Report of the National Advisory Council on Dental Health

Appendix C - Service Delivery Options

The National Advisory Council on Dental Health (the Council) was established as a time-limited group to provide strategic, independent advice on dental health issues, as requested by Minister for Health and Ageing, to the Government. The Council’s priority task was to provide advice on dental policy options and priorities for consideration in the 2012-13 Budget.

Page last updated: 03 September 2012

This Appendix provides information in three tables about the Service Delivery Options for:

  • Children;
  • Adult Card Holders; and
  • Adult Card Holders and Children, as an example of an Integrated Option.

Service Delivery Options for Children

The following table provides information about the Service Delivery Options for Children.
Note: There would be special arrangements in all options to overcome barriers to access for some sections of Indigenous, those with mental health issues or disabilities, homeless, aged care residents and rural and regional areas.

Options Costs Issues
Need:
• There is an increasing prevalence of caries in children.
• 20% of all children do not have adequate access to services.
Objective:
• Improved access for all children up to the age of 18 (5.4 million children), covering basic dental, including preventive and treatment services.
Final costs will depend on level of service, entitlement, and implementation. All estimates should be taken as indicative only. General
- This option would involve an increased investment in child dental services.
- Would require measures to develop workforce capacity to meet increased service demands and address gaps in access to services.
- Note variations in how services are delivered between states, varying from dedicated school dental service arrangements to community–based only, such as NSW and Vic.
- Full implementation would need several years to build child dental system across all states and territories, including building infrastructure and data systems, and establishing standards of care.
- Would require engagement through COAG on funding and service delivery.
- Some states and territories already offer services for all children without means test.

Option 1.
Universal Individual Capped Benefit Entitlement for Children

Estimated cost over the forward estimates from 2012–13 – $3.0b Fully implemented cost– $904m per year

Operation:
- Use an individual capped benefit entitlement system to allow access to basic dental preventive and treatment services (to be defined) through a schedule of benefits.
- Existing MTDP could be a modified and expanded as the vehicle for service delivery.
- Entitlement could be scaled to reflect costs outside metro/regional centres.
- Entitlement could be used in public or private sectors, with schedule benefits set to cost of providing services in public system.
- Use of the public sector free for services in the schedule.
- As part of this option, measures to identify and reach children who face access barriers would be implemented, which may include separate investment in additional infrastructure (e.g. through Medicare Locals, State and Territory Child/School Dental Services).
Implementation
Implementation could be scaled over time to recognise context of fiscal environment and need for phased introduction to allow development of capacity and systems.

Scaling of options applies to a capped benefit entitlement (Option 1) as some states and territories already provide universal access to services.
Options for Scaling (indicative costs over the forward estimates from 2012–13)
A. Eligibility set to children in concession card families:
    2 million children: $1.3b
B. Include children up to low income non–concession card threshold (to be defined):*
    2.9 million children: $1.7b
C. Include children up to FTB–A threshold:
    3.4 million children: $2.0b
D. Include all children:
    5.4 million children:
    Option 1 - $3.0b
    Option 2 - $2.5b


* population estimate indicative only – to be further developed already provide universal access to services.
All Scaled Options
- As some states and territories offer universal access to services, a scaled introduction would need to consider how funding could be provided to ensure target groups have access to agreed service levels.
- Children from families not meeting means test may still have difficulties affording appropriate dental treatment services – this could put pressure on states and territories that provide non–means tested access to public dental services.

Scaled Option A and B
- Means test is inconsistent with MTDP means test, which subsidises access to preventive care for those meeting higher FTB-A thresholds.
Option 2.
Universal Public Dental Access for Children

Estimated cost over the forward estimates from 2012–13 – $2.5b
Fully implemented cost – $717m per year


Operation:
- Use public dental system to provide access to nationally consistent basic dental preventive and treatment services (to be defined) – this would be an enhancement to the existing public dental system.
- States and territories would be able to purchase from private sector services as they build nationally consistent services and coverage.
- Children from card holder families would be provided with access to free basic dental preventive and treatment services.
- Could have limited co–pays for non–card holders, noting that some states and territories already have co–payments.
- As part of this option, measures to identify and reach children who face access barriers would be implemented, which may include separate investment in additional infrastructure (e.g. through Medicare Locals, State and Territory Child/School Dental Services).
- Modelling of cost is based on the public system acting as a limiter of services due to capacity constraints of the system and expectation that some patients will maintain private sector access and not switch to the public system. This results in lower overall costs than the benefit entitlement option.
- Additional measures to reach children who are receiving inadequate service.
Implementation
Implementation could be scaled over time to recognise context of fiscal environment and need for phased introduction to allow development of capacity and systems.

Scaling of options applies to a capped benefit entitlement (Option 1) as some states and territories already provide universal access to services.
Options for Scaling (indicative costs over the forward estimates from 2012–13)
A. Eligibility set to children in concession card families:
    2 million children: $1.3b
B. Include children up to low income non–concession card threshold (to be defined):*
    2.9 million children: $1.7b
C. Include children up to FTB–A threshold:
    3.4 million children: $2.0b
D. Include all children:
    5.4 million children:
    Option 1 - $3.0b
    Option 2 - $2.5b


* population estimate indicative only – to be further developed already provide universal access to services.
All Scaled Options
- As some states and territories offer universal access to services, a scaled introduction would need to consider how funding could be provided to ensure target groups have access to agreed service levels.
- Children from families not meeting means test may still have difficulties affording appropriate dental treatment services – this could put pressure on states and territories that provide non–means tested access to public dental services.

Scaled Option A and B
- Means test is inconsistent with MTDP means test, which subsidises access to preventive care for those meeting higher FTB-A thresholds.

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Service Delivery Options for Adult Card Holders

The following table provides information about the Service Delivery Options for Adult Card Holders.
Note: There would be special arrangements in all options to overcome barriers to access for some sections of Indigenous, those with mental health issues or disabilities, homeless, aged care residents and rural and regional areas.

Options Costs Issues
Need:
• Estimated up to 400,000 adults on public dental waiting lists.
• 42% of card holders have an unfavourable visiting pattern (i.e., do not visit the dentist every year).
• Only 10% of card holders receive treatment in the public system in any one year.
Objective:
• Improved access for all adult card holders (5.1 million adults), covering basic dental, including preventive and treatment services.
Final costs will depend on level of service, entitlement, and implementation. All estimates should be taken as indicative only. General
- This option would involve an increased investment in adult dental services.
- Would require measures to develop workforce capacity to meet increased service demands and address gaps in access to services.
- Implementation would need several years to build child dental system across all states and territories, including building infrastructure and data systems, and establishing standards of care.
- Would require engagement through COAG on funding and service delivery.
- Administering an exceptional circumstances scheme for access to higher level services would be costly at a population level.

Option 3.
Means Tested Individual Capped Benefit Entitlement for Adults – Concession card eligible only

Estimated cost over the forward estimates from 2012–13 – $7.1b
Fully implemented cost – $2.6b per year


Operation:
- Use an individual capped benefit entitlement system for adult card holders to allow access to basic dental preventive and treatment services (to be defined) through a schedule of benefits.
- Existing CDDS could be modified as the vehicle for service delivery if chronic disease patients included as a target group.
- Entitlement could be scaled to reflect costs outside metro and regional centres, and/or to account for increase service costs for certain groups, e.g. chronic disease patients, denture patients.
- Entitlement could be used in public or private sectors, with schedule benefits set to cost of providing services in public system.
- Use of the public sector free for services in the schedule.
- Eligibility could be scaled up to include other groups, e.g., chronic disease patients, low income non–concession card holders.
- Access to higher level services (e.g., crowns, bridges, implants) could be controlled through an exceptional circumstances application process based on advice from expert group.
- Introduce measures to fast track services to patients on public dental waiting lists.
Implementation
Implementation could be scaled over time to recognise context of fiscal environment and need for phased introduction to allow development of capacity and systems.

Access to entitlement can also be scaled up from concession card holders (below). Inclusion of low income non–concession card holders only applies to a capped benefit entitlement (Option 1) as it is not expected that the public system would build capacity for delivering services to this additional group within the 4 year Budget period.

Options for Scaling (indicative costs over the forward estimates from 2012–13)
A. Eligibility set to concession card holders:
    5.1 million adults:
    Option 1 - $7.1b
    Option 2 - $3.0b
B. Include chronic disease dental patients (eligibility to be defined):°
    5.1 million adults:
    Option 1 - $8.3b
    Option 2 - $4.3b
C. Include chronic disease patients and low income non-concession card holders (to be defined):*
    7.6 million adults + chronic disease patients:
    Option 1 - $11.4b


° Estimated costs of including chronic disease patients include broad assumptions about measures to constrain expenditure.

* Population estimate indicative only – to be modelled. Low income non–concession card holder numbers indicative of those on threshold incomes of $60,000 for couples and $30,000 for singles.
Scaled Option B and C
- Introduction of chronic disease population group is unlikely to be able to occur in the short term – increased capacity would need to be developed to ensure service and access standards could be met.
- Any differential access for chronic disease patients would put pressure for equity of services levels and funding for the rest of the population.
- Still to be determined how the chronic disease eligibility gateway would operate. Tightening of chronic disease test would need to be determined based on clinical advice from an expert group.
- Extent of access to exceptional circumstances gateway to be determined (access to higher level restorative items not included in costings).

Scaled Option C
- Unlikely public dental system in Option 2 (Means Tested Public Dental Access for Adults) would be able to absorb low income non–concession card holder adults in the short or even middle term and has not been costed – increased capacity would need to be developed to ensure service and access standards could be met.
Option 4.
Means Tested Public Dental Access for Adults – Concession card eligible only

Estimated cost over the forward estimates from 2012–13 – $3.0b
Fully implemented cost – $1.3b per year


Operation:
- Use public dental system to provide access to free, or limited fee, nationally consistent basic dental preventive and treatment services (to be defined) – this would be an enhancement to the existing public dental system.
- States and territories would be able to purchase from private sector services as they build nationally consistent services and coverage, including access to higher level services in exceptional circumstances.
- Eligibility could be scaled up to include other groups, e.g. chronic disease patients, low income non–concession card holders, but would require similarly scaled increased investment in public system for infrastructure and workforce.
- Access to higher level services (e.g., crowns, bridges, implants) could be controlled through an exceptional circumstances application process based on advice from expert group.
- Introduce measures to fast track services to patients on public dental waiting lists.
- Modelling of cost is based on the public system acting as a limiter of services due to capacity constraints of the system and expectation that some patients will maintain private sector access and not switch to the public system. This results in lower overall costs than the benefit entitlement option.
Implementation
Implementation could be scaled over time to recognise context of fiscal environment and need for phased introduction to allow development of capacity and systems.

Access to entitlement can also be scaled up from concession card holders (below). Inclusion of low income non–concession card holders only applies to a capped benefit entitlement (Option 1) as it is not expected that the public system would build capacity for delivering services to this additional group within the 4 year Budget period.

Options for Scaling (indicative costs over the forward estimates from 2012–13)
A. Eligibility set to concession card holders:
    5.1 million adults:
    Option 1 - $7.1b
    Option 2 - $3.0b
B. Include chronic disease dental patients (eligibility to be defined):°
    5.1 million adults:
    Option 1 - $8.3b
    Option 2 - $4.3b
C. Include chronic disease patients and low income non-concession card holders (to be defined):*
    7.6 million adults + chronic disease patients:
    Option 1 - $11.4b


° Estimated costs of including chronic disease patients include broad assumptions about measures to constrain expenditure.

* Population estimate indicative only – to be modelled. Low income non–concession card holder numbers indicative of those on threshold incomes of $60,000 for couples and $30,000 for singles.
Scaled Option B and C
- Introduction of chronic disease population group is unlikely to be able to occur in the short term – increased capacity would need to be developed to ensure service and access standards could be met.
- Any differential access for chronic disease patients would put pressure for equity of services levels and funding for the rest of the population.
- Still to be determined how the chronic disease eligibility gateway would operate. Tightening of chronic disease test would need to be determined based on clinical advice from an expert group.
- Extent of access to exceptional circumstances gateway to be determined (access to higher level restorative items not included in costings).

Scaled Option C
- Unlikely public dental system in Option 2 (Means Tested Public Dental Access for Adults) would be able to absorb low income non–concession card holder adults in the short or even middle term and has not been costed – increased capacity would need to be developed to ensure service and access standards could be met.

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Service Delivery Options for Adult Card Holders and Children

The following table provides information about the Service Delivery Options for Adult Card Holders and Children, as an example of an Integrated Option.
Note: There would be special arrangements in all options to overcome barriers to access for some sections of Indigenous, those with mental health issues or disabilities, homeless, aged care residents and rural and regional areas.

Options Costs Issues
Need:
• Estimated up to 400,000 adults on public dental waiting lists.
• 42% of card holders have an unfavourable visiting pattern (i.e., do not visit the dentist every year).
• Only 10% of card holders receive treatment in the public system in any one year.
• There is an increasing prevalence of caries in children.
• 20% of all children do not have adequate access to services.
Objective:
• Improved access for all adult card holders (5.1 million adults) and all children to the age of 18 (5.4 million children), covering basic dental, including preventive and treatment services.
Final costs will depend on level of service, entitlement, and implementation. All estimates should be taken as indicative only. General
- This option would involve an increased investment in adult dental services.
- Would require measures to develop workforce capacity to meet increased service demands and address gaps in access to services.
- Implementation would need several years to build child dental system across all states and territories, including building infrastructure and data systems, and establishing standards of care.
- Would require engagement through COAG on funding and service delivery.
- Administering an exceptional circumstances scheme for access to higher level services would be costly at a population level.
Example Integrated Option.
Improved access to basic dental services for adult card holders and all children – means tested capped benefit entitlement for concession card adults only and universal public dental access for children

Estimated cost over the forward estimates from 2012–13 – $10.1b
Fully Implemented cost – $3.3b per year.


Operation:
- The Commonwealth would fund a capped benefit entitlement system for adult card holders to allow access to basic dental preventive and treatment services (to be defined) through a schedule of benefits.
    · Existing CDDS could be modified as the vehicle for service delivery if chronic disease patients included as a target group.
    · Entitlement could be scaled to reflect costs outside metro and regional centres, and/or to account for increase service costs for certain groups, e.g. chronic disease patients, denture patients.
    · Entitlement could be used in public or private sectors, with schedule benefits set to cost of providing services in public system.
    · Use of the public sector free for services in the schedule.
    · Eligibility could be scaled up to include other groups, e.g., chronic disease patients, low income non–concession card holders.
    · Access to higher level services (e.g., crowns, bridges, implants) could be controlled through an application process based on advice from expert group.
    · Measures to fast track services to patients on public dental waiting lists.

- The states and territories would maintain existing funding levels for all children to access nationally consistent basic dental preventive and treatment services (to be defined) – this would be an enhancement to the existing public dental system.
    · States and territories would be able to purchase from private sector services as they build nationally consistent services and coverage.
    · Children from card holder families would be provided with access to free basic dental preventive and treatment services.
    · Could have limited co–pays for non–card holders, noting that some states and territories already have co–payments.
    · As part of this option, measures to identify and reach children who face access barriers would be implemented, which may include separate investment in additional infrastructure (eg., Medicare Locals, State and Territory Child/School Dental Services).
Implementation
Implementation could be scaled over time to recognise context of fiscal environment and need for phased introduction to allow development of capacity and systems.

Access to entitlement can also be scaled up from concession card holders (below).
Options for Scaling (indicative costs over the forward estimates from 2012–13)
A. Eligibility set to concession card holders:
    5.1 million adults: $7.1b
B. Include chronic disease dental patients (eligibility to be defined):°
    5.1 million adults:
    + chronic disease patients: $8.3b
C. Include chronic disease patients and low income non-concession card holders (to be defined):*
    7.6 million adults
    + chronic disease patients:$11.4b

No scaling options have been provided for child portion of option as some states and territories already provide universal access to services.

Universal Public Access for Children (indicative costs over the forward estimates from 2012–13) -
5.4 million children: $2.5b


° Estimated costs of including chronic disease patients include broad assumptions about measures to constrain expenditure.

* Population estimate indicative only – to be modelled. Low income non–concession card holder numbers indicative of those on threshold incomes of $60,000 for couples and $30,000 for singles.
Scaled Option B and C
- Introduction of chronic disease population group is unlikely to be able to occur in the short term – increased capacity would need to be developed to ensure service and access standards could be met.
- Any differential access for chronic disease patients would put pressure for equity of services levels and funding for the rest of the population.
- Still to be determined how the chronic disease eligibility gateway would operate. Tightening of chronic disease test would need to be determined based on clinical advice from an expert group.
- Extent of access to exceptional circumstances gateway to be determined (access to higher level restorative items not included in costings).

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