Prioritization,Incentives,and Resource Use for Sustainable Dentistry: The EU PRUDENT Project

Situational analysis: PRUDENT will comprehensively map the current status of oral health financing in European countries and use this new knowledge to develop a typology of oral health financing in Europe. The situational analysis will include a scoping review and an expert survey, which will feed into the typology of financing and payment systems in oral health care. The findings will help provide understanding of the context for improving oral care financing in subsequent PRUDENT steps.

Consenting of candidate items for essential oral health care benefit baskets: A scoping review will identify a preliminary list of previously suggested essential items of oral health care. Structured group brainstorming will then serve to critically reflect on this preliminary list of items, reach a collective understanding of what constitutes essential oral health care, and establish a refined list of consented candidate items for essential oral health care benefit baskets. These candidate items for essential oral health care are envisioned to inform future priority setting.

Deliberative processes toward implementation of cost-effective and equitable oral health coverage: Priority setting and resource allocation (PSRA) processes have gained increasing traction in addressing health care resource allocation problems given their ability to incorporate multiple stakeholders, address multiple competing objectives, incorporate evidence, and provide transparent, pragmatic, and flexible decision making. PRUDENT will undertake case studies in select countries to test the applicability of PSRA in relation to oral health coverage decision.

Co-production of a harmonized set of oral health system performance indicators: Guided by the WHO Health Systems Framework, PRUDENT will initially map existing oral health system performance indicators with a specific focus on financing aspects. Based on the list of identified indicators, a modified RAND/UCLA appropriateness method will be applied to consent a multicountry harmonized set of oral health system performance indicators. The indicators will form the basis to operationalize PRUDENT’s monitoring framework.

EU-wide monitoring framework for oral health systems performance: Based on the identified performance indicators and essential items for oral care (see above), PRUDENT will develop a multicountry monitoring framework for oral health systems performance. Available data sources with relevant oral health system information will be mapped. PRUDENT will also carry out an online survey of EU citizens’ perception of oral health systems performance in select countries. The information from the citizen survey and existing data sources will be incorporated in a cross-country interactive dashboard.

Behavioral economics lab to decipher the impacts of incentives on providers’ and citizens’ choices: To improve the understanding of demand- and supply-side behavioral mechanisms in the context of oral care markets, PRUDENT builds on state-of the-art stated preference methods to generate an in-depth understanding of how providers/citizens respond to incentives and infrastructures of oral care markets. Discrete choice experiments will serve to identify citizens’ preferences for different dimensions of oral health (particularly oral health–related quality of life), the impact of potential barriers to demand (e.g., out-of-pocket payments), and personal characteristics such as risk aversion and time preferences. Provider preferences will be elicited to decipher their extrinsic and intrinsic motives. In addition, linkage of data from the discrete choice experiments with registry data from Denmark will allow comparisons of real-life choices with stated preferences.

Practice-based study on SES–risk-adjusted capitation payment in the Netherlands (SES = Socio-Economic Status): Leveraging the experimentation clause of the Dutch Health Care Authority (NZA) and a committed stakeholder ecosystem comprising research organizations, health insurers, oral health professionals, and patients, PRUDENT will carry out a practice-based study in the Netherlands to test the implementation of SES–risk-adjusted capitation payments (high SES vs. low SES). The new payment system (= intervention) aims to reduce social inequalities in children/adolescent oral care. To compare the intervention group with the current standard of care (= fee for service), a synthetic control group will be constructed based on routine health insurance data. The evaluation will comprise an outcome evaluation, a process evaluation, and an economic evaluation. Given the dearth of empirical evidence on implementing new payments systems, this practice-based study provides a highly unique opportunity to evaluate the impact and decipher the facilitators and barriers involved in payment systems transformation.

Analysis of a population-wide reform to achieve UHC for oral care in France: Recent reforms in France (i.e., the “100% Santé” scheme), have aimed to improve access to dental care, especially for lower-income groups. These reforms emerged in response to “participative democracy” processes during the 2017 French presidential campaign. The resulting program has started offering an array of prosthetics, ranging from removable to fixed prostheses and crowns/bridges, the cost of which is now being reimbursed by compulsory health insurance. PRUDENT will harness large-scale administrative data to evaluate the extent to which the French “100% Santé” scheme has been achieving UHC for oral care. For methodological triangulation, relevant stakeholders and experts will be interviewed to provide additional insights in and perspectives on the “100% Santé“ scheme.

Multicountry contextualization of oral care–financing reforms: To further enhance the knowledge about the impacts and implementation of oral care–financing reforms, PRUDENT will carry out a realist review to unpack the configurative elements of financing reforms/arrangements in various European countries. This will serve to develop a more particularized understanding of the context-specific adaptability and potential impacts of alternative oral care–financing arrangements.

Needs-adaptive resource and workforce planning for oral health care: The rigidity of current resource- and workforce-planning models is a barrier for potential efficiency gains. To this end, PRUDENT will systematically identify the extent and impacts of dynamic changes in population oral care needs (e.g., due to changes in oral health morbidity or emergence of new oral care delivery approaches). A system dynamics model will be developed to explicitly take account of multiple factors that influence peoples’ oral care needs and to be applicable in the context of the participating European countries.

Regulatory learning to improve oral care financing: Oral care–financing arrangements are governed by EU-wide and county-specific regulatory frameworks. PRUDENT will systematically map currently existing regulatory frameworks for oral care financing and their potential for positive change. The identified regulations for oral care financing will feed into the “PRUDENT Regulatory Sandbox” to support policy and decision makers.

PRUDENT Financing Companion: To reflect on project results with policy makers, citizens/patients, providers, and researchers, a participatory conference will be organized. The feedback received will be consolidated as implementation support tools: (1) policy briefs for national and EU policy makers, (2) decision aids (e.g., for oral health systems monitoring, workforce planning, priority setting), and (3) regulatory sandbox (inventory of regulations through which oral care financing can be improved).

European observatory policy workshop: In collaboration with the European Observatory on Health Systems and Policies, this workshop will bring together key findings from PRUDENT and international experts from policy and practice from various countries. The policy workshop will be geared toward knowledge brokering of evidence and insights into policy makers’ views on concrete implementation.

Executive leadership module: A training module on oral health financing will be developed for policy makers from all relevant health sectors (also beyond oral health).