AUSTRALIAN DENTAL ASSOCIATION

AUSTRALIAN DENTAL ASSOCIATION Federal Pre-Budget Submission 2015-2016

2015-16 Federal Pre Budget Submission Introduction Good oral health is integral to general health and should be available to all Australians. A population in good health is a fiscally and politically attractive vision. Poor oral health impacts an individual s general health, wellbeing and quality of life and, at a societal level adds significant additional cost to the health system in the treatment of chronic conditions which are caused and exacerbated by poor oral health. It is without doubt that early detection and treatment of poor oral health, along with implementation of preventative measures, are effective in improving oral health. The current cost of dental care The Australian Institute of Health and Welfare (AIHW) Health expenditure Australia 2012-13 report indicates that expenditure on dental care was $8.7 billion dollars in 2012-13. While individuals continue to be the largest contributor to the cost of their dental care ($5 billion in 2012-13), oral health remains a significant cost to Australia s health budget both from direct expenditure on dental services and indirectly through general health expenditure. Direct expenditure by the Government on dental care is significant. Excluding incentives provided by the Government through the private health insurance rebate (which could be directly related to dental services), the AIHW report states that the Australian Government contributed almost $1 billion dollars to dental services in 2012-13 (DVA scheme $100m; Health and others $843m). 1 States and Territories contributed a further $657m. However this is not a complete picture of Government expenditure. There are significant indirect health costs incurred by the Government that can be attributable to poor oral health. These indirect costs include the cost of: i. unnecessary visits to general practitioners due to oral health problems; and ii. avoidable presentations to hospital emergency departments with oral health problems. 1 AIHW 2014. Health expenditure Australia 2012-13. Health and welfare expenditure series no. 52. Cat. no. HWE 61. Canberra: AIHW at Table A3 available at http://www.aihw.gov.au/publication-detail/?id=60129548871 accessed 23 January 2015 FEDERAL PRE BUDGET SUBMISSION PAGE 1

The Report of the National Advisory Council on Dental Health estimated that more than three quarters of a million GP visits in 2010-2011 were for specific dental problems. 2 The cost of these visits could be significantly reduced if appropriate oral health care is delivered by dentists who are the best qualified to diagnose and treat dental problems. While the National Advisory Council on Dental Health was unable to specify the costs to the health budget of these unnecessary Medicare payments, reference has been made to estimates ranging from $10 million per annum to up to $300 million per annum. 3 In regards to potentially preventable hospitalisations (PPH) related to dental conditions, the Australian Institute of Health and Welfare reported in 2010 11, that the total number of PPH due to dental conditions was 60,590 or 2.8 separations per 1,000 population. 4 This is a conservative estimate as this figure would not include PPH admissions due to other chronic conditions such as diabetes which are linked or associated with poor oral health. GOOD HEALTH POLICY INVESTS IN PRIMARY CARE These indirect costs could be significantly reduced if Government extends support to programmes in oral health which encourage regular visits to dentists for early detection and treatment. This is particularly so for the aged in the community who may live with chronic conditions and disabilities. Oral Health among the aged it makes sense to prioritise their oral health The ADA maintains that Government should work towards the introduction of targeted national oral health care coverage. However in the current economic environment, the ADA appreciates that this may not be possible and calls upon the Government to consider a staged introduction of such a scheme directed at those groups in society who suffer the most disadvantage. The aged, and in particular those relying on limited incomes, are one such group. The aged are the current focus of ADA advocacy efforts. The economic impact of the ageing population is well known. Oral diseases including dental decay, gum disease and oral cancer are chronic diseases and the aged are particularly susceptible and affected. 5 2 Australian Government. Report of the National Advisory Council on Dental Health: 23 February 2012 available at http://www.aihw.gov.au/publicationdetail/?id=60129543390 accessed 23 January 2015. 3 Ibid at p 19 4 Chrisopoulos S & Harford JE 2013 Oral health and dental care in Australia: key facts and figures 2012. Cat.no. DEN 224. Canberra: AIHW available at http:// www.aihw.gov.au/publication-detail/?id=60129543390 accessed 23 January 2015. 5 AIHW 2014. Australia's health 2014. Australia's health series no. 14. Cat. no. AUS 178. Canberra: AIHW available at http://www.aihw.gov.au/publicationdetail/?id=60129547205 accessed 18 December 2014. FEDERAL PRE BUDGET SUBMISSION PAGE 2

The health needs, including the oral health needs, of the aged population must be addressed and planned for by the Government. The prevalence of oral diseases among people over the age of 65 is significantly higher than for the general population. Over 50 % of Australians over the age of 65 have gum disease or periodontitis. 6 While many more of the aged are retaining their natural teeth, over 20 % of Australians over the age of 65 have complete tooth loss. 7 Those who have retained their teeth often have complex restorations such as THE NEED FOR GREATER PREVENTION AND CARE IN ORAL HEALTH OF THE AGED MUST BE ADDRESSED AS A PRIORITY crown and bridge and/or implants which need particular maintenance and care; care that is often not maintained when motor skills are decreased or cognitive impairment exists. As a group, the aged comprise one of the highest groups of Australians being admitted to hospital due to dental issues. 8 It makes sense from a health perspective and an economic perspective for Government to address the aged as a priority. Good oral health is integral to general health. Risks factors for oral health, particularly periodontal disease and other diseases are increasingly being recognised in health literature. 9 Diabetic patients are more likely to develop periodontal disease and conversely, development of periodontal problems in turn impacts on the ability to maintain a healthy diet and can increase blood sugar and diabetic complications. An association between periodontal disease and heart disease, including its exacerbation has also been established. 10 Linkages have been suggested between periodontitis and other systemic diseases including osteoporosis, respiratory disease, aspirational pneumonia and some cancers. A recent study published in the American Journal of Preventative Health has considered specifically the impact of frequent periodontal treatment on general health in patients living with certain medical conditions. 6 AHIW 2014. Oral health and dental care in Australia: key facts and figures trends 2014. Cat. no. DEN 228. Canberra: AIHW available at http://www.aihw.gov. au/publication-detail/?id=60129548265 accessed 18 December 2014 at page 5. 7 Ibid at p 6. 8 Ibid at p17. 9 Cullinan MP, Ford PJ, Seymour GJ. Periodontal disease and systemic health: current status Australian Dental Journal 2009; 54: (1 Suppl): S62-S69. 10 American Academy of Periodontology see http://www.perio.org/consumer/other-diseases accessed 18 December 2014. FEDERAL PRE BUDGET SUBMISSION PAGE 3

The study found that patients with existing medical conditions, who had had at least one peridontal treatment subsequently had lower medical costs and fewer hospitalisations compared with patients who had not received any treatment for periodontal disease. 11 Residents in aged care facilities are particularly at risk of poor oral health. The ADA is concerned about worsening oral health in residential aged care. Studies have shown that high levels of plaque accumulate on resident s natural teeth and dentures which in turn place them at high risk for developing aspiration pneumonia, a commonly occurring event necessitating transfer to an acute care facility. 12 Dislodgement of teeth, fillings and calculus as well as ill-fitting dentures contributes to this problem. A recent study by Silva et al published in 2014, has found that nursing home residents have high levels of untreated decay, particularly those with high pre-existing medical conditions requiring intensive care. 13 The residential aged care sector must ensure that quality of care is identical to the quality of care provided in other medical facilities. The Government must ensure that every assistance is given to ensure that this is achieved. Prior to admission to residential facilities, the oral health of the aged person should be assessed. The ADA appreciates that in some instances this will be challenging due to availability of suitably skilled practitioners, financial status and the needs of residents. However these challenges are not insurmountable, particularly if there is a formulated oral health policy which promotes and supports appropriate care to residents before being admitted and whilst living in aged care. 11 Jeffcoat MK, Jeffcoat RL, Gladowski RN, Bramson JB, Blum DDS. Impact of Periodontal Therapy on General Health. Evidence from Insurance data for Five Systemic Conditions American Journal of Preventative Medicine 2014; 47(2):166-174. 12 Chalmers JM, Carter KD, Fuss JM, Spencer AJ & Hodge CP. Caries experience in existing and new nursing home residents in Adelaide Gerodontology (2002) 19:30-40. 13 Silva M, Hopcraft M & Morgan M. Dental caries in Victorian nursing homes Australian Dental Journal 2014; 59 321-328. FEDERAL PRE BUDGET SUBMISSION PAGE 4

The ADA s solution for optimal aged oral health care The ADA is proposing to Government that an Age Pension Dental Benefits Schedule (APDBS) be introduced to specifically target the oral health needs of the aged in receipt of the full age pension. The ADA suggests using the existing Child Dental Benefits Schedule as a model to develop the APDBS. How will the Age Pension Dental Benefits Schedule (APDBS) operate - A proposed model Since January 2014, the Child Dental Benefits Schedule (CDBS) has provided families in receipt of Government payments including Family Tax Benefit A, a $1000 allowance every 2 years for basic dental services for children aged 2 to 17 years. Families have received financial assistance to allow their AGE PENSION DENTAL BENEFITS SCHEDULE LESSENING THE BURDEN OF CHRONIC DISEASE HEART DISEASE, DIABETES AND OTHER DISEASES IN AN AGEING POPULATION children to undergo examinations, x-rays and some dental prevention (cleaning, fissure sealants and fluoride treatment). Where needed, they have also had their children s teeth undergo restorative treatment (fillings or root canal) and in some cases, oral surgery (extractions). While there is room for improvement with the CDBS, long term it is the ADA s view that the CDBS will make a real difference to the future oral health of Australian children as they grow into adulthood. Early intervention and preventative treatments are a proven and well established method to prevent poor oral health later in life. The ADA applauds the Government s continued commitment to the CDBS which is estimated to have delivered dental treatment, the vast majority of which has been bulk billed by Australian dentists, to approximately 25% of eligible children. 14 The Dental Benefits Act (DBA) and its subordinate legislation, provides an ideal framework for the funding and delivery of the APDBS. The CDBS under the DBA and the Dental Benefit Rules already provide a universal schedule and descriptors for dental services based upon the Australian Schedule of Dental Services and Glossary Tenth Edition (the Schedule). As the dental services required by the aged will be greater due to their oral health needs, the Schedule in its entirety should be used for the APDBS. The ADA is available to work with the Government to tailor a schedule of treatment specifically for the aged. 14 Australian Government. Official Committee Hansard. Senate. Community Affairs Legislation Committee, Estimates. 22 October 2014. http://parlinfo.aph.gov. au/parlinfo/search/display/display.w3p;query=id%3a%22committees%2festimate%2f5a8a7fa2-b9c7-4b7f-843c-89aa3b145886%2f0000%22 accessed 29 January 2015 FEDERAL PRE BUDGET SUBMISSION PAGE 5

There are also other policy priorities which should be considered to ensure the delivery of optimal oral health care to the aged. An integrated and multifaceted approach is required which takes account of particular circumstances and differing needs. 15 While some aged Australians reside in aged care facilities, the majority reside in the community and, with support, wish to remain living independently. Accordingly in conjunction with the APDBS, the ADA proposes that the Government give consideration to the development of the following structures to support the delivery of oral health care to aged. Priorities for residents in Aged Care The following procedures and appropriate levels of funding should be made available to assist in the care of the elderly residing in aged care: i. where possible, oral health care delivery should take place in dedicated dental surgeries; ii. if required, transport should be made available for those patients able to travel to the dentist; iii. alternatively, specialised treatment rooms including x-ray machines and other equipment should be made available for dentists to treat patients in aged care facilities; iv. oral health education should be compulsory for all non-dental health care professionals treating the aged and this should include an understanding of the need for: an oral health assessment prior to admission to a residential aged care facility as required by aged care standards; oral health screening at regular intervals thereafter; and a daily mouth care plan. v. oral health plans recognising the importance of early intervention in oral health care of the elderly should be developed at all aged care facilities. Priorities for the aged living in the community i. All health care professionals, not just dentists, should be aware of the specific oral health needs of the aged; ii. Oral health screening by a dentist led team should be carried out as an important part of general health checks; and iii. Funding should be provided for fully equipped, comprehensive mobile dental teams to provide screening and treatment for the aged or where practical, transport to local dental facilities. 15 Further guidance on the integration of health care can be taken from the Medicare Chronic Disease Dental Scheme (the CDDS). While no longer operational, the CDDS delivered some valuable care to patients and, significantly, at the highest level of Government, the importance of an integrated approach to oral health care and health care generally, was acknowledged as foundational to targeted oral health policy. FEDERAL PRE BUDGET SUBMISSION PAGE 6

Implementation and Cost the ADA plan The ADA appreciates that reform takes time and careful consideration. The ADA is committed to working in partnership with the Government to ensure this takes place. In addition to working with the Government on the design of the schedule of eligible services, the ADA will develop and offer training programmes for dentists and the broader dental care team to ensure they are adequately prepared for delivering services to aged Australians particularly those living in aged care facilities where the need is greatest. ADA presents below an estimate of annual costs across the forward estimate period to demonstrate the investment required by the Australian Government. Australian population 16 23,708,034 Population over years 65 17 15% 3,3556,205 Of that eligible for full pension 50% 1,778,102 Assume annual uptake of scheme 25% 533,430 Cap Amount/two years $1,000.00 $ 533,430,765 Estimated annual expenditure $266,861,530 Estimated expenditure over four year period $ 1,066,861,530.00 Funding the APDBS The APDBS would be funded from the following sources: 1. Savings which would be achieved by the Government from the elimination of indirect and unnecessary health costs due to poor dental health. As indicated earlier in this submission, a conservative estimate of these indirect costs could be around $350 million per annum. 2. A reduction in the direct expenditure made by the Government to the costs of oral health as disease and decay are diagnosed and treated before more extensive and costly treatment is required. 16 As at 12 January 2015. 17 Estimate (rounded up) from Australian Bureau of Statistics. FEDERAL PRE BUDGET SUBMISSION PAGE 7

Likely Expenditure The National Commission of Audit report states that the proportion of older Australians eligible for the Full Age Pension will decrease over the next twenty years as the proportion of individuals who are selffunded retirees increases. 18 This in effect means that the costs of the APDBS can be contained and in fact will reduce over time freeing up funds to expand eligibility to other aged Australians. Table 1: National Commission of Audit age pension projections Conclusion In conclusion, the APDBS if implemented will be an enormous step forward in the treatment of the oral health of the aged which will have benefits for Australia s health system overall. The APDBS will capitalise on the excess capacity available in the private sector as identified by Health Workforce Australia s Oral Health Workforce Report. 19 This will allow eligible public patients languishing on public dental waiting lists to receive timely care thereby freeing up limited resources within the public dental sector for other eligible Australians. The APDBS will be well received by the community, state and territory governments. 18 Australian Government. The Report of the National Commission of Audit Phase One Towards Responsible Government available at http://www.ncoa.gov.au/ report/docs/phase_one_report.pdf accessed 29 January 2015. 19 Health Workforce Australia 2014: Australia s Future Health Workforce - Oral Health - Overview FEDERAL PRE BUDGET SUBMISSION PAGE 8