Sedan 1999 har Folktandvården i Värmland två alternativa tandvårdssystem: Styckepris- och Kontraktstandvård. I Kontraktstandvård tecknar patienten ett kontrakt med Folktandvården, betalar en fast summa för en specifik tidsperiod, och erhåller sedan vård utan extra kostnader.Det övergripande syftet var att undersöka om de förmodade olika behandlingsfilosofierna i Kontrakts- och Styckepristandvård leder till olika utfall, med bättre oralhälso-relaterad livskvalitet hos patienter i Kontraktstandvård, än hos patienter i Styckepristandvård.Studie I var en litteraturgenomgång av tidigare forskning, med material insamlat genom databassökningar. Studie II, III och IV bestod av material insamlat genom en postenkät under 2003. Enkäten sändes till 1 200 slumpvis utvalda patienter i varje system i Folktandvården Värmland, totalt 2 400 patienter. Studie I. Det fanns indikationer på mer preventiv vård, och i det långa loppet också på minskat behov av restorativa åtgärder i kapitering, jämfört med i fee-for-service. Det fanns för lite material för att kunna dra några slutsatser om produktivitet, tandläkarens tillfredsställelse med sitt arbete och patientens tillfredsställelse med erhållen vård. Studie II. Patienterna i Kontraktstandvård var yngre, hade högre utbildning, var i större utsträckning gifta eller sammanboende, födda i Sverige, och hade bättre allmänhälsa och oralhälso-relaterad livskvalitet än Styckepristandvårdspatienterna. De senare upplevde å andra sidan en högre samhörighet med sitt bostadsområde. Studie III. När andra faktorer kontrollerades i hierarkisk multipel regression fanns ett samband mellan oralhälso-relaterad livskvalitet och tandvårdssystem: Kontraktstandvårdspatienterna hade en signifikant bättre oralhälso-relaterad livskvalitet än Styckepristandvårdspatienterna. Studie IV. I pathanalys med strukturell ekvationsmodellering fanns indikationer på olika underliggande mekanismer i de två systemen. I Styckepristandvård samvarierade patientens uppfattning om vårdgivarens förhållningssätt med den oralhälso-relaterade livskvaliteten: ju mer patientcentrerat förhållningssätt, desto bättre oralhälso-relaterad livskvalitet. Detta samband fanns inte i Kontraktstandvård. Där samvarierade istället hur mycket patienten var beredd att betala för sin tandvård med hur högt hon skattade vårdgivarens förhållningssätt som patient-centrerat: ju mer patienten var beredd att betala, ju högre skattade hon vårdgivaren som patient-centrerad. Detta samband fanns inte i Styckepristandvård. Vad patienten hade betalat för sin tandvård föregående år samvarierade med oralhälso-relaterad livskvalitet i båda tandvårdssystemen: ju mer patienten hade betalat, desto sämre oralhälso-relaterad livskvalitet. Sambandet var dock dubbelt så starkt i Styckepristandvård jämfört med Kontraktstandvård. Sammanfattningsvis fanns det skillnader mellan tandvårdssystemen som hade samband med den oralhälso-relaterade livskvaliteten. Selektionsbias, dvs att olika individer söker sig till olika system, kan inte helt uteslutas, men avsaknaden av multivariata samband mellan exempelvis utbildning, ålder och oralhälso-relaterad livskvalitet indikerar att skillnaderna mellan systemen troligen beror systemfaktorer. Denna konklusion styrktes av att de skillnader som fanns mellan systemen inte var relaterade till bakgrundsvariabler.

Since 1999, the Public Dental Health Service in Värmland has two alternative patient payment systems: Fee-for-service and Contract care. In Fee-for-service, the patient pays per provided service, after treatment. In Contract care, the patient enters a contractual agreement with the Public Dental Health Service, pays a fixed fee for a fixed period of time, and then receives all dental care needed and covered by the contract, without additional costs.The overarching aim was to investigate if the assumed different treatment philosophies in Contract and Fee-for-service care would lead to different outcomes, with patients in Contract care having better oral health-related quality of life than patients in Fee-for-service care. Study I was a literature review of previous research, with material gathered through searches in different databases. Studies II, III and IV were conducted on material gathered through a postal questionnaire in 2003, sent to 1,200 randomly selected patients in each patient payment system in the Public Dental Health Service in Värmland, in all 2,400 patients. Study I. There were indications of more preventive services, and in the long run, of decreased need for restorative care in capitation, compared to in fee-for-service. Regarding productivity, dentists’ satisfaction with their work and patients’ satisfaction with provided care, there was too little information to draw conclusions.Study II. The patients in Contract care were younger, better educated, to a larger extent married or living with somebody, born in Sweden, and had better general health and oral health-related quality of life, than the Fee-for-service care patients. On the other hand, the latter felt a higher degree of social affinity with their housing area. Study III. Controlling for possible confounding factors in hierarchical multiple regression analysis, oral health-related quality of life was associated with patient payment systems: patients in Contract care had significantly better oral health-related quality of life than had the patients in Fee-for-service care. Study IV. In path analyses, using structural equating modeling, there were indications of different underlying mechanisms in the patient payment systems. In Fee-for-service care, the patient’s perception of the caregiver’s patient-centred stance was associated with oral health-related quality of life: the more patient-centred stance, the better the oral health-related quality of life. This relationship was not present in Contract care. There patient-centredness was associated with how much the patient was prepared to pay: the more she was prepared to pay, the higher she ranked her caregiver as being patient-centred. This was not found in Fee-for-service care. What the patient had paid for dental care the previous year was associated with a decrease in oral health-related quality of life in both systems. However, the association was twice as strong in Fee-for-service care, compared to Contract care. In conclusion, there were differences between the patient payment systems, influencing oral health-related quality of life. Even though selection bias cannot be excluded, the fact that the bivariate differences regarding e.g. education and age did not remain in the multivariate analyses indicated that the differences found in oral health-related quality of life probably are due to the payment systems themselves. This conclusion was strengthened by the fact that the differences found in underlying mechanisms in the systems were not related to background variables, but to variables associated with the dental care situation.