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Profitability lever 2 of 3
Follow the Conditions.
Coverage alone does not determine access.
Formulary position, utilization management, prior authorization, step edits, affordability, channel and contracting decide whether theoretical access becomes actual therapy.
Services
Three ways we set the conditions.
Payer and Formulary Strategy
Buy the access that pays for itself.
Explore the service →Net price optimizationChannel Architecture and Net Price Optimization
Every reimbursement instance, routed on purpose.
Explore the service →GPO contractingGPO Contract Management and Validation
Every GPO agreement is a promise Finance has to keep, and report on.
Explore the service →The distinction that matters
Your approval rate is not your access rate. It describes the prescriptions that survived long enough to be measured.
Approval counts the prescriptions that made it through. It says nothing about the ones that stopped at authorization, were abandoned at the counter, or never started because the path looked too hard.
5 Layers of GTN™
Access sets the conditions. Finance carries the result.
The 5 Layers are sequential and causal. Each flows into the next, which is why an access decision made in Phase 1 is still showing up in Gross-to-Net in Phase 3.
Growth strategy
Access at all costs buys availability, not profitability.
Over or under, the result is the same: uptake and market penetration fall short. The work is finding the band in between.
Under-investment
Over-investment
Forecast the revenue deductions first. Then judge performance on what the product actually nets.
Illustrative use case
Volume grew. Net price did not.
A brand in its second year added patients every quarter while Gross-to-Net eroded faster than volume grew. Every contract had been signed on purpose. Nobody had looked at what each reimbursement instance actually cost.
What was happening underneath
Support drained
Copay support was absorbed by accumulator plans without extending days on therapy.
Invoices unvalidated
Commercial GPO invoices and chargebacks were paid without line-level checks against the contract.
Default routing
Prescriptions settled into whichever eligible channel they reached first, not the one that kept the most net.
How Novus Proximus answers it
Advisory that turns the problem into a plan with owners.
- 01Map every pathEvery way the brand can be reimbursed, and exactly what each path deducts.
- 02Validate before payingGPO invoices and chargebacks checked against the contract record and member eligibility.
- 03Set routing rulesBy plan, channel and program eligibility, so each instance lands on its best eligible path.
- 04Measure per instanceNet price per reimbursement instance, reported alongside the quarterly average.
Key concepts
Rethinking Copay Accumulators: Focus on Days-on-Therapy Over Dollars Spent
The true cost of copay accumulators extends beyond immediate financial metrics.
Read on patrickrcoyle.com →From the writingStructure Instead of Spend
A competitive entry turned a category with room in it into a red ocean. The question was whether to answer with money, or with structure.
Read on patrickrcoyle.com →An illustrative composite, not a specific client.
The problem
Most commercialization models were not designed. They evolved. Vendors, programs and channel arrangements were added one at a time until the whole became complexity no one can fully map, and the access assumptions underneath were set before any of it was tested.
What we do
We pressure-test access assumptions against how the category has actually behaved, then design the channel and distribution model on purpose, including Life Sciences Channel Redesign™, so new capabilities are added by design rather than by reaction.
Focus areas
- Payer and formulary assumptions tested against category precedent
- Net price optimization for every reimbursement instance
- Utilization management, prior authorization and step edits
- Channel and distribution architecture
- GPO and payer contract management, validation and member reporting
- Patient-support program integration
Where this shows up first
Access decisions become financial outcomes.
What is agreed at the formulary table is paid for later in rebates, copay support and channel fees.