For more than a decade, pharmaceutical leaders have treated gross to net as a pricing problem.
The focus has been on rebates, PBMs, formulary positioning, and increasingly complex contracting strategies. Entire teams are dedicated to modeling discount structures and negotiating access. Yet despite all of this effort, the gap between list price and net revenue continues to grow.
In 2024, that gap reached an estimated $356 billion across brand-name drugs.
That number should raise an uncomfortable question. If contracting strategy alone could solve gross to net, why does the problem keep getting worse?
The answer is that gross to net is not just a pricing issue. It is also a patient behavior issue.
The part of gross to net most teams never see
Most gross to net models begin at the point of dispensing. They account for rebates, discounts, fees, and chargebacks after a prescription has been filled.
But there is a critical layer of loss that happens before any of that.
It happens when a prescription is written and never converted into a therapy.
Across therapeutic areas, a significant percentage of patients either never start treatment or discontinue early. In some categories, abandonment and discontinuation rates range from 25 percent to as high as 60 percent within the first year.
From a financial perspective, this is not just a clinical issue. It represents revenue that never materializes. A prescription exists, the commercial investment has been made, and in some cases rebate obligations are already in motion. But no net revenue is ever realized.
This is gross revenue that disappears before it even enters the gross to net equation.
Why patients are abandoning therapy
It is easy to assume that cost is the primary driver of abandonment. While affordability plays a role, the underlying cause is often far more human.
Patients are confused.
The average physician interaction lasts only a few minutes. During that time, patients are expected to absorb complex information about their condition, the mechanism of action of a therapy, potential side effects, and long-term expectations. Much of that information is not retained.
After leaving the clinic, patients begin to fill in the gaps themselves. They turn to search engines, online forums, social media, and increasingly, AI tools. The information they find is inconsistent, often biased toward negative experiences, and rarely personalized to their situation.
At the same time, the most trusted voice in healthcare, their physician, is no longer accessible. Research shows that only a small percentage of patients reach back out to their doctor when they have questions.
This creates a trust gap. Patients trust their physician the most, yet make critical decisions without that guidance.
The result is predictable. Uncertainty leads to hesitation, and hesitation leads to abandonment.
The implication for commercial teams
Every abandoned prescription represents a failure to convert intent into action. It is not just a missed opportunity for the patient. It is a direct loss of revenue.
What makes this particularly important for commercial and patient services teams is that this type of loss is avoidable.
Unlike rebates or mandatory discounts, which are structural and often non-negotiable, patient abandonment is influenced by experience, education, and timing. It sits on the demand side of the equation, not the supply side.
This is why it has historically been overlooked in gross to net strategy. It does not fit neatly into traditional financial models. But its impact is substantial.
The white paper highlights a key insight that reframes the entire issue. Every patient who abandons therapy represents gross revenue that never converts to net revenue.
When viewed this way, improving patient initiation and adherence is not just a clinical objective. It is a commercial lever.
Reintroducing the most trusted voice in healthcare
If confusion is the root cause, then clarity becomes the solution. But not all education is created equal.
Patients do not place the same level of trust in every source. They consistently rank their physician as the most trusted authority when making treatment decisions. Yet that voice is largely absent once the patient leaves the clinic.
This is where a different approach to patient education begins to emerge.
The white paper outlines how extending the physician’s voice beyond the clinical visit, through personalized and timely communication, can directly influence patient behavior. When patients receive clear, consistent guidance from their doctor at key decision points, they are more likely to initiate and stay on therapy.
This approach does more than improve understanding. It restores confidence.
What the impact looks like in practice
When patient behavior improves, the financial impact becomes measurable.
The white paper presents a conservative model based on 100,000 annual prescriptions and a modest improvement in abandonment rates. In that scenario, reducing abandonment by just 15 percent results in over $50 million in additional net revenue within the first year.
Importantly, this is not driven by increasing price or expanding access. It comes from better conversion of existing demand.
At scale, especially in high-cost and high-complexity therapies, the opportunity becomes even more significant. In some cases, the potential recovery reaches into the hundreds of millions.
This represents a different kind of growth. It is not about creating new demand. It is about capturing the value that already exists.
A shift in how gross to net is approached
The industry has spent years optimizing gross to net through negotiation. That work will continue to be important. However, it is no longer sufficient on its own.
The next phase of gross to net strategy requires a broader perspective.
It requires acknowledging that revenue loss does not begin at the rebate table. It begins at the moment a patient decides whether or not to start therapy.
By addressing the factors that drive that decision, particularly confusion and lack of trusted guidance, pharmaceutical companies can influence outcomes that were previously considered outside the scope of commercial strategy.
This is the shift from managing discounts to managing conversion.
Access the full white paper
This article highlights a key dimension of the gross to net challenge, but there is much more to explore.
The full white paper provides a detailed breakdown of the financial models, therapeutic benchmarks, and operational frameworks needed to address this issue at scale. It also outlines how physician-led patient education can be implemented in a way that aligns with commercial, medical, and regulatory requirements.
You can download the full white paper here:
The Gross-to-Net Squeeze: How Physician-Led Patient Education Reduces GTN Erosion and Recovers Net Revenue at Scale
What This Means for Pharma Leaders
Gross to net strategy is evolving, whether the industry acknowledges it or not. The companies that continue to focus only on pricing and contracting will keep fighting for incremental gains. The ones that expand their lens to include patient behavior will unlock entirely new sources of revenue.
This shift is not theoretical. It is practical, measurable, and already happening.
To move forward, commercial and patient services leaders should start asking different questions:
- Where in our patient journey are we losing the most patients before therapy even begins?
- How much revenue is tied to prescriptions that are written but never converted?
- Are we reinforcing the physician’s voice after the visit, or leaving patients to figure it out alone?
- What would happen if we treated patient understanding as a core commercial metric, not just a support function?
Because in the end, gross to net is not just about what you negotiate.
It is about what actually gets used.
And the biggest opportunity may not be in reducing discounts, but in ensuring that more patients start and stay on the therapies already prescribed.