Sponsored: myMatrixx

From Reactive to Proactive — Combining Clinical and Data Expertise for Optimal Pharmacy Outcomes

In a reactive industry, pharmacists’ expertise and advanced analytics must be leveraged to get ahead of problematic prescriptions.
By: | October 31, 2019

Pharmacy management in workers’ compensation has been reactive by nature. Historically, pharmacy benefit managers (PBMs) did not have insight into a prescription for a potentially dangerous drug until the injured worker filled the prescription at their local pharmacy. By the time any intervention happened, the patient had likely already taken the drug.

“In the past, we haven’t always known something was happening until a pharmacist processed the prescription. That’s why we managed the clinical side of the industry retrospectively,” said Phil Walls, Chief Clinical Officer, myMatrixx.

Of course, preventing a problem in the first place is always preferable to fixing one that’s already happened.

For clinical pharmacy oversight to truly make a difference in the life of a claim, PBMs need to be able to get out in front of potentially dangerous or inappropriate prescriptions, even preventing them from being written at all.

The need for pharmacy management to become more proactive is clear, and the myMatrixx team believes the solution lies in the integration of true clinical expertise with comprehensive data and artificial intelligence (AI)-driven analytics.

“We’re moving our approach earlier and earlier in the process so we can progress from being reactive to proactive, and eventually fully predictive,” said Cliff Belliveau, Vice President of Business Intelligence at myMatrixx. “That requires a symbiotic relationship between clinical expertise and advanced data analytics.”

Continuation of a Journey Towards Earlier Intervention

Phil Walls, Chief Clinical Officer, myMatrixx

In 2006, myMatrixx launched its Get Ahead of the Claim clinical pharmacy strategy. This program provided a strategy for the clinical pharmacists at myMatrixx to intervene on behalf of the injured patient. Through early intervention, this approach lowered the risk of unnecessary and inappropriate drug therapy and saved countless injured workers’ lives during the devastating opioid overdose epidemic.

According to myMatrixx’s latest Drug Trend Report, client opioid utilization has been reduced by more than 40% over the past three years.

But that’s not good enough. We still see legacy cases where injured patients receive excessive doses of opioids, new claims where marijuana is actually considered a path to return to work, claims for an aging workforce that are managed the same as one for a younger worker, as well as emerging threats such as the dispensing of egregiously priced private-labeled topical products by prescribers,” Walls said.

PBMS also must contend competing and equally valid concerns from other stakeholders involved in a patient’s care. Is it acceptable to prescribe alternative drugs regardless of cost? Is it appropriate to accept liability associated with care that focuses on pain management rather than function?

“These concerns sent us down the path of discovering if we could be advocates to both the injured patient and others involved in his or her care, and the answer is a resounding ‘yes,’” Walls said.

“The key is to intervene on problematic prescriptions even earlier than Get Ahead of the Claim allows. To focus on preventing problems rather than solving them. That led us to develop a strategy that allows us to become more and more proactive and even predictive as technology allows.”

Data is a Key Component of Proactive Pharmacy Management

Cliff Belliveau, Vice President of Business Intelligence, myMatrixx

The first step of that strategy involved an examination of what could be accomplished with existing clinical tools.

For example, myMatrixx’s data analytics platform, Clinical Analytics Results Engine (CARE), captures a patient’s entire case history. Knowing what didn’t work before enables the development of a more effective treatment plan going forward.  It also monitors new data generated on that case in order to track improvement.

“If you bring the data together, it will tell the story for you,” said Walls. “That insight, combined with the knowledge and expertise of our clinical pharmacists, is necessary to redirect these claims and hopefully break the cycle of dependency.”

Additional prescribing and drug data is also generated from myMatrixx’s Alert, Review and Manage (ARM) and One Drug Review programs.

Geared toward new injuries, these early intervention programs monitor prescriber activity and review single questionable prescriptions. They are less comprehensive, but nonetheless add to a growing database of information that can be used to spot troubling trends as they take shape.

The growing popularity of electronic prescribing will make it even easier for PBMs to spot problems even earlier. “With e-prescribing, we’re no longer waiting on the pharmacists to enter prescriptions into the computer system. As soon as the prescriber transmits the prescription, we capture that data and have the opportunity to intervene at the point of prescribing as opposed to the point of dispensing” Belliveau said.

Pharmacovigilance — Leveraging Data to Stay Ahead of Dangerous Drugs

All of that data lends itself to the development of predictive models. AI and machine learning platforms may be able to see familiar trends emerge and raise red flags over drugs that aren’t even on the radar yet.

This will be critical to get ahead of the next wave of dangerous drugs — and there will always be another wave.

“When I first started in workers’ compensation, the number one drug of concern in this industry was Prozac. Can you imagine today if the only thing we had to worry about was the overuse of antidepressants? But that was a really big deal before compounds or opioids had become problematic,” Walls said.

“Pharmacovigilance is monitoring all dangerous drugs. And that can include a broader category of substances than most people realize.”

Benzodiazepines, tranquilizers, amphetamine and even nonsteroidal anti-inflammatories (NSAIDs) are all included in this group. NSAIDs increase the risk of GI incidences and stomach ulcers, which will require their own pharmaceutical treatment. They are also associated with increased risk of cardiovascular events like arrhythmias.

A skilled pharmacist may understand the risks of NSAID overuse, but assessment can’t happen on a broad scale without a similarly broad view of the prevalence of NSAID prescribing.

“A lot of these pharmacists go and look at all these scripts like a long accounting measurement. And what we want to do is scale the ability to effectively look for all dangerous drugs, or drugs that can be abused or misused,” Walls said. “We need to be able to use the data and leverage that with the thought process and the knowledge of pharmacists. And we need to do all that to scale.”

A Comprehensive Suite of Clinical and Data Solutions, Focused on Proactive and Predictive Modeling

Leveraging data and expertise to predict and prevent problems is what every PBM aspires to, but the task is easier said than done.

The key, Walls said, lies in integration. Individually, data platforms, business intelligence reporting and clinical intervention programs cannot support the goal of becoming proactive if they exist in silos. Holistic patient advocacy is vital in the care of an injured worker.

That’s why myMatrixx created the myMatrixx myRxAdvocateSM program, a portfolio of clinical and data services that work together to connect insights and drive more effective intervention strategies. Analytics and reporting platforms, intervention programs, formulary rules and other services are all pulled under one roof to create a comprehensive suite of solutions.

“myRxAdvocate is really about bringing clinical pharmacy expertise and data analytics together to drive lower costs and better pharmacy outcomes in the short term, while enabling pharmacovigilance over the long term,” Walls said, “and it allows us to be advocates to not only the injured patient, but to all stakeholders involved in the care and management of an injured patient.”

“It is an expansion of what we offer now, but with more cohesiveness. It’s more data-driven,” Belliveau said.

In the end, proactive intervention produces better clinical pharmacy outcomes for injured workers. Their safety and recovery are kept top of mind. Better still, the cost savings associated with acting early can be measured definitively.

“When we do the right thing clinically, everyone wins,” Walls said.

To learn more, visit https://www.myMatrixx.com/.

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This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with myMatrixx. The editorial staff of Risk & Insurance had no role in its preparation.




myMatrixx® is a pharmacy benefit management company dedicated to workers’ compensation. The unique combination of myMatrixx and Express Scripts makes us the only workers’ compensation pharmacy benefit manager that can deliver high touch customer service, clinical expertise and actionable data analytics while leveraging Express Scripts’ pharmacy network, comprehensive clinical services, mail order program and specialty solutions to meet the individual needs of our clients and their injured workers. For more information, visit myMatrixx.com.

More from Risk & Insurance

More from Risk & Insurance

Risk Scenario

The Betrayal of Elizabeth

In this Risk Scenario, Risk & Insurance explores what might happen in the event a telemedicine or similar home health visit violates a patient's privacy. What consequences await when a young girl's tele visit goes viral?
By: | October 12, 2020
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

PART ONE: CRACKS IN THE FOUNDATION

Elizabeth Cunningham seemingly had it all. The daughter of two well-established professionals — her father was a personal injury attorney, her mother, also an attorney, had her own estate planning practice — she grew up in a house in Maryland horse country with lots of love and the financial security that can iron out at least some of life’s problems.

Tall, good-looking and talented, Elizabeth was moving through her junior year at the University of Pennsylvania in seemingly good order; check that, very good order, by all appearances.

Her pre-med grades were outstanding. Despite the heavy load of her course work, she’d even managed to place in the Penn Relays in the mile, in the spring of her sophomore season, in May of 2019.

But the winter of 2019/2020 brought challenges, challenges that festered below the surface, known only to her and a couple of close friends.

First came betrayal at the hands of her boyfriend, Tom, right around Thanksgiving. She saw a message pop up on his phone from Rebecca, a young woman she thought was their friend. As it turned out, Rebecca and Tom had been intimate together, and both seemed game to do it again.

Reeling, her holiday mood shattered and her relationship with Tom fractured, Elizabeth was beset by deep feelings of anxiety. As the winter gray became more dense and forbidding, the anxiety grew.

Fed up, she broke up with Tom just after Christmas. What looked like a promising start to 2020 now didn’t feel as joyous.

Right around the end of the year, she plucked a copy of her father’s New York Times from the table in his study. A budding physician, her eyes were drawn to a piece about an outbreak of a highly contagious virus in Wuhan, China.

“Sounds dreadful,” she said to herself.

Within three months, anxiety gnawed at Elizabeth daily as she sat cloistered in her family’s house in Bel Air, Maryland.

It didn’t help matters that her brother, Billy, a high school senior and a constant thorn in her side, was cloistered with her.

She felt like she was suffocating.

One night in early May, feeling shutdown and unable to bring herself to tell her parents about her true condition, Elizabeth reached out to her family physician for help.

Dr. Johnson had been Elizabeth’s doctor for a number of years and, being from a small town, Elizabeth had grown up and gone to school with Dr. Johnson’s son Evan. In fact, back in high school, Evan had asked Elizabeth out once. Not interested, Elizabeth had declined Evan’s advances and did not give this a second thought.

Dr. Johnson’s practice had recently been acquired by a Virginia-based hospital system, Medwell, so when Elizabeth called the office, she was first patched through to Medwell’s receptionist/scheduling service. Within 30 minutes, an online Telehealth consult had been arranged for her to speak directly with Dr. Johnson.

Due to the pandemic, Dr. Johnson called from the office in her home. The doctor was kind. She was practiced.

“So can you tell me what’s going on?” she said.

Elizabeth took a deep breath. She tried to fight what was happening. But she could not. Tears started streaming down her face.

“It’s just… It’s just…” she managed to stammer.

The doctor waited patiently. “It’s okay,” she said. “Just take your time.”

Elizabeth took a deep breath. “It’s like I can’t manage my own mind anymore. It’s nonstop. It won’t turn off…”

More tears streamed down her face.

Patiently, with compassion, the doctor walked Elizabeth through what she might be experiencing. The doctor recommended a follow-up with Medwell’s psychology department.

“Okay,” Elizabeth said, some semblance of relief passing through her.

Unbeknownst to Dr. Johnson, her office door had not been completely closed. During the telehealth call, Evan stopped by his mother’s office to ask her a question. Before knocking he overheard Elizabeth talking and decided to listen in.

PART TWO: BETRAYAL

As Elizabeth was finding the courage to open up to Dr. Johnson about her psychological condition, Evan was recording her with his smartphone through a crack in the doorway.

Spurred by who knows what — his attraction to her, his irritation at being rejected, the idleness of the COVID quarantine — it really didn’t matter. Evan posted his recording of Elizabeth to his Instagram feed.

#CantManageMyMind, #CrazyGirl, #HelpMeDoctorImBeautiful is just some of what followed.

Elizabeth and Evan were both well-liked and very well connected on social media. The posts, shares and reactions that followed Evan’s digital betrayal numbered in the hundreds. Each one of them a knife into the already troubled soul of Elizabeth Cunningham.

By noon of the following day, her well-connected father unleashed the dogs of war.

Rand Davis, the risk manager for the Medwell Health System, a 15-hospital health care company based in Alexandria, Virginia was just finishing lunch when he got a call from the company’s general counsel, Emily Vittorio.

“Yes?” Rand said. He and Emily were accustomed to being quick and blunt with each other. They didn’t have time for much else.

“I just picked up a notice of intent to sue from a personal injury attorney in Bel Air, Maryland. It seems his daughter was in a teleconference with one of our docs. She was experiencing anxiety, the daughter that is. The doctor’s son recorded the call and posted it to social media.”

“Great. Thanks, kid,” Rand said.

“His attorneys want to initiate a discovery dialogue on Monday,” Emily said.

It was Thursday. Rand’s dreams of slipping onto his fishing boat over the weekend evaporated, just like that. He closed his eyes and tilted his face up to the heavens.

Wasn’t it enough that he and the other members of the C-suite fought tooth and nail to keep thousands of people safe and treat them during the COVID-crisis?

He’d watched the explosion in the use of telemedicine with a mixture of awe and alarm. On the one hand, they were saving lives. On the other hand, they were opening themselves to exposures under the Health Insurance Portability and Accountability Act. He just knew it.

He and his colleagues tried to do the right thing. But what they were doing, overwhelmed as they were, was simply not enough.

PART THREE: FALLING DOMINOES

Within the space of two weeks, the torture suffered by Elizabeth Cunningham grew into a class action against Medwell.

In addition to the violation of her privacy, the investigation by Mr. Cunningham’s attorneys revealed the following:

Medwell’s telemedicine component, as needed and well-intended as it was, lacked a viable informed consent protocol.

The consultation with Elizabeth, and as it turned out, hundreds of additional patients in Maryland, Pennsylvania and West Virginia, violated telemedicine regulations in all three states.

Numerous practitioners in the system took part in teleconferences with patients in states in which they were not credentialed to provide that service.

Even if Evan hadn’t cracked open Dr. Johnson’s door and surreptitiously recorded her conversation with Elizabeth, the Medwell telehealth system was found to be insecure — yet another violation of HIPAA.

The amount sought in the class action was $100 million. In an era of social inflation, with jury awards that were once unthinkable becoming commonplace, Medwell was standing squarely in the crosshairs of a liability jury decision that was going to devour entire towers of its insurance program.

Adding another layer of certain pain to the equation was that the case would be heard in Baltimore, a jurisdiction where plaintiffs’ attorneys tended to dance out of courtrooms with millions in their pockets.

That fall, Rand sat with his broker on a call with a specialty insurer, talking about renewals of the group’s general liability, cyber and professional liability programs.

“Yeah, we were kind of hoping to keep the increases on all three at less than 25%,” the broker said breezily.

There was a long silence from the underwriters at the other end of the phone.

“To be honest, we’re borderline about being able to offer you any cover at all,” one of the lead underwriters said.

Rand just sat silently and waited for another shoe to drop.

“Well, what can you do?” the broker said, with hope draining from his voice.

The conversation that followed would propel Rand and his broker on the difficult, next to impossible path of trying to find coverage, with general liability underwriters in full retreat, professional liability underwriters looking for double digit increases and cyber underwriters asking very pointed questions about the health system’s risk management.

Elizabeth, a strong young woman with a good support network, would eventually recover from the damage done to her.

Medwell’s relationships with the insurance markets looked like it almost never would. &

Bar-Lessons-Learned---Partner's-Content-V1b

Risk & Insurance® partnered with Allied World to produce this scenario. Below are Allied World’s recommendations on how to prevent the losses presented in the scenario. This perspective is not an editorial opinion of Risk & Insurance.®.

The use of telehealth has exponentially accelerated with the advent of COVID-19. Few health care providers were prepared for this shift. Health care organizations should confirm that Telehealth coverage is included in their Medical Professional, General Liability and Cyber policies, and to what extent. Concerns around Telehealth focus on HIPAA compliance and the internal policies in place to meet the federal and state standards and best practices for privacy and quality care. As states open businesses and the crisis abates, will pre-COVID-19 telehealth policies and regulations once again be enforced?

Risk Management Considerations:

The same ethical and standard of care issues around caring for patients face-to-face in an office apply in telehealth settings:

  • maintain a strong patient-physician relationship;
  • protect patient privacy; and
  • seek the best possible outcome.

Telehealth can create challenges around “informed consent.” It is critical to inform patients of the potential benefits and risks of telehealth (including privacy and security), ensure the use of HIPAA compliant platforms and make sure there is a good level of understanding of the scope of telehealth. Providers must be aware of the regulatory and licensure requirements in the state where the patient is located, as well as those of the state in which they are licensed.

A professional and private environment should be maintained for patient privacy and confidentiality. Best practices must be in place and followed. Medical professionals who engage in telehealth should be fully trained in operating the technology. Patients must also be instructed in its use and provided instructions on what to do if there are technical difficulties.

This case study is for illustrative purposes only and is not intended to be a summary of, and does not in any way vary, the actual coverage available to a policyholder under any insurance policy. Actual coverage for specific claims will be determined by the actual policy language and will be based on the specific facts and circumstances of the claim. Consult your insurance advisors or legal counsel for guidance on your organization’s policies and coverage matters and other issues specific to your organization.

This information is provided as a general overview for agents and brokers. Coverage will be underwritten by an insurance subsidiary of Allied World Assurance Company Holdings, Ltd, a Fairfax company (“Allied World”). Such subsidiaries currently carry an A.M. Best rating of “A” (Excellent), a Moody’s rating of “A3” (Good) and a Standard & Poor’s rating of “A-” (Strong), as applicable. Coverage is offered only through licensed agents and brokers. Actual coverage may vary and is subject to policy language as issued. Coverage may not be available in all jurisdictions. Risk management services are provided or arranged through AWAC Services Company, a member company of Allied World. © 2020 Allied World Assurance Company Holdings, Ltd. All rights reserved.




Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]