What Are Misdiagnoses Costing Employees and Employers?

Have you ever visited your doctor or urgent care center during cold and flu season and had this conversation?

You: “I have a sore throat, it hurts to swallow, and there’s a lot of pressure around my nose and eyes.”

Doctor: “Well, it may be viral, but let’s start a course of antibiotics in the meantime to see if it helps you feel better. It could be a sinus infection.”

Most of you have probably experienced this. And you dutifully fill the prescription and take the antibiotics, costing you a copay and your employer an Rx claim. You feel better in a couple of days, but who knows if the virus ran its course or if the pills did the job.

This is a very common example of a potential misdiagnosis. You may have been treated for a condition when it was unnecessary and unrelated to your medical problem. While this case is small beans, misdiagnoses on a larger scale is very costly for patients, employers, providers and insurers.

Here’s why:

1. Return visits: When patients don’t get the right care for their needs, they return again and again until they feel better. This means more claims, prescriptions, treatments, and costs for both employees and employers.
2. Duration of care: While some chronic conditions require a lifetime of care, others could be treated in a matter of days, weeks or months. If a patient is misdiagnosed, their actual condition could worsen or require prolonged treatment or medication.
3. Double billing: The patient and the employer are paying for unnecessary treatment in the case of a misdiagnosis. When the patient eventually receives the correct diagnosis, then they pay again.

This whitepaper from PinnacleCare estimates that misdiagnosis and related treatments cost the U.S. healthcare system as much as $750 billion each year. Not to mention the human cost. PinnacleCare’s survey of physicians found that up to 10% of misdiagnoses directly harmed the patient, and some were life-threatening or resulted in the patient’s death or permanent disability.

It would be easy to place sole blame for this problem on physicians, but there are many factors at play with a misdiagnosis. Patients are also part of treatment decisions, and often demand unnecessary procedures “just to be safe.” In the example of the common cold vs. a sinus infection, many of us have been complicit in the decision to take a drug without a clear diagnosis. Patients are eager to clear up their symptoms, so they’ll readily agree to treatments without waiting for test results. Medical journals are full of advice for doctors on how to fend off requests for testing and treatment when the patient’s condition doesn’t warrant it, for example, a biopsy for a suspicious lump when there are no other symptoms.

Patient demand isn’t the only factor - it likely takes a backseat to patient trust. The Atlantic recently reported on doctors who move ahead with unnecessary or outdated treatment despite the latest research. Patients trust their doctors and accept recommendations without seeking a 2nd opinion or reading up on the treatment. This piece recalls a study with cardiologists when asked about patients with narrowed arteries. Even if a patient showed no acute symptoms, the doctor would recommend a procedure to implant a stent because the were concerned about lawsuits, they believed it would relieve patients’ anxiety, and they didn’t fully believe research that showed a stent would be unnecessary:

“And there was one more powerful and ubiquitous reason: (4) Despite the data, cardiologists couldn’t believe that stents did not help: Stenting just made so much sense. A patient has chest pain, a doctor sees a blockage, how can opening the blockage not make a difference?”

 The average patient is not going to argue this point, let alone look up technical medical research on the subject.

This is where employers can come into play as patient educators and advocates. Here are some strategies Artemis Health customers are using:

1. Help employees understand their options.

Most employees place tremendous value on employer-sponsored healthcare, but they don’t understand the inner workings the way benefits professionals do. Make sure you’re sharing not just plan details, but best practices for employees to keep in mind when they need care. Let members know they can and should seek 2nd opinions, do their own research, and use a physician or health center they trust. You can point them to trusted providers through plan management and Centers of Excellence relationships.

2. Build a resource center.

Share thought leadership and resources with employees on how they can best advocate for themselves during diagnosis and treatment. You can partner with experts at your on-site clinics, Centers of Excellence, and medical staffers to build a library of advice that members can access as a part of their benefits program. Collateral should be accessible on mobile and help employees understand the questions to ask at their doctor’s appointments, how to advocate for themselves, and more.

3. Make care accessible.

Whether it’s through on-site clinics, Centers of Excellence, telemedicine programs, or other programs, employers should make it easy for members to access quality care quickly and efficiently. If patients get fast, effective treatment, you can save on duration of care and return visits.

Artemis Health can also help employers make the most of the care they’re offering to employees. Our benefits optimization platform gives employers insights into diagnosis codes, specific prescriptions and their costs, and member behavior. For example, our customers can examine:

• How their members with certain diagnoses are engaging with wellness programs
• Which drugs on their formulary are causing higher costs and inefficient spending
• Comorbid conditions and their effects on members
• The out-of-pocket costs for members based on diagnosis

And this is just the beginning. Get in touch to learn more or schedule a demo.