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As misdiagnosis gets more attention, Highmark adds option for medical second opinions

| Monday, April 10, 2017, 11:00 p.m.

More than 20 percent of patients who visited a Mayo Clinic internist for a second opinion received a completely different diagnosis than they were given during a primary care visit, according to a new study.

The Mayo Clinic doctors revised diagnoses in 66 percent of the visits and confirmed initial diagnoses in 12 percent of the visits, according to the study, which examined medical records of 286 patients from 2009 and 2010.

“That was more than expected,” said study coauthor James Naessens, a Mayo Clinic health services researcher. Based on earlier studies, he had expected second opinions to bring new diagnoses 5 to 10 percent of the time, he said.

The study, published in the Journal of Evaluation in Clinical Practice, used data from patients who had been referred to the clinic by a doctor, a physician's assistant or a nurse. It does not represent the experience of an average patient, Naessens said. Nevertheless, it strengthens evidence that in recent years has brought into sharper focus the problem of misdiagnosis in medicine.

“The delivery of health care has proceeded for decades with a blind spot: Diagnostic errors — inaccurate or delayed diagnoses — persist throughout all settings of care and continue to harm an unacceptable number of patients,” opened a major 2015 report on misdiagnosis from the Institute of Medicine.

The report estimated 5 percent of U.S. adults seeking care each year experience an error in diagnosis, and that diagnostic errors contribute to about 10 percent of patient deaths.

Against that backdrop, insurer Highmark Inc. has hired a company called Best Doctors to review patient medical records of about 200 to 300 people to see if the company can improve patient outcomes or reduce costs.

The nearly 30-year-old company employs top-rated doctors to review medical records and give second opinions, said Dr. David Harrison, the company's medical director.

In between 40,000 and 50,000 consultations per year, the company changes about 40 percent of initial diagnoses, Harrison said.

In about 15 percent of cases, the company's doctors find a completely new diagnosis, Harrison said, and doctors in the other 25 percent of cases find the disease was identified correctly but its severity wasn't accurate or specificity of the disease wasn't fully established.

The company's doctors also review treatment plans and 75 percent of the time recommend changes in treatment courses. The doctors find that about 35 percent of patients who have been told they should consider surgery do not need the surgery, Harrison said.

Getting a diagnosis right is difficult, and doctors face three major hurdles to getting it right the first time, said Harrison, who is a practicing physician.

The first is limited time, he said. Patient visits often last about 15 minutes – not enough to do an extensive medical record review, he said.

With limited time, doctors tend to assume common illnesses are responsible for a patient's symptoms without considering rarer illnesses with similar symptoms that records reviews might reveal.

“Most of the time people can get it right that way, but most of the time is not good enough if you're the individual that receives the misdiagnosis,” Harrison said. “It's not bad doctors; it's a suboptimal system.”

The proliferation of medical data, while it can aid the most accurate diagnoses, also mean that general practitioners or even specialists might not be making as accurate a diagnosis as they could be with more time or better analytical tools, he said.

Lastly, the fragmentation of medical information — patients' medical records are often scattered among several different health systems that communicate poorly with one another — make it difficult for a doctor to take all the relevant information into consideration.

The company reviews diagnoses for insurers and employers, Harrison said, aiming to improve outcomes and save the companies money.

The reviews usually take a week or two depending on patients' medical situations, he said.

Highmark started using Best Doctors about two weeks ago in a pilot program focused on its fully insured commercial members and people who have individual health insurance plans.

Dr. Marylou Buyse, Highmark's senior medical director for health policy and quality, said the insurer is using the company to help improve treatment programs for rare or complicated diseases.

“Our focus is on getting people the best treatment and the best outcomes. We're not doing this because we're focused on diagnostic errors or the need to correct them,” Buyse said.

Any changes in treatment will be up to patients' doctors, she said.

Highmark will track how many times treatment plans are accepted or rejected or changed by Best Doctors, she said.

Doctors or clinicians suggest the Best Doctors reviews, and in the future the insurer may use analytical programs to identify patients who might benefit from the reviews, she said.

Wes Venteicher is a Tribune-Review staff writer. Reach him at 412-380-5676 or wventeicher@tribweb.com.

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