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Tuesday, July 17, 2018

Heart of the matter

Price caps cannot be blamed for the overuse and misuse of stents

Written by G. Karthikeyan | Updated: August 3, 2017 12:00:32 am
stent, stent prices, stent price rate, india stents, indian express news, stent industry india While others have suggested a uniform cap on prices unfairly favours Indian stent manufacturers, Cherian and Kumar think that it is likely to adversely impact indigenous research and innovation.

In their article ‘Address this blockage’ (IE, July 27), K.M. Cherian and Ajeet Arul Kumar acknowledge that the capping of stent prices has made them affordable, but use flawed arguments to suggest that there may be adverse consequences to patients and the indigenous stent industry. A major argument against price capping is that the “latest generation” of stents will not be available to the Indian public at these prices. This is a disingenuous assertion. Successive “generations” of stents in the current era represent small improvements in design which have no documented impact on outcomes that are most important to patients (rates of reblockage, heart attacks or death). In fact, the best performing stents are currently available in the country at or below the current ceiling price. To suggest that “patients hoping to have advanced stents may have to travel abroad” is a misrepresentation.

The second major area of contention has been the impact of price capping on the indigenous stent industry. While others have suggested a uniform cap on prices unfairly favours Indian stent manufacturers, Cherian and Kumar think that it is likely to adversely impact indigenous research and innovation. The truth is that the uniform price cap has reduced the price differential between the foreign-made and Indian-made stents. While the foreign-made stents have been rigorously tested for safety and efficacy in a large number of patients, most Indian stents have undergone perfunctory studies to meet the threshold for approval in India. Therefore, the uniform stent price will, in the long run, likely disincentivise Indian stent manufacturers from conducting the research required to make them major international players. Read Address this blockage here.

Cherian and Kumar also suggest, based solely on their experience, that as a result of the reduction in stent prices, there is a “disturbing increase” in stenting multiple arteries (which may be inappropriate). This is passing off an anecdote as scientific truth and can only be confirmed or refuted by national level data. Second, the inappropriate use of stenting has been the elephant in the room for sometime now. Overuse and inappropriate use of procedures is more a result of unregulated, fee-for-service healthcare delivery and should not be blamed on reduced prices.

Implementing a uniform price cap is no doubt a blunt policy instrument. But this was perhaps the most pragmatic approach available to put an end to widespread price-gouging. However, continued vigilance is needed to guard against unintended consequences. First, the benefit of the reduction in price may not be transferred entirely to patients. Many hospitals can rejig prices of the other components of their angioplasty “package charges” (the price of the stent is just one component) so that the overall price to the patient does not reduce. Second, from a profit maximisation perspective, it should be expected that stent manufacturers will make the ceiling price their target price. Therefore, new (not necessarily better) stents may be introduced into the market which are priced at the ceiling even if their actual market price may be lower. A more nuanced approach, which takes into account safety and efficacy metrics from rigorous studies, should inform stent pricing. This would make indigenous stents internationally competitive and allow entry to true technological advances.

Finally, the stent pricing debate has had the unintended consequence of overstating the importance of stents in the treatment of coronary artery disease. Drugs remain the cornerstone of treatment for stable patients. The use of coronary stents in these patients is only for relief of chest pain that is not controlled with medicines. Only about one-fifth to one-third of patients require stenting or bypass surgery over a period of five years. Stents can be life-saving for patients during a heart attack if implanted in a timely manner. Government intervention is often a response to the widespread misuse of physician autonomy. If, as a profession, we could regulate ourselves so that all our patients receive appropriate care, there would be no need for external regulation.

The writer is a professor of cardiology at AIIMS, New Delhi. Views are personal

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