"Dr. Portland," Traynor said hesitantly. "You don't look well to me. Maybe you should see a doctor yourself."

Dr. Portland threw back his head and laughed. But it was a hollow, mirthless laugh which ended as suddenly as it had begun. "Maybe you're right," he said. "Maybe I'll do that." He then turned and left the room.

Traynor felt stunned. He looked down at Tom as if he expected him to wake up and explain Dr. Portland's behavior. Traynor could understand how doctors might become emotionally involved in their patients' conditions, but Portland seemed unhinged.

Traynor tried one last time to communicate with Tom. Recognizing the futility, he backed away from the bed and slipped out of the room. Warily he looked for Dr. Portland. When he didn't see him, Traynor quickly walked to Beaton's office. Caldwell and Kelley were already there.

"Do you all know Dr. Portland?" Traynor asked as he took a chair.

Everyone nodded. Kelley spoke: "He's one of ours. He's an orthopedic surgeon."

"I just had a very peculiar and unnerving encounter with him," Traynor said. "On my way here I popped in to see my client, Tom Baringer, who's very sick. Dr. Portland was sitting in the corner of Tom's darkened room. I didn't even see him when I first went in. When he spoke, he acted strangely, even belligerently. I imagine he's distraught over Tom's condition, but he said something about not taking all the blame and that there was something wrong with the hospital."

"I think he's been under strain from overwork," Kelley said. "We're short at least one orthopedic surgeon. Unfortunately our recruiting efforts have been unsuccessful so far."

"He looked ill to me," Traynor said. "I advised him to see a doctor, but he only laughed."

"I'll have a talk with him," Kelley promised. "Maybe he needs a little time off. We can always get a locum tenens for a few weeks."

"Well, so much for that," Traynor said, trying to compose himself more in keeping with his role as chairman of the board. "Let's get our meeting underway."

"Before we do that," Kelley said, flashing one of his winning smiles, "there's something I have to say. My superiors are very upset about the negative ruling on the CON for open-heart surgery."

"We were disappointed about that as well," Traynor said nervously. He didn't like beginning on a negative note. "Unfortunately it's out of our hands. Montpelier turned us down even though we thought we'd made a good case."

"CMV had expected the open-heart program to be up and running by now," Kelley said. "It was part of the contract."

"It was part of the contract provided we got the CON," Traynor corrected. "But we didn't. So let's look at what has been done. We've updated the MRI, built the neonatal ICU, and replaced the old cobalt-60 machine with a new state-of-the-art linear accelerator. I think we have been showing remarkably good faith, and we've been doing all this while the hospital has been losing money."

"Whether the hospital loses money or not is not CMV's concern," Kelley said. "Especially since it's probably due to minor management inefficiencies."

"I think you are wrong," Traynor said, swallowing his anger at Kelley's insulting insinuation. He hated being put on the defensive, especially by this young, brazen bureaucrat. "I think CMV has to be concerned if we are losing money. If things get much worse we could be forced to close our doors. That would be bad for everyone. We have to work together. There's no other choice."

"If Bartlet Community Hospital goes under," Kelley said, "CMV would take its business elsewhere."

"That's not so easy anymore," Traynor said. "The two other hospitals in the area are no longer functioning as acute care facilities."

"No problem," Kelley said casually. "If need be, we would ferry our patients to the CMV hospital in Rutland."

Traynor's heart skipped a beat. The possibility of CMV ferrying its patients had never occurred to him. He'd hoped that the lack of nearby hospitals would give him some bargaining power. Apparently it didn't.

"I don't mean to imply that I'm not willing to work together with you people," Kelley said. "This should be a dynamic relationship. After all, we have the same goal: the health of the community." He smiled again as if to show off his perfectly straight white teeth.

"The problem is the current capitation rate is too low," Traynor said bluntly. "Hospitalization from CMV is running more than ten percent above projections. We can't support such an overrun for long. We need to renegotiate the capitation rate. It's that simple."

"The capitation rate doesn't get renegotiated until the contract term is over," Kelley said amicably. "What do you take us for? You offered the present rate in a competitive bidding process. And you signed the contract. So it stands. What I can do is start negotiations on a capitation rate for ER services, which was left out of the initial agreement."

"Capitating the ER is not something we can do at the moment," Traynor said, feeling perspiration run down the insides of his arms. "We have to stem our red ink first."

"Which is the reason for our meeting this afternoon," Beaton said, speaking up for the first time. She then presented the final version of the proposed bonus program for CMV physicians.

"Each gatekeeper CMV physician will be allocated a bonus payment provided his number of monthly hospital days per assigned subscriber stays at a given level. As the level goes down, the payment goes up and vice versa."

Kelley laughed. "Sounds like clever bribery to me. As sensitive as doctors are to economic incentives, it certainly should reduce hospitalization and surgery."

"It's essentially the same plan CMV has in effect at the CMV hospital in Rutland."

"If it works there then it should work here," Kelley said. "I have no trouble with it, provided it doesn't cost CMV anything."

"It will be totally funded by the hospital," Beaton said.

"I'll present it to my superiors," Kelley said. "Is that it for this meeting?"

"That's it," Beaton said.

Kelley got to his feet.

"We'd appreciate all the speed you can muster," Traynor said. "I'm afraid we're looking at a lot of red ink on our balance sheet."

"I'll do it today," Kelley promised. "I'll try to have a definitive answer by tomorrow." With that, he shook hands with everyone and left the room.

"I'd say that went as well as could be expected," Beaton said once he was gone.

"I'm encouraged," Caldwell said.

"I didn't appreciate his impudent suggestion of incompetent management," Traynor said. "I don't like his cocky attitude. It's unfortunate we have to deal with him."

"What I didn't like hearing was the threat to ferry patients to Rutland," Beaton said. "That worries me. It means our bargaining position is even weaker than I thought."

"Something just occurred to me," Traynor said. "Here we've had this high-level meeting that could possibly determine the fate of the hospital and there were no doctors present."

"It's a sign of the times," Beaton said. "The burden of dealing with the health-care crisis has fallen on us administrators."

"I think it's the medical world's equivalent of the expression, 'War is too important to leave up to the generals,' " Traynor said.

They all laughed. It was a good break from the tension of the meeting.

"What about Dr. Portland?" Caldwell asked. "Should I do anything?"

"I don't think there's anything to be done," Beaton said. "I haven't heard anything but good things about his surgical abilities. He certainly hasn't violated any rules or regulations. I think we'll have to wait and see what CMV does."

"He didn't look good to me," Traynor reiterated. "I'm no psychiatrist and I don't know what someone looks like when they're about to have a nervous breakdown, but if I had to guess, I'd guess they'd look the way he does."