Saturday, February 27, 2010

Public Dental Services

The Dental Treatment Services Scheme has shown substantial growth in 2009. A staggering 399,262 (34%) more treatments were provided year to date in 2009 than was targeted. At the end of December 2009, the cumulative number of treatments 'above the line' (i.e., routine services, extractions, fillings) was 1.4 million (35% growth) and the number 'below the line' (i.e., specialties like root and gum treatments) was 144,000 (26% growth).

Amazing how resilient dentistry seems to be to the recession.


Of course one must consider that since the beginning of 2009 a lot more people were granted medical cards, due to the dire economic circumstances of the country. This is what the HSE suggested. But the actual increase in the number of people with medical cards over the year was 55,000; which was 4% above target. So by safely assuming these projections are meaningful and represent normal levels of demand in the system, the increase in supply should be attributed to the demand from new card holders; this is the HSE suggestion.

My rough calculations of this appealing hypothesis suggests some bizarre results: every new medical card recipient got about 8 fillings or extractions AND about 3 root canal treatments! Crazy right, but there's more to consider.. these new recipients were mostly the newly unemployed so as PSRI payers they previously had a very generous dental package (now cut) which included two free check-ups and cleanings per year and sizable reductions for most treatments.

To me, unless i'm missing something, the increase is now down to two possibilities: either the quality of existing medical card holders' teeth declined significantly or dentists started to be more sensitive to the dental "needs" of their medical card-holding clients. The former doesn't seem plausible (a 30% decline in dental health in one year!?) yet there is considerable reason to suspect the latter, given the possible fall-off in dentist services from purely private patients (note: general domestic demand for goods and services in Ireland contracted by about 10% in 2009) .

The phenomenon of 'supplier induced demand' (SID) has been empirically validated in many instances and across health professions; it is well documented in the health economics literature. It can also be controlled and managed and, at times like this, it's probably worth considering.

The raw figures are available from the most recent 2009 HSE Healthstats Report.

11 comments:

Peter Carney said...

"My rough calculations...suggests every new medical card recipient got about 8 fillings or extractions AND about 3 root canal treatments"

I looked at this again, it actually more like all new receipts got an average of 7 fillings/extractions, and 60% of them got root canal/gum treatments. In this case the latter amount seems reasonable enough but the former is still bizarre especially, as i said, given that they are most likely to be just coming from the generous PRSI scheme.

Peter Carney said...

"My rough calculations...suggests every new medical card recipient got about 8 fillings or extractions AND about 3 root canal treatments"

I looked at this again, it actually more like all new receipts got an average of 7 fillings/extractions, and 60% of them got root canal/gum treatments. In this case the latter amount seems reasonable enough but the former is still bizarre especially, as i said, given that they are most likely to be just coming from the generous PRSI scheme.

Peter Carney said...

one additional note: Dentists on the PRSI scheme are also reimbursed by the HSE, despite it being run by the department of social and family affairs. This is news to me. In this case it is important to know that this scheme expired at the end of 2009 and there was considerable 'bookings' made by those eligible for the scheme before the end of the year. Not sure if these figures are included in this but I suspect not. Thought I'd flag it in case of confusion.

Also note that the budget for the PDS (i.e., medical card) and the DTBS (i.e., PRSI) is estimated at €60 million and €68 million respectively for 2009.

Kevin Denny said...

Very interesting numbers. Theres certainly something going on. But I am puzzled as to how it might happen. So a guy gets laid off & gets a medical card? But unless this guy then rushes down to the dentist its hard to see how the increased demand would come about. Unless the dentists are hanging around outside the dole offices ("Pssst, need a few fillings, mate?").

Liam Delaney said...

"The DTSS scheme is a demand led scheme and due to the current economic situation, more people are using public dental services."

The quote from the report is above Peter. This doesn't necessarily mean just that demand is increasing because of more people with medical cards. It seems to suggest that some people can choose public or private and would choose private if they had spare cash. Is it possible that eligible participants don't avail of the designated suppliers during the good times?

Liam Delaney said...

For example Peter, is a filling by any other name a filling, so to speak. For example, is it possible that you get a routine runofthemill filling from your publicly funded one, but can pay privately if you want something more fancy, with the result being that people pay for the fancy one when they have money.

Certainly, the research commissioned by the Department of Health has asked about overutilisation though the report makes it difficult to figure out whether some areas are oversupplying or others are undersupplying (see the major report into the scheme below).

http://bit.ly/c7BDZH

Peter Carney said...

I take your point Liam about switching, but I doubt it. The actual number of switchers would be minimal. I not even sure it a real option. The first question a dentist asks is whether you have PRSI or a medical card or .. both. If you're employed or unemployed, recession or no recession, loaded or poor, these schemes click in.

I came across an article Sarah Burke for the Times during the summer.. it goes a lot further. She cities material the strongly suggest some dentists are making fraudulent claims; in some cases giving some a headful of fillings! it's also suggested that simple procedures are claimed for as complicated one.. she bemoans the lack of checks in the system..

I'll take a look at the report you linked; looks comprehensive.

I'd be surprised if this issue doesn't make headlines this week, then again, maybe not. Nobody seems to like the idea that problems in healthcare are micro based.. "it's the system that's wrong!"..

Liam Delaney said...

Peter - at present, you just have a table showing that expenditure on this scheme went up this year and an intuition that it may be supplier induced demand. Don't read too much into this without looking more carefully at the data and the institutions underpinning these results. If the increase is caused by a mechanism as simple as you suggest, then it would be an interesting question to raise in the news, but you would surely have to rule out more routine explanations first.

Peter Carney said...

Liam,

I have looked closely at this and I haven't reached a conclusion.

I've shown that there are many reasons to be unsatisfied with the simple conclusion drawn in the performance report - its insufficient.

In terms of known facts, basic reason and conservative assumptions, I've suggested that the bizarre increases in activity here might have a supply-side determining factor. I'm not claiming to have forensically examined the data and institutions and I don't intend on doing. Indeed, SID is not a criminal matter nor, for that matter, am I a law enforcer. But it is a problem, and it deserves consideration here.

Just to be clear about the concerns you raised:

1) The (DTSS) scheme, which is the one cited in the report and the one you quoted me, is exclusively for medical card holders. In my thinking about this, i'm assuming the possibility that there was a naming error; and that the figures include PRSI patients.

2) Q: "is it possible that eligible participants don't avail of the designated suppliers during the good times?"

Yes, but highly unlikely. There aren't designated suppliers as such. The vast majority of dentist accept both medical card and PRSI patients. Switching is not a feature cause it's not your choice. The dentist will decide how to charge you for the treatments.

I've also considered Private Medical Insurance that includes Dental Cover. There might be a bit of action here if one assumes that people traded-down their PMI and then started using PRSI entitlements. Cover for dental is a small market and already has lots of deductibles and co-payments in place, it isn't reasonable that this explain the heightened activity levels observed. Moreover, the dentist decides how you pay, and the figures in the report only include PRSI by my assumption.

3)"is it possible that you get a routine runofthemill filling from your publicly funded one, but can pay privately if you want something more fancy, with the result being that people pay for the fancy one when they have money"

It is possible, but it doesn't explain anything that might be going on here. Actually, no, If this was happening we would expect increases below the line to be greater than above the line, the opposite is true. Relatively more routine treatments (35%), to non-routine (26%).

Liam Delaney said...

Your last comment is a lot clearer than the one that preceded mine and a lot less likely to cause confusion about how confident you are in what might be going on here.

Peter Carney said...

Between 1990 and 2007, the Consumer Price Index (CPI) increased by 69%, health costs grew by 147% while dental services increased by 171% (CSO).

(HT Enda H.)