Why the Psychology of Pain Matters for Injured Worker Recovery

Tailoring treatment to a patient’s individual reaction to pain can yield better outcomes for injured workers and payers.
By: | December 14, 2018 • 7 min read

The path to recovery from a work-related injury is not often linear; treatment, rehabilitation and return-to-work is not always simple. Injuries are about much more than a physical insult to the body. Dealing with pain involves psychological and social components as well.


Mismanaging these components could significantly lengthen a patient’s recovery, adding both time and cost to a claim.

“Approximately 20 percent of injured workers experiencing acute lower back pain never fully recover, instead developing a chronic pain condition that can extend the life of a claim for years,” said Kim Radcliffe, senior vice president, clinical operations, One Call.

The key to improving outcomes for both injured workers and workers’ comp payers is addressing all of the biopsychosocial factors that contribute to the experience of pain — both qualitative and quantifiable.

“This clinical approach considers all of an individual’s biological, social and psychological factors, and how each of those factors work individually and in tandem to impact perception of pain, coping mechanisms, and risk of recovery failure,” said Sean Sullivan, senior director of product management, One Call.

In this Q&A, Sullivan and Radcliffe describe what’s involved in a biopsychosocial approach to pain management, and how identifying risk factors early can translate to faster return-to-work and lower total claim costs.

R&I: What makes claims involving chronic pain so costly and complex?

Radcliffe: The amount of time off work for chronic pain can be anywhere from six months to four years. That’s obviously an extreme variation, but someone who does not develop chronic pain could be fully back to work in three to four months, maximum.

The longer a claim is open, the more the employment and indemnity costs pile up. The 20 percent of injured workers that develop chronic pain end up accounting for upwards of 85 percent of the costs associated with treating lower back injuries.

The 20 percent of injured workers that develop chronic pain end up accounting for upwards of 85 percent of the costs associated with treating lower back injuries.

Chronic pain patients are receiving more therapy and more medications, which increases the risk of abuse or misuse. Eventually, unnecessary surgical procedures may be performed to address that pain. The utilization of surgery to resolve chronic pain conditions and the failure rates of those surgeries are pretty high.

R&I: What are the psychological and social factors that contribute to the development of chronic pain from an acute injury?

Radcliffe: A person’s temperament is a big factor. Are they optimistic or pessimistic? Do they drive themselves to high levels of work focus, or do they lack motivation?

Kim Radcliffe, Senior Vice President, Clinical Operations, One Call

There are also psychological components in an individual’s perception of pain. One person might stub their toe and say the pain is a level two out of 10 and go about their day. Another person might say it’s an eight and sit on the couch because they’re afraid of making it worse. That’s not always a conscious choice … that person may just be prone to catastrophizing.

Catastrophizing and fear avoidance can impair a person’s ability to perform normal daily functions even when the injury itself is not severe. Everyone’s response to pain is different.

R&I: In workers’ compensation, what barriers exist to identifying and addressing biopsychosocial factors?

Sullivan: It comes down to compensability and a clear understanding of the inflection points in a claim lifecycle that drive costs. When you’re dealing with a specific physical injury incurred on the job, the impact to the musculoskeletal system can be black and white. But when you get into comorbidities, chronic conditions and the psychosocial components that aren’t as directly related to the injury event, it’s not as clear.

Addressing these types of cost drivers, however, is critical to any program that is advancing a clinically-driven and value-based model of care. I think people in the industry understand this, but may be hesitant to spend more money upfront, even when it means saving as much as 30-40 percent over the long run in appropriately identified claims.

Catastrophizing and fear avoidance can impair a person’s ability to perform normal daily functions even when the injury itself is not severe. Everyone’s response to pain is different.

Radcliffe: I think it’s important to recognize that addressing the psychological or behavioral components of a claim doesn’t mean we’re seeking out other illnesses to treat. People have a fear that digging into those factors will open up a whole other can of worms.


The goal is not to diagnose patients with a psychological condition. We’re addressing the psychological factors that are associated with healing.

R&I: How do you identify these factors in the first place for each patient?

Sullivan: At One Call, we have a broad biopsychosocial solution that consists of two core components — analytics and product diversity. That boils down to first identifying patients at higher risk and then providing them with the right solution to mitigate identified risk. The first component involves stand-alone tools that we’ve continued to refine, in part through collaborations with our analytics partners, like High Line Health. We are also uniquely positioned in the marketplace to tackle population-level risk identification in partnership with health plan administrators and risk managers.

Radcliffe: We use data analytics to look for trends in patient demographics or injury characteristics to identify at-risk patients at a population level. Then, on a case-by-case basis, we use individual screening tools like questionnaires that assess that person’s psychological predisposition as well as their social environment.

The surveys evaluate tendencies like fear avoidance and include a pain catastrophizing scale. Based on the patient’s responses, we look for the specific psychosocial components that could complicate their recovery. Now we can start implementing an approach that takes those factors into consideration.

Sullivan: While surveys just scratch the surface, they provide a host of information to providers who then make small, supplemental changes to the care plan that make a big difference.

R&I: Do providers know what changes to make in their approach to a patient with a psychosocial red flag?

Sullivan: Quality providers often identify and document these types of flags in their treatment notes as variables that may be impacting progress. On one end of the spectrum of providing a holistic solution is provider engagement. This is as simple as calling up the provider when we see red flags on a patient’s file and offering them coaching and support to drive improved injured worker interactions.

Sean Sullivan, senior director of product management, One Call

Further down the spectrum, we make biopsychosocial solutions recommendations for at-risk patients that help physical therapy or home health providers achieve better outcomes.

Radcliffe: We are training our physical therapists, for example, to communicate differently and make sure we focus on function versus pain. Physical therapists can help patients move beyond fear avoidance and understand that they can still move even if they have pain. So we start there.

With no early interventions, only 60 percent of chronic pain patients are back at work one year after injury. When you do bring in the psychological and behavioral services early, that percentage goes up to 90 percent.

Sullivan: For more complex claims, we move into direct patient engagement, so we’re checking in with the injured worker, providing them educational materials on chronic pain and safe use of opioids, or possibly setting up weekly telehealth visits with a behavioral specialist who can help them develop clear recovery and return-to-work goals.

In the most serious cases, we can coordinate cognitive behavioral therapy or in-patient functional restoration programs, but our goal is to identify these issues early enough to prevent utilization of these services.

R&I: How prominent or effective are telehealth services in addressing psychosocial factors?

Sullivan: Telehealth is a really important part of this solution because it allows patients to see a behavioral health specialist from the comfort and privacy of their own home. There is still a stigma attached to receiving help for psychological or behavioral health issues. The telehealth ‘service from anywhere’ model offers convenience, reduces stigma, and can increase engagement.

R&I: Others have used predictive analytics and telehealth services in workers’ comp claims. What makes One Call’s biopsychosocial solution unique?

Radcliffe: The big differentiator of our program is that it combines prediction and prevention. The traditional approach to treating work-related injuries is just biological in nature. So for chronic pain, that means chronic pharmacological intervention in the form of opioids.


That has resulted in a portion of the population with opioid dependency still struggling with chronic pain. That biomedical approach is just not enough.

We’re trying to get to patients before they become part of that population. By identifying the psychosocial factors that put injured workers at-risk, and taking it one step further to connect them with the right services, we’re proactively mitigating the development of chronic pain.

R&I: How do you measure the success of using a full biopsychosocial solution? What improvement in claim outcomes have you seen?

Radcliffe: With no early interventions, only 60 percent of chronic pain patients are back at work one year after injury. When you do bring in the psychological and behavioral services early, that percentage goes up to 90 percent. That also means reduced health care utilization and fewer missed work days, meaning reduced medical and indemnity spend.

Sullivan: We will measure success by objective spend outcomes and qualitative injured worker experience.

As an example, a 2014 JAMA study reported employers spend about $15,000 more for each covered individual who abuses opioids. Some of the One Call solutions on the less-complex side of the spectrum — like provider engagement or using a health coach — cost less than $1,000. You can see how spending a little more on early interventions saves a significant amount over the life of the claim. &

Katie Dwyer is an associate editor at Risk & Insurance®. She 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.


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]