On the road again

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Can Australia deliver on dentistry for Australian teens? Perhaps New Zealand has a private model we can look at, says Andy Kollmorgen

One of New Zealand’s mobile dental units, it comprises two self-contained surgeries, X-ray facilities and a waiting area.
One of New Zealand’s mobile dental units, it comprises two self-contained surgeries, X-ray facilities and a waiting area.

It’s fair to say that Dr Da’ad Dr Al Falahi’s approach to the dental profession is not fixated on finding new revenue streams and building up her practice. Both are noble and necessary pursuits, she realises, but Dr Al Falahi, who graduated from the dental program at the University of Baghdad before being accredited in New Zealand, appears to be on a crusade of sorts.

The downside of making less money has been offset by other rewards, Dr Al Falahi told Bite. Along with a core group of fellow missionaries, she finds job satisfaction in delivering dental care to teenagers who would otherwise avoid it. Dr Al Falahi believes that intervening at such a critical life-stage moment can make the difference between dental health and dental disaster.

Since 1998, Dr Al Falahi has been a key clinician in a project known as the Mobile Smile Unit, a mini convoy of well-appointed surgeries that have been stopping by schools in the Auckland area in an effort to improve teenage oral health. Last year, the three units tended to 30 schools around Auckland’s North Shore region, and treated about 12,000 students between the ages of 13 and 17.

The important thing is that they did it for free, since dental care in New Zealand is government-funded for this age group. (Procedures like plates, crowns and bridges require a special tick from health authorities, but Dr Al Falahi says approval has become quicker and easier as the mobile units have established their credibility.) The units expect to deliver 6000 free check-ups this year.

Ownership of the project has changed hands over the years and currently sits with a well-resourced outfit, Lumino The Dentists, which encompasses 76 practices and had annualised revenue of $NZ69 million as of November 2012.

Dr Al Falahi’s income, however, is limited to what the New Zealand government is willing to pay per procedure. For a filling, the rebate is currently $50, which pales in comparison to the going rate in private practice of around $300.

“It’s a very rewarding job,” says Dr Al Falahi. “But if you’re in it for the money, you’d be doing something else. I’d be a millionaire by now if I’d focused on private practice.”

The primary task of the 15-year campaign has been to convince schools and parents that the mobile unit is a good thing and that taking care of teenagers’ teeth is a good idea. Dr Al Falahi has met her share of challenges on both fronts, especially in schools categorised as Decile 1 or 2 (NZ’s bureaucratic shorthand for schools in lower socio-economic areas).

“These are kids whose parents don’t even care,” says Dr Al Falahi. “When I started out, a lot of kids didn’t have toothbrushes. Some schools were very resistant to us in the beginning.”

School by school, doubt and suspicion have given way to something like gracious acceptance, Dr Al Falahi says. “We’ve got every single school on the North Shore enrolled at the moment. It’s all been about building faith in our brand and faith in our service.”

There are still a few stragglers though. According to Lumino, 30 per cent of eligible students in the Auckland area, or 25,000 teens, aren’t using the free service.

It’s no secret that Australia has its own issues when it comes to getting teenagers—or make that the parents of teenagers—to take up government-funded care. As it happens, the Commonwealth is in the process of figuring out a new and effective strategy. The Medicare Teen Dental Plan is due to shut down at the end of this year and will be replaced by the Child Dental Benefit Schedule.

Australian Dental Association national president Dr Karen Alexander expresses cautious optimism about the latter but says the former was never much of a winner. Uptake was lacklustre, to put it mildly.

“It was a scheme that sort of had the right idea, but there were so many limits, it left a lot of people frustrated. If you actually found a hole in a tooth, you couldn’t put a filling in it. I heard from a lot of angry parents.”

Nonetheless, the intended recipients should also shoulder some of the blame, Dr Alexander adds. “Many people do not value what they get for free as much as they should.”

The biggest fly in the ointment with Teen Dental is a flawed model of compensation, Dr Alexander believes. As with the Mobile Smile Unit project, rebates are capped at a rate well below what dentists would make outside of government funding. Worse for parents, the focus is strictly prevention and maintenance. The costly stuff isn’t covered.

Dr Alexander points out that there’s no shortage of altruistic dentists in Australia—many reduce fees for patients in need “as their contribution to the profession”—but she argues that any national funding scheme has to factor in the realities of the average working dentist.

Regardless of any altruistic impulses, many can’t afford to provide service at reduced rates. “In any government scheme, dentists should be able to charge their usual fee.”

With politics and budgets at play, Dr Alexander’s hope that the final version of the Child Dental Benefit Schedule will pass the reality check for working dentists is tentative. The Australian Dental Association has been given to understand that the new scheme will include the two critical elements missing from the previous one: rebates based on what dentists customarily get paid, and the expansion of those rebates to cover things like fillings and extractions.

It looks like expanded rebates are a done deal. Medicare has publicly stated that “check-ups, X-rays, fillings and extractions will be included”. There are no such guarantees about compensation. And from a parental standpoint, the new scheme is hardly a windfall: total benefits will be capped at $1000 per child over a two-year period, which may not be enough to inspire widespread participation.

Does this mean that Australia is ready for roving teen-care units? Unless such a program is aimed strictly at the outback, Dr Alexander has her doubts. “Once they turn 18, the service stops, and then they haven’t got anywhere to go. It’s better for dentists to establish relationships with patients and get them into a routine of going to a practice rather than expecting the dentist to come to them. Otherwise, all that good work can crumble into nothingness.”

A scheme that works for both practitioners and patients over the long term is a better idea, says Dr Alexander. “After all, we see a lot of problems in the 18 to 25 range.”

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