Gross-to-net pressure has become one of the defining commercial realities in specialty pharma. According to Hoot’s latest executive briefing, manufacturers gave back an estimated $356 billion in rebates, government discounts, 340B obligations, and chargebacks before net revenue was ever recognized.
That number alone changes how commercial leaders think about growth.
The challenge is no longer just formulary access. The larger challenge is what happens after the prescription is written.
Patients are abandoning therapy before the second fill at alarming rates. Commercial teams are investing heavily to secure access, while many patients still leave the office confused, uncertain, and vulnerable to misinformation during the most important decision-making window.
Bob Miglani recently discussed this growing problem and why persistence has become one of the most important commercial conversations in healthcare today.
Bob Miglani discusses the growing “double tax” facing specialty pharma: rising gross-to-net pressure combined with patient abandonment.
The Hidden Cost Most Teams Are Still Underestimating
One of the most important points raised in the discussion is that the industry is effectively paying twice.
First, manufacturers absorb growing rebate pressure and access costs just to secure formulary placement. Then many of those same patients abandon therapy before long-term persistence ever occurs.
Hoot’s executive briefing walks through how that erosion happens in practice. A $500 list price can shrink dramatically after rebates, discounts, and other gross-to-net deductions are applied. Even after securing access, many specialty patients still abandon therapy before the second fill, creating a commercial model where revenue leakage continues long after the prescription is written.
The report also highlights the critical risk window between Days 3 and 30 post-initiation, which is often where uncertainty, fear, and misinformation begin influencing patient behavior. During that period, patients are rarely sitting with their physician. They are at home searching online, reading Reddit discussions, asking ChatGPT questions, and discussing treatment concerns with family members.
That shift has changed the economics of patient engagement entirely.
The Physician Voice Still Carries the Most Trust
Patients increasingly leave the office and search for answers elsewhere. Reddit threads, TikTok videos, Google searches, and AI-generated summaries are now influencing treatment decisions at scale.
The problem is not information scarcity. The problem is trusted communication.
The report emphasizes that patients remain far more likely to continue therapy when they feel connected to the physician who prescribed it. Physician-led education delivered through SMS and video creates continuity during the period where uncertainty is highest.
That shift changes patient education from a support function into a strategic commercial lever.
Download the Full Executive Briefing
The full Hoot briefing expands on the growing gross-to-net spread, the mounting pressure on traditional hub models, and the financial consequences of patient abandonment across specialty therapies. It also explores why persistence is becoming one of the most important metrics commercial leaders can influence in 2026 and outlines practical strategic considerations for organizations trying to protect long-term revenue retention.
Download the Briefing by Clicking Here.
The New Commercial Reality
For years, commercial teams optimized for access.
Now the organizations creating long-term growth are increasingly focused on what happens after access is granted.
Because every patient who persists represents revenue already fought for, already funded, and already earned the right to continue.