Findings from a recent review have shed further light on the financial burden of heart failure (HF) medications on patients, as well as the systemic barriers that hinder cost-effective treatment. Led by Emily F. Lowe, MD, from the University of Colorado School of Medicine in Aurora, the review discussed the multifaceted drivers of high out-of-pocket (OOP) costs and suggested actionable strategies to alleviate the financial toxicity associated with HF management. “High medication costs can lead to poor adherence and worse health outcomes,” said the authors of the paper, which appears online in the January 13 issue of Journal of the American College of Cardiology. “After identifying potential barriers to medication affordability, patients can be directed toward the various cost-saving programs for which they are eligible. “There is progress both in reducing cost and enhancing transparency, and the potential benefits in terms of clinical warrants continued efforts to improve cost transparency in HF management,” the authors wrote. New treatment expense The review emphasizes, that despite its clinical benefits, the cost of newer treatments, such as angiotensin receptor-neprilysin inhibitors (ARNIs) and sodium-glucose cotransporter 2 (SGLT2) inhibitors, can be prohibitively expensive. The authors note that "Variable and growing out-of-pocket (OOP) costs for HF medications can lead to financial burden, financial strain, and financial toxicity for some patients. “This burden is compounded by the complexity of HF, which often coexists with other chronic conditions requiring medications.” The research team went on to highlight that not even Medicare can completely absorb the costs of these guideline-directed medical therapies (GDMT). For example, to follow a comprehensive GDMT regimen, including Angiotensin Receptor–Neprilysin Inhibitors (ARNIs) and Sodium–Glucose Co-Transporter 2 (SGLT2) Inhibitors costs a median of $2,200 annually. Generic compromise The review highlights that while patients can choose generic alternatives like ACE inhibitors or beta-blockers that may reduce this cost, the downside compromises the possibility of achieving optimized outcomes. "When optimal GDMT is not feasible, providers often opt for a regimen that includes only generic medications...resulting in an annual median OOP cost around $160,” the authors wrote. Naturally, the financial strain on patients directly affects adherence to medication with the review revealing that around 20% of older adults reported medication non-adherence because of cost. The non-adherence extends to 21% of patients surveyed, who admitted to skipping refills with 12% splitting or skipping doses to extend the duration of each fill. The burden also falls on clinicians as they struggle to address these financial pressures during consultations. The paper’s authors cite one study in which 74% of physicians felt an obligation to discuss costs with their patients, with only 21% accurately estimating out-of-pocket (OOP) expenses. "Physicians often cite insufficient time (76%) and knowledge (69%) as major barriers," the authors said. Policy solutions The review provided details about a number of impending policy solutions to address these very issues, leaving a cause for encouragement. One such resolution is The Inflation Reduction Act of 2022, which introduced a $2,000 annual cap on Medicare Part D OOP costs that is set to take effect in 2025. The act also serves to provide provisions for drug price negotiations, with reductions of up to 60% expected for key HF medications like sacubitril/valsartan. "These measures are likely to transform the way health care providers and patients think about prescribing costs in the setting of chronic disease and multimorbidity," the review suggests. The team concluded their report by emphasizing the need for greater transparency, patient support and systemic reforms to reduce the financial toxicity of HF medications. "Understanding the determinants of OOP cost can prepare clinicians to engage in cost-sensitive discussions and has the potential to reduce cost-related nonadherence and financial toxicity," the researchers concluded. Review methodology The authors began by gathering insights from clinical guidelines, recent policy updates and a wide range of academic and healthcare sources. The review also assessed scenarios, such as how OOP costs differ based on drug formulary tiering, copay structures and coinsurance rates providing a practical understanding of how insurance plans influence patient expenses. The team also evaluated the effectiveness of cost-saving programs, such as manufacturer discount cards, patient assistance programs and direct-to-consumer pharmacy models. Information from clinical surveys and randomized trials detailing the relationship between medication costs and adherence were integrated into the analysis. The research team also used these data sources to create a framework for clinicians to address financial toxicity in their practice. This was aided by the systematic evaluation of tools like real-time pharmacy benefit systems and policy-driven cost caps. Sources: Lowe EF, Gerasta D, Balser M, et al. Contributors and Solutions to High Out-of-Pocket Costs for Heart Failure Medications. J Am Coll Cardiol. 2024. [Article in Press]. Image credit: thanksforbuying – stock.adobe.com