After the introduction of global budgeting in Taiwan, the total reimbursement for dental services, reimbursement per visit, reimbursement per patient, and reimbursement per dentist all increased significantly while the number of visits per patient decreased slightly. The number of high reimbursement procedures such as root canals, ionomer restoration, and tooth extractions increased while the number of low reimbursement amalgam restorations decreased. Nevertheless, although tooth scaling is a low reimbursement procedure, the number of tooth scalings increased.
Increases in utilization of certain services after universal NHI coverage and global budgeting can be explained in part by the overall increase in patient dental visits. Other changes may be based on dentists’ attitudes regarding services and financial parameters. Increases in root canal procedures, which were less than for other procedures, may be the result of dentists avoiding performing this complicated, arduous procedure in favor of alternative measures such as extraction . A survey found that 80% of dentists thought root canal was underpaid and not cost-effective [10, 11]. In Taiwan, root canal procedures also have a more compex reimbursement process through BNHI. Tooth extraction, besides increases due to the overall increase in patient visits, has great variations in reimbursement based on number of teeth and their location, which may increase procedure complexity, thereby reducing dentists’ willingness to perform extractions in some cases. Dentists may also avoid extractions for children, uncooperative patients or those wih seizure, heart disease and poor health status. However, failure of root canal procedures may contribute to increased extractions. Ionomer restoration is preferred by dentists over amalgam restoration since the latter alters the appearance of teeth and harms the environment . Well informed dentists and dental patients tend to choose ionomer restoration over amalgam restoration , which may help to explain the decrease of amalgam restoration in the present study. Tooth scaling is an essential preventive procedure and relatively easy to perform . Dentists are willing to provide this service given the low relative risk, preventive potential and costs [13, 15]. With regularly scheduled oral examination and teeth scaling, which increased during our study period, other procedures such as root canal and extraction generally decrease.
Results of the present study show that the number of dentists increased by 23.3% between 1996 and 2001 post-NHI and that more dentists did provide more services to more patients. However, a study of the effects of global budgeting on the distribution of dentists and the use of dental care indicates that global budgeting did not effectively improve the distribution and supply of dentists in Taiwan even though the NHI system with global budgeting is a redistributive system that sets budget caps for each healthcare region according to its population (per capita) . Equity in dental care resources was an explicit goal of global budgeting in Taiwan and equitable financial access to all citizens was essentially achieved . The present study showed that, although there were more dentists, per-patient utilization of their services decreased, but not significantly; changes in the number of dental visits and reimbursement amounts per patient were relatively small, which suggests that utilization control is indeed a factor of dental global budgeting. However, in the competitive market within the private sector where 90% of dentists are independent, overall utilization of dental services was reported to increase . Similarly, a study of Blue Cross dental insurance claims in Ontario, Canada, reported an increase in the volume and intensity of services received by adult patients when fee constraints were imposed on the dentists, stressing the importance of fee schedule design and the billing practices of dental service providers .
The dental global budgeting process itself may have influenced the behavior of dentists. In a diffused market like Taiwan’s, the delivery of dental services may have a “trivial” impact on the payment rates of global budgets as previously described . For example, dentists might not have performed procedures that did not yield proportionate levels of income in order to keep their service level in line with its income potential. There may also have been a tendency to shift procedures to public facilities that received additional funding from NHI. Bundling of services for preventive maintenance or recall services, which general dental practices stress as standard good care and which provide a base income, can vary from dentist to dentist; a study that examined the mix of bundled services concluded that this response of dentists to fee controls matched that of other medical markets and that fee schedule adjustments without accompanying regulations often leads to alterations in services offered to patients . While dentists may bundle services to increase revenues within global budgeting, hospitals may admit more patients with discretionary conditions in order to increase revenue . Although these trends may boost revenues of the individual practice or hospital, they may not effectively control expenditures of the system . In this study, data suggest that some healthcare providers may have offered unnecessary services to a large number of patients in the original fee-for-service program, for which providers submitted related bills and received payment from the BNHI.
On the other hand, the BNHI has gradually decreased its subsidy to public hospitals and these facilities may have begun to outsource their dental services. The global budget system was implemented in Taiwan to help compensate for increasing losses and achieve cost containment for the NHI program and data from the present study and others indicate that it has done this to some extent. What still may be needed is additional focus on the per-capita allocation of budgets and an examination of system-wide outcomes and patients’ expenditures to determine if patients’ actual costs are associated with equitable quality care. Socio-economic and geographic factors need to be addressed in any evaluation and/or revision of the NHI, and insurance and visit types have the potential to be altered at the policy level to achieve better overall service outcomes, as suggested by other investigators .
Demand for services differs considerably in countries without a national insurance program. In Mexico, for example, where there is little public financing of dental care, an evaluation of dental expenditures and dental care decision making revealed that socio-economic factors, primarily household capacity to pay, governed whether or not dental care was sought . Mexican citizens must pay out-of-pocket costs themselves and those who seek care do so in the private sector, pointing to inequities in Mexico’s healthcare financing. In Taiwan, where the NHI provides equal coverage to 99% of the population, we would expect uniform utilization of services and demand for care. However, because NHI reimbursement is calculated by health insurance regions with different allocated budgets based on demand and the practice patterns of dentists in the region, the improved access to dental care after NHI does not necessarily reduce the unequal distribution of dental care and dentist supply across the designated geographic regions . Our data agree with this finding. We must consider that distribution of care and of dentists will improve as the system evolves but it will require staying within the mandated coverage guidelines and provision of incentives for dentists to relocate their practices and still maintain their intended income.
This study has several limitations, some due to trends that could not be evaluated using BNHI data. For example, this study lacks basic demographic information about patients and dentists and our data source did not distinguish certain differences such as rural vs. urban practices, male vs. female dentists, and younger vs. older dentists. It has been shown that relatively fewer dentists practice in rural areas . A study by Lee and Jones  indicated that male and younger dentists showed greater policy effects than did female and older dentists. In the present study, the BNHI database from which all data were obtained does not differentiate between resident and attending dentists in hospitals or indicate if dentists practice in more than one location, which raises the possibility that related reimbursement figures may be inaccurate. Also, data about dentist reimbursement may be underestimated because out-of-pocket procedures such as dental crowns and implants are not covered by NHI and some dentists may have spent more of their time doing such procedures. Dishonest claims may also have produced false results. Other limitations included variations in the NHI payment for dental procedures that may differ from patient to patient. Payments for extraction, for example, depend on the number and location of the teeth, amalgam restoration on the number of faces, and ionomer restoration on the materials in the ionomer. There was no measure of quality of service in this study and a study by Chang and Hung  indicated that cost containment comes at the expense of health care quality. Another unknown factor that might influence the number of visits would be the recall policy to encourage follow-up, especially if it differed in hospitals and clinics . Future studies should address these limitations as well as carry the study forward from 2004 to take into account the shift toward population-based funding and to determine if the observed trends continue or if initial unmet needs created only a temporary increase in the number and kind of services provided. The current system provides care to more patients but the question as to whether it is most efficient for those patients and most cost effective for the government remains unanswered.