Here's how you know if your brand is hitting an “automation plateau”.
An automation plateau occurs when efficiency, productivity, and scalability metrics flatten after organizations deploy automation.
For the better part of a decade, the pharmaceutical industry has bought a story about automation in the name of cost cutting. Automate enrollment, automate benefit verifications, automate patient outreach, and the cost curve will bend. And the story sold because it was partly true. The early gains were real. But somewhere between the shift, a new kind of inefficiency came to light. Now, the brands managing advanced therapy solutions end up with some faster processes, but a lot of manual rework to solve for when automation reaches its limit. They’re positioned as the outliers, but for specialty therapies, it’s the rule.
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The price of treating rework as a one-off is. It moves to where it is least likely to be tracked. Vendors are still selling the same promise, often with new branding and a refreshed feature list. The brands are still paying for the same rework, in the form of operating expense and case manager time. And the patients caught in the middle are the ones who can least afford the delay that comes with it. An automation plateau is not a future risk in advanced therapy. It is a current operating condition, and the brands that recognize it first will be the ones who fix it before it becomes a permanent process that feels impossible to untangle.
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And the patients caught in the middle are the ones who can least afford the delay that comes with it. An automation plateau is not a future risk in advanced therapy. It is a current operating condition, and the brands that recognize it first will be the ones who fix it before it becomes a permanent process that feels impossible to untangle.
The plateau is structural, not technological
The natural first response in a situation like this is to read a performance plateau as a technology gap. If a majority of the eBVs are coming back incomplete, get a better eBV vendor, right? But in this case, the technology not working isn’t really the problem.
Best-in-class electronic benefit verification platforms today operate at roughly 90 percent accuracy for pharmacy benefits and 85 percent for major medical coverage, according to performance figures published by EVERSANA. Those numbers are impressive in aggregate. But they hinge upon straightforward processes, not exceptions. And specialty therapy is inherently unique.
“The plateau is not that automation has stopped improving. It’s that it can only go so far before the healthcare system says ‘no more.’”
The plateau is not that automation has stopped improving. It’s that it can only go so far before the healthcare system says “no more.” Payer exceptions require a real human to call a real medical director. Reauthorization gaps that surface six months into therapy, not at enrollment, need human intervention. None of these resolve themselves with another rules engine.
The exception is the program
Specialty medications now face initial denial rates approaching 51% for complex biologic requests, even as 81.7% of appealed denials are fully or partially overturned, according to Pharmacy Times analysis of Medicare Advantage prior authorization data and complex biologics studies. The majority of specialty PA denials are wrong on the merits, and the system corrects them only when somebody appeals. In Medicare Advantage, only 11.5% of denied prior authorizations in 2024 were appealed at all.
This is the part of the workflow where automation does not bend the curve. It cannot read a medical director’s reasoning. It cannot reconstruct a clinical narrative from a chart note that nobody wrote yet. It cannot escalate a denial the algorithm does not know is wrong. The appeals math reveals what most Hub Operations Leads have learned from experience: the exceptions are where the program either delivers or quietly underdelivers, and the headline metrics tend to obscure that fact.
A patient assistance program built for advanced therapy solutions has to be engineered around that reality: you want fast, but you can’t speed up certain things while the core of the issues lag behind in process. There is a meaningful difference between automating a workflow and engineering one. Automation takes the steps that already exist and routes them faster. Engineering identifies which decisions cannot be made by software, places experienced people at those decision points, and builds a clear chain of responsibility so cases move smoothly between the automated and human layers.
“Specialty medications now face initial denial rates approaching 51% for complex biologic requests, even as 81.7% of appealed denials are fully or partially overturned.”
How to know if your brand is on the plateau
A brand is on an automation plateau when its rework rate is rising even as automation coverage looks unchanged. It is on the plateau when exception cases take longer to resolve than they did 18 months ago, because experienced case managers have been redeployed to “value-added” work. It is on the plateau when payer escalations are increasingly raised by HCP offices rather than detected proactively by the hub.
None of these signals appear in a vendor QBR deck. All of them appear in the patient experience.
Evaluate vendors on the work they cannot show you
Any solution you demo will, by design, show you the happy path. You’ll see the cases the automation was built to solve. What you typically won’t see is day 47 of a payer exception involving a non-formulary medical benefit conversion with a step therapy override pending.
The most useful diagnostic questions are the ones that move past the demo. What does rework cost when a case requires three or more touches, and who absorbs that cost? What is your case manager retention rate on the rare disease team, and how many cases does a single experienced case manager carry? When a payer denies, what is the median time from denial to appeal submission, and who writes the clinical narrative in that appeal?
These are the questions that tend to differentiate a true partner from a platform, and the answers tend to surface the difference quickly.
The structural cost of rework is the real metric
Patients enrolled in rare disease and advanced therapy programs face the highest access stakes in pharmaceutical care. In some instances, they may have already waited years for a diagnosis. The therapy that finally reaches them is, in some cases, the only one available for their condition. The patient services infrastructure standing between that prescription and that first infusion is not a back-office function, it’s the brand.
Abubakr Zafar
Specialist, Marketing
Abubakr is a marketing specialist based in Elusa Health's Lahore, Pakistan office. He has direct experience working with Elusa Health's Access Engine team, which supports Elusa Health's patient access operations.
Sources referenced:
eBV accuracy benchmarks (~90% pharmacy / ~85% medical): EVERSANA ACTICS eAccess platform performance, viaDrug Channels, 2023.
Specialty PA denial and appeal rates (51% initial denial rate on complex biologics; 81.7% appeal overturn; 11.5% appeal rate in Medicare Advantage 2024):Pharmacy Times, “Navigating Prior Authorization Denials: A Clinical Pharmacist’s Approach to Appeals.”
