Payment methods have been linked with the professional behaviour of primary care practitioners. The main methods of payment are fee-for-service, fixed salary and capitation payments or combinations of these. The aim of this review was 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.
This review was conducted using the methodology of the Cochrane Effective Practice and Organisation of Care Group (Cochrane EPOC). The Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, The EPOC Group, Specialised Register, EconLit, Dissertations & Theses, PAIS International, Political Science, Worldwide Political Science Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), the NHS Economic Evaluation Database (EED), and Health Economic Evaluations Database (HEED) were searched. ISI Web of Knowledge, grey literature sources and selected journals were also searched. Randomised controlled trials (RCTs) , Non-randomised clinical trials (NRCTs) , Controlled before-after (CBA) studies (at least two sites in each group) and Interrupted time series (ITS) studies were considered for inclusion. Three of the authors selected the studies and undertook data extraction independently. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments.
- Two studies (from five publications) met the inclusion criteria. They included data from 503 dental practices, representing 821 dentists and 4771 patients. Both were cluster RCTs and were undertaken in the United Kingdom.
- 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.
The authors concluded
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.
Brocklehurst P, Price J, Glenny AM, Tickle M, Birch S, Mertz E, Grytten J. The effect of different methods of remuneration on the behaviour of primary care dentists. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No. CD009853. DOI: 10.1002/14651858.CD009853.pub2.