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According to economic theory (1, 2), moral hazard

on the patients side is faced when part or all of the


treatment costs are covered by a third party, and
because of this coverage, the patient has less
incentive to control the costs of treatment. This
may lead to increased demand for treatment (3, 4).
The buying power for dental services is determined
both by income and cost levels. Income elasticity
studies, utilizing cross-sectional data, have sug-
gested that a higher level of income increases the
number of visits more than the actual cost of
treatment (58). With subsidy or insurance cover-
age, the relative cost becomes lower, and patients
are able to purchase more and more costly services
with their income (9, 10).
Studies have shown that the price elasticity of
dental services is low, in the range of 0.10.2 (11),
which means that the demand for dental services is
inuenced very little by changes in fees (4). A
relatively steep demand curve indicates that dental
services can be considered more as necessities than
luxury items (2).
On the providers side, the moral hazard is the
possible effect of knowledge that a thirdparty covers
part or all of the costs. When the income level of the
provider depends on the services he she provides,
Community Dent Oral Epidemiol 2011; 39: 458464
All rights reserved
2011 John Wiley & Sons A/S
A study on moral hazard in
dentistry: costs of care in the
private and the public sector
Tuominen R, Eriksson A-L. A study on moral hazard in dentistry: costs of care
in the private and the public sector. Community Dent Oral Epidemiol 2011; 39:
458464. 2011 John Wiley & Sons A S
Abstract Objectives: The aim of this study was to evaluate the costs of
subsidized care for an adult population provided by private and public sector
dentists. Methods: A sample of 210 patients was drawn systematically from the
waiting list for nonemergency dental treatment in the city of Turku.
Questionnaire data covering sociodemographic background, dental care
utilization and marginal time cost estimates were combined with data from
patient registers on treatment given. Information was available on 104 patients
(52 from each of the public and the private sectors). Results: The overall time
taken to provide treatment was 181 days in the public sector and 80 days in the
private sector (P < 0.002). On average, public sector patients had signicantly
(P < 0.01) more dental visits (5.33) than private sector patients (3.47), which
caused higher visiting fees. In addition, patients in the public sector also had
higher other out-of-pocket costs than in the private sector. Those who needed
emergency dental treatment during the waiting time for comprehensive care
had signicantly more costly treatment and higher total costs than the other
patients. Overall time required for dental visits signicantly increased total
costs. The total cost of dental care in the public sector was slightly higher
(P < 0.05) than in the private sector. Conclusions: There is no direct evidence of
moral hazard on the provider side from this study. The observed cost
differences between the two sectors may indicate that private practitioners
could manage their publicly funded patients more quickly than their private
paying patients. On the other hand, private dentists providing more treatment
per visit could be explained by private dentists providing more than is needed
by increasing the content per visit.
Risto Tuominen
1
and Anna-Leena Eriks-
son
2
1
Department of Public Health, University of
Turku, Turku, Finland,
2
Dental Services
Unit, City of Turku, Turku, Finland
Key words: dental insurance; economics;
health services research; public health
policy
Risto Tuominen, Department of Public
Health, 20014 University of Turku, Finland
Tel.: +358 50 585 2535
Fax: +358 2 333 8439
e-mail: risto.tuominen@utu.
Submitted 25 March 2010;
accepted 11 January 2011
458 doi: 10.1111/j.1600-0528.2011.00609.x
the third party coverage may increase the amount of
treatment offered or direct the choice of treatment
options towards those that are more costly or more
economically rewarding for the provider (12).
A recent study (13) indicated that when physi-
cians had few patients to treat, they were ready to
provide more services per patient. However, some
researchers have also expressed doubts about the
existence or signicance of moral hazard (14).
Thorough dissections of supplier-induced demand
and moral hazard in dentistry have been presented
earlier (8, 15).
The aim of this study was to describe the cost
components of dental treatment provided by pri-
vate and public sector dentists. Decisions to pro-
duce publicly funded dental care either by salaried
employed dentists or by purchasing services from
private practitioners working on a fee-for-service
basis require information on the expected economic
consequences of such choices.
Material and methods
The city of Turku provides subsidized dental care
for all permanent residents. However, demand
exceeds available capacity. National law states that
all treatment courses have to be started within
6 months of the initial appointment. Demand has
been partly satised by purchasing additional
services from private practice providers. Emer-
gency treatment is provided immediately, and
semi-urgent treatment is provided within
36 weeks, but excess demand for nonurgent
treatment results in the use of a waiting list. When
a patient calls to reserve an appointment, he she is
told the expected waiting time and is placed at the
end of the waiting list. Adult people on this waiting
list formed the sampling base for this study.
When they reach the top of the waiting list,
patients are randomly assigned by ofce workers
to attend either a public service (n = 52) or a
contracted private sector (n = 57) dentist. The
patient has to accept the assigned dentist, and
the dentists are obliged to take any patient sent by
the municipality. The numbers of patients and the
treatment procedures are not determined in the
contracts, as the city sends patients on ad hoc basis.
The dental treatment is provided either at the
citys own clinics or in a private practice. The
patients treatment needs have not been deter-
mined before appointing them to different dentists.
The dentist who provides the treatment, both in the
public and the private sector, also makes the check-
up and treatment planning independently. Publicly
funded treatment procedures offered by public and
private dentists are the same. Fixed prostheses and
dental implants are not included in either sector.
The patient pays the same visit and treatment
procedure fees to the treatment provider, whether
the provider is in the citys own clinic or in private
practice. The city pays the costs of the treatment to
the private practitioners according to the private
practice fee schedules that have been agreed by
open competition for a period of 3 years. The
private practitioners make their procedure price
offers in a competition situation, but the magnitude
of the demand forces the city to accept all offers.
Thus, the private practitioners who wish to make a
contract with the city do not need to give any
discounts from their regular fees. The private
practitioners carry the entrepreneurs risk, if a
patient fails to pay his her share as the city does
not make up the shortfall. It is up to the private
practitioner to enforce the payment of patients
shares and to recover debts. Private practitioners
operate on fee-for-service basis, both when their
patient has arrived independently and when sent
by the city. Public sector dentists are salaried, but
may also receive productivity incentives according
to the number of procedures they undertake. The
incentives can form up to one quarter of their
income. Thus, comparison of the two provider
groups does not represent the effects of pure fee-
for-service and salaried provisions, but those of two
remuneration systems in which marginal reward to
the provider of additional services is different.
A sample was drawn systematically from the
waiting list for nonemergency dental treatment. At
the time of the sampling, approximately 3600 adult
patients were listed. The seventh subject on the list
was drawn, and thereafter, every 17th subject was
chosen, producing a sample of 210 subjects. Lack of
earlier data on expected values or their distribu-
tions did not allow formal estimation of required
sample size. Expert opinion of the Chief Dental
Ofcer of the city was utilized. Some of the
sampled subjects did not have a valid mailing
address, and some were unable to read and write
Finnish, and they were omitted from the nal
sample, which was comprised of 188 subjects.
The ethical committee of the Hospital District of
Southwest Finland and the city of Turku approved
the study, and the sampled subjects received a
written description of the sampling, the purposes
of the study, and the planned use and storage of
459
Moral hazard in dentistry
the information they were to provide. This was
followed by a description of the subjects rights
according to the Helsinki declaration. The partic-
ipating subjects were asked to give their written
informed consent and separate written permission
to collect their data from the patient registers.
A questionnaire form, including the above-
mentioned descriptions and permissions, was sent
together with a prepaid return envelope. Demo-
graphic variables collected included gender and
age in years. Level of income was determined by (i)
monthly gross income, (ii) monthly gross income in
the household, and (iii) monthly gross income in
the household divided by the number of members
in the household. In the nal analyses, monthly
gross income in the household was used. Educa-
tional status was originally collected in ve cate-
gories and later dichotomized as (0) basic
education and (1) higher education. Regularity of
dental check-ups during the last 10 years was
solicited, and two dichotomies were formed:
Attending check-ups every year or less frequently
and attending check-ups within every second year
or less frequently. Both dichotomies were used in
the nal analyses. Time since last comprehensive
dental check-up in months was also used. Patients
were asked about the number of dental visits
during waiting time and the sector (public private)
of the treatment provider. Those who had received
dental treatment during the waiting time listed the
types of treatment they had undergone.
Additionally, the patients gave their estimates of
the average time they needed for travelling to and
from the clinic where they had received their
dental treatment. Each patient also gave an esti-
mate of the average time spent in the waiting room
before entering the treatment ofce and a separate
estimate of the time spent in the treatment ofce.
Patients value of time was determined by using
both willingness-to-accept (WTA) and willingness-
to-pay (WTP) approaches. For the WTA approach,
the subject was asked what would be the minimum
sum he she would accept as compensation for
working one hour longer the next working day.
Similarly, for the WTP approach, each subject was
asked to estimate how much money he she would
be willing to give up if he she had an opportunity
to work one hour less the next working day. The
time costs were computed by using both WTP and
WTA approaches as well as their mean values. The
mean values were used in the nal analyses.
Individuals not in paid work mostly left unan-
swered the question of working less, and so their
WTA estimate was used. All dental clinics were in
the range of public transport of the city of Turku,
and in cost calculations, travel expenses were
estimated to be the public transport fee of two
euro per visit, irrespective of the transport method
the patient might have used.
Altogether, 112 subjects (59.6%) returned accept-
ably completed questionnaires. Permission to col-
lect data from their patient records was given by
109 patients. All treatment episodes were com-
pleted within 6 months of the questionnaire study.
The actual numbers of visits and all dental proce-
dures were collected from the patient records of the
treatment providers. Not all the subjects on the
waiting list received treatment; the most common
reasons were moving elsewhere and failure to
attend a given appointment. Questionnaire and
treatment data were available from 104 patients, 52
from each sector. Public and private sector sample
sizes were equal by chance.
Treatment costs for the provider were calculated
by applying the average private practice fees for
each dental procedure, provided by both the
private and the public sector. The treatment costs
were calculated using a societal perspective, where
fees charged from the patients were not taken into
account. The cost estimates using a societal per-
spective represent the costs to the society, irrespec-
tive of the nal payer. In another approach, the
costs to the patients were estimated separately. In
these estimates, the nine euro fee for each visit and
treatment-specic patient charges according to
given treatment were calculated in patient costs,
as well as in provider returns.
In addition to the fees charged by the provider,
patient costs also include time costs. An overall
time cost for a dental visit was computed by
aggregating the costs of time for the estimated
travelling back and forth to the clinic, time in
waiting room before entering the treatment ofce
and time spent receiving the actual treatment.
Patients were asked about possible use of working
hours for dental visits and an estimate of possible
income losses. Total patient costs were estimated
from the sum of the visit and treatment fees
charged by the provider, travel expenses multi-
plied by the number of visits, and overall time cost
also multiplied by the number of visits.
Statistical evaluation of the study groups was
based on the chi-square test for proportions and
Students t-test for means. The distributions of all
cost categories were skewed to the right. Statistical
analyses of the cost data were based on Mann
460
Tuominen & Eriksson
Whitney U-test. Correlation coefcients and one-
way analysis of variance were used. Natural loga-
rithmic transformations of the costs to the provider
and total costs were normally distributed, and linear
regression models were tted for them using SPSS
version 16.0 (SPSS Inc., Chicago, IL, USA).
Results
Patients who received treatment from the public
sector were signicantly (P < 0.01) more likely to be
highly educated than those who received treatment
from private practice providers. Other differences
between the groups were small and nonsignicant
in all sociodemographic and dental treatment char-
acteristics (Table 1). Seven subjects reported that
they had lost income because of dental visits. The
overall time required for providing treatment was
181 days in the public sector and 80 days in the
private sector (P < 0.002). Patient-reported emer-
gency visits and the types of treatment provided
matched well with the actual records of dentists.
On average, public sector patients had signi-
cantly (P < 0.01) more dental visits (5.33) than
private sector patients (3.47), which caused higher
visiting fees. Treatment procedure fees paid by the
patients were slightly, although not signicantly,
higher among public sector patients. Patients treated
in the public sector paid more fees (NS) than those
directed to receive treatment fromthe private sector
(Table 2). Together with more treatment fees, the
patients in the public sector also had higher addi-
tional out-of-pocket costs than in the private sector.
A similar trend was observed in all cost categories
studied (Table 2). The cost of treatment from the
societal perspective was estimated to be higher (NS)
in the public than in the private sector (Table 3).
Patients treated in the private sector paid more
per visit (P < 0.001). The treatment costs per visit to
the provider were higher in the private than in the
public sector (P < 0.001), causing also the total cost
per visit to be signicantly (P < 0.001) higher in the
private than in the public sector (Table 4).
In multivariate regression analyses, when the
effects of other studied variables were simulta-
neously controlled, those patients who needed
emergency dental treatment during the waiting time
for comprehensive care had signicantly more
costly treatment and total costs than other patients.
The overall total time required for dental visits
signicantly increased the total costs. The total cost
of dental care in the public sector was slightly higher
(P < 0.05) than in the private sector (Table 5).
Table 1. Descriptive statistics of the sample according to
the sector of service provision. (Standard deviations in
parentheses)
Sector
Public Private
Characteristic
Mean
Age 47.5 (15.5) 45.2 (18.4)
Net monthly income 2153 (961) 1945 (984)
Emergency visits
during waiting time
2.3 (1.5) 2.6 (3.1)
Time (in minutes)
To travel to the clinic 41.1 (32.3) 49.4 (32.7)
To wait in waiting room 10.3 (6.0) 7.6 (4.1)
To be treated 28.8 (13.8) 28.8 (17.4)
Time since last
check-up (months)
16.1 (30.3) 22.4 (24.9)
Percentage
Women 54.1 53.8
Higher education 42.3 17.3**
Working 63.5 63.5
Retired 25.0 28.8
Regularity of dental check-ups
Annually 19.2 28.8
At least every second year 61.5 57.7
Statistical comparisons between sectors by chi-square test
for proportions and Students t-test for means: **P < 0.01.
Table 2. Median (means and standard deviations in
parentheses) fees paid by patients in public and private
sector. Patients time costs estimated by the mean value
obtained by WTP and WTA methods
Sector
Public Private
Fees
Visiting fees 45.00
(47.94, 31.04)
27.00
(31.60, 21.00)**
Procedure fees 111.00
(127.39, 87.50)
90.40
(128.56, 95.93)
All treatment fees 147.70
(175.33, 116.29)
112.20
(160.16, 114.50)
Other costs
Travel 10.00
(10.95, 6.63)
6.00
(6.93, 5.28)
Time
In travelling 44.88
(79.47, 112.28)
33.33
(56.69, 64.74)
In waiting room 17.92
(22.99, 20.45)
9.58
(13.24, 11.35)*
In treatment 35.83
(59.17, 62.28)
23.00
(40.98, 38.90)
All other
out-of-pocket costs
127.00
(172.59, 179.97)
83.00
(117.84, 106.34)
Total patient costs 267.60
(347.92, 272.25)
192.50
(278.00, 223.34)
Statistical comparisons between sectors by Mann
Whitney U-test.
*P < 0.05; **P < 0.01.
461
Moral hazard in dentistry
Discussion
Both the sampled patients and the treatment
providers were not selected, and they can be
considered to be typical representatives of their
respective groups. The similarities in sociodemo-
graphic and dental treatment characteristics of the
studied patient groups give further evidence of the
randomization without selection bias. However,
the sample size was relatively small, and the
ndings of this study should be conrmed by
studies with larger samples.
Moral hazard occurs when patients with third-
party coverage demand more care or more costly
treatment options and or service providers offer
them more care or more costly treatment than
would have occurred without such coverage. In
fee-for-service private practice systems, the health
care providers income depends on how much and
what type of health care he she provides. This also
depends, at least in part, on the quantity and
quality of the services the patient demands. When a
patient does not need to pay the full amount
him herself, but at least part of the costs is covered
by a third party, economic theory assumes that the
patient is willing to accept more and higher quality
services to maximize his her health utility (16).
Private practitioners who have sufcient private
paying patients probably do not have service
contracts with the city. Those who offer to treat
patients directed by the city probably have fewer
patients than desired with the contract being a
method to satisfy their workload and income
expectations. Thus, the present study setting could
be used to determine whether these private prac-
titioners engage provider moral hazard.
The city of Turku covers the same treatment
costs irrespective of treatment provider. The
patient makes the same copayments for each
specied treatment procedure, and all patients
pay a nine euro fee per visit. Thus, the sample
patients can be considered equally insured whether
they received their treatment from the public or
private sector. Private practitioners were free to
determine the treatment needs of each individual
patient and to provide the treatment they consid-
ered the patient required. The ofcials of the city
did not control the treatment planning or provision
of the private practitioners, but public and private
dentists have the same level of independence when
determining the patients treatment needs.
The same prices were applied to all treatment
procedures, irrespective of the sector in which the
treatment was provided. Although the public
sector dentists are paid a salary with some pro-
ductivity incentives, while in the private sector
income depends completely on the amount and
type of services provided, the use of the same
prices for all treatment procedures enables com-
parison of the two sectors.
In the current study, only very few patients
reported a real loss of income because of dental
visits. Income loss and time to travel and receive
treatment were reported in a questionnaire and
represented the usual situation in the past, which
may include some inaccuracy. However, there is no
reason to expect that the patients who were ran-
domly assigned to receive treatment either from the
public or fromthe private sector wouldreact to these
questions differently. The estimate used for travel
costs was conservative. For several visits during the
Table 3. Median (means and standard deviations in
parentheses) costs covered by patients and provider for
treatments in public and private sector. Patients time
costs estimated by the mean value obtained by WTP and
WTA methods
Sector
Public Private
Costs
Patient costs 267.60
(347.92, 272.25)
192.50
(278.00, 223.34)
Provider costs 332.40
(381.89, 265.84)
243.10
(307.96, 212.78)
Total costs 588.70
(738.79, 512.85)
487.18
(603.75, 402.01)
Statistical comparisons between sectors by Mann
Whitney U-test: nonsignicant.
Table 4. Median (means and standard deviations in
parentheses) costs of dental care per visit to patients
and provider in public and private sector. Patients time
costs estimated by the mean value obtained by WTP and
WTA methods
Sector
Public Private
Costs
Patient fees
per visit
34.00
(33.23, 7.44)
48.12
(48.08, 14.10)***
Other patient
costs per visit
29.50
(33.24, 22.54)
32.00
(41.46, 32.05)
Provider costs
per visit
65.28
(73.21, 42.38)
101.73
(101.28, 37.49)***
Total costs
per visit
125.76
(139.67, 51.07)
188.68
(191.40, 65.35)***
Statistical comparisons between sectors by Mann
Whitney U-test.
***P < 0.001.
WTA, willingness-to-accept; WTP, willingness-to-pay.
462
Tuominen & Eriksson
treatment course, people may have sometimes used
public transport andsometimes their own car. It was
not feasible to use a travel diary to determine the
actual costs of transportation for each visit.
Patient time cost is an important component of
the overall economic burden caused by sickness or
use of health care services (17, 18). Time cost
measures obtained through contingent valuation
methods, WTA or WTP, can be expected to produce
a more comprehensive estimate than if the measure
had been based on productivity loss, which is
usually derived through level of income. When
economic burden estimates are based on income
levels or productivity losses to employers, the
values of leisure time and time outside paid work
are not included. However, such leisure time and
the time of housewives, retired, and unemployed
people also have a value. In WTA measure, each
subject gives his her value estimate for an hour of
lost leisure time, and in WTP measure for an hour of
additional leisure time. One disadvantage of the
WTA and WTP methods is that the respondents are
not in reality offered an opportunity to work more
or less the next working day. The estimates they
give represent a hypothetical situation, and it
remains unclear whether their behaviour would be
different if they actually had to make the contribu-
tions or to accept the compensation.
The nding of the present study that private
practitioners, whose level of income is fully depend-
ing on the amount and type of treatment procedures
they provide, did not offer overall more costly
treatment than salaried public sector dentists cor-
roborates the view of Bessho and Ohkusa (14) that
moral hazard may not play a signicant role when
patients have insurance coverage. However, private
practitioners provided the treatment with fewer
visits, which reduced the visit fees, travel costs and
the time costs of travelling and waiting. Efcient
provision of treatment can be achieved by more
treatment per visit instead of more visits, which was
observed in the private sector. If supplier-induced
demand in private practice had taken place, higher
costs per treatment course would have been ex-
pected in the private sector than in the public sector.
However, if private practitioners had the opportu-
nity to treat publicly funded patients only to the
extent of lling the gaps in their appointment books
and they had otherwise sufcient private paying
patients, then more treatment per visit for publicly
funded patients may also indicate provider moral
hazard (15). On the other hand, private dentists
providing more treatment per visit could be ex-
plained by private dentists providing more than is
needed by increasing the content per visit.
The need for more visits to receive treatment can
be expected to cause inconvenience for patients in
addition to the observed higher patient costs.
Owing to the heavy patient load in the public
sector, the time needed to nalize the treatment
episodes was also twice as long as in the private
sector. This is an additional component that would
further increase inconvenience for patients. Ratio-
nalizing the treatment in the public sector to
include more treatment procedures per visit would
decrease the number of visits per patient, thereby
decreasing the time costs to the patients and
reducing the overall time needed to complete the
entire treatment episode.
These ndings should not be considered as
evidence of the private sector being a recom-
mended mean of providing dental services. This
Table 5. Multivariate regression analyses of selected background variables on natural logarithmic transformations of
provider costs and total costs
Variable
lnProvider costs lnTotal costs
b t-value P< b t-value P<
Age )0.01 )1.13 0.270 )0.01 )1.21 0.239
Time required for a dental visits 0.04 1.56 0.131 0.06 2.47 0.020
Time since last check-up )0.60 )1.65 0.112 )0.61 )1.76 0.090
Level of income )0.00 )2.31 0.029 )0.00 )1.98 0.059
Male sex 0.39 1.92 0.066 0.38 1.93 0.064
Any emergency treatment
During waiting time 0.66 3.21 0.004 0.64 3.26 0.003
Retired 0.47 1.59 0.125 0.55 1.97 0.060
Public sector 0.23 1.18 0.249 0.29 2.21 0.038
Regularity of dental check-ups
At least very second year 0.25 1.16 0.255 0.19 0.93 0.362
Higher education 0.43 1.56 0.132 0.37 1.41 0.170
R
2
0.562 0.621
463
Moral hazard in dentistry
study indicates some productivity differences, but
any possible differences in quality of treatment and
health utility cannot be estimated with the present
data. Furthermore, the available data do not take
into consideration the costs of organizing the
services, constructing and maintaining the clinics,
and overheads.
Multivariate regression models corroborated the
nding of univariate analyses that the total cost of
the treatment is higher in the public sector, and the
difference is not biased by confounding effects of
background factors. The nding that the time
needed for a dental visit had a signicant effect on
total costs but not on provider costs can be consid-
ered as evidence of logical multivariate models.
Patients who needed emergency treatment had
also received more nonemergency treatment, irre-
spective of the frequency of dental attendance and
time since last dental check-up. These patients might
needanalternative queue system. Factors predicting
possible need for emergency treatment have been
identied (19), and the development of modelling
techniques is in preparation to enable priority
allocations (20). Varying scoring systems based on
risk, urgency and other classications (2123) have
been suggested in several medical specialities to
rank patient cases into different queues. Need for
emergency treatment could be considered as one
such ranking argument in dentistry, together with
several general medical conditions like coronary
heart diseases, rheumatoid arthritis and people
undergoing chemotherapy.
The ndings of the present study did not give
direct evidence of moral hazard on the provider
side. The observed cost differences between the
two sectors may indicate that private practitioners
manage their publicly funded patients faster than
their private paying patients. Or, it may indicate
that private dentists provide more treatment per
visit to induce more than necessary treatment.
Assessing this possibility would require data on all
patients health care needs together with specic
treatment procedures performed during the visits.
Acknowledgement
This study was supported by grants from the Hospital
District of Southwest Finland and the City of Turku.
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