Catastrophic out-of-pocket payments for dental treatment: regional evidence from Spain.

BACKGROUND: To estimate the incidence and concentration of catastrophic out-of-pocket payments for healthcare and dental treatment, by region in Spain (calculated as the proportion of households needing to exceed a given threshold of their income to make these payments) in 2008, 2011 and 2015. METHODS: The data analysed were obtained from the Spanish Family Budget Survey reports for the years in question. The study method was that proposed by Wagstaff and van Doorslaer (2003), contrasting payments for dental treatment versus household income and considering thresholds of 10%, 20%, 30% and 40%, thus obtaining incidence rates. In addition, relevant sociodemographic variables were obtained for each household included in the study. RESULTS: With some regional heterogeneity, on average 4.75% of Spanish households spend more than 10% of their income on dental treatment, and 1.23% spend more than 40%. Thus, 38.67% of catastrophic out-of-pocket payments for dental services in Spain corresponds to payments at the 10% threshold. This value rises to 55.98% for a threshold of 40%. CONCLUSIONS: An important proportion of catastrophic out-of-pocket payments for health care in Spain corresponds to dental treatment, a service that has very limited availability under the Spanish NHS. This finding highlights the need to formulate policies aimed at enhancing dental cover, in order to reduce inequalities in health care and, consequently, enhance the population's quality of life and health status.

The economic benefits of increased sugar-free chewing gum in China: a budget impact analysis.

BACKGROUND: To analyze the potential cost savings in dental care associated with increased sugar-free gum (SFG) use among Chinese teenagers and adults. METHODS: The amount of SFG chewed per year and decayed, missing and filled teeth (DMFT) was collected from a cross-sectional survey to create a dose-response curve assumption. A cost analysis of dental restoration costs was carried out. A budget impact analysis was performed to model the decrease in DMFT and the subsequent cost savings for dental care. Three different scenarios for the increase in the number of SFG were calculated. RESULTS: The average cost savings per person in the Chinese population due to increasing SFG use ranged from 45.95 RMB (6.94 USD) per year to 67.41 RMB (10.19 USD) per year. It was estimated that 21.51-31.55 billion RMB (3.25-4.77 billion USD) could be saved annually if all SFG chewers among Chinese teenagers and adults chewed SFG regularly. CONCLUSION: This study suggests that dental care costs could be significantly reduced if SFG use increased in the Chinese population.

Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England.

Background: Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services. Methods: Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios. Results: The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners' contracts in perpetuity, potentially constraining commissioners' abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase. Conclusions: NHS dental practitioners' contracts resemble budget-silos which do not facilitate local resource reallocation. 'Context-specific' factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations.

Funding Accountable Care in Oregon: Financial Models in Two Coordinated Care Organizations.

EXECUTIVE SUMMARY: Oregon's coordinated care organizations (CCOs) are an integral part of a massive statewide reform that brings accountable care to Medicaid. CCOs are regional collaboratives among health plans, providers, county public health, and communitybased organizations that administer a single global budget covering physical, mental, and dental healthcare for low-income Oregonians. CCOs have been given freedom within the global budget to implement reforms that might capture efficiencies in cost and quality. For this study-fielded between 2012 and 2015-we traced the path of the global budget through the interior structures of two of Oregon's most promising CCOs. Using document review and in-depth qualitative interviews, we synthesized and summarized descriptive narrative data to produce case studies of the financial models in each CCO. We found that the CCOs feature substantially different market contexts, governance models, organizational structures, and financial systems.

Health economic analyses of domiciliary dental care and care at fixed clinics for elderly nursing home residents in Sweden.

OBJECTIVES: Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic. METHODS: A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses. RESULTS: The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting. CONCLUSIONS: Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.

Clinical directors' views of centralisation and commissioning of cleft services in the U.K.

BACKGROUND: To determine the views of Clinical Directors working in the United Kingdom (U.K.) Cleft Service with regard to centralisation, commissioning and impact on cleft service provision. METHODS: In-depth qualitative interviews were conducted with 11 Clinical Directors representing regional cleft services. Interviews were transcribed verbatim, a coding frame was developed by two researchers and transcripts were coded using a thematic, 'interpretive' approach. RESULTS: Clinical Directors perceived the commissioning of cleft services in the U.K. to be dependent upon historical agreements and individual negotiation despite service centralisation. Furthermore, Clinical Directors perceived unfairness in the commissioning and funding of cleft services and reported inconsistencies in funding models and service costs that have implications for delivering an equitable cleft service with an effective Multidisciplinary Team. CONCLUSIONS: National Health Service (NHS) commissioning bodies can learn lessons from the centralisation of cleft care. Clinical Directors' accounts of their relationships with specialist commissioning bodies and their perspectives of funding cleft services may serve to increase parity and improve the commissioning of cleft services in the U.K.

Economic analysis of endovascular interventions for femoropopliteal arterial disease: a systematic review and budget impact model for the United States and Germany.

OBJECTIVES: To study the economic impact on payers and providers of the four main endovascular strategies for the treatment of infrainguinal peripheral artery disease. BACKGROUND: Bare metal stents (BMS), drug-eluting stents (DES), and drug-coated balloons (DCB) are associated with lower target lesion revascularization (TLR) probabilities than percutaneous transluminal angioplasty (PTA), but the economic impact is unknown. METHODS: In December 2012, PubMed and Embase were systematically searched for studies with TLR as an endpoint. The 24-month probability of TLR for each treatment was weighted by sample size. A decision-analytic Markov model was used to assess the budget impact from payers' and facility-providers' perspectives of the four index procedure strategies (BMS, DES, DCB, and PTA). Base cases were developed for U.S. Medicare and the German statutory sickness fund perspectives using current 2013 reimbursement rates. RESULTS: Thirteen studies with 2,406 subjects were included. The reported probability of TLR in the identified studies varied widely, particularly following treatment with PTA or BMS. The pooled 24-month probabilities were 14.3%, 19.3%, 28.1%, and 40.3% for DCB, DES, BMS, and PTA, respectively. The drug-eluting strategies had a lower projected budget impact over 24 months compared to BMS and PTA in both the U.S. Medicare (DCB: $10,214; DES: $12,904; uncoated balloons $13,114; BMS $13,802) and German public health care systems (DCB €3,619; DES €3,632; BMS €4,026; PTA €4,290). CONCLUSIONS: DCB and DES, compared to BMS and PTA, are associated with lower probabilities of target lesion revascularization and cost savings for U.S. and German payers.

Effects of cuts in Medicaid on dental-related visits and costs at a safety-net hospital.

We used data from Boston Medical Center, Massachusetts, to determine whether dental-related emergency department (ED) visits and costs increased when Medicaid coverage for adult dental care was reduced in July 2010. In this retrospective study of existing data, we examined the safety-net hospital's dental-related ED visits and costs for 3 years before and 2 years after Massachusetts Health Care Reform. Dental-related ED visits increased 2% the first and 14% the second year after Medicaid cuts. Percentage increases were highest among older adults, minorities, and persons receiving charity care, Medicaid, and Medicare.

Reality check: the cost-effectiveness of removing body checking from youth ice hockey.

BACKGROUND/AIM: The risk of injury among Pee Wee (ages 11-12 years) ice hockey players in leagues that allow body checking is threefold greater than in leagues that do not allow body checking. We estimated the cost-effectiveness of a no body checking policy versus a policy that allows body checking in Pee Wee ice hockey. METHODS: Cost-effectiveness analysis alongside a prospective cohort study during the 2007-2008 season, including players in Quebec (n=1046), where policy did not allow body checking, and in Alberta (n=1108), where body checking was allowed. Injury incidence rates (injuries/1000 player-hours) and incidence proportions (injuries/100 players), adjusted for cluster using Poisson regression, allowed for standardised comparisons and meaningful translation to community stakeholders. Based on Alberta fee schedules, direct healthcare costs (physician visits, imaging, procedures) were adjusted for cluster using bootstrapping. We examined uncertainty in our estimates using cost-effectiveness planes. RESULTS: Associated with significantly higher injury rates, healthcare costs where policy allowed body checking were over 2.5 times higher than where policy disallowed body checking ($C473/1000 player-hours (95% CI $C358 to $C603) vs $C184/1000 player-hours (95% CI $C120 to $C257)). The difference in costs between provinces was $C289/1000 player-hours (95% CI $C153 to $C432). Projecting results onto Alberta Pee Wee players registered in the 2011-2012 season, an estimated 1273 injuries and $C213 280 in healthcare costs would be avoided during just one season with the policy change. CONCLUSION: Our study suggests that a policy disallowing body checking in Pee Wee ice hockey is cost-saving (associated with fewer injuries and lower costs) compared to a policy allowing body checking. As we did not account for long-term outcomes, our results underestimate the economic impact of these injuries.

[Health-care benefits financed from the budget of households in Poland in the West Pomerania Province]. / Gesundheitsleistungen, die in der westpommerschen Woiwodschaft in Polen von privaten Haushalten finanziert werden.

INTRODUCTION: Underfunding of the health systemin Poland causes the patients to bear a proportion of the costs of treatment. AIM: The aim of this study was to gather knowledge of health-care services financed by the patients and socio-demographic factors which are influencing how often they use them. MATERIAL AND METHODS: A diagnostic survey was conducted among 384 residents of the West Pomeranian Province. RESULTS: Respondents most frequently used the paid services of dental care. CONCLUSIONS: The age and health condition impact on the frequency of using self-paid health-care services. condition impact on the frequency of using self-paid healthcare services.

Cost-effectiveness analysis of paclitaxel-coated balloons for endovascular therapy of femoropopliteal arterial obstructions.

PURPOSE: To explore the cost-effectiveness of using drug-eluting balloon (DEB) angioplasty for the treatment of femoropopliteal arterial lesions, which has been shown to significantly lower the rates of target lesion revascularization (TLR) compared with standard balloon angioplasty (BA). METHODS: A simplified decision-analytic model based on TLR rates reported in the literature was applied to baseline and follow-up costs associated with in-hospital patient treatment during 1 year of follow-up. Costs were expressed in Swiss Francs (sFr) and calculated per 100 patients treated. Budgets were analyzed in the context of current SwissDRG reimbursement figures and calculated from two different perspectives: a general budget on total treatment costs (third-party healthcare payer) as well as a budget focusing on the physician/facility provider perspective. RESULTS: After 1 year, use of DEB was associated with substantially lower total inpatient treatment costs when compared with BA (sFr 861,916 vs. sFr 951,877) despite the need for a greater investment at baseline related to higher prices for DEBs. In the absence of dedicated reimbursement incentives, however, use of DEB was shown to be the financially less favorable treatment approach from the physician/facility provider perspective (12-month total earnings: sFr 179,238 vs. sFr 333,678). CONCLUSION: Use of DEBs may be cost-effective through prevention of TLR at 1 year of follow-up. The introduction of dedicated financial incentives aimed at improving DEB reimbursements may help lower total healthcare costs.

Perspectives on providing good access to dental services for elderly people: patient selection, dentists' responsibility and budget management.

OBJECTIVES: To suggest a model for organizing and financing dental services for elderly people so that they have good access to services. BACKGROUND: There are few studies on how dental services for elderly people should be organized and financed. This is surprising if we take into consideration the fact that the proportion of elderly people is growing faster than any other group in the population, and that elderly people have more dental diseases and poorer access to dental services than the rest of the adult population. In several countries, dental services are characterized by private providers who often operate in a market with competition and free price-setting. Private dentists have no community responsibility, and they are free to choose which patients they treat. MATERIAL AND METHODS: Literature review and critical reasoning. RESULTS: In order to avoid patient selection, a patient list system for elderly people is recommended, with per capita remuneration for the patients that the dentist is given responsibility for. The patient list system means that the dentist assumes responsibility for a well-defined list of elderly people. CONCLUSION: Our model will lead to greater security in the dentist/patient relationship, and patients with great treatment needs will be ensured access to dental services.

Simple cost analysis of a rural dental training facility in Australia.

INTRODUCTION: Student clinical placements away from the university dental school clinics are an integral component of dental training programs. In 2009, the School of Dentistry and Oral Health, Griffith University, commenced a clinical placement in a remote rural community in Australia. This paper presents a simple cost analysis of the project from mid-2008 to mid-2011. METHODS: All expenditures of the project are audited by the Financial and Planning Services unit of the university. The budget was divided into capital and operational costs, and the latter were further subdivided into salary and non-salary costs, and these were further analysed for the various types of expenditures incurred. The value of the treatments provided and income generated is also presented. RESULTS: Remote rural placements have additional (to the usual university dental clinic) costs in terms of salary incentives, travel, accommodation and subsistence support. However, the benefits of the placement to both the students and the local community might outweigh the additional costs of the placement. CONCLUSIONS AND IMPLICATIONS: Because of high costs of rural student clinical placements, the financial support of partners, including the local Shire Council, state/territory and Commonwealth governments, is crucial in the establishment and ongoing sustainability of rural dental student clinical placements.

How employers select dental plans in the new era of health law reform.

How employers choose a dental insurance plan for their employees depends on several factors, including how their consultant/broker advises them, their budget and their view of the Patient Protection and Affordable Care Act (ACA). This paper describes the landscape of players and what dentists need to be aware of in this new environment.

Governing decisions of your association.

Every association has some sort of internal structure to make decisions and to do the business of the association. Though the IDA is a member organization, we use a representative form of governing to allow selected members to represent the entire membership. For the Indiana Dental Association, there are two major parts to this governance structure: the administrative body in the Board of Trustees and a legislative body called the House of Delegates. Both are made up of representative members from each of the local component societies or districts.

Use of selected ambulatory dental services in Taiwan before and after global budgeting: a longitudinal study to identify trends in hospital and clinic-based services.

BACKGROUND: The Taiwan government adopted National Health Insurance (NHI) in 1995, providing universal health care to all citizens. It was financed by mandatory premium contributions made by employers, employees, and the government. Since then, the government has faced increasing challenges to control NHI expenditures. The aim of this study was to determine trends in the provision of dental services in Taiwan after the implementation of global budgeting in 1998 and to identify areas of possible concern. METHODS: This longitudinal before/after study was based on data from the National Health Insurance Research Database from 1996 to 2001. These data were subjected to logistic regression analysis. Linear regression analysis was used to examine changes in delivery of specific services after global budgeting implementation. Utilization of hospital and clinic services was compared. RESULTS: Reimbursement for dental services increased significantly while the number of visits per patient remained steady in both hospitals and clinics. In hospitals, visits for root canal procedures, ionomer restoration, tooth extraction and tooth scaling increased significantly. In dental clinics, visits for amalgam restoration decreased significantly while those for ionomer restoration, tooth extraction, and tooth scaling increased significantly. After the adoption of global budgeting, expenditures for dental services increased dramatically while the number of visits per patient did not, indicating a possible shift in patients to hospital facilities that received additional National Health Insurance funding. CONCLUSIONS: The identified trends indicate increased utilization of dental services and uneven distribution of care and dentists. These trends may be compromising the quality of dental care delivered in Taiwan.

[Healthcare expenditure]. / Les dépenses de santé.

Healthcare expenditure is divided between medical infrastructure and individual patient management. Total healthcare costs in France amount to roughly 175 billion euros, financed through public health insurance (77%), private insurance (14%), and individual expenditure (9%). The principal expenditures are for hospitalization (44%), community medical, dental and paramedical care (28%), drugs (20%) and miscellaneous resources (8%). The main factors of rising costs are medical progress and aging. More controllable costs include healthcare provision, the level of reimbursement, public education and information, and physician training. France devotes 9.2% of its gross national product to healthcare, compared to 7-8% in Sweden, Germany and the United Kingdom, representing a diference of about 18 billion euros. In France there is a chronic imbalance between resources and expenditure, creating a cumulative budget deficit of about 100 billlion euros. Major efforts must be made to improve efficiency, and it will be necessary to choose between preserving our healthcare system or our financial system. If the latter is prioritized, healthcare will inevitably deteriorate.

Program director perceived factors for an enhanced advanced education program in prosthodontics recall system.

PURPOSE: A survey study of program directors in Advanced Education Programs in Prosthodontics (AEPPs) was conducted to determine the barriers to and factors that can lead to an enhanced patient-centered recall system. MATERIAL AND METHODS: Surveys were sent to AEPP directors across the United States to assess their program's recall protocol. This survey first identified whether an active recall program existed. Based on the existence of recall, the survey then delved into benefits of recall systems for patients and residents, barriers to the formation of a successful recall system, and factors that can be improved upon for an enhanced recall system. RESULTS: Thirty-two of the 45 programs responded; however, only 28 of the surveys were completed entirely, giving a response rate of 62%. Of these 32 programs, 19 (59.4%) reported having a recall system. A majority of the AEPPs with recall (87.5%) indicated that their system can be further improved. Almost all of the programs without recall (91.7%) indicated that if solutions to the most common barriers to recall were found, they would like to implement one within their program. Some hindrances faced by all programs included budget for initiating and maintaining a recall system, personnel to perform hygiene, a patient tracking system, patient education, and time allocation in the residents' curriculum. Mann-Whitney analyses indicated no statistically significant difference in each factor between programs with and without a recall system. Power analysis suggested that differences in perceived barriers between programs with and without recall systems may have been found if the response rate was 71% or greater. Necessary budget and facilities for initiating or maintaining a recall system may be the greatest difference in barrier importance between programs with and without recall. CONCLUSIONS: Prosthodontic program directors perceived their program's recall system could be improved. If solutions to the most common hindrances were found, almost all program directors desired to establish a recall system within their AEPP. Therefore, a pilot recall system could be valuable in identifying these solutions in establishing an effective recall system for prosthodontic programs within the context of patient health promotion, program curriculum, and financial ramifications.