Secondary Expert Medical Opinions Associated with Treatment Strategy Changes and Substantial Cost Savings for Healthcare Payers.

Overview

abstract

GOAL: Consultations via commercial telemedicine platforms have enabled patients to access a larger network of providers whose secondary treatment recommendations may differ from those obtained by primary care providers. Subsequent changes in treatment recommendations may have meaningful implications for cost value and quality of care. However, despite the increased use of telemedicine, the frequency and type of treatment changes that occur are not well understood. This study evaluates the association between digital expert medical opinions (EMOs), treatment strategy changes, and cost implications, using data derived from a specialized musculoskeletal telemedicine platform. METHODS: Musculoskeletal EMOs from a large commercial digital health organization were retrospectively reviewed between 2020 and 2024. Treatment metrics, including surgical diversion (i.e., declining a surgical procedure), as well as the frequency of diagnosis and treatment plan changes, were calculated using existing client records and reports. Subsequently, an economic analysis was done to extrapolate potential cost savings based on treatment changes. Projections were constructed using average consultation cost savings based on Current Procedural Terminology (CPT) billing data and annual capture rates for a real-world enterprise client. Projections were also extrapolated to clients of various carrier sizes. PRINCIPAL FINDINGS: Among the 544 musculoskeletal EMOs reviewed, 40.1% of consultations resulted in surgical diversion. More than half (53.0%) of treatment plans changed as a result of obtaining EMOs, while the diagnosis change rate was 22.5%. An average cost savings of $8,146.89 per EMO was estimated based on data from a current enterprise client. Extrapolation of this analysis to a medium-sized carrier (10,000 annual claims) and a large-sized carrier (30,000 annual claims) based on data from this enterprise client was estimated to be $754,558.44 and $2,263,675.33, respectively. PRACTICAL APPLICATIONS: Among secondary digital EMOs obtained through a telemedicine platform, more than half of treatment strategies were changed, with surgical diversion observed for 40% of patient cases. Resultant treatment and diagnosis strategy changes may result in increased value for patients, payers, and participating healthcare entities as demonstrated through the economic projections established using real-world data. Further extrapolation of savings based on claim volume, capture rate, and various client sizes may provide additional insights into the utility of telemedicine in other spaces as it pertains to defining appropriate treatment pathways and adjusting optimized costs.