Pearls and Irritations

A recent article in Pearls and Wisdom discussed the issue of “overtreatment” (the provision of unnecessary or low priority care) in dentistry and the associated issue of the conflict between ethics and profits.

While Australia’s health system stands up well to international comparisons on standards, accessibility and affordability (both individual and national) and Australian researchers have provided world leaders in detailing and calling out “overtreatment”, as this article described, not everything in the Australian system has been perfect.

Often problems have been the result of decisions based on perceived political, rather than public health needs and compounded by rushed policy design and implementation and poor oversight in delivery.

This article will provide a case study of one such program, the Chronic Disease Dental Scheme (CDDS). Introduced by Abbott as Health Minister in 2007 (a cynic might point to the looming election at the end of that year) the scheme provided $4250 over two years to pay for dental treatment for individuals with a chronic disease who also had dental needs. GPs were the gatekeeper in that they referred patients to a dentist and were responsible for coordinating the paperwork relating to treatment.

The CDDS soon became massively over-budget and compliance audits were ramped up amid growing suspicions of substantial rorting by dentists. By 2012, more than 700 dentists were under investigation and more than $20 million identified as having been claimed inappropriately (i.e. rorted). By this time the Government, Labor – was in minority and attempts to prosecute the alleged rorters and recover the alleged inappropriate payments were fiercely defended not just by the Australian Dental Association (ADA) but by the Greens in the Senate and by Shadow Health Minister Dutton, who introduced a private members bill to forgive all of the alleged debt. The grounds for “forgiving” were that most of the debt was based on errors in paperwork (the exact requirements for which had allegedly never been made clear to the dentists) and not for failing to provide treatment.

To add to the Government’s growing embarrassment, some of the dentists being pursued for inappropriate claiming were salaried dentists working for state governments or community organisations and had not personally benefited. The employing organisations were claiming the $4250 per patient to pump up their own revenue, but managing to muck up the paperwork to the extent that the employed dentists were being pursued for repayment.

The most excruciating example was the pursuit for repayment (with threats of prosecution) of dentists who had volunteered to work gratis in their holidays for regionally and remote-based community health groups that were servicing disadvantaged communities. (Again, the groups had claimed the benefits without reference to the dentists.) Talk back radio jocks were having a field day.

A further compounder was the struggle for policy areas of the departments to come to terms with what had caused the CDDS budget to blow out. The fact that some dentists were able to organise their practices and develop their networks of referring GPs to the extent that they some were earning millions of dollars annually from the Scheme seemed like it must be fraud. In fact it wasn’t fraud – at least in the sense that the services claimed for had actually been delivered. It was just another example of the capacity of private providers to maximise their profits from a poorly designed and administered government program, as has been reported previously in P&I.

Eventually, a compromise was reached with the ADA and the action dropped against the majority of dentists. In much of this, there were eerie pre-echoes of Robodebt. Most dentists claiming under the Scheme thought they were doing the right thing, but had difficulty demonstrating this as much of the supporting paperwork was supposed to be with the referring GPs, many of whom found this task an irksome and unnecessary irritant.

Unlike the welfare recipients pursued under Robodebt however, the dentists, with the ADA, AMA, Greens and a rampant, Abbott-led Coalition on their side were a much more formidable adversary – especially for a minority government.

Despite the compromise to end the dispute with the ADA, three years later government staff were still engaged in administrative processes to properly inter the toxic remnants of the Scheme.

More forensic detail on the actual operation and technical failings of the CDDS is available.

Another lesson from the CDDS is the danger of an over-reliance on raw data. As is the fashion with many areas of public and private administration, data analytics has been increasingly used for deeper insights and to save staff costs. However, data analytics has its limitations and often needs to be backed up with more prosaic practices, like a human eye on the detail (as Robodebt has so abundantly demonstrated).

As an aside, private health insurers, who also have a financial stake in dental treatment (albeit, most insurers would call it piddling!) may have been more successful in identifying and reining in “overtreatment”.

By 2015, the larger private health insurers were starting to become concerned at the growth in payments for dental care, believing that there may have been a growing element of inappropriate claiming (or inappropriate treatment leading to inappropriate claiming).

Ramping up data analysis showed that this was in fact the case. Examples included a growth in the claims for multi-facet fillings – dentists are apparently rebated on the number of facets (sides) to a filling, amongst other things. The data showed that there had been a disproportionate rise in this, but interestingly, mainly in areas where there was now a perceived over-supply of dentists, like parts of Sydney.

Private Health Funds had different tools available for dealing with this compared to Medicare. If just gently pointing out that a dentist’s claiming seemed massively disproportionate to their peers did not result in adjusted claiming down the track, apparently the Funds could simply “de-recognise” the practitioner, refusing to rebate any claims from their patients.

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