Two heads are better than one

ITIJ 201, Cost Containment Review, October 2017
Tatum Anderson evaluates the nature of second medical opinion services and the role providers of these services are playing in the international travel and health insurance world
Let’s start with a scenario in which obtaining a second medical opinion (SMO) meant a significant change to diagnosis, treatment and cost. A 55-year-old woman was diagnosed with a malignant spinal tumour. A diagnosis of cancer is distressing enough, but her doctors have recommended chemotherapy, radiotherapy and invasive surgery that carries the risk of permanent paralysis. It’s a terrible diagnosis. So, the patient seeks a second opinion. This particular one is outsourced to an independent specialist company that is able to draw on a database of specialists in complex cases.
This new specialist not only looks at her test reports, to check the diagnosis, but sends her biopsy for testing at an independent laboratory.
The result? The tumour is benign. Had the woman gone ahead with the previous set of treatments, her life would have been very different, according to Dominic Howard, director, European sales and accounts at Best Doctors, the company that conducted the second opinion. “She didn’t need the chemotherapy, radiotherapy or the type of surgery that they were going to do to remove it,” he said. “There is a lot of misdiagnosis out there.”
Common practice becomes more crucial
Gaining an SMO is a well-established practice. Cancer treatments and cardiac treatments are common second opinion requests, say assistance companies. In fact, they have been in use for so long, that some remember when wedges of medical documents on individual cases would be couriered to doctors for second opinions. These days, most things are done by email conference call, and there are cloud-based applications so doctors can even communicate with each other and view medical reports at the same time.
But, SMOs could become more crucial. A report from the Mayo Clinic released earlier this year said diagnostic errors are now rife, and costly. Researchers there studied 286 patients referred to its clinic over a two-year period and compared the referring diagnosis to the final diagnosis. They determined the level of consistency between the two and, thus, the level of diagnostic error.
The results were worrying. In 21 per cent of the cases assessed, the diagnosis was completely changed; and 66 per cent of patients received a refined or redefined diagnosis. Surprisingly, only in 12 per cent of the cases was the diagnosis confirmed. 
Raija Itzchaki, president of GMMI, Inc., told the Cost Containment Review that in a study conducted by the company’s contracted vendor, 26 per cent of cases that had been sent for a SMO had a change in diagnosis, while 75 per cent warranted a change in treatment plan.
Diagnostic error could lead to treatment delays, complications leading to more costly treatments, or even patient harm or death, said James Naessens, a Mayo Clinic researcher. And, said the Clinic, the costs associated with these mistakes have been largely unappreciated, despite the fact that they are a direct result of efforts to manage increasing healthcare costs – health insurers often limit access to care outside their network, effectively limiting referrals. What makes things worse is that doctors may be more confident in their diagnostic expertise than warranted in a particular case (although the paper did not follow up on the progress of patients with a second diagnosis to see if it was correct). Patients, without medical expertise, are not aware that there might be a different opinion. 
And in January, The Right Care Series of papers commissioned by The Lancet highlighted underuse and overuse of healthcare around the world. Underuse leaves patients vulnerable to avoidable disease and suffering. Overuse causes avoidable harm from tests or treatments and wastes resources, said authors led by the Lown Institute in Boston with international experts from Harvard, Stanford, Dartmouth and other institutions. The study found that rates of inappropriate total knee replacements were 26 per cent in Spain and 34 per cent in the US; rates of inappropriate hysterectomies were 20 per cent in Taiwan and 13 per cent in Switzerland. And that 6.6 million C-sections around the world are excessive – for more on this, see the article Million-dollar babies on p18. 
The use of expensive and sometimes ineffective technologies was blamed. Shannon Brownlee, senior vice-president at the Lown Institute, said billions of dollars are currently being wasted in the US alone. 
And a report by the US Institute of Medicine released in 2015 stated that most people will experience at least one diagnostic error in their lifetime, and that efforts to improve diagnosis and reduce diagnostic errors have been quite limited.
SMOs in travel
Assistance companies say SMOs, then, might act as a vital break on an inaccurate diagnosis. Specialists able to look through medical notes, scans, prior surgeries, and any other critical information leading to future care plan or a diagnosis can help change the patient’s prognosis or quality of service provided. 
Additionally, they can reduce exploitation, when consumers have inadequate medical knowledge and are dependent on others to determine their needs. An SMO can empower patients because it gives them more information with which to make decisions, according to Brenda Durow, general manager of MSO in South Africa. MSO is the local service partner to Mediguide International, whose members have access to a remote SMO service from a team of top specialists. “A medical second opinion levels the playing field from the funder and consumer perspective to provide a rational and affordable option based on best practice,” she said.
Raija Itzchaki highlighted three main benefits of second medical opinions: “Confirmation of diagnosis (avoiding a misdiagnosis), having additional information available about possible alternative treatment options and possibly the most important is having peace of mind. If the patient has more than one person agree on a diagnosis and treatment plan, the patient will feel more secure and at ease knowing that the necessary steps have been taken to secure optimal care.”
But, crucially, SMOs have the potential to provide cost savings. “There is definitely a place for medical second opinions, especially in areas of high cost and where there is the potential for overtreatment or abuse,” said Durow. A second opinion might be sought for a patient before they receive treatment or go to the US for care, for example.
Best Doctors is so certain that alternative diagnoses tend to result in significant cost savings, it can prove it. It regularly measures the number of cases where it has recommended a change in diagnosis and treatment, and verifies the cost implications. “About 60 per cent of the contracts with employers in the US will have return on investment commitments whereby, at the very least, what they pay us will be equalled by the savings they make,” said Howard. The plan is to introduce cost containment measures in Europe, he said. 
With savings likely, SMOs can sometimes be an effective cost containment tool, say assistance companies. “The value of a medical second opinion as a cost containment tool is usually only evident in a potentially high-cost case, and where the opinion provided is used to ensure best medical outcomes at an appropriate cost,” said MSO’s Durow. “It cannot be used in isolation and needs to be backed by the application of evidence-based protocols.” 
Of course, assistance companies already employ medical audits – analysing bills after the event – as a form of cost containment. But SMOs can determine the necessity of care – before the bill is even produced. 
Gigi Galen Grobstein, CEO of Star Healthcare Network, says SMOs are used by cost containment companies working with an international patient who feels they need a US physician within the specialty to review the medical records, scans, notes and either agree or disagree with the diagnosis or treatment plan. They are also used in international cases that are pre-planned and where the patient is looking for a US doctor to evaluate the case and confirm whether the treatment should be referred to the US for continuation of treatment or a different treatment plan. 
Importantly, they are also vital for flagging potentially fraudulent claims, she said. “Star Healthcare had a case outside the US where we received a bill, saw red flags on the bill (over utilisation, over charges, several diagnoses that did not fit), sent to our second opinion company that agreed with our findings but also found out that the doctor was not even on staff,” she said. “Star informed the client not to pay the bill and considered the bill fraud.”
She adds that one case can inform other similar ones in future. “Second opinions, I believe, can help prepare the PPO and insurance company on the future costs due to the treatment plan which can be outlined for the insured,” she said.
Cai Glushak, chief medical officer at AXA Assistance USA, says SMOs can help avoid unnecessary costs by determining fitness to fly – to curtail care and repatriate a customer. “[These] are more useful for cost control to be able to challenge a live case or a bill,” he said. “When a treating doctor is prolonging the local care for self-serving reasons, patient/family pressure or just because they’re afraid of taking risk, the specialised expertise of an SMO doctor can help resolve.”
After all, it’s an expensive decision to take on whether or how a patient can go home, especially when many treating doctors do not have specialist knowledge on flight physiology. For instance, a patient with a brain injury may benefit from a specialist in flight physiology to determine whether this person can be moved, using normal air evacuation or a low-flying – but more expensive – dedicated plane.
Tanja Roug Wijnen, business development and network manager at assistance company Euro-Center in Cape Town, agrees that second opinions are vital, especially in places where there is corruption, a tendency to keep patients for longer, or to order more tests than is absolutely necessary. In one medical tourism destination where Euro-Center operates, it has even employed a doctor whose job is solely to check medical opinions. That’s because, said the company, some medical facilities are increasingly inflating prices after a significant dip in tourist visits. It discovered that if a second opinion doctor is stationed in the country where these issues happen most frequently, and that doctor can regularly pick up the ways in which hospitals inflate bills, there is an improvement. “If you really monitor the same provider, they give up. They know it’s not worth the hassle,” she said. “The more you do it the less you have to do it.”
But, requesting a second opinion is not as simple as it sounds, and ensuring that cost containment doesn’t trump clinical decisions is vital. Best Doctors says it does not look for the cheapest options, despite its ROI commitments, but the best clinical decision. 
And it is important to ensure the doctor conducting the SMO is appropriately trained. They should be independently chosen and checked for appropriate expertise, not doctors who have volunteered their own services as specialists. And, they shouldn’t be old college friends, either. “We see sometimes that the second opinions go to a physician that the international physician studied with in the US rather than the necessary physician for someone’s diagnosis,” said Grobstein of Star Healthcare. “That delays the process of the second opinion and sometimes proper diagnosis. That doctor isn’t necessarily the right doctor, although [they are] trusted by the doctor that the insurer uses.”
Itzchaki of GMMI said: “In my opinion, it is important that the second opinion is done by a reliable vendor with an excellent reputation in the marketplace. When seeking opinions from hospital systems, I would also recommend utilising centres of excellent that match the specific specialty you are reviewing.”
Euro-Center’s Roug Wijnen says second opinions are embedded into all of its systems. Doctors are on hand at its emergency and central hubs, for example, and double-check all medical reports that come through on complex cases where quick decisions must be made – especially relating to evacuations. Here, conference calls are done as a matter of course. 
Importantly, however, it carries out extensive vetting of providers in each country that it serves, and rates them using a complex system of visits, on-site inspections, questionnaires, cross-referencing, and inspections. It maintains a database of all providers classified according to medical and operational quality criteria; doctors and hospitals are rated as ‘partners’, ‘preferred providers’, ‘neutral’, or are blacklisted.
Those it rates as partners and preferred providers are consistently better at diagnosing and treating patients – and are less likely to have differing second opinions, it says. Hence, it trusts the doctors within these providers with higher ratings more and steers its customers to them, because then it is more reassured that the initial decisions made are the correct ones. 
And research carried out recently in the Greek islands suggests that for patients with insurance policies that stipulate they visit preferred providers, the resulting claims are far less than patients with policies that do not stipulate exactly which preferred providers the customer may go to. “The best cost containment is steerage. Getting people to the right facility in the first place. And once you are there, things generally run quite smoothly,” said Roug Wijnen. “A lot of expatriates want to go to where the local king or president goes to, the expensive one and fancy, but it’s not necessarily the best quality one.”
Market responds to demand
Raija Itzchaki told the Cost Containment Review that GMMI has seen fluctuations in terms of demands for SMOs over the last 25 years, but recently has noted an increase in such requests from the Asia Pacific market. And, she said, the demand is going to grow. “I anticipate this to be especially true for the under-40 age group. Using SMO services is especially a growing trend with treatment in the US, where payers want to confirm that the treatment plan suggested has the best cost and outcome for the patient.”
Second medical opinions, then, form part of a bigger system of cost containment for most assistance companies. They certainly have an important role to play, though, and in many 
areas of the world can be a valuable money-saving tool. n 

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