It would seem that installing an implant is nowhere simpler operation, just take and screw the screw into the jaw. Then you start calculating the cost structure and it becomes clear that you need a radiologist, a surgeon, two assistants - and the time of these people costs money, especially a surgeon who has studied and practiced for ten years, and he has liability to you, including possible criminal, for mistakes. We need an operating room, we need sterile gowns, disinfection, we need to invest in equipment, we need consumables. Moreover, all this must be certified. In a pharmacy, chlorhexidine costs 11 rubles, and an analogue certified for dentistry will cost a couple of orders of magnitude more. A practical example is phosphoric acid gel, which is just penny to manufacture. But when he is certified for four years, one syringe with him starts to cost from 1000 rubles.Moreover, it still needs to be found, because some materials are simply not supplied to Russia, because the manufacturer will not even be able to beat off certification in a couple of years of sales. Adequate people do not agree to Russian implants, and those that will be supported in 20 years are European - they have this guarantee included in the price.
In general, medicine is a rather expensive thing in general. The average Russian citizen pays, roughly speaking, 40 thousand rubles a year only for compulsory medical insurance (in the form of deductions from salaries) - and for this he receives an extremely cheap service based on many things, prices for which are kept low with the help of the federal antimonopoly service and subsidies. But as soon as it comes to something at least a little non-mass - everything becomes more interesting.
But, I think, this still does not explain why in some cases it can cost a million, and not a hundred thousand, to treat teeth. Let's take a closer look.
Approximate cost structure
Dentistry costs:
- Rent of premises (directly to the treatment room, area for equipment, reception).
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Let's take a look at implantation (dental prosthetics), a rather expensive procedure. The screw itself costs 5-10 thousand rubles. 5 is good, 10 is excellent. This is money for the fact that he is thoughtful and that there will be spare parts for this screw in 20 years - otherwise we had a case when a patient needed five units for old-old implants that were no longer supported, and we threw a cry at the clinics of colleagues , found four around the world, but the fifth still had to be creatively solved. To install the implant, you need a physiological dispenser, this is a device that rotates the instrument with the required force to install the implant into the bone. You can turn it with pliers, or you can use this device from 150 thousand to 1.5 million. Another 2 thousand euros is worth a set, which contains all kinds of connectors for this implant. Yes, when you buy hundreds of implants, they give you this set to the clinic. But we have many clinics,and each requires two sets, because they rotate: while one is being sterilized, the other is in operation. There are also two dispensers per clinic: only the motor is not sterilized. You also need handpieces for correct operation, and of different types, nozzles for piezoelectric surgery. We need a warehouse of spare parts, for example, special screwdrivers. To make all this stand up, you need navigation, I wrote about it above. And a scanner. The last scanner cost 45 thousand euros. Then you need a temporary overlay - a CNC milling cutter, a mill in the jargon. The mill costs another 35 thousand euros. And a person who knows how to manage it. Plus a temporary crown from a 3D printer (and its installation) - it turns out that one correctly made new dental prosthesis on the implant, which will serve with a guarantee and will be highly aesthetic, costs a little less than 200 thousand rubles.And if you haven't brushed your teeth long enough and by the age of 45 you need to disassemble half of your jaw - count it. This is even without bone grafting, if the teeth were all in place before arriving at the clinic, or if you are just from a fight and carry two of your own and one of yours (as one patient did, and, warning important questions, a stranger will not be useful).
Patients, by the way, understand all this only when they already face problems. For example, when their implants placed on the eye have had the wrong load for years, which ultimately violates the aesthetics. When they understand that an implant is not for life, and they want guarantees. And the same people in the case of cardiovascular surgery act completely differently.
Here's another example. We have an orthodontist consultation for 4500 rubles lasting five minutes.Patients are somewhat surprised by this. The point of the inspection is to verify that the process is proceeding correctly. In an ordinary clinic, it takes half an hour - the same five minutes the doctor looks into your mouth, and another 25 minutes fills out the papers. The point is not how long the doctor will spend in your mouth, but how much time he has studied before and what practice he has gained. In the overwhelming majority of cases, he says "everything is in order", and this is 1,500 rubles per word, including the preposition. But sometimes it is needed to understand what is going wrong. And for the patient, this is the ability to figure it out in time - a decision at the cost of six months of wearing braces is usually. And when I order a specialist consultation, I want just one hit at a high price. We had a reverse example: an engineer had to come to help with one unit in the clinic. Spent an hour and a half of my time and the time of the head physician of the clinic, examined everything,left and disappeared. But he didn't take a dime from us. As for me, we paid very, very dearly for this free consultation.
And a five-minute examination by an orthodontist is an agreement with a doctor. As soon as the doctor touches the patient in his office with his gaze, he has a medical responsibility. The funniest case of clinics without established processes is when the doctor prescribes treatment, the patient does not agree, and the doctor does not receive a written refusal of treatment. Then comes a very fragile situation from the point of view of legislation. The doctor has not done anything, but is already answering. For example, an orthodontist saw a purulent process - the one from which people die. And I must immediately call an ambulance to pick up the patient. Or a history of heart disease, and there are just traces of pus in the mouth. Under the law, a doctor cannot ask you to open your mouth unless a contract is signed and there is no consent to be examined. That is, not a single patient enters the office withoutso that the legal and administrative framework does not work in the clinic. There is no consultation without inspection, familiarization with the map, photo logging (with us) and filling in the data. And the same photo protocol still requires a place where these pictures are stored - and processes require software that tracks them, and maps require software where they are run. That is, we also have IT. Because the most unreliable in medicine is the opinion of a doctor. And the most reliable is data-driven research. We collect this data for each patient.Because the most unreliable in medicine is the opinion of a doctor. And the most reliable is data-driven research. We collect this data for each patient.Because the most unreliable in medicine is the opinion of a doctor. And the most reliable is data-driven research. We collect this data for each patient.
Well, marketing. Although it is 2-3% in the cost structure, but the site, the mobile application (where we immediately upload your card, survey data, images and photo protocol) - everything is also not taken from an empty place. As well as a call after the operation to check if everything is fine with you.
Why, then, is the OMS so cheap?
Because in compulsory medical insurance there is no task to preserve the patient's teeth, to make them aesthetically pleasing and comfortable. The basic paradigm of the compulsory medical insurance is to preserve the life and efficiency of a person, finding such a balance between the underproduced citizen's GDP and the cost of intervention, so that an optimal economy is obtained. To prevent deaths from complications of caries, teeth were simply torn. And for quite a long time - without anesthesia. Only in 1980 was a decree issued that tooth extraction should be performed with the use of anesthesia in each case. Before that, anesthesia was performed as it went. My grandfather told me that there was a hut on Dzerzhinsky Square. There was a grandmother who poured a glass of vodka for a ruble and removed a tooth. He also deleted there.
Why are some dentists cheap and some expensive?
For about the same reason why some developers have lines of code differently. But in fact, in the question "Why does dentistry cost so much?" there are two aspects:
- Why is it expensive at all.
- And why the same teeth will cost wildly differently for different doctors.
This is expensive because it actually costs so much if you calculate the cost structure. But at the same time, there are shareware compulsory medical insurance treatment and various dentists with low prices who set the range for comparison. And here we come to the second question - the difference in prices.
For example, a patient comes and says: "I'll do it cheaper in Sochi." Yes, it will. I even know who. That blue-eyed woman goes to the clinic without a license. The doctor opened his office at home. Moreover, my patient (failed) is the owner of two clinics with a medical license, only cosmetology. And she calmly explains to me that she goes to the house of some guy who has everything there. He's very cool. She smiles at me at this moment, and I see what is in her mouth. I immediately want to ask if there is certification, is there sterilization? What does he use? How does he store his medicines? Where does he keep them? And everything else, but after. Because there are standards. For example, those teeth that you leave to us after extraction are a complex ritual of their disposal. We take them to the medical waste room to bury themwhich is very well described in the standard. This room is at least four square meters in area with a tank and a refrigerator. The average rental price for premises in Moscow is 30 thousand rubles per square meter per year. That is, we simply pay 120 thousand rubles a year so that we have a tank, into which we drop our gloves. And we have not yet reached compliance with the requirements that ensure the predictability and safety of medical interventions.ensuring predictability and safety of medical interventions.ensuring predictability and safety of medical interventions.
My colleagues-ophthalmologists in such dialogues say very simply: β50 thousand cheaper? Of course you do. If anything, you will buy spare eyes somewhere! " - and the patients seem to guess what the catch is. And there are many teeth, and the loss of a couple of pieces usually does not frighten patients. Just like when removing a tooth, people do not know that if it is difficult, it will take up to an hour to cut it in parts and extract it along pre-planned trajectories. Because in the OMC clinic, they are simply pulled with ticks in 15 minutes without a CT scan, without a plan. In the vast majority of cases, this ends well. In about 10% of cases - complications such as inflammation, but this is even more or less normal. But I have seen cases when the bone was damaged, and when the patient was paralyzed half of the face, because a nerve passes right under this tooth.In filling the canals, it is also quite easy to make a mistake with the subsequent paralysis of the nerve, and we saw enough of this about ten years ago on old protocols.
Profitability of dentistry
We have a top segment clinic at prices. Once every six months, I have a conversation with one of the patients who left about a million rubles with us, about the fact that he would like to open dentistry. As an argument, he shows his check and the Instagram dentists from BMW. As an argument, I show a part of the reporting, where it is clearly seen how profitability changes from 5-10% to one peak of 30% over the year. That is, the average profitability is about 20%. And this is with us, clinics with a very good client base, with a reputation, with expensive unique services and doctors who have made a reputation both in Russia and in world science. Here is Huseyn developed a theory and a mathematical model of a navigation operation to expand the palate in children, children are brought to him from all over the CIS, he also receives them in Italy - they are brought there from Europe. And all the same, the profitability is such.
There is no high margin in dentistry, and there are a lot of risks. Moreover, if some of the risks are covered by investments in equipment and material support (in the expensive segment, you can afford the best consumables on the market, and good tools, and the same diagnostic devices with better resolution, for example), then the other part lies in the field of human interaction.
Our patients in calculating the price, for example, rarely realize that we give a guarantee for work, and not just for materials. That is, if something happens to your ceramic insert in six months, we will do it for free, and will not assign an additional bill. Plus, you need to take into account the complaint budget. This is one of the reasons why we are moving the production of prostheses inside the clinic. Now we make temporary structures using 3D printers and high-precision dental milling cutters. But permanent dentures are still outsourced. Dental technicians provide a warranty for the device, but the doctor is ultimately responsible to the patient. For a number of designs in Russia, simply no one can provide the required level of quality so that doctors feel calm,that's why we order them from European technicians - which adds to the price of the product due to the difference in the cost of work in different countries and due to logistics.
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When we started the clinic, we wanted, in fact, to do applied science, for which, as it turned out, they pay well. But it is very difficult to do science if there is a chance to sit down corny. Yes, in dentistry it is difficult to inflict moderate and severe harm to the patient's health, but nevertheless, as you may know from the media, this happens. In Russia, no matter what papers you sign before the operation, the doctor is still responsible for the result of the intervention. And when it comes to court, usually the court takes the patient's side. This means far from what you think. This means that a sane doctor simply does not tackle difficult cases - this is especially noticeable in surgery and among our fellow cardiologists, for example. Is there a risk? It's a shame, but you should go to another clinic, where the doctor will take this risk on himself. The doctor has a good portfolio,good statistics (if they are kept) - and he does not really want to risk both his responsibility and just statistics, trying to save the patient. As for me, medicine should work a little differently.
In statistics on suicides, alcoholism, drug addiction and clinical depression, plus broken families, dentists have been breaking records for quite some time. Moreover, they often even surpass doctors of other specialties. This is partly due to the fact that it is the dentist who gives the patient maximum discomfort, and patients often take revenge (unconsciously). That is, the doctor is the target of a negative reaction. The dentist is going through a serious rejection.
The dentist also works with conscious patients. A dentist hesitates between providing medical care and providing a service that is not assessed by another colleague, not by the professional community, but your patient may say: "This is how it is for me, this is how I look at it."
Believe me, we would be much safer if patients were quietly lying unconscious, and not trying to direct our actions. Or at least if you didn't have to explain every manipulation. Yes, this is part of professional training, yes, assistants are very helpful. But still.
The next factor in why dentists are not very popular is that almost every doctor - from a gastroenterologist to an orthopedist - has a patient solving a conditionally urgent problem. If the doctor does not help the patient, the patient is likely to feel worse and worse and worse in a fairly short period of time. In dentistry, the most expensive interventions are generally incomprehensible to the patient, since there is no acute pain. We usually treat something a year before the problem occurs, after which it will be necessary to reassemble the jaw. But so far nothing hurts, right? That is, the doctor says that the patient has a cyst, and the patient is not worried about it, but an operation is needed. You can wait, yes. And then the problem happens on a business trip.
Training
As the owner of the clinic, I would like to have a permanent team in whose training I invest. But this is quite difficult: the current model is that the doctor pays for his education out of his own pocket, and I pay him an above average salary, taking this fact into account. At the same time, I do not manage this training and development of the doctor, and at any time I must be ready for the fact that it will be necessary to look for a replacement for him. Of course, there are contracts in which a specialist studies at the expense of the clinic, and then has to work for several years. But this is not a very realistic situation, alas. If a doctor is not interested in working, then he becomes less client-oriented, begins to be a destructive element for the whole team. And so that you understand how much the training costs - normal European courses start from one thousand euros per day.This is not yet about a master class from a specialist on a narrow topic with practice. By the way, we would like to invest in science for the sake of teaching applied technologies in Russia in the distant future.
Dentistry is becoming more expensive due to the lack of a culture of prevention. Once you didn't brush your teeth, then you skipped regular cleaning and examination, then you saved money on a doctor (for example, you went to an apartment with unclear what standards) - and as a result, I would disassemble and reassemble your entire jaw. A step earlier, you could read reviews, get advice and a second opinion. One step earlier - did not wash down the pizza with water. And even a step earlier, your parents could not provide you with anesthesia in pediatric dentistry (and in general it is not a fact that it was then), and you remembered not good doctors and cartoons under nitrogen (this is remembered!), But for the rest of your life you learned that these inquisitors are best served only in acute pain. By the way, actually, teeth should be done with local anesthesia,but due to the mental trauma of patients, we end up having to buy anesthesia machines in surgical boxes for 40 thousand dollars apiece.
During the preventive examination, oral hygiene is done (teeth are cleaned), and targeted images (with very low radiation exposure), which control the presence of hidden caries. And, what is important, the doctor also looks at where you are not cleaning, and corrects your manual skills. It is not your mother who teaches you how to brush your teeth, but the doctor develops and corrects this skill. βDon't do that, because it will lead to recessions. You are cleaning the wrong way. Use this technique. " The skill is usually trained in one or two preventive measures, after which the doctor sees that everything is in order.
Now hygiene itself. You can use a sandblaster (soda) of the Airflow type. On Aliexpress there is for 1.5 thousand dollars, in Moscow clinics they are usually found more expensive, for 900 thousand. The problem is that both devices can be done badly. An expensive device can be done normally. But it is impossible to do well with any apparatus; manual work is needed.
So when you come to dentistry, just look at the prices and estimate the cost structure. If the cleaning costs 3 thousand rubles - either you are in a region with very cheap rent, almost free labor and a clinic with equipment minus the third generation from the current one, which had to be put somewhere, - or some surprise awaits you. It's like dumplings for 200 rubles per kilogram, while meat costs 800 rubles per kilogram. You can roughly estimate the share of meat, the retail markup, the cost of work - and understand that if the truth is written on the packaging, then they should cost at least 500 rubles. The saleswoman has kind eyes, but she still needs to pay a salary.
At the same time, applying the same logic to oral hygiene, patients somehow wonder why it is more expensive than in the basement around the corner.
Is everything sad?
Not. At the same time, Russian dentistry is one of the best in the world in terms of price / quality ratio. We felt this for ourselves when we opened online consultations: IT specialists abroad undergo research, send us pictures to understand whether or not something needs to be done right now, and within a few months they come to Russia, treat their teeth and fly back. to Google to America or Europe. Because a two-three-hour operation in Europe costs 150-200 thousand euros.
Therefore, when we name prices, and patients reflexively ask if a discount is possible, I always answer - yes, it is possible. And I ask what exactly we will save on. For example, you can save on materials. We will choose something Russian better for you. And for some reason no one agrees. Therefore, that 5% discount for Habr - it seems strange to many, but this is a damn big discount. I would say the maximum possible in such circumstances.