When Presbyterian Health Plan denied Dave Bexfield of Albuquerque, New Mexico reimbursement for a multiple sclerosis treatment trial, Bexfield launched a campaign to recover the $200,000 he spent on the treatment. He contacted media, bombarded Presbyterian with calls and emails, and ultimately lined his garage walls with the insurer’s denial letters, according to an August 1, 2014 column by David Segal in the New York Times.
The treatment was a stem cell transplant trial sponsored by the National Institutes of Health. The trial worked in that Bexfield no longer takes M.S. medication and the disease is in remission. But the stem cell transplant was apparently not a covered benefit when Bexfield received the treatment. Ironically, Presbyterian Health Plan added this treatment to the benefits for Bexfield’s plan a few months after he finished the trial. A Presbyterian spokesperson reportedly called the timing “unfortunate.”
Unfortunate indeed for Presbyterian Health Plan in that Bexfield refused to back down. Presbyterian reportedly insisted that the only reason the company had added stem cell transplants for M.S. as a benefit was that the federal government had mandated it. So Bexfield submitted a Freedom of Information Act request and received documents indicating there was no federal mandate. This suggested that Presbyterian had decided on its own based on the treatment’s merits to begin covering stem cell transplants after Bexfield had completed the trial. After receiving many additional letters and media calls, Presbyterian changed course. Presbyterian Health Plan President Lisa Farrell Lujan agreed to reimburse Bexfield not only the $200,000, but also an additional $198,000 in interest at 18 percent, according to the Times.
Boom. The Bounty Effect had arrived at Presbyterian Health Plan, and the company seized the opportunity to change. The Bounty Effect happens when exigent circumstances compel businesses, governments and organizations to change their structures from command-and-control to collaborative. The exigent circumstances were groundbreaking advances in stem cell research. Bexfield’s campaign and the resulting media attention drove The Bounty Effect home. In this situation, Presbyterian adopted a more collaborative approach. Often structural change starts small and grows. This episode may pave the way for more fundamental structural changes at the company.
In my latest book, The Bounty Effect: 7 Steps to The Culture of Collaboration, one of the 7 steps is Processes. And a key process is employing Measurement Counter-Measures which curb the measurement mania that can complicate collaboration and compromise value. The point is that a maniacal focus on measurement can produce the opposite of the intended result. Clearly, Presbyterian’s measurement mania produced myopia in that claims representative had difficulty seeing beyond the numbers.
The $200,000 for the stem cell transplant would cost the insurer in the short run, but the money produces a living, breathing example of an insurance customer who may potentially avoid further treatment for M.S. and save the insurer plenty. One measurement counter-measure is to perform a common sense reality check. If the numbers defy common sense, that’s our cue to pause and reconsider. Employing Measurement Counter-Measures is often the hardest collaborative process for financial professionals to adopt.
Lujan, Presbyterian’s president, is the company’s former CFO and was previously an audit manager with Arthur Andersen. She told the Times that the individual decisions Presbyterian made in Bexfield’s case were correct but that consistent policies had to be balanced against fairness. “When I looked at the forest, I came to a different conclusion than those who had looked at each individual tree,” according to Lujan.
The old reimbursement decision was obsolete, because of scientific breakthroughs. Clinging to an antiquated coverage decision would expose the company to possible litigation, bad publicity, and a hit to its reputation. More fundamentally, the old decision—and the structure that produced that decision—failed the fairness test and the common sense reality check.
The Bounty Effect prompted Lujan to take a key step—but changing the structure requires much more. If only the CEO can see the forest and use a fairness test, the organization flies blind and the business suffers. In adopting a collaborative structure, the challenge for Presbyterian and for many organizations is empowering people at all levels to consider the big picture, participate in decisions and take action. This requires, among other shifts, changing the recognition and reward system and enabling spontaneous interaction so that all Presbyterian Health System team members share a view of the forest and not just individual trees.