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Measurement and
Analysis in Transforming
Healthcare Delivery

Volume 2:
Practical Applications to
Engage and Align Providers
and Consumers
Harry C. Sax

123
Measurement and Analysis in Transforming
Healthcare Delivery
Harry C. Sax
Editor

Measurement and Analysis

in Transforming Healthcare
Delivery
Volume 2: Practical Applications
to Engage and Align Providers
and Consumers
Editor
Harry C. Sax
Department of Surgery
Cedars Sinai Medical Center
Los Angeles, CA, USA

ISBN 978-3-319-46220-2 ISBN 978-3-319-46222-6 (eBook)

DOI 10.1007/978-3-319-46222-6

Library of Congress Control Number: 2016943088

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my children, Ben, Adam and Rachel; it is
for their generation, and those that follow,
that we have to get healthcare right
Preface

To say there is uncertainty in healthcare is an understatement. To suggest that

change is needed is obvious. How we do it, and how we measure the effectiveness
of those interventions is where the real challenge lies.
In my own career as an academic surgeon, I have at times been frustrated by
multiple forces working at crossed purposes. Incentives are misaligned, outcomes
measures do not fully reflect the complexity of the process, and patients are often
overwhelmed with options. Healthcare executives and clinicians try to provide
patient-centric care in a heavily regulated and litigious environment. Yet despite
these challenges, organizations have emerged that are achieving the Institute of
Healthcare Improvement “Triple Aim” of improving the patient experience of care,
improving the health of populations, and reducing the per capita cost of healthcare.
This book hopes to capture the lessons learned by those successes and give the
reader tools and ideas relevant for their own situation.
Although this volume has an emphasis on American healthcare delivery, we have
drawn from experts familiar with alternative models, including single payer systems.
We strove to provide the reader with clear definitions of quality, efficiency, financial,
and appropriateness measures. Chapters focusing on leading change and motivating
others may provide ideas that are applicable in one’s own organization. We hope to
capture lessons learned from the past to reduce the uncertainty of the future.

Los Angeles, CA Harry C. Sax

vii
Acknowledgments

I have been fortunate to have had mentors who helped organize my thinking and
taught by example. Some were supervisors, and many were colleagues. During
residency at the University of Cincinnati, my Chairman, Dr. Josef Fischer, insisted
that excellence was expected and everything else needed an explanation. He pro-
vided me my first understanding of the business concepts of medical delivery and
research. Dr. Seymour Schwartz, at the University of Rochester, gave me my first
job in 1989. He was the ultimate Renaissance man and emphasized the humanistic
aspects of leadership. My colleagues at The Miriam Hospital and Brown University
helped me round out my understanding of medical staff functioning, collaboration
with the community, and how to interface with governmental agencies. We took
risks with data transparency, individual practitioner report cards, and integration of
new technology. The chance to go back to school at age 52 at the Harvard Masters
in Health Care Management Program was energizing and gave me new tools and
insights. As good as the professors were, the 17 other physicians from around the
world were my everyday teachers. We spent more than a few nights in the hotel
lobby, figuring out solutions to case studies…. and our lives. My current Chair at
Cedars-Sinai, Dr. Bruce Gewertz, exemplifies leadership in all he does, with a com-
bination of pragmatism, humor, and a deep understanding of people. He and the
former Chair of Medicine, Dr. Glenn Braunstein, were gracious in creating a new
position for me when I was transitioning my career to focus on healthcare manage-
ment, quality, and safety.
Barbara Lopez-Lucio and her colleagues at Springer gently pushed to keep me
on track with this book and provided alternatives when we hit roadblocks. It has
been a pleasure to work with them.

ix
Contents

1 Healthcare Transformation: What Are the Challenges? ....................... 1

Harry C. Sax
2 Terminology and Applications: Hospital Performance Measures ........ 7
Brett McCone
3 Measurements and Analysis in Transforming Healthcare Delivery:
Terminology and Applications—Physician Performance .................... 25
David Norris
4 Assuring Appropriate Care ...................................................................... 41
Charles E. Coffey Jr. and Teryl K. Nuckols
5 Aligning Medical Staff Within the Academic Medical Center ............. 59
Victoria G. Hines and Michael F. Rotondo
6 Aligning Healthcare Systems ................................................................... 71
Thomas R. Graf and Glenn D. Steele Jr.
7 Influencing with Integrity ........................................................................ 83
Michael R. Williams and Steven R. Sosland
8 Perspectives from Single Payer Systems ................................................. 99
Eyal Zimlichman and Yishay Falick
9 Leadership to Encourage and Sustain Performance ............................. 113
Monica Jain and Bruce L. Gewertz

Index ................................................................................................................. 123

xi
Contributors

Charles E. Coffey Jr., M.D., M.S., F.H.M., F.A.C.P. Los Angeles County +
University of Southern California Medical Center, Los Angeles, CA, USA
Yishay Falick, M.D., M.B.A. Department of Medical Affairs, Ministry of Health,
Jerusalem, Israel
Bruce L. Gewertz, M.D. Department of Surgery, Cedars-Sinai Medical Center,
Los Angeles, CA, USA
Thomas R. Graf, M.D. The Chartis Group, Pine Grove, PA, USA
Victoria G. Hines, M.H.A. University of Rochester Medical Faculty Group,
University of Rochester Medical Center, Rochester, NY, USA
Monica Jain, M.D. Department of Surgery, Cedars-Sinai Medical Center, Los
Angeles, CA, USA
Brett McCone, B.A., M.H.A. Department of Rate Setting, Maryland Hospital
Association, Elkridge, MD, USA
David Norris, B.S-.C.S. MD Insider, Santa Monica, CA, USA
Teryl K. Nuckols, M.D., M.S.H.S. Department of Medicine, Cedars Sinai Medical
Center, Los Angeles, CA, USA
Michael F. Rotondo, M.D., F.A.C.S. University of Rochester Medical Faculty
Group, University of Rochester Medical Center, Rochester, NY, USA
Harry C. Sax, M.D., F.A.C.S., F.A.C.H.E. Department of Surgery, Cedars Sinai
Medical Center, Los Angeles, CA, USA
Steven R. Sosland, M.B.A., B.S. Office of People Development, University of
North Texas Health Science Center, Fort Worth, TX, USA
Glenn D. Steele Jr., M.D., Ph.D. xG Health Solutions, Danville, PA, USA

xiii
xiv Contributors

Michael R. Williams, D.O., M.D., M.B.A. University of North Texas Health

Science Center, Fort Worth, TX, USA
Eyal Zimlichman, M.D., M.Sc. Central Management, Sheba Medical Center,
Ramat Gan, Israel
Chapter 1
Healthcare Transformation:
What Are the Challenges?

Harry C. Sax

Healing is a matter of time, but it is also a matter

of opportunity.
Hippocrates

Overview

With the unprecedented expansion of both capability and cost, medicine stands at a
crossroads—we have the ability to correct defects at the cellular level, yet cannot
deliver consistent, evidence-based, appropriate care to broad segments of society. In
the United States, healthcare expenditures approach 18 % of Gross Domestic Product,
yet measured outcomes in areas such as infant mortality, and access to care are not
commensurate with the resources consumed [1]. Headlines suggest we are killing
over 100,000 patients a year through medical error, yet mandated process measures
with incentives and penalties have not significantly reduced this number [2, 3].
To address these challenges, we must understand the current state, measure relevant
data, and understand interactions of multiple stakeholders to align a cohesive response.
This volume is a complement to Dr. Fabri’s excellent treatise on the mechanics
of measurement. His in-depth analysis of statistical methods clearly outlines the
potential and the limitations of quantitative data. He emphasizes that correlation
may not be causation, and that the application of big data to the individual patient is
different from that of populations. With this as the base, we will focus on what to
measure in the real world, and how to translate those findings into actionable items.

H.C. Sax, M.D., F.A.C.S., F.A.C.H.E. (*)

Department of Surgery, Cedars Sinai Medical Center, 8700 Beverly Blvd;
NT 8215, Los Angeles, CA 90048, USA
e-mail: Harry.Sax@cshs.org

© Springer International Publishing Switzerland 2017 1

H.C. Sax (ed.), Measurement and Analysis in Transforming Healthcare
Delivery, DOI 10.1007/978-3-319-46222-6_1
2 H.C. Sax

The initial chapters outline both quantitative and qualitative measures to aid in
the system design and benchmarking necessary for successful transformation. The
outcomes of single payer systems are examined as many analogies can be drawn to
the move away from fee for service and to global budgeting. Finally, experienced
leaders will share how they combined data with an understanding of human motiva-
tion to achieve remarkable results.
We open focusing on specific definitions of hospital performance. Although
increasing amounts of care are delivered outside of the acute hospital setting, it is
nonetheless critical to understand how resources flow and are consumed, as well as
the quality of what is delivered. From a pubic planning perspective, it is advanta-
geous to reduce duplication of services without impacting access. Further, Birkmeyer
and others have shown a clear relationship between hospital volumes for high index
procedures and better outcomes [4]. McCone’s chapter shares perspectives from the
Maryland Hospital Association’s experience with a statewide All Payer Model and
has an excellent description of how costs are allocated in an acute care setting. For
any organization to survive, expand, and meet its missions, margins are required. As
payment models change, the way we approach this equation must adapt.
The success of any delivery system is highly dependent on the health care pro-
viders within it. Norris describes the mechanism for developing and validating indi-
vidual physician score cards, a highly sensitive issue among doctors. The key to the
acceptance of a performance-based assessment is clear risk adjustment and holding
individuals responsible only for those things over which they truly have control.
Inherent to any assessment of performance is the issue of transparency. Over 20
years ago, New York State published the individual outcomes of cardiac surgeons
and the hospitals in which they worked. The methodology included risk adjustment
and also controlled for volume. The results were as one would expect—after a
period of criticizing methodology—a gradual acceptance ensued. Poorly perform-
ing programs either improved or closed, well-performing institutions were encour-
aged to share their best practices, referrals shifted, and overall results were
significantly enhanced [5]. With the Internet, formal and informal rating systems
abound, but validation of the results and methodology is variable. For those who are
rated, there is a tendency to advertise and celebrate those reports that make one look
good and dismiss those that do not as measuring the wrong things. The techniques
described in this chapter will help in “rating the raters.”
How well we deliver care is one component of transformation—another is
whether the care we deliver is appropriate both for the patient and for those that
must decide how to allocate fixed resources. This is not to imply that care is being
“rationed.” Rather it is to recognize that not all care delivers the best overall out-
come for the patient, given the risks, benefits, and costs. In their examination of
appropriateness, Coffey and Nuckols tackle this tricky question and give practical
example of how organizations have integrated these guidelines for the benefit of the
patient. Guidelines are necessary but not sufficient. A key component remains open
discussions between the patient and their clinician in developing plans of care. This
is especially acute at the end of life when family dynamics often come into play.
1 Healthcare Transformation: What Are the Challenges? 3

Perhaps most telling is physicians’ own choices for their care at the end of life com-
pared to the more aggressive ones they recommend for their patients [6].
In addition to examining individual performance, entire groups of physicians
must be aligned to deliver integrated care. Hines and Rotondo discuss the develop-
ment of a multidisciplinary medical staff group at the University of Rochester.
Academic medical centers have different missions than community hospitals or
smaller primary care groups. Although there is the tendency to feel that the best way
to influence clinicians is to employ them, this is not necessarily the case. Multiple
different methods of risk and gain sharing are available, and one size does not nec-
essarily fit all. It is encouraging that legislation, such as the Comprehensive Joint
Replacement initiative, increases the ability for hospitals and practitioners to share
risk and gain—something that was previously inhibited by Stark Regulations [7].
Success in the emerging healthcare landscape will require all of the tools noted
earlier, combined with seamless vertical and horizontal integration. There are
numerous examples of success in this realm; one of the most cited is the Geisinger
system. Graf and Steele describe their journey of bringing together multiple stake-
holders for the benefit of the patient. What is most striking is that full-time employ-
ment was not a prerequisite to success. Instead, they led a relentless focus on quality,
best practices, and data-driven transparent outcomes. Successful programs that
were initially developed for patients covered by the Geisinger Insurance product
were scaled and opened to broader groups, including at-risk populations. The
patient-centered focus included a guaranteed price for cardiac surgery including
follow-up, as well as the offer to refund patients’ costs, if they were not satisfied
with their care. Clinicians seek to be part of the system [8].
In theory, having accurate data, validated clinical pathways, well trained health-
care providers, and adequate infrastructure should yield consistent, high-quality
outcomes. Yet why is it that many heavily resourced organizations do not reach their
full potential, and others that struggle in poor economic circumstances can flourish?
The key is leadership setting a clear vision and influencing others to follow their
own “True North.” Williams and Sosland relate their experience in two organiza-
tions—Hill Country Memorial Hospital (HCMH) and the University of North Texas
Health Science Center (UNTHSC). HCMH is a critical access hospital in
Fredericksburg, Texas. It was struggling for survival, had poor outcomes, low
patient satisfaction, and a disengaged medical staff. A sentinel event further galva-
nized the community. Leadership responded by focusing on inherent core values, a
willingness to be relentless in open examination of opportunities, and creating a
culture of both accountability and support. Their chapter described a transformation
from a hospital near death to a Baldrige award winner. Similar challenges were
encountered at UNTHSC, an emerging academic medical center in the highly com-
petitive environment of the Dallas Fort Worth metroplex. What becomes apparent is
that driving the transformation of an organization leads to personal growth as well.
Virtually every other developed country has some form of a single payer system
with near universal coverage for basic needs. Zimlichman and Falick, Israeli aca-
demic physicians who also have experience in the American system, focus on what
works and what does not in a single payer system. Israel is a hybrid, with competing
4 H.C. Sax

HMOs, as well as a flourishing secondary market for those patients who wish to pay
more to receive more. Further, Israel recognizes the importance of emerging health-
care technologies and dedicates a specific portion of the budget to innovation.
Similar to the United States, there are challenges with providing care to a large
number of noncitizens from neighboring countries and territories.

Key Concepts

Although each of the chapters has a different focus, several key themes emerge:
• We must acknowledge that there will be variability in outcomes within a popula-
tion and that standardization will reduce some, but not all of that variability.
• Although in Lake Woebegone, “all the children are above average” [9], it is sta-
tistically impossible that every practitioner and system will function in the top
50 %. We must find ways to assess accurately the skills of the practitioner and
assure that they are working in systems that allow them to optimize those skills.
Current dashboards provide some information, but attribution, risk adjustment,
team based care, and the low incidence of key metrics such as mortality make it
difficult to truly identify high- and low-performing physicians.
• All healthcare providers, and those that lead, must develop new sets of skills
centered around the “softer” competencies—emotional intelligence, servant
leadership, and adapting to the different motivators of multigenerational, multi-
cultural workforces.
• We must understand that just because we can do something does not mean we
should do something. The care we provide must be appropriate for the situa-
tion—and this will vary based on age, physical condition, and patient prefer-
ences. In America, we have difficulty discussing care at the end of life and the
dying process. Even support of the dialog between physicians and their patients
has been politicized into “Death Panels” [10].
• We must set reasonable expectations with patients and their families to avoid
disappointment (and possible litigation). Other countries have created stream-
lined arbitration panels, chaired by professionals, that can rapidly evaluate and
compensate a patient harmed by error [11]. Defensive medicine and its associated
costs are reduced. Physicians are still held accountable for true errors of commis-
sion, but there is a stronger tendency toward Marx’s “Just Culture” [12].
• We must recognize that physicians are motivated by multiple factors, one of the
strongest of which is autonomy to make the best choices for and with their
patients. Most of us were drawn to the field for the ability to make a difference in
a patient’s life, and to test and challenge ourselves. Definition of a physician’s
value by the number of work RVUs generated, or contribution margin to a ser-
vice line, is a way to create a disengaged, if nonetheless busy, medical staff.
Under new payment models, physicians will be incented not to provide certain
types of care, and will need to be engaged in other ways that bring value.
1 Healthcare Transformation: What Are the Challenges? 5

• Although beyond the scope of this book, medical education with the significant
monetary and time commitment it entails is creating a generation of physicians who
will spend most of their careers trying to get out from under significant debt. The
incentive to move to better paying subspecialties exacerbates the maldistribution of
primary care practitioners [13]. New options for earlier tracking to desired special-
ties and broadened opportunities for financial support in exchange for public service
may stem this trend. To make sure that physicians are doing what they are uniquely
trained for, we must support non-MD providers practicing at the top of their license.
• Current payment systems are complex, disjointed, and fraught with misaligned
incentives. The pressures to reduce length of stay and penalize readmissions
come without clear resources for improving transitions of care. It is interesting
that many single payer countries, with lower overall healthcare expenditures,
have longer average inpatient lengths of stay [14, 15]. As the United States moves
to more bundled payments and risk-based contracts, it will be vital to encourage
innovative partnerships among all stakeholders. Although fee for service, per se,
will become less prominent, natural market forces will continue to be in play and
tiered levels of care will emerge.
• Finally, we must embrace the current tumult as our greatest opportunity to return
to the core of why we care for our fellow man, both in sickness and in health; that
we as a society are willing to use resources to maintain the vitality of our com-
munity and that we will strive to provide appropriate care, in the right setting, for
the right reasons.

References

1. Organization for Economic Cooperation and Development. Healthcare share of GDP by coun-
try, 2016. Modern Healthcare. 2016. http://www.modernhealthcare.com/article/20160206/
DATA/500035409.
2. Ingraham AM, Cohen ME, Bilimoria KY, Dimick JB, Richards KE, Raval MV, Fleisher LA,
Hall BL, Ko CY. Association of surgical care improvement project infection-related process
measure compliance with risk-adjusted outcomes: implications for quality measurement. J Am
Coll Surg. 2010;211(6):705–14.
3. Altman DE, Clancy C, Blendon RJ. Improving patient safety—five years after the IOM report.
N Engl J Med. 2004;351(20):2041–3.
4. Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in
the United States. N Engl J Med. 2002;346:1128–37.
5. Thourani VH, Sarin EL. Influence of cardiac surgeon report cards on patient referral by cardi-
ologists in New York state after 20 years of public reporting. Circ Cardiovasc Qual Outcomes.
2013;6(6):617–8.
6. Murray K. How doctors die. Saturday Evening Post; March/April 2013.
7. Center for Medicare and Medicaid Services. Comprehensive care for joint replacement. 2015.
https://www.federalregister.gov/articles/2015/11/24/2015–29438/medicare-program-comprehen-
sive-care-for-joint-replacement-payment-model-for-acute-care-hospitals. e pub 24 Nov 2015.
8. Ellison A. Geisinger’s money-back guarantee is about more than refunds. Beckers Hospital
Review. http://www.beckershospitalreview.com/finance/geisinger-s-money-back-guarantee-
is-about-more-than-refunds.html. Accessed 9 Dec 2015.
9. Keillor G. Lake Woebegone days. New York: Penguin; 1986.
6 H.C. Sax

10. Nyhan B. Why the “death panel” myth wouldn’t die: misinformation in the health care reform
debate. Forum. 2010;18:1–24.
11. Gallagher TH, Waterman AD, Garbutt JM, Kapp JM, Chan DK, Dunagan WC, Fraser VJ,
Levinson W. US and Canadian physicians’ attitudes and experiences regarding disclosing
errors to patients. Arch Intern Med. 2006;166(15):1605–11.
12. Frankel AS, Leonard MW, Dehham CR. Engagement: the tools to achieve high reliability.
Health Serv Res. 2006;41(4 Pt 2):1690–709.
13. Phillips JP, Petterson SM, Bazemore AW, Phillips RL. A Retrospective analysis of the relation-
ship between medical student debt and primary care practice in the United States. Ann Fam
Med. 2014;12(6):542–9.
14. Centers for Disease Control. Hospital utilization (in non-Federal short stay hospitals). http://
www.cdc.gov/nchs/fastats/hospital.htm. Updated 27 April 2016.
15. National Health Service. Length of stay—reducing length of stay. 2013. http://www.institute.
nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/
length_of_stay.html.
Chapter 2
Terminology and Applications:
Hospital Performance Measures

Brett McCone

Introduction

Hospital performance measures are created and applied for a myriad of reasons.
They range from purely financial—how much it costs to produce something, to
purely clinical—the patient did or did not contract another condition before dis-
charge. Inherent in the use of hospital performance measures is the desire to increase
value. Health care value is defined as quality (output) divided by cost (input) [1]. To
transform health care delivery, hospital performance measures should be viewed
through the lens of value.
While cost and quality are often the basis of hospital performance measures, it is
important to understand the context of hospital payment incentives. Most United
States hospitals are subject to different payment incentives from Medicare, Medicaid,
and commercial insurance, including Blue Cross plans, health maintenance organi-
zations, etc. The payment incentives, particularly Medicare, can drive behavior that
directly or indirectly affect hospital performance on any measure or series of mea-
sures. Maryland’s All-Payer Demonstration Model is a unique exception that
attempts to align incentives across all payers and is worth exploring further.
In addition to hospital payment incentives, to successfully transform health care
delivery, hospital leaders must be aware of payment incentives for other providers.
In particular, how payment incentives for other providers may not align with hospi-
tal incentives, creating barriers to innovation. It is often not the financial incentive
to try something different, but rather the financial barrier that prevents groups of
providers from aligning with another. Hospital utilization measures, and some hos-
pital “quality” measures can be affected by payment incentives for other providers.

B. McCone, B.A., M.H.A. (*)

Department of Rate Setting, Maryland Hospital Association,
6820 Deerpath Road, Elkridge, MD 21075, USA
e-mail: bmccone@mhaonline.org

© Springer International Publishing Switzerland 2017 7

H.C. Sax (ed.), Measurement and Analysis in Transforming Healthcare
Delivery, DOI 10.1007/978-3-319-46222-6_2
8 B. McCone

At their core, hospital performance measures provide clinical, financial, and

operational leaders tools to manage the daily hospital business, and tools to improve
the long-term efficiency and effectiveness of health care delivery. Clear, accurate,
and timely data capture is essential to any performance measure. Data building
blocks for hospital measurement include basic cost accounting, to complex docu-
mentation and coding. In all cases, the measures are subject to the validity of the
data reported, requiring examination of a measure’s use to address variation among
hospitals, within a specific hospital over time, or both.

Overview

This chapter outlines performance measures in three categories: financial mea-

sures, clinical measures, and “combination” measures that attempt to address hos-
pital value. By definition, the first two categories are easily segregated. The last
category may reflect volume, service mix, service use, or a combination of any of
these, plus measures that are part clinical and part financial. Additionally, perfor-
mance measure uses are discussed. Use of the measure may dictate the best applica-
tion, e.g., absolute performance of hospitals relative to one another, or individual
hospital performance over time. Other considerations include defining hospital
“costs” as hospital expenditures, versus hospital payments, or costs to health plans
and other payers for services rendered.
On the surface, hospital financial measures are straightforward calculations
involving easily reportable data. Basic unit cost measures have been used by hospi-
tals for years to manage operations, from supply spending to departmental effi-
ciency. However, unit costs, or prices paid for hospital expenditures, reflect only one
driver of hospital costs. The other driver of hospital costs is the volume of services
used. Beginning with resource use under a per admission payment system, and end-
ing with resource use in a per capita model, the volume of services used can have a
profound effect on hospital costs and hospital payments.
Cost measures only make up the denominator in the value equation. To provide
value, hospitals must also demonstrate high quality. Clinical performance measures
are used to evaluate the quality of hospital care provided during the stay. These
measures are generally classified into either process measures—did you do some-
thing evidence based to improve the patient’s health, or outcome measures—did the
patient get better or worse as a result of the hospital stay. In both categories, the
underlying data inputs are crucial to how the measures are viewed and how they
change over time.
“Combination” measures may encompass a wide range of calculations to deter-
mine relative performance. A simple utilization measure used to compare hospitals
is case-mix adjusted length of stay, designed to measure hospital inpatient efficiency
while adjusting for differences in service mix. On a case mix adjusted length of stay
basis, the hospital will look more efficient with a decline in patient days. At a broader
level, the same hospital may look no more or less efficient on a case mix adjusted
2 Terminology and Applications: Hospital Performance Measures 9

admission basis if variable costs, or payment levels, do not decline with the decline
in patient days. In a payment system with strong financial incentives to reduce read-
missions, a measure of clinical effectiveness, the hospital may actually keep the
patient the same or even longer, if doing so avoids a readmission. In this case, the
marginal cost of keeping the patient an extra day must be lower than the financial
penalty of having the patient return to the hospital for a second admission.
Payment incentives to hospitals, and, payment incentives to other providers,
affect the overall cost of care. In the example above, the hospital may reduce length
of stay to improve inpatient efficiency by simply shifting service use to another set-
ting like skilled nursing care or home health. The hospital generates a cost savings
but there is a cost increase with the other service use. Depending on the downstream
provider’s financial incentives, the other provider’s cost of care may be below, the
same, or above the truncated hospital use. In the readmission example, the hospital
faces two different financial incentives from Medicare. The hospital will receive
payment for the additional admission (provided it is not a hospital acquired condi-
tion) yet could be subject to a penalty from Medicare if overall readmissions at the
hospital place it in the bottom quartile of national readmission rates.
Finally, the underlying data captured to report hospital performance measures is
an important, if not the most important, driver of results. Hospital financial data
tend to be system generated and then analyzed on a per unit, per day, or per admis-
sion basis. These cost data are derived from the hospital’s underlying direct and
indirect cost. The direct cost of supplies and other items is easily tracked. Allocating
hospital overhead to calculate unit costs including indirect costs is subject to the
method of allocation. Clinical measures tend to come from hospital abstract data
and are manually reported, e.g., Medicare value-based purchasing data, or from
hospital medical record data that rely on physician documentation and the efficacy
of hospital coding. Both areas deserve scrutiny to determine real effect on perfor-
mance measures as they involve manual data capture and a level of professional
judgment from the physician and the coder. Data used for risk-adjusted hospital
comparisons is subject to availability and consistency across hospital, state, and
national sources.

Financial Measures

Hospital financial measures have long been used to assess hospital performance, for
both individual departments and the overall hospital. Hospitals with effective cost
accounting systems can accurately track changes in unit cost performance over
time. On an aggregate basis, hospitals can compare the cost of an admission or
adjusted admission to each other, usually with some risk adjustment. However, the
underlying cost per unit measures may be vastly different without the same cost
allocations. At a very high level, one can also compare hospital and health care costs
on a per beneficiary or per capita basis, though there are a number of factors that
influence the validity of the denominator in this measure.
10 B. McCone

Table 2.1 Unit cost and direct cost

Unit of Measure Direct cost per unit Units Total cost
Med/surg unit Patient days $800.00 3 $2,400
Radiology RVU’s 20.00 50 1,000
Operating room Minutes 40.00 75 3,000
Anesthesia Minutes 0.50 75 38
Supplies Direct Cost 15,000.00 1 15,000
Drugs Direct Cost 100.00 1 100
Total cost per $21,538
admission

Unit Cost Measurement

At a basic level, hospitals can calculate the per unit input cost of service delivery.
Table 2.1 provides an illustration of the direct cost per unit involved in an inpatient stay.
Even this is an inexact science since the staffing costs are typically averaged by
dividing nursing unit expenses by the overall volume for a given period. The same
is true for ancillary service use, though relative value units (RVUs) are used to
equate the intensity of the service performed. Medical supply and drug costs can be
calculated based on the actual use of billable supplies. Non-chargeable supplies,
while usually 100 % variable, are likely lumped into billable supply costs, charged
to the nursing unit and spread over the number of patients served.
Table 2.1 reflects the estimated direct cost of a total joint replacement. As shown
in Table 2.1, the hospital incurred $21,538 amount for the overall stay. Of this
amount, $15,000 was consumed in direct supply cost. The other direct costs for
nursing and ancillary personnel are semi-variable as some level of minimum staff-
ing is required to keep the unit open.1 From a performance measurement standpoint,
the hospital can compute the input costs per unit and try to improve its unit cost
efficiency by reducing the input cost of supplies, labor, or both. While it may be
difficult to compare absolute cost performance at this level to other hospitals, the
hospital can easily measure its cost performance over time to determine if certain
initiatives are working.
Table 2.2 reflects the results of two recent programs implemented by the
hospital.
First, the hospital implemented a different staffing mix, increasing the number of
nurse extenders and decreasing the number of nurses. This resulted in an average
savings of $100 per day, or a 13 % reduction in direct room and board costs. Second,
the hospital implemented a standardized supply program, reducing the cost of the
implant used by $3,000, or 20 %. Overall all, the direct cost for the patient was
reduced by 15 %, largely driven by the reduction in supply cost. Since these compu-

1
For an excellent explanation of direct and indirect costs, and, fixed, variable, and semi-variable
costs in hospitals, see Health Care Budgeting and Financial Management, Second Edition William
J. Ward, Jr. Praeger, an imprint of ABC-CLIO ISBN 978-1-4408-4428-7.
2 Terminology and Applications: Hospital Performance Measures 11

Table 2.2 Direct cost before and after hospital cost reduction programs
Before hospital programs After hospital programs
Direct cost Direct cost
per unit Units Total cost per unit Units Total cost Savings (%)
Med/surg unit $800.00 3 $2,400 $700.00 3 $2,100 13
Radiology 20.00 50 1,000 20.00 50 1,000 0
Operating 40.00 75 3,000 40.00 75 3,000 0
room
Anesthesia 0.50 75 38 0.50 75 38 0
Supplies 15,000.00 1 15,000 12,000.00 1 12,000 20
Drugs 100.00 1 100 100.00 1 100 0
Total cost per $21,538 $18,238 15
admission
Cost savings $3,300

tations reflect only a change in unit costs and not underlying volume, there is no
need to adjust for the variability of costs with volume.
Table 2.3 overlays the indirect hospital costs. Indirect costs include pure fixed
costs (depreciation, interest) and other highly fixed costs (administration, compli-
ance, malpractice expense).
After adjusting for the indirect cost allocation, the total cost of the original exam-
ple is now $29,076. When the savings programs are implemented, the hospital cost
reduction was the same in absolute dollars, but the percentage savings was lower
because the overall cost base is higher.
As reflected in the examples, hospitals can measure the unit cost inputs within
the same service, with or without adjusting for indirect cost. Per unit costs are useful
when measuring the performance of cost reduction initiatives over time, at particu-
lar location. The data are easy to gather and use to compute the result, assuming the
same use.

Per Admission Measures

The next aggregation of hospital cost measurement is typically on a per admission

basis. Unlike the unit cost example, the per admission measure has two cost input
variables—unit cost and the number of units of service used during the stay. When
aggregating data from multiple patients within a single service line, the data may
also be risk or service mix adjusted, based on Medicare Severity Diagnosis Related
Groups (MSDRGs) or some other equivalent of service mix.2 More importantly, if
the payment is the same on a per admission basis regardless of the utilization, any
reduction in utilization should produce a financial return.

2
The term “case mix” is also used interchangeably, referencing an admission or “case” admitted to
the hospital.
 12

Table 2.3 Direct and indirect costs before and after hospital cost reduction programs
Before hospital programs After hospital programs
Direct cost per Indirect cost Direct cost per Indirect cost
unit per unit Units Total cost unit per unit Units Total cost Savings (%)
Med/surg unit $800.00 $280.00 3 $3,240 $700.00 $280.00 3 $2,940 9
Radiology 20.00 7.00 50 1,350 20.00 7.00 50 1,350 0
Operating room 40.00 14.00 75 4,050 40.00 14.00 75 4,050 0
Anesthesia 0.50 0.18 75 51 0.50 0.18 75 51 0
Supplies 15,000.00 5250.00 1 20,250 12,000.00 5,250.00 1 17,250 15
Drugs 100.00 35.00 1 135 100.00 35.00 1 135 0
Total cost per admission $29,076 $25,776 11
Cost savings $3,300
B. McCone
2 Terminology and Applications: Hospital Performance Measures 13

Table 2.4 reflects the same example used in the unit cost analysis.
In this case, the hospital recently improved its discharge efficiency and reduced
its length of stay from 3 days to 2 days. However, we also introduce cost variability
into the equation. As underlying volume increases or decreases, percentages of the
direct and indirect costs are fixed, remaining constant with the change in volume.
For illustrative purposes, we will assume that 80 % of the nursing costs are variable,
reflecting some portion of fixed staffing cost on the nursing unit. In real world man-
agement, nursing unit costs reflect a “step function.” In a step function, costs are
fixed until the increase or decrease in volume justifies opening or closing of a nurs-
ing unit, respectively. We also assume that 90 % of the indirect overhead costs,
administration, patient accounting, etc., are fixed as they remain relatively
unchanged with volume. In this example, the other costs are fixed as they are
assumed to be provided on the first or second day (surgery, X-ray, etc.).
As shown in Table 2.4, the hospital generated a 2 % cost reduction per admission
by reducing the length of stay from 3 days to 2 days. On an individual admission,
the financial performance improved slightly when compared to the unit cost exam-
ple. If length-of-stay improvements are generated on a wide basis, the cost effect
multiplies, particularly if declining volumes result in closing a unit as reflected in
the step function. Some of the indirect cost is also further reduced (e.g., dietary,
housekeeping, etc.), compounding the savings. As an alternative to closing a unit,
additional financial benefits may accrue if the now empty beds are back filled with
patients waiting in the queue for services.
The per admission measure can be useful when comparing costs among physi-
cians in the hospital or when comparing costs across hospitals. Using Medicare case
mix index (CMI), the hospital can aggregate patients by physician in a particular
service line as a useful tool to compare the average cost per patient.3 Comparing
aggregate hospital efficiency can be accomplished by aggregating expenses
generally (all hospital expenses per discharge) or by aggregating expenses for a
particular service if the data are available (e.g., orthopedics, total joint replace-
ments, etc.).
Table 2.5 compares case mix adjusted cost per admission between two physi-
cians, assumed to practice the same type of service (orthopedics) but with a different
mix of cases. Assume the two physicians perform only two types of cases, total joint

3
Though CMI is a measure of the severity of cases treated, it is not a perfect measure. Medicare
CMI is a measure of average resource use, based on the grouping of admissions into categories
with similar service use (e.g., total joint replacement, influenza, etc.). However, the underlying
case weights assigned to a particular MSDRG are based on Medicare claims data and therefore
reflect Medicare patients only. Discharges from other payers may reflect higher or lower resource
use. Applying Medicare CMI to compare all payer per admission costs across hospitals may not
accurately reflect the true service mix as the patient populations can vary. MSDRGs though sever-
ity adjusted, measure severity adjusted resource use as determined by Medicare payments, and
may not reflect patient complexity if applied to all patients. Other groupers, such as the 3M’s All
Patient Refined Diagnostic Related Group (APRDRG) logic use different coding logic and differ-
ent groupings. Case weights may also vary depending on the discharges used to predict the under-
lying resource use. State Medicaid programs use different grouping logics and a different patient
population than the Medicare grouper.
 14

Table 2.4 Direct and Indirect Costs, Volume Changes, and Volume Variability
Before hospital programs After hospital programs
Indirect Indirect
Direct cost % cost per % Total Direct cost % cost per % Total Savings
per unit Variable unit Variable Units cost per unit Variable unit Variable Units cost (%)
Med/surg $800.00 80 $280.00 10 3 $3240 $800.00 80 $280.00 10 2 $2572 21
unit
Radiology 20.00 80 7.00 10 50 1350 20.00 80 7.00 10 50 1,350 0
Operating 40.00 80 14.00 10 75 4050 40.00 80 14.00 10 75 4,050 0
room
Anesthesia 0.50 90 0.18 10 75 51 0.50 90 0.18 10 75 51 0
Supplies 15,000.00 95 5,250.00 10 1 20,250 15,000.00 95 5,250.00 10 1 20,250 0
Drugs 100.00 95 35.00 10 1 135 100.00 95 35.00 10 1 135 0
Total cost per admission $29,076 $28,408 2
Cost savings $668
B. McCone
2 Terminology and Applications: Hospital Performance Measures 15

Table 2.5 Case mix adjusted cost per admission

Physician 1 Physician 2
Average length of stay 5 3
Total costs $750,000 $500,000
Total admissions 10 10
Unadjusted cost per admission $75,000 $50,000
Medicare CMI 5.00 3.00
Case mix adjusted cost per admission $15,000 $16,667

replacements (lower intensity) and spinal reconstruction (higher intensity). Using

these assumptions, we can measure efficiency on a relative, per admission basis.
In this comparison, Physician 1 admitted 10 patients with an average length of
stay of 5 days, with total costs of $750,000, or $75,000 per admission. Physician 2
also admitted 10 patients with an average length of stay of 3 days, with total costs
of $500,000, or $50,000 per admission. Physician 1 reflected a case mix of 5.0, for
a case mix adjusted cost per admission of $15,000. Physician 2 reflected a case mix
of 3.0, for a case mix adjusted cost per admission of $16,667. On an unadjusted
basis, Physician 1’s cost per case is 50 % higher than Physician 2’s cost per case.
After adjusting for CMI, Physician 1’s cost per case is actually 10 % lower than
Physician 2’s cost per case. A strong understanding of risk adjustment is vital in
evaluation of individual physicians as well as negotiating prospective payments.

Per Capita or per Beneficiary Measures

At the highest level, hospital costs can be measured on a per beneficiary or a per
capita basis. This type of measure is best used to compare aggregate costs for a
group of hospitals in a wide geographic area. For example, statewide total hospital
cost or the statewide total hospital payments could be calculated, divided by the
total population, resulting in a per capita cost/payment that could be compared to
other states. (Note: in-migration and out-migration will affect the denominator).
The same measure could also be used to determine per beneficiary costs or pay-
ments for a defined number of beneficiaries in a health plan.
Unlike unit costs or even per admission costs, per capita spending is much more
likely to be affected by the use of services rather than the underlying service cost.
The Medicare Accountable Care Organization (ACO) model seeks to align incentives
by improving population health and reducing avoidable resource use, rewarding the
ACO with financial incentives that can be shared with the participating providers.
The new Maryland All-Payer model uses the same concept to measure hospital
spending, both on a per capita basis and on a Medicare per beneficiary basis.
Table 2.6 compares the year-over-year hospital spending performance of State A on
a per capita basis. In this example, State A reduced hospital spending by reducing
16 B. McCone

Table 2.6 Year over year statewide hospital spending per discharge and statewide hospital
spending per capita
State A Year 1 Year 2 Change % Change
Hospital payments $10,000,000,000 $9,660,000,000 $(340,000,000) −3.4
Discharges 800,000 736,000 (64,000) −8.0
Payment $12,500 $13,125 $625 5.0
per discharge
Hospital payments $10,000,000,000 $9,660,000,000 $(340,000,000) −3.4
Population 5,900,000 6,077,000 177,000 3.0
Payment $1,695 $1,590 $(105) −6.2
per capita

hospital discharges by 8 % while per admission costs actually rose. (For illustrative
purposes, this assumes net zero in-migration and out-migration for hospital services.)
This type of measure is a departure from the historic focus on unit cost and per
admission utilization controls. It is consistent with the triple aim goal to reduce
costs by reducing per capita spending [2], regardless of the underlying cost inputs.
The data may or may not be case mix adjusted, depending on the use. The Maryland
model does not adjust for service mix. Rather it sets a fixed, annual growth ceiling
for all payer per capita spending, and a variable Medicare per beneficiary spending
target, relative to national hospital spending per beneficiary growth.
The Maryland demonstration model is in its third year. Though early in its imple-
mentation, the model has demonstrated early progress by exceeding the required
targets in year 1 [3]. As service delivery evolves under this model, one might expect
consolidation of services, particularly at hospitals with lower volumes that result in
higher fixed costs. In other single payer countries, complex procedures are often
cohorted at fewer locations to allocate indirect and fixed costs over a larger volume
base. The impact of the new Maryland model on the hospital delivery is underway,
though it may be several years before these significant types of market movements
occur.

Hospital Clinical Quality Measures

As the US health care system transforms from volume to value, clinical perfor-
mance measures play an increasingly important role in hospital management, pay-
ment incentive design and consumer awareness. Clinical performance measures
tend to fall into two categories: evidence-based process of care (process) measures
and outcome measures, though there is not a strict definition. A third category,
patient perception of the hospital stay is by definition an “outcome measure,”
reflecting how the patient felt about his or her stay in the hospital. However, these
are not clinical outcomes—hospital acquired infection, mortality, etc. There are
advantages and disadvantages to either category, depending on the context of
2 Terminology and Applications: Hospital Performance Measures 17

measure use. Both clinical measure categories begin with the same idea: how do we
quantify “hospital quality” to inform hospital stakeholders. Over time, the focus on
hospital performance has migrated to outcome measures, but there is conflicting
evidence that measuring outcomes alone can improve quality [4].
One challenge of using clinical performance measures is the sheer volume of
quality data collected. QualityNet.org identifies and organizes CMS quality mea-
sures for different types of service providers [5]. Though comprehensive for CMS,
other payers may require different data reporting. Hospital resources are consumed
because of the vast reporting required. Hospital resources are not only used to col-
lect and report quality data, but also to review, validate, audit, secure, and most
importantly leverage the data to improve the hospital’s relative performance.
This section focuses on CMS’s Acute Care Hospital Quality Improvement
Program Measures since they are consistent across all US hospitals. There are four
main CMS quality incentive programs in the CMS quality improvement environ-
ment. They include:
• Hospital Inpatient Quality Reporting (IQR) program
• Hospital Value-Based Purchasing (VBP)
• Hospital-Acquired Condition Reduction Program (HACRP)
• Hospital Readmissions Reduction Program (HRRP)
These four programs combine both process and outcome measures. In addition
to these programs, clinical performance measures are released on CMS’s
HospitalCompare website for public consumption.

Process Measures

Process of care measures emerged as the first generation of clinical data used to
measure hospital performance. Medicare’s Inpatient Quality Reporting (IQR) pro-
gram was implemented in 2003 as part of the Prescription Drug Act. Initially, hos-
pitals were required to submit process of care data to Medicare or receive a 0.4 %
reduction to the annual Medicare Inpatient Prospective Payment System (IPPS)
payment update. In 2008, hospitals faced a 2.0 % reduction to the annual payment
update if the data were not reported.
Process measures used by CMS have evolved over time, based on the effective-
ness of their adoption. A current IQR process measure is Fibrinolytic Therapy
Received Within 30 min of Hospital Arrival for acute myocardial infarction (AMI)
patients. Fibrinolytic therapy is a proven treatment for the management of AMI,
reflecting improved outcomes by following the process [6]. Prior to 2015, there
were several process measures for AMI treatment originally in IQR, including
Aspirin at arrival and Beta-Blocker prescribed at discharge. These measures have
been removed, not because they were determined to be ineffective, but because they
were “topped out,” as being followed close to 100 % of the time by all hospitals.
These process measures are now voluntarily reported.
18 B. McCone

As referenced in the fibrinolytic therapy example, process of care measures are

clinically accepted based on published and peer reviewed evidence. Once deter-
mined to be effective, the treatment protocol can be built into a hospital’s process of
care, with the expectation that the process will improve patient outcomes. As hospi-
tals continually move toward value-based care delivery, process measures should be
constantly plotted with respect to outcomes, to validate that the supposed process
improvements are improving health outcomes. The topped out measures suggest
that hospitals are following accepted process measures, yet outcomes could vary,
reflecting other clinical improvements or different patient populations that appear
similar on the surface.

Outcome Measures

One definition of a health care outcome measure states it as a measure of quality of

medical care, the standard against which the end result of the intervention is assessed
[7]. Another non-health care source defines an outcome measure as the determina-
tion and evaluation of the results of an activity, plan, process, or program and their
comparison with the intended or projected results [8]. In either case, the outcome
can be defined as the result of something.
Hospital outcome measures may apply to different patient populations within
the hospital. Certain outcome measures have a limited denominator, or patient pool
from which the measure is applied. For example, CMS is collecting hospital
30-day, all-cause mortality rates following AMI hospitalizations. In this example,
the pool of patients is limited to patients that were hospitalized for AMI. Expanding
further, CMS measures rates for central line-associated bloodstream infections
(CLABSI) and catheter-associated urinary tract infections (CAUTI). These out-
come measures reflect the entire pool of patients at the hospital, minus those admit-
ted with an infection.
It is critical to understand how outcome measures can be affected by hospital
interventions, the nature of the population and the intersection of both. One process
measure is use of prophylactic antibiotics received within 1 h prior to surgical
incision, a clinical or hospital intervention. It can be assumed that following this
intervention should lead to better performance on various outcome measures includ-
ing surgical site infections, or in the near term, hospital readmission for surgical site
infections. Other outcome measures, such as 30-day readmission rate for heart fail-
ure patients may correlate with the severity of the patient population. Even of all
process of care measures are followed during the initial hospital stay, if the patient
has significant underlying complications, the readmission rate may be higher. Case
mix adjustments can be used to risk adjust the population used in the 30-day heart
failure readmission example, but CMI may not fully adjust for all underlying clini-
cal differences.
2 Terminology and Applications: Hospital Performance Measures 19

Defining Value: The Intersection of Financial

and Quality Measures

After separately exploring both financial and quality measures, we turn to applying
both to determine hospital value. Value may be determined in the aggregate, overall
cost versus overall quality, or in subcategories, process measures followed versus
resulting outcomes. In both cases, the goal is to determine value, or the quality of
care for the cost, or payment, incurred.
At the highest level, a simple way to examine value is to use an XY plot of hospi-
tal cost versus outcomes. Figure 2.1 reflects an aggregate plot of hospital cost per
admission versus a composite outcome score.
In this example, there are four quadrants, relative to the average of the hospitals
measured: high cost/high quality, high cost/low quality, low cost/high quality, and
low cost/low quality. Though crude, this measure provides basic illustration of value.
On the cost side, a hospital’s cost or payment per admission is inherently
weighted by the average of all costs or payments for the patient population.
Therefore, a hospital with a higher proportion of normal deliveries relative to inten-
sive surgical procedures is expected to have a lower overall cost per admission.
Developing a composite outcome measure is more subjective, depending on the
method of weighting each outcome. Weighting the outcomes equally is one method,
while a different method might weight the outcomes on the volume of each patient
pool reflected in the outcome. In the normal delivery versus surgical case example,
if the hospital has a higher proportion of deliveries, then one might weight the per-
centage of obstetric patients higher to weight the percentage of obstetric complica-
tions higher.
Adjusting one or both sides of the measures (cost or quality) may reveal a differ-
ent picture. For example, large academic medical centers typically have higher

Cost vs. Quality

1.40
1.30
High Quality / High Quality /
1.20
Low Cost High Cost
1.10
1.00
0.90
0.80
Low Quality / 0.70
Low Quality /
Low Cost 0.60 High Cost
0.50
0.40
$- $5,000 $10,000 $15,000 $20,000 $25,000 $30,000

Fig. 2.1 Cost versus quality

Another random document with
no related content on Scribd:
 That was in March. In the Christmas following, when the mere was
locked in stillness, and the wan reflection of snow mingled on the
ceiling with the red dance of firelight, one morning the old man came
hurrying and panting to Tryphena’s door.
“Tryphena! Come down quickly! My boy, my Jason, has come
back! It was a lie that they told us about his being lost at sea!”
Her heart leapt like a candle-flame! What new delusion of the old
man’s was this? She hurried over her dressing and descended. A
garrulous old voice mingled with a childish treble in the breakfast-
room. Hardly breathing, she turned the handle of the door, and saw
Jason before her.
But it was Jason, the prattling babe of her first knowledge; Jason,
the flaxen-headed, apple-cheeked cherub of the nursery; Jason, the
confiding, the merry, the loving, before pride had come to warp his
innocence. She fell on her knees to the child, and with a burst of
ecstasy caught him to her heart.
She asked no question of the old man as to when or whence this
apparition had come, or why he was here. For some reason she
dared not. She accepted him as some waif, whom an accidental
likeness had made glorious to their hungering hearts. As for the
father, he was utterly satisfied and content. He had heard a knock at
the door, he said, and had opened it and found this. The child was
naked, and his pink, wet body glazed with ice. Yet he seemed
insensible to the killing cold. It was Jason—that was enough. There
is no date nor time for imbecility. Its phantoms spring from the clash
of ancient memories. This was just as actually his child as—more so,
in fact, than—the grown young figure which, for all its manhood, had
dissolved into the mist of waters. He was more familiar with, more
confident of it, after all. It had come back to be unquestioningly
dependent on him; and that was likest the real Jason, flesh of his
flesh.
“Who are you, darling?” said Tryphena.
“I am Jason,” answered the child.
She wept, and fondled him rapturously.
“And who am I?” she asked. “If you are Jason, you must know
what to call me.”
“I know,” he said; “but I mustn’t, unless you ask me.”
 “I won’t,” she answered, with a burst of weeping. “It is Christmas
Day, dearest, when the miracle of a little child was wrought. I will ask
you nothing but to stay and bless our desolate home.”
He nodded, laughing.
“I will stay, until you ask me.”
They found some little old robes of the baby Jason, put away in
lavender, and dressed him in them. All day he laughed and prattled;
yet it was strange that, talk as he might, he never once referred to
matters familiar to the childhood of the lost sailor.
In the early afternoon he asked to be taken out—seawards, that
was his wish. Tryphena clothed him warmly, and, taking his little
hand, led him away. They left the old man sleeping peacefully. He
was never to wake again.
As they crossed the narrow causeway, snow, thick and silent,
began to fall. Tryphena was not afraid, for herself or the child. A
rapture upheld her; a sense of some compelling happiness, which
she knew before long must take shape on her lips.
They reached the seaward dunes—mere ghosts of foothold in that
smoke of flakes. The lap of vast waters seemed all around them,
hollow and mysterious. The sound flooded Tryphena’s ears,
drowning her senses. She cried out, and stopped.
“Before they go,” she screamed—“before they go, tell me what you
were to call me!”
The child sprang a little distance, and stood facing her. Already his
lower limbs seemed dissolving in the mists.
“I was to call you ‘mother’!” he cried, with a smile and toss of his
hand.
Even as he spoke, his pretty features wavered and vanished. The
snow broke into him, or he became part with it. Where he had been,
a gleam of iridescent dust seemed to show one moment before it
sank and was extinguished in the falling cloud. Then there was only
the snow, heaping an eternal chaos with nothingness.

Tryphena made this confession, on a Christmas Eve night, to one

who was a believer in dreams. The next morning she was seen to
cross the causeway, and thereafter was never seen again. But she
left the sweetest memory behind her, for human charity, and an elf-
like gift of loveliness.
 HIS CLIENT’S CASE
The “Personal Reminiscences” of the late Mr. Justice Ganthony, now
in process of being edited, are responsible for the following drollery:
—
My first “chambers” were on the top, not to say the attic, floor of a
house in (the now defunct) Furnival’s Inn. I called it “chambers,” in
the plural, on the strength of a coal-cellar, in the window-seat, and a
turn-up bedstead which became a cupboard by day. That accounted
for two rooms, and “the usual offices,” as the house-agents say,
when they refer to a kitchen six feet by eight in the basement.
Trousers, after all, are only one garment, although they are called a
pair.
There I sat among the cobwebs, like a spider, and waited for my
first brief. In the meanwhile, I lived as the spiders do—on hope,
flavoured with a little attic salt. It was not a cheering repast; but, such
as it was, there was no end to it. By and by I was almost convinced
(of what I had been friendlily advised) that it was a forlorn hope—the
sort that leads to glory and the grave; probably by starvation. A
spider has always, as a last resource, his web to roll up and devour. I
ate up my chambers by degrees; that is to say, I dined, figuratively,
day in day out, at the sign of the Three Balls. But this was to
consume my own hump, like the camel. When that should be all
gone, what next? There is a vulgar expression for prog, which is
“belly-timber.” I only realized its applicability to my own case when
my chairs and tables, and other furniture, had gone the primrose way
of digestion. It was the brass fender, a “genuine antique,” that sat
heaviest on my chest.
Furnival’s Inn was not a cheerful place to starve in. There was an
atmosphere of gloom and decay about it, which derived, no doubt,
from its former dealings in Chancery. In the days of its prosperity it
had fed the Inns of Court, as Winchester feeds New College; in my
time it could not feed itself. The rats were at it, and the bugs, which
are the only things I know of that can thrive on crumbling plaster. I
had the distinction of providing some of their rare debauches to the
latter; but that was before I began to crumble myself. Some of my
blood was certainly incorporated in the ancient walls, and was
included in their downfall.
My view, from Furnival’s Inn, was dismally introspective. It
commanded, in the first place, a quadrangle of emptiness; and
included, in the second, an array of lowering and mouldy tenements
like my own, at whose stark windows hungry expectant faces would
glimmer fitfully, and scan the yard for the clients who never came,
and disappear.
There was a decrepit inn, of another and the social type, budded,
like a vicious intestinal growth, within Furnival’s. I used to speculate,
as I looked down at night on its tottering portico, and solemn old
frequenters, and the lights blinking behind its blinds like corpse-
candles, if it were not a half-way house of call for the dead. For, by
day, all business seemed withdrawn from it, and its upper rooms
might have been mortuaries for any life they exhibited. No cheery
housemaid ever looked from their windows to chaff the amorous
Boots below. There was none to chaff. The dead need no boots.
Furnival’s Inn had one gullet, by which the roar of the world came
in from Holborn. Little else came in but tradesmen, and bailiffs, and
an occasional policeman in a thoughtful archæological mood. But the
gullet was a vent as much of exit as of entrance; and by it one could
escape from the madness of ghostly isolation, and mingle with the
world, and look in the pastry-cooks’ windows. Whenever I was
moved to one of these chameleonic foraging expeditions, I would pin
a ticket on my door: “Called away. Please leave message with
housekeeper,” and light my pipe with it when I returned. I wonder if
any one ever read the fatuous legends? To Hope’s eyes, I am sure,
they must have been dinted, like phonographic records, with the
echoes of all the footsteps that ever sounded on the stairs during my
absences.
Those footsteps! How they marked the measure of my
desperation! They were not many, and they were far between; but
not one in all the dreary tale ever reached my attic. Why should they,
indeed? I am free to acknowledge its moral inaccessibility.
Jurisprudence does not, in its convincing phases, inhabit
immediately under the roof. The higher one lives, in practice, the
lower one’s practice is like to be. The law is not an elevating pursuit.
I recognized this in the end; and the moment I recognized it I got
my first client.
One November evening, very depressed at last, I was sitting
smoking, and ruminating over my doleful fate, and thinking if I had
not better shut myself up for good and all in the bed-cupboard, when
I heard steps enter the hall below. My ears pricked, of course, from
force of habit, and from force of habit I uttered a scornful stage laugh
—for the withering of Fortune, if she happened to be by. But, in spite
of my scorn, the steps, ignoring the architects’ offices on the ground
floor (Frost and Driffel, contractors for Castles in Spain), ascended
and continued to ascend—past the deed-engrosser’s closet on the
half-way landing; past the empty chambers immediately below mine
(whence, on gusty nights, the tiny creaking of the rope, by which the
last tenant had hanged himself from a beam, would speak through
the floor under my bed), and higher yet, right up to my door.
Hope, dying on a pallet up three flights of stairs, sprang alert on
the instant. It might be a friend, a creditor, the housekeeper:
something telepathic, flowing through the panels, assured me that it
was none of these things. Tap-tap! so smart on the woodwork that it
made me jump. I swept pipes and tobacco into a drawer. “Come in!” I
cried. Then, as the visitor entered, “John, throw up the window a
little! O, bother the boy! he’s out.”
I don’t know if the new-comer was imposed on. He nodded and
sniffed.
“Tobacco!” he exclaimed. “What an age since I’ve tasted it! Mr.
Ganthony, I presume?”
I bowed.
“Barrister-at-law?”
I bowed again. My plate was in the hall to inform him.
“Accept my instructions for a brief.”
He stated it so abruptly that it took my breath away. If all this was
outside procedure, I was not going to quarrel with my bread and
butter. I motioned him to a chair, and, taking up pen and paper
tentatively, was in a position to scrutinize my visitor.
 His appearance was certainly odd—a marked exaggeration, I
should have pronounced it, of the legal type. His face was very red;
his enormous side-whiskers very white. Large spectacles obscured
his eyes, and he wore his silk hat (of an obsolete pattern) cocked
rakishly over one of them. Add to this that his voluminous frock-coat
looked like a much larger man’s misfit; that his black cotton gloves
were preposterously long in the fingers; that he carried a “gamp” of
the pantomime pattern, and it will be obvious that I had some reason
for my astonishment. But I kept that in hand. A lawyer, after all, must
come to graduate in the eccentricities of clients.
He looked perkily, with an abrupt action of his head, round about
him; then came to me again.
“Large practice?” he asked.
“Large enough for my needs,” I answered winningly.
“H’m!” He sniffed. “They don’t appear to be many.”
“That—excuse me—is my affair,” I said with dignity.
“Of course,” he said; “of course. Only I looked you up—accident
serving intuition—on the supposition that you were green, you know
—one of the briefless ones—called to the Bar, but not chosen, eh?”
I plumped instantly for frankness.
“You are my first retainer,” I said.
His manner changed at once. He pulled his chair a little nearer
me, with an eager motion.
“Thats what I wanted,” he said. “That’s it. The sort that are
suffering to win their spurs. None of your egregious old-stagers, who
require their briefs to be endorsed to the tune of three figures before
they’ll move—‘monkey’-in-the-slot men, I call ’em. Thinks I to myself,
Here’s the sort that’ll be willing to take up a case on spec’.”
My enthusiasm shot down to zero.
“O!” I said, with a falling face; “on speculation!”
“There’s a fortune in it for a clever advocate,” he answered
eagerly. “A fortune! all Pactolus in a nutshell. I’ve had my
experiences of the other kind. They squeeze you, and throw you
away; take the wages of sin, and hand you over to the deuce. What
do you say?”
“If you will give me the particulars,” I answered, without heart, “I
shall be able to judge better. Your client——?”
 He laughed joyously; frowned; put his hat on the floor; crossed his
arms over his umbrella-handle, and glowered ferociously at me,
squinting through his glasses.
“Exactly,” he said; “my client, ha-ha! Here, then, young sir, is my
client’s case.
“His name is Buggins” (I glanced involuntarily at the wall). “He is,
or was, until envy combined with detraction to ruin him, a company-
promoter. As such, his trend was always towards insurance. It
offered the best opportunities to a great creative genius. Buggins,
being all that, recognized the still amazing potentialities in a field of
commerce, which, though much worked, remains unexhausted—
almost, one might say, inexhaustible. In his younger days he showed
a pretty invention in devising and engineering what I may call
personal essays in this line. His Insurance against Waterspouts,
which he worked principally in the Midlands, brought him some
handsome returns with a single generation of farmers. It was based
on a cloud-burst at Bethesda, in Wales, which ruined quite a number.
Other flights of his immature genius were, respectively, Insurance
against Death in Diving-bells; against Death of a Broken Heart;
against Official Strangulation; against Non-fatal Disfiguration by
Lightning; against Death by Starvation (this last was largely
patronized by millionaires). On a somewhat higher plane were his
Provident Dipsomaniary, whose policies matured, or ‘burst,’ as
Buggins phrased it, at the age of eighty-five, an essential condition
being that the holders must put in their claims in person; his Physical
Promotion League, which guaranteed to pay to the parents of any
child, insured in it during his teens, a sum of ten pounds on the
child’s reaching twenty-five years of age and a minimum height of six
feet, and a thousand pounds for every additional inch which it grew
afterwards; his Anti-Fiction Mutual, whose policies were forfeitable
on first conviction of having written a novel (this proved one of the
most profitable of all Buggins’s enterprises for a time; but in the end
the national malady proved incurable, and subscribers fell off); his
Psychical Pocket Research Society, which offered an Insurance
against Ghost-seeing, the policy-holder forfeiting his claim on proof
of his first supernatural visitation (but this was so violently assailed
by the opposition society, which offered to prove that there were not
three people in the United Kingdom who were insusceptible to
spooks, that the scheme had to be abandoned); finally, in this
category, his Bachelors’ Protection Association, which provided that,
if a member reached the age of ninety without having married, he
should receive an annuity beginning at fifty pounds, and rising, by
yearly increments of ten pounds, to ten thousand pounds—figures
which, in a centenarian age, were successful in dazzling a great
many.
“But, by then, Buggins was beginning to master the deep ethics of
his trade, and to realize that its heaviest emoluments were rooted in
the grand principle of profitable self-denial. People will be unselfish if
they see money in it; you can’t stop ’em.
“One other notable venture marks this period of what I may call his
moral transition. That was his inspired scheme for insuring against
illness, in the sense that any policy-holder admitting him or herself to
be seriously indisposed, lost the right to compensation. It would have
proved a godsend in a neurotic age; but the antagonism of the entire
medical profession, with the single exception of the officer appointed
by the company, killed it.
“We come now to Buggins’s final matured achievements. I beg
your pardon?”
I had said nothing; but I suppose there is such a thing as a
“speaking” silence. Certainly, if I had looked as I felt, I was a more
drivelling maniac by now than Buggins himself. The visitor seemed
to shoot out his eyes like an angry crab.
“Young man, young man!” he said warningly, “I begin to be
suspicious that, after all, I may be misplacing my confidence.”
He looked banefully into his hat, where it stood rim upwards on the
floor; then, suddenly overwrought, kicked it fiercely across the room.
The action seemed to restore him to complete urbanity. He smiled.
“So perish all Buggins’s enemies!” he said loftily; “and hail the
grand climacteric!”
He pinned me, like a live butterfly, to the wall behind me with a
fixed and penetrating gaze.
“What would you say,” he said quietly, “to an Insurance against
Brigandage, available to all travelling in Sicily or the Balkans, and
realizable” (his watchfulness was intense) “on the receipt, at the
head-offices in the Shetland Islands, of a nose, ear, or other organ,
attested, under urgency, by the nearest consul, to be the personal
property of the applicant desiring a ransom?”
He paused significantly. “I should say,” I responded drivellingly,
“that, as a feat of pure inspiration, it—it takes the cake.”
“Ah!” He shouted it, and sprang to his feet joyously. “You are the
man for me! You justify my confidence, as the returns justified
Buggins’s daring conception. Would you believe it: within the first few
months, bushels of noses were received at the head-offices, every
one of which Buggins had no difficulty in proving to be false! But,
hush! stay!—there was to be a higher flight!”
He had been pacing riotously up and down. Now he flounced to a
stop before me, and held me once more with his glittering eye.
“It took the form,” he whispered, “of a Purgatory Mutual, on the
Tontine principle, the last out to take the pool!”
I rose, trembling, to my feet, as he burst into a violent fit of
laughter.
“It was that,” he shouted, as he set to racing up and down again,
“which let loose the dogs of envy, spite, and slander. They called him
mad—him, Buggins, mad, ha-ha! It was the fools themselves were
mad. He ignored their clamour; his vast brain was yet busy with
immortal conceptions; he matured a scheme against Death from
Flying-machines” (here he tore off one whisker and threw it into the
fireplace); “he did more—he personally tested the theory of
aerostatics” (here he tore off the other whisker, and stamped on it).
“Too great, too absorbed, he never noticed that the unstable engine
had landed him in the grounds of a private asylum, and, relieved of
his weight, had soared away again. The attendants came; they
seized and immured him; they would not believe his assurances that
he was a perfect stranger. From that day to this, when fortuitous
circumstances enabled him to escape, he has appealed to their
justice, their humanity, in vain.”
Again he stopped before me, and, flinging his spectacles in my
face, rent open the breast of his coat.
“Know me at last for what I am!” he yelled. “I am Buggins, and I
appoint you my advocate in the action I am about to bring against
the Commissioners of Lunacy!”
 The door opened softly, and a masculine face peered round the
edge. Its scrutiny appearing satisfactory, it was followed by the whole
of an official form, which, in its entering, revealed another, large and
passionless, standing behind it.
“Now, Mr. Buggins,” said the first, “we’re a-waitin’ for you to take
up your cue.”
The visitor whipped round, started, chuckled, and, to my relief and
surprise, responded rather abjectly.
“All right, Johnson,” he said. “I just slipped out between the acts for
a whiff of fresh air.”
“Well,” said the man, “you must be quick and come along, or you’ll
spile the play.”
He went quite tamely, and the second official outside received him
stolidly into custody. Mate number one lingered to touch his cap to
me and explain.
“Flyborough Asylum, sir. They give him a part in some private
theatricals, and he tuk advantage of his disguise as a family lawyer
to hook it between the acts. None of us reco’nized him, or guessed
what he’d done, till the time come for him to take up his cue; and
then, with the prompter howling for him and him not answering, the
truth struck us of a heap.”
I was down in my chair, flabby and gasping.
“But what brought him to me?” I groaned.
“Train, sir,” answered the man; “plenty of ’em, and easy to catch
from the suburbs. Why he come on here? Why, his offices in the old
days was in Furnival’s; it were that give us the clue. I suppose, now”
(he took off his cap, took a red handkerchief from it, thoughtfully
mopped his forehead, and returned the bandana to its nest), “I
suppose, now, he’s been a-gammoning of you pretty high with his
insurances? His fust principle in life was always to play upon fools.”
 AN ABSENT VICAR
“Exactly,” said the Reverend Septimus Prior; “the exchange was
the most fortuitous, not to say the most fortunate” (he gave a little
giggle and bow) “possible. Your uncle saw my advertisement,
answered it, and for a brief period he goes to my cure, and I come to
his.”
“Well, if you feel certain,” said Miss Robin, regretfully resting in her
lap the novel she was reading.
Mr. Prior sipped his tea and nibbled his rusk. In the intervals
between, he would occasionally glance at the portrait of a scholarly
cleric, with a thin grim mouth and glassy eyes, which bantered him
from the wall opposite.
“Your uncle—Mr. Fearful?” he had once ventured to ask; and the
niece had answered, “Yes. It is very like him.”
Now he paused, with his cup half-way to his mouth.
“I beg your pardon?” he exclaimed.
Miss Robin put her book to her lips, and looking over it—really
rather charmingly,—yawned behind the cover. She was surprisingly
dégagée for a country vicar’s niece—self-collected, and admirably
pretty; though her openwork stockings, which she did not hesitate to
cross her legs to display, filled him with a weak sense of
entanglement in some unrighteous mystery.
“You said?” he invited her.
“I said, If you feel certain,” she repeated calmly.
“Ah!” he said. “Yes. You mean?”
“I mean,” she said, without a ruffle, “that Uncle Philip may have
settled to swap livings with you pro tem., and may have started off to
take yours, and may have got there—if you feel certain that he has.”
“To be sure,” he answered. “Why shouldn’t I?”
“Had he arrived—when you started—for here?”
“No. Certainly he hadn’t arrived. My train was due. I had to leave a
message; but——”
 She stopped him by dropping her book into her lap; and, clasping
one knee in her hands, conned him amiably.
“Did he lead you to expect a niece among the charges he was
committing to your care—or cure?” she asked.
“Well, I must confess,” said the young man, blushing, “he—ah!
mentioned a housekeeper—Mrs. Gaunt, I think—but——”
“No, of course not,” she interrupted him. “He had forgotten all
about me.”
Mr. Prior gasped, and looked down. This was his first holiday
exchange of livings—an unsophisticated venture, which he was
already half repenting. A suburban cure; a desire for fresh pastures;
a daring resolution; an advertisement in the “Church Times”; a
prompt answer; as prompt an acceptance (after due reference to the
Clergy List); a long railway journey; a tramp, relatively as long, to a
remote parsonage on the road to a seaport; an arrival in the dark; an
innocence of all expectation of, or preparation for him; an
explanation; production of his written voucher, and—here he was,
accepted, he could not but think, on sufferance. But there he thought
wrong. Miss Robin was not near so upset by his appearance as he
was.
“He comes and goes” (she said of Uncle Philip) “without reference
to anybody or anything. We never know what he’ll do next, or who’ll
introduce himself into the house as his friend. It may be a burglar or
a pirate for all we know. All sorts of strange people come up from the
port, and are shown into my uncle’s room, and out again by himself
at the side door. At least, I suppose so. We never know what
becomes of them, or what’s going on, any more than I doubt he does
himself. I dare say they fleece him nicely; and—you may laugh—but
when he’s in his absent moods, you might undress him without his
knowing. Only he’d probably strike you to the ground when he found
out—he’s such an awful temper.”
“Dear me!” murmured the young man; “how very curious. One
hears of such cases.”
“Does one?” said Miss Robin. “I’d rather hear of, than live with
them, anyhow; and in a desert, too. It wouldn’t so much matter if he
didn’t always hold others to blame for his mistakes and mislayings.
He kept me in bed a week once, because he’d read right through a
treatise on explosives in the pulpit, before he discovered that it
wasn’t his peace-thanksgiving sermon.”
“Astonishing!” said Mr. Prior; then added, with a faint smile, “Well, I
can promise you, at least, that I’m not a pirate.”
“No,” she said, “I can see you’re not. Won’t you have some more
tea?”
He was shown to his bedroom by Mrs. Gaunt, who was a stony,
silent woman, bleak with mystery. All night the wind howled round
the lonely building; and the unhappy man, who, in a phase of worldly
revolt, egged on by a dare-devil parishioner, had once read “The
House on the Marsh”, thought of Sarah and Mr. Rayner, and of a
silent weaving of strings across the stairway in the dark to catch him
tripping should he venture upon escape.
He arose, feverish, to a sense of hooting draughts in a grey house,
and went to matins in the gaunt dull church, which stood as lonely as
a shepherd’s hut on a slope hard by. There was nothing in sight but
wind-torn pastures, and, all around, little graves, which seemed
trying vainly to tuck themselves and their shivering epitaphs under
the grass. There appeared nothing in the world to attract a
congregation; but, as a matter of fact, there were a few old frosted
spinsters present, of that amphibious order, a sort of landcrabs,
which forgathers on the neutral wastes between sea and country.
Mr. Prior went back to his dreary breakfast at the Vicarage. His
lady hostess, it appeared, was wont to lie late abed, and did not think
it worth her while to alter her habits for him. The meal, however, had
been served and left to petrify, pending his return from matins. It was
with a consciousness of congealed bacon-fat, insufficiently dissolved
by lukewarm tea, sticking to the roof of his mouth, that he rose from
it, and pondered his next movement. No one came near him. He
looked dismally out on a weedy drive. He rather wished Miss Robin
would condescend to his company. He was no pirate, certainly; but
he believed he would brave, had braved already, much for his cloth.
She had beautiful eyes—clear windows, he was sure, to a virginal
soul. But then, the other end! the white feet peeping through that
devil’s lattice! He tried to recall any authority in Holy Writ for
openwork stockings. Certainly pilgrims went barefoot, and half a loaf
was better than no bread.
 “This will not do, Septimus,” he said, weakly striking his breast. “I
will go and compose my sermon.”
He stepped into the hall. It was papered in cold blue and white
marble, with a mahogany umbrella stand, and nothing else, to
temper its tomb-like austerity. At the further end was a baize door of
a faded strawberry colour.
He was entitled to the run of the house, he concluded. There had
been no mention of any Bluebeard chamber. But, then, to be sure,
there had been no mention of a niece. The association of ideas
tingled him. What if he should turn the handle and alight on Miss
Robin?
He flipped his breast again, frowning, and strode to the baize door.
Beside it, he now observed, a passage went off to the kitchens.
Desperately he pulled the door, found a second, of wood, beyond it,
opened that also, and found himself in what was obviously the
Vicar’s study.
Obviously, that is to say, to his later conceptions of his
correspondent. Otherwise he might have taken it for the laboratory of
a scientist. It was lined with bookcases, sparsely volumed; but five
out of every six shelves were thronged with jars, instruments, and
engines of a terrifying nature. In one place was a curtained recess
potential with unholiness. Prints of discomposing organs hung on the
walls. Immemorial dust blurred everything. There was a pedestalled
desk in the middle, and opposite it, hung with a short curtain, a half-
glazed door which the intruder, tiptoeing thither and peeping, with his
heart at the gallop, found to lead into a dismal narrow lane which
communicated with the road. He returned to the desk, which, frankly
open, seemed to invite him to its use, and was pondering the moral
practicability of composition in the midst of such surroundings, when
a voice at his ear almost made him jump out of his skin.
“Pardon me, sir; but have you the master’s permission to use this
room?”
Mrs. Gaunt had come upon him without a sound.
“Dear me, madam!” he said, wiping his forehead. “What do you
mean?”
“I mean, sir,” she said, in her stony, colourless way, “that this room
is interdict to both great and little, now and always, unless he makes
an exception in your favour.”
“There was no specific mention of it, certainly,” said Mr. Prior,
“neither for nor against. I concluded that the use of a study was not
debarred me.”
“Pardon me,” she repeated monotonously. “I believe you
concluded wrong, sir.”
“The door was not locked.”
“There are some prohibitions,” she said, “that need no locks.”
The inference was fearful.
“Miss June” (ecstatic name!) “and I,” she said, “have never dared
so much as to put our noses inside, and not a word spoken to forbid
it.”
Mr. Prior, to his own astonishment, revolted. Smarting, perhaps,
under the memory of some suspected covert innuendo in a certain
silvery acquiescence in a statement of his made last night, he
revolted. He would prove that he could be a pirate if he chose.
“I shall stop here,” he said, trembling all over. “There was no
embargo laid, and I must have somewhere to write my sermon.”
“Of course,” said a voice; and Miss Robin stood in the doorway—
the most enchanting morning vision, her eyes bright with curiosity.
“I am delighted you support me,” he said, kindling and advancing.
She still looked beside and around him.
“Do you know,” she said, “it is perfectly true. I have not once dared
to venture in here before, though never actually told not to. But that
is all one, I think. What an extraordinary litter!”
She had not ventured! and with the inducement of her petrifying
surroundings! She was uninquisitive, then—“an excellent thing in
woman.”
“Since there is no veto,” he said, incomparably audacious,
“supposing we explore together?”
She looked at him admiringly.
“I should like to.” She hesitated.
“June!” cried Mrs. Gaunt.
“And I will,” said the girl.
But the housekeeper, content, it appeared, with her protest, stood,
not uninterested in the subsequent investigation.
 “Do you not find all this a little remote, a little lifeless sometimes,
Miss Robin?” said the clergyman, greatly daring.
She shrugged her shoulders.
“Eels get used to skinning. It’s not life, of course. But I have to
make the best of it, and there’s no help.”
“Ah, yes, there is!” said her companion, intending to imply the
spiritual, but half hoping she would construe it into the material
consolation.
“What do you mean?” she asked simply.
“Why,” he said, stammering and blushing furiously, and giving
away his case at once, “with your youth, and—and beauty—O,
forgive me! I am a little confused.”
“Where do you live?” she said, fixing him with her large eyes.
“At Clapton,” he murmured.
“It sounds most joyous,” she said, clasping her hands.
Hardly knowing what he did, he pulled the curtain away from the
recess by which they stood, and instantly staggered back. The
housekeeper, who, foreseeing his act, had crept up inquisitively
behind, gave a mortal gasp, and Miss Robin a faint shriek—for,
stretched lifeless and livid on a couch within, lay the stark body of a
man.
For a minute they all stood staring, frozen with horror; then Mrs.
Gaunt began to wring her hands.
“It is the same,” she cried, in awful tones. “I remember him—the
dark foreigner. He wandered up here from the port a week ago; and I
took him in to the master, and he never came out again. I thought he
had let him go by the door there into the lane. O, woe on this fearful
house! Long have I suspected and long dreaded. The sounds, and
the awful, awful smells!”
“Perhaps,” whispered the girl, gulping, and clutching at her breast,
“he died unexpectedly, and uncle put him away here, and forgot all
about him.”
Mrs. Gaunt shrieked, and seizing the clergyman’s arm, pointed—
“Look! Pickled babies—one, two, three! And bones! And a fish-
kettle! It is all plain. He kills them, and boils them down for his
experiments, and by an accident he forgot to empty his larder—his
larder! hoo-hoo!—before he went!”
 She broke into hysteric laughter and gaspings. Miss Robin,
whinnying, tottered quite close up to the young man, who stood
shivering and speechless.
“What can we do to save him?” she whimpered. “Mr. Prior, say
something!”
Thus urged, the unhappy young man strove to press his brain into
a focus with his hand, and to rally himself to what, he felt, was the
supreme occasion of his life. The appealing eyes and parted lips so
close to his would have intoxicated a saint, much more a pirate.
“We must warn him—agony column—from returning,” he
ejaculated, reeling. “Cryptic address—has he any distinguishing
mark?”
“Yes,” she said, with frantic eagerness; “he has a large mole at the
root of his nose.”
“Very well,” he said—“something of this sort: ‘Nose, with large
mole at root of. All discovered. Don’t return!’ ”
“But what is the use of an advertisement? O, Mr. Prior! what is the
use of an advertisement when we know where he is, or ought to be,
and can go——?”
“Do you really think he will be there? It was a blind. O, Miss Robin,
it is evident now it was a blind to cover his tracks!”
“But why should he have designed to escape at all, leaving this—
O, Mr. Prior!—leaving this horror behind him?”
“We can only conjecture—O, Miss Robin, we can only conjecture!
Perhaps because of his conscience overtaking him; perhaps
because, killing in haste, he discovered at leisure that it would not go
into the kettle; perhaps in a phase of that deadly absence of mind,
which, he will have realized by now, the Lord has converted to his
confusion.”
“Well, if you are right. And in the meantime we must get rid of this
—somehow. O, pray think of a means! Do! Do!”
Mrs. Gaunt steadied her storming breast as she leaned for
support, with hanging head, against the door.
“There’s the old well—off the lane,” she panted, without looking
up. “He there might have fallen in—as he went out—and none have
guessed it to this day.”
 It was a fearful inspiration. Mr. Prior, in that moment of supreme
sentient exaltation, abandoned himself to the awful rapture of things.
“June!” he whispered, putting shaking hands on the girl’s
shoulders; “if I do this thing for your sake, will you—will you—I have
a mother—this is no longer a place for you—come to Clapton?”
“Yes,” she answered, offering to nestle to him. “I had supposed
that was understood.”
He was a little taken aback.
“We must move this first,” he said, wringing his damp forehead.
“Who—who will help me?”
It was really heroic of him. In a shuddering group, they
approached together the terrible thing—hesitated—plunged, and
dragged it out with a sickening flop on the floor.
A greasy turban, which it wore, rolled away, disclosing a near bald
head. Its eyes were closed; its teeth grinned through a fluff of dark
hair; a lank frock-coat embraced its body, linen puttees its shanks,
and at the end were stiff bare feet.
“Look, and see if the coast is clear,” gasped the clergyman.
Miss Robin turned to obey, and uttered a startled shriek.
“What are you doing with my Senassee?” cried a terrible voice at
the door.
Mr. Prior whipped round, echoing his beloved’s squawk. A fierce
old man, leaning on a stick, stood glaring in the opening.
“Uncle!” cried the girl.
He advanced, sneering and caustic, pushed them all rudely aside,
dropped on his knees beside the corpse, and, thrusting his finger
forcibly into its mouth, appeared to hook and roll its tongue forward.
Instantly an amazing transformation occurred. A convulsion shook
the body; life flowed into its drab cheeks; its eyes opened and rolled;
inarticulate sounds came from its jaws.
“Ha!” cried the old man; “I have foreclosed on these busybodies.”
Then he rose to his feet, leaving the patient yawning and
stretching on the floor.
“Fearful!” gasped the clergyman.
“Do you address me, sir?” asked the old man, scowling.
“Conjurer!” whispered Mr. Prior.
 “If you like,” snarled the other. “It is a common enough trick with
these Yogis, but one I had never seen until he came my way and
offered to show it me for a consideration. I had forgot he was still
lying there when I agreed to exchange livings with you. (You are Mr.
Prior, I presume?) It was the merest oversight, which I remembered
on my way, and came back by an early train to rectify—none too
soon, it seems, for the staying of meddlesome fingers.”
“Forgot he was there!” cried Mr. Prior.
“And what if I did, sir?” snapped the other. “It was a full week he
had lain tranced; and let me tell you, sir, I have more things to think
of in a week than your mind could accommodate in a century. Why,”
he cried, in sudden enlightenment, “I do believe the fools imagined I
had murdered the man.”
“Look at the babies in the bottles!” cried Mrs. Gaunt hysterically.
“As to you, you old ass,” shouted the Vicar, flouncing round, “if you
can’t distinguish embryo simiadæ from babies, you’d better call
yourself Miss, as I believe you are!”
“I give notice on the spot!” cried Mrs. Gaunt.
Miss Robin stepped up bravely to the young clergyman, and linked
her arm in his.
“And I,” she said. “I think you have behaved very cruelly to me, to
us all, Uncle, and—and Mr. Prior has a mother.”
“I dare say; he seems fool enough for anything,” roared the old
gentleman. “Go back to her, sir! Go to——”
June shrieked.
“Clapton!” he shouted, “and take this baggage with you!”