Financial Toxicity of Medical Management of Heart Failure

Abstract

Optimal medical management of heart failure (HF) improves quality of life, decreases mortality, and decreases hospitalizations. Cost may limit access and adherence to HF medications, especially angiotensin receptor-neprilysin inhibitors and sodium/glucose co-transporter 2 inhibitors. Patients’ experiences with HF medication cost include financial burden, financial strain, and financial toxicity. While there has been research studying financial toxicity in patients with some chronic diseases, there are no validated tools for measuring financial toxicity of HF, and very few data on the subjective experiences of patients with HF and financial toxicity. Strategies to reduce HF-associated financial toxicity include systemic changes to minimize cost-sharing, optimize shared-decision making, implement policies to lower drug costs, broaden insurance coverage, and utilize financial navigation services and discount programs. Clinicians may also improve patient financial wellness through various strategies in routine clinical care. Future research is needed to study financial toxicity and associated patient experiences for HF.

Condensed Abstract:

Heart failure (HF) medications improve quality of life, decrease mortality, and decrease hospitalizations. Cost contributes to suboptimal adherence and access to HF medications. Patients’ experiences with HF cost include financial burden, financial strain, and financial toxicity. There are no validated tools for measuring financial toxicity in HF, and little data on HF-associated financial toxicity. HF-associated financial toxicity may be reduced with changes to cost-sharing, shared decision making, policy implementation, drug price negotiation, insurance reform, financial navigation services, discount/subsidy programs, and various strategies in routine clinical care.

Introduction

Guideline directed medical therapy (GDMT) is the foundation for heart failure (HF) treatment. GDMT improves quality of life, lowers mortality, and decreases hospitalizations for patients with HF, including those with reduced ejection fraction (HFrEF) or those with mildly reduced or preserved EF¹. Though GDMT is of substantial benefit, HF-related expenditures have increased over time and cost may contribute to suboptimal adherence to HF medications^2–6. Studies have shown that cost impacts patients’ willingness to take angiotensin receptor-neprilysin inhibitors (ARNi), such as sacubitril/valsartan, and sodium/glucose co-transporter 2 inhibitors (SGLT2i), such as empagliflozin and dapagliflozin (neither ARNi nor SGLT2i have a low-cost generic available)^4,7. In contrast, cost may have minimal impact on the optimal prescription of HF medications with a generic option including beta-blockers (BB), angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), or mineralocorticoid receptor antagonists (MRA)⁷.

Patients’ experiences with the cost of HF medications include financial burden, financial distress, and financial toxicity. Financial burden is the objective measure of how much income is used towards healthcare costs, including direct out-of-pocket (OOP) costs for treatment, indirect costs for time, travel and changes in employment, and intangible costs (Central Illustration). Financial distress includes the subjective experiences and behavioral implications of financial burden. Financial toxicity refers to the combined effects of financial burden and subjective distress resulting from treatments that lead to both immediate and downstream adverse financial and medical outcomes. The concept of financial toxicity originated in oncology to capture the analogy between the physical toxicity of therapy and the financial challenges experienced by patients as a result of high OOP costs of care, and it is similarly applicable in the setting of HF⁸.

Central Illustration.

Common causes of financial toxicity in healthcare

There are few data on how patients with HF experience and cope with financial toxicity; however it is known that those with HF who report financial toxicity are less likely to adhere to prescribed medications and are more likely to have worse overall health⁹. The purpose of this review is to describe the cost, cost-effectiveness, and value of HF medications, and subsequently discuss the available data on the financial toxicity of HF compared to other chronic diseases. We identify gaps in current knowledge regarding financial toxicity in HF, discuss the impact of insurance on financial toxicity, and propose strategies to mitigate financial toxicity in HF.

Cost, cost-effectiveness, and value of HF Medications

Average OOP spending in HF is higher than other associated cardiac comorbidities, including atherosclerotic cardiovascular disease¹⁰. This is because HF is a chronic disease uniquely characterized by multiple cardiac and non-cardiac co-morbidities (each with their own treatment costs and several of which are associated with poorer health). HF is also associated with hospitalizations that may be expensive and lead to high costs and compromised physical function, compounding experiences of financial toxicity¹¹. Common OOP costs for HF medications are included in Table 1.

Table 1.

Average 30-day OOP cost (lowest cost drug in each class listed for ARB/ACEi)

	No insurance61	Medicare Part D39	GoodRX62	CostPlus63	SingleCare61
ARNi (sacubitril/valsartan)	$843	$47	$316-$346	Unavailable	$656-$663
SGLT2i	$757 (Empagliflozin) $791 (Dapagliflozin)	$45 (Empagliflozin) $47 (Dapagliflozin)	$550-$610 (Empagliflozin) $529-$587 (Dapagliflozin)	Unavailable	$343-$589 (Empagliflozin) $293-$567 (Dapagliflozin)
ARB (Losartan)	$55	< $10	$3-$27	$4.50	$4-$13
ACEi (Lisinopril)	$28	< $10	$1-$12	$3.60	$0.50-$4
MRA	$19 (Spironolactone) $137 (Eplerenone)	< $10 (Spironolactone) $43 (Eplerenone)	$2-$10 (Spironolactone $24-$37 (Eplerenone)	$4.20 (Spironolactone) Eplerenone currently unavailable	$0.75-$12 (Spironolactone) $17-$49 (Eplerenone)
BB	$45 (Metoprolol) $49 (Bisoprolol) $48 (Carvedilol)	< $10 (Metoprolol, Bisoprolol, Carvedilol)	$4-$12 (Metoprolol) $6–20 (Bisoprolol) $4-$36 (Carvedilol)	$3.90 (Metoprolol and Carvedilol) $11.10 (Bisoprolol)	$3-$14 (Metoprolol) $5-$26 (Bisoprolol) $5-$20 (Carvedilol)

Data from the Medical Expenditure Survey (MEPS) shows that HF-related annual total healthcare expenditures have increased 23% per person from 2009–2010 to 2017–2018 ($26,864 to $32,955), and are five times higher than those without HF ($26,864 vs $5,727)⁶. Of this, costs of outpatient care and prescriptions increased the most over time (41% and 24% respectively)⁶. For comparison, myocardial infarction-related and cancer-related expenditures only increased by 16% in the same time period⁶. Between 2017 and 2018, those with HF had an average annual expenditure of $6,063 for medications alone, compared to $1,619 for those without HF (Figure 1)⁶.

Figure 1.

MEPS data on average annual expenditure for medications for those with and without HF⁶.

In addition to raw costs, understanding cost-effectiveness is crucial to the discussion of financial toxicity. Cost-effectiveness describes how well a therapy works in proportion to its cost, and is a metric of how society or an individual may value a therapy (therapies that provide more benefit at lower costs have higher value)^12,13. One way cost-effectiveness is measured is with the incremental cost-effectiveness ratio (ICER), calculated by dividing the cost of a drug by the quality-adjusted life years (QALYs) the drug provides¹².

Sacubitril/valsartan (at wholesale acquisition cost) has been shown to have an ICER of $45,017 per QALY, comparable to other high-value (defined as ICER < $50,000 per QALY) and accepted cardiovascular interventions (such as implantable cardioverter-defibrillator, percutaneous coronary intervention, and left ventricular assist device)¹⁴. Other studies have shown wholesale cost of sacubitril/valsartan for HFrEF to have an ICER of $50,959 per QALY, consistent with high- to intermediate-value (intermediate value defined as ICER between $50,000 and $100,000 per QALY)¹⁵. The cost-effectiveness of SGLT2i for care of HF is somewhat more intermediate. The ICER of dapagliflozin is estimated to be $68,300-$83,650 per QALY, consistent with intermediate-value, and was found to be cost-effective in 95% of probabilistic simulations (defined as ICER <$100,000 per QALY gained)^16,17.

The ACC (American College of Cardiology) and AHA (American Heart Association) have stated that reasonable ICER thresholds for cardiology interventions are $50,000 to $100,000 per QALY, and from the above data ARNi and SGLT2i seem to qualify as such¹⁸. The 2022 ACC/AHA/Heart Failure Society of America (HFSA) clinical practice guidelines, acknowledging the importance of cost-value considerations, also include cost-value statements for each GDMT medication (Table 2)¹. These guidelines consider ARNi, BB, and MRA to be high value, and SGLT2i to be intermediate value for HFrEF¹.

Table 2.

2022 ACC/AHA/HFSA Clinical Practice Guidelines Value Statements on GDMT¹

Drug	Value	Statement
ARNi	High Value	In patients with chronic symptomatic HFrEF, treatment with an ARNi instead of an ACEi provides high economic value
ACEi/ ARB	High Value	In patients with previous or current symptoms of chronic HFrEF, in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value
BB	High Value	In patients with HFrEF, with current or previous symptoms, beta-blocker therapy provides high economic value
MRA	High Value	In patients with HFrEF and NYHA class II to IV symptoms, MRA therapy provides high economic value
SGLT2i	Intermediate Value	In patients with symptomatic chronic HFrEF, SGLT2i therapy provides intermediate economic value

It is worth noting that while cost, cost-effectiveness, and value are important for society, they are measured at a health systems level and must be differentiated from patient level considerations of affordability and financial toxicity¹³. While even the most expensive HF medications are considered high-value treatments with reasonable cost-effectiveness, they may still contribute to financial burden and toxicity for individual patients depending on the degree of cost-sharing and patient specific financial considerations. High OOP costs may be unaffordable and lead to financial burden, medication non-adherence, or compromised lifestyles. The total cost of medications and the portion borne by patients pose different challenges in health policy and the delivery of health care, but the portion borne directly by patients creates direct financial toxicity.

Financial Burden of HF

MEPS data show that 14% of families with a member with HF experienced high financial burden from OOP healthcare expenditures and 5% experienced catastrophic burden¹⁰. Among low-income families these numbers increased to 24% and 10% respectively¹⁰. However, there are few data that integrate both financial burden and subjective distress (that together contribute to financial toxicity) to communicate the impact that finances have on the lives those with HF. MEPS data shows 1/3 of patients with HF experienced financial hardship from OOP medical bills and 13% were unable to pay for their medical bills¹⁹. There is also evidence that OOP costs for HF medications are a significant concern for patients^20,21. However, these numbers do not detail how individuals with HF are impacted by financial burden, how they cope with financial toxicity, or how their family, friends, and caregivers are impacted by the cost of their treatment. While data on financial toxicity of HF are limited, there are studies on the financial toxicity of other chronic diseases that may help frame important issues related to HF.

Applying Lessons Learned from Oncology to HF

Cancer is a prime model of chronic disease in which patients, like those with HF, experience significant financial burden from expensive medications and hospitalizations, altering the ways in which they engage in both their healthcare and non-medical life experiences. Financial toxicity among patients with cancer is associated with decreased treatment adherence, inferior quality of life, and increased cancer-related fatigue²². Patients with high financial burden have higher symptom burden and worse psychological well-being^23,24.

There are no similar studies on financial toxicity for patients with HF, despite the fact that, on average, patients with HF are older than those with cancer, have poorer self-reported health, greater difficulty with activities of daily living, more likely to die suddenly, and more likely to die in a hospital or nursing home or hospice (Table 3)²⁵. In their last two years of life, those with HF had similar total OOP costs as those with cancer ($9,988 vs $9,595) but patients dying of HF had less wealth ($29,895 vs $39,008)²⁵. Patients dying of HF also had greater OOP costs from nursing homes, but lower OOP costs from hospice, doctor visits, and outpatient surgery²⁵. The impact of financial toxicity may therefore be different for those with HF than suggested in studies focused on those with cancer.

Table 3.

Comparison of costs incurred by those dying of HF to those dying of cancer²⁵

	HF	Cancer
Age	80	76
OOP costs	$9,988	$9,595
Wealth	$29,895	$39,008
OOP cost from nursing home	$4,347.8	$1,492.6
OOP cost from hospice	$34.6	$117.7
OOP cost from doctor visits	$799.1	$1,213.9
OOP cost from outpatient surgery	$36.8	$99.8
Percent who died in hospital	36%	28.2%
Percent who died in hospice	3.7%	11.6%

In a survey evaluating the prevalence and impact of financial toxicity among patients with cancer, 68% reported decreased spending on leisure activities and 46% used their savings to help pay for OOP expenses⁸. Other studies suggest almost 20% of patients believe the cost of their treatment has caused their family distress, 11% consider cost of treatment when choosing treatment, and 9% decided against a treatment course because of cost²⁶. Patients with cancer also reported taking less medication than was prescribed, partially filling prescriptions, or avoiding filling prescriptions in order to save money⁸. They were also more likely to report delayed or omitted medical care of family members than those without cancer (implying a ripple effect of financial toxicity on the health of family members)²⁷. Individuals with HF may similarly be forced to weigh lifesaving medications and procedures with the costs of food, shelter, their family’s health, and other basic necessities, but there are presently no data on how they make such decisions.

Given known financial and personal burdens and negative downstream effects on patients and families, policy statements from the American Society of Clinical Oncology have called for discussing cost with patients as a component of high-quality care^28,13. Many oncologists believe financial toxicity should be considered in clinical guidelines, and some guidelines already contain financial toxicity as an important target^29,30. There is a clear need for similar policy statements and clinician support in HF.

Measuring financial toxicity in chronic disease:

The cancer studies mentioned above use tools to measure financial toxicity, which may be adaptable to a HF context. One tool that is validated in oncology is the Comprehensive Score for Financial Toxicity³¹. This is validated as a measure of financial toxicity for patients with cancer, including financial spending, financial resources, and psychosocial response. Such tools have helped measure specific domains of financial toxicity in oncology including total spending, use of financial support, adjustments in lifestyle or medical care to cope with costs³². Adaptations or modifications of such surveys may help obtain vital information on financial toxicity in HF.

Disparities in financial toxicity:

Financial toxicity exacerbates existing health disparities for those with chronic diseases^33,22. Studies on patients with cancer show that financial toxicity is greatest among younger, non-white, and rural patients with cancer, and these patients are more likely to forgo medical care or be lost to follow-up; they are also less likely to have access to clinical trials due to financial concerns^34,35. It is also known that cost sharing exacerbates disparities and decreasing cost-sharing helps address health disparities³⁶. Older age, insurance status, geographic location, employment status, and annual household income are associated with differences in optimal medical management of HF (including lower rates of initiation or higher rates of discontinuation, sub-target dosing, or dose decrease of GDMT), but there is relatively little research on disparities in HF medication utilization with regards to race and/or ethnicity^5,37.

Impact of Insurance on HF medication cost and prescription:

Insurance status may also contribute to disparities in GDMT usage. Insurance premiums and OOP cost for medications are two of the most expensive categories of healthcare spending for patients with HF¹⁰. Insurance status not only impacts the OOP cost of HF medication, but also the optimal prescription of HF medications (Table 1). In an analysis of MEPS from 2014–2018, 51% of patients with HF had private insurance, 48% had public insurance, and 2% were uninsured¹⁰. Premiums were the largest category of healthcare spending amongst insured groups, while medications were the largest category of healthcare spending amongst publicly insured groups¹⁰. While some data suggest privately insured individuals more frequently experience higher financial burden from healthcare costs than those with public insurance, analyses of the CHAMP-HF registry suggest public insurance is associated with sub-optimal dosing of BB, MRA, and ARNi^10,37. In addition, data from the CHAMP-HF registry indicate that SGLT2i use is higher in those with private insurance than those with Medicare or Medicaid (despite Medicaid not having cost sharing for these medications, suggesting potential influences of factors beyond affordability, such as physician bias)³⁸. Prior authorizations, tier strategies, cost-sharing, and step-therapy are all insurance-related obstacles that may reduce optimal adherence to HF medications and worsen financial toxicity of already expensive HF medications.

Medicare:

Older adults are disproportionately affected by HF, more likely to be enrolled in Medicare, have fixed incomes, and have high expenses for comorbid medical care³⁹. Those dying of HF are also more likely to die at an older age than those with other chronic diseases, and more than 80% of deaths from HF occur in those older than 65 years⁴⁰. It is therefore essential to understand Medicare Part D coverage of, or lack thereof, HF medications and how this may contribute to financial toxicity⁴⁰. Table 1 displays average monthly costs for HF medications without insurance and with Medicare part D. Costs for all HF medications are significantly lower with Medicare part D and costs for ARNi and SGLT2i are 16–17 times lower with Medicare part D than for those who do not have insurance. Average monthly OOP costs for quadruple therapy was $94 with Medicare part D, of which $47 was for ARNi and $45 for SGLT2i³⁹. The median annual OOP cost of quadruple therapy was $2,217; this decreased to $1,391 when excluding SGLT2i and $1,322 when including SGLT2i but replacing ARNi with ACEi or ARB³⁹. HF regimens that only included the generic forms of BB, ACEi/ARB, and MRA had OOP costs as low as $3 a month³⁹. Beyond OOP costs, Medicare beneficiaries may face obstacles in obtaining and paying for HF medications due to prior authorizations and step therapy. A study on Medicare coverage of quadruple therapy in 2020 (BB, MRA, ARNi, and SGLT2i) for HFrEF showed that tier ≥3 cost sharing was required by most plans for ARNi and SGLT2i^12,39. Prior authorizations were required for ARNi in 24% of plans and SGLT2i in 5% of plans (tier 3 drugs are often those without generic equivalents, with relatively high copays)^12,39. Step therapy was required for SGLT2i in 5% of plans³⁹. Recent policy changes including the Inflation Reduction Act (IRA) have taken steps to lower the cost of drugs with Medicare, as discussed below⁴¹.

Paths to decreasing systemic sources of financial toxicity

Policy changes:

The IRA allows and requires the federal government to negotiate prices for certain prescription drugs covered by Medicare, requires drug manufacturers to pay rebates to Medicare for increasing prices faster than inflation, caps Medicare OOP spending, and limits Medicare cost-sharing for insulin and vaccines⁴¹. Such policies may decrease HF financial burden and toxicity for those with Medicare but have limitations. Many HF medications may not reach priority level for negotiation and the IRA does not directly change patient co-payments, deductibles, or OOP costs. In addition, the IRA will take years to reach full effect.

Accessibility of health insurance:

While policy changes to provide and expand insurance coverage to more patients may improve financial burden, studies of patients with cancer suggest that having health insurance alone does not eliminate financial distress⁸. A study in Taiwan, a country with universal health insurance, showed that low-income patients had twofold increase in the risk of in-hospital mortality and post discharge events compared with the high-income group, associated with lower GDMT utilization. The persistence of disparities in GDMT prescription and outcomes in a healthcare system with universal health insurance suggests the importance of health insurance quality (it is unclear from the data presented how high OOP costs were), as well as factors apart from insurance coverage that impact optimal prescription of GDMT (such as physician bias)⁴².

Re-evaluating cost sharing:

Many insurance plans limit coverage of HF medications through cost sharing, and these OOP costs (possibly > $2000 per year for HFrEF quadruple therapy with Medicare) are unaffordable for many patients³⁹. Prior data shows cardiovascular medication adherence increases when OOP costs are eliminated⁷. This suggests a need for policies to decrease OOP costs and to re-consider the incentives for cost sharing when there are no high-value generic substitutes available for certain medications (generics for sacubitril/valsartan and dapagliflozin will be available, at the earliest, in 2024 and 2025 respectively)^7,19.

Cost conversations:

There is evidence that OOP costs for medications such as sacubitril/valsartan or an SGLT2i impact patient willingness to take the medication (even when recommended by a physician)⁴. Not only are patients with HF receptive to including OOP cost as a factor in deciding which HF medications to take, they may prioritize cost more than physicians or drug manufacturers; however, studies show few patients report that their physicians initiate conversations about the cost of medications^43,44. While it may be beneficial for physicians to have conversations about cost with their patients, challenges to this strategy include clinician difficulty in appropriately guiding patients to make a decision that is optimized for both their health and finances (Figure 2). This includes errors in accurately estimating each specific person’s cost, difficulty understanding the burden of that cost for each patient given their financial situation, difficulty interpreting how clinical trials generalize to individual patients, and lack of training on how to have such discussions with patients⁴⁵.

Figure 2.

Arguments for and against cost conversations with patients

Pharmacoeconomic perspectives:

Pharmacoeconomics is a branch of health economics that weighs the costs and benefits of a particular intervention in comparison with an analogous alternative, to maximize value for patients, healthcare payers and society⁴⁶. One example of a “reasonable” choice in HF that incorporates cost is that between ARNi and a low-cost generic for an ACEi or ARB that may be an acceptable alternate⁴⁷. 2022 ACA/AHA/HFSA clinical practice guidelines have a class 1A recommendation for use of ARNi in HFrEF, followed by ACEi when ARNi is not feasible¹. The guidelines also include a value statement that “in patients…in whom ARNi is not feasible, treatment with an ACEi or ARB provides high economic value”¹.

It is important to note that the pivotal trial for sacubitril/valsartan was stopped early because of overwhelming reduced mortality, hospitalizations, and HF symptoms with ARNi^12,48. There are data that sacubitril/valsartan reduces hospitalizations and saves costs for HFrEF, and it is possible that suboptimal prescription of sacubitril/valsartan may lead to more downstream financial toxicity from recurrent, and expensive, hospitalizations⁴⁹. However, Medicare coverage data suggest that quadruple therapy with BB, MRA, ARNi, and SGLT2i may be close to $1,000 less per year than if ARNi were substituted with ACEi or ARB; these higher OOP costs might confer harms that outweigh the benefits of the medication³⁹. Further pharmacoeconomic studies comparing ACEi/ARB to ARNi may provide more insight into how to balance the financial toxicity of ARNi with its added health benefits, and it may be reasonable for clinicians to utilize shared decision making with patients when choosing between these medications.

Decision aids may prove helpful in guiding patients between such “reasonable” options⁴⁴. However, some providers have expressed concern that patients may interpret the results of such decision aids as asking them to choose between affordability and improved health (Figure 2)⁴⁴. There is also concern that patients may not interpret the mortality benefits of more expensive medications “appropriately” when weighing these against financial challenges⁴. Interestingly, there are data that priming patients to first consider their finances with a decision aid may actually increase patient willingness to take sacubitril/valsartan^4,47. This highlights the importance of transparency when empowering patients to decide which HF medications are most appropriate for them⁵⁰.

Discount and copay assistance programs:

Programs such as GoodRx, CostPlus, SingleCare may provide lower-cost alternatives for expensive HF medications for individual patients (Table 1). Medications may still be unaffordable with these discounts and sacubitril/valsartan is not yet available through some of these programs. There are also pharmaceutical company and non-profit foundation copay assistance and copay savings cards for medications without a generic option, such as for sacubitril/valsartan, dapagliflozin and empagliflozin^51,52. However, the pharmaceutical company savings card program for empagliflozin requires patients to already have commercial insurance, not have another state or federally funded program paying for their medications (such as Medicare, Medicaid, Veterans Association), is capped at a maximum savings of $175 a month, and is subject to state laws⁵³. In addition, to receive fee assistance for sacubitril/valsartan, patients must earn less than certain annual household income thresholds⁵⁴.

Financial navigation services:

There may be a role for financial counselors, social workers, and financial navigation services to help patients increase their financial literacy and also strategize on how best to afford life-saving medications²². Financial navigation services have been shown to be associated with decreased OOP costs for patients and increased cost savings for hospital systems⁵⁵. Just as oncology centers are now incorporating such resources into their practice (where they may improve quality of life and disease outcomes), there is a need for similar resources integrated within HF and cardiology clinics⁵⁶.

Low-income subsidy program:

The Medicare low-income subsidy program reduces

OOP prescription costs for those who meet criteria for the program⁷. Medicaid-eligible individuals or those with an income under $17,226 and assets under $9,470 are eligible for the full subsidy program, which caps generic copays at $3.60 and brand-name copays at $8.95⁵⁷. With this program, annual out-of-pocket costs for GDMT (carvedilol, sacubitril/valsartan, spironolactone, and SGLT2i) could be under $50. However, for those who do not qualify for the program or who are unaware of it, estimated annual out-of-pocket costs across 23 national Medicare prescription plans averages more than $2300, in addition to nearly $500 in premiums⁵⁸. With an annual income of $20,000, OOP costs could exceed 10% of income. At $47,000, the median income for senior households, OOP costs would make up 5% of income. There may also be a role for expanding this subsidy program to income levels higher than $17,226⁷.

Future directions

HF is a chronic illness that places significant financial strain on patients; however there are very few data describing the nature of financial toxicity in this setting or how it may affect this uniquely vulnerable population. Such information is pivotal to developing strategies for mitigating financial toxicity and improving access to quality HF care. While not studied in a cardiology or HF setting, it is possible that tools validated to study financial toxicity in patients with other chronic diseases may be useful in studying financial toxicity in a HF or cardiology context with minor adaptations. There is also a need for further research on disparities in optimal GDMT prescription with regards to age, sex, gender, race, income, and frailty. Such information will be essential to addressing sources of financial toxicity for patients in order to maximize access and adherence to GDMT, especially for historically marginalized or vulnerable populations.

Comprehensive and optimized HF medical therapy is well supported in clinical trials and has been shown to be cost-effective. Unfortunately, given high costs and restrictive formularies with cost sharing in the United States, these benefits must be weighed against the risks of financial toxicity for each individual patient⁵⁰. Beyond conducting more research and addressing underlying sources of financial toxicity, some have therefore emphasized the importance of physicians making efforts to protect the financial well-being of their patients^59,60. A concerted effort is needed by physicians to openly discuss and help individual patients address and cope with financial toxicity in routine clinical care; this may prove impactful and valuable to patients, given prior data that many patients with HF want to discuss finances with their physician.

We propose 10 strategies for providing financially conscious clinical care that may help improve financial wellness for patients with HF (Figure 3). These include screening patients for financial toxicity, discussing the impact of medical care on finances, and understanding how financial toxicity and social determinants of health change patient health and behavior. Clinicians may also offer resources to patients, such as manufacturer or pharmacy discounts, or connect patients to interprofessional team members who can navigate financial toxicity and social determinants of health. Finally, clinicians may provide cost-conscious care for patients, opting for methods of patient care delivery that are less costly. While such strategies may not be appropriate for every patient, they may serve as a guide to start conversations and propose realistic solutions to help patients mitigate, and cope with, financial toxicity; this may increase optimal HF medical management and help protect patient financial wellness.

Figure 3.

Strategies to improve patient financial wellness in routine clinical care

Highlights.

• Optimal medical management of heart failure improves quality of life and saves lives

• Some HF medications can be unaffordable and contribute to financial toxicity for patients

• Deliberate strategies are needed to mitigate financial toxicity for patients with heart failure

• Future research is needed to describe and reduce financial toxicity in patients with heart failure

Abbreviations and Acronyms:

HF

Heart Failure

GDMT

Guideline Directed Medical Therapy

HFrEF

Heart Failure with Reduced Ejection Fraction

ARNi

Angiotensin Receptor-Neprilysin Inhibitor

SGLT2i

Sodium/Glucose Co-transporter 2 Inhibitor

BB

Beta-Blocker

ACEi

Angiotensin Converting Enzyme Inhibitor

ARB

Angiotensin Receptor Blocker

MRA

Mineralocorticoid Receptor Antagonist

OOP

Out-of-pocket

MEPS

Medical Expenditure Survey

ICER

Incremental Cost-Effectiveness Ratio

QALY

Quality-Adjusted Life Year

ACC

American College of Cardiology

AHA

American Heart Association

HFSA

Heart Failure Society of America