The Path to Fulfill: From Clinical Decision to Medicine in Hand

The Path to Fulfill runs from a clinical decision to the medicine in a patient's hand, and it is the second of three paths on which pharmaceutical value survives or is lost. It passes through benefit verification, prior authorization, affordability support, specialty pharmacy coordination, onboarding and first fill. Most organizations are precise about the things they control and vague about the things they merely influence. This path is made almost entirely of the second kind.

Each step here is administered by a different party operating under different incentives. A payer is managing cost exposure, a pharmacy is managing throughput, a hub is managing case closure, and a prescriber's office is managing clinic time. Every one of those parties is behaving rationally inside its own mandate. Each handoff between them is a point at which a clinically justified decision can stall or quietly end.

The three paths are separate because the reasons they fail have almost nothing in common. The Path to Prescribe fails before a decision exists, through patients who never arrive and diagnoses that come late. This path fails after the decision, in the administrative space where no single party is accountable for the outcome. The Path to Adhere fails later still, across months in which a patient has stopped being anyone's active concern.

That separation matters because a journey without a name has no owner, no budget line and no place on a scorecard. It may be the reason this path has survived largely as it is inside organizations otherwise exacting about cost. The model behind all three is the move from a commercial funnel to a flywheel, and a funnel conventionally ends at the purchase. In pharma the written prescription stands where the purchase stands, which leaves this path on the far side of where commercial attention usually stops.

What the Path to Fulfill actually covers

The path opens the moment a prescriber decides and closes when a patient takes a first dose. Between those two points sits a sequence that varies by product, payer and geography, and rarely looks the same twice. Benefit verification establishes whether coverage exists. Prior authorization establishes whether the payer agrees with the prescriber. Affordability support establishes whether the remaining cost is survivable for a household.

Then come the steps that look administrative and behave decisively. Specialty pharmacy coordination moves a product through a restricted channel carrying its own enrollment requirements. Onboarding covers training, devices, shipping windows and the conversation in which somebody explains what to expect. First fill is the only one of these a commercial organization usually counts, and it arrives last.

The shape of this path deserves stating plainly. No single organization designed it, which means nobody is in a position to redesign it alone. It assembled itself out of the separate rational decisions of payers, pharmacies, providers, hubs and manufacturers across several decades. A system that nobody designed will rarely behave as though somebody had.

How this path fails

This path fails administratively, which is the least dramatic and most expensive of the three failure modes. Nothing breaks in any visible way. Forms sit, queues advance, and a patient with no view of any queue concludes that the therapy is not happening. The decision was made, the clinical judgment was sound, and the outcome quietly diverged from both.

The accountability gap is the mechanism rather than anyone's indifference. A payer is accountable for an adjudication rather than for a therapy started. A hub is accountable for closing a case, which can be closed in either direction. No party in the chain carries accountability for whether the patient ends up on treatment.

What the rejection evidence shows

This is the path with the clearest public evidence. A 2026 JAMA study summarized by Johns Hopkins found insurer rejections reached 40.7 percent of initial brand name attempts in 2024. The same study found that 48.4 percent of those rejected prescriptions were never followed by a fill of that drug or anything in its class within ninety days. The first figure describes a negotiation. The second describes an ending.

No competitor took that value. Almost half the time, a rejection that goes unresolved does not move a patient to a rival therapy, because it removes the therapy from her life altogether. That pattern is what we call value leakage, and its distinguishing feature is that it benefits nobody at all. An illustrative compounded scenario I published with TheyDo traced it as a billion dollars of earned value becoming roughly seven hundred million once prescriptions never filled are counted.

The wider accounting of that gap is the subject of a practice note on the value lost between script and patient. The short version is that the loss concentrates here rather than distributing itself evenly across the three paths. A decision has already been made by the time this path begins, which means the expensive work of persuasion is complete. Losing the patient afterwards wastes the most costly asset the commercial system has.

The six hurdles that accumulate into commercial drag

Friction here arrives as a set of obstacles rather than one, and I name six because six is what organizations consistently find. Administrative burden is the volume of work transferred to a patient or a practice. Disconnected handoffs are the seams between parties where context fails to travel. Lack of visibility is the absence of any single view of where a case actually stands.

Fragmented support is the condition of a patient being helped by several programs and served by none of them. Poor escalation is what happens when an exception has nowhere to go. Process complexity is the compound effect, in which each step is defensible while the sequence is not navigable. Individually these are irritations, and accumulated they become commercial drag, which is friction expressed as an economic variable.

Accumulation is the part most improvement programs miss. A single prior authorization is manageable for a practice that has done it before. The same authorization layered onto a benefit check, a copay enrollment, a pharmacy transfer and a device training session is a different proposition entirely. Every interaction on this path either compounds value or creates drag, and these six hurdles are how the drag gets made.

Is any of this friction legally required?

Regulation takes most of the blame for this path and deserves a good deal less of it. Regulation in this industry governs claims rather than burden. It is exacting about what a company may say regarding efficacy, safety and comparative benefit, and nearly silent on how many times a patient must repeat a date of birth. Almost none of the friction a patient meets between a prescription and a first dose is legally required.

That distinction changes what kind of problem this is. A mandated constraint is something to work within. An unowned one is something available to whoever decides to own it. Compliance review is real and demanding work, though it rarely explains why a hub closes a case without resolving it.

What the companies shortening this path have done

Several companies have already shortened this path, and the method rewards careful reading. They set a cash price and routed around the access sequence altogether, which removes benefit verification, prior authorization and copay administration from the patient's experience in a single move. What Lilly changed with LillyDirect and Novo Nordisk's consumer business are both examined elsewhere in this practice. What matters here is where the decision came from.

It came from commercial leadership, as a pricing and channel decision. No experience function proposed it, no journey map produced it, and no satisfaction score triggered it. A pricing decision turned out to be the most consequential experience intervention available on this path, which says something uncomfortable about where authority over experience sits. The companies that read this correctly understood the obstacle as structural rather than attitudinal.

The move also sets a standard that now applies to everyone, including the companies with no intention of following it. A patient who has obtained one medicine in four minutes on a phone holds that as her reference point. Her next therapy gets compared to it rather than to the category's own history. Consumer-Grade is the name we give that expectation, and it does not adjust downward for the complexity of the science.

How progression on this path is measured

Progression on all three paths is measured on one ladder, which is what makes them a single commercial system rather than three programs. The stages are Scripts Written, Filled, Therapy Started, 90-Day and Persistence. This path owns the distance between the first two stages and most of the distance to the third, which very little else in the commercial measurement stack reports at all.

The yield measures sit on top of the ladder. The Realization Rate is realized value divided by earned value, which is the share of what the science earned that actually became therapy. Customer Value at Risk is earned value multiplied by one minus that rate, which states the shortfall in the currency a finance committee already uses. A company able to quote both numbers can argue about which path to fund, where a company without them is still arguing about whether experience matters.

The signals on this path reach the frontline first, often weeks before any dashboard registers a pattern. A field colleague knows which practice has stopped submitting authorizations long before fill data makes the same observation. Capturing the signal, classifying the barrier, assigning an owner, intervening, measuring progression and learning from the result is the closed loop this path needs and rarely has.

Key Takeaways

The Path to Fulfill runs from a clinical decision to a first dose, through verification, authorization, affordability, pharmacy coordination and onboarding.
Each step is administered by a different party with different incentives, and no party is accountable for whether the patient reaches treatment.
Insurer rejections reached 40.7 percent of initial brand name attempts in 2024, and 48.4 percent of rejected prescriptions were never followed by any fill in that class within ninety days.
Six hurdles accumulate here into commercial drag, namely administrative burden, disconnected handoffs, lack of visibility, fragmented support, poor escalation and process complexity.
Regulation in this industry governs claims rather than burden, so most of this friction is unowned rather than mandated.
Companies that set a cash price and routed around access made a pricing and channel decision that functioned as an experience intervention.

Diagnostic Questions to Consider

Name the single executive accountable for the whole distance between a written prescription and a first dose.
State what proportion of prescriptions written for your brand last quarter resulted in a dispense within thirty days.
List which of the six commercial drag hurdles your patients meet most often, supported by evidence rather than assumption.
Identify which elements of friction in your access sequence are legally required and which are simply inherited.
Describe how a rejected prior authorization in a single practice becomes known to somebody with authority to act on it.

Closing Reflection

This path is where the industry's most expensive work is most often wasted. A clinical decision represents the successful conclusion of everything the commercial system does on the path before it. Losing the patient immediately afterwards, for administrative reasons nobody intended, is a poor return on four decades of accumulated capability.

The honest reading is that this path is unowned rather than broken. Every party in it performs its own role competently, and the gap sits in the spaces between the roles where nobody holds a mandate. That makes it a design gap, and design gaps are fixable in ways that character gaps never are.

The commercial funnel in pharma ends too early, and this path is the first thing waiting on the other side of where it stops. Prescribe, fulfill and adhere belong inside one commercial system, measured on one ladder and owned by somebody who holds the whole distance. I have yet to meet a company that did that work and regretted it.

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.

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[PRACTICE NOTE] Your Call Plan Isn’t the Problem. Your Customer Context Is.

March 15, 2026

Why healthcare professionals now judge pharmaceutical engagement against the best experiences in their lives, and what that means for the future of commercial leadership. When commercial performance falters, the reflex inside many pharmaceutical organizations is to adjust the machinery of field execution. Leaders revisit call plans, recalibrate targeting models, and increase the volume of activity in the hope that more precision or more frequency will restore momentum. For decades this system has been treated as the central instrument of commercial performance, determining which physicians are prioritized, how frequently representatives engage, and how resources are deployed across territories. Yet the growing gap between commercial effort and commercial impact suggests a deeper issue. T he problem is rarely the design of the call plan itself. It is the context in which healthcare professionals now operate. Physicians are navigating increasingly complex clinical, administrative, and informational environments, and that evolving reality now shapes prescribing behavior far more than the cadence of promotional interactions. What many organizations are experiencing is a widening Customer Context Gap. Commercial systems were designed for a time when prescribing decisions could be influenced primarily through promotional interaction and product information. Today physicians operate inside a far more complex reality shaped by administrative burden, reimbursement constraints, digital information overload, and growing expectations for seamless support across the entire care journey. In this environment the physician’s decision is influenced not only by clinical evidence but also by how easily a therapy fits into the practical realities of care delivery. When commercial models remain anchored in promotional activity while the customer’s context has fundamentally changed, even the most disciplined call plan struggles to deliver the outcomes it was designed to produce. Closing this gap requires a different way of thinking about commercial performance. The question is no longer how to optimize promotional activity but how to align the organization around the real journeys through which physicians help patients receive therapy. Prescribing decisions unfold within complex sequences of clinical evaluation, reimbursement navigation, patient readiness, and ongoing support. When commercial strategy is designed around these journeys rather than isolated interactions, the role of the field force begins to evolve. Representatives are no longer positioned primarily as messengers of information but as partners in removing barriers that slow care. Organizations that recognize this shift begin redesigning their commercial systems accordingly, aligning field engagement, digital support, access programs, and patient services around the same goal: helping healthcare professionals help patients move from clinical intent to successful treatment. From Promotional Activity to Customer Journeys The pharmaceutical industry has historically organized commercial activity around the moment of promotion. Call plans, targeting models, and message sequencing were designed to influence prescribing behavior primarily through informational engagement with healthcare professionals. While this model brought structure and scale to commercial operations, it reflects an earlier era in which the path from clinical awareness to prescribing action was comparatively linear. Today the journey is far more complex. Physicians must navigate an intricate landscape of clinical evidence, treatment guidelines, payer requirements, prior authorization processes, patient affordability concerns, and adherence challenges. Prescribing a therapy is no longer a single decision point. It is the beginning of a chain of events that determines whether a patient ultimately receives and remains on treatment. This is why the commercial conversation must expand beyond the traditional moment of prescription to encompass three interconnected journeys. The first is the Path-to-Prescribe , where scientific evidence, clinical education, and confidence in the therapy shape the physician’s willingness to recommend treatment. The second is the Path-to-Fulfill, where access, affordability, patient readiness, and operational support determine whether that recommendation ultimately becomes therapy in the patient’s hands. The third is the Path-to-Adhere , where ongoing patient support, monitoring, and engagement determine whether patients remain on therapy long enough to realize the intended clinical benefit. Science drives the Path to Prescribe, where evidence, clinical education, and confidence in the therapy shape the physician’s willingness to recommend treatment. Experience shapes the Path to Fulfill, where access, affordability, and patient readiness determine whether that recommendation becomes therapy in the patient’s hands. Sustained outcomes depend on the Path to Adhere, where ongoing support, monitoring, and engagement ensure patients remain on therapy long enough to realize its intended clinical benefit. When commercial organizations focus almost exclusively on the first while leaving the latter journeys fragmented and burdened, a significant portion of therapeutic value is lost between intention and impact. In many therapeutic areas, the result appears in the persistent gap between prescriptions written, prescriptions filled, and therapies sustained—gaps that reflect not a failure of science but a failure of system design. Recognizing these three journeys shifts the unit of focus from promotional activity to the real-world pathways through which care is delivered. It reframes the role of the field force, the purpose of digital engagement, and the design of patient support programs around a single objective: reducing the friction that stands between clinical intent, treatment initiation, and sustained patient outcomes. Customer Context Is the New Commercial Variable For much of the pharmaceutical industry’s history, commercial performance was largely explained by a familiar set of variables. Product efficacy, clinical differentiation, promotional reach, and sales force execution determined the trajectory of most brands. When performance lagged, leaders adjusted those levers by refining segmentation, optimizing targeting, and recalibrating call plans. Today those traditional levers still matter, but they no longer explain commercial outcomes on their own. A far more powerful variable has entered the equation: customer context. HCPs now operate within an environment defined not only by clinical complexity and administrative burden but also by rising expectations shaped by their experiences outside healthcare. Physicians are also consumers. In their personal lives they interact daily with companies such as Apple, Amazon, Tesla, and Netflix that anticipate their needs, remove friction, and simplify complex processes through thoughtful design. These experiences quietly reset the benchmark for competence, responsiveness, and respect for their time. When those same physicians step into their clinical roles, they do not shed those expectations. They carry them with them. The contrast between the seamless orchestration of their consumer experiences and the fragmented systems surrounding many healthcare interactions becomes difficult to ignore. What once felt acceptable now feels unnecessarily burdensome. This dynamic represents the Consumer-Grade Imperative. Healthcare professionals increasingly evaluate pharmaceutical engagement not against other pharmaceutical companies but against the best experiences they encounter anywhere in their lives. In this environment even a clinically superior therapy can struggle if the surrounding system makes it difficult to initiate treatment, navigate reimbursement, or support patient adherence. Customer context therefore becomes the new commercial variable. It determines whether scientific differentiation translates into practical adoption. It shapes whether prescribing intent becomes therapy initiation and whether therapy initiation becomes sustained patient outcomes. Call plans were designed to manage activity. Customer context requires organizations to manage journeys. The Field Force in the Era of Customer Context Recognizing customer context as the defining commercial variable inevitably reshapes how the role of the field force is understood. For decades the pharmaceutical sales representative has been positioned primarily as the carrier of scientific information. Call plans optimized the frequency and sequencing of these interactions to ensure that physicians received consistent messaging. That role does not disappear, but the environment surrounding it has changed profoundly. Physicians today are navigating administrative burden, payer complexity, digital information overload, and increasing time pressure. In this environment they are not simply seeking more information. They are seeking clarity, simplicity, and support that helps them navigate the complexity surrounding treatment decisions. This shift transforms the representative from a messenger of information into something far more valuable: a partner in removing friction from the care journey. Conversations move beyond repeating clinical claims toward understanding the practical barriers that physicians and their teams face as they attempt to initiate and sustain therapy for patients. The most effective field forces are therefore supported by commercial systems designed around journeys rather than activities. Representatives are equipped not only with scientific messaging but with the insight and coordination required to address obstacles across prescribing, reimbursement, and patient support. Field engagement becomes a catalyst for problem solving rather than simply a vehicle for promotion. From Call Plans to Customer-Aligned Commercial Systems If customer context has become the defining commercial variable, then the systems designed to support the field must evolve accordingly. The traditional call plan was built to manage activity. It provided structure for how frequently physicians were engaged, how territories were covered, and how resources were deployed. Yet activity alone does not determine whether therapies ultimately reach patients. What determines impact is whether the commercial system surrounding the physician reduces or increases the burden of delivering care. A customer-aligned commercial system begins with the journeys through which physicians help patients move from diagnosis to treatment and beyond. Marketing clarifies the scientific story. Sales provides trusted relationships and real-time understanding of physician needs. Access teams simplify reimbursement pathways. Patient support programs reduce administrative burden. Digital engagement reinforces and extends human interaction. The result is a commercial system that operates less like disconnected functions and more like an integrated network designed to help physicians help patients. This is the essence of Customer Excellence. It aligns the entire commercial enterprise around the real-world context in which care is delivered. The problem was never the call plan. The problem was the context. Key Takeaways Commercial performance in pharma organizations has traditionally been managed through field execution mechanics, yet the effectiveness of those mechanics increasingly depends on how well they reflect the real-world context in which physicians operate. Customer context has become the most pivotal commercial variable as administrative burden, payer complexity, and consumer-grade expectations reshape how prescribing decisions are made. HCPs now evaluate pharmaceutical engagement against the best experiences they encounter anywhere in their lives, raising the standard for clarity, responsiveness, and ease. Optimizing promotional activity alone is no longer sufficient. Commercial success depends on reducing friction across the journeys physicians navigate as they move patients from diagnosis to treatment. Customer Excellence represents the structural response, aligning marketing, sales, access, digital engagement, and patient support around the real journeys of care delivery . Diagnostic Questions to Consider Are we optimizing the activity of our field force, or designing commercial systems that support the real journeys physicians navigate to help patients receive therapy? How well do we understand the administrative, reimbursement, and operational barriers physicians encounter after they decide to prescribe a therapy? Do our commercial systems reduce the burden placed on physicians and their staff , or unintentionally add to the complexity of care delivery? Are we benchmarking our engagement against other pharma companies , or against the best experiences physicians encounter in their lives as consumers? Have our investments in digital platforms simplified the physician’s experience, or multiplied the number of disconnected interactions they must manage? Are we still managing performance through activity metrics alone , or beginning to understand the context that ultimately determines whether therapies reach patients? Closing Reflection The pharma and life sciences industry has spent decades refining the mechanics of field execution. Call plans, segmentation models, and targeting systems brought structure and discipline to commercial organizations. Yet the environment surrounding physicians has evolved far more rapidly than the systems built to support them. Healthcare professionals now operate in a world defined by consumer-grade expectations for clarity, responsiveness, and ease. When the experience of engaging with a pharmaceutical company fails to reflect those expectations, the contrast becomes impossible to ignore. Organizations that recognize this shift will redesign their commercial systems around the realities of modern care delivery. They will move beyond managing activity and toward understanding the context in which physicians help patients receive treatment. In doing so they will close the gap between scientific innovation and real-world impact. Your breakthrough science deserves experiences worthy of it. Together, we turn customer excellence into real-world impact. About the Author Wayne Simmons is a hands-on commercial excellence architect and founder of The Customer Excellence Agency, where he partners with pharmaceutical and life sciences leaders to turn customer-centric ambition into durable commercial advantage. He previously served as Global Customer Excellence Lead within Pfizer’s Chief Marketing Organization and has held leadership roles with Bayer Pharmaceuticals and The Ritz-Carlton Leadership Center. Wayne writes The Customer-Centric Marketer newsletter and is the author of The Customer Excellence Enterprise: A Playbook for Creating Customers for Life. The Customer Excellence Agency: Advancing the Pursuit of Excellence in Service of Science.

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