Growing and Sustaining a Dental Clinic within the Primary Care “Safety Net”

1. Growing and Sustaining a Dental Clinic within the Primary Care “Safety Net” Balancing Act in FQHC Programs: Productivity and Fiscal Impact Bob Russell, DDS, MPH Iowa Department of Public Health

2. Where Do You Start??

3. Issues of Concern for Health Centers Challenges in clinic set-up and design. • Service delivery model • Staffing/recruitment • Dental record keeping • Scheduling • Patient flow • Quality and utilization management

4. Issues of Concern for Health Centers Environmental/financial challenges • Federal/state regulations • Payer mix • Competition for patients • Competition for staff

5. Environment is Important! You’ve gotta know the Territory!

6. Food for Thought: • WARNING:A Community Health Center Dental Clinic is NOT the same as a private practice. • Valuable on-line resources: www.dentalclinicmanual.com • www.ohiodentalclinics.com • “safety net” dental clinic manual

7. Setting Priorities in Primary Care Dental Programs • While individual patients pay for private practice dental services, health centers and public health dental practices are financed through a budget approved by a public or private funding agency.

8. Setting Priorities in Primary Care Dental Programs • A Population-based focus; both in individual patient treatment planning and surveillance of the total population, must be part of an efficient health center dental program

9. Setting Priorities in Primary Care Dental Programs • Service and treatment option priorities must be based on: • availability of resources, • service prioritization, • size of the target population, • disease pattern, • demand of the population, • a reasonable definition of dental health verses ideal restoration.

10. You’ll Feel The Pressure! It isn’t an Easy Life -It’s a real Challenge!

11. Primary Oral Health Care • HRSA’s BPHC has adopted the following definition of Comprehensive Primary Oral Health Care that has appeared in Policy and Program Guidance since 1997: • Range of services should include preventive care and education, outreach, emergency services, basic restorative services, and periodontal services. • Additional services may include basic rehabilitative services that replace missing teeth

12. Issues of Concern for Health Centers Other clinical challenges • Population-based practice • High risk dentistry • Ideal dentistry • Public health concerns • Social needs of population

13. Priorities in Primary Care Dental Programs • The focus of a health center dental program must be to: • decreasethe existing dental disease burden in the target population • preventdisease from starting in the youngest members of the population

14. Working with Health Center Administration You're part of the Team!!!

15. “New” Dentist in Public Health Practice

16. CHC Administrator

17. Productivity • Many factors are involved with productivity, and no single measure will provide an accurate view. • Sites should be reviewing productivity from many perspectives.

18. Productivity • There are four interrelated economic determinants that an oral health program should focus on; • productivity • revenue • cost • quality

19. Productivity • There are two outcomes that have to drive the program; • improved oral health status of the patient population served • a financially viable delivery system

20. Productivity • The facilities can influence productivity, if there are insufficient numbers of operatory units per provider. • Clearly support staff, both in numbers and experience can influence productivity.

21. Productivity • Sites providing comprehensive services may have visits that are lower, and charges that are higher than average. • The important factor to consider is that the site should be fiscally viable and that patients have their oral health care needs met.

22. First Element: Build and Maintain Community Partnerships • Helps in determining community profile and demographic areas of need. • Build local political goodwill and support. • Partnerships help sustain the clinic over time. • Identifies local resources and referral networks.

23. Second Element: Good Delivery System and Design • Comprehensive services with community based needs, culture and family in mind. • Strong emphasis on prevention and education. • Public health emphasis: should aim to maximize distribution of services toward a large population with extensive care needs. • Design should allow good patient flow and volume based on expected local needs.

24. Good Equipment and Appropriate Clinical Procedures are Important!

25. Design to Maximize Efficiency Proper staff / equipment ratios: • 2.5 chairs per dentist. (3:1 ideal) • 1.5 assistants per dentist. (1 per chair ideal) • Add a hygienist as preventive/recall volume increases to keep both providers busy without sharing patients. • Equipment of proven durability for large volume and repeat cycle use. • Waiting area appropriate for clinic size.

26. Prioritization of Services • Level One Emergency Care • Level Two Primary (Prevention) • Level Three Secondary (Restorative) • Level Four Limited Rehabilitation • Level Five Rehabilitation • Level Six Complex Rehabilitation • Level Seven Excluded Services

27. Prioritization of Services Phase I • It is recommended that 75% of care be Phase I care • Level One Emergency Care • Level Two Primary (Prevention) • Level Three Secondary (Restorative)

28. Prioritization of Services The advantages of the first three levels of service are: • Shorter chair time requirements. • Most Medicaid plans reimburse for these services. • Higher revenue generating potential under “Prospective Payment Systems” (PPS) or Cost Based Reimbursement (CBR).

29. Prioritization of Services • Low cost, (minimizing charges against the health centers 330 grant for sliding fee write-offs and uninsured patients). • Provides the greatest health benefit to the greatest number of people for the longest time. • Allows more adaptability to changes in economic environment cycles

30. Successful Practice Profile • The health center dental program concentrate on levels one, two, and three dental services. • If the program provides level four or higher services, patients are charged enough to cover dental lab and supply costs without using 330 grant revenues.

31. Plan for Growth • Expect a growing demand for services. • Portable/mobile equipment options. • School-based preventive programs. • Collaborations with private/public dental practices. • Location should be expandable; both in clinic and patient waiting area.

32. Managing Clinic Appointments • Managed appointment scheduling works best with electronic dental record scheduling and three chairs per FTE dental provider • Two chairs are “appointment” chairs with the third unscheduled for emergencies and walk-ins.

33. Example: Practical Application • In this scenario, the clinic can assign available appointment slots to match financial demographic expectations: • 40% Medicaid • 30% Sliding Fee Scale discount • 10% Insurance • 20% write-off at zero%

34. Managed Appointment Scheduling (12 slots)41% Medicaid; 41% Sliding Fee; 16% Insurance

35. Prior conditions in your Health Center may be less than Ideal You’ll have to adapt, advocate, and educate for change!

36. Leadership in a CHC • Jedi Master or House Elf?

37. Third Element: Set Realistic Financial and Productivity Goals • Services provided should be less than actual cost per patient/encounter. • Comprehensive mix of services should emphasize basic therapeutically acceptable care options. More”bang for the buck.”

38. Third Element: Set Realistic Financial and Productivity Goals • Productivity goals based on practice objectives: services vs. time (encounters). • Range of acceptable: 2500 - 3200 encounters/yr. X FTE Dentist. • 1300 - 1600 encounter/yr. X FTE Hygienist

39. Productivity-All Together Performance Indicators • 1. Relative Value Units (RVUs) per Hour – A minimum of 5 RVUs for a dentist 3.5 RVUs for a dental hygienist. • 2. Encounters per Hour – A minimum of 1.6 encounters per hour or an average of 40 minutes per encounter for both dentists and dental hygienists. • 3. RVUs per Encounter – A minimum of 3 per dentist and 2 per hygienist. This equates to 30 minutes of actual work per encounter.

40. Productivity-All Together • The RVU per hour scale is equivalent to 50 minutes of work per hour. • The RVU per hour rate for dental hygienists is less than the dentist because: • the expense of the hygienist is about one-third less than a dentist. • As a result, the difference accounts as cost per RVU equivalent for both provider types.

41. RVU Productivity Calculation • So for a dentist, you are looking at 1 RVU = 10 minutes time • for a dental hygienist, 1 RVU = 15 minutes time

42. RVU Productivity Calculation • If the UDS average number of dental hygienist encounters (dental hygiene visits) for your state is 1600 dental visits per year, then that would be 3200 RVUs.

43. Productivity = RVU’s • Utilizing the RVU system employed in HRSA Region II, dentists should exceed 42 RVU’s/day.

44. Why RVUs ? • Provides a control against “churning” or minimizing treatment per encounter. • Provides documented evidence of real treatment being performed by CHC dentists. • Allows Dental Directors to monitor real productivity in an encounter-driven environment.

45. Productivity (Revenue) • Based on UDS Data a health center program with one-dentist needs to collectapproximately $300,000 (~$356,396 in 2006) to break even. • It should be noted that this sum includes funds collected from patient care services as well as grant subsidies (proportional allocation) to cover uninsured and underinsured patients.

46. Productivity (Revenue) • Sites should calculate the gross productivity, utilizing full fee charges as one measure of productivity. • Average gross charges: fees should be market rate and should exceed $400,000/dentist/year!

47. Productivity = Encounters • “If” the average cost per encounter is about $117, you would need 2564 encounters to break even or reach $300,000 annually (if average collections also =$117 per encounter). • Assuming roughly 200 work days per year (or 1600 work hrs per year after holidays and vacations). 

48. Productivity = Encounters • Based on 2005 UDS stats Nationwide, the average number of encounters per full time dentist were 2700 per year with 1100 patient service base.

49. Productivity = Encounters • The average number of encounters per Dentist FTE per hour would be 1.7 patients per hour or 13.6 patients per 8 hour day for 2720 encounters/200days/yr. Set as Benchmark Value

50. Realistic Fiscal Policy • Health Center X allocates 20% of its annual $800,000 federal 330 grant toward dental operations to cover estimated 20% uncompensated care: $160,000 • Dental operations can range roughly 11 - 20% of overall cost center operational charges within the health center