Dr. I.B. VIJAYALAKSHMI*  i20175201.jpg

The announcement of policy to cap the price of coronary stents by the central government is truly historic and path-breaking in the health care sector. Coronary Artery Diseases (CAD) causing heart attacks leading to untimely deaths have steeply increased in the country. CAD is no more the disease of rich, even poor are getting affected by this.

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Illustration depicting atherosclerosis in a coronary artery

Apart from other risk factors, the people without any history of excessive smoking or drinking bear the brunt of heart attack, due to fast-paced life-style and work-profile which can cause tremendous stress leading to various life-style diseases.

 

Taking Care of Heart Diseases

India has several big hospitals across the country equipped with world class facilities and eminent cardiologists with sufficient experience. In recent years, the number of angioplasty with stents has tripled as it is safe, effective and non-surgical procedure (no scar on the chest, no anesthesia) and just one-day hospital stay has made it more popular option. However, the prohibitively expensive stents made it difficult for the poor and lower middle class people to go for this. Ordinary citizens could not afford to foot the bill in corporate hospitals due to whopping cost of the drug eluting stents (DES) which are considered to be far better than bare metal stents (BMS).

 

What is the reason for increased cost?

When the cost of Coronary Artery Bypass Grafting (CABG) was anywhere between Rs. 80,000 to 1,20,000, the more attractive Angioplasty with stent was Rs 1,50,000 – 4 to 5 lakhs, making it inaccessible for ordinary man.

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When the expertise to use multiple stents increased, the greed of earning more also increased, as a result more patients started getting 3-4 stents, adding to the cost. On an average, over 12,000 angioplasties are carried out in Mumbai Metropolitan Region annually.  In some hospitals, Angioplasty packages were:

  • General ward (excluding stent): Rs. 80,000;
  • Semi private ward – B Class (excluding stent): Rs. 1,15,000;
  • Private ward – A Class (excluding stent): Rs. 1,90,000;
  • Deluxe Room (excluding stent): Rs. 2,80,000;
  • Suite Room (excluding stent): Rs. 3,40,000.

Why the cost of coronary stents exorbitant?

There’s a huge price disparity in cost of stents.  The average landed cost of an imported DES was only Rs16,918 (ranged between Rs. 12,920 to 19,040 ie $190 to $280). The cost of BMS ranged between Rs 4,760 to 6,120 ($70-$90). But various hospitals were giving package deals – Angioplasty (With 1 Stent) from Rs. 2,20,000 to 3,60,000. The question arises if the original cost was so low, then why the hospitals were charging so exorbitantly?

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The reason was evident, when Maharashtra FDA gave the report to the then state government, it found that a prominent multinational healthcare company was selling DES at Rs 40,710 instead of Rs. 19,040 in India, making a net profit of Rs. 21,670 on each stent.  Further the Indian distributor was selling at Rs. 73,440 (making net profit of Rs. 32,730) while a well-known private Hospital was implanting the stent for Rs. 1.1 lakh. In the bill, it was reflected as Rs. 1.2 to 1.5 lakhs per stent. In the process, making a neat profit of Rs. 76,560 per patient. This sort of middle man making money at three levels was going on throughout the country and had become a big business as more than 5.5 lakhs stents were being used per year. The international companies looked the other way when their distributors were selling the stents at triple the cost on which the DES were being imported. More stents were sold as Indian distributors, who hiked prices for DES, used part of the proceeds to encourage doctors to recommend more and more stents.

Thus the stunt of overpricing stents continued until the Government of India took it up sternly and decided to cap the prices to ensure that common man can also afford the treatment without getting into debt situation. The government led by Prime Minister Modi certainly deserves commendation for the efforts it made in this direction.

The Union Health Ministry issued a notification announcing that coronary stents would be added to the 2015 National List of Essential Medicines (NLEM). The National Pharmaceutical Pricing Authority (NPPA), under Department of Pharmaceuticals (DoP), during a study conducted on pricing of stents in the country, observed that bulk of medical devices including stents consumed in the country are imported and the difference between the landed cost and the Maximum Retail Price (MRP) thereof is very high.

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NPPA had capped prices of bare metal stents at Rs 7,260 and that of drug-eluting and bioresorbable stents at Rs 29,600, on February 13, 2017. The arguments put forth by government on price cap are based on the recommendations of Subcommittee appointed by the judiciary. As per various reports, the current Indian market is around 5.50 lakh stents annually, out of which more than 90 percent are DES. The stent market is growing at around 15% annually and is expected to become the second largest market in the World after China by 2020.

Although the government’s laudatory move initially met with some opposition from Stent manufacturers and distributors but prompt action is being taken to ensure that government’s directions are fully complied with. The National Pharmaceutical Pricing Authority (NPPA) has issued clear orders that manufacturers, importers and retailers are required to implement the price cap without trying to create any artificial shortage.

All the right thinking persons with concern for suffering common man have applauded the efforts of the Government, for taking this bold step to cap prices of stents. This will be a big boon to suffering patients and their families. It is strongly believed that this move shall break the vested interests’ nexus and will result in hospitals becoming transparent with the prices of Stents. Let us hope that more and more people are benefitted by this initiative and are able to cope up with the trauma of suffering from heart ailments effectively.

*Dr. I.B. VIJAYALAKSHMI is the Professor of Pediatric Cardiology at the Bengaluru Medical College and Research Institute, Bengaluru, Karnataka.

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