Gross-to-Net is discussed as an accounting output. It is the financial manifestation of dozens of strategic and operational decisions made long before the first prescription is written.
This post captures a session for Finance and Market Access leaders at Informa Connect on how patient support decisions become Gross-to-Net outcomes. Gross-to-Net is a lifecycle, not a calculation, and value leaks in two places: pharmacy behavior that drifts from manufacturer intent, and payer maximizer programs that shift cost back to the manufacturer. Both stay invisible until accruals rise, so the answer is to design access intentionally and hold every partner to measured accountability.
The session
A room with Finance on one side and Market Access on the other, which is the room where this argument is worth making. The subtitle on the title slide was From Commercial Strategy to Journal Entry, and that is the whole distance the session tries to close. Two days earlier at the same conference I moderated a panel on patient assistance programs under pressure. This was the session where I got to make the case directly.
The argument
Gross-to-Net is a lifecycle, not a calculation. It runs from new product pricing corridors through GPO contracting, copay programs, distribution and government pricing, and only then into accruals and journal entries. Every upstream choice shapes the financial outcome, and almost none of those choices are made by the people who eventually have to defend the number.
That produces a specific and predictable failure. Every Gross-to-Net decision becomes a financial liability that Finance inherits, often quarters after the decision was made, by which point the conversation is about the reserve rather than about the behavior that created it. Four functions are each behaving reasonably and on different clocks. Finance forecasts from historical analogs. Market Access negotiates against future market conditions. Trade manages today’s operations. Accounting trues up to what actually happened. The tension is structural, not a failure of anyone’s judgment.
What has changed
Vertical integration has moved the economics of access without any single decision announcing itself. The next advantage does not come from spending more on affordability. It comes from making sure every dollar spent actually reaches the patient, which requires intentional network design, measured independence and leadership-level accountability from the beginning rather than as a correction.
Where the value leaks
Two kinds, and they behave differently. Pharmacy leakage happens when dispensing behavior, channel steering or performance incentives drift from what the manufacturer designed. Payer leakage happens when accumulator and maximizer programs exploit copay benefits, moving cost back to the manufacturer without improving what the patient actually pays.
Neither announces itself. Leakage stays invisible until accruals rise, margins compress, or a reconciliation stops tying out. The uncomfortable version of this is that expanding access without embedded controls frequently accelerates liability faster than it accelerates revenue.
What to do about it
Taking back control does not mean restricting access or cutting patient support. It means designing access intentionally: optimizing GPO contracting to protect pricing integrity, redesigning copay benefits to reduce maximizer exposure, keeping the right to transition a patient support provider whose performance deteriorates, and preserving partner independence so that patient interests stay central while financial exposure is actively managed.
The question has shifted. It used to be, did the program help patients? It is now, can we prove every transaction was appropriate, compliant and defensible?
Watch
Two short clips from the session.
Where this connects
The ten places a patient can leave are on the philosophy page. The accrual that inherits all of this is Accrual Design, and what happens when the actuals arrive is True-Up Governance. The full speaking record is on the speaking page. The patient-side view of the same ten exits is at Where did your treatment stop? For a company doing this for the first time, with no launch history to align against, the starting position is set out in Your First Launch.
Slides shown are excerpts from the session deck. Former employers and products referenced are matters of professional history. The views expressed are my own and are not made on behalf of any current or former employer. All trademarks belong to their respective owners.