24 March, 2024

Why is angioplasty so expensive?

Introduction:
The cost of angioplasty had been a concern on numerous occasions and was addressed, 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 sometimes exceed that of cardiac bypass surgery and may even vary significantly across centres. A recent attempt by the Government of India to reduce angioplasty costs by price-capping coronary stents led to mixed results. A thoughtful insight on price capping and its implications for India’s healthcare spectrum can be read here.

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 lapses in professional work.

*Please note that this write-up does not aim to justify the high pricing of the angioplasty procedure or criticise the price capping. Rather, I intend to raise the idea that price alone as a matrix for healthcare delivery is not optimal and is destined to have untoward adverse effects. I must disclose my disclosure here. Since I am a cardiologist, my viewpoint may be biased towards the hospital or the clinician. Also, the scenarios described below are generic and may not apply to every situation.

Setup and equipment:
A typical Cardiac Catheterization Laboratory (cath lab) setup is costly for any organization. It involves installing the x-ray equipment and maintaining its standards, computerized systems, need for an infection-free environment, periodic hardware and software upgrades, etc. A modern digital cath lab is built on a 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 Outdated hardware and software must be replaced with new ones to maintain cross-compatibility. Investment in this field demands a rapid turnover for financial viability, short of which hospital systems are not incentivised to invest in upgrades. When the return on investment plummets, compromises happen. Getting a stent placed in a cath lab that hasn’t seen any upgrade in the past 5 years versus an upgraded cath lab can lead to two different procedural outcomes. Selective super high-volume centres can reduce their infrastructure cost per procedure but the same may not be true for an average cath lab nationwide. Have you ever wondered if the cath lab where you are planning for a future procedure ever underwent microbiological surveillance or a radiation audit? An angioplasty package includes not only the equipment’s shared overhead cost but also the cost of maintenance, technological advancements, clinical audit, strategies to reduce radiation exposure, and other ancillary tools.

Consumables/Hardware/Equipment:
This is what draws everyone’s attention. The price of coronary stents was brought down by NPPA in 2017, but stents comprise only a fraction of total consumables cost. Here is a list of consumables (single-use items) needed for a typical angioplasty: Sterile drapes, Sterile gowns/gloves, Introducer needle, Introducer sheath, Introducer wire, Guide catheter, Coronary wire, Pre-dilatation balloon, Stent, Post-dilatation balloon, Manifold, Indeflator set, Contrast, Pressure transducer, Medicines and other miscellaneous consumables. The price for a set of these items can easily add up to 80 thousand rupees (INR) or higher. Occasionally, an angioplasty procedure may require more than one set of equipment. The overall cost of a procedure depends on the quantity and quality of equipment used in a particular procedure. Both international companies (with their tried and tested products) 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, compromises start happening at multiple levels when the cost becomes the sole determinant. Manufacturers 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 a phase where a cardiologist chooses a particular hardware based on price rather than clinical need. An obvious question is why someone should care about the kind of ancillary equipment used when the only thing that stays permanently in the body is a stent. The rationale is simple. Better equipment means easier, safer, and more durable procedural outcomes. While a few clinical issues related to substandard equipment may come to light immediately, others may not become obvious until a few months later.

Manpower:
An average angioplasty procedure involves the primary cardiologist, an assistant cardiologist, 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 as the primary cardiologist. The majority of the patients who undergo angioplasty spend 24 hours in an intensively monitored room where a specialized trained nurse is appointed, and supervised by a physician. The average duration of in-hospital stay after angioplasty is about 48 hours when more than a dozen staff members take care of a patient. A successful clinical outcome not only depends on the number of people serving a particular patient but also on their qualifications and expertise. Skilled manpower rightfully demands higher pay and incentives. Did you know that the salary of a cardiac ICU nurse may be less than that of your house help? While manpower costs are not directly obvious, they do add up. These soft ‘expertise’ charges are not billed directly to the patients as they are cross-subsidised within the hospital charges and equipment or consumables costs. Understandably, as cross-subsidies die out, the quality, as well as quantity of manpower, is destined to suffer. Unfortunately, this phenomenon has already started to dominate in the majority of healthcare setups and is destined to get worse. Next time when you visit an intensive care unit (I sincerely hope you won’t need to but just in case), enquire about the professional qualifications, subject knowledge, and experience of the attending nurse; particularly years since graduation, years worked in a similar intensive care unit, ability to transcribe doctor’s instructions, fluency in the English language (since the majority of the medical literature and communication happens in English), work hours, patient to nurse ratio, access to a break room in case they are tired or need a break/have a meal, services available at their residence (since a lot of nurses stay in a nurses hostel), take-home pay etc. I can confidently say that you will be surprised.

Ethics and Professionalism:
We are wrong to believe that ethics and professionalism should come by default. While such behavioural aspects are vital to both clinicians and healthcare organizations, just as in any other organisation, they, unfortunately, are either considered optional or worse, non-consequential. A professional healthcare system spends more face time per patient, applies clinical principles with much scientific and ethical vigour, encourages multi-disciplinary decision-making, seeks healthy team dynamics, invests in updating medical knowledge, minimizes burnout and cynicism among healthcare providers etc. All these aspects utilize financial resources and incur indirect costs to the system. These aspects cannot be structured directly into any billing platform and, hence can’t be billed to the patients at face value. The financial cost of these attributes, if not factored into the total cost, is dropped early on. The cost of angioplasty can be reduced significantly if ethics and professionalism are not featured in the entire transaction, which, unfortunately, is a common sighting these days. One can easily imagine why the same procedure can be offered at different costs at different centres in the same city.

Uncertainty:
This is one of the most overlooked concepts. The scenario I described above is a typical uncomplicated angioplasty. While a fraction of routine angioplasties follow a typical course, others are met with unique nuances which can be clinical, procedural, or during recovery. At times more than one coronary wire is used to help place a stent. On the contrary, one wire may be enough to place more than one stent in a few simple cases. While a minimum of two balloons is required for any angioplasty, there were times I needed to use more than five. Uncertainties can also range from requiring different medicines at the time of the procedure to the need for additional manpower like a second pair of expert hands or anaesthesia support. The time taken to perform one angioplasty can range from 15 minutes to hours. While such heterogeneity in procedure leads to a wide range in cost incurred per procedure, a patient is typically billed a lump sum ‘package’ amount. Billing the patient for each step and equipment will introduce wide variation in total cost, put undue financial stress on a few unfortunate ones and will be a non-viable approach for any system. A mini-shared risk model is opted for, where each procedure is billed to have some redundancy due to such uncertainties. This system works in patients’ interest because they are relatively shielded if the procedure doesn’t take a typical route. However, any major deviation from the planned procedure has to be billed separately for the system’s financial viability.

Cross-Subsidy:
There is another kind of cross-subsidy at work within the hospital, and it is not particular for angioplasty. Large private organizations routinely cater to patients who cannot afford the costs of a private enterprise. Such patients still preferentially seek medical care in such organizations due to a lack of viable alternatives. When private hospitals design cost structure for any procedure, for example, angioplasty, it identifies what an average charge (plus working profit) would be and then charges higher than that to the privileged sector of society and charges below average to the weaker section of society. This way, hospitals can provide clinical services of a similar quality to those of all walks of life. More so, such cross-subsidies spread through different sub-specialities as well. For example, revenue from the cardiac cath lab may be utilized to run a heart failure program or a tuberculosis ward where recurring costs are not commensurate with the revenues generated from a business standpoint.

While other aspects can be discussed on this topic, I will pause here. 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 to make a positive change in the overall delivery of healthcare and the total cost. Even the best stent is destined to fail if it is not handled by competent personnel in a competent facility with the utmost professionalism and ethical approach.