myMatrixx: Managing Pain - Health Executive - Red Coat Publishing - Inside Healthcare

Florida-based pharmacy benefits management organization myMatrixx has raised the bar on what to expect in the PBM industry. In addition to processing and adjudicating prescription claims from retail pharmacies and managing plan edits for payors and insurance companies, this seven-year-old company also focuses on pain management.

Phil Walls, COO and senior VP of operations

“Many companies process pain medications the same way they do all medications,” said Phil Walls, COO and senior vice president of operations. “We address the unique needs and clinical concerns of and with these patients and the payors involved.”

Because myMatrixx focuses on pain management, a significant number of its payor claims are workers’ compensation-based, including insurance carriers, self-insured funds, and state funds. Although the number one need of these patients is pain management, the other, said Walls, is improving their quality of life through a return to a productive life.

“In the past, we’ve seen these cases linger for a long period of time. The type of therapy the patients received was not always appropriate for long-term care, and the end result was not what either the patient or the payor desired,” he said.

Steven MacDonald, myMatrixx founder and CEO, developed the company in 2001 after a long tenure in the workers’ compensation marketplace and a desire to focus on managing pain. From its inception, myMatrixx has aligned itself with partners that are recognized leaders in their respective fields, such as the University of Utah’s Pharmacoeconomic Outcomes Research Center, the Rehabilitative Institute of Chicago, and Florida-based Linear Solutions. As the company branches out from workers’ compensation but continues to focus on pain management, it has found that strengthening these partnerships and forming new ones are a key element in its success.

“The pain management focus lends itself to auto insurers that manage prescription benefits because there are similar injuries in many cases and similar needs in terms of the prescription medication treatment. We’re also looking beyond our initial focus to a variety of areas, one of which is Medicare Set Aside (MSA).”

Beyond the norm
Typically, MSA patients have already settled their workers’ compensation case and have transitioned from a regulated environment to one in which funds are set aside to cover their medical needs. However, those patients no longer have the guarantees they had when dealing with workers’ compensation.

“These patients quickly find that what they could obtain under workers’ compensation is significantly more expensive when they pay cash,” Walls said. “We help these patients manage their funds and obtain prescription drugs at a lower cost. Our mission is to take the complexity out of the healthcare process for all of our customers—patients, pharmacists, physicians, and payors.”

Between clinical concerns and workers’ compensation, DEA, and pharmacy regulations, patients and providers can be faced with an overly complicated process. The company helps by removing the paper from the workflow with its proprietary Web-based technology. When clients log in at myMatrixx.com, they enter a secure Web site for clients and myMatrixx employees. The portal’s transparency ensures anything myMatrixx employees do, such as making notes on a claim or processing a prescription, is visible in real time to the client. Clients can also communicate directly to myMatrixx through the same portal.

“Our clients can enter our Web site and virtually work alongside our employees,” Walls said. “When clients log in, they only see their patients’ cases. They have all the information regarding the open claim, the injury, whether or not the case has been closed, who authorized physicians, etc.”

Connecting the dots
The Web portal also includes a notes section. Any time myMatrixx employees work on a file, their system notes are open for adjusters and case managers to view. The information also comes into the company’s customer service center via e-mail and is recognized immediately. The Web portal’s transaction profile shows all prescriptions from all sources, including those that were denied, a unique aspect of myMatrixx’s prescription profile. Typically, a prescription profile shows only the medications a patient is taking.

“Our profiles show every medication patients attempted to fill, when they attempted to fill it, why it may have been denied, and if it was subsequently authorized up to that point,” Walls said. “It also shows all sources of prescriptions in one portal.”

Adjusters can see prescriptions processed through myMatrixx’s retail network, those mailed out by its mail service pharmacy, those filled in retail and submitted on paper rather than being processed online, and those dispensed by a physician’s office.

On the clinical side, myMatrixx’s Arm (alert, review, and manage) program allows all parties to evaluate the medications from a pain management perspective. Most PBMs are involved in group healthcare, so the primary cost considerations are for chronic disease states; myMatrixx focuses on pain and injury state management. MyMatrixx reviews thousands of prescriptions and then provides the physicians and pharmacists with information about the patient’s entire medical history.

“Rather than looking at off-label use, we look at whether or not the use is appropriate through the Arm program,” said Walls. “We have all of the elements the pharmacists and physicians may not have access to, can determine if the prescription is inappropriate, alert the doctor, recommend alternatives, and use this program to avoid complications for the patient.”

Beyond technology
In addition to removing the paper from the workflow, myMatrixx is further simplifying its clients’ lives by moving into specialty compounding for pain management. Roughly 2% of the company’s prescription claims are for compounds, which means the medication is not available from a commercial manufacturer and must be specially created.

As more and more of the company’s clients began expressing concern over the cost of compounded prescriptions, and more patients were unable to find pharmacies to fill the prescriptions, myMatrixx realized there was a need not being addressed in its client population.

“Our specially trained pharmacists obtain the raw ingredients, the chemicals, the bases, and whatever is needed and make a unique formula that the doctor has specified for a particular patient,” said Walls. “When our clients came to us, our first thought was that this is one more opportunity for us to take complexity out of the process. We have found that compounded medications enable us as pharmacists to provide physicians and their patients with additional treatment options that can help improve medication compliance.”

MyMatrixx partnered with PCCA (Professional Compounding Centers of America) to ensure the training and execution of its pharmacists was on track. As patients’ needs change, the compounds have become significantly more potent. As a result, quality control measures must be in place. Typically, pharmacies can’t engage in specialty compounding without the necessary equipment, policies and procedures, and quality control measures in place.

“PCCA has been a significant partner in guiding us through this whole process,” Walls said. “We are currently building a compounding center that is fully compliant with US Pharmacopeia guidelines for both sterile and non-sterile compounding in response to our growth and focus on bringing efficient solutions to our customers.”

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