Stopping Medications Safely Is Hard. This Federal Guidance Could Change Everything

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<p>Medication safety is typically framed around choosing the right drug. But in clinical practice, one of the most important medication safety decisions is often: <em>Is this medication still helping this patient more than it may be harming them?</em></p>
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<p>I am constantly asking this question. I am a pharmacist who leads a comprehensive medication management (CMM) service, a system of care where pharmacists work directly with doctors to ensure medications are safe, effective, and treat the conditions they are prescribed for.</p>
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<p>The goal of a CMM is to prevent adverse drug events, a term that encompasses far more than the often discussed and more immediate issues of side effects, allergic reactions, and prescribing errors. People can also be harmed by medication regimens that accumulate over time, continue after the original indication has resolved, interact with new therapies, or no longer align with the patient’s goals, physiology, or risk profile.</p>
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<p>Unfortunately, despite strong evidence that a pharmacist-led CMM improves medication-related outcomes, <a href="https://www.sciencedirect.com/science/article/pii/S1551741119305613">it has not been widely adopted</a> into U.S. primary care because our healthcare system is not designed to pay for them. </p>
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<p>That is why the recent Centers for Medicare & Medicaid Services (CMS) <a href="https://www.cms.gov/files/document/billing-supervised-medication-deprescribing-services-under-pfs.pdf">billing guidance</a> on supervised medication deprescribing, which introduces codes for clinical deprescribing services, is so significant. CMS is now making clear that, when appropriate requirements are met, the clinical work involved in safely tapering patients off of medications, including by pharmacists, may be billed to Medicare using already existing codes for services, including chronic care management, <a href="https://www.medicare.gov/coverage/principal-care-management-services">principal care management</a>, behavioral health integration, and psychiatric collaborative care management. </p>
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<p>Historically, the time pharmacists spent helping patients cut back on potentially dangerous medications was largely unpaid work. This guidance transforms deprescribing into a recognized, revenue-generating service, enabling the expansion of CMMs and improved medication management for at-risk populations. </p>
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<h2 class="wp-block-heading">Deprescribing Is Not “Doing Less”</h2>
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<p>One of the misconceptions about deprescribing is that it simply means telling a patient to stop taking medications. But the <a href="https://www.cms.gov/files/document/billing-supervised-medication-deprescribing-services-under-pfs.pdf">CMS defines deprescribing</a> as the planned, supervised process of dose reduction or discontinuation of a medication when its continued use may no longer provide a net clinical benefit, emphasizing the practice as an active clinical process.</p>
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<p>For a pharmacist, deprescribing often requires:</p>
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<li>A full evaluation of a patient’s medications and supplements</li>
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<li>An assessment of benefit versus harm </li>
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<li>Shared decision-making with the patient and caregiver </li>
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<li>A tapering or discontinuation plan </li>
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<li>Close monitoring for withdrawal, symptom recurrence, or disease relapse </li>
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<li>Coordination with other prescribers and pharmacies </li>
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<li>Documentation of the decision-making process and follow-up</li>
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<li>Dose holds, taper adjustments, or reinstatement when clinically necessary</li>
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<p>In other words, deprescribing is another form of medication management. And in many cases, it is life-saving work.</p>
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<h2 class="wp-block-heading">Impact on Adverse Drug Event Prevention</h2>
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<p>Adverse drug events remain one of the most important and under-addressed threats to patient safety; in 2022, they were reported as the cause of nearly <a href="https://www.ncbi.nlm.nih.gov/books/NBK599521/">175,000 deaths</a>, with over 1.25 million serious events reported. Many were not the result of a single bad decision, but of a system where providers, pharmacies, and electronic systems operate in separate "silos,” communicating infrequently and often ineffectively.</p>
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<p>For example, an individual may start a medication during a hospital stay. Another drug may be added to their regimen by a primary care physician. A third may come from a specialist. The patient may purchase a fourth over the counter. Months or years later, no one provider may be clearly responsible for asking whether the full regimen still makes sense. This is where CMM can make a major difference.</p>
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<p>Deprescribing gives clinicians a structured way to reduce medication-related harm, especially for older adults who are <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC12801748/">more likely</a> to be taking five or more medications, the general definition of a scenario known as “polypharmacy.” </p>
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<p>The <a href="https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.18372">2023 American Geriatrics Society’s Beers Criteria</a>, a set of clinical guidelines designed to help healthcare providers safely prescribe medications for adults 65 and older, remains one important tool for identifying potentially inappropriate medications in older adults.</p>
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<p>However, deprescribing can be a crucial practice for many demographics, and particularly for patients with: </p>
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<li>Multiple chronic conditions </li>
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<li>High-risk medications </li>
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<li>Cognitive impairment </li>
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<li>Fall risk </li>
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<li>Renal or hepatic dysfunction </li>
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<li>Transitions between healthcare settings or providers</li>
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<li>Psychotropic medication exposure </li>
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<li>Two medications of the same class</li>
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<li>Drug-drug or drug-gene interactions</li>
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<p>While many resources and guidelines exist for practitioners and pharmacists, Medicare reimbursement is a crucial step in standardizing deprescribing for these at-risk groups. </p>
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<h3 class="wp-block-heading">Pharmacists Should Be Central To This Work</h3>
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<p>Pharmacists are uniquely positioned to lead and support deprescribing efforts as part of a team-based model.</p>
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<p>Pharmacist-led CMM services help identify medication-related problems, evaluate drug-drug and drug-disease interactions, support taper planning, educate patients, monitor symptoms, and coordinate with prescribers. This is exactly the kind of work that requires medication expertise and longitudinal follow-up. </p>
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<h2 class="wp-block-heading">Where To Find Support in Deprescribing </h2>
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<p>Patients interested in learning more about deprescribing should begin by discussing their medications with their healthcare team, including their primary care provider and pharmacist. In addition, several organizations offer reliable, patient-friendly resources to help individuals better understand their medications and prepare for conversations about reducing or discontinuing therapy.</p>
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<p><a href="http://deprescribing.org">Deprescribing.org</a> is one of the leading evidence-based resources dedicated to deprescribing. It provides free patient decision aids, educational brochures, information on commonly deprescribed medications (such as sleep medications, proton pump inhibitors, diabetes medications, and antipsychotics), and practical questions patients can ask their healthcare providers. </p>
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<p><a href="https://www.bruyere.org/en/our-research">The Bruyère Health Research Institute</a> also develops evidence summaries and educational materials that inform many internationally recognized deprescribing guidelines.</p>
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<p>For broader medication safety information, the <a href="https://home.ecri.org/pages/ismp-about-us">Institute for Safe Medication Practices (ISMP)</a> offers patient education on medication risks, adverse drug events, and safe medication use. </p>
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<p>Older adults and caregivers may also benefit from resources offered by the <a href="https://geriatricscareonline.org/ProductAbstract/ags-deprescribing-toolkit/TK013">American Geriatrics Society (AGS)</a>, including educational materials on potentially inappropriate medications and guidance informed by the Beers Criteria.</p>
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<p>Many academic medical centers and health systems also offer pharmacist-led medication optimization services, comprehensive medication review clinics, polypharmacy clinics, or geriatric assessment programs. Patients should ask their healthcare provider whether these services are available in their community.</p>
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<p>Along with seeking these services, patients may consider asking the following questions to their pharmacist or doctor, to facilitate productive conversations: </p>
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<li><em>Do I still need each of my medications? </em></li>
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<li><em>Which medication is providing the greatest benefit? </em></li>
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<li><em>Are any of my medications increasing my risk of side effects such as falls or confusion? </em></li>
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<li><em>If a medication is no longer needed, how should it be safely tapered? </em></li>
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<li><em>What symptoms should I watch for during the process?</em> </li>
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<p>These questions can help ensure deprescribing decisions are individualized, evidence-based, and aligned with the patient's health goals.</p>
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<h2 class="wp-block-heading">The Path Forward </h2>
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<p>My hope is that this CMS guidance helps move deprescribing from a good idea to a standard part of medication safety practice. We have spent decades building systems to start medications. We need equally reliable systems to reassess, taper, and stop medications when they are no longer helping or may be causing harm.</p>
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