QUALITY: Stents cannot be killed, well perhaps not

So in the latest of the stent wars a new study suggests that Medicare has been saving money as drug-eluting stents have replaced by-passes. This of course is music to the ears of J’n’J & Boston Scientific — not to mention the odd invasive cardiologist. And they’ve been getting, shall we say, a touch aggressive about marketing their product–here’s JSK’s great entry on DTC stent marketing  at Health Populi. (By the way, Jane’s blog is really good. and is keeping those old veterans of the HC blogging world amongst us on our toes!)

However, it’s not clear to me whether the interpretation of this study hasn’t ignored two things in the context of the stent world.

The first is that earlier this year COURAGE essentially showed that medical management is better than stenting (or at least no worse). The other issues is the timing. What we really need to know is the value over the long-term. The data in this study is not old enough to know what happens in the long term–and of course in Medicare we’re all paying over the long term.

But of course four years ago in what is still one of my favorite posts on THCB, a Stanford study showed that in the long-run stents ended up costing considerably more than CABG’s — which is why I said then that we should dump the stent and have a by-pass!

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3 replies »

  1. The market plays little role in setting medical prices in general, and almost no role in setting Medicare’s part B price schedule. Prices for new procedures under part B, including facility fees, are set by the AMA’s RUC. The question of value to the patient is explicitly not part of the RUC’s deliberative process…all that matters is how hard and how long the physcian works.
    What does this mean for the study in question? Only that the “economic analysis” presented is completely conditional on a non-market-based administrative pricing structure. If CMS wanted to make stents cost-effective relative to bypass, it could just lower the price paid for stenting procedures. If CMS wanted to make CABG seem more cost-effective, it could just raise the price for stents. No market here (at least if we exclude the case of the corner solution where prices fall so low that no physician will perform the procedure).
    It’s a meaningless accounting game…questions of social welfare do not apply in situations of non-market-based administrative pricing. The strong price anchor set by RUC/CMS effectively forces private insurers (dwarfed by Medicare and forbidden to collude on payments to providers) to follow the administrative pricing structure.
    When was the last time anybody saw a patient actually pay out of pocket for a life-saving procedure? Dermabrasion, sure. But not anything having to do with the heart.

  2. Ok. Let me try this out.
    The intrinsic value of a potentially life-saving procedure is infinite (to the patient).
    The “market value” of the same thing is, literally, whatever the “consumer” is able to pay – and well beyond.
    This gives incentive to game the system. Yes, stents are less invasive. They’re also cheaper, thus widening the margin. So. “Market value” is still “whatever we can get out of your hide,” and cost is lower. Real value is still infinite, so there is no upper limit to “market value.”
    I realize there are many many clinical advantages or disadvantages, but I humbly ask we acknowledge that “the market,” in which something is worth what someone will pay for it, pollutes the discussion.

  3. What gets lost in all this stent/bypass discussion is that one cannot generalize among all patient groups. Stents are more effective in certain clinical situations, bypasses are more effective in others, and medical treatment alone is more effective in still other patient groups. The problem is that the medical profession has been over enthusiastic in extending stent treatment beyond the groups for which it is most effective, into both those who shouldn’t have stents at all, and those who should have had a bypass instead. Any generalization about “all” patients is going to be wrong.
    The complexity of the situation is further compounded by the fact, as noted in the post, that there may be (and probably is) a difference in the short term benefits and the long term benefits for each treatment, for each individual group. So if this blog, and whomever else wants to speak out on this subject, truly wants to empower patients to educate themselves, it should be careful to make these distinctions.