Introduction by Croakey: There’s a strong economic argument for providing free – or at least affordable – dental healthcare as poor dental health is linked to chronic conditions such as stroke, heart and lung diseases, which place a significant cost on the public health system.
Vulnerable Australians are particularly at risk from oral disease and there are growing calls in the lead-up to the federal election to start the journey towards universal access to oral healthcare.
The Consumers Health Forum CEO Leanne Wells says dental care should be funded under Medicare because otherwise it is simply unaffordable for many Australians who risk long-term illness and preventable hospitalisation.
In the article below Tan Nguyen and Associate Professor Amit Arora, co-convenors of the Public Health Association of Australia Oral Health Special Interest Group, outline how national leadership is required to address this neglected area of public health.
Tan Nguyen and Amit Arora write:
A healthy mouth is fundamental to overall health and wellbeing yet Australia does not have universal access to oral healthcare. Only around 44 percent of Australian adults have “favourable dental visiting patterns” – defined as visiting a dentist once or more a year, usually for a check-up – and 58 percent of the total expenditure for dental care is borne by individuals.
The Greens oral health policy for the upcoming federal election has maintained the party’s long-term position to integrate dental care within Medicare at a substantial cost of $77.6 billion over 10 years. It would include general dental and ‘clinically relevant services’ such as orthodontics (for example, braces) and prosthodontics (for example, crowns). The Greens’ education policy also proposes free university education for dentists.
The National Oral Plan 2015-2024 identified four priority populations who experience a greater burden of oral diseases compared to the general population: people who are socially disadvantaged or on low incomes; Aboriginal and Torres Strait Islander peoples; people living in regional and remote areas; and people with additional and/or specialised healthcare needs. Academic experts have also called for targeted investment for other at-risk groups such as preventive programs for children and oral hygiene programs in aged care settings.
There are persistent and significant oral health inequities experienced by the four priority populations. However, the Greens advocacy for free dental care for everyone can be deceiving since there is no such thing as a free lunch. Any additional investment in healthcare expenditure for one area is usually at the loss of healthcare spending elsewhere. Alternatively, the funds could be raised by population tax (for example, a sugar-sweetened beverages tax or increasing the Medicare levy) but these are unattractive policy positions for the major political parties.
Traditional economic theory suggests there would be a high uptake for goods or services if they were low-cost or ‘free’. However, there are many barriers in access to healthcare, including dentistry, in addition to financial concerns. Data has shown, for example, the utilisation of ‘free’ dental care for eligible children under an existing federal dental program, the Child Dental Benefits Schedule, has only peaked at 38 percent.
Barriers to entry
The private sector provides about 85 percent of dental services in Australia and these practitioners are predominantly dentists trained with the broadest skillset within the definition of dentistry. Other registered dental practitioners can also provide dental care within their defined scope of practice, including dental therapists, dental hygienists, oral health therapists and dental prosthetists. These dental practitioners can manage the most common oral diseases, namely dental caries (tooth decay), periodontal diseases (gum disease) and severe tooth loss. Uniquely, dental practitioners are the only healthcare providers likely to provide diagnostic, preventive, and treatment services unlike in other health fields in medicine.
Dental services have been traditionally remunerated through a fee-for-service funding model, which typically focuses on outputs rather than health outcomes. Coupled with many dental services defined as a restricted dental act, whereby only registered dental practitioners can provide such services, it has created a perfect storm for barriers to entry and limited market competition. These factors have prevented other healthcare providers, who could be suitably trained, to enter the free market of dentistry.
Government-supported places for dental training programs and the existing dental workforce skill mix are not currently optimised to achieve cost-efficiencies. It has been estimated that having a dental workforce skill mix like the Victorian public sector, with an oral health therapist-to-dentist workforce skill mix ratio of 2:3, when applied nationally, could save at least $61.7 million annually under the federal Child Dental Benefits Schedule. It is also noteworthy that training requirements for dentists is at least two more years than for oral health therapists.
Since the provision of oral healthcare has been left to the unregulated free market, dental practitioners are autonomous to choose who they provide dental care to, determine the price of services, and can be selective about the type of services they perform. It would make economic sense for dentists to provide – proportionally as a fraction of clinical treatment time – more complex dental treatment procedures, which attracts grander remuneration, instead of routine dental care. Finding the right balance of the dental workforce skill mix would be a good starting point in achieving oral healthcare efficiencies.
True medical-dental integration
Achieving universal access to oral healthcare is challenging but it requires more careful thought than simply increasing expenditure for oral healthcare and expanding the size of the dental workforce. In medicine, all new and novel types of health services and prescription drugs, which are available in the market, are not automatically funded by Medicare or the Pharmaceutical Benefits Scheme. They are reviewed by an expert panel. The existing list of dental services that are currently government-funded has never been scrutinised methodically for effectiveness, cost-effectiveness, and other important considerations such as health equity.
A fundamental shift is required to efficiently integrate oral healthcare within Medicare in the most cost-efficient way that considers improving health outcomes for patients and fiscal sustainability. The World Health Organization explicitly recognises that universal healthcare does not mean free access to every possible health service for every person. This is unrealistic and unaffordable. Universal interventions still require targeted interventions to address social determinant barriers regarding access to high quality and culturally safe oral healthcare.
The Greens dental policy lacks details but it has highlighted a significant issue between the poor integration of oral health within Australia’s world class primary healthcare system. There are too many young children ending up in hospital, where oral diseases are among the causes of the highest rates for acute potentially preventable hospitalisations.
Time for national leadership
Australia needs national leadership and should appoint a federal Chief Oral Health Adviser to stimulate lateral thinking about how universal access to oral healthcare can be achieved with a funding model that is realistic, affordable and sustainable.
Strengthening true medical-dental integration would need to include the type of dental services that should be funded by an expert panel, the balance of the dental workforce skill mix, and the role of other health practitioners in the provision of preventive-focused oral healthcare.
Tan Nguyen, (pictured L below) is a registered oral health therapist with special interests in dental public health, community engagement, policy, advocacy and effective governance. Associate Professor Amit Arora (pictured R) is a public health academic whose research, teaching and practice focuses on addressing oral health inequities in marginalised populations.