What is health economics?

OBJECTIVES: This paper describes the principles of economics and their application to the promotion, protection and restoration of oral health in populations and the planning, management and delivery of oral health care. After illustrating the economic determinants of oral health, the demand for oral health care is discussed with particular reference to asymmetric information between patient and provider. The reasons for the market failure in (oral) health care and their implications for efficiency and equity are explained. We go on to describe how economic evaluation contributes to policies aimed at maximising oral health gains where resources are constrained. The behavioural aspects of patients´ demand for and dental professionals´ provision of oral health services are discussed. Finally, we outline methods for planning the dental workforce in ways that reflect system goals.

Prioritization, Incentives, and Resource Use for Sustainable Dentistry: The EU PRUDENT Project.

KNOWLEDGE TRANSFER STATEMENT: The EU PRUDENT project aims to enhance the financing of oral health systems through novel evidence and implementation of better financing solutions together with citizens, patients, providers, and policy makers. The multicountry nature of the project offers unique windows of opportunity for rapid learning and improving within and across various contexts. PRUDENT is anticipated to strengthen capacities for better oral care financing in the EU and worldwide.

Supplier inducement. Its effect on dental services in Norway.

In many western countries, supply of dental services exceeds demand, mainly because of the marked reduction in the prevalence of dental diseases during the last 10-15 years. An important issue is whether dentists can counteract this fall in demand by stimulating increased demand and/or utilization for their services. Some evidence that this may be the case was found in the present study, in Norway. The results indicate that demand and utilization for dental services are influenced by supplier inducement.

Accessibility of dental services according to family income in a non-insured population.

The aim of this study was to examine the effect of family income on accessibility to dental services among adults in Norway. The analysis was performed on a set of national data collected in 1989, which was representative of the non-institutionalized Norwegian population aged 20 years and above. The sample size was 1200 individuals. The data were analyzed according to a two-part model. The first part determined the probability of whether the consumer had demanded the services or not during the last year according to family income. The second part estimated how the amount of services utilized depended on family income, for those with demand. The elasticity of the odds of having demanded the services with respect to family income was 0.48. Family income had no effect on the amount of services utilized. Additional analyses also showed that there was no effect of family income on the probability of having received a filling or a crown when visiting the dentist. In Norway, almost all costs for dental services are paid by the consumer. It is not possible from the data alone to say whether subsidized dental care is an effective way of reducing the inequalities in demand.

Accessibility of Norwegian dental services according to family income from 1977 to 1989.

During the last 10-20 yr there has been a marked increase in demand for dental services in most western countries. An important issue is how this increase in demand has influenced inequalities in use of services among different income groups in the population. It is of particular interest to study this in Norway, as almost all the costs for dental care among adults are borne by the patient. The aim of the present study was to examine how the effect of family income on demand for dental services has changed over time. The analyses were performed on three sets of national data from 1977, 1983, and 1989. The samples were representative of the non-institutionalized Norwegian population aged 20 yr and above. Inequalities in use of dental services among different income groups have decreased between 1977 and 1989. However, separate analyses on the data from 1989 showed that some inequalities still exist. A non-selective subsidizing policy for dental care is unlikely to have any great effect in reducing these inequalities. Subsidized dental care is likely to raise the total amount of dental care demanded. However, it is difficult to assess accurately the size of this increase as the elasticity of demand for dental care in Norway with respect to price is unknown.

Supplier inducement--its relative effect on demand and utilization.

The present study examined the relative effect of supplier inducement on demand as opposed to on utilization. Supply of dentists was measured as population: dentist ratio at the level of trade areas. The dependent variable was number of dental visits during the last year. The probability of having any visit was used as the measure of demand. Number of visits, conditional upon having any visit, was used as the measure of utilization. The data were analyzed using Tobit analysis. This analysis gave the fraction of the total effect of a marginal increase in supply that is due to an increase in utilization as opposed to an increase in demand. The analysis was performed on a national sample comprising 1186 adult Norwegians. Supplier inducement had nearly the same effect on demand as on utilization. This finding may be a result of the payment system for dental care, which relates each item of service to the average time it takes to perform that item. Income opportunities for dentists are then fairly independent of whether they spend their time doing check-ups or treatment. The finding indicates that supplier induced demand is a factor to consider in addition to supplier induced utilization when one tries to explain how supplier inducement may affect the unequal distribution of dentists.

Effect of time costs on demand for dental services among adults in Norway in 1975 and 1985.

The aim of the present study was to assess the effect of travel time, time spent on a waiting list and time spent in the waiting room on demand for dental services in Norway. The analysis was performed on two sets of national data from 1975 and 1985, and on one set of local data from 1987. The national data were representative of the non-institutionalized Norwegian population aged 20 yr and above. Travel time had an effect on demand in 1975, but not in 1985. Time spent on a waiting list had no opportunity cost, and did not influence demand. There was a statistically significant association between time spent in the waiting room and demand. However, this association disappeared when the effect of dental attendance pattern was controlled for. Regular attenders had shorter waiting times than those who were irregular attenders. This study has shown that factors such as presence of teeth, family income, and age are more important than travel time on demand for dental services.

How age influences expenditure for dental services in Norway.

Several studies have shown that demand for dental services decreases with increasing age. There is a lack of research to examine how utilization (as opposed to demand) varies with age. This relationship is likely to depend on family income and number of teeth. This study had two aims: Firstly, to examine the relationship between age, family income, number of teeth, and expenditure for dental services in Norway. Secondly, to compare a model where expenditure was the dependent variable with a model where demand was the dependent variable, using the same set of explanatory variables (age, income, and number of teeth). The analysis was performed on a set of national data collected in 1987, which was representative of the non-institutionalized Norwegian population 20 yr and above. The sample size was 1216 individuals. The data were analyzed according to a path analysis design, using regression analysis (OLS). Age had no effect on expenditure after controlling for family income and number of teeth. Expenditure decreased and demand increased with increasing number of teeth. This has two implications: Firstly, expenditure will rise and demand decrease with increasing age because number of teeth decreases with age. Secondly, utilization of dental services is likely to decrease, and demand increase as oral health improves.

Efficiency in provision of public dental services in Norway.

The paper examines productivity in the provision of public dental services in Norway. The main responsibility of the public dental services is to provide care for all children up to 18 years of age. Most dental care is provided by public dental officers. Productivity was measured by estimating a stochastic production frontier from input and output data from the public dental service in Norway. The results indicate that there are increasing returns to scale. Our measure of technical efficiency showed that the level of inefficiency is fairly small. However, the inefficiency is greater when estimated from a deterministic production frontier rather than from a stochastic frontier. One limitation of the present methodology is that it does not say anything about the level of efficiency in the Norwegian public dental service in absolute terms. A greater level of inefficiency would have been identified if a few counties had performed clearly better than the rest.

Future demand for dental care in Norway; a macro-economic perspective.

The future demand for dental care in Norway is discussed on the basis of economic theory. During the next 30 years gross national income will increase substantially due to a marked increase in national income from the sale of oil and gas. On the basis of the model we predict that this increase in income will lead to an increase in demand for dental services in the short run, say for the next 10-15 years. To a large extent this increase in demand is supported by evidence from dental epidemiology. In particular, an increasing proportion of elderly dentate people will demand more services. This picture is different in the long run, say from the year 2010-15 and onwards. Evidence from dental epidemiology indicates that at that stage there will be a fairly high proportion of disease-free individuals in the population who will demand less dental care. Such a trend is also supported by economic theory as long as disease-free individuals consume less dental care irrespective of their income.

Validity of CPITN's hierarchical scoring method for describing the prevalence of periodontal conditions.

CPITN has been a frequently used index in periodontal epidemiology during the last decade. It was originally designed to describe treatment needs in populations. For this purpose, it was decided to record only the worst periodontal condition around each index tooth. Such a recording procedure can be regarded as a hierarchical scoring method. Recently, CPITN has been used and recommended for describing the prevalence of periodontal conditions. For this purpose, the index should give a valid estimate of the true periodontal conditions of the index tooth, and not only a recording of the worst condition. The aim of the present study was to test whether the hierarchical assumption of CPITN concerning treatment needs was valid for describing the prevalence of periodontal conditions in a Scandinavian population. The study population comprised 3330 persons from a rural and an urban area in the county of Trøndelag, Norway. The clinical recording was carried out so that it was possible to analyze the indicators both hierarchically and non-hierarchically. The results showed that nearly all the CPITN indicators scored hierarchically gave a correct estimate of the prevalence of bleeding in the population. CPITN codes 3 and 4 overestimated the prevalence of calculus. The degree of overestimation varied by age and tooth type. Most overestimation of calculus occurred on molar teeth with pockets 3.5-5.5 mm and for individuals 13-14 yr of age. There was almost no overestimation of calculus for those aged 65 yr and above.(ABSTRACT TRUNCATED AT 250 WORDS)

Future treatment needs in children, adults and the elderly.

Future treatment needs for dental services are discussed in the perspective of the objective which the services are meant to fulfill. These are, broadly speaking, equal distribution of services and economic efficiency. Within the Nordic countries, the emphasis has been on equity, perhaps less on efficiency. Equity of utilization is best understood as being a situation where patients with equal needs for oral health care receive equal treatment, in terms of both the volume and the quality of the services. The justification for arguing that equality of utilization is the appropriate measure is mainly based on the externality argument: health-care consumption by one person may be the source of utility to another person. According to that view there are two beneficiaries of dental care: the patient who is sick, and the rest of society who care for the sick patient and who derive utility from seeing the patient become healthy. The public dental services for children in the Nordic countries are organized according to the principle of equity of utilization. Equity of access is best understood as being a situation where people with equal needs have equal opportunity to use dental services. It is a supply-side phenomenon; equal access is achieved when patients with the same needs face the same costs of dental-care consumption in terms of both time and money. The oral health situation among children, adults and the elderly is exemplified by national service data and recent studies.

Relationship between number of teeth and periodontal pockets.

The relationship between number of teeth and the prevalence of periodontal disease is an important factor to consider when planning future needs for periodontal care. This is of particular relevance today, when the level of tooth loss is steadily reducing. The aim of the present study was to examine this relationship. Three dependent variables associated with periodontal disease were included in the analysis: 1. The probability of having pockets 4 mm or more. 2. The mean pocket depth for individuals with pockets 4 mm or more. 3. The number of pockets for individuals with pockets 4 mm or more. Age was included in the analysis as a control variable. The study population comprised 2219 individuals in the county of Trøndelag, Norway. The data were analyzed using logistic regression and multiple regression analysis. The probability of having pockets 4 mm or more increased with increasing number of teeth. The average pocket depth decreased with increasing number of teeth. There was no relationship between number of pockets and number of teeth. The increase in the probability of having pockets with a marginal increase in number of teeth was greatest for those aged 53 years and above. It is concluded that this group of people are likely to have the greatest need for periodontal care.

Longitudinal study of dental health behaviors and other caries predictors in early childhood.

This longitudinal study of 231 preschoolchildren from a medium sized Norwegian town had three aims: firstly, to examine the children's early dental behavior, secondly to study the variation of dental health behavior according to mother's education, mother's dental health, and her dental attendance pattern, and thirdly to identify any behavioral or social predictors of dental caries in 36-month-old children. Data were collected at health centers, using precoded questionnaires and examinations, when the children were 6, 18, and 36 months old. Data about the mothers were collected at the maternity ward. At 36 months of age, 80% of the children were caries free. Favorable dental behaviors were related to toothbrushing and use of fluorides. These behaviors were so well established and consistent at all ages that they can be regarded as norms for this community. The most unfavorable and inconsistent behavior was related to sugar consumption. Dental health education could be most usefully applied to this area, where the greatest potential for improvement in behavior exists. A relationship was found between the children's caries experience and the number of missing teeth of the mother, her dental attendance pattern and her level of education. None of the social or behavioral variables tested had a strong enough association with caries experience to justify their use as caries predictors in this age group.

Recent changes in health related dental behaviors in Norway.

There has been a substantial decrease in the prevalence of caries in younger age groups in the western world during the last 15 years. A corresponding increase has been reported regarding use of preventive remedies. Since prevention and control of dental disease is highly dependent upon personal behavior, investigations of dental health behaviors within subgroups of the population are important for future preventive strategies. Occurrence and changes in individual dental health behaviors in Norway were studied through four sets of cross-sectional data collected in 1981, 1983, 1985, and 1987. Personal interviews performed by trained interviewers were held with probability samples, each of about 1400 persons, covering the Norwegian population aged 15 and above. During the 6-yr period the proportion of individuals who brushed their teeth and used fluoride dentifrice every day increased. The number of people who used toothpicks or dental floss every day also increased from 1981 to 1985. A marked decrease was, however, observed in use of interdental remedies from 1985 to 1987. Daily use of dental floss was reduced by 10 percent points. Logistic regression showed that the reduction in the probability of using interdental aids was most pronounced among those with few teeth. Lower importance attached to dental health education, at all levels, combined with difficult economic times since 1987, might account for the decrease in daily use of interdental aids in Norway.

A comparative study of costs for dental services and dentists' income in the United States and Norway.

The United States and Norway have approximately the same per capita Gross Domestic Product (GDP) and average personal income, but their per capita health spending patterns are quite different. In 1982, the US spent 6.5% of its total health expenditures on dental services while Norway spent 5.4%. A higher percentage of Norwegian adults see a dentist annually as compared to US adults. In 1984, the mean net income of dentists in private practice was $66,940 in the US and $27,125 in Norway; this is respectively 5 and 1 3/4 times the average per capita income in those countries. The American publicly-employed dentist earned approximately two-thirds of what the American private practitioner made, while still earning approximately 50% more than his Norwegian counterpart. Some basic information concerning the ratios of dentists, specialists, and dental hygienists to the population is given. The relative proportion of women dentists in the two countries is contrasted. Finally, data on graduates from the dental schools, enrollment cuts, and estimated dentist to population ratios by the year 2000 are described to compare future manpower that will be available to the two countries. Several dissimilarities in the political and social systems are described and discussed. It is emphasized that caution should be used when interpreting and comparing data about countries with different dental delivery, political, and social systems.

The effect of the price of dental services on their demand and utilisation in Norway.

The aim of the present study was to examine the effect of the price of dental services on their demand and utilisation. These effects cannot be examined in cross-sectional studies when prices are fixed, as they are in Norway, but they can be studied over a period of time, as the price for dental services has changed relative to the prices for other goods. The analyses were performed on 7 sets of data, collected every second year, over the period 1977 to 1989. The samples were representative of the non-institutionalised Norwegian population aged 20 years and over. Price had a different effect on demand than on utilisation. There was no statistically significant association between price and demand. Utilisation decreased with increasing price, and this can be explained in two ways. First, it may express patients' response to reduced prices, and second, it may express the dentists' response to reduced prices. If the latter explanation is correct, this means that the dental care market is rather special. Consumers are not dominant. Dentists, as providers, can, to a certain extent, influence the uptake of the services they provide.

The effect of supplier inducement on Norwegian dental services; some empirical findings based on a theoretical model.

The aim of the present study was to ascertain whether the amount of dental care demanded and the amount of dental care received in Norway were influenced by supplier inducement. There is a fixed price schedule for dental care in Norway, which establishes the framework for the theoretical model on which the empirical studies were based. The model has been developed by Birch (1988), and it describes how the utilisation of dental services may be influenced both by supplier inducement and reduced shadow prices (access costs) when the population to dentist ratio decreases. The sample of 1200 individuals was representative of the non-institutionalised Norwegian population aged 20 years and over. Variables measuring access costs, rationing of care, oral health, unmet need, family income and socio-demographic characteristics of the population were included as control variables. Supplier inducement effects were found on dentist-initiated visits, and on the cost per visit. It was concluded that dentists in areas of excess supply were able to maintain their workload by increasing the demand for and the utilisation of their services. Also, that the existing maldistribution of dentists between the northern and southern parts of Norway is not likely to be altered by allowing market mechanisms to operate on the dental care market.

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.