Volunteerism in Exchange for Dental Care

Despite widespread efforts, a significant number of Americans do not have their preventive and restorative oral health care needs met.¹ In fact, according to the Comprehensive Dental Reform Act of 2012, more than 47 million Americans continued to face difficulties, and only 45% of individuals older than 2 had a dental visit in 2011.² Minority and/or socioeconomically disadvantaged populations, individuals with special health care needs, older adults, and rural communities typically face the biggest challenges with accessing oral health care.^1–3 For the past decade, efforts have helped to increase dental care utilization for children.⁴ However, nonelderly low-income adults continue to face barriers to care.⁴ In 2012, dental care utilization for low-income working-age adults continued to decline.⁵

Barriers that prevent adults from accessing oral health care are the significant number of dental health professional shortage areas, limited acceptance of Medicaid by dentists, low health literacy, cultural and language barriers, lack of transportation, and a lack of dental insurance.^2,6 The greatest barrier, however, is financial.^4,6 In 2014, the American Dental Associations’ Health Policy Institute found not only that a lack of financial resources was the greatest barrier to accessing oral health care, but that this financial barrier was greater for dental than for any other areas of health care.⁴ According to the Michigan Department of Health and Human Services, in 2008 15.6% of Michigan residents did not receive dental care in the previous 12 months due to cost.⁷ A report commissioned by Delta Dental of Michigan reviewed the costs of dental-related emergency department (ED) visits. The report determined that in 2011, more than 7,000 visits were made to the ED for preventable dental conditions; 1,000 of these visits required hospitalization.⁸ The average cost for one single hospitalization due to dental problems is estimated at $12,448.⁸ Contributing to these ED visits and associated costs is the fact that patients often return repeatedly for the same problem because they only receive palliative care.⁸ Most ED physicians and hospital staff are not trained to treat dental problems, therefore, prescriptions for pain medications and/or antibiotics for infection are given for temporary relief.⁸

VOLUNTEER EXCHANGE PROGRAMS

In recent years, several Michigan programs have been developed that provide dental care for patients from low-income backgrounds. These programs require patients to volunteer in their communities, with these hours of community service accepted as a form of payment for care received. The Calhoun County Dentists’ Partnership was the first program to be implemented in 2007 in southern Michigan.⁹ This program is a collaboration of local dentists, free clinics, nonprofit organizations, hospitals and a federally qualified health center. The participating dentists volunteer their time, but provide dental care from their own practices. The cost of the supplies are tax-deductible, but not their services. The income of patients may not exceed 200% of the federal poverty level (FPL).⁹

Once program eligibility has been established, the patient completes a 2-hour oral health class. The patient must then begin to accrue community volunteer hours. Each volunteer hour is equivalent to $25 toward his or her treatment costs, which are determined by the Dentists’ Partnership. To cover a screening, radiographs, and prophylaxis, the patient must volunteer for at least 4 hours. Community Healthcare Connections, the Calhoun County nonprofit that administers the program,¹⁰ makes exceptions to first completing the required oral health education class for dental emergencies, in which case a patient would immediately see a dentist.

Overall, the 45 volunteer dentists see approximately 50 patients per week. After the Calhoun County Dentists’ Partnership program completed its first year, the number of people seeking dental treatment at Bronson Battle Creek Hospital went down 70%.⁹ When patients present to the ED with dental pain, they are referred to the program. Since the inception of this program, repeat visits to the ED by patients with nontraumatic dental-related problems was below 2%.⁷

The Muskegon Volunteer for Dental Care Program is the second Michigan program to accept community service hours as payment for dental treatment, opening in 2014. The program policies are similar to those of the Calhoun County program. One difference is that patients can volunteer for 8 hours to have an urgent dental care need addressed, as opposed to the starting requirements of becoming a patient of record, completing the oral health education class, and first undergoing a prophylaxis.

The third program, Care Free Pay It Forward (PIF), offered no-cost dental care for adults in exchange for community service hours between January 2014 and October 2015. It was a partnership between Care Free, a mid-Michigan nonprofit that provides medical, dental, optometry, and behavioral health services for about 7,000 underinsured and uninsured patients, and the Central District Dental Society of Michigan. Together, they used this volunteerism model to provide oral health care to underserved, uninsured adult citizens of Ingham County, Michigan, and its surrounding areas.

Adults qualified for the PIF dental program if they were without commercial dental or Medicaid insurance, and earned below 250% of the FPL. The PIF program asked patients to complete a series of steps to enroll in the program. The process began with completion of paperwork and eligibility assessment. If eligible, the patient completed 4 initial volunteer hours and then attended an oral health education class at the Care Free Dental Clinic. The patient was then assigned to a local volunteer dentist to receive an examination, radiographs, and a treatment plan. Fees for service were based on the Medicaid fee schedule, and each volunteer hour was equal to $25 toward the cost of dental treatment.

During the 18 months the PIF program was operational, 38 patients and 10 dentists participated.¹¹ Patients volunteered an average of 33 hours to cover the cost of their treatment.¹¹ The cost savings of treatment provided totaled more than $43,800, with each patient receiving over $1,000 in dental services on average.¹¹ While the treatment was limited to oral health education, exams, prophylaxis, radiographs, fillings, and simple extractions, some participating PIF dental providers chose to provide additional services on their own.¹¹ Care Free had to suspend the PIF program in October 2015, due to a reduction in financial resources for program administration and fewer applicants.

DISCUSSION

There are several benefits to volunteer-based programs. First, a greater number of underserved individuals receive dental treatment. Second, with more patients receiving preventive and restorative care, there will likely be a decline in dental-related ED visits, potentially lowering costs. Third, evidence suggests that volunteering may raise aspirations and self-worth, as well as build skills and confidence levels.^10,12 Additionally, there is an increase in community involvement as a result of volunteerism.¹⁰ Another advantage is the potential to raise the patient’s health literacy through oral health education classes. A study that surveyed PIF program participants found that patients’ perceptions of their own oral health grew significantly after participation.¹¹ Additionally, the importance that patients placed on their oral health increased after involvement the program.¹¹

The programs are not without disadvantages. One is whether the volunteer requirement impedes low-income adults from participating, due to work schedules and/or child-care needs. Another possible disadvantage is that in two of these programs, patients must volunteer prior to receiving treatment, making addressing dental emergencies problematic. Limited access to transportation is also a barrier to volunteering and receiving dental treatment.

Spokespersons from each program agreed that the Healthy Michigan Plan, a result of the Patient Protection and Affordable Care Act, has impacted program enrollment. With dental care being provided to an additional sector of the population who are at or below 133% of the FPL but do not qualify for Medicaid, fewer adults showed interest in the volunteer-based programs. Program sustainability is also a concern. Although patients and dentists both volunteer, costs are associated with program administration.

The problem of access to oral health care does not have a one-size-fits-all solution. While volunteering in exchange for dental treatment does not serve everyone, this model has successfully provided a significant number of uninsured and underserved low-income Michigan adults with much-needed dental care.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2017;4(10):46-48.