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Connecting the Dots

Telemedicine, electronic medical record-keeping and the ongoing technology shift that will shape the future of medical management in workers’ compensation.
By: | October 15, 2016 • 7 min read

Optum_roundtable_101516
FROM LEFT, Dan Reynolds, Dr. Nina McIlree, Dr. Brian Buck, Dr. Teresa Bartlett and Dr. Robert Hall.

Technology’s promises and perils are profound in health care and in its sister practice, workers’ compensation; perhaps more so than in any other profession.

In July, Risk & Insurance®, in partnership with the workers’ comp and auto no-fault division of Optum, convened a roundtable of workers’ compensation medical directors to get their take on the top-of-mind issues in their profession.

It didn’t take long for the potential upsides of technology, and some of the concerns that accompany it, to emerge as a dynamic area of discussion.

In addition to his technology-focused comments, Dr. Buck gives some guidance on claims adjuster participation.

One technology innovation that the medical directors focused on intently is telemedicine, the use of which is still in its infancy in group health and workers’ compensation.

“We’re getting a lot of questions about telehealth and telemedicine and what we’re doing in that space,” said Dr. Teresa Bartlett, senior vice president for medical quality with third party administrator Sedgwick.

Optum_roundtable_101516“We’re getting a lot of questions about telehealth and telemedicine and what we’re doing in that space.”

— Dr. Teresa Bartlett, senior vice president for medical quality, Sedgwick

In addition to Dr. Bartlett, attendees included Dr. Brian Buck, medical director for workers’ compensation and claims administration with the Texas Association of School Boards’ Risk Management Fund; Dr. Robert Hall, the corporate medical director at Optum workers’ comp and auto nofault division; and Dr. Nina McIlree, vice president, medical management with Zurich Insurance.

The panel members agreed that conferencing technology which enables a physician to assess and counsel a patient remotely has the power to bridge gaps. In rural areas with poor access to medical specialists, for example, the approach can get care for someone who might otherwise need to travel hundreds of miles to see the right physician.

The approach can also bridge language barriers. Health care organizations can use video conferencing with patients to connect them to a physician or caregiver who speaks their language in cases where physical access to that language speaker would be difficult or not cost-effective.

The panel did have concerns about the “no-touch” aspect of telemedicine, which runs counter to the traditional training that many physicians receive.

“My medical school professors are probably rolling over in their graves now thinking that you might not be able to touch the patient, and physically examine them,” said the Texas Assocation of School Boards’ Dr. Buck.

Dr. McIlree of Zurich said the industry has a lot of ground to make up to ensure both providers and patients are familiar with the technology and can come to trust it.

Dr. McIlree shares some additional thoughts on the topic of evidence-based medicine.

“I don’t think we’ve gone through the evolution where the providers are truly comfortable providing the care through a telemedicine portal,” she said.

“Nor have we gone through the cultural revolution or change management to help the injured workers understand that this is a good thing to do,” she added.

But the panel members agreed that change is coming and that there are substantial upsides with telemedicine. Creating the algorithms that can help caregivers decide when a teleconference check-in is appropriate and which cases mandate a physical visit will be important, the physicians said.

And the use of telemedicine doesn’t signal or mandate a final physical disconnect, said Optum’s Dr. Hall.

He said a series of telemedicine consultations can always be punctuated by a physical visit if the physician feels they are losing touch with the patient, or is concerned that the medical outcome of the case is deteriorating.

Panel members also reported that many physicians are more comfortable conducting an assessment remotely; that it can help their objectivity in many cases.

Optum_roundtable_101516“I don’t think we’ve gone through the evolution where the providers are truly comfortable providing the care through a telemedicine portal.”

— Dr. Nina McIlree, vice president, medical management, Zurich Insurance

“That electronic distance can create a comfort zone,” said Zurich’s Dr. McIlree.

She said industrywide diligence will be required, however, to make sure that any loss of physical proximity doesn’t lead to worse outcomes.

“We’ve got to create the right expectations of what the practitioner will bring to that dialogue,” she said.

“But I think we’re seeing the opportunity for this in a number of interfaces,” she added.

The collaboration between the physician and the claims case manager is another area where telemedicine has real potential. Say, for example, a field case manager is visiting a patient in their home.

Should a medical question come up that the case manager isn’t comfortable handling, they can bring the physician in through a teleportal in situations where it’s difficult or not possible for the physician to be there.

Beyond the technology focus, Dr. Hall shares some ideas on bio-psychosocial issues.

Conversely, if a patient using telemedicine consultation feels that additional patient care or assessment is needed, case managers may be able to provide the human element desired in patient care.

“Do we have someone closer, say from a case management standpoint that can be there with the injured worker?” Dr. Bartlett asked.

“How do we work with those injured workers and caregivers differently so that we don’t lose that personal touch?”

In cases where a claims or case manager can’t physically visit the injured workers’ home, a remote evaluation can facilitate observation of and insight into some of the challenges the injured employee may have getting into their home or accessing items in the kitchen, for example.

As with other areas of information technology, a younger professional, for example, a recent medical school graduate in the early stages of their career, can be more comfortable with telemedicine than a more senior physician.

Optum_roundtable_101516“We can spend more of our time performing bureaucratic tasks than we do spending time with the patient.”
— Dr. Brian Buck, medical director, workers’ compensation and claims administration, Texas Association of School Boards’ Risk Management Fund

In his home state of Texas, the TASB’s Dr. Buck said the Texas Medical Board qualifies telemedicine as the practice of medicine and has strict dispute currently with telemedicine companies, as the issues revolve around insuring patient safety.

“Right now, it’s limited in scope but I see it as a tremendous advance and it will continue to grow,” Buck said.

Electronic Medical Records

Physicians trained in utilizing new technologies, such as electronic medical records, may feel more at ease with this technology than their colleagues who were trained where or when this technology was unavailable.

“They’re comfortable with it,” said Zurich’s Dr. McIlree.

But the EMR has its detractors. Some patients complain that the physician spends too much of the visit typing information into their laptop and not enough time assessing them.

“We can spend more of our time performing bureaucratic tasks than we do spending time with the patient,” said the TASB’s Dr. Buck.

“Every physician you talk to, it adds time to their day and it adds complexity,” agreed Dr. McIlree.

But as with telemedicine, she said, a transition is under way. More and more physicians will become comfortable with electronic medical recordkeeping and the method will result in much better documentation of the patient’s condition.

After all, the storied shortcoming of physicians’ penmanship does have its roots in fact in many cases.

Optum_roundtable_101516“The use of telemedicine doesn’t signal or mandate a final physical disconnect.”
— Dr. Robert Hall, corporate medical director, Optum

“It can also contribute to the quality of care by providing a template to the physician suggesting the necessary elements of a care plan. The provider should be comfortable editing the elements of the information gathering and exam appropriate for the patient. They do not have to rely solely on memory and experience alone to address all the issues of the patient,” she said.

Whether it’s advances in telemedicine or more widespread comfort with the use of electronic medical records, technology has the potential to increase patients’ education about their well-being and lead to better coordination of care: two key aspirations in the medical management of workers’ compensation cases, members of the Chicago roundtable agreed.

“I think these are the things that will significantly advance our ability to get the right care to the right person at the right time,” said Zurich’s McIlree.

Service providers succeeding in the era of rapidly advancing technology will be those that most effectively use technology to create better coordination of care. That means not only getting all the treating physicians on the same page, but sharing important information with case managers, and perhaps most importantly, the patient themselves.

Opinions of the roundtable participants are the opinions of each individual contributor and are not necessarily reflective of their respective companies.
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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Optum. The editorial staff of Risk & Insurance had no role in its preparation.




Healthcare Solutions, Helios and their subsidiaries, as Optum companies, collaborate with our clients to deliver value beyond transactional savings while helping ensure injured workers receive safe and effective clinical care. Our innovative and comprehensive medical cost management programs include pharmacy benefit management, ancillary benefit management, managed care services, and settlement solutions.

More from Risk & Insurance

More from Risk & Insurance

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.

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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.

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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?

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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.

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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.

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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]