As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:
Imagine that tomorrow as you brush your teeth you notice a small lump in your neck. You see your doctor, who diagnoses a nodule on your thyroid gland. She sends you immediately to a surgeon who tells you that you need to have your thyroid gland removed. A thyroidectomy is a big operation, and this is all moving so fast, and you’ve crossed that gauzy boundary from “person” to “patient” in a matter of days. What do you do?
Many of us would seek a second opinion, one of the most time-honored rituals in medicine. A patient, unsure of the accuracy of a diagnosis or the veracity of a treatment plan seeks a second physician to confirm or refute the findings or recommendations of the first physician.
Do second opinions work?
Second opinions—whether they’re a matter of a second radiologist or pathologist reviewing images or slides or an endocrinologist reviewing the case above—have a demonstrable impact on the care delivered to a patient. A commonly cited number is that 30 percent of patients can expect their diagnosis or treatment plan to change with a second opinion, but I’m unable to find the original source of that number. A 2014 systematic review in Mayo Clinic Proceedings, though, found that between 10 and 62 percent of second opinions yield a “major change in the diagnosis, treatment, or prognosis” of a patient.
So it is no surprise that surveys have found that nearly one in five patients who saw a doctor in the past year sought a second opinion, and more than half of patients who are cancer survivors sought a second opinion at some point during their cancer care.
It just makes financial sense: an insurer—or you, the employer, if you’re self-insured—would rather not pay for a $5,000 thyroidectomy when a second consultation and thyroid ultrasound, which cumulatively cost only a few hundred dollars and which likely leaves your neck unscarred, would suffice.
Second opinions appear to help the mental health of patients, not just the accuracy of their diagnoses. An Australian study found that the opinion of a second oncologist gave more than half of cancer patients greater confidence in their diagnosis and treatment plan. A study of neurology patients found that patients were most satisfied with the amount of information and emotional support provided by the neurologist offering the second opinion.
Do insurance providers pay for them?
The majority of insurance plans cover second opinions. It just makes financial sense: an insurer—or you, the employer, if you’re self-insured—would rather not pay for a $5,000 thyroidectomy when a second consultation and thyroid ultrasound, which cumulatively cost only a few hundred dollars and which likely leaves your neck unscarred, would suffice.
Medicare covers second opinions if “a doctor recommends that you have surgery or a major diagnostic or therapeutic procedure,” and if the opinions of the first two physicians differ, will cover a third opinion. And many state Medicaid programs have or have had mandatory “Second Surgical Opinion Programs,” which require patients to obtain a second opinion before surgery as a condition of their coverage.
In Kansas, Medicaid managed care providers Sunflower, United Healthcare, and Aetna all cover second opinions. However, some managed care plans and HMOs do not cover second opinions. Some states, including California and New York, have laws that guarantee HMO members the right to a second opinion. Kansas, to our knowledge, does not have such a law.
Some self-insured employers such as Wal-Mart have taken the leap to insist that their employees go to “Centers of Excellence” for all high-risk procedures like spine surgery and bariatric surgery. The purpose of these trips is not just to get the procedure done; Wal-Mart and others want to know if the procedure is necessary in the first place.
What can employers do to help?
Startups have emerged to help with this process. The telemedicine company 2nd.md advertises heavily on the internet, but we are unaware of the quality of their care or their costs. Docpanel.com provides radiology-specific second opinions. The company best known to me is Grand Rounds, a company which now serves primarily in care coordination, but whose focus was once the connection of patients with specialists to confirm and explain high-burden diagnoses. [disclosure: I once interviewed for a contract position at Grand Rounds, but I have no relationship with the company]
But there is likely no need to go directly to a new vendor. Check with your insurance provider or third-party administrator to confirm that your employees have access to second opinions, and educate your employees about their options. The Patient Advocate Foundation has a brief handout that may be helpful. A delicate balance must be struck: it is usually a mistake to interfere in the relationship between a patient and a trusted practitioner (see our prior post on HyVee and stem cells). It is not a mistake in the slightest, though, to give patients the opportunity to seek out additional opinions in case of uncertain diagnoses or complex treatment plans. The first doctor’s feelings may be bruised in some cases; I’ve been on both ends of that relationship. That’s okay. Those hurt feelings may be the cost of doing business for getting a more accurate diagnosis, a more up-to-date therapy plan, or a more realistic prognosis. And those can potentially have real health benefits to your employees and real dollars-and-cents benefits to your bottom line.