Kristen Laney O'Toole: My MS worsened while waiting for MRI authorization

I was living a healthy, active life as a communications consultant in Pittsburgh. That changed suddenly and dramatically in 2014 when I began experiencing back pain.

As the pain intensified, I realized that something was seriously wrong.

My doctor wanted to do an MRI to officially diagnose what he suspected was a herniated disk. Unfortunately, because of a common policy known as prior authorization, he told me I would need to complete several sessions of physical therapy (PT) and get an X-ray before the insurance company would authorize the MRI.

Week after week, I endured PT sessions without seeing any improvement. In fact, my condition worsened.

By the time I completed this “step therapy” and my insurance company approved the MRI, I could barely walk. The MRI did show a severely herniated disk that led to immediate surgery. But the procedure hid a deeper and much more serious condition.

A week after surgery, I woke up in a hospital rehab unit unable to see or speak. After many tests, the doctors told me I had multiple sclerosis. If I had received the MRI earlier and started on MS infusions, some of my MS symptoms might have been kept at bay.

Maybe I would have never ended up using a wheelchair.

So how did it get to that point?

Prior authorization is a requirement that your physician must obtain approval from your health insurance plan to prescribe a specific medication or procedure for you. Insurance companies use prior authorization as a cost-cutting measure to prevent physicians from ordering too many tests.

But 28% of doctors in a recent survey say prior authorization has led to a serious adverse event for a patient they see.

Since I’ve been diagnosed, I have seen the impact of prior authorization delays because the medications I use to treat my MS symptoms often change. It causes my physicians’ staff and myself to spend hours on the phone to gain necessary approvals.

Fortunately, I’m in a position that I can advocate for myself. Not everyone is that fortunate.

Delays in getting approval for new medication not only impact my health, but my wallet as well.

When I’ve transitioned to new treatments, it often requires prior authorization.

I often don’t know whether I’m approved until the last minute, so then I’ve had to pay full price for the medication, while I wait for authorization. It’s often cost-prohibitive.

State Rep. Steven Mentzer, R-Lancaster, is set to introduce legislation in the coming weeks that aims to decrease patient wait times by streamlining and standardizing the prior authorization process and increasing transparency from insurance companies.

The Pennsylvania Medical Society, the MS Society and the Pennsylvania Chapter of the American Cancer Society are among the bills’ supporters.

Our medical decisions should be made by patients and physicians. Reforming the prior authorization process could prevent others from enduring unnecessary treatment delays, increased costs, hassle, anguish or pain.

Kristen Laney O’Toole is a communications consultant who lives in Ross.