The doctor came out of the cath lab and asked Mandira Bannerji (name changed) to decide quickly if they should go ahead with stenting for her 90-year-old father. It would cost Rs 2.6 lakh. Since he was in the cath lab for angiography, the stenting could be done right then without bringing him to the lab again to undergo the procedure required for stent implantation, largely similar to the procedure for angiography.
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Despite the pressure to decide immediately, she sought time to consult her family. Once the pressure was off and her father returned to the room, the doctors asked if she would like to opt for a "medicated stent", costing Rs 80,000. She was assured there was no difference between the stent suggested earlier and this one in terms of safety.
This happened at a prominent South Delhi hospital, part of a large chain. Mandira wonders why she was offered the vastly more expensive stent as the first option. "Under pressure, I might have said yes without bothering about the cost. If they knew that there was the possibility of stenting when taking him in for angiography, why did they not have a conversation with me about the different kinds of stents, their relative merits and prices? Why not hand me a list of options in writing so that I could take a second opinion to help make an informed choice?" asked Mandira.
Mandira's father required two stents as he had two arteries with over 90% blockage.And the final bill came to about Rs 3.7 lakh. The hospital claims that the cheapest stent they stock is Rs 1lakh and that the patient got it for Rs 80,000 per stent on a discount.
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Mandira's is not an isolated experience. Many patients' attendants are hustled into taking a decision on stenting with the patient on the cath lab table. They are supposedly making a 'choice', but have little or no knowledge beyond what the doctor tells them. The decision is almost entirely in the hands of the cardiologists, and, according to cardiologists, dependent on what brands the hospital management decides to stock.
According to cardiologists, TOI spoke to, when it comes to big corporate hospitals or hospital chains, the stent companies directly strike deals with the hospital on pricing. Stent companies, especially foreign ones, do not like to be caught indulging in unethical marketing practices that, if discovered, might make them liable for prosecution.
In 2011, Johnson and Johnson had to pay $77 million to settle charges of paying kickbacks to doctors in various European countries. Hence, once the pricing deal is struck with the hospital, the dealer or distributor is left to deal with cuts or kickbacks.
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Take the case of one stent brand, Xience Xpedition of Abbott imported into India at Rs 17,000 to Rs 23,000. It's price to patient ranges from Rs 65,000 to Rs 1.5 lakh.
What is true for Abbott's Xpedition is true for almost every stent brand, including Indian ones, which are available for different prices in different hospitals.
For instance, Biomime Aura, a stent brand from Meril Lifesciences, an Indian company, is available for Rs 50,000 in Ganga Ram and for Rs 1lakh in Max. Yukon Choice, a stent brand from an Indian company Translumina, is available for Rs 1 lakh in Max and Rs 23,625 in RML while its import price is just Rs 5,000.
Given this wide variation, the question activists are asking is whether a price cap determined on the basis of an average of price to the hospital can prevent patients getting fleeced or huge margins being used to 'incentivise' doctors & hospitals to use a particular brand.