A cut that doesn't go deep

Hospitals have devised ways and mechanisms to escalate the overall cost of a cardiac-surgery package

Early in February, 58-year-old Mumbai resident Ajmatunissa Khan discovered that two major regions in her heart, the left anterior descending artery and the left circumflex artery, were blocked (over 70%).

Ms. Khan was advised an angioplasty procedure that would involve implanting two drug-eluting stents to open up the arteries. Stent prices had already been capped last year, but by the time the homemaker reached out to her relatives and friends to collect money for the procedures, the key regulator, the National Pharmaceutical Pricing Authority (NPPA), announced a further reduction in stent prices this month. The ceiling price for drug-eluting stents has been reduced to Rs. 27,890 from the earlier Rs. 29,600, which means that Ms. Khan would have to pay Rs. 3,420 less for two stents.

“I don’t have health insurance. I had to borrow all the money from people. For patients like me, any discount is a good discount,” says Ms. Khan, while hailing the government’s decision to cap stent prices. She underwent the procedure at Surana Hospital in Mumbai’s Chembur’s area and the overall ‘cardiac package’ cost her Rs. 1 lakh. For patients such as Ms. Khan, the government’s push in reducing the cost of stents over two consecutive years is a blessing. But several surgeons think otherwise.

Need for balance

“We are going back to the Dark Ages,” says Chennai-based Dr. Mathew Samuel Kalarickal, who is considered the pioneer of angioplasty in India. “To me, the policy appears to be directed towards taking India backwards.” New developments in the field of cardiology would never come to India under such price restrictions and the current price policies were due to decisions being driven by bureaucrats, he argues. Dr. Kalarickal uses third- and fourth-generation stents for a majority of his patients, and this could mean that device manufacturing companies will gradually phase out these top-of-the-line stents due to the price restrictions.

Dr. N.O. Bansal, Head of Cardiology, at the State-run J.J. Hospital in Mumbai agrees.

“There is no reason why we should limit the best technology. From cellphones to kitchen appliances, we have moved on to the best generation of everything. Why not in health then?” he argues, adding that while the government’s move is in the right spirit, it should not be one-sided. He feels that the revised stent prices, which brought down prices only by Rs. 1,700 on drug-eluting stents, have hardly reduced the overall cost of surgery.

“It will dis-incentivise companies from launching newer products here. The government has to find a way of balancing this gradually,” he adds.

In the public-run hospital where Dr. Bansal is attached, while a single artery-single stent package costs about Rs. 60,000, a two-stent package works out to be Rs. 80,000. A three-stent one costs Rs. 1 lakh. Even before the price cap was announced in February, public hospitals would acquire stents at a subsidised cost of Rs. 23,625. But these were the second-generation stents and not the top of the line third- or fourth-generation ones. Does the patient outcome differ with a second-, third- or fourth-generation stent? Dr. Bansal says that there is hardly any difference in the patient outcome but they smoothen the stent-insertion procedure. “For doctors, the deliverability of stents may differ. The newer generation devices are much thinner and can be swiftly manoeuvred even in difficult cases. Thus, complications go down marginally.”

Dr. Prafulla Kerkar, head of the cardiology department at King Edward Memorial Hospital, Mumbai says that most private hospitals have found ways and means to make their profits. “Stent prices may have gone down but private hospitals have increased costs in other areas. Thus the overall costs of angioplasties have not come down,” he says. He is referring to the cardiac catheters, balloon catheters and guide-wires that are required in angioplasty besides the cost involved in medication and stay. The other devices used in angioplasty do not come under essential medicines and hence are yet to be capped. Ms Khan, for example, was first quoted a figure of Rs. 2 lakh for surgery in another hospital. This suggests that hospitals have devised ways and mechanism to escalate the overall cost of a cardiac-surgery package.

“They should be treating the entire procedure of angioplasty as ‘essential medication’ instead of labelling a few devices as essential medicines,” Dr. Kerkar suggests.