Matching patients with “best doctors” pays off dramatically
Insurers can utilize medical referral service for their customers
The health care industry in the United States is in shambles. Physicians who complain that HMO management interferes in the doctor-patient relationship are suing managed care companies, especially health maintenance organizations (HMOs). Consumers complain that, while their insurance premiums are rising, they are being denied the quality care they were promised back in the early 1990s when the managed care movement first started gaining speed.
An organization called “Best Doctors” hopes to have the answer to these problems, and it has targeted the insurance industry in particular and the corporate world overall as means of propagating the message. Best Doctors, based in Arlington, Virginia, and operating since 1992, has constructed a database of confidential, peer-based quality assessments on approximately 30,000 medical specialists in the United States and 20,000 elsewhere. It solicits extensive information on each doctor’s training and practice. Using the resulting, detailed professional profiles, the company offers a “suite” of information services both in the United States and abroad.
Best Doctors management believes that its services can prove beneficial to the insurance industry in the area of controlling workers compensation insurance and reinsurance costs, in assisting the health insurance sector in offering specialized quality medical treatment for its policyholders and, as a byproduct, in providing agents and brokers with value-added products that they can sell with enthusiasm.
But first, the Best Doctors story, which is certainly a story in and of itself. Some companies are born of financial necessity, some of market opportunity and some out of just plain luck. However, Best Doctors began as a response to a personal need of a man who was later to become one of its founders, Greg White Smith. In 1986, Smith was diagnosed with an inoperable brain tumor and given six months to live. But Smith was not ready to throw in the towel. He and one of his Harvard School Law School classmates, Steven Naifeh, had an advantage over other patients.
“As publishers of The Best Lawyers in America, we had developed a method of assessing the quality of professional legal services by conducting extensive telephone interviews in which professionals were asked to rate their peers,” says Naifeh. “This `peer review’ method quickly won the respect of the legal community and, today, Best Lawyers is in its eighth edition and widely regarded as the preeminent guide to the legal profession in the U.S. We used this same method to find the right doctor for Greg.”
In 1986, the two men not only found a doctor to treat Smith successfully, they went on to do the same thing for the medical profession that they had done for the legal profession, using the same peer review method of quality assessment. Since it was founded, Best Doctors has conducted hundreds of thousands of interviews with leading doctors and now processes millions of evaluations every year using proprietary software to create customized ballots in 43 specialties and more than 450 subspecialties.
In 1994, the company began responding to individual requests from patients for help in identifying the right doctors for their particular medical problems. In 1997, the company started offering its database mining service through insurers and other corporations, both in and out of the United States. Best Doctors’ core service, AcuMatch, is a personalized search designed for serious medical problems. A patient is assigned a specially-trained Best Doctors nurse who takes relevant medical information (previous treatment, comorbidities, geographic preferences, etc.), assesses the patient’s medical needs, and matches the patient to the very best medical care available to meet those needs.
“The Best Doctors nurse is available to guide the patient through the complex care, answer treatment-related questions, minimize delays, offer information and resources, and act as a professional medical advocate,” says Naifeh. “The AcuMatch service, which gives the patient a choice of up to three specialists for a single primary diagnosis, can be used either to find appropriate treatment or supplementary expertise for a second opinion.”
And Naifeh can boast some significant success stories. In one case, a 55-year-old quadriplegic with recurrent urinary tract infections contacted Best Doctors after being treated unsuccessfully for more than five years by a succession of eight urologists, all of whom had prescribed regimens of antibiotics that worked only briefly before the infections returned. A search of the Best Doctors database generated a list of four urologists in the country who specialized in urinary tract infections in paraplegic and quadriplegic patients. In the year since the patient began treatment with one of those doctors, the infections have not returned.
In another case, an Oklahoma woman called Best Doctors for help in finding a doctor to treat her thirteen-year-old twin sons, both of whom had been diagnosed with an extremely rare adult lymphoma leukemia that virtually never occurs in children. A search of the Best Doctors database turned up a doctor at the University of Nebraska who managed the case, as well as consulting specialists at three other U.S. institutions. Best Doctors also located consulting doctors in Japan, where the incidence of the disease is higher than in any other country. The twins were eventually put on a hormone therapy protocol and are now responding well.
Three years ago, the Winterthur Insurance Group began working with Best Doctors. Dr. Marco Rindi works as a medical consultant to Winterthur in Italy and he relates this particular case. “A 49-year-old woman here in Italy had been diagnosed with non-Hodgkin’s lymphoma. We used the AcuMatch services to find an expert for a second opinion,” says Dr. Rindi. “After completing 12 cycles of chemotherapy, the woman developed severe toxic effects, received multiple transfusions, and was repeatedly hospitalized. Despite signs of remission, her spleen and liver continued to show enlargement. The U.S. expert identified by Best Doctors reviewed the patient’s record and, after additional tests, concluded that the appropriate diagnosis was follicular lymphoma, not non-Hodgkin’s lymphoma, and that continuing the scheduled chemotherapy program would be inappropriate and harmful. She could have died. Best Doctors accessed its international database to identify a qualified specialist near the patient’s home who worked with the U.S. expert and supervised a new, less-toxic chemotherapy regimen that ultimately led to remission,” says Rindi.
Naifeh says that Best Doctors markets its services to individuals both directly and through insurers, re-insurers, self insured corporations, PPOs, TPAs, case management firms, government entities and affinity groups. “The primary method of making the services available, both in the U.S. and abroad, is by attaching them as a value-add to supplementary insurance policies, such as critical illness, to indemnity health insurance policies and to the catastrophe illness and injury coverage available through medical savings accounts,” he says.
“The applications of our service to the insurance industry are clear,” says Mary Kampman, director of medical resources for Best Doctors. “Our goal, of course, is to provide access to the best medical treatment for patients. But we can also assist insurance companies and reinsurance companies in identifying cases in which claimants should not fall under workers compensation payments. We had one case in which there was a claim involving reflex sympathetic dystrophy (RSD) resulting from an injury in the workplace, necessitating knee surgery. The claimant fell at work, injuring her knees. Subsequently, she had surgery to repair tears and developed symptoms resulting in an inability to work.
“The request for review of records occurred in 1999 at which time a Best Doctor in neurosurgery was contacted to review existing records and give his opinion on the diagnosis, treatment and possible recommendations. In 2000, additional medical records became available and were sent for further review to the same specialist. At that time, his review of the additional medical records did not result in a change of opinion; rather, it further strengthened his opinion that the patient does not have RSD. He further said he does not believe the injury in the workplace is related to her complaints as she has had full recovery from surgery The client who had contacted Best Doctors, an insurance company, has subsequently asked for a discontinuance of benefits under workers compensation.”
Kampman says that this is only one instance where Best Doctors can be of assistance to insurance
companies looking to control claims costs where a specialized diagnosis is essential. But she says there are other applications of Best Doctors’ services. She says that a contract with Best Doctors can be used as a sales tool for insurance companies and their agents and brokers. An automobile insurer, for example, might contract with the firm to add an additional benefit to the medical portion of the auto insurance purchase, so that if an insured driver or passenger were seriously injured in and accident, he/she would have access to the Best Doctors database for treatment.
The Best Doctors approach, of course, is not exactly in line with the way managed care is going at present, where the idea appears to be to control costs by limiting hospital stays and patient treatment. But Kampman says that managed care will eventually have move in the direction of finding the best possible care when needed. And Best Doctors intends to be there.
“Best Doctors has positioned itself to take advantage of the expected growth in these and other forms of `safety-blanket’ private insurance in the next decade as baby boomers, mistrustful of managed care, demand new solutions that provide more flexibility and better care, especially in the event of a life-threatening illness or injury,” she says.
Copyright Rough Notes Co., Inc. Sep 2000
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