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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econanonRobbev M.D. Recent comment authors
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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… Read more »


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… Read more »

bev M.D.
bev M.D.

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… Read more »