79 The impact of orthodontic treatment regulation in the german public health sector on the overuse of orthodontic services

Abstract

Objectives The provision of orthodontic (dental) care is part of the German Public Health sector comprising 90% of German population. The current regulations for the provision of orthodontic care in the public sector have been adopted in 2004 as a negotiation-process between providers and public health insurance companies without patient participation. To date patient-related data on the impact of the 2004 regulation on the quality and quantity of orthodontic services are lacking. In addition, patients (mostly adolescents) preferences and perceptions toward orthodontic treatment are almost unknown. Therefore, we first examined the content of the 2004 regulations in terms of formal criteria for treatment access, diagnostic and treatment guidelines as well as treatment duration. Secondly, we analyzed medical health record data to obtain information on real utilization of orthodontic services as diagnostic and treatment procedures. Finally we examined patient’s preferences and their role in the decision-making process. Method In the first stage we examined the formal criteria of the regulation of orthodontic services regarding treatment access, appropriateness criteria for diagnostic and treatment procedures as well as quality control. In the second stage we surveyed adolescents aged 10 to 14 years (n=2.991, 29% response rate) insured by a public health care insurance company before or at the beginning of treatment related to their perceptions of toward orthodontic treatment need using validated and standardized questionnaires. Finally, in the third stage we analyzed medical record data of patients undergoing orthodontic treatment from 2012–2017 (n=5.514) insured by a second, independent public health care insurance company to obtain quantitative data on the real utilization of detailed orthodontic services including diagnostic records, treatment procedures, costs as well as treatment duration time. Results Treatment guidelines adopted 2004 are mandatory for both providers and insurance companies. They regulate access through objective criteria and define criteria for the use of diagnostic and treatment procedures. Parallel guidelines adopted simultaneously regulate payment system and quality control. The described regulation has following impact on utilization of orthodontic services: Diagnostic procedures as panoramic X-ray and cephalograms were performed routinely (85%–90%) although their use is limited to defined diagnoses according to radiation guidelines and should not exceed 30%. About 64% of the patients received removable appliances despite their inappropriateness and inefficiency in comparison to fixed appliances. The mean treatment duration time was 36 months given that the published standard for a mean duration should be no longer than 18–20 months. Dentists were reported (81% of respondents) to be the primary driver for patients to start treatment. 93% of the patients reported to no complaints before starting treatment. Conclusions The use of inappropriate diagnostic and treatment procedures as well as prolonged treatment duration indicate overuse of orthodontic services in German public health sector. As diagnostic and treatment procedures are strictly regulated by treatment guidelines adopted by provides and public health insurance companies the overuse of orthodontic services seems to be driven by regulators, health authorities and providers.