Value-Added and Sustainable Dental Care
Wertschöpfung und nachhaltige zahnärztliche Versorgung
| Germany’s Dental care system creates significant Value-Added to the German Economy. Compilations for the period 2015-2023 show about twice as high value-added growth as in the economy as a whole. Furthermore, the dental care system contributes to oral health, welfare, and the sustainability of public finances with intelligent incentive structures and its focus on prevention. | Das zahnärztliche Versorgungssystem schafft einen erheblichen Mehrwert für Deutschland. Berechnungen für den Zeitraum 2015-2023 zeigen ein etwa doppelt so hohes Wertschöpfungswachstum wie die Gesamtwirtschaft. Darüber hinaus trägt das zahnärztliche Versorgungssystem durch intelligente Anreizstrukturen und den Fokus auf Prävention zur Mundgesundheit, Wohlfahrt und Nachhaltigkeit der öffentlichen Finanzen bei. |
Sustainable health systems
Sustainable health outcomes and sustainable health financing can go hand in hand. The German dental care system demonstrates value-added growth, universal health coverage, improvements in oral health, and financial stability. The analysis of the various dimensions of the German dental care system from inputs to outputs and outcomes makes visible its impact on health expenditures, universal health coverage, cost of provision, and on value added (see Figure 1).
Figure 1: Dental care satellite accounts
Universal dental care coverage
In Germany, Statutory Health Insurance (GKV) provides comprehensive dental care coverage to its 74 million insured population. Prevention, prophylaxis, basic dental care including fillings, crowns, and X-ray services, as well as advanced periodontal services, orthodontic services, and dentures are fully or partly covered (cost-sharing and bonuses) depending on the regular use of preventive services [2].
In 1989, Germany introduced a bonus program for individual prophylaxis covering children between the age of six and eighteen. They are entitled to free dental check-ups once every six months to prevent caries and early loss of teeth. Documented check-ups entitle participants to higher reimbursement of dentures and bridges.
Cost-sharing
GKV preventive services and cost-sharing have been further developed during recent decades. Today dental care is subject to structured cost-sharing. Basic dental care is free for fillings and general services. In the case of fillings, the costs exceeding the costs of standard care must be paid by the patient. Orthodontic treatments for adults over 18 are not covered by GKV (except in some specific cases). For children, 80-100% of costs for orthodontics are covered by GKV-funds, if the need for treatment is recognized by the sickness fund.
Figure 2: Cost-sharing in dental care, GKV
| Type | Basic coverage | Bonuses |
| Prophylaxis | Children between 6 and 18 every 6 month dental check-up | |
| Fillings and conservative services | Formally no co-payments but patients must pay the difference where the provider charges over the standard price (extra-billing) | |
| Crowns and dentures | Fixed subsidy | Higher subsidy with proof of prophylaxis |
| Orthodontic treatment | For children: Co-insurance (0-20%); For adults: not covered | Reduced cost-sharing for second and subsequent child |
| Implants | Only in special cases § 92 SGB V Abs.1, e.g. facial defects in the case of cancer |
Regarding dentures and crowns, 60% of the costs of standard care are covered by GKV (this is called the “fixed subsidy”). Coverage can increase up to 75% if the insured persons pledge to keep their teeth healthy and prove that they have had annual dental medical checks over the last 10 years before treatment for dentures.
To avoid hardship caused by cost-sharing there are special limits. Patients burdened by the costs of the standard treatment for dentures are eligible for an increased fixed subsidy, i.e. standard treatment for dentures is fully paid by GKV. The definition of hardship includes patients with low income who cannot afford dentures, recipients of social assistance, and persons living in nursing homes [3].
Complementary private insurance
GKV is complemented by private health insurance tariffs (PKV). However, the protection is limited. About one fifth of the GKV-insured possess a complementary private dental insurance [4]. In total, private financing schemes paid 45% of revenues of dental practices in 2023 compared to 55% by public systems. Crucial players in the German private/public dental care system are government units which support dental care for their civil servants, employees, and pensioners.
Preventive services dominate growth
Preventive services increasingly drive the dental care system. In the period 2019-2023, expenditures on preventive services increased by 49% mainly due to the expansion of periodontal services. The overall growth of expenditure on restorative services such as fillings, root canal treatments, extractions, conservative surgical services, dentures, orthodontic services, and implants was 8%, a rate below inflation.
Figure 3: Growth of dental care
Dental practice
Dental care is mostly delivered by privately owned dental practices. About 30,000 solo practices still dominate dental care provision, although group practices and medical centres are increasing as more and more dentists work as employees.
Presently, more than half a million people work in the dental care system. This corresponds to 1.2% of all employees, or 10.6% of the total number of employees in the healthcare system. Of these, 423,000 people (almost 78%) provided dental care for patients directly in solo dental practices.
Dental practice productivity growth is greater than that of health care due to improvements in qualifications, and medical technical progress. The “qualification index” of the labour input has steadily increased. Overall, it can be stated that the innovative strength of dental practices and dental supply companies is highly conducive to growth.
Value-added
Gross value added of the dental system increased by +1,8% p.a. in real terms in the period 2015-2023, a rate higher than that of the economy as a whole (+1.1% p.a.). Simulations of the economic impacts show the positive macroeconomic footprint of a rising demand for dental services, and of the induced effects, considering the backward linkages of the secondary income distribution. This can be concluded from the comparison of direct, indirect, and induced effects.
The contribution of the dental system to welfare results not only from its share in the real development of gross value added, but also from the health impacts. Real growth of the dental system therefore results in an increase in welfare and thus ensures economic prosperity.
Sustainability
The high stability of the compulsorily financed dental care system indicates that Germany has succeeded in providing comprehensive modern dental care to its growing elderly population by expanding preventive services and well-defined restorative services.
Outlook
Despite the incentives for preventive dental services, a recent study of the GKV-fund BARMER based on time series of microdata, shows that treatment with fillings and dentures still dominates dental care in adulthood today [5]. Therefore, further optimisation of oral health and the dental care system seems possible.
References
[1] Bundeszahnärztekammer (2024), Statistik 23/24: Schwarz auf weiß, Berlin.
[2] Social Code Book V, § 22.
[3] Social Code Book V, § 92.
[4] PKV (2019), http://www.pkv-zahlenportal.de (03.12.2024)
[5] Rädel, M., Priess, H.-W., Bohm, S. & Walter, M. (2023). BARMER Zahnreport 2023. Individuelle Mundgesundheit im Langzeitverlauf: Welche Unterschiede gibt es in Deutschland? Berlin.
Authors
Markus Schneider, Thomas Krauss
The PDF-Version of this article can be downloaded here.