How to Offer a Virtual Second Opinion Service at Your Health System

The Clinic by Cleveland Clinic provides virtual second opinions to patients, with access to more than 3,500 physicians at Cleveland Clinic.

Virtual second opinions offered by The Clinic by Cleveland Clinic are making a significant difference for patients and payers, data shows.

The Clinic by Cleveland Clinic is a joint venture of the Cleveland Clinic health system and telemedicine provider Amwell. The Clinic by Cleveland Clinic provides virtual second opinions to patients, with access to more than 3,500 expert physicians at Cleveland Clinic.

Case data from 2023 shows the health and financial impacts of The Clinic by Cleveland Clinic's virtual second opinions:

• 67% of virtual second opinions recommended a diagnosis or treatment plan change
   
• In cases where the primary treatment plan included surgery, the virtual second opinion recommended an alternate treatment 85% of the time
   
• Virtual second opinions recommended hospitalization 62% less often than the primary treatment plans
   
• There was $100,911 average savings per patient for high-cost cases, where the primary treatment plan cost was above $10,000
   
• There was $28,220 average savings per patient with a musculoskeletal condition
   
• There was $8,036 average savings per patient with a cardiovascular condition
   
• There was $4,306 average savings per patient with a cancer-related condition

"The kinds of recommendations that we make can have multiple benefits for the patient in terms of quality of life and a better chance of surviving disease-free or with less pain and disability. Our recommendations can also have benefits for employers and payers," says Peter Rasmussen, MD, chief clinical officer of The Clinic by Cleveland Clinic.

In general, patients request virtual second opinions directly or through their commercial insurance company. Patients who request virtual second opinions directly pay for the service out of pocket. Patients who request virtual second opinions through commercial insurance companies pay for the service through the payer.

There are several steps involved in a virtual second opinion at The Clinic by Cleveland Clinic, Rasmussen says:

• Once a patient requests a virtual second opinion directly or through an insurance company, nurse care coordinators will talk with the patient to understand their clinical concerns and questions.
   
• Within a week, The Clinic by Cleveland Clinic obtains all of the medical records of the patient that are relevant to their clinical condition including imaging. For patients facing a cancer diagnosis, pathology specimens are obtained for pathology interpretation.
   
• A Cleveland Clinic specialty or subspecialty physician reviews the medical records.
   
• The reviewing physician prepares a written report for the patient and their local physician. In most cases, there is a video consult with the patient and the Cleveland Clinic physician who reviewed the medical records.

"We take a fresh look at each patient," Rasmussen says.

Serving the patient's interest and lowering cost of care

Recommending a new diagnosis or change in treatment plan is "quite significant" for patients, Rasmussen says.

"For example, the local physicians could determine that a patient has rheumatoid arthritis causing joint pain and swelling. Our rheumatologists could differ and think it is a connective tissue disease," he says. "This would have a significant impact on the type of treatment that the patient receives. Obviously, if a patient gets a diagnosis that is wrong, they are going to get the wrong care."

Changes in treatment plans can benefit patients and payers, Rasmussen says.

"For example, for a patient with a prostate cancer diagnosis, we potentially would offer the patient three types of radiation treatment. Whereas, the local physicians may only recommend one type of radiation treatment," he says. "Choosing an option that takes less time benefits patients who are still working and minimizes the disruption of their lives; and from a payer's standpoint, it can be tremendously less expensive with no fall-off in cancer survival rates."

When a virtual second opinion recommends an alternative to surgery, the benefits for patients are substantial, Rasmussen says.

"Most people do not want to have surgery unless it is absolutely necessary. There can be alternatives such as physical therapy that lead to tremendous benefits for the patients. It decreases time away from work as well as avoids pain and potential disfigurement," he says. "If surgery is needed and it is the best thing for the patient, then that is what you need to do. But as our data shows, 85% of the time there are alternative treatment options available to patients."

Anything that can be done to avoid hospitalizations generally is going to be in the interest of the patient and lower the cost of care, Rasmussen says. "It reduces the patient's risk of hospital-acquired infections and other problems that can develop when a patient is in the hospital. Generally speaking, an alternative to hospitalization is going to be a lower-cost solution for the payer."

Tips for launching a virtual second opinion service

Rasmussen offered advice for other health systems that may be interested in having a virtual second opinion service.

"There definitely is a time and place for virtual second opinions, whether they are telephone visits or video visits," he says. "At a health system, a virtual second opinion program can fit into the portfolio of services they are offering. It certainly allows a health system to extend its reach beyond its standard geographic footprint."

With state regulations that do not allow physicians to practice medicine across state lines, it is important for physicians offering virtual second opinions to be licensed in multiple states, Rasmussen says.

"You need to pay careful attention to licensure and how the caregivers and physicians are delivering their opinions," he says. "We have chosen to move toward a model of broad licensure among our physicians in the vast number of U.S. states, so that we can create the most robust and meaningful interaction between the patients and our physicians."

The physicians who provide virtual second opinions at The Clinic by Cleveland Clinic each have licenses in about a dozen states, Rasmussen says.

"There is some administrative burden associated with maintaining these licenses. Over time, we have found that an individual physician with administrative assistance can maintain 12 to 15 licenses at a time," he says.

Another key to success in offering a virtual second opinion service is maintaining the "human aspect" of care delivery, Rasmussen says.

"We are using technology to assist with the care delivery for our virtual second opinion program, but there is no replacement for the human side of medicine," he says. "When patients are facing a significant diagnosis, change in their life expectancy, or treatments with side effects, they can be scared. So, we place a heavy emphasis on the human aspect of the virtual second opinion despite the fact that our interaction is delivered through technology."

To foster the human aspect of care delivery, a virtual second opinion service should rely heavily on video interactions with patients, Rasmussen says. "Clearly, over the past five to 10 years, we know that video can convey empathy and compassion as well as make a human connection as opposed to telephone visits or written communication," he says.

Communication training is crucial for virtual second opinion care teams, Rasmussen says.

"Our nurse care team and our patient liaison team all go through science-based communication training to assist in creating the right language for conversations with patients," he says. "We want to create a connection between the patient and our care team. All Cleveland Clinic physicians receive similar training to assist in creating a bond between the physician and the patient."