Four Questions That Can Help Achieve an Unimaginably Great PBM Implementation

Joel Playford, Vice President of Implementation, myMatrixx

Switching to a new PBM is a big decision. Frankly, the time and resources it takes to go through the implementation process are enough to keep many plan administrators from making the switch, even in a less than ideal situation. But if generic substitution, unnecessary prescriptions, and low legacy claim closure — just to name a few of the issues caused by suboptimal PBM service — start to create exorbitant costs, moving to a new servicer can become a sound and necessary choice.

When it is time to switch, implementation becomes priority No. 1. A smooth implementation can make the difference in achieving real value for your program.

Implementations is about delivering on a promise

A PBM can do all things it says it can do, but poor communication, inadequate training, or missed updates to pharmacies can prevent its capabilities from being fully realized. The implementations team are the first people who start to deliver on the promises that a PBM has made to get you to make that switch.

Even in the best cases, that will still involve some hurdles and pain points. One of the most common is simply helping navigate the uncertainty that comes with change. People get used to doing something a certain way and they are often reluctant to train on a new system, even if it’s a better system. Easing this uncertainty and building a bridge from one team to another is fundamental to any implementation strategy, and it’s a great example of the fundamental role good communication plays in delivering effective outcomes.

The implementations team should be able to adapt to any scenario, from simple to complex. But, preparation is key to a smooth transition. Any organization considering switching PBMs can start by asking a few basic questions that can help prepare for a smooth and productive implementation.

1. What are your strategic goals?

It’s certainly true that no two implementations are ever the same. A PBM switch may be an optimization for a smoothly running claims program. In other cases, it’s part of a wide-ranging overhaul.

A successful implementation depends on both the PBM and the client having a clear understanding of the major goals to reach and problems to overcome from the changeover. What is working that you want to keep in place? What are your injured patients struggling with? What level of training does your team need?

Being able to clearly articulate your overall claims strategy, and your specific goals for pharmacy benefits, to your PBM can help create a strong and productive partnership from the beginning.

On the PBM side, you want a team who is experienced and adaptable, and who has worked with similar cases to yours. They should be able to help you develop a strategy that is right-sized for your organization and needs, and have a deep understanding of their own capabilities, from clinical programs to business intelligence. A good portion of the implementation process can come down to educating clients on a PBM’s full capabilities— and demonstrating tangible improvements that can be made.

2. What makes workers’ comp pharmacy unique?

Workers’ compensation pharmacy and group health pharmacy both involve a doctor writing a prescription and the patient filling it at some kind of pharmacy. That’s about where the similarities end. For a PBM implementation to be successful in this space, the PBM and the implementation team need a deep understanding of the industry.

With workers’ comp laws varying by state, and a constantly shifting regulatory landscape, dedicated knowledge and resources are critical. Formulary management is especially important, and you should be asking any prospective PBM about the level of detail, flexibility, and customization they offer with formulary creation and editing. Along with adhering to state laws and regulations, having the right checks and systems in place can ensure safety and value in your claims management plan.

Another key concern is setting up reporting and compliance requirements with the state government, or governments, where the company operates. Certain pharmacy data needs to be reported directly to agencies, and it can vary on a state-by-state basis. Setting this up correctly at the beginning means avoiding potential compliance and regulatory headaches down the road.

Understanding the nuances of the state-based workers’ comp system is one more area where communication and education are important on the PBM side. Different programs have different needs and varying levels of understanding of their work comp-specific goals. Ideally, implementing a PBM system should involve a concierge level of service and a consultative, educational approach with the discovery process.

3. What should you bring to the table?

Implementation is a two-way street. You have all the information on your claims management program and history, while the PBM brings specific knowledge on their systems and workers’ comp pharmacy. Preparation on your end helps ensure a seamless transition where everyone receives communication on what will and will not change and no one experiences any hiccups in their service.

Data preparation is key to this, and you should be ready to have in-depth conversations with your new PBM on how to guarantee a clean data upload into their system. Just as important is follow-up reporting and validation with claims records to begin troubleshooting any issues — from corrupted or duplicate files to open claims you thought were closed — from the very beginning.

A smooth PBM implementation also includes internal and external outreach to anyone who is going to be affected by the changeover. Start making an action plan about who needs to be involved from within your organization and who needs to know outside. Internal stakeholders should know all of the key dates surrounding the transition and when any scheduled system trainings should be.

External stakeholders can include designated physicians, claimants, and any third-party vendors. Claimants should be fully informed on any pertinent information, including the changeover date and when to expect a new pharmacy benefits card, well ahead of going live.

4. What should the PBM bring to the table?

While you have the contacts and knowledge of how your organization is structured and functions, you still need the PBM to be an active partner in this process. Once you sign on the dotted line, PBMs should prioritize making good and efficient use of their client’s time. This means a detailed plan and timeline from the outset with all of the steps that both parties should expect to see.

Look for the following qualities in a workers’ compensation PBM if you want to be sure they can deliver on their implementations promise:

  • Years of experience: How many successful implementations have they led?
  • Project Management Professional (PMP) certification: Is becoming the industry standard. Is one or more members of the implementation team PMP certified?
  • Patient and pharmacy outreach: Is there a communication plan for updating pharmacy information and training claims professionals?
  • Flexibility: Do they know how to work with your specific needs and adapt to surprises and curveballs that come up?

While no project is ever perfect, there’s no reason not to expect implementation to be a turnkey experience as a client, and the right workers’ comp PBM can do this. As someone who has been leading implementations projects here for more than a decade, I can confidently say that myMatrixx has the resources, experience, and a deep understanding of how to build a collaborative strategy.

Reach out to our team to learn more about PBM implementation in workers’ compensation. We’ll help your planning process with a timeline that emphasizes the major milestones and when you should expect to reach them.