Table 4.

Consequences of insurance constraints on patients, caregivers and clinicians

Theme	Quotations	Role
3. Consequences of constraints • Expressing frustration and anxiety Clinician workarounds • Documenting Failure • Changing Recommendations • Rationing Resources	A. There are a lot of …medically unnecessary delays in care. There are times when we decide …someone needs sub-acute rehab, but they don’t have their Medicare benefits or their Medicaid benefits, and so they sit here waiting for a week or two waiting … and at some point, somebody gets frustrated and they go home, like either the patient is like, I’m not waiting here anymore doing nothing. We need to go to rehab because I’m getting weaker, and I’d rather just go home and get home PT, even if that’s not our original recommendation.	Hospital physician
	B. We send people where we think they need more and we end up sending them home and it’s kind of like we have to almost get like documented failure, if that makes sense, like we have to send them home so that they can fail at home so that they can come back in and then we can try different tacks to get them the facility that they need.	Hospital Nurse
	C. They typically pay for 20 days and any days after that is going to be a copayment on the patient’s behalf, and I just kind of feel that’s in direct conflict with what the surgeon has said…	SNF Caregiver
	D. We make our discharge recommendation. That’s within our scope of practice. That’s what’s needed from us. That’s what we’re being asked to do, not only because of our expertise, but also because our payer sources need to know what do they need next and they’re asking us to tell them. Then the therapist feels like their recommendation isn’t being followed and the social worker is saying well, this is all that insurance will cover, and the therapist wants to fight harder to say, can we push them more to do the acute, like we’ll make sure the communication is clear in our notes, as we try all of the time, but if there’s an issue, can we call and talk to the medical director at the insurance or whatever. So, what will happen then sometimes is that the case manager, social worker will ask us to change our notes, which we don’t like to do just based on that recommendation, and we’re talking about this because insurance is all over the place, but it does really become an insur…, a payer source issue [...]	Hospital Physical therapist
	E. Hospitals are getting just as much pressure as we are. And to get people out the door sooner. And as a result of that, they are coming to me sicker, but my facilities do not have any more increased capacity to take care of sicker patients. I have a patient right now who had a massive bleed in his head. He has a trach and he’s not on a ventilator, but he’s on a collar to deliver continuous oxygen. If he develops a pneumonia, I’m gonna have to send him right back immediately because he doesn’t have, because he’s already so compromised.	SNF physician
	F. Right now, I think it’s really hard to do the right thing. It often takes heroic effort and even beyond that, impossible amounts of time to do this for every patient, so that’s why I said I was selective in who I do it for, not based on the person, but based on who I think needs it the most or would benefit from it the most or is at highest risk for harm if with it not being done, but I would love if it was very easy to have a conversation with the person who is going to be taking care of them on the other end, if it was very easy to ensure that the information that was critical got to that person or those people in a time-sensitive and time appropriate manner, if there was feedback for the provider about how things went and how things could be better for the future, cause we all want to improve, it’s not that people do the same crappy job over and over because they want to, if that happens, it’s because they don’t know or it’s challenging to do better.	Hospital physician