Growing and Sustaining an FQHC Dental Clinic: New Dental Directors Training

1. Growing and Sustaining an FQHC Dental Clinic: New Dental Directors Training FQHC Dental Clinic Operations in a Changing Environment 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. Dentist Administrator: Expert or Consultant Public health • Delivery models for individuals • Delivery models for communities • Epidemiology • Quality assurance

15. Public Health at the Local Level Community Task Force Leadership on: • Early Childhood Caries • Water Fluoridation • School Based Soda Machines • Tobacco/Spit Tobacco Use • School Based Sealant Programs • Screenings vs. Treatment Access • Head Start Program

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

17. Roles and Responsibilities:An Internal Review • Participation in management structure • Departmental • Managers’ level • Advisor to all

18. Roles and Responsibilities:An Internal Review • Daily operations • Financial • Participation in management structure • Quality assurance/quality improvement • Strategic planning • Board of directors • Seeking additional resources

19. Issues of Concern for Health Centers • Clinical challenges • Organizational challenges • Environmental/financial challenges • Provider transition from private practice to the health center dental model

20. Dentist Administrator: Expert or Consultant • Financial management • Public health • Government functions • Organizational structure • Legal issues • Ethical issues • Management information systems

21. Roles and Responsibilities: An External Review • Health center representative • Professional and organizational associations • Advocacy • Training programs • Data collection

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

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

24. 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

25. 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.

26. 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.

27. 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.

28. 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.

29. Good Equipment and Appropriate Clinical Procedures are Important!

30. 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.

31. 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

32. 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)

33. 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).

34. 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

35. 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.

36. 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.

37. 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.

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

39. 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.”

40. 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

41. 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.

42. 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.

43. 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

44. 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.

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

46. 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.

47. 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.

48. 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!

49. 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). 

50. 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.