About Robert Shelley
Rob Shelley is the founding partner of Leaf Health.
He has been working as an executive in the Pharmaceutical, Pharmacy Benefits Management, and Pharmacy Benefit Consulting sector for more than 30 years. Rob’s passion is to advocate and help improve the overall competitive position of Leaf’s clients without sacrificing care, or access to services of members.
His expertise includes a broad understanding of the entire health care landscape with a specialization in the pharmaceutical benefit industry. Rob’s area of knowledge includes drug manufacturer formulary rebate administration, recent specialty drug costs and utilization trends, PBM evaluation and audit. He also specializes in the areas of PBM pricing, regulatory and health plan Medicare Part D compliance.
Rob’s past accomplishments include successful management of billion-dollar PBM procurements and audits for leading employers, carriers, TPAs and government entities. Rob was also invited to the White House on two separate occasions to discuss pending ACA legislation.
Prior to creating Leaf Health, Rob specialized in drug manufacturer rebate programs at Gateway Health Partners. Previously, he was Sales Vice President for Optum Rx and corporate-wide Sales Vice President at Catamaran.
About Leaf Health
Leaf Health is a benefit consulting firm focused on solving prescription drug coverage challenges due to ever increasing pharmaceutical expenses.
Leaf Health’s goal is to introduce innovative and creative strategies that allow our clients to preserve the economics of their pharmacy benefit offering with no sacrifice to patient care and outcomes.
Leaf’s approach is a focused, high-touch, tailored model that aligns with our clients’ business.
Our leverage is derived by our experience, creativity and tenacity. Our services center around:
· Innovative coverage strategies
· Aligning payers with the right PBM partner
· Building management of infusion medications
· Where applicable, supporting the growth of our customers
· Ongoing financial and clinical oversight and course correction
Medical Travel & Digital Health News (MTDH): Tell us about your role as the founder of Leaf Health.
Robert Shelley (RS): I started Leaf Health about three years ago after running sales for one of the big three PBM’s.
Now I have over 20 years of consulting experience and have consulted on every type of customer base — from third-party administrators (TPAs) and small mid-market employers to Ford motor company, the federal employee program and some of the largest insurance companies in the country.
We’ve helped to service the middle market – the midsize employers and TPAs serving this sector — because I found that market to be more dynamic, a little more creative and willing to take on new ideas to tackle very real issues with pharmaceutical and prescription drug pricing.
MTDH: Given your level of interest in these issues, are you familiar with medical travel pharmacy?
RS: Yes. We recently toured Health City in the Grand Cayman.
We look at all avenues to try and gather information on opportunities for cost relief on specialty medications. And through that, we’re getting educated on the industry.
MTDH: Do you see it primarily for infusion therapies or other?
RS: No, actually I see it for self-injectable therapies.
There’s a difference between infusion and self-injectables. What we’re seeing is the self-injectables like Humira and Enbrel, the traditional specialty medications you’d see run through a PBM.
We see fantastic cost savings when you go through those channels.
But as far as infusion drugs, what we are noting is that access to those scary high-cost infusion drugs is not universally available to some of these facilities. Those have yet to make it into those markets.
MTDH: What do you envision for bringing down the cost of specialty pharmaceuticals?
RS: There is a significant amount of pressure from a price point perspective on the pharmaceutical companies when they are releasing these drugs. We’re running into a pricing issue here in the United States and there’s the movement by CMS to price index Medicare Part B drugs on an international scale.
On the regulatory side, there is some pressure for pharma to start doing some things differently.
As a result, we’re starting to see the advent of some cost relief through the development of drug manufacturer rebates and the understanding that any future pricing could come up against some forms of international pricing indexes.
We have not seen final guidance from CMS or any real meaningful adjustments on those price points.
The biosimilars are starting to come about on the infusion side. We are seeing some nice movement, but we haven’t seen them on the self-injectable side yet. These are the drugs that we’re talking about in terms of medical tourism.
We’re also seeing a lot of drug benefit carve-out programs where companies are literally carving specialty drugs out of the benefit and no longer covering them.
Employees that are impacted by these decisions are now being voluntarily placed into a program through intermediaries that approach the drug manufacturers through their charitable foundations to see if the drug companies will pay 100% of drug costs.
If there’s an income-based test that allows for this in the mid-market, they’re qualifying these people to get their drugs for free.
MTDH: That’s good to hear.
RS: That is a new market phenomenon and it is picking up.
These are very small companies with less than 20 employees, and they are sprouting up all over the place. What they charge an employer is a percentage of savings or a fixed fee.
These help centers might charge $60 a month in exchange for submitting your paperwork to all the pharmaceutical companies to try and get them to give you compassionate, financial relief through their charitable trust.
Where I see medical travel fitting into all of this is where you have higher compensated employees; but employers are still burdened by the cost of these medications and unwilling to carve out a benefit.
I see that medical travel opens an avenue for these individuals, especially if they can work that treatment protocol into as a few days as possible.
MTDH: How do you see the COVID-19 “new normal” business environment?
RS: I think it’s going to be post-vaccine before we can feel comfortable again. A vaccine or a good understanding of how this disease is fundamentally being transmitted and testing for antibodies will be necessary.
MTDH: Talk about this upcoming webinar series “From Evolution to Revolution: How the Rise of Specialty Pharmacy Drove a New PBM Model” that you are co-sponsoring with AscellaHealth.
RS: We’re working very closely with AscellaHealth on how people can work to procure specialty drugs and how plan sponsors can work to more fundamentally procure these drugs at a more intelligent price point.
We’re also looking to bring in pharmacy benefits-style management on drugs that are not traditionally processed through the pharmacy benefit.
For instance, drugs where a PBM would never process the claim. These individuals are walking into hospitals and they are getting infused medications that could not be delivered to them at their home because they don’t have the training, equipment or experience. This is very different than Humira, which is self-injectable.
AscellaHealth and Leaf are pointing out that there are many opportunities to bring in better management of these types of medications.
It comes in three forms:
One is plan rules that need to be incorporated into an employer’s summary plan documents that describe their benefit plan to instruct people on infusion medication. They need to call and make sure it’s approved.
AscellaHealth can also apply clinical rules to ensure that there aren’t potential opportunities to explore alternative therapies like a biosimilar drug or avoiding waste by looking closely at the dosing regimen. This can save $60,000-70,000 a year on a certain therapy.
We also look at procuring drugs through a different source, such as an AscellaHealth type of network of specialty pharmacies that are very individualized towards therapeutic diseases. If you happen to have hemophilia, you might be able to get that drug at half price through one of their networks. That could potentially save upwards of half a million dollars a year. The webinar series will discuss each pathway in greater detail.
The final webinar of the series airs Thursday, November 12 at 1 pm ET. Register for the webinar here. In the final episode, moderator Michael Baldzicki and industry experts come together to discuss current disruptors such as patient-centered interrogation of treatment adjustments, promotion of biosimilar adoption and active communication throughout the Specialty Rx chain.
Watch the first two episodes covering specialty market trends and the evolution of the PBM business model here.