"Do you feel bad or it's coz it's expensive for you?" Why Obligatory Medical Insurance dentistry has turned into hellish torment

On condition of anonymity, they spoke about the consequences of the “reforms” in medicine in 2018-2019.

Yulia Suntsova, Natalya Seybil

Dentists lose interest in your person as soon as they pick up a card and find out: "free", and this is at best. At worst, you sit in line for an hour and a half or two hours (even if you came by the number on time), let all the “payers” go ahead of you, and when you get to the chair, you suddenly find that you are being reamed without anesthesia.

Russian legislation guarantees every Russian citizen affordable and timely medical care, including through dentistry. Teeth and gums belong to the digestive system, in cases of diseases of which, within the framework of the basic program of compulsory health insurance, free primary health care is provided, including preventive, emergency medical care, specialized medical care, including high-tech (Art. 35 p. 6 of Law No. 326-FZ "On Compulsory Medical Insurance in the Russian Federation").

The patient can count on the free provision of all services related to the health of the teeth, gums and oral cavity, and a preventive examination every six months, including mechanical cleaning of the teeth from tartar (professional hygiene). For all of the above, upon presentation of the compulsory medical insurance policy, the state pays. The money is taken from insurance premiums paid by employers. When treating under Obligatory Medical Insurance, medical organizations and doctors do not have the right to impose paid services or offer to pay extra for better materials. In case of acute toothache, emergency dental care within two hours is required to be provided free of charge by any clinic participating in the implementation of the Obligatory Medical Insurance program.

The compulsory medical insurance program includes the treatment of caries, inflammation of the dental canals (pulpitis) and gums (periodontal disease, gingivitis), purulent inflammation in the oral cavity (flux, abscess), as well as the removal of diseased teeth, the installation of fillings, jaw reduction. If necessary, anesthesia and x-rays of the diseased tooth (teeth) should be done free of charge.

Free dental treatment does not include everything that is NOT associated with threats to the health of teeth and gums, for example, the installation of crowns, implants, bite correction, teeth whitening, etc. aesthetic medicine.

According to a rather sensible idea, regular preventive visits to the dentist, which guarantees timely detection and early treatment of diseases of the teeth, gums and oral cavity, should generally save citizens from paid and expensive dental services.

All these written rules, however, seem to be crossed out with stepping over the thresholds of state dental clinics. Unlike other areas of medicine, in dental clinics you feel like you are indebted to the doctor for the mere fact of taking it.

To pronounce “treat according to compulsory medical insurance”, “an injection is free” and “a seal is also free” seems to be even somehow not decent. The feeling that you are deeply upsetting your dentist by not buying anything before the end of the appointment hangs like a heavy burden.

Treating caries seems to have become something special, which you obviously cannot claim, but you still get it as indulgence. After two hours of humiliating waiting in lines and in an atmosphere of devouring rudeness in the worst traditions of the USSR.

Numerous angry reviews confirm that these are far from the inner experiences of individual and especially vulnerable patients. A huge number of patients face extortion in public clinics.

Here, for example, what impressions of those treated under compulsory medical insurance we found only when we briefly studied the reviews of state dental clinics in Moscow:

“I am pregnant, I came with acute pain. Her [doctor's] first words on raised notes were: "What do you allow yourself, where do you hang your dirty bag!" Instead, you could calmly explain: please hang your package on this chair. Further, her communication with me continued in a boorish tone. I tried to explain what happened to the tooth and what its history was, but she cut me off rudely, saying that she would not treat the tooth, it had to be removed. I explained that I was pregnant, and many doctors will confirm that now it is advisable not to remove anything, you just need to temporarily close the tooth somehow. To this the doctor replied that my pregnancy is my problem. After some time, in the chair, I began to shake all over from pain and worries, because she pounded hard on the aching tooth, pulled my hand several times on my lips and inflamed gums and yelled: “Yes, how are you behaving?!!!”, - which finally brought me to hysterics and, taking advantage of this, added: "Are you registered in a mental hospital? We should check."

“The attitude is bestial, like a second-class person, as soon as the doctors find out that the treatment is over the top. But all the same, by all means they are persuaded to pay services, and the prices are ultimately higher than in paid clinics, and the fillings fly out on the second day. Money is often asked to simply leave the doctor - so, they say, half the price than through the cash register. Under me, a woman with Parkinson's disease was given to fill out 3 forms, but she could not, so they swore at her about this.

“This doctor allowed himself frivolous communication, immediately switched to you with me, asked personal questions. On the treated tooth, after 2 months, caries formed, because of which I laid out a round sum for the redo. Records people through personal messengers. All the time he does not have time, the patients wait for an hour when he finishes with the previous ones. One day this man signed me up at 19:00 (at that time there was almost no one in the hospital), when he made a filling, he began to pester me.

We asked dentists to tell us what happened to dental therapy and why free dentistry has become not free at all?

In the course of conversations, doctors who wished to maintain their confidentiality for fear of losing their jobs confirmed that in the past three years, the system of providing dental care has indeed been radically restructured. Specialists are indeed forced to retrain as salespeople, and failure to fulfill an unspoken sales plan in the medical organization in which they work entails serious sanctions, up to and including dismissal.

- Changes began in 2018-2019. On paper, the MHIF still guarantees the full treatment of patients under compulsory medical insurance, the set of free services has not changed. But at internal meetings with teams, the rhetoric of the leadership changed. The contours of employment contracts have not changed since Soviet times. The salary is charged, "according to the tariff scale" - i.e. for the reception of each patient, the dentist receives a fixed amount (which, in theory, is simply updated from year to year, indexed), and your salary at the end of the month, by and large, should depend on the number of patients received. Another thing is that it has become impossible to find this treatment for Obligatory Medical Insurance in dentistry. In our clinic, it all started with the fact that the deputy head doctor once said at a meeting: “Guys, you get such ridiculous pennies that I feel sorry for you. Start doing business more actively. 15-20% deduct us. We were clearly given to understand that if you occupy an office in this hospital, you should bring it to the hostel, and if you don’t share it, we’ll arrange a sweet life, you’ll quit yourself”, - says the doctor.

Our interlocutor has worked as a dentist-therapist in public clinics (Moscow region) for more than 20 years. As a man of "old principles," he resisted the idea of extorting patients where they were entitled to free care, and was able to hold out at work for another three years from the moment of innovation.

After the introduction in 2018 of a monthly "sales plan" - assigned to each doctor (naturally, at an unspoken, undocumented level), half of the doctors left the clinic within the first two to three months - they were unable to beg for money from patients, our source says. Of the 14 dentists, seven remained at their workplaces.

- We were told - there are no consumables, medicines too, temporary interruptions. Be patient. Cotton wool, alcohol - we will give, but for the time being you buy anesthesia, filling materials. Doctors really began to buy drugs and consumables at their own expense, soon this state of affairs suited everyone, and " temporary interruptions " in supplies became permanent. In the reports, everything was written as it should. It got ridiculous. The commission from the Ministry of Health warned of its visit a week in advance. During this time, materials “for temporary use” were collected from all the surrounding medical institutions “by a string”, which we were forbidden to use on pain of death, because immediately after the departure of the commission they had to be returned back. During the visit of the Minister of Health, a day department with beds was also opened, which was closed immediately as soon as the ministerial check was declared over.

Very soon, the surviving doctors turned into slaves. Mostly specialists who came from the regions or from the fraternal republics remained in the offices, ready to work at half rates for 15-25 thousand rubles a month, - says the source.

Such salaries strongly contradict the May decrees, so double bookkeeping appeared in state clinics and double reports were written - for internal use and for superiors in accordance with all the requirements of the law. Doctors, with the tacit approval of the leadership, began to engage in mass postscripts. If you want to get more than 15 thousand - puff. It is done elementarily - until the end of the month, until the patient's appointment is closed, you can write whatever you want about the supposedly rendered services, the interlocutor adds.

Three years after the innovations, our doctor tried to resist the new order, wrote complaints to the Ministry of Health, Roszdravnadzor, and the Prosecutor's Office. The violations he discovered are shocking:

- According to invoices, all the prescribed drugs, medicines, consumables were allocated and the clinic received them, but they never reached the doctors. Why give them out to doctors when you can resell them, and slave doctors have already resigned themselves to buying everything themselves. At the same time, preparations containing narcotic substances constantly disappeared somewhere, were written off by nurses as lost. At the same time, channels for their resale were built. Some doctors, who literally lay in the cemetery, received salaries in our clinic for two years after their death. What about supervision? He will issue a fine of 100 thousand rubles and leave, which is several times less than the annual salary of a dead soul alone of 300 thousand rubles, at least. That's all arithmetic, that's all supervision, - says the doctor.

Doctors who did not immediately quit were forced to come to terms with the corrupt practices gradually, like frogs from an experiment with a heated pan. I fulfilled the monthly plan for a certain amount, in the next three months another two thousand rubles will be added to the mandatory “production”. Disloyal doctors were first squeezed out psychologically, then, if they did not understand in a good way, with the help of threats, says the source of "NI" .

- For dentists working under compulsory medical insurance, the same regulatory requirements, it does not matter if it is private or public dentistry. Treatment only with domestic materials, tighter control, since funds are transferred from the TFOMS, and “colossal” 9-30 rubles are allocated per patient per month, depending on the insurance company. Many private dentistry simply immediately abandoned this "additional income", - says Alvina Elina, a dentist at a private clinic, to Novye Izvestia.

Alexey Antipenko, a dentist, talks about the “paid norm” as a matter of course in an interview.

- We practically do not have state clinics that operate only Obligatory Medical Insurance. Naturally, the salary of a doctor consists of the base rate for the region, city supplements and a percentage of paid services. Usually, there are enough ... demanding people who come to OMS, no one wants to get involved with them. Losing a job because of these patients is easy, and finding a new job later with a damaged reputation is difficult, says the doctor. - In Soviet times, the norms were developed due to the number of admitted patients. At the beginning of the 2000s, monetary norms appeared. The standards have been written for decades - there is a number of patients, the doctor is not able to accept more at the physiological level. Of course, different patients come, and if the doctor has not handed over the agreed amount, no one will fire him. It is not advisable to kill a cow that is being milked. But yes, there is an incentive for doctors to sell services to a patient and thus earn money... If a doctor does not work out a norm for the number of patients admitted, he is offered to switch to half or a quarter of the rate, which corresponds to the number of patients admitted. This is not a punishment, but compliance with his capabilities...

- "NI": And how is this "paid norm" fixed?

- In the contracts, I, of course, have not seen this. The norm is approved by the clinic. Perhaps the amounts are negotiated orally.

- "NI": Can a doctor defend his interests in court, sue for compulsion to extort from a patient by establishing some internal norm for the provision of paid services?

- Then, I'm sure he will receive a counterclaim for non-compliance with the norm for admitting patients and remain indebted.

- "NI": Why is there so much evidence that even in state clinics, dentists put money in their pockets past the cash register?

- It was, is and will be. Rarely or often - it is impossible to judge, it all depends on the person. All normal clinics put video cameras. Whatever century we live in, the desire for profit remains in human nature.

Our confidential source, a dentist from a town near Moscow, was forced to end his career in budget dentistry in 2020 after repeated threats from the administration.

- I refused to extort money from patients, consistently opposed paid services. Pensioners come to me, my poor fellow villagers. They all know me. How am I supposed to screw them around like that?!

The authorities took action, as they say. First, they began to monitor what time I come and go from work, whether I leave the office for more than 15 minutes. Smoking and toileting strictly according to the allotted minutes, reprimands for violating the rules of the workflow. There was a case with a patient who left 5,000 rubles in his medical record, and then a statement of extortion appeared against me. Failed to prove extortion. Then there were complaints about the "bad doctor," who provided too many free services. For example, according to the standards of “optimized healthcare”, I cannot treat more than one tooth at a time according to compulsory health insurance, but I treated two or three at a time, when I managed to do it in the allotted 30 minutes. Or, as a dentist-therapist in my main profile, I did not have the right to provide services from the spectrum of those that a dentist-surgeon should be engaged in. But I did it. Just for human reasons. Why torture a person with tricks where he will wait for his numbers for two months, if you can cure everything in one go? Or how can one send a man, who is also elderly, with a reamed tooth, to look for a surgeon? As a result, they wanted to charge me with embezzlement - for the materials spent on such supposedly not supposed, but super-services rendered.

Some time later, our interlocutor was threatened with a forced examination for a psychiatric diagnosis, then they promised to set the house on fire and plant drugs. In 2020, he could not stand it and agreed to quit by agreement of the parties.

“A few more years, and there will be no trace of free dentistry, the once pride and huge advantage of our country”, - he says.