The startups that give you a second opinion on costly surgery

See also: From cheap to top-dollar: retiree health care costs in 5 states

That kind of variation is at least partly responsible for America’s outsize medical costs, which are higher per capita than anywhere else. It’s some combination of errors, differences in professional judgement, and a payment system that often creates incentives for doctors to prescribe treatments most lucrative for them. “There is a tremendous amount of misdiagnosis that goes on,” says Lewis Levy, chief quality officer at Best Doctors, which contracts with 50,000 physicians to do remote second opinions for clients. The doctors are recommended by peers as leaders in their field.

Second-opinion services allow employers to take a softer approach than enforcing strict rules requiring workers to get permission before seeking costly treatments. Most companies that offer services like Grand Rounds and Best Doctors make them voluntary, and though there may be incentives to get a medical decision reviewed, workers can usually skip the second opinion or ignore it if they disagree.

That makes the services seem less coercive than restrictive HMO rules. It also means companies sometimes struggle to get workers to use them. “One of the biggest knocks on this is no matter how much you communicate this, at the time the employee needs this, they may not remember that that service is available to them,” says Shari Davidson, vice president of health care cost and delivery at the National Business Group on Health, a nonprofit alliance of large employers.

See also: GOP Patient Rights Bill Prevails

A group of Pittsburgh-area school districts that buy health care together through the Allegheny County Schools Health Insurance Consortium began using Grand Rounds this spring. Outreach through mailings, a quarterly magazine, and direct prompts from Grand Rounds based on peoples’ medical claims have gotten 15 people to use the second-opinion service so far, says Jan Klein, the group’s trustee chairman. “We can’t force it on people,” she says. “Well, we could. But we don’t.”

At least one employee avoided a surgery after the expert reviewer “said absolutely not a good thing to do, not justified, no research that this operation will help this person,” Klein says. Though she expects the service to save money, Klein says getting people the proper diagnosis and treatment is more important. “Sometimes their costs are more than it would have been under the wrong diagnosis,” she says, “but they would have been treated for the wrong thing.”