Consequences of cardiac stent price reductions- patient perspective

As a cardiologist, I am very happy that stent prices have been reduced.
With price reduction, I should be able to treat more patients. But, in reality, this is becoming counter-productive.
For the poor patients, stents will become more expensive and for affording patients newer stents will not be available in Indian market. Only the party which will get benefit by this new rule are medical insurance companies.
On the surface, this article appears insane please read this article completely to know ground reality.

In recent times, cardiology is in news for coronary stents price. We are seeing numerous articles in the newspaper and social media. Even we are seeing posters on roads stating 85% reduction in stent prices by our political party leaders. This looks more like a political stunt.

I do agree some stents were overpriced. At the same, a lot of stents were cheaper. Most commonly used stents were cheaper ones around  INR 18000 to patients. This is because in India (Karnataka) we have plenty of government schemes meant for BPL and also APL card holder. The total package for them is 65000 to 75000 INR including stent and angioplasty procedure.

High top end expensive stents were used for VIPs and those patients  who wished state of art treatment. Now these may become unavailable in Indian market

Stents, prize and politics

Price reduction of coronary stents

This new rule has capped MRP of all drug-eluting stents to not more than INR 31000. Thus does not want to differentiate between the various generation of drug-eluting stents. In consequence, top end stents like premier, alpine, synergy,  expedition and bioabsorbable scaffolds are being pulled back from Indian market leaving only older stents.

Newer top end stents were easily trackable, had a lesser incidence of restenosis. They also had a lesser need of tablets as compared to older stents.

Price reduction and poor patients

Stents for poor BPL patients were already being given at, lower price around 18000  INR and this rule will actually the harm this.

According to a new rule, stents can not have MRP more than 31000 INR. The total profit margin from the production company to a patient can not exceed more than  8%.

In this stent business, stent damage while using and expire due to needing odd sizes is very common. If the profit margin is very much slim, otherwise cheaper stents will become more expensive or disappear from the Indian market after cooling period of six months. There will be no distributors to market the cheaper stents.

This low-profit margin will prohibit prize reduction of future incoming stents also burdening our poor patients. Truthfully speaking we were able to treat poor patients(BPL) with angioplasty because stents were available at cheaper rate i,e around 18000. If these stents become unavailable then main sufferers are BPL patients.

When poor patients were actually being treated with cheaper stents. what is the benefit of the ceiling the MRP for a stent and the fixing percent profit.

Is this just to please medical insurance companies?

Hospitals were sustaining angioplasty package of INR 65000 along with stents because they were able to recover from rich patients. If the government,  induces an increase in the prize of cheaper stents, reduces profit from the rich patient.  Further, passes a rule of increase in minimum labour wages how should hospital sustain?

Implication of stent price reduction for affording patients

Now on affording patients have to get satisfied with older stents only. Because newer stents and those in the pipeline will not reach Indian market.

The cardiologist may find it difficult to treat more complex lesions as older stents are harder and difficult to negotiate through complex lesions this may even increase complication rate.

Loss of employment and difficult supply chain

This new rule may induce loss of employment. Already in India employment is an issue.  In recent times job creation is at lowest.
All stent distributors will close their firm because they can not work at 8% margin. It is not only firm owner will suffer but also his employees will also lose jobs. Hospitals may reduce staff as the profit margin is reduced.
If we don’t have distributors, companies will have to maintain complete supply chain right from the production site to patient. Most of these companies are not tuned for this job. To complicate these further stents come in numerous sizes, just for a mere profit margin of 8% hospital will find it difficult to maintain a full inventory of all sizes.
Imagine small hospitals situated in a periphery doing a fewer number of angioplasties buying stents directly from the companies. It is just not possible for them. The cardiologist there will have limited choice to choose stents for patients thus will compromise results.

Is angioplasty really expensive for poor patients in India

Before passing any rule please note that cardiologists are doing angioplasty for  BPL patient at just 65000 INR. And in Karnataka, 80% of citizens have BPL card and also APL other schemes make this to nearly 100% where packages rates do not cross 70000 INR.

The amount of investment for each cath lab in India is to tune of 2.8 crores to 4.5 crores this excluding building cost. I do not want to go into details of the economics of cath labs and angioplasty in this article. I may write an article in future.

New innovation and cost

The medical field is continuously evolving one, what is considered state of art today or last year may find itself getting replaced by newer technology in coming years.

When new technology arrives it is more often expensive. With newer innovation current or older technology becomes cheaper or totally replaced by newer technology. So, any new innovation has limited time scope in terms of economics.

We have to understand that before delivering any technology huge amount of money is invested in inventing it.

Conclusion

Consequences of capping MRP by this new rule will lead to following:
  1. It is unwise to equate all stents.
  2. Already existing cheaper stents will become more expensive.  This will harm poor patients.
  3. Newer top end stents will disappear from the Indian market.
  4. Only medical insurance companies will benefit from this new rule.
  5. We are not respecting newer innovations.

Author: Dr Umesh Bilagi

MBBS, MD, DM (cardiology). I am Interventional cardiologist. Blogging is my passion. Associate professor of cardiology KIMS Hubli. Director and consultant at Tatwadarsha Hospital Hubli. Owner of Jeevan Jyoti Hospital Hubli. Mobile +91 9343403620.

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