“It would be pretty expensive,” I said.
“But it would pay for itself in time savings,” Lara pointed out. “And probably cut down on transcription errors.” She was hunched over, studying the file on the laptop. “This is really interesting, China. Kelly has put quite a lot of work into this color code. The over-stays—the patients she’s marked with pink—are pretty easy to spot, if you know what you’re after. You can look at the admissions date, and if it’s longer than six months ago and there’s still no discharge, it’s an over-stay. But these others—especially the unqualified—I’m not sure how she came up with them. Maybe she knew them from visits or something.”
Now we were getting somewhere. Lara knew the magic words.
“Discharge,” I said. “Can you spell that out?”
“It goes like this.” She pushed her lips in and out. “According to Medicare rules, patients are expected to die within six months of the date of admission. If they’re still alive at the end of that time, they’re supposed to be discharged by the hospice.”
I looked back at the monitor. “Do you see any cases you recognize?”
“Sure. You can tell from this file which nurses were assigned to the case.” She pointed to an entry. “See? LaM? That’s me.” She smiled. “I remember this guy. Ronald MacDonald, like the McDonald clown, only spelled differently. But there was nothing funny about him. He was a pain in the neck. He was so verbally abusive that Angie, our social worker, recommended that he be discharged for cause. Even the chaplain weighed in on that one.”
“Chaplain?” I asked. “Sorry—this is all new to me. The hospice has a chaplain? And a social worker?”
“Yes. Angie Strickland was our social worker when I was there. Doug Vincent, a very nice man with seminary training, was the chaplain. Doug and Angie both tried to counsel MacDonald, until the old guy kicked both of them out. Even Doug—who always tries to see things from the patient’s point of view—agreed that he should be discharged for cause. That’s Medicare’s term. It means that the patient was so uncooperative that we couldn’t deliver our services.”
“What happened? Was he discharged?”
“Uh-uh.” Lara shook her head firmly. “Marla said no. She hates to lose patients, even those who misbehave. Or to put it more precisely, she hates to lose the reimbursement.” She looked back at the file and traced the data line across the screen with her finger. “But I see she lost him anyway. He died—finally—after a long over-stay. I’ll bet he’s one patient who won’t be missed.”
I fastened on a detail. “Marla hates to lose patients?”
Lara raised an eyebrow. “Well, sure. At one hundred and seventy-two dollars a day, it pays to keep them enrolled for as long as possible.”
“Ah,” I said. “And I suppose it costs less to keep a patient than to add a new one, considering the setup costs, bookkeeping, and all that.”
“Exactly,” Lara said. “But a hospice has to keep new patients coming in to replace the ones who are discharged—through death or whatever. Hospice care is a service, but it’s also a business. A profitable business, or Marla wouldn’t be doing it.”
“How profitable?” I asked.
She tapped a finger against the monitor. “Well, you can do the math. A hundred and seventy-two dollars times a hundred patients is over seventeen thousand dollars—a day. I heard Marla once say that the profit margin is around twelve percent, which means that the hospice is clearing over two thousand bucks a day for every hundred patients on the books.”
“Wow,” I said softly. “Two thousand dollars a day?”
“On just a hundred patients. So—” She let it dangle.
“So if there are two hundred active patients, the profit must amount to something like four thousand a day.” I whistled softly. “That’s one hundred twenty thousand dollars a month. Profit.”
“Right.” Lara said. “And if any of them have to go to a hospital for what’s called ‘general inpatient care’—say, if somebody falls and breaks a bone—the reimbursement shoots way up. It’s nearly seven hundred dollars a day. Of course, the hospice has to pay the hospital out of that, but—”
“But the billing could be faked?” In fact, that had been mentioned in the article I’d read. The patient stayed home, but the billing was changed to inpatient care.
She frowned. “Yes, but the hospital would have to be in on it. Which would make it more complicated. But doable, I guess, if somebody worked at it.” She kept on scrolling through the file, making a little humming sound under her breath. “I’d have to study this for a while before I could tell you what Kelly must have been thinking when she copied these records. That might take some research. Fieldwork, I mean. Actually going out and checking on some of the cases she’s marked ‘unqualified.’”
There was that word again. “Unqualified,” I said. “Who actually says whether a patient is qualified?”
“A personal physician has to report the diagnosis and say that the patient is facing death in six months. The hospice doc has to sign off on it. Then the patient is ‘qualified,’ according to Medicare.” She looked back at the computer monitor. “I can probably tell you more after I’ve had a chance to take a close look at this. I kept my own personal notes while I was working for the hospice. I can check those.”
“That would be great,” I said. “How about if I email a copy of Kelly’s files to your computer right now? Not just the Pecan Springs file, but the other two files, for the branches in Lufkin and Seguin, as well. When you get home tonight, or maybe tomorrow, you could go over them and let me know what you think.”
“I can do that.” Lara looked at me, her forehead puckered. “But I think I’ve already got a pretty good idea what Kelly was trying to do here. She—” She stopped, biting her lip.
“She what, Lara?”
She was silent for a moment, then said slowly, “Look, China. Hospices work under fairly strict Medicare rules. Owners and managers know what they are and what can happen if the rules are violated. Kelly had a reason for pulling these files and marking the records she thought were violations. She must have been thinking about . . .” She let her voice trail off.
I finished the sentence for her. “She was thinking about filing a whistle-blower lawsuit against the hospice, Lara. Two of the phone numbers you gave me this afternoon were Austin attorneys who specialize in that area of the law. Charlie Lipman couldn’t take Kelly’s case because he’s on the hospice board, which was a conflict of interest. He may even be the hospice’s lawyer.”
“A lawsuit against the hospice.” Lara mouth tightened. “Yes, that’s what I was coming to. That means a suit against Marla Blake, doesn’t it?”
“Right. But others could be involved as well. Other owners, for example. Or staff who were directly responsible for the violations—and profited from them.”
“Marla isn’t the only owner,” Lara said slowly. “One of . . . one of the doctors owns half of the business.”
“Really? I saw that there are three doctors on the hospice medical staff. Which one is part owner?”
Lara was chewing her lower lip. “Marla’s son.”
I frowned. So this was a mother-son operation. That was unusual, and interesting. “I read the doctors’ names on the website,” I said, “but I don’t remember one named Blake.”
“His name is Burgess. Christopher Burgess. He’s Marla’s son by her first marriage.”
“I’ve met him,” I said, remembering our conversation at the Friends fundraiser. “He’s very good-looking. And charming, easy to talk to. I had no idea he was Marla Blake’s son.”
“Most people at the hospice don’t know, either.” Lara’s voice had changed, taken on an edge. “Chris doesn’t hang around the office much. But then, neither of the other two docs do. They come in every couple of weeks to review the new cases, but most of the time they communicate via email
and fax.”
Chris? It sounded as if Lara was on friendly terms with him. “How do you happen to know?” I asked. “That Dr. Burgess is Marla’s son, I mean.”
Her glance slid away, and she didn’t answer immediately.
“This might be important,” I said. The fact that she had brought the relationship up suggested that it was somehow significant. There was a backstory here, and I wanted to know it. “How is it that you happen to know that Burgess is Marla’s son?”
She was slow to answer. After a moment, she replied half-reluctantly. “Because I was . . . involved with him. Before Matt and I got together, I mean.”
“Involved,” I said. “Romantically?”
She put up a hand and rubbed her cheek. Another silence, as if she were deciding how much to tell me. Then, slowly, she said, “In the beginning, I liked Chris a lot. He was sweet and fun, and I thought we might . . . well, I thought we might even get married.” Her voice took on a defensive edge. “It would have been nice, you know? Marrying a doc with an established practice and plenty of income. It might sound crass to you, but I even thought that if I married Chris, I could quit work. I was a carhop in high school, I had a half dozen jobs in college, and I waited tables to put myself through nursing school. It sometimes seems as if I’ve been working my whole life.” She gave me a questioning look, as if she were waiting for my objection or censure.
But I was more interested in why she hadn’t married him than why she had wanted to. “But then?” I asked sympathetically, nudging her to tell more of the story. “Sounds like it didn’t work out the way you thought. Was there a reason?”
“Yeah. There was.” She sighed. “I found out that he was in trouble with the Texas Medical Board. Which wouldn’t have been enough, all by itself, to make me pull away. But when I put it together with some other things . . . well, I just got cold feet. It wasn’t for me. And then Matt came back into my life, and I knew that he was the one.”
I’d had a few encounters with the medical board in my earlier incarnation as an attorney and had found that dealing with them was a challenge. They have a habit of circling the wagons, holding secret meetings, and making backdoor deals. The public can see the disciplinary action only after an investigation is final, and getting to that stage can take well over a year—if it happens at all. The investigations into complaints against doctors (and there are thousands every year) are carried out by other doctors, and doctors make up most of the board. Some cynical members of the Texas press have pointed out that when foxes guard the chicken coop, things don’t usually end well. A doctor who is being investigated for harming a patient is free to continue to practice, and to harm others. And when the board actually does get around to disciplining a doctor, it’s often just a slap on the wrist. He gets probation or a temporary suspension when his medical license should have been revoked.
I didn’t want to sound as if I were cross-examining her, so I softened my tone. “So how did you happen to find out about Burgess’ trouble with the medical board?”
With a certain reluctance, she replied, “Well, he said something that made me wonder. I don’t remember exactly what it was, just a funny kind of comment. But later, I couldn’t quite put it out of my mind. You know how those things are? So I went online and searched the medical board’s disciplinary actions back three or four years. I found it.”
“Found what? Was his license suspended?”
“Are you kidding?” Lara laughed shortly. “The board almost never does that. Instead, they put him on probation for a couple of years. He wasn’t supposed to practice without another doctor’s supervision, or prescribe narcotics or painkillers. I guess it’s okay for him to work in hospice, though. That’s mostly where he works now. He’s a palliative care doctor.”
“Palliative care?”
“That’s what it’s called in hospice. The emphasis isn’t on curing a patient, but on making a terminal patient comfortable through the end of life. There’s a focus on symptom and pain management, and on alleviating stress for the patient and the family. Chris—Dr. Burgess—sometimes makes patient visits.” She smiled a little. “That’s how we happened to get together, you know. We both worked on the MacDonald case.”
“Why was he suspended?” I asked. “Were the reasons posted?”
“Yes. There had been three—or maybe four, I can’t remember—medical malpractice suits filed against him. But the thing they got him for—this was a couple of years before I knew him—was that he’d been writing prescriptions for painkillers for the woman he was living with, who had once been his patient. She was killed in a one-car crash, and when they did an autopsy, they found an elevated level of oxycodone in her blood. It was traced back to the prescriptions he’d been writing.”
“Did you tell him what you knew about him?”
“No. Chris isn’t . . . he’s not the kind of person you can talk to about things like that. He is very self-confident, you know? He just kind of brushes criticism away. But I began to . . . well, wonder. So I went online and searched through the medical board’s disciplinary records, and I found something from a later hearing that bothered me.”
“For example?” I prompted.
This time, she was even slower to answer. But finally, she took a deep breath, and said, “There were several allegations of sexual misconduct with patients. The hospital where he was working in Dallas apparently didn’t report them to the police. Hospitals don’t like negative publicity, you know. Coworkers cover up to keep from getting their department into trouble. And management will always believe a doctor over anybody else. But somebody at the hospital must have thought the allegations should be on his record, and they were sent to the medical board. That’s where I found them.”
“I see,” I said. “And then what?”
“Well, I began to think about our relationship. He was . . . he was a rather aggressive lover, I guess you’d say. Rough, sometimes.”
“That’s what you meant when you said there were ‘other things’ that bothered you?”
She pressed her lips together as if she wasn’t sure she should be telling me this. But after a moment, she nodded. “I didn’t like it, you know, but I kind of accepted it, because I thought maybe the relationship was going someplace and I could get him to change. He could be very sweet when he wanted to be. But after a while it didn’t seem okay. There seemed to be a lot of narcotics around his place. And when I put all that together with his probation and the allegations, I got uncomfortable. So I told him I couldn’t see him anymore.”
“How did he react?”
Her mouth twisted. “Let’s just say it wasn’t very pleasant. I was even a little afraid. He’s the kind of guy who expects things to go the way he thinks they should go, and when they don’t, he loses it. But after a few minutes, he would seem to get a grip, and everything was okay again.” She paused, thinking. “Afterward, I realized I had seen him act that way before. I was glad when it was over.”
“Did you ever talk to Kelly about any of this?”
Lara shook her head. “No. I didn’t want anybody to know how foolish I’d been. And of course I didn’t talk to Marla. I figured she already knew about the probation, and I certainly wasn’t going to tell her about the rest of it—the personal stuff, I mean, about Chris and me. But I think he must have told her. Told her something, anyway. She began acting . . . well, a little hostile toward me. It made me uncomfortable.”
I remembered the expression that had flickered across Marla’s face when I mentioned Lara’s name. “Is that why you left the hospice?”
“Yes. I didn’t want to get teamed up with Chris on case assignments, and I didn’t know what he might have told his mother. I quit and got a job over at the Madison Clinic right away, and for better pay, so I came out all right. I just wish that Kelly—” Her voice had a tremor in it, and she had to clear her throat before she could go on. “I don’t kno
w why I’ve told you this, China. It doesn’t have anything to do with . . .” She gestured toward the files on the computer.
“You never know,” I said softly. “It just might.”
If she heard me, she didn’t respond. She was squinting at the monitor screen again. Half under her breath, she said, “Kelly took a really big risk, sneaking into the office at midnight to copy these files. Do you think this might have something to do with that murder she was talking about?” She looked up at me, her eyes dark. “Or with her car wreck?”
“I think it could,” I said. “But we won’t know until we’ve looked at this stuff a little more closely.” I hesitated. “She didn’t tell you what she knew about the murder, and she didn’t tell me. Do you think she might have told her husband?”
Lara thought about that for a moment. “I don’t think so,” she said. “She and Rich were barely talking about their marriage and the business they owned together—the brewery, I mean. I doubt very much that she would have said anything to him about her suspicions.”
“Sounds logical,” I said. I slanted her a look. “Do you happen to know if the cops have cleared him as a suspect in the car crash?”
She nodded. “Apparently. Turns out that he was at the brewery last night, with three other guys, one of them an off-duty police officer. They were together until the police called to tell him about Kelly’s wreck.” She took a deep breath. “Okay, China. Please go ahead and send Kelly’s files to me. I’ll go over them tonight after I get home.”
I got her email address, attached the files, and hit the Send button. I glanced up at the clock and blinked when I saw how late it was.
Blood Orange: A China Bayles Mystery Page 19
