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Channel Architecture and Net Price Optimization

Every reimbursement instance, routed on purpose.

Design the channel and distribution model on purpose, then route each reimbursement instance to the eligible path that keeps the most net price, within payer rules and program eligibility.

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The problem

Most channels were not designed. They accumulated.

Retail, specialty networks, out-of-network pharmacies and direct programs were added one at a time, so the same prescription can meet a very different journey, and a very different net price, depending on where it lands. Default routing leaves the difference on the table on every fill.

Net price optimization, one reimbursement instance at a timeEach reimbursement instance passes through a net price check of payer rules, program eligibility and channel. Of four paths, one is not permitted for this patient, and the eligible path that keeps the most net price is chosen. Across the book, routing each instance this way produces less Gross-to-Net erosion than leaving each on its default path. Net price keptDeductions EACH INSTANCE Net pricecheck Payer rulesProgram eligibilityChannel economics Covered, with copay supportContracted specialty pharmacyELIGIBLE AND HIGHEST NETDirect-to-patient priceCopay support on a government planNOT PERMITTED ACROSS THE BOOKGROSS-TO-NET EROSION Each instance on its default path Each instance routed for net priceLess erosion

Scroll sideways to see the whole diagram.

Illustrative. The eligible path with the most net price differs by patient, plan and program. Routing always follows payer rules and program eligibility; copay support, for example, is never applied to a government plan.
Optimize every reimbursement instance, not the average.

What we deliver

A channel built on purpose, measured per instance.

01Channel mapEvery path a prescription can take, and what each one costs the patient and the brand.
02Routing rulesBy plan, channel and program eligibility, so each instance lands on its best eligible path.
03Pharmacy optionalitySpecialty and independent pharmacies evaluated for benchmarking, data transparency and economic balance.
04Net per instanceNet price per reimbursement instance, reported alongside the quarterly average.

One more thing the channel decides

The right data depends on how the product reaches the patient.

Route to patient sets the data stack and the price benchmark that governs it. Applying a retail lens to a specialty product is one of the most common, and least visible, reasons a Gross-to-Net diagnosis stalls.

Retail oral

Dispensed through the pharmacy channel.

Runs on

Pharmacy claims, including prescription and longitudinal patient data.

Priced againstAMP and Best Price

Specialty buy-and-bill

Administered and billed by the provider.

Runs on

Medical claims and site-of-care data.

Priced againstASP

A retail-trained lens sees almost none of the buy-and-bill utilization, so the leakage it cannot see never enters the diagnosis.

Where it applies

The exits it works, and when.

10 Exits of Therapy™

01Diagnosis
02Provider Access
03Prescription Creation
04Enrollment
05Coverage
06Authorization
07Affordability
08Fulfillment
09Patient Engagement
10Therapy Initiation

Product Lifecycle Phases

Phase 1 · Pre-Launch and Launch ReadinessPhase 2 · Launch and Early CommercializationPhase 3 · In-Market OptimizationPhase 4 · Lifecycle and Loss of Exclusivity

From the work

Where this came from.

Advisory engagement

Lifecycle Profitability, Channel Redesign and Loss-of-Exclusivity Strategy

An established brand redesigning its channel and preparing the market before exclusivity loss.

Read the use case →Key concept

The Pharmacy of the Future Will Not Compete on Dispensing. It Will Compete on Value.

A pharmacy built on dispensing volume is easy to exploit and hard to defend.

Read on patrickrcoyle.com →