Minority report - Australian Labor Party
Introduction
Labor Senators consider that Australia is in the grips of a
dental care crisis, caused in large part by insufficient Federal Government investment
and lack of planning as to Australia’s dental workforce.
The Government abolished the Commonwealth Dental Health
Program (CDHP) in 1996, withdrawing $100 million from public dental services.
Public dental waiting lists have now blown out to 650,000 people around the
country, with many people waiting years for treatment.
As recognised by the majority report – "Statistics are
regularly produced on the deteriorating oral health for many Australians and
lengthy waiting time for treatment."[1]
Labor Senators consider that it is plainly inadequate to
provide funding for acute dental services after the Government has removed its
contribution to general and preventative dental care, as provided through the
CDHP.
It is the view of Labor Senators that the Government has
also failed to adequately plan for Australia’s dental workforce. This lack of
planning over the past decade is already severely limiting the public’s access
to both public and private dental services when and where they need them.
Labor Senators welcome the recent expansion of dentistry
places and the Budget announcement of a new dental school at Charles Sturt University,
however comprehensive and strategic national policies are required to ensure a
long term solution to this crisis. Not enough has been done, in particular, to
address regional and rural demand for dental professionals.
As acknowledged in the evidence / submission, this Bill will
do little to tackle public dental waiting lists and does nothing to improve Australia's
dental workforce problems.
The proposed amendments, if introduced appropriately, will have
the potential to improve oral health and general health conditions for eligible
patients. A large number of noneligible Australians will still find dental
services beyond their reach and will continue to languish on public sector
waiting lists. This is a regrettable situation and one which it is hoped can be
addressed in the near future.[2]
We are concerned that these arrangements will be inequitable and
only benefit those in communities well served by dentists in private practice. There
are only about 9000 practising dentists in Australia. The vast majority of
these work in either central business districts or middle class residential
suburbs of major population centres. AGPN strongly suggests that consideration
be given to how existing schemes that support patient access such as the
Medical Outreach Specialist Program (MSOAP) and the Patient Assisted Travel
Scheme could accommodate access to dental treatment services.[3]
It is the view of Labor Senators that an investment of the
magnitude proposed by the Government should be directed towards a broad based
Commonwealth scheme that better addresses the priority oral health needs of
those groups in the community most in need of assistance.
1.1 Labor Senators do not support the majority
report's finding that this Bill is "a fundamentally important step in
improving access to dental services and care for many Australians."
This Bill - which will allow for the expansion of the
Government’s failing Enhanced Primary Care dental scheme - does not address
many of the shortcomings of the current scheme and Labor Senators are not
satisfied that it should be supported in its current form. As Professor John Spencer
notes in his submission to the Committee, "many Australians who suffer
with poor oral health will not obtain dental services through this Bill."[4]
The Government first introduced
the Enhanced Primary Care dental scheme in July 2004. As was recognised in
submissions to the Committee, the existing scheme has been plagued by low take
up since its introduction. The Department provided figures on the uptake of the
EPC dental items over the first three years as follows:
|
2004-05 |
2005-06 |
2006-07 |
2004-2007
(3 years) |
Services
|
3,157 |
5,532 |
7,754 |
16,443 |
Benefits paid
|
$0.3m |
$0.7m |
$0.8m |
$1.8m |
Patients
|
1,404 |
2,461 |
3,336 |
6,253 |
Providers
|
583 |
743 |
900 |
1,468 |
Source: Submission no2, p.3
(Department of Health and Ageing).
As the Department itself has acknowledged, stakeholders have
identified a number of barriers to the uptake of the existing items.
The main criticisms are that the items are too limited and
inadequately funded. In particular:
- the current limit of three services per year (one of
which must be a dental assessment) is a barrier to dentists initiating
treatment for people with poor oral health. Dental treatment can be started
but not finished in three services, and many patients do not have the capacity
to pay for unfinished work; and
- the current rebate is not high enough to encourage most
dentists to participate in Medicare or to bulk bill the service.[5]
While Labor Senators acknowledge that the Government has
provided for a higher Medicare rebate to be paid under the new policy, it has
failed to address other key problems with the scheme.
The Committee’s attention has been drawn to a range of
problems:
From the ADA:
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 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.[6]
From the AMA:
There is however some ongoing concern that GPs have difficulty
locating a dentist who will accept the rebates as full payment when referring
patients. It is anticipated that other initiatives announced in the last
Federal Budget will go some way to addressing this issue.[7]
From John Spencer:
Second, classifying those medical conditions which are adversely
affected by poor oral health is a difficult task. Poor oral health may quite
plausibly affect nearly all medical conditions through pathways involving
reduced ability to chew, altered food choice and decreased nutritional value of
foods consumed. Alternatively oral symptoms may adversely affect quality of
life, reducing coping and self-efficacy. However, there is lack of research in
these areas. There is difficulty in ruling a line between medical conditions
which are affected or not by poor oral health. At present any decision about
what conditions are included will seem quite arbitrary.
Third, the criteria for inclusion of dental services in a GP
Management Plan are not defined. Uncertainty about specific medical conditions
to be included could lead to either few or many eligible patients receiving
dental care. Past experience with much lower rebates was that few eligible
patients received dental care. If the new arrangements are more attractive to
patients, general medical practitioners and dentists, it is possible that most
people under a GP Management Plan and Team Care Arrangements, estimated at
approximately 400,000, could desire dental care. At the maximum Medicare
benefit for dental services and the level of funding set out in the Financial
Impact Statement only some 45,000 people will receive dental care in any year
of full funding. How then will the one in eight eligible adults under a GP
management Plan be chosen by their general medical practitioner? Will they be
limited to people with particular chronic conditions, specific oral disease or
dental treatment needs, financial circumstances, or none of these criteria.[8]
From the ADA Queensland:
However this only addresses one of the limitations of the
current scheme. The administration of the scheme is still an area that dentists
have expressed concern about. Unfamiliarity with Medicare will continue to
provide a barrier to practitioner involvement...
In summary, current Medicare Dental Services arrangements have
failed to gain popular acceptance by dental practitioners because of financial
and administrative difficulties. Increasing maximum patient rebates is only one
part of the solution to these problems. The successful inclusion of dental
services into Medicare must be done in such a way as to minimise the disruption
to the practice routine of providers. This demands an alteration to the way in
which Medicare is administered with regard to these services rather than a new layer
of administration being imposed on an already highly regulated dental
workforce. As the success of the scheme is reliant on uptake by practitioners,
the administration must be tailored to their needs, which will in turn lead to
outcomes tailored to the health needs of patients.[9]
In addition, Labor has been briefed by stakeholders that the
poor take-up of this program to date has been due to the complex and
restrictive eligibility criteria, limiting coverage to those whose oral health
exacerbates their chronic disease. Despite the fact that the three existing
Medicare items are to be expanded to some 450 items, there is no detail
available as to whether the narrow eligibility criteria of the original program
will be expanded.
The Bill itself explains very little, instead leaving the
detail of the Government’s new program - including the eligibility requirements
for dental providers and patients - to a Ministerial Determination.
In the absence of these details around eligibility it is
impossible to be confident that this program will do anything to address the
dental needs of the 650,000 Australians on public dental waiting lists around
the country.
Further, Labor Senators are concerned that the 450 Medicare
items proposed will only compound the complexity of this program, particularly
for dentists who are not particularly familiar with Medicare.
1.2 Labor Senators do not agree with the majority
report’s finding that the submissions made to the Committee provided broad
support to the Bill. In fact, many of the submissions to, and witnesses before,
the Committee highlighted that the Government’s current Enhanced Primary Care
dental scheme had significant shortcomings and that many of these flaws would
be continued on to the expanded program.
While increased investment and slight modifications to the
scheme were welcomed by some submissions / witnesses, a number noted the
continuing limitations of the scheme. Most particularly the Committee explored
the groups that would not be assisted by the Government’s expanded scheme.
The access to the proposed scheme, by people with special
needs, the aged and indigenous people, was questioned at the hearing. Medicare
figures do not breakdown the usage of the current scheme, so it is difficult to
predict the take up in the new scheme by people who are already identified by
the sector, as having particular oral health needs. While any patient who is
subject to a multidisciplinary care plan for a chronic illness may be eligible
for the scheme, Labor Senators have real concerns that the complex, often
entrenched, oral health issues experienced by older people, people with special
needs, and indigenous Australians, will not be effectively addressed by this
scheme. The current scheme has not been widely used across the community, and
the gaps will not be met by the increased supplement.
1.3 Labor Senators strongly argue against the
majority report’s recommendation that a formal information and education
program targeting dentists be established, including information about the
working of the new Medicare rebates relating to dentistry. Labor Senators are
suspicious that this is a flimsy excuse for yet another Government pre-election
advertising campaign.
It is the view of Labor Senators that providing resources to
such an education program would be wasteful, and that such resources would be
more efficiently and effectively utilised in a broad-based public health
campaign highlighting preventative oral health care. Such a campaign was in
fact recommended by this Committee in its 1998 Inquiry: "That the
Commonwealth, in consultation with the States and Territories and other key
stakeholders in the public and private dental sectors, support the development
of programs to improve the promotion of oral health throughout Australia."
Labor Senators consider that a broad based education
campaign should be based on preventative oral health care, however we note that
such a campaign can only be effective if the accompanying general and
preventative services are available. Such services are not available under the
Government’s acute care program.
Senator Claire Moore
ALP, Queensland |
Senator Carol Brown
ALP, Tasmania |
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Senator Helen Polley
ALP, Tasmania |
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