Inquiry

Overview and key recommendations

Response and implementation

Senate Community Affairs References Committee, Report on Public Dental Services, May 1998

The Inquiry made 9 recommendations, on issues including:

• the need to promote oral health
• the creation of a vocational training program for new dental graduates to encourage work in rural and remote areas
• the expansion of the role of dental auxiliaries such as therapists and hygienists
• support for a national oral health training strategy, specifically including those working in aged care and Indigenous health
• the development and evaluation of pilot programs to address priority groups including pre-school age children, young adult Health Card holders (18-25 years), aged adult Health Card holders (65+ years), the homebound, rural and remote, and Indigenous communities
• the Commonwealth should lead the introduction of a national oral health policy, potentially through the National Public Health Partnership
• this policy should include:
• national oral health goals
• national standards for the provision of, and access to, oral health care
• national strategies and prioritise for oral health care reform, particularly preventative strategies
• minimum service targets
• monitoring of goals through national data collection
• the allocation of resources for a national oral health survey
• creation of a dedicated section for oral health within the Department of Health and Family Services.

The Government response (February 1999) made clear that dental care was a State responsibility:

Notwithstanding the Committee’s finding that some low income earners currently have difficulty accessing public dental services, the Government’s position continues to be that the provision of public dental services is a State responsibility and that the States must resolve the structural, management and financial problems in their dental services. (p.1)

It was also noted that the introduction of the GST meant states would be ‘better off’ than before and could determine their own priorities in terms of the provision of healthcare.

In response to the recommendations:

The Government’s overall response to the recommendations of the report is that by and large, Commonwealth involvement in their implementation would be ineffective. The States must take up those recommendations they consider will improve access and service delivery. For its part the Commonwealth is prepared to assist the States to deliver better services by facilitating the inclusion of reliable oral health data in the National Public Health Information Development Plan, if this is what the States want. (p. 2)

While the Committee recommended a national health strategy be developed, it does not appear that one was implemented until 2015 with the introduction of the National Oral Health Plan.

Senate Select Committee on Medicare – First report – Medicare–healthcare or welfare?, October 2003

Recommendation 10.1 (chapter 10, p. 132):

The Committee recommends that the Commonwealth immediately recommit to a Commonwealth contribution towards public dental health services and negotiate targets with the states and territories, particularly for high need groups.

No response to the Committee report was found. However, Committee Government Senators noted that they disagreed with Recommendation 10.1 (p. 2­­32).

Senate Select Committee on Medicare – Second report – Medicare Plus: the future for Medicare?, February 2004

Recommendation 5.1:

The Committee again recommends the creation of a new Commonwealth Dental Health Program and the active consideration of measures to address workforce shortages in dentistry. (p. xvi and 96)

No response to the Committee report was found.

As explained in this this Parliamentary Library publication exploring Commonwealth involvement in funding dental care (particularly the transition from the Howard to the Rudd Government):

In July 2004, as part of a suite of reforms to Medicare known as MedicarePlus, the government announced the introduction of limited Medicare benefits for patients whose chronic conditions (for example, diabetes), were significantly exacerbated by dental problems. This was consistent with the application of Medicare benefits based on an identified clinical need…

The dental component of the initiative known as the Allied Health and Dental Health Care Initiative (AHDCI) allowed a patient with an Enhanced Primary Care (EPC) plan on referral from a general practitioner, to access Medicare benefits for up to three dental treatments a year from a private dentist, with a maximum rebate of $220 per year. The supply of prostheses such as dentures, bridges, crowns or implants was not covered. (p. 9)

With uptake of the program lower than expected, eligibility was later expanded and the price cap raised.

Senate Standing Committee on Community Affairs, Health Insurance Amendment (Medicare Dental Services) Bill 2007 [Provisions], September 2007

The purpose of the Bill was to increase access to dental treatment under Medicare for people with chronic conditions and complex care needs. The Bill was introduced following the 2007–08 Budget which announced the expansion of the Enhanced Primary Care dental items to provide Medicare rebates and more services to eligible patients. The estimated cost of the expansion was $385.6 million over 4 years from 2007–08. (pp. 1–2)

The Committee recommended (p.10):

• That a formal education program targeting dentists be established, including information about the working of the new Medicare rebates relating to dentistry.
• 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.
• That the Senate pass the Bill.

Australian Labor Party (ALP) Senators provided a minority report dissenting from elements of the majority report which favoured a broad-based Commonwealth scheme (pp. 11–16).

The subsequent Act was registered in early October 2007. This enabled the Health Insurance (Dental Services) Determination 2007 which commenced 1 November 2007 and provided for the Chronic Disease Dental Scheme (CDDS).

The change in Government saw the attempted cancellation of the CDDS, to be replaced by a Commonwealth Dental Health Program (CDHP); however, during 2008 the rescinding of the relevant instruments was disallowed by the Senate (See Health Insurance (Dental Services) Amendment and Repeal Determination 2008 made under subsection 3C(1) of theHealth Insurance Act 1973, 18June 2008 and this Parliamentary Library publication, p. 12).

This Scheme eventually closed on 30November 2012 (see Government and Greens media releases announcing agreement to close the scheme and this Parliamentary Library article for further background).

The Health Insurance Amendment (Medicare Dental Services) Act 2007remains in force; it appears this is because the Act did not specifically establish the CDDS, but rather allowed for a ministerial determination to be made around ‘eligible dental services’. That is, the Scheme could be closed by ceasing the Determination rather than amending primary legislation.

According to the Health Insurance (Dental Services) Bill 2012 inquiry (discussed later in this table), no education campaign was conducted (p. 10). However, it was found that the number of services provided through the expanded CDDS rose substantially, with expenditure on the Scheme at the time of the inquiry to be more than $2.3 billion. (p. 2)

There were also significant concerns about non-compliance with the Scheme.

Senate Standing Committee on Community Affairs, A decent quality of life: Inquiry into the cost of living pressures on older Australians, March 2008

Recommendation 9 of the report (p.xvii) concerned dental care:

The committee recommends that the Government consider the appropriateness of current dental care arrangements for older people. The consideration should involve engagement with the State and Territory governments and aim to introduce measures to increase access to adequate dental care and include a cost-benefits analysis of the impact of inadequate access to dental care on other aspects of the health care system.

A Government response was released in September 2008:

In keeping with its election commitment, the Government’s new Commonwealth Dental Health Program will provide $290 million over three years from 2008–09 to the States and Territories. The Commonwealth, State and Territory Governments are working together to improve the standard of oral health in Australia and this program will help reduce the number of people waiting for public dental treatment by providing up to one million additional services. The Commonwealth Dental Health Program will also provide priority services to people with chronic diseases affected by poor oral health. (p.15)

National Health and Hospital Reform Commission, A Healthier future for all Australians, June 2009

The Commission recommended (p.26):

• the establishment of the Denticare Australia scheme which would meet the costs of either private or public dental health plans. The scheme would be funded by an increase in the Medicare Levy of 0.75%
• the introduction of a 1 year internship scheme prior to full registration
• the national expansion of the pre-school and school dental programs
• additional funding for improved oral health promotions with interventions to be decided based upon relative cost-effectiveness assessment.

There was no systematic response to the report provided by Government. Neither the ALP nor the Coalition expressed support for a Denticare Australia scheme as suggested by the Commission. A summary of stakeholder commentary on the proposals can be found in this Parliamentary Library overview paper.

(Note: The ‘Denticare’ proposal put forward by the Greens differs from that of the Commission)

Report of the review of the Dental Benefits Act 2008,2009

The Committee noted 2 areas (p. 4):

• the Government could consider replacing the single preventative dental check item (Dental Benefits Schedule item 88000) with individual items for each procedure provided to patients during their annual preventative dental check; and
• as the Medicare Teen Dental Plan is in its early stages of operation, the Government could consider evaluating the program once it has matured, as part of the second statutory review of the Act.

The Second Review of the Dental Benefits Act, conducted in 2012 (discussed below) indicates that a single Dental Benefits Schedule item 88000 was retained. Indeed the 2012 Committee rejected the 2009 Committee’s view that the single Medicare item number should be disaggregated into individual procedure items. (p. 21).

The need for an evaluation was again recommended in the 2012 review (discussed below).

Report on the Second Review of the Dental Benefits Act 2008, March 2012

The Committee noted 4 issues (p. 4):

• the Government should consider an evaluation of the operation of the Medicare Teen Dental Plan as part of its review of dental needs and priorities through the National Advisory Council on Dental Health.
• the Panel notes the improvements made in the program’s communications materials to date, and urges the implementation of market research findings from mid-2010 concerning further improvements to the appearance the voucher for the program.
• further work to promote the program to specific groups, including Aboriginal and Torres Strait Islander teens, Cultural and Linguistically Diverse teens, homeless teens and teens living with a disability
• the 30% utilisation rate of the vouchers, coupled with a decline in uptake from 32% in 2009-10 to 30% in 2010-11 was disappointing.

National Advisory Council on Dental Health, Final Report of National Advisory Council on Dental Health, February 2012

• The Government established the National Advisory Council on Dental Health to provide independent advice on dental health issues, including options and priorities for consideration in the 2012–13 Budget. The Council’s report included a goal and a number of aspirations (Chapter 5, pp. 55–64). The first goal was for ‘An integrated national oral health system, as part of the broader health system, that provides equitable access for people in Australia to prevention, promotion and clinically appropriate, timely and affordable oral health care.’ (p. 55) Although the Council was in agreement on the principle of universal access, no model was put forward (p. 56).
• Aspirations included:
• The Council called for oral health to be integrated into general health (pp. 56–57)
• The Council called for equity and access to services (pp. 57–58)
• Better access for children, noting the differences across states and territories (p. 58)
• Supporting oral health across the population through a national oral health campaign (coordinated with states and territories) (p. 59)
• One level of government should be responsible for the delivery of dental services and the division between the Commonwealth and state and territories should be clarified (pp. 59–60)
• ‘The Council recognises that waiting times for services, especially for adults, are unacceptably long, with a public system highly skewed to emergency and urgent care, which undermines access to timely preventive care and to early intervention.But attention needs to be focused on the key cause, which is a lack of funding, not withstanding Commonwealth and states increasing funding over recent years.This has been a blind spot for all governments across Australia over decades.The Council believes that the public sector is underfunded and that long‐term investment will improve access.’ (p. 61)
• Enhance workforce capability, especially outside major cities (pp. 62–63)
• Enhancing data collection, research and analysis (pp. 63–64)
• Chapter 6 outlined options (and costings) for reform for both children and low-income adults (p. 65):
• For children the Council proposed two options for a universal scheme:
• An individual capped benefit entitlement (Option 1), which would cover basic preventive and treatment services.The benefit could be used in the public or the private sector.
• Enhanced access to public dental services (Option 2), which would increase access for all children to basic dental services by enhancing existing public sector services.

For low-income adults:

• A means tested individual capped benefit entitlement (Option 3), which could build on the legislative framework for existing programs.Access to higher level services or caps could be provided in exceptional circumstances.
• Enhanced access to public dental services (Option 4)

The Government welcomed the report.

The report appears to have informed subsequent Commonwealth dental health policies, specifically the Child Dental Benefits Schedule and the National Partnership agreement with states and territories to alleviate pressure on adult public dental waiting lists.

Senate Finance and Public Administration Legislation Committee, Health Insurance (Dental Services) Bill 2012 [No. 2], May 2012

This Bill sought to ‘redress past and future inequities that have arisen from the operation of subsection 10(2) of the Health Insurance (Dental Services) Determination 2007’.

The Committee recommended that the Bill not be passed as ‘the Bill may not be the best way to deal with the problems that have arisen, as the proposed actions would create further inequities.’ (p. 28)

Coalition Senators issued a dissenting report, recommending the Bill be passed.

The Bill did not pass.

Community Affairs Legislation Committee, Dental Benefits Amendment Bill 2012 [Provisions], October 2012

The Bill sought to establish the framework for the Child Dental Benefits Schedule (CDBS), which would subsidise dental care for children aged between 2 and 18 years. This was part of a $4 billion package introduced by the Rudd Government (and co-announced by the Australian Greens). (pp. 1–2)

The CDBS would abolish the CDDS and replace the Medicare Teen Dental Plan (MTDP) that had been introduced in 2008.

The Committee recommended the Bill be passed.

The Bill passedand commenced on 1January 2014.

The CDBS remains in place and open to those children who receive (or whose parent/guardian receives) an eligible government payment.

House Standing Committee on Health and Ageing, Bridging the Dental Gap: Report on the inquiry into adult dental services, June 2013

• The Committee inquired into adult public dental services to help inform development of a new National Partnership Agreement (NPA) on adult public dental that was expected to commence from 1 July 2014. The Committee considered (ToR): demand and wait lists for services; the type of dental services supported by Australian governments; availability and affordability of services for those with special dental health needs; service provision across different regions; the coordination across different levels of government and private health; and workforce issues.
• The Committee made 13 recommendations (pp.xi–xiv), many of which related to the anticipated Adult Dental Services NPA, including:
• the NPA should require state and territory government to improve linkages with private dental service providers and not-for-profits
• allow dental hygienists, dental therapists and oral health therapists to practice independently and pilot a scheme to provide these professionals with Medicare provider numbers
• improve the focus on preventative dental care
• Australian governments develop a formula for the allocation of funding to state and territories under the NPA based on the size and distribution of priority population groups
• include a ‘maintenance of effort’ clause in the NPA so that state and territory governments must maintain public dental clinical activity for adults
• the NPA include a performance and reporting framework to monitor specific Key Performance Indicators (KPIs)
• the NPA include a provision that requires all signatories to begin negotiations for a new agreement at least 12 months prior to the NPA’s expiration
• the Department of Health and Ageing, along with state and territories, consider the creation of a Commonwealth Chief Dental Officer or independent advisory body to improve coordination across Australian government, increase engagement with private providers and provide independent policy advice
• the Australian Government commit to a dental policy framework that guarantees long-term sustainability and funding support for public dental services
• the establishment of an implementation strategy for the National Oral Health Plan 2014–2023
• the Australian Government adopts a strategic policy which supports phased progress toward a universal access to dental services scheme.

No Government response could be found.

In the 2014–15 Budget, the National Partnership Agreement (NPA) for adult public dental services was deferred from 2014–15 to 2015–16. This deferral was expected to result in savings of $390.0million over 4 years, to be invested in the Medical Research Future Fund (MRFF). (p. 137)

In the 2015–16 Budget, a one year NPA on dental services was announced, replacing the deferred NPA committed to by the Labor Government at the time. Further similar agreements on adult public dental services have been negotiated since this time, including the current Public Dental Services for Adults Schedule (to be extended to June 2025 as announced in the 2023–24 Budget (p. 138).

Oral Health Monitoring Group, Healthy Mouths, Healthy Lives: Australia’s National Oral Health Plan 2015–2024, prepared under the auspices of the COAG Health Council, 2015

The National Oral Health Plan did not include recommendations, rather it aimed to set the national direction and provide a framework for collaborative action.

The Plan’s national goals were to improve oral health status and reduce inequalities across the Australian population (p. 16). Four guiding principles were identified:

• population health
• proportionate universalism – ‘everyone should receive some support through universal interventions, while groups that are particularly vulnerable should receive additional interventions and support’
• accessible and appropriate services
• integrated oral and general health (p. 17).

Six foundation areas were identified, each with a goal and a series of strategies and indicators (overview is at p. 18):

• oral health promotion
• accessible oral health services
• systems alignment and integration
• safety and quality
• workforce development
• research and evaluation.

The Plan also identified 4 priority populations: people who are socially disadvantaged or on low incomes; Aboriginal and Torres Strait Islander people; people living in regional and remote Australia’ people with additional and/or specialised health care needs.

In December 2020, the Australian Institute of Health and Welfare released the National Oral Health Plan 2015–2024: performance monitoring report. For the 26 indicators identified, the report found there had been a favourable trend compared to the baseline for 7 indicators, an unfavourable trend for 9 indicators, and no change or no new data for the others (In brief report, p. 4).

Australian National Audit Office (ANAO), Administration of the Child Dental Benefits Schedule, December 2015

The ANAO made 4 recommendations, to which the Department of Health and Department of Human Services agreed. These included actions to identify and treat risks to administration, address low program uptake, improve performance measurement and reporting, and assist in assessing the achievement of program objectives.

In Attachment A (Appendix A) of the report, the Department of Human Services (DHS) response to recommendation 3 stated (p. 59) that it would introduce a formal quality checking procedure for a sample of the records that require manual matching. This would include KPIs. This would be introduced by November 2015.

The 2015–16 DHS Annual Report and 2016–17 report did not indicate whether this was introduced.

Report on the Third Review of the Dental Benefits Act 2008, March 2016

This Review came after the closure of the Medicare Teen Dental Program (31 December 2013) and the transition to the Child Dental Benefits Schedule (CDBS) (1 January 2014).

The Review made 11 recommendations (pp. ix–xii) regarding improvements to the CDBS.

Productivity Commission, Introducing Competition and Informed User Choice into Human Services: Reforms to Human Services – Study Report, November 2016

Chapter 6 examined public dental services (pp. 115-129). Overall, the PC found that introducing greater competition, contestability and user choice in public dental services could lead to better outcomes for patients and the wider community (p. 129).

Community Affairs References Committee, Value and affordability of private health insurance and out-of-pocket medical costs, December 2017

The Committee’s report included a case study on the effect private health insurance has had on private dentistry (pp. 52–58).

After hearing evidence that paediatric dentists had been excluded from private hospitals and day surgeries because the hospitals receive low rebates from private health insurers, the Committee recommended that private health insurers engage in negotiations with private hospitals and paediatric dentists to urgently resolve issues surrounding paediatric dentistry (Recommendation 11, p. x).

The report also discussed ‘preferred provider’ schemes as part of the dental case study, which a number of submitters considered are anti-competitive. This provided context for recommendations to prohibit differential rebates for the same treatments provided under the same product in the same jurisdiction (Recommendation 12), and to request the Australian Competition and Consumer Commission reconsider whether private health insurers’ use of claims processing data is anti-competitive and amend legislation to ensure claims data is not used for commercial gain (Recommendation 13).

The Government response:

• noted recommendation 11, commenting that these are commercial arrangements and therefore to be resolved between insurers, private hospitals and paediatric dentists (p. 6)
• did not support recommendation 12, noting the ability to pay differential rebates is an essential part of the contracting process between insurers and health providers. It further noted that for general treatment services, such as dentistry, preferred provider schemes and insurer-owned clinics are popular with consumers because they give certainty about costs (pp. 6-7)
• Noted recommendation 13, and observed that ‘in many cases, consumers who use an insurer’s own dental or optical centre will normally face no, or lower, out of pocket costs’ and that ‘the Government does not intend to remove arrangements that allow consumers the opportunity for reduced or no out-of-pocket costs by using an insurer-owned service provider’ (p. 7).

Productivity Commission, Introducing Competition and Informed User Choice into Human Services: Reforms to Human Services – Inquiry Report, March 2018

Chapter 12 of the report looked at reforms to underpin more effective provision of public dental services (pp. 357-421) and included several recommendations:

Recommendation 12.1: State and Territory Governments should report publicly against a set of benchmarks of clinically-acceptable waiting times for public dental services, split by risk-based priority levels. Reporting should commence as soon as possible. Governments should also make these benchmarks consistent across jurisdictions as soon as practicable. To facilitate user choice, provider-level reporting should be published monthly. To facilitate performance monitoring, aggregate measures should be included in public dental services’ annual reporting processes (p. 373)

Recommendation 12.2: The Australian, State and Territory Governments should establish outcome measures for public dental services that focus on patient outcomes and include both clinical outcomes and patient-reported measures. Governments should build on the work done by Dental Health Services Victoria on outcome measures, with a view to developing and implementing a nationally consistent outcomes framework. (p.378)

Recommendation 12.3 State and Territory Governments should implement comprehensive digital oral health records for public dental services as soon as practicable. Once implemented, these systems should be incorporated within the My Health Record system. (p. 383)

Recommendation 13.1: State and Territory Governments should introduce a consumer-directed care scheme to public dental services. Under the new scheme, participating providers should be paid based on a blended payment model… (p. 397)

Recommendation 13.2: The Australian Government should direct the Independent Hospital Pricing Authority, in consultation with State and Territory Governments and the dental profession, to immediately commence development of:

• a costing standard for public dental services
• efficient prices for consumer-directed care payments. (p. 397)

Recommendation 13.3: The Australian Government should replace the existing CDBS capped benefit with a capitation payment that is weighted to reflect the oral health care needs of eligible children. (p. 399)

Recommendation 13.4: State and Territory Governments should provide access to consumer-directed care through a risk-based allocation model. Under the allocation model, governments should triage patients for both general and urgent care through an initial assessment. The initial assessment should identify and prioritise access for eligible users most at risk of developing, or worsening, oral disease… (p. 409)

Recommendation 13.5: State and Territory Governments should establish effective commissioning processes for public dental services for those population groups who are not able to choose between alternative providers. (p. 415)

Recommendation 13.6: The Australian, State and Territory Governments should transition to a consumer-directed care approach to providing public dental services by first establishing initial test sites before a staged rollout. (p. 418)

There does not appear to be a response to the report.

Report on the fourth review of the Dental Benefits Act 2008, July 2019

This Review noted 4 issues (p. 8):

• difficulties in obtaining initial parental consent – particularly in Indigenous, rural or remote communities
• literacy level of Informed Financial Consent Forms and Patient notification letters
• number of dentists and level of claiming under the CDBS compared to dentists registered
• barriers to treatment for vulnerable populations as a result of the prohibition on payment for in hospital treatment.

The report also made a number of recommendations relating to the above issues. This included changes to financial consent under Medicare bulk-billing rules and the lowering of the age for CDBS eligibility to 1 year of age.

The scheme is now available to those aged 0 to 17 (for at least one day in a calendar year).

Royal Commission into Aged Care Quality and Safety, Final Report: Care, Dignity and Respect, vol 3A, March 2021

Recommendation 60 (p. 301): Establish a Senior Dental Benefits Scheme:

The Australian Government should establish a new Senior Dental Benefits Scheme, commencing no later than 1 January 2023, which will:

a. fund dental services to people who:i. live in residential aged care, orii. live in the community and receive the age pension or qualify for the Commonwealth Seniors Health Card.

b. include benefits set at a level that minimises gap payments, and includes additional subsidies for outreach services provided to people who are unable to travel, with weightings for travel in remote areas

c. provide benefits for services limited to treatment required to maintain a functional dentition (as defined by the World Health Organization) with a minimum of 20 teeth, and to maintain and replace dentures.

The Government response (2021) outlined (p. 42):

This recommendation is subject to further consideration by 2023. The delivery of adult public dental services is currently a state and territory responsibility for which the Australian Government provides additional financial support through a National Partnership Agreement. The Australian Government also provides funding support for dental procedures conducted for public hospital admitted patients and outpatients under the National Health Reform Agreement.

Following the change of Government in 2022, this recommendation remains subject to further consideration.

KBC Australia, Increasing Dental and Oral health training in rural and remote Australia: Feasibility study, September 2022

An overview of recommended strategies is included on p. 59 (table 4-1). The report recommends a holistic approach to encourage more dental and oral health professionals, especially those willing to work within Modified Monash category 3–7 areas.

The recommended strategies are underpinned by guiding principles (pp. 59–60), which include that programs should complement, rather than duplicate, programs across Australia and jurisdictions. Additionally, there should be monitoring of programs and a focus on Aboriginal and Torres Strait Islander health and students.

The Government is yet to respond to the report.