Second surgical opinion programs: dead or alive?

BACKGROUND: In the 1970s, second surgical opinion programs were established in an effort to improve medical care and to control health care costs. The cost-effectiveness of these programs has been questioned recently. STUDY DESIGN: A retrospective review was conducted of elective second-opinion surgical consultations for members of Local 32B-J of the International Service Employees Union for the years 1993-1994. Nonconfirmed consultations were reviewed against claims history data for the subsequent 2 years. Data were analyzed for rates of nonconfirmation by diagnosis and surgical specialty and for cost-effectiveness benefit. RESULTS: Of the 5,601 second surgical consultations performed, 490 procedures were not confirmed as medically necessary (9%). Claims history survey for these 490 patients for the 2 years following the consultation revealed that no operation was performed in 62%. The highest nonconfirmation rate (41%) was in plastic and reconstructive surgery, followed by gynecology (22%). The cost-benefit ratio for the program was calculated to be 1.34. CONCLUSIONS: A second surgical opinion program confers both cognitive and psychologic beneficial effects on Joint Trust Fund members and their dependents who are advised to undergo elective operations. Our current second surgical opinion nonconfirmation rate is 9%, with hysterectomy, prostatectomy, and bunionectomy among the procedures most frequently nonconfirmed. The cost-benefit ratio was estimated at 1.34.

An analysis of substance abuse patterns, medical expenses and effectiveness of treatment in the workplace: long-term followup.

This study of workplace substance abuse programs indicates that they are effective for many participants and also shows that these programs can significantly lower medical expenses for those who successfully complete them.

Second opinion programs: continued savings from nonconfirmed surgeries.

A second opinion program for elective surgery was one of the first tools utilized by employers to "manage" health care costs. These authors argue that second opinion programs continue to demonstrate their usefulness as part of overall health care cost-management effort.

An analysis of substance abuse patterns, medical expenses and effectiveness of treatment in the workplace.

This article examines the effectiveness of substance abuse treatment offered by the Members Assistance Program of a self-insured union welfare fund. The authors find that medical costs decreased dramatically for participants who were under treatment for at least one year.

The use and value of third surgical opinions.

The results of new research into the contributions of third surgical opinions to health care quality and cost-effectiveness are reported by the Director and top Marketing and Research officers of the Health Benefits Research Center. As executives of the oldest second surgical opinion network in the U.S., the authors were able to test widespread beliefs about second and third opinion programs. Some, they found, did not hold up.

Second opinion for urologic surgery.

Second opinion elective surgery programs provide a mechanism to obtain consultation from a board-certified specialist by patients to whom an elective operation has been recommended. We focus on a second opinion program for urologic cases. Of 931 individuals who received a second opinion for urologic surgery the need was confirmed in 692 (74.3 per cent) and was not confirmed in 239 (25.7 per cent). The most common procedure not confirmed was transurethral resection of the prostate. Common reasons for nonconfirmation were the need for further testing, medication preferable to an operation and symptoms not severe enough to warrant an operation. Of patients confirmed for the need for surgery 28.2 per cent did not undergo an operation, while 33.0 per cent of those not confirmed did.

Podiatric Surgery: the need for a second opinion.

A second-opinion podiatry program, designed to contain costs and enhance the quality of care, was established in the greater New York City area by the Building Service Employees' Health Fund. All nonemergency foot surgery recommended by a podiatrist that cost over $100 was included in this program. Of the 363 individuals who had a second opinion, 82 per cent were confirmed for surgery; however, the confirmation rate among those seeing a podiatrist serving as consultant was 94.3 per cent, while the confirmation rate of those seeing an orthopedists serving as consultant was 49.5 per cent. For every condition, the podiatrists overwhelmingly confirmed the need for surgery. Conversely, the orthopedists were more conservative in their recommendations regarding surgery. The program's cost was $311,813. If a second opinion consultation wasn't required for removal of corns or ingrown toenails, the total would be much less. It seems sensible (economically and medically) to encourage or require a consultation with an orthopedist for conditions such as bunions, hammertoes and heel spurs, and not to require a second opinion consultation for superficial podiatric conditions such as corns and ingrown toenails, which are treated predominantly by the podiatrist.

The current status of surgical second opinion programs.

Second opinion programs proliferated in the 1970s, and most of these were voluntary programs. Until more complete evaluations of voluntary and mandatory programs are done, it seems likely that second opinion programs will continue to be on a voluntary basis. Second opinion programs have been shown to identify potential surplus surgery and are designed to contain costs.

The efficacy of second-opinion consultation programs: a cost-benefit perspective.

This study evaluates a mandatory second-opinion consultation program administered on behalf of a large Taft-Hartley welfare fund providing medical care coverage for 120,000 beneficiaries and covered dependents. During a two-year intake period (1977-1978), 2,284 individuals received second-opinion consultations for an elective surgical procedure recommended by a first-contact physician or surgeon. Of this group, 366 received a nonconfirmation of their need for surgery. Medical claims data were available for 342 individuals in this group, and they constitute the base for the current analysis. A comparable number of individuals who received a positive confirmation were randomly selected and served as a control for estimating program savings. Both groups were followed for a one-year period from the date of their consultations. Total program savings were estimated at $534,791. Of this amount, medical care utilization savings were $361,756 and productivity savings were $173,035. The cost of the program was $203,300, yielding a benefit-cost ratio of 2.63. These findings indicate that mandatory second-opinion consultation programs, which are consumer oriented and intervene before care is rendered, are clearly cost-effective.

Second opinions on elective surgery. The Cornell/New York Hospital study.

Programmes for securing second opinions on elective surgery are designed to help patients make a more informed decision once elective surgery has been recommended. The patient is assessed before surgery is performed, which allows alternatives to be considered. The Cornell/New York Hospital second opinion programme is the only one to have accumulated statistics on voluntary and mandatory programmes. Data from the mandatory programme showed that 18.7% of the 6799 patients screened were no confirmed for surgery. Follow-up data at one year showed that 67.5% of the unconfirmed patients had not in fact had surgery. A cost-benefit analysis showed that for every $1.00 spent there was a benefit of $2.63.

Second opinion elective surgery programs: outcome status over time.

Given the increasing rate of surgery and the escalating costs of hospitalization, it seems appropriate to review the necessity of recommended elective surgery before the surgery is performed. The second opinion elective surgery program is designed to screen patients before they undergo surgery. Findings are based on all not confirmed for surgery cases and an equal number of confirmed for surgery cases who were evaluated one year after their second opinion consultation. Roughly 77.9% of those not confirmed had not had the surgery and, of this, 64.4% reported no medical treatment (potential surplus surgery). Of the 710 not confirmed cases, one third (34.9%) never reported receiving medical treatment. The majority of those individuals confirmed for surgery did have the operation; however, 25.4% had not had surgery one year from their consultation. Thirty-two per cent of the confirmed cases reported never receiving medical treatment. There were 77 individuals (11.1%) who were confirmed for surgery who neither reported having surgery nor any medical treatment (population at risk). Subsequent follow up studies will present a clearer assessment of the ability of the program to screen potential surplus surgery and to realize cost savings.