Equity and the JAMA Network

Abstract

Unfortunately, this issue of affordability and budget impact may have direct implications for the incorporation of SGLT2 inhibitors into routine clinical practice and the related viability of a 4-pillar strategy as a new standard of care.Approximately 67% of the estimated 3.1 million patients with heart failure and reduced ejection fraction in the US are expected to be candidates for SGLT2 inhibitors. 11At the current Medicare Part D drug pricing (approximately $16 per pill), full deployment of dapagliflozin in eligible candidates would increase the annual societal cost of heart failure management by $12 billion.Sacubitril-valsartan, which has had an unexpectedly slow incorporation into US clinical practice since receiving US Food and Drug Administration approval in 2015, is similarly priced, has comparable clinical effectiveness, and is cost-effective. 12 The reasons for its anemic uptake are incompletely defined, but even with full inclusion on formular-ies and elimination of preapproval requirements, use remains very low, and patient-borne out-of-pocket costs may be a key factor. 8Analyses of claims data suggest that rates of abandonment of new prescriptions at retail pharmacies are less than 5% when there are no out-of-pocket costs but increase to approximately 45% when out-of-pocket costs are $125 and 60% when out-of-pocket costs exceed $500. 13 Will the 4-pillar standard of care represent passage into a new era of heart failure treatment, or will the economics of the 4 pillars signal nothing further beyond current practice?With more emerging heart failure therapies on the horizon (eg, vericiguat, omecamtiv mecarbil), clinicians and patients are faced with the possibility of even more (expensive) pillars to come.Hercules, for all his strength of purpose, did not have to contend with the cost consequences of what he did.Modern medicine does.

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