During our time at RIMS 2015, we had Workers’ Comp industry stakeholders participate in WorkCompWire’s “RIMS Review” series, focused on what to look for this year and in the future! Here’s what Cliff Belliveau & Phil Walls of myMatrixx had to say:
What do you believe will be the most significant development in the Worker’s Comp industry in 2015?
Treatment for drug addiction. Opioid use – and expense – has been the number one drug category for many payers for years. Recognizing the risks associated with this category of drugs is associated with a corresponding liability for the physician that prescribed the drug, the pharmacist that dispensed the drug, the nurse case manager that managed the claim, and the insurer that, in a way, funded the addiction.
The FDA has recognized this risk, and as a result, developed their Risk Evaluation and Mitigation Strategy (REMS), which has led to the development of abuse-deterrent formulations of long-acting opioids. This program has proven mostly effective, however, it has also produced the unintended consequence of an increase in the use of heroin. Heroin is cheaper and easier to obtain than prescription drugs, and although that is producing favorable trends, if one only examines the use of prescription opioids, those trends are misleading— indicating a “win” in the battle against drug addiction and its corresponding liability.
As a result, treatment for drug addiction must be paramount among payers. Whether that means covering new maintenance treatments for opioid addiction such as the Zubsolv® (buprenorphine/naloxone) sublingual tablet, or authorization for new overdose recovery agents like the Evzio® (naloxone) auto-injector. The addiction exhibited by these patients turned addicts must be addressed before they turn to street heroin.
What is the top challenge you and your organization are currently working on this year?
Providing real-time and on-demand information in the hands of adjusters and nurses responsible for making authorization decisions. Along with the provision of this information comes a corresponding need for education so that the decision makers recognize the red flags indicating that a claim is becoming high risk. One of the best avenues for provision of this education is through continuing education classes that are relevant to these needs.
Delivering actionable information to adjusters and nurses is a key Business Intelligence initiative. Whether real-time, right-time, or on-demand, a properly designed descriptive analytics solution will reveal valuable data points embedded in the utilization history of an injured worker. Mining drug history data and other patient-specific factors are the keys to enabling a more decision-informed process. As a result, actionable information can easily be provided to adjusters in the form of dashboards, reports, and electronic alerts.
Looking out 5 years, beyond obvious trends, what do you think one big change in the Workers’ Comp industry will be?
Adoption of group healthcare/Medicaid-like clinical pharmacy programs that are not misconstrued as denial of care. These programs include clinically-sound, evidence-based programs such as step-therapy, formulary design, dose limits, length of therapy limits, etc.
Clinical programs will benefit from the evolution of Business Intelligence and Business Analytics practices. To successfully support clinical initiatives, organizations must evolve beyond simple reporting or describing data. This is commonly referred to as descriptive analytics. Organizations will continue to mature to offer the ability to predict drug usage patterns. Enabling this is predictive analytics. The application of predictive analytics in this domain will be carried out through the use of data mining, statistical models, and an ever growing base of rich data.
What is one thing you’d like to promote?
A key initiative at myMatrixx is the development of a real-time, clinically-based smart prior authorization program. This automated PA program will provide necessary information to the decision maker when it is needed most, and will include data points such as morphine equivalent dose (MED), chronicity, guideline restrictions and contraindications at a point in time before the authorization is made.
At myMatrixx, our Business Intelligence and Analytics practice continues to grow. We have several key initiatives underway that will change the way our clients consume information while enhancing their ability to support decisions. While we continue to provide valuable operational, financial, and clinical metrics to our clients, we will also be driving toward solutions in the areas of predictive and prescriptive analytics.
Disclosure:
myMatrixx is a WorkCompWire Ad Partner.
This is not a paid placement.