The effects of fee bundling on dental utilization

Objective. To examine dental utilization following an adjustment to the pro vincial fee schedule in which preventive maintenance (recall) services were bundled at lower fees. Data Sources/Study Setting. Blue Cross dental insurance claims for claimant s associated with four major Ontario employers using a common insurance pla n over the period 1987-1990. Study Design. This before-and-after design analyzes the dental claims exper ience over a four-year period for 4,455 individuals 18 years of age and old er one year prior to the bundling of services, one year concurrent with the change, and two years after the introduction of bundling. The dependent va riable is the annual adjusted payment per user. Data Collection/Extraction Methods. The analysis was based on all claims su bmitted by adult users for services received at recall visits and who repor ted at least one visit of this type between 1987 and 1990. In these data, 2 6,177 services were provided by 1,214 dentists and represent 41 percent of all adult service claims submitted over the four years of observation. Principal Findings. Real per capita payment for adult recall services decre ased by 0.3 percent in the year bundling was implemented (1988), but by the end of the study period such payments had increased 4.8 percent relative t o pre-bundling levels. Multiple regression analysis assessed the role of pa tient and provider variables in the upward trend of per capita payments. Th e following variables were significant in explaining 37 percent of the vari ation in utilization over the period of observation: subscriber employment location; ever having received periodontal scaling or ever having received restorative services; regular user; dentist's school of graduation; and int eractions involving year, service type, and regular user status. Conclusions. The volume and intensity of services received by adult patient s increased when fee constraints were imposed on dentists. Future efforts t o contain dental expenditures through fee schedule design will need to take this into consideration. Issues for future dental services research includ e provider billing practices, utilization among frequent attenders, and out comes evaluation particularly with regard to periodontal care and replaceme nt of restorations.