(15-20 minute read)
This article was originally posted on wesspencer.com.
On a recent open enrollment (OE) visit, I met with an employee to help him through his OE, focusing primarily on his 2018 budget. However, I soon found out that his 2017 had not gone well. In the fall, he was diagnosed with salivary gland cancer.
Within weeks, he was facing surgery. His provider had told him that he must treat (remove) the tumor prior to metastasizing to his lymph nodes, which could kill him. However, the surgery would be difficult and recovery would be painful. He was informed that he could lose his upper left jaw bone and teeth, along with his ability to speak, chew, and taste. Since the surgery would open up his sinus cavity, he would also need to wear a “denture plug” to help with other breathing functions. Of course, there might many unforeseen complications.
Two days before surgery, he decided to seek a third opinion. He had already been referred to the regional “best in class” hospital after asking for a second opinion. The first diagnosis and treatment plan was recommended by his local [HMO owned] hospital, which also recommended immediate surgery. After fighting for a third opinion to be covered, he was denied by his HMO insurance (the payor). He had no out-of-network coverage, and since his request was deemed “not medically necessary” he would need to pay for a third opinion out of his own pocket.
About $10,000 later he found that he did not have cancer. The final scan revealed that the initial test was not well taken, and as he described it; “turns out the tumor was a shadow, just a shi**y picture.”
We continued to discuss his story in greater detail, but I’ll summarize his journey as follows:
Result: No cancer
Keep in mind that I am the adviser who recommends these health insurance plans. I get paid a commission to negotiate a contract between the employer and the insurance company. I left that meeting feeling sick that I was involved (at all) in this type of care, and he still owes $10,000 in uncovered medical bills. Thankfully, he did not go through with such an invasive surgery.
The harsh truth is that misdiagnosis is common. According to the BMJ Quality and Safety Journal, 28% of all cancers are misdiagnosed; other surveys show as much as 60.5%.
Well, in my opinion, here’s who is not:
Patients and their families are too often asked to make very difficult decisions without complete information or education regarding a diagnosis or treatment plan. Whether we like it or not, money does influence a provider’s treatment plan. The problem is, patients are making a life changing decision or trying to alleviate pain, both of which cloud judgement when making these decisions. It is much easier to accept a provider’s treatment plan when it’s assumed that they are the expert.
Unfortunately, the HMO model has created hospital systems that want to treat all patients and rarely refer out. Therefore, patients are not receiving the best care for their specific condition; they’re receiving the best care their HMO can provide, arguably with undue financial influence. In many cases, no treatment is the better option. Hospitals do not get paid if they don’t treat, likely driving the misdiagnosis rates north of 50%. We need to encourage patients to seek opinions from national (or global) centers of excellence, specific to their diagnosis.
First, patients and their families must take ownership of all medical records. Tools, like Globe Healer for example, are now available for very little investment and employers can sponsor this cost. These online platforms organize your medical records by patient, by date, and by condition. These records are owned by the patient, and allow for:
Second, employers must be willing to get involved. Otherwise, the decisions will remain under the control of the insurance carrier and the providers they pay. The process looks something like the following:
Ultimately, we are asking patients to question or validate the opinion a medical expert and this creates an uncomfortable conversation. Also, most employers want less involvement in their employee’s medical care, not more. However, if we continue to operate according to the status quo, nothing will change.
Seventy percent of medical spending is negotiated through private employer health plans. Therefore, the influence belongs to the decision makers in these negotiations. Employers have 2 choices:
To learn more about our strategies and recommendations for cost mitigation, contact us today to discuss further!
June 7, 2018
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