Worsening Heart Failure, Higher Medicare Part D OOP Spending Linked in New Analysis

Out-of-pocket (OOP) spending for patients with heart failure with reduced ejection fraction rose in the event of a worsening heart failure event across the 4 phases of Medicare Part D coverage.

According to published research, in 2020, heart failure–related costs were a median $24,383 per year, with expenses related to hospitalizations accounting for just over 65%, or $15,879, of that total. As recently as that year, 5 million individuals were living with congestive heart failure and new diagnoses accounted for another 500,000 cases.

In addition, the cost totals represent an increase. In 2017, patient-related costs for a heart failure hospitalization averaged $14,631.

Now, a new analysis presented at this year’s American College of Cardiology 70th Scientific Session breaks down heart failure–related costs again—but this time, among those enrolled in Medicare Part D who specifically have heart failure with reduced ejection fraction (HFrEF). This is when left ventricular ejection fraction is 40% or less.

“Studies have shown high clinical and economic burden in patients with HFrEF who experience a worsening heart failure event (WHFE), but Medicare Part D out-of-pocket costs (OOP) are not well characterized,” the investigators noted. “This study evaluated OOP drug spending in chronic HFrEF patients with and without a worsening heart failure event.

Overall, within 1 year after their earliest HFrEF diagnosis, 26% of the entire patient cohort (n = 80,454) had a WHFE. And although the mean (SD) overall OOP costs were already elevated, at $1166 ($1205), those who had a WHFE had to fork over close to 17% more in OOP costs compared with those who did not have a WHFE: $1302 ($1273) vs $1117 ($1176), respectively.

Beyond OOP, or deductible, costs, the authors investigated the 3 other phases of Part D Medicare coverage: the initial coverage period, the coverage gap (or donut hole), and catastrophic coverage.

Not surprisingly, mean OOP costs rose with each successive phase and were higher among those with a WHFE vs those with no WHFE and overall, respectively:

  • Deductible phase: $200 ($134) vs $197 ($133) and $198 ($133)
  • Initial coverage phase: $656 ($414) vs $602 ($414) and $616 ($414)
  • Coverage gap phase: $1044 ($670) vs $1006 ($660) and $1017 ($663)
  • Catastrophic phase: $1161 ($2352) vs $1141 ($2281) and $1147 ($2304)

The analysis also found fluctuating claims levels in each Medicare coverage phase. Just over one-third of the patients overall and in the WHFE and non-WHFE groups had a claim in the deductible phase (34.5%, 33.3%, and 34.9%, respectively). However, these numbers spiked in the initial coverage phase (93.3%, 95.2%, 92.6%) before dropping once again in the coverage gap (39.2%, 44.3%, 37.3%) and catastrophic (10.8%, 12.9%, 10.1%) phases.

For their analysis, the authors used 2018 Medicare 100% Part D fee-for-service claims data on patients with HFrEF and 12 months of enrollment in 2018 (N = 305,373). They defined the heart failure subtype as each participant having “1 inpatient or 2 outpatient claims of systolic heart failure or 1 systolic heart failure plus 1 heart failure outpatient claim.”

Different criteria were used to gauge a WHFE and comprised hospitalization for heart failure or need for an intravenous diuretic by the 12-month mark after receiving their HFrEF diagnosis.

“The findings suggest a high OOP cost burden in patients with chronic HFrEF,” the authors concluded, “especially in those following a WHFE.”


Fendrick M, Djatche L, Pulungan Z, et al. Part D out of pocket payments in Medicare beneficiaries with heart failure with reduced ejection fraction. Presented at: American College of Cardiology’s 70th Scientific Session; May 15-17, 2021. Virtual. Abstract 1038-07. https://www.abstractsonline.com/pp8/#!/9228/presentation/12576