Willingness and ability to pay for unexpected dental expenses by Finnish adults

High costs are known to be a barrier for utilization of dental care and many different systems for reimbursement of care costs exist [1‐3]. In Finland, dental services are provided both by a public and a private sector. In the public sector, adults’ fees are fixed and subsidized by tax revenues. Private fees have always been unconstrained. However, since 1986, part of private fees has been reimbursed by the National Sickness Insurance, financed by employers, employees and taxation. For half a century, the oral health care system favoured younger people (born in 1956 or later) by providing access to the heavily subsidized Public Dental Service (PDS) and by reimbursing their private costs. The middle aged and elderly were expected to use private dentists or denturists (clinical dental technicians) and pay for the treatments out of pocket. In 2002, a National Dental Care Reform opened the PDS for older adults, too. At the same time subsidization of basic dental care in the private sector by the National Sickness Insurance was extended from young adults to all adults including those born before 1956 [4].

As expected, the reform led to increased demand for dental care by adults, especially in the PDS, where treatment remained cheaper than in the private sector even after the reimbursements from the Sickness Insurance. Long waiting lists for the PDS developed, especially in the capital region where the municipalities had, before the reform, heavily restricted adults’ access to dental care in the public sector, due to the high numbers of private practitioners in the area [5].

A nationally representative clinical epidemiological study in 2000 showed that edentulousness among middle aged adults had decreased considerably during the last 20 years and, treatment needs in this "amalgam generation" had increased. The study also showed that persons with low education and income had greater treatment needs than those with high education and income [6]. There is little information on how the fees charged for dental treatment influence utilization of services and treatment requested by patients.

The aim of this study was to assess use of dental services, and willingness and ability to pay for care and related factors among adults. In particular, we were interested in middle aged adults' willingness to pay (WTP) for urgent dental care and their ability to pay (ATP) for unexpected dental expenses at short notice in two hypothetical situations.

Postal questionnaires on the use of dental services were sent to a random sample of 1500 47-59-year-old adults living in the three neighbouring cities of Helsinki, Espoo and Vantaa; they have a total population of one million. A random sample of those born in 1960, 1957, 1954 and 1948 was selected by Statistics Finland. The study was part of the follow-up of the dental care reform in 2002 required by the Ministry of Health from the National R & D Centre for Welfare and Health, which had a legal obligation to collect various data and to monitor developments in the field of social and health care. The inquiry was anonymous and the respondents were under no obligation to complete and return the questionnaires. Approval to conduct the study was given by one of the Directors of the R &D Centre, as was customary when approval by an Ethical Committee was not found necessary. Data collection took place in 2007 and one reminder was sent. The initial response rate was 65.8%. The main questions used in this study were: "When was your latest visit to a dentist and which treatment sector did you use? What would be the highest price you would be prepared to pay to have a lost filling replaced immediately or, at the latest, the day after the filling was lost?" and " How much could you pay for unexpected dental expenses at two weeks' notice, if you suddenly needed more comprehensive care?" The WTP question was open-ended and the ATP question had structured answer alternatives. In Finland, the PDS is obliged to organize urgent emergency dental treatments the same day. A lost filling does not usually require immediate care, however the condition is irritating for the patient and if left untreated for a longer period endodontic treatment may be needed. In practice, getting an appointment with the PDS could have taken several days or weeks; in the private sector, it could have been possible sooner.

Complete answers to the first and second payment question were received from 704 (46.7%) persons in the original sample. This set of responses was used in the analyses. Background information on the respondents was collected from the questionnaire. Under- or over- representation of certain groups was not observed from the data. However, detailed robustness and representativeness numbers could not be computed due to non-existent data.

Logistic regression analysis was used to model the probability of being willing to pay the same or a higher price than replacement of a lost filling would have cost (after reimbursement) in the private sector (80 €) at the time the study was performed. To assess the factors associated with the ability to pay for more comprehensive treatment, ordered logistic regression analysis was used. This method was chosen because there were five classified responses to the second question: EUR <50, EUR 50-99, EUR 100-199, EUR 200-299, and EUR 300-500. Gender, basic education (classified in two classes: comprehensive school and matriculation), professional training (classified in three classes: vocational qualification (school level), vocational qualification (technical college), and university or equivalent educational level), working situation (classified in two classes: at work, off-work), professional status (classified in six classes: entrepreneur, upper clerical employee, lower clerical employee, worker, student, and other), annual income (classified in four classes: EUR <10 000, 10 000-25 000, 25 000-50 000 and >50 000), year of birth, whether the last dental visit was in the private, in the public sector or elsewhere, whether the respondent felt a need for dental care, classified as yes and no, or felt that she/he had benefited from the National Dental Reform classified in yes a lot, yes a little, no, and don’t know, time since the latest visit to a dentist (classified in two classes: within the past year, more than one year) and total costs of dental care in euro in 2006 (or in 2005) were used as explanatory variables. Marginal effects were calculated from the coefficients of the logistic regression and, for the analyses, the level for statistical significance was set at 95%.

In studies of utilization of dental services so called enabling characteristics such as good dental knowledge and willingness and ability to pay are important because patient contributions are required in most oral health care provision systems, including those with various kinds of subsidies. In health economics, WTP and ATP are hypothetical but direct methods to determinate monetary valuations of effects of health care technologies that have been widely used in a broad range of different diseases [7]. WTP has been proven to be a dexterous tool for assessing and revealing either personal or social preferences or both for matters where data is otherwise inaccessible [8]. In our study, the focus was on personal preferences and the objective was hypothetical.^a Hence, while a lot of data on use of dental services and price information can also be relatively easily obtained, in our study the hypothetical focus made the data non-existent. The older middle aged (47-59- year olds) were deliberately chosen for this study because they represent the age groups most in need of dental care in Finland today. They are no longer edentulous but usually have several missing teeth and need comprehensive dental care: restorations, periodontal and prosthetic treatments [6]. Due to the high response rate (for a population study) and because the age and gender distribution in our sample did not differ from the population values in the Helsinki metropolitan area, we consider the material satisfactorily representative of the middle aged population living in the area.

The study showed that frequent use of dental services was more common among adults in the capital region than other parts of Finland [6] which can be explained with on average higher education and better earnings in the population as well as better supply of private dental services in comparison with the rest of the country. In comparison with an earlier study in the same region the proportion of frequent users had increased slightly [9]. Most respondents (76.1%) had used private services and about a third had used public services (28.8%). Although dental care even after reimbursements was considerably cheaper in the PDS than in the private sector, the long waiting lists in the PDS have probably not been attractive to persons used to visiting private dentists with no waiting. Also, private care, after the dental care reform of 2002 [4], should have been less expensive than before. Another possible explanation is that people prefer to go to a dentist they already know. In an earlier study, half (52.9%) of the middle aged respondents had visited the same dentist for ten years or more and only a third (29.5%) for five years or less [9]. In our study, 81.2% of the respondents claimed to have visited the same dentist for more than one year. Private dentists also have recall systems and they send appointments and reminders to their patients [10]. The PDS does not recall adults. A smaller proportion of the respondents claimed to have used both sectors, which in the Helsinki area, most likely means that private patients have used the relatively accessible emergency dental services in the PDS [11].

Replacement of a lost or broken filling was one of the most usual treatments provided in the Public Dental Service Emergency Clinic in Helsinki in 2006 [12] and having access to this kind of treatment was important for an overwhelming majority of the participants in this study, of whom 96.9% retained some or all of their own teeth. In the situation depicted in our study, most respondents (93.2%) were willing to pay a fee that would allow the provision of the necessary fillings. Only 6.8% were willing to pay less and they would probably have chosen extraction. This indicates that most middle aged adults in the capital region put high value on retaining their teeth. It was also obvious that women valued their teeth more than men. Not unexpectedly, willingness to pay a higher price was associated with high income and good oral health. WTP has been shown to be associated with income in other studies about dental care such as periodontal treatments, regular check-ups and dental implants [13‐15]. From result-standardization viewpoint but also from the behavioural economics viewpoint, more studies on relationships between predicted and actual WTP are needed.

The other scenario in our study was not as clearly defined as the first and could be interpreted in many ways: a lost or broken crown, bridge or denture, a surgical operation or endodontic treatment. A frequent intervention in the 47-53 year age group would have been endodontic treatment. This, on a molar tooth, would have had a reference price of EUR 150 in the PDS and EUR 360 in the private sector (after reimbursement). According to the results in our survey, 22% of the respondents would not have been able to pay for endodontic treatment and would probably have had the tooth extracted. About 30% could have had endodontics in the PDS and about half of the respondents could have had this care even in private practice. Here it was obvious that those with greater earnings would have been able to spend more money on comprehensive dental care than those with lower earnings. An earlier study in the capital region showed that treatments provided in middle aged adults varied depending on the patients´ income level. Those with high income had crowns, bridges and implants and those with low income had missing teeth in anterior segments and removable dentures [9].

One of the strengths of our analysis was the possibility of studying and at the same time controlling willingness or ability to pay and income levels. While WTP estimates are sometimes criticised for being biased upwards [16], in our model the ATP and income controlled the bias at least to some extent. In addition, the ATP analysis pointed in the same direction with the WTP analysis and hence provided the results with a more solid basis. In addition, while the positive relationship found between income and WTP and ATP was not surprising, it indicated that, while wealthier people tended to have a preference for the private sector, this preference was not matched to the same extent with their willingness to pay. ATP increased with increasing income, but the increase in WTP did not keep pace with the increase in ATP or income.

There were strong and statistically significant relationships between income and WTP and ATP for unexpected dental treatments showing that those with high income were willing and able to pay more than those with low income. The recently opened access to the PDS should benefit those with lower income and improve quality of dental care for adults.

^aWhen data are available and accessible, WTP analyses offer little advantage since revealed choices are the most convenient way to study people’s preferences.