Every patient deserves access to optimum world class healthcare, especially in an age where India is striving to become an attractive hub for medical tourism. Science and medicine can progress only if we constantly endeavour to improve our quality of care and patient outcomes. This is possible only in a scenario where we appropriately use the best resources available to us. If we compare global reimbursement, our figures stand out as being the lowest in the world. These figures are lower than free healthcare schemes for “below poverty line citizens” in some States… Is there a hidden agenda ?, asks (Dr.) Col. Anil Dhall…
Do we always have to be arbitrary in our decision making? Or, do we feel that all stakeholders in healthcare are defrauding the State? Do we want better healthcare for our citizens? Or, Do we wish to condemn ourselves to inferior/ older devices and substandard care? The Government has issued new reimbursement guidelines for Central Government Health Scheme (CGHS) beneficiaries for coronary angioplasty which defies logic.
Cardiovascular diseases are the No.1 GLOBAL KILLER (with India being the world capital of diabetes and cardio vascular diseases). Coronary Angioplasty with current generation Drug Eluting Stents in suitable patients has become the standard of care globally. Every patient is important and deserves the best therapy and device to ensure chances for superior outcomes, both in the long and short term. The devices under current use have been subjected to large clinical validation through extensive clinical trials. This ensures a reasonable creditability and optimal results. These trials cost billions of dollars in research. Global regulatory processes demand adequate evidence of superiority in terms of large scale outcome analysis.
There is a perception that the therapy may not always be ethical and appropriate. Most developed nations have formulated their own “appropriateness” criteria and carry out random reviews of procedure to ensure process driven utilisation of resources. Every patient deserves access to optimum world class healthcare, especially in an age where India is striving to become an attractive hub for medical tourism. Science and medicine can only progress if we constantly endeavor to improve our quality of care and patient outcomes. This is possible only in a scenario where we appropriately use the best resources available to us.
Most patients who require complex coronary angioplasty procedure are elderly pensioners with meager resources to spend on expenses of modern medicine. By subscribing to contributory health schemes, they try and insure their future in the twilight years of their lives. By enrolling in such schemes, they feel secure that they could fall back on them at a time of ill health and get appropriate and timely care. It is unfair to deprive them of modern health care and current devices available for use today and which are constantly improving and evoluting. They are now facing a bleak future and face the prospect of poorer quality devices with higher risks just because the organisation to which they contributed all their lives has suddenly changed its mind. This is actually a breach of trust and contrary to expectations of the service class. The decision makers today must realise that they are the pensioners of tomorrow.
We all are interested in keeping costs down as it is the tax payer’s money which is being spent. But to deny critical lifesaving and appropriate modern health care to people is not justifiable. Here are the implications of the new reimbursement guidelines for various stakeholders:
GOVERNMENT: Apparent cost cutting, no accountability, no audit, no appropriateness (can still be taken for a ride by inappropriate and unethical practices). There is a potential that this Government notification will only help to make India a dumping ground for outdated older generation products.
PATIENT: More re-use, use of previous/old generation products, increased risk and complication, poor outcomes.
PHYSICIAN: Increasing complications, has to take chances with outcome, less enthusiastic for challenging PTCA, more CABG referral- with more morbidity, longer recovery and hospital stays.
The purchase price of stents is lower than the tender prices approved by several Government institutions. The approved costs are less than those incurred by Government institutions, even though they do not have any capital or HR costs. Why are CGHS beneficiaries being treated so shabbily? … We all are interested in keeping costs down as it is the tax payer’s money which is being spent. But to deny critical lifesaving and appropriate modern health care to people is not justifiable.
HOSPITALS: Not keen to take CGHS/ECHS patients. They may make more re-use of devices due to these restrictions. They also face serious issues with delayed payment and large inexplicable deductions.
DEVICE INDUSTRY: Less enthusiasm to support educational initiatives; will not bring new/modern technology to the country.
It will be prudent to ask :
a) Device Industry: Whether they can provide world class validated current generation products at lower cost?
b) Hospitals: Whether it will be reasonable to treat CGHS panel patients?
c) Physicians: What is the current data position?
d) Pensioners: Do they want second class health care or to or be subjected to re-use of old hardware when what they need most is first class health care?
e) Decision makers: What they would like for themselves and their family?
Some therapies have not been sustainable in the country simply because of financial non viability. Even in the previous CGHS guidelines, BMV procedure was reimbursed @ Rs.12000/, whereas the Inoue balloon itself costs Rs. 65000/- and the procedure with a new balloon costs a self-paying patient Rs.1.5 lakhs. Similarly, peripheral vascular intervention and cardiac electrophysiology has very poor reimbursement leading to the patients not benefitting from these procedures in private empanelled hospitals. Besides, the therapy area has not progressed as the basic procedure itself is not financially viable. This leads to a large section of patients who will either not be treated and will have to lose life/limb or will have inappropriate therapies or may need open surgeries.
The whole world is moving towards minimally invasive therapies, realising that less invasive therapies are more cost effective with decreased hospital stay and therefore use of hospital resources for more number of patients with a faster turn over.
All angioplasties are not the same. Some are simple and require little time, average training and minimal effort while others are complex and require time, planning, expertise and substantial risks. Modern PTCA is evidence based. The use of FFR (fractional flow reserve) has led to a paradigm shift in angioplasty as it now permits determination of the functional significance of coronary stenosis leading to avoidance of unnecessary angioplasties which further improves clinical outcomes. IVUS and OCT help to understand lesion morphology better. IVUS is also helpful in seeking entry to totally blocked vessels and both intra coronary imaging modalities serve to ascertain as to whether a stent has been deployed well. Vascular closure devices help us to ensure prompt hemostasis after a PTCA which leads to early mobilisation, less access site complications, less bleeding and better out comes. All these modern devices improve angioplasty but add to cost.
All accessories are approved by the DCGI for one time usage. As there are “package rates” most hospitals are re-using these stores. There is no system for audit and verification of the microbiological, chemical or physical standards of hardware. A package actually does not cover these costs and if new hardware is used each time, each angioplasty would be a loss making exercise.
The self stated national inflation rates vary from 7 to 10 per cent. There has been no decline in the rates of any of the stores used in an angioplasty. There has been an increase in the rates of Capital Equipment due to the rising value of Euro/ Dollar . There have been an increase in logistic costs of fuel, electricity etc. There are increasing HR costs. There are new costs of NABH standards / approvals etc which have been added. There is increasing procedural complexity with more and more patients opting for PTCA over surgery. As the patient population is getting older and more complex, there are increasing costs of care .
Then how can we possibly have a reduced rate of reimbursement ??? How can we have one therapy area to be treated so perversely ??? Selectively , CGHS has reduced rates of PTCA and Stents. If we compare global reimbursement, our figures stand out as being the lowest in the world . Furthermore, these figures are lower than free healthcare schemes for “below poverty line citizens” in some States. The purchase price of stents is lower than the tender prices approved by several Government institutions. The approved costs are less than those incurred by Government institutions, even though they do not have any capital or HR costs .Then why are CGHS beneficiaries being treated so badly ??? Is there a hidden agenda ?? These figures may set off a detrimental chain reaction among other payer organisations. Why can we not evolve a reasonable price structure ???
Preposterous as it may seem , in today’s day and age, the CGHS approved rate for a super speciality consultation in the National Capital Region ( NCR ) is Rs 58/=. At this rate, the Government expects patients to be attended to by senior physicians holding post-doctoral qualifications. The nobility of the medical profession and Hippocratic oath is invoked by all and sundry when discussing a physician’s reimbursement. It is rather hypocritical considering that the physician and his/her family also have to exist in the present times. Both society and the Government need to compare such absurd reimbursement to any other profession in the country and introspect.
Every human being, professional, organisation, institution or business has to have reasonable compensation and remuneration without misleading / cheating/ resorting to unethical practices. Achieving honest profits and financial viability has to be encouraged and it is the responsibility of the decision makers to avoid being unreasonable. We need to develop patient friendly strategies so that there is a WIN-WIN situation for all and this could include :
a) Guidelines for procedures.
b) Regular audit and application of appropriateness criteria.
c) Spend on R & D and follow up.
d) Validate Indian hardware and publish comparable DATA.
e) Ensure single use of hardware.
f) Reasonable pricing of current generation products with uniform monitoring.
g) Doing away with MRP and credit notes.
h) Transparency at all levels.
There is a new reimbursement coding guideline in the US. While our cost of living may be somewhat less than the US, procedural complexity and risks remain the same with the same expertise, training and difficulty in the performance of the procedure. So we can go ahead and develop our own reimbursement guidelines using a percentage of difference in living costs. It is better not to be penny wise and pound foolish.n
(Dr.) Col. Anil Dhall, Sena Medal, MD, DM, FACC, FESC, FSCAI, FHRS, FCSI is Director Cardiology, Delhi Heart and Lung Institute. He was formerly Senior Adviser & Professor Army Hospital (Research & Referral) Delhi Cantt, Senior Consultant & Unit Head Max Heart & Vascular Institute, Saket, New Delhi, Director & Head Department of Cardiology Artemis Health Institute, Gurgaon.
Cost involved in an angioplasty procedure
The cost of angioplasty not only includes the price of a stent but also incorporates:-
a) Percentage cost of capital expenses on setting up a cardiac catheterisation laboratory, coronary care unit, emergency room, non invasive cardiac hemodynamic laboratory etc.
b) Percentage cost of capital expenses in setting up a hospital.
c) Cost of disposable hardware i.e. sheaths (factor 2.4), 0.035”guide wire, 0.014” coronary guide wire (factor 2.2.), intra coronary balloon (factor 2.2.), intracoronary hardware for special situations like the thrombus extraction catheter, micro catheter, Corsair, Tornus etc. Contrast, Medicines with optional usage of Swan Ganz, Right heart catheter, Temporary Pacing.
d) Cost of linen, sterilisation, logistics and supply chain.
e) Cost of pre and post procedure care including nursing, linen, housekeeping and dietetics.
f) Lab investigations and backend costs.
g) Cost of nursing, technical and paramedical staff.
h) Physician cost including cost of Cardiologist, Anesthesiologist and even stand by Surgical Team.
i) Cost of stent.
j) Cost of rotablator, if used.
k) Cost of FFR (fractional flow reserve), IVUS (Intravascular ultrasound), OCT (Optical coherence tomography) if used.
l) Cost of closure device if used.
m) Cost of future expansion and training of personnel to remain abreast with advances in the field.