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Finance and Public Administration Legislation Committee

BOYD-BOLAND, Mr Robert, Chief Executive Officer, Australian Dental Association

FRYER, Dr Shane, President, Australian Dental Association

Committee met at 09 : 04

CHAIR ( Senator Polley ): The committee will now commence its inquiry into the Health Insurance (Dental Services) Bill 2012 [No. 2]. I welcome representatives from the Australian Dental Association. Information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. The committee has your submission and I now invite you to make a short opening statement. At the conclusion of your remarks I will invite members of the committee to put questions to you.

Dr Fryer : I thank you for this opportunity to present and supplement our written submission to this inquiry. By way of background, the ADA has 13,000 members. We represent over 90 per cent of practising dentists in the country and we have been in existence for over 100 years. The objects of the ADA are to improve the oral health of the community and support members to enhance their ability to provide safe, high-quality professional dental care. To achieve this we have a federal office and branches in each state and territory. The federal office deals with federal government issues and advice on matters that are generic to dentistry, such as a federal government dental scheme, and the branches deal with state and local issues and provide individual assistance to members.

In relation to the Chronic Disease Dental Scheme, the CDDS, the federal office initially dealt with Medicare Australia and sought to inform members of the issues that were identified. We will be tabling some documents today which include some correspondence from Kathy Dennis, who was branch manager, compliance, within Medicare, to demonstrate our point. When there was escalation of Medicare Australia's activity to audits in 2010, it was decided that as this may impact on a dentist's capacity to practice, assistance should be provided by the branches to those members on a one-on-one basis. ADA Inc., which is the federal body, would continue to converse with the Department of Human Services and the Department of Health and Ageing to resolve the issues identified.

I would now like to briefly mention ADA policy on government funding. The CDDS is a government funded dental scheme. The three key points of our policy are that a scheme should be targeted and means tested, should provide long-term effective care to those that are not able to access it and should focus funding and care delivery on that 30 per cent of the population that is not accessing care now. So the ADA did not support the universal nature of the CDDS.

Before I move onto the CDDS, I would like to say that the current level of concern within the profession on a government funded dental scheme is unprecedented. Furthermore, dentistry is not the same as medicine. Dentistry is different. Had this been recognised at the time of the rollout of the CDDS, things may have been very different. We may not in fact be sitting here now dealing with the problems that have arisen.

With respect to the Chronic Disease Dental Scheme, firstly, it is important that the ADA states that it is not here to seek to assist any dentist who has participated in fraudulent activities or has provided inappropriate care. Such issues have appropriate forums in which they are dealt with and the ADA encourages authorities to seek redress against such practitioners through these avenues. We are here though to address what the ADA sees as unjust treatment of dentists that have provided appropriate services to deserving patients yet are being chased by Medicare Australia to refund moneys due to noncompliance with regulatory requirements. That is under section 10—that is, it is administrative noncompliance. Section 10, according to the documentation, requires a dentist to provide to the patient a written plan of the course of treatment, for the dentist to provide a written quotation to the patient for each dental service and for the dentist to provide a copy or written summary of the treatment plan to the medical GP prior to commencing treatment.

You should know that, from the dentists' perspective, they see themselves as being made the scapegoat for an ill-conceived scheme that has exceeded its expected usage, and dentists are now being attacked to redress the budgetary impact that the CDDS is having. The comments published in the press by ministers have painted the dental profession in a bad light by the use of the words 'rorting' and 'overservicing', when in fact what has occurred is some administrative paperwork noncompliance and expenditure incurred that has exceeded government expectations. If dentists are going to participate in ongoing schemes to help deliver care to the needy, some significant bridge-building needs to be done.

Let me also say that ADA advice at the time of the introduction of the proposed scheme was that the government's budget provision failed to address the significant amount of unmet dental need in the community, but sadly this advice was ignored. So what has happened has happened, and the ADA is here to see what can be done to remedy the unsatisfactory situation that has arisen. As we said in our submission, there is no one factor that has caused what has occurred here; it is multifaceted. The ADA's position has been that there was exceedingly bad communication of the details and requirements of the scheme to dental practitioners when it was introduced. The identification of a level of noncompliance with the administrative requirements was something that Medicare Australia seemed to have been aware of from mid-2009, if not earlier, and it was not until 2010 that the issue was brought to the attention of the ADA.

It was from this stage that the ADA, in our view, assumed the role of the educator and carried out the task of letting the members know the details of the scheme. The ADA assumed what should have been the role of the department. The department seemed content to do as little as possible to educate members, perhaps thinking that, as the scheme was to close, education expenditure could be saved. Indeed, if you look at the material allegedly distributed to dentists before this time, as identified by the department in the material it presented to the Senate, you will see that almost as many letters were sent advising of closure of the scheme as were sent with details of compliance requirements with the scheme.

CHAIR: Can I just interrupt you there for a moment. This is supposed to be a short opening statement so that we can maximise the opportunity to ask questions, so can I just ask you to summarise now.

Dr Fryer : Sorry; I thought I had 10 minutes, but that is fine; no problem.

CHAIR: It is about five minutes normally for an opening statement, but if you could just wind it up then we can ask questions.

Dr Fryer : Okay. I will skip to just some pertinent points and take a couple of minutes. I can tell you that the CDDS has provided valuable necessary treatment to many thousands of patients, and that is an important factor. In defence of those patients and other dental practitioners that provided this valuable treatment, all they have done is fail to comply with the section 10 requirements. There are three major issues which are dealt with in our submission, so I will not go through those. The ADA has played a significant role in overcoming the deficiencies that were listed above, as evidenced by the documents that are tendered by us today. We believe that, if it were not for that action, we would be in a much worse situation than we are in. I would conclude by re-emphasising that the causes of this issue are multifaceted, and we are looking to see what can be done to remedy a very unsatisfactory situation that is impacting on the delivery of dental care in Australia.

CHAIR: Thanks, Dr Fryer. Senator Fierravanti-Wells.

Senator FIERRAVANTI-WELLS: Dr Fryer, are you aware of or have you seen the submissions that have been put forward by the Department of Health and Ageing and the Department of Human Services?

Dr Fryer : Yes.

Senator FIERRAVANTI-WELLS: Attached to the submission by the Department of Human Services there is a list of documents that were tabled on 31 October 2011. Have you seen that list of documents? There are 45 of them.

Dr Fryer : I have seen it, yes.

Senator FIERRAVANTI-WELLS: Against the background of all those documents that were provided, as I read the gist of their submission, basically the Department of Human Services are saying, 'We have provided the dentists with all these documents; there is sufficient clarity for them to have been aware of what the issues were in relation to the scheme and what was happening.' What is your response to that, because that seems to be the crux of what this is about?

Dr Fryer : The content of those documents or those publications—and I believe many of them were on their website—spoke a lot more about many things than about the significance of the administrative compliance requirements. But, at the end of the day, the completed audits show that 70 per cent of dental practitioners have been deemed to have failed to comply with the administrative compliance requirements of the scheme.

In any arena, if a teacher had 70 per cent of their students fail an exam, a significant amount of the blame for that occurrence could be attributed to the educator rather than to the student. So although Medicare or the department are saying that they have supplied a significant list of documents and information to us, the emphasis within those documents has not had the same significance which Medicare applied to it when they were auditing the profession.

Senator FIERRAVANTI-WELLS: The gist of your complaint is that, right upfront when the scheme was introduced, pertinent issues were not brought to your attention or highlighted, if I can put it that way, particularly in relation to the compliance requirements?

Dr Fryer : Even in the first introductory letter from the government, back in 2007, it was explained very briefly to the profession that this new scheme would be similar to the DVA scheme—the scheme that dentists are really only familiar with. This is the first encounter that the profession has had and any significant involvement in with Medicare. Even the original letter, from the then health minister, indicated: 'What you have been doing will—

Senator FIERRAVANTI-WELLS: There are similarities—

Dr Fryer : be suitable. It is a very similar scheme, and you are actually able to claim for more items than under the DVA scheme.' The significance of the way Medicare or the department were going to apply the administrative compliance requirements was not spelt out at all. If I can go back to your earlier question. Some documentation has been sent out by the department and it is listed. Can I refer you to page 10 of the submission of the New South Wales branch of the ADA. You will see a boxed, highlighted table indicating that what the department are saying in a lot of their correspondence—and they are listed—is not actually the case.

Senator FIERRAVANTI-WELLS: When did you first become aware that the Labor government were going to shut down the scheme and how did you become aware that they were going to shut down the scheme?

Dr Fryer : I believe it has been a part of the current Labor government's policy that they wanted to shut down the scheme. There have been numerous pieces of correspondence indicating that that was going to be the case. I cannot tell you exactly, but it would have been as early as 2008 that it would have been their platform that they wanted to shut down the scheme and establish what I believe they refer to as a Commonwealth dental health program plan.

Senator FIERRAVANTI-WELLS: My question to you, Dr Fryer, is: when did the association first become aware that the government was going to shut the scheme? A second question following that is: was there dialogue with you as the peak body in relation to the closure of the scheme and what the government proposed to substitute for it?

Dr Fryer : Dialogue has been limited previously. There is current—

Senator FIERRAVANTI-WELLS: Could you be a bit more specific about dates. It would help us if you could. Thank you—to the best of your recollection.

Dr Fryer : On the compliance issues—this is part of the answer to the question—with regard to the scheme, the ADA would have been alerted to it by Medicare very late in 2009. That is when we got involved with the educative process. On 3 March 2008 the department provided documentation indicating that the government intends to discontinue the Chronic Disease Dental Scheme.

Senator FIERRAVANTI-WELLS: All right. When did you first become aware that your dentists were being audited?

Mr Boyd-Boland : In late 2009 I was contacted by Kathy Dennis from Medicare and informed of the fact that there had been some audits that were demonstrating some noncompliance issues. In early 2010 I met with her and we then embarked upon an education program for our members seeking to educate them in relation to the compliance requirements of the scheme. That was done through both our written publication and an educational CD that we provide to all of our members. That educational CD contained an interview between somebody from the ADA and Kathy Dennis, assisting members to identify what it was that they were required to do. Kathy Dennis indicated in that discussion that the audits had been conducted over a period of time and had revealed some noncompliance for a period of about 12 months prior to that date, but that was the first time we became aware of compliance issues within the association—or on the part of dentists within the association.

Senator FIERRAVANTI-WELLS: And the noncompliance was purely of an administrative nature?

Mr Boyd-Boland : Yes.

Senator FIERRAVANTI-WELLS: Did you become aware of any alleged systematic defrauding—as Dr Fryer has said, the sort of blown-out language about some of the activities or supposed activities that the dentists had been engaged in?

Mr Boyd-Boland : The information that was provided indicated administrative noncompliance—nothing to do with any fraudulent activity.

Senator FIERRAVANTI-WELLS: Dr Fryer, reading into your comments and comments that I have made, we have trawled through the innards of what Medicare have done in previous hearings here where we have sought to elicit the nature of those investigations and the amounts that have been recovered or sought to be recovered. I think you are probably familiar with those statistics as well, and you can see that it does appear from the evidence that Medicare have provided to us during estimates that this has been a systematic targeting of dentists as a purely revenue-raising exercise. Do you share that view, and is that the view of the majority of your association?

Dr Fryer : Yes. That is our view, as indicated in our submission. The claims of rorting and fraud have not sat well with a very proud health profession. The total focus on the administrative noncompliance would support those statements.

Senator FIERRAVANTI-WELLS: When you get down to the statistics, and they are produced in your submission and also in that of the New South Wales branch, when you drill down to the number of your almost 12,000 practitioners who have claimed under Medicare who are found to be non-compliant, we are down to 65 of them. The amounts there are sort to be recovered—

Dr Fryer : That is 65 from the completed audits, and that is representing 70 per cent of the completed audits.

Senator FIERRAVANTI-WELLS: Yes. But there is the untold damage. There is so much more damage that has been done to the profession in the whole process.

Dr Fryer : Just recently, as in the last few weeks, we conducted an electronic survey of the membership. That information will be provided to the committee for its reference.

CHAIR: Dr Boyd-Boland, are you seeking to have that document tabled now?

Mr Boyd-Boland : Yes. I have a bundle of documents that I would like tender that indicate the educative program that the ADA embarked upon when aware of the issues. I have been speaking to Mr Bell from the secretariat and I will be seeking to provide that material by way of soft copy, but I do have two copies of the material here.

CHAIR: We will need to have a look at that, if we could.

Senator FIERRAVANTI-WELLS: Mr Boyd-Boland, this is basically correspondence. What is the nature of this? Give us a bit more detail about this material. You surveyed the members?

Mr Boyd-Boland : Yes. There is a report there. I think it is the last document—document 20—which provides a summary of the outcome of the survey that was conducted. The survey was conducted of the whole membership and we had 2,000-odd responses, which I think would indicate a statistically valid result from the survey. It indicates the members' experience with the scheme and experience with the education process. But that is only one of the documents that is tendered. The other documents relate to correspondence between the association since that March 2010 period when we first seriously became aware of the issues of noncompliance.

CHAIR: Can I just interrupt now. In light of the extent of the additional information you are seeking to table at this time, we will need to reflect on this during the tea break and then the committee will make a determination because there are signatures and other things that are and standing procedures, and committees have to be careful about what is actually made public. We will assess that over the break and what is deemed to be able to be put on the public record we will deal with at the time.

Senator FIERRAVANTI-WELLS: Is everyone witness who has provided material happy for their documents to be provided and published on the public record?

Mr Boyd-Boland : The majority of the material is from ADA publications to members.

Senator FIERRAVANTI-WELLS: We can consider that, yes.

Mr Boyd-Boland : There is extracts from our magazine, a copy of a CD, correspondence between ourselves and Medicare officers, and the Minister for Human Services has a letter in there that is tabled.

Dr Fryer : Senator, your question was: has damage been done?'


Dr Fryer : I got sidetracked. The only reason I referred to the survey is that this is what is happening out there in the dental profession world with the average dentist. From that survey, 25 per cent of the members responded that they did not think they would participate in the future public dental scheme. I do not think that is very good. Ninety per cent said that they would be less likely to participate in a public dental scheme. So, in reference to your question, that is the sort of damage that has occurred due to the activities over the last few years.

Senator FIERRAVANTI-WELLS: Dr Fryer, I have received quite a bit of correspondence. It is too much for me to put on the record but certainly the sentiment can be summarised in one email that I received. Joe from Adelaide tells me: 'This has caused undue hardship and stress to myself, my staff and patients. I feel I am fighting for my professional life and integrity.' That is the flavour of a lot of the correspondence that I have received, and I am sure Senator Bushby and other senators as well. Dr Fryer, I wanted to put that on record and to ask you whether it is reflective of the majority of the correspondence and interaction you have received from your membership. I will not go into all of it. Some have written to me about the huge financial impact. People have said to me that is has sent them virtually bankrupt. There has been an enormous personal toll on them, their families and their businesses which cannot be rectified.

Dr Fryer : The simple answer to your question is yes. The financial situation of many members is not good. The expenses of running a dental practice are at about 70 per cent. It can be a little higher and it can be a little lower. For every dollar that has been received from a member, shall we say, from Medicare, the dentist has kept only 30 per cent and the rest has gone on expenses to provide that dental service. Medicare is requesting the whole dollar back so it is a significant financial imposition.

Senator FIERRAVANTI-WELLS: Do you see dentists leaving the profession or being forced out of the profession because of the financial hardship that has been imposed on them?

Dr Fryer : Some members have indicated to us that leaving the profession may be one of their considerations.

Senator DI NATALE: Dr Fryer, can you please explain the past experience of the profession's exposure to Medicare prior to the introduction of the CDDS? Has there been any that you are aware of?

Dr Fryer : The simple answer to the question is no. However, there are some very minor schemes, such as the cleft lip and palate scheme, that a very small group of the profession participate in. But, without a doubt, this is the first significant involvement of the profession with Medicare.

Senator DI NATALE: The scheme was introduced in 2007 by the then Howard government. Can you walk through the process for providing information to dentists and making them aware of how the scheme operated, given that obviously all dental practitioners were eligible to claim under the scheme? Can you tell me a bit about how that information was provided to the profession? I ask that question knowing that some practitioners have approached me and said, 'The first I heard of this was when someone came into my practice with a referral.' So can you explain a bit about how the profession was informed about the scheme, the billing requirements and so on?

Dr Fryer : Documentation was provided to the profession.

Senator DI NATALE: How?

Dr Fryer : Mostly by mail. I do not recall email notification. The first notice was in October 2007, I think, from the then health minister, telling the profession about the new scheme that was to be introduced. But none of the correspondence, as far as we can ascertain, has been provided to all practitioners; even the numbers that have been going out. I think 10,000 booklets were sent out, and there would probably have been 13,000 registered dental practitioners in the country at that time.

Senator DI NATALE: So you think one in three dentists might not have actually received any information—

Dr Fryer : It certainly seems to be the case. But I might defer to Mr Boyd-Boland.

Mr Boyd-Boland : Senator, in the survey that was undertaken, slightly less than 18 per cent indicated that they had received the Medicare booklet.

Senator DI NATALE: Less than 18 per cent indicated they—

Mr Boyd-Boland : Slightly less than 18 per cent—17.8 per cent—of members said they received it in November 2007; 21.6 per cent said sometime in 2008; 16.2 per cent said 2009; 14.6 per cent said 2010; 10 per cent said 2011; and 31.5 per cent said they have never received it.

Senator DI NATALE: Okay, so for the first few years at least, less than half of the profession stated they had not actually seen any information.

Mr Boyd-Boland : That is correct.

Senator DI NATALE: And that was really the only way that the department corresponded with dentists—through the mail via the booklet?

Mr Boyd-Boland : Yes, it was the forwarding of the green Medicare benefits schedule booklet.

Senator DI NATALE: In your view, given it is a significant change in the way that dentists practise, was that adequate?

Dr Fryer : Certainly not. As to the adequacy of that information, I have described the educative process as scant, inconsistent and confusing. Even from our survey, again, of our average member: in 2008-09, 95 per cent were unaware of the administrative compliance and the penalties. In 2010, 80 per cent were unaware—but that was at the end of 2009, when the ADA were notified that Medicare Australia had determined that there was administrative noncompliance; in 2011 it had dropped to 40 per cent being unaware—so the dentists and our members were starting to get the message. I would like to say that every ADA member is now aware—it is not quite that high, but it is certainly down to single figures who are not yet aware.

Senator DI NATALE: But, prior to the audits becoming an issue, what role did the ADA have in liaising with Medicare and ensuring that appropriate information was provided to practitioners?

Dr Fryer : The ADA became aware of the issue, I would say, at the beginning of 2010.

Senator DI NATALE: Okay, so prior to that you did not have any direct correspondence with dentists about how this scheme should be administered and so on? This is not meant to be a criticism; I essentially just want to establish the fact that this was direct communication from the department to dentists.

Dr Fryer : My CEO is indicating to me, Senator, that, in a very limited way, the ADA put some information on our website for members, but it was only in a limited way and, again, at that time the ADA did not consider it was our role but the department's role.

Senator DI NATALE: Okay.

Dr Fryer : When we felt that that the educative process was poor was when the ADA started to get involved.

Senator DI NATALE: I am interested, as I do have limited time, in moving onto what has happened since then. Obviously, the ADA has taken a much more active role since the audits became an issue. The question that worries me is that, while there is increasing awareness of the scheme, the preliminary evidence that I have seen is that in fact there may not be a significant change in administrative noncompliance, based on the most recent audits conducted. Are you aware of that information?

Dr Fryer : No, Senator.

Senator DI NATALE: If there was not a significant change in the rates of administrative noncompliance, subsequent to the involvement of yourselves, and obviously Medicare Australia, would you be concerned that there may in fact be some inherent flaws about the way the scheme is administered?

Dr Fryer : We have been informed that the compliance regimes with this scheme are the most onerous of any scheme that Medicare is administering and controlling. Again, as I intimated in my introductory remarks, if the ADA had been approached and consulted and our advice heeded we would have argued—and still do—that these sort of compliance regimes are not necessary for the efficient delivery of dental services to the Australian community. That is not withstanding that it is appropriate and acceptable that Medicare conduct audits, because they must make sure there is responsible expenditure of public moneys.

Senator DI NATALE: I suppose I am also interested in the rationale for conducting the audits on the basis of noncompliance—namely, not providing a treatment summary back to a GP and so on. In your experience as a professional body, has there been any documented case where the treatment summary that has been provided back to the GP has actually altered the clinical course of treatment?

Dr Fryer : No, I am not aware of any such event. Again, from information that has been supplied from the coalface, shall we say, from our members, the medical GPs have questioned the sending of these reports. I forget the percentage but there has virtually been no contact from the medical GP back to the dentist querying some of the treatment plans.

Senator DI NATALE: In your view, what is the clinical rationale for providing a treatment summary back? What you are saying is that the GPs do not particularly want them and they are not engaging with the profession. In your view, what is the clinical rationale for requiring a dentist to provide a treatment summary back to the treating GP?

Dr Fryer : I am not exactly sure. I can tell you that 86 per cent of the membership from a dental perspective said that section 10 has no clinical benefit relevant to dentistry.

Senator DI NATALE: Can you imagine a scenario under which it may be of benefit? I cannot; I am just wondering if I am missing something.

Dr Fryer : No. Having said that, the dental profession and the medical profession have a good rapport. If a patient presents and the dental practitioner wants updated information on the medical condition of the patient—say, if there are polypharmacy issues and things like that—it is usually only a phone call away. The professions have worked well together on that over many decades.

CHAIR: I would like to take the opportunity to go back to when Tony Abbott and the Howard government introduced the legislation. Could you put on the record what consultation and negotiation the ADA had with that government at that time.

Dr Fryer : From memory there were two meetings of very limited time. As I have stated previously, the advice that the ADA provided was ignored.

CHAIR: Would it be a fair assumption to make that the ADA were not in support of the introduction of the initial legislation?

Dr Fryer : That is a correct assumption.

CHAIR: What is your view now on the current scheme?

Dr Fryer : The ADA's position, as I alluded to in my introductory statement, is that a public dental scheme should be targeted at that disadvantaged group that we know are not accessing dental care at the moment. That, in our view, is a fundamental flaw in this current scheme.

CHAIR: Attempts by consecutive governments to change the program were blocked in the Senate on three occasions. Has the ADA previously lobbied to maintain the scheme as it currently is?

Dr Fryer : No, we have not.

CHAIR: So during the attempts of the government to change that you were not involved in any lobbying to keep the current scheme?

Dr Fryer : That is correct.

CHAIR: In terms of the other health professionals and the limited access that they have to Medicare, are you aware of the administrative requirements of those health professionals and are there any of those requirements that you think would better apply to dentists?

Dr Fryer : I am not aware of the compliance requirements of other schemes with the other health professionals, but I am able to tell you that the compliance regimes that the profession has been working on with the Department of Veterans' Affairs, in the provision of dentistry to veterans, sit very well with the profession. That is the sort of scheme that the ADA thinks is appropriate for compliance regimes.

CHAIR: In relation to other submissions, have you had the opportunity to read the AMA's submission? They have suggested that one profession, namely the dentists, should not be exempt from the legal requirements of Medicare. How would you respond to that?

Dr Fryer : Firstly, in their opening paragraph they indicated that they were not aware of the wide concerns within the dental profession. This clinical compliance is a separate issue. The medical profession have, as I think it is called, a professional services review committee whereby there is peer review assessment of clinical treatment, clinical treatment plans et cetera. The reference here is that we have poorly constructed administrative compliance, and that is the issue. I cannot speak for the AMA, but if it is in relation to clinical compliance—and this is as I have indicated earlier—there are appropriate avenues to address that, and that is correct: if a practitioner is deemed to have not acted appropriately from a clinical perspective appropriate action should be taken.

CHAIR: The Victorian branch of the ADA suggest that the CDDS was conceived for political purposes. Do you know what they mean? Was the consultation process at that time of the implementation of the determination adequate?

Dr Fryer : The consultation, as I said earlier, was not adequate. It is not the association's view but I have heard it mentioned that this scheme was introduced with an election in mind.

CHAIR: You have spoken of, and I think it is already on the record, about the inadequacies of the education process. How would you see compliance with the current determination today?

Dr Fryer : Right now?


Dr Fryer : I would expect that the majority of dentists now know what they have to do. If they do not know what they have to do now they should. Given the educative processes that the ADA has done to demonstrate to the profession how these three main administrative compliances are being utilised to punish the profession—and I chose the word 'punish' on purpose—they should know what they have to do to be able to be compliant now. But either way they are still onerous—and it is poorly constructed.

CHAIR: So would you summarise how this could be changed? The bill that has been proposed, in the view of some, is inadequate. Are you ultimately of the view that this bill would resolve the issues?

Dr Fryer : The ADA's position is that this scheme should be closed down but it should not be closed down until an adequate scheme is put in place to address the dental needs of that disadvantaged group, that 30 per cent of the population who are not getting to the dentist now.

CHAIR: Do you consider that the ADA has a responsibility to educate its members? When there is a significant change is it part of your organisation's responsibility to educate your members? If there is new legislation that impacts on your professional body, is it not the responsibility of not only individuals in that professional body but also the peak body to ensure, whatever the administrative arrangements are, that they are across those?

Dr Fryer : The association has a responsibility to its members in many areas. Education is one of them, but it is not, in the association's view, its responsibility to do the job of a government department.

CHAIR: So you stand by your comments that, at the time when this legislation was introduced, there was inadequate education which then led to those professionals that were accessing public money being ill informed of their responsibilities? So that responsibility falls on the department rather than the individuals who were accessing public money?

Dr Fryer : The law is the law and even though this is bad law it is still the law. We as individuals and the community have to take responsibility. But, having said that, the obvious issues that have arisen with this scheme would indicate from the ADA's perspective that a remedy is required. As we are in a health professional, the compliance issues for the vast majority of cases should be based on clinical parameters not letter writing and correspondence parameters. That is why, as part of ADA's remedy, we are saying closure of the scheme. But we also believe that there should be redemption of the administrative non-compliance penalties that have been imposed on the profession.

CHAIR: This is my final question. This legislation was ill-conceived and politically motivated at the time. The former Rudd government and the Gillard government have tried to change and close down the scheme on three occasions and has been denied that through the Senate. That would have allowed for proper consideration of a more adequate dental scheme for those who need it most in this country.

Dr Fryer : Yes, Senator. But the ADA's focus is on the delivery of quality, adequate dental care to the Australian community. That is where we are always stood and all of our policies are geared towards that, not a political position.

Mr Boyd-Boland : Senator, could I just add something in response to your previous question in relation to the ADA's role. When we were aware of the creation of the scheme we notified our members, we drew their attention to the various resources that were available to practitioners to access the requirements of the scheme. We are now told that these section 10 requirements were core to the program, the core of the system. Nowhere was that highlighted in any of the materials that were published at that time. If you have a look at the material that was published on the website, there were highlighted sections there; none of them specifically refer to the section 10 determination nor the ramifications of noncompliance with that section 10.

CHAIR: They were not highlighted but they were there. I thank you both for your contributions. Senator Bushby.

Senator BUSHBY: Following on from what Mr Boyd-Boland was just saying then, the issue here is not so much whether a technical breach occurred; I think it is accepted by everybody that technical breaches were occurring—in fact, at a very high incidence on the basis of the audit findings so far. Incidentally, do you think that the high level of noncompliance that has been found so far by the audits would be reflected in the broader population of dentists participating in the scheme?

Dr Fryer : From an administrative non-compliance level, yes.

Senator BUSHBY: So the question then is not so much whether they are non-compliant; it is what has led to that high level of noncompliance and what the consequences should be as a result. And that is what this bill is designed to address. If the department is correct and it had provided a comprehensive, educative process that ensured all dentists knew what they were supposed to be doing and the consequences, then it seems to me there are only two explanations for that high level of noncompliance. One is that it was deliberate or, secondly, that dentists were not up to understanding it. Given the academic qualifications that dentists have, you can probably cross that one out straightaway. Surely it is not deliberate either. Logic then takes you back to question the initial assumption, which was that the department is correct that there was a high-level educative process. In your submission you examined the documents. Your counterparts in the New South Wales branch of the ADA have done a very comprehensive analysis of that, and we will go that with the next witness. Do you share my conclusions, working through there, that it is not deliberate and that it is not that dentists are dense but that the educative process was insufficient?

Dr Fryer : That is correct, Senator. As I said, we represent over 90 per cent of dentists in the country. For ADA members, their principal focus—their reason for being when they are at work—is to provide good quality dentistry to the Australian population.

Senator BUSHBY: So, in essence, because it was not deliberate, you could loosely categorise it as accidental. I am looking at your submission and at Medicare Australia's National Compliance Program document. What is that document? Is that something that Medicare Australia put on their website as the approach that they take to non-compliant providers?

Mr Boyd-Boland : Yes. And in this case they have gone from zero to the top level very quickly.

Senator BUSHBY: That is right. In that document they have got what you have reprinted as diagram 1, the compliance model.

Mr Boyd-Boland : Yes.

Senator BUSHBY: It is a pyramid, at the top of which is criminal behaviour and fraud, and Medicare Australia's response is to enforce the law. Next is opportunistic noncompliance and inappropriate behaviour, for which Medicare Australia's response is to correct the behaviour. Going down the pyramid, the next thing is accidental noncompliance, which, from what we have just discussed, is what I would be categorising this as. Medicare Australia's response is to counsel and provide feedback. At the bottom of the pyramid is voluntary compliance, for which the response is help and support. Of those four levels, it seems to me that accidental noncompliance is the most likely. If you really wanted to be Machiavellian in looking at how the dentists have approached it, you could possibly say that it was opportunistic noncompliance. You could say it was inappropriate behaviour if you say that the dentists were choosing not to do it or doing it later, despite the fact that they might have known it. But it is not criminal behaviour, so it is not at the top. So even then it is correct behaviour. So the worst case response from Medicare Australia should have been to correct the behaviour and probably, on the basis of that, to counsel and provide feedback. Is that the approach that Medicare Australia has taken to dentists in this case?

Dr Fryer : In our view, no, Senator. Medicare have not been following this compliance pyramid that they produced. On the next page, our case study on Wilma Johnson clearly demonstrates that an educative process, a demonstration to practitioners on what they should do to be compliant, was not properly—

Senator BUSHBY: Do you believe that Medicare Australia had the option to make an educative choice in how it dealt with these non-compliance issues rather than the very heavy-handed one that they have chosen?

Dr Fryer : Yes. In our view that is what should have happened.

CHAIR: I have to clarify a couple of issues that have not been touched on this morning but that have come through in submissions in relation to overservicing. Firstly I will ask whether you see that there are problems with overservicing. Further to that, it has been suggested that under the CDDS there has in fact been an oversupply of crowns and bridges.

Dr Fryer : The issue of overservicing I think is demonstrating that the significant unmet demand of some sections of the community was underestimated by the government at the time. As I said earlier, we advised them that there was this demand out there. The scheme has, over a two-year period, $4,250 worth that can be claimed. At the current time, I think the average cost per patient is around $1,700. So, if there was significant drive by dentists in this country to overservice, to exploit a public scheme that is providing dentistry to the community, the average would be $4,250.

CHAIR: Thank you very much for your submission and particularly for making yourselves available today to come before the hearing.

Dr Fryer : Thank you.