Call to reprieve dental care scheme – but is it worth saving?

The Chronic Disease Dental Scheme was established to provide Australians suffering from a chronic medical condition with access to dental treatment, before being earmarked for closure at the end of this year. Now campaigners are fighting to save the scheme, despite Government claims it is costing almost $1 billion a year – more than ten times as much as planned. In an exclusive investigation, mojo asks if this is really a policy worth saving.

By PHOEBE ROTH

CAMPAIGNERS are fighting the axeing of a Government scheme to provide chronically ill Australians with dental care. But an exclusive GP survey for mojo reveals the Chronic Disease Dental Scheme was fraught with confusion, over-spending and abuse.

The Medicare scheme, introduced by the Howard government in 2007, entitled people with chronic medical conditions directly related to their dental health to be covered for dental treatment up to the value of $4250 over a two-year period.

But Government figures have revealed that the scheme costs $80 million a month – almost $1 billion a year – ten times the $90 million a year initially estimated.

And a GP survey carried out by mojo has uncovered confusion regarding eligibility criteria, suggesting the scheme was not always reaching those it was set up to help.

Despite its problems, opponents to the axeing of the Chronic Disease Dental Scheme (CDDS) have lobbied hard against its closure. And Opposition Health spokesman Peter Dutton accused the Government of attacking “the most vulnerable people in society” following parliamentary approval to shut the scheme on December 1.

Federal Health Minister Tanya Plibersek has announced plans for a replacement program – a six-year package to give $2.7 billion for subsidised dental care for children in lower income families, as well as $1.3 billion for better access to the public system for low income and special needs adults.

But while the CDDS will cease operation at the end of next month, this new scheme set to replace it will not be be fully operational until July 2014.

The Australian Dental Association (ADA) is among those concerned that in the absence of federal funding for dental care during this hiatus some patients may miss out on necessary dental treatment.

This has led to calls for a reprieve for the program. But is the CDDS really worth saving?

When mojo asked 32 GPs from across Victoria to study eight hypothetical cases, the complex practicalities of running the CDDS were exposed.

In a written survey, GPs were asked to indicate whether or not they would refer a patient under the CDDS. In just two of eight cases were the results unanimous.

A Medicare fact sheet explaining the scheme to GPs told them: “To be eligible, a person must have a chronic medical condition and complex care needs. The patient’s oral health must also be impacting on, or likely to impact on, their general health.”

It was for the GP to decide whether their patient’s dental condition had an adverse effect on their medical condition. These decisions often proved difficult, however, as GPs attempted to satisfy the Medicare guidelines.

Dr John Spilberg, a GP in Narre Warren, said there were major flaws in the guidelines for the CDDS. He said a lack of clarity in the rules had led to inconsistencies, where different doctors disagreed on who was eligible for help under the scheme.

One grey area, he said, was depression. Someone suffering from a mental illness might not look after themselves – or their teeth – properly.

Where dental disease was directly related to the patient’s mental illness, Dr Spilberg said he would refer the patient. But it was far from black and white.

“One person could interpret it as within the guidelines, and someone else will interpret it as outside,” said Dr Spilberg.

Case two proposed a patient with depression, poor self esteem and crooked teeth. Nine GPs said that they would refer the patient under the scheme, 22 said they would not, and one was not sure.

Other scenarios created even more pronounced division. Case six involved a man suffering from prostate cancer with secondary tumours in the bones. 17 GPs said they would give the referral, while 15 said they would not – almost a 50/50 split.

Similarly, there was no consensus on case four, a child with developmental delay and a speech impediment. In this instance, the speech pathologist’s letter said teeth crowding may be exacerbating the speech impediment. Here, 25 doctors said they would employ the CDDS, while seven said “no” or were unsure.

Another sample case involved a Type 2 diabetes patient, whose condition was well controlled with medication. 27 doctors said they would grant the patient the referral, on the basis that diabetes was a condition with complex care needs, regardless of how well it was being maintained. But for the five who said they would not, there was nothing to suggest a breach of the guidelines. In fact, Medicare said it was unable to provide ‘yes’ or ‘no’ answers to these scenarios, adding that it was at the discretion of the GPs following clinical assessment.

Dr Brian Morton, a GP in Northbridge, New South Wales and chairman of the Australian Medical Association (AMA) Council of General Practice said such inconsistencies could have been alleviated with clearer guidelines for practitioners.

“I think the government really needs to look at expensive programs like this and give better guidelines, better parameters,” he said.

Patients were similarly perplexed. They did not understand why they were not entitled to the rebate when their neighbour was.

Dr Penelope Martin, who consults in Wheelers Hill, said she often received negative feedback from patients when she denied them access to the CDDS. “I intensely dislike the GP having responsibility to decide which patients are eligible,” she said.

“In some cases people have actually left me,” Dr Spilberg added.

Dr Morton explained that in this climate GPs were experiencing pressure to include patients who were “borderline”. One survey respondent, a GP practising in Rowville, responded “no” to the diabetes case, but said if he was pushed hard enough by the patient he might be forced to rethink.

And it is not only GPs and patients who had trouble with the scheme. Dr Jeffrey Kestenberg, who owns a dental practice in Coburg, said he and his staff experienced difficulties too.

“There was a lot of confusion, especially early on. We weren’t well trained or well informed about how the scheme was actually going to be implemented. It was sort of thrust upon us,” he said.

The ADA saw evidence of this problem across the dental profession. “When the scheme was introduced, there wasn’t a very good education of dentists about what they needed to do to meet the regulatory requirements,” said Eithne Irving, manager of policy and regulation at the ADA. “It’s so lax - the rules around it are so poor.”

Dr Kestenberg estimated that close to 200 patients had been referred to his practice under the CDDS since it began. The range of illnesses for which GPs were referring their patients included diabetes, chronic heart conditions, asthma and depression.

But some cases are more questionable – even obscure – and Dr Kestenberg had on a number of occasions refused to treat patients whose dental condition, in his opinion, had no bearing on their medical condition.

“I can remember one patient had a benign enlargement of the prostate. Every second man over the age of 50 or 60 has that... it’s not really dentally relevant,” said Dr Kestenberg, who also recalled rejecting a patient referred on the basis of conjunctivitis.

Once patients were accepted under the scheme, they were technically entitled to any treatment they required, whether it happened to be relevant to their medical condition or not.

A diabetic patient could get a new denture to make their front teeth look nicer, even though it would have no constructive influence on their diabetes, while a patient with sleep apnea had to pay for the therapeutic device that could remedy their condition.

Survey participant Dr Sebastian Pavone, who practices in Dandenong, said this was one of the drawbacks of the scheme. “The problem is that the treatment often has no relationship to the illness and the abuse of the system is rampant.”

The final scenario in the survey proposed a patient with osteoporosis, about to start a bone-strengthening treatment called bisphosphonate. A rare but devastating side effect of bisphosphonate is a condition called osteonecrosis of the jaw. Information from the manufacturers of bisphosphonate drugs explains that it is those with an underlying dental vulnerability who are primarily at risk. But, though more than three quarters of GPs surveyed said they would refer in this case, the results were not unanimous.

GPs were also concerned that there was nothing to stop patients requesting additional treatment – treatment completely unrelated to the medical condition for which they were originally referred, including work to improve their appearance.

Dr Kestenberg said this was another significant flaw in the scheme, and a dentist on the Mornington Peninsula, who did not wish to be named, detailed similar experiences.

“A patient may have a broken tooth that may not have anything to do with his current medical condition, but we treat it regardless. There is no specific guideline on this for dentists that I am aware of,” he said.

A spokesperson from the Department of Human Services said: “Provided that the primary reason for the dental service is to improve the oral health or function of the patient, they will be eligible under the CDDS even if the dental service also results in improving the appearance of the patient.”

According to the ADA, the shortcomings of the current scheme have made the dental profession wary of any government proposals.

“Any scheme that [the government] develop now, they must do it in consultation with the profession. Because at the minute the profession’s not very keen on getting involved with Medicare or any government scheme again,” Ms Irving said.

“We believe that it needs to be means tested, and it needs to be targeted to those most in need.”