Prodigy Rx Tackles Transparency in Workers’ Comp Pharmacy

Prodigy Rx wants to change the conversation that payers have with their PBMs in the workers’ compensation space. Payers in this market have complained about pharmacy benefit managers’ pricing methodologies, as well as their lack of transparency and useful reports, said Del Doherty, Pharm.D., co-founder of Prodigy Rx.

Del Doherty, Pharm.D.

“Transparency is a buzzword right now among PBMs, but when we talk about transparency, we mean information,” he said recently in an interview with Formulary Watch. “We want to provide payers any and all information about their pharmacy program. And we will begin by telling payers exactly how we make money.”

Prodigy Rx was founded in 2020 to delivery pharmacy benefits in workers’ comp differently from the traditional PBMs, providing solutions that are transparent and achieve better outcomes for patients. Leveraging technology and clinical solutions to integrate population health management strategies, Prodigy aims to improve patient health, control costs and manage state and federal regulations that oversee workers’ comp.

Payers in the workers’ compensation have expressed concern about PBM pricing transparency, according to a survey last year conducted by CompPharma, a research and consulting firm focused on pharmacy management in workers’ compensation. CompPharma surveyed decision makers, clinical personnel, and operations staff from a broad spectrum of workers’ compensation insurance carriers, third-party administrators, self-insured employers, and state funds about their pharmacy benefit plans.

Pricing and transparency topped the lists of survey respondents about what they want from their PBMs. When asked about problems in workers’ compensation pharmacy, one quarter of respondents in the CompPharma survey mentioned pricing and/or transparency; others mentioned physician dispensing and mail-order pharmacies, while a few complained about PMS’ lack of innovation, declining service, and the lack of differentiation among PBMs.

The consulting company said anecdotal information from payers indicates drug costs account for 8% to 11% of total medical spend in workers’ compensation. Total workers’ comp drug spend was about $3 billion in 2020, according to CompPharma. Pharmacy is a component of workers’ compensation medical expense, which the consulting company estimates to be about $30 billion in 2020.

Analysts at CompPharma said anecdotal information indicates that medical spend in 2020 declined to the fewer injuries, medical visits, and surgeries. The survey results indicate that workers’ compensation prescription drug costs have decreased by about $1.8 billion or 38% over the last decade.

Most PBMs when asked for data sanitize that data, Doherty said. “We at Prodigy tell payers how much money we make on their on their program so that they understand what our incentives are and what disincentives may exist. We have set up our reporting so that our clients can literally see in real time how their pharmacy program is performing. we expect that our customers and our peer clients will hold us accountable.”

Prodigy Rx’s databases are configured to conduct advanced financial modeling and predictive modeling so payers can better understand their pharmacy programs, improve patient outcomes, and pay the lowest net cost. “To us, transparency means presenting clients with simplified and clear drug pricing and complete, unfiltered access to data and information,” he said.

Pass-through pricing, utilization management, and a suite of evidence-based clinical tools are among its offerings. Developed and delivered by a team of PharmDs and other clinicians, Prodigy Rx’s services include medication therapy management, drug utilization review, compound and specialty drug utilization controls, pharmacogenomic drug oversight, and an opioid management program.

“This is not just about contracts and networks. Our reason for existing is to help patients get healthy so that they can live productive lives. And if patients get healthy, we know that we can save we can save payers’ money.”