Rethinking Deprescribing: Who Should Monitor “Drug Overload”?

An astonishing 25% of Americans ages 65 to 69 take at least 5 prescription drugs to treat chronic conditions; among people ages 70 to 79, the number is 46%. Add in nonprescription medications and you’ll find that44% of men and 57% of women older than 65 take 5 or more medications per week. 12% take 10 or more.

At best, polypharmacy can be wasteful and unnecessary. At worst, it can open up a dangerous gateway to adverse drug interactions, multiple coinciding side effects, and other issues that can lead to death. Though most of us would probably prefer to focus on the clinical effects of polypharmacy, we must admit that it’s also expensive. In addition to the price of the drugs themselves, researchers say the costs associated with treating adverse drug interactions could soar to $60 billion over the next decade.

Knowing that medication overload is a real problem, many well-intentioned people have raised their voices and called on physicians to do more to fix it. But maybe physicians shouldn’t be the only ones responsible for reducing polypharmacy. In fact, maybe that burden should fall—at least in part—to health plans.

The Rise of Polypharmacy

The reasons behind the rise in drug overload among older people are manifold and have been detailed before, but understanding the drivers of the problem is crucial to finding solutions to it. Here’s how we got here:

1. The number of effective medications used to treat illnesses that were previously difficult to treat has increased. There are more effective drugs in the marketplace than ever. What physician wouldn’t prescribe them? Especially overwhelmed primary care doctors. For them, it’s easy to rely medications to fix complex problems. For example, writing a prescription for blood pressure medication is more likely to produce a dependable outcome than convincing a patient to improve his diet and exercise more in order to reduce hypertension.
2. Once medication regimes begin, they’re rarely re-examined. Patients who take medication for sleep disorders and stomach reflux, for example, often stay on these drugs for years, even though they’re intended for short-term use. Yearly “medication tune-ups” are an effective way to monitor patient drug intake, but most physicians rarely do them, instead using the limited time they have with patients to address their immediate problems.
3. Our fragmented healthcare system often leads specialists and hospitalists to take a somewhat myopic view of their patients. Individual ailments are treated while holistic patient histories go ignored. Medications are prescribed to inpatients upon discharge, whereupon monitoring their intake becomes the responsibility of the primary care physician, who may not even be aware that hospitalization took place. Ingrained beliefs about professional courtesy lead subsequent physicians to avoid second-guessing their colleagues and to automatically approve renewals.
4. Pharmaceutical advertising “medicalizes” many everyday conditions and turns patients into customers who demand the latest treatments, even when they may not entirely be necessary.

None of these trends is new. Researchers first reported an alarming rise in polypharmacy among older adults in the first part of this century. Since then, a plethora of articles has examined the problem and its causes. The proposed solution always seems to be the same: more physician guidelines. But physicians are already awash in prescribing guidelines; in fact, Medicare requires them to conduct an Annual Wellness Visit, at which medications are supposed to be reviewed. Clearly the guidelines aren’t working. And why would they? As I described above, the polypharmacy problem among older adults is ingrained in our healthcare system. Heaping evermore standards, checklists, and guidelines onto overburdened physicians will not fix it.

A Different Approach

Short of reconfiguring the American healthcare system—or, indeed, the world’s—a better approach is to shift some of the burden of avoiding harmful drug interactions and unnecessary prescribing from physicians to health plans. As the chief pharmacy officer for SCAN, a Medicare Advantage plan that provides coverage to more than 220,000 mostly senior members, I know that plan pharmacists are in the perfect position to champion medication guideline use and trigger medication reviews. Consider the following:

1. Health plan pharmacists have a bird’s eye view of every member’s medical history. Patients often see specialists who do not share the same electronic health record (EHR) systems as their primary care team. Hospital systems also rely on unconnected EHRs. When a patient fills a prescription at one pharmacy chain and another at a different chain, the dispensing pharmacists can’t see the totality of the patients’ medication regimen. But we can. In fact, most of the patient management software used by virtually every health plan today can easily alert plan pharmacists to potential adverse medication interactions. Importantly, we’re also aware when patients are noncompliant, something physicians sometimes overlook.
2. Clinical guidelines around medications are constantly changing. It’s virtually impossible for physicians to keep track of them all. But with the help of our training and our software systems, health plan pharmacists are able to flag drug interactions based on the latest data.
3. Plan pharmacists are less susceptible to pharmaceutical advertising and marketing efforts. By definition, our role is the find the least expensive medications that deliver the greatest benefit to the most people. That puts us in a position to be looking for the smallest number of medications that will improve the health of each patient.

This is not to say that health plan pharmacists should police patient prescriptions. On the contrary, prescribing should always be the responsibility of physicians, who are expertly trained to carry out that function. What I am advocating is a greater role for pharmacists—and especially health plan pharmacists—in advising physicians, guiding their prescribing behaviors and calling for annual “medication tune-ups.”

My hope, moreover, is that as such guidance is dispensed, primary care teams will make stopping or tapering medications that are unnecessary a normal practice. Yet until such a focus on deprescribing takes hold, leveraging programs—and people—already in place is the most expedient way to reduce the troubling trend of medication overload.

Author Information

Sharon K. Jhawar PharmD, MBA, BCGP, is chief pharmacy officer of SCAN Health Plan.