The framework
The 10 Exits of Therapy™
Where patients leave between a diagnosis and a sustained start on therapy, and where forecast revenue leaves with them.
The short answer
What are the 10 Exits of Therapy™?
The 10 Exits of Therapy™ are the ten sequential points at which a patient can delay or discontinue between diagnosis and a sustained start on therapy: Diagnosis, Provider Access, Prescription Creation, Enrollment, Coverage, Authorization, Affordability, Fulfillment, Patient Engagement and Therapy Initiation.
Three of the ten happen before a prescription exists and seven happen after it is written, which is why a forecast built on prescriptions alone misses most of the journey.
Each exit is a place a patient can leave and, at the same moment, a place forecast revenue fails to arrive.
The framework gives every exit a measurement, so the leak can be seen, sized and assigned to an owner instead of being explained after the fact.
The shape of it
Ten exits, in order
The order matters. Each exit has to clear before the next one becomes the problem.
Exit by exit
What happens at each exit, and where it lands in Gross-to-Net
Exit 01 · Diagnosis
No diagnosis, no prescription, no record the patient existed
For the patient. Nobody has put a name to it yet, so nothing downstream can start.
For the manufacturer. The patient has not been identified. Without a diagnosis there is no eligible patient, whatever the forecast assumed.
Where it lands. Layer 1 · Clinical & Product.
Exit 02 · Provider Access
The delay begins before your product is ever considered
For the patient. The clinician who treats this is booked out, or is not in your network.
For the manufacturer. The patient cannot reach a clinician who treats the condition. Wait times, distance and network design all remove patients here.
Where it lands. Layer 1 · Clinical & Product.
Exit 03 · Prescription Creation
Fills that stall before the pharmacy ever sees them
For the patient. The decision was made in the room. The prescription never left it.
For the manufacturer. The treating clinician has decided, and the prescription is never written or never reaches a pharmacy that can fill it.
Where it lands. Layer 3 · Channel & Distribution.
Exit 04 · Enrollment
The program you funded only works for patients who finish the forms
For the patient. A program needs a form, and nobody told you the form existed.
For the manufacturer. The patient never enters the support program that was built to carry them through the steps that follow.
Where it lands. Layer 4 · Affordability & Support.
Exit 05 · Coverage
Your contract decides who is allowed to start
For the patient. Your plan will not pay for that one, or wants something else first.
For the manufacturer. The plan does not cover the product, or requires another therapy first.
Where it lands. Layer 2 · Access & Policy.
Exit 06 · Authorization
A wait with no clock, and no owner watching it
For the patient. A review is running somewhere, and nobody is watching the calendar.
For the manufacturer. A prior authorization is required and it stalls, is denied, or is abandoned before a decision. Your approval rate is not your access rate. It describes the prescriptions that survived long enough to be measured.
Where it lands. Layer 2 · Access & Policy.
Exit 07 · Affordability
A deduction you fund, spent on patients who may still leave
For the patient. The number at the counter changed and nothing about the medicine did.
For the manufacturer. The out-of-pocket cost at the counter is more than the patient can or will pay.
Where it lands. Layer 4 · Affordability & Support.
Exit 08 · Fulfillment
Approval is not arrival
For the patient. The pharmacy cannot get it, or cannot get it to you.
For the manufacturer. The product cannot be dispensed or delivered in time through the channel the patient was sent to.
Where it lands. Layer 3 · Channel & Distribution.
Exit 09 · Patient Engagement
Approved patients who never start, for want of a returned call
For the patient. The first fill happened. Nobody checked whether the second one did.
For the manufacturer. The first fill happens and the next one does not, and no one is watching for the gap.
Where it lands. Layer 4 · Affordability & Support.
Exit 10 · Therapy Initiation
The last exit, and the one nobody is measured on
For the patient. The medicine is in your kitchen, and it is still unopened.
For the manufacturer. The product is in the patient’s hands and the first dose is never taken.
Where it lands. Layer 4 · Affordability & Support.
Using the framework
Start at the first exit, not the loudest one
The exits are sequential, so the earliest one where patients are leaving is the one worth working on first.
A fix at Exit 07 does nothing for a patient who left at Exit 05. Find the earliest exit where patients are leaving, give it a measurement and an owner, then move downstream.
Two sides of one journey
How the 10 Exits of Therapy™ pair with the 5 Layers of GTN™
The exits follow the patient. The layers follow the money. Side A counts. Side B prices the same figures.
Side A of the curriculum teaches the 10 Exits of Therapy™ to commercial teams. Side B teaches the 5 Layers of GTN™ to finance teams. Every exit lands in a layer, so the two sides describe one journey.
Canonical definition: The 10 Exits of Therapy™ in the Patients + Profitability™ Glossary. The philosophy behind both frameworks: The NextGen GTN™ Philosophy.
Take the exits into the room.
The webinar series teaches both sides of the curriculum. Alignment Labs put the people who own each exit in the same room until they agree who owns what.