public preferences for seeking publicly financed dental care and professional preferences for...

Introduction

Access to dental care has recently gained prom-

inence as a health policy issue in Canada. Since

2004, the federal government and five of 10

provincial governments have announced major

investments in publicly financed dental care (1).

Among Organisation for Economic Co-operation

and Development nations, Canada ranks second

last in the public financing of dental care (2).

Dental care is predominantly financed and deliv-

ered via the private sector in Canada, with

approximately 60% accessing dental care through

employment-based insurance, and 35% through

out-of-pocket expenditures (3). In turn, approxi-

mately 4–6% access dental care through some

form of public financing, again via the private

sector (e.g. third party financing programs for low

Community Dent Oral Epidemiol 2010; 38: 152–158All rights reserved

� 2010 John Wiley & Sons A/S

Public preferences for seekingpublicly financed dental care andprofessional preferences forstructuring itQuinonez C, Figueiredo R, Azarpazhooh A, Locker D. Public preferences forseeking publicly financed dental care and professional preferences for struc-turing it. Community Dent Oral Epidemiol 2010. � 2010 John Wiley & Sons A ⁄ S

Abstract – Objectives: To test the hypotheses that socially marginalisedCanadians are more likely to prefer seeking dental care in a public rather thanprivate setting, and that Canadian dentists are more likely to prefer publicdental care plans that approximate private insurance processes. Methods: Dataon public opinion were collected through a weekly national omnibus surveybased on random digit dialling and telephone interview technology (n = 1005,>18 years). Data on professional opinion were collected through a nationalmail-out survey of a random selection of Canadian dentists (n = 2219, responserate = 45.8%). Dental and socio-demographic data were collected for the public,as were professional demographic data for dentists. Descriptive and basicregression analyses were undertaken. Results: The majority of Canadianssurveyed, 66.4%, prefer to seek dental care in a private setting, 19% in acommunity clinic, and 7.6% in a dental school; those that are younger and oflowest incomes are most likely to prefer seeking dental care in a public setting.Most Canadian dentists, 80.9%, believe that governments should be involved indental care, yet only 46% believe this role should include direct delivery. Athird of dentists have also reduced the amount of publicly insured patients intheir practice. Canadian dentists are more likely to prefer those public plans thatmost closely reflect private insurance mechanisms. Conclusion: There appearsto be a policy disconnect between the preferences of those populations wheregovernmental involvement is most warranted, and the current mechanisms forfinancing and delivering dental care in Canada. By concentrating almostexclusively on third-party-type financing and indirect delivery, public dentalcare policy may not be adequately responding to those most in need,especially in an environment where dentists are largely dissatisfied with publicplans.

Carlos Quinonez, Rafael Figueiredo,

Amir Azarpazhooh and David Locker

Faculty of Dentistry, University of Toronto,

Toronto, ON, Canada

Key words: access; policy; publicpreferences; provider preferences

Carlos Quinonez, Faculty of Dentistry,University of Toronto, Toronto, ON, CanadaTel.: 416-979-4908 x 4491Fax: 416-979-4936e-mail: [email protected]

Submitted 12 May 2009;accepted 23 December 2009

152 doi: 10.1111/j.1600-0528.2010.00534.x

income children and social assistance recipients)

(1, 3). In this sense, in Canada, there are very few

publicly owned and financed dental care arrange-

ments, with privately owned and financed

arrangements representing the major form of

service delivery.

The renewed interest in publicly financed dental

care reflects a reaction to the government retrench-

ment of the 1980s and 1990s, where most direct

delivery dental care programs were cut and where

major funding reductions were implemented in

social programs that insured for some dental care

(1). Yet as funding opportunities have become

available, there remain substantially varying views

on how this funding should be structured. For

example, the dental profession prefers to maintain

private delivery, with improvements made to

public fees and administrative mechanisms (4, 5).

While some social welfare groups prefer that

governments reinvest in direct delivery, noting

that this would better meet the needs of socially

marginalized groups, such as the homeless, those

of low income, or those receiving welfare transfers

(6, 7).

In this environment of renewal, there is an

opportunity to explore this historical policy

challenge, namely the tension that exists between

public and private approaches to publicly financed

dental care. In this regard, this paper will test two

hypotheses that hold important policy implica-

tions. Firstly, we hypothesise that socially margin-

alized Canadians are more likely to prefer seeking

dental care in a public rather than private setting,

meaning they would prefer to receive care in a

community clinic. Secondly, we hypothesise that

Canadian dentists are more likely to prefer public

dental care plans that approximate private insur-

ance processes, such as similar levels of service

coverage and remuneration. If these hypotheses are

correct, we will have highlighted an important

policy obstacle, namely the tension that exists

between public and private approaches to

structuring publicly financed dental care in Canada

(i.e. direct versus indirect delivery). The assump-

tion is that the tension between these divergent

policy perspectives complicates the achievement of

changes aimed at improving access to dental care

in Canada (i.e. providing the option of public

settings to populations that invariably experience

more oral diseases and conditions than their

socially advantaged counterparts and that may

hold preferences for seeking care in public

settings).

Methods

Public opinion surveyA 17-item questionnaire was administered in

March 2006 to a nationally representative sample

of Canadian adults by means of a telephone

interview survey using random digit dialling and

computer assisted telephone interview technology

(n = 1005, assumes maximum variance and a 95%

confidence interval of ±3%). A private firm was

employed to collect the data as part of its weekly

national omnibus survey. The participation rate

for this survey is approximately 3%, meaning

that, on average, 32 000–44 000 numbers are

dialled to gather a sample of approximately

1000. Among attempted calls, approximately

21 000 are busy signals, no answer, answering

machine, or invalid numbers. Willingness to

participate in the survey was taken to imply

consent, and no personal identifiers were

collected. The data received by the researchers

was weighted to replicate regional population

distributions, by age and sex, according to 2001

Canadian Census data.

The survey question used in this paper is: ‘If the

government were to go ahead with a public plan,

where would you prefer to seek treatment? A

private dental office; a community clinic; a dental

school?’ This question was dichotomized into

0 = private dental office and 1 = community clinic

in order to only explore the preference to seek

dental care in a community clinic.

Using spss 13.0, simple descriptive analyses were

undertaken. Bivariate logistic regression odds

ratios were used to assess the relationship between

preferences for seeking dental care, self-reported

health and dental care behaviours, and socio-

demographic characteristics. Multivariate logistic

regression odds ratios were then calculated for this

same outcome.

Professional opinion surveyA 26-item questionnaire was sent in October 2006

to a nationally representative sample of Canadian

dentists (n = 1067, assumes maximum variance

and a 95% confidence interval of ±3%). This

number was doubled, and a stratified random start

systematic sample using provincial ⁄ territorial den-

tal regulatory authority listings as sampling frames

was drawn. With minor additions to oversample

specific geographic regions, approximately 12%, or

2219 out of an estimated 18 313 active Canadian

dentists (8) were contacted.

153

Preferences for dental care

Using spss 13.0, simple descriptive analyses were

undertaken. Chi-square analyses were also con-

ducted to assess whether Canadian dentists were

more likely to prefer those public dental care plans

that most closely approximate private insurance

processes.

Results

Public preferencesApproximately two-thirds of Canadian adults,

66.4%, prefer accessing publicly financed dental

care through a private practitioner, as compared to

19.0% through a community clinic, and 7.6%

through a dental school. In terms of what predicts

the preference to seek dental care in a community

clinic, when compared to the oldest of the sample,

it appears that younger Canadians were more

likely to hold this preference (Table 1). It also

appears that those of lower income, poorer oral

health, and those that have experienced a

cost-prohibitive dental care need were more likely

to prefer seeking dental care in a public setting.

When adjusting for the influence of these variables

simultaneously, age and income remain as the only

predictors.

Professional preferencesAbout 1016 dentists answered the survey, yielding

a response rate of 45.8%. The details of this sample

of Canadian dentists and the general findings for

this survey are outlined elsewhere (9). Yet it is

important to note that close to 70% of Canadian

Table 1. The odds of preferring to seek dental care in a public setting

Variables Unadjusted ORa (95% CI) P-value Adjusted ORb (95% CI) P-value

Female 1.2 (0.9,1.7) 0.243Age

18–24 2.5 (1.2,5.0) 0.010 3.9 (1.7,9.2) 0.00225–34 1.8 (1.1,3.2) 0.036 2.6 (1.3,5.3) 0.00635–44 1.0 (0.5,1.8) 0.927 1.5 (0.7,3.2) 0.29145–54 0.9 (0.5,1.6) 0.705 1.1 (0.6,2.6) 0.65255–64 0.9 (0.5,1.8) 0.814 1.1 (0.5,2.6) 0.77165+ Reference Reference

EducationPrimary 1.2 (0.7,2.1) 0.537High school 1.4 (0.9,2.1) 0.087College 0.9 (0.6,1.4) 0.712University Reference

Income<$15K 3.5 (1.7,7.2) 0.001 3.2 (1.4,6.9) 0.004$15–30K 2.8 (1.5,5.3) 0.002 2.7 (1.3,5.5) 0.007$30–50K 1.7 (1.0,3.2) 0.069 1.7 (0.9,3.1) 0.116$50–70K 1.1 (0.6,2.2) 0.731 1.2 (0.5,2.3) 0.650$70–90K 1.1 (0.5,2.2) 0.867 1.1 (0.5,2.3) 0.871$90+ Reference Reference

Self-rating of oral healthPoor ⁄ Fair 1.6 (1.1,2.5) 0.025 1.3 (0.8,2.3) 0.265Good ⁄ Excellent Reference Reference

Visiting patternEmergency only 1.2 (0.8,1.9) 0.322Regular visits Reference

InsurancePublic Insurance 1.0 (0.7,1.4) 0.968Out of pocket 1.4 (0.6,3.0) 0.422Employment insurance Reference

Historical cost-prohibitive dental care needYes 1.7 (1.2,2.3) 0.005 1.2 (0.8,1.8) 0.399No Reference Reference

Include dental care in MedicareYes 1.3 (0.8,2.1) 0.321No Reference

aAll variables entered independently, with n ranging from 489 for ‘Visiting pattern’ to 855 for ‘Gender’.bAll significant variables (P < 0.05) entered simultaneously, n = 693.

154

Quinonez et al.

dentists report that less than 10% of their patients

are covered by public insurance, whereas only a

small minority, 7.6%, report that a majority of their

patients are publicly insured. In terms of opinions

on public care, 80.9% of dentists believed that

governments should have a role in dental care, and

largely define that role within prevention, such as

community water fluoridation (88.1%), population

level education (76.1%), and direct preventive

programs (82.5%). Importantly, only 46.0% of

dentists believed that governments should invest

in direct delivery clinics. Seventy-four percent also

believed that governments are not doing all that

they can to improve the oral health of Canadians,

with the vast majority of dentists, 90.2%, preferring

fee-for-service remuneration above salary arrange-

ments, capitation, or a combination of the former.

Canadian dentists were also asked if they had

ever made a ‘business decision’ to reduce the

amount of public insurance in their practice, and a

third had done so. In this regard, when asked if

they ‘often have disagreements with public plans’,

57.3% of dentists said ‘yes’. When asked what

bothers them about publicly financed care

specifically, on average, dentists noted five things,

most frequently indicating the limited services

covered, low fees, broken appointments, slow

payment and denial of payment. Overall, dentists

report dissatisfaction with public forms of third

party financing in Canada in terms of fees, service

coverage, and administration and management (9).

It also appears that dentists are more satisfied

with public dental care programming that, in part,

is administered by the dental profession, or namely

those programs that most closely reflect private

preferences. For example, comparing the pro-

vincial, profession-administered Alberta Income

Supports program to satisfaction in welfare pro-

gramming nationally, there are significant differ-

ences in satisfaction (Table 2). Similarly, comparing

the profession-administered Alberta Child Health

Benefit to satisfaction in children’s programming

nationally, the same applies (Table 3). Finally, in

Canada’s largest province, Ontario, when compar-

ing the profession-administered Ontario Disability

Support Program to satisfaction in welfare pro-

gramming nationally, there are significant differ-

ences specifically in terms of administration and

management (Table 4).

Table 2. Comparing profession-administered welfareprogramming in Alberta with satisfaction in welfareprogramming nationally

Profession-administeredIncomeSupportsprogram

Welfareprogrammingnationally

Chi-squaretesta

Level of coverageSatisfied 19 244 P < 0.004Unsatisfied 16 556

FeesSatisfied 40 136 P < 0.001Unsatisfied 26 667

Administration and managementSatisfied 19 296 P < 0.005Unsatisfied 9 429

aTesting the null hypothesis that the frequency distribu-tions of satisfaction do not differ.

Table 3. Comparing profession-administered children’sprogramming in Alberta with satisfaction in children’sprogramming nationally

Profession-administeredAlbertaChild HealthBenefit

Children’sprogrammingnationally

Chi-squaretesta

Level of coverageSatisfied 43 327 P < 0.001Unsatisfied 24 457

FeesSatisfied 27 176 P < 0.001Unsatisfied 36 596



Table 4. Comparing profession-administered welfareprogramming in Ontario with satisfaction in welfareprogramming nationally

Profession-administeredOntarioDisabilitySupportProgram

Welfareprogrammingnationally

Chi-squaretesta

Level of coverageSatisfied 121 244 P > 0.05Unsatisfied 224 556

FeesSatisfied 49 136 P > 0.05Unsatisfied 297 667



155


Conclusions

Our hypotheses appear to be true. Socially mar-

ginalized Canadians demonstrate some preference

to accessing dental care in community clinics, a

service option that is for the most part unavail-

able. Yet dentists do not prefer this approach,

instead promoting government involvement in

prevention. Nevertheless, while relatively few

dentists actually treat publicly insured popula-

tions they remain dissatisfied with public pro-

grams that act as third party financing

mechanisms, holding a clear preference for those

public plans that more closely reflect private

insurance processes.

To our knowledge, this is the first study of its

kind to compare public preferences for publicly

financed dental care to professional preferences.

Historically, there are relatively few studies that

explore public preferences (10–15), and most are

non-comparable. Conversely, professional prefer-

ences for publicly financed dental care are well

established in the international literature, and they

reflect similar findings to this study (i.e. dis-

satisfaction with fees, levels of coverage, and

administrative processes) (16–25).

In terms of public preferences, it is noteworthy

that 26.6% of those interviewed would prefer care

provided by a community clinic. Albeit minimal, it

is unknown how much of the public funding for

dental care in Canada is expended on direct

services delivered by the public sector. This means

that the great majority of total expenditures on

dental care in the country are paid to privately

practising dentists and thus, by and large,

Canadians only experience privately delivered

dental care. In such an environment, it is again

surprising that so many would prefer care

provided in community clinics.

In this regard, findings from the public survey

are to some extent perplexing. For example, those

of 18–34 years of age were more likely to prefer

seeking dental care in a community clinic. This is

difficult to rationalize with the knowledge that

younger age groups are generally healthier, have

dental insurance, and have visited the dentist

within the past year (26, 27). This could represent

a cohort effect, potentially pointing to the impor-

tance of Canada’s ‘public’ health care values to

younger age groups, or it could represent the fact

that dental services such as orthodontic care,

aesthetic fillings, and regular maintenance care

are arguably perceived as ‘needs’ now more than

ever, thus promoting and facilitating the idea that

dental care should be publicly accessible.

Setting this aside, it does appear that income

plays a strong role in the preference to seek dental

care in a public setting. This speaks to the impor-

tance of these settings for particular groups (e.g.

low-income youth and adults, emergency visitors),

and points to the general lack of options for many

Canadians. Bedos et al. (28), for example, have

reported that welfare clients in Montreal, Canada,

feel uncomfortable and discriminated against when

visiting private dentists, which helps explain the

preference for public care among those of low

income in this sample.

Also, the finding that dentists want to receive

payment from systems that pay more money,

promptly, and with no questions asked, is hardly

surprising or unique. In Canada, welfare programs

are provincially based, and these programs, espe-

cially for adults, are often very limited in their

coverage, sometimes covering only emergency

visits and paying dentists to only treat the worst

condition (1). Further, public welfare programs

(unlike private employment-based plans) generally

do not pay fees consistent with professionally

determined fee guides. So again, it is not surprising

that dentists are dissatisfied with fees and the

narrow range of services covered, and this dissat-

isfaction, while higher for the publicly adminis-

tered programs, is common to the profession

administered plans as well. This being said, it is

significant that dissatisfaction levels drop for

those programs that reflect professional ideology,

such as Alberta’s profession-administered public

programs. These programs tend to reflect private

levels of service coverage and remuneration, gen-

erally require less adjudication, and the provincial

dental association has significant control in setting

public fees (1). On the other hand, in Ontario, the

profession and government have had more diffi-

culty agreeing on fee schedules, yet the profession

does administer the Ontario Disability Support

Program plan. Thus in this case, dissatisfaction

does not vary from national averages, but does so

for administration and management.

It can also be said that the findings for Tables 2

and 3, with their limited n numbers, are not

necessarily reliable. Nonetheless, the trends are

clear, with satisfaction ratings completely reversing

or magnifying in all cases when comparing the

Alberta plans to national satisfaction averages. In

this sense, it is arguable that these findings are

reliable relative to their consistency.

156

Quinonez et al.

Further, it can be argued that patient preference

for where care is received is a very different issue

than professional preferences for publicly funded

care. Simply put, even though some patients prefer

to receive care in a public setting, concerns

regarding bureaucratic issues for dentists do not

necessarily represent a major policy obstacle. In

this sense, access to care may be influenced by

ownership of premises and remuneration arrange-

ments but also by a whole host of other factors,

including co-payments, geographic location,

cultural preferences, et cetera. Nevertheless, it has

been recognized that the dental profession has

played the single most significant role in not only

structuring dental care in western states, but also

dental care policy in those states (29). Thus profes-

sional preferences go some way in defining the

policy direction governments are willing to take.

Yet currently, even though most dentists remain

dissatisfied with remuneration processes in Can-

ada, and in turn report limiting the number of

publicly insured patients they treat, they still

remain reticent to support alternative service

delivery options such as community clinics. In

short, there is a disconnect between what govern-

ments arguably should do to treat those most in

need, with the policy directions they are willing to

consider in the face of professional pressures

(which, if alleviated, would arguably lead to the

exploration of other service delivery options).

To this end, it is important to consider other

general limitations in the study’s findings. For

example, as a result of sampling phone numbers to

collect data for the public survey, we have captured

a particular segment of Canada’s population,

namely those that have telephone landlines. Recent

Statistics Canada data demonstrates that those with

the lowest incomes are more likely to opt for

cellular telephones, meaning they are completely

missing from this study’s sampling frame (30). Our

sample has thus likely under-represented the lower

income segment of Canada’s population.

In terms of the professional survey, our response

rate is low, but it is also similar to a recently

reported average of 52% amongst physician mail

surveys (31). Asch et al. (32) did find that in 1991

dentist mail surveys achieved response rates of

approximately 65%, yet in lieu of historically

declining rates for professional mail surveys (33,

34), our survey’s response rate does appear

positive. Moreover, our response rate is compara-

ble to recent mail surveys of Canadian dentists,

with rates of anywhere between 15.8 and 55.2%

(35–39). Ultimately, our sample’s demographics are

comparable to census data available for Canadian

dentists (8, 9), and to other recent descriptions of

larger samples of the same (36, 40).

In closing, there appears to be a disconnection

between the preferences of those populations

where governmental involvement is most war-

ranted, and the current mechanisms for delivering

publicly financed dental care in Canada. By con-

centrating almost exclusively on indirect delivery,

public dental care policy may not be adequately

responding to the preferences of those it is meant to

serve, especially in an environment where dentists

remain largely dissatisfied with public plans. To

move forward fully in this time of dental public

health care renewal, Canadian policy leaders will

need to rationalize the reasons for why we do not

change this aspect of dental care policy. Ultimately,

while some would argue that changes in access

numbers might only be minimal, policy leaders

would nevertheless allay a barrier that is arguably

unreasonable, especially if the aim is to improve

access to dental care.

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