Workers’ compensation clients are unique. Injured worker populations, injury types, and the impact of industry trends vary from client to client, and these things can influence what a client looks for when choosing their pharmacy benefit manager (PBM). Luckily – or unluckily – the market also has a variety of PBMs. From established brands to startups, clients are met with promises of lower prices, fancy portals, and faster processes. But, for the greatest value and impact, what clients need is a PBM, like MyMatrixx by Evernorth, which manages claims comprehensively with robust solutions that deliver high-touch support, evidence-based clinical oversight, and outstanding customer service.

“Providing a comprehensive approach to pharmacy benefits isn’t easy to do and it isn’t easy to find,” states Mike Cirillo, president, MyMatrixx. “Everyone wants to save money, but just because a company offers the lowest price doesn’t mean they deliver the greatest value. Remember, the most expensive drug is the one that should have never been dispensed in the first place. A comprehensive PBM will have the programs in place to help make sure that doesn’t happen,” he continued.

“It’s so important for clients to educate themselves on the nuances and differentials between PBMs to determine if they are getting what they need when it comes to cost, care, process, service, and support,” said Cirillo.

A comprehensive approach brings it together, so everyone benefits from lower pharmacy costs, better clinical care, injured worker safety, faster return to work or function while reducing the workload burdens on an already stressed adjuster workforce.

Comprehensive Service Vs. Multi-Vendor Approach to Pharmacy Benefit Management

Mike Cirillo, President, MyMatrixx

With most things in life, it’s better to see the big picture to understand how things connect and impact one another. The same is true with workers’ comp claims. Depending on the injured worker and the injury there could be one prescription or five, a single visit to the ER or multiple treatments and providers, low and high risks, and varying costs through the life of the claim. Just because a vendor leases a pharmacy network or processes pharmacy transactions, or pays paper bills doesn’t mean they are equipped to be a PBM.

“A PBM is much, much more…,” stressed Cirillo. “…and a comprehensive PBM, like MyMatrixx, has the in-house solutions in place to manage, monitor, customize, and advise throughout the life of a claim,” explains Cirillo.

Without this, clients are forced to engage and rely on multiple vendors for services such as bill review and retrospective clinical solutions. This eliminates the consolidated view of a claim, which isn’t in the best interest of the injured worker or the client.

Fundamentals of a Comprehensive PBM

Cirillo stressed that clients should work with a PBM that supports and controls the following fundamentals of claim management.

A clinical team and oversight to best address a client’s needs

A comprehensive PBM will have clinical pharmacists on staff prepared to answer pharmacy-related questions, address client concerns, and review and collaborate around treatment plans and formularies that best address a client’s overall and case specific needs.

“MyMatrixx has 35 clinical pharmacists on staff,” said Cirillo. “When an adjuster, pharmacy, or a physician call with questions, we have the right team in place to intervene and address,” he continued.

The MyMatrixx on-staff clinicians are pharmacy experts who manage cases and patient care. “They are the front lines of our work. They help ensure patient safety, prevent adverse drug reactions, collect data, and educate injured workers and their providers,” said Cirillo. They also assist clients with direction and providing valuable outreach to physicians and patients to ensure they are getting appropriate care and a prescription regimen.

Additionally, MyMatrixx has a separate clinical pharmacist team dedicated to assisting clients with customizing their program to meet their unique needs and challenges. Customizations include everything from plan rules, formularies, and intervention guidelines to drive the lowest possible cost.

Data and analytics that fosters continuous improvement

A key requirement and great benefit of working with a comprehensive PBM is the ability to consolidate multiple sources of data to create a single view of the injured worker, the injury, the treatment plan, and pharmacy needs of a claim. When using a multi-vendor approach, the burden to create a consolidated view falls back to the adjuster who may not be trained to address the various medical disciplines required to manage the case.

Leveraging a consolidated data set (injured worker, injury, medical and pharmacy services) enables a comprehensive PBM to identify high-risk claims early and, more importantly, to drive proactive interventions to reduce risk and cost. This is particularly important when managing legacy/long-term claims or cases with significant pain management issues.

“From a pharmacy management perspective, prescription medications are a significant cost driver with legacy claims,” Cirillo said. Claims that are 10+ years old see drug costs that are 12 times higher than first year claims.¹

By analyzing claim data, MyMatrixx has had great success intervening on long-term cases by introducing new tools or medication alternatives to help control or reduce an injured worker’s use of opioid and other dangerous medications.

“As someone with a strong finance background, I believe in the power of data to drive change. Analyzing data helps uncover the truth and understand the program’s drivers. Rather than solely looking at past performance, data enables you to identify emerging challenges, pain points, and trends in the program,” he said.

Data also enables clients to make changes at the individual injured worker level, fostering continuous improvement. Leveraging data can be a huge part of maintaining a positive trajectory in the program.

Directly connected contracts for maximum benefits

When selecting a PBM, it is crucial to understand who holds the contracts with pharmacies and what that entails. In simple terms, do you own the network pharmacy contracts or is it a leased arrangement?

“This directly relates to the financial value derived from contract ownership and compliance. A comprehensive PBM that is directly connected to the contracts enables lower cost, greater adherence to therapies and increased compliance with all federal, state, and other regulatory requirements. The farther removed the PBM is from the contract owner, the greater the risk factor,” Cirillo said.

An out-of-network conversion strategy that makes sense
It’s essential that a PBM have the procedures and processes in place to manage out-of-network bills. Not just a process to make sure the bills are paid, but processes to bring and keep future transactions in network, ensure that every bill is clinically adjudicated, and also to capture claim data. Failing to do so allows bad actor pharmacies to continue operating out-of-network and that is counterproductive, Cirillo shared.

A regulatory and legislative program to influence change

The workers’ compensation industry is overrun with federal and state regulations and legislative changes – especially when it comes to pharmacy. Information from these can be confusing and contradictory, so it’s important for a comprehensive PBM to have the people and the processes in place to monitor and what is happening across the industry.

MyMatrixx has invested in an expert team who proactively engage with state legislatures and monitor regulatory shifts, always with our clients in mind. “That’s not something you will see with a startup PBM,” assured Cirillo. The MyMatrixx team understands the industry and works to inform our clients what changes will mean and to advocate for and influence change on their behalf.

Technology And Process Must Work Together

Digital tools — including patient portals, data collection and automation — have become cornerstones in the workers’ compensation space. But not all technologies are the same. Having the greatest portal doesn’t always equate to having the most effective processes in place. It’s what a comprehensive PBM does with the technology that proves its value.

“There can be a big difference between a glitzy, flashy portal and the infrastructure behind it,” Cirillo said. “Technology and data tools are constantly evolving, and companies continue to update their offerings to stay competitive and provide the best service to their clients.”

A good practice, yes, but it’s important that the tech tools and offerings are used appropriately and with the end goal of helping partners improve efficiency, make informed decisions, and deliver greater results. A full-service PBM that provides useful, innovative technological support shows dedication to helping clients continually succeed.

“We’re investing heavily in innovation to stay ahead of the curve,” Cirillo stated. This includes developing solutions and services that address the evolving needs of our clients and their employees.

“Right now, we’re working on risk scoring and the integration of medical information with pharmacy data for better adjudication and identification,” he said. “We’re searching for the holy grail of digitizing medical data to analyze injury codes, medical procedures performed, and how they align with National Drug Codes, medications, dosages, and day supply to drive outcomes.”

This level of information would give clients greater insight into their business but would also provide adjusters with information to make educated decisions within a claim and free up their time by eliminating mundane tasks.

A Foundation of Support

With several startup PBMs entering the market, it can feel overwhelming to choose a partnership that not only offers the best customer service, patient outcomes, cost savings, technologies and more, but also one that delivers stability and follows through on its promises.

MyMatrixx is owned by Evernorth, a large coordinate health solutions company, which lends to a foundation of strength and support. With this, MyMatrixx can use its combined volume of group health and workers’ compensation to secure the lowest costs available for clients. It also enables the team to drive clinical compliance and better behaviors from pharmacies through direct contracts and relationships.

“When we need something, we can get a response quickly. We’re not multiple steps removed by leasing from a leaser or processor. This level of control translates to better cost containment and improved outcomes,” said Cirillo.

With a deep focus on both improving patient outcomes as well as driving down costs, MyMatrixx brings its extensive network of pharmacies, advanced technology, trained on-staff clinicians and commitment to exceptional customer service into every partnership.

The Choice Seems Clear

Proper pharmacy benefit management is the key to achieving better outcomes, costs, and patient experiences. “That’s the real difference a comprehensive PBM brings to the table,” Cirillo added.

Ranked the #1 PBM since 2019², MyMatrixx works with clients to deliver value through financial outcomes, clinical oversight, technology, reporting, analytics, and overall service. Cirillo concluded, “Our focus will always be on the injured worker and delivery and driving successful outcomes.”

To learn more, visit: https://www.MyMatrixx.com/pbm-solutions.

¹ https://www.ncci.com/Articles/Documents/Insights-Research-Brief-Formulary-Post-Reform.pdf

² 2023-PDM-Survey-Public.pdf (comppharma.com)

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.