Towards more evidence-informed policy making for preventing oral diseases

Abstract

Oral diseases seriously affect people's quality of life and impose a considerable economic burden to society. Although largely preventable, they remain highly prevalent among European societies. A multi-layered oral health-promotional approach intends to improve patients risk behaviours and utilization of prevention-focused services by tackling their underlying drivers located in health system determinants and the wider socio-environmental milieu. For both aspects, interventions building upon the steering mechanism of economic incentives have been increasingly proposed. The aim of this dissertation is to provide useful evidence to policy makers about how policy interventions based on economic incentives may serve as a helpful tool for preventing oral diseases. By means of a simulation-based cost-effectiveness analysis, it was shown that a 20% ad valorem tax on sugar-sweetened beverages may substantially improve oral health and reduce the caries-related economic burden in terms of treatment costs avoided. Using the Dutch population as a reference case, taxation would result in an average of 2.13 caries-free tooth years per person and, on a population level, prevention of 1,030,163 caries lesions. The intervention was found to save a total of 159.01 million euros of dental care expenditures. Benefits would be the greatest for younger age groups and reduced sugar consumption through taxation postpones caries onset to a later point in life. Market-oriented reforms in healthcare systems are intended to improve the quality of care and to contribute to cost containment by meeting consumer preferences more efficiently. Since increasing health expenditures for citizens have been observed in this context, it is questionable whether such interventions can improve prevention-oriented utilization of oral healthcare services. In 2012, the Netherlands established the so called “free market experiment”, which allowed providers of dental care to set the prices for their dental services themselves. Using large-volume health insurance claims data and exploiting this natural experiment in Dutch dental care, the effects of a liberalization of service prices were identified with regard to changes in utilization patterns of prevention-oriented dental services. Hereby, pooled regression with individual fixed effects was applied. Analysis showed substantial increases in prices and patients’ out-of-pocket contributions for dental services following the liberalization with differences in increases between types of services. Variations in price and out-of-pocket price increases support the hypothesis of different levels of asymmetric information for first-stage and follow-on services. In response to the experiment, the proportion of treatment sessions containing prevention-oriented services decreased significantly by 3.4% among adults and by 5.3% for children and adolescents. Price liberalization affects the composition of treatment sessions towards a decreasing use of preventive services, suggesting a shift in the reason for seeing a dentist from a regular-preventive perspective to a symptom-based restorative approach. The presence of asymmetric information implies that patients are not capable of assessing the quality and necessity of service to a sufficient extend. This highlights that incentives to promote high value oral care should tie to the supply-side directly, since those approaches don’t leave the judgement about quality to the consumer alone. In this context, performance-oriented provider payment systems are considered a sensible strategy to optimize healthcare. On basis of routinely collected administrative data and using difference-in-differences analysis, the impact of adding performance-oriented bonus payments to salary on the utilization of dental care was evaluated. For this purpose, natural variation in financial incentives in a large ambulatory care setting was exploited. A significant increase was observed in utilization for directly and indirectly incentivized treatment items. An increase in overall utilization in response to introducing bonus incentives was also found. These findings suggest that combining salary with bonus payments has the potential to extract improved performance in oral healthcare. Since the definition of target parameters for performance-based remuneration followed a rather pragmatic approach, the question remains how suitable target parameters for performance-oriented payment systems in oral healthcare can be designed. A set of core items for strengthening patient-centred and prevention-oriented oral healthcare was established by means of broad stakeholder consensus. These measures are able to serve as a starting point for target parameters of a performance-based remuneration system focusing on patient-centred and prevention-oriented oral healthcare delivery. This dissertation provides novel evidence about how policy interventions based on economic incentives may serve as a helpful tool for preventing oral diseases. However, careful analysis and monitoring is warranted to adequately weigh the intended and unintended consequences of those policies.