once
you’re in the hospital stay, you belong to the hospital.”
Even seasoned congressional staffers found it impenetrable.
One aide on the Senate Finance Committee confessed to Sullivan, “I can’t
explain this to my boss without a whiteboard and a tranquilizer.” She laughed
at the time, but the comment haunted her. “If staffers couldn’t understand it,
how could patients?”
In the summer of 2006, CMS staff convened a series of
“listening sessions” with stakeholders. Sullivan chaired them from the head of
a long government-issue table. On one side sat the hospital associations; on
the other, the laboratory coalitions. In between, patient advocates,
oncologists, and a sprinkling of congressional aides. The meetings were polite,
but the tension was palpable.
Hospitals warned of unbundling. Labs warned of financial
ruin. Patients told harrowing stories. “Everyone had sincerity on their side,”
Sullivan says. “And sincerity is very persuasive. But sincerity is not policy.”
What Sullivan and her colleagues faced was not just a policy
gap but a definitional void. If the date of service remained fixed at
the collection date, labs were frozen out. If it floated indefinitely,
hospitals cried foul. The 30-day archive rule solved one corner of the puzzle
but left the larger one intact: what about fresh surgical specimens tested
shortly after discharge?
By August 2006, the solution had coalesced in drafts of the
proposed Physician Fee Schedule rule: create an exception. If a test was
ordered at least 14 days after discharge, the date of service would shift to
the date of performance. The number was not scientifically derived; it was
bureaucratically derived. Seven seemed too short—too obviously a loophole.
Twenty-one seemed too long—clinically unworkable. Fourteen was Goldilocks.
“I wish I could tell you there was a grand theory,” Sullivan
says. “But it was just a number that annoyed everyone equally.”
As she recounts this, Sullivan leans forward, as if still in
that Baltimore conference room. Her voice takes on the dry precision of
regulatory prose. “The date of service of a clinical laboratory test, for a
patient who was a hospital inpatient or outpatient, shall be the date the test
is performed if ordered by the patient’s physician at least 14 days after the
patient’s discharge.”
She delivers it like scripture, then collapses into
laughter. “There it is,” she says. “The sentence that launched a thousand
audits.”
For outsiders, the absurdity is difficult to convey. What
sounded like a calendar quibble became the fulcrum of the molecular lab
industry’s economics. For years afterward, conference presentations in oncology
included a slide explaining the 14 Day Rule. Patient advocacy groups lobbied
against it. Congress held hearings about it. And yet, to this day, the
regulation survives largely unchanged.
In Sullivan’s telling, the drama of the 14 Day Rule was not
that it was cruel, or unjust, or even particularly foolish. It was that it was
banal. “People wanted villains,” she says. “But it was just us, in Baltimore,
trying to make the edits run on the claims system.”
# # #
FOUR
Great. Here is Section IV: “The Meetings” — in the
Janet Malcolm / New Yorker style, focusing on scene and atmosphere.
About ~1,100 words.
The Woman Who Invented Fourteen Days
IV. The Meetings
The conference rooms at CMS headquarters in Baltimore were
indistinguishable from one another—rectangular, fluorescent-lit, drab. If there
was a design philosophy, it was to sap the will to grandstand. And yet in the
summer of 2006, these rooms briefly became the stage for a drama of hospitals,
laboratories, and patients locked in a debate about a number: fourteen.
Mary Sullivan chaired the sessions from the head of the
table. She carried no gavel, but she had the air of someone who could stop a
shouting match by raising an eyebrow. “The listening session,” she says, “is
one of the great Washington euphemisms. It means we invite you to speak, we
nod, and then we go back to our offices and do what we were going to do
anyway.”
Still, people came. They filled the plastic chairs with
position papers, prepared remarks, and palpable grievances. On one side sat
representatives from the American Hospital Association, dressed in the dark
suits of people who understood how to find the Rayburn Building without a map.
Across from them, the lab coalitions—Quest, LabCorp, a handful of specialty
genomic startups that looked like children at a family reunion. Interspersed
were patient advocates: men in baseball caps who had survived colon cancer,
women with pink scarves for breast cancer awareness. At the edges of the room
hovered congressional aides with yellow legal pads, scribbling furiously and
betraying their confusion with every furrowed brow.
The script was predictable. The hospitals spoke of the
sanctity of bundling. “The DRG system is designed to capture all services
related to the inpatient stay,” one vice president intoned. “Allowing
laboratories to bill separately undermines the integrity of the payment
system.”
The labs countered with stories of delay. “We cannot survive
if our claims are tied to hospitals that have no incentive to pay us,” a
LabCorp attorney said. “These are advanced tests, ordered by oncologists making
treatment decisions. The hospital’s global payment has nothing to do with
them.”
Then came the patients. A man named George, sixty-five, from
Ohio, stood to describe his wife’s ovarian cancer. “The doctors said they
needed to run a test,” he said, “but the hospital wouldn’t release the tissue
until they figured out who would pay. By the time it was resolved, it was too
late.” His voice broke, and for a moment even the lobbyists looked down at
their shoes.
Sullivan listened to all of it, stone-faced. She knew that
sincerity, in this arena, was currency—but also a distortion. “Everyone had a
story,” she recalls. “And every story was true. That was the problem. No one
was lying. But no two truths fit together.”
The staff analysts who accompanied her—young, overworked,
loyal—took notes in careful longhand. They would later spend hours parsing the
testimony, distilling it into a single line in the preamble of the Federal
Register. Several commenters expressed concern that the proposed rule could
delay access to medically necessary molecular testing.
The translation always amused Sullivan. “You could have a
man weeping in front of you, and it became a single clause,” she says. “That’s
bureaucracy. It’s not cruelty. It’s compression.”
The real debates happened afterward, in Sullivan’s office,
where she gathered her senior team. There was Theo, a lawyer who had once
clerked for the D.C. Circuit and spoke in footnotes; Janet, a
nurse-turned-analyst who still carried a clinician’s indignation into every
meeting; Raj, a quiet Indian statistician who seemed to find joy in the
elegance of claims edits. Together, they wrestled with the problem.
“What if we made it ten days?” Janet suggested at one point.
“Too neat,” Theo said. “Looks like we pulled it out of a
hat.”
“What about twenty-one?”
“Too long,” Sullivan said. “Clinically, oncologists will
revolt.”
“Fourteen?” Raj offered.
They paused. Fourteen had the odd quality of sounding
deliberate without being obvious. It was not a week, not a month, not divisible
into a tidy fraction of anything else. It was, as Sullivan would later put it,
“a number no one loved.”
The listening sessions took on a strange rhythm. Hospitals
rehearsed their fears of “fragmentation.” Labs rehearsed their pleas for
survival. Patients rehearsed their tragedies. And Sullivan rehearsed her
neutrality, the art of nodding at incompatible truths. “You couldn’t let
yourself be moved by the most eloquent speaker,” she says. “That was the surest
way to make bad policy.”
Once, after a particularly heated exchange, a congressional
aide pulled her aside and asked, “Why don’t you just split the difference?” She
smiled and said, “That’s exactly what we’re trying to do. The difference just
happens to be fourteen.”
The irony, of course, was that none of the stakeholders
really understood how the rule would operate once it was in place. Hospitals
assumed they would retain control of claims; labs assumed they could find
workarounds; patients assumed someone, somewhere, would do the right thing.
Even Sullivan and her team only dimly appreciated the ripple effects. “We
thought we were clarifying,” she says. “We didn’t realize we were planting a
time bomb.”
The mood in the meetings oscillated between earnestness and
farce. At one, a hospital lobbyist accused the labs of “picking Medicare’s
pocket.” At another, a lab attorney accused hospitals of “holding patient
tissue hostage.” Patient advocates shouted “Shame!” like an audience at a play.
And all the while, Sullivan sat in the middle, hands folded, knowing that the
regulation was already half-written.
When I ask her what she remembers most vividly, she doesn’t
mention the testimonies. She mentions the coffee. “It was always terrible,” she
says. “That weak government coffee in brown plastic carafes. By the third
session I realized everyone was talking past each other in a caffeine fog.”
She recalls slipping away during a break to the atrium,
where sunlight slanted through glass panels onto the beige carpet. “I remember
thinking: I am in charge of defining a date. Just a date. And yet the entire
molecular diagnostics industry is staring at me like I’m holding their future
in my hand.”
The sessions ended, as they always did, with no resolution.
Stakeholders filed out, muttering to reporters. The aides went back to their
bosses with memos that began, The issue remains contentious. And
Sullivan returned to her office, where a draft rule awaited her signature.
The 14 Day Rule, as it would come to be known, was not born
in those meetings. It was born in the silences afterward—in the moments when
Sullivan and her team weighed numbers like ten, twenty-one, and fourteen, and
asked themselves not what was right but what would survive.
FIVE
The Woman Who Invented Fourteen Days
V. The Fourteen Days Emerge
On August 22, 2006, the Federal Register published a
notice that few outside the cloistered world of Medicare payment policy would
ever read. It was a proposed rule—volume 71, page 49065—that contained within
its bureaucratic prose a sentence that would alter the molecular diagnostics
industry for years to come. It suggested, in essence, that when a laboratory
test was ordered more than 14 days after a hospital discharge, the date of
service would be deemed the date of performance.
The sentence was so compact as to be invisible. It lay
buried among hundreds of pages of updates about physician fees, geographic
adjustments, and arcane payment tweaks. Yet, like a landmine, it would detonate
once stepped on.
Mary Sullivan remembers the day well. “We had been drafting
for weeks,” she says, “arguing over verbs and participles. When it finally
appeared in print, it looked inevitable. But I knew how rickety it really was.”
The choice of fourteen days was, as she has told me
repeatedly, less a matter of science than of survivability. “Seven days looked
like gaming,” she says. “Twenty-one was too long for oncologists. Fourteen felt
like the bureaucratic middle ground. If everyone groaned, I figured we were
close to right.”
The internal debates at CMS had been tortured. Lawyers
feared the rule would be challenged as arbitrary. Clinicians worried it would
delay care. Programmers fretted about how to code the exception into the
claims-processing system. “At one point,” Sullivan recalls, “our IT lead told
me, ‘You’re asking the system to know the difference between ten days and
fifteen days. That’s like asking it to know the difference between Tuesday and
next Tuesday. It doesn’t think that way.’”
But in the end, they coded it.
When the draft was sent to the Office of Management and
Budget for clearance, Sullivan accompanied it with a memo that tried to make
the rule sound more principled than it was. She described the 14-day interval
as a “reasonable proxy for distinguishing inpatient care from post-discharge
care.” She inserted words like “clarify,” “standardize,” and “protect program
integrity.”
Reading the memo now, from the comfort of her French Quarter
balcony, she smiles at her own artfulness. “You learn to make things sound
inevitable,” she says. “The trick is to use words that nobody wants to oppose.
Who is against clarity?”
OMB staff were skeptical, but not enough to block it. They
asked whether fourteen had any clinical basis. Sullivan replied, with
bureaucratic frankness, “It is a compromise interval, chosen to balance
competing concerns.” She recalls the silence on the phone. “They didn’t like
it,” she says. “But they didn’t have a better number.”
Once published, the proposed rule triggered the usual 60-day
comment period. Comments poured in—dense letters from hospital associations,
anguished pleas from labs, heartfelt notes from patient advocates.
Congressional offices sent inquiries. The responses revealed a striking
confusion. Many readers misinterpreted the rule altogether, believing it
applied to all outpatient lab tests, or that it prohibited molecular testing
within 14 days altogether.
“People kept asking me if the test was illegal during the
window,” Sullivan recalls, shaking her head. “No. It was billable—just bundled.
But the difference between ‘illegal’ and ‘bundled’ was not one the public
grasped.”
The confusion seeped upward. Senior HHS officials, when
briefed, asked whether patients would be denied tests. “We said no, but we
couldn’t promise there wouldn’t be delays,” Sullivan says. “Hospitals had no
incentive to pay for tests they weren’t billing for. Labs had no incentive to
run tests they couldn’t bill. The patient was in the middle.”
The arbitrariness of the number haunted her. “I knew we’d be
asked, over and over, why fourteen,” she says. “I dreaded the moment in a
congressional hearing when someone would lean forward and say, ‘Why not
thirteen?’”
To prepare, she devised a narrative. Fourteen, she would
say, was chosen after extensive consultation with stakeholders, as the interval
that best separated inpatient from outpatient care. It was half a month, two
Sundays, a period that gave physicians time to reflect before ordering
additional tests. “It was nonsense,” she admits now. “But it sounded just
plausible enough.”
The truth, as she describes it, was that the number was less
important than the act of drawing a line. “Without a line, we were in chaos,”
she says. “With a line, we were in resentment. Chaos is worse.”
Among her staff, the publication of the proposed rule was a
moment of anticlimax. They had labored over its language for months, and now it
was out in the world, greeted with a shrug by the public and a groan by the
insiders. In the basement office, the analysts joked about it as if it were a
child they had birthed reluctantly.
“Raj called it our Frankenstein,” Sullivan recalls. “He
said, ‘We stitched it together from scraps, and now it’s going to walk the
earth forever.’ We all laughed, but I think he was right.”
As the comment period closed, Sullivan prepared for the next
step: finalization. That would mean sifting through the hundreds of letters,
classifying them as supportive, opposed, or confused, and drafting responses
that would appear in the preamble of the final rule. The task was both
mind-numbing and politically delicate. Each response had to acknowledge the
comment, explain why CMS was not persuaded, and assure the reader that the
agency cared deeply.
“It was performance art,” Sullivan says. “You had to write
as if the agency were a patient listener, when in fact the decision was already
made.”
One letter from a cancer advocacy group still lingers in her
memory. “They told the story of a woman whose lung cancer recurred, and whose
doctor wanted an EGFR test. The claim was denied, and she lost precious weeks.
They begged us not to let this happen again.” Sullivan pauses. “We didn’t
change the rule. But I never forgot the letter.”
By December 1, 2006, the final rule was published. The
number fourteen had survived. The definition of date of service had been
enshrined in regulation at §414.510. The die was cast.
Looking back, Sullivan sees the moment as both prosaic and
fateful. “It was one line in the Federal Register,” she says. “But it
reshaped an industry.”
She smiles wryly. “That’s the thing about bureaucracy. You
spend months on it, you publish it, and the world barely notices. And then,
years later, you realize you’ve accidentally created a monument.”
SIX
The Woman Who Invented Fourteen Days
VI. The Aftermath
When the 14 Day Rule took effect on January 1, 2007, nothing
happened. At least, nothing visible. Hospitals did not collapse, labs did not
shutter, patients were not storming the gates of CMS. It was, in its first
weeks, like a stone dropped into a pond whose ripples spread underwater,
unnoticed by the ducks.
“The thing about payment rules,” Mary Sullivan says, “is
that their impact is rarely immediate. They seep. They work their way into the
cracks of billing offices and claims systems. At first, no one knows what’s
wrong—only that checks aren’t arriving.”
In the first quarter of 2007, hospital associations declared
victory. Their members had been reassured that the rule preserved the DRG’s
integrity. Hospital CFOs assumed the laboratories would simply adjust.
“Hospitals are built to win by inertia,” Sullivan notes. “They don’t need to be
clever, only patient.”
Labs, by contrast, panicked. For national reference labs,
accustomed to billing directly for outpatient services, the rule was a shock.
Claims for molecular tests ordered within two weeks of discharge were suddenly
denied, not by CMS, but by the automated claims-processing systems that
implemented the new edit. Phone calls to carriers produced baffling answers.
“The date of service falls within the hospital stay,” clerks recited, “and
therefore payment is bundled.”
The word bundled became, for a season, a curse in the
lab world. Executives used it in investor calls as if describing a natural
disaster. At trade meetings, PowerPoint slides explained the new “14 Day
Problem” with arrows and timelines. Pathologists whispered about specimens
being “hostage” in hospitals.
One midwestern oncologist, quoted in a professional
newsletter, captured the absurdity: “I can order a KRAS test on day 13, and the
lab won’t get paid. If I wait one more day—day 14—suddenly it’s billable. What
happened to the patient in those twenty-four hours? Nothing. What happened to
the money? Everything.”
Sullivan, back in her Baltimore office, received a steady
stream of letters. Some were indignant, others plaintive. All shared a sense of
bewilderment that such a trivial-seeming rule could have such concrete effects.
Congressional staffers called, asking her to explain the mechanics to their
bosses. “I had one aide tell me he’d tried to brief his senator with a
flowchart,” she recalls. “After ten minutes, the senator said, ‘I don’t get it.
Just tell me who to yell at.’”
The yelling began. Advocacy groups framed the rule as a
barrier to cancer care. Editorials in niche oncology journals denounced it as
“bureaucratic overreach.” Labs lobbied Congress for relief. Hospitals, wary of
being painted as villains, issued careful statements about their commitment to
patient care.
Inside CMS, the mood was defensive. “We had expected
confusion,” Sullivan says. “We hadn’t expected melodrama.” She found herself
summoned to meetings with senior HHS officials who asked, incredulously,
whether the rule had been vetted. “Of course it had,” she told them. “By
lawyers, actuaries, clinicians, programmers. The whole orchestra.”
But the orchestra metaphor only went so far. What Sullivan
saw was a feedback loop: each time a patient advocacy group told a tragic
story, labs amplified it, Congress repeated it, and hospitals scrambled to deny
it. “The narratives began to outrun the reality,” she says. “Patients weren’t
being denied tests. They were being delayed. Which, in oncology, is bad
enough.”
The irony, as Sullivan sees it now, was that the fiercest
critics often misunderstood the rule. Many believed it prohibited tests within
fourteen days, rather than bundling them into the hospital payment. “I kept
trying to explain: the test is allowed. It’s just not separately reimbursed.
But that distinction is invisible to patients, and infuriating to labs. They
heard: We won’t pay you. Which was, in effect, true.”
The labs adapted by lobbying physicians to delay orders
until after the two-week window. This led to its own kind of absurdity:
oncologists deliberately waiting to order tests, not for clinical reasons, but
for billing ones. “We had created a shadow calendar,” Sullivan says. “Doctors
were making decisions not by tumor stage but by Medicare’s stopwatch.”
By late 2007, the fallout had reached Capitol Hill in
earnest. Congressional letters to CMS multiplied, each demanding explanations.
Senators recited patient anecdotes on the floor. One particularly theatrical
representative held up a paraffin block in a hearing, declaring, “This tissue
is trapped by bureaucracy.” Sullivan watched the broadcast from her office and
sighed. “They made it sound like we had locked the block in a vault,” she says.
“In reality, it was sitting in a pathology lab fridge.”
The confusion reached such heights that even senior HHS
officials began to distance themselves. At one meeting, an undersecretary asked
Sullivan bluntly, “Why did you pick fourteen?” She gave her rehearsed answer
about balancing inpatient and outpatient care. The undersecretary frowned. “Why
not fifteen?”
She still laughs at the memory. “That was Washington in a
nutshell,” she says. “We had gone from life-and-death oncology to a debate
about calendar arithmetic.”
For the labs, the financial hit was real. Startups that had
banked on rapid growth in molecular testing found themselves squeezed. Some
delayed new test launches, fearing the reimbursement morass. Others sued
hospitals for nonpayment. A few pivoted to outpatient-only markets. “The rule
didn’t kill innovation,” Sullivan says. “But it certainly gave it a limp.”
Hospitals, meanwhile, enjoyed an unearned windfall. Bundling
meant they absorbed payments for tests they never performed, and for which they
had little incentive to pay outside labs. “Hospitals weren’t malicious,”
Sullivan says. “They were just rational actors. Medicare had told them the
money was theirs.”
Looking back, Sullivan describes the first year after the
rule as a period of “slow dawning horror.” Not because the consequences were
catastrophic—they weren’t—but because they were so perversely misaligned with
the intent. “We wanted to create clarity,” she says. “Instead we created
distortion.”
Yet she also resists the temptation to dramatize. “People
say to me, ‘Mary, you changed the future of molecular oncology.’ That’s
flattering, but not true. Science was going to move forward no matter what. We
just made it stumble over a speed bump.”
The 14 Day Rule would continue to haunt CMS for years,
spawning exceptions, carve-outs, and eventual revisions. By the mid-2010s,
molecular pathology tests were granted the ability to be billed directly by the
performing lab, a concession to reality. But the phrase “14 Day Rule” never
died. It became a kind of shorthand, a shibboleth, in lab policy circles. At
conferences, speakers would sigh and say, “As you all know, the 14 Day Rule…”
and the room would groan in weary recognition.
Sullivan, retired now, follows these echoes with a mixture
of pride and resignation. “I wanted to be remembered for being steady, for
keeping the machine running,” she says. “Instead I’m remembered for a number.
Fourteen.”
She pauses, as if hearing the brass band on the street
below, though it is only the hum of the refrigerator in her kitchen. “There are
worse legacies,” she says. “At least it’s not thirteen.”
SEVEN
The Woman Who Invented Fourteen Days
VII. Sullivan as a Character
Profiles of government officials tend to fall into one of
two modes. Either the subject is portrayed as a heroic reformer, wielding
policy like a sword against entrenched interests, or else as a faceless
bureaucrat, lost in a forest of forms and acronyms. Mary Sullivan fits neither
mold. She is not heroic; nor is she faceless. She is, instead, something rarer:
a character who embodies the strange psychology of bureaucracy itself—its
combination of dutiful precision and moral evasiveness.
“When people ask what I did at CMS, I usually say, ‘I was a
punctuation clerk,’” Sullivan tells me. “It’s not quite true, but it captures
the feeling. You spend your days arranging words so that money flows in the
intended direction. And then you discover that a comma you moved has made a
whole industry furious.”
There is a deliberate modesty in her self-description.
Colleagues remember her as one of the most capable managers in the agency,
someone who could absorb a torrent of contradictory demands and reduce them to
a workable sentence. Yet she cultivates an air of detachment, as if to insist
that none of it was truly hers. “I didn’t invent the payment system,” she says.
“I just kept the gears greased.”
Sullivan’s character is shaped, in part, by the
contradictions of her career. She rose to authority in an institution that
prizes anonymity. CMS administrators are rarely known outside their narrow
circles; their signatures appear in the Federal Register, but not in
newspapers. “We weren’t like NIH, with celebrity scientists,” she says. “At
CMS, your reward was surviving another rule cycle without Congress yelling too
loudly.”
And yet, paradoxically, she became notorious—at least among
labs—for a single definition. The 14 Day Rule turned her, briefly, into a
figure of fascination. She was quoted in trade press, invited to panels,
denounced at conferences. “It was bizarre,” she recalls. “I’d be introduced as
‘the woman who gave us fourteen days,’ as if I had done it to amuse myself.”
The irony, she says, is that the number was not even hers.
It emerged from the collective muddle of meetings, drafts, and compromises. But
in bureaucracy, responsibility tends to coalesce around a face. Sullivan’s
face.
To understand her, one must accept the peculiar neutrality
of the bureaucrat’s worldview. For Sullivan, decisions were rarely about right
or wrong. They were about feasible or unfeasible, defensible or indefensible,
stable or unstable. “We weren’t ethicists,” she says. “We were engineers of
payment systems. Our morality was whether the claims processed.”
This detachment could sound chilling. When I ask whether she
ever worried about patients harmed by delays, she tilts her head, as if
weighing the question on an invisible scale. “I worried,” she says. “But I also
knew that every policy creates both harm and benefit. The hospital that loses
money on one rule may survive because of another. The patient who waits for a
test may benefit from a different coverage expansion. It’s a system, not a
morality play.”
And yet, beneath her words, there is an undercurrent of
unease. She admits that certain stories—the widow whose husband’s cancer test
was delayed, the young oncologist pleading for an exception—stayed with her. “I
told myself it was anecdote,” she says. “But anecdote is what policy looks like
up close.”
Janet Malcolm once wrote that journalists, like
psychoanalysts, are engaged in a form of betrayal: they expose the private
logic of their subjects to the public gaze. Writing about Sullivan, I feel a
different tension—that of revealing the moral gymnastics of bureaucracy. To
listen to her is to glimpse how intelligent people reconcile themselves to
decisions that appear, in retrospect, both arbitrary and consequential.
“I don’t think of myself as cynical,” Sullivan says. “But I
do think of myself as realistic. If you can’t live with compromise, you
shouldn’t work in government.”
Her realism sometimes veers into fatalism. She describes the
policymaking process as “a river you can steer, but never dam.” You push the
current toward clarity, and hope it doesn’t flood the wrong villages. “The 14
Day Rule was a levee,” she says. “It held back chaos. It also diverted water
where we didn’t expect.”
Her colleagues describe her as calm, dryly humorous,
allergic to melodrama. She had little patience for ideological grandstanding.
Once, when a consultant delivered an impassioned speech about “saving the
future of genomic medicine,” Sullivan is said to have replied, “That’s nice,
but we need to know whether your CPT code has a valid modifier.”
Her humor, however, is not cruelty. It is survival.
Bureaucrats, like nurses and undertakers, cope with the proximity of human
drama by focusing on the technical details. “If you dwell on the stakes,” she
says, “you paralyze yourself. So you dwell on the words.”
There is also, in Sullivan, a distinctly feminine
pragmatism. She came of age in an agency still dominated by men, where
authority was performed in booming voices and thick binders. She preferred
quiet competence. “Mary never raised her voice,” a former analyst tells me.
“She didn’t need to. She had the patience of someone who knew she would outlast
you.”
That patience defined her management style. She let staff
argue, vent, even insult one another, before gently steering the conversation
back to the regulation at hand. “You never left Mary’s office thinking you’d
won,” the analyst says. “But you always left thinking you’d been heard.”
In New Orleans, she describes herself more bluntly. “I was a
sponge,” she says. “I absorbed the anger, the fear, the self-interest. And then
I wrung it out into a regulation.”
The paradox of her legacy is that she is remembered for a
number that she neither cherished nor despised. “I don’t love fourteen,” she
says. “I don’t hate fourteen. Fourteen was just… available.”
She compares it to the way jazz musicians in the Quarter
improvise on a standard. “You take what’s there—a melody, a chord change—and
you bend it. You don’t plan every note. You make do. Policy is like that.
Fourteen was a riff.”
Listening to her, I am struck by the banality of the origin
and the intensity of the aftermath. The industry reads epic meaning into the
rule; Sullivan sees only the residue of compromise. “I think people want policy
to have intention,” she says. “They want to believe someone thought it all
through. The truth is, a lot of policy is cobbled together from duct tape and
half measures. Fourteen is the duct tape.”
As she speaks, a brass band begins to play outside—an
afternoon wedding procession. The music is joyful, messy, improvised. Sullivan
leans on the balcony rail, watching. “I used to think bureaucracy was dull,”
she says. “Now I see it’s a kind of jazz. Everyone blows their own tune, and
you try to make it sound like a song.”
She pauses, then adds: “The only difference is that in jazz,
no one sues you afterward.”
EIGHT
The Woman Who Invented Fourteen Days
VIII. Reflection in the Quarter
In the mornings, Mary Sullivan walks to the French Market
for coffee and fruit. She nods to the vendors who know her by sight, if not by
name. On Saturdays, she listens to the brass bands that stake out the corners
of Royal Street, their horns flashing in the sunlight. The rhythms of New
Orleans life are slow, unhurried, improvisational. They are everything the
rhythms of CMS were not.
“It’s a relief,” she says. “For thirty years, my days were
measured in deadlines—proposed rule, comment period, final rule. Now they’re
measured in parades.”
And yet, she cannot fully leave behind the calendar she
helped to invent. The 14 Day Rule follows her like a ghost. Former colleagues
still call for her recollection of “original intent.” Younger analysts cite her
name in footnotes. Lab executives, upon discovering her identity at a
conference, have been known to lean in with an accusatory smile: So you’re
the one.
She doesn’t resent it. “At least it means I left a mark,”
she says. “Most bureaucrats leave only dust.”
The irony of her legacy is not lost on her. The 14 Day Rule
was meant to be a temporary clarification, a modest fix to a definitional
problem. Instead it became a permanent irritant, a policy every stakeholder
knew by name. “In Washington, nothing is so permanent as the temporary,” she
says.
This permanence is what unsettles her in retrospect. “We
assumed Congress would revisit it. We assumed the industry would adapt and move
on. We assumed someone, somewhere, would improve on it. Instead, it calcified.
Fourteen days became gospel.”
It is the paradox of bureaucracy: the very tools designed to
make policy flexible—the proposed rule, the comment period, the annual
updates—can also fossilize it. Once a rule is written into the Code of Federal
Regulations, it acquires an inertia all its own. “Undoing a regulation,”
Sullivan says, “is harder than writing one.”
In the French Quarter, she reflects on this with a kind of
amused fatalism. “When you’re young, you think you’ll make bold changes. When
you’re old, you realize your real accomplishment was to keep the machine from
collapsing. The 14 Day Rule was not bold. It was ballast.”
I ask whether she ever regrets it. She shakes her head. “I
don’t regret. But I do wonder. If we had chosen ten, or twenty-one, or thirty,
would the world look different? Probably not. But maybe a few patients would
have gotten their tests sooner. Maybe a few labs would have survived longer.”
She shrugs. “It’s impossible to know. Bureaucracy doesn’t give you
counterfactuals.”
What she has, instead, is the freedom of retirement. Her
days are filled with small pleasures: a good novel, a stroll down Chartres
Street, the sound of jazz seeping through open shutters. Sometimes she attends
policy conferences as a kind of anthropological tourist. “I sit in the back,
unrecognized, and listen to people argue about rules I helped write fifteen
years ago,” she says. “It’s like watching a play you once acted in. You
remember your lines, but the cast has changed.”
At one such meeting, she heard a panelist declare that the
14 Day Rule had “nearly strangled innovation.” She chuckled quietly. “I wanted
to stand up and say, ‘If a number in the Federal Register can strangle
your innovation, maybe it wasn’t that robust to begin with.’ But I stayed
quiet. Retirement has taught me the virtue of silence.”
Sullivan’s reflections carry the dry detachment of someone
who has lived inside bureaucracy long enough to see its absurdity and its
inevitability. She describes CMS as “a factory for paradoxes.” It was an
institution that could change the fate of billion-dollar industries with a
comma, yet remained invisible to the public. It employed some of the brightest
minds in health policy, yet was derided as faceless. It was both overbearing
and underpowered, both feared and ignored.
Her own career reflects these paradoxes. She wielded immense
influence, but rarely felt powerful. She made decisions that affected millions,
but never thought of herself as a decider. “Power in bureaucracy,” she says,
“is not like power in politics. It’s not a spotlight. It’s a lever in a
machine. You pull, and something moves. You don’t always know what.”
In the style of Janet Malcolm, one is tempted to ask: what
kind of person reconciles herself to such a role? The answer, in Sullivan’s
case, is someone who takes solace in precision. She found meaning not in grand
narratives but in clean sentences, in rules that ran without contradiction. Her
satisfaction came from seeing chaos reduced to an edit in a claims system.
And yet, there is also a trace of melancholy. “I spent my
life writing definitions,” she says. “And definitions are cages. They capture
reality, but they also distort it. The 14 Day Rule captured something—it drew a
line. But it also distorted care in ways we couldn’t foresee.”
Late in the afternoon, as the sun slants over the Quarter,
she tells me a story. Shortly after retiring, she received a letter from a
molecular pathologist she had never met. It was handwritten, in looping script.
“He thanked me,” she says, “for creating a rule that forced his company to be
more innovative. They had to redesign their tests to fit around the payment
window. He said it made them better.”
She laughs. “That was the only thank-you note I ever got for
the 14 Day Rule.”
In the end, what does she think her legacy is? She considers
the question carefully, as if drafting a preamble to her own obituary. “I think
my legacy is that I kept the system moving,” she says. “Not gracefully, not
perfectly, but moving. And maybe that’s all you can ask.”
On the street below, another brass band has begun. The music
is raucous, joyful, slightly off-key. Sullivan leans on her balcony rail,
watching the parade snake past. “This is how I like to think of bureaucracy,”
she says. “Messy, noisy, full of competing voices. Somehow it keeps going
forward.”
She smiles, faintly. “Fourteen days. Half a month. Hardly
anything. And yet, somehow, forever.”
Here’s a ~1,000 word interview profile of Mary Sullivan in the French Quarter, written in the style of Truman Capote — lush, observant, slightly gothic, blending fact and atmosphere.
The Woman with Fourteen Days
The rain in New Orleans was of the soft, insinuating kind, the kind that slicks the cobblestones of Chartres Street until they gleam like lacquered wood. At the corner of a wrought-iron balcony, overlooking the street below, sat Mary Sullivan. She was small, birdlike, her hair cut short, her glasses catching the dim light as though they were meant to shield her from memory as much as the late afternoon.
I had come to ask her about a rule—about fourteen days, about a sentence in the Federal Register that had become an axis for laboratories, hospitals, and cancer patients. But what I found was a woman who had survived bureaucracy like a soldier survives a war: with scars disguised as anecdotes, with laughter disguising fatigue.
“People think the 14 Day Rule was a grand conspiracy,” she said, setting down her coffee. “It wasn’t. It was an accident that calcified.” She smiled faintly, as if the words were a secret shared only with the rain.
Capote, had he been here, might have lingered on the way her hands folded when she spoke—neatly, carefully, like two files being aligned. She had spent her career at CMS, writing definitions that looked like nothings and became everythings. The 14 Day Rule was her legacy, though she wore it the way an ex-con wears an old number: grimly, ironically, but without shame.
“I live in a place now where rules are ornamental,” she said, gesturing toward the Quarter below, where a man in a white suit and Panama hat strolled by with a woman much younger than himself. “There are noise ordinances here, but the brass bands play through the night. There are open-container laws, but everyone carries a drink. It’s liberating, really. After decades of parsing commas, I live in a place where commas are ignored.”
Her voice was low, but decisive. There was no mistaking the steel behind it.
We spoke of origins. She had grown up in Massachusetts, the daughter of a postal worker and a school secretary, raised on the logic of schedules. Her father believed in the holiness of timetables: the mail came at eleven, lunch at twelve-thirty, supper at six. Her mother kept report cards with the careful pride of an archivist. Mary, surrounded by definitions of days and duties, found her vocation early. “I suppose I was destined to define time,” she said. “Fourteen days was just an extension of my childhood.”
When she came to Washington, she was not looking for glory. “I wanted a steady job. I wanted to be useful.” She found herself at HCFA, later CMS, immersed in the first great upheaval of Medicare: the DRGs, the prospective payment system, the transformation of hospitals from open ledgers to closed bundles. “I liked it,” she admitted. “It was clean. It was logical. Until it wasn’t.”
Her account of the 14 Day Rule has the quality of gothic comedy. A definition meant to clarify became a trap; a number chosen almost casually became a shibboleth. “We thought we were fixing a billing problem,” she said. “Instead, we created a world where oncologists marked calendars like children waiting for Christmas.”
She leaned back in her chair, and her laugh was short, brittle. “Fourteen days. Not thirteen, not fifteen. Fourteen. The mind reels.”
Around us, the Quarter pulsed. A trumpet somewhere wailed, joined by a tuba, then drums. The music swelled, intrusive, joyous. Sullivan watched with the expression of someone who has learned to see systems in every scene. “That’s bureaucracy,” she murmured. “A brass band. Everyone blowing their own horn, but somehow moving in one direction.”
Capote might have lingered here, describing the shadows against the peeling pastel walls, the puddles reflecting neon signs, the mournful grandeur of a place where celebration and decay are twins. For Sullivan, the city was a mirror of her work: improvisational, contradictory, absurd.
I asked her if she regretted it—if she wished she had chosen a different number, or no number at all. She tilted her head, the birdlike gesture again, her eyes narrowing. “Regret is for novelists,” she said. “In government, you don’t have that luxury. You make a compromise, you put it in writing, and you live with it. If you regret every compromise, you drown.”
There was a pause. Then she added, almost softly: “But I do wonder. About the patients who waited. About the labs that folded. I wonder if a few days mattered.”
The silence after her words was filled by the hiss of tires on wet streets.
She described the meetings, the listening sessions in Baltimore. Hospitals in navy suits, labs with binders thick as dictionaries, patients who rose and told stories that hushed the room. “Everyone was sincere,” she said. “That was the problem. Sincerity was everywhere, but sincerity couldn’t reconcile contradictions. Sincerity doesn’t balance a budget.”
I thought of Capote’s Kansas interviews, his ability to render bureaucrats and killers with equal intimacy. Sullivan, though not tragic, possessed that same implacable ordinariness. She was a woman whose life had intersected with countless lives she would never meet, in ways she could neither foresee nor undo.
In retirement, she has adopted a kind of stoic irony. She tells her story without embellishment, as though it belongs to someone else. “I was a punctuation clerk,” she repeats. “I adjusted commas. The rest is interpretation.”
And yet, she is aware of her notoriety. “In certain circles, I am infamous,” she said, smiling faintly. “At lab conferences, people whisper. Fourteen days! As if I were a villain in a fairy tale.” She shook her head. “I am no villain. I am just the woman who made a choice. Fourteen days was the choice. History did the rest.”
The rain stopped. The air smelled of magnolia and beer. Down the street, the brass band had grown louder, its beat irresistible. Tourists fell in behind it, second-lining, waving handkerchiefs in the humid air. Sullivan leaned on the balcony rail, watching.
“This is my life now,” she said. “Not rulemaking. Watching parades.”
She spoke with a kind of quiet finality. But then, almost as an afterthought, she added: “And yet, the phone still rings. Young staffers call and ask: What did you mean, back then, when you wrote it? I tell them the truth. We didn’t mean anything. We meant to survive the year.”
Capote would have ended here, with the image of the retired bureaucrat gazing down on a parade, haunted by a number, unrepentant but not untouched. I end here too, with Mary Sullivan leaning on her balcony, the Quarter alive below, and the faint echo of fourteen days lingering in the air, like a refrain.
