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Patient Stories

Rx in Reach Georgia

Rep. Kim Schofield's Story

Georgia, District 60

Since 2000, I have been living with a chronic disease known as Systemic Lupus which ranges from mild to life threatening. In June 2018, I had been experiencing low back and neck pain for several weeks. I woke up every day with a gnawing headache and moderate to extreme pain. I used over the counter medications and lidocaine patches to manage my pain in order to continue with my daily routines. The pain was draining. It would take 3 months before I could see a specialist. I had a heavy travel schedule and deadlines to meet in the Georgia General Assembly.

My headache began to intensify. I began to feel dizzy, nauseous and began vomiting. One of the physicians checked my vitals and I was immediately sent to the emergency room. The high level of pain had raised my blood pressure to the point of a potential stroke. Having been triaged in the Emergency Room, I followed up with a Back and Spine Specialist. He prescribed nerve block injection in my back and neck to relieve the pain and which would allow me to continue on a vigorous travel schedule for legislative business.

Five days before the schedule out-patient procedure, I received a call from the specialist’s office informing me that the injection procedure “had been denied by your insurance.” The physician attempted to do a peer to peer review to try and overturn the decision but it was denied. Furthermore, I was told by the insurance company that I must go to physical therapy for 6-8 weeks before injection coverage would be considered.

I explained that the stress of physical therapy while I am currently experiencing a high level of pain is not a realistic option. I spoke directly with the Utilization Manager stating my protest over their decision to override the physician’s recommendations, I even submitted additional clinical information from my rheumatologist who treats my lupus and confirmed the specialist’s course of action was indeed the best treatment for me. Once again, the insurance company denied the injection insisting that I must go to physical therapy for 6-8 weeks.

I was at my wits end so I decided to reach out to the lobbyist that represents this insurance company. I was appalled that this insurance company made a decision about my healthcare treatment despite the authorization and recommendation from the medical professionals that prohibited me from continuing in my role as an elected state legislature. After discussing my health situation in detail, he was able to make a few calls. Several days later, I received a call from my insurance carrier that the injection procedure was approved.

I am thankful I had someone I could call who could run my need up the flagpole. What I am not happy about is that I had to make the call. Imagine having to leverage my role as an “elected official” in order to receive pain relief. I am one of the millions of people who live in chronic pain. It has become a customary, “fail first” practice that medical procedures, medications, devices and treatment plans prescribed by clinicians are denied approval by health insurance companies. As a patient; I say to insurance companies: stop risking my health. As a legislator, I say: I will fight for legislation that eliminates step therapy protocols so physicians have a clear and expeditious process that will allow them to prescribe the best drug and treatment for their patient’s medical needs.

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