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Jan 18, 2013

Extortionate dental care is our national disgrace

Having that hard, white stuff in your mouth fixed up at a reasonable cost should not be such a pipe dream -- the Brits do it at low cost. It's unacceptable that dentistry is so unaffordable in Australia.

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Dentist chair

“Hello hello, this is your dentist calling.” It was 7.45 on a grey London morning, and there he was on the phone. “It is time for your check-up.” Was this real? Was I awake, or dreaming it? Was he outside the front door? Only the fact that my dentist is a British Asian with an Indian lilt stopped it from being the opening scene of some sort of slasher movie.

But that’s what a genuine public health system looks like. Dental care, like all other health care in the UK, is free, and the dentists hound you whenever your six-month appointment comes due. It’s a neat little system, based on the inherent paternalism of the NHS — in order to get free care, you have to be registered with a local dentist, and in order to stay registered, you have to go for a regular check-up (thus letting the dentist click over her/his fees from the government).

Should you skip it, you’ll be thrown off the dentist’s list, and when you have a real dental emergency you’ll be stuffed. Even then, there is always one free clinic in each major city that will see you, free, no questions asked, with a two to three-hour wait and a fast track for those in great pain.

The London one is in the Whitechapel Hospital, a towered Gothic extravaganza, close to Jack the Ripper’s old haunts. Using it is like being drafted into a Victorian painting: hours passed in a tiled waiting room, steam on the windows, children screaming, South African dentists coming out for their next case, with blood on their apron and pliers in their hands. But they have lovely lovely gas, and no one gets turned away.

That’s an essential part of any health service. That it’s never been a part of the Australian Medicare system is a standing disgrace — both to the Hawke/Keating who failed to fully integrate it into the Medicare system from the start, the Howard governments who stripped $100 million out of such services as there were, and the Rudd/Gillard government, who cancelled the chronic care dental scheme and had to be dragged towards a Denticare scheme kicking and screaming by the Greens.

There was one push by a major party to have guaranteed dental care for Australians, by opposition leader Kim Beazley. Unfortunately, Bomber, with unerring political savvy, announced the policy on the day the US invaded Iraq and it rather got lost in the melee. Nothing is easier to ignore, since anyone who can afford it will pay whatever they need for dental care when a crisis hits. Those who can’t — the old, the poor, indigenous people disproportionately — suffer in silence. Free and low-cost clinics are locally managed, ad hoc and often more or less invisible to the people who need them most.

But now there’s been movement on this issue, the Dental Association has come to the party — by suggesting we should be training fewer dentists, so that those who make it through can continue to charge through the nose for working in your mouth. This is despite the fact Australia has only a fair to middling ratio of dentists to population — about 1:2000, compared to something closer to 1:1200 in Northern Europe and Japan. The US ratio is halfway between, but is skewed because about 20% of the population get no dental treatment whatsoever.

The public-spirited thing for the Dental Association to do would have been to call for more funding, so that all these new dentists — coming through new dental schools at places such as James Cook and La Trobe, all of which the Dental Association objected to — would have work to do. Given the ADA is complaining about underemployment of some dentists, and that the waiting times for free dental clinics is averaging three years, that would seem the obvious solution.

“The greatest disparity is between rural and urban services, with, for example, beachside Sydney having five times the number of dentists of rural NSW.”

But of course the other thing the ADA wants to protect is pricing, and high labour costs, to preserve the stupendous income potential of the members within the charmed circle. Just as the AMA used to be known as “the Painters and Doctors Union” for its rigorous exclusion, the dentists are a sort of Molarside Workers Federation, protecting their own.

The aim is not merely to keep fees high — it is to make them look inevitably high, as if the sheer and often urgent necessity of the service is somehow a “natural” reason for its huge costs. That is nonsense of course. Whatever material costs are involved in things like caps and crowns, the major cost is the hourly rate for the dentist’s time. In the Whitechapel chamber of horrors in the ’90s, I had a three-session root canal and the eventual cost was … 14 pounds. You can be sure that the UK government wasn’t refunding that dentist the 986 pounds or so that I would have been charged as a private patient.

The magical nature of dentistry — that having some white hard stuff in your mouth fixed should be something you have to save up for, tremble in fear over at night — needs to be demystified, just as the old idea that a doctor’s appointment was a luxury not a right has been knocked down.

Essential to that is lowering the expectation that medical training is the pathway to a ludicrous income, rather than merely a decent one. There has been some movement towards this, with the creation of a dental internship scheme. But at the same time the Chronic Disease Dental Scheme was closed because treatments billed to it had ballooned to $3 billion, from a projected $600 million or so. Had the Greens not pushed for Denticare and the Dental Health Reform Package as a replacement, Labor would have been happy to allow public dental treatment to lapse into its previous slipshod state.

The greatest disparity is between rural and urban services, with, for example, beachside Sydney having five times the number of dentists of rural NSW. The numbers there — one dentist for every 5000 people — is a third-world level of medical care.

The answer to that is obvious, and it would also serve the task of demystifying medical services and medical costs: a scholarship scheme, for dentists and doctors, bonding them to three to five years’ rural work depending on the level of support, with a punitive buy-out clause. Should the Painters and Doctors, and the Dentists object, they should be threatened with an influx of foreign doctors. After all, if we shipped in 300 Cuban-trained doctors for remote services, the problem of indigenous health would be greatly mitigated overnight.

‘Twould be better to extend medical training to our own people, but needs must. In our current state, it is cheaper for many Australians to fly to the UK, take advantage of the NHS-Medicare reciprocal scheme and get their teeth done here.

What greater condemnation could there be than that we are worse than British dentistry?

Guy Rundle — Correspondent-at-large

Guy Rundle

Correspondent-at-large

Guy Rundle is Crikey's correspondent-at-large. He was co-editor of Arena Magazine for 15 years, and has written four hit stage shows for Max Gillies, two musicals, numerous books and produced TV shows including Comedy Inc and Backberner.

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44 thoughts on “Extortionate dental care is our national disgrace

  1. Michael Lines

    This is a very vexed issue. I’m a dentist, not in private practice, and I find it disgraceful that a first world country like ours, people seem to be unable to access quality dental care.

    But there are many facets to this story.

    The failure to incorporate dental care into Medicare was the fault both of the Government at the time and the dental profession itself in the early 1980s. Those same parties have failed to address the issue spectacularly since then – both sides of politics are at fault. As to the costs to patients, simply saying that prices are too high is kind of missing the point. Dentistry is an expensive business to run. If you want to work as a dentist there is a minimum level of infrastructure you must provide by law – the dental chair, the instruments, the consumables and the office furniture are simply the things that the patient will notice. Behind the scenes there is a whole raft of back office equipment and materials – including sterilisation, record keeping and storage, IT etc. And this is just to comply with the law. If you are going to practice safe and ethical dentistry you need to employ at least two people (a chairside dental assistant and a receptionist) in addition to yourself. All of that has to be paid for and maintained – so the practice running costs are high to begin with. These things are not necessarily under the control of dentists and most of the equipment and material we use is imported from overseas. If you are getting prosthodontic work done (dentures, crown and bridge work, implants etc) you will require the services of a dental laboratory, who will levy fees on the dentist to make the prosthesis you are getting. Add to that, issues such as registration fees, mandatory professional development courses and professional indemnity insurance, all of which are actually there to protect members of the public, not the dentist, and you start to get an idea of where those dentists fees are actually going.

    The statement by Guy Rundle that the cost of the dentists time is the greatest factor in the cost of dental care is simply not true. Sorry Guy, do better research, I’d be very keen to see where you got that information from.

    Then there is the question of quality. The fact is that in medicine as in anything else, you get what you pay for. Dentistry in Thailand may be cheap, and there’s a reason for that. Just ask yourself, do you really understand what legal, ethical and professional framework they are adhering to? Are you confident in their infection control protocols? Many of my colleagues, especially prosthodontic specialists tell me horror stories about dental work done on the cheap in foreign countries that they have to fix up when a patient gets referred to them with a major problem, particularly implants. Buyer beware! As to British dentistry – I have direct experience of this and I can tell straight away when someone has been treated under the British NHS. I have had numerous expat Brits (invariably with multiple large amalgam fillings) tell me that they are sure that they didnt really need many of those fillings and that they thought the Dentist was either doing it for practice, or because the NHS was paying, not the patient. I cant confirm whether that is true, but I have heard it repeatedly from numerous people. One does have to wonder about the incentive structure there.

    But finally, the greatest frustration all dentists face: patient compliance. People simply dont take good enough care of their teeth. The dental profession has been trying to put itself out of business for 100 years through such efforts as oral health promotion, education in oral hygiene and fluoridation of drinking water (the WHO describes this as one of the single most effective public health interventions in human history). The vast majority of dental problems can be prevented through simple measures such as cleaning your teeth properly and reducing the refined sugars and sources of acid in your diet. Its amazing how many people dont do simple things such as this, then go on to develop major dental decay problems as a result and then complain when they have to pay to have them fixed. I just ask, what do you believe your health is worth?

    It is a little irritating to us that we keep being told we are overpaid, that we overcharge and that we have a privileged and protected position in society. Well, thats not my experience, nor any of my colleagues. Sure some are making a very good living, but they’re also working very long hours to do that. Dentistry is a cottage industry in Australia and they are running a small business, ultimately just like any other and they face the same pressures, demands and rewards as any other small business, with the added complication that they are bound by very strict legal and ethical requirements.

    In my perfect world, everyone would have ready access to all aspects of health care at minimal or no cost, but I’m a social democrat idealist. The world at the moment is not quite built that way, but we are working toward this. Should dentistry be funded under a universal health care model – of course it should. How we achieve that without sending the country broke is the issue. Simply blaming the dental profession and accusing them of profiteering achieves nothing and avoids the real issues – greater attention toward preventative health care so that problems dont happen in the first place and making all health care, including dentistry more affordable to conduct.

  2. GF50

    Good on you Micheal, You must be the only dentist in practice that has any altruism. This really doesent exist! Where are you practising and what is your Phone no:?
    I have had some experience with dentists/oral surgeons as I worked in RPAH dental clinic. I worked with some great dentists way back. Now I find that most dentists consider /and advertise that they are “cosmetic dentists”. Basic good actual dentistry is not practised with any regard to bite /alignment, best result for a functional mouth. They suggest orthodontic realignment of 60yr+ teeth,( only 7K +, ) that had no problem before latest replace 50yr old ammalgam (cusp snapped off) and removal of all old fillings and crown all teeth. Hello 30K!! nothing wrong with my teeth or the alignment. Have always had comment as to great teeth and super smile:)
    tfw, agree with your comment esp the rip off that occurred and the Govt chasing repayment from some dentists to the tune of $50+ million. Don’t even get me started on the medico’s , most of whom were on the free Uni system that own the private hospitals that mean they are far too busy being millionaires on the public teat, to operate in the centres of excellence Public Teaching Hospitals, that taught them all they know EXCEPT ETHICS. Dr shop folks. you are all entitled to excellence of care! Go to a Public Hospital and give them your private Health Cover card. You have to pay your surgeons fees (no anaethetists fees) and your bed is paid for by your fund. win! win! You have not sucked on the public teat and have added much needed funds to the Public system! without supporting the two tier system, and believe me the Public Hospital is by far and away, Worlds best practise.! Sorry all this is not available to those living in rural areas as excellence comes at a price and requires specialist staffing and extremeley expensive equipment. You have to travel, pros and cons to living/making a living.

  3. Michael Lines

    Guy,

    Sorry, but thats exactly what you implied, intentional or not and I’m pretty sure this is exactly how it was taken by what is clearly an agitated and engaged audience. In fact it was this single comment which finally prompted me to launch a response. Something I would not normally do. But thats Ok, you have now clarified your position. My take on this is that the Government (and the non-dental parts of the health care sphere are quite happy for the attention to focus on what dentists charge, and give the impression that that is the problem, and in this way they can duck responsibility for doing anything realistic about instituting genuine preventative measures and treating the unmet need.

    As I showed above, there are a of of cost pressures in all health care industries, and dentistry is probably more subject to that than most. The actual physical plant and equipment are fixed assets thats true, but like all fixed assets, they wear out and require regular maintenance and repair – they are not set and forget. Speak to anyone who operates earth moving machinery – they know all about this kind of thing. Dentists need this stuff to do their work, and unless you work for the Government as I do, nobody is going to give you several hundred thousand bucks worth of machinery for free. You will have an overdraft the size of an average mortgage. Plus the staff – they dont come cheap, especially good ones. Everything has to be paid for. My point is there is a lot of bulldust circulating around this and everyone wants to blame the dentists solely. Well, its not that simple. Everyone seems to have a story about some rip off merchant dentist – well I’m curious about that too, Id like to see some evidence. There may be some charlatans and overchargers out there, but I cant help thinking theres more to each of these stories than we’re told. I’m really curious about the “1.3 Bn” to pay for dental exams too- theres something pretty fishy about that claim.

    As to solutions, I agree there are probably many ways to fix this, and I would like to see them implemented. Many of my colleagues are sceptical though, (most people are when confronted with changes affecting their workplace – just ask Journos about the Blogosphere), but that reflects their doubt that this or any other government is going to invest the kind of money that it will take to create a real difference. The way your article is framed you make it sound like the dentists conspired to make this situation. Well, thats not the case. The ones running private practices are running a small business in competition with eachother and are free to charge whatever it takes to cover their costs and ultimately what the market will stand – and thats what they are doing. The unmet need exists because there is a large group of the population who are unable or (in a great many cases) simply unwilling to pay this. The trouble is that they have no other alternative than the extended waiting list in publicly funded clinics because successive State Governments have not allocated sufficient funding to this.

    The bottom line is that the dentists in private practice are not the enemy here – lack of funding of public dental care is the real issue.

    Most dental graduates dont want to work in state clinics because the pay is lousy, the workload immense and the treatment you are able to provide is very limited. I blame state governments for this because health care is their responsibility (but they’re ducking for cover behind the Feds). But in addition, I wonder about peoples’ priorities sometimes. I am aways amazed by how much people will spend on a car, or even having one fixed, but baulk at paying to have something inside their own head fixed so that it doesn’t cause pain or infection. I have seen some truly shocking things in patients mouths and have wondered how they can live with them. Its testimony to the resilience of people I suppose.

    As to my own situation, questions of what I get paid and practice turnover are pretty meaningless – I work in a large Government organisation which wears green a lot. My salary is about 113K a year. I work whatever hours are required (at least 7am – 5pm) and there is no such thing as paid overtime. The benefit is that I can give patients whatever treatment they need to maintain their oral health without worrying about their capacity to pay.

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