Reimbursement
of dental care
Björn Söderfeldt
Department of Oral Public Health, Malmö University,
Sweden
FDI 2008
Three basic systems in
reimbursement of dental care:
• Fee-for-service (FFS)
• Capitation (CAP)
• Salary (private or National
Health Service)
The systems are analytical categories
and can be combined in many ways.
They can also be combined with
Third-party-payment (TPPS) in
insurance systems, and with Patient
payment systems (PPS)
Patient payment system:
The patient pays before or after
treatment
Subscription care: The patient pays a
set fee in advance for dental care
during a given time period, according
to a risk classification. Can be
combined with CAP
The various European models for
dental care have different
combinations of the systems. FFS is
the rule for adults with varying access
to salaried public systems. CAP as a
system occurs primarily in child care
(Widström, Eaton 2004)
There are theoretical pros and cons
for all systems (Grytten 2005):
• FFS
Assures quality
Nonselective
Market imperfections
impair cost-effectiveness
Opens for supplier-induced
demand
“Overtreatment” ?
• CAP
High effectiveness
Equality in access
High administration costs
Patient selection
Under-treatment ?
• Salary
Predictable cost
No money in patient
contacts
Low efficiency
Low productivity
In public systems: fiscal
problems
There is no “best” system!!
However, should systems be judged
only by efficiency or productivity?
There are also moral aspects!!
Dentistry is a human service
occupation, and as all human
services, it is morally founded. The
core of the work is
THE CLINICAL ENCOUNTER
The clinical encounter
Gender
Age
Training
Personality
Dentist
Care organization
Work load
Control over work
Financing system
Clinical
judgment
E
n
c
o
u
n
t
e
r
Gender
Age
Experience
Personality
Health
Fear
Selfesteem
Patient
Social class
Education
Resources
Ethnicity
What is the moral aspect of
the encounter?
Dental care is a GOOD that should be
distributed.
The discourse of distributive justice in
moral philosophy is therefore relevant.
(Miller “Social Justice” 1985)
RIGHT
You should have something good because you
are entitled to it according to law, agreement or
natural rights
The basic principle of bureaucracy
In CAP, you acquire a right to care,
most obviously in subscription
systems
VIRTUE
You should have something good because you
deserve it, due to virtue or payment
The basic principle of the market
In FFS, you are entitled to care if you
pay for it
NEED
You should have something good because you
need it
Three kinds of need:
1. Subjective need - only the shoe wearer knows
where it pinches
2. Objective need - someone else decides what
you need
3. Emancipatory needs - the perception of needs
depends on the perceived opportunities for
realization
In public salaried systems, it can be
possible to set need as distributive
principle
The clinical encounter revisited
Professional
Patient
Objective
need
Emancipatory
need
Right
Virtue
Subjective
need
Bureaucrat
Supermarket
Schlaraffenland
Therapy
bureaucrat
Human
being
Citizen
Customer
Spoiled child
Professional
patient
Human
being
Basic hypothesis
Harmony when relations are
congruent
Disharmony and conflict when
incongruent
Theory is nice, but evidence is scarce.
In a comprehensive review of 2507
articles, aiming to find system
comparisons, Johansson et al (2007)
found:
• A long-term tendency of decreased
caries incidence in CAP
• CAP decreases restorative treatments
• CAP increases preventive care, mainly
preventive advice and fissure sealants
• Productivity does probably not decrease
with CAP
• Neither does dentist nor patient
satisfaction
Great uncertainty and limited materials
A recent contribution: An evaluation of
subscription care vs. FFS in a
salaried system in the county of
Värmland, Sweden, as to the effects
on oral health (Johansson et al 2007)
The Public Dental Service in the
county of Värmland introduced
subscription care 1999. A comparative
survey was done 2003 on 1324
patients (sample 2400, response rate
57 %).
OHIP-14 used to measure oral
health, SF-36 for general health
Bivariate analysis
Johansson et al. Patients’ health in contract
and fee-for-service care. I. A descriptive
comparison. Swed Dent J. 2007; 31: 27-34
Demographic differences
Subscription care
FFS
• Mean age: 42 yrs (SD 13)
• Mean age: 52 yrs (SD 17)
– Range: 21-87 yrs
•
•
•
•
•
96 % born in Sweden
76 % married/cohab
14 % elem educ
35 % college
42 % high affinity to
neighborhood
– Range: 21-89 yrs
•
•
•
•
•
91 % born in Sweden
70 % married/cohab
36 % elem educ
22 % college
49 % high affinity to
neighborhood
Significant differences, p<0.05
Oral health related quality of life
(OHIP-14), index
Range: 0-56
Low value, better oral health related quality of life
Subscription care
FFS
•
•
•
•
•
•
•
•
Mean= 4.9
CI 95%=4.53-5.33
SD=5.3
Median= 4.0
Mean= 6.9
CI 95%=6.22-7.54
SD=8.3
Median= 4.0
Significant difference, p=0.019
OHIP-14, dimensions
Subscription
FFS
(680≤n≤684)
(616≤n≤624)
Mean (SD)
Mean (SD)
p
Functional limitation
0.3 (0.8)
0.6 (1.3)
<0.001
Physical pain
1.9 (1.5)
2.2 (1.8)
0.023
Psychological troubles
1.1 (1.5)
1.4 (1.9)
0.063
Physical disability
0.3 (0.8)
0.7 (1.3)
<0.001
Psychological disability
0.7 (1.1)
1.0 (1.5)
0.003
Social disability
0.2 (0.7)
0.4 (1.0)
0.007
Handicap
0.3 (0.8)
0.6 (1.2)
<0.001
Dimension
General health (SF-36), dimensions
Subscription
FFS
(678≤n≤685)
(604≤n≤628)
Dimension
Mean (SD)
Mean (SD)
p
Physical function
92.7 (13.6)
84.6 (21.8)
<0.001
Role function-physical
84.5 (29.6)
77.0 (36.6)
0.002
Pain
77.1 (24.1)
74.5 (26.8)
0.221
General health
78.0 (19.1)
72.4 (21.9)
<0.001
Vitality
64.6 (23.2)
65.3 (24.9)
0.267
Social function
87.8 (19.6)
84.9 (22.4)
0.045
Role function-emotional
84.7 (30.3)
83.1 (32.9)
0.570
Psych well-being
79.0 (18.2)
78.5 (18.9)
0.962
Multivariate analyses
Johansson et al. Multivariate analyses of patient
financial systems and oral health-related quality of life.
Submitted manuscript
Regression models
Dependent variable: OHIP-14
Range: 0-56
p≤0.001 fo all models
Variable
Finance system
Model 1
Finance system: FFS (vs. subscription)
1.95
Adj R2
0.02
Variable
Model 2
Finance system
Finance system: FFS (vs. subscription)
1.40
Economic factors
Willingness to pay (11 categories)*
-0.26
Paid previous year (11 categories)*
0.96
Adj R2
0.08
* Reference category: ”0-500”. Range: 0-5 001 SEK or more
Variable
Model 3
Finance system
Finance system: FFS (vs. subscription)
1.62
Economic factors
Willingness to pay (11 categories)
-0.24
Paid previous year (11 categories)
1.00
Sex: Woman (man)
0.55
Age (21-89)
-0.02
Adj R2
0.08
Individual factors
Variable
Model 4
Finance system
Finance system: FFS (vs. subscription)
1.28
Economic factors
Willingness to pay (11 categories)
-0.20
Paid previous year (11 categories)
0.97
Sex: Woman (man)
0.54
Age (21-89)
0,03
Birth country: Other (Sweden)
4.11
Marital status: Single (married/cohab)
0.75
Education: Secondary (elementary)
-1.11
Individual factors
Social factors
College (elementary)
-0.77
Social anchorage (2-8)
0.30
Adj R2
0.11
Variable
Model 5
Finance system
Finance system: FFS (vs. subscription)
0.89
Economic factors
Willingness to pay (11 categories)
0.00
Paid previous year (11 categories)
0.74
Individual factors
Sex: Woman (man)
Age (21-89)
-0.11
0,03
Finance system
Finance system: FFS (vs. subscription)
-0.02
Social factors
Birth country: Other (Sweden)
2.97
Marital status: Single (married/cohab)
0.89
Education: Secondary (elementary)
-0.87
College (elementary)
Psychological factors
-0.15
Social anchorage (2-8)
0.17
Dental Anxiety Scale (4-20)
0.37
Humanism Scale (8-40)
-0.09
Self-esteem Scale (6-24)
-0.37
MHLC – Powerful others (2-10)
0.14
MHLC – Internal (2-10)
0.01
MHLC – Chance (2-10)
0.23
Adj R2
0.18
Variable
Model 6
B0
13.49
Finance system
Finance system: FFS (subscription)
0.92
Economic factors
Willingness to pay (11 categories)
0.04
Paid previous year (11 categories)
0.70
Sex: Woman (man)
-0.02
Age (21-89)
-0.01
Birth country: Other (Sweden)
2.90
Marital status: Single (married/cohab)
0.40
Education: Secondary (elementary)
-0.65
Individual factors
Social factors
College (elementary)
Psychological factors
Health factors
0.14
Social anchorage (2-8)
0.10
Dental Anxiety Scale (4-20)
0.25
Humanism Scale (8-40)
-0.09
Self-esteem Scale (6-24)
-0.13
MHLC – Powerful others (2-10)
-0.01
MHLC – Internal (2-10)
0.15
MHLC – Chance (2-10)
0.21
Sense of coherence (20-91)
-0.08
SF-36 Physical component (PCS) (9.51-71.04)
-0.08
SF-36 Mental component (MCS) (-0.12-69.66)
-0.08
Adj R2
0.23
Cautious conclusion about Värmland:
There may be characteristics in the
subscription care system itself that
have positive impact on oral health
General conclusions:
1. No possible evidence-based system
recommendations
2. Systems should be evaluated as to their
effects on health
3. Dentistry is not only production but
primarily CARE
4. More research needed with a
comprehensive perspective
THANK YOU FOR YOUR ATTENTION!
Bjorn.Soderfeldt@mah.se