The highly controversial payment reform of dentists in France: Seeking a new compromise after the 2017 strike

Transformation of dental services from a governmental model to a revenue-generation model of operation in a tertiary care hospital: a health economics assessment

BACKGROUND

Healthcare in Saudi Arabia is under transformation from a national free health service to a system paid either by insurance or governmental funds. This change will impact the model of operation including dental services.

OBJECTIVES

Estimate the revenue of the Department of Dentistry based on an insurance-based billing system.

DESIGN

Medical record review SETTING: An academic tertiary care hospital in Riyadh PATIENT AND METHODS: Data on outpatient visits for the period 2015-2019 was extracted from the electronic health records. The billing data was categorized by specialty and current procedure terminology (CPT) code. The revenue stream for each CPT code was estimated and compared between the actual cost of service for each CPT code billed price, and average price of the market leaders in private practice.

MAIN OUTCOME MEASURE

Revenue generated by the department.

SAMPLE

339 421 outpatient visits for 22 056 patients.

RESULTS

Female and males made 179 555 (52.9%) and 159 858 (47.1%) outpatient visits, respectively. Outpatient divided by the age groups: ≤14,15-65, >65 years were 58 868 (17.3%), 251 552 (74.1%), 29 001 (8.5%), respectively. The visits divided by specialty were as follows: general dentistry 28.1%, pedodontics 12.5%, orthodontics 7.1%, endodontics 7.0%, oral and maxillofacial surgery 6.9%, prosthodontics 4.4% and periodontics 3.3%. Outpatient visits to the nursing clinic and hygienist amounted to 30.7%. The median number of visits per patient per year was 5 (range, 1-63), which increased to 6 (range, 1-110) in 2019. The annual revenue plateaued in 2019 at 13 983 538 SAR (3 728 943 USD) with only a 2.2% of increase from 2018. Out of 292 CPT codes, 44.8% were priced below the actual cost. Moreover, 28.4% showed pricing below actual cost, but higher than the price of the market leaders. There was an annual loss of revenue of 10.1% due to incorrect pricing of CPT codes. Average productivity of the dentist and hygienist amounted to 2263 and 760 visits per year, respectively.

CONCLUSIONS

There is a need for improvement in delivery of care, cost-containment, productivity and amendment of charge description master pricing.

LIMITATIONS

The sample did not include data from the period 2020-2022 due to the restriction of dental services due to the COVID-19 epidemic.

CONFLICT OF INTEREST

None.

Governance tensions in the healthcare sector: a contrasting case study in France

Background

Political and managerial reforms affect the health sector by translating into governance tensions. As identified in the public management literature, these tensions come from the diffusion of management principles and practices from the business world. These tensions manifest at four levels: institutional, organisational, managerial and instrumental. The aim of this research is to understand how these tensions are expressed in healthcare organisations of different status.

Methods

We conduct a contrasting case study exploring the cases of two French healthcare organisations, one private for-profit (clinic) and one public not-for-profit (cancer treatment centre). Our analyses are mainly based on the content analysis of 32 semi-structured interviews conducted with staff (nurses, doctors, management and administrative staff) of these two organisations.

Results

Our results show that these tensions can be distinguished into three categories (tensions on professional values, standards and practices) which are expressed differently depending on the type of healthcare organisation and its main management characteristics.

Conclusions

Unexpectedly, in the for-profit organisation, the most intense tensions concern professional standards, whereas they concern professional practices in the not-for-profit organisation. These analyses can help guide policy makers and healthcare managers to better integrate these tensions into their political and managerial decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07401-4.

Do health systems cover the mouth? Comparing dental care coverage for older adults in eight jurisdictions

Oral health is an important component of general health, yet there is limited financial protection for the costs of oral health care in many countries. This study compares public dental care coverage in a selection of jurisdictions: Australia (New South Wales), Canada (Alberta), England, France, Germany, Italy, Sweden, and the United States. Drawing on the WHO Universal Coverage Cube, we compare breadth (who is covered), depth (share of total costs covered), and scope (services covered), with a focus on adults aged 65 and older. We worked with local experts to populate templates to provide detailed and comparable descriptions of dental care coverage in their jurisdictions. Overall most jurisdictions offer public dental coverage for basic services (exams, x-rays, simple fillings) within four general types of coverage models: 1) deep public coverage for a subset of the older adult population based on strict eligibility criteria: Canada (Alberta), Australia (New South Wales) and Italy; 2) universal but shallow coverage of the older adult population: England, France, Sweden; 3) universal, and predominantly deep coverage for older adults: Germany; and 4) shallow coverage available only to some subgroups of older adults in the United States. Due to the limited availability of comparable data within and across jurisdictions, further research would benefit from standardized data collection initiatives for oral health measures.

Factors associated with disparities in out-of-pocket expenditure on dental care: results from two cross-sectional national surveys

Background

Socioeconomic differences in oral health and dental care utilization are a persistent problem in many high-income countries. We evaluated demographic, geographic and socioeconomic factors associated with disparities in households’ out-of-pocket expenditure (OOPE) on dental care, and the effect of ongoing dental health reform on these disparities.

Methods

This cross-sectional analysis used data collected in two Israeli Household Expenditure Surveys conducted in 2014 and 2018. OOPE for dental care was estimated using a two-part multivariable model. A logistic regression was used to examine the likelihood of reporting any OOPE, and a log-transformed linear regression model examined the level of expenditure among those who reported any OOPE.

Results

In 2018, OOPE on dental care accounted for 22% of total health expenditure for all households, whereas among those who reported dental OOPE it reached 43%. Households with children up to age 14 years reported lower OOPE, regardless of ownership of supplementary health insurance. Owning supplementary health insurance had a heterogeneous effect on the level of OOPE, with a significant increase among those with 0–8 years of education, compared to households without such insurance, but not among those of higher educational level. In 2014, Arab ethnic minority and residence in the country periphery were associated with a greater likelihood for any OOPE and higher amounts of OOPE on dental care. While the gaps between Jewish and Arab households persisted into 2018, those between peripheral and non-peripheral localities seem to have narrowed.

Conclusions

The burden of dental OOPE on Israeli households remains heavy and some disparities still exist, even after the implementation of the dental health reform. Expanding the dental health reform and addressing barriers to preventive dental care, especially among Arabs and those of lower educational level, may help in reducing households’ private expenses on dental care.

Implementation and impact of a dental preventive intervention conducted within a health promotion program on health inequalities: A retrospective study

Background

The objective of this retrospective survey was to evaluate after one year, the conditions and impacts of a dental sealant intervention conducted in New Caledonia, within a health promotion program. A greater or at least equivalent quality and impact of the intervention was expected for children living in socially deprived regions with the greatest health needs.

Methods

The study population was the schoolchildren, aged 6 years in 2016, who benefited from the dental sealant program (n = 2532). The study sample was randomly selected in 2017 from that population (n = 550). The children's dental status was evaluated at school in 2017 and compared with that recorded in 2016 during the sealant intervention allowing the calculation of the retention rates and one-year carious increment on first permanent molars. Socio-demographic variables (gender, public/private school) and conditions of sealant placement (school/dental office, presence of a dental assistant) were recorded. The carious increment was explained using a mixed multiple random-effects regression. A mediation analysis was conducted to assess the respective contributions of the retention rates and the region of origin on caries increment.

Results

The participation rate was very high (89%) and on average, children had 83% of their dental sealants present after one year, 31% fully and 52% partially present. Caries increment varied depending on the sealant retention rate as well as on the region (North, South, Islands). The mediation analysis showed that living in a deprived area (The Islands) was a strong determinant for high caries increment particularly when the retention rates were low.

Conclusions

This study showed a high participation rate and acceptable effectiveness as measured with the one-year retention rates, for a fissure sealant intervention conducted in real-life conditions and integrated in a large health promotion program. Nevertheless, the intervention was not effective enough to totally balance the influence of health determinants, especially in socially deprived sectors characterized by greater dental needs.