Panel II Patient mobility for dental treatment and services between Austria and Hungary

Transcription

1 Panel II Patient mobility for dental treatment and services between Austria and Hungary Juliane Winkelmann, Gabriele Schmied European Centre for Social Welfare Policy and Research Eszter Kovacs, Gabor Szocska Semmelweis University

2 Dental tourism to Hungary 1. Austria s perspective and findings - Methods - Motivations and scope - Regulatory provisions for reimbursement - Experiences and insights of Austrian patients and dentists - Preliminary implications 2. Hungary s perspective and findings - Methods - Trends and history of dental tourism in Hungary - Patients motivation and satisfaction - Quality issues

3 Methods Literature review Inquiries and data requests of health insurances on reimbursements Qualitative in-depth interviews with: opportunistic sampling, convenience and maximum variation sampling 11 semi-structured interviews with patients aged years (8 females, 3 males) 6 semi-structured interviews with dentists in Vienna and survey from 4 dentists from Lower Austria

4 Why do Austrian patients seek dental care in HU? Motivations Driving Forces Cost-advantage is major driving force, in particular for prosthetic treatments (non-removable) crowns implants - bridges Hungary Austria Removable : Total dental prosthesis Non-removable: Full ceramic crown Sources: Fee guideline for Austrian dentists, Websites of dental practices in Hungary Secondary forces Short distances to treatment centres (Vienna Sopron: 74km) Recommendations from relatives and friends Overall service quality and customer service (spa, massage, taxi etc.) Marketing of Hungarian dentists and dental tourism on internet sites and Austrian newspapers

5 Austrian context No health insurance coverage for fixed prosthetic treatments Most patients travel to Hungary for treatments not covered by health insurance >> 80% of AT survey respondents paid dental treatment in Hungary OOP, only 20% were partially reimbursed (Österle et al, 2006) Hungarian Context High density of dentists in Hungarian border regions >> 768 inhabitants per dentist in Budapest, 1,090 in Sopron Almost 2/3 of all practices in Western Hungary provide services to foreigners >> in Sopron (Western Hungary) 42% of all practices report more than 60% of income from foreign patients (Österle, 2009) Most common services offered to foreign patients are fixed dental replacements: fillings, implants and partial denture procedures

6 Scope of dental treatment in Hungary >> No exact numbers of patients travelling to Hungary for dental treatments available due to OOP spending Estimates compiled from various sources: 70,434 Austrians travelled for dental treatment to HU in 2006 (Österle et al. 2009) Questionnaire Survey sent in 2007 via the Hungarian medical chamber to registered dentists (85.4% of all dentists) in Western Hungary and Budapest. 160,000 Austrians seek dental treatment in HU per year (Konsument 2005) Estimate based on consumer survey 100,617 extrapolated from Austrian Health Survey per year (2006/07, Statistik Austria) Representative survey with a random sample, N= Assumption of 100,000 patients/year = ~ 1,2 % of Austrian population

7 Regulations for reimbursement in Austria What is reimbursed? Removable prosthesis (set of false teeth, removable dental bridge) and crowns for the mounting of removable bridges: Allowances ranges 50% 80% (depending on health insurance ) Authorisation of the health insurances required, Replacement after 4-6 years possible Non removable prothesis partially refunded if medically necessary (cancer, cleft lips) What s not reimbursed? Fixed treatments (crowns, pivot teeth, not removable bridges, implants) Four health insurances pay small amounts for crowns ( /unit)

8 Details of reimbursements Specific data on number of patients that applied for reimbursements for dental treatment in HU obtained from 4 health insurances: Health insurance fund N of patients with dental treatment from HU applying for reimbursement Regional health insurance of Burgenland (2011) Regional health insurance of Styria (2011) Regional health insurance of Vorarlberg 94 (2010) Health insurance of farmers: SVB 519 (2011) Major reimbursed services are: Tooth extraction Root treatment extirpations Radiology Dental clearance

9 Qualitative interviews: Patient s experiences Reasons for moving to Hungary for dental treatment: Fixed dentures not paid health insurance - lower prices in HU recommendations of friends, relatives A Single tooth would be possible (in Austria) but I needed a reconstruction of 13 teeth (C9) I saw how pretty the dentures of my friend are, they do not look like artificial teeth (C1) Satisfaction with dental treatment in Hungary: Good: Low prices; appropriate quality; service orientation: friendliness, advice, no waiting time; technical equipment; professionalism Not so good: travel time, medical examination, post-treatment care Quality improvement of the treatment in Hungary leads to competition between Austrian and Hungarian dentists

10 Insights from Austrian dentists Experiences of 10 Austrian dentists: Receive patients for preparatory procedures for further treatment in Hungary But mostly receive patients to treat problems resulting from treatment in Hungary >> patients are afraid to return to Hungary/ practices disappeared Austrian dentists only receive patients with problems >> bias in perception Work from Hungary is often of good quality similar to Austria Evaluation of quality of Hungarian treatments: Fast treatment and implementation of prosthetic treatments, comprehensive preparative procedures are often neglected: >> dentures are applied on teeth/dental bone which are in inappropriate state Lack of clarification of long-term consequences to patients (issue of warranty) Quality problems equally observed with patients treated by Austrian dentists

11 Preliminary conclusions Main reason to go is low cost; e.g. lower out-of-pocket cost for non-reimbursed services Patients appear happy with what they get - all inclusive service tourism Austrian dentists observe quality gaps due to fast treatments inappropriate preparation >> BUT: quality standards narrowed in recent years >> Austrian dentists face thus more competitive pressure Policy implications: - Enable patients to informed choices over treatments - Ensure continous post-treatment care (through information exchange) - Gaps of research on cross-border dental treatment (scope & capital flow)

12 Hungary s perspective and findings

13 No way to hurt, we might sedate but we also cure your wallet.

14 Background Basic principle in the EU: Free movement of persons, workers, services, goods and capital (14/2 EC) Increasing mobility, impact on EU regulation, legislation (Exter 2002) Mobility of professionals 2005/36/EC EU Directive about the mutual recognition of professional qualifications (having acquired their professional qualifications in a Member State to have access to the same profession) Patient mobility 2011/24/EU Directive on the application of patients rights in cross-border health care (clarifies the rules on access to healthcare in another EU country, including reimbursement)

15 Methods Literature review grey literature, data on dental tourism Interviews with dental professional bodies (10) Hungarian Medical Chamber Dental Department Hungarian Dental Association National Advisory Board of Healthcare Dental Department and Council (Previously Professional Advisory body of Dental and Oral Disease) National Institute of Oral and Maxillofacial Diseases National Committee for Hungarian Dentistry National Dental Public Health Authority - Chief Dental Officer Association of Leading Hungarian Dental Clinics Hungarian Dental Tourism Company Dental Clinic leaders specialized on dental tourism Questionnaire survey (N=273)

16 Trends 1. Source: Kámán, 2010

17 Trends 2. Source: Tolnai et al. 2009, p. 39.

18 History of dental tourism in Hungary The beginning Dental tourism started in Hungary years earlier than in other European countries. Attila Kámán MD., Leader of Association of Leading Hungarian Dental Clinics

19 History of dental tourism in Hungary The beginning 2. In Hungary particularly in Western Hungary cross border dental care appeared in the 80 s and increased progressively in the early 90 s. The wave of foreign Austrian and German patients seeking for dental care beyond borders started (Balázs & Österle 2008). Later on in the 90 s Italian patients arrive to Hungary for dental care.

20 History of dental tourism in Hungary Before the EU accession Budapest became the second most significant area in dental tourism and more accessible (Österle, Balázs & Delgado 2009) due to good cost/benefit rates of dental treatments increasing prices in Western European countries appearance of low-cost airlines in 2003 Not only neighboring countries but other European countries arrived to Hungary for dental care (Kámán 2010, Ruszinkó 2010).

21 History of dental tourism in Hungary After the EU accession Hungary gained the leading position in dental tourism in Europe in 2008 (Szűcs 2012). Nowadays, dental tourism has approximately 20 years tradition in Hungary.

22 Patient satisfaction 1.

23 Patient satisfaction 2. Source: Wagner C., Dobrick K., Verheyen F. EU Cross-Border Health Care Survey WINEG Wissen 02. Hamburg: TK p. 16.

24 Patient motivation Source: Klar 2010

25 Quality issues Dentists use standards in high percentage in order to ensure safety and high quality. Attila Kámán MD., Leader of Association of Leading Hungarian Dental Clinics

26 Quality Code of Practice 1. Dentistry is made up of different specializing fields. In order to provide the possible highest standard of remedy a team of specialized dentists is essential: The practices employ a minimum of ten dentists / oral surgeons to hold specializing diploma. 2. The safety of the medical care depends on the respective utilization of the existing capacity: Practices are equipped with a minimum of 5 modern dental medical operating units and prepare at least 1500 units of aesthetic tooth replacements a year. 3. Modern dental technology demands an adequate medical experience: Practices placed a minimum of 1000 implants a year in the past 2 years. 4. Using all advantages given by today s computer technology secure patient care and high quality patient satisfaction: Practices use cutting edge technology CAD-CAM (Procera, Cercon, Cerec, Everest) and pre-implantation surgery planning methods on a daily basis. 5. The quality of treatment strongly relate to the quality of the surgeries equipments: All materials and instruments are of the highest quality and only sourced from reputable manufacturers: (KaVo, Siemens, Morita, Castellini, ADec, WH, Nouvag, NSK, Trophy, DeTrey, Kerr, Nobel, Zimmer, Friadent, etc.) 6. The development of medical attendance makes it possible to provide the best yet affordable treatment available for every patient: Practices ensure that all practitioners work within industry recognized protocols, including clinical governance and undergo regular internal clinical audits and assessments. They also participate in ongoing dental and hygienist clinical education and professional development courses.

27 Quality Code of Practice The precision of diagnosis is the key factor to enhance prevention, therapy and rehabilitation: Practices dispose both digital intra-oral and panoramic X-ray equipments. 8. It is essential to keep attention to patients' safety: Companies possess great value profession liability insurance throughout Europe. 9. The quality of patient care has to be credited by external experts: Practices aspire to introduce an audited quality assurance system. 10. Up-to-date knowledge is not possible without excellent international communication: Practices employ multilingual staff (6 languages). 11. Precise administration is the foundation to high quality patient care, this includes post-treatment follow-ups and a good customer relations: The practices employ a team of coordinators and customer care staff. 12. It is very important to create a safety environment for foreign patients during their stay: Practices operate their distinctive transfer service. Source:

28 Conclusions Cost/benefit ratio was appreciated even before the EU accession Long traditions in dentistry affordable price, good quality, good professionals With the 2011/24/EU Directive on Cross border health care the transparency of cross border care and patients rights, liability will be provided