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frustration
EHFCN - PRAGUE - JUNE 2015 1
• Can you help us improve the control to and the assessment of reimbursed dental care?
frustration
EHFCN - PRAGUE - JUNE 2015 2
• Fact: the quality of dental care is suboptimal (not only) in Belgium. There is not enough money for new techniques and there are many restrictions on reimbursement (implants, endodontics…)
• At the same time we are convinced that some of the money is lost reimbursing non-delivered dental care. Can you help us resolve this longterm frustration?
frustration
EHFCN - PRAGUE - JUNE 2015 3
• No dentists working in our administration• Technicity of the matter: composites and GIC glass
ionomer cement are often radiolucent and not visable for the eye or even on X-rays
• We can not oblige patients to submit to an examination of the mouth by an expert (which would cost us also a lot of many)
• Nevertheless we tried in 2 different ways
I. Restorative Dental Care:repeated billing
EHFCN - PRAGUE - JUNE 2015 4
for interventions on the same tooth
An investigation-conducted by the National Investigation Unit-done by Marc Eisenhuth M.D., Erik Koopmans M.D., Anne-Laure Buisson Stat.-presented by Georges DUSART, M.D.
studied population: 7,176 dentists
EHFCN - PRAGUE - JUNE 2015 5
(2007- 2009)conserving dental care
dental fillings coronal restoration
applied on the same tooth by the samedentist, ambulatoryof insured patients over 15 years oldrepeated billing in 1 year
Scope
‘Waste’ ?
EHFCN - PRAGUE - JUNE 2015 6
investigation: all the Belgian dentists initial period as reference
1 June 2008 – 30 November 2008 ‘first intervention’ semester
observation period: 1 December 2008 – 30 November 2009 check: billing repeated?
definition ‘repetition rate’ (RR): numerator: number of interventions billed in
reference period and repeatedly billed for a same tooth within 1 year later.
denominator: number of all the interventions billed in the reference period.
Waste ?
EHFCN - PRAGUE - JUNE 2015 7
rates in reference period: cfr BARMER median repetition rate:
average repetition rate:
7.4%
8.5% international literatur and Belgian experts no link with factors
social: 88.9% repetitions applied on not socially
protected (without increased refund) cfr BARMEReconomic: the dentist’s global activity
total amount billed for conserving care total amount billed to the health insurance
geographic: negligible differences between provinces
Waste
EHFCN - PRAGUE - JUNE 2015 8
conclusion: repetition rate > 10% is
inacceptable : incorrect billing (dental care not
administered) OR low quality care
(unnecesarryexpensive)
RR < 10% < € 100
1
EHFCN - PRAGUE - JUNE 2015 9RR > 10% > € 100
How did we stay in touch?Campaign by letter
2A
2BRR > 10%
2C
The impact
EHFCN - PRAGUE - JUNE 2015 10
AS A RESULT OF THE FIRST LETTER :
79.6% of all dentists initially > 10% : now < 10% …
impact on budget: € 8.5 mio reductionin conserving dental care (4.7%)
general impact on behaviour
The impact
EHFCN - PRAGUE - JUNE 2015 11
AS A RESULT OF THE SECOND LETTER
(after a new observation period)174 repayment requests for a total amountof € 274 152from € 100 to € 15 444 per dentist (RR>10%)IF NO REIMBURSEMENT: legal administrative procedure for imposed reimbursement (via Committee and Chamber of First Instance)
Lessons learned
data supply by health insurance funds have to be
quick reliable
data mining toolswell thought-out investigationdesigninformationeffective legal instruments to copewith waste
EHFCN - PRAGUE - JUNE 2015 12
II. DURATION OFCARE/DENTIST’S
DIARY
EHFCN - PRAGUE - JUNE 2015 13
Determining a minimum duration for types of care to check the timetable and the maximum amount of reimbursable care by the dentist ?
DURATION OF CARE/DENTIST’S DIARY
EHFCN - PRAGUE - JUNE 2015 14
ACADEMICAL REFERENTS :UCLouvain (UCL) ULBruxelles (ULB) ULiège (ULG) UZLeuven (KUL) VUB Jette
DENTISTS /THE COURTS EXPERTS :Mr P. PietteMme M.Thomas
DURATION OF CARE/DENTIST’S DIARY
Definition:
1S : Restoration of 1 surface cavity
2S : Restoration of 2 surfaces cavity
3S : Restoration of 3 or more surfaces cavity
CU : Restoration of cusp / incisal edge
CR : restoration of crown (total restoration of the tooth)
EHFCN - PRAGUE - JUNE 2015 15
DURATION OF CARE/DENTIST’S DIARY
EHFCN - PRAGUE - JUNE 2015 16
ENDODONTIC TREATMENT :
1R : 1 Root Canal Treatment 2R : 2 Root
Canals Treatment 3R : 3 Root Canals
Treatment 4R : 4 Root Canals Treatment
AS : time-saving with assistant / second chair
DURATION OF CARE/DENTIST’S DIARY
7
EHFCN - PRAGUE - JUNE 2015
1S 2S 3S CU CR AS
EXP 1 30 min 30 45 60 -25%
UCL 30 min 30-45 45-60 45-60 60 -33%
EXP 2 *15-20 min 15-20 15-20 15-20 15-20 -10%
ULB 20-30 min 40 50 50 60 -25%
ULG 15 min 20-30 30-45 45-60 60 -50%
KUL 30 min 37 45 30-60 75-90 -33%
VUB 30 min 37 45 60 90 -20-25%
* +anesthesia If Necessary : 10-15 min1
DURATION OF CARE/DENTIST’S DIARY
EHFCN - PRAGUE - JUNE 2015 18
1R 2R 3R 4R AS
EXP 1 30-45 min 45 60 60 -25%
UCL 60 min 60 90-120 90-120 -33%
EXP 2 30 min 30-45 45 60 -10%
ULB 60 min 80 100 120 -25%
ULG 30-45 60 60-90 60-90 -33+
KUL 60-75 min 75 90-120 150 -33%
VUB 60 min 60-75 90 120 -20-25%
APPLICATION IN A REAL FILERecuperation of € 360 000 over a 2y period Confirmed by an administrative procedure
EHFCN - PRAGUE - JUNE 2015 19
DURATION DEPENDING ON THE DENTIST X
DURATION ACCEPTED BY THE DENTIST X
AVERAGE
IN MIN.
1S 3 min. 6 min 24-25
2S 5 min. 6min 30-32
3S 5 min. 6 min 39-42
CUSP 7 min. 11 min 41-50
CROWN 7 min. 11min 55-60
Under our influence….VALUES « P »
EHFCN - PRAGUE - JUNE 2015
• The technical dental board (mainly composed of representatives of the profession) has elaborated a ceiling system for billing in a fixed periods.
• The coefficient P is the time investment of thedentist for a well determined dental care• P-value reflects the time and complexity of thedental care concerned.• P-value also reflects the cost of the used (diposable)equipment).
20
Under our influence…. VALUES « P »
EHFCN - PRAGUE - JUNE 2015 21
P values will concern only the extreme outliersExceeding the ceiling P200 = non conforming
care,
(Article 73 bis §2 of the health care law).
Value of the reimbursement = financial damage suffered by the compulsory insurance estimated by the assessment and control medical service of the NIHDI.
(Artcle 142 §1 of the health care law).
Frustration
EHFCN - PRAGUE - JUNE 2015 22
- Your experiences ?????- Determing a minimum duration for types of care- Repeating restorative dental care- Other paths to follow when assessing dentalcare?