The effect of different methods of remuneration on the behaviour of primary care dentists

Financial incentives within remuneration systems (methods of payment) can influence the behaviour of clinicians working in primary care environments. Systematic reviews in medicine have found that changing the way that doctors are paid can produce substantial changes in the types of activities that are undertaken. For example, paying a fee for specific services can increase the quantity of services delivered, although this may not produce an improvement in patient outcomes.

The main methods for remunerating primary care dentists include:

1. fee-for-service payment (a payment made to a dentist for every item of service or unit of care that they provide);

2. fixed salary payment (a lump sum payment made to a dentist for a set number of working hours or sessions per week);

3. capitation payment (a payment based on the number and types of patients whose care the dentist takes responsibility for); and

4. blended payment (combination of above).

Our review identified two studies examining the effects of different methods of remuneration on the behaviour of 821 dentists from 503 dental practices, involving 4771 patients. Both were conducted in the United Kingdom. One study investigated the impact of a fee-for-service payment and an educational intervention on the placement of fissure sealants in permanent molar teeth. The second study compared the impact of capitation payments and fee-for-service payments on primary care dentists’ clinical activity and the levels of dental decay that were experienced across the two payment systems.

The first study found an increase in clinical activity related to fee-for-service payments. In the second study, dentists working under capitation arrangements restored carious teeth at a later stage in the disease process than fee-for-service controls. In the capitation arm, the dentists tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but tended to give more preventive advice.

There was insufficient information regarding cost-effectiveness of the different remuneration methods.

Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence is low/very low for all outcomes.

Authors' conclusions: 

Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

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Background: 

Methods of remuneration have been linked with the professional behaviour of primary care physicians. In dentistry, this can be exacerbated as clinicians operate their practices as businesses and take the full financial risk of the provision of services. The main methods for remunerating primary care dentists include fee-for-service, fixed salary and capitation payments. The aim of this review was to determine the impact that these remuneration mechanisms have upon primary care dentists’ behaviour.

Objectives: 

To evaluate the effects of different methods of remuneration on the level and mix of activities provided by primary care dentists and the impact this has on patient outcomes.

Search strategy: 

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 7, 2013); MEDLINE (Ovid) (1947 to 11 June 2013); EMBASE (Ovid) (1947 to 11 June 2013); EconLit (1969 to 11 June 2013); the NHS Economic Evaluation Database (EED) (11 June 2013); and the Health Economic Evaluations Database (HEED) (11 June 2013). We conducted cited reference searches for the included studies in ISI Web of Knowledge; searched grey literature sources; handsearched selected journals; and contacted authors of relevant studies.

Selection criteria: 

Primary care dentists were defined as clinicians that deliver routine or mainstream dental care in a primary care environment. We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments. Primary outcome measures were: measures of clinical activity; volume of clinical activity undertaken; time taken and clinical session length, or both; clinician type utilised; measures of health service utilisation; access and attendance as a proportion of the population; re-attendance rates; recall frequency; levels of oral health inequalities; non-attendance rates; healthcare costs; measures of patient outcomes; disease reduction; health maintenance; and patient satisfaction. We also considered measures of practice profitability/income and any reported unintended effects of the included methods of remuneration.

Data collection and analysis: 

Three of the review authors (PRB, JP, AMG) independently reviewed titles and abstracts and resolved disagreements by discussion. The same three review authors undertook data extraction and assessed the quality of the evidence from all the studies that met the selection criteria, according to Cochrane Collaboration procedures.

Main results: 

Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach.

One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes.

The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists’ clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.

There was insufficient information regarding the cost-effectiveness of the different remuneration methods.

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