Something to Smile About Dental Program

State: MD Type: Model Practice Year: 2004

Garrett County, Maryland is a rural community located in the Appalachian Mountains of Western Maryland. Prior to the initiation of the Garrett County Health Department’s (GCHD) “Something to Smile About” dental program, there were many barriers to dental care, including a lack of dentists, reluctance on the part of providers to accept dental insurance, and cultural norms that do not include regular preventive dental care. Although dental care for pregnant women and children was a benefit provided through State Children’s Health Insurance Program in Maryland (MCHP), many families were unable to access care. A kindergarten survey conducted in 1998 by the GCHD that revealed that 41 percent of all children had untreated dental decay. A phone survey conducted of MCHP recipients revealed that over 37 percent of children over age 3 had not visited a dentist. Over 60 percent of parents reported that they had not been able to use their MCHP card for dental care. Furthermore, although 98 percent of the families could identify a family doctor only 62 percent were able to identify a family dentist. The purpose of the “Something to Smile About” dental program is to improve dental outcomes for children in Garrett County, Maryland. The primary targets are pregnant women and children eligible for MCHP. The secondary target includes all dentally underserved residents of Garrett County, Maryland. A total of 49.8 percent of the target population was reached. This program’s objectives are: To increase the number of children and pregnant women who receive dental care.  To establish an outpatient dental surgery center in the local hospital.  To increase the percentage of households with a fluoridated water supply. To establish a fluoride rinse program in all elementary schools in the county. To provide a sliding fee scale for adult dental patients who otherwise could not afford emergency dental care. To increase the amount of dental health education being provided to the community. Key elements needed to replicate the practice include:Having a local network comprising of dentists, the health department, the school system, local hospitals, and community action agencies. A comprehensive local strategy to address lack of dental care and preventable dental caries. An infrastructure for payment and reporting mechanisms. Willing partners. Available funding for equipment.
Garrett County is identified as a Health Professional Shortage Area for dentists and primary care providers. The Garrett County ratio of one dentist to every 2,993 residents is far higher than the recommended ratio of one dentist to every 1,300 residents. The health department met with area dentists who identified several reasons that so few children and pregnant women were receiving dental care as an MCHP benefit. Dentists reported that: The MCOs reimbursement rate was too low. They often had claims denied. The turn around time on receiving reimbursement was too long. There was an added burden placed on dental offices in the form of electronic claim submission, which required a substantial investment for technology and office staff training. GCHD responded to these concerns by: Developing a network of community dentists. Negotiating a higher rate of reimbursement. Assisting network dentists with claim submission. Guaranteeing payment for valid claims. Starting a public health dental clinic. Renewing its efforts in community health education around dental issues. GCHD also developed a dental clinic located in the Garrett County Health Center. A dental surgery center was also established in the local hospital where a general dentist provides dental care while the patient is under general anesthesia. The network also worked together to advocate for fluoridation of community water supplies. Three municipalities have subsequently voted to fluoridate their water. Oral health education has been increased in the public schools through the use of a dental hygienist, community outreach workers, an AmeriCorps member employed at GCHD, and three private dentists who volunteer in the health education program.
Agency Community RolesGCHD acts as a developer and manager of the network of community dentists, dental care providers, health educators in schools and the community, grant writers (grants to fluoridate the public water systems), and underwriters (health department assumes risk by paying claims of network dentists within 30 days of submission). GCHD staff has the skill and infrastructure to maximize the percentage of claims paid, while many dental offices do not. The dentists in the community network have agreed to charge patients at a rate lower than their normal fee schedule. They also provide health education, limited dental care for adults, and public awareness pro bono. GCHD spends a great deal of time studying the issues before initiating new programs. By “always consulting before deciding” (ACBD), a spirit of goodwill has been established between local dentists and GCHD. In addition, GCHD has assisted local dentists by providing continuing education opportunities and taking a lead on local dental association initiatives like promoting Children’s Dental Health and Oral Cancer Awareness Months and involving the dentists in the campaign to fluoridate public water systems. Costs and ExpendituresExpenses for 2004 include salaries and contractual dentists ($438,907), operating expenses ($70,765), equipment ($43,901), and fixed charges ($34,115). Total expenses were $587,688. The program’s income comes from MA and MCHP fees ($527,000), categorical grants from the Office of Oral Health ($50,000), Sliding Fee Scale ($3,000), and county funds ($7,688). The program’s total income is $587,688. An important consideration is that the GCHD negotiated a rate with the MCOs that was 30 percent higher than they previously paid to stand-alone dental offices. This rate has remained the same for three years; however, GCHD may need to negotiate a higher rate as inflation increases the cost of service. The sliding fee scale was just added in 2003 and is only applied to patients who have no insurance and are over the poverty level. One opportunity that is being pursued is a local application for a Federally Qualified Health Center (FQHC). If funded, the FQHC may be able to pay for some services for patients, though those are currently being written-off. Implementation October 1998: GCHD surveyed the community about unmet dental needs. February 1999: GCHD applied for Rural Health Outreach Grant. January 2000: GCHD was notified of the grant award. February 2000: The Towns of Mt. Lake Park and Loch Lynn Heights voted to fluoridate their water systems. February 2000: A meeting was held with all dentists in the county. From August 2000 to November 2000, GCHD signed contracts with MCOs and community dentists. October 2000: The towns of Mt. Lake Park and Loch Lynn Heights began the fluoridation of water systems. January 2001: Community dentists began to see MCHP and MA patients through the network. April 2001: GCHD contracted with dentists to provide dental care in health department facilities with used equipment. July 2001: Dental surgery began in Garrett County Memorial Hospital. October 2001: GCHD dental services moved into a new dental clinic. July 2002: Deer Park voted to fluoridate water system. July 2003: The fluoride rinse program began in all elementary schools in Garrett County. February 2004: GCHD began seeing uninsured patients on a sliding fee schedule. March 2004: The extraction clinic began one day per month in health department. June 2004: The Deer Park fluoridation system began.
The dental hygienist from the Garrett County Health Department screens children each year during kindergarten registration. Records are compiled to determine the number and percentage of children with untreated dental decay. Percentage of children registering for kindergarten with untreated dental decay in 1998 was 41%. In 2003, it had decreased to 34%. In 1998, the percentage of families on public water system with fluoridated water was 29%. In 2004, this percentage had increased to 68%. From 2000 to 2002, the number of children receiving services increased from 517 to 1128. Enrollment also increased from 1096 to 2290. The MCHP encounter data was influenced by the clinic going 11 months without a dentist in 2002. In 2001 when the clinic had a dentist for 10 months the utilization rate was 63%. Data for 2003 is not yet available but with the addition of a dentist for all 12 months it is anticipated that the utilization rate to be close to 75%.
SustainabilityOriginally supported with a three-year grant of $196,000 per year from HRSA, the program is now self-supporting. Moreover, dentists in the community are supportive of the program, as evidenced by their assisting with health education efforts and volunteering time in the adult clinic operated at the health department’s facilities. Physicians make referrals to the clinic and are very supportive of the program. Other referral sources are WIC, Healthy Families, and the Department of Social Services. Lessons LearnedStaff learned that it is important to have a detailed work plan, especially when purchasing equipment. They initially purchased used dental equipment, which needed to be replaced at a later date. Staff also learned that it was important to meet with each of the dentists in the community individually, since a few were initially threatened by the health department’s providing dental care. Key Elements ReplicationTo replicate the program, remember to keep local dentists involved in the process and negotiate aggressively with the MCOs. GCHD had to make the MCOs realize that they would not be able to get a contract with a dentist in the county without working with the health department. Once the MCOs realized this, they were willing to increase their fees. The dental surgery center is not only a necessity for treating young patients who require multiple extractions or restoration; it is also a very good source of income for the program. It was important to work closely with municipal governments when proposing fluoridation of water. Private dentists were very good expert witnesses for the public hearings.