When I used to work with pharmacy students, there was nothing more eye opening than taking them on a “patient home visit” — often to an assisted-living facility.   
  
There was before the “brown bag” talk, and after.   
  
Patients would gather all their medicines in a bag. We’d walk in the door with a list of their active prescriptions based on insurance claims. Students would quickly realize that’s not the half of what patients are taking – meds with an outdated shelf life, over-the-counter meds, PRN meds, samples and supplements (including topicals).   
  
Sometimes they’re even trying a family member’s or neighbor’s medication — really.   
  
One patient I recall was feeling lethargic and dizzy all the time, likely from her dangerously low heart rate. She had six prescriptions. Turns out, she was on 15 medications, some which were prescribed long ago. She apparently paid cash for a few.   
  
Three of her medications lowered the heart rate. So we worked with her providers to safely remove one of those drugs, keeping her heart rate within target and eliminating her symptoms.  
 
Overmedication Madness  
 
Before joining Wellvana as SVP of Medical Cost and Clinical Strategy, I worked as a clinical pharmacist. I would get calls from geriatricians who almost always had the same request: Can you get this patient off at least one of their meds?   
  
The National Institutes of Health says the regular use of five medications counts as polypharmacy. But it’s very common for patients with multiple chronic conditions to have a dozen or more meds. 
  
Polypharmacy is a huge issue for primary care physicians in value-based care, and not necessarily because of the high cost of many prescription drugs. It’s about the cascading effects of being over-medicated.   
  
The tales of polypharmacy quickly turn into horror stories.   
  
Misdiagnosed with Dementia   
  
A 93-year-old man shows up at Cleveland Clinic completely bedridden. His health had declined rapidly after a heart-related hospitalization two years prior. Weakness, fatigue and confusion made him completely dependent on his family. They decided it must be dementia.  
  
His family was actively moving him into a nursing home until an astute geriatrician took a closer look. This patient was on four different medications for anxiety. Taken together, especially in such an elderly patient, they magnified his fatigue, wrecked his balance and slowed his cognitive abilities.   
  
The patient was also on 4x the recommended dosage for one medication.   
  
In the time it took to taper the meds, this patient went from bedridden to using the bathroom independently.   
  
That’s practicing life-changing medicine.  
  
The Triple-A Antidote  
 
There’s an understandable hesitancy to remove anything prescribed by another physician. Plus, it takes time to coordinate with all the specialists involved. But if a medication is not serving the patient, they deserve our time and attention.   
 
Anti-Fall  
Falls can turn into a downward spiral, even for reasonably healthy patients. And poor medication management can directly contribute — dizziness, lightheadedness, loss of balance. Falls are the top cause of injury-related hospitalizations and cost Medicare $31 billion a year. Right there is all the value you need to justify focusing on coordinating prescriptions.   
  
Affordability  
We often underestimate the financial strain on patients. Many seniors struggle to afford their medication — roughly 1 in 4 according to KFF’s tracking poll. Half of Medicare Advantage beneficiaries have annual incomes below $25k. Nearly three-quarters lack any retirement savings. Fewer scripts to fill each month makes a big difference for anyone on a fixed income.    
  
Adherence   
If patients can’t afford to fill their prescriptions or are confused about what to take and when, the chances for adherence tank. Value-based care is all about streamlining care, including their medications. Poor adherence in the U.S. is tied to an estimated $500 billion in avoidable healthcare costs each year.    
  
A Break for Beers  
 
When working against potentially inappropriate medications, most geriatricians refer to the Beers Criteria, named for geriatrician Mark Beers. It’s updated every three years, with the most recent version from 2023.  
  
The criteria come straight from the American Geriatrics Society. A panel of experts looks at all the available data and recommends medications for the list. If a class of drugs appears, like benzodiazepines, it may be doing more harm than good for Medicare patients.  
 
Older adults absorb, metabolize and renally excrete medications differently. Guiding principles include simplifying the dosing schedule, using the lowest effective dose, and considering an adverse drug event with any new symptoms.   
  
For patients enrolled in Foundational Care™, Wellvana’s nurses prioritize medication reconciliation. They’re talking through prescriptions after any hospitalization and more regularly for patients with multiple chronic conditions. The materials patients receive also help them understand the importance of reconciliation and staying current with their prescribed medication regimen.  
 
Details on ‘Deprescribing’ 
  
“The problem with clinicians is it’s really easy for us to start medications, and it’s really hard to stop,” says Matt Rosenberg, MD, Wellvana’s Chief Medical Officer who still runs his practice in Jackson, Michigan.   
  
So I taught him a new word — “deprescribing.” It’s the planned process for how to reduce or stop medications that are no longer providing a benefit or even causing harm.  
  
Our friends in Canada have developed some helpful materials for physicians who may be new to the concept and need help with how to approach specific patient cases.    
 
We can all agree that more healthcare doesn’t necessarily mean better healthcare.   
 
Likewise, deprescribing is key to good prescribing.