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

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

Prof. Spencer —Yes, it has.

CHAIR —We thank you for the submission that you have provided to the committee. We have a couple of questions arising out of that but, before we put those to you, would you like to make an opening statement about the issues that the committee is examining today?

Prof. Spencer —Certainly. I think it would be widely recognised in the dental profession, and may eventually be recognised within the community, that this bill represents quite an important event in the financing of dental services in Australia. It is an important but somewhat constrained step in improving oral health and access to dental care for a particular subgroup of the Australian population.

I want to make a number of specific points about the bill. The bill’s premise is limited to people who have chronic conditions and whose poor oral health actually affects their underlying medical condition or the management of that condition. This accepts the notion that dental care and oral health in some ways are only important when they complicate the management of an underlying disease. I have used a quote from the US Surgeon General, ‘You cannot be healthy without oral health,’ to indicate that a strong argument should certainly be made that oral health is important in its own right and not just because of its impact on any underlying chronic medical condition.

My second point is that defining what underlying medical conditions could be adversely affected by poor oral health is quite a difficult task. While there are some obvious situations—I could use the example of diabetes—where poor oral health is thought to complicate the management of a diabetic patient’s condition, there are many situations where our evidence base linking poor oral health to a medical condition is far less well developed. So this leaves quite a bit of uncertainty about just what conditions should be included in this particular bill.

I have tried to give an example, which perhaps is somewhat extreme, where it could be argued that poor oral health leads to an altered capacity to chew, which flows on to changes in choice of food, which might flow on to changes in the nutritional value of people’s diets, all of which could affect the underlying general health of anyone within the community. Also, poor oral health might lead to people experiencing symptoms they might struggle to cope with, which certainly might lead them to feeling less able to manage their health in general—the notion of coping and self efficacy over their health—which again might rebound on how their general medical conditions might be managed in their lives. I think at one end of the spectrum it is possible to argue that almost any medical condition that someone has might be affected by poor oral health. Drawing a line about what medical conditions will be in and what medical conditions will be out of this particular bill, and the provision of care under it, is quite a difficult task.

My third point is simply about the definitions of the medical conditions that, in the end, will be included and, therefore, who will get dental treatment under the bill. It might be argued that this might not be very much of an issue. Past experience has been that the uptake rate of dental treatment under these sorts of arrangements in the last several years has been very low. But the bill actually outlines very substantial financial support for dental care. It is now some 10-fold higher than was previously the situation, and it is likely that many additional people will be seeking dental care under the bill’s arrangements. Therefore, if you work through some simple calculations—maybe they are worst-case scenarios—you find that the bill and the attached financial impact statement imply that around 45,000 people, at the lowest end of the estimates, would receive dental care under these arrangements. That is something like one in eight of the people who are currently being managed under GP management plans and team care arrangements. It becomes a bit of an issue as to how general practitioners will choose which patient of eight that they have under such plans will receive dental care.

The documentation that I have seen does not clear up this issue particularly well. It implies that this would be left to the clinical judgement of the general medical practitioner. While that is an appropriate starting point, it certainly does not indicate how in the future we should learn from the experiences had by general practitioners and dentists under such a bill and how we should refine and finetune the selection criteria of just what medical conditions are appropriate for a person’s dental care to be covered under such a bill.

The last area I have tried to highlight is that the provision of dental services is a fairly substantial expenditure of the Australian government. It will rank second behind the 30 per cent private health insurance rebate paid towards dental insurance in terms of the quantum of dollars involved. Therefore, I think it behoves us to ensure that the expenditure and the services under it are monitored well and that we ensure that we get the maximum benefit for the community out of that expenditure. I have made some suggestions as to how there needs to be a focus on collection of information at both a patient level and a population level to appropriately evaluate this sort of program over the next four years.

CHAIR —Earlier you raised a point concerning the uncertainty about what chronic conditions can connect with a person’s general health or their oral health. That is an issue which has been ventilated quite a lot in the committee hearing this morning. I point out that the department did confirm that the cost of the item will essentially be demand driven so that if indeed there are not 45,000 but 145,000, or whatever the number of people, who claim these rebates then that will be the number of people treated. It will not be rationed or limited by the number of dollars currently allocated in the bill. That question leads then to the other question: with the uncertainty that you have pointed out about just what the connections are that a doctor needs to make between chronic conditions and oral health, in terms of our recommendations to the Senate, are there any suggestions you can make to us as to what we can do to eliminate or reduce that uncertainty?

Prof. Spencer —The only reasonable suggestion that one can make at this stage is we need to learn from research that is actually being conducted in this area. We need to collate what is known from the existing research literature about the links between poor oral health and underlying medical conditions and maybe the effectiveness with which they are managed. The research literature in this area is not huge. That is a ‘one direction only’ effect that the bill outlines, and that eliminates many known linkages between oral health and general health where maybe general health is impacting upon oral health, which is the opposite direction to what this bill implies is its underlying premise. Clearly, we need to be learning from on-the-ground experience of general practitioners, dentists and patients involved in such a program as this. I think it increases not just the necessity for there to be a rigorous evaluation of how these sums of money are used but also the value of linking specific research activity—it might initially be through general medical practitioners—and increasing the emphasis on research to determine just what the impact is of improving the oral health of their patients with chronic diseases under these sorts of schemes or how they assess it in terms of general health outcomes of those patients.

CHAIR —So you would recommend that, as the legislation is rolled out, there be more research and that the uptake and the nature of the uptake be monitored, but you would not suggest that we change the provisions of the legislation at this point?

Prof. Spencer —It really is, I think, a very difficult task to sort of rationally draw a line in the sand about exactly what medical conditions would be in and what medical conditions would be out at the moment. There is a lot of interest in the dental community and the wider public health community about possible links between oral disease and systemic or general health. But many of these have a reasonably limited level of evidence available to support them. We would talk about the jury still being out. I think that is the difficulty that people would face in trying to draw up a prescribed list of medical conditions at the moment, as the evidence really just is not strong enough to substantiate what is put on the list and what is left off the list.

Senator MOORE —Following on from the point that you are making, my understanding is that this scheme is actually building on the pre-existing scheme that has been around since 2004 and that there has been extensive effort made to see what caused the less than optimal uptake—and I am trying to get those words absolutely right—of the previous scheme so that we can build on a better one in the future. Have you had a chance to have a look at the previous scheme?

Prof. Spencer —I have certainly had a look at some of the available statistics on the previous scheme and have published in the Medical Journal of Australia some brief comments upon those. All we really had was what I basically call ‘encounter data’. It just indicated the total number of individuals who had been supported for their dental services under the old rebates over time. I certainly did not have access to any further information on, for instance, the age and sex breakdown of those people or any of their other social characteristics and I had no information on the underlying medical conditions they may have had. There is a lot that I do not know about how the previous scheme was working, but we all know that there was a very low uptake under the previous scheme.

Senator MOORE —Were you involved in any of the discussions that were held, in terms of looking at moving forward, and any of the industry consultations about the program?

Prof. Spencer —No, I was not.

Senator MOORE —My understanding from today’s evidence from the department is that the guidelines under which this scheme is going to operate are very much based on what was in existence, impacted by the feedback that they have had from the industry, while also mirroring what is happening with the DVA scheme. So it is all a bit of an amalgam. The guidelines are going to pick up the issues that you were raising around giving support to GPs in making their decisions about who they would consider should get this and who should not. I imagine they would be public guidelines. So it may be useful for you, if you do get the chance, to have a look at that.

Prof. Spencer —Certainly.

Senator MOORE —That seems to pick up a lot of the concerns that you have raised in your submission and in your evidence today; that it is about what constitutes a stimulant for people having access to this or not—and we have not got those yet.

Prof. Spencer —They will be important. The comment that I was going to make was certainly anecdotal. I think the low uptake of the previous iteration of this sort of program really rested on some issues like the rebates being set up in a way which was really quite at odds with the way in which the vast majority of dentists in Australia practise—that is, a fee-for-service basis within their private general practices. The notion of a flat rebate for a first, a second and a third visit or consultation was really at odds with the way in which dentists will raise their fees for any individual patient and, through that, to whoever is funding the service. Certainly the new scheme pulls it into line with programs such as the DVA one in which dentists have participated extensively in the past.

In terms of the dentists’ participation, I think the new arrangements are much more aligned with their usual practices. What is a little less certain is how medical general practitioners make their decisions about what patients to even seek to refer to a dentist. I do not really know whether the existence of this new scheme is going to generate greater activity from the GPs, but my feeling—and this is just a sort of hunch here—is there is such a substantial level of funding available for dental care that this will in a sense be patient demand driven, and I would imagine that general practitioners will be very quickly under request from their patients to organise a referral for general dental care.

Senator MOORE —Yes. One of the things the department has said is that there is going to be an extensive education campaign for GPs and dentists about how this scheme will operate. I think that has come out of the feedback they have had with the first scheme as well. I forgot to ask the department about the community information campaign about how they will be advised about their rights in this process—I might ask that later. You are actually at the university dental school in Adelaide; is that right?

Prof. Spencer —Yes, I am at the School of Dentistry, University of Adelaide.

Senator MOORE —I am also interested in the workload implications: if this is going to generate more people being able to access services what the impact is going to be there. Have you got any comments on that?

Prof. Spencer —I was going to immediately respond that we are talking fairly marginal increases potentially in the demand for dental care, if the numbers involved are 45,000 or 90,000. Although we have a fairly tight sort of supply of dental services in the community at the moment, we are not talking such huge numbers of new and additional visits to dentists and services that would be involved in this particular program that it would cause me undue concern. What I think I should be well aware of is the comment that you have attributed to departmental representatives this morning—that is, if the demand is several times higher than what might be anticipated under this program, the size of the program will simply grow. It is possible that there is a very large group of people in our community who have various chronic medical conditions which could be included under this scheme. Diabetics alone would be a substantial number of people, if they all received what we would call medically necessary dental treatment under this bill, getting quite an additional amount of dental care. There may be some difficulty in obtaining appointments and care within reasonable time periods.

Senator MOORE —In terms of access, one of the things that came out was that, whilst it is very clear that the public health system is there to provide dental services to a range of people now, this is addressing the fact that there needs to be better access for some people—I think the figures we have been told are 85 per cent of dentists in Australia now work in the private system.

Prof. Spencer —Yes, they do and certainly this bill would cover dental care that is for people who are going to be largely outside of the eligible group for public dental care, but that is not entirely the case. Among those who are eligible for public dental care, around 60 per cent of them seek their dental care in the private sector. Many are old or older adults in our community. Many will have medical conditions that may actually see them seeking to be part of this GP management plan and the team care arrangements, but the numbers could grow quite quickly.

Senator MOORE —Yes, and your submission talks about the numbers of people who are under a GP management plan and team care being estimated at approximately 400,000. I do not think any scheme is looking at that degree of increase, but somewhere between 45 and 400. Planning for the future along those lines is really important to make it work.

Prof. Spencer —Absolutely. And there is almost a tenfold difference there. If it were to flow through into the financial impact of this bill, you would be talking about very substantial amounts of funds flowing into dental care. I feel that accentuates the need for there to be rigorous monitoring and evaluation, in the sense of having at least an associated notion of more formal research—collaborative partnership research between the medical and the dental professions—about the benefits that might flow from people’s full oral health being attended to, in terms of the management of their medical condition.

Senator MOORE —To the best of your knowledge, is there any research of that nature happening now?

Prof. Spencer —In very briefly responding to the invitation last week, I returned to some material that I had aside on this sort of area. There are a limited number of studies of key areas where the management of people’s medical condition seems to have been compromised by poor oral health. There are examples: diabetes is one where the link seems to be reasonably accepted. With patients who have heart problems that actually require surgery—valve replacements and the like—clearly there is some evidence that the effectiveness, the outcomes, of the surgical interventions for their cardiovascular disease are influenced by poor oral health. With renal disease, in renal dialysis and other things, poor oral health is thought to be important. And for anyone who is presenting for transplantation, poor oral health is thought maybe to work against the best outcomes for that. So not all of these are—transplantation certainly is not—what we would call chronic medical conditions, which seems to be the definition that is being used for the medical circumstances in which this bill would operate.

There are numerous other examples where medical and dental conditions are thought to be tightly linked but, again, it is not necessarily in the direction of the poor oral health influencing the general health. I might mention things like irradiation for head and neck cancers. We know that leads to dramatic complications in terms of oral health, but the directionality there is exactly the opposite of that in the premise behind this bill.

Senator BOYCE —Professor, you just talked about transplantation, but surely a transplant would only occur if someone did have a chronic condition—that is, there would be an underlying chronic condition that had led to the transplant being necessary.

Prof. Spencer —That might be the case, and I did not get any sense, when I read the bill, that transplantation, for instance, would be something that would be managed by a GP management plan and team care arrangements. I guess that simply shows that I do not know exactly what medical conditions will be in or out of those sorts of arrangements.

Senator BOYCE —Do you have knowledge of the state dental services and systems and their operations?

Prof. Spencer —I head up a centre that looks at all population oral health matters across Australia, so we deal a lot with states and territories.

Senator BOYCE —You commented in your submission that there are a lot of Australians with poor oral health who would not obtain dental services under the bill. Compare that with a statement in the federal Department of Health and Ageing’s submission which points out that, in Australia, state and territory governments are responsible for the planning, funding and delivery of public dental services—including that to concessional patients and children. I wonder if there will be any opportunity here for the state services—which appear to be chronically underfunded and have enormous waiting lists—to improve their delivery.

Prof. Spencer —I think there is. This bill will certainly impact upon the delivery of public dental services at the state and territory level insofar as the eligible clientele for those public dental services are people with chronic medical conditions. The existence of Medicare dental services arrangements would either draw some people out of public dental care—which they might be eligible for and waiting for—into the private sector for those services or it might simply retain people outside the system who will obtain their care in the private sector instead of seeking it in the public sector.

CHAIR —That is a good thing. Obviously the state systems are pretty overloaded at the moment and drawing people into the private sector would surely relieve the overall burden of unmet need in the dental system at the moment.

Prof. Spencer —The only tempering comment I would make to that is that some 60 per cent of those who are eligible for public dental care already seek their care in the private sector.

Senator BOYCE —Is that not because the public sector simply does not function?

CHAIR —Yes.

Prof. Spencer —It is a combination of things really. Some of it might be regarded as a comment upon the long waiting lists for general dental care in the public dental services. Some of it might be for people being regular visitors to a private dentist for most of their adult life and, when they retire and obtain the age pension, making them eligible for public dental care, they want to continue to get care from a private practice dentist they have come to know. So it is a bit hard to work out exactly the dynamics by which many of those people make choices about seeking their care in the private sector.

CHAIR —On the question of the cost of the scheme, in evidence this morning the witness from the Australian Dental Association questioned whether the Medicare model—the universality principle in the Medicare model—was appropriate for this scheme. They suggested that a different model might be applied, for example, where access to the scheme was means tested. Do you have any thoughts about whether Medicare is the right kind of model for this kind of access to dental care?

Prof. Spencer —This is not a universal program; this is a targeted program where eligibility is defined by the existence of a chronic medical condition and being—

CHAIR —But it is universal in the sense that it is not means tested. Anybody in any income bracket can access this.

Prof. Spencer —There certainly has been some discussion since the policy was announced that there would be individuals who are financially very independent and very capable of financing their own care, and who may also be privately insured, who will end up being eligible for this sort of program. In an environment where there are many adults in the Australian community who are struggling to purchase private dental care, some people might feel that that is relatively inequitable.

CHAIR —What do you feel?

Prof. Spencer —This is not applying the basic universality principle to dental services; this is a targeted program. In some respects the individuals who are targeted here are those who are ill. That is always a good starting point for targeting a program. Whether one wants to add a second layer of eligibility using income or assets tests or something like that is, I think, a secondary question here.

Senator MOORE —I have a question on the cost. I am trying to get my head around the amount of treatment that can be covered, because the program is built on the program that offers three sessions at around $200—to $4,250 over two years. Where do you think the figures come from? I know you do not know exactly, but do you have any idea? Secondly, from a dental perspective, is $4,250 worth of services an amount that could reasonably be seen as an average treatment cost?

Prof. Spencer —This is clearly well-supported dental treatment in terms of the capping that is applied here at $4,250 within a two-year period. The expenditures that the community in general make on dental care are much lower than that. The average adult in Australia seems to spend a figure in the low $300 range a year on dental services. That average is of course made up of many people who are spending very little because they are not visiting dental services—or they are visiting public dental services and receiving dental treatment in the main at no direct cost to themselves—through to people who are spending very large amounts of money. This would appear to be quite generous support for the management of these people’s dental needs. It would certainly cover all routine dental care very adequately. The reason why it is that high is that there is clearly an indication that some less than routine dental treatment will also be covered under the program. That pushes the maximum ceiling up.

Senator MOORE —How much do dentures cost?

Prof. Spencer —I could not give you an exact figure, but if you are talking about full upper and full lower dentures they are probably in the order of $1,000 to $1,500. A single partial denture might be in the same sort of range—maybe $1,500. If you include crown work of various sorts—maybe endodontic treatment crown work—then you can very quickly find yourself looking at several thousand dollars for a treatment plan.

Senator MOORE —One of the big differences in this scheme compared with the previous one is the inclusion of those things. It was very much demand driven. We heard from the community that, for many people, that was one of their major costs. My understanding is that this scheme is very much mirrored on the DVA system, which does offer those things.

Prof. Spencer —It does and it does seem to be mirrored on the DVA arrangement. The only comment that I would make is that the spirit that surrounds the provision of care under DVA is that these are people who have put themselves in harm’s way for the nation’s good and we have every reason to provide them with the best of care. At its maximum limit, this scheme seems to open the door to a very high quality of dental care being provided to those people who are eligible.

Senator MOORE —Some of the questions that I have left with the department to look at concern the impact on people in aged care facilities and also Indigenous health. Has your school done work in either of those areas specifically?

Prof. Spencer —Absolutely.

Senator MOORE —If you have a look at the department’s submission, they have given us a very useful diagram that compares the existing scheme with the new one, and the changes. A component that has been put in both is that if people who live in aged care facilities have one of the GP-generated programs, they will be eligible for this. I am trying to get a sense of how many people in aged care facilities access private care in this way. Secondly, we have evidence from other hearings that chronic disease is particularly evident in the Indigenous population and you would therefore think that their access to these services would be higher, percentage wise, than that for other parts of the population. The department is going to look at Indigenous take-up of these schemes as opposed to specialised Indigenous dental services, which we are getting some figures on. Do you have any comments on those two special needs groups?

Prof. Spencer —We have conducted quite a lot of research among both groups. It would be reasonable to say that a high percentage of older adults in Australia who are in residential aged care facilities would have a chronic condition and complex needs. Therefore, a very high percentage of the 150,000-odd Australians who are in residential care might fit the criterion in terms of chronic disease. What I am unaware of is what percentage of the people in aged care facilities are under a GP management plan or team care arrangements.

Senator MOORE —We have asked the department to see whether they can find out.

Prof. Spencer —I do not know the answer to that but it would be a very interesting thing to know. If they are not under such arrangements at the moment, I am sure that there are going to be patients and dentists who would like them to be. In the area of Aboriginal health in Australia, we are all well aware of the very high rates of particular chronic conditions such as diabetes, which I would have thought would have captured a high percentage of the adult Aboriginal population into such a program, theoretically. But again I am unaware what percentage might have their medical needs managed in a way where they satisfy the basic criterion of already being in a GP management plan and team care arrangement.

CHAIR —Thank you for your evidence today and the time you have spent with the committee. It has been very useful indeed.

Committee adjourned at 12.08 pm