The Society

CHAPTER 7

Faneuil Hall had been a gathering place for the artists and intelligentsia of Boston for more than 250 years. Over that time, its grasshopper weathervane, still perched atop the building’s cupola, had become a symbol of “The Hub,” a city characterized by liberal thinking and more than 140 colleges and universities. Samuel Adams and other patriots once spoke beneath its roof, rallying the colonists to strike for independence from the British. None of the building’s history was lost on Will as he parked in a nearby garage, entered the first-floor market area, showed his ID to the guard blocking the stairway, and ascended to the second-floor meeting hall through a metal detector.

There were still nearly forty-five minutes to go before he and Boyd Halliday were scheduled to square off. A sign at the foot of the stairs, adjacent to the metal detector, announced that, for security reasons, ticketed guests only would be admitted beginning thirty minutes before the forum. Two managed-care executives shot to death, a third killed by a bomb. Speculation on the killer’s identity and motive was rampant, with most guesses leaning toward a disgruntled HMO patient or patient’s relative. There was some pressure from law enforcement to postpone the forum or to cancel it altogether, but in the end, it was felt that the second floor at Faneuil Hall was small enough for private security and the police to cover, and that the public was sick of bending to terrorist threats of any kind.

The meeting hall was inspiring-an elegant seventy-six-foot square featuring a thirty-foot-high ceiling and walls adorned with portraits of George Washington, Samuel and John Adams, and Daniel Webster, among others. Doric columns supported a three-tiered balcony running along the sides and back of the hall. Four hundred wooden folding chairs had been set out in neat rows. All would soon be filled. At the front of the hall was a stage and on it a draped dais with five name placards-Boyd Halliday, Excelsius Health; Marshall Gold, Excelsius Health; Roselyn Morton, Wellness Project; Thomas Lemm, MD, Hippocrates Society; Willard Grant, MD, Hippocrates Society.

Willard!

Could the forum possibly be off to a worse start, Will wondered. First, matters surrounding Grace Peng had eliminated his rehearsal time, now Willard. Will disliked the name as much today as he had the first time he was teased about it. He disliked it as much as he hated beets. He disliked it enough to have insisted that the shortened version be on all his diplomas and certifications, and had not changed it legally only because he had never gotten around to it.

“Why not William?” he asked as his mother was cleaning him up from yet another losing fight.

“Too common,” was her stock answer.

Then, when Will was eight, Willard, the story of a social misfit who raised rats to be killers, hit the movie houses. Three years of being called Ratboy honed his temper and fighting skills, and cemented his feelings.

Willard.

“So, I think we’re ready, yes?”

Will spun to the voice. Tom Lemm appeared calm enough. He was, as usual, conservatively dressed-dark suit, solid brown bow tie.

“Ready as we’re going to be.”

“I checked the PowerPoint stuff. It looks pretty darn good if I do say so.”

“PowerPoint always looks good. What we have is pretty dry, Tom.”

“Facts, not anecdotes. That’s what Jeremy said would win the day for us. I thought we agreed on that.”

“I suppose we did. Tell me something, how did they know my name was Willard?”

“No idea. Not from me, that’s for sure. You’ve always been Will to me. Why, is there a problem?”

“No. No problem. Who’s Marshall Gold?”

“Halliday’s business manager and right-hand man-sort of a data nerd, I think. I just met him for the first time.”

“I’ve never even met Halliday in person.”

“Well, thar she blows,” Lemm said, indicating a pair of men just to their left. “Let’s get the intros over with.”

Marshall Gold, late forties, close-cropped gray-black hair, gold wire-rimmed glasses, met them first and shook Will’s hand firmly.

“I’m pleased to meet you, Dr. Grant,” he said, perhaps maintaining his grip for an extra instant. “You have the reputation as quite an excellent surgeon. We’re happy to have you on our panel of provider physicians.”

“Thanks. Is that your job, the provider panel?”

“Along with the other duties that go along with being Mr. Halliday’s personal assistant. I understand you two haven’t met each other yet. We should take care of that right now.”

Will had seen some photos of the Excelsius Health CEO, but none of them conveyed the force of the man. He was slightly taller than Will, perhaps six-one, with dense, pure white hair, the weathered face of an outdoorsman, and eyes so intensely gray that Will wondered if he was wearing some sort of tinted contacts.

“So, Dr. Grant,” he said, impaling Will with those eyes. “After years of sniping at us in the press, you finally get the chance at an all-out frontal assault.”

Will was immediately en garde.

“I hadn’t intended any sort of assault, Mr. Halliday, just a dissemination of the facts as I know them.”

“Yes, of course, facts. That will be refreshing.”

That did it. Halliday had only one chance to make a first impression, and as far as Will was concerned he had used his poorly. They were enemies and would remain so until the man did something incredibly admirable.

“I had been led to believe that this evening was going to be a civil discussion of the issues,” Will said, feeling the heat in his face that used to follow being called Willard.

Halliday’s smile held no warmth.

“Dr. Grant, you are publicity director of an organization that is trying to hurt my company, if not put it out of business altogether. I intend to be civil with you only as it suits my purposes.”

“Well, well, well, I see that we’ve all gotten acquainted with one another,” Roselyn Morton gushed as she approached the four combatants.

She was a lusty woman, straight out of the society pages, meticulously coifed and wearing a form-fitting designer dress that aesthetically could have been a size larger, or even two. The four men introduced themselves and shook her hand, although it was clear to Will that she and Halliday had some prior connection.

Morton took several minutes to review the format of the evening, which she said was to be a brisk, issue-oriented presentation and discussion surrounding managed care. There was to be a fifteen-minute opening from each side, followed by ten minutes each spent addressing the points made by the other. Next there would be five questions for each team chosen by a Wellness Project committee from audience submissions, with a strict two-minute limit on the answers.

“If I tell either of you that time is up, I would like you to stop immediately,” she said. “Mr. Gold and Dr. Lemm may speak at any time, but the minutes they take will be counted against your side. Lastly, there will be five minutes for each team for summation. The side that goes first at the beginning will go last here. If all goes well, we’ll be done in an hour and twenty minutes. Questions?”

“Who goes first?” Will asked.

Roselyn Morton looked over at Halliday.

“Oh, I’m sorry, Dr. Grant,” Halliday said. “I was asked about this a couple of weeks ago, and said it was perfectly all right with me if your side went first.”

“Did Dr. Purcell know that?”

“I assume so.”

“Well, he didn’t say anything to me about it.”

“Gentlemen, gentlemen,” Morton pleaded, “supposing we simply flip a coin. Winner goes first. Dr. Grant?”

“Heads,” Will said, certain only that if Halliday wanted him to go first, there must be some disadvantage for him to do so.

“Heads it is,” Morton sang out.

From a spot beside the stage, Will and Tom Lemm watched the sellout crowd assemble. There were uniformed security people patrolling the main floor and up in the balcony, and Will knew there were police scattered about in street clothes as well. Reporters and cameramen filled the back of the hall.

“So, Will, what’s your take on Boyd Halliday?” Lemm asked.

“Clearly not a man who enjoys coming in second.”

“Do you?”

“I hope I don’t disappoint you, Tom, but my finish-first-at-all-costs phase caused me nothing but trouble and pain. Most of the time now I’m more than satisfied with just competing and trying my best, regardless of whether I win or not. In fact, except for in the OR, I think winning is often vastly overrated. Christ, is that the governor?”

“This is big stuff, Will.”

“Tell me again why I’m the one with the dueling pistol and you’re the second?”

“Because I’m dull and I can’t stand to lose. Listen, don’t worry. You’ll handle this guy fine.”

Jim Katz and his wife, Julia, entered with Gordo and his wife, Kristin. Behind them came Susan, who was unaccompanied but looked less drab and bookish than usual in a tweed wool suit. Cameron was the first to spot Will and pointed him out to the others, who smiled and waved. Then he left the group to give Will a bear hug.

“No kilt?” Will asked.

“Knowing your curiosity about what lies beneath, I dinna want to distract you. Are you ready for battle, Braveheart?”

“Gordo, the truth is this all sounded better when I said I’d do it than it does right now.”

“I can’t believe it. The lad is cool as kelp in the operating room, and here he is shaking in his boots.”

“I can’t help it if I’m allergic to humiliation.”

“Well, you better be entertaining. I told Kristin this was our night out for the month.”

“Hey, easy does it. I can’t handle any more pressure.”

“Well, then, make us proud.”

“I’ll try.”

“What’s this Willard thing?”

“A misprint.”

Roselyn Morton’s opening remarks were neutral enough, although at one point she did aver that excesses in the former system of fee-for-service health care gave birth to the need for major health-care reform, a conclusion that Will felt was debatable.

Wait! Will wanted to scream as he heard his introduction beginning. Wait, I’m not ready yet! I’m not ready yet! And for God’s sake, please don’t call me-

“Dr. Willard Grant.”

To polite applause, Will took the stack of notes he and Lemm had prepared, which included pages with the PowerPoint slides printed on them, and woodenly approached the podium. Clearly, he appreciated now, it would have been better to go second. With no idea what approach Halliday was planning to take, he would have to stick to the script he and Lemm had put together.

“It has been well over twenty years,” he began, “since the onset of myriad attempts to reform the fee-for-service delivery of medical care that many physicians grew up with. The current incarnation, an alphabet soup of various forms of managed health care, has pitted physicians and patients alike against insurance companies, physicians against other physicians, and even physicians against patients. There are lawsuits upon lawsuits, skyrocketing physician dissatisfaction, rampant early retirement, and an unprecedented malpractice crisis.

“Many managed-care programs feature coverage called capitation, in which primary-care physicians are paid a set amount to deliver care to a patient for a year. Any lab tests, X-rays, and specialist consultations are paid for from that up-front money. What remains at the end of a year is what the physician gets to use to pay the expenses of his practice and feed his family. The initial amount paid is hardly large, and primary-care physicians know they are in essence being paid to cut corners. If a doctor goes over the budget in his evaluation and treatment, the excess is his responsibility.”

Will glanced briefly at the audience for anyone nodding in sympathy and understanding with his points. If there were such people out there, he missed them. A few already seemed asleep. With the help of the PowerPoint tables and charts, Will illustrated that there are more uninsured now than there were before health-care reform began-more than forty million. He spoke of the more than 350,000 patients refused care in hospital emergency rooms last year because they couldn’t pay. He showed graphs comparing the per-patient cost in the U.S. versus countries with national health insurance, such as Canada and Great Britain. Careful to omit the three who had recently been murdered, Will listed the astronomical salaries and stock holdings of the top ten managed-care executives in New England. He was just halfway through his initial presentation when Roselyn Morton announced that he had one minute left.

Surprised and flustered, Will tried to sift through his notes to those facts he felt would have the most impact. What he succeeded instead in doing was to shove most of the sheets over the edge of the podium, where they floated to the floor like mutant leaves. For the first time since he began his presentation there was a reaction from the audience-a collective gasp, peppered with some sympathetic whispers and some not-so-sympathetic laughter. For a frozen moment, Will stood there, uncertain whether to go for his notes or to try and ad lib one or two final points. Instead, with a mumbled thanks, he scooped up the sheets and returned to his seat.

“You did great,” Lemm whispered.

“Did you like that little touch at the end? Inspired, I think.”

“Who hasn’t dropped something in their life?”

“I’m sure they’re all thinking that very thing, Tom, and not something like, He’s a surgeon?”

Boyd Halliday, smiling, strutted up to the microphone, his white hair glistening beneath the elegant chandelier.

“Rumor has it,” he began, “that the President is going to create a new cabinet post to oversee managed health care. However, Congress has insisted that the secretary he appoints will only be allowed to hold office for three days.”

Will groaned. Two seconds and the man had already won over the audience with self-deprecating humor. A minute later, Halliday switched on a film, possibly done by an Oscar winner, which made managed care seem responsible for everything that was good about America and American medicine. Where Will’s data was presented in PowerPoint, with a character occasionally moving aimlessly on the screen, Halliday’s film, Together We Can Make a Difference, used Disney-level animation and a score that had some in the audience tapping their feet. Where Will presented columns of statistics, Halliday showed smiling children and scrubbed Midwesterners, each relating a heartwarming account of how their managed-care company came to the rescue during their darkest hour. What statistics he did present had to do with unchanged maternal/child health despite strict HMO limitations on their hospital stay together, and patient satisfaction that exceeded surveys done when fee-for-service was the way to go.

Halliday’s final minutes were spent looking at cost savings for various medical conditions since the managed-care revolution. By the time he had finished, Will doubted there was a soul in the hall who wasn’t a believer in the man’s cause. Both Will and Lemm took notes for the rebuttal period, but there was so much flash and so little substance in Halliday’s presentation that it was hard to find any point on which they could gain much purchase.

You want to do this part? Will wrote on the legal pad before them.

You’re doing fine, Lemm wrote back. Just relax a little bit, and you will succeed.

If Will succeeded at anything over the minutes that followed, it was at not embarrassing himself any further. Rather than attempt to refute the glossy-but-vacuous picture painted by Halliday, he completed his factual presentation and added some of the data they had not included on the PowerPoint program. He felt a bit more animated, but the audience still seemed lost to his point of view.

Before taking over the microphone, Halliday held a prolonged, whispered conversation with Marshall Gold. For a moment, Will thought Gold might take over as a gesture of fairness to their thoroughly beaten opponent, but it was Halliday who again stepped to the mike. This time, the CEO of Excelsius Health took him on point by point in a structured, mechanical defense of the positions of managed care. Round two was much less of a defeat for Will and the Society than round one had been, but it was a defeat nonetheless. It had to have been bookish Marshall Gold who had so quickly and effectively organized Halliday’s rebuttal phase, and Will found himself grudgingly admiring the man.

The questions submitted by the audience and chosen by the Wellness Project panel were all softballs, which both Will and Halliday handled without a hitch, though also without doing any significant damage to the other. Will rated round three as a tie, but weighted it significantly below the first two in terms of impact. Time had just about run out.

Halliday’s summation was a nifty, professionally done PowerPoint show that made the one Will had presented look at best unimaginative.

Efficiency and cost-cutting are not the least bit incompatible with compassionate health care. .

While HMOs may at times not have an extensive choice of physicians, patients can rest assured that those we do select have been carefully screened not only for ability, but for a history of psychiatric, drug, or alcohol problems. .

Statistics have shown that our restrictions on length of hospitalizations have not compromised surgical outcome in the least. .

Statistics also show no change in morbidity or mortality even though we are paying surgeons less than they earned per case under fee-for-service. .

Smug son of a bitch, Lemm wrote on the yellow pad.

He has reason to be, was Will’s reply.

“Well, here are the notes for your concluding statement, Will,” Lemm whispered, handing over a stack of five-by-seven cards, some of which Jeremy Purcell had prepared. “I think this’ll be pretty good.”

Halliday concluded his remarks and returned to his seat accompanied by generous, appreciative applause. Will remained in his seat for several seconds after his name was called out. The night was nearly over, and in truth, from what he could tell, he hadn’t accomplished a damn thing. It wasn’t as if he had mortally wounded himself or the Hippocrates Society and its goals, but he certainly hadn’t helped to promote them, either. He carried the file cards to the podium, then took a few more seconds to scan the crowd. It was, he realized, the first time he had made any real contact with them.

Yes, of course, facts, Halliday had said. That will be refreshing. . Dr. Grant, I intend to be civil with you only as it suits my purposes. .

Suddenly, with barely a hint from inside himself that he was going to do it, Will took the stack of note cards and set them aside. Then he lifted the microphone from its stand and carried it to the side of the podium.

“Mr. Halliday has spoken a great deal tonight about statistics,” he began, with no clear idea where he was headed. “I took biostatistics in medical school. I was hardly a legend in the course, but I did pass. One thing I learned was that well-designed, truly meaningful, unflawed clinical studies are about as rare as. . as a day without dozens and dozens of conflicts between physicians of every specialty and the insurance companies charged with deciding what they can and cannot do for their patients, and how much they will be paid for doing it. Put another way, if you happen to be the person being shipped from one ER to another because your HMO doesn’t perceive your illness to be life-threatening, statistics that say you’ll make it through your crisis without dying don’t mean a hell of a lot.

“In addition to biostatistics, I also took a course entitled ‘The Art and Practice of Medicine.’ That one I did do quite well in. Basically, what we learned about in the art and practice of medicine was people-not the kind of actors we saw in that movie, scrubbed and healthy and happy, but people who are sick. . or injured. . or confused-real people often at the very crossroads of their lives. People like Roy, a ten-year-old boy hospitalized by his pediatrician for profound malnutrition. Fifty-four pounds he weighed. It took an extensive, delicate evaluation, but finally the diagnosis of anorexia was made-an unusual though not unheard of occurrence in a boy of this age. Tube feedings and intensive family therapy helped the pediatrician and psychiatrist and nurses to save his life. Imagine if this was your child and he had died. Imagine the devastation to the survivors. But doctors doing what they had studied and trained to do kept that nightmare from happening. The point? Well, through a clerical mistake, Roy’s discharge diagnosis was listed as anorexia, not malnutrition. Same boy, same illness, same miraculous outcome, different word. Alas, whereas the family’s HMO would have paid for the lifesaving hospitalization if the diagnosis was written as malnutrition, the bureaucrats who decide such things adamantly and forever refused to pay for anorexia-a diagnosis they considered psychiatric, and therefore not covered by the family’s plan.

“Recently, Karen, a registered nurse in a hospital not far from here, with fifteen years of unblemished service, committed a fatal medication error. An investigation concluded that she was exhausted and harried because corporate cost-cutting had left her floor woefully short of registered nurses, and she had been picking up extra shifts and performing extra duties on those shifts. Do you think she or the family of the dead patient want to hear about statistics and dollars saved by substituting LPNs and aides for RNs?”

There was no movement at all among the hundreds in the audience. No sound. Will cleared his throat, then took a sip of water. Seated in the center of the fourth row, Gordon Cameron made eye contact and almost imperceptibly nodded. Will plunged ahead, feeling like a halfback who had broken through the line and was now running free in the open field.

“Last week a fifty-three-year-old loving, caring internist by the name of Mark White was chastised and threatened by a non-MD managed-care official for ordering excessive diagnostic tests on his patients. That call was the final straw for this physician, who had never been sued, who did volunteer work at a free clinic, who was a past chief of medicine at his hospital, and whose filled-to-overflowing practice was as totally devoted to him as he was to it. He spoke briefly to his staff and to the patients in his waiting room. Then he put on his coat and left. . Quit. . Just like that. . Good-bye, Dr. White.

“A survey by the Western Journal of Medicine recently reported that the average primary-care physician spends forty minutes a day dealing with managed-care hassles, mostly around referral and prescription issues. Since there are around one hundred thirty-seven thousand primary-care docs with managed-care contracts, that translates into more than twenty-one million hours of patient-physician interaction lost to those hassles. Using the average three visits per patient per year, and an overly generous twenty minutes per visit, more than twenty-one million patients could have had access to a primary-care physician during the time those docs are now spending on managed-care issues.”

Will paused to let the notion sink in. He still had no clear idea how he was going to wrap things up, but he sensed that desperation had led him to the path he should have been traveling all evening-that medicine must be, at its core, always and ever, about each individual patient. He caught movement out of the corner of his eye, and initially thought that either Roselyn Morton was coming over to give him the hook or Boyd Halliday was about to turn the forum into a free-for-all. Instead, Tom Lemm approached and handed him a typed sheet.

“I think this might be just what you need,” he whispered.

Will scanned the paragraph and immediately understood.

“So, where does this leave us?” he asked the crowd. “Fee-for-service has been deemed too expensive, and managed care is too, well, managed. Under the one system, lots of doctors were felt to be making too much money. Under the other, managed-care executives are pocketing tens if not hundreds of millions, while searching daily for ways to further cut services and payments, as well as ways to weed out from their coverage those who are most in need of proper health care-the old, the infirm, and the poor. In Europe and Canada, nationalized health care has been at least as successful as the system we have in place. If nothing else, all of the citizens of those countries have access to care. Whether it is their system, or a hybrid of theirs with our own, changes are needed and needed desperately.

“I want to close with this note that we received at the Hippocrates Society and that my trusted cohort Dr. Tom Lemm just produced for me. It’s from a man who works in an auto-body shop north of Boston-one of those regular guys I was talking about. I seriously doubt we’ll ever be seeing Vic Kozlowski in any promotional videos. He doesn’t suffer from a dramatic, life-threatening illness. But believe me, Vic has something to say to all of us gathered here tonight. So here he is, in his own words.”

For emphasis more than any physical need, Will cleared his throat again and took another sip of water.

“I don’t think it’s really appropriate for my doctor to do, Vic writes, but every time I visit him he tells me about how the HMOs are dictating every move he makes and ruining his practice. Then he tells me he shouldn’t even be saying such things because he might get in trouble. It makes me so sad. He is a wonderful doctor, but he’s scared to speak up against the HMOs.

“It’s bad for me, too. I can’t get an antibiotic that I need because it’s not on the HMO-approved formulary, but the ones that are in there either don’t work or make me so sick they don’t stay in my body. So, if I do what’s best for me and get the medication that works, the payment is more than fifty dollars. Well, I don’t have to tell you that to a family of four with one income, that is a hard chunk.

“We already pay sky-high rates, and they keep rising while our copays keep rising as well. The bottom line is I feel I might as well be uninsured. The doctor doesn’t make me feel confident and the circle is never-ending. The patient is the butt of the whole thing. I truly believe that America is helpless. I am so nervous every time I get sick. This probably seems totally trivial to you, but believe me, most of the patients in this country feel the same way I do. Thanks for reading this.”

Will walked back around the podium and replaced the microphone. “And on behalf of myself, Dr. Lemm, and the Hippocrates Society, thank you all for caring enough to attend tonight.”

The huskiness in his voice was as surprising as it was unintentional.

Several silent seconds passed. Then the applause began, building like the sound of a river churning downstream toward a falls. Then, with Gordo leading the way, slamming his huge hands together, most of the crowd rose, cheering out loud. Thoroughly drained, Will nodded sheepishly and returned to his seat. Still the clamor continued. Roselyn Morton took the microphone and thanked the audience and participants, but it was doubtful anyone heard through the noise. The forum was over. Will sat for a time until he felt reasonably confident his legs would hold him, then descended the steps to the main floor, where he was mobbed. Gordo, Jim, and their wives hugged him. Susan squeezed him tightly and whispered something about his making the whole profession proud. Several members of the Society pumped his hand and said no one had ever done so much for their cause so quickly.

As the crowd began to disperse, Will’s attention was drawn to a woman standing off to the side, wearing tight-fitting jeans cinched with a heavy-buckled belt, a tan silk blouse, and a black vest. Her face was fascinating-vibrant and intelligent-with scattered freckles across the bridge of her nose and wide, emerald eyes that seemed possessed of their own light. For a time, she just stood there, eyeing him curiously until the last of the well-wishers had departed. Then, her gaze still fixed on him, she approached and handed him a business card.

“Please give me a call,” she said, punctuating the request with the tiniest wink.

Before he could speak a word, she turned and was gone. Her jeans highlighted an athletic, totally appealing behind. She moved with confidence and perhaps even a bit of swagger. Will watched until she had disappeared down the stairs. The vacuum she created in front of him was immediately filled by a few lingering fans, each anxious to tell him how his spontaneity and emotional sincerity had snatched victory from the jaws of defeat. When at last he was alone, the woman’s face still dominating his thoughts, he took a look at her card.

Patricia Moriarity

Detective Sergeant

Massachusetts State Police