How would it be to walk into a general practice with a toothache and be triaged to see the oral health therapist, who assesses and then develops an oral health care plan? They are then qualified to provide dental treatment but may also involve a GP or dentist across the corridor for further assessment. It is time to dream this could become a reality if Labor is prepared to embrace the mouth, gently.
It could be started immediately by listing oral health therapists as part of the primary care team (general practice and others), in the Government’s recently proposed most radical restructure of primary care funding since the introduction of Medicare. Such therapists could focus on oral disease prevention and health promotion. Dentists could be added later.
Currently the radical restructure ignores the mouth. This restructure was initiated by a taskforce chaired by Mark Butler, Health Minister. Further detail on the restructure was addressed by a committee chaired by the First Assistant Secretary for Primary Care. With such senior people driving the restructure one could reasonably expect that suggested changes or a variation of them will be implemented over time.
The Federal Government’s main funding for general practice is through fee for service i.e. you receive a service, and the Government provides a set rebate, the value of which depends on the service. The provider can charge a copayment of whatever value. If no copayment is charged it is called bulk billing. There are other Government payments to general practice for a variety of things which are not related to an individual service. These other payments currently make up less than 10% of Government funding for general practice.
Central to new changes is a move to increase the percentage of general practice funding through non fee for service payments from the current less than 10% to 40%, and adjust them for socio-economic status, rurality, and complexity. Funding will now aim to enable general practices to employ a variety of other health care providers in the practice to promote a comprehensive primary health care team, consisting of GPs, Allied health, nurses, Nurse Practitioners, Midwives, and social support services. Oral health therapists and Dentists are primary care providers. Put them in the list and finally, the mouth is into Medicare.
Importantly, it is suggested that the changes be introduced gradually, with an aim of reaching the 40% target by 2032. This is partly because the changes are quite complicated and cover much more than the above. In addition, the resistance of the medical profession needs to be carefully managed. Lastly, spending extra money on health, education, and welfare is not a priority of this Labor Government unless it has an immediate political impact.
There are a variety of proposals to get the mouth into Medicare. The Greens propose having a rebate system like Medicare to address the issue. There are three problems. Firstly, there is the cost. Labor leadership does not have a ‘crash or crash through’ Whitlamesque visionary who can see the political, economic, and social benefits of equitable access. Minister Butler’s comments reflect that reality. The second is that it would mean adopting a fee-for-service rebate system. That doesn’t work well with doctors’ visits because copayments decided by doctors mean patients can’t afford to go. The same would almost certainly happen with dentists. The Child Dental Benefits Schedule (a limited fee for service scheme introduced in 2014) relies on dentists to participate. Sixty percent don’t, most likely reflecting the fact that eligible patients would not be able to afford the copayments these dentists would charge. A recent review of that scheme concluded there is only a 40% take up of the scheme. The third problem is that it would lead to a federally subsidised dental profession which would then resist any change away from fee for service medicine. That change is precisely what the restructure is intending. It is resisted by doctors’ organisations because it affects their income and autonomy. We don’t need dentists as another adversary to patient centred care. Resistance from dentists was part of the reason Whitlam ignored the mouth in 1974. Doctors’ resistance was enough of a problem then.
Butler said on Q&A recently,
“It’s in our platform that we would one day move to incorporate dental care into Medicare, which conceptually makes sense……We don’t have the ability to [incorporate dental care into Medicare] right now”.
We do. Doing it slowly and carefully is so much better than ignoring it for another 50 years
The mouth has been largely forgotten by Federal Governments since dental care was left out of Whitlam’s Medibank and Hawke’s Medicare for financial and political reasons. The opportunity now exists to start putting the mouth back into the body to address the huge inequities in access to dental care across the country.