PBM Report Calls for Larger Focus on Behavioral Health Care for Injured Workers

Nancy Grover

Sarasota, FL (WorkersCompensation.com) – “While the conventional wisdom has been for workers’ comp payers to avoid paying for psychiatric drugs because of the associated long-term escalation in the cost of the claim, there is reason to believe this is no longer the most practical course of action,” wrote Phil Walls, chief Clinical Officer for myMatrixx. “Mounting evidence for a bidirectional relationship between chronic pain and mental health is demonstrating that behavioral health solutions can help long-term cases achieve positive outcomes.”

The comments represent a significant change in the management of workers’ compensation claims, which typically have shied away from addressing an injured worker’s mental health or emotional conditions. Writing in the pharmacy benefit manager’s latest Drug Trend Report, Walls said there is a “unique opportunity for long-term cases” with targeted interventions. “In fact, early intervention guided by our identification of suitable candidates can dramatically impact both drug spend and claim duration.”

The annual report analyzes the major drivers of workers’ compensation retail pharmacy spend among myMatrixx’ payers. The 2020 report was especially noteworthy, given the impact of COVID-19. Overall, drug utilization decreased 4.9 percent while cost per days’ supply decreased by 2.6 percent. But some of the statistics are not quite what they appear, due to the pandemic’s effect. The authors focused specifically on three major trends.

The COVID Impact

Older workers’ compensation claims typically generate higher medication use and, therefore, higher costs than newer claims. One of the anomalies of the pandemic was a reduction in new workers’ compensation claims, due to high unemployment and/or more people working from home. The effect was a skewing of the numbers.

“…the reduction in new claims for 2020 caused older claims to distort the average overall Rx utilization, leading to a statistical increase of 12.2% at the individual injured patient level,” the report says. “myMatrixx has labeled this the ‘COVID distortion effect.’ In other words, while there was no major change in Rx utilization behavior at the patient level, the decrease in new claims makes it appear that there was.”

New claims dropped by 19.3 percent. While the percentage of injured workers with new claims was 35.3 2019, it was just 28.5 percent in 2020, raising the percentage of claims that were at least one year old. The average pharmaceutical spend on a new workers’ compensation claim is $214.96, while that number increases to $2,758 for claims more than 10 years old.

Treating injured workers with COVID-19 symptoms was not an overall cost driver, according to the report. Retail prescription spending was less than 0.2 percent of total spend. But there was a slight increase in spending on some medications. “Most notably, hydroxychloroquine use went up drastically when it was believed to be effective for treating COVID-19,” the report says. “After further studies showed it was not effective for prevention or treatment, its Emergency Use Authorization was withdrawn and Rx utilization began to decline.”

The issue of COVID-19 vaccines was also addressed in the report. Many workers’ compensation stakeholders have asked how these will be handled by PBMs going forward.

“Presently, the cost of vaccines is being absorbed by the federal government under Emergency Use Authorizations (EUAs),” the authors wrote. “As more vaccines are approved through regular U.S. Food and Drug Administration (FDA) channels and brought to market like other vaccines, we expect that they will be covered under private insurance as preventive care.”


“As we looked at our own data from the previous year, myMatrixx found that opioid spending declined by 1.2% in workers’ compensation cases, pointing to a decrease in Rx utilization,” according to the report. “…the rate of decline is lower than previous years, and our clinical team is investigating potential causes for this trend, particularly regarding the COVID distortion effect as referenced.”

Paying for opioids decreased by more than 15 percent in 2020, which outpaced the decline in overall drug utilization, which was 11.4 percent. However, spending on opioids increased by 0.2 percent, from $219.04 to $219.48 per injured worker from 2019 to 2020.

Behavioral Health Care

The effects of the pandemic — being isolated at home or forced to work in potentially hazardous conditions — increased the incidents of anxiety, sleep disturbance es and depression. myMatrixx saw an increased Rx utilization trend for many medications that address these conditions, despite cost reductions for them. The report looked at the psychotropic medications prescribed in terms of Rx utilization trend per injured worker and days supply cost trend.

Therapy Class Rx Utilization Trend Days supply cost trend

Antidepressants 16% increase -7% decline

Antipsychotic 16.6% increase -2.9% decline

Hypnotics 3.4% increase -1.7% decline

Stimulants 9.2% increase -6.1% decline

Anti-anxiety agents 4.8% increase -10.4% decline

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