Rheumatologists should include cost, ability to pay in RA treatment discussions
Shared decision-making between rheumatologists and patients with rheumatoid arthritis can be negatively impacted by third-party insurance providers if coverage is uncertain or insufficient, and physicians should aim to include treatment costs and ability to pay in their deliberations at point-of-care, according to data published in Arthritis Care & Research.
“Numerous treatment options are now available for patients with RA, and shared decision-making is considered best clinical practice,” Pauline Binder-Finnema, PhD, MPP, of Yale University School of Medicine, and colleagues wrote. “Yet, despite the apparent influence of cost on patients’ adherence to treatment recommendations, few studies have examined this factor at point-of-care or whether ability to pay influences [shared decision-making] processes and outcomes.”
To better understand of how insurance coverage relates to treatment escalation in RA, and to evaluate the perspectives of rheumatologists and their patients with RA at point-of-contact during shared decision-making, Binder-Finnema and colleagues audiotaped patient-physician interactions at four academically-affiliated RA clinics. Between May 2016 and June 2017, the researchers recorded 156 visits. All patients were approached for consent prior to each visit, and researchers were not in the room during patient-physician discussions.
All recordings were transcribed verbatim, and later read and re-read by all researchers, who analyzed the discussions using qualitative Framework Analysis. Binder-Finnema and colleagues then identified data-driven phrase-codes for disease-modifying antirheumatic drug type, escalation and cost factors by interrater agreement and matrixed onto a spreadsheet using Microsoft Excel
According to the researchers, most patients with RA, aside from those with effective insurance coverage, had shared decision-making discussions impaired by thirdparty insurance providers with the ability to authorize the preferred choice of DMARD. This triangulated form of deliberations negatively affected efficiency in the discussions, impaired timely treatment and was a barrier to shared decision-making regarding health risks and symptom improvement.
“The necessity of adequate, stable and predictable insurance coverage defines effective decisional deliberation and, by proxy, best clinical practice,” Binder-Finnema and colleagues wrote. “Appeals for greater cost transparency as it supports effective [shared decision-making] at the point-of-care should be made. One-size-fits-all managed care drug formularies may lack necessary sensitivity to capture individual RA patient needs, which these findings suggest can seriously dismantle [shared decision-making].”
The researchers noted, “Our findings support patient uncertainty about affordability as a problem that can substantially work against effective [shared decision-making] during treatment deliberations, and can upend the overall quality of the clinical encounter in RA.” – by Jason Laday
Disclosure: Binder-Finnema reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.