While CAP plans may reduce costs, the relationship between the quality of care and CAP plans is not self-evident.¹ From one point of view, it would seem logical that capitation would result in the dentist’s denying treatment or providing cheaper services, since this would increase the profitability to the dentist. From another point of view, however, the more preventive services dentists provide, the more they might avoid the later more costly restorative services.

Marcus,² in discussing the issues surrounding quality of care, noted that abuse of fee-for-service, or FFS, dental benefit plans can lead to overtreatment and excessive use of expensive services and materials, with underuse of less expensive ones.

In CAP plans, abuse can result in lack of access to care, undertreatment and reduced time spent by dentists with patients. The problem is made more complicated because of the lack of evidence and consensus about appropriate care. While financial incentives may lead some providers who accept CAP plans to deny needed services and some providers who accept FFS plans to provide unneeded services, demonstrating these abuses would be difficult to determine without a consensus regarding the appropriateness of care.

While there has been considerable discussion on the quality issue, there has been relatively little empirical investigation within dental care. In a study of six practices that accepted CAP plans and five practices that accepted only FFS plans, Atchison and Schoen³ found that neither system routinely met criteria and standards for good dental practice.

In a controlled trial in England and Scotland that compared CAP-plan with FFS-plan dental care for children, the results showed that those covered under the CAP plan had fewer filled teeth and more carious untreated teeth, had fewer radiographs taken and were recalled less frequently than those covered under the FFS plan.^4–6 The dentists who accepted the CAP plan, however, provided more preventive care (advice on prevention, prescription of fluoride supplements, dietary advice, hygiene advice) than did the dentists who accepted the FFS plan.

Preventive dentistry is an important aspect of quality. One assumption is that it should increase in CAP programs. The results in the literature indicate conflicting notions. As discussed previously, the study in the United Kingdom found that some primary preventive services were performed more often with the CAP plan.^4–6 Beazoglou and colleagues⁷ found that patients in an FFS plan received double the volume of preventive services as those in a CAP plan. They also found that CAP plans consistently substituted less expensive procedures for more expensive ones. Again, when there is not a consensus on the effect on oral health of less costly procedures, it is difficult to judge the quality of care.

For a dental benefit plan to be attractive to consumers, the enrollment cost and copayments must be competitive, and the services covered must be accessible and relevant to the health needs of the patient. CAP plans generally have lower premiums and lower out-of-pocket costs for consumers. To be attractive to providers, however, they must offer reasonable compensation for the services rendered. Given the level of compensation in many CAP plans, Marcus and colleagues⁸ have shown, the provider can only obtain reasonable compensation by lowering the number of patient visits per year or the percentage of enrollees using the plan. Dentists also can enhance their incomes by providing more services that are not covered by the plan for which they are permitted to collect their usual fee.

We conducted a study to examine the impact of CAP and FFS dental plans on the enrollees’ satisfaction with their plans and their satisfaction with their dentists.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Market typology. Since economic markets for dental benefit plans in the United States are variable, our first step in selecting the sample of plans to study was to characterize markets for dental health maintenance organizations, or DHMOs. This has been described previously.⁹ We developed an index for the degree of penetration of HMOs into the dental market by examining the number of dental plans in a given state, the percentage of the population covered by the plans and the rate of growth in the plans over the past five years. From this work, we identified four states that would ensure different levels of DHMO penetration. The markets we selected were California (19.8 percent DHMO penetration), New Jersey (7.3 percent DHMO penetration), Michigan (4.6 percent DHMO penetration) and North Carolina (0.07 percent DHMO penetration).

Plan typology. We contacted 109 Fortune 500 companies whose operations appeared to include at least one of the four markets we had selected. From these, we recruited 10 that agreed to participate. The selection of the companies was determined by our need to meet the sampling objectives of the study and by cost and practicality criteria. We chose a purposive sample to ensure that it included companies that had plans that met predetermined criteria. One company withdrew from the study. A second company was dropped because it was located only in California and had no variation in its plans.

The dental benefit plans of these eight companies included indemnity service; preferred provider organization, or PPO, plans; and CAP plans. Among these, there was only one that had the full characteristics of a PPO. There were a number of Delta Dental plans that resembled PPO plans, but these are not generally considered to be PPO plans. As there was only one true PPO plan, we elected to classify the plans based on method of payment to the dentist and who bore the financial risk. Thus, the plans are categorized as FFS or CAP.

Among the eight companies, there were 42 combinations of company, market and plan type.¹⁰ Table 1 shows the type of variations encountered. For example, company no. 1 had one CAP plan that was offered in all four markets. The monthly dual-party premium (an enrollee plus one dependent) for this plan ranged from $27.75 to $31.46 (including both employer and employee contribution), depending on the market. The company had two FFS plans, both of which were offered in Michigan, while just one was offered in North Carolina and the other was offered in California and New Jersey. Company no. 2 was located only in California, and it had one FFS and one CAP plan. Company no. 5 had four CAP plans in Michigan, the premiums of which ranged from $34.55 to $48.60. Company no. 7 was in only one market, Michigan, and it had two FFS plans, the premiums of which were $32.00 and $48.00.

View this table: [in this window] [in a new window]   TABLE 1 MARKET, PLAN TYPE AND DUAL-PARTY PREMIUM* FOR DENTAL PLANS IN THE EIGHT COMPANIES STUDIED.

Sample. We used a stratified random sample for the study. We used a list of enrollees in each of the 42 plans and stratified the number of people to be included by market and plan type. The sample size distribution for plan type, monthly premium and market are shown in Table 2. More subjects were enrolled in FFS plans than in CAP plans. The seven plans with a dual-party premium of less than $30.00 had a total of 440 subjects. The 11 plans with a dual-party premium of $30.00 to $39.99 had a total of 565 subjects. There were 841 subjects in the 16 plans that had a premium between $40.00 and $49.99. The eight plans with a dual-party premium $50.00 or higher had 494 subjects in the sample. Almost 27 percent of the sample was in company no. 1, which had nine combinations of plan type and markets. Company no. 5 had 10 combinations of plan type and markets and was the only other company with more than 20 percent of the sample. The California and Michigan markets each had about one-third of the sample.

View this table: [in this window] [in a new window]   TABLE 2 DISTRIBUTION OF SAMPLE BY PLAN TYPE, DUAL-PARTY PREMIUM* AND MARKET.

We contacted subjects by telephone until we either got a refusal or could not make contact after approximately 10 calls. The person we interviewed on the phone was the primary person insured in the plan. We continued the process until we met our target number for each plan or we reached a point at which the returns on our efforts were too low to warrant continuing. The response rate was higher in the CAP plan group (66 percent) than in the FFS plan group (54 percent). Within a market, the largest range in the response rate was in New Jersey (63 percent CAP plan and 48 percent FFS plan). The highest response was for CAP plans in North Carolina (80 percent) and the lowest were for CAP plans in Michigan and for FFS plans in New Jersey (both 48 percent).

Analysis plan. We generated descriptive statistics for the entire sample using a statistical software package. Analytically, the two dependent variables we selected to examine were satisfaction with plan and satisfaction with dentist. We conducted a bivariate analysis for both outcome variables using the ² statistic. We set the significance level at P < .05. For the multivariate analysis, we treated both dependent variables as ordinal outcome variables, and we used multinomial regression analysis. For each of the independent variables such as type of plan and amount of monthly premium, we determined a reference group. Since both education and income were significantly correlated (P < .001), we used only income in the analysis. We used coverage-specific premiums rather than the dual-party premiums shown in Table 1. Coverage-specific premiums use each enrollee’s coverage, whether it is individual, dual-party or family premium. We did not include out-of-pocket cost in the analysis of satisfaction with the plan because of the strong correlation between these variables. We set the significance level at P < .05.

The questionnaire had five possible responses for satisfaction. As shown in Tables 3 and 4, the "very dissatisfied" and "dissatisfied" categories had few responses. As a result, for both the bivariate and multivariate analyses, we combined these two response categories and referred to this group as "not satisfied." There was no need to combine any other groups as there were enough people in the categories.

	RESULTS

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Overall, subjects said they were satisfied with both their dentists and their dental plans. Eighty-eight percent were either very satisfied or satisfied with their dentist and 79 percent were very satisfied or satisfied with their dental plan (Tables 3 and 4).

Seventy-four percent of the sample said they had been covered by their plan for five years or more, and only nine percent had any other dental coverage. Eight percent had gone outside the plan to see a general dentist. Twenty percent had individual coverage, 26 percent had dual-party coverage, and 54 percent had family coverage. The median dual-party premium of the plans was $41.74 per month ($22.40–$61.75). All subjects were enrolled in a medical plan, and 69 percent were in a managed care plan, 17 percent were in a PPO, and 14 percent were in a nonman-aged care plan.

Sixty-two percent of the sample reported spending less than $100 annually out of pocket for their care, and 91 percent spent less than $500. Eighty-six percent of respondents reported that the amount of time they waited for an appointment was reasonable for both emergency and nonemergency care. Only eight percent reported needing dental care but not getting it. Eighty-nine percent used the plan during the year. Of the 11 percent who did not have a dental visit, the most common reasons for not seeing a dentist were "Had no dental disease," "Did not think dental care was important enough," "I’m afraid of dental treatment or dentists" and "The dentist I wanted was not in the plan."

Bivariate analysis. There was a significant difference (P < .05) between the CAP-plan and FFS-plan groups with respect to satisfaction with their dental plan (Table 3). The percentage of FFS plan enrollees who were very satisfied with their plan was almost twice as great that as for the CAP plans (47 to 24 percent). Nineteen percent of CAP-plan enrollees were dissatisfied or very dissatisfied, compared with 6 percent of the FFS-plan enrollees.

With respect to satisfaction with their dentist, FFS-plan enrollees were significantly more satisfied than those in CAP plans (Table 4). Ninety-seven percent of FFS-plan enrollees were either very satisfied or satisfied with their dentist compared with 78 percent of CAP-plan enrollees. The percentage of FFS enrollees who were very satisfied (72 percent) was more than twice that of the CAP group (34 percent). Eleven percent of those in CAP plans were dissatisfied or very dissatisfied with their dentists compared with 2 percent of those in FFS plans.

Multivariate analysis. Table 5 presents the results of the multinomial logistic regression model for the dependent variable "satisfaction with the plan." When we controlled for other variables, we found that those in FFS plans were significantly more likely to be very satisfied than not satisfied (P < .05). The odds ratio, or OR, of 0.25 means that those enrolled in FFS plans were four times more likely to be very satisfied than not satisfied with their dental plan. Market was not significant. Among the demographic variables of sex, race/ethnicity, income and age, the only significant differences were those in the lowest income group being almost twice as satisfied than those in the highest income group (OR = 1.85). Older enrollees were more satisfied than younger ones. Enrollees in plans with higher premiums were significantly more satisfied than those in plans with lower premiums (P < .05). Those reporting an unmet need for dental care were much less satisfied with their plans than those whose needs were met.

	DISCUSSION

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The results of this study show that the type of plan in which people were enrolled had a significant impact on their satisfaction with the plan. Those in FFS plans were four times more likely to be very satisfied than not satisfied with their dental plans than were those in CAP plans. The multivariate analysis controlled for the other variables included in the model such as plan premium and enrollee characteristics (income, sex and race/ethnicity).

Because CAP plans have more restrictions on enrollees’ choices of dentists, we felt it was important to know if this affects how enrollees in these plans feel about their dentists. We used an overall measure of enrollees’ level of satisfaction with their dentists. This question followed a number of more specific questions that addressed enrollees’ satisfaction with whether the dentist listened to what the patient said, explained treatment adequately, provided quality care and was thorough in the examination. It is likely that these items were among those considered by the respondents in their overall assessment of the dentist. The ORs show that those in FFS plans were more than 16 times more likely to be very satisfied than not satisfied with their dentists.

The type of dental benefit plan in which people were enrolled had a significant impact on their satisfaction with the plan.

The relative lack of satisfaction with plan and provider may be one of the main factors that will influence the future growth of CAP plans in dentistry. CAP plans, which had been the most rapidly growing segment of the dental benefits plans industry, slowed toward the end of the 1990s and declined 8 percent in 2000. At the time this study was conducted, dental PPO plans were the fastest-growing segment of the dental benefits industry.¹⁴

As we noted previously, the premiums for these plans were relatively high, so it was not possible to assess the effect of low-premium plans on enrollee satisfaction. There was, however, a wide range of premiums within these more generous plans, which did provide us with the opportunity to assess their effect. We found that higher premiums paid by the companies for their dental benefit plans was related to greater enrollee satisfaction with their dental plans. There was no significant relation of the premium to enrollees’ satisfaction with their dentists.

An important finding in this study was that certain factors that might be thought to be important in satisfaction with dental plans or dentists were not significant in the multivariate analysis when controlling for other factors. We thought that satisfaction with dental plans might have been related to market penetration of DHMO plans, and we selected the sample of companies we studied to ensure as wide a range of such plans as was practical. We observed no market effect. DHMO penetration in markets is much less than that of medical HMOs. The market with the largest penetration was California, where there was less than 20 percent penetration of DHMO plans. In contrast, 69 percent of those interviewed for this study were in HMO medical plans. If DHMO penetration had been different in the markets we studied, perhaps we would have had a greater opportunity to observe a market effect.

We found that sex and race/ethnicity were not significantly related to satisfaction. With respect to income, the only significant difference was that those earning less than $50,000 annually were more satisfied with their plans than were those earning more than $100,000 annually. This finding highlights the value that people with lower incomes place on their dental benefit plans. We found no difference in satisfaction with the enrollees’ dentists between the lowest and highest income groups. We assessed out-of-pocket cost only with respect to satisfaction with dentists and found that only enrollees in the highest out-of-pocket cost category (> $350) were less satisfied with their dentists when compared with those in the no out-of-pocket cost category. As we expected, plan enrollees with perceived unmet dental needs were less satisfied with both their plans and their dentists.

In this study, we focused on only two aspects of what could be considered a three-legged stool, the plan and the enrollee. Missing was the dentist, the third leg of the stool. More research is needed to understand better the differences between CAP and FFS plans and how provider reimbursement methods affect dentists’ behavior. In this study, we were unable to evaluate dentist compensation under the two types of plans because such information was not available from the plans. The extent to which premium level is a proxy for dentist compensation is not known.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Those enrolled in dental benefit plans were generally satisfied with both their dental plans and their dentists. The major findings of our study were these:

– FFS-plan enrollees were four times more likely to be very satisfied than dissatisfied with their dental plans compared with those in CAP plans;

– FFS-plan enrollees were 16 times more likely to be satisfied with their dentists than were CAP-plan enrollees;

– the premium level was related significantly to enrollees’ satisfaction with their dental plans, but it was not related to enrollees’ satisfaction with their dentists;

– the higher the premium, the higher the enrollees’ likelihood of being satisfied with their dental plans;

– the extent of DHMO penetration in a dental market was not related significantly to enrollees’ satisfaction with their dental plans.

Enrollee satisfaction is an important element in the future of dental benefit plans, but it is only one part of the picture. Ultimately, the broad policy and public health issue is the impact that dental plans have on the oral health status of patients and the use of the services. Subsequent articles will examine information of self-assessed oral health and use of dental plans by those enrolled in these dental plans.