Would dentists accept a new Denticare scheme?

There is ongoing debate about the need for and acceptability of any new government funding schemes for dental care. What does history tell us about how any new schemes would be adopted?

As we wait for the Government response to the Senate Select Committee to find out whether there will be increased public funding to improve access to dental care, it is important to consider how well any new schemes would be accepted by dental practitioners, given some practitioners continue to express concerns that increasing government control of dental funding would ultimately lead to lower average fees, limits on the amount of care provided and by extension lower incomes for dental practitioners.

Certainly we have seen that in recent times, with a freeze on rebates which affected not only Medicare but also the Child Dental Benefits Schedule (CDBS). The impacts on medicine have been dire, with AMA President Steve Robson saying it has resulted in a primary care system struggling to survive, with falling bulk billing rates and patients waiting longer to access a GP. Although the freeze was introduced in 2013 as a temporary budget measure by the Labor government, it was continued by the new Coalition government in 2014 and extended until 2020.

There was a similar pause on indexation of the amount of dental benefits payable under the CDBS until January 2021, even though the original intention of the CDBS was to index the program annually. The CDBS cap of $1000 over two years has now increased to $1095 since the pause was ended, and the rebates paid to practitioners have also increased 9.5% from 2014 to 2024. Average private practice dental fees for a range of items have increased depending on the treatment, from 3.1% for an examination, 7% for fissure sealant or a scale and clean, to 13.4% for restorations between 2014 and 2022, which suggests that even with the pause in indexation, CDBS fees have mostly kept pace with average private practice dental fees over the past decade.

Of course, as they say with investment advice, past performance does not necessarily equate to future results, and so there is no guarantee that CDBS rebates or the cap will continue to increase in the future.

Despite these issues with CDBS fees and caps over the past decade, the program is well utilised by dentists (although it continues to have low patient utilisation which is an ongoing concern). Around 80% of all dentists use the CDBS each year, which is a measure of broad acceptance of the program.

Since it commenced in 2014, bulk billing rates for the CDBS have also continued to rise - even during the period where there was a pause in benefit indexation. Currently 95.2-98.8% of services provided through the CDBS are bulk billed, up from 79.5-96.8% in 2013/14. This is much higher than bulk billing rates for Medicare GP visits, which are trending in the opposite direction.

There are also concerns that public dental schemes such as the CDBS and the Chronic Disease Dental Scheme (CDDS) before it have arbitrary caps or limits on the total amount of care a patient can access - limits that do not exist in Medicare for medical services. These caps are clearly designed as a cost containment measure for governments, but don’t factor in that some patients may require a significant amount of care that would exceed the cap. However, an analysis of cohort years (the first of the two-year eligibility period) in the latest review of the CDBS found that around 88 per cent of children spend less than $900 of their benefit cap, with only 12 per cent spending $900 or more. And in fact around 53% spend less than $400. So whilst there is concern for a small proportion of children with extensive and high care needs, the cap is sufficient for the majority of children. Nonetheless, it is important to consider the impact of arbitrary caps for adult patients and how that might influence care provided.

Finally, it's worth engaging in a little constitutional history in order to understand the bounds of what is actually possible (and perhaps more importantly what is impossible) to achieve with future funding programs.

When the government amended s.51(xxiiiA) of the Constitution in 1946 to provide a wider range of health and social security benefits on a national basis to Australians in the post-war period, they also added a clause that allowed the government to legislate for and fund the provision of dental services. Importantly though they added an important caveat – ‘but not so as to authorise any form of civil conscription.’ What does this mean, and why is it important?

Effectively this means that the government has no power to either compel dental practitioners to enter into government salaried employment to provide dental care, or to be able to compel them to provide services for a prescribed fee. That is an important protection, meaning that dental practitioners can choose not to accept publicly funded schemes, and that if they do choose to participate they have the ability to charge their usual fee to patients (or in essence charge patients a gap or co-payment between the government rebate and their usual fee).

This is why understanding our constitutional and legislative history is instructive to understanding our current situation and where advocacy might lead to in the future:

• The government can enact a new publicly funded dental scheme to expand services to other population groups such as low-income adults

• The government can set a fee schedule for this new scheme

• Dental practitioners can choose whether to participate in the scheme or not

• Dental practitioners who choose to participate can then choose whether to accept the government rebate only (bulk bill) or charge a co-payment

Private dental practitioners have strongly embraced publicly funded dental programs in the past, stretching back to the Commonwealth Dental Health Program in the 1990s. More recently dentists utilised the CDDS to the tune of $2.8 billion between 2008 and 2013, and around $350 million is claimed through the CDBS each year. So I am inclined to give more weight to the actions of dental practitioners who actively utilise such schemes, rather than the words of a minority who might oppose further expansion of publicly funded dental care (noting that there is no compulsion for these opponents to participate in any new government funded programs).

Rather than focusing on what potential new schemes can NOT be, we are better focusing on what they SHOULD be, to ensure that we don’t stand in the way of progress that will allow more Australians to access care.