on the patients side is faced when part or all of the
treatment costs are covered by a third party, and because of this coverage, the patient has less incentive to control the costs of treatment. This may lead to increased demand for treatment (3, 4). The buying power for dental services is determined both by income and cost levels. Income elasticity studies, utilizing cross-sectional data, have sug- gested that a higher level of income increases the number of visits more than the actual cost of treatment (58). With subsidy or insurance cover- age, the relative cost becomes lower, and patients are able to purchase more and more costly services with their income (9, 10). Studies have shown that the price elasticity of dental services is low, in the range of 0.10.2 (11), which means that the demand for dental services is inuenced very little by changes in fees (4). A relatively steep demand curve indicates that dental services can be considered more as necessities than luxury items (2). On the providers side, the moral hazard is the possible effect of knowledge that a thirdparty covers part or all of the costs. When the income level of the provider depends on the services he she provides, Community Dent Oral Epidemiol 2011; 39: 458464 All rights reserved 2011 John Wiley & Sons A/S A study on moral hazard in dentistry: costs of care in the private and the public sector Tuominen R, Eriksson A-L. A study on moral hazard in dentistry: costs of care in the private and the public sector. Community Dent Oral Epidemiol 2011; 39: 458464. 2011 John Wiley & Sons A S Abstract Objectives: The aim of this study was to evaluate the costs of subsidized care for an adult population provided by private and public sector dentists. Methods: A sample of 210 patients was drawn systematically from the waiting list for nonemergency dental treatment in the city of Turku. Questionnaire data covering sociodemographic background, dental care utilization and marginal time cost estimates were combined with data from patient registers on treatment given. Information was available on 104 patients (52 from each of the public and the private sectors). Results: The overall time taken to provide treatment was 181 days in the public sector and 80 days in the private sector (P < 0.002). On average, public sector patients had signicantly (P < 0.01) more dental visits (5.33) than private sector patients (3.47), which caused higher visiting fees. In addition, patients in the public sector also had higher other out-of-pocket costs than in the private sector. Those who needed emergency dental treatment during the waiting time for comprehensive care had signicantly more costly treatment and higher total costs than the other patients. Overall time required for dental visits signicantly increased total costs. The total cost of dental care in the public sector was slightly higher (P < 0.05) than in the private sector. Conclusions: There is no direct evidence of moral hazard on the provider side from this study. The observed cost differences between the two sectors may indicate that private practitioners could manage their publicly funded patients more quickly than their private paying patients. On the other hand, private dentists providing more treatment per visit could be explained by private dentists providing more than is needed by increasing the content per visit. Risto Tuominen 1 and Anna-Leena Eriks- son 2 1 Department of Public Health, University of Turku, Turku, Finland, 2 Dental Services Unit, City of Turku, Turku, Finland Key words: dental insurance; economics; health services research; public health policy Risto Tuominen, Department of Public Health, 20014 University of Turku, Finland Tel.: +358 50 585 2535 Fax: +358 2 333 8439 e-mail: risto.tuominen@utu. Submitted 25 March 2010; accepted 11 January 2011 458 doi: 10.1111/j.1600-0528.2011.00609.x the third party coverage may increase the amount of treatment offered or direct the choice of treatment options towards those that are more costly or more economically rewarding for the provider (12). A recent study (13) indicated that when physi- cians had few patients to treat, they were ready to provide more services per patient. However, some researchers have also expressed doubts about the existence or signicance of moral hazard (14). Thorough dissections of supplier-induced demand and moral hazard in dentistry have been presented earlier (8, 15). The aim of this study was to describe the cost components of dental treatment provided by pri- vate and public sector dentists. Decisions to pro- duce publicly funded dental care either by salaried employed dentists or by purchasing services from private practitioners working on a fee-for-service basis require information on the expected economic consequences of such choices. Material and methods The city of Turku provides subsidized dental care for all permanent residents. However, demand exceeds available capacity. National law states that all treatment courses have to be started within 6 months of the initial appointment. Demand has been partly satised by purchasing additional services from private practice providers. Emer- gency treatment is provided immediately, and semi-urgent treatment is provided within 36 weeks, but excess demand for nonurgent treatment results in the use of a waiting list. When a patient calls to reserve an appointment, he she is told the expected waiting time and is placed at the end of the waiting list. Adult people on this waiting list formed the sampling base for this study. When they reach the top of the waiting list, patients are randomly assigned by ofce workers to attend either a public service (n = 52) or a contracted private sector (n = 57) dentist. The patient has to accept the assigned dentist, and the dentists are obliged to take any patient sent by the municipality. The numbers of patients and the treatment procedures are not determined in the contracts, as the city sends patients on ad hoc basis. The dental treatment is provided either at the citys own clinics or in a private practice. The patients treatment needs have not been deter- mined before appointing them to different dentists. The dentist who provides the treatment, both in the public and the private sector, also makes the check- up and treatment planning independently. Publicly funded treatment procedures offered by public and private dentists are the same. Fixed prostheses and dental implants are not included in either sector. The patient pays the same visit and treatment procedure fees to the treatment provider, whether the provider is in the citys own clinic or in private practice. The city pays the costs of the treatment to the private practitioners according to the private practice fee schedules that have been agreed by open competition for a period of 3 years. The private practitioners make their procedure price offers in a competition situation, but the magnitude of the demand forces the city to accept all offers. Thus, the private practitioners who wish to make a contract with the city do not need to give any discounts from their regular fees. The private practitioners carry the entrepreneurs risk, if a patient fails to pay his her share as the city does not make up the shortfall. It is up to the private practitioner to enforce the payment of patients shares and to recover debts. Private practitioners operate on fee-for-service basis, both when their patient has arrived independently and when sent by the city. Public sector dentists are salaried, but may also receive productivity incentives according to the number of procedures they undertake. The incentives can form up to one quarter of their income. Thus, comparison of the two provider groups does not represent the effects of pure fee- for-service and salaried provisions, but those of two remuneration systems in which marginal reward to the provider of additional services is different. A sample was drawn systematically from the waiting list for nonemergency dental treatment. At the time of the sampling, approximately 3600 adult patients were listed. The seventh subject on the list was drawn, and thereafter, every 17th subject was chosen, producing a sample of 210 subjects. Lack of earlier data on expected values or their distribu- tions did not allow formal estimation of required sample size. Expert opinion of the Chief Dental Ofcer of the city was utilized. Some of the sampled subjects did not have a valid mailing address, and some were unable to read and write Finnish, and they were omitted from the nal sample, which was comprised of 188 subjects. The ethical committee of the Hospital District of Southwest Finland and the city of Turku approved the study, and the sampled subjects received a written description of the sampling, the purposes of the study, and the planned use and storage of 459 Moral hazard in dentistry the information they were to provide. This was followed by a description of the subjects rights according to the Helsinki declaration. The partic- ipating subjects were asked to give their written informed consent and separate written permission to collect their data from the patient registers. A questionnaire form, including the above- mentioned descriptions and permissions, was sent together with a prepaid return envelope. Demo- graphic variables collected included gender and age in years. Level of income was determined by (i) monthly gross income, (ii) monthly gross income in the household, and (iii) monthly gross income in the household divided by the number of members in the household. In the nal analyses, monthly gross income in the household was used. Educa- tional status was originally collected in ve cate- gories and later dichotomized as (0) basic education and (1) higher education. Regularity of dental check-ups during the last 10 years was solicited, and two dichotomies were formed: Attending check-ups every year or less frequently and attending check-ups within every second year or less frequently. Both dichotomies were used in the nal analyses. Time since last comprehensive dental check-up in months was also used. Patients were asked about the number of dental visits during waiting time and the sector (public private) of the treatment provider. Those who had received dental treatment during the waiting time listed the types of treatment they had undergone. Additionally, the patients gave their estimates of the average time they needed for travelling to and from the clinic where they had received their dental treatment. Each patient also gave an esti- mate of the average time spent in the waiting room before entering the treatment ofce and a separate estimate of the time spent in the treatment ofce. Patients value of time was determined by using both willingness-to-accept (WTA) and willingness- to-pay (WTP) approaches. For the WTA approach, the subject was asked what would be the minimum sum he she would accept as compensation for working one hour longer the next working day. Similarly, for the WTP approach, each subject was asked to estimate how much money he she would be willing to give up if he she had an opportunity to work one hour less the next working day. The time costs were computed by using both WTP and WTA approaches as well as their mean values. The mean values were used in the nal analyses. Individuals not in paid work mostly left unan- swered the question of working less, and so their WTA estimate was used. All dental clinics were in the range of public transport of the city of Turku, and in cost calculations, travel expenses were estimated to be the public transport fee of two euro per visit, irrespective of the transport method the patient might have used. Altogether, 112 subjects (59.6%) returned accept- ably completed questionnaires. Permission to col- lect data from their patient records was given by 109 patients. All treatment episodes were com- pleted within 6 months of the questionnaire study. The actual numbers of visits and all dental proce- dures were collected from the patient records of the treatment providers. Not all the subjects on the waiting list received treatment; the most common reasons were moving elsewhere and failure to attend a given appointment. Questionnaire and treatment data were available from 104 patients, 52 from each sector. Public and private sector sample sizes were equal by chance. Treatment costs for the provider were calculated by applying the average private practice fees for each dental procedure, provided by both the private and the public sector. The treatment costs were calculated using a societal perspective, where fees charged from the patients were not taken into account. The cost estimates using a societal per- spective represent the costs to the society, irrespec- tive of the nal payer. In another approach, the costs to the patients were estimated separately. In these estimates, the nine euro fee for each visit and treatment-specic patient charges according to given treatment were calculated in patient costs, as well as in provider returns. In addition to the fees charged by the provider, patient costs also include time costs. An overall time cost for a dental visit was computed by aggregating the costs of time for the estimated travelling back and forth to the clinic, time in waiting room before entering the treatment ofce and time spent receiving the actual treatment. Patients were asked about possible use of working hours for dental visits and an estimate of possible income losses. Total patient costs were estimated from the sum of the visit and treatment fees charged by the provider, travel expenses multi- plied by the number of visits, and overall time cost also multiplied by the number of visits. Statistical evaluation of the study groups was based on the chi-square test for proportions and Students t-test for means. The distributions of all cost categories were skewed to the right. Statistical analyses of the cost data were based on Mann 460 Tuominen & Eriksson Whitney U-test. Correlation coefcients and one- way analysis of variance were used. Natural loga- rithmic transformations of the costs to the provider and total costs were normally distributed, and linear regression models were tted for them using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). Results Patients who received treatment from the public sector were signicantly (P < 0.01) more likely to be highly educated than those who received treatment from private practice providers. Other differences between the groups were small and nonsignicant in all sociodemographic and dental treatment char- acteristics (Table 1). Seven subjects reported that they had lost income because of dental visits. The overall time required for providing treatment was 181 days in the public sector and 80 days in the private sector (P < 0.002). Patient-reported emer- gency visits and the types of treatment provided matched well with the actual records of dentists. On average, public sector patients had signi- cantly (P < 0.01) more dental visits (5.33) than private sector patients (3.47), which caused higher visiting fees. Treatment procedure fees paid by the patients were slightly, although not signicantly, higher among public sector patients. Patients treated in the public sector paid more fees (NS) than those directed to receive treatment fromthe private sector (Table 2). Together with more treatment fees, the patients in the public sector also had higher addi- tional out-of-pocket costs than in the private sector. A similar trend was observed in all cost categories studied (Table 2). The cost of treatment from the societal perspective was estimated to be higher (NS) in the public than in the private sector (Table 3). Patients treated in the private sector paid more per visit (P < 0.001). The treatment costs per visit to the provider were higher in the private than in the public sector (P < 0.001), causing also the total cost per visit to be signicantly (P < 0.001) higher in the private than in the public sector (Table 4). In multivariate regression analyses, when the effects of other studied variables were simulta- neously controlled, those patients who needed emergency dental treatment during the waiting time for comprehensive care had signicantly more costly treatment and total costs than other patients. The overall total time required for dental visits signicantly increased the total costs. The total cost of dental care in the public sector was slightly higher (P < 0.05) than in the private sector (Table 5). Table 1. Descriptive statistics of the sample according to the sector of service provision. (Standard deviations in parentheses) Sector Public Private Characteristic Mean Age 47.5 (15.5) 45.2 (18.4) Net monthly income 2153 (961) 1945 (984) Emergency visits during waiting time 2.3 (1.5) 2.6 (3.1) Time (in minutes) To travel to the clinic 41.1 (32.3) 49.4 (32.7) To wait in waiting room 10.3 (6.0) 7.6 (4.1) To be treated 28.8 (13.8) 28.8 (17.4) Time since last check-up (months) 16.1 (30.3) 22.4 (24.9) Percentage Women 54.1 53.8 Higher education 42.3 17.3** Working 63.5 63.5 Retired 25.0 28.8 Regularity of dental check-ups Annually 19.2 28.8 At least every second year 61.5 57.7 Statistical comparisons between sectors by chi-square test for proportions and Students t-test for means: **P < 0.01. Table 2. Median (means and standard deviations in parentheses) fees paid by patients in public and private sector. Patients time costs estimated by the mean value obtained by WTP and WTA methods Sector Public Private Fees Visiting fees 45.00 (47.94, 31.04) 27.00 (31.60, 21.00)** Procedure fees 111.00 (127.39, 87.50) 90.40 (128.56, 95.93) All treatment fees 147.70 (175.33, 116.29) 112.20 (160.16, 114.50) Other costs Travel 10.00 (10.95, 6.63) 6.00 (6.93, 5.28) Time In travelling 44.88 (79.47, 112.28) 33.33 (56.69, 64.74) In waiting room 17.92 (22.99, 20.45) 9.58 (13.24, 11.35)* In treatment 35.83 (59.17, 62.28) 23.00 (40.98, 38.90) All other out-of-pocket costs 127.00 (172.59, 179.97) 83.00 (117.84, 106.34) Total patient costs 267.60 (347.92, 272.25) 192.50 (278.00, 223.34) Statistical comparisons between sectors by Mann Whitney U-test. *P < 0.05; **P < 0.01. 461 Moral hazard in dentistry Discussion Both the sampled patients and the treatment providers were not selected, and they can be considered to be typical representatives of their respective groups. The similarities in sociodemo- graphic and dental treatment characteristics of the studied patient groups give further evidence of the randomization without selection bias. However, the sample size was relatively small, and the ndings of this study should be conrmed by studies with larger samples. Moral hazard occurs when patients with third- party coverage demand more care or more costly treatment options and or service providers offer them more care or more costly treatment than would have occurred without such coverage. In fee-for-service private practice systems, the health care providers income depends on how much and what type of health care he she provides. This also depends, at least in part, on the quantity and quality of the services the patient demands. When a patient does not need to pay the full amount him herself, but at least part of the costs is covered by a third party, economic theory assumes that the patient is willing to accept more and higher quality services to maximize his her health utility (16). Private practitioners who have sufcient private paying patients probably do not have service contracts with the city. Those who offer to treat patients directed by the city probably have fewer patients than desired with the contract being a method to satisfy their workload and income expectations. Thus, the present study setting could be used to determine whether these private prac- titioners engage provider moral hazard. The city of Turku covers the same treatment costs irrespective of treatment provider. The patient makes the same copayments for each specied treatment procedure, and all patients pay a nine euro fee per visit. Thus, the sample patients can be considered equally insured whether they received their treatment from the public or private sector. Private practitioners were free to determine the treatment needs of each individual patient and to provide the treatment they consid- ered the patient required. The ofcials of the city did not control the treatment planning or provision of the private practitioners, but public and private dentists have the same level of independence when determining the patients treatment needs. The same prices were applied to all treatment procedures, irrespective of the sector in which the treatment was provided. Although the public sector dentists are paid a salary with some pro- ductivity incentives, while in the private sector income depends completely on the amount and type of services provided, the use of the same prices for all treatment procedures enables com- parison of the two sectors. In the current study, only very few patients reported a real loss of income because of dental visits. Income loss and time to travel and receive treatment were reported in a questionnaire and represented the usual situation in the past, which may include some inaccuracy. However, there is no reason to expect that the patients who were ran- domly assigned to receive treatment either from the public or fromthe private sector wouldreact to these questions differently. The estimate used for travel costs was conservative. For several visits during the Table 3. Median (means and standard deviations in parentheses) costs covered by patients and provider for treatments in public and private sector. Patients time costs estimated by the mean value obtained by WTP and WTA methods Sector Public Private Costs Patient costs 267.60 (347.92, 272.25) 192.50 (278.00, 223.34) Provider costs 332.40 (381.89, 265.84) 243.10 (307.96, 212.78) Total costs 588.70 (738.79, 512.85) 487.18 (603.75, 402.01) Statistical comparisons between sectors by Mann Whitney U-test: nonsignicant. Table 4. Median (means and standard deviations in parentheses) costs of dental care per visit to patients and provider in public and private sector. Patients time costs estimated by the mean value obtained by WTP and WTA methods Sector Public Private Costs Patient fees per visit 34.00 (33.23, 7.44) 48.12 (48.08, 14.10)*** Other patient costs per visit 29.50 (33.24, 22.54) 32.00 (41.46, 32.05) Provider costs per visit 65.28 (73.21, 42.38) 101.73 (101.28, 37.49)*** Total costs per visit 125.76 (139.67, 51.07) 188.68 (191.40, 65.35)*** Statistical comparisons between sectors by Mann Whitney U-test. ***P < 0.001. WTA, willingness-to-accept; WTP, willingness-to-pay. 462 Tuominen & Eriksson treatment course, people may have sometimes used public transport andsometimes their own car. It was not feasible to use a travel diary to determine the actual costs of transportation for each visit. Patient time cost is an important component of the overall economic burden caused by sickness or use of health care services (17, 18). Time cost measures obtained through contingent valuation methods, WTA or WTP, can be expected to produce a more comprehensive estimate than if the measure had been based on productivity loss, which is usually derived through level of income. When economic burden estimates are based on income levels or productivity losses to employers, the values of leisure time and time outside paid work are not included. However, such leisure time and the time of housewives, retired, and unemployed people also have a value. In WTA measure, each subject gives his her value estimate for an hour of lost leisure time, and in WTP measure for an hour of additional leisure time. One disadvantage of the WTA and WTP methods is that the respondents are not in reality offered an opportunity to work more or less the next working day. The estimates they give represent a hypothetical situation, and it remains unclear whether their behaviour would be different if they actually had to make the contribu- tions or to accept the compensation. The nding of the present study that private practitioners, whose level of income is fully depend- ing on the amount and type of treatment procedures they provide, did not offer overall more costly treatment than salaried public sector dentists cor- roborates the view of Bessho and Ohkusa (14) that moral hazard may not play a signicant role when patients have insurance coverage. However, private practitioners provided the treatment with fewer visits, which reduced the visit fees, travel costs and the time costs of travelling and waiting. Efcient provision of treatment can be achieved by more treatment per visit instead of more visits, which was observed in the private sector. If supplier-induced demand in private practice had taken place, higher costs per treatment course would have been ex- pected in the private sector than in the public sector. However, if private practitioners had the opportu- nity to treat publicly funded patients only to the extent of lling the gaps in their appointment books and they had otherwise sufcient private paying patients, then more treatment per visit for publicly funded patients may also indicate provider moral hazard (15). On the other hand, private dentists providing more treatment per visit could be ex- plained by private dentists providing more than is needed by increasing the content per visit. The need for more visits to receive treatment can be expected to cause inconvenience for patients in addition to the observed higher patient costs. Owing to the heavy patient load in the public sector, the time needed to nalize the treatment episodes was also twice as long as in the private sector. This is an additional component that would further increase inconvenience for patients. Ratio- nalizing the treatment in the public sector to include more treatment procedures per visit would decrease the number of visits per patient, thereby decreasing the time costs to the patients and reducing the overall time needed to complete the entire treatment episode. These ndings should not be considered as evidence of the private sector being a recom- mended mean of providing dental services. This Table 5. Multivariate regression analyses of selected background variables on natural logarithmic transformations of provider costs and total costs Variable lnProvider costs lnTotal costs b t-value P< b t-value P< Age )0.01 )1.13 0.270 )0.01 )1.21 0.239 Time required for a dental visits 0.04 1.56 0.131 0.06 2.47 0.020 Time since last check-up )0.60 )1.65 0.112 )0.61 )1.76 0.090 Level of income )0.00 )2.31 0.029 )0.00 )1.98 0.059 Male sex 0.39 1.92 0.066 0.38 1.93 0.064 Any emergency treatment During waiting time 0.66 3.21 0.004 0.64 3.26 0.003 Retired 0.47 1.59 0.125 0.55 1.97 0.060 Public sector 0.23 1.18 0.249 0.29 2.21 0.038 Regularity of dental check-ups At least very second year 0.25 1.16 0.255 0.19 0.93 0.362 Higher education 0.43 1.56 0.132 0.37 1.41 0.170 R 2 0.562 0.621 463 Moral hazard in dentistry study indicates some productivity differences, but any possible differences in quality of treatment and health utility cannot be estimated with the present data. Furthermore, the available data do not take into consideration the costs of organizing the services, constructing and maintaining the clinics, and overheads. Multivariate regression models corroborated the nding of univariate analyses that the total cost of the treatment is higher in the public sector, and the difference is not biased by confounding effects of background factors. The nding that the time needed for a dental visit had a signicant effect on total costs but not on provider costs can be consid- ered as evidence of logical multivariate models. Patients who needed emergency treatment had also received more nonemergency treatment, irre- spective of the frequency of dental attendance and time since last dental check-up. These patients might needanalternative queue system. Factors predicting possible need for emergency treatment have been identied (19), and the development of modelling techniques is in preparation to enable priority allocations (20). Varying scoring systems based on risk, urgency and other classications (2123) have been suggested in several medical specialities to rank patient cases into different queues. Need for emergency treatment could be considered as one such ranking argument in dentistry, together with several general medical conditions like coronary heart diseases, rheumatoid arthritis and people undergoing chemotherapy. The ndings of the present study did not give direct evidence of moral hazard on the provider side. The observed cost differences between the two sectors may indicate that private practitioners manage their publicly funded patients faster than their private paying patients. Or, it may indicate that private dentists provide more treatment per visit to induce more than necessary treatment. Assessing this possibility would require data on all patients health care needs together with specic treatment procedures performed during the visits. 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