Method of payment for children's dental services by practice type and geographic location.

The purpose of this project was to evaluate practice type and geographical differences in methods of payment accepted for children's dental services. A survey was mailed to 2000 general dentists and 1000 pediatric dentists randomly selected to provide representation from the 50 United States. Dentists were asked to specify the type of practice and the state in which they primarily practice. The survey included Medicaid, dental insurance, preferred provider organizations (PPO), and self-payment as payment options. Dentists were asked to indicate whether they never, occasionally, or frequently accepted each option of payment for children's dental services. Responses were received from 1245 (42%) dentists, including 723 general dentists and 522 pediatric dentists. Chi-square statistical analysis revealed significant practice type and regional differences in the acceptance of Medicaid for payment. Pediatric dentists accept Medicaid more frequently than general dentists (P < 0.001). Most dentists accept dental insurance and self-payment, while few indicate involvement with a PPO. The study revealed significant practice type differences only in the acceptance of Medicaid as payment for children's dental services. On a geographic basis, there were significant differences in the acceptance of Medicaid and dental insurance.     

Dentists' participation in capitation and preferred provider organization dental plans

BACKGROUND: In 1998, the American Dental Association Survey Center conducted a telephone and mail survey of U.S dentists in private practice in an effort to determine the extent of dentists' participation in capitation and preferred provider organization, or PPO, dental plans and the characteristics of dentists who participate in those plans. METHODS: An initial phone screening survey was conducted with a random sample of 11,550 dentists in private practice. Dentists who indicated that they participated in capitation or PPO dental plans received a follow-up mail survey asking specific questions concerning these two types of dental plans. RESULTS: Almost one-half of responding dentists indicated that they participated in either capitation or PPO dental plans. However, far more dentists reported participating in PPO dental plans than in capitation dental plans. The majority of participating dentists' patients were reported to be fee-for-service patients. CONCLUSIONS: Dentists' participation in PPO dental plans generally increased from that indicated in previous surveys, though participation in capitation plans declined. There was some regional and demographic variation in participation in these dental plans, but such differences were not large. Pricing and concerns about quality of care continue to be the primary concerns of nonparticipating dentists. PRACTICE IMPLICATIONS: Dentists reporting participation in PPO dental plans are becoming more common, but such plans still do not cover the majority of participating dentists' patients. A large percentage of nonparticipating dentists cite pricing and concerns about quality care as reasons for not joining these plans.     

Network capitation practices: a new concept

The percentage of consumers in the U. S. covered by dental insurance has increased dramatically over the last 10 years. As dental insurance grows, it is becoming increasingly important to examine the context of dental care payment systems. At present, almost all insurance programs are geared toward the fee-for-service system, which reimburses dentists a fixed sum for each type of procedure. The exceptions to fee-for-service dental insurance plans are few. A capitation program for dental care, which reimburses dentists a fixed amount per enrolled patient regardless of services rendered, offers many advantages for both consumers and providers and should be available as an option. Network capitation represents a new approach to the payment of dental care. A network capitation program is being developed in the United States and will use an approach involving two contracts, one which will be used with an insurance company, and the second with a network of private practitioners. The insurance company will supply dental practices with dental patients and funds on a capitation basis. Patients will be given the choice of fee-for-service or capitation. Network capitation allows fee-for-service solo or group practitioners to incorporate capitation patients into their practice.     

Payment systems and incentives in dentistry

In this commentary, we discuss the advantages and disadvantages of the following incentive‐based remuneration systems in dentistry: fee‐for‐service remuneration, per capita remuneration, a mixed payment system (a combination of fee‐for‐service remuneration and per capita remuneration) and pay‐for‐performance. The two latter schemes are fairly new in dentistry. Fee‐for‐service payments secure high quality, but lead to increased costs, probably due to supplier‐induced demand. Per capita payments secure effectiveness, but may lead to under‐treatment and patient selection. A mixed payment scheme produces results somewhere between over‐ and under‐treatment. The prospective component (the per capita payment) promotes efficiency, while the retrospective component (the fee‐for‐service payment) secures high quality of the care that is provided. A pay‐for‐performance payment scheme is specifically designed towards improvements in dental health. This is done by linking provider reimbursements directly to performance indicators measuring dental health outcomes and quality of the services. Experience from general health services is that pay‐for‐performance payment has not been very successful. This is due to significant design and implementation obstacles and lack of provider acceptance. A major criticism of all the incentive‐based remuneration schemes is that they may undermine the dentists’ intrinsic motivation for performing a task. This is a crowding‐out effect, which is particularly strong when monetary incentives are introduced for care that is cognitively demanding and complex, for example as in dentistry. One way in which intrinsic motivation may not be undermined is to introduce a fixed salary component into the remuneration scheme. Dentists would then be able to choose their type of contract according to their abilities and their preferences for nonmonetary rewards as opposed to monetary rewards. If a fixed salary component cannot be introduced into the remuneration scheme, the fees should be ‘neutral’; that is, they should just cover the costs of the services provided. This is one way in which supplier‐induced demand can be limited and costs contained.     

Characteristics of dentists participating in capitation and Preferred Provider Organization dental plans

BACKGROUND: In 1998, the American Dental Association Survey Center conducted a telephone and mail survey of U.S. dentists in private practice in an effort to determine the extent of dentists' participation in capitation and preferred provider organization, or PPO, dental plans and the characteristics of dentists who participate in those plans. METHODS: An initial telephone screening survey of a random sample of 11,550 dentists in private practice was conducted to identify dentists who participated in PPO or capitation dental plans. Dentists who participated in either of these plan types then were asked to complete a mail survey on their plan participation. RESULTS: The majority of dentists participating in either type of dental plan reported having never left a dental plan. Dentists who belonged to more than one PPO or capitation plan reported that a larger percentage of their patients were enrolled in these plans and that more of their practice's gross income came from the plans. Participation in PPO and capitation plans has had a positive impact on the practices of many of the responding dentists, particularly with regard to expanding their patient base. CONCLUSIONS: The authors found that the majority of dentists participating in PPO dental plans found it to be a positive experience overall. Dentists participating in capitation plans were less satisfied; more than 50 percent of capitation plan participants reported some level of dissatisfaction with the plans. The majority of dentists participating in a PPO plan expected to renew participation when their current contract expired; a much smaller percentage (though still a majority) of responding capitation-plan participants indicated the same. PRACTICE IMPLICATIONS: Responding dentists' overall indication of satisfaction with their current PPO plan participation probably indicates further growth for these dental plans. On the other hand, capitation plan participants seem much less satisfied with their plans. PPO plans, therefore, seem much more likely to be the type of plan that dentists will choose in the future.     

NYSDA Membership Survey. How the components stack up

There are many similarities and differences between the demographic characteristics of dentists, their practice arrangements, business activities, income and other factors, which do not follow the purported "downstate-upstate" dichotomy. In each district society, most respondents are sole proprietors, and 26+ years is the most frequently reported period of time in practice. A great majority of dentists in most component societies work 32+ hours per week, and average 50 to 56 scheduled and six to nine emergency visits per week. $175,000+ was reported most frequently as the net income of dentists in eight component societies. A small percent of practitioners belong to IPAs and capitation plans. A small percent accepts Medicaid patients. A somewhat larger percent belongs to DR plans. A much greater percent belongs to PPO arrangements. Approximately 25% of respondents expect that their primary occupation will change in the next 10 years, with the vast majority anticipating no longer being in dental practice.     

Influence of patients perception on their acceptance and understanding of dental care within an education system

This study examined the effects of conditions (that is, the fee structure and the easy of obtaining a dental appointment) on patient understanding and cooperation in clinical practice for dental hygiene and dental students. A questionnaire was given sequentially to 1483 patients attending the Tokyo Medical and Dental University dental hospital on "clinical education and patient satisfaction". Direct participants consisted of 650 patients, of which 213 (32.8%) were male and 422 (64.9%) female. The remaining 15 (2.3%) did not specify their gender. Patients who were satisfied with care received by dentists tended to be older compared to patients who were dissatisfied with dentists. The difference was significant (p < 0.001). Acceptable conditions for patients such as fees and appointments at the clinical session had an effected on patient acceptance of clinical training. The findings of this study suggest that patient satisfaction should be considered as part of the reasons for patients accepting dental care by students in their clinical education programs. Fees and appointment schedules strongly affect patient acceptance of clinical education.     

New Assumptions Concerning IP As and Cost of Dental Care

Objectives : Previous studies suggest that fee-for-service (FFS) patients receive more treatment and at a greater cost than capitation patients. In this study treatment plans of dentists who are members of an independent practice association (IPA), a preferred provider organization (PPO), or who are paid their usual fee for service are compared. Methods : A carefully selected and trained professional actor, with actual dental disease and recent radiographs, was sent to the offices of general practice dentists for an examination and treatment plan. To one group of dentists ( n =21) the patient said he was a member of a PPO plan served by that dentist, to a second group ( n =15) he said he was a member of an IPA plan served by that dentist, and to the third group ( n =19) he said he would pay by the traditional FFS method. Results : IPA dentists recommended more restorations (mean=9.60) than those in the PPO program (mean=5.95) or those paid by the traditional FFS method (mean=5.58). The anticipated mean cost to the patient was higher for the IPA dentists ($1,815.20) compared to the other two types (PPO=$1,186.24, FFS=$1,470.42). Conclusion : The IPA models studied in this investigation permitted dentists to charge copayments for most treatments beyond basic services. This type of IPA might be similar to a fee-for-service model that provides practitioners with an incentive to do more rather than less treatment.     

Supply Decisions among Dentists Working within a Fixed-fee System of Dental Care Provision

In Norway fees for dental treatment did not increase at the same rate as prices for other goods and services during the 1980s. The aim of this study was to examine how this decrease in fees in real terms has influenced dentists' work decisions with respect to supply of services. Data on characteristics of the dentist and the dental practice were collected for 1979, 1984, and 1986. The dependent variable was supply of dental services, measured as the number of patient care hours worked per annum. The hourly fee for dental care was equivalent to dentists hourly wage rate. Supply increased as fees decreased. This could be explained either as a response of the patient or the dentist to reduced fees. Although the data did not give conclusive evidence as to which effect was most important, the authors have put forward the view that the main effect was dentists' response to reduced fees. The main argument put in favor of this view is that dentists have an overall knowledge of the effect of a change in fees on their income. The impact of a change in fees is much greater on the provider who supplies the services to many individuals over a long period of time, than on an individual consumer who buys the services once or twice a year. It was concluded that, in the short run, a fixed-fee schedule may not be very effective in limiting costs for dental care.     

Overservicing in dental practice--ethical perspectives.

Overservicing or the acceptance of unnecessary, inappropriate, excessive or fraudulent treatment is regarded as sanctioned lying, cheating or stealing and thus constitutes unethical conduct and a breach of the integrity of the profession. During the past year the media have repeatedly reported that the private sector is bloated with overservicing: one of the most important factors contributing to the increasing inflation of health care costs. Overservicing is an ethical problem presenting with a conflict situation among the interests of the patient, the provider and the funder. For example, since dentists are in a position to gain financially from their professional recommendations, they are at risk of having a conflict of interest: by overservicing they collect more fees. Low medical aid tariffs, delayed payment of benefits, oversupply of dentists, decreasing business and the spiralling costs of dental materials and equipment are the primary causes of high practice overheads and low cash-flow levels. Dentists may seek alternatives such as overservicing or unnecessary treatment to generate income and to improve their cash flow and/or profit. The main motives for overservicing are economic survival and financial gain. Some dentists may overtreat unintentionally due to out-dated treatment philosophies or where criteria for diagnosis and effective care are not clear, leading to variation in treatment decisions. Some overservicing may be due to patient-initiated demand. Dentists are largely unregulated as to the appropriateness or necessity of treatment decisions because of their professional status. Society trusts that their professionals will put the benefit of those they serve above their own self-interests. The aim of this review is to provide dentists with some guidance to the process of ethical decision making, the ethical principles involved, moral rules, and guidelines for professional standard of care. Business considerations whether profit, financial gain or economic survival should never justify overservicing by the dentist. If the patients' best interests are always considered, the profession of dentistry can ethically exist within a business structure.     

Dental Providers' Attitudes Regarding the Application of Fluoride Varnish by Pediatric Health Care Providers

Objectives: To ascertain what proportion of dental hygienists and dentists in Indiana, United States, support the application of fluoride varnish in medical offices, and to determine if support differed by dental provider characteristics, practice characteristics, a limited assessment of knowledge about fluoride, or use of fluoride. Methods: Practicing dental hygienists and dentists in 2005 were asked to fill out a mail questionnaire. Logistic regression models tested the association of independent variables with support for medical providers applying varnish. Results: Response rates were 36% (dental hygienists) and 37% (dentists); median year of graduation was 1988 and 1981. Sixty‐six percent of respondents were in solo practices, 82% of dentists in general practice, 5% in dental pediatrics, and 13% were other specialists. While 51.2% of dental professionals agreed that medical practices could apply fluoride varnish, 29% responded “none” should be allowed, and 19% were undecided. In the multivariable logistic regression for support of medical practices applying fluoride versus not supporting it, three practice characteristics and two measures of fluoride use were significant. Provider characteristics and a limited assessment about knowledge about fluoride were not significant. Conclusions: Half of dental professionals felt that it was appropriate for medical providers to apply fluoride varnish; pediatric dental professionals were less supportive. A few dental practice characteristics were associated with acceptance of the use of fluoride varnish by medical care providers: targeting messages to dental hygienists and those with practices in mixed rural‐urban areas may be a useful approach to garner greater support for this medical/dental partnership.     

Clinical decision making by dentists working in the NHS General Dental Services since April 2006

In April 2006 a new contract was introduced that governed how NHS General Dental Practitioners would be funded for the services they provide. This study looks at the impact that the contract has had in the three years since its introduction, evaluating its influence on the clinical care that patients receive and the clinical decisions that dentists are making. This qualitative service evaluation involved interviewing 12 dentists representative of a range of NHS dentists involved with the new NHS dental contract using a semi-structured approach. We found evidence that the new contract has led to dentists making different decisions in their daily practice and sometimes altering their treatment plans and referral patterns to ensure that their business is not disadvantaged. Access to care for some patients without a regular dentist can be compromised by the new contract as it can be financially challenging for a dentist to accept to care for a new patient who has an unknown and potentially large need for treatment. Cherry-picking of potentially more profitable patients may be common. The incentive is to watch borderline problems rather than to treat if a treatment band threshold has already been crossed and treatment may be delayed until a later course of treatment for the same reason. Dentists often feel that complex treatments (for example, endodontic treatments) are financially unviable. Some dentists are referring difficult cases that might previously have been treated 'in house', such as extractions, to another provider, as this enables offloading of costs while potentially retaining full fees. Younger and less experienced dentists may be further pressured.     

Capitation dentistry: incentives and implications

Capitation is an incentive-based form of payment for dental care. Unlike fee-for-service benefit plans, the nature of reimbursement in capitation plans provide dentists with the necessary incentives to perform appropriate and necessary level of care, seek less costly but effective alternatives, and place an emphasis on prevention. This paper examined how some of these incentives work and their effects on the practice of dentistry.     

Ohio dental care providers' treatment of young children, 2002

BACKGROUND: Adequate access to dental care for young children--particularly those from low-income families--is a public concern. The authors conducted a survey of Ohio dental care providers to examine factors influencing their willingness to care for these children. METHODS: Random samples of Ohio general practitioner (GPs) dentists and pediatric dentists (PDs) and all Ohio safety-net dental clinics completed a mail survey regarding treatment of children aged 0 through 5 years. The authors categorized responses by provider type and further analyzed GPs' responses by years since graduation and geographic character. RESULTS: Few Ohio GPs (8 percent) recommended a first dental visit by 1 year of age. While 91 percent of GPs treated children aged 3 through 5 years, only 34 percent treated children aged 0 through 2 years, most often for emergency visits or examinations. Only 7 percent of all GPs and 29 percent of PDs accepted patients enrolled in Medicaid without limitations. CONCLUSIONS: Children's being young (0-2 years of age) and having Medicaid as a payment source made GPs substantially less likely to treat them. Children's being enrolled in Head Start made GPs somewhat more likely to treat them. PRACTICE IMPLICATIONS: New strategies for ensuring dental care access for young children from low-income families are necessary. Such strategies may take the form of interpeer advocacy, education, practice incentives or creation of coordinated GP and PD teams.     

Dental safety net capacity: An innovative use of existing data to measure dentists’ clinical engagement in state Medicaid programs

Background

The demand for dentists available for state Medicaid populations has long outpaced the supply of such providers. To help understand the workforce dynamics, this study sought to develop a novel approach to measuring dentists’ relative contribution to the dental safety net and, using this new measurement, identify demographic and practice characteristics predictive of dentists’ willingness to participate in Indiana's Medicaid program.

Methods

We examined Medicaid claims data for 1,023 Indiana dentists. We fit generalized ordered logistic regression models to measure dentists’ level of clinical engagement with Medicaid. Using a partial proportional odds specification model, we estimated proportional adjusted odds ratios for covariates and separate estimates for each contrast of nonproportional covariates.

Results

Though 75% of Medicaid‐enrolled dentists were active providers, only 27% of them had 800 or more claims during fiscal year 2015. As has been shown in previous studies, our findings from the proportional odds model reinforced certain demographic and practice characteristics to be predictive of dentists’ participation in state Medicaid programs.

Conclusions

In addition to confirming predictive factors for Medicaid enrollment, this study validated the clinical engagement measure as a reliable method to assess the level of Medicaid participation. Prior studies have been limited by self‐reported data and variations in Medicaid claims reporting.

Practical implications

Our findings have implications for state Medicaid policymakers by enabling access to data regarding dental providers’ level of participation in Medicaid in addition to identifying factors predictive of such participation. This information will inform Medicaid program plans and provider recruitment efforts.     

Scottish dentists' preferences for remuneration and their opinions on the scope of General Dental Service treatment

A questionnaire was sent to a list of what was considered to be all dentists currently in practice in the General Dental Service (GDS) and Community Dental Service (CDS) in Scotland; 72% responded. The dentists were asked to indicate the general method by which they would prefer to be paid, given a choice of fee for item-of-service, salary or capitation. Opinion was split among the GDS respondents, between fee for item-of-service (34.9%), a salaried system of payment (32.6%), or a service based on differing remuneration systems for the dental care of adults and children (22.5%). Only 22.6% of GDS respondents said they would prefer a capitation system for the treatment of child patients. Most CDS respondents said they preferred to be salaried. Dentists in both services were asked if they felt there was a need to extend the range of treatment items which are currently permitted in the GDS; most felt that there was. About 80% of all respondents felt that there was a need to allow payment for various items of preventive dental care within the GDS. Almost a third of GDS respondents also mentioned various items of restorative dental treatment which they felt should be funded (a concern which fewer CDS respondents (6.7%) mentioned). Few respondents suggested any other additional types of treatment items.     

The Capitation Study. 2. Does capitation encourage more prevention?

The results of a 3-year parallel, controlled clinical trial comparing a capitation system of payment for the dental care of children with fee-for-service, showed that capitation offered dentists more clinical freedom. Dentists in capitation used this to provide more preventive care, particularly advice to parents on the control of dental disease in their children. In contrast, few fissure sealants were placed and few topical fluoride applications were made under either system. However, parents in both systems were satisfied with the preventive service their children received and were confident of their ability to control their children's dental disease. The effect of this increased preventive activity was not yet apparent within the period of the study.