The Society

CHAPTER 9

Impassioned Plea Helps Doc Lambaste Managed Care

Four hundred of the city’s best and brightest, including Governor John A. Fromson, sat in stunned silence at Faneuil Hall last night as Fredrickston surgeon Willard Grant emotionally and effectively chastised managed-care companies for placing profits before patients and before physicians. .

The article was the headliner in Section B of the Globe-the City Section. There were two copies of the paper on Will’s desk when he arrived at the office, along with two copies of the article itself, neatly cut out by the Associates’ dauntless receptionist, Mimi. There was also a copy of the Herald, which contained an article saying essentially the same thing, albeit in many fewer words.

Will had begun his day as usual by making rounds at the hospital, where nearly everyone seemed already to have heard about the forum and his unofficial victory over Boyd Halliday. Several people-two nurses, a lab tech, and a ward secretary-buttonholed him to share their own angry managed-care stories. Two others felt the need to tell him how pleased they were with the care their HMOs were providing for their families. Even his patients seemed to have heard some version of the debate.

Will persistently denied doing anything special, but in truth he was puffed over the turnabout he had been able to effect in the encounter with Halliday. He was not, however, at all pleased that the Willard cat had been let out of the bag. Even his office staff was surprised and amused that he was not a William. It didn’t help that the classic horror flick that had initially caused his dubbing as Ratboy had not too long ago been remade, and to generally favorable reviews, as well. As he flipped through a dozen excited e-mails, mostly from Hippocrates Society colleagues, Will wondered if he had ever even bothered telling the twins his true given name. Most likely, he acknowledged, even if he hadn’t, Maxine had found a way.

In addition to the article, Mimi had dutifully left a copy of the day’s appointment schedule on his desk. Patient visits, sandwiched about the removal of a large fatty tumor from a woman’s back, were light. This was exactly the mellow, stress-free day he would have prescribed for himself after an evening that hadn’t ended until nearly two in the morning.

He was scanning the list of patients when he remembered the card Detective Sergeant Patricia Moriarity had given him, along with the request that he call her. He had little doubt she wanted to speak to him about the managed-care murders. Others in the Hippocrates Society had already been questioned. He took the card from his wallet and studied it absently as he thought about the woman. In all likelihood there had been a shoulder holster and pistol under her vest. Except for the one time a friend had dragged him to a firing range, he had never even held a real handgun. Patricia Moriarity lived by one. He gave a moment’s thought to calling her, then wedged the card alongside his desk blotter, protruding out as a reminder. This just wasn’t the time he wanted to be grilled about serial killings and his views on managed care.

“Dr. Grant, it’s Mimi. Could you come out here, please?”

Will did as the intercom requested and found Grace Peng-Grace Davis, he remembered-seated alone in an otherwise empty waiting room. He was struck, as he had been yesterday, with the remarkable transformation in the woman, who had essentially been a bag lady not that many years before.

“Do you have a moment to speak with me?” she asked, quite obviously agitated and distressed.

“Sure, come in to my office.”

She settled into one of the two walnut-stained, Danish modern chairs that Jim Katz’s interior-decorator wife had chosen for each of the offices.

“My insurance company is Steadfast Health,” she said.

“I’ve done some business with them.”

Will hadn’t actually had all that much contact with the company, but he had operated on a number of patients whom they covered. From what he recalled, Steadfast Health was smaller than most of the HMOs, and for the most part more civil.

“Well, they are refusing to allow you to do my surgery.”

“When did they say that?” he asked, wondering if somehow last night’s forum and the resulting publicity could have already had some undesirable fallout.

“Yesterday. Just in case there was some clause or other like the one they have requiring preapproval for everything, I called them shortly after we got home from here to inform them about the change we wanted from Dr. Hollister to you. The woman who answered the phone checked around and then called me back to say they have a contract with Excelsius Health that includes the requirement that the referral surgeon is the only one allowed to operate on Steadfast Health patients.”

Will was stunned. Was this yet another managed-care game?

“What do you mean contract?” he asked. “What’s Excelsius Health got to do with this?”

“From what I was told when my primary-care doctor scheduled my mammogram, Steadfast Health is too small to have cancer centers the way Excelsius Health does, so their patients are X-rayed at the Excelsius mammography clinics, and if they need it, they’re treated at the Excelsius cancer centers. Then, I guess, Steadfast Health reimburses them somehow.”

“Well, this is just crazy,” Will said. “I’m on the provider panels for both Steadfast Health and Excelsius.” Even though, he chose not to add, Excelsius had tried several times in the past to have him removed from their provider list for various technicalities, including failure to get a form in on time.

“No matter what,” Grace said, “my husband and I have decided that we want you to do my biopsy, even if we have to pay for it ourselves. We have some money saved and-”

“Stop right there. This is absolute nonsense. You aren’t going to have to pay for this yourselves.”

The oversize manila folder with Grace’s mammograms in it was still propped against his desk from the previous evening. It was ironic and somewhat amusing that he had completely missed the Excelsius Health label in the upper left corner. Briefly, he scanned the films once more. The cancer was as he remembered-not huge but, in truth, indisputable. Biopsying the lesion would be technically simple, as would be its removal, provided there were no local lymph nodes with cancer in them. If the cancer had spread to the nodes-a part of the system draining foreign matter from the body-a meeting with the oncologist would be worth having to decide whether removing the lump or the upper outer quadrant of the breast would be statistically the best way to go.

Charles Newcomber was the radiologist who had read the mammogram, dictated his reading, and subsequently referred his patient to Susan. Emphasizing his title to the Excelsius Cancer Center operator, Will had no problem getting patched through to the man, who had a rather high-pitched voice and a fairly pronounced British accent.

“Dr. Newcomber,” Will said after introducing himself, “I’m here with a Mrs. Grace Davis, who had a set of mammograms that you correctly read as showing probable cancer.”

“Well, I’m certainly relieved at being deemed correct about such a thing.”

“Oops. I’m sorry, Doctor. I hope you know that’s not what I meant. I really do apologize.” Will expected the man to say something that would help ease his discomfiture, but there was only silence from the radiologist. “I. . um. . the problem I’m calling about is that you referred Mrs. Davis to Dr. Susan Hollister, who is one of my partners.”

“Yes?”

“Well, it turns out that Mrs. Davis and I have a history together that goes back more than ten years.”

“How sweet,” Newcomber said.

Will sensed his neck redden, but held his tongue in check. Newcomber was part of the Excelsius Health family. It was quite possible he was aware of the forum and its aftermath. Perhaps he had even been there.

“Dr. Newcomber, Mrs. Davis is here with me right now. She would like me to perform her surgery. I have spoken with Dr. Hollister, and she has no problem with the change.”

“I’m afraid that isn’t possible.”

“What?”

“Dr. Grand, first of all, this cancer center has an approved list of consultants from which we select a surgeon based on our patients’ hometown and any sexual preference. Dr. Hollister is on that list. You, sir, are not. Secondly, I have made it a point to personally get to know any surgeon to whom I make a referral. I don’t know you at all. If Mrs. Davis has a problem with that, I suggest she make an appointment to come in and share her concerns with me.”

Will could barely speak.

“Dr. Newcomber,” he managed, “who is your supervisor?”

“I am the supervisor, sir,” came the acid reply.

“Well, you’re not the boss!” Will shot. “And my name’s Grant, not Grand.”

He slammed the receiver down.

A call to information gave him the number of the headquarters of Excelsius Health. He and Boyd Halliday had mixed it up yesterday, and Will was more than ready for another go.

“There’s no way they’re going to get away with this,” he muttered as much to himself as to Grace.

“Excelsius Health, the leader in cost-effective, comprehensive health care. How may I direct your call?”

“This is Dr. Grant. Mr. Halliday’s office, please.”

“One moment.”

“Boyd Halliday’s office. May I help you?”

“This is Dr. Will Grant. May I speak with Mr. Halliday, please?”

“Dr. Willard Grant? From last evening?”

“That’s right.”

“Um. . just a moment, please.”

For nearly two minutes, Will sat with the phone pressed to his ear, listening to a Spanish flamenco guitar piece and looking across at Grace. Her transformation, while certainly remarkable, was not the only one of its kind he had encountered. Over his years as a physician and as a volunteer at the Open Hearth, he had known a number of alcoholics and drug addicts who had failed at rehab again and again, only to suddenly get it and become straight and sober forces for good in their own lives and the lives of many others. His own dentist had survived a horrible stretch of drinking, during which he was hospitalized more than two dozen times in a ten-year period. Now, twenty years into recovery, the man was something of a saint, practicing his craft with wonderful skill, while helping countless men and women in and out of his profession to face their demons and prevail.

“Dr. Grant?”

“Yes.”

“Marshall Gold here. Mr. Halliday is at an all-day conference. Is there anything I can do to help you?”

The time spent on hold had done nothing to help Will calm down. Barely pausing to breathe, he recounted the situation with Grace Davis and his disturbing conversation with Charles Newcomber.

“I am on the provider panel for both Steadfast Health and Excelsius,” he railed, “and so there is absolutely no reason to prevent me from caring for this woman-”

“Dr. Grant-”

“I promise you, if Boyd Halliday doesn’t intercede in this case and set matters straight, he’d better be watching the news and reading the papers, because I won’t hesitate to bring Grace Davis to them and-”

“Dr. Grant,” Gold repeated calmly.

“What?”

“We’re sorry for the confusion. We have no problem honoring Mrs. Davis’s request to switch to you for her surgeon.”

“You don’t?”

“No, sir.”

“But Newcomber-”

“The arrangement we have with Steadfast Health has, from time to time, generated some confusion. I’m sorry that you, of all physicians, on the day after the Faneuil Hall forum, of all days, have been caught up in it. Hopefully, in the very near future, Steadfast Health and Excelsius will be merging, and such misunderstandings will be eliminated altogether.”

The freight train of Will’s anger screeched to an immediate halt.

“You can speak for Halliday on this matter?”

“As I said, you are not the first physician to be caught up in this sort of situation. So long as you are a provider on our panel, which I most certainly know you are, you have been screened in depth by our credentialing committee and have been deemed to be a quality physician.”

“I. . well. . thank you, Mr. Gold. Thank you very much. Mrs. Davis will be very pleased to hear that.”

“Is there anything else?”

“No. No, I guess not.”

“Dr. Grant, I assure you, we are not the soulless, money-grubbing monsters you have worked so hard to portray us as.”

“Maybe you’re not,” Will replied distantly. He set the receiver down softly.

“So, I guess you’re my surgeon,” Grace said.

“I guess I am. I don’t know why I’m sitting here feeling like a jerk when I didn’t even do anything but stick up for our rights. The company made the offensive call, then the company took it away. It’s as simple as that.”

“It’s as simple as that, except that you have passion for your profession and your patients and don’t want to have that stolen away from you.” She stood and set copies of the morning’s Globe and Herald on his desk. “I’ll make an appointment for you to examine me and speak to me and my husband about what’s in store for us, and also to schedule the biopsy. With any luck, you’ll get to help save my life a second time. I’m not sure I subscribe to this one, but an ancient Chinese belief is that if you save someone’s life, you are responsible for that person and what she does with the rest of her life, having presumably cheated the fates out of an intended victim. If that’s really true, I would wager you have quite a number of souls on your plate.”

Before he could respond, she reached across the desk, briefly took his hand in hers, and was gone, leaving the faintest scent of something springlike swirling in the air.

Will checked the morning’s schedule once again. He still had ten precious minutes to review lab reports and dictations and to sign the stack of payment requisitions for those companies who refused to allow a rubber stamp, proxy, or any signature other than his in black ink. Two minutes into the ten, his private, direct line-the line reserved for family, close friends, and other physicians-began ringing.

“Dr. Grant?”

The voice was tinny-mechanical and robotic-the sort of distorted, disembodied, computer-generated voice that telemarketers were using more and more to announce that you had just been chosen to receive three free days and two free nights at one of Orlando’s newest resorts, or to ask you to call for the absolute lowest mortgage rates possible, even if you have been refused credit in the past. Only this call had come in on a number that none but the most dogged, resourceful telemarketing firm could ever have obtained. Will resisted the impulse simply to hang up.

“Who is this?” he asked.

“Is this Dr. Grant?” the totally creepy voice asked again.

“It is. Now, who is this? What do you want?”

“You did well last night, Dr. Grant. Very well.”

“Use your regular voice or I’m hanging up,” Will managed, though with less force than he had intended.

“All in good time. We are very proud of you, Doctor. Very proud. These companies have got to be made to pay for all those they have killed.”

Will sank back in his chair, stunned at the notion that this might be the one who had recently murdered three people. However, within just a second or two, his surgeon’s mentality kicked in and was demanding action. He snatched up a pen and wrote the caller’s words down as closely as he could remember.

“Are you responsible for the killings?” he asked, searching his thoughts for any other action he should be taking. Aside from staying focused and prolonging the conversation as long as possible, he could think of nothing. Along the margin of the paper, he wrote:

?Man?

?Woman?

Halting speech?. . On purpose?

We. . not I

We. . not I

Several times. .

“This is war,” the voice said. “In war people die. These corporations earn millions off the blood of the innocent. You implied as much last night. Now you are one of us. You are our brother in this war-a fellow soldier. If you need us, we will be there for you. If we need you, we expect your cooperation. Top drawer of your desk-back left corner. We are counting on you to deliver the message that we are engaged in a holy war to avenge the innocent.”

There was a click and, an instant later, a dial tone.

Will continued writing furiously until he was certain that most of the chilling diatribe was on paper. Finally, he scanned the transcript. His handwriting was deplorable under the best of circumstances and would have been the butt of office jokes had not Gordo Cameron’s been even worse. Carefully, he reprinted those words that were particularly illegible. Then, his palms unpleasantly damp, he pulled open the top drawer of his desk and peered down at the contents. In the back left, on top of the usual melange of letters, articles, notepads, photographs, prescription pads, paper clips, writing implements, and scattered surgical instruments, was a plain white business-size envelope with the flap tucked in, not sealed. Inside were two pieces of white index cards, each three inches square. A C was printed on one with some kind of marker. An N was printed on the other. Aware that he had done the wrong thing by touching the envelope at all, Will carefully replaced the letters and set the envelope back where it was in his desk.

Then, with an unpleasant gnawing in his gut, he slid Patricia Moriarity’s business card to the center of his blotter and called.