Expansion of Dental Services in Safety Net Clinics

POLICY STATEMENT

The landmark 2000 report, Oral Health in America: A Report of the Surgeon General, identifies huge disparities in the oral health status of certain populations in the United States and challenges the nation - the health care community, policy makers, public and social service agencies, educators, insurers, et al. - to work together to develop strategies to increase access to oral health care. Two other recent reports, Healthy People 2010 and the ADA’s Future of Dentistry list increased partnerships as essential to building oral health care infrastructure and realizing the vision of improved oral health care for all.

Research found that community health centers,  local health departments and private, not-for-profit groups provide services for the needy and concluded that “dental safety-net clinics are a viable model for helping low-income and other underserved patients get the care they need,” and recommended that “support for the expansion of the dental components of safety-net and other community clinics should continue as a partial response to the access problem.”

Expansion of dental services at safety net clinics can be an effective way to expand access to dental care for underserved populations.  This expansion can be accomplished in more than one manner.  One option is the addition of a bricks-and-mortar dental clinic on-site or satellite to an existing clinic. Advantages of physically expanding an existing community clinic to provide care include:

• Easy access to dental care for referrals by medical providers, especially as they counsel expectant mothers and determine the risk status of young children
• Continuity of care provided by a dental home
• Ability to have dental student externships – benefiting the students’ development as dentists
• Ability to draw on the expertise of experienced dentists who may not be able to become dental school faculty, but can provide teaching and oversight at these clinic sites

Alternatively, when limited resources or lack of physical space make expanding a particular site unlikely, a community clinic can contract with dentists within their service area to provide care.  The advantage for the community clinic to contracting with private dentists is they can greatly expand access to dental care for their patients, usually allowing patients to secure appointments with much shorter wait times, without making a significant capital investment in facilities and equipment.

In 2003, the Connecticut Health Foundation commissioned the Children’s Dental Health Project (CDHP) to investigate strategies to improve access to dental services for underserved populations.  CDHP involved the National Association of Community Health Centers and legal counsel to develop a publication entitled Increasing Access to Dental Care Through Public/Private Partnerships: Contracting Between Private Dentists and Federally Qualified Health Centers. This handbook describes everything from how a safety net clinic obtains the authority to provide dental services and secures funding, to payment mechanisms, scope of contracted services, risks, accountability, includes a model contract and more. An updated version of the handbook is available on the CHDP website.

Both the American Dental Association and the National Association of Community Health Centers have endorsed and promoted this concept.  However, one of the barriers to widespread implementation of this contracting arrangement has been something known as the “four walls” test:  In practice this test is more of a concept open to interpretation by states than a definitive federal standard that must be satisfied. Under these criteria, the patient must have a medical record at the FQHC, must use the FQHC as a medical home, and must obtain primary care services at the center that meet the patient’s needs. A patient who meets these criteria is considered to be a patient of the FQHC and thereby must  be served within the “four walls” of the FQHC.

In order to address the perceived barriers created by the “four walls” concept, the 2009 Child Health Insurance Reauthorization Act (CHIPRA) contained the following provision (Title V, Section 501(c)(1)):  [A state plan for medical assistance must] “provide that the State will not prevent a Federally-qualified health center from entering into contractual relationships with private practice dental providers in the provision of Federally-qualified health center services.”

CDA supports the role that safety net clinics provide in caring for underserved and uninsured populations. CDA supports that expansion of dental services in safety net clinics by initially facilitating communications between clinics and dental components, being an information resource and providing technical assistance to members or community organizations seeking to expand their local safety net clinics to include dental services.

Revised January 2011