Risk Scenario

Down for the Last Time

An already fragile bank teller is knocked down and cannot get back up, thanks to her appetite for prescription painkillers.
By: | November 6, 2012
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

Part One

Morning was coming slowly on this cold Boise Monday for Mia French, a bank teller with the Copper Bank & Trust Co.

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Thankful at least for the strong coffee in the paper cup beside her, Mia was working on getting her drawer counted for the bank’s opening, which was less than 20 minutes away. She had to force herself every day to get her drawer ready; concentration for her was a real problem.

Mia stared glumly at the pedestrians walking on the snowy streets outside and the grey canopy of sky above them and sighed.

“What am I doing here?” Mia thought to herself. She had moved to this mountain state six years ago, but things weren’t going that well these days. She had few friends and her work relationships weren’t all that fulfilling.

The caffeine helped, but this was the way Mia, who had struggled since the age of 13 with depression, started most of her work days.  She was better in the summer, but these cold winter days in Boise really knocked her down.

Within 18 minutes, Mia herself would be literally knocked down.

It happened like this: When the branch manager walked forward to unlock the front doors of the bank, two massive men, dressed all in black with nylons obscuring their faces and carrying sawed-off shotguns, rushed in the door. One knocked the manager down brutally with the butt of his gun while the other made for the teller windows.

Scenario Partner

Scenario Partner

He was up and over the top of the counter before anyone could budge. A girl behind Mia screamed in terror. Mia turned to look at her and felt a blinding shock of pain hit her right knee.

In swinging down from the counter, the thug, who weighed at least 225 pounds, had come down on her leg, essentially kicking her knee out from under her.

Mia screamed as she hit the ground but the thug was unmerciful.

He prodded the shocked, prone girl with the twin barrels of the gun.

“Get up,” he said, his voice muffled from the nylon over his face.

He threw a cloth bag at her where she lay in the ground, shuddering and gasping from the pain in her knee.

“Get up and fill this bag,” he said.

“I can’t get up,” Mia said. She started to weep in pain and fear.

The thug stuck the barrels of the gun against her cheek and nudged her face.

“Get up I said,” the brute muttered threateningly.

Moaning from the pain, Mia managed to pull herself up to a standing position and started emptying her cash drawer into the bag she had been given.

***

To the in-network physician who oversaw Mia’s care after her release from the hospital, Mia appeared withdrawn, almost dazed.

“Perfectly natural under the circumstances,” he said to himself as he typed notes in his laptop, as he covertly assessed Mia’s appearance during a follow-up office visit.

Mia’s hair was oily and her skin sallow. She appeared listless, her only gesture playing with a hank of her hair, twining it and untwining it around one finger, like a child in winter in a boring math class.

The physician decided to keep Mia on an opioid painkiller to be taken every four to six hours as needed.

“You’ve had a very rude shock,” the doctor said. “It’s going to be a while until you get over this.”

“I’ll be okay,” Mia said. But when she said it, she didn’t make eye contact, her eyes still locked on the hank of hair she had round her finger.

Her words and her manner were unconvincing, but the doctor decided to let nature take its course.

Part Two

The doorbell to Mia’s apartment rang. It was the postman. She knew without looking that it was him, and she also knew what he had.

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This, six months in from the bank robbery that had severely damaged her knee and her psyche, was Mia’s favorite time of the month. It was when her supply of medications arrived, efficiently shipped to her from the pharmacy.

Before her injury, Mia had lived from day to day with what could be described as mid-range depression. She had trouble getting up in the morning and found really nothing to get interested in or excited about in any given day. But now that depression had deepened.


Unable to break free from depression’s grip, Mia on an almost daily basis succumbed to sobbing fits. She had also put on thirty pounds, which was impeding the recovery from her knee injury.

A patient wanting to make a good comeback from a bad knee injury like Mia’s would have to work really hard in physical therapy. Mia just wasn’t putting in the effort and was balking at efforts on the part of therapists to make her work the joint.

She was acting like they were hurting her every time they touched her, when all the therapists were doing was trying to help her get her full range back.

Mia’s doctor had noticed that she wasn’t breaking free from the dark clouds that had haunted her since her injury. But instead of referring her to a therapist, he had added Prozac to her prescription regimen.

On top of that he had added a second prescription for an even stronger pain medication. Most patients with this kind of injury were off meds in a matter of days as they progressed through physical therapy. Mia was now six months out and on a pain killer more appropriate for an end-of-life cancer patient.

***

Carol Hagee, the claims supervisor for the carrier that owned the claim, had seen enough. She communicated her desire to her contracted pharmacy benefit manager that they begin to intervene in the case.

The case had already gone too far, in the claim supervisor’s opinion, and her direction to the PBM was emphatic, to say the least.

“Get a grip on this doctor, he’s mismanaging this woman’s treatment,” Carol told her counterpart at the PBM.

Maybe the PBM, which already felt itself on tenuous ground with this carrier due to previous missteps, committed a fear-based overreaction.  Maybe they just lacked the communication skills or the tactical sense to effectively interact with a physician in a case like this.

Whatever the reason, the email they sent to the treating physician was way over the top. Making matters worse was they sent a copy of it to Mia.

The physician’s reaction to the email was not in keeping with anybody getting a grip on anyone or anything. He effectively stopped talking to the PBM and their subsequent calls and emails went unanswered.

This last chapter was all that Carol Hagee needed. She had seen enough of this PBM in action over the last two years. The carrier sent out RFPs for a new PBM.

Part Three

Daphne French, Mia’s elder sister by three years, was in her sunny, warm Montecito garden when she got a call from her mother Gretchen.

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Things had just broken Daphne’s way in life. She had starred as an outside striker on her college volleyball team and had put away a tidy sum as a professional player before marrying the heir to one of Santa Barbara County’s wine making estates.

Living in different states and being at different places in their lives, Daphne and Mia seldom spoke on the phone and their visits were even less frequent, but what Gretchen said made Daphne reach out to her sister.

“I just talked to her,” Gretchen said. “I’m serious Daphne, I’m worried she’s going to hurt herself if we don’t move.”

Daphne was on a Boise-bound plane out of LAX by sundown.

When Mia opened the door to her apartment, Daphne was heart-sick at what she saw.

Mia’s face was bloated to the point where she was almost unrecognizable.

“Hi,” Mia said, taken aback by the sudden appearance of a sister who had so clearly bested her.

Tears welled in Daphne’s eyes.

“Can I come in Mikey’?” Daphne said, using a nickname only the two of them knew.

“Sure,” Mia said quietly and, using a cane, turned and made her way back to the couch, in front of a television set that was working at a disturbingly high volume.

Alone with her sister, Mia broke and let the grief tumble out of her. She told Daphne that there were days when she felt she would be better off dead. Not from the pain in her knee, but from the pain in her heart and head.

Daphne was washing up in Mia’s bathroom when she did something she felt she had to do. She tapped open the door to Mia’s medicine cabinet and got a look inside.

The sheer volume of pill bottles and their terrifying labels told her plenty. Daphne too, had seen enough.

You don’t win the Manhattan Beach Open by being timid, and Daphne wasn’t. She got on the phone with HR at the Copper Bank & Trust Co.

“Are you trying to turn my sister into a drug addict? Hello, she suffers from depression! Might not be a good idea to put her on narcotic pain killers!”

That and the mention of some Century City lawyers that she knew woke some people up.

The next plane that Daphne was on, Mia was with her.

Daphne put Mia in a guest room of her villa. Daphne had a friend nearby, a good therapist; Mia agreed to see her.

The PBM that took over Mia’s case inherited a mess, especially in the area of the physician relationship.

The doctor was not taking calls or responding to letters. But the new PBM had a better touch in managing physician relationships than the previous one did.

This is what their letter looked like.

The letter created a better treatment umbrella for Mia. The PBM put the treating physician in touch with Mia’s therapist.

They started working together as a team, dialing back Mia’s meds, even communicating with her physical therapy practice.

A year after the robbery, Mia was taking walks on the beach and talking about getting back to work.

“One thing I’m sure about. I don’t want to go back to Boise. At least not right away. I’m too alone there.”

“I don’t think you should,” Daphne said.

“Is it okay if I stay with you for a while longer?” she said.

“Of course Mikey.”

Summary

Poorly handled written communication between a pharmacy benefit manager and a treating physician made a difficult workers’ compensation case much more painful than it should have been.

1. Communicate with care: The first pharmacy benefit manager in this story made a big mistake when it crafted a poorly written letter to the treating physician. The accusatory tone of the letter put the physician on the defensive. The problem was compounded by the letter being cc’d to the patient, making the physician even more defensive.

2. Screen for depression: Mia French had a pre-existing mental condition that would have been a big red flag for any physician considering giving an opioid pain reliever to her. Asking one simple question, “Have you ever suffered from depression?” could have made managing Mia’s case much easier and been better for her overall health.

3. Find an advocate, be they friend or family: People suffering from depression or a substance abuse problem need help from someone who knows them very well, who can put aside professional jargon and get through to them. Mia’s sister Daphne and her mother Gretchen save this case by caring enough to reach out to Mia and take decisive action on her behalf.

4. Don’t be afraid to make a change: Relationships are only good if they work for both parties. Carol Hagee makes the right move by seeing the writing on the wall and switching pharmacy benefit managers. There is a right way to do things and a wrong way to do things and Carol was professional enough to not only see the difference but take action.

5. Speed matters: Any case manager who is watching someone with a joint injury stay on opioids for months, rather than days, is waiting too long to intervene. Joint injuries are generally self-limiting and resolve fairly quickly. If opioids are used for a long period of time, it may indicate that either the injury is more severe than initially thought or that there may be issues with the patient that should be closely watched. Communication with the prescriber is key.

6. Use an integrated, team approach: It’s usually not possible to collect all members of the treatment team — physician, therapist, physical therapist, the pharmacy benefit manager and the carrier — in the same room. But there is no reason with today’s communication options why they can’t network as a team. Getting all sides of the story gives the best perspective on the patient’s condition and leads to better outcomes.

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]

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The R&I Editorial Team can be reached at [email protected]