The stealth market access strategy that’s quietly making manufacturers millions

Most pharmaceutical manufacturers are unintentionally leaving tens of millions on the table.

There is an under-the-radar market access strategy that some manufacturers have implemented, but many others remain unaware of. Companies that adopt this approach often see a significant increase in sales and revenue, or at the very least, avoid missing potential revenue opportunities.

If this strategy is so lucrative, why doesn’t everyone use it?

The strategy is counterintuitive, and directly against a company’s main strategic initiatives, and there is usually a knowledge gap at the executive level on this market access topic. This strategy is negatively correlated with pharmaceutical companies’ core initiatives because it creates scenarios where revenue is optimised, but payer coverage is reduced or even eliminated.

Of the sixty different pharmaceutical companies I have worked with, nearly every client has said they are focused on increasing payer coverage and speed, regardless of the situation. That said, when executives are presented with robust financial models showing trade-offs between coverage and revenue, some are willing to consider alternative approaches. Still, if you are running market access for a pharma company and you pitch the executive team on a plan that reduces coverage without showing a clear revenue upside, that conversation is unlikely to go over well.

Also, pharmaceutical CEOs rarely come from market access backgrounds. They rely on their teams to design access strategies, and since those teams are incentivised to maximise coverage, that is what they prioritise. For these reasons, this strategy is rarely pursued, even though it can generate significant value.

What the strategy is and how it works

The strategy I am referring to is the provider push strategy.

At a high level, you weigh the value of rebate spend required to achieve a given level of coverage versus how much revenue could be retained if patients access the drug through medical exception processes. This involves evaluating:

• The cost of educating providers
• Whether providers are willing to write medical exceptions for the product
• Whether providers are more likely to follow through on rejected scripts with support, such as reimbursement specialists who guide them through the process
• Whether providing forms, payer-specific coverage guides, and exception pathways increases uptake
• Cost benefit analysis of eVoucher buy-downs for commercial patients; specialty hub and hub light solutions; third party PA assistance platforms and solutions

When the strategy works best

This strategy is most effective for competitive therapeutic areas. Payers do not value the same factors that matter to patients and providers.

For example, in therapeutic areas like Parkinson’s disease, growth hormone deficiency, or low testosterone, payers do not pay for convenience, nor do they value unique routes of administration. Indeed, payers generally ignore better patient-reported outcomes. In the growth hormone example, cheaper products require daily injections, while more expensive products are injected weekly: payers do not take into consideration patient preference, so they will not cover the weekly products without steep rebates and potential step therapy protocols, depending on rebate levels.

Providers, however, may be willing to write medical exceptions to help patients avoid daily injections, and this creates two possible scenarios to test.

First, offer large rebates to secure broad coverage, while potentially still subject to step failure conditions.

Second, offer no rebate, rely on the provider push strategy, and support exceptions.

By comparing the lost revenue from rebates with the loss of scripts due to weaker coverage, the provider push strategy can be found to yield higher net revenue. In many competitive classes, rebates must be so deep that worse coverage, offset by provider support, still results in more profit. Additionally, if providers push utilisation strongly enough, payers may eventually grant coverage even without heavy rebates, or potentially less required prior therapy failures before allowing access to a drug.

The roadmap to determine if the provider push strategy is viable is to conduct primary market research on both payers and providers, in order to understand:

• If payers are willing to accept medical exceptions, and what different step actions providers take
• If the certain disease state and target product profile of the product is strong enough
• If providers are willing to work through rejections of medical exceptions
• If these steps impact the percentage of medical exceptions accepted

Of course, actual dynamics will vary by therapeutic area. Patient advocacy, KOL influence, and local payer rules often determine how much traction a provider push strategy can achieve. Each market must be modelled carefully.

The provider push strategy remains under the radar because it goes against conventional wisdom and misaligns with standard company objectives. Yet, it has worked successfully at multiple manufacturers. The essence of the strategy is straightforward. By accepting weaker coverage, more money can sometimes be made because the revenue lost to script abandonment is smaller than the revenue saved by avoiding massive rebates.

Don’t unintentionally leave potentially tens of millions on the table: implement this under-the-radar market access strategy – work counterintuitively – and avoid missing potential revenue opportunities.

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About the author

Seamus Cole is the founder and president of Priority Healthcare Consulting. Bringing over 10 years of experience delivering strategic insights to pharmaceutical manufacturers. He has served as lead consultant for more than 60 different manufacturers on market access strategy, supporting clients across a wide range of therapeutic areas. His expertise includes payer contracting strategy, launch uptake acceleration, messaging refinement, and solving complex access and reimbursement challenges.