Report of the National Advisory Council on Dental Health

Options for Low Income Adults

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

      There are significant barriers to dental care for lower income adults. As noted in Chapter Three, around 42 per cent of adults eligible for public sector dental care have an unfavourable visiting pattern and up to 400,000 adults are on public dental waiting lists.

      The main objective of the adult options is to improve oral health by dealing with the existing oral health problems, thereby laying a foundation for more effective preventive measures into the future.

      The Council has developed two options to addressing the oral health needs of lower income adults, based on current systems for dental service delivery. The first would use a means tested individual capped benefit entitlement, building on existing legislative frameworks. Alternatively, the second would provide basic preventive and treatment services through the public dental system. These options are designed as a stepping stone on a path to a universal access program.118

      118 The interaction of the adult options with the CDDS is considered on page 77.

      Option 3 – Access to a means tested individual capped benefit entitlement

      The objective of this option is to improve access to dental services to concession cardholder adults by funding access to basic preventive and treatment.

      Operation

      This option would provide an individual capped benefit entitlement for all concession card holder adults. This would be funded by the Commonwealth.

      Limited access to more complex high end items (e.g. bridges, crowns and implants) could be provided through a separate ‘exceptional circumstances’ mechanism.

      The benefit entitlement could be used to access care in the private or public sector. This would complement existing arrangements under the CDDS and allows patient choice as to the location of care.

      Patients would access clinically necessary services on a calendar year basis from either the public or private sector. Dental practitioners would be able to provide services based on the schedule of benefits, up to the value of the entitlement. Services provided in the public sector would be free to the patient.

      The individual capped benefit entitlement would cover a schedule of services. An example of a schedule has also been developed by experts from the Council (refer to Appendix K). Access would be means tested to include only cardholder adults.

      As discussed in Chapter Two, there are more than 400,000 patients on public dental waiting lists. As they wait, these patients’ oral health is deteriorating, and they may end up with other medical conditions as a result. Therefore, as a first step, an option that can be implemented before the broader adult option described above, is to provide additional funding to states and territories for treatment for these patients. The majority of the Council believe that this must be implemented as an integral part of broader dental reform. Without an ongoing major investment in a broader program, this measure would create increased demand for public dental services and result in longer public dental waiting times.

      Timing of implementation

      In the short term, workforce and infrastructure capacity constraints will limit the extent to which demand can be met. The take–up rate of the scheme is expected to gradually increase, as capacity to provide services increases. The foundational support measures described later in this chapter will contribute to this increase in capacity.

      Scalability

      This option sets the foundation for longer–term increased coverage. The eligibility criteria should be expanded over time to include other groups such as chronic disease sufferers (who are currently receiving services under the CDDS program) and lower income, non–concessional patients. The addition of both of these groups would provide benefits for over 7.6 million people: 5.1 million concession card holders; 2.3 million low income non–concessional patients; and an estimated 176,000 chronic disease sufferers currently accessing Commonwealth dental benefits,119 noting that the majority of current chronic disease patients would be included in the first two groups.

      119 Estimated number of CDDS patients at time of administering a new scheme.

      There may be natural scaling of this option, as some proportion of concession card holders hold private health insurance and they may prefer to access private services through this mechanism.

      The indicative costing below includes both the individual capped benefit entitlement program and a measure to address waiting lists. The measure for addressing waiting list patients would be an additional $343 million in 2012–13.

      Table 6.3 – Projected expenditure for Option 3.

      Option 3 ($ billion) 2012–13 2013–14 2014–15 2015–16 Total cost over the forward estimates Annual cost once fully implemented
      Option —access for concession card adults, plus a waiting list measure 0.3 2.1 2.3 2.5 7.1 2.6
      Option – including chronic disease patients, plus a waiting list measure 0.3 2.3 2.7 2.9 8.3 3.1
      Option – including chronic disease and other low income adults, plus a waiting list measure 0.3 3.2 3.7 4.0 11.4 4.2

      Note: Estimates do not include the transitional costs associated with any affected legacy programs. Numbers may not add due to rounding.

      Comments

      The key advantage of this option is that it is a simple and coherent scheme, that operates on the scale and scope required to redress current deficits in access to dental services and the population’s oral health, starting with concession card holders and moving to support for all adults.

      Under this approach the Commonwealth has funding and policy responsibility for the program. The states and territories retain a service delivery role and the details of how this would work in practice would require consideration at a formal intergovernmental level.

      If states and territories continue to be responsible for particular population sub–groups with special oral health care needs, where the new outreach activities will draw more people into active participation in dental service programs, this would also need consideration at the intergovernmental level.

      Under this option, the Commonwealth Government would gain wide–ranging patient–based service data which would be available to inform planning and improvements to the scheme.

      Option 4 – Enhanced access to public dental services

      This option is aimed at increasing access for lower income adults to basic preventive and treatment services by enhancing the public sector.

      Operation

      All concession card holder adults would be eligible for public dental services, including basic preventive and treatment services.

      The Commonwealth would fund services and the states and territories would deliver them. Per capita costs of the program would be set at the value of providing basic preventive and treatment services in the public system.

      Services would be provided free of charge or with limited co–payments. States and territories could purchase services in the private system where extra capacity is required (as is the current practice).

      An ‘exceptional circumstances’ mechanism could be implemented to allow access to higher end services, which could be provided in the private sector and in teaching institutions.

      Timing of implementation

      This option has the same objectives as the individual capped benefit entitlement; the key difference is the model chosen to deliver the services.

      In the short term, program requirements and the funding model would need to be developed through agreements with the states and territories negotiated through a formal intergovernmental process. Such agreements would need to cover: funding; data reporting; accountability for outcomes; building increased capacity in the public system; and requiring consistent service levels across the states and territories. The Council expects that these agreements and further implementation arrangements would take at least 12 months to finalise.

      During this period, the Council would expect that broad consultation with the public and profession would take place. In the short to medium term, the take–up is likely to be limited by the capacity constraints of the public sector, although work could be contracted out to the private sector as required. As this capacity is built up through the foundational support activities (see below), there would be a gradual increase in take–up, with full implementation and capacity expected to be reached around the end of 2016.

      As noted in Option 3, an option can be implemented to provide additional funding to states and territories for treatment for waiting list patients.

      Scalability

      This option could potentially be expanded to include non–card holder chronic disease patients, who account for around 20 per cent of those who currently access the CDDS. Additional low income groups that are not eligible for public dental services could also potentially be given access. Together this would cover over 7.6 million patients. Such an approach would only be possible in the medium– to long–term, requiring agreement from states and territories and significant additional capital funding for public infrastructure.

      The indicative costing below includes both the individual capped benefit entitlement program and a measure to address waiting lists. The measure for addressing waiting list patients would be an additional $343 million in 2012–13.

      Table 6.4 – Projected expenditure for Option 4.

      Option 4 ($ billion) 2012–13 2013–14 2014–15 2015–16 Total cost over the forward estimates Annual cost once fully implemented
      Option as described above, plus a waiting list measure 0.3 0.7 0.9 1.1 3.0 1.3
      Option including chronic disease patients, plus a waiting list measure 0.3 1.1 1.3 1.6 4.3 1.8

      Note: Estimates do not include the transitional costs associated with any affected legacy programs. Numbers may not add due to rounding.

      Comments

      As with Option 3, the Commonwealth would take policy and funding responsibility for concession cardholder adult treatment. The states and territories would be responsible for delivery. This would need to be formally negotiated at an intergovernmental level.

      By using state and territory expertise, infrastructure, workforce and system arrangements this option is less costly than the individual capped benefit entitlement. Compared to the capped benefit entitlement option, this arrangement reduces expenditure by $4.1 billion over the forward estimates period. On an ongoing basis it would cost $1.3 billion less per annum at full implementation.