Gross-to-Net Was Never About the Numbers. It Was Always Patients + Profitability™.

The short version: revenue leakage declines because patient leakage declines first. Gross-to-Net is the financial record of every commercial decision that touched the patient journey, so the fastest way to improve it is to name the three worst friction points in that journey, quantify the net-price impact of each, and remove them.

For much of my career, Gross-to-Net was viewed as one of the last stops in the commercialization process. It lived quietly within Finance, emerging at month-end through accruals, reconciliations, rebates, chargebacks, and government pricing calculations. Success was measured by how accurately organizations could explain what had already happened.

At the time, that made perfect sense. GTN reflected the financial consequences of commercial decisions that had already been made.

What Gross-to-Net Actually Is

It is worth being precise about what Gross-to-Net actually is. GTN is the average net price a manufacturer keeps per unit after all of the drug-channel and healthcare-segment deductions are taken out: rebates, chargebacks, discounts, copay assistance, 340B, fees, and returns. But even that undersells it. GTN is really about recognizing the revenue you expect from a patient before you ever see them show up at a pharmacy or in a clinic. It is a price placed on a relationship that has not yet happened.

The scale is not incidental. Drug Channels Institute estimates that manufacturers' total Gross-to-Net reductions across brand-name drugs reached $416 billion in 2025, up from $356 billion in 2024. That is the annual distance between what the industry lists and what it actually keeps.

Looking back, I believe we misunderstood what GTN really was.

What We Misunderstood

GTN was never simply measuring financial outcomes. It was measuring the cumulative effect of thousands of commercial decisions made across an organization. Every contracting strategy, every distribution choice, every patient support program, every affordability initiative, every pharmacy relationship, and every payer negotiation ultimately converged in one place. GTN became the financial language of commercialization, even though we continued to treat it as an accounting function.

The industry has spent decades becoming remarkably good at explaining yesterday while investing far less energy in understanding what is happening today.

That distinction is becoming increasingly important.

Commercialization has grown dramatically more complex. Patients navigate increasingly fragmented journeys. Pharmacies have evolved into sophisticated clinical and financial intermediaries. Payers continue to redesign benefit structures. Copay maximizers, accumulators, alternative funding programs, 340B evolution, vertical integration, direct-to-patient models, and artificial intelligence are reshaping the environment faster than many organizations can redesign their operating models.

Yet many manufacturers still organize themselves as though each of these challenges belongs to a different department.

Each function performs exceptionally well within its own responsibilities, but the patient experiences none of those organizational boundaries. Neither does the financial outcome. The patient experiences one journey, and the organization ultimately experiences one Gross-to-Net.

The Future of GTN Is Alignment, Not Accounting

This is why I have increasingly come to believe that the future of GTN has very little to do with accounting.

Its future lies in organizational alignment.

One of the greatest misconceptions in healthcare is that patient access and profitability exist in tension with one another. My experience has consistently suggested the opposite. Organizations that reduce friction throughout the patient journey often create greater predictability throughout the commercial model. Therapy begins sooner. Persistence improves. Forecasts become more reliable. Commercial investments become more intentional. Revenue leakage declines because patient leakage declines first.

Patients and profitability are not competing objectives. They are reflections of the same system functioning well, or functioning poorly.

The industry data supports this. IQVIA Institute research found that roughly 9 percent of new prescriptions are abandoned at the pharmacy counter, but that figure climbs to approximately 45 percent once the patient's out-of-pocket cost exceeds $125, and above 60 percent once it exceeds $500. In the year that analysis covered, that 9 percent amounted to roughly 634 million prescriptions left at the counter. Those are not accounting events. They are patients deciding, at a counter, that they cannot proceed. Every one of them eventually arrives in a forecast.

What This Looked Like in Practice

Let me make that concrete, because I lived it. One of the first things we did when I became a CFO was step back and look at how the patient journey around one of our medicines had actually evolved, not through any fault of the brand, but in the real world. The therapy had moved into specialty pharmacies that, through no fault of their own, did not yet have deep clinical experience managing a serious adverse event like hand-foot skin reaction. So when a patient developed it, the instinct was to wait for the next oncologist visit rather than to act. And for a patient in pain, waiting too often meant abandonment.

On the P&L, that abandonment looked like softening persistence and a forecast that missed. But that was the echo, not the event. The event was a patient walking away from a therapy that was working. So we treated it as a journey problem rather than a finance problem. We connected those patients directly with support, and we equipped the pharmacies to make the right call to the physician and get the titration right rather than stop, so that a manageable side effect became a dose adjustment instead of a discontinuation. Patients stayed on therapy. Outcomes improved. And the revenue leakage we had been struggling to explain in the accrual simply declined, because the patient leakage declined first.

The most important thing we gave those patients was not persistence, or net price, or a cleaner forecast. It was hope. For anyone who knows the medicine, that word is fitting: HOPE is the name of one of lenvatinib's own trials.

It is worth knowing what that trial actually was. HOPE enrolled 52 patients with anaplastic thyroid cancer across 17 institutions. Anaplastic thyroid cancer is one of the most aggressive malignancies in medicine. One-year survival in the study was under 12 percent. The investigators called it HOPE anyway.

I have thought about that choice for a long time. They did not name the trial for what the data were likely to show. They named it for what they were trying to give the patient.

Somewhere between that trial and the pharmacy counter, we change vocabularies. We begin saying adherence, persistence, conversion, capture, leakage. None of those words are wrong. I use them constantly, and the chart below is drawn in exactly that language. But every one of them describes the patient from the outside, as volume the enterprise is trying to hold onto.

Both descriptions are true. They are the same event viewed from two positions. A patient who stops therapy in month three is a persistence event in a forecast and a person who ran out of reasons to keep going at their own kitchen table. The bucket leaks and someone loses hope. Same moment, described twice.

You do not stop the leak by staring at the leak.

What I have learned is that you can only fix it from one of those two positions. You do not stop the leak by staring at the leak. You stop it by asking why that particular patient ran out of reasons, and then removing whatever it was. Sometimes it is money. Sometimes it is a side effect no one prepared them for. Sometimes it is twelve days of silence after a prior authorization.

Fix those, and the bucket stops leaking. In that order. Never the reverse.

Hope is not a soft word in this business. It is the thing that has to survive every hand-off in the journey. When it does not, nothing downstream works. Not the outcome. Not the forecast. Not the Gross-to-Net.

A brand's prescriptions leak at every point of patient friction.

Before AI Can Help, the Organization Has to Agree

Artificial intelligence will undoubtedly accelerate this transformation, but I believe many organizations are asking the wrong question. The conversation often begins with which models to deploy or which processes to automate. Those are important questions, but they are not the first questions.

Before artificial intelligence can make better decisions, organizations must first agree on what defines a better decision.

AI cannot align an organization that remains fundamentally disconnected.

It cannot reconcile competing incentives between Finance, Commercial, Market Access, Trade, Patient Services, Government Pricing, and Operations. It cannot replace leadership. It cannot create a shared understanding of the assumptions that drive commercialization. Those responsibilities remain uniquely human.

What AI can do is amplify organizations that have already achieved alignment. It can connect patient journey signals, pharmacy behavior, payer dynamics, channel performance, affordability programs, forecasting assumptions, and financial outcomes into a continuously learning system that allows leaders to recognize change before it becomes financial leakage. But amplification cuts both ways. Point that same capability at an organization that is not aligned, and it will industrialize the misalignment: faster, at scale, with more confidence and less accountability.

The Harder Frontier Is Continuity

Which is why the harder frontier is not artificial intelligence at all. It is continuity. As manufacturers finally begin engaging patients directly, they do it through many hands: ten vendors hired to solve ten slices of a single journey, each capable within its own slice and, by design, disconnected from the rest. What breaks is the journey itself. At every hand-off the patient is effectively re-tokenized, a new identifier standing in for them at each vendor, and unless those tokens are deliberately reconciled, the thread of their data is cut, so each touchpoint begins again rather than building on the one before it. Left unmanaged, those seams harden into data gaps. And when you point AI at a process stitched together from gaps, it does not fail quietly; it hallucinates the operation, confidently narrating hand-offs, statuses, and outcomes that never occurred, because no single entity holds the whole. Governance is what closes those seams. It has to be built in by contract, by design, by training, and by culture, all at once, so that one entity maintains continuity across every hand-off, and the intelligence built on top of it is describing something real.

Human Intelligence First. Then Artificial Intelligence.

This is where most of the industry has the sequence backwards. Nearly every large organization I speak with is out shopping for an AI-enabled GTN solution, whether a model, a platform, or a copilot, as though the technology itself were the missing piece. It rarely is. What is missing, almost always, is the human intelligence to connect the patient and profitability journey in the first place: to define what a good decision looks like, to reconcile the hand-offs, to keep the entire journey in a single frame. That work cannot be bought as software. But do it, and artificial intelligence finally becomes worth deploying, because now the large language models you point at the problem have a coherent, connected reality to learn from. They stop hallucinating, because there are no gaps left for them to invent across, and their output arrives in a form a human can actually read, trust, and act on. The order is everything: Human Intelligence first, to connect the journey; then Artificial Intelligence, to scale it. Reverse it, and all you have automated is the confusion.

From What Happened to What Should We Do Next

That represents a profound shift in thinking.

That evolution is larger than GTN. It represents the emergence of a new commercialization operating model.

Patients + Profitability™

Over the past several years, my own thinking has continued to evolve beyond GTN itself. I no longer view commercialization as a collection of independent functions. I see it as an interconnected system where every commercial decision ultimately influences both the patient's experience and the financial sustainability of innovation. When those two outcomes improve together, organizations become more resilient, launches become more successful, and innovation becomes more sustainable.

That philosophy became the foundation for everything I have since built. Patients + Profitability™ is the belief that better patient outcomes and stronger financial performance are not competing ambitions. They are the natural result of better commercialization.

Where to Start on Monday

Prior authorization is the clearest case. A study published in JAMA in July 2026, analyzing more than two million attempts to fill single-source brand-name prescriptions, found that initial rejections rose from 24.3 percent in 2018 to 40.7 percent in 2024. Nearly half of those rejected attempts, 48.4 percent, were never followed by a fill of the prescribed medicine or a same-class alternative within 90 days. The patients who did eventually get treated waited an average of 12 days after that first rejection. Twelve days is not an administrative statistic. It is a patient in pain, waiting.

If you lead a brand or a P&L and you want somewhere to start on Monday, it is simpler than it sounds. Map the three worst points of friction in your patient's journey: the prior authorization that drags, the copay that surprises, the side effect no one prepared them for, the hand-off that quietly drops. Then put a net-price number on each. That number is your Gross-to-Net, told forward instead of backward. Then go fix the friction. The finance tends to take care of itself.

Where This Is Heading

I believe that is where our industry is heading, not toward better accounting, but toward better alignment. Not toward isolated technologies, but toward intelligent systems that connect every commercial decision back to the patient.

Because GTN was never just about the numbers.

It was always about understanding the journey that created them.

And perhaps, after all these years, that journey has always been about something much bigger than Gross-to-Net.

It has always been about Patients + Profitability™.

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Sources and Notes

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.