NEW ORLEANS -- The current boom in implanting tubular devices called stents in heart arteries may go bust when hospitals realize they are losing their profit margins, a researcher has concluded in a study presented at the annual meeting of the American Heart Association.
And if that happens, heart care will take several steps backward to the detriment of patients, Duke University Medical Center cardiologist Dr. Eric Peterson warned. "Sadly, hospitals now need to look at how every dollar is spent, and 'stenting' may become a luxury they can't afford."
Cardiologists insert the mesh-like structures to keep arteries open after clogs have been cleared by balloon angioplasty. Because of its effectiveness, stenting has quickly become a popular procedure: This year, it is estimated that 170,000 stents will be inserted in American hearts, compared to almost none five years ago.
Peterson performed a detailed examination of the costs associated with doing an angioplasty alone, or an angioplasty that delivers a stent. Analyzing the results in about 400 patients, he found that stenting costs about $13,000 -- roughly $2,000 to $3,000 more than regular angioplasty.
To many cardiologists and patients, that extra expense is well worth it, because inserting a stent structure in an artery has been proven to reduce the rate of recurrent blockages in the artery, Peterson said.
But, depending on who is paying the bill, he said these procedures may be a bad financial deal for the hospital.
Medicare gives hospitals one price (from $10,000 to $13,000 depending on the kind of hospital) through its payment system to perform either an angioplasty or an angioplasty that delivers a stent. And managed care companies usually may pay much less than that, Peterson said. That means that, rather than making a slight margin off a regular angioplasty, hospitals are losing thousands of dollars every time a stent is used.
To date, cardiologists have not made decisions on whether to use a stent or not based on how much money their hospitals make or lose, Peterson said. In part, that's because the costs of stenting have fluctuated as the devices and the procedure have been perfected. But the primary reason is that money wasn't such an issue in the past. "Now, with the onset of managed care and diminishing reimbursement from all payers, hospitals need to be very cost conscious."
In looking at medical records, Peterson found out that the extra cost of stenting is not due to medication or length of hospital stay. It is in the fixed price of the devices, which usually cost around $1,600 each, and the extra angioplasty balloons, costing up to $600 each, that are needed to insert the stents.
So now what was a "win/win" situation for patients and society -- better immediate outcomes and less need for repeat procedures -- has become a losing proposition for hospitals, Peterson said. "A treatment that carries a large financial burden may not stay popular," he said.
One obvious answer to the dilemma is to convince the Health Care Financing Administration, the federal agency responsible for setting Medicare reimbursement rates, to set two different prices for the two procedures. But so far, HCFA has been unwilling to do this, Peterson said.
Another solution may be a capitated system of heart treatment, in which a hospital receives a set amount of money to care for a single individual over time. In that system, the benefit of stenting in reducing the need for patients to return to the hospital will likely be recognized.
Peterson said that the trade-off between new, but costly, improvements in patient care and the ability of hospitals and other providers to absorb the differences in reimbursements will become more and more of an issue. "These are growing problems that are going to concern hospitals in the future when their economic motivations are increasingly placed in direct conflict with their desire to do the best for patients," he said.
In a plenary session talk on "The Financial Fallout From the Stent Explosion" to be given Wednesday morning at the conference, Dr. Daniel Mark will review what is known about the benefits and costs of stenting versus balloon angioplasty. Mark, director of the Duke Outcomes Research and Assessment Group, said stenting does "reduce the need for repeat angioplasty and bypass surgery during the year following the procedure. Reduced follow-up procedures allow stenting to recoup some of the extra costs associated with this form of therapy."
Up to 25 percent of patients who had angioplasty will need a repeat procedure in the follow-up year, Mark said. With stenting, current evidence is that the repeat procedure rate falls to about 16 percent, and to fully pay back the extra costs of the procedure, current projections suggest that the repeat procedure rate will need to fall to around 9 percent, Mark said. "Ongoing trials including the latest stent technology will help define how close doctors have come to achieving this level of effectiveness," he said.