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STANDING COMMITTEE ON COMMUNITY AFFAIRS
27/08/2007
Health Insurance Amendment (Medicare Dental Services) Bill 2007

CHAIR (Senator Humphries) —I declare open this public hearing of the Senate Standing Committee on Community Affairs. The committee is taking evidence today on the inquiry into the Health Insurance Amendment (Medicare Dental Services) Bill 2007. I welcome Dr Neil Hewson from the Australian Dental Association, who is joining us by teleconference.

Dr Hewson —Good morning.

CHAIR —Good morning, and thank you very much indeed for taking this call from us. I am Gary Humphries, the chair of the committee. With me in the committee room are Senator Claire Moore from Queensland, who is the deputy chair, and also Senator Sue Boyce from Queensland. Are you in Sydney, Dr Hewson?

Dr Hewson —I am actually based in Melbourne.

CHAIR —Information on parliamentary privilege and the protection of witnesses and evidence has been provided to you, I understand.

Dr Hewson —Yes.

CHAIR —We have the submission that the ADA has provided and we thank you very much for that. Would you like to start with an opening statement about the issues that the committee is looking at? We have some questions to ask you but we are happy for you to make a statement to kick off.

Dr Hewson —Sure. Firstly, the ADA is very happy that the federal government has recognised that it does need to play a greater role in the provision of dental care to Australians, so we welcome this amendment to the act so that people will receive benefits if they have chronic disease. The ADA is also very pleased to see that there is some recognition of the importance of dental health and its relationship to general health.

We also note other federal government initiatives in recent times, including increased Commonwealth supported places to existing dental schools, the establishment of the School of Dentistry and Oral Health at Griffith University and the proposed establishment of a school of dentistry and oral health at Charles Sturt University, more rural clinical placement funding, the undertaking by the minister to conduct a dental workforce review, and dental scholarships for Indigenous students. However, the ADA strongly believe that the model of delivery that has been proposed is not appropriate for dentistry and for targeting those most in need.

I would like to make some comments about our position regarding Medicare in general. The ADA and others believe that Medicare is not a suitable vehicle for the delivery of dental care. The author of the original Medicare plan, Professor Deeble, recognised this and stated that the provision of dental care should not come within Medicare. He is quoted as saying at the first Senate select committee that the main problem with Medicare covering the dental industry is its basic uninsurability. He said:

… insurance works for best for things that are episodic and unpredictable. Dental illness is slow: it is not episodic and it is not unpredictable, because you know you have it for quite a long time. You do not suddenly discover that you have a dental problem. It should be treated, but it should not be treated within an insurance approach.

Two other Senate select committees have also concluded that Medicare is perhaps not the appropriate vehicle for delivering dental programs.

The ADA reaffirms its view that any dental program should be selectively targeted for those most in need and that there should be other programs with regard to whole-of-life preventative initiatives. With regard to the revised EPC program, there are positives in that, and one is the inclusion of dental prosthesis, which will create more comprehensive and effective outcomes for many patients. Another is the increase in funding available for dental treatment from the proposed $2,000 per year to $4,000 over two years, which effectively will mean that more people will be able to obtain a complete course of treatment than would be able to if the quantum were confined to $2,000. So this is an improvement on the scheme that is currently in position which, up till now, has failed.

We believe there are negatives to the scheme. The first and most important is that it is not targeted to the financially disadvantaged, when it should be the case given that limited funding is made available. Under this proposal, the very wealthy are still covered. It does not have the limitations on frequency of replacement of dentures, as is the case with the DVA program, and it does not utilise dental experts, as is also the case with the DVA program. The proposed rebate level of 85 per cent of DVA fees, a discount on already discounted fees, will make it extremely difficult for dentists to provide treatment on a rebate only basis. The development and inclusion into Medicare of more dental items outside the universal coding system, the Australian Schedule of Dental Services and Glossary, adds confusion and is not required.

The ADA does have a view on how the federal government could have a role in dental health. The ADA also understands that it will take time for measures—for example, the increased training numbers—to take effect. The ADA believes that the federal government could do the following things to improve the community’s dental health. It could train adequate numbers of dentists and allied dental personnel. Steps have already been taken in this direction; however, as promised by the health minister, a review should be conducted before any more new dental schools are established. It could fund a dental program structured on the DVA scheme and targeted to the financially disadvantaged, with conditions on states to fund their programs to agreed levels. Such a program should cover the minimum costs of basic dental care. It could fund a postgraduate clinical placement year—which could also be called an intern program—with the states providing the infrastructure and the clinics. This would greatly assist with workforce shortages and would provide services in rural and remote communities and in the public sector. The government could fund oral health promotion as per the smoking cessation and the skin cancer promotions, which are already being done by the federal government. This is an investment in the future to save costs by reducing the need for dental treatment. It could promote and fund universal prevention measures such as water fluoridation. The ADA remains committed to assisting all governments to find the best ways to improve the community’s oral health.

CHAIR —Thank you. I will ask you some questions that will allow us to go individually through the issues that you raised about the reasons that the Medicare model would not be appropriate for dental services. It is likely that a first blush impression of that comment would, on the part of someone who has worked with the present system, be that we already have a system for rebating health costs—for covering health costs and supporting the cost of those things—in the hands of the patient—that is, the Medicare system. I assume that the suggestion you are making is that a separate and different model needs to be established for dental services and it would be a departure from that and potentially more complex and costly administratively. Can you again run through the particular issues that you said would necessitate a different model from Medicare for dental services?

Dr Hewson —Ironically, one of the problems with Medicare is that it has certain rules that suit medicine but do not suit dentistry. That is part of the reason—

CHAIR —Give me some examples of those.

Dr Hewson —Universality is one. Government-funded schemes should be targeted and should not be universally available. I cannot remember all the other changes that would have to be made to the system. You do have an administrative model that works really well—that is, the DVA scheme. We believe that if you have got something that works really well in dentistry why not use that as your model and expand on that.

CHAIR —I am not familiar with the DVA scheme, and I am not sure that the rest of the committee is. Can you outline the reasons that that model is better than the Medicare model?

Dr Hewson —One of the other things that I do not think you can do under Medicare is put in limitations. For example, dentures can only be done every eight years or so under the DVA model. One of the other things that we believe is really important is that the DVA model has dental advisers who can keep an eye on things to make sure that people are not abusing the system. But, importantly, when you have people who are special cases, they can assess them and make sure that those people get the appropriate treatment, even though it might be ‘outside’ the normal run-of-the-mill regulation for that system. The DVA system has been in place for many years now and the advisers are extremely important and very helpful; they help people like me to give appropriate treatment to special patients. I might only need to use them once or twice a year, but when I do it is important to get a good outcome for that patient.

CHAIR —These advisers are advisers to the dentist, not to the patients?

Dr Hewson —No, they are employed by the Department of Veterans’ Affairs, so they give feedback to the department on how the system is working and all that sort of stuff. Also, if they suspect that someone is rorting the system, they can detect that. If I have a special patient I might have to write a written report about that patient, which goes to the adviser. That adviser will then see whether it is a legitimate case and, if so, approve the proposed treatment plan or, if not, not approve it.

CHAIR —You mentioned the unfamiliarity of dentists with the way in which the Medicare system works. In your submission you say that, because of the low returns with the present rebate arrangements or the present item numbers that you can access through Medicare for dental services, most dentists have consciously stayed away from the current scheme. That is partly, I assume, to do with a lack of education of dentists about how Medicare works and about how they can use it. Do you think there is likely to be a lot of consumer resistance, as it were, from dentists to become involved in the Medicare system?

Dr Hewson —I think part of that has been solved by Medicare adopting the Australian Schedule of Dental Services and Glossary coding systems, so that will make it a lot easier. That was one of the problems. But also the interaction between doctors and dentists was a problem. To be fair, that is one of the things that has been approved and one of the things that we have worked very hard on with the department. They have worked very hard to make that more user friendly for dentists; therefore making it easier to accept because of the administrative loads.

CHAIR —If this legislation is passed do you think, though, that there should be an active program to educate dentists about how Medicare works and to smooth the process of them becoming major users of it?

Dr Hewson —Of course. When the first program was introduced, the ADA, both federally and through its branches, ran a lot of articles, provided information to members, and there was a booklet. We have done it in the past and we will do it in the future. But we are all creatures of habit and dentistry is locked into a system of how it describes dental treatment. So any system to make it smooth and easy to be administered by dentists needs to have the same sort of system; as I have said, the adoption of those dental item numbers by Medicare will help a lot in that regard.

CHAIR —Finally, you are saying to the committee that you think that dental services should not be based on the universality principle that Medicare works on, that they should be means tested, in effect, so that the funding is directed to those on the lowest incomes?

Dr Hewson —Yes. One of the things I did not mention in the government initiatives is the rebate on health insurance, and so that also applies to ancillary cover. The recent national oral health survey clearly showed that just over half the Australian population were managing their dental requirements very well under the existing system and yet half were not because they are extremely disadvantaged and just cannot afford it—I think they called it the two Australias—and there are other people who perhaps need to be encouraged to make dentistry a higher priority. We think if you have that sort of divide, you should concentrate on those in most need. The other thing is that, if dentistry did come fully into Medicare, the overall costs would be large. Currently, the total spend on dentistry is about $5 billion, so you could imagine that, if it came under Medicare, the total cost could be anything up to $10 billion.

CHAIR —Thank you for that.

Senator MOORE —Thank you for the submissions. We have a couple. I am interested about the interaction between the ADA and the department and/or the government about the development of these processes. I know that you have a strong lobbying program, and I am just trying to find out, in terms of interaction, what role your association has had in the development of the way these policies will work.

Dr Hewson —We, with a lot of other people through the National Oral Health Alliance, have lobbied the federal government to take a role. We have spoken with both sides of the House about our view, which I have already explained to you, and then, once the government decided to go down a certain path, we had three or four meetings, I think, with the department to try and make the EPC program, given all its constraints, as user friendly and as good as possible.

Senator MOORE —We have had quite a fulsome submission from the department. My understanding is that this round of dental projects has been built on the previous enhanced service delivery program that came out a couple of years ago. Was your association involved in any review or assessment of the previous scheme to see how it worked and, hopefully, to see whether the new round could be better?

Dr Hewson —I do not know whether we formally were, but certainly, in our discussions and our meetings with the department and our discussions with the minister and the shadow spokesman, we have expressed our concerns with the program.

Senator MOORE —Can you find out, just in terms of process, whether your organisation was formally approached about the previous round of enhanced—I forget the term, but you know what I mean—

Dr Hewson —Yes.

Senator MOORE —Was there any formal arrangement, as the chief professional group in the industry, to see what your concerns were and to give formal feedback? I totally understand the fact that you are regularly, through the National Oral Health Alliance, working with everybody, but, as it has been made clear to us that this is building on the previous program, I want to see what the process was to evaluate the previous program before going forward with the new one. I would just like to find out whether there was a formal approach. That would be good.

Dr Hewson —I will follow up on that for you—

Senator MOORE —That would be great.

Dr Hewson —but I can recall that we did have a meeting some time ago to get some feedback on that.

Senator MOORE —Good. When the first round was brought in, and also during the process after that, one of the questions that arose was the interaction between the medical practitioner and the dental practitioner. The programs rely on a referral from a doctor, and there was some discussion about how that worked and what the process should be. You refer to that in the submission. Could you let us know how you believe that is working and what that link is with the clear understanding that this program is only available if the dental issues can be linked to another chronic disease?

Dr Hewson —I think we understand that pretty clearly. In the past system the paperwork was a bit cumbersome, but I think that that has been addressed. We have had discussions with the department about conditions and the various relationships between dental health and chronic diseases, so that has been one area that I think has been pretty productive.

Senator MOORE —Is that done at the local level? The way I read it—and I have not read all the guidelines, and I really should, and I know that the new round of guidelines has not been not written yet—the process is that a local GP determines that their patient has one of a list of conditions that could be affected by their dental health, and then they refer to a local dentist. Is that how it goes?

Dr Hewson —Yes.

Senator MOORE —What kind of paperwork does the local dentist have to look at to make sure that it is all kosher?

Dr Hewson —I do not know the details of that—

Senator MOORE —Okay, I will follow it up with the department.

Dr Hewson —but I do know that we have discussed it and that the process will be more efficient and easier to do than it is currently.

Senator MOORE —In terms of the amount, we know that the previous program had a limited number of visits per year. The new program has a significantly enhanced amount of money and a patient can have work done to that level. Can you give me some idea of what 4½ grand covers in dental terms? I go to the dentist regularly and sometimes I pale when I see the bills. What kind of value is 4½ grand of dental work—what can it achieve?

Dr Hewson —If it does not involve really complex treatment it can achieve a lot. The Australian Dental Association is really happy that the amounts have been increased and that it is not now connected to the safety net—it is separate in that way—so we are quite happy with that. But if someone needed a couple of crowns, that would take up maybe $3,000 of it.

Senator MOORE —I will get some more detail from the department. To me, the figure is just one of those things—until you see the schedule and what it covers it is hard to get an idea.

Dr Hewson —The schedule is pretty comprehensive. A few things have been taken out. One of the reasons it is important is that often people who are chronically ill and have a lot of problems are also people who have very bad dentition and they are not able to be brought back to dental health very easily.

CHAIR —What is it that you said?

Senator MOORE —What is dentition?

Dr Hewson —Your teeth.

Senator MOORE —They have bad teeth?

Dr Hewson —Yes. Those two things often go hand in hand. That is one of the things we discussed early on. It is really good that the government took that on board, particularly allowing the $4,000 to cover two years but being able to have the work done in a year. You can get someone dentally fit without having to delay it—an excellent initiative.

Senator MOORE —Is that a term that is used—’dentally fit’?

Dr Hewson —Yes.

Senator MOORE —It makes sense to me but I have just not heard it before. So you are talking about someone’s whole dental fitness?

Dr Hewson —Yes.

Senator MOORE —That leads me to my last question, which is about now being able to get dentures and other prostheses. There seemed to be a huge issue with the previous scheme in that dentures were not covered. Under this one they are allowed to be covered. Are there any limitations from a dental point of view about what you can and cannot provide?

Dr Hewson —I do not think there are; that is one of our points. Under the DVA scheme—

Senator MOORE —There are limitations with time.

Dr Hewson —there are limitations as to how often you can replace these things, but this proposed EPC scheme does not have that. This is another one of those examples of where the Medicare rules do not often fit in very well with dental issues. We would suggest that there should be some limitations on that. With that rule, if there is a special case—it is justified and argued—it is one of the things you could go to the dental advisers for. They can assess it and say, ‘Yes, this person does need to have dentures a bit earlier.’ That ties together quite nicely the two things we think any dental scheme should have.

Senator MOORE —I have another question; your answer reminded me of it. I am interested in the dental adviser. In your submission and a couple of others we have a comparison of the DVA scheme and the enhanced scheme that the government has put forward. We hear many complaints from DVA people about their access to services. In terms of the dental advisers I am interested to know, from the association’s point of view, how such a scheme would work within this program if it were to be considered and what the value of those people are. You mentioned it in your verbal submission but there seems to be a core difference. I will be asking the department as well from their understanding. We do not have a national dentist in the way we have a national physician or a national scientist. Also we had the chief medical—

Dr Hewson —Chief dental officers.

Senator MOORE —I know that in the past your organisation has been quite keen on having a national dentist, or whatever the right term is. But in terms of the advisory network and the enhancement of the program, how would dental advisers—which I know are in the DVA system—be able to operate within the system, however it pans out?

Dr Hewson —One important thing is that they are responsible to whatever scheme they are in—so they are responsible to the DVA system, not the providers. They are very useful for two reasons. Firstly, they are a good means of detecting ‘medi-fraud’, or whatever you like to call it—and unfortunately all professions have people who are likely to do these things. But the best thing—and you have to have rules in any scheme or it will not work—is that they enable people under, say, the DVA program to be treated properly outside the rules. They allow for special cases to be treated adequately and properly. That is their greatest value. Secondly, they are a good form of feedback for the government on how the scheme is going, where the problems are and how it needs to be modified and all that sort of stuff. They provide an independent or in-house resource to monitor any program as well.

Senator MOORE —So it is like an advisory council?

Dr Hewson —Yes.

Senator MOORE —From what I can see, every government has some sort of advisory council—ministerial advisory councils or professional advisory councils—that feeds in to enhance knowledge and interaction. Is there anything of that kind in dentistry that you are aware of?

Dr Hewson —No, not that I am aware of. They are the only people I know, and they certainly do have that role within DVA. That is quite useful because the bureaucracy is constantly changing and people move around. So to have expert advice within your own system and not to have to rely entirely on lobby groups like ours is a really valuable thing for any program to have.

Senator MOORE —And you also link in the state-federal alliance. We all know that dental care relies on effective services at the state and federal level, but some kind of ministerial advisory group would be able to have state people on it.

Senator BOYCE —Dr Hewson, you spoke a number of times about the potential for people to be able to abuse or rort the system, as compared to the DVA system. Could you give us some examples of the way people might do that?

Dr Hewson —One example is dentures. You can make a denture each year. That would be one way. But you can propose a service in any health program. Where the advisers come in is that they have a bit of an idea of the patterns, so if something is a bit unusual they can detect it. The other thing is that, if something is unusual and it is genuine, the dentist can approach those people and talk to them about that case beforehand.

Senator BOYCE —I was just having trouble imagining someone rushing in to have extra fillings put in or something. I was wondering what sort of—

Dr Hewson —They might want a crown when something else might be quite adequate, or something like that. Patients might want to use the system, even though they are dentally fit, to have different types of restorations.

Senator BOYCE —As I understand it, the GP would not be referring people if they were dentally fit. Is that your understanding of it?

Dr Hewson —Yes, it could be.

Senator BOYCE —I am interested in the eight-year time limit on dentures within the DVA system. Could you explain how that was arrived that?

Dr Hewson —I think that just happened over time. Usually people need to replace dentures only if their mouth changes shape. Normally that only occurs over a long length of time. Your jaw has a base structure and then it has what is called the alveolar part, which is the special bone that holds teeth. When you extract teeth, there is no longer any function for that special part of the bone, so it tends to resorb away with time. It is progressive and goes on all the time, so dentures will eventually not fit because of that. So it was found over time that the eight years was an appropriate length of time and that, for most people, their dentures would remain and fit well within that time frame.

Senator BOYCE —Would you expect that, if most people’s dentures were comfortable and functional, it would not be very likely that they would want new ones?

Dr Hewson —You might like a spare one, for example. If you drop one and it breaks, it is handy to have another one.

Senator BOYCE —As someone who leaves reading glasses all over Australia, I understand that.

Dr Hewson —It is a system that seems to work really well. As I said, if people do need them before that, the dental adviser role helps those people. No-one is missing out. I guess it is a bit of a mechanism for containing costs.

Senator BOYCE —We have received a submission from the Australian Dental Association and a submission from the Queensland branch of the Australian Dental Association. They comment in their submission that about 85 per cent of dentists are currently in the private sector and that there would appear to be adequate spare capacity to fill the need anticipated by an increase in dental services that would come through here. We have also had a submission from the Australian General Practice Network, expressing concern that the new arrangements may only benefit those in communities well served by dentists, which they characterise as ‘central business districts and middle-class residential suburbs of major population centres’. I was wondering if you would like to comment on those two different approaches.

Dr Hewson —Ironically, my practice is in a low-socioeconomic area. When the Commonwealth Dental Health Program was in operation, we were able to see patients under that scheme. It will depend a little bit on location. There will be some rural and remote practices that will struggle because they are flat-out now. But, by and large, I think the experience with the Commonwealth Dental Health Program and under the voucher systems when they have operated in various state jurisdictions have shown that the profession is willing to see these patients. The people are spread over all practices, and you do not need each dentist to see a lot of these people a week. So I think there is a pretty good capacity to handle this. Of course, we currently have a workforce shortage and a maldistribution of the workforce. A lot of that, hopefully, will be addressed with the increased numbers that are now training.

Senator BOYCE —Due to the fact that this system will enable dentists to fill any spare capacity in practices that are not in very big population areas, I was also wondering if there might not be some potential to encourage people to set up practices in areas that they may not otherwise have seen as having a critical mass to support a practice.

Dr Hewson —I do not know whether there are many areas where that applies. I suppose that would apply in very small rural areas. It may, but I do not know. I do not really have a view on that.

Senator BOYCE —The Queensland submission says that child tooth decay rates are increasing. Would you talk a little bit about that and about what the Dental Association’s response has been?

Dr Hewson —They are increasing a little bit but they are increasing from a very low rate up to a tiny little bit, so it is still a very small increase. The latest figures that have just been done indicate that they are perhaps now plateauing. The reasons for these we are not absolutely sure of. One of the possible reasons is that people are using a lot of bottled water which does not have fluoride in it. Another possible reason is this: to reduce mottling of teeth and fluorosis of teeth, the current recommendation is that children under six use low-fluoride toothpaste. That may be having an effect as well. That is still something that is being monitored. We are still not sure why that has actually happened, but I think that, encouragingly, it looks like that little increase may be now plateauing out.

Senator BOYCE —Can you put a percentage on that?

Dr Hewson —We could send you that. But we are going from nearly the best decayed/missing/filled rate—DMFT is what it is called—in the world to what is still nearly the best, so it is not a huge, dramatic increase. But of course any increase is very worrying, so that is one of the things that are being monitored quite closely.

Senator MOORE —I am following up what Senator Boyce asked you. The national oral health survey seemed to indicate that some more research is going to be needed generally but also in particular on an issue of the fluoridation debate, which is always raging in Queensland, that unless people get their fluoride as children there will be a question about how effective it will be. Is that right? I remember reading something of that kind in that survey book.

Dr Hewson —The main effect of fluoride is now believed to be an ongoing one. Fluoride is actually really important for older generations too because a lot of older people have gums that have receded and so the roots of their teeth are exposed, which are softer and more susceptible to decay. Fluoride has a topical effect which is important. It also interferes with some of the bacteria that produce the acid in the plaque that causes decay. While it has some role in the formation of the tooth, it is more the ongoing thing—so it is not the case at all that it is only beneficial to children.

Senator MOORE —I am constantly surprised by how strongly people have views on fluoride. It ignites a room, particularly an ALP conference. Is there anything that you want to add, while you have got the microphone, in terms of the need for ongoing research into the whole area of dental services and dental care?

Dr Hewson —Yes, I think there is. The workforce is one of the things—not only the numbers, but the mix of it. One example is that the Charles Sturt set-up is going to be half BOH and half dentists. We would argue that in a rural area you actually need dentists. In fact, you might even need to have a program where dentists do another year before they practise rurally, because in rural and remote areas you are on your own and you do not have the support systems and you are not in a position where you can refer things off, like I can here in metropolitan Melbourne—so there is research needed there. I am sure that if you asked us we could come up with other things that need to have more research done into them.

CHAIR —Dr Hewson, thank you very much for your evidence today. It has been very useful as a way of kicking off our inquiry this morning. Thank you for the submission that you provided as well.

Dr Hewson —My pleasure.

CHAIR —You have taken a couple of things on notice.

Dr Hewson —Yes, the child decay rates and the formal arrangement regarding the feedback on the current enhanced primary care system.

CHAIR —We have to report by the middle of next week, so it would be of great benefit to the inquiry if you could provide those to us as early as possible.

Dr Hewson —Okay.

CHAIR —Thank you.

Proceedings suspended from 10.15 am to 10.29 am