JOHN K. HARCOURT, DDSC, FRADCS, FICD, Editor

WHERE DOES RESPONSIBILITY LIE?

The pattern of dental disease in the community is certainly changing, but so too are methods of delivering dental services. We hear a great deal about third-party systems in dentistry, alternative delivery systems, alter- native payment systems, capitation dentistry, health maintenance organizations, retail store dentistry, franchised dentistry, and so on. Small wonder that members of the practising profession are confused by it all.

At first sight, it would seem reasonable that some form of universal insurance against dental disease is warranted. However, experience in Australia and in other countries would suggest that dentistry is not like other health problems. Medical and surgical conditions are not predictable so that it is desirable, or as in Australia imposed by the Government on all taxpayers, to maintain health insurance throughout a lifetime. On the other hand, consumers can take out dental insurance before they undertake a course of dental treatment, and then opt out once the work has been completed. Under such circumstances, dental insurance schemes on their own are not really viable and thus are usually offered as an adjunct to other medical or hospital insurance packages. Many so-called dental insurance schemes could more properly be called dental pre-payment schemes.

A number of forms of dental insurance schemes for large groups such as trade unions have been proposed. Such schemes often involve the dentist being asked to enter into a contract with the sponsor to provide dental services for group members at some form of discounted fee. The only schemes probably acceptable to private practitioners are those based on the UCR (usual, customary and reasonable) fee principle. Fees are usual if they are those charged by an individual dentist for all patients, customary if they are within the range of usual fees charged by dentists of similar training and experience in similar geographical or socio-economib areas of society and reasonable if they meet the above criteria and are justifiable in the circumstances of the case in question. Such fees are negotiated with the sponsor by dentists entering the scheme and must lie within certain

Australian Dental Journal 1986;31:6. 459

permissible fee limits which are updated from time to time. Patients receive a rebate at an agreed percentage of the fee charged. This was the system adopted by Australian Dental Plans which was introduced by the Australian Dental Association in the mid 1970s. That ADP failed is a matter of history, but had the economic conditions at that time been more favourable ADP most certainly would have been a great success, and would have formed a model for the development of other similar schemes.

With the intrusion of third parties into the delivery of dental care, questions of divisions of responsibility can arise. This is particularly so with some of the current schemes where patient rebates are related to the services that have been performed. Under such circumstances there is sometimes a tendency for accounts to be manipulated in order to attract higher rebates. Also, such schemes can lead to overservicing as has been alleged to have occurred in some areas of medical treatment.

Even with such schemes, it still goes without saying that the patient enters into a contract with the dentist for the provision of certain services, and is therefore responsible to the dentist for the payment of the dentist’s fee. It should make no difference to the nature of the treatment rendered that the patient happens to be in a pre-payment or insurance scheme - that is a matter between the patient and the insurer between whom another contract exists. Unless the dentist has entered into a scheme agreeing to charge a differential fee for insured patients, the third party insurer has no right to attempt to influence either patient or dentist in relation to services performed or fees charged.

Thus the responsibility for treatment clearly lies with the dentist, and the responsibility for meeting the fee lies with the patient. A further respon- sibility may exist between the patient and the insurer if that insurer has agreed to meet part of the cost of the patient’s dental care.

Returning to the notion of contract dentistry, dentists in private practice have for many years entered into government-sponsored contracts, because of a sense of responsibility to disadvantaged groups such as pensioners and veterans, and in those circumstances they have been prepared to accept considerably lower fees than would otherwise be charged. It is also the responsibility of governments to see that fees paid to participating dentists are regularly reviewed and updated in line with the changes in the Consumer Price Index, and that dentists are not kept waiting for their reimbursement for inordinate periods of time as has happened in the past.

Any form of discounted dentistry is said to lead to a lowering of standards, and to a measure of overservicing as has been reported in the British Health Scheme. It remains the responsibility of the dental profession to ensure that high standards of dental care are maintained in the face of increasing pressures from third parties for a share of the dental dollar.

460 Australian Dental Journal 1986;31:6