Ummid.com: National: Monday, July 02, 2018.
In September
2014, a small lawyer Sangwan went to Metro Hospital in Faridabad, a suburb of
Delhi. His friend’s brother needed a coronary stent a wire mesh planted in an
artery to open up blood flow fitted into his heart. The hospital charged his
friend more than Rs 1 lakh for this, without mentioning the device’s maximum
retail price. “I asked the doctor to provide us with the purchase bill for the
stent,” the lawyer said. “He refused.”
That refusal
brought advocate to the centre of the storm sweeping through India’s Rs 6.7
lakh crore healthcare industry today. He filed a PIL in 2015 that made the
Indian government crack the whip on the country’s Rs 3,300 crore coronary stent
industry, ending years of rampant profiteering.
In India, at
least 30 million people suffer from cardiovascular problems and over two
million die of heart attacks and strokes each year. For them, stents have
become essential. There are over 2,00,000 heart surgeries every year. This is a
great demand that led to a racket of extraordinary proportions. Government data
revealed that our hospitals are selling stents at margins of up to 654%.
On February
13, 2017, the National Pharmaceutical Pricing Authority (NPPA), the primary
agency for fixing drug prices, notified a price cap of Rs 7,260 for bare metal
stents (those without any coatings) and Rs 29,600 for modern drug eluting
stents. The latter have a polymer coating, which gradually releases a drug to
ensure that the blockage doesn’t reoccur. Till then the average retail price
for a bare metal stent was Rs 45,000, while drug eluting stents were priced at
around Rs 1.2 lakh.
NPPA said:
“During deliberations, it was found that huge unethical markups are charged at
each stage in the supply chain of coronary stents, resulting in irrational,
restrictive, and exorbitant prices in a failed market system driven by
information asymmetry between the patient and doctors, pushing patients to
financial misery; and whereas under such extraordinary circumstances, there is
an urgent necessity, in public interest, to fix the ceiling price of coronary
stents to bring respite to patients.” If the authority itself asks for some
other authority, what will happen to the poor patient?
In September
2014, lawyer Sangwan said that Metro Hospital bill was more than Rs 3.2 lakh.
He filed a plea under the Right to Information Act to find out the number of
hospitals in Delhi that performed angioplasty. He found 54 such hospitals and
the rates of stents varied across the facilities.
To one of his
RTI requests, the government said that stents came under the Drug and Cosmetic
Act, but not covered under the National List of Essential Medicines (NLEM).
This list identifies medicines that must be made affordable for citizens. He
filed a PIL at the Delhi High Court in February 2015, to get stents included in
NLEM. The High Court directed India’s Chemical and Fertilizers Ministry to take
action.
It did not
take any action for months. In a contempt petition he questioned the laxity of
government in October 2015. Only in July 2016, the central government added
stents in the NLEM. Sangwan had to file another PIL to limit maximum retail
price of stents. The RTI plus PIL plus direction plus contempt threat made the
government to place a cap on rates in February 2017.
Sangwan filed
another RTI to know if stents came under the drugs or metal category in
November 2014. Sangwan called it a brutality of doctors to say “the
distributors, hospitals, and doctors are hand in glove with each other and they
are the ones making the money. The product should come directly from the
manufacturers to the patients.”
(https://qz.com/915197/a-lawyer-took-on-indias-profiteering-hospitals-to-end-the-obscene-overpricing-of-cardiac-stents/)
Where does
the problem lie? Just about 1% of the hospitals in the country are accredited,
the rest flout norms and rules. Once accredited, the margins of bona fide
healthcare service providers come under pressure because of the cost of
following prescribed norms and putting in place the required systems. And with
shrinking margins, hospitals come to increasingly rely on pharmacy sales,
medical devices, and medical diagnostic testing.
The cap on
stent pricing, therefore, will hit their balance sheets further, unless it is
made up for by increasing the overall cost of cardiac procedures that use such
devices.
If a heart
patient knows the actual cost of the cardiac stent, he will realise how much
the hospital looted him. He should be strong enough to withstand the shock. We
don’t know how many suffered heart attack after knowing this exploitation. One
small lawyer has to fight against this injustice. Where are the great doctors?
Don’t they know this loot?
The National
Pharmaceutical Pricing Authority recently reduced the price of drug eluting
stents (DES) by about Rs 2,300. It may be just under Rs 28,000 now. The cap on
bare metal stents increased from Rs 7,400 to Rs 7,660. These caps are excluding
GST. On February 14, 2017, NPPA had capped the price of bare metal stents at Rs
7,400 and of DES at Rs 30,180, bringing down prices by as much as 85% in an
effort to make angioplasty affordable.
(https://timesofindia.indiatimes.com/india/cardiac-stent-price-cap-lowered-further-to-rs-28000/articleshow
/62889521.cms) Do you know who protested? Hospitals! It is these ill-health
shops that made unhealthily huge profits on stents alone. All patients should
patiently believe that Surgeons do not know this stent racket. They don’t even
protest.
Almost 95% of
these DES are used in India. Downing prices are great news for them. The
authority, which had received several complaints about overcharging on
catheters, balloons and guide wires used for angioplasty, also made public its
analysis of trade margins on these consumables which ranged from over 150% to
400% over import price.
But whether
doctors and directors of the hospital companies are honestly transferring the
benefit to the patients? Why this wisdom did not prevail on national
authorities all these decades? Why the commercial cardiac centers were are
allowed to make huge money?
The NPPA has
asked for the price of catheters, balloons and guide wires to be mentioned
separately in hospital bills. This is the transparency requirements. Patients
should insist upon this. NPPA does not direct, the government does not
prescribe penalties. It does not assure the people that their loss will be
recovered and fraudsters will be punished.
After the cap
on stent prices, hospitals had jacked up charges for catheters, balloons and
guide wires, making these consumables more expensive than the stent, thus
minimising the benefits of the price cap. The NPPA analysis of trade margins on
these consumables has shown that the highest margin was on balloon catheter,
where the MRP was on average 400% over the import price and 234% higher than
the price to distributors.
The media
reported about the tactics of commercial hospitals, saying: “Even as the NPPA
sets into motion an examination of the price of consumables, which could lead
to a price cap, hospital procedure charges continue to be jacked up by
hospitals with widely varying charges being extracted from patients across
India.” There is no law at present which allows the government to regulate
these charges and for transparency about the pricing and quality.
All India Drug
Action Network (AIDAN) issued a statement welcoming the price revision and
asked for expansion of price cap to consumables as a necessary step to making
procedures like angiography and angioplasty more affordable and accessible to
patients. AIDAN also demanded that NPPA write to the Competition Commission of
India to conduct an investigation on the large hospital chains for abusing
their dominant position and overcharging for angioplasties post the price cap.
There should be raids on these big shops to save the patients and expose the
exploitation.
The prices of
stents and their quality are the source of unethical scandals in both private
and public sector in our country. There is very less information available
about actual cost, taxes, and the selling price of the stents and similar other
things that are placed in body for treatment of various ailments.
This is the
darker side of the private hospitals in which the scams flourish and common
patient is exploited very badly. None reveals actual price of a stent.
How about
orthopaedic products, including those used in knee and hip replacement
surgeries? What is the actual cost and the price the patient is paying? We need
not remember the dacoits and robbers, as there are hospitals with roaring
profits and doctors with roaring practice therein.
[Madabhushi
Sridhar Acharyulu is an Indian academic and Central Information Commissioner.
He was a Professor at Nalsar University of Law in Hyderabad. A recent article
published by Hyderabad-based daily THE HANS INDIA, Jun 19,2018, is reproduced
here on the occasion of Doctors’ Day, on July 1.]