Jeffrey A. Singer and Bautista Vivanco
A 2024 Commonwealth Fund survey compared prescription rates among seniors (aged 65 and above) in 10 different countries, including the US and Canada (Figure 1). According to the survey, 54 percent of American seniors regularly take four or more prescriptions. For Canadians, this rate is 43.9 percent. A 2020 survey in the Journal of the American Medical Association found that US seniors had a mean of 4.3 prescriptions, with 40 percent reporting the use of five or more prescriptions in the past 30 days, which is the threshold for what medical researchers call polypharmacy. The American Medical Association and professional and public health organizations around the world have recognized the link between polypharmacy and “senior morbidity” and have encouraged practitioners to minimize the number of medications they prescribe to seniors.
Some degree of polypharmacy is clinically appropriate in patients with genuine multimorbidity. The concern is not medication count per se, but the persistence of low-value and explicitly discouraged drugs in settings where review and restraint are unrewarded.
In December 2025, The Wall Street Journal reported that many American seniors are prescribed far more medications than clinical guidelines recommend. The Centers for Medicare and Medicaid Services (CMS) granted the Journal’s reporters access to data on the 46 million seniors enrolled in Medicare Part D, the prescription drug benefit, which covers most medications seniors use. A significant number are given drugs listed on the Beers Criteria list—medications the American Geriatric Society considers potentially inappropriate for older adults because they increase the risk of confusion, falls, hospitalizations, and other adverse outcomes. For example, of the 7.6 million seniors the Journal analysis found were taking eight or more drugs, 3.6 million had prescriptions for at least one medication on the Beers list. (See Figure 2.)
The analysis implicitly raises a troubling question: why does this pattern persist despite decades of clinical guidance warning against polypharmacy and inappropriate prescribing in the elderly?
A Parallel Problem: Diagnostic Upcoding in Medicare Advantage
At the same time, a substantial body of evidence documents systematic diagnostic upcoding in Medicare Advantage. Under the Centers for Medicare and Medicaid Services’ risk-adjustment formula, Medicare Advantage plans receive higher payments for enrollees coded with additional or more severe diagnoses. Providers and plans, therefore, have strong incentives to document a higher illness burden—often in ways that are technically permitted but financially misleading. Numerous audits, investigations, and settlements have demonstrated that this is a widespread practice rather than just isolated incidents (see Table 1).
The Wall Street Journal reported in January 2025 on its year-long investigation of UnitedHealth Group and other large insurers that provide Medicare Advantage plans, revealing they encourage their providers to add diagnostic codes for patients to secure larger payments from CMS. In some cases, the insurers send nurses to visit patients at home and diagnose conditions their doctors had previously missed. A month later, the Journal reported that the Justice Department was probing UnitedHealth Group for these practices.
Upcoding is not limited to health insurers who offer Medicare Advantage plans. Research suggests that hospitals and clinicians engage in upcoding to increase payment by third-party payers. In one news report, the CEO of Elevance Health, the health care company formerly known as Anthem, told investors, “We also do see a subset of providers employing more aggressive coding tactics,” adding that some organizations may be “inappropriately leveraging” the independent dispute resolution process. In that same report, health care companies Centene and Molina attributed the rising morbidity in their Affordable Care Act portfolios partly to what they described as increasingly aggressive provider coding.
Commercial insurance increases third-party-payer moral hazard by rewarding providers for describing care as more complex or patients as sicker, while shielding both doctors and patients from the actual costs. Since private insurers pay significantly more when paperwork shows greater severity, small adjustments in documentation can lead to large revenue increases—without any real change in the care provided.
The Incentive Link: Diagnoses and Prescriptions Reinforce Each Other
These two phenomena are interconnected results of the same incentive structure.
Diagnoses justify prescriptions, and prescriptions reinforce diagnoses. A patient labeled with multiple chronic conditions appears sicker on paper, making additional medications seem clinically appropriate. Those prescriptions, in turn, signal medical complexity that supports higher risk-adjusted payments. While no single study directly traces Medicare risk-adjustment incentives to individual prescribing decisions, evidence from institutional settings, risk-adjustment research, and stewardship and decision-support interventions strongly suggests that payment design shapes prescribing behavior.
The Beers list is revealing because inappropriate prescribing does not appear to occur at random; it is more commonly observed in systems where neither doctors nor patients directly face the full cost of adding another medication—a pattern that aligns with economic theory and empirical research linking weaker cost accountability to higher levels of low-value care. Polypharmacy and potentially inappropriate prescribing are especially common among older adults in institutional settings and among patients taking many medications, where there is often scattered oversight and responsibility. In contrast, studies have shown that structured stewardship, monitoring, and clinical decision-support tools—which improve feedback and accountability—reduce inappropriate prescribing, suggesting that clearer responsibility and oversight can help lower the use of low-value drugs.
Is It Simply Carelessness or Bad Medical Culture?
A valid question is whether Beers’ list prescribing reflects negligence, outdated training, or a permissive prescribing culture rather than financial motives. These factors are present and should not be ignored. Some clinicians trained before the Beers criteria were widely emphasized. Others inherit long medication lists and are understandably hesitant to destabilize patients who seem clinically stable.
But culture and habit alone cannot explain the extent, persistence, and systematic nature of inappropriate prescribing among seniors. If this were mainly a knowledge issue, decades of education, warnings, and electronic prescribing alerts would have significantly reduced it. Instead, Beers’ list of medications remains common precisely where the system makes continuation easier than reconsideration.
Deprescribing is time-intensive, cognitively demanding, and poorly reimbursed. Continuing an existing prescription is fast, defensible, and financially neutral. In a third-party payer system that rewards documented complexity and intervention—but not restraint—human habit predictably aligns with financial incentives rather than counteracting them.
A System Problem, Not a Physician Problem
Most clinicians are acting in good faith. What is often described as physician carelessness is more accurately understood as the interaction between human limitations and a payment system that systematically discourages medication review and deprescribing.
Patients do not feel price signals. Physicians are rarely rewarded for stopping medications. Medicare Advantage plans are not penalized for polypharmacy unless it results in an acute, billable adverse event. The result is a system that quietly but reliably encourages excess.
Overmedication as a Policy Outcome
Overmedication is often seen as a failure in quality of care. It is actually a success of payment design. The system achieves exactly what it encourages: more diagnoses, more prescriptions, and increased spending.
The same government-designed incentives that encourage Medicare Advantage plans and providers to inflate diagnoses also promote polypharmacy and the ongoing use of unsuitable medications in seniors. Overmedication is not mainly a failure of medical ethics or clinical expertise; it is an expected result of skewed incentives in a government-run third-party payer system.
More guidelines, more lists, and more oversight will not fix a problem created by incentives. As long as Medicare pays more for greater documented illness and more medical interventions, policymakers should expect polypharmacy—and inappropriate prescribing—to persist.
Conclusion
America’s seniors are not merely overmedicated; they are caught in a system that rewards overdocumentation and overtreatment. The same government-designed incentives that encourage Medicare Advantage plans and providers to inflate diagnoses also promote polypharmacy and the ongoing use of unsuitable medications in seniors. Overmedicating seniors is not primarily a failure of medical ethics or clinical expertise; it is an expected outcome of skewed incentives in a government-run third-party payer system.
Blaming physicians might feel emotionally rewarding, but it hides the more uncomfortable truth. If policymakers truly want to protect seniors, they need to address the incentives built into Medicare itself. Until then, overmedication will continue to be a common feature of the system, not a rare exception.
