The framework
The 5 Layers of GTN™
How commercial decisions become the Gross-to-Net number, one layer at a time. Taught in full here as Side B of the NextGen GTN™ curriculum.
The short answer
What are the 5 Layers of GTN™?
The 5 Layers of GTN™ are the five sequential, causal layers through which commercial decisions become the Gross-to-Net number: Layer 1 Clinical and Product Foundation, Layer 2 Access and Policy, Layer 3 Channel and Distribution, Layer 4 Affordability and Patient Support, and Layer 5 Financial Visibility and Enterprise Performance.
Each layer flows into the next. The label and clinical position set what access is possible. Access and policy set which contracts and what government pricing exposure follow. Channel design sets who takes title and what chargebacks look like. Affordability and support design determine whether coverage converts to a filled prescription. Only then does the number become visible to Finance.
Treating Gross-to-Net as a Layer 5 problem means managing the echo instead of the event.
That is why a problem that surfaces in Layer 5 was almost always created in Layer 2, 3 or 4. The layer that notices a variance is rarely the layer that caused it.
The shape of it
Five layers, ten exits, one number
Each layer answers one question about the patient. Ten patient exits land across the first four layers. The fifth catches none of them directly and inherits all of them.
Layer by layer
What each layer decides, and how it shows up in Gross-to-Net
Layer 1 · Clinical & Product
Where the number is first imagined
What it decides. The label and the clinical position. Together they set what access is possible later and define the patient population the forecast is built on.
Exits that land here. 01 Diagnosis and 02 Provider Access.
How it shows up in Gross-to-Net. As a population that was forecast and never located. Every later variance then gets explained by uptake, price or channel, because those are the only variables anyone can still see.
Layer 2 · Access & Policy
Whether the patient is permitted to get there
What it decides. Formulary position, the contracts and rebates that buy it, the utilization management that comes with it, and government pricing exposure.
Exits that land here. 05 Coverage and 06 Authorization.
How it shows up in Gross-to-Net. As rebates paid for access, and abandonment during a wait nobody owns. You bought the formulary position. The utilization management came with it.
Your approval rate is not your access rate. It describes the prescriptions that survived long enough to be measured.
Layer 3 · Channel & Distribution
How it physically reaches them
What it decides. Who takes title, which distribution and specialty pharmacy partners carry the product, and where care is delivered.
Exits that land here. 03 Prescription Creation and 08 Fulfillment.
How it shows up in Gross-to-Net. As chargebacks, 340B and fees, plus site-of-care drift that moves your net price without anyone changing a price.
Layer 4 · Affordability & Support
Whether they can afford to start and stay
What it decides. Copay assistance, patient support program design, and how enrollment and follow-up actually work for the patient.
Exits that land here. 04 Enrollment, 07 Affordability, 09 Patient Engagement and 10 Therapy Initiation.
How it shows up in Gross-to-Net. As copay and program spend, and approved patients who never convert to a first fill. Four of the ten exits land here, twice as many as any other layer, and this is the layer owned by a function that is not measured on Gross-to-Net.
Layer 5 · Financial & Reporting
What all of it did to net revenue
What it decides. How the result is accrued, reconciled, reported and explained.
Exits that land here. None directly. It inherits all ten.
How it shows up in Gross-to-Net. As the consequence of every exit, months later, as a single number Finance is then asked to explain. Layer 5 does not have a measurement problem. It has a measurement inheritance.
Using the framework
Read a variance upstream, not where it surfaced
The layers are a diagnostic order. Start where the number moved, then walk back to the layer that made it possible.
- Name the variance. Start with the line in Gross-to-Net that moved: a rebate accrual, a chargeback rate, copay spend, or a gap between approvals and first fills.
- Trace it to the layer that created it. Rebates paid for access sit in Layer 2. Chargebacks, 340B and fees sit in Layer 3. Copay and program spend sit in Layer 4.
- Name the patient it depends on. Every line in the number is justified by a patient who had to get through the exits to become revenue. Find the exit where they left.
- Name who owns the transition. Most leaks sit between functions that are each correct about their own segment. The fix belongs to whoever owns the handoff.
The Knowledge Library works the same way. Every article is filed by the layer that created the problem rather than the layer that noticed it.
Two sides of one journey
How the 5 Layers of GTN™ pair with the 10 Exits of Therapy™
The 10 Exits of Therapy™ describe the patient's path. The 5 Layers of GTN™ describe the same journey as the enterprise records it.
In the NextGen GTN™ curriculum, Side A follows the 10 Exits of Therapy™ and Side B follows the 5 Layers of GTN™. The two sides pair by topic.
| Layer | Exits of Therapy that land there |
|---|---|
| 1 Clinical & Product | 01 Diagnosis, 02 Provider Access |
| 2 Access & Policy | 05 Coverage, 06 Authorization |
| 3 Channel & Distribution | 03 Prescription Creation, 08 Fulfillment |
| 4 Affordability & Support | 04 Enrollment, 07 Affordability, 09 Patient Engagement, 10 Therapy Initiation |
| 5 Financial & Reporting | None directly. Inherits all ten. |
Canonical definition: The 5 Layers of GTN™ in the Patients + Profitability™ Glossary. The philosophy behind both frameworks: The NextGen GTN™ Philosophy. The other side of the journey: The 10 Exits of Therapy™.
Take the layers into the room.
The webinar series teaches both sides of the curriculum. Alignment Labs put the people who own each layer in the same room until they agree who owns what.
Frequently asked questions about the 5 Layers of GTN™
What are the 5 Layers of GTN™?
The 5 Layers of GTN™ are the five sequential, causal layers through which commercial decisions become the Gross-to-Net number: Layer 1 Clinical and Product Foundation, Layer 2 Access and Policy, Layer 3 Channel and Distribution, Layer 4 Affordability and Patient Support, and Layer 5 Financial Visibility and Enterprise Performance.
Why are the 5 Layers of GTN™ sequential and causal?
Each layer flows into the next. The label and clinical position set what access is possible, access and policy set the contracts and government pricing exposure that follow, channel design sets who takes title and what chargebacks look like, and affordability and support design determine whether coverage converts to a filled prescription. A problem that surfaces in Layer 5 was almost always created in Layer 2, 3 or 4.
Which layer carries the most patient exits?
Layer 4, Affordability and Support. Four of the 10 Exits of Therapy™ land there: Enrollment, Affordability, Patient Engagement and Therapy Initiation. That is twice as many as any other layer, and it is owned by a function that is not measured on Gross-to-Net.
Why does Layer 5 catch no exits directly?
Layer 5, Financial and Reporting, receives the consequence of every exit months later, as a single number it is then asked to explain. It does not have a measurement problem. It has a measurement inheritance.
How do the 5 Layers of GTN™ relate to the 10 Exits of Therapy™?
The 10 Exits of Therapy™ describe the patient path. The 5 Layers of GTN™ describe the same journey as the enterprise records it. In the NextGen GTN™ curriculum, Side A follows the exits and Side B follows the layers, and the two sides pair by topic.
Who created the 5 Layers of GTN™?
Patrick R. Coyle created the 5 Layers of GTN™ as Side B of the NextGen GTN™ curriculum. The canonical definition lives in the Patients + Profitability™ Glossary at patrickrcoyle.com.
Definitions of the terms used here: the Patients + Profitability™ Glossary.