Why price control of stents is undesirable
Recently, the global media reported about an Egyptian donkey show-jumping like a horse. What was an asinine idea earlier, has now been turned on its head by one determined donkey that does barrel leaps, with a bit of equine grace.
So, does this mean that donkeys—known to stubbornly plod along with heavy loads—could now enter equestrian events, or maybe get to the Olympics? Even eventually replace horses? Unlikely, any reasonable person would think.
One outlier instance cannot make two species—which are at different points on the evolutionary map—identical.
To a cardiologist, the current debate on heart stents and their pricing sounds somewhat similar to the above example. What was once a complex, practical problem has been twisted into an emotive conundrum. The government’s intent is noble, but the many actors in this drama and the conflicting views have led the discussion in a direction that seems to (1) challenge the fundamental right of a patient to choose the stent she wants and mostly pays for; (2) wipe away almost two decades of device-development and innovation by equating different generations of stents together by imposing arbitrary price control; and (3) effectively signal to innovators that there is zero incentive to invest and bring in newer technologies that improve patient outcomes.
So why is price control of stents undesirable? Isn’t price control good for the patient, as she gets the stent cheaper?
The problem is not so much price control, but how it is imposed. Lower prices are always better for the consumer; however, if there is no element of market forces determining prices, there will be no reason for a medical device company to iterate and come up with a stent that has a better deliverability and better outcomes than the one previously available on the market.
Stents have evolved over almost two decades—through what clinicians call four generations—largely because companies making stents competed and came up with better stents every few years. Every such technological breakthrough (loosely called generation) has to go through extensive trials and approval processes of regulators. This takes years. And even after a newer generation is brought to the market, interventional cardiologists still need to adopt it in their practice.
A newer generation does not make the earlier generation defunct; it actually means that the advance offers better deliverability for an interventional cardiologist; simply put, the cardiologist can guide the stent better inside the arteries of the heart, the stent can be deployed in torturous anatomies that could not be earlier reached, there is lesser potential for vessel damage, etc. Patient outcomes obviously improve. Simplistically put, the older generation still does the job—propping open an occluded vessel and allowing blood flow to be restored to the heart—but the newer generation just does it better.
To the average reader, a stent is just a small tube that is inserted into a blocked blood vessel. However, to an interventional cardiologist, no two stents are the same. In fact, qualifying all these different generations of stents as similar by imposing a similar price is akin to pricing a Maruti 800 same as a Mercedes-Benz S-Class. Will Mercedes-Benz ever innovate if that happens?
We have to view the need for innovation in the context of the disease burden in India. Cardiovascular is the leading cause of non-communicable disease deaths (23.3%) in our country. The other important statistic to note is the National Intervention Council (NIC) registry data—just over 3,10,000 stents are used annually. The gap between the two numbers tells the story—we need every innovation there is in cardiac care to bridge the gap. Clamping down prices arbitrarily will only widen it.
Even as I campaign for science and innovation, I am acutely aware of tragic cases of unaffording patients crumbling under the load of high stent prices. While stents prices have come down in the last few years and a good quality CE/USFDA approved stents are available at R25,000 for those in need, more needs to be done. Solving this issue is not a solitary responsibility, but government, hospitals, clinicians, industry, insurance all have a part to play.
The Central Government Health Scheme (CGHS) mechanism and state insurance schemes are great references for drawing lessons. Making the earlier generation of stents available at lower prices and cross-subsidising these by higher prices for newer generations from those who can afford could be one way of rationally approaching the pricing issue. Appealing to the industry to voluntarily reduce prices in patient interest could be another.
What matters in the entire process is the intent. Patient benefit, in the short and long term, needs be the lowest common denominator. That would be a good start.
The author is a senior interventional cardiologist based in Ahmedabad