Even during the COVID-19 pandemic, rising drug costs continue to grab attention and headlines. In fact, a recent Gallup poll indicates that Nine in 10 adults in the United States have concerns about rising drug costs due to COVID-19.1 Of course, these concerns aren’t just limited to group health and self-pay, but can also have a serious effect on the workers’ compensation industry.

Against this backdrop, PBMs in the workers’ comp space are constantly seeking ways to reduce overall costs for their clients while still delivering positive outcomes for injured workers. For myMatrixx, these two goals go hand-in-hand. By following a broad pharmacovigilance strategy built on clinical oversight and deep analysis of decades of drug data, they were able to reduce spending for the workers’ compensation drug plans they manage by 6.1% last year, according to their recently released 2019 Drug Trend Report.

“Helping our clients balance appropriate care for injured workers while responsibly keeping costs down is the most important thing we can do for workers hurt on the job,” said Mike Cirillo, President, myMatrixx. To accomplish this, myMatrixx focused their resources on several key areas, including reducing opioid utilization, increasing generic efficiency and keeping an eye out for emerging trends and threats in the industry.

Saving Lives and Lowering Costs Through Reduced Opioid Utilization and Aggressive Generic Substitution

According to myMatrixx Chief Clinical Officer Phil Walls, continuing downward pressure on opioid utilization is absolutely a priority. “While significant progress has been made in decreasing opioid utilization, it should continue to be an area of concern; and we’re glad to report a 10.7% decline in opioid spending last year.” In fact, according to the myMatrixx Drug Trend Report, 73.1% of payers spent less on opioids in 2019 versus 2018, part of a five-year consecutive decline in spending. Added Walls “That is something that benefits everyone involved and is the result of strategies including the myMatrixx myRxAdvocate pharmacovigilance program, government initiatives and concentrated provider awareness and education.” Thanks to these efforts, many myMatrixx clients are actually experiencing no opioid utilization for new claims. According to Cirillo, the effects of these efforts go far beyond bottom lines, “Through this highly focused strategy to reduce opioid utilization, our pharmacists are literally saving patient lives every day.”

Another tentpole in reducing spend for payers was closely measuring the efficiency and utilization of generic drugs. Perhaps the most significant success story in 2019 was an aggressive generic substitution campaign in the wake of the expiration of the Lyrica® patent last July. myMatrixx reported that these efforts resulted in 91.8% of all Lyrica prescriptions being converted to the generic equivalent pregabalin within four weeks and 96.4% within 180 days of expiration of the patent.

Staying Ahead of Emerging Cost Drivers

The Drug Trend Report also shares data surrounding a number of emerging trends which myMatrixx believes will drive the industry and warrant increased awareness. Perhaps chief among these is the continuing growth in spending on specialty drugs and how it can lead to the rise of so-called “super-spending” in certain cases. “Super-spending can be defined as annual drug expenditures in excess of $250,000 for a single patient,” says Walls. “This term originated in the commercial market, but we’re starting to see it in workers’ comp as well. At myMatrixx, we’ve been able to identify a number of claims that fit this definition, one with drug costs in excess of one million dollars a year.” Since the existence of these claims can be seriously disruptive to any business’s bottom line, myMatrixx is already focused on solutions. “One point of good news is that patents are starting to expire on specialty drugs, and in the above case, we were able to generate more than $400,000 a year in savings through generic substitution of a specialty drug,” elaborated Walls.

Just like the country at large, the workers’ comp industry is also dealing with the health care needs of an aging workforce. Traditionally, the workers’ comp system has seen a high percentage of middle-aged employees. In 2019, the myMatrixx clinical team identified that 35% of injured workers in their database were aged 55 years or older. This has resulted in the need for rigorous guidelines, as these older patients can come with very specific needs and accompanying high costs. Says Walls, “Certain drugs, such as opioids, should be prescribed to senior patients only with caution, if at all, while alternatives to opioids like NSAIDs can cause cardiovascular complications. There are several solutions for this that myMatrixx has implemented, particularly, better management of these cases at both the point of prescribing and dispensing.“

Yet another focus area in the report is on rising usage of physician-dispensed private label topicals. Walls explains that while myMatrixx has all but eradicated pharmacist prepared compounds as an issue that payers face, they’re gaining a greater understanding of an emerging threat known as private-label topicals. “This is a subcategory of topical drugs which can represent egregious drug pricing with little or no added clinical benefit,” Walls explained. These private-label products are the newest concern to evolve from physician dispensing and have moved the dial from hundreds to thousands of dollars in excessive costs. However, Walls elaborated that myMatrixx has already developed a client-specific solution, aligned with unique jurisdictional guidelines, which has led to proven results for a broad range of their clients.

These are just some of the ways myMatrixx has been able to combine clinical expertise and data analysis to create positive outcomes for injured workers while reducing drug costs. If you’re interested in learning more about these and other key driving trends, myMatrixx invites you to download their 2020 Drug Trend Report.

Source

1. https://news.gallup.com/poll/312641/nine-concerned-rising-drug-costs-due-covid.aspx