For the insurer, it might be less expensive to get this information—a reaffirming opinion or a game-changing suggestion—than to wait, delay treatment, or pursue the initial course of treatment. “However, the positives were tempered by the fact that you hadn’t actually seen the patient or talked to them,” added Dr. Merati. “I felt that it was important to direct my comments to the care team.”
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February 2023According to Dr. Gillespie, with second opinion services, patients have access to the reviews of a wide range of specialists who may be experts in certain subspecialties that aren’t readily available in their location. “Patients can have some of their questions answered about a disease process that weren’t answered to their satisfaction or understanding during their interaction with their provider. More often than not, they can be reassured that a proposed plan of care is sound and consistent with current guidelines and high-quality care. Rarely, patients can be informed that there are less invasive or less morbid options that should be considered and discussed with their provider.”
Positives for the treating provider include increased trust from the patient if the expert agrees with the plan of care. “The expert may offer additional points that the treating provider may want to consider in their treatment plan,” Dr. Gillespie said. “Along with the financial compensation for the work, the expert providing the second opinion will have the satisfaction of promoting high-quality care on a global level.”
As for the payer, “most of these [second opinion] services are covered by the patient’s insurance plan,” added Dr. Gillespie. “The expert can reinforce that a proposed plan of care is within the standard of care and of high quality.”
Steven S. Chang MD, director of the head and neck cancer program at Henry Ford Cancer Institute in Detroit, noted that virtual second opinion services are good generally for patients and providers, allowing patients to seek additional opinions outside of their region.
“Many institutions and regions have their own biases or menu of treatment options that will differ from those at other institutions,” Dr. Chang explained. “One difference is that institutions usually maintain a specific portfolio of clinical trial offerings based on the preferences and populations they serve. Some areas may offer de-escalation trials, while others offer surgical trials for the same disease type. Some places may have a new drug that was developed locally and will offer it to their own population. Even in the absence of clinical trials, these services allow patients to seek expert opinions without having to travel—they can determine ahead of time whether it’s even worth traveling for an alternative treatment.”
Dr. Chang said that he sees very little downside from second opinion services when they are used correctly. “The biggest drawback is usually the lack of a good physical exam for certain conditions,” he said, “but much of the discussion can be performed without a physical, and if there’s enough interest, an in-person visit can be scheduled,” he added.
“Now, with the current financial reimbursement available, they allow for physicians to bill the time that they spend doing this,” noted Dr. Chang. Although a few places already had second opinion services that charged a flat fee and usually took a long time to turn around, this is no longer the case.
According to Dr. Gillespie, other potential negatives to second opinion services are that the expert may have limited knowledge of the patient and local resources. “An opinion like this cannot offer definitive decisions—only points that should be discussed between the patient and their local provider,” he said. Also, because the expert may not fully know which options are available in the patient’s location, said Dr. Gillespie, any opinions given must be empathetic and supportive of local physicians and must avoid sowing mistrust within the primary doctor–patient relationship.
Ethics and Finances
While second opinion services fit well into the medical landscape ethically and financially, there certainly are some challenges. “They’re an adjunct to medical care and nothing more,” said Dr. Sumer. “They cannot and should not replace the primary doctor–patient relationship but supplement it only.”
Ethically, Dr. Chang believes that the provision of second opinion services is the right thing to do—the only ethical concern is with diversity, equity, inclusion, and justice. “Some patients may not have the capability to access a second opinion service and instead may need a clinic-to-clinic telemedicine visit, which can be more challenging to schedule but is still something that can be done to accommodate a patient,” he noted.
“It’s always ethical to improve a patient’s understanding and knowledge of their disease process,” said Dr. Gillespie. He noted that most of the information shared by the expert is already available to the patient online. “The expert fills a critical role as a personal filter of sometimes conflicting information online for patients who may be overwhelmed. They offer the best evidence in a way the patient can more easily understand.” He noted that the cost of the second opinion consultation is “generally low compared to the total cost of a patient care pathway and is a good value if it increases patient trust and adherence with the ultimate plan of care.”
Otolaryngology Focus
But how much of an otolaryngology focus can a patient expect from one of these services? How many otolaryngologists serve as staff members for them?
Based on Dr. Merati’s experience at Best Doctors and Grand Rounds, he said that the companies were good at understanding what information otolaryngologists needed. In joint reviews, for example, if a laryngologist and a gastroenterologist both reviewed a case, the notes from the non-otolaryngologist expert were quite high level.
Dr. Gillespie noted that many of these services rely on identified experts who are leaders in their area of subspecialty and are expected to be well informed in high-quality care and current treatment guidelines. Unfortunately, according to Dr. Sumer, the number of otolaryngologists available on these platforms tends to be limited relative to the overall number of experts these services typically field.
Dr. Chang suggested that as devices that record physical examinations improve, such second opinion services will become more common. “I think this is the right thing for the patient experience and patient care,” he said.
Katie Robinson is a freelance medical writer based in New York.