This month, the Centers for Medicare & Medicaid Services (CMS) took an important patient-centered step by proposing rules requiring faster, more transparent prior-authorization decisions for prescription drugs. Regulators are finally signaling recognition of a truth pharmacists have known for years: Information patients need to fill a prescription often arrives too late to matter.
That truth applies well beyond prior authorization. Across the prescription ecosystem, pricing, coverage, and authorization data routinely surface at the pharmacy counter rather than upstream, leaving patients, providers, and pharmacists to reconcile inconsistent answers under pressure. If the CMS reforms succeed, it will be because they target a systemic issue: The last mile of the prescription journey has been optimized for transactions rather than for clarity. The next frontier is applying that same rigor to pricing itself.
Access friction is a system problem
Despite significant investment in patient engagement, adherence programs, and digital access tools, 27 percent of written prescriptions go unfilled due to payer rejections and patient abandonment. Payer friction, cost surprises, and workflow breakdowns drive much of that loss. The scale of payer friction alone is striking: 82 percent of physicians report that prior authorization can lead patients to abandon a recommended course of treatment. No single stakeholder owns the problem, which is part of why it persists. Pharmacies absorb the fallout at the counter, while providers spend hours chasing down callbacks and prior authorizations, and patients, caught in the middle, walk away from the care they need.
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The industry has historically responded to accessibility issues by introducing additional systems and workflows, rather than aligning existing ones. Each addition can help in isolation, yet the aggregate effect is tool sprawl. Prescribers and pharmacists now toggle between systems that return different answers for the same prescription. When information presented upstream does not match what shows up at dispensing, trust erodes quickly.
Pharmacy counter bottlenecks
For all the attention paid to upstream prescribing workflows, the pharmacy counter remains the point where misalignment is most visible. Pricing discrepancies, outdated coverage data, and unresolved prior-authorization status surface when the patient is already at the register. Pharmacy staff absorb the friction in real time, calling prescribers, waiting for faxes, then reprocessing claims, and explaining surprise costs to patients who often walk away.
These breakdowns create more operational burden. They introduce rework, slow throughput, and compound workload to already-stretched pharmacy teams. Every rejection that lands at the counter represents a workflow that broke somewhere upstream. The dispensing moment is where cost, coverage, and clinical intent are supposed to converge.
Building confidence
Patient anxiety about prescription costs is at record highs. Six in 10 adults worry about affording their prescription drug costs, the highest share since tracking began in 2018. The downstream effect is measurable: Research examining patient pricing behavior found that fill rates drop sharply from 89 percent to 53 percent between $15 and $35 out of pocket, and once costs cross that $35 threshold, the majority of patients abandon their prescription.
Price transparency has become an accepted principle across health care in response to that pressure, with more than 30 states enacting some form of drug price transparency legislation, alongside federal rules and employer action. Transparency alone, however, has produced a new problem: inconsistency. A real-time benefit estimate presented to a prescriber in the electronic health record (EHR) may differ from the cash-pay or discount card options available to the patient, and both may differ again from the final adjudicated price at the pharmacy counter. Each number may be technically accurate within its own system, yet collectively they erode confidence.
What pharmacies, prescribers, and patients need is price confidence, meaning the figure quoted upstream is what patients encounter at the register. Prescriber, payer, pharmacy, and patient-facing systems return aligned, actionable guidance rather than competing data points. Confidence is what converts transparency from a policy talking point into an operational reality.
Fixing the last mile
Closing the gap requires real-time data alignment across the ecosystem, designed for end-to-end coordination rather than isolated touchpoints. In practice, three structural priorities matter most. The stakes are higher than they appear, with roughly one in four patients switching pharmacies to save as little as $5, suggesting even modest pricing misalignment can carry real fill-rate consequences.
First, pricing and coverage data should reflect actual adjudication logic rather than estimates or static files. When pricing data lives in a standalone tool rather than being embedded directly into the pharmacy management system through an API, a mismatch becomes more likely. That is because a figure may be accurate in isolation, but out of sync at the point of dispensing. Live integrations across pharmacy benefit managers (PBMs), EHRs, pharmacies, and discount networks are the foundation of alignment.
Second, the solutions that surface pricing and coverage must live inside the workflows people already use. Standalone tools that require clinicians or pharmacists to leave core systems introduce the same friction they were meant to eliminate. Embedded intelligence through an API connection inside the EHR, the pharmacy management system, and the patient-facing experience is what turns information into action.
Third, the industry should measure success at the point of dispensing. Metrics that stop at a price-check miss the question that matters: Did the patient leave with the medication their clinician intended? Reaching that result depends on whether every stage of the prescription journey, from prescribing to adjudication, surfaces the same pricing and coverage information.
The CMS proposal is a reminder that structural reform is possible when stakeholders align around a shared definition of the problem. Patients and pharmacists have long waited for consistent answers at the counter. The move from transparency to price confidence is how the industry closes that gap.
This essay is cited in the KevinMD record on prior authorization.
Joseph Kleiman is president of Buzz Health, leading the company’s strategy, partnerships, and operations to help expand access to more affordable prescription medications and improve price transparency across the health care ecosystem.
With more than 25 years of experience building and scaling businesses, including serving as chief financial and operating officer of BuzzRx, Kleiman has a strong track record in strategic planning, operational leadership, and growth. Earlier roles include founding the consulting firm Projixx, serving as chief operating officer of 944 Media, and cofounding Bullseye Wireless. Kleiman shares updates on LinkedIn.
