More and more preschools and K-12 schools in the U.S. are being asked to allow oral health services to be delivered onsite, according to an issue brief released February 28 by the Association of State and Territorial Dental Directors (ASTDD).
The report, which gives an overview of the issues surrounding the use of mobile dental vans and portable dental equipment in schools, provides examples from communities and states, lists resources for those looking to start or expand programs, and suggests recommendations for action and further research.
With the increasing acceptance and use of dental sealants to prevent dental decay, school-based sealant programs have grown exponentially, according to the ASTDD. In the 2010 Synopses of State and Territorial Dental Public Health Programs, published by the Centers for Disease Control and Prevention, most states (78.4%) reported supporting dental sealant programs targeted to elementary schoolchildren. A 60% decrease in tooth decay has been documented in multiple studies when sealants are provided through a school-based or -linked program, the ASTDD said.
Barriers remain
Provision of basic restorative care for young children can sometimes be accomplished in a mobile van, if treatment is not extensive and the child is cooperative, the study noted. This is particularly helpful in areas with a limited number of pediatric dentists or rural areas where dental clinics or practices are not easily accessible.
In 2010, state-supported or -operated mobile or portable programs provided preventive care in 16 states and restorative care in 25 states, the ASTDD noted.
Financing for such programs is usually provided through a combination of grants, public and private insurance, agency budgets, state tobacco settlement funds, fees, donations, and volunteers. Programs are administered by public and private entities such as Federally Qualified Health Centers, state or local health departments, universities, community-based nonprofit and for-profit groups, humanitarian and church groups, individual practitioners, or private entrepreneurs.
However, "some states do not allow services to be provided in community settings by dental hygienists or other healthcare providers unless a dentist is onsite, making mobile and portable service delivery a less viable and more expensive option in those states," according to the ASTDD report. Available national data show that in 2008 less than 37% of children in Medicaid received any dental services, and several states reported rates of 30% or less.
Malpractice insurance and other liability issues present additional barriers to "out-of-office" provision of care using mobile vans and portable equipment, the study authors noted. Questions about liability for service delivery by the individual provider or the program owner/administrator should be clarified, as well as liability for the school where services are delivered.
States regulate healthcare via mobile and portable care through licensing, certification for who can receive payment, and payment policies, structures, and rates. Reimbursement issues include low Medicaid reimbursement rates, coverage in out-of-office settings, differing state policies on direct reimbursement to dental hygienists, duplicate billing by multiple providers for diagnostic and preventive services, and lack of reimbursement or confusing reimbursement policies for administrative and outreach services.
Liability concerns
A number of states have adopted laws and regulations governing licensure requirements, certification, and/or staffing for mobile or portable dental programs, the ASTDD noted. These include California, Florida, Indiana, Kansas, Louisiana, Maryland, Mississippi, Missouri, New York, South Carolina, Tennessee, Texas, and Virginia. Other states are in the process of considering such regulations.
In addition, the Federal Trade Commission has advocated in a number of states to actions by legislatures and/or professional boards on healthcare delivery and scope of practice, including dental. For example, the agency has written letters to various states arguing against bills that would restrict who can provide or administer mobile dentistry services in school settings.
State policymakers have also addressed the issue of liability and tax and legal implications for dental professionals who volunteer for a mobile-portable dental program, the ASTDD noted. As of 2003, 21 states had adopted charitable immunity laws that make a specific reference to dentists or dental care. In addition, the federal Volunteer Protection Act offers certain protections from liability for properly licensed volunteer clinicians working with nonprofit or governmental agencies.
Continuity of care
The majority of the mobile-portable dental programs in the U.S. are well-managed, the study authors noted, but a few offer limited care or operate as "one-visit only" programs across multiple states while aggressively marketing their services and competing with local programs or practitioners. Such programs see a high volume of children in one day but do not provide follow-up care, according to the ASTDD. This leaves families to pay out-of-pocket costs for additional diagnoses or the rest of their care, thus creating additional burdens on parents and the local care systems.
Working with schools, parent groups, dental societies, and health departments at the outset to assess community needs and develop programs to meet the needs is key to having successful programs, the study authors noted. Also, successful programs have sought ongoing commitments from multiple funding sources early on in addition to seeking reimbursement for services from insurers, the ASTDD said.
Finally, the ASTDD makes several recommendations for action at both the state and federal levels, including the following:
- Create a database of state laws, rules, and regulations related to mobile or portable dental services and school oral health services.
- Collect examples of best practices or promising models for providing dental services in preschool and school settings using mobile and portable systems.
- Research additional ways to maximize reimbursement and other funding or cost-sharing mechanisms in light of healthcare reform.
- Develop or adapt already existing manuals and templates for schools and preschools to use in making decisions and creating contractual arrangements and policies for onsite mobile and portable dental services.
- Develop statewide tracking systems of mobile and portable dental services provided in or for preschools and schools. State oral health programs would need to work closely with state departments of education and state Medicaid and CHIP dental programs.
- Consider use of teledentistry in combination with portable programs in schools to improve consultation and electronic records options, as well as the most efficient use of personnel in areas where access to care is difficult.
