Costs of a Second Surgical Opinion A PROPOSAL TO INVESTIGATE THE IMPACT OF THE

A PROPOSAL TO INVESTIGATE THE IMPACT OF THE

SECOND SURGICAL OPINION REQUIREMENT

Approximately 60 percent of the American population is covered by private health care insurance programs (Congressional Budget Office, 1989). Most of these programsthe very great majorityare either fully or partly funded by employers, while the remainder are funded fully by the covered individuals and families. For the remaining 40 percent of the population, the delivery of health care services is either (1) funded by the federal government (for approximately 25 percent of the population, primarily through the Medicaid program), or by individuals and families in the financial position to pay for health care services at the time of delivery, or (2) deferred. When all is said and done, approximately 12 percent of the country's population is without any formal health care insurance coverage, and is not in a financial position to fund such services as required.

The proposed research is concerned with the approximately 60 million persons who receive Medicaid funded health care services. Medicaid, however, must also be prepared to deal with the approximately 30 million persons who are without any formal health care insurance coverage, and are not in a financial position to fund such services as required. The working poor

without health care insurance tend to postpone medical consultation and treatment, to avoid incurring costs they

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re services. With respect to funding, the second surgical opinion requirement is prospective in character, because (1) performance of a surgical procedure is not authorized in the absence of a concurring second surgical opinion, and (2), once approved, the procedure is funded at an amount established prior to performance of the surgical procedure. The various costbased reimbursement procedures, which are, in part, replaced by the second surgical opinion requirement replace, are retrospective in character. Prospective procedures establish the amount of reimbursement prior to the delivery of health care services, while retrospective procedures establish the amount of reimbursement subsequent to the delivery of health care services. The second surgical opinion requirement, with respect to provider reimbursement, was introduced by the federal government along with a general prospective payment system (PPS), and a system for the selection of providers to deliver health care services funded by the federal government, which is known as 4the preferred provider organization (PPO) system. Under PPS, the costs for health care services are established before the services are delivered, as opposed to the more traditional after d

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