The blanket agreement for implementing “zero co-pay” for dentures seems to have delighted the French Dental Association1 – something that rarely happens! This is because the negotiations on curbing charges for dentures have also been coupled with a hike in charges for routine treatments, something the dental profession has been hoping for and demanding for years. The compromise achieved is likely to have a much greater effect on dental health in France than on balancing the healthcare budget.
Sights are firmly set on curbing reluctance to seek treatment and boosting prevention
A survey conducted in 2016 by the first-tier healthcare system2 among nearly 29,000 people revealed that 39% of insureds had already given up having dentures fitted, in a majority of cases, for financial reasons.
It is easy to understand why, considering that the average co-pay falling on households for denture work amounts to 40 %3. With the average price for a porcelain and metal crown of €540 the patient’s co-pay is currently €216. For bridges these figures can be three times higher.
Even though dentures only represent 12 %4 of treatments carried out by dentists, they represent two thirds of their income and the co-pay falling on insureds. This is because routine treatments are subject to controlled pricing whereas the pricing of dentures is free, something which Nicolas Revel, general manager of CNAM says brings about a certain degree of off-setting between the two types of treatment.
This is why creating a “100% healthcare” basket of covers for all denture needs must inevitably bring about a hike in prices for routine treatments. Price increases will be more than just homoeopathy. For example, root canal treatment on a molar will increase from €82 to €110. The aim is not just to satisfy dentists while negotiating the 2019/2023 National Agreement but to reorient treatment towards prevention by improving reimbursement of routine treatments. With this in mind, dental check-ups for young people between 3 and 24 will be fully reimbursed. New effective treatments, such as applying fluoride varnish to children’s teeth where there is a risk of tooth decay, will also be reimbursed.
3 treatment levels and 3-stage implementation
In order to keep the promise of “zero co-pay” for dentures, the reform envisages creating three treatment levels. The “100% healthcare” basket of fully reimbursed treatments will cover 46% of denture treatment routines (as observed in 2017). Porcelain crowns will be available for teeth that are visible (incisors, canines and first premolars) but patients will have to make do with metal crowns for the other teeth. On average, the introduction of “zero co-pay” will save patients from €100 to €200 per crown! The reform also creates a basket of treatments with curbed pricing corresponding to 25% of treatments. Porcelain/metal crowns for second premolars would come within this category. Patients would have to dip into their pockets for such treatment but would have affordability guaranteed since pricing would be capped at €550. Finally, 29% of treatments, where more sophisticated techniques or materials are used, will still be offered at prices fixed freely.
There will be three milestone dates for the introduction of “zero co-pay”. 1 April 2019 will see the application of initial capping of prices for crowns. “Zero co-pay” will then come into effect from 1 January 2020 for crowns and bridges, with new price caps. In the end, removable resin dentures will come into the “100% healthcare” basket as from 1 January 2021.
Does the impact on public health measure up to the financial effort?
The cost of these measures has been estimated at €1.2bn over 5 years with nearly €700m falling on the first-tier health insurance system and €500m on complementary (second-tier) insurers. There is a real fear that premiums will rise. In the short term, if the reluctance to seek treatment is as widespread as the studies suggest then the catch-up effect could generate huge extra costs. Over the longer term however, the agreement signed with the dental profession ensures some control over pricing. But above all, the agreement brings the hope of reducing overall expenditure by putting the accent on prevention and treatments aimed at keeping teeth rather than having to fit dentures. Today, only 43%5 of people in France visit the dentist at least once a year whereas in Denmark the figure is 85% and in Germany 71%. The reform envisaged should increase this figure by eliminating the cost factor that keeps people in France from going to the dentist. The financial balance of the reform is therefore based on a daring gamble as per the proverb: “Prevention is better than cure”.
1 Syndicat des chirurgiens dentistes
2 Assurance maladie / Sécurité sociale / CNAM
3 Source : first tier health insurance scheme
5 Council of European Chief Dental Officers, CECDO data sheet 2014