Fatal Cure

6

Traynor arrived at the hospital with time to spare for his afternoon meeting. Instead of going directly to Helen Beaton's office, he went to the patient area on the second floor and walked down to room 209. After taking a breath to fortify himself, he pushed the door open. Being chairman of the board of directors of the hospital had not changed Traynor's aversion to medical situations, particularly bad medical situations.

Conscious of breathing shallowly in the presence of the seriously ill, Traynor moved across the darkened room and approached the large orthopedic bed. Bending over and scrupulously avoiding touching anything, he peered at his client, Tom Baringer. Tom didn't look good, and Traynor didn't want to get too close lest he catch some awful illness. Tom's face was gray and his breathing was labored. A plastic tube snaked from behind his head, feeding oxygen into his nose. His eyes were closed with tape, and ointment oozed out between his eyelids.

"Tom," Traynor called softly. When there was no response, he called louder. But Tom did not move.

"He's beyond responding."

Traynor jumped and the blood drained from his own face. Except for Tom, he'd thought he was alone.

"His pneumonia is not responding to treatment," the stranger said angrily. He'd been sitting in a corner of the room. He was cloaked in shadows; Traynor could not see his face.

"He's dying like the others," the man said.

"Who are you?" Traynor asked. He wiped his forehead where perspiration had instantly appeared.

The man got to his feet. Only then could Traynor see that he was dressed in surgical scrubs, covered with a white jacket.

"I'm Mr. Baringer's doctor, Randy Portland." He advanced to the opposite side of the bed and gazed down at his comatose patient. "The operation was a success but the patient is about to die. I suppose you've heard a variation of that quip before."

"I suppose I have," Traynor said nervously. Shock at Dr. Portland's presence was changing to anxious concern. There was something decidedly strange about the man's manner. Traynor wasn't sure what he would do next.

"The hip has been repaired," Dr. Portland said. He lifted the edge of the sheet so Traynor could see the tightly sutured wound. "No problem whatsoever. But unfortunately it's been a fatal cure. There's no way Mr. Baringer will walk out of here." Portland dropped the sheet and defiantly raised his eyes to Traynor's. "There's something wrong with this hospital," he said. "I'm not going to take all the blame."

"Dr. Portland," Traynor said hesitantly. "You don't look well to me. Maybe you should see a doctor yourself."

Dr. Portland threw back his head and laughed. But it was a hollow, mirthless laugh which ended as suddenly as it had begun. "Maybe you're right," he said. "Maybe I'll do that." He then turned and left the room.

Traynor felt stunned. He looked down at Tom as if he expected him to wake up and explain Dr. Portland's behavior. Traynor could understand how doctors might become emotionally involved in their patients' conditions, but Portland seemed unhinged.

Traynor tried one last time to communicate with Tom. Recognizing the futility, he backed away from the bed and slipped out of the room. Warily he looked for Dr. Portland. When he didn't see him, Traynor quickly walked to Beaton's office. Caldwell and Kelley were already there.

"Do you all know Dr. Portland?" Traynor asked as he took a chair.

Everyone nodded. Kelley spoke: "He's one of ours. He's an orthopedic surgeon."

"I just had a very peculiar and unnerving encounter with him," Traynor said. "On my way here I popped in to see my client, Tom Baringer, who's very sick. Dr. Portland was sitting in the corner of Tom's darkened room. I didn't even see him when I first went in. When he spoke, he acted strangely, even belligerently. I imagine he's distraught over Tom's condition, but he said something about not taking all the blame and that there was something wrong with the hospital."

"I think he's been under strain from overwork," Kelley said. "We're short at least one orthopedic surgeon. Unfortunately our recruiting efforts have been unsuccessful so far."

"He looked ill to me," Traynor said. "I advised him to see a doctor, but he only laughed."

"I'll have a talk with him," Kelley promised. "Maybe he needs a little time off. We can always get a locum tenens for a few weeks."

"Well, so much for that," Traynor said, trying to compose himself more in keeping with his role as chairman of the board. "Let's get our meeting underway."

"Before we do that," Kelley said, flashing one of his winning smiles, "there's something I have to say. My superiors are very upset about the negative ruling on the CON for open-heart surgery."

"We were disappointed about that as well," Traynor said nervously. He didn't like beginning on a negative note. "Unfortunately it's out of our hands. Montpelier turned us down even though we thought we'd made a good case."

"CMV had expected the open-heart program to be up and running by now," Kelley said. "It was part of the contract."

"It was part of the contract provided we got the CON," Traynor corrected. "But we didn't. So let's look at what has been done. We've updated the MRI, built the neonatal ICU, and replaced the old cobalt-60 machine with a new state-of-the-art linear accelerator. I think we have been showing remarkably good faith, and we've been doing all this while the hospital has been losing money."

"Whether the hospital loses money or not is not CMV's concern," Kelley said. "Especially since it's probably due to minor management inefficiencies."

"I think you are wrong," Traynor said, swallowing his anger at Kelley's insulting insinuation. He hated being put on the defensive, especially by this young, brazen bureaucrat. "I think CMV has to be concerned if we are losing money. If things get much worse we could be forced to close our doors. That would be bad for everyone. We have to work together. There's no other choice."

"If Bartlet Community Hospital goes under," Kelley said, "CMV would take its business elsewhere."

"That's not so easy anymore," Traynor said. "The two other hospitals in the area are no longer functioning as acute care facilities."

"No problem," Kelley said casually. "If need be, we would ferry our patients to the CMV hospital in Rutland."

Traynor's heart skipped a beat. The possibility of CMV ferrying its patients had never occurred to him. He'd hoped that the lack of nearby hospitals would give him some bargaining power. Apparently it didn't.

"I don't mean to imply that I'm not willing to work together with you people," Kelley said. "This should be a dynamic relationship. After all, we have the same goal: the health of the community." He smiled again as if to show off his perfectly straight white teeth.

"The problem is the current capitation rate is too low," Traynor said bluntly. "Hospitalization from CMV is running more than ten percent above projections. We can't support such an overrun for long. We need to renegotiate the capitation rate. It's that simple."

"The capitation rate doesn't get renegotiated until the contract term is over," Kelley said amicably. "What do you take us for? You offered the present rate in a competitive bidding process. And you signed the contract. So it stands. What I can do is start negotiations on a capitation rate for ER services, which was left out of the initial agreement."

"Capitating the ER is not something we can do at the moment," Traynor said, feeling perspiration run down the insides of his arms. "We have to stem our red ink first."

"Which is the reason for our meeting this afternoon," Beaton said, speaking up for the first time. She then presented the final version of the proposed bonus program for CMV physicians.

"Each gatekeeper CMV physician will be allocated a bonus payment provided his number of monthly hospital days per assigned subscriber stays at a given level. As the level goes down, the payment goes up and vice versa."

Kelley laughed. "Sounds like clever bribery to me. As sensitive as doctors are to economic incentives, it certainly should reduce hospitalization and surgery."

"It's essentially the same plan CMV has in effect at the CMV hospital in Rutland."

"If it works there then it should work here," Kelley said. "I have no trouble with it, provided it doesn't cost CMV anything."

"It will be totally funded by the hospital," Beaton said.

"I'll present it to my superiors," Kelley said. "Is that it for this meeting?"

"That's it," Beaton said.

Kelley got to his feet.

"We'd appreciate all the speed you can muster," Traynor said. "I'm afraid we're looking at a lot of red ink on our balance sheet."

"I'll do it today," Kelley promised. "I'll try to have a definitive answer by tomorrow." With that, he shook hands with everyone and left the room.

"I'd say that went as well as could be expected," Beaton said once he was gone.

"I'm encouraged," Caldwell said.

"I didn't appreciate his impudent suggestion of incompetent management," Traynor said. "I don't like his cocky attitude. It's unfortunate we have to deal with him."

"What I didn't like hearing was the threat to ferry patients to Rutland," Beaton said. "That worries me. It means our bargaining position is even weaker than I thought."

"Something just occurred to me," Traynor said. "Here we've had this high-level meeting that could possibly determine the fate of the hospital and there were no doctors present."

"It's a sign of the times," Beaton said. "The burden of dealing with the health-care crisis has fallen on us administrators."

"I think it's the medical world's equivalent of the expression, 'War is too important to leave up to the generals,' " Traynor said.

They all laughed. It was a good break from the tension of the meeting.

"What about Dr. Portland?" Caldwell asked. "Should I do anything?"

"I don't think there's anything to be done," Beaton said. "I haven't heard anything but good things about his surgical abilities. He certainly hasn't violated any rules or regulations. I think we'll have to wait and see what CMV does."

"He didn't look good to me," Traynor reiterated. "I'm no psychiatrist and I don't know what someone looks like when they're about to have a nervous breakdown, but if I had to guess, I'd guess they'd look the way he does."

The buzz of the intercom surprised them all, especially Beaton who'd left explicit instructions there were to be no interruptions.

"Some bad news," she said once she hung up. "Tom Baringer has died."

The three fell silent. Traynor was the first to speak: "Nothing like a death to remind us that for all the red and black ink, a hospital really is a very different kind of business."

"It's true," Beaton said. "The burden of the work is that the whole town, even the whole region, becomes like an extended family. And as in any large family, someone is always dying."

"What is our death rate here at Bartlet Community Hospital?" Traynor asked. "It's never occurred to me to ask."

"We're just about in the middle of the road," Beaton said. "Plus or minus a percentage point. In fact, our rate is better than most of the inner-city teaching hospitals."

"That's a relief," Traynor said. "For a moment I was afraid there was something else I had to worry about."

"Enough of this morbid talk," Caldwell said. "I have some good news. The husband-and-wife team that we and CMV have been recruiting so actively has decided to come to Bartlet. So we'll be getting a superbly trained pathologist."

"I'm glad to hear it," Traynor said. "That brings pathology up to speed."

"They've even purchased the old Hodges house," Caldwell added.

"No kidding!" Traynor said. "I like that. There's something wonderfully ironic about it."

Charles Kelley slipped into his Ferrari coupe, started the engine, and gave it some gas. It responded like the engineering marvel it was, pressing him against the seat as he accelerated out of the hospital parking lot. He loved to drive the car, especially in the mountains. The way it hugged the road and cornered was a true delight.

After the meeting with the Bartlet Hospital people Kelley had phoned Duncan Mitchell directly, thinking it was a good opportunity to make his presence known to the man at the pinnacle of power. Duncan Mitchell was the CEO of CMV, as well as of several other HMOs and hospital management companies in the South. Conveniently the home office was in Vermont where Mr. Mitchell had a farm.

Kelley had not known what to expect and had been nervous when he called, but the CEO turned out to be gracious. Although Kelley had caught the man preparing to go to Washington, he had generously agreed to meet with Kelley outside the Burlington Airport general aviation building.

With CMV's Learjet in its final stages of fueling, Mitchell invited Kelley into the back of his limousine. He offered Kelley a drink from the limo's bar. Kelley politely refused.

Duncan Mitchell was an impressive man. He wasn't as tall as Kelley, yet he emanated a sense of power. He was meticulously dressed in a conservative business suit with a silk tie and gold cufflinks. His Italian loafers were dark brown crocodile.

Kelley introduced himself and gave a brief history of his association with CMV, mentioning that he was the regional director for the area centered around Bartlet Community Hospital, just in case Mitchell didn't know. But Mitchell seemed acquainted with Kelley's position.

"We eventually want to buy that facility," he said.

"I assumed as much," Kelley said. "And that's why I wanted to come to talk with you directly."

Mr. Mitchell slipped a gold cigarette case from his vest pocket and took out a cigarette. He tapped it thoughtfully against the case's flat front surface. "There's a lot of profit to be squeezed out of these rural hospitals," Mitchell said. "But it takes careful management."

"I couldn't agree more," Kelley said.

"What is it you wanted to talk about?" Mr. Mitchell asked.

"Two issues," Kelley said. "The first involves a bonus program the hospital wants to initiate similar to our own with our hospitals. They want to cut down on hospitalization."

"And what's the other?" Mitchell asked. He blew smoke up toward the ceiling of the car.

"One of our CMV physicians has begun acting bizarrely in response to post-operative complications in his patients," Kelley said. "He's saying things like he's not to blame and there's something wrong with the hospital."

"Does he have a psychiatric history?" Mr. Mitchell asked.

"Not that we can determine," Kelley said.

"Regarding the first issue, let them have their bonus program. At this point it doesn't matter about their balance sheet."

"What about the doctor?" Kelley asked.

"Obviously you'll have to do something," Mitchell said. "We can't let that type of behavior go on."

"Any suggestions?" Kelley asked.

"Do what you need to do," Mitchell said. "I'll leave the details up to you. Part of the skill of running a large organization like ours is knowing when to delegate responsibility. This is one of those times."

"Thank you, Mr. Mitchell," Kelley said. He was pleased. It was obvious to him that he was being given a vote of confidence.

Elated, Kelley climbed out of the limousine and got back into his Ferrari. As he was pulling out of the airport he caught a glimpse of Mitchell walking from his car to the CMV jet.

"Someday," Kelley vowed, "it'll be me using that plane."