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 • 9 min read
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.

Scenario_DownForLastTime

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.

Scenario_DownForLastTime

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.

Scenario_DownForLastTime

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]

Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.

Advertisement




Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.


R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.

Advertisement




We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?

Advertisement




Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.

Advertisement




Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now an where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.

Advertisement




More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

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