Three-pronged approach leads to industry low for cost of opioids
MyMatrixx officials say that identifying and focusing on potentially at-risk claimants immediately in the claims process benefits both the injured worker and the payer.
"It's a philosophy," said Matt Schreiber, vice president of marketing. As the industry started focusing on the cost of settlement, specific to the Medicare set-aside, myMatrixx focused on the reasons for the high prescription costs. "We said 'we need a program that looks at the claim well ahead of the increased utilization before the claim becomes an issue.'"
The result is a three-pronged approach:
- Alert, Review, Manage.
- myRisk Predictor.
- Drug Regimen Review.
Alert, Review, Manage.
The alert phase identifies and intercepts potentially problematic claimants. "We as an organization have been very successful in using data and technology to quickly identify opportunities and get involved by alerting claims handlers and physicians instead of just processing transactions for a discount and later coupling it up against clinical rules," Schreiber said.
Clients' data is driven through algorithms that look for specific triggers that alert an adjuster and the joint clinical team, allowing claims handlers and others to communicate with one another and move to the next phase.
In the review phase, myMatrixx clinical staff conducts a thorough investigation. "We go through a review process to make sure the medications and the frequency of these medications are appropriate," said Phil Walls, chief clinical and compliance officer. "We also make sure the claimant isn't exhibiting other red flags for potential abuse or fraud such as physician or pharmacy shopping."
The manage part involves communicating with physicians and working with the claimant to wean him off opioids and possibly onto an alternative, non-addictive medication.
"It has helped contribute to our sub 30 percent total cost of opioids so far in 2012. We're very proud of that," Schreiber said. "The industry as a whole is running anywhere from 34 to 37 percent. MyMatrixx recognizes there are so many variables that can cause an increase in opioid use, especially those claims that are significantly older, but it's our philosophy and client participation that helps us achieve these strong results."
Schreiber said a key is that the program runs in real time, enabling the identification of problems instantly. He explained that the platform and technology can drive instant alerts in many directions, similar to group health.
Someone with a nonoccupational back injury could go to a physician who might prescribe an opioid. When he attempts to fill the medication, it is identified as a drug requiring step therapy at the pharmacy and the patient is most likely given a non-opioid painkiller that is consistent with pain therapy guidelines.
"It happens in real time. The pharmacist is alerted and calls the doctor and the doctor switches [the medication]," Schreiber said. "In workers' comp ...the doctor writes a script and it is blocked at the pharmacy, but the pharmacist doesn't call the physician."
Instead, the pharmacy contacts the PBM, which is in contact with the claims adjuster. "More times than not, the adjuster says OK and approves the medication," Schreiber said. "This is not ideal."
Schreiber said technology alerts the adjuster and myMatrixx.
"It is imperative to get involved in such cases immediately, as it is much harder to get the injured worker off opioids once they start," said Walls.
The company has systems that identify prescribing anomalies immediately, as well as programs that run in the background that contact the physician to reduce the amount of opioids the physician prescribes, Schreiber explained. "So in communicating with that physician, we may be able to get the doctor to prescribe an alternative. MyMatrixx also uses the technology to score-card the physician. This becomes a valuable tool in negotiating change."
MyMatrixx uses predictive modeling to categorize claimants into various risk stratifications. Those with higher scores are deemed at risk for abuse or misuse of prescription medications -- opioids as well as non-narcotics.
Since perception of risk can vary between populations, "the modeling tool can be customized based on numerous factors and data points," Schreiber said. "We look at different patterns: the age of the claimant, the age of the claim, the claimant's sex, morphine equivalent dose, diagnosis codes, and pull it all together to identify risk."
Drug Regimen Review. The result of myRisk Predictor is a detailed report that goes to clients and possibly the physician. In cases that need to be pursued, a detailed Drug Regimen Review is created. "The DRR makes recommendations that have traditionally identified appropriate medication alternatives, resulting in significant savings both short term and long term," Schreiber said. "There are usually several avenues physicians can take during a course of treatment. We see our role as an educator with the physician in this process through peer-to-peer and pharmacist-to-physician dialogue. In the end, the patient receives the best care possible with all of the parties involved."
Read more at the WorkersComp Forum homepage.
July 9, 2012
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