- Email: [email protected]
Germany’s dental health care system
Dental care and service delivery are accomplished using a team approach; dentists are freed to focus on more complex procedures and treatment planning; and more emphasis can be given to prevention and oral health promotion. Dental hygienists and therapists can facilitate community-based oral health programs. However, caries prevalence may not be greatly improved among Indigenous groups even with water fluoridation, topical fluoride use, and oral health education. Often these approaches do not create a sustainable change in oral health literacy and behavior because of the strength of the underlying social and cultural disadvantages. Inequities may require attention before long-lasting changes can be accomplished. Incorporating traditional practice and primary health care into oral health care builds on the traditional medical and dental practices, which are widely used, easily accessed, socially and culturally acceptable, and usually part of the area’s cultural heritage. When traditional practice is integrated into primary health care, the result may be a combination of traditional healers and oral health care providers working together. Traditional methods often have been investigated and explained scientifically. Traditional practitioners may be valuable resources when attempting to understand what is culturally appropriate and how the community needs can be met. Fluoride and other acute care procedures can be readily incorporated in many situations. Often traditional healers also retain an aura of authority in the community and provide counseling and support community customs. Medical and dental practitioners should recognize and respect the value of traditional approaches. However, potentially harmful traditional practices require evaluation before use. If the practitioner does not consult with community leaders and plan interventions accordingly, lack of cultural understanding and trust, along with compromised communication with Indigenous communities, can sink even the best intentions. Key elements for success in combined interventions include the following:
Targeting patients at different points in the lifespan
Distributing oral health educational material to caregivers and expectant mothers Using Indigenous health workers in oral health promotion efforts Presenting materials bilingually Integrating oral health promotion into existing programs Advertising in local media
Discussion.—The literature has documented several oral health interventions and initiatives for use with Indigenous populations. Most face significant disparities in oral health delivery and face difficulties in access to care and access to culturally appropriate, community-focused care. Risk conditions such as poverty, unemployment, inadequate housing, and poor education underlie these inequities in health care. Dental outreach programs, the integration of dental services with primary health care delivery, the incorporation of traditional approaches with primary and oral health care, and the extension of the dental team through OHPs offer ways to provide dental care for underserved Indigenous communities.
Clinical Significance.—Indigenous peoples present unique attributes that require a tailored approach to delivering oral health care. Further research is needed, but programs should be geared to serve the family and community, resolve multidisciplinary issues, and address the significant disparities in oral health that currently exist in Indigenous populations.
Patel J, Hearn L, Gibson B, et al: International approaches to Indigenous dental care: What can we learn? Austral Dent J 59:439-445, 2014 Reprints available from L Slack-Smith, School of Dentistry M512, The Univ of Western Australia, 35 Stirling Hwy, Crawley WA 6009; e-mail: [email protected]
Germany’s dental health care system Background.—European Union (EU) member states cooperate in many areas, including the harmonization of health care systems. However, the organization of health care and provision of oral health care are determined by each member state. Sometimes surprising variations exist between countries. Germany is considered to have high health
248
Dental Abstracts
care expenditures, which has led to several recent reforms. A review of the provision of oral health care in Germany, the largest system in the EU, offers information on the insurance and payment systems, cost reimbursement issues, preventive and oral health promotion efforts, the oral health care workforce, epidemiology, and recent and upcoming changes.
Insurance and Payment Systems.—Health insurance can be statutory or private, with the Gesetzliche Krankenversicherung (SHI) system occupying a central position. SHI requires membership in a state-approved ‘‘sick fund,’’ to which 86% of the German population belong. The fund reimburses legally prescribed standard packages of health care that include oral health care. The SHI is organized regionally, and all the funds provide similar benefits, which are provided on a contractual basis. Regional associations of SHI dentists provide legally defined dental services and ensure that these services meet all the legal and contractual requirements. About 80% of German adults and 60% to 70% of children use dental services annually. Practice-based dentists and other health professionals are paid according to a fee scale, with two fee schedules for each profession— one for SHI services and one for private providers. Both guarantee patients free access to a wide range of basic health care services. Membership in a sickness fund entitles the spouses and children of the insured to use its services. Contributions to the SHI from insured persons and their employers are fixed at a national level and applied uniformly to the separate public sick funds. In addition, the government subsidizes the health fund. Legislative action is the only way to influence costs, but sick funds are responsible for cost containment. Private health care funds provide a complete health service for those who opt out of the SHI or add to coverage for those who remain in it. About 11% of the working population has private insurance. Premiums are lower and packages are more flexible in the private plans, but coverage only extends to the individual insured person and does not cover the spouse or children. A few dentists (about 450 of the estimated 69,236 dentists in Germany) are employed by the Public Dental Service (PDS), which operates in some states to conduct oral health screenings for children and group prevention activities. Parents are told about the needed treatments, then they arrange for treatment. Public services also cover dental care in hospitals, universities, and the Armed Forces. Federal states that offer few or no publicly funded oral health screenings use private practitioners to provide most oral health care. Reimbursement.—SHI covers 100% of the costs for clinical and radiographic examinations, diagnoses, fillings, oral surgery, preventive treatments for children, periodontology, and endodontics. Light-cured composites are reimbursed at the rate of an amalgam filling, with the patient covering the additional charge. SHI funds pay 80% of orthodontic care for children if the treatment is covered by the
fund. If the treatment is not covered, the parents must pay for the costs or obtain a private insurance policy. Prevention and Health Promotion.—In addition to PDS group prevention efforts, private dentists developed a preventive program for local kindergartens and schools. In addition, regional dental chambers have founded regional and national councils to promote oral health for children and adolescents. At the federal level, the Regional Working Groups for Children’s Dentistry and Dental Hygiene are responsible for implementing group prevention activities. Oral Healthcare Providers.—Auxiliary personnel are not allowed to work outside of a dentist’s supervision. The types of auxiliary personnel who work in dentistry include dental chairside assistants (dental nurses), dental hygienists, and dental technicians. To be a chairside assistant requires 3 years of training in a practice, attendance at a vocational school, and successfully passing an examination conducted by the regional dental chamber. This person may then complete further training to become a specialized chairside assistant, a dental administration assistant, a dental prophylaxis assistant, or a dental hygienist. About 182,000 dental nurses, over 15,000 specialized dental chairside assistants, and just over 600 dental hygienists are practicing in Germany. Germany also has a high number (58,000) of dental technicians. These individuals are not allowed to treat patients but must complete 3 years of vocational education and dental laboratory training as well as perform well on an examination conducted by the Chamber of Handicraft. Dentists receive their training at 31 publicly funded dental schools and one private dental school. To enter the dental university, students must pass the general qualifications for entrance to the university and pass the Medical Courses Qualifying test. Undergraduate studies require 5 years and include a state examination certificate, which is required for registration as a dentist in a regional dental chamber. To work in the SHI system, the dentist with a German diploma must complete 2 more years of supervised practice in the system, then apply for admission. A dentist with a diploma from the European Economic Area (EEA diploma) does not have to have the additional vocational training. Continuing professional education (CPD) is mandatory, with a minimum requirement over a 5-year cycle of 125 credit points (1 hour of CPD equals 1 credit point). Every 5 years monitoring is done. Dentists must also complete training in ionizing radiation protection every 5 years. Dentists can complete postgraduate Master studies through mostly part-time courses offered at universities. These provide enhanced skills but do not confer the title of specialist. The six dental specialties that are recognized
Volume 60
Issue 5
2015
249
in most areas of Germany are oral surgery, orthodontics, dental public health, periodontology, general dentistry, and pediatric dentistry. Training to be a specialist lasts 4 years and is accomplished in university clinics and recognized training practices, except for dental public health training, which is accomplished in the workplace and at an academy. After training, the specialist must pass an examination conducted by the regional dental chamber. Epidemiology.—National epidemiological studies are conducted every 10 years. They indicate caries prevalence in children and young adults has diminished markedly since the early 1980s. Mean national decayed-missing-filled-teeth (DMFT) was 0.7 for 12-year-olds, 1.8 for 15-year-olds, 14.5 for adults age 35 to 44 years, and 22.1 for 65- to 74-yearolds in 2005. One percent of the adults and 22.4% of those age 65 to 74 years are edentulous, with the older adults having received prosthetic treatment. Fixed prosthetics have been used to replace 49% of the missing teeth in adults, and removable partial dentures have been used for 89% of those in adults over age 65 years. Deep pockets exist in 0.8% of adolescents, 20.5% of adults, and 39.8% of those over age 65 years. Advanced periodontal breakdown is most common among smokers with low basic educational levels. Changes.—Reforms have been introduced or are contemplated to (1) improve oral health care for persons needing nursing care, (2) change the electronic health insurance card into an electronic health card that permits electronic data transmission, (3) perform internal and external quality management in dental practices, and (4)
provide online evaluation programs for potential patients. Patients’ rights efforts include clarifying what is required in all patient records, including a liability clause, information on the specific procedures to be followed when treatment fails, and information on patient participation in treatment measures and specific rights of the patient. Registry of critical incidents has also been proposed to prevent errors and provide an effective quality assurance process for inpatient and outpatient care.
Clinical Significance.—Evaluators foresee that demographic changes, medicotechnologic progress, and decreasing SHI revenue will increase the cost of health care in Germany. To maintain the high care standard currently in place will require linking medical and dental fees to the quality of the services. Patient outof-pocket expenses will likely rise through higher insurance premiums, taxes, additional contributions, or flat rates of payment.
€m E: The healthcare system and the proZiller S, Eaton KE, Widstro vision of oral healthcare in European Union member states. Part 1: Germany. Br Dent J 218:239-244, 2015 Reprints available from S Ziller, Dept of Prevention and Health Promotion (German Dental Association, BZAEK), Chausseestrasse 13, D-10115 Berlin, Germany; e-mail: [email protected]
Managed Care Practice models Background.—Dental school graduates find themselves with a mountain of debt, which makes purchasing a practice seem overwhelming. Older dentists are retiring, with too few new dentists to replace them. Preferred provider organizations (PPOs) press for profitability in dental practices, yet consumers are spending less on dental care and the trend is expected to continue. More doctors are working in group practices, and the same thing could easily occur in the field of dentistry. Changes are coming and dentists will have to navigate them while juggling all of the demands of providing excellent patient care. Options for Practice Types.—A management services organization (MSO) usually operates in return for 10% of the gross production. Dentists interested in the MSO type
250
Dental Abstracts
should look for referrals and read all the fine print to be sure they know what they’re getting into. Group dental practices may be owned and operated by dentists, by MSOs, by dental support organizations (DSOs), or by dental management organizations (DMOs). Generally non-dentist owners take on nonclinical tasks such as personnel management, purchasing, office space, patient flow, marketing, practice analytics, and insurance and leave the dentist-employees to conduct clinical care activities only. Models for Private Practice.—The three main paths to choose from if you want to remain in private practice are the traditional model, the outsourcing model, and the selling model. In the traditional model the dentist is responsible
Targeting patients at different points in the lifespan
Distributing oral health educational material to caregivers and expectant mothers Using Indigenous health workers in oral health promotion efforts Presenting materials bilingually Integrating oral health promotion into existing programs Advertising in local media
Discussion.—The literature has documented several oral health interventions and initiatives for use with Indigenous populations. Most face significant disparities in oral health delivery and face difficulties in access to care and access to culturally appropriate, community-focused care. Risk conditions such as poverty, unemployment, inadequate housing, and poor education underlie these inequities in health care. Dental outreach programs, the integration of dental services with primary health care delivery, the incorporation of traditional approaches with primary and oral health care, and the extension of the dental team through OHPs offer ways to provide dental care for underserved Indigenous communities.
Clinical Significance.—Indigenous peoples present unique attributes that require a tailored approach to delivering oral health care. Further research is needed, but programs should be geared to serve the family and community, resolve multidisciplinary issues, and address the significant disparities in oral health that currently exist in Indigenous populations.
Patel J, Hearn L, Gibson B, et al: International approaches to Indigenous dental care: What can we learn? Austral Dent J 59:439-445, 2014 Reprints available from L Slack-Smith, School of Dentistry M512, The Univ of Western Australia, 35 Stirling Hwy, Crawley WA 6009; e-mail: [email protected]
Germany’s dental health care system Background.—European Union (EU) member states cooperate in many areas, including the harmonization of health care systems. However, the organization of health care and provision of oral health care are determined by each member state. Sometimes surprising variations exist between countries. Germany is considered to have high health
248
Dental Abstracts
care expenditures, which has led to several recent reforms. A review of the provision of oral health care in Germany, the largest system in the EU, offers information on the insurance and payment systems, cost reimbursement issues, preventive and oral health promotion efforts, the oral health care workforce, epidemiology, and recent and upcoming changes.
Insurance and Payment Systems.—Health insurance can be statutory or private, with the Gesetzliche Krankenversicherung (SHI) system occupying a central position. SHI requires membership in a state-approved ‘‘sick fund,’’ to which 86% of the German population belong. The fund reimburses legally prescribed standard packages of health care that include oral health care. The SHI is organized regionally, and all the funds provide similar benefits, which are provided on a contractual basis. Regional associations of SHI dentists provide legally defined dental services and ensure that these services meet all the legal and contractual requirements. About 80% of German adults and 60% to 70% of children use dental services annually. Practice-based dentists and other health professionals are paid according to a fee scale, with two fee schedules for each profession— one for SHI services and one for private providers. Both guarantee patients free access to a wide range of basic health care services. Membership in a sickness fund entitles the spouses and children of the insured to use its services. Contributions to the SHI from insured persons and their employers are fixed at a national level and applied uniformly to the separate public sick funds. In addition, the government subsidizes the health fund. Legislative action is the only way to influence costs, but sick funds are responsible for cost containment. Private health care funds provide a complete health service for those who opt out of the SHI or add to coverage for those who remain in it. About 11% of the working population has private insurance. Premiums are lower and packages are more flexible in the private plans, but coverage only extends to the individual insured person and does not cover the spouse or children. A few dentists (about 450 of the estimated 69,236 dentists in Germany) are employed by the Public Dental Service (PDS), which operates in some states to conduct oral health screenings for children and group prevention activities. Parents are told about the needed treatments, then they arrange for treatment. Public services also cover dental care in hospitals, universities, and the Armed Forces. Federal states that offer few or no publicly funded oral health screenings use private practitioners to provide most oral health care. Reimbursement.—SHI covers 100% of the costs for clinical and radiographic examinations, diagnoses, fillings, oral surgery, preventive treatments for children, periodontology, and endodontics. Light-cured composites are reimbursed at the rate of an amalgam filling, with the patient covering the additional charge. SHI funds pay 80% of orthodontic care for children if the treatment is covered by the
fund. If the treatment is not covered, the parents must pay for the costs or obtain a private insurance policy. Prevention and Health Promotion.—In addition to PDS group prevention efforts, private dentists developed a preventive program for local kindergartens and schools. In addition, regional dental chambers have founded regional and national councils to promote oral health for children and adolescents. At the federal level, the Regional Working Groups for Children’s Dentistry and Dental Hygiene are responsible for implementing group prevention activities. Oral Healthcare Providers.—Auxiliary personnel are not allowed to work outside of a dentist’s supervision. The types of auxiliary personnel who work in dentistry include dental chairside assistants (dental nurses), dental hygienists, and dental technicians. To be a chairside assistant requires 3 years of training in a practice, attendance at a vocational school, and successfully passing an examination conducted by the regional dental chamber. This person may then complete further training to become a specialized chairside assistant, a dental administration assistant, a dental prophylaxis assistant, or a dental hygienist. About 182,000 dental nurses, over 15,000 specialized dental chairside assistants, and just over 600 dental hygienists are practicing in Germany. Germany also has a high number (58,000) of dental technicians. These individuals are not allowed to treat patients but must complete 3 years of vocational education and dental laboratory training as well as perform well on an examination conducted by the Chamber of Handicraft. Dentists receive their training at 31 publicly funded dental schools and one private dental school. To enter the dental university, students must pass the general qualifications for entrance to the university and pass the Medical Courses Qualifying test. Undergraduate studies require 5 years and include a state examination certificate, which is required for registration as a dentist in a regional dental chamber. To work in the SHI system, the dentist with a German diploma must complete 2 more years of supervised practice in the system, then apply for admission. A dentist with a diploma from the European Economic Area (EEA diploma) does not have to have the additional vocational training. Continuing professional education (CPD) is mandatory, with a minimum requirement over a 5-year cycle of 125 credit points (1 hour of CPD equals 1 credit point). Every 5 years monitoring is done. Dentists must also complete training in ionizing radiation protection every 5 years. Dentists can complete postgraduate Master studies through mostly part-time courses offered at universities. These provide enhanced skills but do not confer the title of specialist. The six dental specialties that are recognized
Volume 60
Issue 5
2015
249
in most areas of Germany are oral surgery, orthodontics, dental public health, periodontology, general dentistry, and pediatric dentistry. Training to be a specialist lasts 4 years and is accomplished in university clinics and recognized training practices, except for dental public health training, which is accomplished in the workplace and at an academy. After training, the specialist must pass an examination conducted by the regional dental chamber. Epidemiology.—National epidemiological studies are conducted every 10 years. They indicate caries prevalence in children and young adults has diminished markedly since the early 1980s. Mean national decayed-missing-filled-teeth (DMFT) was 0.7 for 12-year-olds, 1.8 for 15-year-olds, 14.5 for adults age 35 to 44 years, and 22.1 for 65- to 74-yearolds in 2005. One percent of the adults and 22.4% of those age 65 to 74 years are edentulous, with the older adults having received prosthetic treatment. Fixed prosthetics have been used to replace 49% of the missing teeth in adults, and removable partial dentures have been used for 89% of those in adults over age 65 years. Deep pockets exist in 0.8% of adolescents, 20.5% of adults, and 39.8% of those over age 65 years. Advanced periodontal breakdown is most common among smokers with low basic educational levels. Changes.—Reforms have been introduced or are contemplated to (1) improve oral health care for persons needing nursing care, (2) change the electronic health insurance card into an electronic health card that permits electronic data transmission, (3) perform internal and external quality management in dental practices, and (4)
provide online evaluation programs for potential patients. Patients’ rights efforts include clarifying what is required in all patient records, including a liability clause, information on the specific procedures to be followed when treatment fails, and information on patient participation in treatment measures and specific rights of the patient. Registry of critical incidents has also been proposed to prevent errors and provide an effective quality assurance process for inpatient and outpatient care.
Clinical Significance.—Evaluators foresee that demographic changes, medicotechnologic progress, and decreasing SHI revenue will increase the cost of health care in Germany. To maintain the high care standard currently in place will require linking medical and dental fees to the quality of the services. Patient outof-pocket expenses will likely rise through higher insurance premiums, taxes, additional contributions, or flat rates of payment.
€m E: The healthcare system and the proZiller S, Eaton KE, Widstro vision of oral healthcare in European Union member states. Part 1: Germany. Br Dent J 218:239-244, 2015 Reprints available from S Ziller, Dept of Prevention and Health Promotion (German Dental Association, BZAEK), Chausseestrasse 13, D-10115 Berlin, Germany; e-mail: [email protected]
Managed Care Practice models Background.—Dental school graduates find themselves with a mountain of debt, which makes purchasing a practice seem overwhelming. Older dentists are retiring, with too few new dentists to replace them. Preferred provider organizations (PPOs) press for profitability in dental practices, yet consumers are spending less on dental care and the trend is expected to continue. More doctors are working in group practices, and the same thing could easily occur in the field of dentistry. Changes are coming and dentists will have to navigate them while juggling all of the demands of providing excellent patient care. Options for Practice Types.—A management services organization (MSO) usually operates in return for 10% of the gross production. Dentists interested in the MSO type
250
Dental Abstracts
should look for referrals and read all the fine print to be sure they know what they’re getting into. Group dental practices may be owned and operated by dentists, by MSOs, by dental support organizations (DSOs), or by dental management organizations (DMOs). Generally non-dentist owners take on nonclinical tasks such as personnel management, purchasing, office space, patient flow, marketing, practice analytics, and insurance and leave the dentist-employees to conduct clinical care activities only. Models for Private Practice.—The three main paths to choose from if you want to remain in private practice are the traditional model, the outsourcing model, and the selling model. In the traditional model the dentist is responsible