How A Health Care Captive Director Drives Better Patient Outcomes

Experience with advocacy at a young age shaped Heather McClure’s passion to drive optimal outcomes and protect both patients and physicians.
By: | April 5, 2019 • 8 min read

As the person charged with building the insurance captive infrastructure for Oklahoma’s sprawling academic health care system, Heather McClure’s experience and skill set was an ideal fit.

At a young age, McClure had a family member who was a high-IQ underachiever with undiagnosed learning disabilities — the kind of kid who children bullied on the playground and was misunderstood by teachers in the classroom.

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Outrage on his behalf and a precocious talent for advocacy helped shape McClure. Those early lessons stuck with her.

“It was my responsibility to speak up,” McClure said. “I was the person who could translate.” As a girl in the Oklahoma of the 1970s and 1980s, she learned early to confront injustice without appearing confrontational. “I learned to be a speaker of truth to power, without aggression or hostility.”

Influenced by a friend’s parent, a legal aid attorney, McClure knew in high school that she would be an attorney, too. In college, she majored in journalism and political science, good prep for law school. A class on law in medicine refined her focus.

McClure spent the next decade as a litigator at a law firm, then directed litigation in-house for a large nonprofit health system in north Texas with a captive insurance structure.

Meanwhile, the market for professional liability insurance hardened across the country. Premiums for the University of Oklahoma (OU) academic medical practice spiked nearly 300 percent despite its good risk profile. To stabilize costs, OU created a captive, domiciled in Vermont.

In 2006, the CEO of the medical practice called McClure to run the Vermont-domiciled captive, build infrastructure within the parent organization in Oklahoma and manage its risks. She lived in Dallas and had kids in school there. She loved her job. She said no thanks.

He persisted.

“After three long calls,” she recalled, “he said the magic words: ‘You were born and raised in Oklahoma. You need to come home and help us.’ Something in me melted.”

She agreed to a hybrid telecommuting arrangement so she didn’t uproot her school-age children, hitting the road to Oklahoma at 5 a.m. two or three days per week. As it happened, OU was the perfect place to unleash the zeal for advocacy from her youth, giving a voice to the voiceless and vulnerable.

Captive as Advocate

OU Medicine is big. The academic medical practice includes two health sciences campuses, three partner hospitals, a cancer center, a breast health network and a rehab hospital.

McClure is chief risk officer for the system. She’s also an executive director of operations for OU’s academic medical practice, which covers 2,300 faculty physicians, resident physicians and medical students. That’s a lot of professional liability to manage and insure.

Heather McClure, chief risk officer, OU Medicine

McClure assumed management of OU’s captive when it was already eight months old, “but it’s her baby,” said Kyle Sweet, managing partner, Sweet Law PLC in Oklahoma City and a defense counsel panel member.

Her baby, he clarified, and that of an army of captive-model evangelists she flipped after a brief challenge by some who thought OU shouldn’t be in the self-insurance business.

McClure calls herself a “coach and teacher for the captive model,” which “allows an organization to put its money where its mouth is by controlling its own risks and betting on itself to do better than a for-profit insurance company.”

In the first years, McClure had to win over internal and external skeptics who saw captives only as a financing tool rather than a safety improvement tool.

She and her team set about building patient safety committees and a risk and claims management staff. She persuaded the board of directors to fund risk grants for safety initiatives. The risk profile improved, starting the positive trend that continues today.

McClure described the captive formula: Improved safety = fewer injuries = lower losses = more $ for operating budgets for a high-quality practice

For example, Sweet credits the captive with reducing informed consent-related claims by funding the purchase of technology that supplements the required informed consent process.

“Patients are properly informed and therefore safer, and physicians spend the same amount of time with patients,” Sweet said.

An additional benefit, McClure said, is that the modules answer more questions than patients could absorb in a single conversation with a provider.

The captive funds many more programs, such as online risk management education for physicians and other providers. It also funds a team of three board-certified physicians who spend 20 percent of their time helping clinical risk managers respond to real-time risk events, assessing trends and setting a vision for patient safety.

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The commercial insurance model doesn’t preclude that kind of vigilance, but the captive model motivates hypervigilance, McClure said. “You pay closer attention when you have skin in the game.”

The captive has saved millions of dollars in premiums, she said, but perhaps its greatest value is elevating the importance of safety and risk to the highest levels of leadership.

For example, said Amy Middleman, M.D., a physician specializing in adolescent medicine, McClure joined her in defining best practices and policies regarding the confidentiality of adolescent patient records, which reduces the risk of tragic outcomes.

“Confidentiality is the major tenet of adolescent care,” Middleman said. Think: gender issues, pregnancy, depression, substance abuse, etc. — all the things that make adolescence a struggle. “If a teen feels uncomfortable talking to a parent, we want her to talk candidly to a provider for medical recommendations, not to friends and the internet.”

“Heather understands the issues and is willing to fight for the rights of vulnerable adolescents who otherwise don’t have a voice in a large system run by adults. She’s moving the care of adolescents forward in Oklahoma,” Middleman said.

Incident Reduction

Although McClure is employed by the provider organization, she emphatically sees no conflict of interest between patients’ well-being and her role in facilitating the captive model. “Our focus is not defending every claim to the max and taking it to trial,” she said.

When negative outcomes occur, McClure’s childhood role of translator and advocate kicks in. She explains what happened to patients and families.

“I can translate when patients and providers don’t speak the same language. There is never a conflict with finding out what happened and telling patients the truth.”

When there may be culpability, “we want to make patients whole. We can act swiftly and creatively because we have no need to wait for a separate insurance company to fund compensation for families and patients.”

“She wants to change the world. She truly cares.” — Andrea Jones, president, Healthcare Insurance Professionals

That makes a huge difference to families, McClure said, and it’s often a pleasant surprise.

In the absence of negligence, she said, “we try to explain the bad outcome. The attempt at communication goes a long way to heal resentment.”

Incident prevention extends to the education of future physicians. “We’re meeting a lot of educational goals with captive funds,” Sweet said. OU surgical residents’ training includes mock cross-examinations and depositions based on actual cases. That training, according to surveys of residents, doesn’t necessarily alleviate anxiety around litigation, but it eases anxiety around obtaining and managing professional liability insurance.

“That’s revolutionary,” Sweet said. “Heather’s using the captive not only to improve the quality of service and medical outcomes. She’s also improving physicians’ quality of life.”

She Just Cares

After speaking with a handful of McClure’s friends and associates, the descriptive words start to repeat. Advocate, of course. Tactful. Politically adept. Dog with bone. Passionate but cool-headed. Multitasker.

Andrea Jones, president, Healthcare Insurance Professionals, traveled with McClure to a meeting of the Vermont Captive Insurance Association (VCIA), on whose board McClure is finishing two three-year terms. A work crisis arose.

“Heather was out of town, texting and multitasking,” said Jones, a friend and colleague. “Most people would say, ‘that can wait a day,’ but she left the room to deal with the drama. She returned after a while, back on her game as if nothing had happened.”

Todd Hagemeier, managing director, Alliant Insurance Services, saw that nimbleness in action last year when the captive brought the professional and general liability risks of the teaching hospitals under its cover. The two policyholders have crossover leadership but retain separate structures.

Jointly funding and managing their risks meant a delicate merger of the aligned interests of the hospital system, the medical practice and the captive insurance company (where she is chief legal officer). “Heather gave herself a crash course in all of the complex legal and regulatory work necessary to accomplish the organization’s complex goals,” he said.

“She maintained the trust of all these people with big personalities,” Hagemeier said. Apart from the mechanics of risk financing, the networking and problem solving, “managing multiple bosses is a rare skill. She’s like a sponge to benefit her organization.”

At the same time, he said, she engaged in frequent speaking engagements to educate others about the benefits of the captive model, including meetings of captive and risk management associations whose members are leaders in their fields: telecom, agriculture and health care.

McClure is licensed to practice law in Texas, where she lives; Oklahoma, where she works; and Vermont, the largest domicile in the United States to captives. It boasts 48 of the Fortune 100 companies and over another thousand with risk across the country.

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Vermont’s financial regulation statistics are impressive, she said, but the real key to her loyalty is that “every time I call the Vermont insurance regulators to ask a question or brainstorm a solution, they pick up the phone and talk.”

Educating professionals about the captive model has been an important part of her role as a board member.

“I keep going back to ‘passion,’ ” said Jones. “She wants to change the world. She truly cares.”

That passion extends to her job — to her commitment to captives, to her family, to advocacy for the voiceless and vulnerable, and to her commitment to geriatric rescue dogs nobody else would take on.

McClure interrupted one phone interview for this profile to attend to a veterinary emergency for her 17-year-old miniature dachshund, Tootsie. Tootsie is back at home and doing well. &

Susannah Levine writes about health care, education and technology. She can be reached at [email protected] Michelle Kerr is associate editor of Risk & Insurance. 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.

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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 and 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]