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

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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
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Where Do You Start??
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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

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Issues of Concern for Health Centers

• Environmental/financial challenges
• Federal/state regulations
• Payer mix
• Competition for patients
• Competition for staff

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Environment is Important!
Youve gotta know the Territory!
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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

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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.

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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

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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.

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Youll Feel The Pressure!
It isnt an Easy Life -Its a real Challenge!
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Primary Oral Health Care

• HRSAs 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

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Issues of Concern for Health Centers

• Other clinical challenges
• Population-based practice
• High risk dentistry
• Ideal dentistry
• Public health concerns
• Social needs of population

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Priorities in Primary Care Dental Programs

• The focus of a health center dental program must
  be to
• decrease the existing dental disease burden in
  the target population
• prevent disease from starting in the youngest
  members of the population

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Dentist Administrator Expert or Consultant

• Public health
• Delivery models for individuals
• Delivery models for communities
• Epidemiology
• Quality assurance

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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

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Working with Health Center Administration
You're part of the Team!!!
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Roles and Responsibilities An Internal Review

• Participation in management structure
• Departmental
• Managers level
• Advisor to all

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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

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Issues of Concern for Health Centers

• Clinical challenges
• Organizational challenges
• Environmental/financial challenges
• Provider transition from private practice to the
  health center dental model

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Dentist Administrator Expert or Consultant

• Financial management
• Public health
• Government functions

• Organizational structure
• Legal issues
• Ethical issues
• Management information systems

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Roles and Responsibilities An External Review

• Health center representative
• Professional and organizational associations
• Advocacy
• Training programs
• Data collection

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Productivity

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

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Productivity

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

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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

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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.

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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.

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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.

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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.

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Good Equipment and Appropriate Clinical
Procedures are Important!
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Design to Maximize Efficiency

• Proper staff / equipment ratios
• 2.5 chairs per dentist. (31 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.

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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

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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)

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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).

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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

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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.

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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.

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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.

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Prior conditions in your Health Center may be
less than Ideal
Youll have to adapt, advocate, and educate for
change!
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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.
  Morebang for the buck.

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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

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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.

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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.

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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

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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.

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Productivity RVUs

• Utilizing the RVU system employed in HRSA Region
  II, dentists should exceed 42 RVUs/day.

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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.

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Productivity (Revenue)

• Based on UDS Data a health center program with
  one-dentist needs to collect approximately
  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.

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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!

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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). 

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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.

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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
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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

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Realistic Fiscal Policy

• All non-clinical revenue resources should be
  allocated proportionately for dental as a cost
  center within the health center

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Ways to Improve Bottom Line

• Maximize triage and short emergency visits use
  that extra chair!
• Focus on services covered by Medicaid and/or
  state S-CHIP programs.
• Seek local charity grants for specific cases like
  maternal care, elderly and special needs.
• Seek to perform the greater balance of total
  services toward revenue generation .
• Lower supply and overhead costs.

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Active Promotions

• Health Centers must actively promote their
  services to target population to assure adequate
  patient flow in all demographic and payer
  categories.
• Promotions must be culturally relevant and
  focused toward major social outlets utilized by
  target population.

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Productivity

• Use of additional operatories and assistant staff
  significantly increase the marginal rate of
  return on investment and increase productivity.

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No Margin, No Mission Rule

• While services may be limited under tight
  budgets, there is no service if you are not open.
• Those that survive today get to play tomorrow
  when times are better.
• While ideal dental care is desirable, a limited
  variety - but good quality care- is great when
  the alternative is no care at all.
• We cant be or give all things to all people.

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With so many patients needing so much, youll
feel rushed
Keep your cool, there is always another day!
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The Need Can Be Extensive and Sometimes
Overwhelming!
You are certainly needed and youll know youre
making a difference!!