Factors related to insurance and use of oral health care

Several studies have identified the factors affecting oral health care utilization and especially the importance of dental insurance in the demand for and utilization of oral health care services (Sintonen and Linnosmaa, 2000; Suominen-Taipale, 2000; Stoyanova, 2004).

The expense of oral health care makes many people avoid dental visits (Bagewitz et al., 2002;

Macek et al., 2004). Consequently, cost-sharing schemes through third party or health insurance have attempted to reduce or remove cost barriers and to ease the access to oral health care (Furino and Douglass, 1990; Damiano et al., 1990; Eklund, 2001). Since financial barriers were eased or removed, out-of-pocket expenses were reduced and the buying power of users was improved, perceived needs could be more easily transformed into expressed need or demand (Penchansky, 1981; Furino and Douglass, 1990).

2.5.1. Insurance status and demand for oral health care

Both individuals and service providers can substantially influence demand for and utilization of oral health care (Parkin and Yule, 1988). As a financial factor of the health care system, the

22 Table 2. Oral health care delivery services in Iran Reimbursement to dentistType of servicesPaymentPersonnelEligibilityFundingSettingType of provider Salary

Examination, scaling, simple fillings, extractions, fissure sealants, fluoride therapy

80-90% subsidization for target population3 FOP4 for rest of population

Dental therapists DentistsEveryoneGovernment budget PDCs2MHME1 Salary Examination, radiography, scaling, simple fillings, extractions, full dentures Free of charge Dentists hired by public insurance Employed people with their family (50% of Iranian population)

Premium: 70% by the employer (government), 30% by the employee

Clinics owned by public insurance Public insurance Fee-for-service80-90% subsidization Private dentists contracted by public insurance

Private and public clinics contracted with public insurance Fee-for-service All oral health care services80-90% subsidization Private dentists contracted by commercial insurance

Employed people with their family (10% of Iranian population)

Premium: by the employer as fringe benefits

Private and public clinics contracted with commercial insurance

Commercial insurance Fee-for-service All oral health care servicesFOP4Private dentistsAll peopleDirectly out- of- pocketPrivate clinicsPrivate sector 1 Ministry of Health and Medical Education 2 Public Dental Clinics 3 children up to 12, pregnant and lactating mothers 4 Fully out-of-pocket

presence of dental insurance, meaning third-party payment, is positively related to an increase in the demand for, and utilisation of, oral health care (Bendall and Asubonteng, 1995; Brennan et al., 1996; So and Schwarz, 1996; Manski, 2001; Abraham et al., 2003; Slack-Smith and Hyndman, 2004).

An insurance scheme raises oral health care demand through two mechanisms: It lowers the price for oral health care and raises the consumers’ effective income by enhancing their buying power (Grembowski et al., 1988). In other words, it influences patients’ purchasing power for oral health care (McDermott, 1986). Variables like dental attendance and the reason for the visit should be regarded as measures of demand (So and Schwarz, 1996), since it is the users who determine the action. Although adverse selection may explain some of the differences in dental attendance between insured and non-insured subjects, it is likely that the insurance coverage is a dominant predictor of dental attendance (Manski, 2001). It has been shown that insured persons are more likely to report frequent visits (Manning et al., 1985; Locker and Leake, 1993;

Brennan et al., 1996) and to have frequent check-ups (Newman and Gift, 1992; Lang et al., 1994; Woolfolk et al., 1999; Sohn and Ismail, 2005) than are the non-insured.

2.5.2. Insurance status and utilization of oral health care

Cost sharing is expected to exert an influence on the quantity of the health care services consumed (Chalkley and Robinson, 1997; Nguyen, 2008). The findings from the Rand Health Insurance Experiment in the USA (Manning et al., 1985) have quite clearly shown that as the amount the patient has to pay decreases, the use of oral health care increases. Those who were randomly assigned to care with no co-payment (free care) used the most care. Those who reported having dental insurance also received more oral health care services than did those who had no insurance (Jack and Bloom, 1988; Gift, 1997).

Patient’s acceptance of the best treatment plan is directly related to the availability of a financial subsidy to pay for the treatment (Harr, 2002). Coverage levels of dental insurance are assumed to affect the amount and the mix of care services consumed (Mueller and Monheit, 1988).

Insured patients receive more preventive care, crown and bridge, and endodontic treatment and less dental extraction (Brennan and Spencer, 2002; 2005; Sweet et al., 2005; Brennan et al., 2008). In Denmark, during the period 1975–1990, a new utilization pattern, consisting predominantly of diagnostic/preventive oral health care services, replaced the previous pattern which contained predominantly restoration/extraction services (Schwarz, 1996)

2.5.3. Acceptability of oral health care

Since today’s patients are well informed of health issues, highly aware of their rights, and increasingly concerned about the quality of care they receive (Douglass and Sheet, 2000), dental providers must carefully consider all expectations of their present and forthcoming patients in order to maintain a successful practice (Tickle et al., 1998).

Patients generally assess and express acceptability of service, technical and interpersonal factors, and service fees by defining what is desirable or undesirable, and by expressing satisfaction or dissatisfaction with the care they received to indicate their perception of the dentist and the services she/he provides (Hashim, 2005).

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Patients’ assessment of oral health care services is a complex process that relies on their knowledge and expectations (Goedhart et al., 1996; Newsome and Wright, 1999b; Nguyen and Häkkinen, 2006). Patients’ expectations are based on their experiences, environment, socio-demographic background, and personality (Lahti et al., 1992; Freeman, 1999 a; b). In addition, characteristics of the health care delivery system affect patients’ assessments (Newsome and Wright, 1999b; Skaret et al., 2005).

The patient does not have sufficient expertise to evaluate the extent and quality of the services supplied. The supplier therefore plays two roles: to act as the patient’s advisor and to offer health care. In his/her role as advisor, all dentists should supply services based on oral health evaluation and social status and patient costs, regardless of their private economic interest (Grytten, 2001a).

Several studies in developed countries have reported details of dental insurance schemes and their impacts on oral health care. Such studies are rare in developing countries, usually with treatment-oriented health care delivery systems which may discourage regular use of oral health care services. Patterns of adults’ behaviour for receiving care according to insurance status may thus differ from those in developed countries with prevention-oriented health insurance schemes.