Dental Fee Guides
In 1998, the Alberta Dental Association did something that had not happened before in Canada: They eliminated the Fee Guide, creating a free and open market for dental fees. Over time, there arose a large fee discrepancy between Alberta and other provinces in Canada. It has become a political hot potato, and the provincial government has put pressure on the Alberta Dental Association and College (ADA+C) to reintroduce a fee guide. Although popular with the general voting public, is a fee guide really the solution to access to oral health care issues?
In the media in Alberta and across Canada, many articles have been written. Regretfully, there are basic questions no one has really asked: Why was the Fee Guide eliminated in Alberta? Is there evidence that fee guides improve access to care? Who benefits from having a fee guide in Alberta? And what are the real solutions to improved access to care?
In the mid-1990s, the Federal Competition Bureau of Canada (CB) published an article on the subject of dental fee guides in the province of Ontario. They determined that 97 percent of dentists charged fees that were identical to the published Fee Guide, rendering it a de facto schedule of fees (aka price fixing). The CB concluded that the Fee Guide created a floor below which dentists were not encouraged to go and therefore inhibited price competition.
Based on this study, the Alberta government went to the Alberta Dental Association and recommended elimination of the Fee Guide. The Alberta Dental Association eliminated the Fee Guide in 1998.
What happened after that? The Alberta economy boomed, the population grew and demand for dental services increased faster than the number of dentists. Shortages of dental personnel, including registered dental hygienists, registered dental assistants and qualified, experienced dental reception personnel, drove salaries upward due to supply and demand. (As one business coach told me at that time, “If you want to play, you gotta pay.”) Other effects of a strong economy drove costs dramatically upward (rent, for example).
The Alberta Ministry of Health document, “Alberta Dental Review, February, 2016” concluded that some procedures completed in Alberta were 25 to 44 percent more expensive than in other provinces (not all procedures—just some of them, and they did not list what procedures they did examine). However, the same document demonstrated that costs to run dental offices in Alberta were up to 45 percent higher than in other provinces. Additionally, an analysis of the Canada Revenue Agency revealed dentists’ average take-home income was the same as other dentists in Canada, supporting the higher cost of business statement of ADA+C. Yet the solution identified in Alberta Health was to have a fee guide published again.
Do fee guides improve access to care? According to the May 2010 Canadian Dental Association, there are no differences in access to care among the various provinces in Canada. The Montreal Economic Institute published in 2013 that Canadians had better access to dental care than did citizens of the UK, Australia, the US, Japan or Finland. There is no evidence that a fee guide improves access to dental care.
Who really benefits from having a fee guide reintroduced in Alberta? The impetus for a fee guide was pushed by the millions of dollars spent lobbying the government by the for-profit dental benefits insurance companies who stand to have better predictability of spending in benefits coverage and thereby maximize their profits. I have asked the insurance companies repeatedly: If the fees were reduced by 25 percent, would they reduce the premiums to their customers by 25 percent? Silence has been my only response.
Access to care is the real issue. Although opinion surveys state Albertans are avoiding dentistry due to the fees, what impact has income reduction and high unemployment in our current economy played in this decision to avoid dentistry? The ultimate goal is increased access to care for the poor, seniors, children of low income families and the disabled. These are the populations that really need help with regard to oral health care, and a fee guide, no matter what level of fee is determined, is not a solution to removing the real barriers to access to care for these people.
Some provinces provide payment for dental care for seniors and children up to their teenage years and more comprehensive dental benefits for the disabled (not to mention the dismal dental benefits programs for the First Nations people in Canada). These publicly-funded programs are the most effective methods of removing barriers to access to care for those in greatest need. Why did previous Alberta governments eliminate these programs in times of abundance?
To increase competition, you need to have a free market with open public access to information in dentistry that is relevant, accurate and complete, as opposed to the severe restrictions imposed by the current ADA+C’s advertising restrictions, a situation currently being challenged in the courts.
A fee guide is not the solution to the access to oral health care equation. Restoration and improvement of publicly-funded oral health care solutions and a free market with free, comprehensive public access to information about dentistry and the dental professionals providing oral health care is.
In 1997, the Alberta government demanded we eliminate the Fee Guide, and in 2017 the Alberta government demanded we have one again; access to dental care for the poor, the disabled and the vulnerable populations will not change.