Clinician and Patient Responses to US Health Insurers' Policies: A Qualitative Study of Higher Risk Patients.

Eaton TL, Danesh V, Jones AC, Kimpel CC, Sevin CM, Su H, Toth KM, Valley TS, Iwashyna TJ, Boehm LM, McPeake J. Clinician and Patient Responses to US Health Insurers' Policies: A Qualitative Study of Higher Risk Patients. Health services research. 2025 Jun 1; 60(3):e14615, DOI: 10.1111/1475-6773.14615.

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Abstract:

OBJECTIVE: To identify specific ways in which US health insurance triggered changes in care and interrupted the encounter between clinicians and patients in post-intensive care unit (ICU) clinics. STUDY SETTING AND DESIGN: This naturalistic qualitative study was nested within a randomized controlled trial that evaluated the feasibility and preliminary efficacy of a telemedicine ICU recovery clinic intervention. Adult participants were referred to a multidisciplinary ICU recovery clinic after septic shock or acute respiratory distress syndrome (ARDS) in a Southeastern US academic medical center. DATA SOURCES AND ANALYTIC SAMPLE: Data were collected from 2019 to 2021. Telemedicine ICU recovery visits within the intervention group were used in this analysis. ICU recovery visits at 3- and 12-week intervals after hospital discharge were recorded and analyzed based upon the constant comparative method. Responses were initially open coded and then consolidated with the Donabedian Model of assessing healthcare quality by two investigators to organize themes and subthemes, with discrepancies in coding resolved by consensus. PRINCIPAL FINDINGS: Thirty-three clinic visit transcripts from 19 patients revealed health insurance-related issues commonly elicited by clinicians. One in three patients raised health insurance-related issues during their clinical encounter. Structural barriers to ICU recovery included high out-of-pocket spending, the complexity of interfacing with health insurance companies, and health insurance literacy. Patients initiated modifications to intended care to overcome insurance-related barriers to recovery, including nonadherence to prescribed medications and treatments and crafting unsafe "workarounds" to recommended healthcare, with consequences to their recovery. CONCLUSIONS: We found that health insurance complexity and high out-of-pocket costs compromise the quality of care and recovery experienced by ICU survivors. These findings emphasize the need for solutions at the policy, payor, and healthcare system levels to mitigate barriers to ICU recovery created by health insurance, which can adversely influence affordable, timely, and appropriate critical illness survivor care. TRIAL REGISTRATION: NCT03926533.