This question has been asked multiple times on numerous occasions, and was addressed to, in part, by price capping of coronary stents (metal scaffolds put inside blood vessels of the heart to keep the vessels open) in 2017 by NPPA.
The overall cost of angioplasty may at times exceed that of cardiac bypass surgery and may even vary across centers. Recent attempt by the Government of India to reduce angioplasty cost by price capping of coronary stents led to mixed results.
In this article, I try to break down the costs associated with typical coronary angioplasty. This will help you understand the intricacies of cost structure and why simply price capping one product may not impact the overall cost, or even worse, may lead to serious lapse in professional work. I must put my disclosure here. Since I am cardiologist myself, my viewpoint may be biased favoring the hospital or the clinician as a general. Also, the scenario described below are generic in nature and may not apply to every healthcare organization.
Click here to understand difference between angiography and angioplasty.
Setup:
A typical Cardiac Catheterization Laboratory (cath lab) setup is a costly venture for any organization. It has to do with installation of x-ray equipment and maintaining its standards, computerized systems, need for infection free environment, periodic hardware and software upgrade etc. A modern digital cath lab is built on highly sophisticated computerized platform that needs to be maintained free of bugs and upgraded periodically to keep up with technological advancements. Outdated hardware and software need to be replaced with new ones to keep up with cross compatibility. Financial investment in this field demands a rapid turn over, short of which hospital systems don't find any incentive to invest in any upgrade. When return on investment plummets, compromises happen. Getting a stent placed in a cath lab which didn't see any upgrade in past 5 years versus an upgraded cath lab can lead to two different procedural outcomes. High volume centers are able to reduce their infrastructure cost per procedure but same can't be said for an average cath lab in the nation.
Equipment:
This is what draws everyone's attention. Prices of coronary stents were brought down by NPPA in 2017, but stents make up only a fraction of total equipment cost. Here is a list of equipment needed for a typical angioplasty: Introducer needle, Introducer sheath, Introducer wire, Guiding catheter, Coronary wire, Pre-dilatation balloon, Stent, Post-dilatation balloon, Manifold, Indeflator set, Contrast, and Other miscellaneous consumables. Each equipment adds cost to the procedure, and overall cost will depend on quantity as well as quality of equipment used in a particular procedure. Both international companies (with their products tried and tested in lab and outside) as well as locally made (with variable testing standards or no testing at all) products are available in the market. As healthcare becomes more price sensitive, institutes tend to rely more on cheaper alternatives. More so, when price becomes the most important determinant, compromises start happening at multiple levels. Companies will readily drop prices till we don't ask for quality and hospitals may reuse equipment (after re-sterilization) to further cut the incurred cost. We certainly have entered the phase where prime determinant of which equipment a cardiologist will choose is cost. Now, why should a patient care about the kind of equipment being used when the only thing that stays permanently in the body is stent? The rationale is simple. Better equipment means more easier and safer procedure. While few clinical issues related to poor equipment choice may become obvious immediately, few may not.
Manpower:
An average angioplasty involves a primary cardiologist, first assistant, and a scrub technician. The team is further assisted by at least 3 technicians/nurses in the room. An army of recovery room staff who manages the patient both before and after the procedure is as important part of the team at the primary cardiologist itself. Majority of patients who undergo angioplasty spend 24 hours in intensive monitored room where a specialized trained nurse is appointed, supervised by a physician. An average duration of in-hospital stay after angioplasty is about 48 hours where a patient is taken care of by more than a dozen staff members. A successful outcome not only depends on quantity of manpower, but also its quality. Skilled manpower rightfully demands higher incentives and pay. While these costs are not directly obvious, they do add up. These soft 'expertise' charges are not billed directly to the patients as they are cross subsidized within the equipment and consumables cost. Understandably, as cross subsidies die out, the quality as well as quantity of manpower is destined to suffer.
Ethics and Professionalism:
We are wrong to believe that ethics and professionalism should be taken for granted. While such behavioral aspects should be vital to both clinicians as well as healthcare organizations, they unfortunately are either considered optional or even worse, non-existent. A system by acting professionally spends more time with individual patient, applies ethical measures, participates in multi-disciplinary decision making, seeks second opinion etc. All these aspects are resource utilizing and incur indirect costs to the system. These aspects can not be structured directly to any billing platform, hence can't be billed to the patients at its face value. If such things are not reimbursed, either directly or indirectly, these attributes are dropped early on. Cost of an angioplasty can be dropped significantly if ethics and professionalism are not featured in the entire transaction. One can easily imagine why the same procedure can be offered at different costs at different centers of the same city.
Uncertainty:
This is one of the most overlooked concepts. The scenario I described above is a typical uncomplicated angioplasty. In fact, only a small percentage of all angioplasties follow this typical course. Most of the procedure is met with some uncertainties which can be clinical, procedural, or during recovery. At times more than one coronary wires are used in the same procedure just to help place one stent. On the contrary, one wire may be enough to place more than one stent in few easy cases. While a minimum of two balloons are required for any angioplasty, there were at times I needed to use more than five. Uncertainties can also range from requiring different medicines at the time of procedure to need for additional manpower like anesthesia support etc. Time taken to perform one angioplasty can range from 15 minutes to hours. While such heterogeneity in procedure leads to wide range in cost incurred per procedure, a patient is typically billed a lump sum 'package' amount. Billing the patient for individual steps and equipment will introduce wide variation in total cost, put undue financial stress to few unfortunate ones and will be a non-viable approach for any system. A mini-shared risk model is opted where each procedure is billed to have some redundancy for such uncertainties. This system works in patients' interest because they are relatively shielded in case the procedure doesn't go a 'typical' route. Obviously any major deviation from planned procedure has to be billed separately for system's viability.
Cross Subsidy:
There is another kind of cross subsidy at work within the hospital and this is not particular for angioplasty. Large private organizations routinely see patients who can not afford costs associated with private enterprise. Such patients still preferentially seek medical care in private organizations due to lack of other viable alternatives. When private hospitals design cost structure for any procedure, for example angioplasty, it identifies what an average charge would be and then charges higher than average to the privileged sector of society and charges below average to weaker sector of society. This way, hospitals are able to provide similar quality service to all sections of society. More so, such cross subsidies spread through different sub-specialties as well. For example, revenue from cardiac cath lab may be utilized to run heart failure program where recurring costs are highly subsidized or to run a tuberculosis ward.
I hope I was able to shed some insights on where all the money goes for angioplasty, and why simple price capping on one product is unlikely make any positive change in overall delivery of healthcare, as well as total cost. Even the best stent is destined to fail if it is not handled by competent personnel, in a competent facility, in the most professional and ethical manner.
I am sure there are many related questions on this topic which I haven't answered here. Please feel free to contact me with any queries you may have and I will try to answer those.