Better Access. Better Outcomes. Better Business.
Healthcare innovation only creates value when it reaches the patient.
Updated September 2026
Not opposing objectives. Interdependent ones.
Patients + Profitability™ is the philosophy behind all of Patrick R. Coyle’s commercialization work. It holds that the patient journey and the economic journey are the same journey seen from opposite sides, so patient friction and revenue leakage are the same problem.
Patients + Profitability™ is built on the belief that patient outcomes and sustainable profitability are not opposing objectives. They are interdependent. Innovation creates possibility, but possibility has little value to a patient who cannot access it. Access turns innovation into treatment, treatment creates the opportunity for outcomes, and sustainable economics allow innovation to continue.
Break any one link and the loop stops. An innovation nobody can reach does not produce outcomes, and outcomes nobody can fund do not produce the next innovation.
The patient experiences healthcare as one journey even when the industry operates as many disconnected organizations, systems and transactions. Our responsibility is therefore not merely to optimize each part, but to make the entire journey work, from discovery to access to outcome, and to build a healthcare ecosystem capable of doing it again for the next patient.
The patient journey and the economic journey are not two different journeys. They are the same journey viewed from opposite sides.
The Silent Leak™
The Silent Leak™ is revenue lost to patient friction that no single function sees, because each function’s own metrics look acceptable. It is the distance between a product’s approval rate and its access rate, and The 10 Exits of Therapy™ is how it is measured.
Not denied.
Never counted.
The patients who left before any system was watching. No rejection, no appeal, no variance, because nothing about them was ever recorded. You are paying for them either way.
Your approval rate is not your access rate.
A 90% prior-authorization approval rate sounds like an effective access strategy. But it only measures prior authorizations that were actually submitted.
Proportions are illustrative. The point is not how large the uncounted group is, but that the number describes only the rightmost slice.
It tells us nothing about the patient whose PA was never started, the prescription that rejected at the pharmacy and disappeared, or the patient who abandoned before reaching the process being measured.
Your approval rate describes the survivors. Your access rate would describe everyone who needed therapy. The distance between those two numbers is the Silent Leak™, and it is where patients, and revenue, disappear together.
The 10 Exits of Therapy™
The 10 Exits of Therapy™ is a framework that maps the ten points between diagnosis and a sustained positive outcome where a patient can leave therapy, and assigns a cost to each. The ten exits are Diagnosis, Provider Access, Prescription Creation, Enrollment, Coverage, Authorization, Affordability, Fulfillment, Patient Engagement and Therapy Initiation.
The Silent Leak™, itemized. Ten points where a patient can become discouraged, delayed or disconnected. Each one is a place a patient leaves. Beneath each, in teal, is what it costs the enterprise when they do.
Diagnosis
No diagnosis, no prescription, no record the patient existed
Provider Access
The delay begins before your product is ever considered
Prescription Creation
Fills that stall before the pharmacy ever sees them
Enrollment
Patients must complete the forms to get the funding
Coverage
Your contract decides who is allowed to start
Authorization
A wait with no clock, and no owner watching it
Affordability
A deduction you fund, spent on patients who may still leave
Fulfillment
Approval is not arrival
Patient Engagement
Approved patients who never start, for want of a returned call
Therapy Initiation
The last exit, and the one nobody is measured on
If you are a patient or caregiver rather than an operator, the same ten exits are written for you at For patients and caregivers, in plain language and with no cost lines.
Ten exits, and one number that contains all of them. On the Gross-to-Net waterfall, everything above sits inside a single bar.
One bar. Ten reasons.
Every exit below is a place a patient stopped. Together they are the largest line on the waterfall, and the only one with no owner.
Ten exits, ten functions, ten systems, ten denominators. Each is right about its own segment. None holds the whole.
Four of the ten sit in Affordability & Support. Together $185K, thirty eight percent of the leakage, more than any other layer.
Diagnosis
No diagnosis, no prescription, no record the patient existed.
Symptoms are attributed to something more common. The referral is never made, or the confirming test never ordered. In rare disease this runs to years.
No claim, no chart entry, nothing to count. These patients did not leave your funnel. They never entered it.
Remaining after this exit: $904K · 904 patients
Provider Access
The delay begins before your product is ever considered.
The next appointment is weeks out. The prescriber who can write it is not in network, or not the physician the patient already sees.
Time to therapy stretches before your brand is a candidate. Whatever can start today gets tried first.
Remaining after this exit: $859K · 859 patients
Prescription Creation
Fills that stall before the pharmacy ever sees them.
Written and never transmitted. Routed to a pharmacy that cannot dispense it. Or the record system offers the alternative first, and the alternative gets signed.
Demand your promotion created, converting to someone else’s fill. The call was logged. The outcome was not.
Remaining after this exit: $825K · 825 patients
Enrollment
Patients must complete the forms to get the funding.
The form wants detail the patient does not have to hand, and a signature the office returns in its own time. It arrives when a person is least able to do paperwork.
You funded a program that only works for the patients who finish. Services reports enrollments completed, not enrollments attempted.
Remaining after this exit: $773K · 773 patients
Coverage
Your contract decides who is allowed to start.
Not covered, tiered out of reach, or a documented failure on something else required first. None of that is an accident. It is the shape of the agreement.
The one exit the manufacturer designed. Access owns the contract. Nobody owns the patient who fails its conditions.
Remaining after this exit: $735K · 735 patients
Authorization
A wait with no clock, and no owner watching it.
Documentation somebody assembles between patients. A denial on a criterion the submitter could not see. An appeal that competes with the next person in the waiting room.
No dashboard counts days elapsed, so nobody is ever late. Payer, office and hub each hold a piece, which is to say no one holds it.
Remaining after this exit: $674K · 674 patients
Affordability
A deduction you fund, spent on patients who may still leave.
The remaining cost is more than the household carries this month. The card does not apply to their plan type. The assistance caps in month seven.
A Gross-to-Net deduction already booked. You paid it, it sits in your accrual, and the patient left anyway.
Remaining after this exit: $600K · 600 patients
Fulfillment
Approval is not arrival.
The pharmacy cannot source it this week. The shipment needs a signature nobody is home for. Cold chain wants a window that does not fit a job.
Every upstream step worked and the product still did not arrive. Distribution counts shipments sent. Doses received is a different number.
Remaining after this exit: $571K · 571 patients
Patient Engagement
Approved patients who never start, for want of a returned call.
The onboarding call goes to voicemail twice and is not tried a third time. The patient is waiting to be told what happens next. It was theirs to start.
Diagnosed, prescribed, enrolled, covered, authorized, funded, shipped. Every one of those dollars is already spent. The hub closes the case as delivered.
Remaining after this exit: $532K · 532 patients
Therapy Initiation
The last exit, and the one nobody is measured on.
A self-injection nobody trained them for. A side effect profile explained once, months ago. The decision gets made in a car park by someone holding the product.
The only exit where the patient already has your product in their hand. No function is measured on whether they took it.
Remaining after this exit: $512K · 512 patients. This is the number your waterfall starts from.
The six-bar chart is the one on the NextGen GTN™ homepage. The ten bars beneath it are what the orange bar contains, and the dashed line running through them is the prescription: three of the ten happen before it exists, seven after it is written. The split across the ten, and the convention of one patient per thousand dollars of demand, are illustrative and are there to show shape, not size: no manufacturer publishes this decomposition, because no system produces it. That is the point. The government and commercial deductions have owners, accruals and auditors. The larger number to their left has none, and it is the only one of the three that a patient can feel.
Four questions beat one answer.
The Four Questions are the decision discipline Patrick R. Coyle uses in place of a single recommendation: what conditions must be present for a strategy to work, what information would improve the decision, which transition needs clearer coordination, and what other explanation should be considered.
I would rather a team carried these out of the room than carried my conclusion.
What conditions need to be present for this strategy to work?
Conditions
What additional information could improve the decision?
Information
Which transition would benefit from clearer coordination?
Transition
What other explanation should be considered?
Alternative
Every framework on this page fails the moment the fourth question stops being asked.
The philosophy is free. The application is the work.
Reading this changes nothing on its own. The same question governs every dollar of commercial spend: which patient was this justified by, and did that patient ever arrive?
The Library
Field guides, case studies and the ecosystem map, including the Product Lifecycle Phases.
The enterprise view
Where the ten exits land inside the enterprise, and why a problem that surfaces in reporting was created somewhere else.
Learn, align, transform
The curriculum teaches it, the Alignment Labs™ put the people who own each transition in one room, and the advisory work applies it.
Better Access. Better Outcomes. Better Business.
Healthcare innovation only creates value when it reaches the patient.
Frequently asked questions about Patients + Profitability™
What is Patients + Profitability™?
Patients + Profitability™ is the philosophy that patient outcomes and sustainable profitability are interdependent, not opposing. Innovation creates possibility, access turns it into treatment, treatment creates the opportunity for outcomes, and sustainable economics allow innovation to continue. Break any one link and the loop stops. The patient journey and the economic journey are the same journey viewed from opposite sides.
What is The Silent Leak™?
The Silent Leak™ is the population of patients who leave therapy before any system records them. They are not denied. They are never counted. Because approval metrics only capture prior authorizations that were submitted, an organization can report a healthy approval rate while losing patients it never saw. It is usually the largest line on the revenue waterfall with no assigned owner.
What are The 10 Exits of Therapy™?
The 10 Exits of Therapy™ are the ten sequential points where a patient can delay or discontinue: Diagnosis, Provider Access, Prescription Creation, Enrollment, Coverage, Authorization, Affordability, Fulfillment, Patient Engagement and Therapy Initiation. Three happen before a prescription exists and seven happen after it is written. The framework gives each exit a measurement so the leak can be seen, sized and owned.
Why is approval rate not the same as access rate?
Approval rate measures the prior authorizations that were submitted and approved. Access rate measures how many diagnosed patients actually started and stayed on therapy. The gap between them is every patient who exited before a request was ever filed. A manufacturer can have a high approval rate and a low access rate at the same time.
How does patient friction show up in Gross-to-Net?
Patient friction creates revenue leakage. Every exit that goes unmeasured becomes an unexplained variance somewhere downstream: in accruals, in true-ups, in copay and support spend that never converted to a filled prescription. Gross-to-Net is the financial echo of how well the enterprise executed the patient journey, which is why the number cannot be fixed inside finance alone.
Who is Patients + Profitability™ for?
It is for commercial, finance, market access, patient services and channel leaders in life sciences who each own one piece of the same journey. Each function can be green while the aggregate is red. The philosophy gives them one shared map so the handoffs between functions become visible and accountable.
Definitions of the terms used here: the Patients + Profitability™ Glossary.