By Erik Skinner | Vol . 28, No. 24 | July 2020
A QUICK LOOK INTO IMPORTANT ISSUES OF THE DAY
Rural communities face a range of barriers to accessing oral care. There are geographical barriers, such as long distances or difficult terrain, but also societal barriers, such as lack of transportation, lack of insurance and a shortage of oral health providers. Rural communities are also more likely to experience higher rates of poverty, and regions with higher rates of poverty have significantly fewer dentists per person (4.1 per 100,000) than the national average (61 per 100,000). Rural residents, on average, have less money, fewer teeth, more cavities, greater challenges accessing care and poorer overall health than their nonrural counterparts.
State legislators craft and support oral health policies to reduce provider shortages and improve access in a variety of ways to address rural oral health disparities. They consider bills that address physical barriers to access to care, finance oral health services, increase the number of oral health providers, and establish oral health services in primary care and virtual settings in rural communities. Boosting the health care workforce, insurance access and coverage, and teledentistry are common approaches to increasing oral services in rural communities.
Teledentistry consists of a range of services that include video consultations, sharing images and records among providers, provider education courses and patient monitoring to address a patient’s oral health. It is an emerging tool to connect rural and nonrural residents to care. While challenges related to reimbursement, quality of care and patient safety exist, teledentistry can increase a practice’s capacity to screen for disease and connect patients with appropriate care. Twenty-three states explicitly allow the practice of teledentistry, with most state Medicaid agencies authorized to provide reimbursement. In 2020, Utah and Virginia amended their state codes to establish the practice of teledentistry.
The children’s teledentistry program at the University of Rochester’s Eastman Institute for Oral Health illustrates how teledentistry can improve coordination and care in rural settings. Dental practices saw more patients with remote appointments, identified more patients in need of treatment, connected them to care and managed follow-up appointments. Similarly, Extension for Community Healthcare Outcomes (ECHO) is a collaborative model of medical education and care management that allows clinicians to receive online training in a range of specialties to manage complex conditions efficiently and effectively. These models connect rural communities to more experts and improve communication during times of crisis. The University of Missouri and UTHealth both support ECHO projects.
Another state strategy to overcome geographical challenges in rural areas is delivering oral health care through a mobile dental services model. At least 40 state Medicaid programs reimburse for mobile dental services, but many mobile clinics use a mix of reimbursement, grant funding and donations.
In 2019, Connecticut enacted HB 7122 to address the long distances many rural residents travel for oral health services. The bill allows a mobile dental clinic to submit claims for Medicaid reimbursement for services within 30 miles from the fixed dental location associated with the clinic. There are exceptions for three rural counties, extending the distance limit to 50 miles. It also authorizes licensed dentists and dental hygienists who meet licensure requirements to provide services.
In 2019, Maine enacted HB 1014, which added an Early and Periodic Screening, Diagnostic and Treatment (EPSDT) dental coordinator to the state Medicaid agency. The law requires the coordinator to author a report with the state’s Rural Health and Primary Care Division. The report must include geographic areas the division’s oral health programs do not cover, as well as recommendations for funding levels and program improvement.
Several states have policies authorizing oral health professionals to support public health workforce efforts to deliver care in rural and underserved areas. For example, dental hygienists often practice in a number of public health settings such as schools, nursing homes and community health centers, and they can practice in all 50 states. In 43 states, dental hygienists can practice outside a dental office, either independently or under the supervision of a dentist, after meeting certain requirements. Indiana and Massachusetts authorize public health dental hygienists to practice in a broader range of settings. In 2019, Illinois and Wisconsin authorized dental hygienists to practice in public health settings through legislation.
All states have loan repayment incentives for dental providers who agree to practice in rural or underserved areas to address oral health provider shortages. In 2019, Maine HB 502 increased the maximum loan payment amount to eligible dentists from $20,000 to $25,000 if they agree to practice in underserved areas, most of them rural. Florida enacted HB 843 to establish the Dental Student Loan Repayment Program. It supports dentists who practice in public health programs located in certain dental health professional shortage areas and medically underserved areas, which often include rural communities.
The federal government works in collaboration with states on oral health issues facing rural populations. The Health Resources and Services Administration (HRSA) works broadly on Oral Health Workforce Development. The agency bolsters state efforts to attract providers to underserved and rural areas, expand facilities and services, establish teledentistry programs and train the existing workforce, among other activities.
Due to oral health provider shortages in rural areas, states and the federal government also support an array of different student loan repayment programs and scholarships for which dental providers may be eligible. These programs provide payments for loan debt in exchange for a dentist or oral health provider working in an underserved or rural setting. HRSA’s National Health Service Corps’ State Loan Repayment program supports dentists in rural areas by improving access to oral health providers in rural communities. HRSA also provides technical assistance for oral health infrastructure, including investments in information technology and telehealth projects.