One month after a heart stent costing a few hundred yuan was placed, those expected and unexpected outcomes.

【Summary】At Qian Mu's hospital, an angiography costs 2000 yuan, but only 150 yuan in the department.

At Qian Mu's hospital, an angiography costs 2000 yuan, but only 150 yuan in the department. "The department's commission is very low, and even less in the doctor's bonus. Young doctors earn 19 yuan for one angiography." Qian Mu spends the day in the operating room, performing eight or nine such procedures.

 

Previously, patients with vascular stenosis of around 70% would receive stents, but now it's only above 80% - this is one of the most anticipated effects of the national centralized procurement. When the water content of the cost of consumables is squeezed out, medical behavior returns to the treatment itself. However, The opposite of what was expected also occurred.

 

In January 2021, for most cardiology departments in public hospitals across the country, the number of patients undergoing coronary stent surgery increased significantly.

 

This was the first month after the national centralized procurement of coronary stents reduced the average price of more than 10,000 yuan to more than 700 yuan, and was implemented in major public hospitals across the country. Some patients who were preparing for elective surgery (non-acute myocardial infarction) in December of the previous year learned about the "price cut" of the national centralized procurement of coronary stents through the media and waited until January - this choice would save them at least tens of thousands of yuan in treatment costs.

 

△ On January 10, in the interventional operating room of a hospital in Henan Province, a patient receiving coronary stent surgery under the price reduction policy of the national centralized procurement. (Image from People's Vision)

 

The cardiology departments of public hospitals also fell into a state of chaos in January: A tertiary hospital in Wuhan once experienced a shortage of stents that won the bid in the centralized procurement; several cardiologists in a tertiary hospital in Shanghai found that the number of stent models available for surgery had decreased, and some patients' coronary artery stenosis required a long stent, but due to the "disappearance" of long stents, they had to install two short stents.

 

By February, the cardiology departments of major hospitals gradually returned to normal. The number of patients who underwent coronary stent surgery before the year was "released", and the number of patients undergoing coronary stent surgery in some public hospitals gradually returned to the average number of the previous year, and some hospitals even had fewer.

 

A cardiologist from a tertiary hospital in Wuhan mentioned that previously, patients with vascular stenosis of around 70% would receive stents, but now it's only above 80% - this is one of the most anticipated effects of the national centralized procurement; when the water content of the heart stent is squeezed out, medical behavior returns to the treatment itself.

 

But the opposite of what was expected also occurred.

 

Several individuals from the procurement departments of different hospitals in the north and south stated that the use of drug-eluting balloons, which are more expensive than coronary stents before centralized procurement - about 20,000 yuan - increased significantly in January and February.

 

Drug-eluting balloons are a new technology used in patients with vascular stenosis in recent years, and cardiology calls it an "invisible stent".

 

This is a concern expressed by Hu Dayi, a well-known expert and opponent of excessive coronary stent implantation, after the national centralized procurement of coronary stents last year: The price reduction of heart stents does not mean the disappearance of over-medicalization. If over-medicalization still exists, the next thing to increase in price will be drug-eluting balloons, and other irregularities will also occur.

 

In some large tertiary hospitals, the implantation of coronary stents was once an important source of hospital income. They have successively received new requirements from their hospitals, asking doctors to increase the amount of coronary stent surgery, "high volume, low margin".

 

After doctors gradually changed their behavior of installing several stents on one patient, the requirement to increase the volume of surgery can only be achieved by "siphoning" patients from primary hospitals and surrounding provinces and cities. However, doctors have lost their enthusiasm for this "high volume, low margin". "This will squeeze our time for technological innovation and the development of high-difficulty surgeries." A young cardiologist said.

 

In another month, it will be time for some hospital cardiology departments to distribute quarterly bonuses. Some young cardiologists are waiting for this day. After the thousands of yuan in income that the department director or hospital department used to distribute as bonuses from coronary stent "rebates" disappeared, they are worried whether the new policy can make up for that lost income?

 

January: Disappearance of long stents and shortage of centrally procured heart stents

 

In January, what made cardiologists, especially those in small and medium-sized hospitals, most headache was the shortage and incomplete models of some heart stents that entered the national centralized procurement.

 

Before the national centralized procurement of heart stents, the delivery of heart stent manufacturers was very active, and there were always manufacturer representatives asking whether there was a shortage, and they always came to the hospital to do some auxiliary work. After the centralized procurement, the delivery of manufacturers has become significantly less active. Because the profit of heart stents has been greatly reduced, there is a cost for each delivery. In the past, manufacturers would not calculate the delivery cost, but after the profit decreased, the delivery cost would also be considered.

 

A cardiologist reflected that the larger the volume of coronary stent surgery in a hospital, the less likely it is to have a shortage. Because there is no need to worry about not being able to use them up, manufacturers will be more at ease and prepare all models for the hospital at once, with several sets of each model in the hospital. However, for small and medium-sized hospitals that only use a few hundred stents a year, because the models of heart stents will expire if they are not used up, manufacturers do not know how to deliver them.

 

Qian Mu, a attending physician in the cardiology department of a tertiary hospital in Shanghai, strangely found that around January 2021, the long stents available in the operating room seemed to have evaporated, disappearing from the hospital.

 

He quickly understood the reason: During the period of huge profits from stents, which often cost tens of thousands of yuan, the extra material cost of long stents compared to short stents was negligible for both manufacturers and distributors, and the price of long and short stents of the same brand was the same. However, in the era of stents costing hundreds of yuan, when the average price of stents costing tens of thousands of yuan dropped to 700 yuan, and the lowest winning bid was only 469 yuan, the extra material cost of long stents became "sky-high" in the eyes of manufacturers and distributors.

 

With the profit margin greatly reduced, manufacturers prefer the high-volume, low-margin short stents. In their view, no matter how large the lesion is, short stents can always be used, but long stents may not be.

 

The disappearance of long stents made Qian Mu, who was used to choosing stents according to the length of the lesion, very helpless. "Originally, for a lesion, a 38 mm stent was needed, but when I asked, the hospital didn't have it, so now I can only install two short stents for the patient." Only short stents are available, so patients with coronary lesions can only be treated by placing multiple stents. The difficulty of the surgery has increased for the doctors.

 

Doctors' diagnostic and treatment behaviors have changed.

 

Zhang Yi (pseudonym), a cardiologist at a tertiary hospital in Wuhan, has experienced the process of heart stents dropping from more than 20,000 yuan to more than 10,000 yuan, and then to 700 yuan today.

 

Over the past month or so, he has encountered the same question from different patients almost every day: "With such a large price drop, won't the quality be compromised?" He always answers patients: "This stent was already in use by hospitals even before the centralized procurement; the government only lowered the price, it's not because the quality was compromised."

 

Most patients listened to his explanation, but a few were still uneasy and transferred to other reputable private hospitals that offered imported cardiac stents.

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This scenario seems familiar. After the national volume-based drug procurement, patients holding domestic generic drugs that cost only a dozen yuan a month similarly questioned doctors about whether the quality was different. "After patients take the centrally procured generic drugs, they quickly feel that the effect is no different and won't ask again later. But a cardiac stent, once implanted, doesn't show immediate results, and it's difficult for patients to gauge its quality," Zhang Yi explained.

 

However, at least for now, there have been no cases where patients and their families refuse to undergo emergency, mandatory cardiac stent surgery due to the lack of imported stents.

 

Several cardiologists stated that the likelihood of needing a cardiac stent for approximately 70% heart vessel narrowing, as was common in the past, has now almost vanished. For most patients who don't need a cardiac stent or multiple stents, doctors will no longer actively persuade them to have one installed.

 

Furthermore, when dealing with complex cases, doctors are increasingly deciding whether and how many cardiac stents to implant based on examination results, rather than solely on their own judgment.

 

Some complex patients sometimes require intravascular ultrasound (IVUS). This examination is expensive, costing around 10,000 yuan. After the examination, if the patient needs stents, they would also be fitted with one or more cardiac stents costing 20,000 yuan or even more.

 

Before the centralized procurement of cardiac stents, both doctors and patients felt that the price of cardiac stents was already high, and the examination fee of over ten thousand yuan would further increase the total treatment cost. Therefore, doctors tended to use their experience to help patients decide the number of stents to implant, and avoided IVUS whenever possible. However, now if a patient needs an IVUS examination, doctors will choose to use IVUS to examine the patient.

 

"This examination can very accurately determine whether a patient needs a stent and how to implant it, which is actually better for the patient."

 

After this examination, doctors also feel relieved. Based on past experience, doctors sometimes estimated that the severity of the condition might require 1 or 2 stents, but during the actual surgery, if they found that an additional stent was needed, they would have to spend time communicating with the patient's family due to the significantly higher cost.

 

But now, based on the IVUS examination results, both doctors and patients are more likely to accept the cardiac stent implantation plan.

 

There are also a few patients who find the IVUS examination, costing over ten thousand yuan, to be expensive – more than 10 times the price of a 700 yuan cardiac stent – and will directly ask the doctor to skip the examination and implant the cardiac stent directly.

 

However, after the price of cardiac stents dropped, some patients with non-complex conditions and less than 70% vascular narrowing, who previously didn't need cardiac stents, were arranged for additional IVUS examinations. "When the price of cardiac stents goes down, the cost of examinations goes up; this situation also occurs with some unregulated doctors," Zhang Yi admitted.

 

Increased use of drug-coated balloons

 

A 68-year-old male patient who suffered an acute myocardial infarction was fortunate to receive timely treatment; a stent was implanted within an hour of onset, and he was discharged smoothly soon after, returning to normal life. The patient and his family thanked the doctor for saving his life, but they later discovered that a drug-coated balloon was used during the procedure, and the balloon cost more than 20,000 yuan above the centralized procurement price of a stent.

 

This is a patient story recently recounted by Hu Dayi in an article. Hu Dayi reviewed the medical records and believed that the use of that balloon was completely unnecessary, constituting overtreatment.

 

Drug-coated balloons are a new technology applied to patients with vascular narrowing in recent years. They use special balloons with drugs coated on their surface, which, after expanding within the blood vessel, can evenly distribute the medication onto the vessel wall, thereby resolving the patient's vascular narrowing issue without implanting a stent. Cardiologists refer to it as an "invisible stent."

 

When interviewed by "Badian Jianwen" a few months ago, he predicted: After the centralized procurement of stents, the usage of balloons in cardiac interventional procedures might significantly increase. Recent multi-faceted inquiries by "Badian Jianwen" have also confirmed this.

 

Jiang Changsong, an associate researcher at the National Healthcare Security Administration Research Institute of Capital Medical University, told "Badian Jianwen" that friends from the equipment departments of two Grade A tertiary hospitals in Beijing reported to him: "The use of drug-coated balloons has surged a bit, possibly more than usual."

 

A doctor from the Cardiology Department of Shanghai No. 10 Hospital also mentioned: "The usage of balloons has significantly increased, whether it's plain balloons or drug-coated balloons."

 

The dean of a hospital in Xuhui District, Shanghai, provided specific data: "Last year, the proportion of drug-coated balloon usage (in our cardiology department) was about 40%, and in January and February this year, it was around 45%."

 

Why did the centralized procurement of stents have such an impact on balloon usage?

 

The aforementioned hospital dean explained that at the current stage, major hospitals across the country must use stents from volume-based procurement, but manufacturers cannot keep up with the supply, making it difficult to obtain sufficient quantities of commonly sized stents. Therefore, "at this stage, we can only supplement with drug-coated balloons." He added that in addition to drug-coated balloons, some high-end stents outside the centralized procurement list are also sometimes used, which patients are usually "willing to accept."

 

A cardiology expert from a southern province explained that the national cardiac stent centralized procurement policy is a contributing factor to the increased use of drug-coated balloons, but in recent years, even before the national cardiac stent centralized procurement, there has been an increasing trend in the use of drug-coated balloons.

 

Drug-coated balloons represent an innovative application of cardiac interventional technology in recent years. Some clinical studies have shown that the long-term prognosis of cardiac stents is not ideal, leading medical experts to consider whether cardiac surgeries can adhere to the principle of "intervention without implantation" — which can reduce the irritation to the body caused by implanted foreign objects. In this trend, he believes that even without centralized procurement, we would now be in an era of increasing drug-coated balloon procedures and biodegradable stents.

 

However, this treatment method is not suitable for all patients. Can balloons completely replace stents? Not necessarily. Clinically, their indications differ.

 

The indications for drug-coated balloons have certain limitations, primarily suitable for in-stent restenosis, coronary small vessel disease, and bifurcation lesions, and cannot completely replace stents.

 

Which interventional material to use specifically depends on the individual's condition. Some patients are suitable for drug-coated balloons, while others are suitable for stents. Doctors should evaluate based on the specific condition.

 

A doctor from the Cardiology Department of a top-tier hospital in Shanghai explained: "For some surgeries where both stents and drug-coated balloons can be used, doctors tend to prefer drug-coated balloons after centralized procurement; or in borderline cases where a stent may or may not be placed, they will choose to use drug-coated balloons more often."

 

So, will there be overuse in the market for drug-coated balloons?

 

The aforementioned doctor stated that relevant departments actually control the usage of drug-coated balloons, and the medical insurance department is also monitoring their use.

 

"There's a regulation in Zhejiang that the use of drug-coated balloons in all interventional surgeries cannot exceed 10%. Shanghai doesn't have such a regulation, but the medical insurance bureau is monitoring." He said that a hospital in Shanghai was criticized for overusing drug-coated balloons.

 

Impact on doctors after centralized stent procurement: Doctors feel a psychological gap.

 

In the first month after the national centralized procurement of coronary stents was implemented in Shanghai, Qian Mu's income decreased by 30%. "Foreign sales reps are all unemployed, I'm already lucky."

 

What he felt more was a sense of grievance—being on call 24 hours a day, still performing myocardial infarction surgeries in the middle of the night, yet the returns were not as expected. While the prices of consumables decreased, the surgical price adjustment plan had not yet been introduced. As Qian Mu's income significantly decreased, his enthusiasm was also severely impacted.

 

 

Coronary angiography, balloon dilation, and stent implantation are the procedures that best represent the technical expertise of cardiologists. 8 Health learned that, nationwide, the average cost of these three procedures is around 8550 yuan. However, in Shanghai and Beijing, the two regions with the richest medical resources and most developed economies, the surgical costs are the lowest, with Shanghai's being just over 4000 yuan.

 

At Qian Mu's hospital, an angiography costs 2000 yuan, but only 150 yuan in the department. "The department's commission is very low, and even less in the doctor's bonus. Young doctors earn 19 yuan for one angiography." Qian Mu spends the day in the operating room, performing eight or nine such procedures.

 

A person close to the National Healthcare Security Administration told 8 Health that Beijing's medical service prices have already been adjusted, and Shanghai's adjustment plan is still under discussion. "It will definitely be adjusted later, probably to the national average price." He believes that at the national level, the adjustment of medical service prices involves many aspects and still requires caution and extensive research.

 

Regarding income compensation for doctors after the reduction in consumable prices, the National Healthcare Security Administration issued the "Opinions on Supporting Measures for National Organized Centralized Procurement and Use of Coronary Stents" in December 2020. The document states that for varieties within the scope of coronary stent centralized procurement, medical insurance funds will be managed under a separate budget. The saved medical insurance funds, after evaluation, can be retained by medical institutions at a proportion no higher than that for nationally organized drug centralized procurement.

 

"Doctors might not be aware of the supporting policies." Jiang Changsong explained that, for example, a 10,700 yuan stent dropped to 700 yuan after centralized procurement. Calculated at a 60% actual reimbursement rate, medical insurance saved 6,000 yuan (medical insurance surplus funds).

 

In regions where payment is based on services, hospitals using a selected stent will receive a separate bonus from medical insurance at the end of the year. The standard of the bonus is determined by the hospital's evaluation score for using the selected product, with the highest bonus not exceeding 50% of the medical insurance surplus funds. In regions where DIP/DRG payment is implemented, the medical insurance payment standard for diseases/disease groups will not be lowered in the first year.

 

"The supporting document clearly states that after the medical insurance surplus funds are awarded to hospitals, they are mainly used for doctors' performance. To put it bluntly, it's equivalent to legalizing the kickbacks doctors used to get in their personal pockets."

 

A resident doctor in the Cardiology Department of a top-tier hospital in a southern province has been waiting for her quarterly bonus in March. She has a premonition that her bonus income might significantly decrease. Previously, hospitals and departments would distribute "rebates" from cardiac stent manufacturers to them in the form of bonuses. "This part amounted to several thousand yuan per month, but now it's gone."

 

Furthermore, she was unaware of the "medical insurance surplus retention" policy, which returns a portion of the saved funds to hospitals. In her opinion, for necessary surgeries like acute myocardial infarction, doctors have basic professional ethics and cannot simply not perform them.

 

However, for doctors with lower seniority like her, a decrease in surgical enthusiasm is a fact. The hospital's latest policy orientation is that when the price of cardiac stents significantly decreases and a patient cannot use multiple stents, the hospital encourages more surgeries and "small profits but quick turnover"—attracting patients from grassroots levels or other provinces to undergo procedures.

 

"This means our workload will greatly increase, and not only will our income not increase, but more importantly, we won't have time to study complex and difficult cases." She is more worried about her future career.

 

Tan Zhuozhao | Author

Wu Jing | Author

Fang Shuchen | Author

Zhu Xueqi | Author

Wang Chen | Editor

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