Shit…this was not good. Drummond turned to leave and stopped.

  “Dain, what happened after you testified…in front of Congress?”

  “I pissed off the wrong people, so I left the CIA to become a linguist.”

  61

  Natalya Baturina walked around the suite, stooping to pick up after Pan Jiang. She smiled thinking of her daughter—like Jiang, not a gifted housekeeper. Jiang’s dirty clothes lay on the floor and were strung over various furniture pieces. The couch, unmade. And dirty towels were piled in the corner of the bathroom. She picked up the clothes and started a load of laundry but left the towels for housekeeping.

  Baturina sat on the coach to finish reading an article discussing the psychology of Chinese women that she abstracted from the Internet. What she explained to Drummond regarding Jiang’s behavior was accurate. As a woman, Baturina may be able to reach Jiang. It would be impossible for Jiang to tear down the protective screen built up over a lifetime of Chinese culture without professional help.

  Baturina heard the jingle on the dryer signifying the load of clothes had finished drying. She gathered up the dark-colored clothing in her arms and dropped it on the bed. The clothes were still warm, and the scent of laundry soap was fresh. She sorted the clothes—T-shirts, socks, and underwear. When Jiang entered the room, she saw her clothes laundered and folded.

  “Why are you kind to me?”

  “Small acts of kindness make this world tolerable. I can’t tell you how may loads of laundry I’ve done for my daughter. I knew she would visit, even when away at college. It was assumed her mother would always do her laundry. I planned it.

  “Cup of hot tea?”

  Jiang nodded, and Baturina poured two cups. She carried both cups to the couch, and the two sat on either end clutching warm cups and sipping tea.

  “There was never a feminist movement in Russia,” Baturina said. “Women have always been equals. I was raised in an environment where both my parents and society confirmed my worth as a human being. It’s normal for a young woman, irrespective of race and ethnicity, to have a healthy sense of self-worth. To love, one must first love self. I’ve read Chinese women have emotional struggles,” Baturina continued. “Why should a son be more desirable than a daughter?”

  Baturina’s statements—validating feelings of self-worth—were dangerous words…thoughts that challenged the sanctity of a culture whose underpinnings were conforming to collective interests. Baturina had no idea what the Chinese government was capable of doing. Neither did Jiang, until her attempted suicide. They had monitored her Internet usage. They were waiting for her at the subway station. When she jumped, an undercover officer had tackled her, knocking her to the ground before she cleared the rail.

  Jiang was hoping to save face with the Chinese government by assenting to participate in the contest. They led her to believe the release of her mom and dad was possible.

  Still, Baturina is a gift, Jiang thought. She makes me want to live.

  62

  Chris Drummond’s oversized suite had a sitting area with sweeping views of the south shore. It was comfortable, with stuffed leather chairs and a carved wood table.

  “I’m jealous…The views from up here are fantastic,” Lowsley said. “The views from the third floor are obstructed by palm fronds.” Lowsley set up the cribbage board. It was made of exotic dark wood with gold inlay. The pegs were carved elephant ivory.

  Drummond poured Coke into two glasses filled with ice and placed the beverages on stone coasters.

  “This first hand won’t count. I’ll walk you through the mechanics and scoring. I’ll deal.”

  Lowsley shuffled and dealt six cards to each player. Drummond placed two cards, turned over, next to the cribbage board, and Lowsley added two cards to form the crib. Drummond cut the cards. The card turned over was a jack of hearts. Drummond scored two points. He moved his peg.

  “Twenty-five percent of Medicare’s expenditures are incurred in the last year of a patient’s life, according to the medical literature.

  “The law of diminishing returns—greater quantities of health care consumption yield lesser incremental benefit,” Lowsley said.

  Drummond played an eight of spades. Lowsley followed with a seven of diamonds, announcing a running total of fifteen, and moved his peg two spots. Drummond played a seven of clubs for a pair worth two points. Lowsley played a seven of spades for three-of-a-kind worth three points. The running total was twenty-nine. Drummond couldn’t play, so he said, “Go.”

  Lowsley played a two of clubs. “Thirty-one for two,” Lowsley said.

  “It’s a societal issue—expensive treatments to prolong life, often with marginal benefit, come at a great hidden cost. Patients who desire miraculous care should not be denied, but the financial cost ought to be borne by the patient.

  “Our country needs to have a prophylactic conversation to establish reasonable boundaries and expectations. Citizens have been frightened into thinking they’ll be denied care by ruthless death panels—but these care decisions shouldn’t be made entirely by the patient’s provider of care.”

  Drummond played a five of spades, and Lowsley followed with a king of diamonds.

  “It’s an education issue. Human beings expect and deserve compassion at end of life. Many patients would choose a pathway of comfortableness, surrounded by loved ones in their final days. For them, it’s a better quality of life than being hospitalized.”

  Drummond played a queen. Lowsley played a three of spades.

  “What are your recommendations?” Drummond asked.

  “We advise HHS to issue a white paper to raise awareness of the issue—twenty-five percent of Medicare costs are incurred in the last months of life. This is not understood by mainstream society. The white paper should list alternatives, including palliative care—an approach using a team of interdisciplinary professionals to guide the final days, weeks, and months of a person’s life, emphasizing quality of life, keeping patients comfortable through pain management, and choosing an appropriate setting, which for many patients is home care. Second, we require all legal documents be in place to obtain insurance. Advanced health care directive (living will) and durable power of attorney are necessary documents, so when a medical emergency arises, the care team understands the patient’s wishes.”

  Drummond counted first. “Fifteen two, fifteen four, fifteen six.”

  “If citizens of our country are not willing to have this debate, the hard choices will fall to ACOs. We can frame the discussion in the context that this situation is unacceptable, but the federal government will not be the arbitrator.”

  Lowsley counted. “Fifteen two, fifteen four.” He turned over the crib and counted. “Fifteen two, fifteen four, and a run of three makes seven.”

  63

  Peter Lowsley dropped the stack of iron plates on the Nautilus machine, finished with his second set of leg extensions.

  “Despite what people believe, the root cause of cross-national pharmaceutical pricing, the prices citizens in different countries pay for the same prescription drug, is a function of income differential between nations,” Lowsley said.

  “Wealthy nations pay more. Brand name drugs cost thirty percent more in the US, but generic drugs are priced on par with other countries, according to the literature,” Drummond said.

  “The brand name pricing structure in the US is conducive to earning a return on invested capital for research and development. America has been the purveyor of pharmaceutical research and development for the world, and those costs have been borne disproportionately by the US health care system and nations with higher incomes,” Drummond said. He was standing two machines away, performing tricep extensions.

  “The problem with implementing a ‘most favored nation’s clause’ is poorer nations can’t afford drugs. Access in poor countries is choked off because of monetary barriers.”

  Vogel, who was stretching on a floor mat, walked over. “Investing in biotechnology stocks has been a source of consistent returns for my clients. Research is expensive…Many blockbuster drugs cost a billion dollars to develop and receive FDA approval…Higher risk-taking necessitates the potential for higher returns,” Vogel said.

  “The conundrum is how to balance continued incentives for research and development and reduce cost.”

  “My solution was to ‘skinny up’ the cost structure of Big Pharma,” Drummond said.

  “Take Biological Sciences, Inc., insanely profitable, nineteen percent operating margins, but if you drill down into their cost structure, it’s evident opportunities exist to pare costs without compressing margins. Last year’s cost of goods sold was twenty-two percent of revenues. A mere thirteen percent was spent on research.”

  Drummond sat down on a row machine and adjusted the tension.

  “Here’s the kicker—thirty-two percent of revenues were spent on selling, general, and administrative expenses. They ought to be embarrassed.”

  Drummond extended his legs and pulled the handle to his chest. As the machine recoiled, Drummond’s body slid down the bar, his legs bending as his knees came to his chest. He grunted as he exhaled, extending his legs and pulling the bar to his chest again. He settled into a cycle of twenty-nine pulls per minute, burning 740 calories per hour, according to the digital readout.

  “Our proposal should reduce the cost structure of drug manufacturers by disapprobation of marketing expenses. We leave the patent structure and brand name pricing differential in place to incent drug development but reign in prodigality.”

  64

  President Cannon was being briefed by his defense secretary in the Oval Office. Premier Tong had been quoted in China Press two hours ago denouncing the United States for participating in the Cobra Gold military exercises off the coast of Thailand. An annual exercise, the Strait of Malacca—a geography of high strategic importance—was a key “choke point” because it was the shipping lane used by China to transport oil from the Middle East. Premier Tong warned that if Uncle Sam continued naval and air force maneuvers in the area, it may precipitate an accidental military clash. He was reminding the United States of the history of “inciting incidents” and world wars. Tong communicated his intention to have China’s aircraft carrier patrol the region from the Persian Gulf to the Bay of Bengal. His defense secretary was dismissing it as saber rattling but suggested he flank the Joint Chiefs, whom, he believed, would be chomping at the bit to defy the Chinese by expanding military maneuvers.

  65

  Peter Lowsley pushed the button on his wrist to activate his stopwatch, and they started running. At 6:15 a.m., it was already seventy-two degrees. The still morning air was perfect for running. By midafternoon the breezes were steady, until dinnertime when they tapered. Thump, thump, thump…The sound of rubber soles echoed off the boardwalk. Drummond lengthened his stride to match Lowsley’s gate.

  “Once FDA approved, new technologies diffuse rapidly, often gaining a toehold in Medicare before adoption in the commercial market. Medical device research and development costs are borne by the US health care system—the same arc as the pharmaceutical industry.”

  They were nearing the north shore. They ran past a trailhead leading to the beach, and Drummond made a note to check it out. He liked this side of the island because of the rock bluff.

  “The widespread use of expensive technologies inflates our health care spending,” Lowsley continued. “According to OECD’s data, we perform ninety-one MRI procedures per one thousand population, compared to a mean for other nations of forty-one per one thousand.

  “We either trust a market-based system or not. Prescriptive approaches—quality assurance, referrals protocols, certificate-of-need schemes, require resources to administer and are often not effective.

  “My inclination is not to engage in separate regulation—let the market determine the true cost-benefit threshold for technology adoption. I say we rely on ACOs and risk-based contracting. It’s our default position. That’s why we chose a structure that supports a market-based approach.”

  Drummond saw the aquatics building in the distance.

  “I’m going to drop off at the fountain,” Drummond said.

  “I’ll turn a couple more laps—see you at breakfast.”

  66

  Bent at the waist, placing his arms on his thighs, Chris Drummond needed time to recover from the run. A productive session, but he noticed Lowsley had a tendency to quicken his pace each successive mile—the last one, sub 6:30. Standing upright, he placed his hands on his hips, inhaling, to enlarge his rib cage in an effort to slow his respirations. He was walking toward the beach to cool down when Dain came into view. His back was to Drummond, crouched, shoveling sand into a nylon bag. The bags were stacked in rows, two wide, eight feet long, and three feet high, resembling cords of wood. His quick math estimated each stack was around a hundred bags. Drummond closed to seventy-five feet when Dain called his name over his shoulder.

  “Aren’t you a tad old to be making sand castles?” Drummond said.

  Dain finished filling a bag and tossed it to the side. Standing, he brushed his shorts to wipe off sand that was caked to his moist hands. His body was drenched in sweat.

  “Ahlam said they use the bags to control flooding…tropical storms in the summer—not hurricanes, but high winds. Nylon, woven mesh, and self-sealing. Dain pointed to a plastic zip-tie sewn into the nylon at the open end. He picked up a partially filled sand bag and held it between his knees. Using his thumb and index finger, he zipped the bag shut.

  “Variegated sand—where they dredged the material is coarse, whereas the natural beach sand is fine.

  “I’m still working on configuring the perimeter sensors,” Dain said.

  “Did we have visitors last night?”

  “No. The sensors were green—all quiet. But I started night patrols.”

  “Sorry about the sand castle crack; I recognize our situation is serious. How will you explain the sand bags to the others?” Drummond said.

  “I’m not going to explain it…unless they ask.”

  “And if they ask?”

  “It’s a new cross-training workout—one I learned in the military. I’d be happy to proctor a cardio workout for anybody who feels left out. They can bring yoga mats down to the beach…take the stress off their knees.”

  “What’s your assessment of English law?” Drummond asked. “You live in London.”

  “I keep a P.O. box in London. I live wherever the job takes me. I can tell you the yellow pages aren’t filled with personal injury advertisements.”

  “Lowsley and I were discussing medical malpractice tort reform. We’re leaning toward a recommendation for modification of English Rule—losing party pays all attorneys’ fees but the rule only applies to those who initiate suit.”

  67

  Chris Drummond flipped through the pages of the schedule Baturina prepared, counting the days left to the mandatory reporting deadline. The contest regulations required each team to submit an interim proposal. They had four days to submit. The regulations were sparse—left to the discretion of the team of what to include with the first submittal. Drummond was looking for a natural break in content. He made the decision to limit their initial proposal to developed ideas. It was important for the team to make a strong showing out of the gate, and Gupta needed time to work his magic. Drummond made a note to have Gupta explore the login procedure. The instructions said to log onto the secure website, enter the access code Drummond received with the dossiers, and attach any files. He didn’t expect a problem, but….it was technology. Drummond drained his third cup of coffee and headed to the bathroom to brush his teeth. His session with Lowsley started in ten minutes.

  “If we tackle behavioral risks this morning, I’ll include our write-up with the initial filing. I reviewed the master schedule. My feeling is we need to turn over what we have completed to Gupta by noon today. He was vague about how much time he needed.”

  “It was in my notes to raise that question also,” Lowsley said.

  “Lifestyle choices—obesity, alcohol, tobacco, and recreational drug use result in higher consumption of health care resources, at greater cost. Health care premiums ought to price in higher premiums for known risk factors. It’s no different than higher life insurance premiums for tobacco users. They can build a nomogram to price risk by performing a regression analysis using claims data,” Drummond explained.

  “For example, thirty-five percent of US adults are obese, compared with seventeen percent for other countries. Obesity is a risk factor for hypertension, high cholesterol, diabetes, cardiovascular disease, and respiratory and musculoskeletal problems. The slope for morbidity risk turns curvilinear once you cross the obesity threshold,” Lowsley remarked.

  “It’s an area we need to emphasize more. These people need a better support system,” Drummond said.

  “What are the policy considerations if we propose behavioral-risk insurance underwriting?”

  “The carrot approach works better than the stick approach. We offer incentives to change behavior along with formal interventions—dietary and nutritional education, exercise, and cessation programs.”

  68

  The team, minus Rakesh Gupta, had met three consecutive evenings to debrief. Gupta had locked himself in the Satwa conference room after Lowsley and Drummond gave him the files. The team was pinched to make the first reporting date, twenty-two hours from now, and pressure was mounting.

  “You need to be more assertive with Gupta,” Baturina said. “According to housekeeping, he’s not slept for three nights. That can’t be good for his health.”

  “I hear you, but I’ve broached the subject, twice. The last time he stuck his finger in the air and made a circular motion and muttered ‘vamp till cue,’ which I interpreted as let him finish. He sounded agitated and never took his eyes off the computer screen. He told me to leave him alone…it’s how he does his best work. Why shouldn’t I believe him?”

 

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