Chapter 2
Reaction to the proposals
2.1
While the committee received a limited number of submissions to its
inquiry, most contributors welcomed the introduction of the Child Dental
Benefits Schedule (CDBS) and the broader dental reform package.
2.2
The Australian Dental Association (ADA) and the Australian Medical
Association (AMA) both issued press releases following the government's
announcement welcoming the policy and legislative proposals. The ADA stated:
The re-direction of federal funding to Australia’s children
and adults on low incomes or in rural areas will prove to be a sound
investment. We know that if dental care can be provided to children then their
long-term dental health will be significantly improved. Early intervention and
preventive treatments are a proven and well-established method to prevent poor
dental health in later life...Currently about 65% of Australians receive
regular dental care. The ADA believes the new program will provide assistance
to many Australian families previously unable to access regular care, as a sure
way of helping them to avoid a path where their dental health will deteriorate.[1]
2.3
The AMA concurred with the ADA:
This is a huge improvement on the existing dental
scheme...There is less bureaucracy and red tape, and the program is better
targeted at those with the greatest need. While it is not a universal system,
it will go a long way towards improving the dental health of the Australian
community.[2]
2.4
The Consumers Health Forum of Australia (CHFA) described the reform announcement
as a 'big win for the whole community', and commended the focus on preventative
dental care for younger generations,[3]
while the Australian Council of Social Service also applauded the reform
announcement.[4]
2.5
In their submission the ADA also pointed to the evidence base that
supports the investment in child oral health from both a health and a financial
perspective:
Investment in the oral health of children is a sound and
sensible investment as it may result in a long-term monetary saving for government
and the community by minimizing future deterioration in dental health. There is
a substantial body of evidence indicating that early intervention and
preventive treatments provided early in life are a proven and well-established
method to prevent poor dental health in later life.[5]
2.6
The CHFA also cited evidence that child tooth decay is on the rise and
expressed support for the proposals on that basis:
According to statistics cited
in the National Advisory Council on Dental Health’s final report, the prevalence
of child tooth decay and cavities and the average number of teeth affected by
dental disease in children has increased since the late 1990s. Poor oral health
in childhood is a strong predictor of poor oral health in adulthood. CHF
therefore welcomes the emphasis on children’s dental health, which has the
potential to establish good oral health and reduce the likelihood of future
problems.[6]
2.7
The Australian Healthcare and Hospitals Association (AHHA) were
similarly supportive of the measures, stating in their submission that they
accorded with current AHHA policies that include:
- the entitlement scheme for eligible children as it ensures that
children and adolescents receive good quality care...;
- enhanced access to public dental services for people on low
incomes...;
- ensuring people on low incomes can access treatment earlier...; and
-
the creation of an expert group to oversee the implementation of
the scheme...[7]
2.8
While there was broad consensus supporting the expansion and increased
resourcing of public funded dentistry there were issues raised on the detail on
the measures.
2.9
The main issues identified in both the submissions received by the
committee and the oral evidence included:
- the commencement date of the CDBS;
-
the details of the services that will be available under the
scheme;
- the consultation with the profession;
- the funding arrangements for the proposed scheme;
- the transitional arrangements for those patients currently being
serviced under the Chronic Disease Dental Scheme (CDDS); and
- the eligibility criteria for the scheme.
Commencement date
2.10
In its 11th Alert Digest of 2012, the Senate Standing
Committee for the Scrutiny of Bills (Scrutiny Committee) raised the issue of
the Bill's delayed commencement date. The Scrutiny Committee noted:
The bill will commence on 1 January 2014, the planned start
date for the Child Dental Benefits Schedule. Although the explanatory
memorandum does not expressly address the reason for delayed commencement, it
does note that the caps applying to different groups and services that will be
applicable under the Dental Benefit Rules (see item 17) will reflect the
outcomes of consultations with dental professions in developing the schedule of
services, which will occur after the passage of the Bill (see page 3).
In the circumstances, the Committee leaves the question of
whether the delayed commencement is appropriate to the Senate as a whole.[8]
2.11
In response to questions about the issue of the delayed commencement the
ADA agreed that it was a period that would allow for 'appropriate consultation
and development time'[9]
in the design of the scheme.
Details to be determined in the Dental Benefits Rules
2.12
Significant details that will affect the operation of the CDBS have not
been included in the Bill. The dental services which will be covered under the
scheme, as well as the maximum entitlement eligible children under the scheme,
having already been announced by the Minister, are not specified in the Bill.
Rather, these details are proposed to be included in amendments to the Dental
Benefits Rules.
2.13
The ADA discussed the schedule of services that should be available
under the CDBS. The expressed the hope that all relevant preventative and
therapeutic services should be included with flexibility built in to ensure
long term oral health. They also suggested that 'hospital and day-stay
procedures provided under general anaesthetic' be included in the scheme.[10]
2.14
The South Australian Government submitted that the schedule of dental
services outlined in the Report of the National Advisory Council on Dental
Health should form the basis for the services that should be provided under
the CDBS.[11]
2.15
The AHHA and the ADA also recommended that this schedule of services be
adopted but the AHHA pointed out that the list includes services for adults and
children so 'requires further consideration and refining for application in the
child and adolescent oral health arena'.[12]
During the committee's hearing the AHHA expanded on their submission by saying
that it is not only the services available that will need to be clearly defined
but also the 'frequency of accessing [the program] ...and the guidelines for
operation'.[13]
2.16
In addition to the Schedule included in the Report of the National
Advisory Council on Dental Health the ADA also suggested that there should
be scope to treat exceptional cases:
It has been said that the new scheme will include basic
services and simple restorative work and simple check-ups and cleans. But in
all clinical scenarios, as you would be aware, you are going to get individual
variation and there should be provision put in place, through an exceptional
case scenario shall we say, where if the clinician feels that the specific
schedule of services does not cover that particular patient there is an avenue
that is able to be pursued to provide the appropriate clinical treatment.[14]
2.17
The Department of Health and Ageing (DoHA) responded to questions on
what progress had been made in devising an appropriate Child Dental Benefits
Schedule by stating that they had not started working on it in any great detail
yet but would do so after the legislation under consideration has passed.[15]
Mr Maskell-Knight from DoHA also discussed the possibility of modelling the
work on that of the Department of Veterans' Affairs who also run a dental
benefits schedule:
The Department of Veterans' Affairs actually run a dental
benefits schedule at the moment, so they have dental advisers contracted to
assist them. We piggyback off that, so we will be talking to them. We will
sketch something out, and I imagine that we will then going to talk to our ADA
friends, who gave evidence earlier, and consulting with them in some detail
about what they believe should be in and out, what the conditions should be and
so on...
Then we will need to talk to all the hygienists and the
therapists. And we will need to talk to the states and territories, as they
will clearly be significant.[16]
2.18
When asked about the provisions for exceptional cases and whether the
department had considered how this would be administered Ms Kerry Flanagan from
DoHA responded that for administrative reasons the responsibility for providing
that care could lie with the states and territories:
Administratively, the workload involved in that is very
significant. One of the factors we took into account in striking the $1,000
over two years was that it allows an appropriate range of services. The other
thing we took into account was that even though we are trying to have a clearer
responsibility between the Commonwealth covering kids and the states covering
low-income adults, it is still possible for the states to deliver services to
children. So if there were exceptional circumstances—such as we described
earlier on with kids with disabilities, for example—that might need a more
complex range of services to be delivered, then we would see the states perhaps
providing those.[17]
Consultation processes
2.19
One of the issues related to the services that will be provided was
around the need for consultation with the sector during the development of the
schedule of services. The ADA submitted that the administrative arrangements
for the Chronic Disease Dental Scheme (CDDS) 'reflected a medical model of
service' because '[t]he CDDS required the patient's medical practitioner to act
as a gatekeeper for the provision of dental services'.[18]
The ADA were strongly of the view that in this case the dental profession
should be fully consulted to ensure that the scheme is administratively
suitable for the their profession rather the medical profession:
The ADA would also like to state that, before the
implementation of any new scheme, there is a requirement for a number of
factors to be met. There should be full consultation with the profession, to
make it dentally effective—that is, it fits into dental practice and not
medical practice.[19]
2.20
The ADA linked the need for full consultation with the need for
education processes to combat the caution from the profession that may prevent
dentists utilising the scheme:
It is proven that the lack of education of the profession led
directly to the high rate of administrative noncompliance in the initial years
of the [CDDS] scheme, at least until early to mid-2011.[20]
There will need to be reassurance from the association, and
there will be caution. I do not think there is going to be a surge of dentists
taking up any new scheme without a full and long lead-up time in the education
process on how they need to function under the new program.[21]
2.21
According to the ADA the consultation process should allow time to
ensure that these education processes could be carried out:
...there should be the delivery of that information to the ADA
for dissemination to the membership. We have magazines, journals, e-news, the
web site and direct email communication—not with every dentist in the country
but 90 per cent of them. We are able to get in contact with 90 per cent of
dentists in the country.[22]
Funding arrangements for the Dental Reform Package
2.22
The Minister has announced that the Commonwealth will provide over $4.2
billion for its Dental Reform Package between 2014 and 2020. This comprises
$2.7 billion in funding for the operation of the CDBS; $1.3 billion in
funding for adults through state public dental services under a National
Partnership Agreement; and $226.4 million for a flexible grants program for
both private and public sectors for reforms in dental infrastructure and
workforce initiatives.[23]
2.23
This funding is in addition to that allocated in the 2012-13 Budget to
increase the capacity of the dental workforce ($158.6 million over four years);
alleviate pressure on public dental waiting lists( $345.9 million over three
years); provide support for national oral health promotion activities ($10.5
million over three years); and pro bono dental services ($0.5 million over
three years).
[24]
The package also involves the closure of the CDDS from 1 December 2012.
2.24
Most submitters agreed that the level of funding is a good first step.
The AHHA were supportive of the Commonwealth funding for children's dental
services as this will 'free up resources for the treatment of more low-income
adults'.[25]
2.25
All submitters agreed that the success of the program in terms of
delivering increased publicly funded dental services was dependent on the states
and territories maintaining their investment in public dental services. The
government expects the money currently provided by the states and territories
to deliver services will be re-directed to providing services for adults from
low-incomes or with other eligible needs.
2.26
DoHA said in evidence that they were in the process of developing a
methodology that would make the flow of funds to the states and territories
from the Commonwealth contingent on current investment levels in the states and
territories:
What we want to do is measure the level of output in 2011-12
and then use that as a baseline level of output and then tie funding under the
National Partnership Agreement to increments in the throughput. We invented the
notion of the DWAU—I had to get that on record in Hansard. All the
states and territories collect information from the public service providers
based on the ADA schedule, which is a three digit schedule, so the initial
consultation is an item 11. It then goes up until you get into prosthodontics,
interdontics and all sorts of other things. As long as we are able to collect
the number of each DVA item or ADA items that the states carry out, we can use
some sort of relativity to convert that down to a common unit of effort. We
will then be able to monitor that over the life of the agreement. As I said,
our aim is to link funding to increments in the level of output.[26]
The department expects
an additional 1.4 million adults will be treated through the states and territories
as a result of the package.[27]
2.27
Dr Dooland from AHHA suggested that while the funding may be at a
similar level to that for the CDDS it will address more issues than that single
program:
With the additional funding that has been outlined in the
government's reform agenda, I will point out that when we cost cash flow from
year to year, for instance, in 2014-15, this is actually a billion dollars. So
it is very much of the scale of the expenditure on the chronic disease dental
program. However, it actually has the characteristics that Prue Power mentioned
in terms of addressing the various aspects of public policy in dentistry that
have to be addressed to make an ongoing, sustainable program.[28]
2.28
Dr Dooland added that the funding will increase the capacity of both
public and private dentistry to meet demand:
With the new funding that has been announced for the public
dental sector—both that announced in the previous budget and in the national
partnership agreement from 2014—the states and territories will build up their
local infrastructure and local workforce capacity. They will be able to do
that. Dentistry has already responded to the workforce shortage of the 2000s
and dentists are coming through the training programs at required rates and
overseas trained dentists are coming as well. But we will also contract a
significant amount of dentistry to the private sector. There is capacity in the
dental workforce to do that. It will not lead to price problems. The scale is
not such that it will lead to cost problems, pressure or inflation—that will
not happen.
[29]
2.29
The ADA welcomed the funding, saying it was a sound investment, but a
'limited investment'. Dr Fryer from the ADA also commented that the initial
funding for the CDBS in 2013-14 could be as little as $57 per child depending
on how many children are treated.[30]
2.30
DoHA explained that the funding of $194 million in the first year is structured
to reflect their estimate that 80 per cent of the eligible population will take
up the services on offer, and that they expect this to occur in the latter part
of the year as this has been the situation under the teen dental health program
that the CDBS is replacing:
The estimates are based, I think, on an 80 per cent takeup in
the eligible population...
The experience under the Medicare Teen Dental Plan is that
there is a very back-end-of-the-year skewing of when services happen. I think
dentists and children all go on holiday in January, families are getting back
to school in February and shortly after that you run into Easter. So the first
half of the year is very light on. I think from memory it is about one-third to
two-thirds, or something close to that, between the first six months and the
second six months of the calendar year.[31]
2.31
Mr Maskell-Knight continued that the funding for the second year of the
CDBS will be significantly higher and the department expects that this will
equate to around $200 per child but that many children will have very low
needs:
Yes, $200-ish. I am doing it in my head. It will be around
one-fifth of the maximum. That is actually for one year, as well. The $1,000 is
for two years...
The thing about dealing with average numbers is that we
expect there will be a lot of children who will have very low needs. They will
have a consultation, a scale and clean and will be sent home. At the other end
there will be children that need lots more significant work done.[32]
2.32
The AHHA stated that their research suggested that 81 per cent of
children would have their needs met by the $1000 cap. The ADA also agreed that
'for the vast majority of children that will cover most of their dental needs'.[33]
2.33
Associate Professor Zoellner, Chairman of the Association for the
Promotion of Oral Health (APOH) was the only contributor to disagree with the
$1000 cap being appropriate:
I think that the cap which is proposed of $1,000 spending per
patient over a two-year period—and its focus, again, on basic care only—is
misguided. First of all, very few children will actually require anything like
that sort of amount of funding. Most children in Australia have very good
dental health. Nonetheless, although there are only a handful of children,
there are some children who will have particular problems, and they will
require more advanced care. It seems to me that, especially in the light of the
fact that such children will draw very little upon the public purse, it is
particularly mean spirited to suggest that children who require more advanced
care and more advanced dentistry should be denied access to that service. This
is particularly in the light of the fact that there are some children with
chronic disease who have benefited from the Medicare Chronic Disease Dental
Scheme and that these children will be particularly disadvantaged by this focus
suddenly upon basic dentistry only and this limitation to only $1,000, to be
available over a two-year period.[34]
Committee View
2.34
The committee welcomes the investment generally and is of the view that
the levels of funding are appropriate in the current financial climate. With
specific regard to the $1000 cap for treatment over two years under the CDBS
the committee believes this to be appropriate. However the committee would
also support the establishment of an exceptional cases procedure whereby
treatment can be provided under the CDBS, in accordance with strict clinical
criteria, in cases where the $1000 cap would not be sufficient. The committee
would envisage the provision of hospital-based dental treatment to be covered
under such a procedure.
Closure of the Chronic Disease Dental Scheme
2.35
The APOH opposed the closure of the CDDS Scheme. Associate Professor
Zoellner told the committee that while the scheme was not perfect it correctly
targeted the cohort in most clinical need:
...it does not really make clinical sense, because the real
burden of dental disease in the Australian community is not in the child
population. The real burden of dental disease is in the ageing group. Indeed,
the Medicare Chronic Disease Dental Scheme particularly supported care which
was medically required, medically indicated. So it really makes, to me, very
poor clinical sense to withdraw medically necessary dental services from the
aged group and from, in fact, the population with the greatest clinical need
for dental treatment and then to send these services somehow to another group
in the population who generally require low levels of care. [35]
2.36
In contrast Dr Dooland from the AHHA expanded on his previous point by
saying that the proposed Dental Reform Package addresses a much broader range
of issues than the CDDS did:
The program needs to clearly identify the target group with
high needs. It needs to have a balance between short- and long-term focus—that
is, a balance between the immediate needs of the high-need group and the
long-term oral health outcomes of the community. The program needs to address
the foundation issues, which are workforce and infrastructure development. And
the program needs to do the most good for the greatest number of people. We
believe the government program meets all of these characteristics much better
than the CDDS does at the moment.[36]
2.37
While supporting the proposed reform package overall, and the closure of
the Chronic Disease Dental Scheme (CDDS) the ADA expressed concern regarding
the timeframe for the closure of the scheme, claiming that many patients will
miss out on essential treatment as a result of the 30 November 2012 cut-off
date:
A 12-week period, to complete treatment, will mean that
patients under the CDDS will not be able to finalise their treatment plans.
Treatment of the chronically ill, for which this Scheme was designed, is often
complex, requiring an extended period of time. Complex treatments are often
staged to allow adequate healing... The ADA calls on the Australian Government to
recognise that it is critical that arrangements are put in place to allow for
treatment services to be completed even if this requires introducing a
transition process for existing patients on a case by case basis.[37]
2.38
Dr Dooland questioned exactly how much impact the closure of the scheme
would have, as he argued that many users of the scheme would generally not
access public dental services outside the CDDS:
The chronic disease dental program has been used by the state
and territory dental services and we advise people about the program; some
state and territory dental service more than others, and you can see that in
the level of use. I also pointed out that from the example I am most familiar
with in terms of data, in the second-highest user of the chronic disease dental
program, South Australia, there has been no change in demand for the public
dental services at all. That is because a substantial part of the users of the
chronic disease program are cardholders who would not otherwise use the public
dental service. In that sense, the public dental services are somewhat
insulated against a flow back of demand from the chronic disease closure. [38]
2.39
Primarily for the reasons above Dr Dooland also told the committee that
in the short term the states and territories would have sufficient funding to
cover the treatment costs of those transitioning from the CDDS:
People often forget that funds have been put aside in the
previous federal budget to provide additional funding to the state and
territory dental services. Those funds start from December-January in this
financial year. With the chronic disease program closing about the same time, there
is not a gap in that situation. [39]
2.40
The department also told the committee that they believe there will be
sufficient capacity through the states and territories to treat those patients
who have not completed their treatment under the CDDS. The department stressed
the importance of reaching an agreement with the states and territories by the
end of November to cover transitional arrangements:
Senator Bushby: ...And the reason I just wanted to ask
that is that in your evidence and the evidence of others today is that for
those who have access to services under the CDDS, the answer for them in terms
of their options for dental care is the increased money that you are putting in
here. That needs to be delivered by the time the CDDS finishes for them to be able
to access that—certainly, in the near term.
Ms
Flanagan:
That is correct, and we are working very, very hard under the direction of
government to ensure that we have an agreement signed, sealed and delivered by
the end of November.
2.41
The committee noted that both state governments[40]
that submitted to the inquiry supported the reform package.
Eligibility of the CDBS
2.42
The CDBS replaces the Medicare Teen Dental Plan that provided dental
services to teenagers who met the following criteria:
- be aged between 12 and 17 years; and
-
satisfy the means test for the program:
- the teenager must be receiving either Abstudy, Carer Payment,
Disability Support Pension, Parenting Payment, Special Benefit, or Youth
Allowance; or
- the teenager’s family/carer/guardian must be receiving either
Family Tax Benefit Part A, Parenting Payment, or the Double Orphan Pension in
respect of the teenager; or
- the teenager’s partner must be receiving Family Tax Benefit Part
A or Parenting Payment; or
- the teenager must be receiving financial assistance under the
Veterans’ Children Education Scheme (VCES) or the Military Rehabilitation and
Compensation Act Education and Training Scheme (MRCAETS) and cannot be included
as a dependent child for the purposes of Family Tax Benefit because they are 16
years or older.
2.43
The CDBS will have similar eligibility criteria except for extending the
age range from 2-17 years, or as DoHA expressed in evidence, ' it is
essentially based on the same architecture.'[41]
2.44
Associate Professor Zoellner from the APOH submitted that the
eligibility criteria 'breaks three fundamental [principles] of Medicare. In
that the new scheme is: Means Tested...; Limited with regard to age...; and Limited
to basic service only.'[42]
2.45
The committee did not receive any other evidence in support in this
view. As cited in paragraph 2.5 of this chapter the ADA welcomed the focus on
the proposed age group by citing evidence suggesting that good dental health
early in life has long-term benefits. In the committee's hearing the ADA
further discussed the evidence that supports the focus on children:
I will quote from a recent report from the Australian
Research Centre for Population Oral Health that undertakes all the oral health
research for the AIHW, the Australian Institute of Health and Welfare. Their
report from 2011 indicates that in 2006 the proportion of children with caries
in their baby teeth—the deciduous teeth—ranged from 40 per cent in four- to
five-year-olds to up to 60 per cent in six- to eight-year-olds. Even in the
permanent teeth in five-year-olds one per cent had evidence of decay while 58
per cent of 15-year-olds had evidence of decay in their permanent teeth. So we
think that the problem is probably at the other end.[43]
2.46
Dr Fryer from the ADA also cited disadvantage as being a factor in poor
oral health:
...there is a differential depending on your socioeconomic
status, with it being worse in the more disadvantaged families than in the
wealthy.[44]
2.47
The AHHA also cited evidence that suggests that good oral health as a
child is, at the very least, a good indicator of good oral health as a young
adult:
There is internationally published literature to show that
children who get regular dental care have ongoing improved oral health up to
the stage where that has been assessed well, which is into the teenage years.[45]
2.48
With regard to Associate Professor Zoellner's evidence that under the
new scheme service will be 'restricted to basic service only',[46]
the committee received no evidence to support this statement given that the
schedule of services to be provided under the scheme has not yet been devised.
Committee View
2.49
The committee agrees with the majority of contributors that the scheme
is targeted appropriately at children and will provide long-term health
benefits for those that participate in the scheme. The committee also supports
the means testing element of the scheme that while agreeing that universal
public dental service provision is a long-term goal, adopting a scheme that as
a first step attempts to tackle oral health inequality caused by socio-economic
disadvantage is the correct strategy. As previously discussed the committee is
hopeful that all services required to address children's dental needs will be
available, and looks forward to the publication of the children's dental
services schedule in the coming months.
2.50
The committee also looks forward to the outcome of the government's
negotiations with the states and territories and hopes that the agreements will
ensure that there will be no gaps in service provision for any clinically
necessary treatment that commenced under the CDDS.
The role of other dental health professionals
2.51
The AHHA submitted that forthcoming discussions with all parties,
including the states and territories, on the implementation of the scheme
should include the expansion of the role of oral health therapists, dental
therapists and dental hygienists.[47]
The Government of South Australia also supported an increased role for other
dental health professionals by supporting the award of MBS Provider Numbers to
those professionals independent of dentists:
The current Dental Benefits Rules 2009 only allow dental
therapists, dental hygienists and oral health therapists to provide services
under the existing Teen Dental Plan on behalf of dentists and dental
specialists. One way of ensuring the dental workforce can be most efficient
will be to award Medicare Provider Numbers to dental therapists, dental
hygienists, and oral health therapists.[48]
Committee View
2.52
The committee supports the extension of the role of dental therapists,
dental hygienists, and oral health therapists within Medicare. The committee
received evidence that described the typical services that will be required for
children under the scheme and agrees with the Government of South Australia
that allowing other dental professionals to administer services under Medicare
would increase the efficiency of the scheme.
Recommendation 1
2.53
The committee recommends that the bill be passed.
Senator Claire Moore
Chair
Navigation: Previous Page | Contents | Next Page