Pay-for-performance : paying by results in oral health indicators .

ISSN Online 0719-2479 ©2014 Official publication of the Facultad de Odontología, Universidad de Concepción www.joralres.com In Chile, comprehensive dental care for 6-year-old children is included in the Explicit Health Guarantees System (GES, “Garantías Explícitas en Salud”), which came into force for the first time in 2005. Moreover, payment mechanisms to providers of healthcare services have been used in many countries as one of the strategies for improving management and equal access to health services1. Chile has been using the per-capita payment mechanism to finance primary health care (PHC) since the 1990s. Pay-for-performance for health professionals and other staff working at PHC services has also been used since 2003. In this context, health goals for collective performance have been set. Additional salary incentives based on the achievement of predefined indicators are offered to health workers. Among these goals is the rate of dental discharge in 6-year-old children, beneficiaries by the Chilean National Health Fund (FONASA) and currently registered at their respective health centers2. Recently Cornejo-Ovalle et al. published a paper titled “Pay-for-performance and efficiency in primary oral health care practices in Chile”3. The study findings suggested that efficiency of dental health providers at PHC centers in the Metropolitan Region of Chile was significantly higher in years when the rate of dental discharge for 6-years-old children was used as a goal for collective performance. That is, the payment mechanism associated with performance indicators in addition to salary improved the rate of dental discharges in that period. Indeed, based on data from the Metropolitan Region, the annual rate of discharge increased, on average, 160 per 1.000 beneficiaries aged 6 when pay-for-performance (P4P) was used, in comparison to years in which P4P was not used. In addition it was reported that there was a relationship between the rate of discharges and the Human Development Index (HDI) of each municipality, because the municipalities with the lowest HDI achieved even significantly higher rates. Because people who belong to the most vulnerable socio-economic groups have poorer oral health and less access to dental services than people with higher socioeconomic level4, it seems important to continue using strategies aimed both at improving the management and efficiency of dental services and at reducing health inequities. According to our results3, P4P can be considered, among others, as one effective strategy to address inequalities in oral health care, and in the access to dental care for users of public health services in Chile. It is worth mentioning that a high percentage of children as early as at 2 years of age have a history of caries (17%)5. While in the 4 year-old population, this prevalence increases to 48%5, reaching 70.4 % in 6-year-old children. However, these figures hide marked inequalities, since the situation is significantly worse in children from families and communities with lower socio-economic status. Therefore, it seems appropriate to develop new approaches with respect to the health goals of the current decade, favoring the achievement of indicators of oral health in children and adolescents. There should be considered, among others, payment mechanisms as strategies for clinical and human resources management. Particularly, we propose to review dental indicators included in the goals for collective performance. That is, incorporating the rate of caries-free children as one of the indicators associated with the pay-for-performance scheme (health goals). Regarding the operationalization of this goal, the social determinants of health should be considered as one EDITORIAL LETTER TO THE EDITOR

In Chile, comprehensive dental care for 6-year-old children is included in the Explicit Health Guarantees System (GES, "Garantías Explícitas en Salud"), which came into force for the first time in 2005.
Moreover, payment mechanisms to providers of healthcare services have been used in many countries as one of the strategies for improving management and equal access to health services 1 .Chile has been using the per-capita payment mechanism to finance primary health care (PHC) since the 1990s.Pay-for-performance for health professionals and other staff working at PHC services has also been used since 2003.In this context, health goals for collective performance have been set.Additional salary incentives based on the achievement of predefined indicators are offered to health workers.Among these goals is the rate of dental discharge in 6-year-old children, beneficiaries by the Chilean National Health Fund (FONASA) and currently registered at their respective health centers 2 .
Recently Cornejo-Ovalle et al. published a paper titled "Pay-for-performance and efficiency in primary oral health care practices in Chile" 3 .The study findings suggested that efficiency of dental health providers at PHC centers in the Metropolitan Region of Chile was significantly higher in years when the rate of dental discharge for 6-years-old children was used as a goal for collective performance.That is, the payment mechanism associated with performance indicators in addition to salary improved the rate of dental discharges in that period.Indeed, based on data from the Metropolitan Region, the annual rate of discharge increased, on average, 160 per 1.000 beneficiaries aged 6 when pay-for-performance (P4P) was used, in comparison to years in which P4P was not used.
In addition it was reported that there was a relationship between the rate of discharges and the Human Deve-lopment Index (HDI) of each municipality, because the municipalities with the lowest HDI achieved even significantly higher rates.
Because people who belong to the most vulnerable socio-economic groups have poorer oral health and less access to dental services than people with higher socioeconomic level 4 , it seems important to continue using strategies aimed both at improving the management and efficiency of dental services and at reducing health inequities.
According to our results 3 , P4P can be considered, among others, as one effective strategy to address inequalities in oral health care, and in the access to dental care for users of public health services in Chile.
It is worth mentioning that a high percentage of children as early as at 2 years of age have a history of caries (17%) 5 .While in the 4 year-old population, this prevalence increases to 48% 5 , reaching 70.4 % in 6-year-old children.However, these figures hide marked inequalities, since the situation is significantly worse in children from families and communities with lower socio-economic status.
Therefore, it seems appropriate to develop new approaches with respect to the health goals of the current decade, favoring the achievement of indicators of oral health in children and adolescents.There should be considered, among others, payment mechanisms as strategies for clinical and human resources management.Particularly, we propose to review dental indicators included in the goals for collective performance.That is, incorporating the rate of caries-free children as one of the indicators associated with the pay-for-performance scheme (health goals).
Regarding the operationalization of this goal, the social determinants of health should be considered as one

REFERENCES.
of the elements that can be used to adjust the percentage of the indicator established as a goal within the local reality.In addition, this would involve strengthening the family and community integrated approach of primary health care teams, as well as intersectoral collaboration as they are fundamental intervention strategies that would be required to achieve this goal.Furthermore, this would align health goals with both the family health care and community health model with the recently implemented program "Sowing Smiles" ("Sembrando Sonrisas"), that is one of the commitments of the current administration.

Marco
EDITORIAL LETTER TO THE EDITOR DOI: 10.17126/joralres.2015.046Pay-for-performance: paying by results in oral health indicators.
Cornejo-Ovalle.Public Health Unit at the Research Institute of Dental Sciences, School of Dentistry, Universidad de Chile.María Angélica Cereceda.Odontopediatrics, School of Dentistry, Universidad de Chile.