Frustration EHFCN - PRAGUE - JUNE 20151 Can you help us improve the control to and the assessment of...

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

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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

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(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’ ?

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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 ?

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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

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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

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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

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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

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II. DURATION OFCARE/DENTIST’S

DIARY

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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

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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)

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DURATION OF CARE/DENTIST’S DIARY

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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

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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

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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).

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Under our influence…. VALUES « P »

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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

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- Your experiences ?????- Determing a minimum duration for types of care- Repeating restorative dental care- Other paths to follow when assessing dentalcare?