the impact of the new nhs dental contract d. bonetti, j. clarkson, m. chalkley, c.tilley and l....
TRANSCRIPT
The Impact of the new NHS Dental Contract
D. Bonetti, J. Clarkson, M. Chalkley, C.Tilley and L. Young
Overview
• NHS dentistry before and after the “New Contract”
• Economics of the New Contract
• Some initial estimates of the impact of the New Contract
• Summary – Policy implications
NHS Dentistry before and after the New Contract
• Focus on ‘high street’ dentistry
• NHS is (still) the major funder/purchaser– Contracts with independent contractors Self-
Employed General Dental Practitioners (GDPs)
• England and Wales: GDS Contract, PDS Contract• Scotland : GDS Contract + some salaried dentists
NHS Dentistry before and after the New Contract
• The public perception– ‘Disappearing’
– Being replaced by ‘expensive’ private care– Abandoning people to their own fate
Man pulls out own teeth with pliersOct 19, 2007A man has described how he pulled out seven of his own teeth because he was told to wait for an appointment to see an NHS dentist.Taxi driver Arthur Haupt used pliers and a technique he had learned in the army to carry out the DIY dentistry.He said he was forced in agony into taking the drastic action because he was given a three-week wait by staff at his local NHS dental surgery and couldn't afford the £75-a-tooth treatment he was quoted by a private practice.
NHS Dentistry before and after the New Contract
• The context– In both Scotland and England & Wales about
50% of adults and 70% of children have been seen by an NHS dentist in the last 18 months. The former has fallen a little since 1995, the latter has risen.
– Private sector provision is rising
NHS Dentistry before and after the New Contract
• The `New Contract’– Comes into effect in 2006 in England & Wales– Replaces both GDS (Fee-for-Service) and PDS (quasi
salary)– Specifies payment in terms of per completed
treatment (in 4 bands)– Introduces a new ‘contract currency’ UDA with each
banded treatment given a UDA score.– Complex transitional arrangements but in essence it
is £/UDA– Contract specifies volume and price. If under volume
dentist ‘refunds’ if over volume …. ?
NHS Dentistry before and after the New Contract
12.0Treatment requiring laboratory work3
3.0Fillings and extractions2
1.2One of a specified set of possible treatments provided to a patient in circumstances where:
1. prompt care and treatment is provided because, in the opinion of the dental practitioner, that person’s oral health is likely to deteriorate significantly or the person is in severe pain by reason of their oral condition; or
2. care and treatment is only provided to the extent that it is necessary to prevent that significant deterioration or address that severe pain
1 URGENT
1.0Routine examination, scaling and diagnostic procedures1
UDADescriptionFeeband
Bands of treatment under the New Contract
Economics of the New ContractComparative Statics
• Consider the intensity of treatment of a patient t• New Contract replaces Fee-for-Service ( a
smooth continuous function in t) and quasi-salary (a smooth zero sloped payment function) with stepped payment function.
• How will this impact on treatment decisions given:– Variation in dentists– Variation in patients?
Economics of the New ContractComparative Statics
)(tP
t
Quasi salariedFee for service (self-employed)‘New’ Contract (self-employed England)
Economics of the New ContractComparative Statics
Economics of the New ContractComparative Statics
Economics of the New ContractComparative Statics
Economics of the New ContractComparative Statics
Economics of the New ContractComparative Statics
0 5 10 15 20 25 30
100
50
50
100
150
200200
72.5
v N t( )
v S t( )
v F t( )
300 t
0 5 10 15 20 25 30
100
50
50
100
150
200200
72.5
v N t( )
v S t( )
v F t( )
300 t
Economics of the New ContractDynamics
• In practice dentists may not adjust instantaneously:– Adjustment costs– Learning regarding new arrangements– Changes in administrative arrangements for
new contract (monitoring) are still on-going
Economics of the New ContractDynamics
• New contract was announced in principle in April 2005
• Initial 3 years of new contract is 'transitional'
• Initial price set in relation to work done in the year prior to introduction of new contract
• Dentists may thus have been adjusting treatment in anticipation
Economics of the New ContractSummary
• Static Model– Treatment intensity determined by
• contract, • case mix,
• dentists preferences and costs -- b(.) and c(.)
– Number of treatments determined by• treatment intensities
– Expect bunching of treatment at thresholds– Impact of New Contract is ambiguous
• Expect adjustment + Anticipatory effects
Estimating the Impact of the New Contract
• Dentist behaviour (numbers treated and treatment intensities) before and after contract introduction confounded by changes in case mix, dentists’ costs, practice style etc.
• Use individual level data and a differences-in-differences design (use Scottish GDS dentists as control).
Estimating the Impact of the New Contract
• Data– Administrative records for a sample of 98 (62 England
and 36 Scotland) newly qualified dentists for the period October 2005 to November 2006.
– Observe number of courses of treatment and for each treatment (about 170,000) which UDA band its falls
– (for Scotland we have the full items of treatment but these are no longer recorded in England)
– We have the dentist’s ID and characteristics and some characteristics of the patient undergoing the treatment.
Estimating the Impact of the New Contract
0
20
40
60
80
100
120
140
160
180
200
Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06
England & Wales Scotland
• Mean number of courses of treatment per dentist per month
Estimating the Impact of the New Contract
• Proportion of courses of treatment in Band 1 (low treatment intensity)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06
England & Wales Scotland
Estimating the Impact of the New Contract
• Proportion of courses of treatment in Band 2 (high treatment intensity)
0
0.02
0.04
0.06
0.08
0.1
0.12
Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06
England & Wales Scotland
• Econometric specification (courses of treatment)
Estimating the Impact of the New Contract
Estimating the Impact of the New Contract
• Results – Courses of Treatment (CoT) estimate of– Fixed effects regressions – Negative coefficient => positive impact of new contract
12160.177-1.3609.245-12.585ALL
7060.2341.2011.46813.792GDS
5990.000-4.8107.029-33.792PDS
ObservationsP>ttSEDENTISTS
•Mean number of CoT is 125
•R Square approx. 0.62, mainly due to FE
Estimating the Impact of the New Contract
• New Contract has had little impact on previous Fee-for-Service dentists
• But has increased number of courses of treatment by more than 15% for previously PDS dentists
Estimating the Impact of the New Contract
• Distribution of Treatments across Bands
35104688372278644497Observations
37583355Dentists
7.276.259.185.453
37.6632.641.3934.172
51.451.6445.4556.861
2.569.512.752.581u
1.1201.230.95Na
ScotlandEngland & WalesScotlandEngland & WalesBand
April 2006 - November 2006October 2005 - March 2006
• Econometric specification (treatment intensity - band)
Estimating the Impact of the New Contract
Estimating the Impact of the New Contract
• Results – Bands– Fixed effects linear probability regressions – Negative coefficient => positive impact of new contract– Bands 1u and 2 combined (due to classification issues)
•Results here are not affected by previous contract
•Results qualitatively similar in MNL and Mixed MNL specifications
171224980.000-4.4200.005-0.024Band 3
171224980.000-5.4100.015-0.083Band 1u2
171224980.0005.5900.0180.098Band 1
Observations
DentistsP>ttSECoef.
Estimating the Impact of the New Contract
• New Contract has substantially reduced (increased) the probability of low (high) intensity treatments.
• Effect is similar across both previous FFS and PDS dentists
Estimating the Impact of the New Contract
• Reconciling CoT and Banding Evidence– CoT seems to suggest treatment intensity decreasing
(for PDS) and constant for GDS following contract change.
– Band Evidence (up-banding) suggests intensity increasing
– Therefore some evidence that previous intra-marginal patients are being treated less intensively, whereas patients close to the next band are having more intense treatment.
• The stepped payment function is resulting in treatment intensity ‘bunching’.
Summary – Policy
• New Contract a response to lack of availability• Theory of incentives embodied in new contract is
not clear• Contract seems to have incentivised more
treatments– But limited to the PDS (the previous experiment to
solve the NHS’s problems!)
• Unanticipated consequences – “Up-Banding” of patients