Fewer than one in five dental offices offer services covered by CNAS. Why don't doctors want to work with the Social Insurance? Does this happen in other countries?

Less than one in five dental offices offer services reimbursed through CNAS. Why don't doctors want to work with the Health Insurance Fund? Is this happening in other countries? Out of the 17,450 dental offices operating in the country, only 3,737 had a contract with the Health Insurance Fund. This means that for many patients, paying health insurance does not guarantee them access to a practice where they can benefit from reimbursed dental services. - Why don't more offices work with CNAS? Doctors talk about the problems and difficulties they face. In some counties, dental services are not even contracted. - The problem is not, however, exclusively Romanian. Other European countries also face difficulties in convincing dental doctors to work in the public health insurance system. - The article is part of the Pulse project, an international journalistic consortium that HotNews is a part of and which offers the public documented and diverse perspectives, with information from several countries, about issues of great public interest. The text was written by Alina Neagu (HotNews – Romania), Kim Son Hoang (Der Standard – Austria), Francesca Barca (Voxeurop – France), and Petr Jedlička (Denik Referendum – Czechia). "There are many counties that do not contract with the territorial insurance funds, do not contract dental services. They just don't want to, even if there is demand," says in a dialogue with HotNews Smărăndița Păcuraru, a dental doctor in the commune of Grajduri in Iași county and vice-president of the College of Dental Doctors. And this is one of the problems of the system: not all dentists work under contract with the Health Insurance Fund. What are their reasons? "The prices reimbursed by the Health Insurance Fund are extremely low." One of them is related to the prices reimbursed by the Health Insurance Fund. "They are extremely low. The reimbursement level does not cover the actual costs of operating a practice," adds the vice-president of the College of Dental Doctors. In the calculation, in addition to the treatment actually provided by the doctor, consumables, equipment maintenance, the necessary contracts for the operation of the practice, utilities, taxes, and other expenses, which have "increased tremendously lately." Dental doctors say that higher funding would automatically allow a larger number of patients access to treatments. For example, the doctor Anna Maria Pangică says that if they multiplied "the amount they receive from the Health Insurance Fund in a month by 8-10 times," they could treat almost all the patients who reach the threshold of the practice without asking them to pay out of pocket. Furthermore, instead of being extended, the grid of reimbursed services has decreased in recent years: from 94 reimbursed procedures in 1999 to only 32 services currently. Especially in the case of children, there are services that are performed but are not in the reimbursed grid, adds Dr. Smărăndița Păcuraru, vice-president of the College of Dental Doctors. If a cavity appears on the same tooth, CNAS no longer reimburses the treatment. It gives the example of treating a cavity on one of the tooth surfaces. If another carious lesion appears on the same tooth, in another area, the doctor cannot report a procedure performed on the same tooth in a short interval. "There were periods when fillings on the same tooth were reimbursed once every 5 years. Now, the Health Insurance Fund reimburses me for one procedure on a tooth every 2-3 years. I cannot work for free between these intervals," explains the vice-president of the College of Dental Doctors. "For example, in the case of a child who comes with a cavity: they do not brush their teeth very well. They eat sweets, it is difficult with the diet, because it is easier to eat a chocolate bar from the store than cooked food at home. And half a year or maybe a year later, another lesion appears on the same tooth. Most of the time it happens between the surfaces of the teeth. And then, what do they tell their parents? I cannot work for free anymore." The College of Dental Doctors has made demands to the Health Insurance Fund to increase the number of procedures. Under the current conditions, Dr. Smărăndița Păcuraru states that for services provided through the Health Insurance Fund "we are not talking about profit. There is no profit. It is just a way to help patients, within the limits of financing." How much money does a dental office receive monthly under contract with CNAS? The amounts reimbursed by offices for dental services vary depending on the doctor's preparation, as well as other factors, such as compliance with the contract with CNAS and, above all, the area where the office is located – offices in rural areas receive a higher amount than those in urban areas. Furthermore, a general practitioner can receive more money than a specialist or a "simple" doctor without professional grade – dental doctors can practice and open offices without completing residency. Those who also do residency become specialist dental doctors and, later, general practitioners. The average amount a practice receives in a month is 6,000 lei, but this is an "indicative reference," and the amounts can differ, explains Smărăndița Păcuraru, a dental doctor in a commune in Iași county. Higher ceilings in rural areas Anna Maria Pangică, whose office is in Bucharest, says that the amount reimbursed monthly, usually for her office, is 5,000 – 6,000 lei per month. In rural areas, the ceilings are higher: 7,100 lei for doctors without professional grades, approximately 9,000 lei for specialist doctors, and approximately 10,000 lei for general practitioners, shows Dr. Smărăndița Păcuraru. The main reason is the attempt to attract dental doctors to work in rural areas. The problem is that these amounts are indicative, not guaranteed. Smărăndița Păcuraru says that at one point, the College of Dental Doctors managed to obtain the transformation of the indicative amount of 6,000 lei per month into a guaranteed amount. Later, the amount became indicative again. "And because of this, with this indicative amount, I can tell you that at the municipal level in Bucharest, the ceiling for a specialist doctor, from that 6,000 lei, has reached 4,000 lei." The ceiling actually varies depending on the funds available from the Health Insurance Fund, says Anna Maria Pangică. In her case, for this reason, the reimbursement budget for her office has recently decreased by 35%. Other countries try to attract dentists to rural areas Attracting dental doctors to work in rural areas is a challenge in other countries as well. In France, approximately 60% of localities do not have sufficient dental doctors. This is generally the case for rural localities, not large cities. A survey conducted by the Center for Research on the Study and Observation of Living Conditions (Crédoc) in 2025 showed that 44% of the French surveyed consider that they live in an area with a shortage of dentists. In rural localities, one out of two residents declares that they face difficulties in making appointments with a dental doctor. Access to dental doctors is a major problem in some rural regions of Czechia, where even in private clinics, the waiting time can be several weeks. The law in Czechia provides the obligation to ensure a network of dental offices so that every locality has a dentist within a maximum distance of 35 kilometers by car. However, the law does not establish how many patients must be served by this network in the respective area. Local authorities try to attract dental doctors by offering them housing, but sometimes this solution does not work in isolated localities. "When I know that I have to enter services through scheduling, I am simply terrified." Another reason invoked by dental doctors is the bureaucracy related to contracting with CNAS and evaluating offices. Every two years, offices must submit evaluation files again, with documents such as bank account, sanitary authorization for operation, the office's CIF or the certificate of registration in the single register of offices. Invoices for equipment, and more recently for consumables and instruments, are also required. The file can thus reach approximately 120 pages and must be submitted every two years. There is also the issue of the IT system and the validation of services by CNAS. The doctor says that there have been situations when they had to work at night to be able to transmit the necessary documents to the Health Insurance Fund, because the IT system was not working. "When I know that I have to enter services through scheduling, I am simply terrified. The validation doesn't work, the validation doesn't work. There have been situations when we had to stay up until 3 in the morning to be able to send the invoice so that the services would be paid to me, because the reporting schedule was not working," says Dr. Smărăndița Păcuraru. This is added to the obligation to have a three-hour daily schedule for reimbursed services, given that the ceilings are limited, especially in urban areas, and they are sometimes exhausted in a few days. Under these conditions, the amount reimbursed by the National Health Insurance Fund does not always represent sufficient incentive for doctors. The situation can be different in large clinics, where many dental doctors work. The patient can be referred from surgery to prosthetics and endodontics, and in such a practice, a larger number of procedures can be performed than in a practice where there is only one doctor contracted with the Fund, and the amounts for reimbursed services increase. The country in Europe where half of dentists avoid working with the insurance system In Austria, out of a total of approximately 5,500 registered dental doctors, 2,600 had a contract with the health insurance system in 2014. In 2024, their number decreased to 2,377. To increase the number of dentists who work based on contracts within the health insurance system, the authorities are trying to improve working conditions by increasing the reimbursement rates from health insurance, reducing bureaucratic requirements, and decreasing the workload. Austria is threatened, in a few years, by a crisis of dental doctors. Among the causes are the growing wave of retirements and the conditions considered unattractive for doctors who want to work in the public system and offer health insurance-covered services. As a result, some dental positions under contract with the insurance system remain unfilled, and access to medical services is put at risk. 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