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  “Before I present a couple of cases,” he began, “I want to say that advance ticket sales for our forum with Boyd Halliday of Excelsius Health are brisk, and we already may have sold out Faneuil Hall. When I’m finished, Tom has some announcements to make regarding that event, which is going to be held despite the recent managed-care murders.

  “As many of you know, my writing is about as dynamic as a snail derby. Thankfully, our committee has Randy Harrington, who continues regularly to submit wonderful letters to the editor and op-ed pieces to both papers as well as some suburban publications. This past month two of them have been published, one in the Globe. I hope you’ve had the chance to read them. If not, they are on our web site. Randy, could you take a bow?”

  Harrington, a slightly built pediatrician with a pediatrician’s penchant for colorful bow ties, did as he was asked.

  “Will Grant is a much better writer than he would have any of us believe,” Harrington said after the applause had quieted, “especially for a surgeon.”

  “Roughly translated,” Will replied, “that means I know several words with more than one syllable and own at least five books that don’t require crayons.”

  Tom Lemm laughed loudest of all.

  “So,” Will went on, “as you know, your crack publicity and public relations committee members are constantly casting about for stories we might submit to the papers or at least present to you all. Tonight I have two of them in which our friendly neighborhood HMOs combine medicine and mathematics to give the best possible care to their constituents.

  “A Newton psychiatrist writes: I admitted a twelve-year-old boy from orthopedics to our inpatient adolescent unit. He had bilateral ankle fractures sustained after jumping off the peak of the roof of his family’s garage. It was no challenge to diagnose the boy with major depressive illness and to conclude that his leap was a bona fide suicide attempt. I contacted the medical director of his HMO and requested a two-week hospitalization to do intensive family work in an attempt to provide him with a safer home environment, to initiate antidepressant medication, and to monitor his pain meds since one fracture needed to be repaired with an open reduction. I presented the case, including the mental-status exam, which was positive for a profoundly depressed mood, constricted affect, suicidal ideation, substance abuse, feelings of hopelessness and worthlessness, and sleep and appetite disturbances.

  “Now, tell me again, the HMO medical gatekeeper asked, how high was the building he jumped off?

  “What has that got to do with anything? This kid is hell-bent on killing himself. He needs at least fourteen days in the hospital.

  “I’ll ask you again—how high was the garage?

  “Two stories, I said. What difference does it make?

  “If it really was two stories, he said, I’ll give you two days of initial authorization.

  “Two days?!! So if it was three stories I’d get three days?

  “Two days is what I can give you. You can call back after that and request approval for more, but I can’t guarantee you’ll get them.

  “If this were your son, I’m sure your response would be different, I said. But, then again, he’d probably be dead by now, you Janus-faced bastard.

  “The gatekeeper hung up on me. Eventually I got a total of six days for the kid. In the lobby the day he was discharged, I heard his father call him a little jerk. The next day I submitted my resignation from the hospital and started looking for a nonclinical job. Thank you, managed care.”

  The ending, tragic though it was, brought sustained applause. The members’ exuberance was born purely of frustration. Every one of them had encountered similar, logic-defying bureaucratic stonewalling of the way they wished to practice medicine.

  “You had to have made this up,” someone cried out.

  Will shook his head.

  “I don’t have that kind of imagination,” he said. “These are real stories from real people. Okay, one more math-and-medicine case, this one a quickie from a surgeon in Worcester. Patient comes to see her with bleeding, horribly painful hemorrhoids. The guy’s done everything his family doc asked him to—soaks, suppositories, stool softeners, rubber donut. Finally, sleepless, in constant pain, bleeding through a pad, and unable to sit at work, he comes in for surgery. The surgeon dutifully calls for the HMO’s preapproval and is stunned to have the young voice on the phone ask how large the hemorrhoids are. Clearly the lad is parroting questions off a computer screen, the surgeon writes. What difference does it make how large or small they are, she asks, THEY’RE KILLING HIM!!! Just say you’ll pay for this man’s care and let me fix him up. Ma’am, I’m afraid I can’t do that, the kid says. I need to know the size of the hemorrhoids before I can approve payment for the surgery. Okay, okay, okay, says the surgeon—on the faculty at the medical school, incidentally—the guy’s hemorrhoids are roughly the size of Nebraska. The lad making medical decisions for his HMO over the phone thinks for a few seconds, fills in the blank on his screen, then approves the procedure.”

  The laughter this time was heartfelt, but also a bit edgy. Having medicine practiced over the telephone by HMO MDs or, even worse, non-MDs was a constant sore point for most of the Hippocrates Society members.

  “That’s it until next month,” Will said. “Back to you, Tom.”

  Lemm returned to the podium and silenced those who were still buzzing over Will’s cases.

  “One last piece of business,” he said. “As many of you know, Jeremy Purcell, who was to champion our cause at next week’s forum, has had emergency bypass surgery. He’s reasonably stable at White Memorial but has been absolutely forbidden to participate in the debate. We can’t back out of the deal, so we need to select someone who can face up to Boyd Halliday. Jeremy has promised to make his notes and slides available and to spend time coaching whomever we choose. As a last resort, I will do this, but you all know as well as I do that I am a plodder—a behind-the-scene type of guy. I’ll help, and even sit beside our champion, but we really need someone with more panache than I have, someone with just the right balance of intellect, passion, and humor.”

  Will, focused approvingly on Lemm’s words more than on the man himself, suddenly realized that the Society’s president was staring directly over at him. Before he could react, an internist from Springfield had waved his hand and shouted out, “I nominate Will Grant!”

  “Second!” a dozen voices rang out.

  “Third!” someone yelled.

  “Fourth!”

  Lemm waved the members to quiet down.

  “Will,” he said earnestly, “I know you must be feeling like you’ve been set up. Well, I am here to assure you that you have.” Laughter. “Calm down! Hush up, please, all of you. I’m sorry, Will. I apologize for making light of this. And seriously, it was Jeremy who suggested you as his replacement just yesterday, and the executive committee agreed. I know there’s not much time for preparation, but we will help you in any way we can, and if you want me, I’ll be right up there on the stage beside you as your aide-de-camp.”

  There was absolute silence throughout the auditorium.

  Will sighed. He knew he desperately did not want to publicly debate the flamboyant president of Excelsius Health. He also knew that he couldn’t say no to the Society.

  “I’ve been humiliated and utterly degraded before,” he said without leaving his seat. “I suppose that means I’m well prepared for an encounter with Boyd Halliday.”

  “Will . . . Will . . . Will . . . Will,” someone began chanting, as if they were ringside at a prizefight. One hundred and forty joined in.

  “Will . . . Will . . . Will . . . Will.”

  “There being no further business,” Lemm shouted out over the din, “I’ll see you all at Faneuil Hall. Nice job, all. Meeting adjourned.”

  Of all the dumb things, Will thought, as he drove out through the largely deserted parking lot. You are no more equipped to match up with Boyd Halliday than you are to bat against Pedro Martinez. He pulled of
f to the side of the road, set his palm pilot on the wheel, and called up Tom Lemm’s cell phone number. Lemm would just have to do it. Before he could dial, his own cell began ringing.

  “Dr. Grant?” a woman’s voice asked.

  “Yes.”

  “This is Ellie Newell. I work in the comptroller’s office at the hospital. Mr. Davidson is my boss. I called him about this, and he called Mr. Brodsky. Apparently, Mr. Brodsky told him you would want to hear what’s just happened.”

  Seth Brodsky was the longtime CFO of Fredrickston General.

  “What’s this about?” Will asked.

  “It’s about your patient, John Doe, in the ICU.”

  “He’s not John Doe anymore. He just woke up and told us his name. It’s Langley, Jack Langley from Des Moines, Iowa.”

  “Yes, I know,” Ellie said. “I just spoke to his wife.”

  “You did?” Will had called Marybeth Langley just a few hours before.

  “I also spoke with an officer at Midwest Industrial Care, the HMO that covers the Langley family.”

  “And?”

  “Dr. Grant, correct me if I’m wrong, but it seems Mr. Langley is still facing a long hospitalization.”

  “If there are no serious setbacks, he is. The man was essentially dead when he was brought in. It’s a miracle he’s alive at all. I would guess ten more days. Maybe even two weeks.”

  “His bill already—counting, among other factors, the cost of the ER, the OR, the surgical team, the recovery room, the ICU, and a number of consultants—is in excess of forty-five thousand dollars.”

  “I’m not surprised.”

  “Well, Midwest Industrial has flatly refused to pay anything and will not pay for any subsequent care.”

  “That’s ridiculous. What reason did they give?”

  Ellie Newell hesitated.

  “Well,” she said, “the insurance company has a strict policy regarding all surgery. No coverage unless the procedure is preapproved by them or approved within twenty-four hours.”

  “But the man was in a coma!”

  “I know.”

  “How can they do this?”

  “Mr. Davidson told me that you of all doctors wouldn’t even bother asking that question—that you’d already know the answer.”

  Will felt himself deflate.

  “You know, Mr. Davidson is absolutely right,” he said. “He’s absolutely right. Thanks for calling me.”

  Will ended the call, then called Tom Lemm.

  “Tom, it’s Will.”

  “Hey, I hope you’re not upset with me for the way I railroaded you back there. Desperate situations call for desperate measures.”

  “No problem,” Will replied. “I was just calling to see if we could get together tomorrow. We’ve got a lot to do before next week.”

  CHAPTER 6

  Marybeth Langley was a petite, energetic woman with a sweet face and manner. For the week since Will’s call, she had been spending nights in a small B&B in downtown Fredrickston and days at the bedside of her husband, Jack. Despite the persistent refusal of their HMO to pay for any of Jack’s surgery, consultations, or hospitalization, she and her husband had decided to remain at FGH and under Will’s care until it was medically appropriate for him to return to lowa. Finally, that time had arrived.

  It was mid-afternoon on a chilly, gray Thursday, the day of the Faneuil Hall managed-care forum. Will had repaired an electrician’s painful hernia in the morning, then worked his way through a reduced office schedule. He wanted to leave at least an hour for a final review of the mass of notes and articles he had accumulated regarding the shortcomings of managed care—especially Jeremy Purcell’s insights and strategies. Throughout college and medical school, Will never took an exam that he felt truly ready for, but never had he felt as ill-prepared for anything as he did for this debate. Saying yes to Tom Lemm and the Hippocrates Society was certainly noble enough, but it was evolving into one of the dumbest, most impetuous things he had ever done. He reminded himself for the hundredth time that he could only do what he could do, and then turned his attention to discharging his prize patient. The titanic struggle the two of them had endured together had forged a friendship that went well beyond the usual doctor–patient relationship.

  “So, Jack,” Will said, “it looks like this is it.”

  “Looks like.”

  Langley had proven to be a bright, well-read man—a laconic Midwesterner with a subtle sense of humor, who listened to country-western music almost around the clock and loved his job selling heavy machinery, although his life’s dream had once been to become a veterinarian. The pictures of and by Langley’s kids had been taken down and packed. Nurse’s discharge instructions had been checked over by Will, then given. Langley, dressed in chinos and a loose-fitting Kansas City Royals sweatshirt, was seated in a wheelchair, the required mode of transportation for discharge.

  For nearly a minute, nothing was spoken. Will, distracted momentarily from the impending forum, was trying to remember when he had ever felt so good about a case. Jack Langley was alternating between projecting what it would be like to hold his kids again and wondering when he would be able to return to work.

  Marybeth, deeply religious, was processing her overwhelming gratitude for the droll, soft-spoken, surprisingly unassuming man who had saved her husband’s life, and thanking God that there were men and women in the world who could do what he had done for their family. She knew very little of him except that he was divorced and had two children, and that her husband, in his understated Midwestern way, absolutely adored him. Silently, she prayed that life was treating him well. Earlier in the day Will had quite casually mentioned that he had arranged for himself and all of the consultants to rub their charges off the massive balance sheet she and Jack were facing. She took a wad of tissues from her purse and dabbed at the corners of her eyes.

  “So,” Will said finally, “you’ll keep in touch?”

  “Of course.”

  “And you’ll have your doctor call me straight off if there are any problems?”

  “I don’t expect there’ll be any—not any medical ones, anyway.”

  Will sensed a fullness building in his throat. He had never had that much reserve about crying in public, but this just wasn’t a time he wanted to.

  “I heard some interesting news last night,” Marybeth said, as if sensing Will’s predicament. “I was talking to my cousin Peggy. She lives in a suburb of Des Moines. She was telling her friend Claire about what was happening to us with the HMO refusing to pay and all. Well, it turns out Claire used to work as a claims adjuster for that same HMO. She says that she and the others who worked her job were instructed by the company to reject one out of every ten claims out of hand. Don’t even bother to come up with a reason, just reject it. It seems the company had tried this approach to saving money and found that only thirty percent of the rejected claims were ever contested by the doctors. They just didn’t have the time or resources to battle over such things.”

  “Lord. I’d like to say I’m surprised and stunned, but I’m not. In many instances, the cost involved in disputing an HMO decision makes it not worth it. I’ll make sure our hospital isn’t one of the seventy percent in this case, but I hope you’re planning on fighting this, too.”

  “My cousin Pam’s husband is a big-time attorney in Des Moines,” Marybeth said, “as well as being one of the most obnoxious people on the planet. I’ve already spoken to him. He says he specializes in making people wish they had never crossed paths with him.”

  “That’s quite a specialty. Well, Jack,” he said, taking the man’s hand in his, “you’ve been one hell of a patient. I don’t throw around the term hero very frequently, but you are certainly one of mine.”

  “And you’re certainly one of ours,” Marybeth said. Not waiting for a handshake, she threw her arms around Will’s neck. “Thank you, Doctor,” she whispered in his ear. “Thank you for saving my husband’s life.”

  Dr. Jeremy Pu
rcell hadn’t been nearly as much help as Will had expected. For one thing, some pneumonia and a urinary-tract infection from the catheter were keeping him down. For another, his notes, while impressive in volume and scope, were not that well organized or easy to read. With Tom Lemm’s help, they had put together a reasonable, albeit dry, presentation. They even had a PowerPoint production of sorts, although it would never win any prizes for flair.

  Anxious to get in some final rehearsal, Will hurried back to the office, where he had left the carton full of notes, articles, and slides in preparation for the trip into Boston. He was Custer, riding off to inspect the troops, only this time he knew what Little Bighorn held in store.

  Fredrickston Surgical Associates occupied most of the second floor of the Medical Arts Building. The airy central waiting area was half full. On a Thursday, they would be Susan’s and Gordo’s patients. Will felt relieved knowing that none of them was his. He still had an hour or so to review before making the thirty-five-mile drive into Boston.

  “We’re all excited about tonight, Dr. Grant,” the receptionist said.

  “Are you coming, Mimi?”

  “Once we knew you were going to be part of it, my husband and I tried getting tickets, but there are none. It’s a sellout.”

  “You might be just as well off staying home together and watching professional wrestling. The guy Halliday who will be representing managed care has been preparing for months. I’ve had a week.”

  “Oh, Dr. Grant, you’ll do great.”

  “I wish I had your confidence.”

  “Just tell them all what goes on around here with all the paperwork and delayed payments and grumpy patients.”

  “I may do that.”

  “Excuse me, Dr. Grant?”