LESLEY RUSSELL. The dental divide – and the decay of public dental services (ABC News, 21.08.18)

Aug 23, 2018

The noisy public debate about patients’ out-of-pocket costs and their consequences reaches a crescendo when it comes to oral health and dental care.

Nowhere are the growing inequalities in health between poor and rich, rural and urban, Indigenous and non-Indigenous, highlighted more than in dental health.

An Aussie smile is an instant indicator of socioeconomic status, employability and self-esteem. It’s also a predictor of physical health.

The costs of this divide are revealing. Of the total annual spend on dental care ($9.9 billion in 2015-16), individuals contributed 58 per cent in out-of-pocket costs.

Little wonder that 44 per cent of uninsured Australians and 20 per cent of those with insurance delay or avoid going to the dentist.

Twenty per cent of those who do go to the dentist are unable to proceed with recommended treatment because of cost.

That leads to some shocking statistics: one in four children aged 5-10 years have untreated tooth decay in their primary teeth and one in 25 Australians aged 15 and over have no natural teeth.

Some 5.7 million Australians are living with at least one dental or oral health issue. About one in five Australians do not get the recommended level of oral health care.

The picture is worse for Indigenous Australians, especially in remote communities where sugar-laden processed foods are ubiquitous but dental services are scarce.

Medicine and dentistry not treated the same way

Bad teeth and poor oral hygiene are not simply cosmetic problems but the cause of sickness, disability and even death.

Poor oral health is linked to malnutrition (especially in the elderly), heart infections, coronary heart disease, stroke, poor outcomes in pregnancy, and aspiration pneumonia.

Across the nation, there were 67,060 preventable hospitalisations for oral health conditions in 2015-16 (10 per cent of all preventable hospitalisations), at an estimated cost of some $230 million.

Increasing tooth decay has seen a surge in general anaesthesia for children needing dental treatment in hospitals.

Yet medicine and dentistry remain distinct practices that have never been treated the same way by the healthcare system, health insurance funds, policymakers and the public.

The Whitlam government did not include dental care in Medibank (the precursor to Medicare) because negotiations with doctors’ groups consumed all their efforts and because the states and territories already had public dental systems.

Now the Commonwealth and the states jointly fund public dental services for people on low incomes through National Partnership Agreements. Total expenditure by governments in 2015-16 was $2.4 billion.

But while 36 per cent of the population is eligible for public dental services, there is capacity to provide services to only about one-fifth of this group.

No wonder there are long waits for public dental services: in 2015-16 the “best” average waiting time was 87 days in Western Australia, the worst was 916 days in Tasmania.

Video: ‘Dental care has to be part of healthcare’ Australians have high levels of dental decay (ABC News)

Calls to implement Medicare-style system

Over the years the Commonwealth has funded a number of dental programs which have come and gone with the governments that proposed them. Today only the Child Dental Benefit Schedule remains.

Ancillary private health insurance (held by 55.7 per cent of the population) provides dental cover, but it’s expensive and does not do what insurance is supposed to — protect against unexpected costs.

It generally provides only limited, capped assistance for dental services, which means the majority of adults with private health insurance for dental work face out-of-pocket costs for their dental visits.

The situation is aggravated because there are no standard fees for services provided by dentists or other dental professionals; the regulation of dentistry does not extend to pricing or defining appropriate treatment methods.

Although Australia has an oversupply of dentists on a population basis, 80 per cent work in private practice in metropolitan areas.

As a consequence, people living in rural areas report the highest levels of complete tooth loss, the lowest levels of dental insurance coverage and the highest levels of dissatisfaction with their dental health.

There are calls to address the inequalities and inequities in dental health by implementing a Medicare-style system.

The biggest hurdle is cost: given the level of unmet need, that could be as high as twice current expenditures, up to $20 billion per year. Some experts call this an “impossible dream”.

Recent polling reveals 48 per cent of Australians favour abolishing the taxpayer subsidy for private health insurance and using the savings to fund dental care.

This could deliver as much as $12 billion, which combined with current dental costs and savings in indirect costs to the economy (estimated at $1.2 billion), could fund a program providing basic dental care to all, similar to the Denticare program proposed by the National Health and Hospitals Reform Commission.

There’s much that can be done (that must be done) to address this.

What can we do about it?

If a Medicare-style program is a step too far and too expensive, I pragmatically offer a set of smaller options that could be implemented to put the mouth back into health care and close the dental/medical divide:

  1. Government funding should focus on the best-value investments, which span three broad areas: fluoridation, preventive services for children, and preventive and treatment services for the poor and those with special needs.
  2. Dental and medical professionals must become partners in delivering health care services. This should entail some shared training, a recognition that dental services are an integral part of primary care, inclusion of dental information on Personally Controlled Electronic Health Records and professional courtesies around patient referrals.
  3. A “Dental Health Service Corps” made up of dentists and dental staff, doctors, nurses, community/Aboriginal Health Workers and public health professionals could ameliorate the maldistribution of the dental workforce and take oral health services and education where they are needed.
  4. Health promotion activities around tackling obesity, smoking and substance abuse, breastfeeding and better management of chronic conditions and the use of multiple medications need to include oral health information. Help with oral hygiene is also a critical aspect of care for the frail aged, people with mental illness, people with disabilities and those on certain medication regimes.
  5. Governments should consider establishing emergency dental services within hospital emergency departments, at least on weekends.
  6. If private health insurance funds are serious about greater involvement in primary care to keep patients out of acute care, they must consider providing better access to dental care with reduced out-of-pocket costs.

Dr Lesley Russell is an adjunct associate professor in the Menzies Centre for Health Policy at the University of Sydney.



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