7

At 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.