Oral health-related quality of life and patient payment systems

Abstract: Since 1999, the Public Dental Health Service in Värmland has two alternative patient payment systems: Fee-for-service and Contract care. In Fee-for-service, the patient pays per provided service, after treatment. In Contract care, the patient enters a contractual agreement with the Public Dental Health Service, pays a fixed fee for a fixed period of time, and then receives all dental care needed and covered by the contract, without additional costs. The overarching aim was to investigate if the assumed different treatment philosophies in Contract and Fee-for-service care would lead to different outcomes, with patients in Contract care having better oral health-related quality of life than patients in Fee-for-service care. Study I was a literature review of previous research, with material gathered through searches in different databases. Studies II, III and IV were conducted on material gathered through a postal questionnaire in 2003, sent to 1,200 randomly selected patients in each patient payment system in the Public Dental Health Service in Värmland, in all 2,400 patients. Study I. There were indications of more preventive services, and in the long run, of decreased need for restorative care in capitation, compared to in fee-for-service. Regarding productivity, dentists’ satisfaction with their work and patients’ satisfaction with provided care, there was too little information to draw conclusions. Study II. The patients in Contract care were younger, better educated, to a larger extent married or living with somebody, born in Sweden, and had better general health and oral health-related quality of life, than the Fee-for-service care patients. On the other hand, the latter felt a higher degree of social affinity with their housing area. Study III. Controlling for possible confounding factors in hierarchical multiple regression analysis, oral health-related quality of life was associated with patient payment systems: patients in Contract care had significantly better oral health-related quality of life than had the patients in Fee-for-service care. Study IV. In path analyses, using structural equating modeling, there were indications of different underlying mechanisms in the patient payment systems. In Fee-for-service care, the patient’s perception of the caregiver’s patient-centred stance was associated with oral health-related quality of life: the more patient-centred stance, the better the oral health-related quality of life. This relationship was not present in Contract care. There patient-centredness was associated with how much the patient was prepared to pay: the more she was prepared to pay, the higher she ranked her caregiver as being patient-centred. This was not found in Fee-for-service care. What the patient had paid for dental care the previous year was associated with a decrease in oral health-related quality of life in both systems. However, the association was twice as strong in Fee-for-service care, compared to Contract care. In conclusion, there were differences between the patient payment systems, influencing oral health-related quality of life. Even though selection bias cannot be excluded, the fact that the bivariate differences regarding e.g. education and age did not remain in the multivariate analyses indicated that the differences found in oral health-related quality of life probably are due to the payment systems themselves. This conclusion was strengthened by the fact that the differences found in underlying mechanisms in the systems were not related to background variables, but to variables associated with the dental care situation.

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