Payment systems and incentives in dentistry

Pressing issues for oral care quality improvement: findings from the EU DELIVER project

BACKGROUND

While oral health often takes a backseat to other health domains, it silently affects nearly half of the Worldwide population. The DELIVER project, funded by the EU's Horizon Europe program, seeks to develop a blueprint model for improving the quality of oral health care for everyone.

METHODS

Applying the Nominal Group Technique (NGT), 17 stakeholders from various backgrounds participated in identifying pressing issues for oral care quality improvement across practice, community, and policy levels.

RESULTS

The results revealed significant differences at the different levels, with accessibility emerging as a prominent issue, encompassing affordability, availability, and acceptability of oral healthcare services.

CONCLUSIONS

These findings emphasizes the need for policy reforms, increased investments, and a shift towards preventive and patient-centered dental care practices. It highlights the importance of collaborative efforts with multi-stakeholders and prioritizing pressing issues on a multi-level to drive positive change in improving oral care quality.

Wimpole Timings study

Introduction Studies show that changes to dental incentive structures and treatment timings impact behaviour among UK general dental practitioners (GDP). Since 1980, the British Dental Association (BDA) has conducted panel inquiries to understand the time taken to complete dental treatments, the most recent of these being the 1999 Heathrow Timings study.Aims Given significant changes to the UK general dental service (GDS) since 1999, this research aims to gain a refreshed understanding of the time involved to complete clinical treatments in the UK and gain insight into working hours.Materials and methods This study adopted a mixed-method research design, adapted from the BDA's Heathrow Timings study. Averages for 34 adult and 12 children's treatments were found using an online survey and group discussion with 15 GDPs.Results Overall, GDPs worked 35.23 hours per week, at an hourly rate of £39.94. Comparison to the Heathrow study in 1999 shows an increase in time to deliver multiple treatments, including clinical examinations, root canals, extractions, composite fillings, porcelain veneers, acrylic full dentures and children's extractions.Conclusion Overall, this study provides a current and updated insight into dental treatment times performed by GDPs in the UK and highlights a decrease in working hours and real-term earnings of GDPs over the past 20 years.

Painless cost control as a central strategy for universal oral health coverage: A critical review with policy guide

AIM

This study aimed to critically review the methods used to control the significantly increasing costs of dental care.

METHODS

Through a comprehensive search of the available literature, the cost control (CC) mechanisms for health services were identified from a healthcare system perspective. The probable applicability of each CC method was evaluated mainly based on its potential contribution to oral health promotion. Each mechanism was then classified and discussed under any of the two headings of financing and service provision. An operational guide was finally presented for policy-making in each of the three main models of healthcare systems, including National Health Services, social/public health insurance and private insurance.

RESULTS

From a total of 142 articles/reports retrieved in PubMed, 73 in Scopus and 791 in Google Scholar, 35 were included in the final review after eliminating the duplicates and screening process. Totally ten mechanisms were identified for CC of dental care. Seven were discussed under the financing function, including cost sharing, preauthorization, mixed payment method and an evidence-based approach to benefit package definition, among others. Three further methods were classified under the service provision function, including workforce skill mix with emphasis on primary oral healthcare providers, development of primary healthcare (PHC) network and an appropriate use of tele-dentistry.

CONCLUSION

Painless control of dental expenditures requires a smart integration of prevention into the CC plans. The suggested policy guide emphasizes organizational factors; particularly including the development of PHC-based networks with midlevel providers (desirably extended-duty dental hygienists) as the frontline oral healthcare providers.

Singapore dentists' attitudes toward dental care provision for older adults with disabilities

OBJECTIVES

This study aimed to assess dentists' attitudes toward providing dental care for older adults with disabilities in Singapore and the factors influencing their willingness to provide care.

BACKGROUND

Dentists face a rapidly ageing patient demographic. Practitioner unwillingness to circumvent the attending challenges of care provision prevents older adults from accessing the dental care necessary for better oral and systemic health. Previous studies have reported on dentists' attitudes toward caring for older adults with disabilities; however, these are mostly limited to dependent older adults and exclude frail, community-dwelling older persons.

METHODS

A cross-sectional study was conducted in 2020 using a self-administered questionnaire. Quantitative data analysis was presented in the form of descriptive statistics, followed by bivariate analyses.

RESULTS

There were 193 respondents, a response rate of under 9%. Dentists were less willing, confident and involved in the care of older adults with disabilities as the individual's severity of impairments increased. Less than half of respondents were willing to treat individuals with severe disabilities in cooperation (23.3%), swallowing (30.6%), mobility (33.7%) and communication (45.1%). Dentists with training in geriatric dentistry were more willing to provide care. However, younger dentists, general dental practitioners, private practitioners and public sector dentists had specific restraining and driving forces, which further modulated their willingness to provide care.

CONCLUSIONS

The current areas of training needs among Singapore dentists are in severe impairments of swallowing, communication, cooperation and mobility. Further geriatric dentistry training may effectively increase dentists' willingness to provide care; however, additional specific targeted interventions are also needed.

Exploring avoidance of dental care due to dental fear and economic burden -A cross-sectional study in a national sample of younger adults in Norway

AIM

To assess the prevalence of dental avoidance due to dental fear and economic burden and its distribution by utilization of dental care and socio-behavioural characteristics.

METHOD

A sample of 9052 Norwegian adults aged 25-35 years was invited to participate, and 2551 completed electronic questionnaires regarding lifetime prevalence of dental avoidance due to fear and last year prevalence of dental avoidance due to economic burden.

RESULTS

Cancelled- and avoided ordering appointments due to fear amounted to 14.7% and 30.5%, respectively. Avoidance of dental visits due to cost was 37.7%. Frequency of cancelled appointments due to fear was 30% and 16.6% among participants attending dental care several times annually and seldom, respectively. Multiple logistic regression revealed that avoiding dental visits due to cost was less likely among participants with higher household income (OR 0.4, 95% CI 0.3-0.5) and more likely among participants with dental care need (OR 1.8, 95% CI 1.2-2.7). Cancelled and avoided appointments due to fear was most likely among those with need for dental care and lower education. Early unpleasant experience with dental care remained a covariate of avoidance behaviour due to fear.

CONCLUSION

14.7%, 30.5%, and 37.7% confirmed cancelled appointments due to fear, avoided ordering appointments due to fear, and avoided visiting the dentist due to cost. Avoiding dental care due to fear and economic burden was more and less common among participants with respectively, frequent and seldom use of dental care. Dental avoidance behaviours were highest among socially disadvantaged groups, indicating a hole in the welfare state model that needs political consideration.

The role of income and frequency of dental visits in the relationship between dental sealant use and resin fillings after extended coverage: a retrospective cohort study

BACKGROUND

Prevention and treatment services use is closely associated with socioeconomic factors, such as income. This study aimed to investigate the relationship between implementing the sealant program and resin fillings restoration and to explore the role of income and frequency of dental visits in this relationship.

METHODS

This retrospective cohort study used the cohort database from the National Health Information Database of the National Health Insurance Service. The study population comprised 494,731 children born in 2007. A logistic regression model for the experience of resin fillings and a linear regression model for weighted utilization of them were used to identify the independent effects of dental sealants, income, and frequency of dental visits. All analyses were conducted using the SAS Enterprise Guide version 7.1 (SAS Institute Inc., Cary, NC, USA).

RESULTS

The ratio based on income level was almost proportional in all groups except the medical aid group, which had a rate as high as that of the wealthier group. Children without sealants were 1.05 times more likely to have resin fillings than others after adjusting for income level and frequency of visiting dental clinics in the final model. However, an opposite relationship between sealant experiences and resin fillings was observed in the previous model without dental visits. The gap in the weighted resin filling scores according to socioeconomic variables showed a similar tendency.

CONCLUSIONS

Income and frequency of dental visits might be confounding factors for the relationship between dental sealant and resin fillings. It is necessary to consider the complex relationship between socioeconomic indicators and service use while studying oral health inequality.

Geographic patterns of dental service use in the Child Dental Benefits Schedule: 6 years of claims in the Longitudinal Study of Australian Children

ISSUE ADDRESSED

This article explores the geographic patterns of claims within the Australian Government's Child Dental Benefits Schedule (CDBS).

BACKGROUND

The CDBS is a means-tested schedule implemented in 2014 to improve access to dental services for children. Under the schedule, eligible children receive funding to subsidise dental services.

METHODS

This study used data from the Longitudinal Study of Australian Children and linked data from the Medicare universal healthcare system, to examine dental service use amongst a subset of children aged 10 and 14 years. Dental service items were classified using Two-step Cluster Analysis, and appointments were analysed using multinomial logistic regression. Geographic characteristics were included as predictor variables.

RESULTS

The study found that the majority of dental appointments were non-operative (70.7%, n = 5808), with diagnostic, radiographic, and preventive items being the most common. There were slightly higher proportions of operative appointments (fillings and extractions) compared with non-operative appointments in remote and very remote areas, low socio-economic areas, and Queensland and Northern Territory. Cluster analysis identified eight groups of non-operative appointments and four groups of operative appointments. New South Wales had a higher proportion of 'prophylactic IV' appointments than any other State and Territory, which included debridement and topical fluoride services.

CONCLUSION

Cluster analysis identified distinct groups of non-operative and operative appointments, each with unique characteristics. The distribution of appointments varied by State/Territory and region.

SO WHAT

Further research and interventions are needed to ensure equitable access to services and a shift to preventive care for disadvantaged populations of Australian children. Exploring alternative funding models that support clinically relevant claims, rather than maximising financial benefits such as time-based renumeration models should be explored.

Do Norwegian private dental practitioners with too few patients compensate for their loss of income by providing more services or by raising their fees?

OBJECTIVE

In Norway, supply of dental services exceeds demand, mainly because of the marked improvement in dental health during the last few decades. The aim of the study was to investigate whether private dental practitioners counteract a fall in demand for their services by providing more services or by raising their fees.

METHODS

The data were collected using a questionnaire that was sent to all private dental practitioners in Norway. Altogether 1237 practitioners responded, which gave a response rate of 56%. Our sample was representative of the population of practitioners in Norway. As a measure of patient supply, responses from the following questions were used: 'Based on an overall assessment of economy, workload and other personal factors, is the number of regular patients adequate? If not, do you wish to have more patients, or fewer patients?' The outcome variables were dental fees, length of recall interval and mean cost per visit. The data were analysed using ordinary least square regression and a linear probability model. The following characteristics of the private dental practitioners were included as control variables: age, gender, work experience in years and whether they worked in a solo practice. To test the robustness of the findings, a supplementary analysis with the patient as the unit of analysis was carried out, using survey data of Norwegians aged 20 years and older. Based on this survey, the relationship between population: dentist ratio and mean cost per dental visit were examined.

RESULTS

Nearly 40% of all practitioners reported that they had too few patients. They compensated for their loss of income by raising their fees, by recalling their patients more often and by increasing the cost per visit. The finding in the supplementary analysis using survey data from patients was similar to the findings in the main analyses using survey data from private dental practitioners.

CONCLUSION

The findings show that practitioners have market power. They were able to counteract a fall in demand for their services by providing more services and by raising their fees. The dental profession should be encouraged to provide appropriate services, in the present situation where supply exceeds demand.

Inequality in access to dental services in a market-based dental care system: A population study from Norway 1975-2018

OBJECTIVE

To examine income-related inequalities in access to dental services from 1975 to 2018. In Norway, dental care services for adults are privately financed. This may lead to income-related inequalities in access. In the early 1970s, that is, at the beginning of the study period, there were marked inequalities in access to dental services according to personal income. However, from the beginning of the 1970s, there has been a large increase in gross national income per capita in Norway as a result of the growth of the oil and gas industry. This increase in income also meant that people with a low income in 1975 had a rise in their level of income. According to the law of diminishing utility, an increase in income leads to higher consumption of dental services for people with a low level of income compared to people with a high level of income. The study hypothesis is that the inequalities in access to dental services that existed in 1975 became less over time.

METHODS

Statistics Norway collected samples of cross-sectional health survey data for the following years: 1975, 1985, 1995, 2002, 2008, 2012 and 2018. For each sample, individuals 21 years and older were drawn randomly from the non-institutionalized adult population using a two-stage stratified cluster sample technique. Inequalities were measured using the concentration index. The dependent variable was the use of dental services during the last year, and the key independent variable was equivalized household income.

RESULTS

The concentration index for inequalities in use of dental services according to income decreased from 0.10 (95% CI = 0.09, 0.11) in 1975 to 0.04 (95% CI = 0.03, 0.05) in 2018. The decrease was particularly large from 2002 to 2012. This was a period with a large growth in gross national income.

CONCLUSION

People with a low income had a marked increase in their purchasing power from 1975 to 2018. This coincided with an increase in demand for dental care for this low-income group.

Cross-Sectional Analysis of Oral Healthcare vs. General Healthcare Utilization in Five Low- and Middle-Income Countries

Oral health is integral to overall health and is often neglected, especially in low- and middle-income countries (LMICs). Oral disease, including untreated dental caries, affects nearly 3.5 billion people globally, contributing to poor health and quality of life. To examine the relationship between the utilization of general healthcare and oral healthcare, we conducted an exploratory cross-sectional study of first-visit interview data collected from a convenience sample of 3,422 low-income mothers and 4,324 children aged 6 months through 6 years participating in a community-based oral health and nutrition program in five LMICs (Ecuador, El Salvador, India, Nepal, and Vietnam) from 2006–2015. We used descriptive and exploratory association analysis to identify patterns of oral healthcare utilization for mothers and children compared to medical care utilization, specifically maternal prenatal care and child immunizations. Overall, 89.6% of the mothers had received prenatal care for at least one child, but only 76.4% had ever received dental care and 50% were currently suffering from oral health symptoms, primarily oral pain. Mothers who received prenatal care were significantly more likely to have accessed dental care compared to those who had not received prenatal care (OR = 2.62, 95% CI: 2.06, 3.32). Overall, 95.4% of the children had current immunizations, but only 30.1% had ever received dental care, and 32.4% were currently suffering from oral pain. Children whose immunizations were up-to-date were more likely to have received dental care, with a significant association in Ecuador (OR = 3.29, 95% CI: 2.06, 5.30). Compared to utilization of general healthcare, oral healthcare was under-utilized by mothers and children in our sample from five LMICs. Integration of prevention- and treatment-oriented oral healthcare into primary medical care services, particularly prenatal care and child immunizations, could help increase access to oral healthcare and improve women's and children's oral health.

Dentists´ and Dental Hygienists´ experiences of the Capitation Contract System-the dilemma of conflicting loyalties

OBJECTIVE

The Capitation Contract system (CCS) is a payment model adopted by the Swedish Public Dental Health Service (PDHS). Patients enrolled in the CCS are usually assessed as being at lower risk of dental disease and are more regular dental attenders than those treated by Fee for Service (FFS). With increasing numbers of patients and CCS enrolments, Sweden faces a shortage of dental personnel. Our aim was to analyse dentists´ and dental hygienists´ perceptions and experiences of the capitation contact system.

MATERIAL AND METHODS

Eleven dentists and dental hygienists from three Swedish regions participated in online qualitative interviews conducted according to the Grounded Theory methodology.

RESULTS

When working with CCS the informants tried hard ´to find a balance between attitudes, compliance with guidelines and clinical resources´. Not all patients were offered CCS, even though they qualified: among other determinants were the informants' interpretations of guidelines and regulations, clinical resources, and patient interest.

CONCLUSIONS

When dental resources are in balance, the informants appreciate the CCS and consider it to be favourable to patient health but are aware of conflicting loyalties of their dual roles of insurance sales agent and care provider. The informants´ individual mindset affects which patients are offered CCS enrolment.

Pay-for-performance and dental procedures: A longitudinal analysis of the Brazilian Program for the Improvement of Access and Quality of Dental Specialities Centres

OBJECTIVE

Evaluate the impact of a pay-for-performance program on changes in the number of dental procedures performed by public secondary dental care services in Brazil.

METHODS

A longitudinal study was carried out with 932 public Dental Specialities Centres (Centro de Especialidades Odontológicas - CEO) that participated in the pay-for-performance Program for the Improvement of Access and Quality of Dental Specialities Centres Services (PMAQ/CEO) and 379 non-CEO centres with secondary dental production. The non-CEO and a group of CEOs did not receive financial incentives from the PMAQ-CEO and served as control groups. Three CEOs groups received additional financial incentives of 20%, 60% or 100% over maintenance values, based on their performance scores. The outcome was the increase (yes/no) in the number of dental procedures between 2011/2013 and 2015/2017. Analyses were carried out using logistic regressions.

RESULTS

The number of specialized procedures increased in 48.4% of the services, 44.6% among non-CEO, 52.3% among CEO with no financial incentive and 59.1% among CEO with 100% incentive. The fully adjusted model showed that CEOs receiving 100% of the financial incentive had greater odds of increasing the production of dental procedures (OR = 1.65, 95%CI: 1.09-2.51). Services that increased the number of specialist dentists had (OR = 2.35, 95%CI 1.88-2.94). Municipalities that increased in coverage of private dental insurance had OR = 0.98 (95%CI: 0.94-1.02), and those with higher coverage of primary dental care had OR = 1.02 (95%CI: 0.99-1.05).

CONCLUSION

Pay-for-performance may increase the production of dental procedures by CEOs, and mechanisms explaining it must be further investigated.

Willingness to Pay for Preventive Dental Care Amongst Older Adults

OBJECTIVE

The aims of this study were (1) to investigate willingness to pay (WTP) for preventive and curative dental care procedures and (2) to determine the factors that influence older adults' WTP for dental care.

METHODOLOGY

Older, independently living adults from Singapore aged 60 years and older and eligible for government-subsidised dental care were nonrandomly recruited for this study. Data were collected using questionnaires and a clinical examination which recorded details of caries experience, number and distribution of posterior occluding contacts, prosthodontic status, and periodontal status. Using a contingent valuation method, participants were asked to rate WTP in Singapore dollars [SGD$] for 4 aspects of care: dental fillings, dental scaling, dental extraction, and disease prevention advice. Negative binomial regression was used to assess the relationship between the predictor variables associated with WTP for dental fillings, scaling, extraction, and preventive advice.

RESULTS

The mean value of WTP for a dental filling was SGD$30.23 (SGD$31.05), for scaling was SGD$30.28 (SGD$29.46), for dental extraction was SGD$35.08 (SGD$58.54). In a multivariate model, factors associated with higher WTPfees were as follows: (1) dental filling: age (younger), level of education (higher), and frequency of dental visits (regular); (2) scaling: level of education (higher), agree that dental problems affect overall health, and frequency of dental visits (regular); (3) dental extractions: age (younger), level of education (higher), frequency of dental visits (regular), and prosthodontic status (not wearing); (4) preventive advice: age (younger), gender (male), ethnicity (Chinese), level of education (higher), marital status (married), self-perceived oral health (good), and dental visits (regular).

CONCLUSIONS

The findings of our study suggest that older adults are willing to pay most for extraction and least for preventive advice.

Dental Policy Lab 2 - towards paying for health in dentistry

The first Alliance for a Cavity-Free Future (ACFF)/King's College London Dental Policy Lab, held in 2017, identified the need for a review of dental payment systems in order to see progress towards achieving improvements in caries and cavities. The lack of incentivisation for preventive intervention and care has long been a barrier to progress. The second Dental Policy Lab, held in July 2018, focused on this issue with the overarching question: 'How can we create and implement acceptable prevention-based dental payment systems to achieve and maintain health outcomes?' Using a design approach and participatory research, 29 participants from five stakeholder categories developed a blueprint report that aims to serve as a framework to adapt or create remuneration systems that are compatible with evidence-based dentistry with a focus on preventive care. Aimed at policymakers and policy entrepreneurs, this blueprint provides guidance and potential solutions using several international examples. The report and accompanying infographic explored in this paper have been well received and have helped to frame discussions in several country settings, with a direct implementation which is being trialled in France in 2021.

Rationalisation and 'McDonaldisation' in dental care: private dentists' experiences working in corporate dentistry

Introduction This study examines how dentists experience the corporatisation of dentistry and the impacts of rationalisation. The emergence of corporate dentistry in the early twenty-first century has introduced greater competition into the dental marketplace. Ritzer's theory of 'McDonaldisation' explores the rationalisation of services through corporatisation and provides an apt framework with which to understand the qualitative insights gathered through this project.Methods Semi-structured interviews and reflective journals were used to collect insights from dentists who were working in private practice. Data were then subjected to thematic analysis.Results A total of 20 private dentist participants provided 22 separate interviews and multiple reflective accounts. Following analysis, three key themes emerged: 1) opportunities provided by corporate dentistry; 2) balance between professionalism and commercialism in corporate dentistry; and 3) competition between independent and corporate dentistry.Conclusions The participants' insights demonstrate how Ritzer's four dimensions of rationalisation - efficiency, predictability, calculability and control - have been encapsulated by corporate dentistry in Australia. Corporate interests in Australian dentistry are perceived to improve competition and offer opportunities for younger and less experienced dentists, but the findings also suggest that those leading corporate dentistry need to ensure that rationalisation does not diminish the caring relationship between dentists and patients.

Reorienting Oral Health Services to Prevention: Economic Perspectives

Despite the recognized need to change the emphasis of health services by shifting the balance from treatment to prevention, limited progress has been made in many settings. This is true in oral health, where evidence for preventive interventions that work has not been systematically exploited in oral health services. While reorienting health services is complex and context specific, economics can bring a helpful perspective in understanding and predicting the impact of changes in resource allocation, provider remuneration systems, and patient payments. There is an increasing literature on the economics of different prevention approaches. However, much of this literature focuses on the costs and potential savings of alternative approaches and fails to take into account benefits. Even where benefits are taken into account, these tend to be narrowly focused on clinical outcomes using cost-effectiveness analysis, which may be of little relevance to the policy maker, patient, and the public. Some commonly used economic approaches (such as quality-adjusted life years and incremental cost-effectiveness ratios) may also not be appropriate to oral health. Using alternative techniques, including wider measures of benefit and employing priority setting and resource allocation tools, may provide more comprehensive information on economic impact to decision makers and stakeholders. In addition, it is important to consider the effects of provider remuneration in reorienting services. While there is some evidence about traditional models of remuneration (fee for service and capitation), less is known about pay for performance and blended systems. This article outlines areas in which economics can offer an insight into reorientation of health systems toward prevention, highlighting areas for further research and consideration.

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe

INTRODUCTION

Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care.

OBJECTIVES

To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries.

METHODS

A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis.

RESULTS

Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme.

CONCLUSION

Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system.

KNOWLEDGE TRANSFER STATEMENT

The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases.

Planning the oral health workforce: Time for innovation

The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop ‘fit for purpose’ healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery.

Forecasting future dental health expenditures: Development of a framework using data from 32 OECD countries

Objective

To (1) develop a framework for forecasting future dental expenditures, using currently available information, and (2) identify relevant research and data gaps such that dental expenditure predictions can continuously be improved in the future.

Methods

Our analyses focused on 32 OECD countries. Dependent on the number of predictors, we employed dynamic univariate and multivariate modelling approaches with various model specifications. For univariate modelling, an auto‐regressive (AR) dynamic model was employed to incorporate historical trends in dental expenditures. Multivariate modelling took account of historical trends, as well as of relationships between dental expenditures, dental morbidity, economic growth in terms of gross domestic product and demographic changes.

Results

Estimates of dental expenditures varied substantially across different model specifications. Models relying on dental morbidity as one of the predictors performed worst regardless of their specification. Using the best‐fitted model specification, that is the univariate second‐order autoregression [AR(2)], the forecasted dental expenditures across 32 OECD countries amounted to US$316bn (95% forecasted interval, FI: 258‐387) in 2020, US$434bn (95%FI: 354‐532) in 2030 and US$594bn (95%FI: 485‐728) in 2040. Per capita spending in 2040 was forecasted to be highest in Germany (US$889, 95%FI: 726‐1090) and lowest in Mexico (US$52, 95%FI: 42‐64).

Conclusions

The present study demonstrates the feasibility and challenges in predicting dental expenditures and can serve as a basis for improvement towards more sustainable and resilient health policy and resource planning. Within the limitations of available data sources, our findings suggest that dental expenditures in OECD countries could increase substantially over the next two decades and vary considerably across countries. For more accurate estimation and a better understanding of determinants of dental expenditures, more comprehensive data on dental spending and dental morbidity are urgently needed.

Overtreatment as an ethical dilemma in Australian private dentistry: A qualitative exploration

BACKGROUND

The phenomenon of overtreatment in dentistry is under-explored and has not been the subject of much research inquiry. Most dental care in Australia is provided by practitioners in private dental practice. This research expands understanding of how the nexus between professionalism and commercialism in dentistry is impacted by the phenomenon of overtreatment.

METHODS

Data were collected through recorded interviews and written reflections from private dentists working in the Australian context. The data were then examined using thematic analysis to understand common themes and reveal deeper insights.

RESULTS

A total of 20 participants were recruited for this study. Participants spoke of their experiences in practice where financial targets and pressure from practice owners to provide high-cost treatments presented challenges to their professionalism. The participants expressed that the way in which dentistry is remunerated based on activity was a motivation towards engaging in overtreatment. The participants also spoke of finding a balance between commercialism and professionalism within private dental practice.

CONCLUSIONS

Participants' reports provided insights into how the mismanagement of the commercial elements of private dental practice led to a transactional ('buyer beware') relationship between the consumers and providers of dental services, rather than a relationship founded upon professional altruism and trust. Consumer empowerment through the commercialization of dentistry has potential to be a positive influence on the patient experience in accessing dental care. However, this research has shown that the shift of power through consumerism also risks attenuating professional appreciation of the imbalanced nature of the patient-clinician relationship in dentistry.

Advancing value in oral health through meaningful measurement

Central to all value-based purchasing (VBP) approaches are value metrics, the measurements used to drive improvement, facilitate payment, and evaluate results of VBP programs. This article outlines approaches for adopting meaningful measurement systems that can be used to support VBP in the near term and identifies systemic changes critical to developing more robust measurement systems to advance VBP in the future.

Educational inequalities in access to fixed prosthodontic treatment in Norway. Causal effects using the introduction of a school reform as an instrumental variable

OBJECTIVES

Equality in access to dental services, independent of level of education, is an important aim of Scandinavian welfare policy. In Norway, this policy is the main justification for a dental public subsidy scheme for adults. An important part of the subsidy scheme is to cover the cost of fixed prosthodontic treatment, including implant-based crowns and bridges for premolars, canines and incisors. A stated policy goal is to secure equal access to everybody in need of these services, independent of their level of education. The aim of this study was to estimate the causal effect of education on the probability of receiving fixed prosthodontic treatment in the adult Norwegian population.

METHODS

During the period 1960-1972, all municipalities in Norway were required to increase the number of compulsory years of education from seven to nine years. We used this education reform as the instrumental variable to create exogenous variation in the individual's number of years of education. The education data were combined with data from the Norwegian Health Economics Administration, which contained our outcome variable. Our sample included individuals with 9 years education or less. Altogether 113 237 individuals were included in the study.

RESULTS

For men, the first stage regression coefficient was 0.87 (confidence interval: 0.82-0.92). This means that the reform resulted in 0.87 additional years of education. For men, the probability of receiving fixed prosthodontic treatment increased by 0.67 percentage points per additional year of schooling. For women, the first stage regression coefficient was 0.84 (confidence interval: 0.79-0.88). The second stage regression coefficient was small (= 0.0022) and not statistically significant at a conventional level.

CONCLUSION

From a welfare policy point of view, for men, the subsidy scheme has not succeeded to redistribute resources so that dental services are accessible independent of their social status.

Main Factors Leading to Supplier-Induced Demand in Iran: A Comprehensive Review

Context: Supplier-induced demand (SID) is one of the challenges of health systems, leading to unbearable expenses, particularly for people. Objectives: The present study aimed to investigate the factors leading to SID in Iran. Data Sources: The present study is a comprehensive systematic review focusing on studies of SID up to the end of May 2018 in six English databases, five Persian databases, and two search engines. The exclusion criteria were publications in languages other than Persian and English and publications after May 2018. Data Extraction: A data extraction form was used to record authors' names and specifications, year of publication, the city of the study, language, purpose, methodology, data collection method, and factors influencing the induced demand. The risk of bias was assessed using a standard risk of bias tool. Results: We found 514 papers. Eventually, 16 papers met the inclusion criteria, and they were selected for the study. We found 11 papers in the Persian language and five articles in English. The design of 37.5% of the articles was qualitative, 31.25% analytical, 25% descriptive-analytical, and 6.25% descriptive. Factors influencing SID were classified at four levels including meta-level (Ministry of Health and Medical Education (MoHME)), macro-level (universities of Medical Sciences), meso-level (service providers), and micro-level (patients). Conclusions: According to the results of this research, creating SID can lead to serious challenges for health systems, service providers, patients, and insurance organizations. Therefore, health managers and policymakers need to design appropriate strategies such as adopting the evidence-based approach to purchasing services by the insurer and approval of standards and rules to reduce such SID.

Osteoporosis risk assessment in primary dental care-The attitudes of Swedish dentists, patients and medical specialists

OBJECTIVE

To explore and identify the attitudes of dentists, patients and medical specialists regarding implementation of osteoporosis risk assessment into Swedish primary dental care.

BACKGROUND

Osteoporosis is a major health problem leading to fragility fractures. As shown in academic-based research, dental radiological examination can be used for osteoporosis risk assessment. A substantial number of patients undergo radiographic examinations in primary dental care each year, but little is known about implementation of osteoporosis risk assessment in this setting.

MATERIALS AND METHODS

A qualitative research approach using focus group discussions and manifest content analysis was applied. Five focus groups with dentists and representatives from patient support groups and a single individual interview with one medical specialist were included in the sample.

RESULTS

From the manifest content analysis, three categories emerged: (a) barriers to change in practice, (b) benefits to change in practice, and (c) needs and requirements prior to change in practice. Most participants felt that there was insufficient knowledge of osteoporosis as well as a heavy existing workload. A concern was expressed about medical practitioners' willingness to take on responsibility for patients referred by dentists. Representatives from patient support groups highlighted a lack of knowledge about osteoporosis among both the general public and the medical professionals. Clear guidelines and improved communication channels between stakeholders would have to be established to ensure a smooth treatment path for patients.

CONCLUSION

Despite interest in osteoporosis risk assessment in primary dental care, there are political, workflow and educational barriers that must be overcome for successful implementation.

A Survey of Common Payment Methods and Their Determinants in Dental Clinics, in Tehran, 2018

Objective  It is believed that the payment method to dentists may affect their treatment decisions. Although payment systems may enhance job satisfaction, reduce the costs, and make better treatment decisions, there is little information about how to achieve these objectives. The aim of the present study was to survey the payment methods and the related factors in dental clinics of Tehran.

Materials and Methods  Using the latest list published by the Iranian Ministry of Health, we visited all dental clinics located in Tehran, and used a checklist to collect the data of the type of management, geographical location of the clinic in Tehran, payment method and its amount, history of payment method changes in the last decade, relationship between the amount of payment and the position of technical supervisor dentist, any difference in the amount of payment to male and female dentists and to young and experienced dentists. Then, the relationship between the amount of payment and the above-mentioned variables was investigated.

Results  The governmental sector tends to use fixed salary methods and the private sector usually uses the fee-for-service (FFS) method. Geographical location, type of management, date of establishment, and having the position of technical supervisor dentist had a significant relationship with the amount of payment. The dentist’s gender and years of experience did not have any relationship with the amount of payment.

Conclusion  According to the results of the present study, the method and amount of payment to dentists were related to the date of clinic establishment, having the position of technical supervisor dentist, and geographical location of the clinic. These factors could be considered as the main elements in balancing costs in clinics and improving job satisfaction among dentists.

Ending the neglect of global oral health: time for radical action

Oral diseases are a major global public health problem affecting over 3·5 billion people. However, dentistry has so far been unable to tackle this problem. A fundamentally different approach is now needed. In this second of two papers in a Series on oral health, we present a critique of dentistry, highlighting its key limitations and the urgent need for system reform. In high-income countries, the current treatment-dominated, increasingly high-technology, interventionist, and specialised approach is not tackling the underlying causes of disease and is not addressing inequalities in oral health. In low-income and middle-income countries (LMICs), the limitations of so-called westernised dentistry are at their most acute; dentistry is often unavailable, unaffordable, and inappropriate for the majority of these populations, but particularly the rural poor. Rather than being isolated and separated from the mainstream health-care system, dentistry needs to be more integrated, in particular with primary care services. The global drive for universal health coverage provides an ideal opportunity for this integration. Dental care systems should focus more on promoting and maintaining oral health and achieving greater oral health equity. Sugar, alcohol, and tobacco consumption, and their underlying social and commercial determinants, are common risk factors shared with a range of other non-communicable diseases (NCDs). Coherent and comprehensive regulation and legislation are needed to tackle these shared risk factors. In this Series paper, we focus on the need to reduce sugar consumption and describe how this can be achieved through the adoption of a range of upstream policies designed to combat the corporate strategies used by the global sugar industry to promote sugar consumption and profits. At present, the sugar industry is influencing dental research, oral health policy, and professional organisations through its well developed corporate strategies. The development of clearer and more transparent conflict of interest policies and procedures to limit and clarify the influence of the sugar industry on research, policy, and practice is needed. Combating the commercial determinants of oral diseases and other NCDs should be a major policy priority.

Unintended consequences and challenges of quality measurements in dentistry

BACKGROUND

In recent years, several state dental programs, researchers and the Dental Quality Alliance (DQA) have sought to develop baseline quality measures for dentistry as a way to improve health outcomes, reduce costs and enhance patient experiences. Some of these measures have been tested and validated for various population groups. However, there are some unintended consequences and challenges with quality measurement in dentistry as observed from our previous work on refining and transforming dental quality measures into e-measures.

MAIN BODY

Some examples of the unintended consequences and challenges associated with implementing dental quality measures include: a de-emphasis on patient-centeredness with process-based quality measures, an incentivization of unethical behavior due to fee-for-service reimbursement systems, the risk of compromising patient and provider autonomy with plan-level measures, a disproportionate benefits of dental quality measurement going toward payers, and the risk of alienating smaller dental offices due to the resource-intensive nature of quality measurement.

CONCLUSION

As our medical counterparts have embraced quality measurement for improved health outcomes, so too must the dental profession. Our ultimate goal is to ensure the delivery of high quality, patient-centered dental care and effective quality measurement is the first step. By continuously monitoring the performance of dental quality measures and their continued refinement when unintended consequences are observed, we can improve patient and population health outcomes.

Do Patients With More Education Receive More Subsidized Dental Care? Evidence From a Natural Experiment Using the Introduction of a School Reform in Norway as an Instrumental Variable

BACKGROUND

In Norway, for several dental conditions, a substantial part of treatment costs are reimbursed by the National Insurance Scheme. Ideally, the probability of receiving subsidized dental care (SDC) should be independent of social determinants of health, such as education, so that dental services are accessible to everyone independent of their social status.

OBJECTIVE

The main objective of this study was to estimate the causal effect of education on the probability of receiving SDC in the adult Norwegian population.

RESEARCH DESIGN

During the period 1960-1972, all municipalities in Norway were required to increase the number of compulsory years of education from 7 to 9 years. This education reform was used to create exogenous variation in the education variable. Since municipalities implemented the reform at different times, we have both cross-sectional and time series variation in the reform instrument. Thus we were able to estimate the effect of education on the probability of receiving SDC by controlling for municipality fixed effects and trend variables.

SUBJECTS

This study included all Norwegian adults, born during the period of 1947-1958.

MEASURES

Information about education (number of years), whether the individuals had received SDC, place of residence (municipality) was collected.

RESULTS

The probability of receiving SDC was found to increase by 2 percentage points per additional year of education.

CONCLUSION

People with the most resources benefit the most from a universal welfare scheme that is addressed to reach everybody. We suggest providing information about the subsidy scheme in a way that is easily available and understandable to all individuals, independent of their level of education.

Applying the theory of planned behavior to self-report dental attendance in Norwegian adults through structural equation modelling approach

BACKGROUND

Understanding factors that affect dental attendance behavior helps in constructing effective oral health campaigns. A socio-cognitive model that adequately explains variance in regular dental attendance has yet to be validated among younger adults in Norway. Focusing a representative sample of younger Norwegian adults, this cross-sectional study provided an empirical test of the Theory of Planned Behavior (TPB) augmented with descriptive norm and action planning and estimated direct and indirect effects of attitudes, subjective norms, descriptive norms, perceived behavioral control and action planning on intended and self-reported regular dental attendance.

METHOD

Self-administered questionnaires provided by 2551, 25-35 year olds, randomly selected from the Norwegian national population registry were used to assess socio-demographic factors, dental attendance as well as the constructs of the augmented TPB model (attitudes, subjective norms, descriptive norms, intention, action planning). A two-stage process of structural equation modelling (SEM) was used to test the augmented TPB model.

RESULTS

Confirmatory factor analysis, CFA, confirmed the proposed correlated 6-factor measurement model after re-specification. SEM revealed that attitudes, perceived behavioral control, subjective norms and descriptive norms explained intention. The corresponding standardized regression coefficients were respectively (β = 0.70), (β =0.18), (β = - 0.17) and (β =0.11) (p < 0.001). Intention (β =0.46) predicted action planning and action planning (β =0.19) predicted dental attendance behavior (p < 0.001). The model revealed indirect effects of intention and perceived behavioral control on behavior through action planning and through intention and action planning, respectively. The final model explained 64 and 41% of the total variance in intention and dental attendance behavior.

CONCLUSION

The findings support the utility of the TPB, the expanded normative component and action planning in predicting younger adults' intended- and self-reported dental attendance. Interventions targeting young adults' dental attendance might usefully focus on positive consequences following this behavior accompanied with modeling and group performance.

Perceptions of primary health care service users regarding dental team practices in Brazil

BACKGROUND

The Unified Health System (SUS) is the Brazilian set of public health services that offers global access to health care and disease treatments for all citizens. These services have been evaluated by means of a national survey assessing the users' perceptions.AimTo explore and characterize the SUS users' perceptions regarding primary dental team practices in the five Brazilian geographical regions.

METHODS

Descriptive study. The sample consisted of 37 262 subjects. Data were collected by means of the Ministry of Health survey, conducted between 2012 and 2014. Variables used in the present study are associated with SUS users' perspectives of satisfaction, access, and use of services. The study utilized bivariate data analysis, and dichotomous variables were derived for analysis following 95% reliability.FindingsThis study observed similarities and proportionality of perceptions in the Brazilian territory. In most macro-regions, dental teams did not develop an active search for dental treatment absentees. However, the SUS users reported very good and good perceptions, which were homogeneously distributed across five Brazilian regions, thereby showing an overall positive perception of primary dental treatment.