White Paper

Three Myths About PBM Pricing Every Workers’ Compensation Payer Should Know

Workers’ comp payers that prioritize price-per-pill risk poor clinical outcomes and higher overall costs in their pharmacy programs. A focus on quality of care will always produce the best results.

White Paper Summary

Pharmacy costs in workers’ compensation have been declining steadily for nearly a decade — down $1.1 billion over the past eight years, in fact. But that rosy news has a thorn.

Cost is just one indicator of workers’ comp program success, but it is one that can also hide problems. On the positive side, lower spend can be the result of reduced drug utilization or improved formulary management, reflecting attentive claims handling and strong clinical engagement.

In contrast, it could also signify that payers are simply choosing to direct their dollars elsewhere, prioritizing the minimization of upfront expenses and shifting investment away from the proactive clinical services that good PBMs have to offer.

Mike Cirillo, president of myMatrixx, believes the latter trend has become far more prevalent.

“When payers just see the numbers going down year over year, they can be lulled into a false sense of security,” he said. “People have stopped talking about clinical engagement, clinical outcomes and good claims management. Instead everybody is talking about price.”

Much of the current messaging in the marketplace promotes models that prioritize lowest price-per-pill over strong clinical management means to generate savings. When examining any pricing model however, it’s important to separate myth from fact and know the important role that strong oversight plays in a claim strategy.

To help, here are three myths that have developed in the market and reasons why prioritizing clinical management — which must include a comprehensive pharmacovigilance program to ensure clinical appropriateness and improve patient outcomes — along with price will generate greater value at a lower cost over the long term.

To learn more about myMatrixx, please visit their website.

As a PBM focused on workers’ compensation, myMatrixx is dedicated to highly proactive customer support and a full suite of data-driven pharmacy, clinical and regulatory solutions to mitigate risk and safely guide injured workers on their path to recovery.

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