Built Nationally, Lost Locally: Where Market Access Strategies Fail

The missing middle

By the time a product reaches your market, most of what you will be judged on as a local market access professional has already been decided. The comparator, the evidence package and the price corridor are fixed long before the first local conversation. Yet you are measured on pricing and reimbursement outcomes, on formulary listings, on regional uptake.

Manoj Sood calls the space between the two the missing middle, and it has three symptoms: a gap in ownership, a difference in language between headquarters and affiliate, and no feedback mechanism running back the other way. Global teams work in launch cycles, so by the time your launch arrives they are often already on the next one.

Does your access strategy change when it crosses from headquarters into the affiliate, or is it simply repeated more loudly?
 

A contact list is not a decision map

Local teams cannot move the price corridor or change the evidence package. What they can change is how well they understand who actually decides. That is not a matter of job titles, and it takes five questions:

• Who says yes? The person or the body that makes the decision, not the person who is easiest to reach.

• Where do they sit? Which committee, and whether that sits within your remit or another part of the organisation.

• How often do they meet? And when does a dossier have to be submitted to be reviewed at that meeting.

• Where does the money come from? The financial trail: who pays for the product, out of which budget, and how it is secured.

• Who can reverse it? Once a decision is made, it is hard to undo, so know who can challenge it.

Plenty of teams believe they have done this because they hold a list of names. If the list cannot tell you who says yes and when, it is a contact list, not a segmentation.
 

The people in the plan are rarely the people who decide

A familiar pattern, drawn from several launches: a specialty medicine wins national reimbursement. Twelve months later, some regions and hospitals are performing well and three or four are not. Look back at the account plan and the reason becomes visible.

The plan was written by national access managers, sales directors and country leads, and it named the people they knew: mostly KOLs, who are usually the same KOLs advising your competitors. The people who actually decided, the hospital pharmacy budget holder, the drugs and therapeutics committee, the lead prescriber at the referring centre, appeared nowhere in it.
 

Five measures that describe access better than price does

What usually gets reported is formularies and listings. Those tell you whether the paperwork moved. These five tell you whether patients are actually being prescribed the medicine, and how many of them:

• Time to first funded patient, measured against the plan rather than as an average.

• Label usage. Is the product being used across its licence, or has that been narrowed?

• Reach. Are you treating the patient numbers you expected, or a fraction of them?

• Net price realisation. What is actually kept after rebates and agreements.

• Revenue risk avoided. Rarely measured, and rarely credited to access.

Manoj describes companies celebrating a record launch on the strength of formulary listings, then finding two percent market share a year later. The listings were real. Some were green, some amber, some red, and several came with restrictions nobody had reported.
 

National approval is not the same as access

Reimbursement can be won on paper and lost in the detail of the wording. Evolocumab, a case in the public domain from over ten years ago, received a positive NICE appraisal and funding within three months, which looked like an unqualified success. The recommendation restricted the indication to a cohort far narrower than the licence, and the treated population ended up a small fraction of those who should have been eligible.

The lesson Manoj draws is about the fallback plan. If a product is heading for rejection or for a narrow recommendation, the question to have answered in advance is which managed entry agreement or alternative route could get patients treated, rather than accepting a restriction simply to secure the label of an approval.
 

A cost line or a capability

How access is treated internally decides how it is funded. The difference shows in what each version can say for itself:

One distinction worth keeping straight in that conversation: capability is the set-up and size of the teams engaging with payers, while competency is the skills those teams bring. Both need answering, and they need answering separately.
 

Three questions to take back to your team

1. Can you name three people who actually decide for your lead product locally, by name rather than by title?

2. Can you show the value your team created this year beyond the price?

3. Is access reported in your organisation as a capability with outcomes, or as a cost line with a budget?
    

About the expert:

Manoj Sood, expert trainer of The Pharma Commercial Market Access Course, is a senior commercial strategy and market access consultant with over 20 years of experience across global, regional, and affiliate organisations in the life sciences industry.

• He has held senior roles at Abbott, Pfizer, Shire, and Novo Nordisk, and currently advises biopharmaceutical companies on pricing strategy, market access frameworks, and commercial capability.

• At Novo Nordisk, he developed a proprietary six-step Commercial Market Access Framework adopted across international markets.
  He has designed and delivered capability programmes for more than 200 commercial and market access professionals across Europe, applying adult learning principles to build skills that transfer directly into the field.

• His teaching is grounded in real-world application: he draws on live experience from payer negotiations, managed entry agreements, and cross-functional launch programmes to make every concept immediately actionable.