Outside four walls: Health centers improving access to dental care
All children enrolled in Medicaid are entitled to dental benefits as part of the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT), but only 40 percent of enrolled children had a dental visit in 2010. Access to dental care remains an issue for children, and states report that most dentists treat few or no Medicaid or Children’s Health Insurance Program (CHIP) enrollees, although both programs cover dental services. The health care safety net is small and fragmented when it comes to oral health, and provided dental care to only 10 percent of children in Medicaid in 2009.
With the support of the Pew Charitable Trusts Children’s Dental Health Campaign, NASHP recently looked at how Federally Qualified Health Centers (FQHC), a key component of the safety net, may provide a promising way to expand access to dental services for low-income children. A 2011 Institute of Medicine report recommended that dental services be provided at a variety of community locations in order to reach vulnerable populations, such as low-income children, and that FQHCs be encouraged to provide care outside of their four walls. Through the use of portable equipment, FQHC providers can go in to schools, day care centers, Head Start programs, WIC sites, and others, to provide dental services to low-income children where they live, learn, and play.
In a NASHP query to state primary care associations (PCAs), a number reported that FQHCs are providing dental services offsite in their communities. We also explored with PCAs what policies or practices facilitate or challenge delivery outside FQHCs’ four walls.
- Reimbursement policies. Offsite FQHC dental programs may be most viable in states that reimburse FQHCs at their usual Prospective Payment System (PPS) rate, as fee for service rates for dental care usually are substantially lower than PPS. While the application for licensing can be burdensome, New York reimburses for dental services provided at all licensed offsite locations served by FQHCs at the PPS rate. However, NASHP’s scan suggested offsite reimbursement policies are variable across states.
- Staffing models. The most common policy mentioned that facilitates the development of offsite dental programs is one that allows dental hygienists to provide services under the general supervision of a dentist. A policy permitting general supervision allows dental hygienists to provide approved services without a dentist at the location with them. New legislation in Michigan, called the “second pair of hands,” allows for a dental assistant to support a dental hygienist without a dentist at the site. This policy was also cited as something that would further facilitate the expansion of offsite dental services.
- Regulations on the delivery of care offsite. Massachusetts developed useful regulations supporting the use of portable equipment to provide dental services. The regulations include requirements about where services can be provided, what the physical space should look like, and how patient records, and parental consent should be handled. The regulations also include information on referrals from offsite locations. This is another advantage of having FCHCs support offsite dental programs since FQHCs are often able to refer children seen offsite back to the FQHC for any further treatment, or have connections to providers in the community where these children can be seen.
- Onsite dental caseload. One significant barrier to expanding dental services to offsite locations is the current dental caseload of FQHCs. Limits on Medicaid coverage for adult dental benefits means that adults often seek care at FQHCs that are required to provide care regardless of the patient’s ability to pay. Difficulties in meeting communities’ dental care needs because of a large adult dental caseload with little or no Medicaid reimbursement are exacerbated by a continued need for additional dentists and other dental providers at FQHCs.
While barriers and opportunities vary from state to state, many FQHCs are successfully delivering dental care offsite to children, as well as to others, such as nursing home residents, by moving outside their four walls. States looking to address the dental care access problems that exist throughout the country might want to take a look at how policies related to reimbursement, portable equipment, or staffing could better support the role of FQHCs in delivering dental care to vulnerable populations.