“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 a
fter 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.
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