Op-Ed: Prescribing Cascade Is Avoidable—If We Empower Pharmacists to Intervene

In an untold number of pharmacies across the country, pharmacists witness the same daily, frustrating pattern play out before their eyes.

It goes like this: a person comes up to the counter to fill or refill 1 or more of the several medications they’ve been prescribed by their many providers. Each of these medications addresses an isolated symptom removed from the broader picture of that person’s health. One drug leads to an unwanted adverse effect, which leads to another prescription, which triggers yet another complication.

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This prescribing cascade is both common and completely avoidable. Individual physicians are working in time-strapped practices, with medication as just 1 possible tool to use to meet patient needs. But in most communities, pharmacists have little opportunity to intervene at the point of care and clinical decision-making. With pharmacists an arm’s length away from care teams, the cycle continues unchecked, and patients suffer for it.

The US health care system spends an estimated $528.4 billion annually on avoidable medication-related costs, driven by factors like nonadherence, unnecessary prescriptions, adverse drug reactions, and dosage-related complications.¹ These factors frequently lead to unnecessary hospitalizations. The burden of these costs is felt across the entire health care system, from overwhelmed emergency departments to people helplessly struggling with worsening health conditions.

Most of these medication-related issues are completely preventable. Pharmacists have the expertise necessary to mitigate this with education and simplification of regimens but can have limited to no impact from behind the pharmacy counter, where the incentives are prescription volume and speediness in filling what the doctor ordered.

The Case for Integration

There is a growing body of published evidence that demonstrates the value of clinical pharmacists and pharmacy technicians in primary care teams.^2-5 Yet, despite our extensive training, too many pharmacists remain confined to transactional roles. The movement to integrate pharmacists into primary care teams is ongoing, and adoption isn’t as broad in the US as it should be.

A major reason is misaligned incentives: in our predominantly fee-for-service health care system, there’s little motivation to invest in pharmacists when providers are paid based on volume rather than outcomes. Hiring a pharmacist to get medications right is often seen as an operating expense rather than a strategic investment.

Further, pharmacists are not federally recognized as Qualified Healthcare Providers (QHPs) under Medicare, which throttles our ability to bill for services and results in significantly lower reimbursement rates. Although some state Medicaid programs and commercial insurers have taken steps to reimburse pharmacists for direct patient care, broad reform is necessary to enable integration at scale.

Even within some collaborative agreements, the depth with which pharmacists can engage in care remains limited. However, a confluence of trends in care delivery and payment may change this paradigm—and health plans have an outsized part to play in facilitating that transformation.

Designing a Model That Works

The rise of multi-modal care delivery models, wherein an interdisciplinary care team is responsible for managing patient populations on a local level through virtual and in-home settings, is the ideal environment for embedding pharmacists firmly within care teams. Provider collaboration is even further incentivized when these models are designed within a value-based care framework.

Where permitted by law, this model enables pharmacists to provide essential guidance on complex medication regimens for the highest-risk, highest-cost patients, and guide deprescribing of unnecessary drugs or harmful combinations for those who are most vulnerable to getting caught up in the infamous prescribing cascade. Working hand-in-hand with physicians, pharmacists within this model can help tailor interventions to improve adherence, reduce complications, and prevent hospitalizations. Under these formal collaborative practice agreements, they have the flexibility to make medication adjustments, streamlining care and freeing up physicians from tasks they’d otherwise find laborious.

Working in homes and communities gives pharmacists rare insight into the social drivers that impact health—how people live, manage their medications, and navigate barriers to care. These insights can be shared back to interdisciplinary care teams to inform better care decisions. Within this practice environment, people benefit from expertly guided medication management, physicians are supported in their treatment decisions, and pharmacists are granted the freedom to have a much more direct impact on patient care.

Over time, these face-to-face encounters help pharmacists build meaningful relationships with people that not only improve clinical outcomes but help rebuild trust in care teams and the healthcare system.

I’ve seen the impact of this model firsthand. Last year, I began working with a woman whose diabetes was dangerously uncontrolled, and who had disengaged from her previous care due to serious mental illness and a lack of trust in her providers. In our early telehealth visits, she’d give me curt, 1-word answers. I soon learned she lived alone, with no caregivers nearby, and due to her weight, she couldn’t walk more than a block to get her medications.

When my team and I began visiting her in her home, things changed: we were able to get to know her better and slowly earn her trust, and our provider simplified her regimen based on my recommendations. By April of 2025, her hemoglobin A1c was just above the diagnostic threshold for type 2 diabetes (6.6%) and her blood pressure was controlled. Better yet, she asked us to help her find a new primary care physician—one she could get up and walk to.

This is what top-of-license work looks like for pharmacists. The cycle playing out daily in pharmacies, hospitals, and homes has gone on long enough. It’s time to let pharmacists break it.

REFERENCES

1. Watanabe JH, McInnis T, Hirsch JD. Cost of prescription drug-related morbidity and mortality. Ann Pharmacother. 2018;52(9):829-837. doi:10.1177/1060028018765159

2. Jain SH. Can Pharmacists Help Reinvent Primary Care in the United States? Forbes. October 10, 2018. Accessed June 5, 2025. https://www.forbes.com/sites/sachinjain/2018/10/10/can-pharmacists-help-reinvent-primary-care-in-the-united-states/

3. Carroll AE. The Unsung Role of the Pharmacist in Patient Health. The New York Times. January 28, 2019. Accessed June 5, 2025. https://www.nytimes.com/2019/01/28/upshot/pharmacists-drugs-health-unsung-role.html

4. How Pharmacists Can Drive Patient Engagement, Value-Based Care. VBC Exhibit Hall. March 28, 2019. Accessed June 5, 2025. https://library.vbcexhibithall.com/how-pharmacists-can-drive-patient-engagement-value-based-care/

5. MacKinnon GE. Concept for embedded primary care pharmacist practitioners (PCPPs): a disruptive value-proposition. Pharmacy (Basel). 2020;8(4):195. doi:10.3390/pharmacy8040195