The Human Face of Prior Authorization
Lack of healthcare transparency. The tensions caused by prior authorizations. The tradeoffs between cost and care. These aren’t abstract concepts to Myndshft’s Director of Talent, Maria Montoya. Here is her story.
“You’re too young to be here.” After trite introductions, those were the first words spoken by a silver-haired surgeon explaining the implications of my breast biopsy.
Two months after my 30th birthday, flanked by my mother and husband, this man laid out the road ahead: first there would be surgery, likely not chemo, no radiation. It was still early, but nonetheless clear that I had breast cancer.
I recall nervously skimming the breast cancer treatment pamphlets he handed me, looking for somebody I could identify with but finding only stock images of older women. It left me wondering, “how is this possible?”
Given my age, I was referred to genetic testing and counseling at an in-network provider. I went to that appointment thinking I would simply pay the in-network specialist copay. Checking out of the appointment, however, I was stuck with an unexpected bill, six times larger than I had anticipated.
I argued with the discharge staff, talking in circles explaining how I shouldn’t be paying more than my copay. I gave them my debit card anyway – money I was scraping to save for the road ahead – money they would end up reimbursing me later after they reconciled their billing.
My genetic counselor recommended that I complete a more comprehensive testing panel, given my family’s history of cancer. BRCA 1 & 2, while commonly known to cause breast cancer, are only two of a myriad of carcinogenic genes. Since I tested negative for both, I wanted more answers and information to inform my treatment. Would a double mastectomy make sense? What’s my risk for a new tumor? Would I have to go through this horrendous journey again in the future? Answers to these questions were tangled in the helixes of my genes, so I had my blood drawn.
One month later, I was unnerved to find out that the fuller-panel BROCA test was denied by my insurance, and would pile on over $4,000 out of pocket. Given the mounting treatment-related medical bills that I had already accumulated, I opted to forgo the test. I felt like my future was held hostage in a vile, shelved in a lab. I’m still not sure what my risk is for a new tumor, and that reality is haunting, despite being several years out of treatment.
The tests that I was able to pay for proved to be useful. One test was able to assess my risk for recurrence, which was unusually high given that I was diagnosed at an early stage (and age). The implication, however, was that I had to go through chemotherapy after all.
Being a glutton for punishment, I switched jobs, and thus insurance plans, in the middle of treatment. With this new plan in force, I recall waiting for my second infusion, confident that all insurance-related issues were copacetic. However, before beginning that day, there were rumblings and rumors from the clinical staff that this treatment required prior authorization, which hadn’t yet been completed. Suddenly anxious and concerned about whether or not I would get the care I needed, I decided to move forward with the infusion anyway, not knowing the potential costs of chemo.
In hindsight, this could have been a financially disastrous decision.
While I was incredibly lucky that my insurance plan inevitably covered my treatment, I had mixed emotions about having dodged a financial bullet. On one hand, I was (ironically) grateful to move through chemotherapy as planned, and adhere to a sense of predictability during an unpredictable time. On the other hand, the sinking feeling of seeing the price tag on the “this is not a bill” for tens of thousands of dollars for one infusion session made me more nauseous than the therapy itself. I had no idea that I was standing so close to a financial cliff.
When navigating cancer treatment, the path in front of you is shrouded in ambiguity and ambivalence between options. You can do your best to stay present, but the constant worry of “what if” is ubiquitous.
This is frequently compounded by the uncertainty of “how much is this going to cost? Is the treatment or prevention worth it? What are my risks if I forego this treatment because, what if I can’t afford it?” Knowing the cost of treatment would have been exceptionally helpful. The “what ifs” still linger, but I have a little more peace of mind these days, several years out of treatment, and now working to solve the very problem I experienced personally.
This journey gifted me with remarkable compassion for the patients we touch with our products. To date, Myndshft has helped more than 81,000 people get through treatment with more clarity and certainty, and with a confidence that I wish I had when I went through it. Nevertheless, I’m lucky. I feel fortunate to work for a company so singularly focused on helping patients get the care they need faster, by reducing the administrative burden for providers. Not everyone gets the chance to work toward a mission that hits so close to home in their personal lives, and yet here I am.
Our work – my work – deeply matters. There is a feeling of injustice that patients bear when they are caught between receiving the care they need, and not knowing how much it’s going to cost them. We (patients) never asked for the health circumstances we experience, yet we’re forced in isolation to navigate a maze of appointments, follow-ups, phone calls, statements, and bills that we neither desired nor anticipated.
Nobody asks to be a cancer patient, yet we have to advocate for our own care, and the administration and coordination thereof, like its a part-time job. I get to work toward minimizing that injustice, and that’s nothing short of – well – really freaking awesome.
If you’re reading this, chances are you or someone you love had to obtain prior authorization to receive care at some point in life. If you’ve ever had to deal with it first hand, hats off to you for making it through the maze.
I urge you to tap into that feeling of anxiety and impatience, and imagine a stadium of 81,000 people all in the same boat. Picture them pacing through the isles wondering if their infusion would be approved. Imagine them checking their cell phones every two minutes to see if they missed a call from their provider that they can schedule the next lab draw, or that they got the test results they needed, and could map out a treatment plan accordingly. Now, imagine you could do something to ease their worry.
There is a reality in which you have the ability to help millions of people worry less, heal more, and shed the title of “patient” faster than they could have without you. Whether you work with us or for us, you’d be working to free providers up to focus on the work that matters – helping people expeditiously get the care their need. To get more information about our products, please contact us here. If you’d like to work for us, please visit our careers page.