sick to the teeth...

You may recall a blog post a few months back on dental services in Ireland. Essentially, I pointed out that a staggering 399,262 more treatments were provided by dentists to medical card patients in Ireland during 2009. That was a full 34% more treatments carried out than was projected by the HSE based on year-on-year trends since the scheme's inception in 1994. It is true that there were more medical card holders in 2009, but only 4% more. I strongly suggested that it is completely infeasible for this extra 4% of people to have induced 34% more demand in the system and that the alternative possibility -- a 30% decline in dental health in one year -- is equally ludicrous. The figures are strongly suggestive of the phenomena of supplier induced demand. The phenomena is well documented in the international health economics literature and often arises with "free" schemes essentially because 'the supplier of the service is also the demander' (..due to the inherent information asymmetry in the health care environment that requires a trust relationship between the health professional and their patient).

The HSE, faced with these 'inexplicable' increases and substantial narrowing of their overall budget during 2010, decided to cap the amount payable for the scheme to the pre-2009 level; the amount paid before the incredible 34% increase in dental services. The immediate response of the Irish Dental Assoc. was to claim that their members would now only be able to offer emergency services and oral examinations. I have heard no update on this position since.

So what is new??

In June, two dentists brought a case to the High Court to seek an injunction against the HSE implementing the spending cap. The claimed that the measures were a breach of contract, and would have "disastrous consequences" for them as dentists and "a dramatic effect on public health". The were successful, and won an injunction against the HSE preventing them from implementing the spending cap.

The CEO of the Irish Dental Assoc. welcomed the decision saying that he had "huge concerns for the dental health of the country". He described the HSE's move as "unsafe, unworkable, and unethical" and further went on to say that "it would hit the most vulnerable in our society hardest". The HSE subsequently appealed to the Supreme Court against the High Court injunction, but a 'stay' was placed on the High Court's injunction. So, from what I can decipher, a full hearing will now go ahead later this year (most likely early October)

The story looks like it will continue for some time. I can't help but wonder, however, if the case for supplier induced demand might be worth a hearing? I've heard nothing about it so far (apart from comments here) and I certainly think it is an issue worth considering in this case. At the very least, the Irish Dental Assoc. could be asked to explain the 34% increase in their services during 2009.

Evaluating State Programmes: “Natural Experiments” and Propensity Scores

DENIS CONNIFFE, VANESSA GASH, PHILIP J. O’CONNELL

The Economic and Social Review, Vol. 31, No. 4, October, 2000, pp. 283-308

Abstract: Evaluations of programmes — for example, labour market interventions such as employment schemes and training courses — usually involve comparison of the performance of a treatment group (recipients of the programme) with a control group (non-recipients) as regards some response (gaining employment, for example). But the ideal of randomisation of individuals to groups is rarely possible in the social sciences and there may be substantial differences between groups in the distributions of individual characteristics that can affect response. Past practice in economics has been to try to use multiple regression models to adjust away the differences in observed characteristics, while also testing for sample selection bias. The Propensity Score approach, which is widely applied in epidemiology and related fields, focuses on the idea that “matching” individuals in the groups should be compared. The appropriate matching measure is usually taken to be the prior probability of programme participation. This paper describes the key ideas of the Propensity Score method and illustrates its application by reanalysis of some Irish data on training courses.