The Commercial System Is a Link in the Therapeutic Value Chain
The therapeutic value chain is the full sequence of work that carries a scientific discovery from a laboratory to a patient who is actually better for it. It runs through discovery, development, trials, regulatory approval and manufacture, and it does not end there, because a medicine that has been made has still not been received. The commercial system occupies the last and least examined stretch of that chain, where a therapy either reaches a person or quietly does not. Institutions rarely map the parts of their work they have not yet learned to govern.
In pharma, the commercial system is part of the therapeutic value chain. Experience is the mechanism by which that value is realized as patient and commercial impact. The rest of this page tries to earn those two sentences rather than assert them.
How the industry draws its own value chain
Draw the chain the way the industry draws it and a clean progression appears. Discovery leads to development, development to trials, trials to regulatory approval, approval to manufacture, and then the line reaches a cliff. Everything past that cliff gets filed under commercialization, as though the scientific work had ended and the selling had begun. That division may be the oldest and most consequential piece of architecture in the business, and it is wrong in one specific way.
The consequence is visible in how each half gets governed. Upstream of approval, claims are tested, methods are documented, and people are trained to doubt their own results. Downstream, the primary instrument of governance is a revenue number. Two halves of one chain are held to standards that have almost nothing in common with each other.
The chain does not actually end at approval, though, and it never did. It starts with the science and it ends with patient therapy. The clinical decision sits at the pivot point between those two ends, and that decision depends on the commercial model more than the industry tends to say out loud.
What the commercial system does in the chain
The commercial system has two jobs inside the chain, and both are easier to state than to do. The first is to put the state of the art in front of the clinical decision before that decision is made. The second is to see the decision through. Neither of those is selling.
Consider what the first job actually requires. A clinician has minutes and the evidence base has thousands of papers, which makes the transfer of scientific knowledge to the point of care a logistics problem as much as a persuasion one. Somebody has to carry what is known to where it will be used, in a form a working physician can act on. Call that selling if you like, though the chain treats it as knowledge transfer.
The second job is less glamorous and largely determines whether the first one mattered. Between a decision and a dose sit benefit verification, prior authorization, affordability support, pharmacy coordination and a first fill that may never happen. Operating that system is the work of the Path to Fulfill, and it is where the chain most often breaks after everyone involved has already agreed. The months that follow belong to the Path to Adhere, where therapy is either continued or quietly abandoned.
The clinical decision as the pivot point
Everything in the chain narrows to one moment and then widens again. Before the clinical decision, the chain concerns what is known, and the question is whether the right knowledge arrives in time to be used. After it, the chain concerns what happens, and the question is whether a decision survives contact with a system nobody designed as a whole.
That pivot depends on the commercial model in ways the industry rarely states plainly. The commercial model determines which clinicians encounter current evidence, how quickly, in what form, and with what support standing behind the decision they then make. Change the commercial model and you change the distribution of clinical decisions, which is a claim about therapy rather than a claim about share.
The same dependency runs backwards after the decision. A clinician who has watched three previous patients fail to obtain a therapy will weigh the fourth decision differently, and reasonably so. Experiential friction in fulfillment therefore feeds back into prescribing, which is one reason the two cannot be managed as separate businesses.
Why a failure there is a therapeutic failure
Here is where the argument turns. If the commercial system is a link in the chain rather than a layer bolted onto its end, then a failure there is a therapeutic failure and not only a revenue one. A molecule that works and does not reach a patient has the same clinical outcome as a molecule that does not work. The difference lies only in where the failure gets recorded.
The industry records one of those failures with great care and the other almost nowhere. A failed trial produces a publication, a post mortem and a change in method. A therapy that never reached the patient who was prescribed it produces a variance to forecast. Same outcome for the patient, two entirely different institutional responses.
This is the reason experience cannot sit where pharma has tended to put it, beside the brochure rather than inside the chain. Scientific value is realized when the patient accesses, starts, continues and benefits, not when the script is written. Written prescriptions are intent rather than realized value, which is a harder sentence to accept than it first looks.
What does the arithmetic of leakage show?
Numbers make this case better than argument does. Work I published with TheyDo set out an illustrative compounded scenario rather than a benchmark, and its shape matters more than its precision. A billion dollars of earned value becomes roughly seven hundred million after prescriptions that are never filled. It falls again after early discontinuation, and settles close to four hundred and fifty million realized after long term adherence erosion.
No competitor takes the difference, which is what makes the pattern value leakage rather than lost share. Read the ladder as a therapeutic measure and it changes character entirely. Every increment of that loss is a patient who was prescribed something and did not receive its benefit. The money is only how the industry happens to be keeping score.
Public evidence supports the shape of it. 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. Cost does similar work further along the path. Of prescriptions with a final cost above 250 dollars, 61 percent are not picked up by patients, according to IQVIA data reported in Managed Healthcare Executive.
Each of those percentages describes a decision that had already been made. The clinician judged, the patient agreed, and the chain then failed somewhere on the way to a dose. The commercialization label hides all of it, because nothing in it resembles selling.
The attrition that deserves respect
An argument like this can be pushed too far, and it usually is. Some attrition along the chain reflects sound clinical judgment or an informed patient choice, and those decisions deserve respect. A physician who reconsiders, or a patient who weighs a therapy against her own life and declines it, has not been failed by anybody. The chain worked in those cases, even though the script never became a sustained therapy.
The work is to separate those cases from the other kind. The other kind is where somebody could not move forward because information was unclear or responsibility was unresolved. A patient who stops because she chose to and a patient who stops because nobody told her what to expect are counted identically in most systems. I have rarely seen a company that could tell the two apart with any confidence.
That distinction is what keeps this argument honest. Without it, a case about commercial failure becomes a case for wanting patients on drugs rather than a case for wanting patients served. The point is not volume. The point is that nobody should lose a therapy to an unanswered question.
What standard does a link in the chain inherit?
Membership in the chain comes with obligations, which is the practical consequence here. Pharma already holds its science to an evidentiary standard and its manufacture to a precision standard. It holds its conduct to a reputational and trust standard that boards treat as a governance matter. The commercial system has never been held to a standard of its own.
That absence is a design gap rather than a failure of anybody's competence, which is why it survives inside companies full of capable people. No function was ever handed the brief to write the standard, so experience was left to default while brand and product were carefully designed. Consumer-Grade is what supplies the missing standard, expressed as a specification rather than an aspiration. Its conditions are recognition, anticipation, coherence, effort, resolution and visibility, with thresholds set per organization.
A standard without a measure stays decorative. The share of earned value that becomes sustained therapy is the Realization Rate, and earned value multiplied by one minus that rate gives Customer Value at Risk. Those two numbers put the last link of the chain into the currency a finance committee already uses. Pharma does not have a sales problem, it has a systemic value realization problem, and a Realization Rate is what makes that arguable rather than rhetorical.
What changes when the chain is drawn correctly
Redrawing the chain changes what experience is for. It stops being a service question and becomes the mechanism by which therapeutic value is realized. CX in pharma is not altruism, because it determines whether scientific and commercial value survives the journey. That sentence often lands badly with people who expected a softer argument, and it probably should.
Redrawing it also changes where the capability belongs on an organization chart. Launch excellence, marketing excellence and sales excellence are each treated as disciplines with owners, budgets and bodies of practice. Customer Excellence is the fourth of those domains and the one pharma never built, which is why it belongs beside them rather than beneath them. A fourth pillar reporting into one of the other three will keep losing every argument about priority.
In the work I have done inside large commercial organizations, the companies that moved furthest did one unglamorous thing first. They redrew their own value chain on a single page and found that it did not stop at approval. Almost everything else followed from having to look at that drawing.
Key Takeaways
- The therapeutic value chain starts with the science and ends with patient therapy, which places the commercial system inside it rather than after it.
- The commercial system has two jobs in the chain, putting the state of the art in front of the clinical decision and then seeing that decision through.
- A molecule that works and does not reach a patient has the same clinical outcome as a molecule that does not work.
- The value leakage ladder is an illustrative compounded scenario, and every increment of loss in it is a patient who did not receive a benefit.
- Some attrition reflects sound clinical judgment or informed patient choice, and the work is to separate those cases from unresolved responsibility.
- A link in the chain inherits the chain's standards, which is what Consumer-Grade supplies for a commercial system that has never had one.
Diagnostic Questions to Consider
- Draw your own value chain and state whether it stops at approval or at sustained patient therapy.
- Name the executive accountable for the stretch of chain between a clinical decision and a dose.
- State your current Realization Rate and the method used to calculate it.
- Describe how your organization distinguishes informed patient choice from attrition caused by unresolved responsibility.
- Explain which standard your commercial system is held to today, and who set it.
Closing Reflection
Arguments about where a line sits on a diagram sound academic until you notice what the line decides. It decides what gets measured, who gets held accountable, and which failures a company is obliged to explain. Move the line and those three things move with it, often faster than anyone expected.
I have found that the hardest part of this case is not its logic but its implication. If the commercial system is part of the therapeutic value chain, then commercial leaders carry a therapeutic responsibility, and few of them were hired on that understanding. Some will experience it as a burden, and others may recognize it as the reason they came into this industry at all.
The science here is often extraordinary and the experience surrounding it is frequently ordinary. That gap may be the most solvable problem in pharma, because nothing about it requires a discovery. It requires a company willing to accept that its chain runs all the way to a patient who is better, and willing to be measured on the whole length of 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.
