{
    "abstract": "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.\nThis 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.\nData 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.\nThirty-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.\nWe 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.\nNCT03926533.",
    "authors": [
        {
            "affiliation": "VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.\nDepartment of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.\nInstitute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.",
            "firstname": "Tammy L",
            "initials": "TL",
            "lastname": "Eaton"
        },
        {
            "affiliation": "Center for Applied Health Research, Baylor Scott & White Health, Dallas, Texas, USA.\nDepartment of Medicine, Baylor College of Medicine, Houston, Texas, USA.",
            "firstname": "Valerie",
            "initials": "V",
            "lastname": "Danesh"
        },
        {
            "affiliation": "School of Nursing, Vanderbilt University, Nashville, Tennessee, USA.",
            "firstname": "Abigail C",
            "initials": "AC",
            "lastname": "Jones"
        },
        {
            "affiliation": "School of Nursing, Vanderbilt University, Nashville, Tennessee, USA.",
            "firstname": "Christine C",
            "initials": "CC",
            "lastname": "Kimpel"
        },
        {
            "affiliation": "Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.",
            "firstname": "Carla M",
            "initials": "CM",
            "lastname": "Sevin"
        },
        {
            "affiliation": "School of Nursing, Vanderbilt University, Nashville, Tennessee, USA.",
            "firstname": "Han",
            "initials": "H",
            "lastname": "Su"
        },
        {
            "affiliation": "CRISMA Center, Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.",
            "firstname": "Kelly M",
            "initials": "KM",
            "lastname": "Toth"
        },
        {
            "affiliation": "Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.\nDepartment of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA.\nVA Center for Clinical Management Research, Ann Arbor, Michigan, USA.\nCenter for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA.",
            "firstname": "Thomas S",
            "initials": "TS",
            "lastname": "Valley"
        },
        {
            "affiliation": "VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.\nDepartment of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA.\nDivision of Pulmonary & Critical Care Medicine, School of Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.\nDepartment of Health Policy and Management, Johns Hopkins University, Baltimore, Maryland, USA.",
            "firstname": "Theodore J",
            "initials": "TJ",
            "lastname": "Iwashyna"
        },
        {
            "affiliation": "School of Nursing, Vanderbilt University, Nashville, Tennessee, USA.\nCritical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University, Medical Center, Nashville, Tennessee, USA.",
            "firstname": "Leanne M",
            "initials": "LM",
            "lastname": "Boehm"
        },
        {
            "affiliation": "The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK.",
            "firstname": "Joanne",
            "initials": "J",
            "lastname": "McPeake"
        }
    ],
    "conclusions": null,
    "copyrights": "\u00a9 2025 The Author(s). Health Services Research published by Wiley Periodicals LLC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.",
    "doi": "10.1111/1475-6773.14615",
    "journal": "Health services research",
    "keywords": [
        "ICU recovery",
        "access to care",
        "adverse events",
        "financial hardship",
        "health insurance",
        "post\u2010ICU clinic",
        "workaround"
    ],
    "methods": null,
    "publication_date": "2025-04-25",
    "pubmed_id": "40275640",
    "results": null,
    "title": "Clinician and Patient Responses to US Health Insurers' Policies: A Qualitative Study of Higher Risk Patients.",
    "xml": "<Element 'PubmedArticle' at 0x7885038700e0>"
}