Productivism and dental overtreatment

Unquestionably, the ambition to offer quality care to all citizens at an acceptable cost for the state is a failure. Social satisfaction is partially achieved at the expense of safety.  A chronic deficit has forced Social Security to divert its attention from its public health mission. It refuses to take responsibility for its mismanagement and accuses the dentists of taking advantage of a monopoly rent. Its administrators deem the traced path is the right one and should be followed with stricter supervision of undisciplined « liberals ». The Minister of Health shares  her lack of knowledge in dental microeconomics with the Minister of Economy who is a neophyte in this area.

To avoid bankruptcy two strategies were possible:

  • Restrain the amount of dental procedures performed by better prevention and optimization of care. It is the choice of the Nordic countries, Switzerland or Canada, who beat quality dental records for controlled budgets.
  • Lower the cost of dental procedures by authoritarian pricing of private care. This is the choice made by France, which now holds the record with the lowest dental fees in Europe and still wants to reduce prices rather than volume! As Balzac said, “the bottle does not matter as much as the drunkenness”.

In 1975, the SS health branch offers dentists benefits in exchange for moderation of their fees. The deleterious barter between low-cost dental care and prosthetic free market fees is endorsed by the Minister of Health, National Insurance and representative unions who are very close to the Order of Dental surgeons. This barter condemns dentists to perform exceedingly cheap dental care without being able to benefit from it, except by indulging in productivism and compensating their losses by unjustified prosthetic procedures. Generating a considerable price distortion between regular dental care and prostheses, the barter principle sentenced basic care to mediocrity and the functional and aesthetic restorations to become the lucrative trade that worries the Minister of health, Marisol Touraine.

When two-thirds of his time has been dedicated to work for his “overlord”, cultivating his private “plot of land” revives the dentist’s hope to boil the pot. But to be sustainable, any prosthesis must have healthy foundations. Unfortunately, the vice introduced by too rapid implementation of the founding care leaves traces. These are quantified by the High Health Authority which reports 34% of infections on root-canal-treated teeth, i.e. 2.5 million per year! Once crowned, these teeth cost each year 2.2 billion euro to patients and tax payers; due replacement would cost over 6 billion.

Over diagnosing pulpal pathologies was elicited by our « world-acclaimed social protection » model:  7.5 million teeth are devitalized annually against 15 million in the United States which are 5 times more populous. How can we account for this massive production of low-paid care if not by the corrupting effects of the barter wanted by our unions and their Social Security cronies? Would then two thirds of root canals be only justified to provide dentists unstoppable arguments to promote their crown sales?

Since unfairly low prices are causing productivism which dries the insurance funds, the decision of Mr. Macron to authoritatively lower the price of prostheses will only amplify the natural over productive reaction which will lead to achieving more useless prostheses and more unacceptable mutilations and more budget deficit. Is that too complicated to understand for a Polytechnician?  For trade unions, a devitalized tooth should be crowned. This concept is no longer relevant in the scientific literature of the 21st century, but alternative treatments are not refundable. Aggravating factor, 42% of devitalized teeth will be restored with base-metal cast posts-and-cores  which were  shown  in 2004 to be useless, dangerous for the roots and expensive for its finances by social security!  75% of the cast post-and- cores are not deemed relevant or consistent with the data acquired from science. Yet social security reimburses millions each year. Inclusion of this new   procedure into the nomenclature had been considered by unionists a social breakthrough  … for dentists. Evidence-based collusion between negotiators cannot be better demonstrated.

Treating regular cavities at excessively low rates makes overtreatments inevitable. To properly execute an obturation paid € 41, an hour of work is needed, while the fixed costs of the practice are more than double that price. This explains the appealing effect of « the traditional French dental sandwich »: quick root-canal, Nickel-Chromium post-and-core and porcelain crown done in 2 hours and charged €900.

Those who understood that such a system was unsustainable choose to bypass it by directing their diagnosis to specialties less essential to public health (implantology and aesthetic dentistry) or by overcoming tariff and ethical rules of Social Security.

The poor political choice made for the population constitutes a serious breach in their commitment to serve the general interest that bears upon regulatory bodies of the dental profession. A profound reform should help patients and practitioners retrieve their freedom of conscience. Unions refuse any changes likely to reverse a corrupting paradigm that protects them. The Order of Dentists supports those unions from which it draws its power. After a recent close scrutiny of the National Court of Auditors on our profession no specific anomaly, except outrageously high dental fees, was pinpointed! The National Competition Authority which is under control of the Minister of Economy should be alerted about the collusion related to dominant positions of the main players in oral and dental health.

The profession must organize itself to supplement the shortcomings of a sclerotic administration and a corrupting state.  The establishment of an organization similar to the physicians’ “Sector 2” would offer patients access to quality dental care which is forbidden by the providential state.

The Minister refuses this measure considered too liberal and prefers to keep governing our profession as overlords once governed their serfs.  But this was until 1789 only.

What do you think? What should be done?

If you come from one of those lucky  advanced democracies (which my observations show to be highly correlated with the standards of dentistry!) like Denmark, Canada, Germany or even the U.K., would you please bring us the enlightenment of your own experience?

Many thanks for your cooperation.

Jean-Jacques DUPUIS