Hospitalizations and Medications Drive High Cost in Indian HF Patients: Decoding ICMR Study & What Can Be Done?

Published in Global Heart, the study assessed 1,859 heart failure patients enrolled from 21 hospitals across India. Researchers found that average annual out-of-pocket (OOP) spending accounted for a staggering 92.6% of total healthcare expenditure among HF patients.

High Hospitalization Costs and Early-Onset HF Deepen Financial Toxicity

The average hospitalization expense per patient was around 1.18 lakh INR, while the average out-of-pocket expenditures exceeded 1.06 lakh INR. Nearly 38% of households had catastrophic health spending, and 17.7% of families used distress financing tactics such as borrowing money, accepting loans, or selling assets to continue treatment. Researchers discovered that heart failure in India affects people while still in their productive working years, with patients' average ages of only 55.9 years, which is at least 10-15 years younger than the Western or other Asian HF registries.

Cost Burden Dynamics in Indian Heart Failure Patients

• Heart failure (HF) is a chronic, progressive illness that necessitates lifelong medication, frequent hospital stays, frequent monitoring, and recurrent investigations—all of which significantly raise healthcare costs over time (1).
• The typical hospital stays, according to the study, was five days, and individuals who were hospitalized more than once experienced much more financial difficulty. Compared to 30.1% of patients in urban areas, 45.6% of patients in rural areas had catastrophic medical expenses, making them especially vulnerable (1).
• Nearly one-third of patients and households reported a decrease in monthly income after receiving an HF diagnosis, according to researchers, underscoring the dual burden of growing medical expenses and diminished earning potential (1).
• A systematic review assessing the association between copayment, medication adherence and outcomes in patients with HF & T2D found that lower copayments were associated with higher medication adherence, which in turn was linked to better health outcomes and lower overall healthcare costs (2).

Improving Access and Optimizing Utilization of Affordable Sacubitril/Valsartan Therapy in Heart Failure Management

The ICMR study highlights that out-of-pocket expenditure remains a major driver of financial toxicity among Indian patients with heart failure (HF), emphasizing the need for affordable long-term Sacubitril/Valsartan therapy to support sustained adherence and optimize clinical outcomes.

Sacubitril/valsartan, a cornerstone of guideline-directed medical therapy (GDMT), has consistently demonstrated benefits in reducing HF hospitalizations, slowing disease progression, and improving cardiovascular outcomes. However, continuation of therapy after discharge is often affected by recurring medication expenses, largely uncovered by health insurance in India.

Currently, several widely prescribed Sacubitril Valsartan brands in India continue to carry substantial long-term treatment costs for heart failure (HF) patients.

Commonly used leading brands of Sacubitril Valsartan are priced between INR 15–52 per tablet. However, it is noteworthy that there are certain high-quality Sacubitril Valsartan formulations also available at nearly INR 8 per tablet. Such cost-effective treatment options need to effectively considered in heart failure patients, when indicated.

At a typical twice-daily dosing schedule, monthly therapy cost with major expensive Sacubitril Valsartan formulation options may exceed INR 3,000 per month, while several other commonly prescribed brands range at therapy cost between INR 900–2,700/- per month. Among the most cost-effective Sacubitril Valsartan formulation options, when considered, may lead to a therapy cost of approximately INR 480 per month, making it nearly 47%–85% more affordable.

The cumulative cost-benefit to the patient for a chronic disease like heart failure over a long period is significant.

Given that HF requires lifelong GDMT therapy, such affordability may play a crucial role in improving medication adherence after discharge, reducing treatment interruptions, and lowering the long-term out-of-pocket financial burden on patients and families, while also reducing the cost associated with risks of hospitalisations with heart failure.

Figure 1: Effect of Affordable Treatment on HF Outcomes

Potential Real-World Implications for Healthcare Stakeholders

This study underscores the urgent need to strengthen long-term, affordable heart failure (HF) care in India. Recurrent hospitalizations, chronic medication expenses, and high out-of-pocket spending continue to place a substantial financial burden on patients and families. Improving access to cost-effective guideline-directed medical therapy (GDMT), alongside better outpatient financial support, could help improve adherence after discharge, reduce rehospitalizations, and ease the overall economic burden associated with chronic HF management.

Figure 2: Key insights from the ICMR study

Expert Opinion

Should future Indian cardiovascular insurance models include mandatory outpatient drug coverage for chronic HF to improve adherence and reduce rehospitalization burden?

“Yes, outpatient drug coverage should become a core component of future Indian HF insurance models. In real-world practice, most heart failure costs arise after discharge through lifelong medicines, repeat consultations, and monitoring. When patients pay out-of-pocket every month, adherence drops, especially in lower-income and rural families, eventually leading to avoidable rehospitalizations. The study quite rightly reinforces that insurance reduces financial stress, but inpatient-only coverage is insufficient for a chronic disease like HF.”

What is the practical importance of cost-effective medications in heart failure care?

“Cost-effective medications are extremely important in heart failure care because HF is not a one-time treatment, it is lifelong management. In Indian clinical practice, we often see patients doing well initially for a few months, but discontinue medicines because of monthly financial burden. That directly affects adherence, symptoms come back, increases repeat hospitalizations, and worsens outcomes. After switching them to a more affordable sacubitril-valsartan option, adherence improves significantly, along with symptom control, exercise tolerance, and overall quality of life. The practical goal is to choose therapies that are both evidence-based and realistically sustainable for patients and families over the long term.”

The ICMR study underscores OOP spending & financial burden among Indian heart failure patients, and suggests that affordable, evidence-based therapies are critical for improving adherence, thereby reducing rehospitalizations, and lowering long-term economic burden in real-world care.