Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011) / Chapter Skim
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4 Settings of Oral Health Care
4 Settings of Oral Health Care
Pages 157-192
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From page 157... ...
This chapter gives an overview to the delivery of care in both private practices and safety net settings, including descriptions of their patients, staffing, challenges, and successes. The capacity of the system to care for vulnerable and underserved populations will be addressed, as well as particular non-financial challenges.
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. Staffing Independent dentists usually employ one or more individuals in the private practice setting, with an average of 4.8 total staff members per dentist (ADA, 2009b)
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. In the private practices of independent dentists, dental hygienists work, on average, almost 47 weeks per year and 24 hours per week (ADA, 2009b)
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do not have any patients covered by public sources. Expenses and Income In 2007, the average gross billings per owner from the primary private practice for all independent dentists was approximately $774,000 (or about $656,000 per dentist in the practice and $500 per active patient)
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accounted for 59 percent of gross billings from the primary private practice of all independent dentists (ADA, 2009c)
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, FQHC look-alikes, non-FQHC community health centers, dental schools, schoolbased clinics, state and local health departments, and not-for-profit and public hospitals. Each type of provider offers some type of dental care, but the extent of the services provided and the number of patients served varies widely.
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From page 163... ...
, and the health care reform bills includes $11 billion for a Community Health Centers Trust Fund that will allow FQHCs to expand access and make capital improvements, and $1.5 billion for a new National Health Service Corps Trust Fund.4 FQHCs are required to provide certain services -- including preventive, but not comprehensive, dental services -- either in the clinic or by referral. In 2008, 80 percent of the 1,080 FQHCs provided on-site dental services, and 88 percent provided dental services on site or by referral (Anderson, 2010; Cottam, 2010)
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From page 164... ...
A large number of FQHC dentists previously worked in the private sector; 31.9 percent reported previously working as a private practice owner, partner, or associate, and 18.5 percent reported previously working as an employee dentist in a private practice (Bolin, 2010)
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. Very little data are available about the dental care provided at FQHC look-alikes because they are not required to submit detailed information to the Department of Health and Human Services about visits.
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. In addition to on-site clinics at dental schools, dental students also provide care through community rotations in FQHCs and community health centers (ADA, 2010)
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were developed to provide basic health care services, including dental care, in elementary and secondary schools. SBHCs are perhaps the most convenient care location for both children and parents because they eliminate the need for transportation, parent time off, and missed school.
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. Mobile dental clinics are often operated by other safety net provid 6Patient Protection and Affordable Care Act, Public Law 148, 111th Cong., 2nd sess.
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Examples of policy development through state-level dental public activities include mandating that all children in kindergarten, second, and sixth grades receive an annual dental examination in Illinois (Conis, 2009) ; requiring Medicaid recipients in Iowa to have a dental home and receive preventive dental care (Rodgers et al., 2010)
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, local health departments (LHDs) also provide a variety of oral health services.
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. In the past, HRSA has also supported local public health infrastructure by training state dental directors and other dental public health professionals and offering technical assistance to state and local health departments through the regional dental consultant program described above (Geiermann, 2010)
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. Remote Area Medical, founded in 1985, is a nonprofit, charitable organization that provides free health care, dental care, eye care, veterinary services, and technical and educational assistance to remote populations around the world, but most typically in Appalachia (www.ramusa.org)
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From page 173... ...
Very few dentists work in large practices, and often are in solo practice. Most of the expansion in the capacity of the private practice has been due to increased use of other personnel, such as dental hygienists and dental assistants, which allows them to delegate some responsibilities (Beazoglou et al., 2009; Brown, 2005)
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Specifically, they looked to FQHCs, health centers, community hospitals, school-based clinics, and dental schools. Overall, they estimated that 7.4 million individuals were already being served in those sites of care, and that there was only capacity to add another 2.6 million patients.
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From page 175... ...
Compared with other safety net providers, only FQHC dental clinics have a definable source of long-term funding. While the number and size of FQHCs are likely to expand, they do not have the capacity to care for all the unmet needs of vulnerable and underserved populations.
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From page 176... ...
includes financial assistance to dentists who plan to teach or are teaching in general; pediatric or public health dentistry; and faculty loan repayment programs for general, pediatric, and public health dentists who agree to serve as full-time faculty. In addition, under Title VII, individuals from disadvantaged backgrounds who agree to serve as faculty for at least two years at dental and dental hygiene schools are eligible for the Faculty Loan Repayment Program.8 Overcoming Barriers in the System The current oral health care system is not well designed to overcome barriers to caring for vulnerable and underserved populations.
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From page 177... ...
During the course of the case management program, the number of dentists participating in the program went from 2 to 28, and the percentage of Medicaid-eligible patients receiving dental care increased from 9 percent to over 40 percent. Other, comparable case management programs (some of which also included a reimbursement rate increase)
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From page 178... ...
to dentists who review the materials, make diagnoses, and develop treatment plans. Then, the field-based professionals provide preventive services such as oral hygiene instruction, prophylaxes and fluoride varnish, temporary restorations, and refer patients needing dental services to dental clinics or private practices.
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From page 179... ...
Since 2003, several other state FQHCs have established similar programs that currently provide oral health care to low-income children in over 200 public schools and Head Start programs. The estimated number of children treated each year is over 10,000 and growing rapidly (Bailit et al., 2010)
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. As of July 2010, Marshfield clinic operated seven dental clinics in rural Wisconsin; at that time, the number was projected to increase to nine by 2011, and they planned to operate 16 dental clinics throughout the state by 2016 (Nycz, 2010)
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. Head Start programs are required to determine whether a child has received age-appropriate preventive dental care within 90 days of the child entering the Head Start program.9 If a child has not received appropriate care, the Head Start program must help the parents 9 Code of Federal Regulations, Office of Human Development Services, Department of Health and Human Services, title 45, sec.
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From page 182... ...
To foster access to oral health for children enrolled in Head Start, in 2006, the Office of Head Start invested $2 million in grants to 52 Head Start, Early Head Start, and Migrant/Seasonal Head Start programs for the Head Start Oral Health Initiative; grantees received supplemental funding for 4 additional years. While grantees reported successfully developing partnerships with community organizations and providers who would serve Head Start children, educating staff about the importance of oral health, and incorporating oral health education into the curriculum, they reported that they likely could not sustain much of the oral health programming when the grant funding ended (Del Grosso et al., 2008)
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In these cases, portable equipment is increasingly being used to provide on-site, community-based care in settings such as nursing homes, group homes, schools, and Head Start centers. For example, Apple Tree Dental (Apple Tree)
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. Recently, retail dental clinics have been proposed as an alternative site of dental care (Scott, 2009, 2010)
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• Only a small portion of private-sector oral health care is supported by publicly funded programs such as Medicaid. • An array of programs provides oral health care to underserved and vulnerable populations, including FQHCs, dental schools, and health departments.
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2004. State and community models for improving access to dental care for the underserved -- a white paper.
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. Report to the Oral Health Ac cess Committee: State case studies: Improving access to dental care for the underserved.
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2010. Doctor, my tooth hurts: The costs of incomplete dental care in the emergency room.
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2002. An ABCD program to increase access to dental care for children enrolled in Medicaid in a rural county.
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2009. Preventive dental care for young, Medicaid-insured children in Washington State.
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2004. Teledentistry in the United States: A new horizon of dental care.
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Journal of the American Dental Association 138(7)
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