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  Jake, like Karen, had a sense of foreboding.

  On Saturday afternoon Karen and Jake entered the nave of Our Redeemer Lutheran Church and sat in a pew near the back. An amateurish organist played “Abide with Me,” softly. Floral arrangements flanked the altar, with diagonal, Miss America-type sashes across them, reading, “Beloved Husband” and “Adored Father.” One read “Valued Employee—Shoreview Memorial Hospital.” Larry lay in an open casket in the middle of all this plant life, looking like an inexpertly rendered Madame Tussaud’s model.

  Anne Delaney, wearing her oft-employed black suit, sat down next to Karen. “Check out who’s got the front row seats,” she whispered.

  Paula Conkel, the deceased’s widow, sat nearest the aisle in the front pew to the right of the altar. Paula was short, just slightly overweight, and wearing her hair in the same heavily sprayed flip as in college. It had been out-of-date even then.

  On her right were her two children, a seventeen-year-old boy and a fifteen-year-old girl. Karen remembered Larry confiding to her, “Paula and I haven’t had sex since Jennifer was born.” Fifteen grim years in the same house, married, without sex or emotional intimacy. Surely, someone as likable as Larry deserved better, she had thought. To the right of the children was Ben McCormick, the lawyer, looking as stern as a hawk. To Ben’s right was a fair-haired woman who looked about forty years old.

  “Who’s the blonde?” asked Karen. “McCormick’s wife?”

  “Hardly,” whispered Anne. “McCormick’s wife is about twenty-two. That’s Lisa Fuller, good friend of Paula’s. She’s also a nurse at Shoreview.”

  “Hmmm,” said Karen. “Maybe it’s time to troll for a little free information.”

  After the agonizingly long service, Jake slipped outside for a cigarette. After some obligatory small talk with Paula about how good Larry looked and how hard it must be for them all, Karen introduced herself to Lisa Fuller.

  “I understand Larry and Paula were more or less estranged for the past few years,” Karen said.

  “I guess that’s sort of true,” Lisa conceded. “He kept an apartment, but he stayed at the house sometimes. Kind of strange. He had his own little separate room at the house. The weirdo even had a lock on it, but Paula used to go in through the window and snoop anyway. Some marriage. I guess they were trying to keep things going until the kids were out.”

  This is great, thought Karen. Push this a little.

  “From what Larry said, they really had no physical relationship for a long time.”

  “True,” allowed Lisa. “Paula said the same thing. I guess sometimes a man just loses interest in his wife.”

  What the hell, go for it, thought Karen. “Especially if the wife sleeps around.”

  Lisa stiffened and clenched her jaw. “Now, wait a minute. That’s not fair. Paula tried to be a good wife to Larry.”

  Karen pressed. “Larry told me sometimes she was seeing more than one other man at the same time.”

  “Oh, yeah? Did Larry tell you about his own affair? It was a lot more serious than any of Paula’s.”

  A large, pale hand clamped onto Lisa’s shoulder. It belonged to Ben McCormick. “Lisa,” he interrupted. “Why don’t you go look after Paula. She needs a good friend right now.” McCormick propelled Lisa away from Karen.

  “So good to see you again, Karen,” he said. “Sorry it has to be under such unfortunate circumstances.”

  “Gee, Ben,” said Karen with a touch of sarcasm, “I didn’t know you were so close to the Conkels.”

  Ben disregarded the comment. “Will you be in your office Monday?”

  “Sure, Ben. Want to stop by for doughnuts?”

  “My process-server will be stopping by with some documents. I assume you will accept service on behalf of Shoreview Memorial?”

  “Serve whomever you like, Ben. Our lawyers, Winslow & Shaughnessy, will let you know if you blow it.”

  McCormick smiled and nodded. “Always a pleasure to do business with you, Karen. I’m looking forward to this.”

  As McCormick walked away, Karen said, “I’m not.”

  CHAPTER

  10

  Monday morning, Karen found herself waiting in Joe Grimes’s office, and it made her uneasy. It made her uneasy because she was practical and Joe’s office was impractical. She hated waste and Joe’s office was wasteful. But mostly, she was uneasy because Joe’s office was a legal problem for the hospital. The Internal Revenue Code, Karen knew, stated that none of a tax-exempt hospital’s earnings could “inure to the benefit of a private individual” Shoreview enjoyed an exemption from income tax because it was engaged in charitable activities and was supposed to use its funds only for those charitable purposes, not to shower lavish perks on its executives. Karen had read just a few years ago about the head of the nation’s largest charity using the charity’s money to tour Europe with his girlfriend. It was a famous example of illegal private inurement.

  When the IRS auditors came to Shoreview Memorial, the CEO’s office would be locked. It was a shrine to private inurement. It was more lavish than the opulent offices of the senior partners at the large corporate law firm in Chicago where Karen had clerked during law school.

  Karen understood the rationale for ostentatiously decorating corporate law offices. Besides creating an environment in which the most privileged and wealthy clientele felt comfortable, it sent a message. The message was: “What we do for our clients is uniquely valuable, and we protect and enhance their wealth so effectively that they gratefully pay us enough money to waste on Persian rugs, French writing tables, and paneling hewn from English walnut trees.”

  In the case of Joe Grimes’s grandiose office, Karen saw no such rationale. Joe was the administrator of a struggling, tax-exempt hospital in a stagnant blue-collar town, but he had an office that looked like the boudoir of a decadent sheik. It was over 800 square feet, more than three times the size of any other office in the hospital. Its size amplified the economic impact of Joe’s decision to install a parquet floor and subsequent decision to rip the floor out two months later in favor of hand-painted Spanish tile, which gave the place the acoustics of an airplane hangar. The desk, at which he rarely worked, was a monstrosity of ebony and black volcanic glass with gold inlay, on which he displayed his daily copy of the Wall Street Journal. The walls were covered with taupe grasscloth and framed tapestries. The custom titanium blinds could be opened and closed by remote control, but they were always kept closed to conceal the jarring view of a parking lot and a fast food restaurant. There was nothing in the room so functional as a bookcase or a file cabinet. Instead, there were polished stone casual tables holding up ceramic vases and exotic objets d’art from Mediterranean locales Joe could not have named. The most distinctive touch was a grouping of three enormous, waist-high terra-cotta urns from Morocco, one of which served as a pot for an unhealthy-looking palm tree with brown-tipped fronds.

  The only message Joe’s office sent, thought Karen, was: this man is a pretentious fool.

  Joe Grimes walked briskly into his office, a black leather attaché case, which Karen guessed was empty, in his left hand and a pair of kid driving gloves in his right. Joe drove a leased BMW convertible, compliments of the hospital, ostensibly for use on hospital business. Karen called it the “private inurement mobile.” When Joe arrived, she had been waiting for thirty-five minutes.

  “Sorry I’m late, Karen,” Joe said, casually tossing his Burberry trench coat over a Moroccan urn. On his slightly overweight body he wore a black cashmere double-breasted Italian pinstriped suit with pointed lapels and, in Karen’s judgment, a bit too much cologne. Mousse slicked his dark brown hair straight back. “My meeting with the CEO of Connors Manufacturing ran over. I think we may be able to do a deal with Connors to use the hospital as their exclusive health care provider.”

  Connors Manufacturing was a company that assembled lamps, with a grand total of twelve employees.

  “So, Karen, where do we stand on Jefferso
n’s MRI deal?”

  “No progress. There are significant legal problems with your whole concept.”

  “Karen, we need that MRI. We needed it yesterday.”

  Several years earlier, Shoreview Memorial’s competitor, St. Peter’s, had acquired a Magnetic Resonance Imager, or MRI, an expensive piece of diagnostic equipment that uses strong magnetic forces to produce high-resolution pictures of a patient’s internal organs. With these pictures, doctors at St. Peter’s were able to diagnose many conditions at a much earlier stage than Shoreview Memorial did using its older imaging devices.

  “We’re not just losing patients to St. Pete’s because we don’t have an MRI,” said Joe. “We’re losing prestige. It’s a PR disaster.”

  “Easily solved,” said Karen. “Just authorize the acquisition. The hospital can manage to lease or finance an MRI. We don’t need the clinic in on it.”

  Joe moved around to the front of his desk and sat on a corner, dangling a leg. Karen recognized this as Joe’s “let’s talk turkey” pose.

  “Karen, we need the clinic as our partner on the MRI. That’s our edge on St. Pete’s. If the docs get a cut of the action from the MRI, they’ll send their patients here for an MRI when they need one, instead of to St. Pete’s.”

  “Sure,” said Karen. “If their cut is big enough, they’ll send ’em here for an MRI even when they don’t need one.”

  Joe leaned forward and grinned. Apparently, he had failed to note her sarcasm.

  “Now you’re getting it,” he said. “I just read a study that showed physicians order four times more diagnostic tests when they own the equipment.”

  “Fancy that.”

  “Yeah. When the doc gets in on the profit from using the MRI, all of a sudden he decides a lot more of his patients need MRIs. Pretty cool.”

  “Maybe,” Karen replied, “but the clinic won’t put up any money to buy the MRI, and a joint purchase with a hospital where they refer patients is illegal.”

  “Oh, hell, so what?” Joe swung his foot. “Like you said, the hospital can get an MRI on its own. So why don’t we just give the clinic fifty percent ownership? With the extra patients they’ll put in here, we’ll still come out ahead. It’s a win-win deal.”

  Karen rubbed her temples. She had explained this to Joe at least three times already.

  “Because it would be illegal. What credible explanation is there for giving away half of a multimillion-dollar piece of stuff?”

  Joe failed to realize the question was rhetorical. “Because we’d get more patients in here! Come on, Karen!” His voice echoed in the cavernous office.

  Karen was continually amazed that Joe’s inability to grasp legal concepts was exceeded only by his brilliance at grasping duplicitous business schemes. “That’s the point, Joe. It would be prohibited private inurement, because you’d be giving away something the hospital owns to private individuals. It’s an obvious kickback for referrals, a clear violation of the Medicare Antikickback Law. And if the docs have an ownership interest in the equipment and then order tests for their patients, it’s a violation of the Stark Ethics in Patient Referrals Law.”

  “Come on. Stop trying to make a federal case out of this.”

  “It is a federal case,” said Karen. “You’d be violating three different federal laws.”

  Joe stood and moved back behind his desk. It seemed to Karen that his suit had somehow become rumpled during the conversation, maybe because his posture was sagging. Joe’s cologne or hair mousse or whatever it was seemed to have acquired a sour nuance.

  “Lawyers and their never-ending technicalities,” he said, flipping his hand toward the ceiling. “If we want to do something nice for the physicians who support this hospital and its mission, why do the feds have to stick their noses in?”

  “Because if they don’t, the money the docs receive for sending patients for hospital or diagnostic services gets so rich, a lot of doctors just can’t resist the temptation to put patients in the hospital or order tests or therapy when it isn’t needed,” said Karen.

  “Doctors would never do something like that,” Joe replied.

  Karen tilted her head and cocked an eyebrow. “Show me your driver’s license, Joe,” she said.

  “Why?”

  “I want to see if you were born yesterday.”

  Joe gave her a half-smile. “Okay. Touché.” He chuckled. “I remember a few years back, some physicians I knew made more money from the kickbacks than they made practicing medicine. Amazing how much hospitals are willing to pay for admissions, or how many more tests and services are ordered when the physician shares the profits from the equipment.”

  “Those are the simple facts of hospital economics, Joe.” Karen and Joe both understood that hospitals and other health care providers wanted, like other businesses, to increase their revenues every year. It was a simple matter to sell more health care services by giving physicians, who control the process, incentives to order more tests and more therapy, and put more people in the hospital for longer periods. At least it had been a simple matter until the federal government, which pays a large portion of the tab for health care through its Medicare and Medicaid programs, passed laws to control health care costs by prohibiting certain financial incentives to encourage physicians to order more services.

  “And the simple facts of hospital economics are what matter to me,” said Joe, “not all those convoluted laws. We need to improve the bottom line, and the Board of Directors wants to see that improvement fast. What’s the downside of violating these federal laws?”

  “Fines big enough to bankrupt us. Exclusion from the Medicare program. There are even prison sentences attached to certain violations. But the good news is you’d be in a federal penitentiary, not a state prison.”

  Joe karate-chopped the air with the side of his hand. “Look, Karen, everybody knows there’s almost no enforcement of these laws. Other hospitals violate them, and we’re at a competitive disadvantage if we let ourselves be hamstrung. You’re supposed to be the smart lawyer, figure out how to do what I want without getting us in trouble. Obfuscate the audit trail. Set up dummy corporations. Pay the docs for consulting services. Do what lawyers do. Just get the deal done!” He flopped down in his throne-sized desk chair, put the tips of his fingers together and rolled his head. “Was there something else, Karen?”

  “I thought I was here to talk about Larry Conkel.”

  “Oh, yeah,” Joe said, absently. “What’s the deal on that one?”

  Karen explained the cause of death and the warranty disclaimer. She reminded Joe of the notice from State Mutual Insurance threatening the hospital’s malpractice coverage. She concluded with a description of Anne Delaney’s interview with Paula Conkel and her attorney, Ben McCormick.

  “So what do you plan to do?” Joe asked, leaning back in his chair. “This one’s clearly in your area of accountability.”

  Thanks a lot, thought Karen. Joe seemed to be taking this with remarkable nonchalance.

  “I had our attorney, Emerson Knowles at Winslow & Shaughnessy, fax a retainer letter to McCormick. We had the catheter tested; when we get it back, it will be placed in safekeeping. I’m researching the insurance issues myself. I’ll be retaining a cardiologist from Johns Hopkins to review the chart and the angiogram.”

  Joe sat forward and frowned. As Karen expected, he didn’t like the idea of getting outside doctors to critique the performance of his own medical staff. Outside opinions could not be controlled. “What’s the point of that?”

  “To get an independent opinion on the catheterization and the surgery,” Karen explained. “Whether or not we can get at the manufacturer, it will help the hospital’s position if the physicians are implicated. More pockets from which to get the settlement. Besides, before I authorize a settlement offer I need to know if Bernard or Herwitz mismanaged the case.”

  “What’s wrong with an internal review by the doctors on our own medical staff?” asked Joe.

 
Karen paused. She pursed her lips to one side. “I’d prefer to have the truth.”

  “Enough cynicism,” Joe declared. He extended an index finger toward Karen. “Get one thing straight. Shoreview Memorial is not going to denigrate its own medical staff, especially not two members of the Jefferson Clinic Board of Directors. It’s not in anyone’s best interests.”

  Joe straightened the knot in his red silk club tie, placed his fingertips on the top of his desk, and lifted his jaw. “I’m tired of people trying to blame everything on the doctors. These are fine physicians, dedicated men, respected by their colleagues.” He reached out with his hands, palms up, fingers spread. “Invaluable to this community and this hospital.”

  “They’re big admitters,” Karen conceded.

  Joe sat down and gazed at Karen. “You understand. Good.” He jabbed the surface of his desk with his forefinger. “Karen, you are to handle this case with a minimum of ballyhoo. No publicity. No trial. No implicating the doctors. They deserve our protection. Nail the insurance company if you can. If you can’t, get rid of this thing for $2 million or less and keep the doctors out of it.”

  Karen was stunned. Was Grimes really authorizing a settlement at nearly twenty percent of the hospital’s liquid net worth, less than a week after the incident? Premature, she thought. Irrational. Fishy. Why was he in such a hurry?

  Joe leaned back in his chair. “I spent the holiday in Vail,” he said, suddenly affable, his way of signaling to Karen that the interview was over. “Did you stay in town?”

  “Saw my parents.”

  “I hope they are well,” said Joe. “Give my best to Jack.”

  Karen returned to her office and the blinking light on her telephone console.

  “You have five new messages in your mailbox. Message one, received Monday at 7:15 A.M. To hear the message, press 2.” Karen pressed 2.