A study on moral hazard in dentistry: costs of care in the private and the public sector

"To enroll or not to enroll": a qualitative study on preferences for dental insurance in Iran

BACKGROUND

Oral public health services are included in primary healthcare. Although oral diseases are preventable, improving oral health has become a concern in many countries. Evidence shows that functioning insurance coverage can significantly increase the use of dental health services, improve quality of services, and reduce financial barriers to utilization. Little evidence exists on households' preferences for dental insurance in Iran. This study seeks to identify the households' preferences for dental insurance in Tehran-Iran.

METHOD

This is a qualitative study. We interviewed 84 participants who visited selected public and private dental clinics in Tehran-Iran, from October 2018 until January 2019. All interviews were recorded and transcribed verbatim. We used a mixed inductive/deductive approach for thematic analysis of the interviews.

RESULTS

We identified two main themes and 12 sub-themes: pecuniary attributes (insurance premium, coinsurance, insurance coverage granted, discounting option, reimbursement of expenses), and non-pecuniary attributes (notification status, ethical issues, benefits package, contract providers with health insurance, quality of service centers, administrative process, and dental insurance scheme).

CONCLUSION

Our participants considered both pecuniary and non-pecuniary attributes for choosing a dental insurance package. Our findings could help, we envisage, policymakers understand Iranian households' preferences for a dental insurance scheme that they afford to buy.

Complementary health insurance, out- of- pocket expenditures, and health services utilization: A population- based survey

Background: Studies have shown that people using complementary health insurances have more access to health services than others. In the present study, we aimed at finding the differences between out- of- pocket payments and health service utilizations in complementary health insurances (CHIs) users and nonusers. Methods: Propensity score matching was used to compare the 2 groups. First, confounder variables were identified, and then propensity score matching was used to compare out- of- pocket expenditures with dental, general physician, hospital inpatient, emergency services, nursing, midwifery, laboratory services, specialists and rehabilitation services utilization. Results: Our results revealed no significant differences between the 2 groups in out- of- pocket health expenditures. Also, the specialist visits, inpatient services at the hospital, and dental services were higher in people who used CHIs compared to nonusers. Conclusion: People did not change their budget share for health care services after using CHIs. The payments were equal for people who were not CHIs users due to the increase in the quantity of the services.

Investments and costs of oral health care for Family Health Care

OBJECTIVE

To estimate the investments to implement and operational costs of a type I Oral Health Care Team in the Family Health Care Strategy.

METHODS

This is an economic assessment study, for analyzing the investments and operational costs of an oral health care team in the city of Salvador, BA, Northeastern Brazil. The amount worth of investments for its implementation was obtained by summing up the investments in civil projects and shared facilities, in equipments, furniture, and instruments. Regarding the operational costs, the 2009-2012 time series was analyzed and the month of December 2012 was adopted for assessing the monetary values in effect. The costs were classified as direct variable costs (consumables) and direct fixed costs (salaries, maintenance, equipment depreciation, instruments, furniture, and facilities), besides the indirect fixed costs (cleaning, security, energy, and water). The Ministry of Health’s share in funding was also calculated, and the factors that influence cost behavior were described.

RESULTS

The investment to implement a type I Oral Health Care Team was R$29,864.00 (US$15,236.76). The operational costs of a type I Oral Health Care Team were around R$95,434.00 (US$48,690.82) a year. The Ministry of Health’s financial incentives for investments accounted for 41.8% of the implementation investments, whereas the municipality contributed with a 59.2% share of the total. Regarding operational costs, the Ministry of Health contributed with 33.1% of the total, whereas the municipality, with 66.9%. Concerning the operational costs, the element of heaviest weight was salaries, which accounted for 84.7%.

CONCLUSIONS

Problems with the regularity in the supply of inputs and maintenance of equipment greatly influence the composition of costs, besides reducing the supply of services to the target population, which results in the service probably being inefficient. States are suggested to partake in funding, especially to cover the team’s operational cost.

Factors affecting sick leave prescribing by dentists

OBJECTIVES

The aim was to examine the prescribing of sick leave by dentists and factors affecting prescribing practices.

METHODS

A questionnaire study covering sick leave-prescribing practice during the preceding year and in response to 16 hypothetical patient cases was conducted among 1132 Finnish dentists. The effects of both dentist-related and local structural background variables on sick leave prescribing were studied.

RESULTS

During the preceding year, dentists who were young, male, or practicing in small municipalities prescribed more days of sick leave than comparator groups. In response to the 16 hypothetical cases, dentists prescribed a mean of 31.6 days of sick leave (range, 0-98 days). The dentists with a specialty degree in oral and maxillofacial surgery prescribed longer sick leave than other dentists. Dentists working only in public dental services (PDS) and older dentists prescribed significantly less sick leave than others.

CONCLUSIONS

There is considerable variation among dentists in sick leave-prescribing practices. The most significant factors affecting this variation are having a specialty in oral and maxillofacial surgery and working only in PDS. Further education and guidelines on dental sick leave prescribing are needed.

Private dentists assess treatment required as more extensive, demanding and costly, than public sector dentists

OBJECTIVES

The aim was to evaluate whether contracted private practitioners assess required treatment more extensive, demanding and economically more rewarding than mainly salaried public sector dentists and to estimate the cost consequences of using these alternative providers.

METHODS

All dental services included in comprehensive treatments funded by the city of Turku and provided to adult patients during the year 2009 were recorded. Patients were distributed randomly without any determination of treatment needs before appointing them to different dentists. Treatment courses for 7432 patients in public clinics included 63 906 procedures and for 2932 patients assigned to treatment by contracted private practitioners included 21 194 procedures. Public sector dentists were mainly salaried with production incentives, and private practitioners worked purely on a fee-for-service basis. The cost estimates were based on the distributions of competence classifications recorded by the providers, which also formed the basis for reimbursement.

RESULTS

For each studied treatment category with more than one competence classification, private contractors were less likely than their public sector counterparts to give an assessment of simple or less demanding: 8% versus 29% of examinations, 46% versus 69% of periodontal treatments, 63% versus 85% of extractions, 31% versus 46% of fillings, 18% versus 35% of root canals. The excess cost to society varied from 7.0% for root canal treatments to 21.3% for extractions, causing on average 14.4% higher cost level from use of private practitioners compared with public sector dentists.

CONCLUSIONS

Private practitioners systematically classified the treatment procedures they provided as more demanding, and therefore more economically rewarding, than their public sector counterparts. The findings indicate that the costs of publicly funded dental care may be increased by the use of private dental contractors.