Ecosystem Strategy: The Next Competitive Gameboard in Pharma
Institutions compete where they can keep score. The gameboard that gets measured becomes the gameboard that gets managed, and the one that goes unmeasured goes unclaimed. For four decades the competitive gameboard in pharma was the prescriber's attention and the formulary's coverage. Both are still contested, and neither is where the next advantage will be decided.
The new gameboard is the set of parties standing between an approved medicine and a patient on sustained therapy. A manufacturer owns none of them and can rarely compel most of them. Each one holds a piece of the outcome the brand is eventually graded on. That arrangement is not a failure of anyone's competence, and it deserves to be described plainly before it is judged.
I have spent most of my career inside commercial organizations asked to deliver outcomes they did not control. The people were capable and the intent was real. What was missing was a structure built to carry what the organization was being asked to carry. Ecosystem strategy is the work of building that structure, and it belongs to commercial leadership rather than to an experience function.
The gameboard moved while the scoreboard stayed in place
Prescriber attention and formulary coverage were the right gameboard when the decision and the dispense sat close together. A physician decided, a pharmacy filled, a patient started, and the interval between those events was short enough to ignore. Specialty medicine, prior authorization, step therapy and benefit design have stretched that interval into a journey with many owners. The commercial system kept measuring the decision while the value increasingly turned on everything after it.
A tenet I hold says it in fewer words. The commercial funnel ends too early. Prescribe, fulfill and adhere belong in one commercial system. Most commercial organizations remain instrumented for the first of those three. That is why the second and the third can still look like somebody else's problem.
The parties standing between an approved medicine and therapy
Name them without complaint, because complaint is the least useful register available in this conversation. The physician decides and the payer funds. The pharmacy benefit manager adjudicates, the specialty pharmacy dispenses and the hub coordinates what follows. A nurse educator onboards the patient, and the patient lives with whatever the chain produces.
Each party has its own incentives, its own cycle time and its own definition of a good month. None of those definitions is wrong inside the business that holds it. The composite of their work is what the patient actually experiences, and the composite is what the brand answers for. Nobody designs the composite, which is most of the opportunity and most of the difficulty.
Deloitte reported that only 28 percent of HCPs believe pharma's customer engagement strategies meet their needs, while 82 percent of life sciences executives are satisfied with those same strategies. A gap that wide is rarely a measurement error, and it is more often the signature of a system graded from the inside by the parties who designed it.
Position in a chain is a strategy question
A manufacturer cannot acquire its way to control of that chain and cannot regulate it into alignment. What remains is to architect a position inside it, which is a different competence from running a channel. Running a channel assumes authority over the parties in it. Architecting a position assumes the opposite, and designs instead for influence, visibility and standing.
That distinction matters because it decides who the work belongs to. Channel management sits with commercial operations and performs well when authority is clear. Position architecture sits with the people who set strategy, because it trades one form of advantage for another. The decision to shorten a path, carry a cost or stand up a front door is a strategy decision with a profit and loss consequence.
It is also the point at which the Consumer-Grade standard stops being a matter of conviction and becomes a matter of design. Pharma companies are patient-centric by nature, and that was never the constraint. The constraint is that experience has been left to default while brand and product were deliberately designed. Default is survivable inside a controlled transaction and expensive inside a chain the company does not control.
The nine workstreams that build onto the existing stack
The question that follows is what actually gets built. My answer is the Consumer-Grade Architecture, nine workstreams that build onto the pharma stack rather than replacing it. The word onto matters, because nothing here asks an organization to retire the systems it already runs. Regulated systems of record stay in place and keep doing their work. The architecture adds the layers the existing stack was never designed to hold.
The first three establish contact and sight. The Existing Pharma Core stays where it is, carrying the regulated systems of record the business already depends on. A Unified Pharma Front Door gives patients and prescribers one coherent place to arrive, rather than a brand by brand collection of portals and phone lines. Interaction Observability and Listening captures what happens in those arrivals, so that friction becomes visible as data rather than as anecdote.
The next three turn contact into context and action. Customer Context and Enterprise Memory holds what the organization already knows about a person, so nobody has to explain themselves twice. Journey Intelligence and Orchestration reads where someone sits on the Path to Prescribe, the Path to Fulfill or the Path to Adhere, then moves the next step toward them. Experience Delivery and Resolution closes the issue that was found, which is the workstream most programs quietly skip.
The last three decide whether any of it survives contact with the enterprise. Value Realization and Learning ties interventions to progression, so the architecture earns its budget on evidence. Leadership Governance and Operating Model assigns ownership across functions that have never shared a number before. Trust Privacy Compliance and Human Oversight keeps all of it inside the obligations the industry rightly carries.
Components are tailored per organization, and the sequence that fits one portfolio may be wrong for another. What does not vary is the dependency between the layers, because an organization cannot orchestrate a journey it cannot observe, and cannot observe one it has given customers no place to enter.
What the structural moves already visible actually reveal
Several companies have read the chain correctly and changed its structure rather than improving the experience around it. Setting a cash price and routing around benefit adjudication removes steps from the Path to Fulfill rather than smoothing them. The same logic runs through what Lilly changed with its direct channel, through how Novo Nordisk came to describe its own market, and through the direct to patient pricing move at Bristol Myers Squibb.
Each of those was a pricing and channel decision taken by commercial leadership rather than by an experience function. Each company identified the specific structural gate standing between its science and its patients. Then it changed the structure instead of improving the experience around the gate. That sequence is the lesson, and it is available to organizations that will never run a storefront.
David Ricks, Lilly's chair and chief executive, named the problem this way: "A complex U.S. healthcare system adds to the burdens patients face when managing a chronic disease". Mike Doustdar, chief executive of Novo Nordisk, told investors at JPM26 that the obesity market behaves "a lot more as a consumer business than a traditional medication". Both statements describe a category learning that the chain can be rearranged. Both also imply that somebody will rearrange it.
For most brands the gate is not price
The honest qualification belongs here, because the cash price move fits a narrow set of circumstances. For most brands the gate is not price at all. It is the interval between the written prescription and the first dose, and the quiet attrition in the months that follow. That interval rarely appears on a commercial dashboard, because no single function is accountable for the time inside it.
Rejections of initial brand name prescriptions rose from 24.3 percent in 2018 to 40.7 percent in 2024, according to a JAMA study summarized by Johns Hopkins. Almost half of those rejected prescriptions, 48.4 percent, were not followed by any fill within 90 days. The science did its work in those cases. The chain around it did not carry the result.
Some of that attrition reflects sound clinical judgment, and some of it reflects an informed patient choosing differently. Those decisions deserve respect and should never be counted as leakage. What remains once they are set aside is the part the commercial system can address, and it is usually larger than leadership believes. Value leakage names that remainder, and much of it is recoverable without a single new indication.
Progression proves an ecosystem position, not announcements
An ecosystem position is proved by progression rather than by partnership announcements. A press release names an intention. A stage ladder names a result, and the two correlate far less often than leadership teams expect. The measure that settles it is the Realization Rate, which is realized value divided by earned value.
Customer Value at Risk follows from it directly, as earned value multiplied by one minus the Realization Rate. That figure is the share of value a brand has already earned and has not yet collected. No competitor takes the difference, which is what makes it the most available growth on the page. It sits in the chain, between the parties nobody designs across.
Read that way, ecosystem strategy stops being an innovation agenda and becomes a value realization agenda. The share of earned value that becomes sustained therapy is the number that tells leadership whether the position is real. Customer Excellence is the discipline that holds the three paths in one system, and it is the fourth domain of commercial excellence alongside launch, marketing and sales. Brand, product and experience multiply rather than add, which means a weak third leg discounts the other two.
Key Takeaways
- The competitive gameboard has moved from the prescriber's attention and the formulary's coverage to the chain of parties standing between an approved medicine and a patient on sustained therapy.
- A manufacturer owns none of those parties and can rarely compel most of them, which makes position architecture a strategy question rather than a channel management question.
- The Consumer-Grade Architecture names the nine workstreams that build onto the existing pharma stack, running from observability through orchestration to governance and oversight.
- Several companies changed the structure of the chain rather than the experience around it, and each of those was a pricing and channel decision taken by commercial leadership.
- For most brands the gate is the interval between the prescription and the first dose rather than the price, and some attrition inside that interval reflects sound clinical judgment.
- An ecosystem position is proved by the Realization Rate and by Customer Value at Risk rather than by the number of partnerships announced.
Diagnostic Questions to Consider
- Name every party standing between your approved medicine and a patient on sustained therapy, and state which of them your organization can actually influence.
- Identify the specific structural gate between your science and your patients, and say whether it is price, interval or coordination.
- State your current Realization Rate by brand, and the Customer Value at Risk that follows from it.
- Describe which of the nine Consumer-Grade Architecture workstreams your organization already runs, and which it has never stood up.
- Assign one accountable owner for the interval between the written prescription and the first dose.
Closing Reflection
The gameboard metaphor can be misleading in one respect, because a gameboard implies a contest with fixed rules. The parties between an approved medicine and a patient on therapy are not opponents. Most of them are doing what their own incentives were built to reward. The advantage goes to the organization that sees the whole board and designs its position on it deliberately.
That work is slower than a campaign and more durable than a quarter. It asks commercial leadership to own an interval it has historically treated as somebody else's. The organizations that take it on will not look dramatically different from the outside at first. The difference shows up in the share of their earned value that reaches a patient still on therapy a year later.
Exceptional science deserves an exceptional commercial system. The gameboard has moved, and the scoreboard will follow it eventually. The organizations that move first will have spent the intervening years building the architecture that everyone else will later have to buy.
About the Author
Wayne Simmons is the founder of The Customer Excellence AGENCY and the author of The Customer Excellence Enterprise (Wiley, 2024). He is founding faculty of the MS in Customer Experience Management at Michigan State University's Broad College of Business. He led global customer excellence in Pfizer's first Chief Marketing Organization and in Bayer's Customer Powerhouse.
The Customer Excellence Agency: Advancing the Pursuit of Excellence in Service of Science.
