Rohit Gupta and Robert Rouse

Image Credit: Adobe Stock Images/Steve Cukrov

Priya, 38, had been living with a rare autoimmune disease for years. Finally, her rheumatologist wrote a prescription for a biologic drug that promised to restore mobility.

But it took weeks to secure authorization from her insurer and she hit other hurdles. The specialty pharmacy couldn’t source the drug, the copay cost thousands of dollars, and the shipment date was uncertain.

By the time she received the medication, Priya’s optimal treatment window had passed, leaving her frustrated and anxious.

Now, imagine if after Priya’s physician had written the prescription, she was immediately invited into a branded digital ecosystem that educated her about options. She signed an online consent and qualified for doorstep delivery, nurse on-boarding, and clear pricing.

"Manufacturers can truly win the paradigm shift from selling molecules to managing experiences, with commercial execs able to draw ever closer to demonstrating patient-centric leadership. Employers can see healthier employees and lower absenteeism. And the U.S. healthcare system could benefit from less waste, fewer intermediaries, greater transparency, lower costs, and better outcomes."

Her employer stepped in to cover the cost through a carve-out negotiated directly with the drug manufacturer. She received the drug the next day and, with patient support, adhered to therapy.

This nearly frictionless process is neither a complete reality nor a total fantasy. But it marks what could become the new frontier of pharma leadership thinking.

Pharma has traditionally operated via a value chain that moved from manufacturer to wholesaler/distributor to pharmacy to patient, with reimbursement via the payer/pharmacy benefit manager (PBM). Patients sat at the very end of that equation. Success was measured in units sold and formulary access.

Driven by rising patient expectations for convenience, transparency, and speed, as well as frustration with opaque rebates and middlemen (namely PBMs), pharma executives are considering a fresh approach. 

Here, the patient journey becomes the strategic North Star, toward which three “directs” form a continuum.

: The channel for awareness and engagement brings the patient in via a product portal, digital campaigns, or direct outreach rather than only through the physician-referral engine.

: Enables diagnosis through telehealth and gets the medicine to the door, with manufacturer (or authorized partner) handling prescription, logistics, delivery, support and monitoring.

: Secures funding, ensuring coverage despite PBM rebate barriers, by contracting directly with manufacturers for lowest net cost.

In the not-so-distant past, manufacturers avoided owning fulfilment due to moral hazard and regulatory risk. 

That is, if a company both promoted and delivered therapy to patients, compliance teams worried about undue 

. Thus, logistics remained fragmented, as PBMs, wholesalers, and pharmacies all dug in.

Today, DTP and direct delivery are more feasible thanks to improvements in logistics, regulatory frameworks, and the interplay among digital, telehealth, and real-world data.

These advances have transformed DTP from risk to strategic opportunity, and several pharma companies are jumping at the chance to shorten the value chain and put the patient at the center.

While a handful have begun selling their drugs direct to consumers, some are starting to explore DTP offerings that combine a DTE model, too.

 a DTP platform in the U.S., starting November 1, for its biologic Cosentyx (secukinumab), promising cash-paying patients a 55% discount off list price. Novartis positions the platform as proof-of-concept for direct-selling specialty medicines and has said it is exploring a DTE model to expand access.

 interest in a DTP model, as well, to reduce costs and bypass intermediaries such as PBMs. While Roche has not publicly committed to a full-scale DTE employer model yet, its channel thinking underscores the strategic logic of direct engagement.

As to employers’ incentive to participate, they are the ultimate payer for commercial lives in the US, through either self-insured or fully insured plans. As a result, they carry responsibility for both direct and indirect costs when employees are sick.

The traditional PBM model often sees rebates negotiated from manufacturers but, critics contend, these are seldom passed through entirely to employers. Like drugmakers, employers want more transparency, predictability and access.

DTE arrangements, in which businesses partner directly with manufacturers on high-impact therapies where payer access is constrained, allow employers to achieve their goal—lowest net cost for drug utilization—while eliminating PBM incentives to keep prices high and pad rebate revenue.

They can also shorten employee time-to-therapy, reduce absenteeism and improve productivity. Exclusive PBM contracts, on the other hand, lock patients into restricted treatment choices and generate dead-weight loss in the system.

If employers replace the PBM’s role, how to prevent a cost explosion, you ask? Through several mechanisms, including outcome-based pricing (where payment is contingent on patient benefit), analytics dashboards to monitor overuse, along with targeted therapy carve-outs, and governance controls.

In effect, the system may mirror traditional adjudicators but with different incentives, greater transparency and shared accountability rather than opaque rebates. DTE stops short of eliminating PBMs altogether.

Doing so entirely would expose smaller employers, Medicare, and exchange populations to volatility. The future logic is not “post-PBM” but “power rebalanced.” 

Manufacturers, employers, and patients share more of the value chain, as PBMs continue providing population-level administrative infrastructure—a hybrid model designed to enhance efficiency, transparency, and patient experience.

Nor should manufacturers fret about the effect on incentive compensation (IC). In a DTP model, the revenue attributable to reps will remain meaningful. Moreover, as agents of manufacturers, sales reps can play a big role in driving this new continuum.

Consider how Eli Lilly, which announced a platform allowing patients to access and fill prescriptions for its brands online last year, including obesity medication Zepbound, is 

With LillyDirect, the company has seen an increase in new-to-treatment Zepbound vials and captured an increased percentage of GLP-1 market share, based on initial results from 

But reps—traditionally the strongest channel in the promotional arsenal—remain important in this new paradigm. With categories like obesity, diabetes, and migraine becoming increasingly commoditized, the ultimate tiebreaker could be the physician, and that needs reps’ outreach and influence.

Drugmakers that leverage field forces to engage physicians around brand differences, including comprehensive DTP platforms, stand to gain competitive advantage against those that don’t.

Direct models aren’t without their own speed bumps. In the U.S., about 27 million people are uninsured, often due to part-time, gig work, or other gaps in employer-sponsored coverage. Millions more are unemployed or under-insured.

Given that DTE models rely on employer-sponsored health coverage, patients’ outside employer plans would be excluded. Yet even partial market penetration is meaningful.

Industry estimates suggest that if DTP and DTE platforms reach just a small percentage of patients receiving specialty medicines, the industry can shorten time-to-therapy by a substantial amount, reduce administrative overhead materially, and enable access to the latest innovations in medicine.

Even conservative modeling suggests billions of dollars in productivity gains across employers and millions of improved patient outcomes. Critics once argued that a manufacturer delivering a drug directly to patients risk undue influence.

But today’s models are different in three critical ways:

In terms of transparency, cash price makes the savings visible. Novartis, for instance, says the Cosentyx direct price 

 average savings that insurers and PBMs receive.

Second, when it comes to compliance and quality, logistical infrastructures and regulatory frameworks (such as GDP (good distribution practice) and GMP (good manufacturing process) support safe fulfilment and traceability. 

Third, with direct channels, manufacturers and employers can track adherence, outcomes, and real-world evidence, not just prescriptions written, all of which is a boon for outcomes measurement.

In other words, rather than influence, what emerges is orchestrated support, fewer intermediaries, faster access, and patient empowerment. For patients like Priya, the difference between this multi-channel model and its predecessor could be profound, promising less red tape, faster access, lower cost, and better support.

Manufacturers can truly win the paradigm shift from selling molecules to managing experiences, with commercial execs able to draw ever closer to demonstrating patient-centric leadership. Employers can see healthier employees and lower absenteeism. 

And the U.S. healthcare system could benefit from less waste, fewer intermediaries, greater transparency, lower costs, and better outcomes.

The DTP, DTC, and DTE models aren’t meant to replace traditional systems but reengineer them. They highlight value, reduce friction, and center the patient. This is how the next decade of pharma looks—not just innovative drugs but innovative access.

Rohit Gupta and Robert Rouse are partners at 

Articles

As the three models converge, expect a bigger role for sales reps, minimal impact on incentive compensation, and a boon to the healthcare system.