sou · GVB319 · 2008-01-01 00:00:00 — The commissions assignment, in accordance with the additional directives given to it by the government in , has been to propose a new dental care support system for adults con- sisting of a high-cost protection scheme and a dental care voucher that can be used for part-payment of subscription dental care or regular preventive visits to the dentist or dental hygienist. Under the high-cost protection scheme, compensation equal to 50 percent of the costs between 000 and 15 000 and 85 percent of the costs in excess of 000 will be payable. The commission may also calculate other levels of support. The dental care voucher shall be worth every other year or longer. One condition is that the introduction of a new dental care support system should not make it more difficult to offer subscription dental care. A review of the regulations governing the recovery of dental care compensation when fixed or removable prosthodontic procedures have to be re- peated shall also be performed. The commission shall propose how the administrative burden of companies can be reduced as a result of the regulations. The proposals shall be financed within the cost framework for the 2008 dental care support system, as specified in the 2007 Budget (just over billion). The government makes the following assessment as regards peo- ple who are currently entitled to increased compensation because of a long-term and much greater dental care need as a result of a long-standing illness or disability. The new high-cost protection scheme, as proposed by the commission, will provide greater pro- tection for many people who need extensive and costly treatment. Dental care costs for those who primarily need regular preventive treatment may increase slightly. It is the governments assessment, however, that the most urgent reform is the provision of reason- able high-cost protection to those who currently dont have any. The government will consider special measures for those who, due to disability or illness, find it difficult to do anything about the condition of their teeth and hence have a major dental care need. This issue is not covered by the ongoing investigation, however, but will instead be dealt with in due course. Based on the original directives given to it by the previous gov- ernment in , the commission has submitted two interim reports. The second interim report presented analyses and submitted proposals in principle for the design of a new dental care support system. These more or less form the basis of the proposals now being submitted. The state dental care support system focuses on providing all adults with financial support for basic dental care. It also offers some support for prosthodontic measures. Compensation will be paid in fixed amounts per measure. For those aged 65 and over, there is a special high-cost protection scheme for prosthodontic measures. Included in the state dental care support system is also special support for people who have a greater dental care need as the result of an illness or disability. Compensation from the state dental care support system is mainly paid as a fixed amount per measure performed. Dental care support is also payable in another form of compensation for what is known as subscription dental care, which is offered by several Swedish county councils. Subscription dental care means that the care provider offers dental care for a predetermined fee. The state compensation is also a fixed amount per patient and year. Dental health has undergone favourable development in since the 1970s. An increasing number of older individuals have more and more of their own teeth left. The explanations for this include successful preventive dental care and the use of fluoride substances. The state dental care financial support system has pro- vided more people with access to dental care at reasonable prices. The major improvement in dental health is mostly attributed to the 1980s. The present rate of improvement is not as evident and there are signs of it subsiding. The Swedish adult population can be roughly divided up into different generations based on their dental health. The 20–39 age group is dominated by individuals who mostly have all their own teeth left, few fillings and relatively good periodontal conditions. This generation has grown up with access to different fluoride sub- stances (The fluoride generation). In comparison, the 40–59 age group has on average less teeth, a greater number of fillings, more crown and prosthodontics and root canal work and slightly worse periodontal conditions (The fillings generation). This is even more evident in the 60+ age group, in which the vast majority of both conventional and jawbone-anchored prosthodontics (im- plants) can be found (The prosthodontic generation). Many in- dividuals in the oldest age groups lack either all or most of their teeth and have removable prosthodontic replacements. As dental health improves, the need for dental care increases. This is sometimes referred to as the dental care paradox. The greater the number of own teeth in ones mouth, the greater the need for repair and maintenance. At the same time, dental health improvement also leads to a change in the nature of the increased dental care need and places clear emphasis on preventive measures. The frequency of visits to the dentist has increased in a long-term perspective but decreased in recent years. The frequency of visits has dropped by five percent since 1999. There is a major discrep- ancy between the 16–19 age group, who are entitled to free child and adolescent dental care, and the 20–24 age group, who are not. This difference has increased over time. Around 85 percent of the adult population visit the dentists at least every second year. The frequency of visits is lowest in the 20– 29 age group and among the over-75s. Basic dental care is responsible for the vast majority of all dental care administered, measured in terms of the number of measures performed. Between 2000 and 2005, there has been a shift in dental care consumption, from basic care to prosthodontics. This change can be exclusively explained by an increase in prosthodontic treat- ment and is not due to a reduction in the amount of basic dental care being administered. The commission sees a clear connection between the trend in dental care consumption and how the dental care support system is designed. The introduction of the high-cost protection scheme for people aged 65 and over for prosthodontics has led to a substantial increase in dental care consumption for this patient group, whilst consumption for patients in the 60–64 age group has decreased. Patients who are 60–probably wait until they are before having prosthodontic treatment. Prices charged by dental care providers rose dramatically after free pricing was introduced in 1999. The rate of price increase has fallen in recent years, however. In the commissions opinion, it is difficult to determine with any certainty the causes of the dramatic increase in prices between 1998 and 2005. The commission believes, how- ever, that most of the increase can be explained not only by the fact that the costs of producing dental care have risen but also because the previously regulated prices were too low. The fact that most of the rise in price can be explained by higher costs and a stifled need for price increases means that the price trend cannot ostensibly be seen as a pretext for greater regulation. The dental care market does not function perfectly, but there are few markets that do. As described above, it is difficult to make a market efficient simply by regulating it. Regulation is a substitute for effective competition. The aim should therefore be to stimulate a natural development in the way the market works. The commission has not been able to find any structural expla- nation for the differences in price increase for different treatment measures. It is likely, in the commissions view, that the price of different treatment measures has been adapted to the costs of per- forming them. There has been considerable variation in the rate of price in- crease among different county councils between 1998 and 2006. The commission believes that this variation cannot solely be ex- plained by differences in costs during this period, i.e. that the in- crease in costs has not been the same for the county councils. It is also likely that there were already differences in productivity and price levels in 1999 due to structural differences that only became apparent after prices were deregulated. The dental care market The dental care market by no means functions perfectly. There are significant market shortcomings as a result of market power and unevenly distributed information. A dental care reform would lead to the state increasing its share of total dental care funding still further. Both these factors advocate public regulation aimed at im- proving the way the dental care market works and allowing the public sector to monitor the market more closely. All regulation risks creating more problems than it solves, e.g. inhibiting a natural development of the market. A balance between different aspects must therefore be struck in order to create an effective regulatory framework. and aware patients have the potential to increase market efficiency. Surveys show that dental care patients are not enough and lack information as to the market conditions. Measures therefore need to be taken to improve patients knowl- edge of the dental care market. Having a minority of patients who are may suffice, provided their mobility puts enough pres- sure on care providers. It is very difficult to say much about the conditions as regards competition between the private and public sectors on the dental care market. The commission feels however that the requirement for county councils to disclose their public dental care services separately should be strengthened. Transparency must increase to clarify whether the public dental care services are being subsidised or not. Models of dental care compensation There are two basic forms of dental care compensation: compensa- tion per patient (capitation) and compensation per treatment measure (unit price). There are pros and cons of both systems. Capitation compensation can create problems relating to adverse selection, patient selection and undertreatment. On the other hand, there are no financial incentives for care providers to overtreat patients in such a system. Furthermore, a capitation system will make dental care costs predictable for both the patient and the state. A unit price system is cost-driven both regarding price and vol- ume. Care providers are given financial incentives to increase pro- duction, heightening the risk of overtreatment. On the other hand, unit price compensation mostly solves the problems of adverse selection samples, patient selection and undertreatment. The 65+ reform illustrates the problems that can be created with a unit price compensation system. Guarantees, both spoken and written, are most common when it comes to prosthodontic treatment, for which almost all care pro- viders provide a guarantee for the treatment measure performed. The length of the guarantee corresponds to the period during which the does not pay any com- pensation for repeat procedures, i.e. one year for removable prost- hodontics and two years for fixed prosthodontics. Care provider guarantees do not always cover repeat procedures performed by another care provider. This may lead to a certain amount of insecurity for the patient since the issue of the cost of a repeat procedure by another care provider is partly unregulated. Under the agreement between private dentists and the , however, the patient is refunded for repeat procedures by a different care provider as far as prosthodontic treatment is concerned. From a consumer and patient perspective, it is vital that there are enough guarantees. Even if the Act is not ap- plicable to dental care services, the commission still feels that the basic starting-point should be that the regulations relating to dental care guarantees should not differ significantly from the regulations governing guarantees for other services. In the commissions opinion, therefore, compulsory dental care guarantees should not be regulated by law but should instead be a matter between the care provider and the patient. The essence of the Act should however apply in the area of dental care and patients shall naturally have the chance to complain about a service with which they are dissatisfied. The issue of guarantees on the dental care market should be closely monitored, however, and the neces- sary measures taken should patient security not be upheld to a suf- ficient extent. Fixed price dental care An insurance-based solution as part of the state dental care support system, known as fixed price dental care, should be a general system adapted for and applicable by both private and public care providers in a way that is competition-neutral. The system needs to cover nationally defined and homogenous risk groups in order to create the right conditions for agreement portability and market mobility. The commission concludes that the current subscription dental care system does not fulfil the requirements that must be put on a general dental care insurance model. The short-term scope for de- veloping todays subscription dental care into such a system seems relatively limited. There should be more scope in the longer term to develop insurance solutions, however. The commission points to four fundamental issues that need to be solved in order for fixed- price dental care to become the dominant system on the market. These issues concern what is to be insured; who is to be the insur- ance provider; whether insurance is to be compulsory or voluntary; and the issue of standardised or differentiated premiums. When these issues are completely solved, bearing in mind the need for competition neutrality, the commission sees scope for developing a national system that offers dental care at a fixed price for all pa- tients and for which state support can be made available. Even if todays subscription dental care does not fulfil the re- quirements placed by the commission on a fixed-price dental care system, it has a number of important benefits that further the aim of creating a health-preserving and health-promoting profile for dental care. Entering into a subscription agreement means that pa- tients divide their dental care costs over a period of time and are tied to a specific care provider, two factors that can help a number of groups to establish regular contact with their dentist. The com- mission feels therefore that subscription dental care should be given the chance to develop and be offered by both private and public care providers in a competition-neutral way. The way the state dental care support system is currently designed does not provide any real high-cost protection for patients aged 20–64 years. Support is currently given in relatively small amounts to a large number of patients, making dental care only slightly more financially accessible. There is high-cost protection for prosthodontic treatment for patients who are 65 and over and this is analysed in more detail below. In the commissions opinion, state control of dental care is both weak and divided. The availability of national statistics on dental health, dental care costs and dental care consumption is very limited, making monitoring and evaluation more difficult. Knowledge management within dental care is rela- tively poorly developed. The overarching aim specified in the Act for good dental health and dental care on equal terms for the entire population is fundamental to the new dental care support system. In addition, the commission feels that a new dental care support system shall: comprise a simple and coherent model, have a health-promoting focus, allow both the state and the patient to easily predict the costs and benefit the patient. Considerably more state resources will be set aside for dental care in connection with the proposed new dental care support system. To be able to control which types of dental care will have access to the support, the commission feels that a regulatory framework should define the type of care that is sufficiently prioritised and cost-effective to qualify for state dental care compensation. The reasons for applying restrictions to the compensation system are therefore purely economic. In a situation with considerably strengthened yet still limited dental care resources, and with a compensation model that is basically cost-driven, it is essential to have a regulatory framework that specifies the scope and the limits of the states undertaking. Current and future dental care offers evermore advanced and costly forms of therapy. increasing demands from the patient for a very good aesthetical outcome, this underlines the need for a clear prioritisation of state resources. The commission feels that reimbursable care shall refer to ad- ministered treatment that is based on a diagnosis or adequate risk assessment and a treatment plan. Based on a diagnosis made by the care provider or a predefined condition, certain measures shall qualify for dental care support. On the other hand, repeat proce- dures, such as fillings or prosthodontics, performed for purely aesthetical reasons shall not qualify for compensation under the dental care support system. The regulations defining the type of dental care that qualifies for compensation should stress the fact that the care focuses on pre- ventive measures, on freedom from pain and disease, the ability to chew and speak unhindered and an appearance without obvious, disturbing features. The commission submits a proposal for definitions of some types of reimbursable dental care procedures. This proposal should serve as a starting-point for further development of the regulatory framework. The proposal divides reimbursable dental care into five areas: 1.Check-ups, examinations and diagnostics 3.Disease treatment and pain relief 5.Rehabilitating and habilitating care The commission is of the opinion that the distinction between ba- sic dental care and prosthodontics in the current ordinance on dental care charges should be abolished, since it no longer reflects any prioritisation or anything meaningful from a dental care point of view. There shall be one or more reimbursable treatment measures for each diagnosis. If the care provider performs a different measure based on the diagnosis, e.g. using a different type of material or therapy, only the value of the reference price of the reimbursable measure in accordance with the dental care support system will be payable. If several different measures qualify for compensation, the measure with the lowest reference price should form the basis of the compensation. The government places no restrictions on more expensive treatment being implemented, but limits state funding to a certain, predetermined standard. It is proposed that the value of the dental care voucher be every other year to patients aged 30–74 years and every other year to patients in the 20–29 and 75+ age groups. The patient can choose to use the voucher once a year, to a value of and respectively, or once every second year, to a value of and respectively. The voucher can be used as part-payment for a dental care visit to any dentist or dental hygienist, or as part-payment for subscrip- tion dental care. It is proposed that the voucher take the form of a credit balance at the and not an actual document of value. It is proposed that the system be administrated via the IT- based system for the new dental care support, which the Social In- surance Administration is developing at the request of the govern- ment. It shall be possible to continue to develop the special dental care model, known as subscription dental care, within the new dental care support system. To this end, it shall be possible to use the proposed dental care voucher as part-payment for subscription dental care. The voucher will therefore replace the current basic amount for subscription dental care. The proposed value of the voucher will mean a slight reduction in state compensation to sub- scription dental care for patients in the 30–74 age group, but a con- siderable improvement for patients in the 20–29 and 75+ age groups. In the second alternative high-cost protection scheme, there is scope for increasing the value of the voucher, which would strengthen subscription dental care compensation still further. It is proposed that regulation of subscription dental care be in principle the same in the new dental care support system as in the current one. The commission submits proposals on a number of points, however, aimed at improving the monitoring and evaluation of subscription dental care, and leading to better control of dis- bursed compensation. The commission proposes in its main alternative that the high-cost protection scheme shall provide compensation equal to 50 percent of the costs between 000 and 000 and 85 percent of the costs over 000. The commission has also calculated the costs of a second alternative in which the higher cost limit is 000. The calculation of dental care compensation as part of the high- cost protection scheme is based on the proposed reference prices, not the actual costs incurred by the patient. The calculation does not include that part of the cost paid for using the dental care voucher and not the patients fee for any subscription agreement entered into. The high-cost protection is valid for a compensation period of one year. The compensation period starts from the date a reim- bursable treatment measure is finalised. At the request of the pa- tient, the care provider can register the start of a new compensation period before the previous period has expired. The 65+ age group The commission feels that patients who are 65 or over should be completely covered by the new state dental care support system. This means that the current high-cost protection scheme for prosthodontic treatment for this age group will be replaced by the proposed high-cost protection scheme. The costs of the current high-cost protection scheme have spiralled out of control and led to a great deal of time-consuming administration. Its construction has a number of shortcomings, primarily regarding the following: The current high-cost protection scheme for older people does not offer them any real high-cost protection, since their actual costs have exceeded 700, the amount decided on when the scheme was first introduced. The way the scheme is constructed has led to this 700 being the lowest threshold, a base amount to which further costs have been added, primarily in the form of Furthermore, the fact that the current scheme only covers prosthodontic treatment has led to important basic dental care being neglected for financial reasons. The patient has a finan- cial incentive to undergo prosthodontic treatment ahead of basic dental care, which is contrary to the self-explanatory approach that it is normally better to preserve genuine parts rather than replace them with spare parts. Finally, the way the current scheme is con- structed has also led to threshold effects, i.e. patients aged 60–64 have been delaying their visit to the dentists until they are covered by the high-cost protection scheme. This has led to care not being administered when the need arises, but instead at a later date. There is therefore a risk of an accumulation of care needs, leading to poorer welfare for the individual and socioeconomic inefficiency. Including the 65+ age group in the new dental care support system solves this incentive problem. The financial consequences mean that the support to this age group will basically remain un- changed.