I almost died because of insurance prior authorization rules. Pennsylvania has legislation to fix them. | Opinion
Today I'm joining Pennsylvania lawmakers with a simple message: Reforming the prior authorization process could prevent unnecessary treatment delays, hassle, and health risks.
As an active 48-year-old athlete, I don’t fit the mold of your typical cardiac patient. I exercise 6-7 days per week and have normal weight and blood pressure. But when I started having chest pains in November, I knew something was wrong.
My cardiologist, Dr. Kenneth Mendel, ran a number of tests. My EKG came back fine. My stress test replicated my symptoms but did not show the changes usually seen when blood flow to the heart is restricted.
On Dr. Mendel’s recommendation, I had a coronary calcium test. This test placed me in a top decile (91 percent) for my age/race for having calcium deposits on my coronary arteries and suggested that my pains could really be angina — a type of chest pain caused by reduced blood flow to the heart.
During the next five months, I improved my diet, lost 15 pounds, and got more sleep. But the attacks continued.
As they became less frequent but more intense, Dr. Mendel recommended a cardiac catheterization to determine if my attacks were a result of a blocked artery.
To my surprise, Dr. Mendel called later that day with bad news: My insurance carrier, Independence BlueCross (IBC), denied the prior authorization required to do the cardiac cath. It turns out, I didn’t fit all of IBC’s criteria to do the procedure.
Dr. Mendel spent 40 minutes on the phone with IBC’s designated radiology benefit manager to plead my case to no avail. I would have to delay the procedure and appeal.
Three days later, as I was returning home from a family outing, I experienced two attacks in one night. My wife took me to the emergency room.
The hospital did an emergency cardiac cath (no prior authorization necessary) and found I had a 95 percent blockage in my left anterior descending artery (LAD, or the “widow maker”) and an 80 percent blockage in my left circumflex artery.
I had been walking around with a ticking time bomb in my chest. The three stents they put in opened the blockages and likely saved my life.
How did it get to that point? Pure and simple: An insurance company making medical decisions without evaluating me and overruling an experienced physician who placed the test results into the context of my symptoms.
Insurance companies say prior authorization prevents physicians from ordering unnecessary tests and controls health spending. But in my case, IBC’s denial led to a four-day hospital stay and the cost of my care soared.
Use of prior authorizations have increased in recent years, and it is starting to impact care around the nation. Twenty-eight percent of doctors in an American Medical Association survey reported this year say prior authorization had led to a serious adverse event for a patient they see.
In the weeks following my hospital stay, I felt great. The chest pains I experienced on a regular basis have disappeared and I can now jog with my teenage daughter.
My case proves that medical decisions should be made by patients and their doctors — not by a third-party using a checklist. My condition didn’t check all their boxes and the insurer negated my cardiologist’s experience and judgment.
An increase in the stress on my heart or a small increase in the blockage to my LAD could have given me 30 minutes to live. It nearly cost me my life.
Our state House of Representatives has pushed legislation that aims to standardize the prior authorization process and increase transparency from insurance companies. The Pennsylvania Medical Society and Pennsylvania Chapter of the American College of Cardiology are among the bill’s supporters, and I spoke Monday at a news conference with Pennsylvania lawmakers to move this bill forward.
We have a simple message: Reforming the prior authorization process could prevent others from enduring unnecessary treatment delays and increased costs, hassle, anguish, or pain.
Ross Waetzman is a director at Gavin/Solmonese where he works to save companies from going into bankruptcy. He resides in Garnet Valley with his wife and two kids.