• Center on Health Equity and Access
  • Clinical
  • Health Care Cost
  • Health Care Delivery
  • Insurance
  • Policy
  • Technology
  • Value-Based Care

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

Article

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.”

Reference

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

Related Videos
Pat Van Burkleo
Robert Groves, MD
Pat Van Burkleo
James Robinson, PhD, MPH, University of California, Berkeley
James Robinson, PhD, MPH, University of California, Berkeley
Carrie Kozlowski
Carrie Kozlowski
Carrie Kozlowski, OT, MBA
Shawn Gremminger
Marjorie Robinson, UPMC Health Plan Member
Related Content
© 2024 MJH Life Sciences
AJMC®
All rights reserved.