Florida Oral Health

Safety Net

• What is the dental “safety” net?   
• How many private-practice dentists have publicly insured patients in their care across the nation?  
• What other private or voluntary activities of dentists support the dental safety net?  
• What public facilities offer dental care to underserved populations?  
• What federal authorities support the Dental Safety Net?  
• What State Action and Best Practices support the Dental Safety Net?  
• Where can I get more information?

What is the dental “safety” net? 

• The dental safety net includes facilities, providers, and payment programs to support dental care for underserved populations.
• Nationwide, safety net providers are a source of dental care for Medicaid and uninsured patients who do not have access to private providers or elect care in a community-based facility that offers multiple health and social services. 
• Workforce needs are an ongoing challenge to staff safety net institution as only about 4-8% of dentists practice in the safety net.   

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How many private-practice dentists have publicly insured patients in their care across the nation?

• An estimated 6% of patients cared for by general dentists and 18% of patients cared for by pediatric dentists are publicly insured.  Only 13,000 private practice dentists (about 8% of practitioners) care for 30% or more publicly-funded patients.
• Overall, 92% of dentists in US are in private practice.  

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What other private or voluntary activities of dentists support the dental safety net?

• In addition to the services of private-practice dentists who participate in Medicaid and CHIP, volunteer programs, nationwide, offer free care through groups such as Donated Dental Services, Give Kids a Smile, Missions of Mercy, and Remote Area Medical.  

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What public facilities offer dental care to underserved populations?

Community Health Centers (CHCs)

• Among various types of CHCs are
  • “Federally Qualified Health Centers (FQHCs)” and “Tribal Health Centers” that meet federal governmental criteria for services and access. These organizations receive funding directly from the federal government and are paid by Medicaid on a “per-visit” basis.
  •  “Look Alike Health Centers” that meet similar criteria but do not receive federal funding
  • Community Health Centers supported by State, County, and Local governments or private philanthropy.
• Federally-affiliated health centers are located within designated health profession shortage areas that qualify as such either by geography or population served. 
  • Federally Qualified Health Centers (1,080 nationwide), both public and private non-profit, meet criteria established by Medicare and Medicaid Programs 
  • Federally Qualified Health Center Look-Alikes are certified as “health centers” under Section 330 of the PHS Act, but do not receive grant funding. 
  • Outpatient health programs/facilities operated by tribal organizations or urban Indian organizations.

School-Based Health Centers (SBHCs)

• During 2004-05, Two out of five SBHCs (522 sites) offer some level of dental services— including screenings (38%), preventive care (20%), and comprehensive dental care (8%).  
• SBHCs are sponsored by hospital/medical centers (31.5%); community health centers (24%); health departments (17%); school systems (10%); or others.

Dental schools and Dental Hygiene Programs

• Dental hygienist students, dental students, and dental specialist residents provide care to patients under faculty supervision in the nations nearly 60 dental schools and 355 dental hygiene programs.
• Dental schools are increasingly incorporating community-based learning and care for the underserved as specific aspects of their curriculum.

Hospital Emergency Rooms

•  Hospital Emergency Rooms provide only medication to relieve pain and infection but are very rarely equipped and staffed to provide definitive dental treatment. CHCs report that they partner with hospitals to reduce inappropriate ER use by diverting patients to the CHC for definitive care. Emergency departments have reportedly become “expedient sources of care because they are open 24 hours a day, cannot turn patients away without screening them and many are located in urban areas accessible by public transportation.” (Center for Studying Health System Change. Issue Brief No. 120, May 2008) 

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What federal authorities support the Dental Safety Net?

• FQHCs receive direct federal support through a program known as the “330 funding”
• The Children’s Health Insurance Program Reauthorization of 2009 explicitly authorizes FQHCs to contract with private dentists in order to expand availability of oral health care for its clients. Under such contracting, Medicaid pays the FQHC for the care and the dentist is paid through an independently contracted arrangement with the FQHC. Such contracting requires respect of FQHC and Medicaid regulations and rules.
• ACA (Healthcare Reform) includes a number of provisions to bolster the safety net including:  
  • Expansion of Dental Clinics in Schools and FQHCs through funding for capital expenditures
  • Expansion of funding for dental training with priority for community-based training
  • Expansion of the National Health service Corp for dentists seeking loan repayment by working in health centers
  • Analysis and evaluation of safety net facilities by the Medicaid and CHIP Payment and Access Commission (MACPAC). 

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What State Action and Best Practices support the Dental Safety Net?

• State oral health plans make recommendations for safety net enhancements (State plans can be accessed at http://www.cdc.gov/oralhealth/state_programs/OH_plans/index.htm. A table comparing plans is available at website at: http://cdhp.org/resource/comparison_state_oral_health_plans.
• Best Practices, including multiple ASTDD models & approaches at: http://www.astdd.org/index.php?template=sdescfull.php&bpareport=Access%20to%20Oral%20Health%20Care%20Services:%20Workforce%20Development. For 2009-2010, see:
  • Open Wide Program – Connecticut (http://www.astdd.org/bestpractices/pdf/DES08002CTopenwide.pdf)
  • Healthy Kids Dental – Michigan (http://www.astdd.org/bestpractices/pdf/DES25001MIhealthykids.pdf)
  • UM Dental School Partnership with Community Health Centers (http://www.astdd.org/bestpractices/pdf/DES25002MIdentalschool.pdf)
  • School-based Preventive Dental Program – New Hampshire (http://www.astdd.org/bestpractices/pdf/DES32003NHschoolprogram.pdf)
  • Tooth Tutor Access Program– Vermont (http://www.astdd.org/bestpractices/pdf/DES51001VTtoothtutor.pdf)
•  Other State Activities
  • Demonte Driver Project is building a workforce of private practice dentists who accept Medicaid in Maryland (see:  http://www.deamontesdentalproject.org/team)
  • In Maryland, foreign-educated dentists who completed US pediatric dentistry fellowship programs in health centers provided significant care to underserved populations. 
  • New York and Delaware require a minimum of one year of postdoctoral training for state licensure, often in community sites. (Edelstein, JPHD, 2010). 

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Where can I get more information?

    * Edelstein BE. The dental safety net, its workforce, and policy recommendations for its enhancement. Journal of Public Health Dentistry 70;2010: 532-539.

    * American Dental Association: 2005 Survey of Dental Practice: Characteristics of Dentists in Private Practice and their Patients. Chicago.

    * CDHP: FQHC Handbook.

    * Institute of Medicine. The US oral health workforce in the coming decade: workshop summary. Washington: The National Academies Press; 2009.

    * NASBHC: SBHC National Census.

    * JADA Continuing Education: Dental safety net: Current capacity and potential for expansion.

    * FQHCs: Authorized by Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act; Funded by Section 330 of the Public Health Service Act.

    * American Indian Programs/Facilities: Indian Self-Determination Act, P.L. 96-638; Indian Health Care Improvement Act, P.L. 94-437.

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