By Russell R. Barksdale, Jr.
For over a decade, the United States has consistently led the world in per capita prescription drug spending. In 2023, pharmacy costs represented 27% of total healthcare expenditures, a significant increase from 21% in 2021. This growing financial burden has become a focal point for healthcare cost managers and policymakers alike, especially as the demand for high-cost therapies continues to climb.
Prescription drug marketing has reached unprecedented levels, reflecting the direct correlation between marketing investments and profitability. One striking example is the surge in demand for glucagon-like peptide-1 receptor agonists (GLP-1RAs), used to manage type 2 diabetes and obesity. These drugs, despite their clinical utility, highlight the escalating out-of-pocket costs patients face. Yet, this is only one piece of a larger, deeply complex puzzle of rising pharmacy costs.
Pharmacy Benefit Managers (PBMs) play a pivotal role in this pharmaceutical landscape. Originally created to simplify drug distribution and lower costs through group purchasing, PBMs have evolved into key influencers of drug pricing and accessibility. Their responsibilities often include determining formulary exclusions (uncovered medications), processing prescription claims, and promoting generic or lower-cost alternatives. While these activities aim to manage costs, concerns have grown over their lack of transparency and potential conflicts of interest.
Critics argue that PBMs may prioritize financial gains over patient affordability and access. Their complex rebate structures and opaque contractual agreements have come under increasing scrutiny, prompting calls for heightened oversight. With healthcare inflation projected to persist at double-digit rates into 2025, PBMs are likely to remain central in policy discussions on drug pricing reform.
Polypharmacy—the use of multiple medications by a single patient—presents another significant challenge. It can lead to side effects, drug interactions, and inappropriate medication regimens, complicating diagnoses and treatment outcomes. Many patients, particularly those managing chronic conditions, take five or more medications daily without a clear physician-driven plan for deprescribing or reducing unnecessary treatments.
Polypharmacy disproportionately affects individuals with comorbidities and chronic diseases. As patients age, they often see multiple specialists, each contributing to an expanding list of medications. Without adequate coordination, this can result in medication regimens that grow unchecked, increasing risks of cognitive and physical decline, hospitalizations, and even mortality. Ensuring that every healthcare provider has an accurate and comprehensive list of a patient’s medications, including over-the-counter supplements, is vital for effective care.
The financial impact of polypharmacy is equally significant. Patients on fixed incomes may struggle to afford their medications, while the broader healthcare system faces substantial costs from nonoptimized medication therapies. In 2018, these therapies were estimated to cost over half a trillion dollars annually in the U.S., encompassing both direct drug costs and the expenses of adverse events caused by inappropriate medication use.
To address polypharmacy, healthcare professionals are increasingly utilizing evidence-based tools such as the Beers Criteria and STOPP/START Criteria. These frameworks help identify potentially inappropriate medications and guide decisions about medication optimization and deprescribing. Deprescribing involves systematically discontinuing medications under a physician’s supervision when their potential harms outweigh their benefits.
While deprescribing is critical to patient-centered care, it remains an emerging area of practice. More research is needed to establish evidence-based protocols and refine best practices. Advances in clinical decision support systems (CDSS) can assist providers by identifying inappropriate medications and enabling targeted interventions. Even modest improvements in medication management can lead to significant reductions in adverse effects, enhanced patient outcomes, and lower healthcare costs.
Anticholinergic medications can impair cognitive function and increase fall risk. Commonly prescribed for conditions like overactive bladder, depression, and Parkinson’s disease, these drugs block acetylcholine, a neurotransmitter critical for memory and muscle function. Long-term use of anticholinergic medications has been linked to an increased risk of dementia, though direct causation remains unproven. Nonetheless, their known associations with confusion and fall risk underscore the need for cautious prescribing, guided by physicians.
The drivers of rising pharmacy costs are multifaceted, ranging from intricate PBM agreements to the cumulative effects of polypharmacy as medical issues emerge over time. Addressing these challenges requires a coordinated effort across healthcare providers and patients.
Improving care requires increasing face-to-face physician time and enhancing coordination among specialists to ensure comprehensive, patient-centered approaches. Advancing research into deprescribing practices and medication optimization is equally essential. While decades of investment have refined the initiation of medications, a complementary science for discontinuing unnecessary drugs is critical.
Collaboration among physicians, pharmacists, and other healthcare providers is vital for improving medication safety, reducing unnecessary drug use, and fostering a culture of continuous evaluation. By building on existing tools and emphasizing physician-led medication reviews, the healthcare community can optimize regimens, minimize adverse drug interactions, and improve patients’ quality of life.
Ultimately, addressing the complexity of pharmacy costs will require systemic reforms and individual efforts to prioritize responsible prescribing and deprescribing practices. By focusing on these strategies, healthcare professionals can work toward a sustainable system that prioritizes patient well-being and maximizes the value of healthcare investments. In the end, healthcare outcomes must align with the resources devoted to achieving them.
Russell R. Barksdale, Ph.D., MPA/MHA, FACHE
President & CEO, Waveny LifeCare Network
Russell R. Barksdale, Jr., Ph.D, MPA/MHA, FACHE is President & CEO of Waveny LifeCare Network
