Second-opinion medical services can be an effective benefits cost-containment tool for mid-market employers as treatment costs for complex cases such as cancer and back injuries are soaring.
The services are available to fully insured and self-insured employers, regardless of size, and can be purchased either on a case-by-case basis or under a contractual arrangement in which the employer pays a per-employee fee each month.
In many cases, the service more than pays for itself given the nominal cost—usually less than $1,000 per case—compared with the cost of treatment for many complex cases, experts note.
According to recent data collected by three major second-opinion medical service providers, misdiagnoses are discovered in up to 20 percent of medical cases and treatment changes are recommended in more than half of them.
Jonathan Schaffer, a physician who is managing director of the Cleveland Clinic's MyConsult Online Medical Second Opinion service, said one case resulted in savings of more than $150,000 when treatment changes were implemented for a 61-year-old patient who had undergone spinal fusion surgery.
"Her doctor wanted to extend the fusion further up her spine, but we found that the previous fusions didn't create the appropriate spinal curvature," he said.
Part of the reason for the high frequency of misdiagnoses and incorrect treatment plans is that many physicians do not regularly address complex cases such as those being referred for second opinions, said Dr. Joseph C. Kvedar, director of the Center for Connected Health at Partners HealthCare System Inc. in Boston. Partners has provided second-opinion services remotely for 17 years, the past 10 online via Partners Online Specialty Consultations, a service available on a retail basis for individuals or on a contract basis to employer groups.
According to a recent analysis of 330 oncology cases by Partners, 12 percent of the cases reviewed resulted in changes in diagnosis, while 90 percent resulted in either a new plan or a significant change in prior treatment plan, he said.
"I don't think it's a knowledge deficit of local providers, but those doctors aren't treating a particular disease over and over" like the specialists at Partners are, Kvedar said.
"There is a lot of variation of care around the United States," said Stephen Ferzoco, a Boston-based surgeon who provides second-opinion services at Best Doctors Inc. "The basic stuff gets done very, very well," he said. "We all try to practice evidence-based medicine, but sometimes it's stuff that we can't find information on."
As part of its second-opinion service, Best Doctors consults with patients' treating physicians to educate them about conditions and treatments to which they may not have been exposed in their regular medical practices, Ferzoco said.
Best Doctors was founded 22 years ago by several Boston physicians to serve mostly large, self-funded employers, said Evan Falchuk, president and chief strategy officer. But as the cost of health care rises for employers of all sizes, he is seeing more interest among smaller and midsize employers who pay $2 to $3 per employee per month for Best Doctors' second-opinion service.
"Everybody wants to have a healthier workforce. I can do everything I can to help my employees stop smoking and lose weight, but if they get sick through no fault of their own, they need help to navigate the system," he said.
For example, in the case of a patient who was not responding to lung cancer treatment, "Best Doctors reviewed medical records and found that the patient had previously been treated for thyroid cancer. The evaluation discovered that the thyroid cancer had metastasized in his lungs, so it wasn't lung cancer. This is typical. Twenty percent of people end up with the wrong diagnosis in general," Falchuk said.
MyConsult also began offering its services to large, self-insured employers when it launched in 2002, said Schaffer, "but in the last couple of years, the smaller employers are becoming more interested, so we now have employers with as few as 500 employees."
While the majority of the employers using MyConsult are self-insured, some insured employers also are making the service available to employees case by case. The cost averages about $565 per case, with an additional $180 charged if pathology is needed, he said.
Schaffer said Cleveland Clinic doctors disagree with initial diagnoses in 11 percent of cases. In 15 percent of cases, they find the need for further testing. In 22 percent of the cases reviewed, minor changes to treatment plans are recommended, moderate changes were recommended in 26 percent of cases and major changes were recommended in 18 percent of cases.
Dave Thomas, benefits manager at Development Dimensions International Inc., a Pittsburgh-based human resources consulting company that provides health insurance to about 1,000 employees and dependents, signed up for the Best Doctors service as a cost-containment tool Jan. 1 after learning about it through the Pittsburgh Business Group on Health.
He said the service "gives employers an opportunity to get involved in the management of the illness, not just paying the claims."
While Thomas said it is too early to calculate the return on investment, he knows that two employees have used the service so far and that one resulted in a different course of treatment.
"It's really aimed at simply making sure treatment is appropriate and provided in a cost-effective way. The spin with Best Doctors is, they really look at the case much as you would expect a team of medical professionals in a teaching hospital to come in and look at all the details and then start fresh to make sure the diagnosis is correct, what treatment options are available, and whether the one selected is the best and reflects the latest thinking."
Because the cost is less than $4 per employee per month, DDI extended the program to all employees, regardless of whether they are enrolled in its benefit plan.
"We think it's a valuable tool to give them," Thomas said.
Christine Whipple, executive director of the PBGH, negotiated a discount with Best Doctors as part of the coalition's ongoing effort to provide services and programs to member employers to help them better manage their health care costs. "We saw it as more than a second-opinion service. It is a more personalized and consultative service to determine the right course of treatment. When we're facing health issues, we all want that feedback and input," she said.
John Myers, president of AIM Mutual Insurance Co., a workers compensation insurer in Burlington, Massachusetts, that offers Best Doctors to its 150 employees, said sometimes a second opinion can alleviate the fear that often accompanies a serious diagnosis.
He said after Best Doctors corroborated the diagnosis of one employee who was facing complicated surgery, "it relieved the employee's concern, and it also confirmed that the treating physician was a good one and there was no need to change doctors."