By Paul King, Chief Client Officer, and Cliff Belliveau, Chief Innovation Officer
A strong pharmacy benefit management (PBM) program not only leverages a strong network for transaction discounts, it also provides tools to its clients to effectively manage utilization to ensure medications are safe and affordable enhancing a patient's return to health and capability.
Timely pharmacy intervention can assist payers and workers' comp claim administrators in staying ahead of medication challenges that can derail a claim, leading to increased costs and extended patient recovery times.
Clinical intervention tools offered by myMatrixx, have demonstrated success across many claim types. Two areas that stand out include: dangerous drug combinations and Medicare / Pre-settlement opportunities. Many payers in workers’ comp have multiple claims in their portfolio with one or both of these cost and safety issues without being aware of them.
Our Clinical and Safety Evaluation, CASE Rx®, is a retrospective clinical intervention program that our experts use to identify and address these and other pharmacy risks that can derail claims. Here’s why dangerous drug combinations and Medicare pre-settlements have become such big issues in workers’ comp pharmacy, and how our unmatched clinical intervention capabilities can help.
Dangerous drug combinations increasing overdose risk and workers' comp claim costs
Opioid misuse continues to receive considerable and deserved attention in both workers’ compensation and general health care. An important and related concern is the significant Health and Mortality risk associated when dangerous drugs, including opioids, especially if they are prescribed in combination with other drugs with a high potential of misuse, such as benzodiazepines or gabapentinoids.
Not only do dangerous drug combinations increase the risk of misuse and safety concerns such as overdoses, but they tend to also lead to increased claim duration and costs. According to the most recent myMatrixx Drug Trend Report, for injured patients taking short-acting opioids, prescription benzodiazepines are associated with nearly tripled claim costs.
There are state-level initiatives in the form of prescription drug monitoring programs (PDMPs) designed to provide prescribers, dispensers and law enforcement with information about previous and concurrent prescriptions for controlled substances.
However, not all states mandate their use and both providers and other public health agencies often underutilize them. Factors like lack of physician coordination especially in regard to physician dispensing, multiple payer types and automatic prescription renewal combined with PDMP underutilization can mean injured workers may have these dangerous concurrent prescriptions without awareness from the claims program.
Costly settlement and Medicare compliance
A workers’ compensation Medicare set-aside arrangement (MSA) is an agreement that sets part of a workers’ compensation settlement aside to pay for future medical services related to the injury, including medications. This is to ensure that injured workers have coverage after settlement without using Medicare funds.
Negotiating MSA settlements has become a lengthy process in workers’ compensation because of the long timeframes of care involved. For example, an injured patient with a $1,000/month allocation for prescription drugs and a 30-year life expectancy will have a costly settlement for drug coverage alone. The pharmacy aspect of this settlement requires careful scrutiny to ensure that the MSA agreement is both safe and necessary for the patient, and cost-effective for the payer.
One example from a cost perspective is checking for medications that are in the pipeline to become generics so that payers aren’t paying for costly name brand drugs when a lower cost equivalent is going to be available in a few months to years. In other cases, physicians may be able to wean injured workers off opioids when they are no longer medically necessary for the injury. Changes such as these over 20 to 30 years can result in savings of tens-of-thousands to over a million dollars in the final MSA. When one considers that opioids are not recommended for senior patients, and then these changes not only decrease the amount of the set-aside, they also decrease risk for the patient.
During the pre-settlement negotiation, it is extremely important for payers to take a holistic look at the current pharmacy regimen, including lifetime utilization and cost. This is another in which our CASE Rx® program's timely intervention can save payers money while improving the health and safety of injured patients.
How the CASE Rx®️ clinical intervention program helps you get ahead of the claim
To identify the highest risk claims for pharmacy intervention, including dangerous drug combinations and pre settlement claims, our CASE Rx® programemploys a 30-point algorithm to identify high risk claims to be reviewed for potential intervention. Categories include clinical effectiveness, safety, cost and age of the claim.
After identifying claims and performing a comprehensive utilization review, at the client’s direction, our clinical team can present the findings to the prescribing physician. The goal is to intervene to modify the injured workers’ drug regimen from a safety, effectiveness or cost standpoint. If the client elects to modify its prescription benefit, myMatrixx can implement those changes.
Here are four reasons why CASE Rx® is unmatched in getting workers' comp payers ahead of the claim:
- Ideal Candidate Identification: A 30 data-point algorithm that comprehensively measures patient risk. Many competing intervention processes only look at morphine equivalent dose (MED) for opioids.
- In-House Clinical Pharmacy Intervention: At myMatrixx, our pharmacists are experienced in performing direct clinical intervention.
- Implement Benefit Changes: As a pharmacy fulfillment agent, we have the ability to assist clients in implementing changes to its pharmacy benefit and ensure they are reflected in the claim.
- Detailed Analytics and Outcomes Reporting: As a pharmacy benefits manager (PBM), at the client’s direction, we can pull comprehensive data to analyze utilization trends that competing claims management agents don’t have.
To learn more about the power that our CASE Rx® clinical intervention program can have for your workers' compensation claims strategy and patient safety, get a free CASE Rx® by filling out a short online form. You can also reach out to our clinical team if you have questions at clinical@myMatrixx.com.