Download The Impact of the new NHS Dental Contract

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 SelfEmployed 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 pliers
Oct 19, 2007
A 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
Bands of treatment under the New Contract
Feeband
Description
UDA
1
Routine examination, scaling and diagnostic procedures
1.0
1 URGENT
One 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
1.2
2
Fillings and extractions
3.0
3
Treatment requiring laboratory work
12.0
Economics of the New Contract
Comparative Statics
• Consider the intensity of treatment of a patient t
• New Contract replaces Fee-for-Service ( a
smooth continuous function in t) and quasisalary (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 Contract
Comparative Statics
P (t )
Quasi salaried
Fee for service (self-employed)
‘New’ Contract (self-employed
England)
t
Economics of the New Contract
Comparative Statics
Economics of the New Contract
Comparative Statics
Economics of the New Contract
Comparative Statics
Economics of the New Contract
Comparative Statics
Economics of the New Contract
Comparative Statics
200
200
200
150
150
100
100
v N ( t)
v N ( t)
v S ( t)
200
v S ( t)
50
50
v F ( t)
v F ( t)
0
5
10
15
20
25
0
30
50
50
 72.5 100
 72.5 100
0
t
30
0
5
10
15
t
20
25
30
30
Economics of the New Contract
Dynamics
• 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 Contract
Dynamics
• 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 Contract
Summary
• 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
•
Mean number of courses of treatment per dentist per month
England & Wales
Scotland
200
180
160
140
120
100
80
60
40
20
0
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
Estimating the Impact of the New
Contract
•
Proportion of courses of treatment in Band 1 (low treatment intensity)
England & Wales
Scotland
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
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
Estimating the Impact of the New
Contract
•
Proportion of courses of treatment in Band 2 (high treatment intensity)
England & Wales
Scotland
0.12
0.1
0.08
0.06
0.04
0.02
0
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
Estimating the Impact of the New
Contract
• Econometric specification (courses of treatment)
Estimating the Impact of the New
Contract
• Results – Courses of Treatment (CoT) estimate of
– Fixed effects regressions
– Negative coefficient => positive impact of new contract
DENTISTS
SE
t
P>t
Observations
ALL
-12.585
9.245
-1.360
0.177
1216
GDS
13.792
11.468
1.20
0.234
706
PDS
-33.792
7.029
-4.810
0.000
599
•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
October 2005 - March 2006
Band
April 2006 - November 2006
England & Wales
Scotland
England & Wales
Scotland
Na
0.95
1.23
0
1.12
1u
2.58
2.75
9.51
2.56
1
56.86
45.45
51.64
51.4
2
34.17
41.39
32.6
37.66
3
5.45
9.18
6.25
7.27
55
33
58
37
44497
22786
68837
35104
Dentists
Observations
Estimating the Impact of the New
Contract
• Econometric specification (treatment intensity band)
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)
Coef.
SE
t
P>t
Dentis
ts
Observati
ons
Band 1
0.098
0.018
5.590
0.000
98
171224
Band 1u2
-0.083
0.015
-5.410
0.000
98
171224
Band 3
-0.024
0.005
-4.420
0.000
98
171224
•Results here are not affected by previous contract
•Results qualitatively similar in MNL and Mixed MNL
specifications
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