I have written a few articles about my belief that Market Access works on hub services and getting favorable coverage, while commercialization teams are in charge of revenue, unit sales, and HCP messaging. I have worked on hundreds of projects on both sides and built my assumption based on that experience. I thought very few manufacturers did their Market Access research early enough to test how potential access scenarios would impact HCP behavior, revenue, and forecasts.

I think it is only fair to update my stance based on new information I have been hearing recently. Market Access has moved further upstream than I thought. I do not think this shift is happening everywhere, but I have now seen enough examples that I no longer think they are exceptions. When I started my newsletter a year ago, I did not think Market Access had much of a role in upstream revenue decisions. This made no sense to me if manufacturers wanted to have a successful launch. Ten years ago, there were fewer payer barriers. You could get away with working in silos, and some smaller manufacturers launched without an Access team whatsoever.

As the payer landscape has become more restrictive and nuanced, I have felt manufacturers need Market Access involved earlier. I am now starting to see that shift happen. This is also consistent with broader industry thinking that Market Access perspectives need to be incorporated earlier into clinical development and launch planning.

What I Am Seeing

Two consulting firms from other boutiques told me they incorporate Access into commercialization planning ahead of time. I also ran a poll asking how often manufacturers incorporate Access ahead of time. Half of respondents (n=14) thought manufacturers do this 20% to 50% of the time.

Last week, I met with a manufacturer brand lead who I worked with on a sales forecast eight years ago. So I know Market Access was not involved then. They now have quarterly meetings between Access and Commercial to review how Access impacts sales and their forecast. Another Access lead told me he was hired to run commercialization and forecasting. I had never seen Market Access this upstream, let alone running point guard.

Two other brand leads from large pharma companies told me that for their blockbuster drugs, Access and Commercial work closely together. However, their lower revenue brands still tend to work in silos, with Access functioning further downstream.

What This Means for Brand Leads

Market Access has moved upstream, but the shift is uneven. Larger assets may be moving faster, while smaller brands and smaller manufacturers may still treat Access primarily as a downstream function. I think Market Access will continue becoming more involved in commercialization and potentially take more responsibility for revenue decisions. There are still many manufacturers that do not incorporate Market Access as a core revenue function, and I think this will hurt launch success.

If Market Access is not working with the revenue team on future launches or helping monitor current launches, I think they need to start. Payer restrictions can influence patient access, HCP behavior, uptake, and ultimately revenue. Market Access is becoming too important to treat as something that gets figured out after the major commercial decisions have already been made.

It will also be interesting to see whether more companies give Market Access a seat at the C-suite level. If payer dynamics can materially change revenue, why does Market Access often have less representation in the rooms where major revenue decisions are made?

Who Should Own Commercialization?

I have always thought it is much harder to teach a commercialization person without a Market Access background all the access nuances and terminology than it is to teach an access person revenue, unit sales, and forecasting.

I know some smaller companies still launch products without anyone dedicated to Access and let the market take its course. I think that is a terrible idea. If I were trying to control costs and could only make one hire, I would hire an Access person and have them heavily involved in commercialization rather than hire a commercialization person and have them figure out access issues as they arise.

I think we will continue seeing more companies move access upstream as payer restrictions become more important to launch performance. The question I am interested in now is how far upstream Market Access ultimately moves and whether we eventually see more Access leaders represented at the C suite level.

How Effective Is Your Access Strategy?

I created a 1 minute Market Access Launch Assessment (average completion time so far 45 seconds) with 10 questions around Market Access and forecasting readiness. The questions focus on some of the areas where I have seen manufacturers make preventable mistakes because research or planning happened too late.

How do you know if your product is commercially viable under different reimbursement dynamics? How do you know if you should invest in Phase III without understanding how payers could respond to different clinical and pricing scenarios

No information is required to receive your score and general assessment. BUT if you provide your email, I will write a FULLY human, personalized analysis based on each answer you provide. (Two brand leads have already provided their email!)

I hate giving my email just as much as you because it usually leads to a whole bunch of promotional spam. If you have been following my newsletter, you know I do not bombard you with promotional material.

1 Minute of Your Time for 1 Hour of Mine

You are trading 1 minute of your time for 1 hour of mine. You will get 1 email. I am personally reviewing your answers one by one and writing the analysis based on my experience across 350+ projects and the mistakes I have commonly seen trip manufacturers up.

You can take the readiness assessment here: https://tally.so/r/PdJ6Z0

Brand leads can answer based on an upcoming launch or a previous one.
Consultants/data providers feel free to answer how you think the average manufacturer brand lead would.

Subscribe now

Over the last few weeks, I challenged people on LinkedIn to provide me with a novel drug that launched this year outside Germany and got access, not just regulatory approval. Three posts totaled around 8K views. Many people on LinkedIn have been posting around the theme of: launches are down in the EU, but we cannot say for sure it is due to MFN.

Interpharma said roughly 1/3 of innovative medicines did not reach patients in Switzerland. What about the other 2/3? Names? Reimbursed? Can patients get them? Everyone was posting that they are down 1/3 when I think the impact is much higher than that.

IQVIA said novel drug launches are down, but we cannot say for sure whether MFN is the cause. That implies launches are still happening. I have a hard time with this argument. IQVIA has access to far more launch data than I do. If an organization with extensive global launch data cannot show us the counterexamples, why is no one able to provide any? Some CEOs have publicly stated that they are delaying launches or would reconsider launching in certain reference countries because of MFN. Companies have also pulled drugs from reference countries. I cannot find many examples of novel drugs launching, getting reimbursed, and reaching patients in these countries.

The math that confuses me about why people are saying we can’t say for sure if MFN is having an impact. ~50 novel drugs launch in the U.S. annually based on the 3-year average. Roughly 65% reach leading European countries. Excluding Germany, there are 7 major reference countries. Very rough math:

25 drugs × 7 countries × 65% ≈ 114 potential country-level launches over 6 months.

With that many potential examples, surely someone should be able to provide a few recent examples of a novel drug that launched, was reimbursed, and reached a patient in an MFN reference country? One consultant took me up on the challenge, ran my question by her network, and could not find much. She did find Myqorzo (Cytokinetics), which received reimbursement in the Netherlands.
Its annual price:
U.S.: ~$106K/year
Germany: ~$25K/year
Netherlands: ~$25K/year (estimated, public price unknown/my guess)
➡️ U.S. is 4.3× more expensive

I found another example: BridgeBio’s ATTRUBY/BEYONTTRA. BridgeBio licensed European commercialization rights to Bayer in 2024, before the current MFN dynamics. My hypothesis is they would not have structured the deal the same way if they knew about MFN.
U.S.: ~$244K/year
Switzerland: ~$110K/year
➡️ U.S. is 2.2× more expensive

Usually people will DM or comment with the answer. The only DMs I got from consultants were essentially, keep me in the loop if you find any examples. Since posting on LinkedIn, a few other consultants reached out to me, some with senior titles at large firms. They said almost everyone is in a holding pattern. Even with Spain and secret deals to hide the price, manufacturers are scared to take the risk and launch in reference countries. I was given one example that fully launched in reference countries with “secret” pricing deals. I was told so far it has been worth it and they have not been caught yet. One of their brand leads reads this newsletter. :)

What all this means going forward
I disagree with the idea that MFN might be having an impact, but we cannot say for sure. I think it is already having a huge impact on delayed launches. I previously mentioned the incentive dynamics of MFN. The average annual wage in the U.S. is about $71K. Across the 7 major reference countries I have been looking at outside Germany, the average is about $54K. The U.S. does not “subsidize” other countries. Manufacturers charge different prices because countries have different markets, reimbursement systems, and willingness to pay. Having a rule where the price needs to be the same in reference countries and America will not necessarily make other countries meet the U.S. halfway. They have their own budgets and are not going to suddenly pay dramatically more for drugs because the U.S. changes its pricing rules. If you charge 4x more in the U.S., where a huge portion of your revenue comes from, you are not risking that U.S. price by launching in a much smaller country at a substantially lower price until it is clearer what is going to happen.

If MFN continues, I think two things happen.
1. First, fewer novel drugs launch in reference countries.
2. Second, innovation takes a hit.

Impact on Forecasts:
Forecasts factor in revenue from outside the U.S. If a drug hypothetically loses 20% of expected revenue, some borderline investments no longer look as attractive. I have built forecasts that estimate the probability a drug will be profitable. Taking 20% of expected revenue away can change the decision in closer scenarios. The smaller manufacturers who did not sign a deal on MFN are the ones most at risk. The larger companies were voluntold and shook down for a deal, but they have the cash flow to deal with it. Smaller companies with only a few drugs that depend on revenue from reference countries have much less room for error. While biased, I think it is unfair when companies committed billions of dollars in capital over a decade and then a rule was introduced that they had no way to predict when those investments were made. I previously predicted that I think MFN eventually passes over. I have heard RUMORS that the current administration could declare victory on lower prices and move away from MFN. I even saw one person brazen enough to post on LinkedIn that it would happen.

What it Means for Clinical Trials
Companies deciding whether to continue clinical trials or whether products are feasible are making these decisions with years to go. They may even start asking questions such as, do we change the molecule slightly or change dosing so we can have the same but different product in reference countries? My thought is that by the time many of these molecules come to market, MFN will be repealed or substantially changed. I said this in my last article, but eventually some novel therapy will come out and will not launch in reference countries. Patient advocates will put it in the spotlight and pressure on MFN.

If I was a Brand Lead-Things I Would Consider
There are two paths, and which one makes sense depends on your risk tolerance and how replaceable your revenue from reference countries is.
The cautious path: Do not launch in reference countries unless others do and do not get hit with the pricing rule. Let someone else test the enforcement.
The aggressive path: Be the rabbit. Launch now under current MFN dynamics using secret pricing deals where available, betting that MFN gets repealed or substantially loosened before enforcement catches up with you. Someone has to go first, and if you are willing to be that company, you get first-mover access to reference country revenue and patient reach while everyone else sits in a holding pattern. The risk is if MFN stays and gets enforced. You may need to pull the product from those countries, and pulling access you already gave patients is not a clean reset. It is a visible event, one that could draw patient advocacy pressure and press attention at your company, not just at the policy. That pressure could work in your favor if it accelerates a carve-out or enforcement pause, but it is a bet, not a guarantee, and you would be the one absorbing the reputational exposure while the rest of the industry watches.

If you are in clinical trials, you likely will not have to worry about MFN years from now. I have a hard time seeing MFN surviving long term without exceptions being made for innovative therapies. Someone in this administration, the next, or the one after will eventually realize tying U.S. drug prices to reference countries does not make sense if all it does is slow U.S. innovation and limit access in reference countries. I understand the concern about high drug prices in the USA and fixing them, but MFN ain’t it.

Disclaimer: These are my opinions. I have no way to predict this. Tracking EU launches is not my specialty, and I have only done market access and strategy in the U.S.

IQVIA — https://www.iqvia.com/locations/emea/blogs/2026/07/tracking-mfns-impact-on-innovative-medicine-launches?utm

Interpharma — https://www.interpharma.ch/en/blog/press-release-one-in-three-new-innovative-medicines-not-submitted-for-reim-bursement-by-health-insurance-companies/?utm

Many pharma teams work in silos, and payer and HCP teams have different objectives and incentives. There are often gaps between teams that go unnoticed. HCP teams are responsible for strategy with prescribers and are often the ones who speak in terms of revenue and conduct the majority of strategy market research. Payer teams are usually focused on obtaining favorable coverage and ensuring market access capabilities are in place, such as copay support, prior authorization support, reimbursement specialists, and financial assistance programs.

While my experience is not reflective of everyone’s, I started in HCP strategy and later moved into payer strategy, which is not a common career path. Typically, companies want someone who has spent their entire career in HCP strategy or their entire career in payer strategy. This applies to both pharmaceutical manufacturers and consulting firms. Across more than 350 projects, whenever I presented HCP strategy, no payer teams were involved. At the time, I knew very little about payer strategy, yet I was helping build seven-figure forecasts and go-to-market strategies.

When I later moved into payer strategy, my job was presenting market access strategy to senior leadership and executives. I did not conduct the research or build the decks. Which allowed me to accumulate a lot of strategy insights quickly. I presented the findings, answered questions, and discussed strategy. I noticed the opposite. HCP strategy teams were never in those meetings. Looking back, I now see many opportunities where payer and HCP teams could have worked together more effectively. Earlier in my life, I worked as a professional window cleaner. Once you have done that job, you can never unsee a dirty window. In the same way, I can no longer unsee how much opportunity there is for manufacturers whose payer and HCP teams work more closely together.

2. Prior Authorization/Market Access Has a Bigger Impact Than Teams Realize

HCPs hate the paperwork involved with prior authorizations more than many teams realize. This is well documented. The latest AMA study of more than 1,000 physicians found that 79% reported prior authorizations sometimes or always lead to patient abandonment, and 94% said they somewhat or significantly contribute to physician burnout.

If you are still not convinced, a study published in The Permanente Journal found that physicians leaving clinical practice were, on average, nine years younger than they were in 2008. Just under 45% cited administrative hassle and workplace stress as reasons for leaving. Payer restrictions also grow every year. As they become more complex, understanding them becomes more important. Payer strategies recycled from years ago become less relevant over time.

3. The Market Access Opportunity Most Teams Miss

HCPs will, in many cases, prescribe the drug that is the least hassle. Depending on the therapeutic area, one of the biggest drivers of market share may be easier-to-navigate market access. This topic is rarely discussed or brought up to leadership. HCP teams build strategies to drive revenue but usually are not market access experts. Market access teams build programs and services but are rarely asked whether improving those programs or increasing awareness of them would generate more revenue. The idea that HCPs may, in some situations, value market access more than efficacy may sound surprising, so here are a few examples. Some came from comments under Mark Cuban’s post asking why physicians do not fight denials more publicly. One physician had a standalone post saying that the best access support services can dictate what gets prescribed. When I read those comments, I started thinking that better access services could drive more market share than many teams realize. Many executives still believe in the outdated idea that if a product has the best efficacy, it will naturally find its way to patients

.

4. What I Found When I Tested It

I pitched, won, and delivered strategy work on this topic. Some manufacturers told me they had no leakage due to insurance, the best hub services, strong cost support, and that HCPs already understood their coverage. One of the biggest things I tell manufacturers is that perception is reality.

Then the research comes back. In some cases, a large majority of respondents say they prescribe less of what they believe is the best product because they expect denials or because it is denied more often than competitors. The percentage of prescribers and practice managers who reported losing patients because they were unaware of cost support or reimbursement specialist services was significantly higher than clients expected.

Just because services exist does not mean prescribers know about them or use them. Manufacturers also rarely ask questions such as, “Do you prescribe less of a product because you perceive the prior authorization process to be more difficult?” Many teams assume that if a service exists, there is awareness of it. So far, it has been eye-opening for manufacturers to hear directly from prescribers and practice managers about their market access services. Claims data cannot capture this, yet it is what many manufacturers rely on to make strategic decisions.

5. Why Manufacturers Continue to Miss It

This is where I think the biggest opportunity exists. HCP teams are usually responsible for HCP strategy, but they generally do not have a market access background. When they conduct market research, conjoint studies, or attribute testing, the focus is usually on efficacy, safety, dosing, and other clinical attributes. How many times do you think they test the importance of attributes such as better hub services, fewer denials, or better reimbursement specialists? Honestly, likely close to zero, yet these are often the first things HCPs ask about and, in many cases, say are the most important. Market access teams, on the other hand, focus on coverage, prior authorizations, reimbursement support, and patient services. They are rarely asked revenue questions, such as whether improving these services or increasing awareness of them would change prescribing behavior. That leaves a gap. Manufacturers often have strong feedback loops around clinical messaging. They know whether efficacy messages resonate. They know whether a dosing message is compelling. Very few have the same feedback loop for market access.

6. How the information can be (& is being) used

After answering these questions for teams I have worked with, clients now have data showing how many HCPs prescribe them less because they are perceived as more difficult to access, how many are unaware of reimbursement or cost support services, and which beliefs about coverage are incorrect. That gives leadership something they can act on. They can improve awareness, educate prescribers, invest in services that matter, and measure whether those changes increase market share. From what I have seen, many manufacturers still invest disproportionately more in HCP strategy than payer strategy. As payer restrictions continue to grow, I think integrating the two will become increasingly important for driving market share.

Feel free to reach out to learn more about how you can leverage these insights. You can email me at seamus@priorityhcconsutling.com or schedule time on my calendar through my website: https://priorityhcconsulting.com/

The two things that surprised me most were:

1. How few manufacturers understood when payers publish coverage policies.

2. How restrictive those policies can be during launch.

I don’t fault manufacturers for not knowing this. That’s why companies hire experts to fill in the gaps. What concerns me is when many companies ask these questions and when they receive the answers.

Why timing matters

Many manufacturers evaluate expected payer coverage only months before launch. By that point, the HCP forecasting work is often complete, and commercial planning is already underway. If physicians estimate they will prescribe a drug immediately, but coverage delays access for several months, the forecast may overestimate early uptake unless those barriers are incorporated into the model. Looking back, I assumed life saving drugs would receive immediate coverage, but that isn’t how it works in the US market. After my first payer project, I became curious about what happens when a drug receives a second indication. Usually, almost always, coverage is more favorable the second time around.

Many payers already cover the product to label, meaning a newly approved indication can receive immediate coverage instead of being placed on a blocked list. Physicians already know how to prescribe the drug, navigate prior authorizations, and work through the reimbursement process. I also view an additional indication as an opportunity for manufacturers to receive a second chance with payers. Once a payer establishes a coverage position, they generally do not revisit it unless something meaningful changes, such as generic entry, new regulations, or a new indication.

That creates an opportunity to improve coverage rather than starting over. One notable exception is the GLP 1 market, where obesity has faced much more restrictive coverage than diabetes because of the enormous eligible patient population and budget impact. As a general rule, unless the indication dramatically changes the economics, day 0 coverage for a new indication often begins where the previous indication left off.

Why forecasts miss this

One interesting implication is how many companies forecast sales demand. Many interview physicians, ask how much of the product they expect to prescribe, estimate market share from those responses, and then apply a haircut because physicians tend to overestimate. I don’t believe physicians overestimate to the extent many companies assume. For first launches, physicians are often answering as if coverage will be available immediately, when it usually is not. For second indications, the opposite may happen. If companies apply the same forecasting methodology, they may still take a haircut even though the product launches into an environment where favorable coverage, physician familiarity, and reimbursement pathways already exist.

That is a very different launch environment. One pattern I have noticed is that many of the products that outperform sales expectations, which is relatively rare, have multiple indications. There are several possible reasons:

• Coverage is often more favorable.

• Physicians already know how to prescribe the product.

• Hospitals and clinics may already stock the product.

• Payers have a harder time managing products with multiple indications, especially when competitors do not share the same labels.

  I included some notable launches with multiple indications that blew past their sales goals below:

Key takeaways

Manufacturers are very good at evaluating clinical differentiation. I believe they spend far less time considering how much multiple indications can change the market access environment.

Perhaps the biggest forecasting mistake is treating every launch like a first launch.

In many cases, an additional indication enters the market with years of payer decisions, physician familiarity, reimbursement processes, and operational infrastructure already in place.

Understanding what HCPs want to prescribe versus what happens under market access constraints are two very different numbers. Many pharma forecasts still treat them as one and use what HCPs say they will do.

Manufacturers usually ask me three questions:

1. How quickly will payers publish a policy for our product?

2. How do we speed this up?

3. How restrictive will coverage be at each time point?

Auto Payer Launch Policies

Back in 2013, curative Hepatitis C therapies came to market and payers began implementing new-to-market blocks for cost control measures. What this means is that on day 0 of launch there was an automatic policy in place. The policy either covered the class, required prior authorization, provided open access with few restrictions, or blocked coverage altogether. As the years have gone on and I have tracked this, more and more plans have adopted automatic blocks. According to MMIT, approximately 95% of covered commercial lives are subject to a new-to-market block at launch on the pharmacy benefit.

Policies are not always publicly available during the first 12 months, but coverage decisions appear to be increasingly front-loaded. In my experience, payers are making decisions sooner and sooner, partly to put pressure on manufacturers to offer rebates. There is also significant pressure from manufacturers on payers to publish policies sooner because they want HCPs to understand the requirements needed to prescribe the drug as quickly as possible.

Paying to Learn How to Speed Up Coverage

Many manufacturers have asked me, and a some have paid for research, on how to speed coverage up. Unfortunately, payers rarely make exceptions for individual products, and a significant unmet need can also mean significantly higher costs. I once told a manufacturer in a rare disease that this was likely the case, but they still wanted to conduct the research to show leadership they had explored every option and to make sure they were not the exception. While surprising, it is understandable. Spending a relatively small amount to confirm something that could have major business implications makes sense.

There have been two instances where I told CEOs their product was unlikely to receive coverage sooner. One of their response was “we appreciate all your other insights Seamus but we know our therapeutic area better than you”. I later heard the CEO essentially repeat my conclusion verbatim on an earnings call a year later. Payers do not view unmet need the same way as patients or HCPs. They have their own timelines and processes for determining when a policy will be published.

There is one example where I believe a manufacturer may have been able to accelerate coverage decisions and policy availability.

**Disclaimer: I have never worked with this manufacturer and do not know the exact details of its contracts. My understanding comes from public information, industry discussions, and company statements.**

Novartis stated that it had already been working closely with payers on outcomes-based agreements, five-year installment payment options, and rapid coverage processes for Zolgensma. The company said it was “partnering to accelerate coverage decisions” and had more than 15 payers already in advanced discussions before launch.

Novartis likely created outcomes-based agreements to obtain coverage on day 0, which I have never personally seen before. My hypothesis is that payers wanted to reduce risk and gain certainty around the total cost of therapy. In my experience, many outcomes-based contracts never materialize because payers want more concessions than manufacturers are willing to provide.

In this case, Novartis may have been willing to offer enough value to reach an agreement and have policies established earlier. They also appear to have worked with payers well in advance and built strong relationships prior to launch. To me, this is unusual and likely reflects the unique dynamics of a $2.1 million gene therapy. Shortly after launch, Novartis reported coverage agreements with more than 20 commercial plans covering roughly 40% of commercial lives and described the launch as one of its most successful from an access standpoint. Based on publicly available information and company statements, they achieved substantial early coverage for a $2.1 million gene therapy, which is uncommon.

A later statement from Novartis noted that approximately five months after launch, around 90% of commercially insured patients had coverage for Zolgensma. While the Novartis example is interesting, it is not my biggest takeaway. My bigger concern is that manufacturers are often conducting this type of payer research only months before launch, while the HCP intent forecasts used to project sales were completed years earlier.

Whether a policy is published three months sooner or later matters but understanding how coverage restrictions will influence prescribing behavior matters far more.

What This Means for Pharma Going Forward

Having a publicly available policy created sooner is generally unlikely. If you are launching a second or third product in an established category and the product is not truly groundbreaking, it is unlikely that policy timelines will accelerate. If you are a brand lead, I would recommend communicating this reality to the executive team early. In my experience, many leaders do not learn this until shortly before launch and sometimes struggle to believe it. My view is that manufacturers should be cautious about spending six figures on research focused solely on how to accelerate policy publication timelines unless there is a very strong reason to believe their product is an exception.

If, and it is a big if, you have a rare disease therapy or a very expensive product, it may be possible to get payers to publish policies closer to launch. You would likely need to engage payers early and be willing to give up enough value for the arrangement to make sense from their perspective.

Payers work for organizations with financial objectives. Their role is balancing access, risk, and cost. My personal belief is that manufacturers may need to give up too much value to make this worthwhile. The tradeoff of obtaining earlier coverage and having policies available for HCPs at launch could make it worthwhile in certain situations.

What It Means for Forecasting

This brings me to what I believe is the larger forecasting issue. My biggest concern is that this type of payer research is often conducted only months prior to launch, while HCP intent forecasts used to project sales are completed years earlier. As a result, there are market access barriers that manufacturers do not yet know about and therefore cannot incorporate into their forecasts. In my experience, very few manufacturers test how market access barriers influence HCP behavior, even though the impact can be substantial. Physicians may be willing to prescribe a product without constraints, but their behavior can change significantly when faced with prior authorizations, step edits, exclusion lists, high patient cost share, or other access restrictions.

The question I continue to come back to is: “if the market access team, whose job is to understand these barriers, is still learning about them only months before launch, how is the HCP forecasting team expected to accurately build uptake curves years earlier without that information?”

This creates a situation where HCP intent is often used as a proxy for market share, even though the most important variables influencing access have not yet been identified, measured, or tested. This leads to over forecasting and too much capital being allocated to sales teams and manufacturing capacity.

At Priority Healthcare Consulting (PHC) we bridge the gap between HCP and Payer forecasting. Learn more with a 30-minute no-risk discovery call. Click here to set up a time.

Knowledge can be the cause of a lot of misunderstanding and miscommunication.

In the book Made to Stick, an experiment is described where one person taps out the melody to a song like “Happy Birthday” and another person tries to guess the song. The person tapping the song guesses how often the listener will correctly identify it. Their average estimate was 50%.

The actual average was 2%!! The person tapping the song had the melody playing in their head and assumed it was much easier to guess. They had a knowledge advantage and assumed the other person shared that knowledge.

The Knowledge Gap

This happens far more often than people realize, and it is very relevant in the pharmaceutical industry. It has happened to me. I have given my graphic designer image ideas that felt crystal clear to me, but I also had the image in my head and he did not. As a result, sometimes the first draft looks different than I expected.

I live and breathe forecasting and may assume certain things are obvious. For example, I might assume clients know that forecast results have a range of risk, such as +/- 7%. Then we get to the end of a project and spend a week discussing whether a weight should be adjusted by 1%, even though I know it changes nothing because it falls well within the forecast uncertainty. I now make sure to communicate key concepts like this up front.

The Same Problem Exists in Pharma

For pharmaceutical manufacturers, one surprise that regularly comes back from research is the percentage of participants who recall the manufacturer’s message. This occurs across stakeholders including surgeons, physicians, payers, patients, and caregivers.

Deloitte’s global survey of more than 190 HCPs and 50 pharmaceutical executives from the top 25 life sciences companies found that 82% of executives were satisfied with their customer engagement strategies, while only 28% of HCPs felt those strategies met their needs.

There have been other studies showing that message recall is often significantly lower than manufacturers expect. Manufacturers live, sleep, eat, and breathe their products for years, sometimes decades. Their level of knowledge significantly exceeds what their target stakeholders recall. Some of them are hearing about the product for the first time while the manufacturer has known about it for a significant time.

I have received feedback from payers who were uncertain where a client’s product fit into the treatment pathway after meeting with the manufacturer. I suspect most manufacturers would assume that information was clearly communicated after a single interaction.

Perception Is Reality

The same applies to HCPs. More than occasionally, research results show that participants recall the efficacy of a client’s product as lower than it is, or recall a competitor’s efficacy as higher than it is.

When I share those results, the client often responds:

“THAT’S NOT TRUE!” (The ones who yell at me tells me they care- I appreciate the passion for their brand)

Then I remind them that perception is reality. Then they agree with this new reality. The stakeholder does not make decisions based on what the manufacturer intended to communicate. They make decisions based on what they remember.

Why It Matters

The main takeaway is that the longer you are familiar with something and the more you know about it, the more likely you are to assume certain things are understood. You may unknowingly skip steps in your logic or incorrectly assume your message was fully understood by the target audience.

Sales teams, MSLs, and anyone communicating a product message need to understand that stakeholders are busy and likely know far less about the topic than they do. That creates a risk that the message is not fully understood.

The manufacturer assumes the message was delivered. The stakeholder assumes they understood it. Neither assumption is always correct. Sometimes the result is lower product adoption, weaker commercial performance, and scaling back future investments based on the incorrect belief that the message was already understood.

The standard assumption is: a brand loses patent protection, generics flood the market, and revenues crater almost overnight. For some products, high-volume oral solids in commodity categories, it could be true. But for a surprisingly large number of products, the cliff is more of a gradual slope, or does not materialize on the timeline anyone expected. Here is what I have seen, and why.

What I Have Seen in the Field

I was hired to evaluate whether a manufacturer should buy a product that had faced generic competition for four months. The selling manufacturer was arguing that 90% of branded share would hold due to loyalty. What I found was that all the dynamics I will describe below made the revenue appear stable initially, but once generics were added to formulary and step edits were implemented, branded share dropped off a cliff. Looking back at the sales curve now, it was not a gradual decline. The sales dropped sharply.

I have also done payer loss-of-coverage analyses for manufacturers and regularly see companies surprised by the lag in how quickly payers update coverage for generics. It is much slower than how quickly they create policies for new launches. The trend I see is that coverage updates for generics typically happen over 3 to 12 months. New launches are front-loaded toward earlier coverage decisions, while generic coverage shifts tend to happen later on that timeline.

The result is a dangerous middle period: share looks stable, teams assume loyalty is holding, and then the formulary changes hit all at once. Understanding why this lag exists and how long it is likely to last is what I will walk through below.

The 180-Day Exclusivity

The Hatch-Waxman Act granted the first filer of an Abbreviated New Drug Application a 180-day period of market exclusivity, a reward for the legal and financial risk of challenging a patent via a Paragraph IV certification. The intent was to accelerate generic entry by creating an economic incentive. It creates an incentive for that one generic product to get to market sooner. An unintended consequence that manufacturers may not realize is that it often slows down aggressive payer contracting.

If only one generic is on the market, a payer may only get a 10% rebate (Hypothetical number). If 3 or more generic products are on the market, it increases competition and negotiating power, which can lead to higher rebates and more favorable economics for payers long term. As a result, some payers may wait out the 180 days before aggressively contracting. Some brand teams may incorrectly assume they have stronger brand loyalty during this phase while only one generic has been on the market for a few months. The exclusivity period may help a generic get to market sooner, but it can also incentivize payers to take a more relaxed approach until more products are available.

Supply Concerns

Payers have also told me that at the start of a launch, generic manufacturers compete heavily on price and may cut corners. There can also be supply-related issues. If only 1 to 2 generics are on the market and payers aggressively shift utilization toward them, shortages become a major concern. Payers want confidence that supply and restocking are stable before aggressively managing utilization.

Generics also require broad distribution across major wholesale networks such as McKesson, AmerisourceBergen, and Cardinal to achieve reliable pharmacy-level availability. Early in a launch, before those relationships are fully established and before demand becomes predictable, pharmacies may not routinely stock a new generic, particularly for lower-volume specialty products. Patients and prescribers may encounter substitution failures simply because the generic is not consistently on the shelf.

P&T Cycles

Perhaps the most systematically underestimated source of generic share lag is the formulary review process. Some payers take 3, 6, or even 9 months to review a new formulary or indication change, and updates may not be implemented until the next plan year. Manufacturers that expect these changes to happen instantly are often surprised by how slowly they occur.

This lag is also asymmetric. In my experience doing payer coverage analyses, new brand launches receive front-loaded coverage decisions because payers need a policy in place quickly. Generic coverage shifts work the other way. Payers are in less of a hurry because the status quo, covering the brand, already exists. The operational urgency simply is not the same.

Implications for Forecasting and Strategy

Do not rely on a standard S-curve. An HCP intent forecast that does not account for these dynamics may ironically overforecast loss of share early and underforecast loss of share later, which is exactly the pattern I have observed across multiple products.

Many forecasting models implicitly assume rational economic behavior happens instantly across the system. In reality, payer governance cycles, contracting timelines, supply validation, and operational implementation create delays that compress into a later, steeper drop rather than a smooth erosion curve.

If you are looking to buy a branded asset that recently faced generic entry, the coverage dynamics may not hold as expected. Many teams are surprised because they assume payers will immediately push generics if it saves money. In practice, there are multiple reasons this does not always happen, including the 180-day exclusivity rule, waiting for more entrants to improve contracting leverage, and waiting out potential supply or manufacturing irregularities.

The key question is not whether generics will erode share. They will. The question is when and how fast, and the honest answer based on what I have seen across real products and real payer conversations is almost always later and than the model predicted.

I created a document that shows the impact recent generics had on brand share where public data was available to provide directional insights. (Click underlined text for link)

Time 1 Market Access is planned too late
Some companies try to save money and leave market access to much later. During or after phase II many companies do not do market access research. They focus on HCP KOL ad boards to decide whether to move forward and sometimes use this to build investor confidence, especially among smaller or capital constrained manufacturers.

I understand why. They want to conserve capital and avoid bad news early. They do not know what final efficacy will look like, so the work can feel premature. But this is why scenario testing exists.

You can ask questions such as what is the minimum efficacy, safety, and reported outcomes needed. How restrictive is the class today. How restrictive might it be in three years. Many companies are flying blind and leave these questions for later.

Time 2 Endpoints
End of phase II and into phase III planning. Manufacturers typically design endpoints to maximize probability of approval. If one trial has an 80% chance of approval but would lead to restrictive coverage, versus another with a 70% chance of approval but stronger coverage, the first is often selected. From an economic perspective the second may be the better decision.

It is hard to estimate how often this happens, but it shows up more in companies with capital constraints or pressure to raise funding. Talking about payer barriers does not help their story. If investors are comfortable, the incentive is to optimize for approval. I understand the logic. But once phase III is complete and payers react with restrictions or lack of coverage, the ship has sailed.

Time 3 HCP Intent Forecasts
Manufacturers run HCP intent forecasts during phase III to plan capacity. Hundreds of millions can be allocated to manufacturing and hiring. There is an expectation of revenue that supports future R&D, acquisitions, and operating expenses.

The issue is timing.

Market access work often happens too late. Access teams then uncover barriers that were never modeled such as step therapies, strict prior authorizations, and higher tiers that increase patient cost.

The HCP intent forecast was done years earlier, so there is no way to test how physicians and patients respond to these barriers. The impact can be significant. I have seen misses as high as 80x.

The industry often attributes this to HCP overestimation. Let us say a physician says they would prescribe a oral therapy to 7 of 10 patients because it avoids daily injections. Do we really believe that becomes 2 of 10 in the real world. Or is it more likely the product is stepped through a competitor, assigned high cost share, or placed on an exclusion list.

From what I have seen many companies do not model these barriers. They rely on HCP intent and apply a generic haircut because doctors overestimate. Physicians are not factoring in payer restrictions that will ultimately determine access.

In conclusion
Many launch failures are attributed to market access, yet it is often deprioritized from a budget and timing perspective. It becomes a checklist item later in development when it can no longer influence key decisions. Companies learn about barriers after the fact when they could have designed around them or planned for them earlier.

I would recommend engaging payer ad boards in phase II, including current and recently retired decision makers, to pressure test likely coverage scenarios. These should be repeated over time since the market is not static.

Market access teams should integrate with those designing clinical trial endpoints. Endpoints should be tested with payers to understand how they may impact coverage. By phase III companies should have a clear view of expected barriers and should measure two things, HCP intent and intent after market access constraints.

These are the misses Priority Healthcare Consulting helps clients avoid.

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Patient health is a sensitive topic. It gets more complex when what companies are incentivized to maximize profit. I am not arguing if that is the correct way for the system to be set up, but it is how it operates. CEO of Pfizer said they are not launching a drug in France because it does not make financial sense. CEO of AstraZeneca yesterday basically said assume our sales are zero in reference countries as a conservative number, but we will do everything in our power to launch there. The CEO of AZ is being more politically correct with phrasing but basically said the other countries might not get new drugs or there could be delays.

Here is what I predict what will happen. Keep in mind this is my opinion and I have no way to know for sure as this is a new dynamic for me. I have given quite a few presentations on new policy or new payer dynamics such as copay accumulators, maximizers, AFPs, etc. A lot of manufacturers ask me what other manufacturers are doing. They wait for someone else to make the move and try to learn from their mistakes or copy them if it is working. They want someone else speeding to get the ticket first to see what their move should be. They do not want to risk getting the ticket.

I think there is too much risk to launch in a reference EU country. I think all companies will follow the leader and wait for someone else to make the first move. So short term I think most manufacturers will hold off or delay launching in the EU. From a strategy perspective it is most profitable as I laid out the reasons in my last article.

If and only if we think the policy holds up long term, I would have a few different recommendations for manufacturers such as change the formulation in clinical trials just ever so slightly so you can launch the same but different product in reference countries. The issue is clinical trials take forever. So companies have to decide if the policy will hold long term. I do not think it will.

I think manufacturers might try to negotiate a deal so they can launch under different terms. They might rely on patient advocates to bring more media attention on the matter. I think long term patient advocates will speak up in the EU which puts pressure on policymakers. Saying it is not fair, their countries cannot afford the same pricing the US can. The news will run these stories. They likely will highlight patients with the disease where a product will help that cannot get it because it is not being released. Again I have no way to predict this, but that is what I expect.

If we want a less sensitive product. Let us say a personal autonomous flying car is available at a fair price. The US government says they have to charge the same price everywhere. If a majority of profits come from the US at a higher price, they only launch there. The CEO might have a different tone. “We want to launch it at the rest of the world cheaper but the US government has our hands tied. We make a lot less money and we would not recoup the investment made as it was very expensive to make. We will not launch in the rest of the world under any circumstance as it makes no financial sense. Feel free to put pressure on the US government and if we are allowed to release the product cheaper we are more than happy to do so. But we cannot make it work in your countries at the price you are able to afford.”

Short term, I expect manufacturers to hold off or delay with launching in the EU and wait for someone else to make the first move. Long term, manufacturers need to decide if this policy is permanent. If they think it is permanent, they need to think of unique ways to launch in those markets. If they think the policy will not hold, they do not have to change anything.

In this article, I will break down, from my view, why Inbrija, the digital products from Pear Therapeutics, and Aduhelm failed to reach their sales goals.

It is important to learn from mistakes so they do not happen again. Based on my experience and how I have seen things sequenced, it is not always done in the order that I believe is optimal. The expected market access barriers need to be figured out earlier than the HCP intent forecast that predicts market share. This is not always the case. It is also difficult to figure out market access barriers, as payers have competing incentives, so it is hard to reliably predict how they will cover.

One good way to get a better understanding is to look at how similar market dynamics have been covered for other drugs. How to best do this differs by firm. I personally think working with payers as early as Phase II, even through advisory boards, is a good idea. Then run a few of them and keep a close relationship with payers. Yes, the downside is it costs more money to run them early and multiple times, but I think it is important to understand what they plan on doing and to partner with them.

You should run scenario tests to see what makes your product viable. Questions such as what level of efficacy and safety gets covered, and at what tier, should be addressed. You should have a general idea here, which is not always the case. There is sometimes a belief that solving an unmet need, or having a benefit that doctors or patients really like, guarantees access. That is directionally true but a very dangerous assumption.

Examples

Inbrija
An inhaled levodopa formulation with a unique route of administration.

In situations like this, HCP and patient research often shows strong enthusiasm and excitement. However, in many cases, payer perspectives on dynamics such as a unique route of administration are either not incorporated early enough or not fully reflected in forecast assumptions. By the time teams approach launch, forecasts are already committed and difficult to adjust.

The issue is that once a coverage decision is made, payers usually do not update it unless there is a meaningful event, such as a new indication or generic competition. It is possible to renegotiate, but often only with meaningful pricing concessions.

Pear Therapeutics
I will not rewrite the exact same thing, but this appears consistent with a pattern seen in other launches involving new categories that solve an unmet need.

Even when the clinical value is clear, coverage can be restrictive. In some cases, payers may be hesitant to broadly cover new categories due to concerns about setting precedent across similar future therapies.

Aduhelm
A more complex and controversial case. The science was weak, which is a major reason it did not hit sales goals.

My question is why the forecast was so large ahead of time when the industry knew there were challenges such as limited efficacy, side effects, high cost, and an infusion requirement. I cannot say market access was the main reason for the miss, but the restrictive coverage environment clearly played a role. This was also an unprecedented coverage case that would have been hard to predict.

The pattern

These are not isolated cases.

Knowing payer coverage is not easy due to conflicting incentives, but it is critical. Some manufacturers, especially smaller ones, skip proper landscape assessment and lack a clear view of how similar products are actually covered.

I have completed hundreds of presentations, and it might surprise you what dynamics market access teams and executives have not fully considered prior to launch.

For instance, a unique route of administration not getting covered at a premium. I have given just under 20 presentations on this dynamic. In many cases, Heads of Market Access, VPs, and Directors are confident they will achieve favorable coverage with a premium. Yet I see those products on exclusion lists today.

It is not their fault, in my opinion. If the executive team is not thinking about these dynamics and has already communicated to investors and the board that a higher price can be charged and access will follow, the plan becomes locked in. It can be difficult for access teams to push back without risk right before launch.

Why this matters

Most forecast misses are due to missing or underweighted variables that would discount them, such as market access.

• Coverage is more restrictive than expected

• Patients do not make it through the system

• Behavior does not change as easily as modeled

What we are doing about it

I teamed up with Justin Yu to build a syndicated report that looks at key exclusions across large payers and the rationale behind them based on publicly available data. We map how similar product dynamics are actually being covered so companies are not operating on incorrect assumptions.

This is not meant to be perfect. It is meant to be directionally right and early enough to flag payer barriers to consider.

With AI, this type of analysis no longer requires a 200K retainer. With domain knowledge and AI, we can aggregate, validate, and deliver it at an affordable price.

We are trialing this offer at 20K. For a small additional fee, we can look at a few similar class dynamics to your product and show how restrictive payers have been.

If you are making allocation decisions without a clear view of how similar products are covered, you are taking on avoidable risk early on in the process.

Final thought

Using AI, Justin ran a search on what types of products Express Scripts excludes as of 2026. I do not think this sort of information is presented, called out, or appreciated by pharma teams.

His full LinkedIn post: https://www.linkedin.com/posts/justinsyu_heor-access-pharma-share-7452929526789206016-kOrD?utm_

The answer it gives? 42. The issue is with the questions that were asked. Were the right questions asked at the start?

So much precision from the supercomputer, but the answer ended up being unusable. 42 represents biotech’s HCP intent forecasts. It’s a very precise number and the correct answer based on the inputs that were asked. HCP intent is valuable as it helps manufacturers segment and understand the potential demand for their products.

The Missing Variable that needs to be tested is Market Access.
The failure in the book and movie is asking the wrong question from the start. Biotech faces this issue when they want to understand product market share uptake. The HCP intent team asks what doctors will prescribe during Phase III, but from what I have seen, the market access team is never looped into any discussion. Go-to-market capital decisions are made without accounting for market access.

The biotech industry needs to include the market access team in the forecasting process earlier. Market access barriers need to be understood ahead of HCP forecasts in order to grasp how they impact HCP behavior.

Vogon Bureaucracy = Payers
The Vogons show no emotion. They only follow a process.

The same goes for payers. They are focused on controlling costs. They are not always optimizing for the patient. They use step edits, strict prior authorizations, and higher copays for drugs. These actions are meant to curb HCP behavior. It’s literally why they do it. Yet biotech industries assume HCP intent is a good proxy for real-world uptake and stays constant after the introduction of these barriers.

The author’s premise is that expecting the universe to follow expectations and stay constant is absurd. Biotech’s belief that HCP intent stays constant after market access restrictions is equally absurd.

Arthur Dent = Leadership Post-Launch
Arthur is confused because reality does not follow the logic he expected.
Leadership after launch: “Doctors said they would prescribe our drug! We have a better product, and it solves an unmet need! So why don’t our sales reflect this?” Many manufacturers believe a better drug, patient support, or HCP support will result in good sales. Unfortunately, this is not always the case, as many superior drugs don’t perform as expected, while inferior drugs are used due to access issues. Just because you don’t plan for market access in your forecast doesn’t mean it’s nonexistent.

Comfort in the Wrong Answer
Sometimes the industry prefers the wrong answer. For instance, a 60% HCP intent forecast is much easier to accept and communicate to investors than a 10% access-adjusted share. HCP intent forecasts are not questioned because they are the status quo. They are comfortable and familiar. One CEO told me he wants a higher number for HCP intent to raise money, get bought out, and let someone else deal with the overestimation. I can accept this reason for using HCP intent, but I disagree with the premise behind it.

Conclusions
“42” represents the wrong questions, not the wrong answer. Incomplete? Yes, but not wrong. HCP intent + no access integration + biotech = 42.

And to be honest, this number is about as reliable as all HCP intent forecasts in isolation for products that will face payer barriers. Why pay money for an over-optimistic number from another galaxy? At that point, you might as well use 42% and save six figures.

About PHC

At PHC, we integrate market access into HCP forecasts, providing two sets of numbers: HCP intent and access-adjusted market share. Learn more about our team and experience here: https://priorityhcconsulting.com/about-us/.

Feel free to schedule a call on my calendar, and I can walk you through a 3-minute demo. I dislike long meetings like everyone else, and I can complete it in just 15 minutes.

The first concept is most pharma companies are public and their sole purpose is to make as much money as possible, not do what is best for patients. Yes, helping patients makes them more money, but the company has a legal responsibility to shareholders.

The second concept is that Europe covers differently than the U.S. The U.S. does not subsidize the EU, Canada, and others. Manufacturers charge the max amount their countries can absorb. So the idea of them allowing a higher price due to the policy is not a likely outcome.

Europe is stricter than the U.S. when it comes to covering new agents and what they will pay for. They have NICE, and if the drug does not solve enough of an unmet need at a price they do not support, it is not covered. The UK is extremely strict in particular with this. I did research in Brussels, and if an oncology drug extends a patient’s life by only a few days and costs hundreds of thousands, it is not covered.

The U.S. usually covers novel drugs and is less strict than the EU, but access often comes with restrictions like prior authorizations, step edits, and higher patient cost sharing. There would be an uproar if patients were told they cannot access a therapy at all, which is one reason premiums continue to rise. In general the U.S. leans toward broader access and innovation, while Europe is more willing to limit access based on cost effectiveness.

No one will argue what the 24K average yearly premium for a family of four does to Americans’ quality of life, as this would misalign with all healthcare players in the space, including consultants like me. I remember putting into Excel Biogen’s initial cost of Aduhelm of 56K multiplied by 7.2M Alzheimer’s prevalence. Over 400 billion dollars a year TAM. It was estimated it could have doubled already high premiums for Medicare for a product with AEs and limited efficacy. From a moral perspective it is uncomfortable, but from a business perspective, if they got away with it, it would have been one of the largest heists in healthcare history. Done legally in front of everyone’s eyes. USA approved and covered with restrictions. Imagine the impact on premiums if the drug had efficacy in the USA and that led to fewer restrictions. EU, it never had a chance and wasn’t even covered with restrictions.

The CEO of Pfizer said they would not release in France, and the posts on LinkedIn were all about how surprising this was. It does not surprise me the CEO of Pfizer said that, as it is what I would have recommended if asked. What surprises me is that he said it publicly. Maybe it is a signal to policymakers that companies are not bluffing and that other countries could lose access to new drugs.

Let’s go into the math and incentives that show how things play out. Let’s say the manufacturer charges 80 percent more for a drug in the USA and the USA is where around 50 percent of profits come from depending on the company.

Either you lower your price to where Europe would support the drug, or you lose all of Europe. It is not a situation where Europe meets the USA halfway.

So the question becomes
Do you want 50 percent of 100 percent
Or 100 percent of 20 percent
Half the market, with full profit in the U.S.
Or the full market, but at significantly reduced pricing
For example
If expected sales are 1 billion
Do you want to make 500 million and not launch in Europe
Or 200 million and launch in both the U.S. and EU
If you were a profit maximizing CEO, what would you do?

One thing that is a little unfair as a forecaster is how a policy can have such a large impact on expected return on investment. It costs around 2.6B when accounting for failed drugs, and these costs have to be recouped. When forecasting, you assume X revenue in the USA and X in Europe. Clinical trials are long, and these decisions were made years ago, with large capital allocations tied to them. Now companies may lose ~50 percent of profit from not launching in Europe or be forced to lower price, which changes what was viable. The policy was made quickly, but decisions were made years earlier.

This is now a variable that needs to be considered. If a drug is borderline or just barely worth the risk, the recommendation may shift to not commercializing, as policy can change the economics with little warning.

Things for consideration.

Holding off on launching in Europe for the math reasons laid out. Consider strategies like different dosing options for Europe, or slight modifications to maintain flexibility across markets. The challenge is clinical trials take years, and that effort may be wasted if the policy changes again.

Amgen withdrew Repatha from Denmark citing pricing pressure, and Indivior pulled Subutex and Suboxone from some European markets due to unfavorable economics. Neither explicitly said MFN, but something to think about. Companies have done this is in the past when there are generics so I cannot say if there is a relationship between the two.

Global pricing policies create unintended consequences. If price in one country directly impacts another, companies have to evaluate whether maintaining access in one region affects feasibility in another. Large price differences introduce uncertainty into long term access.

Questions you need to answer soon if you have not already done so. Where are we most exposed to international reference pricing risk. How do we balance access in one country in the short term versus long term access across all markets.

When payers make a coverage decision at launch, they analyze EVERYTHING. They have medical directors, pharmacy directors, physicians, and other P&T members review the drug to determine how it should be covered. They look at it under a microscope and in great detail and do not miss much. They also have all new drugs mapped out ahead of time and have an idea, or at least a guess, of what they think manufacturers might cost and impact. They look at high spend areas and novel drugs or gene therapies that might charge a premium. They are prepared, and any manufacturers who try to leave out key details usually lose trust for the current product and potentially their portfolio.

Although all manufacturers in my experience expect coverage almost instantly, it occurs in a 3 to 12 month period that is usually frontloaded. It is later than they expect but still relatively quick.

Payers want to pressure manufacturers to give rebate concessions and they have a new to market block until coverage. The manufacturer knows the decision that is made will be hard to reverse. It puts contracting pressure on manufacturers as they only have a small window to come to an agreement.

What is surprising to almost all is how payers cover after launch.

First, if you do not get coverage the first time, showing up a second time usually does not move the needle much in terms of what is possible. When a second coverage decision is made, it is usually due to supply issues, indication changes, policy changes, new indications, loss of an indication, new technology, generics, or new drugs entering the market.

Payers go from actively looking at everything in extreme detail to a more relaxed and laid back approach the second time around, which catches manufacturers off guard. Many manufacturers I have worked with expect a new indication policy to be updated as quickly as their initial launch.

It is almost like kids asking on a long drive
Are we there yet
Are we there yet
Are we there yet

Except it is manufacturers asking me after a new indication or event
Is the policy out yet
Is the policy out yet
Is the policy out yet

It usually takes much longer, as operationally it is much harder for payers to track events compared to new drugs that are FDA approved and announced.

It both helps and can hurt depending on the manufacturer’s situation.

For example, if a competitor generic has supply issues and you explain this to payers, they can add you to formulary and forget to ever take you off.

If a client’s product loses an indication, for instance goes from 1L+ to 2L+, many times payers never update the policy and cover off label. This surprises many manufacturers who do not believe this is possible, but it is.

Another example I saw was products receiving a black box warning. The competitor manufacturer tried to alert payers and the payers said they will let doctors decide, which is surprising given how restrictive they can be on formulary. My belief is they do not have the operational capacity to deal with every change, so they do not.

In conclusion

Payers are highly coordinated and proactive at launch.
After launch, they are far less responsive than most manufacturers expect.

If you miss the first decision window, you are often stuck with it.
If something changes later, it may take far longer than you think for payers to react.

Below is an image to help you understand the difference of launch vs after. They go from peak scrutiny to operational lag and inconsistency.

The pharmaceutical industry has a bit of an overoptimism issue. In order to bring a drug to market, the CEO must pitch a compelling story. If not enough capital is raised, the drug dies. Right now it is industry standard to build that story off what doctors say they will do. But what doctors say they will do and what actually happens is not always connected to the market.

Manufacturers rarely, if ever, build their forecasts off real world uptake, but instead build hiring, capacity, and future investments off stated HCP intent.

I have worked on around 35 market access forecasts, and teams consistently ask about coverage and uptake around 6 to 10 months prior to launch. By that point, the original HCP forecast has already been built, often years earlier, without incorporating how access will shape behavior.

There are many drugs that can be identified at the end of phase 2 that are unlikely to meet expectations without changes to access strategy. Yet manufacturers often move forward, either due to sunk cost or because payer barriers are not fully accounted for early enough.

What happens to your forecast when access friction is introduced?

A step through a competitor
A higher patient cost
A prior authorization requiring specialist confirmation

Does market share hold?
Or does behavior change?

I have seen extremely large misses. The more payer barriers a product faces, the greater the disconnect between expected market share and what actually plays out in the real world.

Leadership allocates significant resources to manufacturing, hiring, and future R&D based on these forecasts.

The worst case I have seen is a 52x miss. The CEO described an “odd” disconnect between what physicians said they would do and what was reimbursed, attributing it to unforeseen market access dynamics. Were they actually unforeseen, or simply never accounted for? If you forecast HCP intent, that is the number you get. It cannot be compared to real world uptake.

Forecasts are not wrong and accurate for the assumptions they are built on.

The issue is that those assumptions often exclude the single biggest driver of real world uptake.

Market Access.

If you want to forecast real world uptake, you need to work with payers ahead of time, understand likely barriers, and test how HCPs will react under those conditions.

_____________________________________________________________-

Update on (Priority Healthcare Consulting) PHC
This is the type of work we help our clients get right. We integrate market access upfront in forecasts to provide more realistic outputs for C suite teams.
We have a 30+ year veteran who built a nine figure consulting company.
Another award winning market access veteran with 30+ years obtaining favorable coverage in competitive classes.

Feel free to see the team here or schedule time if you would like to see a three minute demo on how we solve this.
https://priorityhcconsulting.com/about-us/

Things Payers Will Almost Always Ask For
Payers will always ask manufacturers for head-to-head data and for pricing information on the product. Usually, the market access team will not reveal their pricing strategy during the first engagement with payers, but it is important to have a clear rationale to explain why pricing cannot yet be provided. If not handled well, this can create an awkward situation or risk losing trust.

Payers will also always ask and want to know what unmet need the product solves. This should be stated clearly and credibly. Payers expect manufacturers to articulate what specific problem the product addresses and why it matters in the real world.

How to Successfully Include Portfolio Contract Conversations with Payers
In general, manufacturers with many products like to use portfolio contracts and leverage a more utilized product to obtain favorable coverage for one in a more competitive category. Manufacturers need to understand payer perceptions of this approach and the best way to position it.

Many strategies I have seen are executed incorrectly and make payers defensive when manufacturers directly say they want to portfolio contract. Payers generally have a negative perception of portfolio contracting and view it as a tactic used to block competitors. Often, account teams are too aggressive in pushing the idea, which leaves a bad impression.

A large company I have seen successfully navigate this conversation presents the concept in a passive, non-threatening way that payers appreciate. They simply explain that they are open to portfolio contracting and share what it could look like, but ultimately leave the decision to the payer. This approach feels collaborative rather than coercive and is much better received.

A Market Access Strategy That Failed Miserably and Why
Another watchout is overplaying a small competitive advantage.

One example was a manufacturer with a branded product that had a slight advantage over a competitor’s branded product. There were also many generics in this market. Payers recognized the advantage, and the manufacturer was excited to leverage it to obtain favorable coverage and increase revenue.

However, they decided to price the product higher than the competitor’s branded product and ultimately received exclusions or poor coverage. Had they priced it the same, the story would have been stronger: “we are better and the same price.” That positioning likely would have driven uptake.

Instead, payers acknowledged the small benefit but preferred the lower-priced competitor. The lesson is not to overplay a small benefit. A small pricing misstep can have a large negative impact on revenue. The manufacturer’s attempt to gain slightly higher margins ended up reducing overall revenue.

Quantitative demand market research plays a critical role early in the product lifecycle. Small missteps at the outset can undermine credibility, delay decisions, and create friction with senior leadership.

When studies miss timelines, teams may lack insights needed to inform clinical trial design. When data are collected or interpreted poorly, manufacturers risk building brand strategy on inputs that do not hold up in the real world. In both cases, outcomes reflect poorly on the brand team in front of leadership, regardless of where responsibility technically sits. The bigger risk is having a confident strategy built on data that does not reflect how the market will behave.

Based on our decades of combined experience across demand and forecasting engagements, we have identified recurring issues that cause demand studies to stall, lose credibility, or miss their strategic window. This article focuses on the risks brand teams should be aware of and what to watch for to avoid downstream mistakes.

Involve All Impacted Stakeholders Early

Demand studies often inform decisions far beyond marketing, including sales sizing, manufacturing planning, financial forecasts, and clinical strategy. If these stakeholders are not aligned at the start, issues tend to surface late, when changes are costly or impossible.

Early involvement may add complexity, but it significantly increases acceptance of results and reduces rework when forecasts are reviewed by leadership.

Align Early on What the Study Can and Cannot Deliver

A common example is when a forecast can only predict within a ±5% confidence range, but the vendor does not communicate that the forecast is only accurate within those 5 percentage points. This can lead to back-and-forth discussions over a 1% difference after the project is complete. It sets unrealistic expectations, and the pharma brand lead may not be aware of the limitations and may incorrectly assume the forecast is more accurate than it is.

Another example is expecting scenarios to rank perfectly as planned. In a study testing nine scenarios across groups of fifty physicians, overlapping confidence bands made exact ranking unrealistic. Because this was not clearly communicated upfront, it led to extended debate and a loss of trust in the data. These outcomes are realistic and should be explained early.

Be Realistic about Recruitment, List Studies and Timelines

Manufacture brand teams often assume that a large proportion of a target customer list will convert to completed interviews. In reality, completion rates for these lists may be as low as one percent. Vendors may accept projects on a best-efforts basis, while brand leads interpret that as full recruitment.

Clear communication around realistic expectations and a willingness to stick to best practices when assumptions do not align are very important. In some cases, including non-target respondents may also be appropriate if their product use could affect overall supply or lead to shortages. This should be discussed upfront after the vendor runs into the issue.

Both PHC and APEX commit to a minimum sample size, while scoping projects such that a larger N may be achieved on a best-efforts basis. It is better to be surprised on the upside than disappointed on the downside. Vendors must also be prepared to decline projects with requirements that cannot be met, particularly when overpromising is used to win work.

When feasibility is not aligned upfront, projects risk missed deadlines or compromised samples. This often surfaces at the worst time, when leadership is expecting numbers to support an upcoming earnings call or resourcing decision. Make sure your vendors (like PHC and APEX) check feasibility with recruiting partners and aligning on what is realistic is essential to meeting timelines.

Avoid Overloading Product Profiles

Brand teams often want to include every clinical detail in product profiles used for forecasting. In practice, respondents are busy. Excess detail increases the risk that key differentiators are missed or misunderstood. Seamus once worked on a project where improved dosing frequency was the only differentiator. The dosing information was buried in seven pages of clinical data in a target product profile. The manufacturer did not want to thin out any of the material and did not want to highlight/bold dosing to avoid bias. Unfortunately, few participants picked up on the differences. In practice, showing less and clearly calling out key differences by bolding or highlighting often leads to better data.

Structure Profiles for How Respondents Think

Product profiles should follow a logical flow aligned with how respondents process information. For drugs, this often means starting with indication, followed by efficacy, then safety.

When multiple products are evaluated, structured comparison formats can reduce fatigue and improve consistency. Poor structure introduces noise that looks like insight but is not.

Key Takeaways

When these considerations are not addressed upfront, there is a lack of trust in the data, timelines can be missed, and insights arrive too late to inform quarterly reviews and leadership decisions. Alignment at the start determines whether results are trusted at the end. Over precision and overpromising slow decisions by inviting scrutiny that takes away from the what the study aims to solve. The strongest demand studies are designed with an understanding of how results will be interpreted, challenged, and used to inform strategy.

Quantitative Demand Market Research Execution Checklist

This checklist captures execution and rigor considerations that support the recommendations outlined in the article.

Created by the founders of two boutique quantitative pharma firms (2026):
Eric John, Founder of APEX
Seamus Cole, Founder of PHC

Planning and Scoping

• Confirm all forecast data inputs required and identify which must come from primary research

• Align to minimum and stretch sample sizes before fielding

• Validate feasibility assumptions with recruiting partners

• Confirm whether non-target respondents may influence supply or utilization

• Consider designing a worst-case scenario, as the biggest risk in forecasting is over-projecting. This is very common and can lead to over-hiring capacity and unrealistic cash-flow expectations

Sampling and Data Quality

• Design samples large enough to support forecast confidence bands

• Anticipate data-cleaning needs given increasing survey fraud

• Monitor incoming data continuously rather than post-fielding

• Confirm rules for respondent exclusion before analysis

• Some clients like to use their own target or account lists to recruit, which can create bias due to pre-existing positive relationships and lead to inflated results

• Keep surveys under 35 minutes. Research shows attention drops sharply beyond this point

• Avoid adding marketing “nice-to-have” content that detracts from the primary research objective

Weighting and Representation

• Assess whether weighting is required to reflect market reality

• Align stakeholders on how weighting may affect subgroup interpretation

• Document weighting logic clearly for downstream review

Survey and Profile Design

• Limit product profile length to essential differentiators

• Structure profiles in a logical order aligned with respondent expectations

• Use comparison formats where appropriate to reduce fatigue

• Pretest surveys to identify confusion or misinterpretation

• Even well-written questions can still be misinterpreted by some participants

Behavioral Measurement

• Define timeframes clearly for expected product use

• Favor scenario-based questions over abstract ratings

• Allow respondents to reference prior answers to improve consistency

• Include measures to assess the likelihood of stated behavior occurring

• Use 7–9 point rating scales. Five-point scales often compress responses and limit analytical value

Contextual Considerations

• Decide whether usage should be captured as percentages or patient counts

• Account for concomitant use where relevant

• Include “no use” options to capture market expansion

• Use open-ended responses to contextualize quantitative outputs

• Anticipate how results could contradict expectations and include open-ended questions to address those scenarios

Important note:
All clients have market share implications or internal expectations for how data “should” look. Even when the data are correct, leadership may question results (e.g., “Why is share 8% instead of 20%?”). Open-ended data are critical to defend and explain these outcomes.

Analysis and Interpretation

• Align early on confidence intervals and acceptable precision

• Avoid over-interpreting small numerical differences

• Set expectations around scenario-ranking limitations

• Document assumptions and constraints clearly

Communication and Governance

• Ensure stakeholders understand how results should and should not be used

• Prepare clear explanations for expected areas of pushback

• Align on messaging before presenting to senior leadership

• Any number shared with a CEO is often taken at face value and amplified

• Explicitly clarify which number is being referenced and whether discount factors (e.g., market access, prescriber education) should be applied

Additional Questions for Consideration

• Always ask participants whether they would like to participate in future research (it is essentially malpractice not to)

• This enables follow-up if particularly insightful or unexpected responses emerge

• Include at least one market access question, such as willingness to push through a rejected claim

• Many companies only learn about market access barriers after launch. This is avoidable with better upfront research

About the Authors

Many advisors caution against writing openly about launch strategy because it is typically something teams pay for. I understand that concern, but unfortunately for them, I enjoy sharing what I have learned and hope it helps future launches go more smoothly. In this article, I will be writing about a launch strategy that I have personally seen work in practice. Some effective launch tactics are simple and under discussed, which is why they are worth making explicit.

What is surprising is not that this strategy works, but that it is not always formalized, despite being relatively easy to implement and capable of driving meaningful revenue impact.

The strategy

You create a draft payer policy that reflects the best coverage you believe is reasonable and defensible for your product prior to launch and a coverage decision being made. You then share this document with payers.

I interviewed several payers, and a meaningful portion said they would consider adopting what is shared if they believe it is fair and well constructed. Some said they would not use it, and others were unsure whether it would influence them. Still, even limited adoption can have positive business implications.

Payers, like most people, will often accept help if it reduces their workload. If you do the groundwork and present a thoughtful, balanced policy, there is a real chance it will be considered. This approach is most effective for first in class products, differentiated therapies, and products without multiple lower cost alternatives with similar efficacy.

How you present the policy is very important. I touched on this in a prior article on payer messaging. You cannot position it as, “this is how we want you to cover our product because it solves an unmet need.” That framing will not work with payers.

Instead, account managers or MSLs should position it as follows: we recognize this is a unique product and that coverage criteria may not yet exist. We put together a draft authorization document to help reduce some of the administrative burden and wanted to share it in case it is useful. The message should always be that the payer’s judgment comes first and that the intent is simply to help with the initial work.

This strategy should not be used if the team is trying to reach too far by pushing coverage that is clearly not considered fair by payers, especially when pricing is materially higher or when expecting parity with established competitors.

The result

Payers do not like being told what to do, and they value being treated as trusted partners. My hypothesis for why this approach is not used more often is due to a lack of knowledge that it can be used effectively. Launch teams are managing dozens of workstreams, and this tactic is easy to overlook unless someone is explicitly thinking about how to reduce payer friction early.

In practice, the value of this approach is less about proving incremental impact and more about shaping early access dynamics. When payers start from a reasonable, well constructed policy, launches are less likely to pick up unnecessary restrictions that are difficult to unwind later. For a strategy that requires minimal effort and no change to core launch execution, that alone makes it worth considering.

About the Author

The issue was that I selling a product for around 20 dollars. When you factor in ad costs of over one dollar per click, plus shipping, packaging, and product costs, I needed a conversion rate of 10 percent, which is extremely high. That experience taught me something obvious but powerful. The economics of advertising favor high margin products.

A mediocre digital strategy for a high-priced product can outperform an excellent campaign for a low priced one.

Working in the pharmaceutical space, this lesson stuck with me. Many pharmaceutical products cost tens or even hundreds of thousands of dollars, sometimes over one million. That means a very small conversion rate can deliver meaningful results.

Trends in Digital Marketing

To test the landscape in 2025, I tried to market a fake product to see if I could target people with a specific disease. Facebook’s policies made that nearly impossible due to strict privacy rules such as HIPAA and GDPR. I also could not target disease specific Reddit subgroups.

That said, some manufacturers seem to have found compliant ways to effectively reach patients.

On LinkedIn, I have noticed ads that appear to target prescribers but are written in ways that appeal to patients. One manufactures ad caught my attention and led to a page asking if the visitor was a patient or prescriber. The patient side included a full patient journey and educational resources. My hypothesis is that they structured the ad to legally appear prescriber focused while still engaging patient audiences in an appropriate way.

On Facebook, I saw very few pharmaceutical product ads, suggesting that Meta remains strict with its ad approvals.

On Google, many manufacturers buy top keywords related to their disease areas and create landing pages that split audiences between prescribers and patients. Clicking the patient side often leads to a journey based education site.

Reddit, however, seems to be the most open platform. It claims not to target based on user behavior, but that appears questionable. After one quick Google search about sleep apnea, my Reddit feed was full of sleep apnea ads. I spent an hour browsing my Reddit feed for the sole purpose to see how many ads would be shown and saw SEVEN separate ads for pharma products in that one sitting. I included a few below.

If it is compliant, more manufacturers should consider taking advantage of Reddit’s advertising opportunities. With such high product prices and small conversion thresholds, the ROI potential is enormous. I have had a Reddit account for over six years, and this is the first year pharma ads have been consistently visible. As long as manufacturers and Reddit remain within regulatory guidance, this trend will likely continue.

Creative Strategies I Have Seen

I discovered one of the most unique digital strategies I have ever seen this year.

A company purchased their products disease name URL. Example www.DiseaseName.com, not the manufacturer’s name, and built a site that looked like a patient support community. In reality, it funneled patients toward the company’s product website and featured a video detailing the patient journey. I wanted to include the manufacture, but I am certain they do not want any public attention. If you like this post (or reach out to me for it) I will send you the link in a follow-up email so you can see what the manufacture did.

I do not know the exact economics behind this approach, but the strategy likely delivered a positive return on investment. Legality may vary depending on the claims and disclosures used, but for smaller companies operating within fair balance and regulatory rules, unbranded awareness sites could be a creative approach to engage patients responsibly.

Conclusion

Facebook remains difficult for advertising. Google performs as expected with manufacturers buying key disease terms. Reddit currently appears wide open and full of opportunity. On LinkedIn, ads can be positioned for prescribers but written in a patient friendly way to reach both audiences.

For smaller companies, buying a disease named domain and building a patient support site that funnels to your brand page could be an efficient strategy if done within legal boundaries.

Digital marketing is not something I offer my clients, but from a financial standpoint, more manufacturers should consider using these tools. With high product prices and small conversion thresholds, even a few additional patients can create a significant return on investment.

My articles are meant to be shared, feel free to forward this along to the marketing department or other colleagues if you think it would be helpful.

For current subscribers, I am also offering a complimentary 19-minute briefing for you and your team. If you would like to go deeper on AFPs or ask specific questions, reach out via email or LinkedIn to schedule time. I’ve delivered this briefing in paid settings previously; there’s no upsell and nothing held back.

What Are Alternative Funding Programs

Alternative funding programs are vendors that promise employers savings on specialty drugs. They do this by taking advantage of gaps in the pharmacy benefit system. They remove certain drugs from insurance coverage, make patients look uninsured for those drugs, and then try to get the product for free through manufacturer patient assistance programs or find cheaper versions in other countries. These programs can lower what employers and patients pay, but they largely do it by shifting more of the cost onto the manufacturer through patient assistance.

Some programs target lower income but insured patients and tell them they will get the medication for free. Once the drug is carved out of coverage, the patient can be pushed into a patient assistance program that was never meant for insured people. Another method is helping patients get medication outside the United States. Patients can bring in a ninety-day supply for personal use, but organizations cannot import drugs. These programs work around that by pointing patients to places like Turkey or the United Kingdom.

People in pharma say these programs can be unsafe and fall into legal gray areas. Supporters say drug prices are too high and these programs help patients get treatment. Some people online say they will take the risk if it means lower cost.

Why AFPs Matter for Strategy

In my last article, I wrote that many launches miss goals because teams are not aware of market access barriers. AFPs are one of those barriers. Even some PBMs do not fully understand how they work, and many pharma launch teams only see the impact once performance drops.

What This Means for Your Business

The larger your patient assistance program is, the bigger the impact AFPs can have. You need to know what percent of insured patients are getting carved out.

Here is the example that makes this real:

If your drug is priced at one hundred dollars and twenty percent of patients get it through a program that sources it for ten dollars, your average revenue falls to eighty two dollars per patient. Across many patients, this adds up fast.

International price differences can also matter later in launch. This usually does not affect early revenue because most products launch in the United States first, but it becomes relevant once the drug is available and priced overseas or in an extended indication.

What Manufacturers Are Doing

One legal example is AbbVie Inc versus Payer Matrix. Several companies including Genentech, Eli Lilly, and Johnson and Johnson have changed patient assistance rules so patients involved with AFPs no longer qualify. Manufacturers are also likely putting more effort into state and federal policy. They are raising safety concerns, especially the chance of unsafe medication when drugs are sourced outside the United States. There have been no confirmed cases yet, but one example would shift the entire discussion.

AFPs will likely keep growing with cost-focused employers unless rules change. This is why manufacturers are tightening eligibility, joining more policy discussions, and watching foreign sourcing closely.

How AFPs Impact Launch Performance

Launch teams need to understand how AFPs change early launch results. When insured patients get carved out and placed into manufacturer assistance, spending grows faster than expected. Revenue does not match patient demand. What looks like strong demand may not convert into sales. Many companies that launched in recent years likely did not plan for these shifts. I expect more companies will be caught off guard if they do not include AFPs in launch planning, especially for drugs priced far above global markets.

Where AFPs Are Heading

Three years ago, I wrote an article on this topic and I thought these programs would stay small. I assumed that if they used money meant for uninsured patients, advocates would push back, and that foreign sourcing would be too hard to scale. That was only partly true. The financial incentive is stronger than expected. If an employer can avoid paying tens of thousands of dollars for one patient, they will consider these programs. More vendors entered the space, and AFPs are now big enough for manufacturers to notice real access and forecast issues.

AFPs will likely keep growing unless states or federal agencies set clearer rules. This is why manufacturers are tightening eligibility, getting more involved in policy, and tracking sourcing risks. This debate will continue to focus on who patient assistance is supposed to support. Advocacy groups want funds to go to uninsured patients. Employers want lower spend. Manufacturers have more influence, but they need to balance access and affordability. These programs make many people uncomfortable, and that alone keeps pressure on them. One safety issue would change everything. Manufacturers will keep updating eligibility rules, improving support programs, and working with regulators.

AFPs are no longer hidden. They now affect launch planning, forecasting, and patient support. Companies that do not plan for their impact may hurt their launch performance. You do not need to be an expert on AFPs, but you do need to plan for them.

About the Author

According to Deloitte “One third of today’s drug launches miss expectations, according to the analysis of 284 new drugs approved in the United States between 2012 and 2021.”
(Source). This is in line with other reports.

So why do a sizable percentage of pharmaceutical products miss their launch goals? Most consultancy firms highlight market access as a main driver and then try to pinpoint it to one specific reason, but in reality, there are several factors at play.

One of the biggest mistakes in market access is not shaping the planning for a pharmaceutical launch early enough.

Here are some of our key observations on why market access can end up as an afterthought:

1. Lack of Market Access Focus from the Executive Team

Many executive teams do not come from a market access background. Executives, and especially chief executives, often have a commercial background. They have to sell to investors, sell to raise money for their product, and sell the company vision. Market access is complex, and they often underestimate the barriers they will face.

2. Hesitant to Spend Money

Bringing a product to market is a major investment. Smaller companies that are not yet cash positive are often very mindful with budgets and delay investing in market access teams or payer research. Many prefer to wait until just before approval, but by that point it is likely to be too late to gather the insights that are needed.

3. You Cannot Address Barriers You Are Not Aware Of

Companies are often unaware of many market access barriers they will face. If you are not aware of an issue, you cannot solve it. When Priority Healthcare Consulting reviewed barriers with more than twenty different market access leads and discussed ways to speed up medical exceptions at launch, many were surprised to learn that even a product superior to a competitor can be blocked from coverage at launch until a decision is made by the P&T committee. This is counterintuitive to many teams but happens frequently.

4. Overconfidence and not Connecting Research to Market Access

One of the biggest problems is that executives and strategy leaders have too many other areas to prioritize. By the time they look into market access, it is often too late to address the barriers they will encounter. We have seen companies start payer research only a few months before launch, at which point it is nearly impossible to make meaningful changes.

Market access teams sometimes overplay small attributes, only to find after launch that what they thought justified a premium is viewed very differently by payers. At the same time, while R&D teams are experts with clinical trials, they tend to have little knowledge on what endpoints and data will be essential to grant the desired market access outcome. When these two teams talk early, clinical trial design can be optimized for payer requirements. We think here is really where one of the biggest disconnects happen!

5. Planning in Silos

Many pharma brands don’t fail because of weak data. They fail because Commercial, Medical, and Market Access plan in silos. It’s not about skill. It’s about cross-functional collaboration and how early it starts. Many times, the forecasting & planning teams do not collaborate with the market access teams and have only a basic understanding of market access. Their focus is primarily on forecasting expected sales, while the market access team focuses on securing optimal coverage. As a result, forecast teams often fail to correctly incorporate the impact of payer restrictions, access barriers, and reimbursement dynamics into their models, leading to overly optimistic projections.

“Great science alone doesn’t win. Success happens when the teams build the plan together. Not when they “align later.” If your teams aren’t building the plan together, they’re building separate futures.” -Verena Langsdorf

Conclusion

If we were the CEO or market access lead of a company, we would make market access a priority much earlier and do the following:

· Ensure that market access, commercial and medical align on the brand story early, build the overall plan together from day one and connect their individual plans to it.

· Make the teams review the phase III clinical trial design together and settle on clinical endpoints that 1) underline the unique benefit of the brand 2) strengthen the value proposition and 3) are considered important and relevant for payers

· Invest in market access and pricing dynamics at least 18 months before phase three. Engage with payers early and get their input into the planned endpoints. Get them to highlight any gaps or areas of improvement they see to avoid restrictions later.

Investing early in market access pays off. Once payers make a decision that is less favorable than expected, it becomes almost impossible to change their minds later.

About the Authors