Fatal Cure

2

Harold Traynor fingered the mahogany and inlaid gold gavel he'd bought for himself at Shreve Crump amp; Low in Boston. He was standing at the head of the library table in the Bartlet Community Hospital. In front of him was the lectern that he had had built for the hospital conference room. Scattered on its surface were his extensive notes which he'd had his secretary type up early that morning. Stretching out from the lectern and scattered down the center of the table was the usual collection of medical paraphernalia in various stages of evaluation by the hospital board. Dominating the confusion was the model of the proposed parking garage.

Traynor checked his watch. It was exactly six P.M. Taking the gavel in his right hand, he struck it sharply against its base. Attentiveness to detail and punctuality were two characteristics Traynor particularly prized.

"I would like herewith to call to order the Executive Committee of the Bartlet Community Hospital," Traynor called out with as much pompousness as he could muster. He was dressed in his best pin-striped suit. On his feet were freshly polished elevator shoes. He was only five foot seven and felt cheated as far as stature was concerned. His dark, receding hair was neatly trimmed and carefully combed over his apical bald spot.

Traynor spent a great deal of time and effort preparing for hospital board meetings, both in terms of content and his appearance. That day he'd gone directly home to shower and change clothes after a day trip to Montpelier. With no time to spare, he did not stop at his office. Harold Traynor was an attorney in Bartlet specializing in estate planning and tax work. He was also a businessman with interests in a number of commercial ventures in the town.

Seated before him were Barton Sherwood, vice chairman; Helen Beaton, president and CEO of the hospital; Michael Caldwell, vice president and medical director of the hospital; Richard Arnsworth, treasurer; Clyde Robeson, secretary; and Dr. Delbert Cantor, current chief of staff.

Strictly following parliamentary procedure as specified in Robert's Rules of Order, which he'd purchased after being elected to the chairmanship, Traynor called on Clyde Robeson to read the minutes of the last meeting.

As soon as the minutes had been read and approved, Traynor cleared his throat in preparation for his monthly chairman's report. He looked at each member of his executive committee in turn, making sure they were all attentive. They were, except for Dr. Cantor who was, typically, bored and busily cleaning under his fingernails.

"We face significant challenges here at the Bartlet Community Hospital," Traynor began. "As a referral center we have been spared some of the financial problems of smaller rural hospitals, but not all of them. We're going to have to work even harder than we have in the past if the hospital is to survive these difficult days.

"However, even in these dark times there is occasional light. As some of you have undoubtedly heard, an esteemed client of mine, William Shapiro, passed away last week of pneumonia coming on after knee surgery. While I very much regret Mr. Shapiro's untimely passing, I am pleased to announce officially that Mr. Shapiro had generously designated the hospital as the sole beneficiary of a three-million-dollar insurance policy."

A murmur of approval spread through the people present.

Traynor lifted his hand for silence. "This charitable gesture couldn't have come at a better time. It will pull us out of the red and push us into the black, although not for long. The bad news for the month is the recent discovery that our sinking fund for our major bond issues is considerably short of its projected goals."

Traynor looked directly at Sherwood, whose mustache twitched nervously.

"The fund will need to be bolstered," Traynor said. "A good portion of the three-million-dollar bequest will have to go to that end."

"It wasn't all my fault," Sherwood blurted out. "I was urged to maximize return on the fund. That necessitated risk."

"The chair does not recognize Barton Sherwood," Traynor snapped.

For a moment, Sherwood looked as if he might respond, but instead he remained silent.

Traynor studied his notes in an effort to compose himself after Sherwood's outburst. Traynor hated disorder.

"Thanks to Mr. Shapiro's bequest," Traynor went on, "the sinking fund debacle will not be lethal. The problem is to keep any outside examiners from getting wind of the shortfall. We can't afford to have our bond rating change. Consequently, we will be forced to put off floating a bond issue for the parking garage until the sinking fund is restored.

"As a temporary measure to forestall assaults on our nurses I have instructed our CEO, Helen Beaton, to have lighting installed in the parking lot."

Traynor glanced around the room. According to the Rules of Order, the matter should have been presented as a motion, debated, and voted on, but no one moved to be recognized.

"The last item concerns Dr. Dennis Hodges," Traynor said. "As you all know, Dr. Hodges disappeared last March. During this past week I met with our chief of police, Wayne Robertson, to discuss the case. No clues as to his whereabouts have surfaced. If Dr. Hodges did meet with foul play, there has been no evidence of it, although Chief Robertson allowed that the longer Dr. Hodges is missing, the more likely it is that he is no longer living."

"My guess is he's still around," Dr. Cantor said. "Knowing that bastard, he's probably sitting down in Florida, laughing himself silly every time he thinks of us wrestling with all this bureaucratic bullshit."

Traynor used his gavel. "Please!" he called out. "Let's maintain some order here."

Cantor's bored expression changed to disdain, but he remained silent.

Traynor glared at Dr. Cantor before resuming: "Whatever personal feelings we may have about Dr. Hodges, the fact remains that he played a crucial role in the history of this hospital. If it hadn't been for him this institution would be merely another tiny, rural hospital. His welfare merits our concern.

"I wanted the executive committee to know that Dr. Hodges' estranged wife, Mrs. Hodges, has decided to sell her home. She relocated to her native Boston some years ago. She had held out some hope that her husband might resurface, but based on her conversations with Chief Robertson, she has decided to sever her connections with Bartlet. I only raise this matter now because I think that sometime in the near future the board might wish to erect a memorial befitting Dr. Hodges' considerable contributions to Bartlet Community Hospital."

Having finished, Traynor gathered up his notes and formally turned the meeting over to Helen Beaton so that she could give her monthly president's report. Beaton stood up in her place, pushing her chair back from the table. She was in her mid-thirties with reddish-brown hair cut short. Her face was wide, not unlike Traynor's. She wore a businesslike blue suit accented with a silk scarf.

"I've spoken to several civic groups this month," she said. "My topic on each occasion was the financial plight of the hospital. It was interesting for me to ascertain that most people were generally unaware of our problems even though health-care issues have been almost constantly in the news. What I emphasized in my talks was the economic importance of the hospital to the town and the immediate area. I made it very clear that if the hospital were to close, every business and every merchant would be hurt. After all, the hospital is the largest employer in this part of the state. I also reminded everyone that there is no tax base for the hospital and that fundraising has been and will remain key to keeping the doors open."

Beaton paused as she turned over the first page of her notes. "Now for the bad news," she said, referring to several large graphs illustrating the information she was about to relay. She held the graphs at chest height as she spoke. "Admissions for April were twelve percent over forecast. Our daily census was up eight percent over March, and our average length of stay was up six percent. Obviously these are serious trends as I'm sure our treasurer, Richard Arnsworth, will report."

Beaton held up the last graph. "And finally I have to report that there has been a drop in utilization of the emergency room which, as you know, is not part of our capitation agreement with CMV. And to make matters worse, CMV has refused to pay a number of our ER claims, saying the subscribers violated CMV rules."

"Hell, that's not the hospital's fault," Dr. Cantor said.

"CMV doesn't care about such technicalities," Beaton said. "Consequently, we've been forced to bill the patients directly and they are understandably upset. Most have refused to pay, telling us to go to CMV."

"Health care is becoming a nightmare," Sherwood said.

"Tell that to your representative in Washington," Beaton said.

"Let's not digress," Traynor said.

Beaton looked back at her notes, then continued: "Quality indicators for April were within normal expectations. Incident reports were actually fewer than in March and no new malpractice actions have been initiated."

"Will wonders never cease," Dr. Cantor commented.

"Other disturbing news for April involved union agitation," Beaton continued. "It was reported to us that both dietary and housekeeping have been targeted. Needless to say, unionization would significantly add to our financial problems."

"It's one crisis after another," Sherwood said.

"Two areas of under-utilization," Beaton continued, "are the neonatal intensive care unit and the linear accelerator. During April, I discussed this situation with CMV since our fixed costs for maintaining these units are so high. I emphasized it had been they who demanded these services. CMV promised me that they would look into ferrying patients from areas without these facilities to Bartlet and reimbursing us accordingly."

"That reminds me," Traynor said. As chairman, he felt he had the right to interrupt. "What is the status of the old cobalt-60 machine that the linear accelerator replaced? Have there been any inquiries from the state licensing division or the nuclear regulatory commission?"

"Not a word," Beaton answered. "We informed them the machine is in the process of being sold to a government hospital in Paraguay and that we are waiting for the funds."

"I don't want to get involved in any bureaucratic snafu with that machine," Traynor warned.

Beaton nodded and turned to the last page of her notes. "And finally, I'm afraid I have some additional bad news. Last night just before midnight there was another attempted assault in the parking lot."

"What?" Traynor cried. "Why wasn't I informed about this?"

"I didn't hear about it until this morning," Beaton explained. "I tried to call you as soon as I heard, but you weren't in. I left a message for you to call back but you never did."

"I was in Montpelier all day," Traynor explained. He shook his head in dismay. "Damn, this has to stop. It's a PR nightmare. I hate to imagine what CMV thinks."

"We need that garage," Beaton said.

"The garage has to wait until we can float a bond issue," Traynor said. "I want that lighting done quickly, understand?"

"I've already talked to Werner Van Slyke," Beaton said. "And he's already gotten back to me that he's been in touch with the electrical contractor. I'll follow up on it so that it's done ASAP."

Traynor sat down heavily and blew through pursed lips. "It's almost mind-boggling what running a hospital today entails. Why did I get myself into this?" He picked up the current meeting's agenda, glanced at it, then called Richard Arnsworth, the treasurer, to give his report.

Arnsworth got to his feet. He was a bespectacled, precise, accountant type whose voice was so soft everyone had to strain to hear him. He started by referring everyone to the balance sheet each had received in his information packet that morning.

"What's immediately obvious," Arnsworth said, "is that the monthly expenses still significantly outstrip the monthly capitation payments from CMV. In fact, the gap has expanded relative to the increase in admissions and lengths of stay. We're also losing money on all Medicare patients not enrolled in CMV as well as all indigents who are not enrolled in any plan. The percentage of paying patients or those with standard indemnity insurance is so tiny we cannot cost-shift enough to cover our losses.

"As a result of this continued loss, the hospital's cash position has deteriorated. Consequently, I recommend switching from one hundred and eighty days investing to thirty days."

"It's already been taken care of," Sherwood announced.

When Arnsworth took his seat, Traynor asked for a motion to approve the treasurer's report. It was immediately seconded and carried with no opposition. Traynor then turned to Dr. Cantor to give the medical staff report.

Dr. Cantor got to his feet slowly and leaned his knuckles on the table. He was a big, heavyset man with a pasty complexion. Unlike other presenters he didn't refer to notes.

"Just a couple of things this month," he said casually. Traynor glanced over at Beaton and caught her eye, then shook his head in disgust. He hated Cantor's jaded behavior at their meetings.

"The anesthesiologists are all up in arms," Dr. Cantor said. "But of course it's expected now that they have been officially informed that the hospital is taking over the department, and they're to be on straight salary. I know how they feel since I experienced the same situation during Hodges' tenure."

"Do you think they'll sue?" Beaton asked.

"Of course they'll sue," Dr. Cantor said.

"Let them," Traynor said. "The precedent's been well established with pathology and radiology. I cannot believe they'd think they could continue with private billing while we're under capitation. It doesn't make sense."

"A new utilization manager has been chosen," Dr. Cantor said, changing the subject. "His name is Dr. Peter Chou."

" Will Dr. Chou cause any problems for us?" Traynor asked.

"I doubt it," Dr. Cantor said. "He didn't even want the position."

"I'll meet with him," Beaton said.

Traynor nodded.

"And the last item concerning the medical staff," Dr. Cantor said, "involves M.D. 91. I've been told he's not been drunk all month."

"Leave him on probation just the same," Traynor said. "Let's not take any chances. He's relapsed before."

Dr. Cantor sat down.

Traynor asked if there was any new business. When no one moved, he asked for a motion to adjourn. Dr. Cantor eagerly "so moved." After a resounding chorus of "yeas," Traynor struck the gavel and ended the meeting.

Traynor and Beaton slowly gathered up their papers. Everyone else trooped out of the conference room, heading for the Iron Horse Inn. When the sound of the outer door closing behind the departing group drifted back to the room, Traynor's eyes met Beaton's. Leaving his briefcase, Traynor stepped around the table and passionately embraced her.

Hand in hand they hurriedly left the conference room and retreated across the hall to a couch in Beaton's office as they had so many times before. There in the semi-darkness they made frenzied love just as they had after each executive committee meeting for almost a year. It was a familiar scenario and didn't take long. They didn't bother to remove their clothes.

"I thought it was a good meeting," Traynor said as they rearranged their apparel after they were through.

"I agree," Beaton said. She turned on a light and went over to a wall mirror. "I liked the way you handled the lighting issue for the parking lot. It avoided needless debate."

"Thank you," Traynor said, pleased with himself.

"But I'm worried about the financial situation," Beaton admitted as she reapplied her makeup. "The hospital has to break even at the very least."

"You're right," Traynor admitted with a sigh. "I'm worried too. I'd love to wring some of those CMV people's necks. It's ironic that this 'managed competition' nonsense could very well force us into bankruptcy. That whole year of negotiations with CMV was a lose-lose situation. If we hadn't agreed to capitate, we wouldn't have gotten the contract and we would have had to close like the Valley Hospital. Now that we did agree to capitate, we still might have to close."

"Every hospital is having trouble," Beaton said. "We should keep that in mind, although it's hardly consolation."

"Do you think there is any chance we could renegotiate the contract with CMV?" Traynor asked.

Beaton laughed scornfully. "Not a chance," she said.

"I don't know what else to do," Traynor said. "We're losing money despite our DUM plan that Dr. Cantor proposed."

Beaton laughed with true mirth. "We have to alter that acronym. It sounds ridiculous. How about changing from Drastic Utilization Measures to Drastic Utilization Control. DUC sounds a lot better than DUM."

"I kind of like DUM," Traynor said. "It reminds me that it was dumb to set our capitation rate so low."

"Caldwell and I have come up with an idea that might help significantly," she said. She pulled a chair over and sat down in front of Traynor.

"Shouldn't we be getting down to the Iron Horse?" Traynor said. "We don't want anybody getting suspicious. This is a small town."

"This will only take a moment," Beaton promised. "What Caldwell and I did was brainstorm about how the consultants we hired came up with a capitation rate that has proved to be too low. What we realized was that we'd provided them with hospitalization statistics that CMV had given us. What no one remembered was that those statistics were based on experience CMV had with its own hospital in Rutland."

"You think CMV gave us fraudulent numbers?" Traynor asked.

"No," Beaton said. "But like all HMOs when they are dealing with their own hospitals, CMV has an economic incentive for their doctors to limit hospitalization, something the public has no idea about."

"You mean like actual payments to the doctors?" Traynor asked.

"Exactly," Beaton said. "It's a bonus bribe. The more each doctor cuts his hospitalization rates the bigger the bonus. It's very effective. Caldwell and I believe we can fashion a similar economic incentive here at Bartlet Community Hospital. The only problem is that we will have to fund it with some start-up capital. Once it's operational, it will pay for itself by reducing hospitalization."

"Sounds great," Traynor said with enthusiasm. "Let's pursue it. Maybe this kind of program, combined with DUM, will eliminate the red ink."

"I'll arrange a meeting with Charles Kelley to discuss it," Beaton said as she got her coat.

"While we're on the topic of utilization," Beaton said as they started down the long hall toward the exit, "I hope to heaven that we're not going to get the Certificate of Need for open-heart surgery. It's crucial we don't. We have to keep CMV sending their bypass patients to Boston."

"I agree wholeheartedly," Traynor said as he held the door open for Beaton. They passed out of the hospital into the lower parking area. "That was one of the reasons I was in Montpelier today. I've started some behind-the-scenes negative lobbying."

"If we get that CON we'll be looking at a lot more red ink," Beaton warned.

They arrived at their respective cars which were parked side by side. Before he climbed behind the wheel, Traynor glanced around the dark parking area, particularly up toward the copse of trees that separated the lower lot from the upper.

"It's darker out here than I remembered," he called over to Beaton. "It's like asking for trouble. We need those lights."

"I'll get right on it," she promised.

"What a pain!" Traynor said. "With everything else we have to worry about, we've got to worry about a damn rapist. What are the details about last night's episode?"

"It occurred about midnight," Beaton said. "And this time it wasn't a nurse. It was one of the volunteers, Marjorie Kleber."

"The teacher?" Traynor asked.

"That's right," Beaton said. "Ever since she got sick herself she's been doing a lot of volunteering on weekends."

"How about the rapist?" Traynor asked.

"Same description: about six feet, wearing a ski mask. Ms. Kleber said he had handcuffs."

"That's a nice touch," Traynor said. "How'd she get away?"

"It was just lucky," Beaton said. "The night watchman just happened along while making his rounds."

"Maybe we should beef up security," Traynor suggested.

"That's money we don't have," Beaton reminded him.

"Maybe I should talk to Wayne Robertson and see if the police can do any more," Traynor said.

"I've already done that," Beaton said. "But Robertson doesn't have the manpower to have someone up here every night."

"I wonder if Hodges really did know the rapist's identity?"

"Do you think his disappearance could have had anything to do with his suspicions?" Beaton asked.

Traynor shrugged. "I hadn't thought of that. I suppose it's possible. He wasn't one to keep his opinion to himself."

"It's a scary thought," Beaton said.

"Indeed," Traynor said. "Regardless, I want to be informed about any such assaults immediately. They can have disastrous consequences for the hospital. I especially don't want any surprises at an executive board meeting. It makes me look bad."

"I apologize," Beaton said, "but I did try to call. From now on I'll make sure you are informed."

"See you down at the Iron Horse," Traynor said as he got into his car and started the engine.