Why guideline-directed medical therapy depends on more than guidelines: microeconomics of medication use in heart failure.

Despite substantial mortality benefits, fewer than 25% of individuals with heart failure with reduced ejection fraction (HFrEF) receive all four pillars of guideline-directed medical therapy (GDMT), with underuse driven in part by economic and policy factors. Three clinician- and policy-relevant considerations may improve GDMT optimization. First, reduce patient cost sharing for GDMT at the public policy level. Evidence from national surveys demonstrates medication cost is a significant driver of nonadherence, particularly among economically vulnerable populations. Economic analyses have repeatedly shown GDMT produces high value welfare gains and cost-efficient savings through hospitalization and morbidity reduction. Second, enhance medication price transparency which is often obscured by insurance benefit design and complex rebate flows. Third, reduce overly burdensome administrative and formulary barriers. Cost containment mechanisms including prior authorizations and formulary limitations may delay or prevent initiation when applied to high-value therapies such as GDMT. Addressing these economic factors at both the policy-level and clinician-level is essential for translating GDMT into population-level survival gains. Therefore, this review integrates publicly available microeconomic data, economic theory, and health policy evidence to identify structural barriers to equitable GDMT optimization as well as provide pragmatic, policy-relevant solutions to aid clinicians in improving national adoption of GDMT.