Wednesday, August 26, 2015

New Ways For Patients To Get A Second Opinion

For many patients, it has become a routine part of the medical process: Get a diagnosis or treatment plan and then seek a second opinion.
A growing number of online services are offering second opinions and some are seeing increasing patient demand for a second set of eyes.
Some of the services are sponsored by established medical centers, including Massachusetts General Hospital and Cleveland Clinic. Others are independent businesses that work with specialists on a consulting basis. Employers increasingly are contracting with such services, and insurance companies at times require patients to get a second opinion, such as for surgery.
Studies show as much as 20% of patients seek second medical opinions; in specialties such as oncology, the rate is more than 50%. And recent research has found that second opinions often result in different diagnoses or treatments.
Second-opinion services are “one of those areas that is growing fairly quickly,” saidGregory Pauly, chief operating officer of the Massachusetts General Physician Organization at Massachusetts General Hospital. The hospital’s online second-opinion service, which started about eight years ago, handled about 10,000 cases last year compared with fewer than 1,000 five years ago, he estimated. The growing demand for second opinions, which cost between $500 and $5,000 depending on the case, has come from patients, including people from overseas, and companies that are including the service as part of employee benefits, he said.
Dr. Pauly said opinions are most often requested in areas such as cancer, neurosurgery, cardiology and orthopedics.
Patients can request their medical records be sent to an online second-opinion service, which might order additional tests if needed. The services are especially helpful for people who live far from major academic centers that cover a range of physician specialties. Many insurance policies cover in-person second opinions but don’t pay for online services unless they are offered as part of an employee’s health plan.
Some experts say patients should seek a second opinion outside of their normal institution or health-care network. “There are sometimes internal cultural approaches to treatment and it’s probably necessary for patients to go outside to get a new approach,” said F. Marc Stewart, president of the Patient Advocate Foundation, a nonprofit that helps patients access medical care. However, transferring care to another doctor can be challenging if the doctor is out of a patient’s insurance network, said Dr. Stewart, a medical oncologist and medical director of the Seattle Cancer Care Alliance.
For patients faced with a serious or life-threatening illness, second opinions might steer them to different treatment opportunities that are less invasive, have fewer side effects or are more targeted to their particular circumstance, said Beth Moore,executive vice president of program strategy for the Patient Advocate Foundation, “You don’t always know what’s available unless you seek a second opinion,” she said.
Ms. Moore said in-person second opinions are better in cases that may require sophisticated tests, such as with rare diseases. When two doctors have divergent recommendations, she recommends getting a third or even fourth opinion.
“Patients are often fearful that their physician will be offended” when seeking a second opinion, said Ms. Moore. “We’ve found that not to be the case. You’re going to want the experts to discuss your case in an open way once the second opinion has been issued.”
Easily diagnosed conditions, such as sinusitis or shingles, don’t call for a second opinion. But second opinions can be important when symptoms don’t go away despite treatment; when diagnosis is unclear or appears to involve a serious or rare condition; or when treatment options are risky or harmful, said Hardeep Singh, a patient safety researcher at Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston.
A recent study Dr. Singh co-authored looked at data from Best Doctors Inc., an independent service that offers second opinions online to companies and insurance carriers that offer them as a benefit. The researchers reviewed 6,791 second opinions; there were changes in diagnosis 14.8% of the time and changes in treatment 37.4% of the time.
About 60% of the patients ended up following the recommendations from the second opinion, according to the study, published in April in the American Journal of Medicine. However, Dr. Singh said, “we don’t know whether the ultimate diagnosis for these patients ended up being the correct one.”
SecondOpinionExpert Inc., a website based in Dana Point, Calif., that launched this spring, says it provides second opinions for $300 and the option for a video conference consultation for an additional $200. The fees generally aren’t covered by insurance plans.
Some patients can take the process to extremes, said Mark Urman, the company’s vice president of physician relations and quality assurance. “You have to be careful, you can sometimes get too many opinions and all it does is confuse you more and then you don’t know what to do,” said Dr. Urman, who is an attending cardiologist at Cedars-Sinai Heart Institute in Los Angeles.
Dr. Urman said most of his patients who seek second opinions are those for whom he has recommended a procedure or surgery that is elective. When a patient comes to him for a second opinion, about 75% of the time his opinion will be similar to the previous doctor, he said.
Cleveland Clinic set up an online second-opinion service, MyConsult, more than a decade ago. In recent years, the number of patients served has grown 15% to 25% a year, boosted especially with patients who live far from the clinic and with corporate clients. MyConsult charges $565 for a consultation and $745 if it includes a pathology review.
Cleveland Clinic doctors who review cases disagree with the original diagnosis about 11% of the time, said Jonathan Schaffer, managing director of MyConsult and an orthopedic surgeon. They make moderate changes to treatment in 24% of cases and major changes in 16% of cases. “These numbers can have some pretty significant health-care implications,” said Dr. Schaffer.
Linda Smith, a 67-year-old in New Albany, Ohio, was diagnosed last year with a precancerous lump in her breast. She had it surgically removed and underwent five weeks of radiology treatments. When her doctor then recommended she take a chemotherapy pill, Ms. Smith sought a second opinion through Cleveland Clinic’s MyConsult, which was included in her employee health insurance.
The MyConsult pathologists determined Ms. Smith had had a different type of precancerous lump than was originally diagnosed, she said. They told her she hadn’t needed the five weeks of radiology treatments.
To resolve the conflicting viewpoints, Ms. Smith sought a third opinion, not covered by her insurance, that concurred with the MyConsult diagnosis. “I missed all this work and I missed this key training,” said Ms. Smith, a design engineer for a telecommunications company.
Ms. Smith said in the future she will always seek additional medical opinions, even if she has to pay for it. “Doctors make mistakes and medicine is always changing,” she said


  • Second opinions generally aren’t needed for easy-to-diagnose cases, such as sinusitis or shingles, experts say. Save second opinions for conditions where a diagnosis is unclear, involves a serious or rare condition or when treatment options are risky.
  • Most doctors expect and encourage second opinions. Being open and honest with your primary physician that you want another viewpoint will help should you later need the experts to discuss your case together.
  • If possible seek a second opinion from a doctor or specialist in a different institution or network. Institutional cultures are real so it’s good to get an outside and different perspective.
  • Getting a second opinion that confirms the first opinion can be reassuring to patients.
  • If your first and second opinions differ, consider getting a third or even fourth opinion. But getting more than that may just end up causing confusion.
  • In many cases an online second opinion will suffice, although insurers generally don’t cover them unless they are included in your employee benefits. For some conditions, especially rare ones, an in-person visit is best.