Mental Health

The Mental Health Piece

Workers' comp needs a more focused approach to mental health issues.
By: , and | August 1, 2013 • 7 min read

Lowering total health costs so that businesses and communities can use the savings to invest in jobs is essential to long-term economic recovery. To achieve this, it’s imperative that a wide-angle lens be placed on the ability of individuals to truly manage their health. 

There is little argument that health care costs are rising as a result of uncontrolled chronic conditions, coupled with a treatment emphasis on symptomatic relief instead of using evidence-based clinical guidelines.

Key signs of poor health management include a general lack of adherence to treatment, overloaded emergency departments, lost work days and presenteeism (being physically at work but mentally distracted). All of these indicators reflect the sick-care focus that is the hallmark of our piecemeal treatment system.

Workers’ compensation carriers need look no further than their horrendous combined ratios to know that there is something seriously wrong with our health care management system, of which workers’ compensation is, of course, just a small piece.

We believe the underlying culprit of poor health management is the lack of a coordinated approach to meeting the patient’s health needs through a whole-health approach that includes mental health solutions.

Health care providers, government policymakers and other stakeholders must start doing a better job of focusing on mental health as a part of the whole-person approach. We need to see patient-centered care as inclusive of mental and behavioral health care. As former Surgeon General Dr. David Satcher put it, “there is no health without mental health.”

It is generally accepted that the most prevalent physical conditions (like lower back pain, heart disease, diabetes, asthma, etc.) often are accompanied by a comorbid psychiatric condition. Ignoring this reality is costly and results in poor health care outcomes. People with diabetes and depression, for example, have four times the health care expenditures as those with diabetes alone.


Comorbidities can also decrease adherence to prescribed treatment plans. Individuals with depression are three times more likely to be non-compliant with their medical care plans.

Yet, despite the research, most people who need mental health counseling do not receive it. According to national epidemiologic surveys in the United States, the majority (about two-thirds) of people with symptoms of substance abuse and mental disorders receive no treatment at all for their conditions.

Lack of coordination and effective care management have clear implications for disability and return to work. People with chronic medical illnesses with co-occurring mental health conditions make up a considerable portion of disability costs.

As evidenced in a recent DMEC Employer Behavioral Risk survey of employers, absence can be reduced and return to work can be accelerated by incorporating a mental health professional into the mix of care providers.

DMEC has also found that health plans and plan sponsors (employers) under-report levels of depression and anxiety in their populations compared to rates of prevalence. At the same time, they see high levels of disability days, emergency room visits, and acute care, all of which increase when mental illness is under-managed.

Leverage EAPs

Data continue to prove that employers are experiencing a crisis in the prevalence and cost of mental health and stress in the workplace. For instance, a 2011 ComPsych survey revealed that 29 percent of employees said they came to work on at least five days during the year when they were too stressed to be effective. That figure was up 19 percent from the previous year.

One solution is already within reach for most employers — an employee assistance program (EAP).  Based on a 2012 DMEC Behavioral Risk survey, fully 97 percent of employers surveyed had an existing EAP program. But whether they are using it effectively in many cases is arguable.

In another study, by the Journal of the American Medical Association, it was found that a systematic program to identify depression and promote effective treatment significantly improved clinical and workplace outcomes.

Employers can receive a significant return on investment from outreach and enhanced treatment of depressed workers for a cost of only $100 to $400 for low- to moderate-intensity interventions.

Effective changes can be made by:

* Broadening the use of behavioral health screening, evidence-based guidelines and measurement-based care that emphasizes treating to remission and improved functioning.

* Leveraging and promoting the existing solutions that typically go under-utilized, such as EAPs.

* Increasing the application of psychotherapy (such as cognitive behavioral therapy, or CBT) to treat the mind and body.

* Maintaining an early and consistent focus on return to work and recovery.

* Emphasizing functional improvement with a goal of return to work as a crucial component of treatment.

* Aligning incentives to reward improved outcomes of engagement, adherence, and quality.

Potential for Cost Savings

Screening people with chronic physical conditions to see if they have an accompanying mental condition is a useful tool for addressing comorbid mental health issues early on. Screenings can also assist in monitoring and managing chronic conditions and depression, as well as stress levels, adherence to condition management and even pain management. In essence, rather than prescribe a potentially addictive and costly pill, why aren’t we using cognitive therapy to get at the bottom of what’s bothering people?


Patients with diagnosed diabetes, arthritis, osteoporosis, musculoskeletal conditions, cancer, low back pain, RSD (reflex sympathetic dystrophy) hypertension, and obesity develop depression and anxiety at rates 30 percent to 50 percent higher than the rest of the population.

Research shows these patients often don’t stick to treatment regimens, resulting in higher costs for rescue treatments. They’re also prone to increased and sometimes inappropriate use of narcotics and alcohol, increased inpatient and outpatient days and a host of other issues.

Back to Work Faster

Several workers’ compensation payers are already employing cognitive therapy for claimants who suffer from chronic pain and psychosocial issues that hinder their recovery and return to work. When applied properly, this evidenced-based approach can help claimants return to work sooner and avoid chronic pain problems by helping them cope with work-related problems and emotional issues.

A recent study conducted in the Netherlands and published in the Journal of Occupational Health Psychology found that employees absent due to common mental health disorders returned to the job on average 65 days earlier when provided with work-focused CBT, saving employers an average of $5,275 per employee.

Simple screening tools can also be leveraged in a variety of settings. A short behavioral screen should be used at community clinics, urgent care clinics, biometric/lab testing, and with health risk assessments at the worksite.

A DMEC 2012 Behavioral Risk Survey revealed that the most effective return-to-work programs utilized referrals and the promotion of the employers’ EAP. An EAP can help strengthen bonds and can foster a focus on return to work and recovery. 

Fully 63 percent of respondents to the survey refer their employees to an EAP and 57 percent actively promote these programs.

Both at work and at home, an EAP can foster an environment that increases productivity and employee retention.

The survey also found that the growth of the use of any mental health professional for psychological or psychiatric claims was significant, with 65 percent of firms using them for case management in 2012, compared to 48 percent in 2010.

Plans and purchasers must call for inclusion of behavioral health in the broader application of total health management. Additionally, there should be performance incentives that reward the time spent in assessing, evaluating and managing behavioral health issues, especially when managing chronic or acute care. Integrated data and collaboration across disciplines will be necessary.

The timing of this call to action on whole patient care is important. Between the 2008 Mental Health Parity Equity and Addiction Act and the 2010 Affordable Care Act, nearly every aspect of the nation’s health care system is undergoing change.  A large part of that change is that individuals are being asked to take responsibility for their health.

Improved health behaviors are paramount to getting better outcomes. Improvement in lifestyle choices and point-of-care choices as well as adherence to care management are imperative to hold down total costs.

But for those with under-diagnosed or undermanaged depression and anxiety, the task can be daunting.

We can make our joint voices heard and we can make an impact on the lives of our employees and patients by treating the whole person as one fully integrated system. We can impact both health care cost savings and human cost savings by focusing on the whole person approach to health.

Marcia Carruthers is Chairman of the Board of the Disability Management Employer Coalition (DMEC). She can be reached at [email protected]

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.


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.


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?


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.


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.


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]