Prior Authorization Burden: What a Manufacturer Can Actually Do

Prior authorization burden is the administrative work that a payer's approval requirement transfers onto a prescriber's office and a patient. A manufacturer cannot change the payer's coverage criteria or the adjudication decision, though it can change almost everything about how that work gets done. That distinction carries the whole of the operating answer, and most writing on this subject never reaches it. Advocacy asks the payer to stop. Operating guidance asks what already sits inside a manufacturer's control.

Institutions rarely distribute work to whoever is best equipped to absorb it. They distribute it to whoever cannot refuse. Prior authorization is a legitimate utilization management mechanism, and that belongs at the front of any honest account of it. Payers use it to confirm that an expensive therapy is being used as indicated, which is a reasonable thing for the party carrying the cost to want established.

The problem was never that the mechanism exists. The problem is that the burden of operating it has been distributed to the two parties least equipped to absorb it. Those two parties are a prescriber's office and a patient. Neither of them designed the process, and neither of them holds any authority over how it runs.

A second gap sits underneath the first and does more damage. No party in the chain is accountable for the outcome of the process as a whole. A payer is accountable for an adjudication, a practice for clinic throughput, a hub for case closure, and a manufacturer for prescriptions written. Nobody is accountable for whether the patient reaches the therapy her physician selected.

Why the mechanism is legitimate and the burden is not

A payer reviewing a high cost therapy against its indication is doing something defensible. Specialty products carry real cost exposure, and some share of prescribing does fall outside the evidence supporting it. A mechanism that checks for that is a reasonable instrument rather than a hostile one.

Where the design turns punitive is in volume, repetition and opacity. A single authorization is manageable for a practice that has done one before. The same request arriving from many payers, each with its own criteria, portal and documentation standard, becomes a staffing problem rather than a clinical one. Every individual step can be defended while the sequence as a whole remains impossible to navigate.

The patient experiences none of that detail and all of its consequence. She was told a therapy had been chosen for her, and then nothing happened for a period nobody could specify. A person with no visibility into a process will often conclude that the process has ended.

What the evidence actually shows

The public evidence here is unusually clear for a commercial topic. 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. Almost half of those rejections turn out to be an ending rather than a stage.

The view from inside the practice supplies the other half of the picture. A 2024 AMA physician survey found 93 percent of physicians reported that prior authorization delays care, and 82 percent reported that it at least sometimes leads to patients abandoning treatment. Those are the people operating the mechanism daily, reporting on its effects rather than its intent. Neither figure implicates anyone's competence, and the two together describe a process working as designed while producing an outcome none of its parts was asked to prevent.

Is any of this friction legally required?

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 long an office spends assembling a payer submission. Almost none of the friction inside an authorization is required by law.

That changes the category of the problem. Constraints written into law get worked around. Constraints nobody owns get picked up by whichever party decides the outcome matters to it. This process sits in the second category, which is a more hopeful finding than it first sounds.

The six hurdles that turn burden into drag

Authorization sits on the Path to Fulfill, the stretch between a clinical decision and a medicine in a patient's hand. Friction on that stretch accumulates as several distinct obstacles, and six of them recur often enough that I name them. 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. Process complexity is the compound effect of the other five arriving at once.

Authorization is the one process on which all six tend to appear together. Friction is an economic variable, and accumulated friction becomes commercial drag. A practice that meets all six will, rationally enough, begin steering toward products that do not demand the whole sequence. That steering rarely appears in any report as a consequence of burden.

What a manufacturer controls and what it does not

The useful question is narrower than the debate usually allows. Two things sit outside a manufacturer's control entirely, which are the payer's coverage criteria and the adjudication decision itself. Everything else about the operation of this process is addressable, and most of it is addressable without anyone's permission. Confusing those two categories produces the two standard failures.

The first failure is lobbying when the work to be done is operating. A company convinced that the criteria are the whole problem directs its energy at policy, which may be worthwhile and will not change a single case this quarter. The second failure is giving up, on the reasoning that none of this belongs to us. Both conclusions follow from the same category error.

Five moves that sit inside that boundary

The first is documentation quality. A manufacturer can equip an office with clinical support material that matches what payers actually ask for, rather than material built for a promotional purpose and repurposed under pressure. Completeness at first submission is often the largest single determinant of how long a case takes.

The second is the time an office spends assembling that material. Hours of clinic staff time per case are a cost the manufacturer's requirements caused and the practice absorbs. Reducing those hours is a design exercise in forms, templates, prefilled fields and criteria mapping, and it needs no external approval. Practices remember which products are cheap to prescribe administratively, and that memory outlasts any campaign.

The third is visibility into where a case currently sits. A practice that can see status stops making the calls that consume its afternoon, and a patient who can see status stops concluding that nothing is happening. Visibility is one of the six Consumer-Grade conditions for a reason, because a person's tolerance for waiting depends largely on knowing what she is waiting for.

The fourth is a named owner for exceptions. Most authorization processes handle the standard case adequately and collapse on the unusual one, which is where the clinically urgent cases tend to concentrate. An escalation lottery, in which an exception travels wherever the last person sent it, is the arrangement I find most often rather than a deliberate one. Replacing it means naming a person, giving that person authority, and publishing how a practice reaches them.

The fifth is measurement, and it is the one most often missing. A manufacturer that cannot state how many of its authorizations reach approval, and how long they take, has no basis for improving either. Approval rate and cycle time are the two numbers that turn this process into something managed rather than endured.

How the burden becomes a commercial number

Burden stays a complaint until somebody expresses it in the currency a business review already reads. The Realization Rate is realized value divided by earned value, which reports 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 as money. Authorization failure tends to be among the larger contributors to that shortfall.

What makes the number persuasive is that no competitor takes the value. An unresolved authorization frequently does not move the patient to a rival therapy, because it removes the therapy from her life altogether. That pattern is what I mean by value leakage, and its distinguishing feature is that nobody gains from it. The wider accounting of it is the subject of a practice note on the value lost between script and patient.

Why nobody in this chain is failing

Everyone involved here is doing their own job competently. The payer reviews against published criteria. The practice triages against finite clinic hours. The hub closes cases against a defined service level, and the manufacturer promotes against a share target.

The failure sits above all of those jobs, at a level where nobody holds a mandate. No role in the current arrangement is defined as accountable for whether a clinically justified decision becomes a therapy. That absence is structural rather than cultural, which means it responds to design rather than to exhortation. Design gaps can be closed in ways that character gaps never can.

What closes it is an operating loop rather than a program. Capturing the signal when a case stalls, classifying the barrier, assigning an owner, intervening, measuring progression and learning from the result is the sequence, and the frontline usually sees the signal first. In my experience a field colleague knows which practice has quietly stopped submitting authorizations weeks before fill data reveals the same pattern. The standard that loop has to meet was set outside this industry, by every other service in a patient's life.

Key Takeaways

Prior authorization is a legitimate utilization management mechanism, and the problem is how the burden of operating it has been distributed.
The two parties least equipped to absorb that burden, a prescriber's office and a patient, are the two now carrying most of it.
The payer's coverage criteria and the adjudication decision sit outside a manufacturer's control, while almost everything about the operation of the process sits inside it.
Documentation completeness, assembly time, case visibility, a named exception owner and measurement are the five moves available without anyone's permission.
Regulation in this industry governs claims rather than burden, which leaves almost none of this friction legally required.
No role in the current arrangement is accountable for whether a clinically justified decision becomes a therapy, which makes this a design gap.

Diagnostic Questions to Consider

Name the single executive accountable for whether an authorization on your largest brand reaches approval.
State your current approval rate and your median cycle time for authorizations on that brand.
Estimate the hours of clinic staff time your access requirements consume per case, supported by evidence rather than assumption.
Describe what happens to an urgent exception today, including who receives it and how a practice reaches that person.
List which parts of your authorization documentation exist because a payer requires them and which exist because nobody has reviewed them.

Closing Reflection

This process consumes an extraordinary amount of capable human effort to produce an outcome nobody wanted. Clinic staff spend afternoons on portals, hub agents work queues conscientiously, and payer reviewers apply criteria as written. The effort is real, and the result is often a patient who concluded, reasonably enough, that her therapy was never going to happen.

The honest reading is that the mechanism is defensible and its operation is unowned. A manufacturer that accepts the first half of that sentence and acts on the second half has far more room to move than most assume. The payer's criteria will stay where they are for now, while the time, the clarity, the visibility and the ownership are all available this quarter.

What this asks for is a company willing to treat burden as an economic variable rather than as an industry grievance. Measured that way, authorization stops being a policy topic and becomes a yield question with a named owner and a number attached. That is a change in category rather than a change in effort, and it is available to any organization that decides to make 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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