From the Hansard, 21 July 2012
Second reading: Health Insurance (Dental Services) Bill 2012
Senator DI NATALE (Victoria) (10:16): Over the past year I have made reforming the nation's dental health system one of my top priorities as a senator, and in fact my party has made it one of its clear priorities. In our agreement to support the Labor Party in government, the Australian Greens made sure that dental health was a significant part of that agreement, Why did we do it? We did it because there is an enormous need in this country to reform our dental system. As a wealthy country, we have poor oral health relative to our wealth. Cost is a huge barrier to treatment. There is not just an enormous health cost associated with this, but there is also an enormous social cost. The Chronic Disease Dental Scheme was implemented because we know there is an association between poor oral health and chronic disease. We know that poor oral health is associated with greater rates of infection, malnutrition and so on.
As I have said, it is not just a health issue; it is a social issue. People who are missing their teeth and are waiting for dentures, often for many years, on public dental waiting lists are less likely to get a job. Imagine sitting in front of a prospective employer missing your front teeth; you are automatically behind the eight ball. The same applies to people who are looking for a property in the rental market. Real estate agents are more likely to make a value judgment about you if you are missing your teeth. That is a fact and it is why this is one of the great reform challenges that faces this nation. It is right up there with other important reforms like the National Disability Insurance Scheme. In my view, it will be one of the greatest reforms since the introduction of Medicare.
Shortly after taking my seat in the Senate, I was approached by a number of dentists who were being audited through the Medicare Chronic Disease Dental Scheme. Despite being a health professional, I did not know much about the scheme—it was not a scheme I had a lot to do with—but the more I learnt about the situation and the more I met dentists who were having similar issues or were in similar circumstances, the more I became convinced that something was seriously wrong.
The Chronic Disease Dental Scheme was the first step for most dentists into Medicare, and I think we need to explain how that scheme works. It was introduced by the Howard government. It is a scheme that essentially says that if you have a chronic disease, you see your GP, your GP can make a referral to a dentist and you are entitled to about $4,200 worth of treatment over a couple of years. There have been criticisms of the scheme and I will talk about those shortly, but the scheme also has benefits. Firstly, we are getting an enormous public investment into dental care, and that is a good thing. Having public money invested in dental care is a good thing. Eighty per cent of people who access the scheme have concession cards. While there is a legitimate criticism around the notion that high-income earners might access treatment, let us be clear that the vast majority of people accessing this scheme hold concession cards—80 per cent—and that is because there is an association between chronic disease and income.
One of the legitimate criticisms of the scheme is that some—a minority—high-income earners are entitled to treatment at the expense of other people who may need treatment but cannot afford it. There is also a question of the scope of service offered through the scheme and should we be providing high-end services to some people, rather than providing a broader range of services to more people and providing good preventative dental care. That is a legitimate criticism. What became apparent as I spoke to dental practitioners who have participated in the scheme was that it was the first time they had been involved in a Medicare scheme; they had very little knowledge of how Medicare worked; and their entry into Medicare was very poorly managed. The rest of us in the medical profession are very familiar with Medicare—we have been working in it for many years—but that is not true of dentists and dental prostheses. In circumstances where you have a new group entering into a Medicare scheme, the department has a huge responsibility to make sure it is managed properly. In our view that was not done. The information that was disseminated to dentists was not done properly. We have had a number of inquiries into the matter, and it is very clear to me that, while some of this information was communicated, it was not communicated as effectively as it should have been.
Medicare is a very complex beast. Even medical doctors often find themselves in trouble because of the complexity with the scheme. It is why we have a professional services review board. In this case, we have to remember that a number of requirements were placed on dentists that are not expected of GPs. It is my firm belief that many of the dentists who took part in the scheme—in fact, the vast majority—acted in good faith to deliver services to people who were eligible for those services and in urgent need of those services, but they fell foul of some of the administrative requirements under the scheme.
I also think it is unfair that we have practitioners who were required to repay the entire amount for the delivery of those services despite the patient being happy, those services being provided well and, in many cases, those practices having spent considerable amounts of money in delivering the treatment, when you consider the staff, equipment and other resources necessary to provide dental services. This is a problem that has resulted in enormous stress and hardship to a number of dentists and I think it is fair to say that it has threatened the viability of otherwise thriving practices that are providing important dental care to the community. None of us have any sympathy for any practitioner who acts unethically, who seeks to defraud the department, but it is very clear in my view that the vast majority of dentists do not fall into this category. I acknowledge Senator Moore's statements about being familiar with the scheme, and it is important that dentists are, but it is important to put on the record that the government has in fact used terms like 'fraud' and 'rorts' and so on for any dentist who has fallen foul of this scheme, and I think that language is not helpful.
We have worked very hard on this issue. We have met with a number of dentists. We have made repeated representations to government on behalf of affected dentists. I have to say I am very pleased that we have finally seen an announcement by the government on this front. During Senate estimates on 29 May, the Minister for Human Services, Senator Kim Carr, made a very clear statement that included some of the following comments: What matters is the resolve of this department to face up to the mistakes, to fix them and to make sure they do not occur again. I think it is important to recognise that they have acknowledged there have been some mistakes and that they intend to fix them. He went on to say:
It is our view that we need a retrospective change to the dental services determination within the near future that creates greater flexibility about the compliance arrangements, while still protecting important principles of public policy.
This retrospective change to the determination would bring the compliance arrangements more closely in line with other parts of Medicare. He went on to talk about the flaws in the scheme and said that the 'determination established different requirements, with less flexibility in implementation, than equivalent schemes elsewhere in Medicare'.
Under Medicare you see a GP, a service is provided and you are essentially bulk-billed or those services are charged through Medicare. In this case, unlike other cases, a referral from a GP to a dentist is necessary and in return that dentist needs to provide a treatment summary to the GP and also needs to provide a written quotation to the patient. In some cases the dentists were not charging any out-of-pocket costs. In some cases the dentists were salaried dentists and stood to gain nothing by manipulating the scheme, and I can understand why some dentists did not see the need to provide a written quote. It makes sense that in those circumstances people would have assumed that that was not necessary. I go back to the point that those requirements were not made clear to all dentists from the outset of the scheme, particularly considering this is a profession that has had very little experience with Medicare. The truth is that the government is seeking to change the regulation that is going to enable them to revisit all of the audits, and I think that is very important. We are pleased that is going to happen and we support the government in its endeavours in this review.
I think now that it is important to discuss the coalition bill, and I do acknowledge that Senator Bushby has worked hard on this issue. It is a somewhat unusual alliance having the Greens and the coalition working together on an issue like this, but on this issue I think it is a reflection of the fact that there has been something seriously wrong with the way the scheme has been administered in this regard and that there has been an injustice committed. We do support the intent of the bill, which is that this injustice be remedied. We do, however, acknowledge that there are concerns around the way the bill is structured and in fact whether this bill would achieve its aims. We have had some advice that there are some serious problems around the way that this bill is structured. The bottom line is that, in light of the minister's announcement, where there is an intent to review all of the audits, as a show of good faith we are going to work with the government on their proposed solution rather than support this bill in the parliament. I will, however, say that this bill could be revisited in the near future if in fact we do not get a resolution to this issue.
We will hold Minister Carr to his word. He said that in his view it was his expectation that some, but by no means all, audit findings will change as a result of the proposed review. In our view, 'some' means the vast majority. It is very clear that, in practical terms—and I go back to the minister's statements—the amended determination will trigger a reassessment of all audit activity. So far, we know that 95 audits have been concluded and 66 practitioners have been found to be non-compliant. What we know about those 66 practitioners is that the vast majority have delivered services to patients who needed them and they in fact have been found to be non-compliant on the basis of a simple administrative error—that is, they have not sent a treatment summary back to the GP or they have not provided a written quote. As I said, in the vast majority of cases that is an insignificant administrative error. As somebody who practises as a GP, I have to say that not getting a treatment summary back from a dentist probably would not make much difference to me. I will speak for myself and some of my colleagues: we would not know the difference between a molar or an incisor. As GPs we do not make good dentists. What we want to know is that a dentist has seen the patient and that the work has been done and the patient is satisfied with that work. That is what is important here. So, in terms of the clinical impact of these administrative decisions, in our view it is insignificant—there is no clinical impact from most of these audits. We have heard about some individual cases. We heard from Senator Bushby about Wilma Johnson. We also have met with Wilma and we wholeheartedly endorse Senator Bushby's comments. There are a number of other dentists involved in these audits, including Helen Arabatzis, Roger Sharpe and Dragon Antolos. Helen Arabatzis, for example, a dentist doing terrific work in my electorate of Victoria, received notification that she would be audited. She was asked to repay hundreds of thousands of dollars, which threatened the viability of a dental practice delivering important services to people in my electorate. That came at a difficult time for Helen; I do not think she will mind my saying that she was heavily pregnant and was facing a number of issues. I think it would be generous to say that the way in which the government has handled this issue has been clumsy and heavy-handed.
We acknowledge the statements made by the Minister for Human Services, Senator Kim Carr. I think it is refreshing in politics to see a minister admit that a mistake has been made and that it is his responsibility to rectify that mistake. We are prepared to work in good faith with the government to resolve these issues. As I have said, it is our expectation that, for the vast majority of the audits that will be reviewed, a different determination will be made, but we reserve our right to revisit this bill in the future should that not occur.
The Chronic Dental Disease Scheme is far from perfect—I acknowledge that. We are working in good faith with the government to replace the scheme with something better. It is a fundamental reform, it is an important reform and it is a reform that is necessary in a country that is as wealthy as Australia and can afford government investment in good oral health. We remain absolutely committed to reforming dental care, but we do believe that no potential reform will succeed unless the dental profession is consulted, is fully engaged and is strongly supportive of any new scheme. That is why it is critical that we resolve this issue and resolve it quickly. It is important for the individual dentists involved, some of whom I have mentioned—it is critical for their individual circumstances—but it is also really important if we are going to go on to develop a national dental scheme that will be an important and significant advance for the health of Australia's community. Overhaul of the scheme is still on our agenda. We are keen to work with the government to find a way to get a government funded scheme that satisfies both the profession and the community.
The response from the government on this issue has created many months—years for some dentists—of terrible stress and uncertainty. We feel for them. We hope that they understand that our decision not to support this bill is a show of good faith and a sign of confidence that the government has acknowledged that an error has been made and that it intends to fix it. The key tasks now are to continue working on the development of a new national dental scheme, to resolve this issue and to allow dentists to get back to doing what they do best: providing critical dental care for the Australian community.