OBJECTIVES:A pilot NHS dental contract was introduced in Northern Ireland between 2015 and 2016, which involved changing the method for paying general dental practitioners working in the NHS from fee-for-service (FFS) to capitation-based payments, providing an opportunity for a robust evaluation. We investigated the impact of a change in payment methods on clinical activity and the quality of care provided. DESIGN:A difference-in-difference (DiD) evaluation was applied to clinical activity data from pilot NHS dental practices in Northern Ireland compared to matched control NHS practices and applied to a questionnaire survey of patient-rated outcomes of health outcomes and care quality. We estimated the impact on access to care, treatment activity levels, practice finances and patient-rated outcomes of care of a change from FFS to a capitation-based system for 1 year, as well as the impact of a reversion back to FFS at the end of the pilot period. RESULTS:The monthly number of registered patients in the pilot practices increased more than the control practices during the capitation period, by 1.5 registrations per 1000 registered patients. The monthly reductions in the volumes of all treatments in the pilot practices during the capitation period were much larger than the control practices, with 175 fewer treatment items. All measures rapidly returned to baseline levels following reversion from capitation back to FFS. NHS income per month increased in pilot practices, by £5920 per month (calculated on FFS item cost basis) more than controls in the capitation period. The analysis of patient questionnaires suggest found that patients notice differences only in waiting times, skill-mix and number of radiographs, but not on other measures of healthcare process and quality. CONCLUSION:General dental practitioners working in the NHS respond rapidly and consistently to changes in provider payment methods. A move from FFS to a capitation-based system had little impact on access to care, but did produce large reductions in clinical activity and patient charge income. Patients noticed little change in the service they received. This shows that changes in remuneration contracts have the potential to meet policy goals, such as meeting the expectations of patients within a predictable cost envelope. However, it is unlikely that all policy goals can be met simply by changing payment methods. Therefore, work is also needed to identify and evaluate interventions that can complement changes in remuneration to achieve desirable outcomes.

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目标:2015年至2016年之间,北爱尔兰引入了NHS牙科试点合同,该合同涉及将NHS工作的普通牙科医生的支付方式从按服务付费(FFS)改为按人头支付的支付方式,从而为可靠的评估。我们调查了付款方式变更对临床活动和所提供护理质量的影响。
设计:将差异差异(DiD)评估应用于北爱尔兰NHS试点牙科实践的临床活动数据,与相匹配的对照NHS实践进行比较,并应用于对患者预后的健康结果和护理质量进行问卷调查。我们估算了从FFS改为基于人为的系统1年的护理对获得护理,治疗活动水平,实践财务状况和患者评级的护理结果的影响,以及在治疗后恢复为FFS的影响。试用期结束。
结果:在人为干预期间,试点实践中每月注册患者的数量增加了超过对照实践,每1000名注册患者中增加了1.5个注册。在人为戒断期间,试点实践中所有治疗量的每月减少量大大多于对照实践,减少了175个治疗项目。从人头设置恢复为FFS后​​,所有衡量指标均迅速恢复到基线水平。试点实践的每月NHS收入增加了5920英镑(按FFS项目成本计算),超过了停职期间的控制水平。对患者问卷的分析表明,患者仅在等待时间,技能组合和X射线照片数量上注意到差异,而在其他医疗过程和质量指标上则没有差异。
结论:在NHS工作的普通牙科医生对供应商付款方式的变化迅速且始终如一地做出了反应。从FFS过渡到基于人头的系统对获得护理的影响不大,但确实导致临床活动和患者收费收入的大幅减少。患者注意到他们所接受的服务几乎没有变化。这表明薪酬合同的变更有可能实现政策目标,例如在可预测的费用范围内满足患者的期望。但是,仅通过更改付款方式就不可能实现所有政策目标。因此,还需要开展工作来确定和评估可以补充薪酬变动以实现理想成果的干预措施。

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