Managing a patient’s workers’ comp and group health needs safely and effectively
While both are designed to support patient health, they were built for different purposes. Workers’ compensation focuses on injuries and illnesses arising from employment, with employers assuming responsibility for medical treatment, wage replacement, and return-to-work support. On the other hand, group health addresses an individual’s broader healthcare needs and preventative health measures and is funded through employer and employee contributions.
Because these systems operate under different regulations, reimbursement structures, care management models, and stakeholder networks, they often function independently of one another. The result is a fragmented healthcare experience for the very people both systems are intended to serve.
One Patient. Multiple Providers. Greater Risk.
For individuals navigating both workers’ compensation and group health, care is often delivered through separate physicians, pharmacies, and benefit managers. What seems like a minor administrative distinction can create significant clinical and financial challenges.
Through our parent company, Evernorth Health Services, we have been able to analyze prescription activity to identify group health members who also had an active workers’ compensation claim. Of the group health members evaluated, about 10-12% were simultaneously receiving workers’ compensation benefits and over 60% of those received medications from the same therapeutic class between their injury-related and group health related conditions. Of the common therapeutic classes, 40% of the medications were non-steroidal anti-inflammatory drugs (NSAIDs) and 3% were opioids. We also found that:
- 99% of the patients used different physicians for their workers’ compensation and group health treatments and patients averaged 7-10 prescribers as part of their care.
- 95% of the patients filled their corresponding prescriptions through different pharmacies and patients used an average of three pharmacies.
- The inconsistency in providers, information sharing and pharmacies was also associated with duplicate drug therapies for muscle relaxants, antidepressants, and anti-anxiety medications.
- High-cost medications that were denied under group health were often approved and dispensed through workers’ compensation.
These findings suggest that healthcare decisions may be made without a complete understanding of the patient’s full medication profile or overall health status. When workers’ compensation and group health operate in separate silos, the separation may contribute to fragmented care, delayed recovery, and unnecessary costs. Plus, multiple providers and multiple pharmacies may increase the risk of duplication of therapy, drug-drug interactions, patient confusion, and lack of treatment adherence.
Those consequences and risks should be a red flag to employers and payors who are contracting with separate group health and workers’ compensation PBMs, which may contribute to additional medication utilization and costs and may create patient-safety concerns.
Connecting the Healthcare Journey
At its core, continuity of care is about ensuring that healthcare professionals have a more complete view of the patient, regardless of which benefit system is paying for treatment.
In its most effective form, continuity of care allows workers’ compensation and group health stakeholders to share relevant information, identify potential risks, and coordinate interventions that support both injury recovery and overall health. Rather than operating as isolated islands of information, the two systems become connected parts of a broader healthcare ecosystem.
When that connection exists, patients can benefit from safer and more coordinated treatment. Providers can make more informed clinical decisions. Employers and payors gain greater visibility into risks and opportunities for intervention. Most importantly, recovery becomes more efficient, effective, and patient-centered.
Bridging the Divide
At MyMatrixx by Evernorth, we believe the future of workers’ compensation lies in treating the whole person, not just the injury.
We are advancing continuity of care in two important ways.
1. Expanding Our Focus Beyond the Injury
Every injured worker brings a unique health profile that extends beyond the workplace injury itself. Chronic conditions, behavioral health concerns, existing medications, and social factors can all influence treatment decisions, recovery outcomes, and claim costs.
In addition, expanding presumptive coverage laws across many states may increase the number of workers’ compensation claims involving conditions such as cancer, chronic obstructive pulmonary disease (COPD), PTSD, anxiety, and other complex health challenges. These conditions can significantly affect medication therapy, clinical outcomes, and overall wellbeing.
For example, following an injury or surgery, individuals with diabetes often benefit from enhanced education and care coordination to maintain glycemic control, reduce the risk of complications, and support optimal healing. Coordinated communication among treating providers can help ensure the injured worker understands the critical role that managing their diabetes plays in achieving the best possible recovery from their work-related injury.
By taking a whole-person approach, MyMatrixx is developing solutions that help address the interconnected factors influencing recovery, which support safer, more coordinated care.
2. Creating Greater Alignment Across Healthcare Benefits
As part of Evernorth, MyMatrixx has a unique opportunity to collaborate and leverage shared expertise across workers’ compensation and group health.
We are exploring opportunities to better identify and support employers and health plans seeking integrated approaches to care delivery. By aligning insights, clinical expertise, and pharmacy strategies across healthcare benefits, we can help improve patient outcomes while uncovering new efficiencies and cost-saving opportunities.
With continuity of care, MyMatrixx clinical pharmacists are better equipped to identify potential drug interactions, therapeutic duplications, or other medication-related concerns across workers’ compensation and group health benefits and then facilitate communication between prescribers. This coordination can benefit the safety and health of the patient and creates a path for employers and payors to manage prescription utilization and costs of claims.
The MyMatrixx Difference
For more than two decades, MyMatrixx’s success has been built on deep clinical expertise, advanced analytics, and a commitment to protecting injured workers through safe, effective pharmacy management.
Continuity of care represents the next evolution of that commitment.
By connecting injury-related care with a broader view of overall health, we can help ensure medications are appropriate, accessible, affordable, and clinically aligned across the healthcare journey. This approach can support smarter interventions, better-informed decisions, improved patient safety, and ultimately better outcomes for everyone involved.
Healthcare works best when the full picture is visible. Continuity of care helps bring that picture into focus.
For more information about MyMatrixx and our workers’ compensation pharmacy benefit solutions, contact sales@mymatrixx.com.
Partner Post:
This is a sponsored post from WorkCompWire marketing partner MyMatrixx by Evernorth.