A cost and production analysis of hospital dental care programs

To provide hospital dental programs with useful information about the expansion of dental services and the identification of pertinent financial information, a production function and cost function analysis was performed. Results showed that hospital ownership (public or private) and size of the dental clinics were associated with the cost of providing dental services and the volume of services provided. Among 23 hospitals studied, private hospitals had a much lower cost per visit, had more paid attending dentist staff, paid their resident dentists less, and had significantly more billings paid by Medicaid and by patients than public hospitals. When stratified by ownership and size, these basic differences were accentuated for the small clinics. Except for primarily the Medicaid and self-pay billings, the characteristics of large public and private hospital dental clinics were extremely similar. Multiple regression analysis found that a decrease in cost per visit was associated with more visits to dentists and more to hygienists. Production of dental services could be increased by increasing the number of attending dentists, hygienists, and residents. Preliminary econometric analysis reveals that the optimal mix of attending dentists to resident dentists should be approximately 1.8 full-time equivalent (FTE) resident for every 1 attending FTE dentist to produce the most dental services at the lowest cost.     

Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?

Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. We propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. We apply this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing (1) independent private sector providers; (2) social franchises of private providers; (3) non-government organization (NGO) providers; and (4) government providers on these three factors. Franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. Our results highlight that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific.     

Achieving health outcomes through professional dental care: comparing the cost of dental treatment for children in three practice modes.

The search for effective strategies to deal with prevention and treatment of oral disease focuses on children as a natural target population. This article reports data on the comparative costs of delivering dental care to children via (1) a school-based practice using Expanded Function Dental Auxiliaries, (2) a school-based practice without EFDAs, and (3) a group of unrelated private dental practices operating independent of the school system. Utilization of a dentist's services varied significantly between the children assigned to private care and those assigned to the school-based programs, but it cost less per patient to provide dental treatment through the private practitioners. If school-based practices are clearly more effective in reducing dental disease, in the long run the need for manpower and resources in these programs might be lowered to a point where they will become more cost-effective than private practices. If the two delivery modes are equally effective in reducing dental disease, however, results from the study indicate that private practices are more cost-effective and will probably maintain their cost-effective advantage over school-based programs.     

Accessibility of and client satisfaction with dental services in Melbourne

Abstract: Public dental clinics play an important role in delivering dental services to Australian adults on low incomes. Our objective was to compare the accessibility of and client satisfaction with the two main types of public dental service providers in Victoria and with private practice services. Clients attending the Royal Dental Hospital of Melbourne, Northcote Community Health Centre and private practices in Melbourne were surveyed. The hospital's clients faced the greatest ecological and organisational obstacles, while private clients faced the greatest financial and desirability obstacles. Community centre clients faced fewer ecological and organisational obstacles than hospital clients, with the exception of long waiting times. Private practice clients were more satisfied overall, and had better continuity of care. Private practice clients were more satisfied with access, availability and convenience than community centre clients, who in turn were more satisfied than hospital clients. There was no distinction between private practice and hospital clients on satisfaction with 'pain and treatment', but community centre clients were less satisfied. There was no significant difference between client group evaluations of interaction with the dentist. Regardless of the effects of the Commonwealth Dental Health Program, distinctions between various service types and public clinic types are likely to remain, because of their different settings. The contrast between a central hospital and a community health centre, in terms of the ecological and organisational obstacles to care, points to the advantages of putting dental services close to the communities they serve.     

Separating financing from provision: evidence from 10 years of partnership with health cooperatives in Costa Rica

OBJECTIVE: This article examines the impact of contracting health care provision to health care cooperatives in Costa Rica. METHODOLOGY: The article uses a panel dataset on health care outputs in traditional clinics and cooperatives in Costa Rica from 1990-99. RESULTS: Controlling for community socioeconomic characteristics, annual time trends and clinic complexity, the cooperatives conducted an average of 9.7-33.8% more general visits (95% confidence interval), 27.9-56.6% more dental visits, and 28.9-100% fewer specialist visits. Numbers of non-medical, emergency and first-time visits per capita were not different from the traditional public clinics. These results suggest that the cooperatives substituted generalist for specialist services and offered additional dental services, but did not turn away new patients, refuse emergency cases, or substitute nurses for doctors as care providers. Cooperatives authorized 30.4-60.5% fewer sick days (95% confidence interval), conducted 24.7-37.2% fewer lab exams, and gave out 26.7-38.3% fewer medications per visit than the traditional public clinics. Real total expenditure per capita in cooperatives was 14.7-58.9% lower than in traditional clinics. CONCLUSIONS: The findings suggest that cooperatives might, with an appropriate regulatory framework and incentives, be able to combine advantages of public and private approaches to health care service provision. Under certain conditions, they might be able to maintain accessibility, a sense of mission and efficiency in service provision.     

Evaluation of immunization knowledge, practices, and service-delivery in the private sector in Cambodia

A study of private-sector immunization services was undertaken to assess scope of practice and quality of care and to identify opportunities for the development of models of collaboration between the public and the private health sector. A questionnaire survey was conducted with health providers at 127 private facilities; clinical practices were directly observed; and a policy forum was held for government representatives, private healthcare providers, and international partners. In terms of prevalence of private-sector provision of immunization services, 93% of the private inpatient clinics surveyed provided immunization services. The private sector demonstrated a lack of quality of care and management in terms of health workers' knowledge of immunization schedules, waste and vaccine management practices, and exchange of health information with the public sector. Policy and operational guidelines are required for private-sector immunization practices that address critical subject areas, such as setting of standards, capacity-building, public-sector monitoring, and exchange of health information between the public and the private sector. Such public/private collaborations will keep pace with the trends towards the development of private-sector provision of health services in developing countries.     

Assessment of waste amalgam management in dental clinics in Ramallah and al-Bireh cities in Palestine

The behavior of dental health personnel was examined with regard to the handling and proper disposal of wastes generated at common dental clinics, and some of the amounts of waste they produce were estimated. In January 2002, a random sample of 37 dental clinics was chosen in the cities of Ramallah and al-Bireh. The visited clinics were distributed between 31 private practices and six public/NGO dental clinics. The dentists were asked about the methods they follow in disposing and discarding of amalgam wastes. An average dentist is estimated to place two small, seven medium and nine large amalgam restorations releasing 22.6 grams of mercury each week. The majority of amalgam wastes ended up in trash or drain.     

Creating a successful school-based mobile dental program

BACKGROUND: Dental disease is one of the leading causes of school absenteeism for children. This article describes the creation and evolution of the St. David's Dental Program, a mobile school-based dental program for children. METHODS: The dental program is a collaboration of community partners in Central Texas that provides free dental care to low-income children in schools without relying on reimbursements or government funding. RESULTS: Since 1998, the program has provided 132,791 screenings for oral health treatment needs and 38,634 encounters for sealants or treatment. In 2005, the program provided $2.1 million worth of services at a cost of $1.2 million (not including donated services). Factors important to the program's success included sustained funding for general operating costs; well-compensated clinicians to deliver care and experienced human service workers to manage program operations; the devotion of resources to maximize consent form return rates; and the development of strong relationships with school district and individual school staff. CONCLUSIONS: By removing cost, time, transportation, and bureaucratic barriers, the program was able to reach more children than fixed-site clinics. The program was a merging of private and public health dentistries. This model can be useful to other communities in light of the unmet need for dental care and tighter federal, state, and local government budgets.     

Children's Access to Dental Care in Connecticut's Medicaid Managed Care Program

Objective: To describe dental care utilization and access problems in Connecticut's Medicaid managed care program, using quantitative and qualitative research methods. Methods: Using Medicaid managed care enrollment and encounter data from Connecticut, utilization rates for preventive care and treatment services are determined for 87,181 children who were continuously enrolled in Medicaid managed care for 1 year in 1996–97. Sociodemographic and enrollment factors associated with utilization are identified using bivariate and multivariate methods. Dental providers and practices where children received services are described. Qualitative methods are used to characterize problems experienced by families seeking dental care during the study period. Results: Only 30.5% of children continuously enrolled in Medicaid managed care for 1 year received any preventive dental services; 17.8% received any treatment services. Children who received preventive care were eight times more likely to have received treatment services. Utilization was higher among (a) younger children, (b) children who lived in Hartford and in other counties served by public dental clinics, and (c) children enrolled in health plans that did not subcontract for administration of dental services. Just 5% of providers, primarily those in public dental clinics, performed 50% of the services. Families whose children needed care encountered significant administrative and logistical problems when trying to find willing providers and obtain appointments. Conclusions: Access to dental care is a problem for children in Connecticut's Medicaid managed care program. Several features of managed care have negatively affected access. Public dental clinics served many children across the state and contributed to higher utilization of preventive care and treatment services among children living in Hartford.     

Private provision of 'outreach' clinics to fundholding general practices in England

OBJECTIVES: To establish the contribution of the private sector in providing outpatient 'outreach' clinics in general practitioner fundholding practices. METHOD: Postal survey of all 13 first-wave fundholders and four of the 13 second-wave fundholders in the former South East Thames Region of the National Health Service in 1995. RESULTS: Fourteen practices responded. Ten practices had set up at least one medical specialist 'outreach' clinic and 12 at least one paramedical clinic since becoming fundholders. Eight practices reported their arrangements for consultant 'outreach' clinics and ten practices their arrangements for paramedical clinics. Forty-nine per cent of the total medical specialist hours and 46% of total paramedical hours were provided by private practitioners. The largest number of hours provided privately was in gynaecology. CONCLUSION: This small study identified considerable private provision of fundholders' 'outreach' clinics. However, there is no system in the NHS to monitor the extent of this market, the types of activities undertaken or the relative quality and cost of the services provided.     

Primary health care in an academic medical center.

In 1975-76 a one-year longitudinal study of the delivery of primary care services was carried out at all ambulatory institutional facilities in Durham County, North Carolina and in 47 of 50 community private practices covering the broad fields of surgery (including urology and orthopedics), medicine, pediatrics, and ob/gyn. The present paper focuses on the private and public clinics of Duke University Medical Center. Data were analyzed to document differentials in sociodemographic characteristics of patients attending these two systems of care. Results showed that patients attending the private clinics are predominantly white and covered by private insurance, while patients attending the public clinics are predominantly black and heavily dependent on Medicaid coverage. The potentially detrimental effects of a two-class system of care on the health of patients, as well as on the education of students, is discussed in the context of a scant medical literature on this subject.     

Outcomes of enhanced prenatal services for Medicaid-eligible women in public and private settings.

OBJECTIVE: With changes in Medicaid, more low-income women are receiving prenatal care in private practice settings. The authors sought to determine whether private settings can provide the enhanced prenatal support services for low-income women that have been offered for decades in public settings. METHODS: The authors analyzed birth outcomes of Medicaid-eligible women receiving care from public and private providers certified to deliver enhanced prenatal care services, which included assessments of nutritional, psychosocial, and health educational risks and individualized counseling along with clinical care. Birth outcomes were compared by type of provider setting using multivariate logistic regression models to adjust for differences in risks and use of care. RESULTS: Among settings certified to deliver enhanced perinatal support services, private physicians'' offices had the best risk-adjusted birth outcomes and public health department clinics the worst, while public hospital clinics had outcomes no different from private physicians'' offices. Adjusted for prenatal care use, outcomes were still better for women seen in private physicians'' offices than for women seen in public health department clinics, community clinics, or private hospital clinics. CONCLUSIONS: The findings suggest that given a certification process, private providers can provide enhanced support services as effectively as providers in public practice settings.     

Evaluating infection control practices among dentists in Valcea, Romania, in 1998.

OBJECTIVES: To evaluate infection control knowledge and practices, provide training on universal-standard precautions (USP), and improve infection control knowledge and practices among dentists. SETTING: Private and public dental offices in Valcea, Romania. METHODS: Information about the use of hepatitis B vaccine, knowledge of and training in USP, perceived risks of disease transmission, and infection control practices was gathered from a sample of dentists through interviews, direct observations, and a survey administered during a training session. RESULTS: Interviews among dentists and direct observations of infection control practices revealed that resources were often scarce in public clinics; however, availability of supplies in private or public clinics often did not correlate with adherence to proper infection control. Of 125 registered dentists, 46 (37%) attended the session and completed the survey. Of these, 75% worked in public clinics, 40% in private practices, and a few in both. More than 50% believed that the prevalence of hepatitis B virus (HBV) was low in their patients compared with the Romanian population. Only 26% of dentists had received hepatitis B vaccine. Dentists reported a mean of six percutaneous injuries a year. Most (89%) reported that gloves were effective in preventing HBV transmission; 24% wore them for every patient. Most used dry heat sterilization; however, chemical disinfectants were also used. CONCLUSIONS: Resources were limited, receipt of hepatitis vaccine was low, and infection control knowledge and practices varied. Training and education are needed regarding the importance of USP, hepatitis B vaccination, and alternative practices when resources are insufficient.     

Vaccine delivery to newly arrived refugees and estimated costs in selected U.S. clinics, 2015

BackgroundNewly arrived refugees are offered vaccinations during domestic medical examinations. Vaccination practices and costs for refugees have not been described with recent implementation of the overseas Vaccination Program for U.S.-bound Refugees (VPR). We describe refugee vaccination during the domestic medical examination and the estimated vaccination costs from the US government perspective in selected U.S. clinics.MethodsSite-specific vaccination processes and costs were collected from 16 clinics by refugee health partners in three states and one private academic institution. Vaccination costs were estimated from the U.S. Vaccines for Children Program and Medicaid reimbursement rates during fiscal year 2015.ResultsAll clinics reviewed overseas vaccination records before vaccinating, but all records were not transferred into state immunization systems. Average vaccination costs per refugee varied from $120 to $211 by site. The total average cost of domestic vaccination was 15% less among refugees arriving from VPR- vs. nonVPR-participating countries during a single domestic visit.ConclusionOur findings indicate that immunization practices and costs vary between clinics, and that clinics adapted their vaccination practices to accommodate VPR doses, yielding potential cost savings.     

Dual provision or duplication? A survey of family planning provision.

BACKGROUND: Family planning has been delivered through dual provision by general practice and community based clinics since its inception. This may be perceived as duplication of services and can be regarded as an area of possible disinvestment in a climate of rising health care costs. AIM: A survey of family planning service provision across a health district was carried out to establish the potential to rationalise current service provision by studying the pattern of service provision in the district and the links between family planning clinics and general practices. METHOD: A postal questionnaire and covering letter were sent to all practices and clinics in May 1997. Following analysis, results were,fed back to clinic staff and general practitioners through accredited meetings. RESULTS: Basic family planning was universally available to the population at all practices and clinics. Clinics offered a wider range of services, especially specialist services for psychosexual counselling and hormonal implants. Very few separate services for young people were identified. Within the primary care sector there was little 'out-of-hours' provision of contraceptive services. Half of the practices responding had used or would use family planning services as referral centres; implants and psychosexual services attracted most referrals. CONCLUSION: An understanding of the complementary nature of the services in primary care and community FP clinics was achieved and agreement was reached that disinvestment in clinics locally was not appropriate. The need to raise public awareness of availability of all contraceptive services was identified. Services in general practice and community clinics are complementary and need to develop a joint strategy to ensure an effective, comprehensive service. Quality of care needs to be examined in future work.     

Is reimbursement for childhood immunizations adequate? evidence from two rural areas in colorado.

OBJECTIVE: To assess adequacy of reimbursement for childhood vaccinations in two rural regions in Colorado, the authors measured medical practice costs of providing childhood vaccinations and compared them with reimbursement. METHODS: A "time-motion" method was used to measure labor costs of providing vaccinations in 13 private and public practices. Practices reported non-labor costs. The authors determined reimbursement by record review. RESULTS: The average vaccine delivery cost per dose (excluding vaccine cost) ranged from $4.69 for community health centers to $5.60 for private practices. Average reimbursement exceeded average delivery costs for all vaccines and contributed to overhead in private practices. Average reimbursement was less than total cost (vaccine-delivery costs + overhead) in private practices for most vaccines in one region with significant managed care penetration. Reimbursement to public providers was less than the average vaccine delivery costs. CONCLUSIONS: Current reimbursement may not be adequate to induce private practices to provide childhood vaccinations, particularly in areas with substantial managed care penetration.     

Utilization of public and private dental services in Sibu,Sarawak: a sociodemographic appraisal and types of treatment received

This study investigated the sociodemographic profiles of patients attending public and private dental clinics and the types of treatment received. Patients (n=454) were interviewed using a structured questionnaire at two public and four private clinics in Sibu District, Sarawak. Generally, Chinese (74.7%), females (60.0%) and urban dwellers (83.7%) were more likely to visit the dentist. Both clinics had more females and more Chinese but private clinics had a lower percentage of female attendees (53.1% versus 67.0%) but a higher percentage of Chinese (85.0% versus 64.5%). Private attendees were younger (mean age of 31.0 years compared to 41.0 years) and from higher income households (median value of MR 2,000 versus MR 900) than public attendees. Treatments were mostly curative and a third of the visits were associated with painful conditions. Age (p=0.006), gender (p=0.003), ethnicity (p<0.001) and household income (p<0.001) were associated with the type of clinic visited. Choice of clinic was not related to having painful conditions (p=0.970). To ensure a more affordable and equitable distribution of oral healthcare, health planners need to identify disparities in the utilization of services and differences between public and private attendees.     

Different dental care setting: does income matter?

In this paper we consider the use of mobile dental clinics as a means of improving access to dental care among primary school children in Southern Thailand by reducing the opportunity cost of service use to parents. Parents' willingness to pay (WTP) is measured for three different services provided in a community hospital dental clinic and a school-based mobile clinic. Although the service setting does not affect significantly the WTP for treatment directly, the estimated positive association between WTP and income is modified by setting. The results indicate that the potential for mobile clinics to increase utilization of services among primary school children is associated with parents' income, with the difference in valuation of dental services between the two settings being less among lower income parents than higher income parents. However, even among lower income parents our results indicate that the potential for increasing service utilization among children depends on the improvements in access associated with the mobile clinic not being achieved at the opportunity cost of lower levels of effectiveness.     

A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.