* * * *
Fernandez wasn’t in his office. His secretary, dressed like Elvira, thought he’d gone home but wasn’t sure and obviously didn’t care.
My tactical plan exhausted, I decided to head home myself for an early dinner and movies with Doug’s boys. I rescued my coat, which wasn’t any drier, except now it smelled bad and hung on me like a wrinkled foreskin.
I peeked into emergency on my way out. I immediately wished I hadn’t.
Sylvia Green’s eyes were brimming with tears. The nurses went quiet at my entrance. Everyone focused on the floor. It was embarrassing. I waited. No one spoke. Sylvia started to look more mad than tearful, and for that I was grateful. But it was clear that I had to be the one to break the silence.
“Okay, everyone, what the hell is going on?”
The nurses looked at one another, but still no one said anything.
I turned to Sylvia. “Syl, are you all right?”
She looked at me and decided on angry. “No, I’m not all right!” she answered, her eyes flashing. Wrenching a chart off the wall, she strode down the hallway to her next patient.
The silence only got worse after she left.
“Look, I need to know what happened.”
Lisa Gray, sheepish, offered, “It’s the killings.”
“What do you mean?”
She glanced at her friends for support. They continued to keep the floor under observation. Nevertheless, she went on. “Those two detectives, they got us all in a room and started asking a lot of questions.”
Everybody got more intent on studying the floor, and I got angry. “What the hell’s going on here?”
Silence.
“Lisa!” It was a plea.
“Okay. But promise you won’t be mad.”
“Lisa!” More like an order this time.
“Okay, okay! Like I said, they asked a bunch of routine questions. You know, how we work, how the shifts are arranged.” She shrugged. “They asked about the doctors. At first it was innocent, how you guys work your shifts, who works when ... that kind of stuff. Then they wanted to know who was really good with procedures, lines, that kind of thing.”
“ ‘That kind of thing’ include intracardiac injections?”
“Yes, but we didn’t know they’d use any—”
“And you gave Sylvia’s name.”
“Well, you know how good she is,” Lisa said defensively. “We’re proud of her.”
“Any other names you were proud of?”
“A few.”
“Oh, Jesus, who?”
She hesitated.
“Lisa!”
“Popovitch, Kradic, Jones, and”—she took a breath— “and you.”
Now I knew what had been bothering Susanne.
“It’s okay about me. They’re not interested anymore, but do the others know of the high honor you’ve accorded them?”
“No, just Sylvia.”
“Why?”
“I guess she’s the only one they questioned.”
“Questioned! Here? While she was on duty?” I knew the interviews would be scheduled at the convenience of the police, but I’d naively assumed they’d start with off-duty doctors and conduct the sessions in private, not ambush a doctor trying to run the ER at the same time.
“No, not here. They took her to their interview room before her shift started. She told us what they asked about when she got back. That’s the worst part—they asked about her mother’s death.”
I couldn’t have heard right. “Her mother’s death?”
She nodded, and the incredulity of the other nurses matched my own.
A year ago her mother had been admitted over Christmas with severe flu and aggravated heart disease. She’d come in with acute respiratory distress, cardiac failure, and chest pain. She was eighty-seven, and we prepared for the worst. To our surprise, she recovered and went home in a couple of weeks. Two days after that, she collapsed at home in acute pulmonary edema and arrested in the ambulance on the way back to the ER. When she got here, it was too late.
It wasn’t that anyone had been negligent on discharge, but more could have been done. An echocardiogram to better assess the function of the heart and the use of an ACE inhibitor to reduce the load on the heart were options available but not taken.
The echo had a waiting list from budget cutbacks. The additional medication simply hadn’t been thought about at the time.
While neither omission was cause for a lawsuit, Sylvia had been bitter. I’d held her hand while we sat together in the nursing station. She’d told me how her family had been prepared for her mother’s death but gained hope again when she’d recovered, been discharged, and seemed to have beaten the odds.
At that moment Kingsly had gone stumbling by. Sylvia had looked at his lurching backside and started to sob. “That’s the son of a bitch who cut the very echo time that might have made a difference. Maybe I could have had her a while longer. Just a little while.”
I’d been unable to say anything then. Now I was furious that this moment would be used against her. And how did they know?
I spun out of the room and went down to the examining cubicle, where I found Sylvia dutifully preparing to repair a gaping facial cut on a young girl.
I waited until she finished replacing a dressing pad, then excused myself to the patient and led Sylvia out to the hall.
“Syl, I’m furious. Those cops were way out of line!”
“Damn right they were.”
I put my arm around her shoulder and gave her a hug. “Listen, for what it’s worth, I’ll scream bloody murder to stop those jerks from harassing you and any of us around here.”
She looked a little mollified. “Us?”
“Yep, they’ve been on my case since Monday. At least they were until someone tried to run me over yesterday.”
“Oh my God! I thought it was an accident. Who was it?”
“I’ve no idea.”
A slow, sardonic smile transformed the horrified expression on her face. “If that’s what it takes to get clear, I’ll settle for staying on the list”
“I need to ask you something. When your mom died, who else did you mention Kingsly cutting the echo time to?”
Her mouth became a hard, thin line before she spoke. “Hurst!” she snarled.
* * * *
I only half heard the PA as I walked out of the building. A code 44 was being called for nine west. Nothing unusual, a code 44 means a psychiatric disturbance and brings a gang of orderlies to restore peace, one way or another. I hear it announced a dozen times a day and never really pay attention.
It was 5:10, and the parking lot was already dark. In the distance, low rolls of thunder mixed with the drone of commuters heading home. The resultant grumbling noise made this daily evacuation seem more desolate than usual. The air was something to be chewed before breathing.
Lightning danced up the hospital walls, then left them invisible again in the black, but not before I glimpsed a lone bowed figure, like a cathedral gargoyle, on the roof of the west wing—the wing that had only eight floors.
Nine west was the roof.
The next flash caught a huddle of white figures creeping up behind the figure in the dark suit. In the dying illumination I saw the man step forward as calmly as if entering an elevator. The return to black enveloped his drop, but not even thunder could mask the wet, soft thud of his impact on the pavement ahead of me.
Fluttering down after him in the soft descent of a wounded cardinal was a wisp of scarlet. A flicker of lightning caught its brilliance until it landed and disappeared in the spreading ooze of mud and blood.
Chapter 13
The chief of psychiatry leaping off the roof of his own hospital was the lead story in all Buffalo’s TV, radio, and newsprint media. Even the trashy tabloid
Police News
out of New York City, which usually focused exclusively on their own body count, led off page three with a wire photo of poor Gil’s remains—only the feet poking from under a sheet, of course.
“Psychiatrist Jumps!”
“Suicide!”
“Killed!”
The stories underneath contained a spatter of quotes.
“He’d seemed distracted lately.”
“He’d stopped caring about how he dressed.”
“He hadn’t looked well recently.”
Now everyone was saying they’d known something, but no one had done anything. In medical circles we called it the retroscope, perfect hindsight.
I couldn’t read the stories. I kept imagining that moment when his brain was still cognizant of onrushing cement and inevitable death was milliseconds away. Was there time for a final no?
Immediately the media recounted the details of Kingsly’s murder they’d been reporting for nearly four days. Most of them hinted at the possibility of a connection between the two deaths and left the question tantalizingly up in the air. There was no mention of embezzlement so far, but it would be a while before our story even got off the front page or was relegated to the end of a newscast.
We buried Dr. Gil Fernandez that Sunday, and with him, Bufort buried his murder investigation.
The cemetery was a large green oasis around which the rest of the city sprawled. Covered with trees and slopes of mowed grass, it would have been the perfect place for families to have picnics—except there were a few centuries’ worth of tombstones. Rich and poor, black, brown, and white, people whose ancestors had come from far continents; all lay at peace together. It was the inverse of the American ideal—men and women equal in death, not quite having managed it in life.
The questions I’d not had the chance to ask Fernandez thudded into my thoughts with each ritual toss of earth on the closed casket.
Was the money in the unexplained account that Bufort found actually the surplus that Fernandez had bragged about so often? Was that what Fernandez meant when he’d boasted that psychiatry paid its own way?
Was it dirty money, Gil? Otherwise, you would have stood up and proudly claimed responsibility for it and pulled Bufort back from a false lead.
That’s what I finally realized was missing from our last meeting together.
I also remembered Voyzchek requesting the emergency psych roster for last July. I’d thought it peculiar that she would ask us, because Fernandez drew up the psych on-call schedule.
But had she noticed something, Gil, and wanted to check it out behind your back? Obviously Bufort had, and when he announced he was looking closely at the salary pools, you knew you were going to get caught. For fraud.
A man of God started some words. Some more dirt hit the coffin.
I thought I knew how it was done. It had to be with fee-for-service patients, and their care had to be government funded. Psychiatrists in a teaching center can bill both for patients they see themselves and patients the residents see in their name under their supposed supervision. So even legitimate billings to Medicare or Medicaid might not seem familiar to a psychiatrist looking at computer records six weeks later. They’d just put an unremembered session down to an uneventful supervision signed off to them by a resident. This happened a dozen times a week per psychiatrist. When billing records showed increased claims, no one would remember enough about the exact amount of their supervision activity to suspect an error. Supervision was sometimes done too much at a distance anyway, but residents liked the apparent autonomy. They got to play real doctor and erroneously rated staff who kept out of their way as “good teachers.” And it suited the staff. If their billing statements showed they did a lot of this “teaching,” in a university center it was the currency of tenure.
The secretaries for the salary pool would prepare and submit bills in the name of supervising psychiatrists, having power of signature in billing claims for the entire staff.
So, Gil, you could add hours of claims for sessions never done, hours per day per week per psychiatrist. With a staff of twelve, at a rate of one hundred an hour, and two to three bogus supervised hours a day per doctor per year, an extra million would be easy.
A last handful of earth arched into the grave. A wisp of dust hung in the air, then vanished. The mourners had finished. The man of God hadn’t. His words drifted in and out of my thoughts.
It could be done only in a salary pool, Gil, and only in a psych pool at that. Your docs would bring into the pool an annual income reflecting both their work with patients and money generated by supervised sessions. Out of this total, two-thirds would be paid back to the physicians as salary. The balance would be used to cover operating expenses. Even so, your docs would end up innocently taking home a little extra—and who questions a raise, or a year-end statement that shows increased productivity?
“Look what I’m worth,”
each would think, or
“I knew I was working harder.”
The documented increase would be readily taken as a well-deserved pat on the back.
We were now in a moment of silence. A lone plane droned overhead.
Nor would Medicaid or Medicare officials handing out these funds call psych patients and ask for a detailed account of their treatments and the hourly breakdown. The bureaucrats got away with checking with Mr. Jones if indeed Dr. X had seen him on such-and-such a date for pneumonia, thus verifying the billing. But no way would the public tolerate bureaucrats delving into psychiatric matters, even at the excuse of avoiding fraud, such was still the stigma of mental illness. So they acted only on patient-generated complaints, and those would mostly be for some claim of abuse, usually sexual.
So, Gil, you could bill a little extra here, a little extra there, and as long as your staff didn’t diddle the patients, you ‘d be safe.
But you got careless. I know now why Voyzchek wanted July’s roster. Because she was on vacation then, had switched with someone at the last minute, had let us know, and found a substitute. But she probably hadn’t changed your master list. As long as the roster’s covered, none of us really keeps track of who’s away. So you did your usual creative billing, including her name. She might not know how many hours she supervised, but she ‘d catch supervision billed to her while she was on the beach in Acapulco.
How did it start, Gil? The dashing champion of care daring to steal from the bureaucrats and deliver it to the healers? More funds for research? Special patient programs and equipment? I’d like to think so; at least I’m pretty sure it started that way.