He shows analysis of claim receipts from Kokilaben Dhirubhai Ambani Hospital in Mumbai. In June 2016, the average monthly cost of a balloon—an implant used in the angioplasty procedure—was Rs 26,620 ($404); in April 2017, it had almost tripled to Rs 74,576 ($1,134). Similarly, average costs of consumables were up 8 times over the same period, from Rs 8,000 ($121) to Rs 69,200 ($1,052).
If the hospitals are trying every trick in the trade to get the patient or the insurer to pay, the stent manufacturers are reducing the choices available to the patient.
The stent manufacturers have asserted that they have no intention to keep high-end stents in a regulated market. In September, US-headquartered Abbott withdrew two stents (Absorb and Xience Alpine) from the market*. The price of these stents was Rs 1,80,000 ($2,737) and Rs 1,60,000 ($2,433) respectively, which was capped at Rs 29,600 ($450) without taxes. Other stent manufacturers are slowly withdrawing their new generation stents, and flooding the market with older generation ones.
“Generation 1, 2 and 3 stents by MNCs have flooded the market since price control. So have Chinese stents. The drug regulator could say that the newer stents’ efficacy is not proven. But how do you prove that iPhone 8 is better than iPhone 4? The rich, who want iPhone 8, are the real losers,” said an office-bearer from the Cardiologist Society of India.
It was these margins that hospitals claim were cross-subsidising the poor, making hospitals ensure easy revenue and treat patients covered by state schemes and still deliver good clinical outcomes. The rationale may be valid for large corporate hospitals, but they constitute only about 10% of all hospital beds in the country.
What about the poor, who find themselves at the doors of public-funded government hospitals, which house about 20% hospital beds?
A zero-sum game
Dr Sundeep Mishra, Professor of Cardiology at the All India Institute of Medical Sciences (AIIMS) in Delhi, does not know why he is being asked questions on the impact of price ceiling for stents. Because at AIIMS, like many other public funded hospitals, the price has been negotiated and capped for a couple of years now. A price that was already lower than the cap decided by the drug regulator. The high volume of patients makes this negotiation possible.
At AIIMS, where 1200 angioplasties are conducted annually, the price of stents is ceiled at not more than Rs 25,000 ($380). Dr Mishra, also the former chairperson of the National Intervention Council and editor-in-chief of the Indian Heart Journal, says that only drug-eluting stents, which are approved by the US FDA, are used at the hospital.
Similarly, at GB Pant Hospital, New Delhi and Jayadeva Hospitals, Bengaluru, where a total of about 10,000 angioplasties are conducted every year, higher than any other public hospital in the country, the prices of stents were capped at a maximum of Rs 23,000 ($350) and Rs 28,000 ($425), respectively.
“Public hospitals were not affected by capping at all,” reiterated Mishra. “Price control is a good concept but if the government wants to pass on the benefit to patients, it needs to be thought in a holistic way. Stent pricing is just one component,” he added.
The more important question here is: is the drug regulator capping prices of ‘essential’ devices?
Cardiologists from private hospitals have argued that coronary stents and knee implants—two devices whose prices are controlled by the drug regulator this year—are hardly essential as other options exist, like medication. They are lucrative for hospitals as they generate revenue from patients who are looking to improve their quality of life, as was reported by The Ken in August.
The patient is the loser in this cat and mouse game. So is the government, which has not been able to ensure that the benefit reaches the patient over the long term.
Healthcare in India is financed in three ways—via a government scheme, insurance provider, and by cash. Though it is accepted wisdom that the first two make healthcare affordable over time, the government chose a short-sighted move and the quick credit that came with it.
No healthcare policy borne out of only one narrative that ‘private hospitals are thieves’ is going to be a long-term solution. “At some point, the government will have to realise that it provides healthcare services to a quarter of the population, while rest of the population depends on profit-motivated hospitals. Crossfire between regulator and hospitals hurts the patient, collaboration does not in the long run,” said the CEO of a health insurance company in Gurugram.