2020 Drug Trend Report
myMatrixx releases our annual Drug Trend Report as a comprehensive analysis of the major drivers in the sector of workers’ compensation retail pharmacy. Delivering the report in 2021 has required us to examine the truly unprecedented circumstances of the last 12 months, and undoubtedly, 2020 was a historic year. The emerging COVID-19 pandemic affected every industry, including our own. With the emergency public health declaration in March 2020, businesses had to adapt quickly, and often without the ability to develop longterm strategies.
Even in less turbulent years, the future is not easy to predict. Major events such as COVID-19 only compound this uncertainty by disrupting our 2020 expectations. However, myMatrixx faced shifting challenges quickly and directly. We are proud to have adjusted rapidly with no disruption in service to our clients. As it became clear that the pandemic would be an ongoing concern, we analyzed our data — gleaning insights that help our clients navigate these uncertain times.
Overall, despite an extremely unpredictable 2020, myMatrixx is excited to share both positive outcomes and uniquely historic data in this year’s report.
For payers with a workers’ compensation program managed by myMatrixx, overall Rx utilization decreased 4.9% and cost per days’ supply decreased by 2.6%.
2020 In Review
Our analysis of 2020 workers’ compensation drug data also enabled us to identify the most important drivers for 2021. For the purposes of this report, the myMatrixx clinical team is focused on three major trends in particular as we continue to develop effective strategies for workers’ compensation clients in 2021 and beyond.
The COVID distortion effect: How a decrease in new claims is drastically influencing Rx utilization statistics
One of the most significant events in workers’ compensation resulting from the pandemic has been the decrease in new claims due to widespread unemployment and the move to remote work. One unforeseen consequence of this decrease, identified by our clinical and business intelligence teams, is a distortion in Rx utilization rates at the individual injured patient (claims) level. As we have previously identified, and will discuss further in this report, new workers’ compensation claims are associated with lower Rx utilization and expense, while older claims have greater prescription use and expense.
This means that the reduction in new claims for 2020 caused older claims to distort the average overall Rx utilization, leading to a statistical increase of 12.2% at the individual injured patient level. myMatrixx has labeled this the “COVID distortion effect.” In other words, while there was no major change in Rx utilization behavior at the patient level, the decrease in new claims makes it appear that there was.
The evolving picture of COVID-19 treatment for workers’ compensation
Evaluating drug trends in workers’ compensation is impossible without discussing the COVID-19 pandemic. As mentioned, with so many employees either out of work or working in a highly modified environment, myMatrixx clients have seen an overall decrease in new injuries, and therefore, in new claims.
Work-related COVID cases, such as among frontline health care workers and first responders who have been exposed to the virus, have only had a limited impact on retail pharmacy spend in workers’ compensation. Additionally for pharmaceuticals that are required for compensable cases, such as inhalers or cough suppressants, myMatrixx was and will continue to be very quick to respond to implement any necessary formulary updates for clients.
The myMatrixx clinical pharmacy team has received numerous questions about the COVID vaccines, and how they will be handled by workers’ compensation pharmacy benefit managers (PBMs). Presently, the cost of vaccines is being absorbed by the federal government under Emergency Use Authorizations (EUAs). As more vaccines are approved through regular U.S. Food and Drug Administration (FDA) channels and brought to market like other vaccines, we expect that they will be covered under private insurance as preventive care. For more on COVID-19 vaccines and their potential effects on workers’ compensation, please visit our frequently updated COVID-19 resource site where you will find our latest vaccine position paper.
Continuing the pressure on opioid misuse on multiple fronts
While COVID-19 is undoubtedly the biggest story of last year, the ongoing efforts against opioid misuse among injured workers is another subject that continues to require attention in our industry. One of the biggest questions is the longer effect of the pandemic, including extended lockdowns and treatment delays, on opioid usage.
As we looked at our own data from the previous year, myMatrixx found that opioid spending declined by 1.2% in workers’ compensation cases, pointing to a decrease in Rx utilization. As this report will discuss, the rate of decline is lower than previous years, and our clinical team is investigating potential causes for this trend, particularly regarding the COVID distortion effect as referenced.
myMatrixx continues to put pressure on opioid spending and misuse through a range of efforts including enhanced alerts and interventions designed to identify and decrease opioid risk.
State of Mind
Behavioral care takes on a growing role in workers’ compensation
We also see the need for a larger focus on the role of behavioral health care in the treatment of injured workers. While the conventional wisdom has been for workers’ comp payers to avoid paying for psychiatric drugs because of the associated long-term escalation in the cost of the claim, there is reason to believe this is no longer the most practical course of action.
Mounting evidence for a bidirectional relationship between chronic pain and mental health is demonstrating that behavioral health solutions can help long-term cases achieve positive outcomes. myMatrixx believes targeted behavioral health interventions offer a unique opportunity for long-term cases, especially those with high opioid Rx utilization rates, to overcome chronic pain and reduce drug dependence. In fact, early intervention guided by our identification of suitable candidates can dramatically impact both drug spend and claim duration.
As we continue to investigate the lasting effects of COVID-19 on the workplace, we are as committed as ever to promoting safety for workers and delivering value to payers. Our fully dedicated clinical team is always here as a resource and we encourage you to reach out to your Clinical Account Executive and team of myMatrixx pharmacists at firstname.lastname@example.org regarding the information contained in this report.
In a year like no other, declining drug spend continues for myMatrixx payers
In 2020, payers with a workers’ compensation program managed by myMatrixx saw decreases in overall Rx utilization and cost per days’ supply.
Rx utilization at the injured patient level was impacted by three separate effects: the COVID distortion effect, the age-of-claim effect and the age-of-patient effect. This resulted in an apparent increase in average Rx utilization per injured patient of 12.2% from 2019 to 2020. myMatrixx continued to drive down costs in 2020 by 2.8%, which brought the total trend to 9.3%.
Prescription utilization can be measured two ways: at the aggregator level for an entire market or at the individual patient level
Average spending on opioids remained relatively flat at 0.2%, which is attributed to the COVID-19 distortion effect. Our clinical solutions, aggressive client management and changes in state and federal policy focused on opioid prescribing helped us manage opioid spend in a turbulent year.
myMatrixx identified a decline in the percentage of new claims from newly injured workers in 2020, contributing to the COVID distortion effect
myMatrixx Clinical and Safety Evaluation Rx — CASE RxSM — was developed to help claims professionals address inappropriate, ineffective or unnecessary drug therapies that often drive up costs in older claims. Our dedicated clinical team is equipped to perform CASE Rx reviews for any injury or disease condition to provide valuable clinical insights and actionable recommendations that have the potential of positively affecting the course of therapy and the patient’s overall condition.
Both the age-of-claim effect and the age-of-patient effect require highly customized clinical pharmacy strategies developed for individual injured patients. myMatrixx rejected the “one-size-fits-all” approach early on in the evolution of our clinical strategy. Instead, we worked with numerous patients and prescribers to develop CASE Rx. We combine this with comprehensive business analytics to identify appropriate candidates for this individualized approach, which includes:
- Reviewing the injured patient’s medical history
- Evaluating each medication in the current regimen from a risk versus benefit analysis
- Recommending discontinuation of drugs with appropriate or safer alternatives
- Developing step-by-step weaning schedules
- Conducting a guidelines-based tele-pharmacy intervention with prescribers
- Documenting, measuring and tracking results
The evolving picture of COVID-19 treatment
COVID-19 related medications: Symptomatic treatment
Compensable treatment of COVID-19 symptoms has had minimal impact on retail prescription spending for workers’ compensation – composing less than 0.25% of total spend. However, Rx utilization among selected drugs increased significantly compared to 2019.
Most notably, hydroxychloroquine use went up drastically when it was believed to be effective for treating COVID-19. After further studies showed it was not effective for prevention or treatment, its Emergency Use Authorization was withdrawn and Rx utilization began to decline.
U.S. Food and Drug Administration. Medications not indicated as effective for the treatment of COVID-19. https://www.fda.gov/
The COVID-19 pandemic, and the quarantine in particular, had a significant impact on the delivery of health care for patients and physicians, although the impact to workers’ compensation was not always the same as with group health care and other payer types.
This number lags behind other markets primarily because of the higher number of opioid and other controlled substance prescriptions used in workers’ compensation. According to Surescripts, the nation’s largest health information network, as of 2018, 85% of all prescriptions for non-controlled substances were sent electronically and only 31% for controlled substances. That ratio will rapidly change with the adoption of the SUPPORT for Patients and Communities Act1 which went into effect on January 1st of 2021, and requires electronic prescribing for all controlled substances under Medicare Part D. In addition, more than half of all states are on their way to requiring that prescribers use e-prescribing for opioids, controlled substances, or all prescriptions, which will impact workers’ compensation as well.
1 Uhrig, P. (2019). Reviewed April 2021. It’s Official: Half of All States Will Soon Require E-Prescribing to Combat the Opioid Epidemic. https://surescripts.com/news-center/intelligence-in-action/opioids/it-s-official-half-of-all-states-will-soon-require-e-prescribing-tocombat- the-opioid-epidemic/
As part owner of Surescripts, myMatrixx, an Express Scripts company, is uniquely positioned to maximize the use of electronic prescribing, increasing efficiency, accuracy and patient safety for injured workers.
It’s in a payers best interest to utilize home delivery whenever possible. myMatrixx has specialized Home Delivery options customized for payers to drive down costs. This includes, but is not limited, to injuries related to:
- Catastrophic claims
- Injured workers living in frontier counties
- Use of maintenance medications especially applicable to presumption claims
Keeping the focus on proper opioid usage
Opioid prescribing is down while opioid spending per injured worker remains unchanged
Spending on opioids for payers with pharmacy benefits managed by myMatrixx declined by 15.1% in 2020, outpacing the decline in overall Rx utilization, which was 11.4%.
Average spending on opioids per injured patient utilizing opioids was relatively flat 0.2% — going from $219.04 to $219.48 per injured patient per year, for payers between 2019 and 2020.
Naloxone is an opioid reversal agent that can greatly limit the chance of fatal overdoses among those at high risk for opioid misuse. In recent years, physicians have been encouraged to provide naloxone prescriptions along with prescriptions for opioids; and some states have given pharmacists the authority to dispense it when patients fill opioid prescriptions. Even as availability for naloxone increases, though, less than 1% of injured workers filled a prescription for an opioid overdose antidote in 2020.2
2 Kasbekar R.M., Ambizas E.M., (2019). Reviewed March, 2021. An Overview of Naloxone for Pharmacists. U.S. Pharmacist, 44(3):6-9. https://www.uspharmacist.com/article/an-overview-of-naloxone-for-pharmacists
The growing role of behavioral care in workers’ compensation
Addressing mental health can improve return-to-work outcomes and curb opioid misuse
As identified by Express Scripts, during the early months of the COVID-19 pandemic, quarantines and lockdowns had a significant impact on the use of psychotropic drugs in America. For more information, please see Evernorth’s Express Scripts PBM special report on America’s State of Mind.
In December 2020, myMatrixx observed in our panel discussion with industry experts entitled, Transportation Safety and COVID-19, that injured workers experience a similar sequelae of events following a significant injury that the rest of America faced at the start of the pandemic. Many are isolated at home, often in pain and without meaningful work. Others are required to work in potentially hazardous workplaces. Anxiety, sleep disturbances and depression are on the rise. Not surprisingly, we found increased Rx utilization trend for many psychotropic drugs and opioids.
Not addressing the mental health of injured workers can delay return-to-work, increase the risk of opioid addiction or both.
Although mental health conditions rarely can be proven as work-related on their own, they often arise as a result of work-related injuries.
Use of medications for the treatment of mental health conditions increased between 2019 and 2020, even as cost trends for the drugs declined
The age of the claim is also a central factor among injured workers who filled a prescription for a mental health condition. Understandably, use of mental health medications is greatest among those with longer-term injuries.
Certain drug combinations highlight the need for early intervention with behavioral care
A primary area of concern is combinations of drugs, particularly opioids and benzodiazepines, which have an especially high risk of misuse when prescribed together. The myMatrixx clinical team is responding to this trend by offering enhanced alerts and interventions designed to decrease opioid misuse.
The following two charts, Age of Claims by Dangerous Combination and Total Claim Cost by Dangerous Drug Combinations, are derived from data included in a 2014 Study. This external data was included to highlight the significance and need for early intervention with behavioral care.3
*Data from a 2014 Study published in the Journal of Occupational and Environmental Medicine
- The presence of prescription benzodiazepines extends claim duration and is associated with more than tripled costs, from $10,801 to $34,613.
- Likewise for injured patients taking short-acting opioids, but not long-acting opioids, the presence of prescription benzodiazepines is associated with nearly tripled claim costs, from $43,438 to $123,311.
- For injured patients taking long-acting opioids, the presence of benzodiazepines is associated with a 51% increase in claim costs, from $139,734 to $211,097.3
Although state prescription drug monitoring programs (PDMPs) were developed to provide prescribers with information about previous and concurrent prescriptions for controlled substances, not all states mandate their use. Furthermore, according to the Association of State and Territorial Health Officials, “While PDMPs have contributed substantially to safer prescribing and dispensing of controlled pharmaceuticals as well as reducing drug diversion, they are often underutilized by state and other public health agencies.”4
myMatrixx can detail how myRxAdvocateSM and the pharmacovigilance programs developed by myMatrixx augment the effectiveness of PDMPs.
3 Lavin, R. A., Tao, X., Yuspeh, L., & Bernacki, E. J. (2014). Reviewed March, 2021. Impact of the Combined Use of Benzodiazepines and Opioids on Workersʼ Compensation Claim Cost. Journal of Occupational and Environmental Medicine, 56(9), 973-8. DOI:10.1097/ jom.0000000000000203. https://pubmed.ncbi.nlm.nih.gov/25046322/
4 (Undated). Reviewed March, 2021. Prescription Drug Monitoring Programs: Tools for Education, Epidemiological Surveillance, Prevention, and Early Intervention. Association of State and Territorial Health Officials. https://www.astho.org/Rx/Brandeis-PDMP-Report/
Maximizing value by maximizing generic Rx utilization
Generic utilization and efficiency
Among our clients, use of generic medications continues to increase — from 87.0% in 2019 to 88.6% in 2020. Notably, 10.1% of all payers that utilize myMatrixx to manage their prescription drugs attained 100% generic Rx utilization among drugs with generic equivalents.
By achieving optimal mix of the maximum clinically appropriate generic fill rate for each therapy class, payers could have saved an additional $23.7M in 2020. For example, pregabalin, the generic form of Lyrica® introduced in July 2019, continued to result in savings for payers as it gained market share in 2020.
On average, a pregabalin prescription saves payers 40% compared to Lyrica, yet Lyrica is the number one drug that prescribers indicate is medically necessary to be dispensed as a brand, also referred to as DAW1. Following Lyrica in terms of brand medically prescribing are Lidoderm® (lidocaine) patches and Percocet® (acetaminophen/oxycodone) both with long-established generics.
To receive FDA approval, generic drugs must be fully equivalent to their brand-name counterparts. As a result, patients rarely need the brand-name version of a medication when a generic alternative is on the market. However, a major driver of high prescription drug prices in the United States is prescribers mandating DAW1 for drugs such as Lyrica.
myMatrixx pharmacists often intervene to ensure that the branded product is medically necessary when DAW1 is indicated. In just one example, a myMatrixx clinical pharmacist found no medically necessary reason to dispense brand Valium® (diazepam) and Percocet when reviewing one case. By substituting the generic equivalents, cost savings amounted to more than $4,100 per month.
*Includes both traditional and private-label topicals, as discussed in this report.
Spotlight on specialty therapies
Top 10 specialty classes and medications
In 2020, specialty medications were responsible for only 0.7% of all retail prescriptions for workers’ compensation, but they drove 9.5% of costs. This disproportionate impact on costs represents a ratio of 13.5 to 1, which is up from 11.8 to 1 in 2019.
Leading the way in spending on specialty drugs is cancer medications, which increased 40.4%, driven primarily by a 29.1% rise in Rx utilization.
Top 10 therapy classes and insights
Looking ahead to 2021 and beyond
Pipeline drugs to watch
Although the patents on the above drugs have not yet expired, there are significant opportunities for cost-savings interventions on these drugs prior to the launch of generic versions. Half of these drugs have been active intervention targets for myMatrixx One Drug Review program.
myMatrixx’s comprehensive pharmacovigilance program is designed to create significant drug cost savings without compromising injured patient care.
OxyContin experienced a 21.4% decrease in prescriptions last year as a result of myMatrixx management of unnecessary or inappropriate opioid use
In calculating trend, prescription drug use was considered for payers with a stable injured worker base, defined as having a change in user volume of less than 50% from 2019 to 2020. Nonprescription medications and prescriptions that were dispensed in hospitals, long-term care facilities and other institutional settings were not included in our analysis. Rx utilization, determined on a per-patient-per-year (PPPY) basis, was calculated by dividing the total days’ supply of medications by the total number of users in a year. Market share was determined by calculating the percentage of total days’ supply of medication represented each medication in a therapy class. Prescription drug costs were calculated by adding together ingredient cost, taxes, administrative fees and dispensing fees.
The author of this report wishes to thank the following individuals for their contributions:
- Cliff Belliveau
- Mark Eatherly
- Kim Ehrlich
- Amanda France
- Rochelle Henderson, PhD
- Janelle Jenkins
- Ellen Johnson
- Amy Landwehr
- Michael Nguyen, PharmD
- Kat Romanowski
- Brian Williams, PharmD
- Sulzer Inc. Agency