IMPORTANCE: For patients with heart failure with reduced ejection fraction (HFrEF), treatment with sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, has become increasingly preferred over angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs). However, sacubitril-valsartan is much more expensive than generic ACE-I/ARBs. It is unknown whether the high cost of sacubitril-valsartan is offset by lower spending on hospitalizations and other treatments. OBJECTIVE: To compare total and out-of-pocket health care spending among Medicare beneficiaries initiating sacubitril-valsartan vs ACE-I/ARBs for HFrEF. DESIGN, SETTING, AND PARTICIPANTS: This was a cohort study using data from Medicare fee-for-service claims with propensity score matching of Medicare beneficiaries with HFrEF. Data analysis was performed from November 2022 to December 2023. EXPOSURE: Initiation of sacubitril-valsartan or an ACE-I/ARB. Patients were matched by propensity score based on 104 covariates, including demographic characteristics, comorbidities, baseline annual spending, and baseline use of health care services. MAIN OUTCOMES AND MEASURES: Mean total and out-of-pocket health care expenditures during the 365 days after initiating sacubitril-valsartan or an ACE-I/ARB. Censoring for incomplete follow-up was addressed using Kaplan-Meier probability weighting. Cost differences, cost ratios, and 95% CIs were calculated using a nonparametric bootstrapping method with 500 samples drawn with replacement. RESULTS: Among 13 755 matched pairs of Medicare patients with HFrEF (mean [SD] age, 77.5 [7.5] years
5138 [39%] 80 years or older
9949 females [36%] and 17 561 males [64%]), mean annual total health care spending per person was similar for sacubitril-valsartan initiators and ACE-I/ARB initiators (difference, 01
95% CI, -32 to 593). Sacubitril-valsartan initiators had higher prescription drug costs (difference, 911
95% CI, 704 to 113), lower inpatient costs (difference, -90
95% CI, -468 to -2), lower outpatient costs (difference, -30
95% CI, -64 to -1), and higher annual out-of-pocket spending (difference, 09
95% CI, 3 to 08). CONCLUSIONS AND RELEVANCE: This cohort study found that Medicare beneficiaries initiating sacubitril-valsartan to treat HFrEF had similar total health care spending as those initiating ACE-I/ARBs
higher prescription drug spending was offset by lower inpatient and outpatient spending. However, sacubitril-valsartan use was associated with higher patient out-of-pocket costs, which may exacerbate health disparities and limit access and affordability.