Health insurance amendment (Medicare dental services) Bill 2007
THE INQUIRY
1.1
The Health Insurance Amendment (Medicare Dental Services) Bill 2007 (the
Bill) was introduced into the House of Representatives on 16 August 2007. On 16 August 2007, the Senate, on the recommendation of the Selection of
Bills Committee (Report No. 14 of 2007), referred the provisions of the Bill to
the Community Affairs Committee (the Committee) for report on 5 September 2007.
1.2
The Committee received nine submissions relating to the Bill and these
are listed at Appendix 1. The Committee considered the Bill at a public hearing
in Canberra on Monday, 27 August 2007. Details of the public hearing
are referred to in Appendix 2. The submissions and Hansard transcript of
evidence may be accessed through the Committee's website at https://www.aph.gov.au/senate_ca
.
THE BILL
1.3
The purpose of this Bill is to amend the Health Insurance Act 1973 in
order to increase access to dental treatment under Medicare for people with
chronic conditions and complex care needs.
1.4
In the 2007-08 Budget, the Commonwealth Government announced an
expansion of the current Enhanced Primary Care dental items (Medicare items
10975 to 10977) to provide higher Medicare rebates and more services to
eligible patients. From 1 November 2007, eligible patients will be able to
access Medicare benefits for dental services of up to $4,250 (including any
Medicare Safety Net benefits where applicable) over two consecutive calendar
years. This amount may be used for any combination of dental services covered
by Medicare under this measure, depending on the clinical needs of the patient.
1.5
New Medicare items will be introduced for services such as dental
assessments, preventative services, extractions, fillings and other restorative
work, and dentures. These items will be based on the current Department of
Veterans’ Affairs (DVA) Schedule of Dental Services, with some modifications.
1.6
The Medicare dental items will be targeted at people with chronic
conditions and complex care needs where the person’s oral health is impacting
on, or is likely to impact on, their general health. The new measure will make
it easier for these people to access dental services in the private sector when
they need treatment or to receive preventive care. To be eligible, a person
needs to be managed under a GP Management Plan and Team Care Arrangements.
Residents of aged care facilities can also access the dental items if they are
managed by a general practitioner under a multidisciplinary care plan. All
patients will need to be referred to a dentist by their GP. It is expected that
approximately 200 000 patients will access the new dental items over the first
four years of the measure.[1]
A comparison of the existing and new MBS dental items is at Appendix 3.
1.7
The estimated cost of the measure is $384.6 million over four years
allocated as follows:
|
|
2007-08 |
2008-09 |
2009-10 |
2010-11 |
Total |
|
Administered
|
$53.3m |
$113.9m |
$94.2m |
$110.4m |
$371.7m |
|
Departmental - Health and
Ageing
|
$0.6m |
$0.2m |
$0.1m |
$0.1m |
$1.0m |
|
Departmental - Medicare Australia
|
$3.4m |
$3.0m |
$2.7m |
$2.7m |
$11.8m |
|
TOTAL
|
$57.2m |
$117.1m |
$97.1m |
$113.2m |
$384.6m |
Source: Submission 2, p.4 (DoHA).
ISSUES
1.8
The Bill was generally supported by those providing submissions and
evidence to the Committee, though the need to expand on these initiatives was
clearly expressed. The Australian Medical Association expressed 'its desire
that further funding initiatives be rolled out to broaden access to dental care
beyond those with chronic conditions and complex care needs'[2]
and the Australian General Practice Network supported 'broader access to
Medicare benefits for dental treatment for people on low income thresholds and
health care card holders'.[3]
1.9
The Australian Dental Association (ADA) also welcomed the Federal
Government’s 'recognition of the greater role it must play in the improvement
of the oral health of needy Australians' and hoped 'that this initiative is the
first of many initiatives that will occur in relation to dental care delivery'.[4]
1.10
Professor John Spencer commented that:
This is an important, albeit very constrained step in improving
the oral health and access to dental care among the Australian population.
Nonetheless, there are several issues [that] should be discussed with regard to
this Bill and its rationale.[5]
Chronic medical condition and
impact on oral health
1.11
The underlying premise of this Bill, that patients
with chronic conditions and complex care needs often have poor oral health
which adversely affects their medical condition or general health, attracted
considerable discussion.
1.12
Professor Spencer made several points on this issue. Firstly, he
referred to a quote from the US Surgeon General – 'You cannot be healthy
without oral health' – that challenges the premise 'that poor oral health is
only important in so far as it affects a chronic medical condition or its
management' and argued that the quote 'acknowledges that oral health per se
is important, even without an identifiable increase in the severity or
complexity of the management of any medical condition'.[6]
1.13
Secondly, the Professor submitted that 'classifying those medical
conditions which are adversely affected by poor oral health is a difficult task',
and commented:
Poor oral health may quite plausibly affect nearly all medical
conditions through pathways involving reduced ability to chew, altered food
choice and decreased nutritional value of foods consumed. Alternatively oral
symptoms may adversely affect quality of life, reducing coping and
self-efficacy. However, there is lack of research in these areas. There is
difficulty in ruling a line between medical conditions which are affected or
not by poor oral health. At present any decision about what conditions are
included will seem quite arbitrary.[7]
1.14
The Department spoke to the issue of connection between chronic
conditions and poor oral health, and how they expected the scheme to operate:
Mr Eccles—Professor Horvath [Chief Medical Officer] alluded to
this at Senate estimates. Our understanding of the impact of poor oral hygiene,
poor dental health, on chronic conditions is growing all the time. In
particular, there is a growing body of evidence about the link between heart
disease and poor dental health. It is important to bear in mind that this is
about people presenting with chronic conditions where, in the GP’s view, they
would benefit from dental treatment. That could be early-stage gum disease,
acute infection or a whole range of things, but the focus is very much on
people with chronic conditions who do need dental health care.
CHAIR—Because of that chronic condition?
Mr Andreatta—No. Under the enhanced measure that we are talking
about now, people would be eligible to access these items where their oral
health is either impacting on their medical condition, their chronic condition
or their general health. So it is a broader eligibility criterion that we have
adopted.
Mr Eccles—It is the same pathway into the general practice—it is
people with team care plans or people who are under a GP management plan where,
in the doctor’s view, their oral health is impacting on, or is likely to impact
on, their health.[8]
1.15
With GPs now having to form a view on the impact of oral health and with
the increased range of dental services being provided under the scheme, the
issue arose as to whether GPs had the clinical capacity to assess eligibility
against the new criteria included in the MBS dental schedule. The Department
has given attention to this issue:
On the fundamental point about the capacity of GPs to understand
the item, that is why it is going to be very important that we get the
information and the communication activities right.
We know that the professional associations that represent
dentists and the GP groups are working together to try and work out how we can
make sure that GPs, who are going to be the starting point for this, have a
better and more comprehensive understanding of the link between how they care
for someone and when dental treatment might be useful in managing someone’s
chronic condition. We are very aware of that, so that will be something we will
be doing up front, and we are going to be pretty well ready to go as soon as or
if the legislation is passed. From that point, it will be a matter of
monitoring the uptake, monitoring the progress and continuing the dialogue with
the GP groups and the dental groups, just to make sure that we have got this as
right as we can.[9]
Targeted funding
1.16
The ADA was concerned that Medicare was being used as the model of
delivery for the dental care program because Medicare, by its very nature, does
not discriminate on the basis of financial need. They remain dissatisfied that
funding under this program 'remains universally available to Australians rather
than being targeted to the financially disadvantaged and particularly those
numerous Australians on dental waiting lists'. The provision of financial
assistance for dental care to those that can afford such treatment is in the ADA’s
view an inappropriate use of the limited funds on offer. The ADA reaffirmed its
view 'that any dental program should be selectively targeted for those most in
need and that there should be other programs with regard to whole-of-life
preventative initiatives'. The ADA has argued for the adoption of a DVA type
scheme for a means tested identifiable group of Australians to receive the
benefit from the limited available funds.[10]
1.17
While some aspects of the DVA scheme have been used as a model for this
scheme, the Department commented on the issue of the Medicare model as opposed
to the DVA model:
I think the Medicare model is considered to be the most
appropriate means for, if you like, the mainstream population. One of the
benefits of this is the focus on improving the links between general practice
and dentistry. The approach of building on the Medicare schedule was by far the
most efficient, effective and well-understood mechanism.[11]
Rebate levels and item numbers
1.18
The ADA expressed concern at the possible rebate levels and the impact
this would have for participating dentists:
It seems likely now that the Scheme will apply a model where the
DVA is seen as a “schedule” fee and provide a rebate of 85%. When the DVA fee
is already at a significant discount to the average fee, we see no reason why a
further discount ought to be applied. With statistics available to demonstrate
that dentists already provide pro bono services of about $11,500 per dentist
per year or, approximately 10% of their average income, no further discount
over and above that provided in the DVA scale ought to be required.
It has been pointed out to the Department and to the Minister
personally by representatives of the ADA that this proposed level of fee rebate
will cause reluctance on the part of dentists to adopt the Scheme on a rebate
only basis. The ADA has advised that quite often eligible patients cannot
afford a gap payment and thus dentists would be providing these services at a
significant discount and in some cases not covering costs.[12]
1.19
The ADA considered that the adoption of a DVA scale of fees would
address these concerns and that an annual review of the rebate must be provided
commensurate with dental cost indices.
1.20
The ADA also argued that the creation of new item numbers to describe a
series of procedures that altered the Australian Schedule of Dental Services
and Glossary could create confusion. This Schedule was a universal coding
system, accepted by dental schools, the private health funds and all dentists.
1.21
The Department has indicated in its proposed implementation arrangements
that the dental items and rebate levels will be set out in a new Medicare
Benefits Schedule Dental Book. Because of the increased range of services that
will be eligible under the new scheme, there will be 'around 450 new items' in
the Schedule – a significant increase from the current three. However, the
Department advised that the new Schedule:
will be based quite largely on the DVA schedule, which is one of
the things that resulted from the consultation that we had with the ADA...there
is substantial mirroring of items even down to the numbering that they use to
minimise the administrative burden on dentists. I think it is fair to stay that
there is substantial mirroring of the item types and descriptions.[13]
1.22
With the schedule not yet being finalised, the Committee again raised as
a matter of principle an issue of parliamentary process about which it has
previously expressed concern. The Committee regards as undesirable having to
consider legislation without access to the detail of how the scheme will
operate (as outlined in subsequent delegated legislation). It notes that the ministerial
determination providing detail of this scheme is a disallowable instrument, and
it therefore foreshadows that it may undertake some formal scrutiny of that
instrument when it is tabled in the Parliament.
Dental experts
1.23
The ADA expressed concern that there was no expert dental supervision of
the dental program similar to that provided under the DVA dental services
scheme. The ADA contends that dental experts are best able to provide advice on
the development of the program, monitor progress and provide feedback for the
government, deal with special cases with a degree of flexibility enabling
adequate and appropriate treatment, and detect aberrant practices.[14]
1.24
The Department commented on the issue of including a similar level of expert
dental supervision to that provided under the DVA scheme:
Logistically and financially, it would be another level. I do
not think they are necessary to achieve the outcomes we are trying to achieve.
There are a number of reasons cited by the ADA for dental assistants. Part of
it was for the ongoing review to make sure that there is a legitimacy of care.
I believe that we have mechanisms in place through Medicare audits, through
complaints and through the role of the PSR in monitoring this activity to be
able to give us the same level of comfort on that.[15]
Special needs patients
1.25
The ADA noted that the treatment required by many special needs patients
is beyond the capacity of the private surgery setting of many dental
practitioners and sought clarification as to whether these patients are
eligible to be treated in hospitals. According to the ADA, special needs
patients are finding it increasingly difficult to receive the complexity of treatment
that is needed.
1.26
The system should support these patients and deliver the best possible
care available. The ADA argued that if the situation of special needs patients was
jeopardised by divisions of responsibility between State and Federal governments,
then the Federal Government should take a leadership role and assist those in
the community who are deserving of prompt treatment and ensure that State
Governments also play a role and meet targets.[16]
1.27
In raising this issue with the Department, the Committee noted the
situation where a treatment that could be performed in a dental surgery may,
for special needs patients, produce a more satisfactory outcome if performed in
a hospital under a general anaesthetic. The Department indicated that a dentist
would not be covered treating in a hospital under the Medicare arrangements,
but undertook to have discussions with the ADA concerning their issues with
special needs patients.[17]
Referral by GP
1.28
The AMA did note that there was 'some ongoing concern that GPs have
difficulty locating a dentist who will accept the rebates as full payment when
referring patients'. However, they anticipated that other initiatives announced
in the Budget will go some way to addressing this issue.[18]
1.29
When a GP determines that their patient has a chronic condition that
could be affected by their dental health, the referral process to a dentist
requires the GP to use the referral form provided by the Department of Health
and Ageing or a form that substantially complies with the form issued by the
Department. The ADA commented that the paperwork required with the previous
system was a bit cumbersome, but this had been addressed through discussions
with the Department about conditions and the various relationships between
dental health and chronic disease.[19]
The Department advised that:
We have spoken to both the dental and the GP professions and
they have both said the referral form that they currently use under the EPC
items is the most appropriate way of communicating between the two provider
groups. So we have retained the referral form that is needed, though we may
streamline it a little in terms of the content.[20]
Ceiling on eligibility for
treatment
1.30
Professor Spencer noted that the criteria for inclusion of dental
services in a GP Management Plan are not defined. Uncertainty about specific
medical conditions to be included could lead to either few or many eligible
patients receiving dental care. However, if the new arrangements are more
attractive to patients, GPs and dentists than is the current scheme, it is
possible that most people under a GP Management Plan and Team Care
Arrangements, estimated at approximately 400,000, could be eligible for dental
care. If this level of eligibility were to be realised, there was concern that,
with the expenditure over four years expected to be $384.6 million, many
eligible patients may not receive dental treatment under the scheme.[21]
1.31
The Department was able to allay this concern by advising that should
the uptake be greater than estimated, outlays would be increased to cover the
level of take-up 'much as is the case with any Medicare item'.[22]
Communication/Education programs
1.32
The AGPN noted that the uptake of items under the Enhanced Primary Care
Scheme had been modest and recommended the need for 'a communication strategy
to bring together local networks of GPs and dentists to raise awareness of the
new items and provide an orientation to their use'.[23]
1.33
The ADA (Queensland Branch) noted that dentists were unfamiliar with
working in the Medicare system. The ADAQ remarked that the administration of
the Enhanced Primary Care Scheme was still an area that dentists were concerned
about and that unfamiliarity with Medicare would continue to be a barrier to
practitioner involvement. They suggested:
The introduction of a scheme administered under a Medicare model
requires a commitment to realistic and appropriate education and information
for practitioners. Where the previous system has failed to gain acceptance is
where this information has been provided in language and format familiar to
existing Medicare providers but totally foreign to dentists. This includes not
only the paperwork requirements (reporting and accounting) but also the allowable
fee levels.[24]
1.34
The Department acknowledged the need for educating dentists:
We certainly accept the need for information and education for
dentists as well, particularly when it comes to the administrative aspects: the
requirement to provide a quote, the role of Medicare Australia’s hotline and
all the things that were outlined in our submission about how we expect the
process to work. There will need to be some education information provided...
It would be us and Medicare as one going to the ADA and using
the ADA, if you like, as one means. I am sure that we will also be directly
approaching dentists as part of information campaigns. Most likely, we will do
it through the ADA.[25]
Monitoring and evaluation
1.35
Professor Spencer noted that the expected costs over four years will
make expenditure under this scheme the second highest outlay on dental services
by the Federal Government and that such an outlay will need to be actively
monitored and evaluated. It is likely that ‘fine tuning’ will be required to
ensure satisfactory processes lie behind the provision of Medicare Dental
Services and the best outcome is achieved for the expenditure. Professor Spencer
proposed that:
To inform these judgements, evaluation needs to be conducted at
two levels: one among persons receiving Medicare Dental Services, and another
at the population level. Among persons receiving Medicare Dental Services
profiling of these patients and what services they receive would be an expected
routine part of any administrative overview. However, a number of more specific
questions might reasonably be asked about the persons receiving Medicare Dental
Services:
- the reasons for seeking
care,
- the social, medical and
other relevant characteristics of those who received care,
- the oral problems they had,
- the impact dental care had
on their underlying medical condition and its management, and
- the perceptions of the
process from general medical practitioners dentists and persons involved.
At the population level it is important to understand the
coverage achieved by Medicare Dental Services among those persons with chronic
disease and complex needs and those who are under a GP Management Plan and Team
Care Arrangement. Such questions can only be answered by planned evaluation
activities. The implementation of such evaluation activities early in the
program is of high importance if the management of the interface between oral
and general health is to be improved in Australia.[26]
CONCLUSION
1.36
In 1998 the Committee undertook an inquiry into dental services.[27]
In the intervening years there has remained considerable debate over access to
dental services in Australia. Statistics are regularly produced on the
deteriorating oral health for many Australians and lengthy waiting time for
treatment. The power to plan and responsibility for the delivery of dental
services and care between the Commonwealth, States and Territories has also
been the subject of much debate.
1.37
The Committee considers that the significant expansion of the Enhanced
Primary Care dental scheme proposed in this Bill is a fundamentally important
step in improving access to dental services and care for many Australians. The
Committee supports the measures being introduced in the Health Insurance
Amendment (Medicare Dental Services) Bill 2007 and recognises the broad support
that the Bill has received.
1.38
The Committee considers that it is most important that the provisions of
this Bill are implemented efficiently and effectively. It is therefore recommending
that an education program to ensure that dentists are fully informed of the
changes be established and that monitoring and evaluation of the changes occur
to ensure that all eligible people are able to access the benefits proposed by
this scheme.
RECOMMENDATIONS
Recommendation 1
1.39
That, while noting the Department's acceptance of the need for
information and education of dentists, a formal education program targeting
dentists be established, including information about the working of the new
Medicare rebates relating to dentistry.
Recommendation 2
1.40
That early monitoring and evaluation of the scheme be undertaken to
ascertain who is accessing the rebates and for what conditions, and ascertain
if the criterion that a 'patient's oral health must be impacting on, or likely
to impact on, their general health' is well understood and consistently
applied. Monitoring and evaluation should cover both the immediate recipients
of Medicare dental services and the broader population level.
Recommendation 3
1.41
That the Senate pass the Health Insurance Amendment (Medicare Dental
Services) Bill 2007.
Senator Gary
Humphries
Chair
September 2007
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