Does capitation affect the delivery of oral healthcare and access to services? Evidence from a pilot contact in Northern Ireland

Hill, Harry; Birch, Stephen; Tickle, Martin; McDonald, Ruth; Donaldson, Michael; O’Carolan, Donncha; Brocklehurst, Paul

doi:10.1186/s12913-017-2117-3

Cited by 13 publications

(7 citation statements)

References 22 publications

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“…Capitation-based services should theoretically result in less treatment and more prevention, as effective prevention reduces demands on the provider without reducing provider income, although evidence for primary care physicians did not support this (Gosden et al 2000). In a pilot project switching some primary care dentists from FFS to capitation in Northern Ireland, treatment volumes fell but preventive interventions did not increase (Hill et al 2017). Pay-for-performance models have been investigated for doctors in hospital settings with no impact found on patient outcomes, although quality of care did improve (Mathes et al 2019).…”

Section: The Economic Issues In Reorienting Oral Health Servicesmentioning

confidence: 99%

Reorienting Oral Health Services to Prevention: Economic Perspectives

2021

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Despite the recognized need to change the emphasis of health services by shifting the balance from treatment to prevention, limited progress has been made in many settings. This is true in oral health, where evidence for preventive interventions that work has not been systematically exploited in oral health services. While reorienting health services is complex and context specific, economics can bring a helpful perspective in understanding and predicting the impact of changes in resource allocation, provider remuneration systems, and patient payments. There is an increasing literature on the economics of different prevention approaches. However, much of this literature focuses on the costs and potential savings of alternative approaches and fails to take into account benefits. Even where benefits are taken into account, these tend to be narrowly focused on clinical outcomes using cost-effectiveness analysis, which may be of little relevance to the policy maker, patient, and the public. Some commonly used economic approaches (such as quality-adjusted life years and incremental cost-effectiveness ratios) may also not be appropriate to oral health. Using alternative techniques, including wider measures of benefit and employing priority setting and resource allocation tools, may provide more comprehensive information on economic impact to decision makers and stakeholders. In addition, it is important to consider the effects of provider remuneration in reorienting services. While there is some evidence about traditional models of remuneration (fee for service and capitation), less is known about pay for performance and blended systems. This article outlines areas in which economics can offer an insight into reorientation of health systems toward prevention, highlighting areas for further research and consideration.

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Section: The Economic Issues In Reorienting Oral Health Servicesmentioning

confidence: 99%

Reorienting Oral Health Services to Prevention: Economic Perspectives

2021

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“…Our research group used data from the pPDS to independently evaluate the effect the newly introduced capitation payment system had on the delivery of primary oral health care and access to services in Northern Ireland. 4,50 This independent study was published in 2017 and treated the pPDS as a natural experiment comparing the NHS treatment claim forms submitted between April 2011 and October 2014 from the 14 Oasis practices with those of a group of matched, control GDS practices, remunerated using the GDS retrospective FFS system. This study could find no evidence of patient selection (excluding high-need patients) in the Oasis practices.…”

Section: The Evolution Of a New Nhs Dental Contract In Northern Irelandmentioning

confidence: 99%

Impact of changing provider remuneration on NHS general dental practitioner services in Northern Ireland: a mixed-methods study

Brocklehurst

Tickle

Birch

et al. 2020

Health Serv Deliv Res

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Background Policy-makers wanted to reform the NHS dental contract in Northern Ireland to contain costs, secure access and incentivise prevention and quality. A pilot project was undertaken to remunerate general dental practitioners using a capitation-based payment system rather than the existing fee-for-service system. Objective To investigate the impact of this change in remuneration. Design Mixed-methods design using a difference-in-difference evaluation of clinical activity levels, a questionnaire of patient-rated outcomes and qualitative assessment of general dental practitioners’ and patients’ views. Setting NHS dental practices in Northern Ireland. Participants General dental practitioners and patients in 11 intervention practices and 18 control practices. Interventions Change from fee for service to a capitation-based system for 1 year and then reversion back to fee for service. Main outcome measures Access to care, activity levels, service mix and financial impact, and patient-rated outcomes of care. Results The difference-in-difference analyses showed significant and rapid changes in the patterns of care provided by general dental practitioners to patients (compared with the control practices) when they moved from a fee-for-service system to a capitation-based remuneration system. The number of registered patients in the intervention practices compared with the control practices showed a small but statistically significant increase during the capitation period (p < 0.01), but this difference was small. There were statistically significant reductions in the volume of activity across all treatments in the intervention practices during the capitation period, compared with the control practices. This produced a concomitant reduction in patient charge revenue of £2403 per practice per month (p < 0.05). All outcome measures rapidly returned to baseline levels following reversion from the capitation-based system back to a fee-for-service system. The analysis of the questionnaires suggests that patients did not appear to notice very much change. Qualitative interviews showed variation in general dental practitioners’ behaviour in response to the intervention and how they managed the tension between professional ethics and maximising the profits of their business. Behaviours were also heavily influenced by local context. Practice principals preferred the capitation model as it freed up time and provided opportunities for private work, whereas capitation payments were seen by some principals as a ‘retainer fee’ for continuing to provide NHS care. Non-equity-owning associates perceived the capitation model as a financial risk. Limitations The active NHS pilot period was only 1 year, which may have limited the scope for meaningful change. The number of sites was restricted by the financial budget for the NHS pilot. Conclusions General dental practitioners respond rapidly and consistently to changes in remuneration, but differences were found in the extent of this change by practice and provider type. A move from a fee-for-service system to a capitation-based system had little impact on access but produced large reductions in clinical activity and patient charge income. Patients noticed little difference in the service that they received. Future work With changing population need and increasing financial pressure on the NHS, research is required on how to most efficiently meet the expectations of patients within an affordable cost envelope. Work is also needed to identify and evaluate interventions that can complement changes in remuneration to meet policy goals. Trial registration Current Controlled Trials ISRCTN29840057. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

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“…In all four of the home countries new approaches to NHS dental contract reform all seek to focus on prevention, expand access, reduce inequalities and contain costs. Studies by our research group show that the type and volume of activity provided by dentists is very sensitive to the way they are paid (29)(30)(31)(32). The approach in England has been one of slow evolution with piloting of new contracts in a small number of selected practices over the last 5-6 years.…”

Section: Rationale For Current Studymentioning

confidence: 99%

How effective and cost-effective is water fluoridation for adults?

Moore¹

2020

http://isrctn.com/

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Minor changes  Normally can be made by an authorised member of staff and do not need formal approval.  Information relating to minor changes can be summarised when a new version is issued.  Indicated by points, for example, V1.1 contains a minor change to V1.0. Major revisions  An appropriate authority (Study Steering Committee and NIHR) should usually approve major revisions.  Each major revision should contain a summary of all the minor changes that it incorporates, in the version control table  Whole numbers are used to indicate a revised version, for example, V2.0 is a revision of V1.0.

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Does capitation affect the delivery of oral healthcare and access to services? Evidence from a pilot contact in Northern Ireland

Cited by 13 publications

References 22 publications

Reorienting Oral Health Services to Prevention: Economic Perspectives

Reorienting Oral Health Services to Prevention: Economic Perspectives

Impact of changing provider remuneration on NHS general dental practitioner services in Northern Ireland: a mixed-methods study

How effective and cost-effective is water fluoridation for adults?

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