A
t 9:30, Malachi Ross was in his office, in his leather Eames chair, a cup of coffee grown cold on the glass table in front of him. Across from him, in his wheelchair, a yellow notepad on his lap and a tape recorder next to Ross’s coffee, sat Jeff Elliot. Through the vertical blinds, Ross was looking past the reporter, out over downtown from the seventeenth floor. But he noticed neither the lights of North Beach dancing below him nor the stars clear in the wind-swept sky above. He hadn’t eaten since breakfast, yet felt no hunger.
They’d been at it for almost a half hour, and Ross had brought the discussion around to himself, his background. How he’d joined the Parnassus board as a doctor whose original job was to provide medical legitimacy for the company’s profit-driven business decisions. This was back in the first days of aggressive managed care, and Ross told Elliot that he had come on as the standard-bearer for designating a primary care physician, or PCP, for each patient as the gatekeeper of the medical fortress, a concept which by now had pretty much become the standard for HMOs everywhere in the country.
“But not a popular idea,” Elliot observed.
Ross came forward in his chair and met the reporter’s eyes. “Give me a better road and I’m on it tomorrow,” he said. “But basically it works.”
“Although patients don’t like it?”
A resigned shrug. “Let’s face it, Mr. Elliot, people are hard to please. I think most patients appreciate the efficiency, and that translates to satisfaction.” He wanted to add that in his opinion, people were overly concerned with all the touchy-feely junk. The body was a machine, and mechanics existed who knew how to fix it when it broke. The so-called human element was vastly overrated. But he couldn’t say that to Elliot. “It’s really better for the vast majority of patients.”
“And why is that?” the reporter asked. “Doesn’t it just remove them from any kind of decision loop?”
“Okay, that’s a reasonable question, I suppose. But I’ve got one for you, although you won’t like the sound of it. Why
should
they be in it?” Again, he held up his hand, stopping Elliot’s response. “It’s hard enough to keep this ship afloat with professionals who know the business. If patients had the final say, they’d sink it financially. Now I’m not saying we shouldn’t keep patients informed and involved, but—”
“But people would demand all kinds of expensive tests they don’t really need.”
Ross smiled with apparent sincerity. “There you are. Healing takes time, Mr. Elliot, and you’d be surprised at how many health problems go away by themselves.”
He stood up and went over to the small refrigerator at the corner of the room and got out a couple of bottled waters. He gave one to the reporter and sat back down.
“Look,” he said, leaning forward and speaking, ostensibly, from the heart. “I know this must all sound pretty callous, but nobody’s opposed to losing the money on tests if they’re necessary. Hell, that’s what insurance is all about, after all. But if
fifty
guys show up month after month, and each one gets his test when only five really need it, then instead of Parnassus losing twenty-five grand, which is covered by premiums, we lose a quarter mil. To cover that, we’d have to increase premiums and copays by a factor of ten, which nobody can afford. So the whole system falls apart, and no one gets any health care.”
Elliot drank some water. “But let’s say out of the fifty guys who want their tests, ten in fact need them. Not five. What happens to them?”
“They get identified, Mr. Elliot. Maybe a little late, which is regrettable. Nobody denies that. They’re tough choices, I admit. I personally wish nobody had to go through any pain ever, honest to God. That’s why I became a doctor to begin with. But it’s my job now to keep this ship afloat, and if we tested every patient for everything they wanted as opposed to everything they truly needed, we’d sink like a stone, and that’s the cold, hard truth. Then nobody would get any tests because nobody could afford them. You think that would be better?”
“Let me ask you one,” Elliot replied. “I’ve heard a rumor you haven’t paid some of your doctors. Would you care to comment on that?”
Ross kept on his poker face, but Elliot’s awareness of this fact startled and worried him. He also thought he knew the source of it—the always difficult Eric Kensing, who’d admitted Baby Emily and then, he suspected, been Elliot’s source on the breaking story. But he only said, “I don’t know where you would have heard that. It’s not accurate.”
This evidently amused the reporter. “Is that the same as not true?”
Ross sat back in an effort to appear casual. “What we did was ask our doctor group to loan a sum to the company, with interest, that would come out of the payroll reserve. It was entirely voluntary and we’ve paid back everyone who’s asked.”
Jeff Elliot had been sitting listening to Malachi Ross’s apologies and explanations for over an hour. Now the chief medical director was talking, lecturing really, about the rationale for the Parnassus drug formulary, maybe hoping that Jeff would spin the self-serving chaff into gold in his column, get some PR points for the group in Ross’s coming war with the city.
“Look,” Ross said, “let’s say the Genesis Corporation invented a cancer-curing drug called Nokance. The budget to research and develop the drug and then shepherd it through the zillions of clinical trials until it got FDA approval comes in at a billion dollars. But suddenly, it’s curing cancer and everybody wants it. Sufferers are willing to pay almost anything, and Genesis needs to recoup its investment if it’s going to stay in business and invent other miracle drugs, so it charges a hundred bucks per prescription. And for a couple of years, while it’s the only show in town, Nokance gets all the business.
“But eventually the other drug companies come out with their versions of Nokance, perhaps with minute variations to avoid patent disputes—”
“But some of which might cause side effects?”
A pained expression brought Ross’s eyelids to half-mast. “Rarely, Mr. Elliot. Really. Very rarely. So look where we are. These drugs also cure cancer, but to get market share, they’re priced at ten bucks. In response, Nokance lowers its price to, say, fifty dollars.”
“That’s a lot more than ten.”
“Yes it is, and you’d think that once we educate people, tell them all the facts, everybody would stop using it and go for the cheap stuff, wouldn’t you?”
“They don’t?”
“Never. Or statistically never. Given the choice, the patients almost always choose Nokance. It’s the brand name people recognize. There’s confidence in the product.”
“Like Bayer aspirin.”
“Exactly!” Ross silently brought his hands together, as though he was applauding. “So—and here’s the point—although it costs us forty dollars more
per scrip
to supply the Nokance, if we approve it and keep it on the formulary, it costs the patients the same amount it always has, which is ten bucks, the drug copay. So we delist it.”
“The Nokance?”
“Right.”
“But—this is still hypothetical now—you’re saying it’s good stuff and you don’t let your patients get it.”
“They can get it, but we won’t pay for it. If we did, it would wipe us out. We’re dealing with extremely small margins for the survival of the company here. You’ve got to understand that. The point is that Nokance isn’t the only stuff that works. That’s what I’m trying to get through to you. The generics do the job.”
Elliot had his own very strongly developed ideas about drug formularies. He had been suffering from multiple sclerosis for over twenty years, and on the advice of his doctors, he sometimes thought that he’d tried all the various generics in the world for his different and changing symptoms. Not invariably, but several times—at least enough to have let him develop a healthy skepticism—he’d experienced side effects or discomfort with the generics. When he’d gone back to the brand name, the problems vanished. So Ross would never sell him on the universal benefit of generic drugs.
“So just to be clear on your position,” Elliot said, “your view is that this gatekeeping and cost cutting, from managed care to generic drugs, is essentially consistent with your Hippocratic oath, for example. Where the emphasis is first to do no harm, then to heal.”
“Basically, yes.” Ross seemed pleased with this take on it, but Elliot knew he wouldn’t be for long. “We’re in medicine, Mr. Elliot,” he continued. “The goal is maximum wellness for the most people.”
“And there’s no conflict between your business interests and the needs of your patients?”
“Of course there is.” Ross was leaning back in his chair comfortably, his legs crossed. “But we try to minimize it. It’s all a matter of degree. The company needs to sustain itself so it can continue doing its work.”
“And also make a profit, let’s not forget. You’ve got to show earnings, though—right?—to please your investors?”
Ross smiled and spread his hands in a self-deprecating way. “Well, we’re not doing too well at that lately.”
“So I hear.” Elliot came forward in his wheelchair, spoke in a friendly tone. “Do your investors ever express displeasure with the salaries of your officers and directors?”
Ross blinked a few times, but if the question bothered him, he covered it quickly. “Not often. Our board members are skilled businesspeople. If the pay weren’t competitive, they’d go elsewhere. Good help is hard to find, and when you find it, you pay top dollar for it.”
“And this good help, what does it do exactly? Run the company?”
“That’s right.”
“And yet you’re close to bankruptcy.” It wasn’t a question, but Elliot let it hang for a beat. “Which makes one wonder if lesser-paid help could do any worse, doesn’t it?”
Fisk and Bracco may have come across as a matched pair to their fellow homicide inspectors, but they really couldn’t have been much more different from each other as human beings. And this meant they were different kinds of cops, too.
When it got to be five o’clock, Harlen Fisk asked his partner if he’d drop him off at Tadich’s, the city’s oldest restaurant. In spite of his pregnant wife and baby boy waiting at home, he’d be meeting his aunt Kathy and several of her supporters for dinner and schmoozing well into the night. He didn’t invite Bracco to join them, and there were no hard feelings either way. The fact was, Fisk was a political animal with his eye someday in the distant future on political rewards.
By contrast, Bracco was the son of a cop, but even so, until he got the promotion to homicide, he hadn’t clearly understood how much his father’s connection to the mayor was affecting his career, how much the regular guys resented him. And he’d never asked for special treatment—it had simply come with the territory. Political people in the department thought they could make the mayor happy by being nice to the Bracco boy, and they weren’t all wrong.
But when Fisk had told him that he was thinking about going to his aunt, the city supervisor, to complain about their continued ill-treatment on the fourth floor, Bracco had talked his partner out of it. One thing he’d learned from his father was that cops didn’t whine. Ever. The thing to do was talk to Glitsky, he’d said. Ask straight and deal with the answer, which was that there was probably no intentional homicide here with the hit and run, and hence nothing to look into.
Bracco believed that this was the truth. But what else was he doing with his time?
So after he dropped Harlen off downtown, he spent a few hours checking leads that they’d picked up on the car during the course of the day. He didn’t expect any results, but you never knew. His experience in hit and run had taught him that most of the time, the drivers would wait until they thought nobody was looking for their car anymore. They’d park it out of sight, keep the garage door closed. After a month, they would take it to a car wash or body shop. And that would be the end of it.
But maybe this time—long odds, but possible—it would be different. They’d gotten eleven patrol call-ins during the day. These were vehicles fitting the description that were parked at the curb or in driveways around the city, reported by patrolling cops. Fisk hated this kind of legwork. Bracco, on the other hand, put in a couple of hours checking out each and every one. The impact that had thrown Markham would have left a sign even on an old, thick-skinned American car, and a quick walk around with a flashlight would tell him if he would need to come back with a warrant. But none of the cars had anything close.
Not exactly knowing why, he killed another half hour walking through the parking garage at Portola Hospital, but there wasn’t one old green car. So, feeling like an idiot, he sat in his car and wrote some notes to jog his memory tomorrow—check the Rent-A-Wrecks, don’t forget the call-ins to H&R from citizens interested in the reward from the supervisor’s fund (ten thousand dollars for information leading to the arrest and conviction, et cetera).
Finally, on his way home after a piroshki gut-bomb he bought at a place on Nineteenth Avenue, he decided to head back up to Seacliff, to Markham’s house. Start, as Glitsky said, with the family. Look at the cars parked outside. After all, he reminded himself wryly, he was the car police.
“Can I help you?”
Bracco straightened up abruptly and shone his flashlight across the hood of the white Toyota he was examining. It was the last one of what had been twenty-three cars parked on Markham’s block. The beam revealed a man of above-average height, who brought a hand up against the glare, and spoke again in a harsh, strained voice. “What the hell are you doing?”
Bracco noted with alarm that he was reaching into his jacket pocket with his free hand. “Freeze. Police.” It was all he could think to say. “Don’t move.” Bracco didn’t know whether he ought to flash his badge or draw the gun from his shoulder holster. He decided on the latter and leveled it at the figure. “I’m coming around this car.” His blood was racing. “Don’t move one muscle,” he repeated.