The role of payments systems in influencing oral health care provision

Introduction: The unique characteristics of dental disease, such as its predictability, non-communicability, ease of diagnosis, and its extensive prevention possibilities, should result in greater cost control and an expectation of a better operation of the market mechanism than in general health care. These differentiating features, however, also increase the likelihood that services are over-consumed and/or over-provided. The most influential feature determining efficient resource use in health care provision is the type of payment system. A per capita system serves as a link between the dentist’s future income and service provision, and provides equity in terms of coverage and access. The result is that patients may benefit from fewer unnecessary treatments, and encounter more preventive activities. The system is limited by the potential for under-treatment and problems with patient selection. With fixed salary, the dentist's income is independent of service provision, with incentives for low production, which leads to high costs per patient. Salaried dentists generally provide more prevention services, and allow the targeting of services to priority or ‘special needs’ groups. The patient benefits from the greater equity of a service and the location of services can be determined by community needs. Fee-per-item is the most common payment system in dental service provision for adults, where the dentist is rewarded according to the amount of work undertaken. Fee-per-item removes the incentive for supervised neglect or to cherry pick patients. It also solves the problems of patient selection and under-treatment, associated with capitation financing. Fee-per-item can encourage the use of services by patients on the advice of the dentist with the result that costs can be inflated with little impact on oral health itself. In the absence of a system of probity, dentists can manipulate demand and set fees, and provided moral hazard can occur in the form of supplier inducement. This review discusses the role of payment systems in influencing oral health care provision. Conclusion: The optimal dental contract may be a ‘blended’ payment system whereby dentists receive a proportion of their income through capitation, a proportion from allowances and proportion from fee-per-item of service

Comment

When it was put to me that I should set forward my comnents on "Industrial relations: a framework for review" (the Green Paper in 2 volurncs published by the Governtnent to stimulate constructive discussion on the future stnu:turc or the machinery of industrial relations in New Zealand) I found my self in something of a quandary. Both volumess and more particularly volume 2, bring together a great deal of information with which people should be familiar befoew they attempt to discuss the subject. But the Green Paper also poses a large number of propositions on which it invite agreement or disagreement

Do economic incentives influence the provision of dental services in a third-party funded dental scheme?

Objectives:To investigate whether the provision of dental services is influenced by economic incentives in a third-party funded dental service in the Republic of Ireland. Methods:Four treatment items were identified as outcome variables. These items were characterised by variation in regulation among administrative regions or variation in regulation over time. The items were Extra Oral Radiographs, Endodontics, Prolonged Periodontal Treatment, and Surgical Extractions. Claims data were obtained from the Primary Care Reimbursement Service (PCRS), formerly known as the General Medical Services Payments Board (GMSPB). Population data were obtained from the Central Statistics Office. Data were obtained from the Principal Dental Surgeons in Ireland who apply local regulatory or price controls for certain items of treatment. The data were analysed to determine the impact of the variation in regulatory approach on claims data among the eight regional health administrative areas whilst controlling for known clinical or population structural factors. Results There was a substantially lower than average provision of Extra-Oral Radiographs in regions where regulation was stringently applied.The provision of Prolonged Periodontal Treatment was positively correlated with price. The dentist-to-population ratio is positively correlated with claims for Surgical Extractions. ConclusionsThere is evidence from within the funding system that economic incentives, arising from either the contract itself or due to the geographical structure of the dentist workforce in Ireland, leads to variations in certain items of service provision which are potentially inefficient and independent of known treatment need

Cost-outcome description of clinical pharmacist interventions in a university teaching hospital

Background: Pharmacist interventions are one of the pivotal parts of a clinical pharmacy service within a hospital. This study estimates the cost avoidance generated by pharmacist interventions due to the prevention of adverse drug events (ADE). The types of interventions identified are also analysed. Methods: Interventions recorded by a team of hospital pharmacists over a one year time period were included in the study. Interventions were assigned a rating score, determined by the probability that an ADE would have occurred in the absence of an intervention. These scores were then used to calculate cost avoidance. Net cost benefit and cost benefit ratio were the primary outcomes. Categories of interventions were also analysed. Results: A total cost avoidance of €708,221 was generated. Input costs were calculated at €81,942. This resulted in a net cost benefit of €626,279 and a cost benefit ratio of 8.64: 1. The most common type of intervention was the identification of medication omissions, followed by dosage adjustments and requests to review therapies. Conclusion: This study provides further evidence that pharmacist interventions provide substantial cost avoidance to the healthcare payer. There is a serious issue of patient’s regular medication being omitted on transfer to an inpatient setting in Irish hospitals

The implications of regional and national demographic projections for future GMS costs in Ireland through to 2026

BACKGROUND: As the health services in Ireland have become more resource-constrained, pressure has increased to reduce public spending on community drug schemes such as General Medical Services (GMS) drug prescribing and to understand current and future trends in prescribing. The GMS scheme covers approximately 37% of the Irish population in 2011 and entitles them, inter alia, to free prescription drugs and appliances. This paper projects the effects of future changes in population, coverage, claims rates and average claims cost on GMS costs in Ireland. METHODS: Data on GMS coverage, claims rates and average cost per claim are drawn from the Primary Care Reimbursement Service (PCRS) and combined with Central Statistics Office (CSO) (Regional and National Population Projections through to 2026). A Monte Carlo Model is used to simulate the effects of demographic change (by region, age, gender, coverage, claims rates and average claims cost) will have on GMS prescribing costs in 2016, 2021 and 2026 under different scenarios. RESULTS: The Population of Ireland is projected to grow by 32% between 2007 and 2026 and by 96% for the over 70s. The Eastern region is estimated to grow by 3% over the lifetime of the projections at the expense of most other regions. The Monte Carlo simulations project that females will be a bigger driver of GMS costs than males. Midlands region will be the most expensive of the eight old health board regions. Those aged 70 and over and children under 11 will be significant drivers of GMS costs with the impending demographic changes. Overall GMS medicines costs are projected to rise to €1.9bn by 2026. CONCLUSIONS: Ireland’s population will experience rapid growth over the next decade. Population growth coupled with an aging population will result in an increase in coverage rates, thus the projected increase in overall prescribing costs. Our projections and simulations map the likely evolution of GMS cost, given existing policies and demographic trends. These costs can be contained by government policy initiatives

The implications of regional and national demographic projections for future GMS costs in Ireland through to 2026

As the health services in Ireland have become more resource-constrained, pressure has increased to reduce public spending on community drug schemes such as General Medical Services (GMS) drug prescribing and to understand current and future trends in prescribing. The GMS scheme covers approximately 37% of the Irish population in 2011 and entitles them, inter alia, to free prescription drugs and appliances. This paper projects the effects of future changes in population, coverage, claims rates and average claims cost on GMS costs in Ireland

Technology use among patients with cardiovascular disease: an assessment of patient need for a technology enabled behavioural change intervention.

Effective Cardiac Rehabilitation (CR) can significantly improve mortality and morbidity rates in relation to cardiovascular disease; however, uptake of traditional community-based long-term is very low. PATHway (Physical Activity Towards Health) will provide individualized rehabilitation programs, through an internet-enabled sensor-based home exercise platform that allows remote participation. The purpose of this study was to assess the level of interest and use of technology by individuals living with CVD in order to inform the design of a technology-enabled CR programme. Method: A technology usage questionnaire based on a previous study investigating the role of technology and mHealth in a CVD population was used (Dale et al., 2014) to ascertain the current level of technology use. All patients attending the Phase Four community cardiac rehabilitation HeartSmart programme (MedEx) were recruited (N=67; 66.2 years, SD= 8.55, Males =76.1%, Females=20.9%). Results: Technology usage was high with 60% of participants owning a smartphone and 85% accessing the internet (54% of whom access it everyday). Participants endorsed the idea of technology enabled cardiac rehabilitation, indicating that they found the idea ‘ appealing’. 79% were interested in receiving ongoing CR support via their smartphones, 79% were interested in receiving CR via the internet. It was found that 52% of patients found the idea of a virtual rehabilitation class appealing. Conclusion: This study provides support for the patient need for a technology enabled behavioural change intervention, specifically through the provision of an internet-enabled sensor-based home exercise platform that allows remote participation in CR exercise programs

Uptake to a community based chronic illness rehabilitation programme (CBCIR): Is there a gender disparity?

Background: Multi-morbidity and chronic conditions pose a threat to population health. Despite known benefits of rehabilitation using structured exercise, uptake to such programmes remain sub-optimal. The aim of this study is to identify the psychosocial and health related fitness correlates of uptake to a CBCIR in men and women, with the secondary aim of identifying the rate of uptake. Methods: Participants referred to a CBCIR via GPs and hospitals completed an induction process. This introduced them to the CBCIR programme and got them to complete a multi-section questionnaire (including instruments on physical activity, exercise self-efficacy, intentions for exercise, and perceived family/friend social support) and complete a battery of physical health measures (including the Incremental shuttle walk test (ISWT), a lower body strength test and body mass index (BMI)). Post induction participants who attended an exercise class were classified as ‘Uptakers’, whilst those who never came back were classified as ‘Non-Uptakers’. Class attendance was objectively monitored by the researchers. Data were analysed using SPSS, and are presented using means, standard deviations and proportions, group differences are examined via t-tests and logistic regression was used to predict uptake. Results: A total of 441 participants (56% male; average age 64.3 ±12 years completed induction measures. Overall, 77% were identified as Uptakers (81% female, 74% male, p=0.068, 2-sided). Among men, Uptakers reported more days of 30mins moderate to vigorous physical activity (t(111) = -2.499,

Co-design and user validation of the MedFit App: a focus group analysis

This abstract details the development phase of the formative research process outlined by the Medical Research Council, used to develop a theoretically informed Android App, named MedFit, to enhance disease self-management and quality of life in adults with cardiovascular disease (CVD). The overall aim of the app is to increase physical activity minutes of adults with CVD. A key part of the development phase, which is the focus of this abstract, is the co-design and user validation of the MedFit app

Behavior Change Techniques in Physical Activity eHealth Interventions for People With Cardiovascular Disease: Systematic Review

Background: Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe, accounting for 4 million deaths per year and costing the European Union economy almost €196 billion annually. There is strong evidence to suggest that exercise-based secondary rehabilitation programs can decrease the mortality risk and improve health among patients with CVD. Theory-informed use of behavior change techniques (BCTs) is important in the design of cardiac rehabilitation programs aimed at changing cardiovascular risk factors. Electronic health (eHealth) is the use of information and communication technologies (ICTs) for health. This emerging area of health care has the ability to enhance self-management of chronic disease by making health care more accessible, affordable, and available to the public. However, evidence-based information on the use of BCTs in eHealth interventions is limited, and particularly so, for individuals living with CVD. Objective: The aim of this systematic review was to assess the application of BCTs in eHealth interventions designed to increase physical activity (PA) in CVD populations. Methods: A total of 7 electronic databases, including EBSCOhost (MEDLINE, PsycINFO, Academic Search Complete, SPORTDiscus with Full Text, and CINAHL Complete), Scopus, and Web of Science (Core Collection) were searched. Two authors independently reviewed references using the software package Covidence (Veritas Health Innovation). The reviewers met to resolve any discrepancies, with a third independent reviewer acting as an arbitrator when required. Following this, data were extracted from the papers that met the inclusion criteria. Bias assessment of the studies was carried out using the Cochrane Collaboration’s tool for assessing the risk of bias within Covidence; this was followed by a narrative synthesis. Results: Out of the 987 studies that were identified, 14 were included in the review. An additional 9 studies were added following a hand search of review paper references. The average number of BCTs used across the 23 studies was 7.2 (range 1-19). The top three most frequently used BCTs included information about health consequences (78%, 18/23), goal setting (behavior; 74%, 17/23), and joint third, self-monitoring of behavior and social support (practical) were included in 11 studies (48%, 11/23) each. Conclusions: This systematic review is the first to investigate the use of BCTs in PA eHealth interventions specifically designed for people with CVD. This research will have clear implications for health care policy and research by outlining the BCTs used in eHealth interventions for chronic illnesses, in particular CVD, thereby providing clear foundations for further research and developments in the area