Is value-based healthcare a strategy to achieve universal health coverage that includes oral health? An Australian case study

The 2021 Resolution on Oral Health by the 74th World Health Assembly supports an important health policy direction: inclusion of oral health in universal health coverage. Many healthcare systems worldwide have not yet addressed oral diseases effectively. The adoption of value-based healthcare (VBHC) reorients health services towards outcomes. Evidence indicates that VBHC initiatives are improving health outcomes, client experiences of healthcare, and reducing costs to healthcare systems. No comprehensive VBHC approach has been applied to the oral health context. Dental Health Services Victoria (DHSV), an Australian state government entity, commenced a VBHC agenda in 2016 and is continuing its efforts in oral healthcare reform. This paper explores a VBHC case study showing promise for achieving universal health coverage that includes oral health. DHSV applied the VBHC due to its flexibility in scope, consideration of a health workforce with a mix of skills, and alternative funding models other than fee-for-service.

Did Dental Insurance Expansion Improve Dental Care Needs Among Korean Adults? Difference in Difference Analysis

BACKGROUND

In 2012, the Korean government expanded dental insurance for the elderly to promote improved access to dental care. We examined the causal effect of this policy on dental care needs, focusing on low-income older adults.

METHODS

We compared data before and after policy implementation using double difference (DD) and triple difference (DDD) analyses. We used the nationally representative data from the Korea National Health and Nutrition Examination Survey from 2010 and 2016-2018. Individuals aged ≥65 years were included in the treatment group, and individuals aged <65 years were included in the control group.

RESULTS

Dental insurance expansion was associated with a paradoxical increase in perceived unmet dental needs among elderly individuals (8.8 percentage points increase, 95% CI: 4.7 to 13.0). However, there were improvements in dental prosthetics outcomes (denture wearing [4.0 percentage points, 95% CI: 0.2 to 7.9] and dental implants [5.0 percentage points, 95% CI: 2.1 to 7.9]; P < 0.01). Upon analyzing low-income elderly individuals using DDD analysis, we found that the insurance expansion led to a 21.6% smaller increase in unmet dental needs among low-income adults, compared to high-income adults (95% CI, -35.0 to -8.5; P < 0.01).

CONCLUSION

Dental insurance expansion in South Korea resulted in improvements in access to dental prosthetic services overall. It also led to a smaller increase in unmet dental needs among low-income older adults, compared to high-income adults.

Oral health inequality among Indonesian workers in South Korea: role of health insurance and discrimination factors

Background

The health of migrant workers is becoming an important public health issue. Although there are an increasing number of migrant workers in Korea, the health status in migrant populations remains unknown. The aims of this study were (1) to evaluate the association between income and self-rated oral health (SROH), and (2) to assess the role of health insurance and self-perceived discrimination in the association between income and SROH among Indonesian migrant workers in Korea.

Methods

Information about self-reported income, SROH, coverage/utilization of health insurance (HI), living difficulties related to oral health (LDROH), oral health literacy (OHL), and discrimination were obtained from Indonesian migrant workers in Korea (n = 248). The main explanatory variable was income, and SROH was an outcome variable. Logistic regression analyses were performed controlling for age, gender, HI, LDROH, OHL, and discrimination. The paths from income to SROH were analyzed using the Partial Least Square-Structural Equation Model (PLS-SEM).

Results

Among Indonesian migrant workers, the lower income group had the highest probability of a poor SROH compared to the higher income group. The variables showing a high explanatory power were discrimination among the low income group and HI among the middle income group. In PLS-SEM, the variables such as HI, LDROH, OHL, and discrimination contributed 11% to explaining the association between income and SROH.

Conclusion

A monotonic gradient was revealed among migrant workers according to the association between income and SROH. Discrimination and HI contributed to oral health inequalities.

Inequality in dental services: a scoping review on the role of access toward achieving universal health coverage in oral health

BACKGROUND

Improving access to health services is a way towards achieving universal health coverage (UHC) in oral health. The purpose of this review was to map the determinants of access to dental services within a UHC framework.

METHOD

Scoping review methods were adopted for the review. PUBMED, Scopus, ISI Web of Science and ProQuest were searched for academic literature on determinants of access to dental services in OCED countries. Articles published in the last 20 years were included. No restriction was placed on study methods; only articles in English language were included. Qualitative synthesis was conducted, along with a trend analysis and mapping exercise.

RESULT

A total of 4320 articles were identified in the initial search; 57 articles were included in the qualitative synthesis. The results indicate 7 main themes as the determinants of access to dental services: family condition, cultural factors, health demands, affordability of services, availability of services, socio-environmental factors, geographical distance. Defined determinants of access to dental services, family condition, cultural factors and geographical access to dental services can fill the population axis of the UHC cube. Health demands and affordability of services fill the gap of financial protection as another axis of the UHC cube and finally, availability of dental services and socio-environmental factors are aligned with the appropriateness of services, the third axis of the UHC cube.

CONCLUSION

According to the results, family condition and cultural, health demands, affordability and availability of services, social environment, and geographic factors can affect dental health access and equality. Socio-cultural determinations also need to be considered in applied planning. Addressing these factors to improve access to dental services can pave the way for achieving universal health coverage in oral health and should be considered in different levels of policymaking.

An Investigation of the Association between Health Screening and Dental Scaling in Korea

Dental disease is one of the most prevalent chronic diseases worldwide, and its expenditure is continuously increasing. Periodontal disease is increasing as a chronic non-communicable disease in adults and older people. Health screening has been shown to be cost-effective and improves the quality of life through the early detection of diseases. This study aimed to analyze the relationship between national health screening and dental scaling as a preventive service for periodontal disease. The study used sample cohort data from 2002 to 2015 provided by the National Health Insurance Sharing Service in South Korea. A logistic regression analysis of the utilization of dental scaling was performed to identify the independent effects of national health screening. People who underwent health screening showed a higher tendency to undergo dental scaling. Additionally, disparities in utilization according to socioeconomic status were reduced among those who underwent screening. The intervention to extend dental coverage could be more beneficial when combined with health screening, encouraging more people to participate and reducing inequalities in utilization.

Community Water Fluoridation: Caveats to Implement Justice in Public Oral Health

Community water fluoridation (CWF), a long-established public health intervention, has been studied for scientific evidence from both of yea and nay standpoints. To justify CWF with scientific evidence inevitably leads to ethical justification, which raises the question of whether oral health is of individual concern or social responsibility. As dental caries is a public health problem, public health ethics should be applied to the topic instead of generic clinical ethics. From both pro- and anti-fluoridationists’ perspectives, CWF is a public health policy requiring a significant level of intervention. Thus, there needs to take further considerations for justifying CWF beyond the simple aspect of utility. For further ethical considerations on CWF, three caveats were suggested: procedural justice, social contexts, and maintenance of trust. The process to justify CWF should also be justified, not simply by majority rule but participatory decision-making with transparency and pluralistic democracy. Social contexts are to be part of the process of resolving conflicting values in public health interventions. Public trust in the dental profession and the oral healthcare system should be maintained over the considerations. This article suggests accountability for reasonableness as a framework to consider infringement by CWF for public justification of its implementation.

Trends in Self-Rated Poor Oral Health Among all Age Populations in Korea from 2007 to 2015: Monitoring Expansion of Dental Insurance

OBJECTIVES

This study explored trends in self-rated poor oral health (SRPOH) from 2007 to 2015 among all age groups to monitor changes after the expansion of dental insurance.

METHODS

Repeated cross-sectional data from 2007 to 2015 Korea National Health and Nutrition Examination Surveys were collected and analysed. The respondents (n = 20,199) were categorised into four age groups: 0-19, 20-44, 45-64, and ≥65 years. The outcome variable was SRPOH, with independent variables being socioeconomic factors, sex, household income, and education. The age-sex standardised prevalence rate was calculated to determine trends, and complex samples logistic regression analysis was performed to confirm the factors affecting SRPOH.

RESULTS

Self-rated poor oral health prevalence decreased significantly from 2007 to 2009 (25%) to 2013 to 2015 (14%) in the age groups of 0-19 and 20-44 years (P < 0.05), whereas the SRPOH prevalence in the age groups of 45-64 and ≥65 years did not undergo any significant changes. Although the prevalence decreased by 6% among older adults, over 40% older women still experienced SRPOH. A sex gap increased with age but did not change over time. SRPOH was strongly associated with sex, income, and education across all age groups; the association did not notably change from 2007 to 2015.

CONCLUSIONS

Self-rated poor oral health improved among younger people in Korea. The gender gap in the prevalence increased with age and persisted over time. However, income was the strongest determinant of SRPOH among all age groups, regardless of dental insurance expansion. Further studies should aim to draw causal inferences to explore the policy impact of dental insurance benefits.

Social backgrounds, oral behaviors and dental service utilization among Thai older adults: data from the national oral health survey

Purpose

The number of older adults in Thailand is currently increasing. To create the appropriate oral health service for this age group requires an understanding of the factors that are associated with their dental service utilization. This study aimed to determine the associations between social backgrounds, oral behaviors and dental service utilization among Thai older adults.

Design/methodology/approach

This was a cross-sectional study on a representative sample of older adults in the 8th Thai National Oral Health Survey (TNOHS). Data of 4,130 Thai older adults were collected through interviews. The association between social backgrounds, oral behaviors and dental service utilization were investigated using chi-square and logistic regression models.

Findings

Of the older adults aged 60–74 years old, 38.4% had used dental services in the last 12 months. Smokers used dental services the least (32.1%). Location, income, education and social welfare were significantly associated with dental service utilization. Among the oral behaviors evaluated, smoking was significantly associated with low dental service utilization.

Originality/value

Thai older adults with a poor social background including location, income, education, entitlement to the Universal Coverage Scheme (UCS) and smoking made less use of dental services.

Has the Health Insurance Coverage of Scaling Contributed Positively to Periodontal Health in Korea?

This study aimed to evaluate the effectiveness of the health insurance coverage of dental scaling (introduced in 2013) using the Community Periodontal Index of Treatment Needs parameter among Korean adults aged 20 years or older. We used the Korea National Health and Nutrition Examination Survey data from before and after 2013 to analyze the statistical significance and associations of the covariates with the prevalence of healthy periodontal tissues, prevalence of people in need of scaling, and prevalence of periodontal diseases. The results showed that the prevalence of healthy periodontal tissues increased by 4.9% (from 34.2% to 39.1%), the number of people in need of scaling decreased by 5% (from 65.9% to 60.9%), and the prevalence of periodontal diseases increased by 7.2% (from 23.4% to 30.6%). Moreover, after the scaling coverage policy, the odds ratio of the prevalence of healthy periodontal tissues was 1.10 times higher, the prevalence of the need for scaling was 1.5 times higher, and the prevalence of periodontal diseases was 0.90 times lower. Therefore, the state should formulate policies that provide dental biofilm management through a disclosing agent, impart education about oral hygiene, and develop a health management system that enables the concurrent management of periodontal diseases and systemic diseases.

Insurance coverage expansion and inequalities in unmet oral healthcare needs in Korea: Repeated cross-sectional analysis, 2007-2015

OBJECTIVES

This study aimed to evaluate whether Korea's 2012 health insurance expansion of adult dental care coverage reduced income-based oral health inequalities.

METHODS

This study analysed nationally representative repeated cross-sectional data from waves IV to VI (2007-2015) of the Korean National Health and Nutrition Examination Survey. The main outcome variable is unmet dental needs due to cost, and the independent variable is household income. Further, the slope index of inequality (SII) and the relative index of inequality (RII) were calculated. Calculations were adjusted for income and stratified by age group, gender and survey period. Data from the three waves were pooled to estimate the SII and RII trend coefficients between survey years. These were tested using two-way interaction terms for each age group and gender.

RESULTS

Some changes in income-based inequality trends were identified. Relative and absolute inequalities in unmet needs (indicated by the RII and SII) decreased over time for most age groups. However, this trend was not observed for older women.

CONCLUSIONS

Income-based inequalities in unmet dental needs persisted among older women in Korea despite the insurance expansion. By contrast, after the 2012 insurance expansion, the absolute and relative inequality in unmet dental needs decreased for young and middle-aged as well as older adults.

Did expanded access to denture services improve chewing ability in the Korean older population? Results of a regression discontinuity analysis

The Korean National Health Insurance expanded the dental insurance in 2012 to cover denture services for older adults. We analyzed whether the new policy improved of chewing ability in the eligible population. We used regression discontinuity (RD), a quasi-experimental design, to analyze the effects of the expanded dental insurance. We analyzed data from the Korea National Health and Nutrition Examination Survey conducted in 2010 and 2015. The study population consisted of two groups: the treatment group, aged 65 and above who were eligible; and the control group, under 65 years of age who were not eligible for the dental insurance benefit. The main outcome evaluated was self-reported chewing difficulty. The RD analysis showed that in 2015, the chewing difficulty in aged above 65 was 2.2% lower than in those aged under 65. However, the difference was not statistically significant (P = 0.76). The results from the falsification testing of predetermined covariates, placebo cut-offs, and bandwidths validated our main conclusion. The expansion of dental insurance benefits to include dentures for the older adults did not improve the chewing ability in the eligible population. Future studies should evaluate long-term outcomes of oral health as well as the social impacts on the elderly.

Did Expanded Dental Insurance Improve Chewing Ability in the Older Korean Population? Results of an Interrupted Time-series Analysis

Background

In 2012, the Korean National Health Insurance extended its coverage to include denture services for older adults. We examined whether the new policy resulted in improved chewing ability in the eligible population.

Methods

We used interrupted time-series (ITS) analysis, a quasi-experimental design, to analyze the effect of the policy. We used data from the Korea National Health and Nutrition Examination Survey conducted from 2007 to 2016–2018. The study population consisted of two groups: the treatment group, aged 65 years or older and eligible for the dental insurance benefit; and the control group, those younger than 65 years and ineligible. The main evaluated outcome was self-reported chewing difficulty.

Results

The ITS analysis showed that chewing difficulty decreased annually by 0.93% (95% CI, −1.30 to −0.55%) and 0.38% (95% CI, −0.59 to −0.16%) after the policy extension in the older than 65 and younger than 65 groups, respectively. However, we could not conclude that the insurance extension affected chewing difficulty because there was a decrease in the control group as well.

Conclusion

Chewing ability improved in both older and younger adults regardless of dental insurance coverage for older adults. Other exogenous factors probably led to the improvements in chewing ability as well as dental insurance benefits.

Did the Expansion of Insurance Coverage for Oral Health Reduce Self-reported Oral Health Inequalities in Korea? Results of Repeated Cross-Sectional Analysis, 2007-2015

BACKGROUND

In 2009, the South Korean government expanded universal health insurance to include oral health services. In the present study, we sought to examine whether improved access resulted in a reduction in income-based self-reported oral health inequalities.

METHODS

We analyzed repeated cross-sectional data from the Korea National Health and Nutrition Examination Survey (KNHANES) waves IV through VI (2007-2015). We analyzed self-reported oral health status among 68,431 subjects. Changes in oral health inequalities across four income levels (low, middle-low, middle-high, and high) were assessed with the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII).

RESULTS

The average oral health status of children and adolescents improved the most over the observation period. The absolute magnitude of oral health inequalities (measured by the SII) improved for most groups, with the notable exception of young male adults. By contrast, the ratio of poor oral health between high- and low-income groups (measured by the RII) changed little over time, indicating that relative inequalities remained resistant to change.

CONCLUSIONS

The expansion of dental health insurance may not be sufficient to move the needle on self-reported oral health inequalities among adults.

Trends in the utilization of dental outpatient services affected by the expansion of health care benefits in South Korea to include scaling: a 6-year interrupted time-series study

Purpose

This study utilized a strong quasi-experimental design to test the hypothesis that the implementation of a policy to expand dental care services resulted in an increase in the usage of dental outpatient services.

Methods

A total of 45,650,000 subjects with diagnoses of gingivitis or advanced periodontitis who received dental scaling were selected and examined, utilizing National Health Insurance claims data from July 2010 through November 2015. We performed a segmented regression analysis of the interrupted time-series to analyze the time-series trend in dental costs before and after the policy implementation, and assessed immediate changes in dental costs.

Results

After the policy change was implemented, a statistically significant 18% increase occurred in the observed total dental cost per patient, after adjustment for age, sex, and residence area. In addition, the dental costs of outpatient gingivitis treatment increased immediately by almost 47%, compared with a 15% increase in treatment costs for advanced periodontitis outpatients. This policy effect appears to be sustainable.

Conclusions

The introduction of the new policy positively impacted the immediate and long-term outpatient utilization of dental scaling treatment in South Korea. While the policy was intended to entice patients to prevent periodontal disease, thus benefiting the insurance system, our results showed that the policy also increased treatment accessibility for potential periodontal disease patients and may improve long-term periodontal health in the South Korean population.