Negotiating MFN - Part 4: The Commercial Opportunity Companies May Be Missing

MFN has created a multiplayer strategic negotiation with new value on the table

This is Part 4 of Negotiating MFN, the final and most important piece in the series. Part 1 examined GENEROUS country exposure; Part 2 examined GLOBE and GUARD country exposure; Part 3 examined the strategies available to companies in GENEROUS countries. Now we address the broader strategic game that MFN has created - and the very substantial commercial opportunity that most companies have not yet identified.

Ever since Albert Bourla’s Pfizer seized first mover advantage in the MFN wars, a strategic game has been afoot. Conventional market access approaches, in which negotiations are largely seen as bilateral, no longer maximise value. Companies now find themselves in a multiplayer game that existing playbooks cannot navigate. 

The GENEROUS exposure analysis most companies are now doing (which products, which markets, what US sensitivity) is necessary. But it addresses only half the problem. The other half - the larger half - is the strategic opportunity the same framework has created. 

The bilateral trap 

Most companies run GENEROUS country negotiations the way they always have: each country managed by a local team, within a national HTA process, chasing the best available price in that market. The negotiations are connected in the analytics - the pricing team models the US impact - but they are run separately, by different people, using the playbook that worked before GENEROUS existed. 

That may be wrong at a fundamental level. GENEROUS has created direct strategic interdependencies between negotiations: the price achieved in France moves the US reference point; the decision on whether to launch in Canada reshapes the price distribution across the whole basket. These are not bilateral negotiations with a common reporting line. They are moves in a single connected game - with the value overwhelmingly concentrated in the US pot. Treating them separately means playing that game with no strategy for the game itself. 

Non-launch changes everything 

At the centre of this is something that deserves to be stated plainly. 

Non-launch in a GENEROUS basket country is no longer simply a bad outcome. For specific assets in specific markets, it can be the value-maximising option - because the selection effect explained in Part 1 (removing a low-price country shifts the whole reference distribution upward) can deliver more US value than the ex-US revenue forgone. 

The moment that is true, every negotiation the company is in changes. A payer who has always assumed the company must ultimately accept a price - because non-launch was too costly to contemplate - is no longer negotiating with that company. Non-launch has become a genuine Best Alternative to a Negotiated Agreement. A real BATNA, not a rhetorical one. That shift transfers leverage from payer to company in a way that has not happened in international pharmaceutical negotiation in a generation. 

The value hiding in plain sight 

Where non-launch is economically viable, the company has something new to trade: the choice of whether to launch. A credible commitment to launch - to deliver access a payer wants and cannot compel - is a tradeable asset. It creates a deal space that did not exist before. 

What can you get for it? Some of the answer sits in the basket countries themselves - the bespoke access deals, increasingly combining access with investment, that we covered in Part 3 and its companion paper. But the most interesting deal space is not in the basket countries at all.

The IRA horse-trade 

Consider. A company has a product already through IRA negotiation, priced at a Maximum Fair Price in the US. It also has a late-stage asset for which the GENEROUS arithmetic is difficult: launching in certain basket countries would depress the MFN reference in ways that materially damage the US outlook. 

The standard approach treats these separately: the IRA product is a CMS matter, the GENEROUS position a market access problem. The more interesting approach recognises that CMS and the company each have something the other wants. 

CMS would like better economics on the MFP product. The company would like its GENEROUS deal restructured so that certain countries are excluded from the reference basket for the new product - giving it the freedom to launch in markets it otherwise could not, without adverse US consequences. Neither is available through the standard process. Both may become available through a structured exchange. 

The ‘Zone of Possible Agreement’ is real - in fact, it’s massive. The US gets better drug pricing on an existing negotiated product. The company gets deal architecture that unlocks access it would otherwise have to forgo. Patients in basket countries get a medicine they might not otherwise receive. 

And this is one structure among many. The MFN framework has created a landscape in which value sits unexploited in the connections between negotiations that most companies still treat as separate. The companies that find those connections first will capture that value. The rest may leave it on the table - or hand it to competitors who saw the game more clearly. 

What it takes to play 

Playing this game requires a view of the whole: the entire portfolio and pipeline across the basket, mapped against US pricing sensitivity and the deal space available in each market. It requires deal design that spans multiple negotiations and counterparties. And it requires a read on the US policy environment - CMS included - that goes beyond what most global commercial teams have ready access to. 

No company has this fully assembled. We are not claiming to have all of it ourselves: the US government affairs expertise sits inside companies, and the best versions of this work will combine that expertise with external negotiation counsel – the ability to identify where value such as that described here is hidden and to execute on complex, multiparty deals with precision - and deal design capability. 

What we are confident about is the opportunity. Companies that begin to treat global launch strategy as moves in the game - rather than as a portfolio of bilateral market access negotiations - will find options the current approach cannot see. The window is open now: the frameworks are still forming, the precedents are still being set, and most competitors are still playing the old game. 

This is the last in Negotient’s four part series, Negotiating MFN, examining how companies and policymakers are navigating the new global pharmaceutical pricing landscape. 

Negotient is a strategic advisory firm specialising in complex public-private negotiations. Our global pharma practice works with a small number of companies on the market access, pricing and investment-linked negotiations where the commercial stakes are highest. Enquiries: info@negotient.com