Patient Access Barriers: Six Classes, Six Different Owners

A patient access barrier is anything standing between a prescribing decision made in a patient's favor and that patient actually starting and staying on therapy. The term is used loosely across this industry to mean coverage, and coverage is only one barrier class among several. That looseness decides which barriers get funded, instrumented and owned, and which ones keep their effect while losing their name.

Organizations tend to name a problem after the part of it they already measure. Coverage is measurable, contractible and owned by a function with a budget, so coverage became the whole of access in common usage. The classes that carry no instrument and no owner were never argued away. They were simply never counted.

Most writing on this question is either advocacy aimed at payers or a pitch for a support program. Neither of those leaves an operator with a usable taxonomy. Six classes recur often enough across therapeutic areas that I treat them as distinct, each with its own owner and its own remedy. Three of them a manufacturer already instruments reasonably well. The other three sit partly inside several functions and wholly inside none.

The three classes the industry already instruments

Coverage is the first and the most familiar. It asks whether a therapy sits on formulary and at what tier, and it is owned by market access and resolved through contracting. This is the one class with a mature instrument already behind it, which is why progress here is real and is often mistaken for progress on access as a whole.

Adjudication is the second class, covering prior authorization, step therapy and medical necessity review. Those are legitimate utilization mechanisms whose operating burden falls on a prescriber's office and on a patient. A 2024 AMA physician survey found 93 percent of physicians reported that prior authorization delays care. The mechanism is defensible and the distribution of the work is the problem, which is the subject of a separate piece on prior authorization burden.

Affordability is the third. It asks what a patient pays at the point of collection, and it is partly owned already through copay programs, foundations and bridge supply. Those instruments are well built and well staffed, which is why affordability is often reported as a handled problem. Whether a patient knows her cost before she arrives at the counter is a different question, and almost nobody owns that one.

The three classes nobody owns

Administrative barriers are forms, enrollment, benefit verification, documentation and repeat requests for information already supplied. Access owns the policy, the hub owns the case, the field owns the relationship, and the household owns the paperwork. No role in that arrangement is defined as accountable for how much work a patient and an office are asked to absorb.

Informational barriers are the absence of an answer to three questions a patient and an office ask continuously. What happens next, who is doing it, and when it will be done. This is the cheapest class to fix and the least often measured, because nothing in a standard business review asks whether anyone knew where a case stood.

Continuity is the sixth and the least visible of them. It asks whether responsibility is held when a case stalls, or whether a stalled case simply stops moving until somebody chases it. Most access operations have no named holder for a case that stops, and stalled cases are rarely the simple ones.

Why cost discovered at the counter is its own barrier

Affordability is usually treated as a question of price, and price is only half of what decides the outcome. A cost a patient learns about in advance is a decision she can prepare for, discuss with her physician and plan around. The same cost discovered at the point of collection arrives at the moment she has the least information and the least recourse. Those are two different barriers wearing one label, and they call for different work.

The evidence on what happens at that moment is unusually plain. Of prescriptions with a final cost above 250 dollars, 61 percent are not picked up by patients. That figure describes a decision made at a register by someone who had no way to rehearse it. The wider pattern of prescriptions never collected is taken up in a separate piece on prescription abandonment.

Resolving cost itself requires contracting, foundations and funding, all of which take money and time. Resolving cost discovery requires telling a patient what she will pay before she stands at a counter. One of those is slow and expensive, while the other is largely an engineering exercise available this quarter.

Where a barrier stalls matters more than its type

Barriers are usually described by their type and are far better described by where they stall. Type tells you what an obstacle is made of, while location tells you what work will actually move it. A barrier that stops a patient before a first fill belongs to the Path to Fulfill, the stretch between a clinical decision and a medicine in hand. One that stops her in month three belongs to the Path to Adhere, where the question is continuation rather than initiation.

Before a first fill, an affordability barrier is usually a surprise, and the remedy is cost transparency, a bridge supply and a fast enrollment path. In month three it is rarely a surprise, because by then the patient knows her number. The remedy there is a renewal that does not break, a reauthorization handled before it lapses, and a plan year change somebody anticipated.

The same nominal barrier therefore needs different work depending on where it bites. Programs built by type tend to underperform for exactly this reason, because they apply one remedy across two mechanisms. Classification by location is what turns a barrier inventory into an operating plan.

Why this friction is unowned rather than mandated

The compliance explanation deserves examination, because it is the one most often offered. Regulation in this industry governs claims rather than burden. The rules are exacting about what a company may say regarding efficacy, safety and comparative benefit, and close to silent on how many forms a household completes. Almost none of the friction a patient meets between a prescription and a first dose is legally required.

That changes the category of the problem rather than its size. A constraint written into law has to be worked around, while a constraint nobody owns can be picked up by whichever party decides the outcome matters to it. Unowned friction is available in a way mandated friction never is. Six obstacles recur across these classes often enough that I name them, and they accumulate rather than arriving singly.

Administrative burden is the volume of work transferred to a practice or a household. Disconnected handoffs are the points where context stops traveling between parties. Lack of visibility is the absence of any single view of where a case currently sits. Fragmented support describes a patient helped by several programs and served by none of them.

Poor escalation is what happens when an exception meets a queue instead of a person, and process complexity is the compound effect of the other five arriving together. Friction is an economic variable, and accumulated friction becomes commercial drag. No single one of those obstacles ends a therapy, which is why each of them survives review on its own merits.

Why no one in this chain is failing

Every party in this chain is doing its own job competently, and that qualification belongs at the front of the argument rather than the end of it. The payer adjudicates against published criteria, the practice triages against finite clinic hours, the hub closes cases against a service level, and the manufacturer promotes against a share target. Each of those jobs is performed to standard by people who would recognize no failure anywhere in their own numbers.

The failures cluster in the spaces no organization chart describes. Between a benefit verification and an enrollment, between a hub case closing and a pharmacy stocking, between an approval and the patient being told about it. Those spaces have no owner because no function's mandate reaches across them. A design gap of that kind responds to design, which is a more useful finding than any judgment about effort.

I have found this to be the hardest point to carry inside an organization. A leader hearing that patients fall out of a journey will often look for the function that dropped them. The honest answer is usually that no function dropped them, because no function was holding them. Capable people and an incapable handoff can coexist for years without anybody noticing the difference.

How barrier resolution is actually measured

Resolution is almost always reported in activity. Enrollments completed, cases touched, calls answered and satisfaction scored all describe what a support organization did rather than what a patient achieved, which is why they can rise while access gets no better.

Progression is the alternative, and it is measured on a stage ladder. Scripts Written, Filled, Therapy Started, 90-Day, Persistence. Each stage names a state a patient either reached or did not, which makes the drop between any two stages the location of a barrier rather than an inference about one. Written prescriptions are intent, not realized value, and a ladder is what holds that distinction in view.

The economics follow directly from the ladder. The Realization Rate is realized value divided by earned value, which reports the share of what the science earned that became therapy. Customer Value at Risk is earned value multiplied by one minus that rate, which states the shortfall in money. Expressed that way, a barrier stops being a service complaint and becomes a line a commercial review already knows how to read.

What makes that number persuasive is that no competitor takes the value. A patient who never starts a therapy she was prescribed rarely moves to a rival product, because the therapy left her life rather than changing brands. Nobody gains from a loss of that kind, which makes access resolution a yield question with a named owner and a number attached to it.

Key Takeaways

A patient access barrier is anything standing between a prescribing decision and a patient starting and staying on therapy.
Coverage is one of six barrier classes, and it is the only one most manufacturers already instrument well.
Administrative, informational and continuity barriers sit partly inside several functions and wholly inside none of them.
Cost discovered at the point of collection is a different barrier from cost itself, and it is far cheaper to resolve.
Where a barrier stalls decides its remedy, which is why programs built by barrier type tend to underperform.
Resolution is measured as progression on a stage ladder and priced through the Realization Rate and Customer Value at Risk.

Diagnostic Questions to Consider

List your access barriers by class and name the single owner accountable for each one.
State the share of patients who know their out of pocket cost before they arrive at a pharmacy counter.
Describe what happens to a stalled case today, including who holds it and how long it typically sits.
Separate your barrier inventory by where it stalls, before a first fill and after it, rather than by type.
Report your largest brand's progression at each stage of the ladder rather than the activity your support programs completed.

Closing Reflection

An extraordinary amount of capable effort is spent in this chain to produce an outcome nobody wanted. Hub agents work their queues conscientiously, clinic staff spend afternoons on payer portals, and access teams negotiate positions they then defend. The effort is real, and the patient at the end of it has often concluded, reasonably enough, that her therapy was never going to happen.

The useful reading is that most of what stands between her and that therapy was never mandated and was never designed. It accumulated, piece by defensible piece, in the spaces between functions that each did their own work correctly. Burden distributed that way can also be withdrawn that way, which is why I treat access as an operating problem rather than an industry grievance.

Scientific value is realized when the patient accesses, starts, continues and benefits, not when the script is written. A company holding that sentence as a measurement commitment rather than a sentiment will find the six classes easier to see and harder to leave unowned. The barriers that cost the most are rarely the ones anybody chose.

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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