Examining Insurance Complications in the Shared Decision Making Process for Rheumatoid Arthritis

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The addition of third-party insurance companies in the shared decision-making process complicated efficiency in terms of participants' decisions as well as timely treatment.

For patients with rheumatoid arthritis (RA) who are considering changing treatment, the ability of third-party insurance providers to authorize treatments complicates the shared decision-making process, according to results published in Arthritis Care & Research.

Researchers audiotaped visits at 4 RA clinics, at which time participants had to decide whether to change their treatment between May 2016 and June 2017 (n=156). They transcribed the audiotapes verbatim and analyzed them using qualitative framework analysis.

The researchers included 156 participant recordings in which the consultation involved statements from the clinician regarding worsening symptoms and a need to escalate treatment. Approximately 30% of participants had private insurance, 38% had Medicare, 21% had Medicaid, and 8% had no known source of insurance.

The results indicated that third-party insurance providers who had the power to authorize or reject a participant’s preferred disease-modifying antirheumatic drug (DMARD) often interrupted or changed participants’ decisions. Participants with effective insurance coverage did not have these issues.

Participants’ confidence about affording a particular DMARD significantly affected their decision process. For participants whose insurance would not cover the desired treatment, clinicians were unable to offer medically necessary treatment until a payment option was found.

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The researchers found that the addition of third-party insurance companies in the shared decision-making process complicated efficiency in terms of participants’ decisions, as well as timely treatment. It also created a barrier to discussions of health risks and symptom improvement that occurred when the process occurred between participants and clinicians alone.

“Rheumatology care providers should aim to incorporate treatment costs and ability to pay into their deliberations so individualized out-of-pocket estimates can be considered during triangulated [shared decision making] at point-of-care,” the researchers wrote.

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Binder-Finnema P, Dzurilla K, Hsiao B, Fraenkel L. A qualitative exploration of triangulated shared decision making in rheumatoid arthritis [published online October 28, 2018]. Arthritis Care Res (Hoboken). doi:10.1002/acr.23801