Transformation of dental services from a governmental model to a revenue-generation model of operation in a tertiary care hospital: a health economics assessment.

ABSTRACT

BACKGROUND: Healthcare in Saudi Arabia is under transformation from a national free health service to a system paid either by insurance or governmental funds. This change will impact the model of operation including dental services. OBJECTIVES: Estimate the revenue of the Department of Dentistry based on an insurance-based billing system. DESIGN: Medical record review SETTING: An academic tertiary care hospital in Riyadh PATIENT AND METHODS: Data on outpatient visits for the period 2015-2019 was extracted from the electronic health records. The billing data was categorized by specialty and current procedure terminology (CPT) code. The revenue stream for each CPT code was estimated and compared between the actual cost of service for each CPT code billed price, and average price of the market leaders in private practice. MAIN OUTCOME MEASURE: Revenue generated by the department. SAMPLE 339 421 outpatient visits for 22 056 patients. RESULTS: Female and males made 179 555 (52.9%) and 159 858 (47.1%) outpatient visits, respectively. Outpatient divided by the age groups ≤14,15-65, >65 years were 58 868 (17.3%), 251 552 (74.1%), 29 001 (8.5%), respectively. The visits divided by specialty were as follows general dentistry 28.1%, pedodontics 12.5%, orthodontics 7.1%, endodontics 7.0%, oral and maxillofacial surgery 6.9%, prosthodontics 4.4% and periodontics 3.3%. Outpatient visits to the nursing clinic and hygienist amounted to 30.7%. The median number of visits per patient per year was 5 (range, 1-63), which increased to 6 (range, 1-110) in 2019. The annual revenue plateaued in 2019 at 13 983 538 SAR (3 728 943 USD) with only a 2.2% of increase from 2018. Out of 292 CPT codes, 44.8% were priced below the actual cost. Moreover, 28.4% showed pricing below actual cost, but higher than the price of the market leaders. There was an annual loss of revenue of 10.1% due to incorrect pricing of CPT codes. Average productivity of the dentist and hygienist amounted to 2263 and 760 visits per year, respectively. CONCLUSIONS: There is a need for improvement in delivery of care, cost-containment, productivity and amendment of charge description master pricing. LIMITATIONS: The sample did not include data from the period 2020-2022 due to the restriction of dental services due to the COVID-19 epidemic. CONFLICT OF INTEREST None.