Mandatory Second Opinion Programs: Minimum Disruption, Maximum Impact

by Pamela Guggina, MD, and Mike Hough

Amongst its many services, Advance Medical offers a mandatory second opinion program (MSOP), born from an observation that 39% of initial diagnoses and 60% of patient treatment plans receive a recommendation to change from their original path of care.1 Implementing MSOP has the potential to avoid costly and unnecessary procedures that waste money and lead to increased risk and lower quality of life. Furthermore, a second review of medical decision making allows members to obtain the best possible care, which can prevent disability, lost productivity, and downstream complications from unnecessary procedures.

The adage of “doing it right the first time is always less expensive” applies to healthcare. When patients receive a correct diagnosis and/or treatment early in their care, the less extensive that care will be. There are opportunities to improve the quality of care and, subsequently, the quality of life of members through an independent review. Second opinions in general have been shown to enhance clinical decision making2 and offer important improvements in the quality of healthcare.3 There is considerable medical evidence that outside review prior to planned surgery leads to fewer operations.4 Patients generally believe that second opinions are valuable.5

While there are multiple ways to implement a second opinion program (i.e., voluntary programs, incentivized programs, mandatory programs for certain procedures, etc.), payers are increasingly adopting MSOPs due to their accessibility and reliability and the guarantee that employees are receiving accurate care.

In 2016, a healthcare facility and services company launched an MSOP for the nearly of its 30,000 members. Its employee base includes a large proportion of healthcare workers, a population with significant overall disease burden. Members of the health plan only receive full payment coverage for major interventions, such as surgery, if independent specialists in the field have reviewed their care plan and medical charts through their MSOP.

Advance Medical’s MSOP works as follows: First off, it is entirely managed by actively practicing board-certified physicians, called Physician Case Managers. These physicians obtain detailed medical records, often hundreds or even thousands of pages, not simply visit summaries or claims data. They compile these records and then have experts review primary imaging, such as MRIs, CT scans, and X-rays that are obtained directly from healthcare facilities. Based on these reviews and direct conversations with patients by the physician case manager, experts make their determination. This physician oversees the entire process and functions as an advocate physician for patients, helping them understand their medical records and the proposed procedure.

In a study conducted by Advance Medical, out of 24 MSOP reviews, 50% of cases had a major change in treatment, 17% had a minor change, and 33% had no change. Avoided costs from an inappropriate surgery amounted to $424,540 on a national average, claims-paid basis.6 That is over $17,000 per review or $26,000 per changed review.

The right diagnosis and treatment are critically important early in a patient’s care. In addition to upfront surgical cost savings, there are a multitude of downstream benefits, such as a decrease in lost productivity, absenteeism, and disability claims due to prolonged surgical recovery times. In the end, implementing a MSOP resulted in cost savings and improved member care by ensuring that members did not receive dangerous and/or inappropriate and/or ineffective treatment.

1 Advance Medical Book of Business Data as of Dec. 31, 2016.
2 Vashitz G, Pliskin JS, Parmet Y, Kosashvili Y, et al. “Do First Opinions Affect Second Opinions” Journal of General Internal
Medicine. 2012;27:1265-1271.
3 Gertman PM, Stackpole DA, Levenson DK, et al. “Second Opinions for Elective Surgery—The Mandatory Medicaid Program
in Massachusetts.” The New England Journal of Medicine. 1980;302:1169-1174.
4 Yanamadala V, Kim Y, Buchlak QD, Wright AK, Babington J, et al. “Multidisciplinary Evaluation Leads to Decreased
Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study.” Spine. 2017;42(17):E1016-E1023.
5 Payne VL, Singh H, Mayer, Levy L, et al. “Patient-Initiated Second Opinions: Systematic Review of Characteristics and
Impact on Diagnosis, Treatment, and Satisfaction.” Mayo Clinic Proceedings. 2014;89(5):687-696.
6 Advance Medical Database of Large Employer Claims-Paid Costs for Procedures.

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