[PRACTICE NOTE] The Value Lost Between Prescription and Patient

I dismantled a "healthy" enterprise customer experience program because it could not answer the questions that mattered to the business.

Earlier in my career, I inherited an enterprise customer experience program that was, by every conventional measure, in good health. It had a budget, executive sponsorship, relationship and transactional surveys, and an established advocacy score. The program was functioning as designed. What it could not demonstrate was whether any of it was making a meaningful difference to the business or its customers.

I retired the surveys and the score, realigned the stakeholders, and rebuilt the program around a different understanding of experience. The decision cost me political capital and a year of goodwill, but it remains one of the most consequential decisions I have made in this discipline.

The questions I put in their place were simple to state and considerably harder to answer. Where were customers getting stuck? Why? And how much of that friction was of our own making? I was no longer interested in measuring experience primarily as a reflection of how customers felt about us. I wanted to understand whether they could accomplish what they had set out to do, where their progress was interrupted, and what our organization was doing to help or hinder it.

That distinction becomes particularly consequential in pharma. Commercial organizations know how many scripts are written. They know how many campaigns have been launched and how many field interactions take place. They can report, in aggregate, how many patients are receiving treatment. What they often cannot see with comparable clarity is the interval between those facts, where a clinically appropriate prescribing decision either becomes treatment received or quietly does not.

A script may be rejected, abandoned, delayed, or lost in a series of handoffs. A patient may begin treatment but discontinue because a manageable barrier was never addressed. Each event has its own causes, consequences, and potential remedies. Yet the commercial organization may have no consolidated account of what happened, why it happened, or whether anyone could have prevented it. That interval is where much of the potential value of the science is either realized or lost, and too often, the books close before the story does.

The commercial system is part of the therapeutic value chain. Its failures have both human and economic consequences.

This is the conclusion that now anchors my work. A pharma company's commercial system is not merely a promotional apparatus attached to its scientific enterprise. It is a critical link in the therapeutic value chain, helping determine whether healthcare professionals receive the information they need to make informed treatment decisions, whether patients can obtain prescribed therapies, and whether those patients receive the support necessary to continue treatment when clinically appropriate.

In short, science establishes therapeutic potential. The system and experiences through which people encounter, access, and use that science helps determine how much of that potential is realized.

Consider what happens when a patient never begins an appropriate therapy because an avoidable access problem remains unresolved. The patient loses an opportunity to receive the expected therapeutic benefit, while the manufacturer loses the revenue associated with treatment that never began. When a patient abandons treatment because of an administrative breakdown, an unresolved affordability issue, or a preventable failure of coordination, the consequences again extend in two directions.

These are not equivalent losses. A patient's health cannot be reduced to a revenue calculation, and revenue is not evidence of therapeutic benefit. But when avoidable barriers prevent appropriate care, the same failure can produce both unrealized therapeutic value and unrealized commercial value. The industry often manages these consequences as separate concerns. Patient access, brand performance, field effectiveness, and patient support sit within different functions, each with its own measures and accountabilities. The human consequence may appear in one report, the financial consequence in another, and the operating failure that connects them in neither.

The problem is not necessarily a lack of concern. It is a failure of visibility and accountability, compounded by an accounting convention that recognizes commercial success at the prescribing decision without consistently following what happens afterward. Organizations cannot systematically manage value they have never learned to follow.

Not every patient who stops represents a failure. Distinguishing choice from friction is where the work begins.

Treatment may not begin or continue for sound clinical reasons. A physician may reconsider the therapeutic approach, a patient may make an informed decision not to proceed, or a payer may make a coverage determination that the manufacturer cannot control. These circumstances differ, and they should not be collapsed into a single measure of commercial loss. The goal is not to ensure that every patient starts therapy or remains on it indefinitely. The goal is to understand why progression stops and determine which barriers can and should be addressed.

That requires separating legitimate clinical and patient decisions from failures of access, coordination, communication, and support. It also requires distinguishing what a manufacturer can directly control from what it can appropriately influence through collaboration with other participants in the care journey. The work is to identify the portion attributable to avoidable friction and take responsibility for the parts of that friction the organization creates or has the ability to resolve.

In my experience, organizations that have never attempted this separation tend to assume that legitimate clinical decisions and patient choice account for more noninitiation than a closer examination reveals. That assumption deserves to be tested, not accepted as an explanation. Doing so changes the nature of the commercial conversation. Instead of asking only how to generate more scripts, leaders can also ask how much clinically appropriate demand is failing to become treatment, what is preventing it, and what the organization could do differently. The answers expose problems that conventional measures of commercial activity were never designed to reveal.

Every step can work as designed while the patient still fails to progress.

Much of this avoidable friction originates in the difference between how a pharma company is organized and how it is experienced. Internally, the company operates through brands, functions, channels, hubs, specialty pharmacies, and field teams. Each has legitimate responsibilities, defined processes, performance expectations, and organizational boundaries. Externally, a practice trying to resolve an access issue does not experience those boundaries. It experiences whether someone can help. A patient who must explain the same problem to four different people does not experience organizational design. They experience the burden of repetition.

The distinction is easy to overlook because the failure often cannot be located within any individual step. The practice submits the required documentation. The hub processes the referral within its service level. The pharmacy attempts contact according to protocol. Each participant completes the assigned task, and every dashboard is green. Yet the patient still does not know when treatment will begin. Nothing in that sequence necessarily violates a process standard. The failure emerges from the relationship between the steps, not from the performance of any one of them.

Individual performance and collective outcomes have become disconnected. Each function can demonstrate that it did its job, but none can demonstrate that the system accomplished what those jobs were supposed to achieve together. The measurement system confirms that work was completed without establishing whether the patient actually progressed. This is the fundamental weakness of managing an interconnected journey through measures of isolated activity. A system can satisfy every internal performance requirement while continuing to impose unacceptable effort, delay, and uncertainty on the people it exists to serve.

Heroics subsidize flawed design and conceal the true cost of performance.

There is another reason these failures remain difficult to see. Capable people routinely compensate for them. A field colleague makes an additional call. An access specialist finds a personal contact who can resolve a stalled case. Someone uses an informal escalation route because the formal process has reached its limit. A manager intervenes to move an issue that has been circulating between functions. The customer may eventually get the help they need, but leadership sees the resolution without necessarily seeing the exceptional effort required to produce it, the other work displaced, or the likelihood that a customer without the benefit of that intervention would still be waiting.

Heroics are a subsidy, particularly in the field, where colleagues routinely compensate for failures elsewhere in the commercial system. Their extraordinary efforts keep a flawed operating model functioning while concealing the true cost of its deficiencies. An organization that depends on discretionary effort to fulfill its promises has made individual commitment a substitute for institutional capability. I have enormous respect for the people who make these interventions. They often understand customer needs and the barriers to progression more deeply than the formal processes designed to serve them. But their resourcefulness should become intelligence for redesigning the system, not a permanent means of compensating for its shortcomings.

Every successful escalation should trigger an examination of why it was necessary, how often the same barrier occurs, and what must change so that the next customer does not depend on finding the right individual. This is where field excellence must evolve from celebrating individual problem solving to building an organization that learns from it. The objective is not to eliminate human judgment or exceptional service, but to ensure that exceptional effort is no longer a prerequisite for an acceptable outcome. The true measure of field excellence is not how often colleagues overcome the system, but how effectively the system improves because of what they discover.

In pharma, reliability is an operating discipline with therapeutic consequences.

My time at The Ritz-Carlton Leadership Center taught me that exceptional service becomes reliable when it is supported by an embedded operating system. Standards establish expectations, ownership makes responsibility explicit, and leadership behavior reinforces the conditions under which employees can exercise judgment and resolve problems. Continuous learning converts individual experience into organizational improvement. None of these elements removes the importance of human care. They make that care more dependable.

What I did not fully appreciate until I worked inside pharma was how much more consequential this discipline becomes when the thing being navigated is a person's treatment. An unresolved service failure in hospitality can compromise a guest's experience. An unresolved access failure in pharmaceuticals can delay a clinically appropriate treatment, increase the burden on a practice, or contribute to a patient abandoning therapy. The consequences are different, but the operating principle carries over: good intentions and capable employees cannot compensate indefinitely for a system that makes reliable delivery unnecessarily difficult.

In this context, reliability is more than a service attribute. It is one of the conditions through which therapeutic value becomes accessible to the people who may benefit from it. That should change how commercial leaders think about the architecture of their organizations, the capabilities they invest in, and the outcomes for which they hold themselves accountable.

Leadership must govern the connected contribution, not just the performance of its components.

If the commercial system participates in the therapeutic value chain, the unit of management must extend beyond the individual function, channel, or interaction. Leaders must be able to see and govern the connected contribution those components make to customer and patient progression. This requires explicit accountability for the points where responsibility changes hands, because handoffs are often where uncertainty increases, information is lost, and additional work is transferred to the practice or patient.

It also requires defined procedures for what happens when the expected process fails. Exception handling is not a peripheral service activity. It is where the adequacy of the operating model is tested. Measurement must follow progression across the journey, identifying where people encounter barriers, how long resolution takes, and whether interventions produce meaningful improvement. Sentiment remains valuable, but it cannot substitute for evidence of what customers were able to accomplish.

Equally important is treating frontline observation as intelligence about the enterprise. The field often sees the consequences of fragmented design before anyone at headquarters does. On the frontline, the reps, account managers, medical colleagues, and access specialists encounter the repeated questions, unresolved barriers, and improvised workarounds that reveal where the system is failing. Those observations should not disappear into call notes, anecdotal reports, or isolated escalation channels. They should enter a defined process through which barriers are identified, classified, assigned, resolved, and used to improve the underlying system.

No single function can accomplish this alone. The barriers frequently extend across organizational and external boundaries, which is precisely why they require coordinated ownership. This is the role I see for Customer Excellence as an enterprise capability. It is not stewardship of an advocacy score, nor is it another function competing for ownership of the customer. It is an operating discipline that connects an accurate understanding of what people are trying to accomplish with the organizational decisions that determine whether they can accomplish it. Its purpose is to make the performance of the whole visible, actionable, and accountable.

The next source of commercial advantage is what happens after the prescription.

The economic case for this shift is becoming more consequential. In therapeutic categories where competing medicines offer comparable clinical benefits, differentiation cannot rest entirely on the product or the promotional activities that support it. Access requirements, affordability, treatment complexity, and the ability to coordinate support can all influence whether an appropriate prescribing decision becomes treatment received and sustained. These factors do not replace clinical efficacy, safety, or the independent judgment of healthcare professionals and patients. They influence whether the potential established by those considerations can be realized in practice.

For commercial leaders, this expands the definition of performance. Script generation remains paramount, but it is an incomplete account of commercial value creation. A brand that generates substantial demand while losing patients to avoidable friction may be underperforming in ways that its traditional measures do not reveal. Increasing promotional activity will not necessarily correct those losses. The more consequential question is how reliably the commercial system converts appropriate demand into treatment received and sustained, and whether it can improve that reliability within the boundaries of responsible care and patient choice.

This creates a different basis for investment decisions. Instead of assuming that more commercial activity is the primary route to growth, leaders can examine whether improving access, coordination, and support offers a meaningful opportunity to recover value already created but not yet realized. It also creates a different standard of accountability. Commercial success cannot be fully understood at the point of prescribing when the business depends on what happens afterward.

The implications extend beyond the performance of an individual brand. Customer Excellence becomes a source of organizational capability, one that strengthens the commercial system's ability to deliver on the promise of its science. As clinical differentiation narrows in some therapeutic categories, the reliability with which a company helps customers navigate the path to appropriate treatment can become an increasingly consequential source of competitive distinction. This advantage is not created by adding another service program or technology platform. It is built through the less visible work of connecting responsibilities, removing structural friction, and making the entire system accountable for its contribution.

Yes. I dismantled a relatively healthy customer experience program because it could not answer the questions that mattered. What replaced it was harder to build, harder to manage, and harder to defend initially. But it gave us something the original program could not: a defensible account of where customers were struggling, what was causing that friction, and what the organization could do about it.

That experience changed my understanding of Customer Excellence and, ultimately, of the commercial enterprise itself. When a pharma company promises the benefits of exceptional science, the system through which people reach that science is not adjacent to the value. It is part of how the value shows up, and it deserves to be designed, measured, and governed with the seriousness that implies.

CONCLUSIONS

The leadership test is whether the organization can account for the patient's progression with the same rigor it applies to the performance of its individual functions. If it cannot explain where appropriate treatment is being lost, why it is being lost, who is accountable, and what is being done to address preventable barriers, it does not yet have a complete account of commercial performance.

LEADERSHIP QUESTIONS

Use these five questions to challenge what your organization assumes, expose what its dashboards cannot see, and establish accountability for turning appropriate prescribing decisions into treatment received.

1. How much appropriate prescribing intent fails to become treatment, and how much of that loss is preventable?

Claims data can help estimate the gap between prescriptions written and prescriptions filled, but it cannot fully explain why patients fail to start therapy. How much reflects clinical judgment, informed patient choice, payer decisions, or avoidable friction? Without a credible understanding of these causes, access discussions become debates about attribution rather than decisions about what can be improved.

2. Who is accountable for the patient’s progression from prescription to treatment initiation, and do they have the authority to act across organizational boundaries?

A shared objective, steering committee, or vendor contract does not, by itself, establish end to end accountability. Someone must have the mandate to identify failures, mobilize the relevant functions and partners, and ensure that unresolved barriers receive an accountable response. Without that authority, each participant can fulfill its responsibilities while the patient continues to wait.

3. If every hub, pharmacy, and field dashboard were green tomorrow, could you demonstrate that patients were starting treatment any faster?

This question exposes the difference between measuring operational activity and measuring the outcomes that activity is supposed to produce. Service levels, referral processing times, and completed contacts describe the performance of individual components. They do not necessarily establish whether patients are progressing, where delays accumulate, or whether the system is improving. Leaders need visibility into both.

4. How much of your access performance depends on the extraordinary efforts of individual employees rather than the reliability of the operating model?

Consider what would happen to treatment initiation if your most resourceful access specialists, field colleagues, and informal problem solvers were suddenly unavailable. Would established processes deliver the same results, or would unresolved cases begin to accumulate? The answer reveals how much organizational performance depends on individual ingenuity, what that dependence costs, and where the system remains vulnerable.

5. When the frontline identifies a recurring barrier, how long does it take to change the process that created it, and who has the authority to make that decision?

Collecting frontline intelligence is not the same as acting on it. The critical test is whether a repeated observation can trigger investigation, establish ownership, produce a change across the relevant functions, and demonstrate that the change worked. If resolution still depends on personal relationships, informal escalation, or the persistence of whoever identified the problem, the organization has a listening capability but not a reliable improvement system.

[Schedule a Diagnostic Conversation →]