Can price control create treatment Bias?

Levitt and Dubner in their book Freakonomics quote a medical study which found that obstetricians in areas with declining birth rates are much more likely to perform cesarean section deliveries than obstetricians in growing areas – suggesting that when incomes start falling doctors try to ring up more expensive procedures.

This is an example of a treatment bias.

Is it possible that the stent-price control could also be giving birth to treatment biases.

(Just as a background – Stent prices were slashed in India by 85 per cent in 2017. This well-intentioned price control measure was aimed to ease the financial burden on patients undergoing angioplasty, the jury is still out if the major centers, to compensate for the income loss, just increased the interventional cardiologist’s (hereafter cardiologist) fee, and hospital charges such as those for operating theater usage, nursing services, beds, medical supplies, food etc., thus bringing the price of the procedure to where it was with the higher priced stents! The overwhelming evidence is that they did. And this brought in bias in the Business Model, almost mutilated it.

Protagonists of this severe price control say that the measure at least made the hospitals start receiving through formal channels, the unaccounted money which was earlier going to cardiologists and that tier 2 and tier 3 towns saw some dip in procedure costs which the major centers evaded as described above. Referring to the multiplying volumes of angioplasty they also say that this is because angioplasty has become more affordable. Those who disagree contend that this is because the number of stents placed per person is increasing! The truth might be a mixture of the two contentions.)

However, is a more deceptive treatment bias emerging due to stent price control? Is the diagnoses of blocked-calcified lesions increasing, which might explain the resurgence of Rotablators—a specialised burr used by skilled cardiologists to remove calcification. Although rotablation is vitally necessary for blocked-calcified arteries as a prerequisite for angioplasty and the Rotablator-pioneering company has taken great pains in training cardiologists on this sophisticated technique, there is no guarantee that a less skilled operator won’t attempt to game the system – feigning just a single rotation of the drill to justify charging for it in the bill.

There is so much subjectivity in medical decision making that such price controls, more often than not, create a cascade of adverse unintended consequences which grow with time.

To truly make Indian healthcare more affordable, policymakers must – as an extension of the Hippocratic tradition – first ensure that their policy does no harm! Engendering treatment biases is harmful to the patients. Only through a comprehensive understanding of the ecosystem, keeping lessons drawn from historical precedents of price control in sight and consulting the stakeholders and the informed can India embark on a path towards a more resilient and equitable healthcare system.