sick to the teeth...

You may recall a blog post a few months back on dental services in Ireland. Essentially, I pointed out that a staggering 399,262 more treatments were provided by dentists to medical card patients in Ireland during 2009. That was a full 34% more treatments carried out than was projected by the HSE based on year-on-year trends since the scheme's inception in 1994. It is true that there were more medical card holders in 2009, but only 4% more. I strongly suggested that it is completely infeasible for this extra 4% of people to have induced 34% more demand in the system and that the alternative possibility -- a 30% decline in dental health in one year -- is equally ludicrous. The figures are strongly suggestive of the phenomena of supplier induced demand. The phenomena is well documented in the international health economics literature and often arises with "free" schemes essentially because 'the supplier of the service is also the demander' (..due to the inherent information asymmetry in the health care environment that requires a trust relationship between the health professional and their patient).

The HSE, faced with these 'inexplicable' increases and substantial narrowing of their overall budget during 2010, decided to cap the amount payable for the scheme to the pre-2009 level; the amount paid before the incredible 34% increase in dental services. The immediate response of the Irish Dental Assoc. was to claim that their members would now only be able to offer emergency services and oral examinations. I have heard no update on this position since.

So what is new??

In June, two dentists brought a case to the High Court to seek an injunction against the HSE implementing the spending cap. The claimed that the measures were a breach of contract, and would have "disastrous consequences" for them as dentists and "a dramatic effect on public health". The were successful, and won an injunction against the HSE preventing them from implementing the spending cap.

The CEO of the Irish Dental Assoc. welcomed the decision saying that he had "huge concerns for the dental health of the country". He described the HSE's move as "unsafe, unworkable, and unethical" and further went on to say that "it would hit the most vulnerable in our society hardest". The HSE subsequently appealed to the Supreme Court against the High Court injunction, but a 'stay' was placed on the High Court's injunction. So, from what I can decipher, a full hearing will now go ahead later this year (most likely early October)

The story looks like it will continue for some time. I can't help but wonder, however, if the case for supplier induced demand might be worth a hearing? I've heard nothing about it so far (apart from comments here) and I certainly think it is an issue worth considering in this case. At the very least, the Irish Dental Assoc. could be asked to explain the 34% increase in their services during 2009.

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.