From Data Gaps to Revenue Gains: Harnessing the Power of Comprehensive Data to Drive GTN

Today's guest post comes from Thomas Luby, Sr. Vice President, Business Development at PHIL.

Thomas discusses the challenges brands face as they manage gross-to-net (GTN) performance while simultaneously enhancing patient access and adherence. He lists the key performance indicators that can help brands improve GTN.

To learn more, watch PHIL’s free on-demand webinar: Four Patient Access Barriers to Address for High-Impact Programs.

Read on for Thomas's insights.

From Data Gaps to Revenue Gains: Harnessing the Power of Comprehensive Data to Drive GTN
By Thomas Luby, Sr. Vice President, Business Development at PHIL

Growing market access barriers are compelling retail and specialty-lite pharmaceutical manufacturers to seek new approaches to optimize revenue and enhance patient access. Traditional data sources and siloed solutions are no longer sufficient to address the challenges of formulary exclusions and rising patient out-of-pocket costs. Success in today's market requires comprehensive visibility across the patient journey to drive meaningful improvements in gross-to-net (GTN) performance.

MARKET PRESSURES ARE RESHAPING MANUFACTURERS’ BOTTOM LINES

An increasingly complex market access landscape is putting pressure on gross-to-net (GTN) margins, creating revenue optimization challenges for pharmaceutical manufacturers. According to recent data, the total value of manufacturers’ GTN reductions for all brand-name drugs reached a staggering $334 billion in 2023, marking a 10% increase from the previous year.

There are several factors contributing to this erosion. Pharmacy benefit managers (PBMs) are tightening negotiations with manufacturers, placing more brands on formulary exclusion lists. In 2024 alone, there were at least 600 drugs excluded from the formularies of the three largest PBMs (Caremark, Express Scripts, OptumRx). To secure formulary placement, pharmaceutical companies must offer higher rebates, which sometimes reach 50% to 70% of their gross revenue.

According to a 2024 report, manufacturers spent $23 billion in 2023 on copay assistance programs to offset patient out-of-pocket costs. Pharmacy under-reimbursement–when the PBM reimburses the pharmacy less than the brand’s acquisition cost–also increases manufacturer subsidies.

In this challenging landscape, brand teams need more insight into the market access issues that are impacting patient access and adherence so they can drive GTN more effectively.

TRADITIONAL DATA SOURCES LEAVE CRITICAL BLIND SPOTS

Manufacturers are mostly leveraging a range of traditional data sources–distributors, internal sales, and pharmacies–to gain insight into their GTN performance, but they still face challenges in obtaining a full picture. Attempting to extrapolate and predict market share and territory-level information for a brand from these incomplete data sets fall short of gaining actionable insights on pivotal data points, such as:

• Provider behavior performance in completing prior authorizations (PAs), including script quality rates, average completion times, and the correlation between submission quality and approval rates
• Reasons for claim rejections, including details of formulary restrictions, step therapy requirements, and coverage limitations that may vary across payer types and geographic regions
• Rejection codes and approval/rejection timelines, along with the downstream impacts on patient initiation rates and time-to-therapy metrics

Moreover, disparate data sources often miss critical dimensions of market access dynamics, including:

• Provider office workflow bottlenecks that delay or prevent successful PA submissions
• Patient out-of-pocket variations across different plans and their effect on adherence
• Bridge program utilization patterns and their effectiveness in preventing therapy delays

Fragmented data limits manufacturers' ability to gain comprehensive insights across the prescription journey. While traditional data sources provide discrete views into prescriptions, coverage, and fulfillment, they fail to illuminate critical patterns in PA success rates, provider behavior, and patient persistence. This hampers brand teams' ability to make data-driven decisions about field team deployment, contracting strategy, and hub service design, leaving significant opportunities for improving patient access and brand performance unexplored.

THE NEW KPIS FOR DRIVING GTN

The following key performance indicators (KPIs) are essential to effective GTN management in today’s pharmaceutical landscape.

Prescriber-level metrics

• PA completion rates: Percentage of PA requests successfully completed and submitted to payers out of the total number initiated
• PA drop-off rates: Percentage of PA requests abandoned or never completed after initiation

Plan-level metrics

• PA approval rates: Percentage of approved PA requests compared to total submitted
• PA response times: Average time between PA submission and receipt of the payer's decision
• PA determination: Percentage of PAs denied due to a specific reason

Pharmacy-level metrics

• Covered dispense rates: Percentage of scripts filled and dispensed with insurance coverage
• Under-reimbursement rates: Frequency and extent to which pharmacy reimbursements fall below their acquisition cost for medications

Patient-level metrics

• Program enrollment rates: Percentage of eligible patients who enroll in the support program
• Copay card usage: Utilization rate of copay assistance among eligible patients
• Refill rates: Percentage of patients who refill their medication within the expected time frame based on their prescribed dosing schedule

Leveraging these KPIs empowers teams to improve affordable access to their brands and enhance GTN performance by making data-informed decision around:

• Improving prescriber PA submission processes
• Identifying plans not adhering to negotiated terms
• Preventing lost dispenses due to under-reimbursement
• Optimizing copay assistance programs
• Reducing nonadherence due to affordability challenges

MAXIMIZE GTN IMPACT WITH END-TO-END INSIGHT

Leveraging data-driven insights is key to ensuring patient access and optimizing GTN. The PhilRx Digital Hub empowers life sciences brands with real-time visibility into critical KPIs — at the script, provider, and territory level — helping them identify and overcome market access barriers while maximizing financial performance.

Watch this webinar to learn how to navigate today’s biggest access challenges and enable the success of your patient support programs, with experts from PHIL and Blue Fin Group.

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