The Customer Has Changed. Pharma’s Commercial Model Hasn’t.

Picture a cardiology waiting room on a Tuesday morning. A sales representative sits with a tablet on her knee, hoping for four minutes with a physician who may or may not come out. She knows the data cold and knows his prescribing history better than he does.

The trouble is that the decision she has come to influence was not made in that building. It was made months ago by a P&T committee at the health system that bought the practice, shaped by a clinical pathway, and constrained by a formulary negotiated by a PBM she has never met. She is waiting to see the one person in the chain with the least freedom to act on what she says.

We Modernized Everything Except the Premise

Pharma has spent twenty years modernizing its commercial model. We digitized the sales force, built omnichannel engines, and surrounded brands with access, medical, patient services, analytics, and now AI teams. We have more data about the customer than ever. We may also have the wrong customer.

Commercialization was built on a durable assumption: at the center of the treatment decision sits a physician. Segment them, message them, reach them, and the prescription follows. For decades that was a reasonable approximation. It is becoming a dangerous one.

The doctor can want your medicine and still not prescribe it, or prescribe it and never get it to the patient. The payer can cover it while adding enough friction to collapse utilization, and the pathway can decide before the patient enters the room. That is not a channel problem. It is a customer-model problem.

The Prescriber Is Losing Sovereignty

In 2012, 60.1% of physicians worked in private practice. By 2024, it was 42.2%, with more than a third in hospital-owned practices and another 12% employed or contracted directly by hospitals. That is not an employment statistic. It is a redistribution of decision power.

Inside an integrated system, the physician works within an enterprise formulary, preferred pathways, site-of-care policies, EHR prompts, and risk-sharing targets. The physician still makes the clinical call, but someone else designed the architecture around it. Pharma has invested heavily in the person making the visible decision and far less in those designing the invisible environment.

IQVIA has made this point about oncology: consolidation has created network-level pathway control that the old academic-versus-community split obscures. Two oncologists who look identical in the CRM may live in entirely different decision systems. Commercially, they are not the same customer.

The Prescription Is No Longer the Moment of Truth

For years, the prescription was the ultimate proof of commercial success. Increasingly, it is barely the beginning. IQVIA found that in 2025, 70% of commercial attempts to fill a new branded medicine were initially denied coverage, up from 57% in 2021.

You can win the evidence, the positioning, the physician, and the prescription, and still lose the patient. Yet most organizations still separate demand generation from market access, as if one creates the customer and the other handles paperwork downstream.

Access is commercialization. So are reimbursement, patient support, site of care, and pathway inclusion. They are not functions orbiting the brand. They are the brand experience.

Pathways Are Customers Without Faces

A pathway does not attend a dinner program, answer a research interview, or appear on a call plan. Yet pathways, order sets, and decision-support rules now embed treatment choices upstream, at enormous scale.

We used to ask, “Why did Dr. Smith choose Competitor A?” Now we must ask, “What system of decisions made Competitor A easier, cheaper, or more institutionally normal for Dr. Smith to choose?” Those questions demand very different capabilities.

If the barrier is a pathway, a prior authorization, infusion capacity, or an EHR default, no reprint or speaker program will move it. We keep treating system problems with communication solutions, then wondering why behavior doesn’t change.

The Patient, and the Chord

While power consolidated above the physician, the patient gained power below. Patients arrive having searched, asked ChatGPT, and joined communities, often with preferences already formed. Many now meet manufacturers directly through offerings like LillyDirect and PfizerForAll; Deloitte’s 2025 survey found 23% of consumers had used a direct-to-consumer health offering, more than half of them for prescription drugs.

I find it useful to think musically. The prescription used to be a single note played by a soloist, and you could tune your whole instrument to that player. Today it is a chord, sounded by the physician, the formulary committee, the payer, the pharmacist, the nurse navigator, and the patient deciding whether to fill the script.

Why Knowing Hasn’t Been Enough

The industry’s problem is not that it fails to see this shift. Every brand plan has a slide on organized customers, and key account management has been launched and relaunched for fifteen years. What is missing is the willingness to let the insight rearrange the machinery.

An organization becomes whatever its metrics reward. If the unit of measurement is the individual prescriber, the organization optimizes for prescribers, whatever the strategy deck says. The account manager gets a title without authority, and the field keeps calling on physicians whose prescribing is decided elsewhere, because that is what the bonus pays for.

We bolt an integrated customer model onto a disintegrated organization, then conclude that integrated models don’t work.

Map Power, Not Just Customers

Pharma’s segmentations, from high writers to evidence seekers, mostly describe people. What companies now need to understand is power: who can initiate, approve, or veto a decision, who creates friction and who removes it, and who determines whether the patient ever receives the drug. That map shifts by health system, therapeutic area, even molecule.

This changes the unit of competition. If the customer is a physician, the goal is to change preference. If the customer is a decision system, the goal is to change the conditions under which decisions occur, with a clinical story for the physician, an economic one for the payer, an operational one for the IDN, and a human one for the patient.

It changes insights too. Four separate studies of HCPs, payers, patients, and IDNs stapled together are not an understanding of the market, because those people interact in the real world. We have studied the nodes; now we must study the network. Here AI can help, because networks move continuously while most segmentation studies freeze the market and live on for three years.

From Reach and Frequency to Friction and Flow

For generations, commercialization ran on reach and frequency. The next model needs a different principle: friction and flow. Where does the right patient’s journey from diagnosis to treatment stall, and what would make the right clinical decision easier to execute?

That ambition is larger than selling. Market access moves to the center of brand strategy, and patient services become the last mile of the brand’s promise rather than a cost center. Medical, commercial, access, and insights organize around shared customer problems, within the compliance boundaries that exist for good reason.

And the scorecard changes. Pathway inclusion, time to therapy, pharmacy abandonment, and pull-through after formulary wins sit alongside prescriber volume, instead of letting prescriber volume stand in for the whole story.

System-Centric, Human-Centered

We have long talked about becoming customer-centric. But which customer belongs at the center: the oncologist, the payer, the pathway committee, the pharmacist, the patient? Put any one there and you misread the market. The future organization must be system-centric enough to see where power lives, and human-centered enough to remember why the system exists.

Underneath the formularies and prior authorizations is a person who is sick and trying to get better. The real test of a commercial model is not whether we delivered the message or generated the prescription. It is whether an appropriate patient actually received the medicine.

Which brings me back to the rep in the waiting room. She is not obsolete; the assumption that her four minutes decide the game is. In a better model, she walks in knowing how the pathway treats her therapy, which access barriers are stalling scripts, and who sits on the committee next quarter. She plays in an ensemble, not a solo to an empty hall.