Dr. Leesa Cornell, CMO, confronts Benjamin Huffman, insurance executive, at a Memorial Day picnic, where tensions rise over insurer policies and ED crowding.
This medical fiction tale is one of a collection of stories that are like “Final Destination” meets “The Monkey’s Paw” (W. W. Jacobs, 1902). As such, they are tragedies that appeal most to readers who enjoy the inexorable pull of a story arc that leads to doom. The technical details surrounding the event are drawn from real cases in the US OSHA incident report database or similar sources and are therefore entirely realistic, even if seemingly outlandish.
Benjamin A. Huffman graduated with honors from sociopath school—that is to say, a renowned MBA program. In that program, he’d been taught the cardinal importance of the bottom line, clever methods to externalize and socialize risk, and effective ways to drive shareholder value. Naturally, he found a suitable career at a health insurance company, in which his primary focus was avoiding unnecessary payouts. Ben loved his job and typically received a quarterly bonus for overperforming.
Dr. Leesa Cornell had always been a bit of an adrenaline junkie. As a little girl in pigtails, she was more likely to be found chasing yellowjackets, rescuing bees from the birdbath, and freewheeling like a demon down the road to the cemetery than sitting indoors with a coloring book. She was also the middle school student toting a human atlas in her backpack, and was adept at pulling splinters out of little hands and feet. In high school, she was the one who took over when the school nurse vomited at the sight of Jimmy McBride’s hand after it had gone between his bicycle chain and the sprocket. To no one’s surprise, Leesa eventually attended medical school and matched into emergency medicine.
Leesa went on to volunteer with Médecins Sans Frontières, but didn’t serve her full term. Although eager to stay and continue in her efforts, losing her leg to an improvised explosive device earned her an unwanted early release and a solemn send-off. Back home, her prosthetic limb took some getting used to, but Leesa was not one to back down from a challenge. Soon, she could dash about the ED almost as nimbly as she had before.
Leesa’s journey to becoming the youngest CMO in the hospital group was partly due to luck, partly through goodwill of her colleagues, and mostly due to countless hours devoted to caring for her patients and staff and doing public outreach on safety and harm prevention. While she continued to see a small number of patients, her time was mainly spent on physician hiring and training, poring over quality, safety, patient satisfaction, and performance reports, and keeping expenses from blowing the budget. She also spent many hours trying to figure out why her staffing was seemingly cast in stone in spite of the ED demand growing month on month, year on year. ED crowding was now her number one headache, bigger even than the tensions between nurses and doctors and administration, and making sure physicians stayed compliant with policies, protocols, and metrics. Continuous efforts to improve efficiency and reduce readmissions showed no effect; The ED seemed to clog up faster and faster. Operational numbers showed that while productivity had gone up 15% because of process improvements, demand had more than doubled and showed no signs of slowing.
Capacity was not something Leesa could really impact. She could argue for more staff, but that was always a hard sell and a protracted battle. She could try harder to improve her patient flow processes, including adding a pair of “quick look” triage nurses at the intake, but she could eke out only about 5% to 10% more capacity doing that. Finally, the performance and availability of ancillary services and destination points of care were utterly beyond her control. If there was no mental health bed available to which the ED could refer a patient, no amount of wishing for one would help. The ED team was pretty good at phoning around, even out-of-state, but the ED often boarded such patients overnight or longer, waiting for a bed to open up somewhere.
At the health insurance company, Ben had found a few ways to get costly members off the list. While regulations were making that harder, Ben was a clever and resourceful guy whose ingenuity at skirting them was renowned. Since the downstream social costs were externalities to the corporation, pushing costly people off insurance was pure profit. Ben didn’t know what happened to those people, with the purgatory of high-risk pools and the no-man’s land between losing insurance and the obstacles of testing to get covered by Medicare and Medicaid.
At the other end of this process, Leesa was becoming very aware how high deductibles were leading to less use of primary care and greater utilization of her ED. She was also very aware that when people lost their insurance and didn’t yet qualify for Medicare or Medicaid, they tended to come to the ED when they got sick or when they didn’t address something early that primary care could manage. Revocation of mental health coverage by insurers also resulted in people in crisis in the ED.
One Monday afternoon, several of the senior staff at the hospital were showing their faces at a Memorial Day picnic jointly-hosted by the hospital chain, two pharmaceutical companies, and one of the big health insurers. Upon arrival, Leesa thanked the greeters while accepting a free tote bag, water bottle, and small American flag. The tchotchkes varied in quality: the tote was roomy and worth keeping; the water bottle bore the logo of the insurance company and was made of cheap plastic which probably leaked; the little flag was surprisingly sturdy, with an actual cloth fly and a steel shaft ending in an impressively sharp point. People were waving their flags about enthusiastically. Several had pushed theirs into the lawn to mark their picnic spot, and a few had even threaded their flags through their baseball caps. Leesa rolled hers up and held it while peering around for anyone she knew.
After a few speeches by the sponsors and the hospital director, Leesa found herself clutching a dripping hot dog in one hand, the rolled-up flag and a plastic cup of wine in the other, with her tote bag slung over one shoulder, now stuffed with her handbag, a brain-shaped stress ball, and a bag of caramel-and-salt-coated red, white, and blue popcorn. She was considering whether to just eat the messy hotdog that was causing a rivulet of juice and ketchup to drip down her calf, swig the steadily-warming wine, and go home. Distracted by hot dog fluids seeping into her shoe, Leesa walked right into the outstretched arm of the chief of psychiatry, Barbara. Barbara was clearly furious and, also clearly, she and the guy wearing the designer shades and Polo shirt with whom she was arguing had both skipped the hotdog line and triple-dipped the wine.
“Leesa, get a load of this!”
Barbara angrily explained to Leesa that the reason the ED had been increasingly slammed with mental health patients was a new policy by the insurer, gesturing at Polo guy. The conversation took a turn for the worse when Leesa jumped in, describing a recent case in which a patient had been boarded for over 24 hours in the ED because he no longer had insurance coverage, and no mental health beds were available. Ben, Polo guy, snorted in response, then condescendingly explained that this was an “externality.” That insurers had to focus on liquidity and shareholder value, and while difficulties and delays were regrettable, they were not the responsibility of the insurer. Leesa retorted that attempted suicide was hardly just a “difficulty” and that it went far beyond “regrettable.” Voices rose, insults flew, and Barbara threw her wine. Then, Ben placed a hand on Leesa’s chest and gave her a little shove. She swayed back in surprise but, having learned the ins and outs of maintaining balance, she quickly swayed forward with great momentum.
Perhaps Leesa intended to copy Barbara by throwing her wine at Ben the Polo guy, but the hand holding the wine was also clenching the little flag, and maybe her arm had other ideas. Ben stumbled backwards, mouth agape, eyes wide. He bumped into the edge of a food-laden picnic table before toppling over flat on his back, his head plopping neatly onto a platter of potato salad. Lying there with a lumpy white halo around his head and a little flag fluttering gently, firmly planted in his chest, Benjamin A. Huffman’s heart quivered and stopped. Moments later, Ben’s eyes glazed over, oddly resembling the deviled eggs on the platter next to which he drew his final breath.
