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Getting Ahead of the Claim is not only the company's primary strategy of managing prescription drug and ancillary medical benefits for its customers, it's also a key component in the overall clinical experience.

"For us, getting ahead of the claim ensures our entire team works in partnership with clients, pharmacists, physicians and any other entity to focus on a claim from the onset," says Steven MacDonald, chairman and CEO at myMatrixx. "Of course, it's critical that we provide the necessary level of clinical oversight and advice to ensure appropriate protocols from the day we begin to manage a claim, not when an injured patient approaches eligibility for a medicare set-aside allocation (MSA) settlement.

"To be blunt, we provide comprehensive clinical oversight ... all the time," MacDonald says. "It's something that's in the company's DNA--We simply follow our Core Values."

In brief, that involves doing what's right in reviewing every transaction including electronic retail and mail service prescriptions, paper bills, rejections and other transactions against an injured worker's history--the full claim. myMatrixx follows that path regardless of the injured worker's age or the age of a claim.

"It allows for early, immediate intervention with the treating physician(s) by our clinical pharmacists at a point in time where we can significantly decrease the rate of drug spend, regardless of the opportunity for a potential settlement," explains Phil Walls, chief clinical and compliance officer at myMatrixx. "We focus on drug mix, lower cost alternatives, and appropriateness."

The result is myMatrixx clients save on their injured worker's drug spend from the time a claim is active, compared to receiving expert clinical advice at the end of a claim's lifecycle, when it's too late. And this is true of all drugs--not just the opioids. With an industry leading generic substitution rate of 80.2 percent, myMatrixx delivers 19.2 percent lower cost per script and 0.97 fewer prescriptions per claim per year when compared to industry and competitor benchmarks.

Naturally, a huge part of getting ahead of the claim means constantly updating and upgrading to stay current with the latest changes and trends. myMatrixx recently did just that by adding significant enhancements to its already successful Opioid Management Program (OMP), which offers key stakeholders--clients, injured patients and physicians - added tools for dealing with the increased use of opioids in workers' compensation health care, a potentially destructive path for payer and patient if not properly managed.

Walls explains that while opioid therapy represents a significant and necessary component of pain management, it's also no secret that opioids and other controlled substances represent an area with significant potential for fraud and abuse.

For example, there were recent arrests and seizures in cases of Florida "pill mills," where doctors allegedly dispensed more than 660,000 dosage units of Oxycodone. One Drug Enforcement Administration (DEA) administrator, in fact, said that "Prescription drug abuse is our country's fastest growing drug problem." The problem is so severe that Florida law enforcement is proposing that fingerprints be required of people filling schedule II prescriptions at pharmacies.

In addition, recent studies show a 423 percent increase in expenditures for opioids used for back pain without demonstrated improvement in patient outcomes or disability rates. And, a 2008 study by the California Worker's Compensation Institute involving166,366 injured workers with medical back conditions without spinal cord involvement uncovered that 854,244 opioid prescriptions were dispensed, with an average of 5.2 prescriptions per claim.

Other dangers from unmanaged opioid use include a higher rate of inpatient hospitalizations; a higher possible risk factor for long-term disability; and related costs associated with overuse, misuse and addiction, (the most commonly diverted controlled prescription drugs are opioid pain relievers). For instance, in 2009, an estimated 5.3 million Americans aged 12 and older reported non-medical use of prescription pain medications within the past month, a 20 percent rise over 2002 estimates. Plus, opioid abusers had significantly higher prevalence rates for a number of different health factors compared with non-abusers, including non-opioid poisoning, hepatitis (A, B or C), psychiatric illnesses and pancreatitis, which were 9-78 times higher.

Clearly, staying ahead of claims that involve opioids and the potential hidden costs can avoid potential disaster for both payer and patient, says Walls.

Improvements to the myMatrixx program, which is embedded within the company's innovative Alert, Review, and Manage (ARM) capability, focus on helping to better manage opioid therapy from the date of injury forward using evidence-based pain management guidelines. For example, Actiq, a powerful and very expensive pain medication, has been virtually eliminated from use by myMatrixx's injured patients, accounting for less than .046 percent of all medications. Overall, opioid use is down 16.2 percent vs. industry benchmarks.

myMatrixx's opioid management involves a special subset of the ARM process that trigger a review of prescribing patterns. This could include inappropriate use of powerful pain medications such as Actiq or Fentora, reliance on expensive name-brand medications, or excessive use and/or duration of use of typically accepted skeletal muscle relaxants.

"Using advanced technology and our predictive modeling database, we alert everyone in the process as soon as these medications are dispensed, beginning a system of reviewing an injured patient for any issues," Walls says.

The OMP also now offers enhanced triggers that alert appropriate stakeholders to prescribing patterns that may indicate that opioid use is not optimally managed, including

-- Premature use of opioids in opioid-naïve patients

-- Off-label use of opioids intended only for end-stage cancer pain

-- Inappropriate use of long-acting opioids at the onset of treatment

-- Use of name brand opioid medications with no valid health reason

-- Multiple opioid prescriptions or the use of multiple prescribers or pharmacies, and other proprietary clinical edits.

"The goal is always to better manage opioid usage from the onset of treatment," Walls says.

He adds that by analyzing a claim via myMatrixx's advanced technology and predictive modeling database, everyone in the process is alerted immediately and the system begins the process of reviewing an injured patient for issues.

The company's OMP is made even more robust with the development of patient-specific recommendations based on appropriateness of therapy and guidelines such as the Official Disability Guidelines (ODG). myMatrixx clinical staff can then provide physicians with detailed information for making improvements in opioid therapy, such as conversion dosages for alternative opioids with better therapeutic profiles and weaning guides, when required.

In addition, the company's Technology Plus platform and approach combines advanced technology, expert clinical support, productivity-improving processes, real-time alerts and comprehensive reporting to simplify the management of worker's compensation claims.

"The result is a reduction of costs and improved outcomes for clients and their injured workers," Walls says.

Walls adds that the center of all Drug Therapy Management at myMatrixx is the aforementioned ARM program, which is part of a comprehensive communication platform that starts with real-time data delivered right to the claims professional's desktop and progresses to letters and phone consultations to partner with the physician.

"The program's automated system of clinical oversight is highly flexible and customizable," Walls says.

To that end, ARMs may be comprised of clinical concerns, financial concerns and Fraud Waste and Abuse (FWA) concerns, or any combination of these areas. And, unlike clinical programs developed for disease management, ARM focuses on concerns unique to injury state management, including:

-- Relatedness

-- Appropriateness

-- Fiscal Responsibility

-- Excessive dose or duration of therapy

-- Targeted Interventions

-- Measurable Outcomes

Each myMatrixx ARM is tied to one or more measurable actions, is initiated after review by a staff pharmacist and is presented in a Targeted Intervention Letter to the physician. If needed, a referral to case management can be generated.

"The ARM program is designed to track and measure the impact of these targeted interventions, measuring changes in prescribing and/or spending," says Walls. "Clients can work directly with our clinical team to modify existing ARMs to develop customized alerts that target specific areas of concern to their cases."

Concludes myMatrixx CEO MacDonald, "It may sound obvious, but it's vital to get ahead of the claim. Not only does it help the patient receive the most effective health care, but it also saves clients money. Part of the process is management, but along the way, we also can also uncover hidden costs related to prescription drug use."

For more information, and to help your company get ahead of the claim in workers compensation, contact myMatrixx at (800-785-0884) or visit mymatrixx.com.

(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance® on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com/.)

April 27, 2011

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