1. Balancing Act in FQHC Programs: Productivity and Fiscal Impact
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
Each of these items must be creatively addressed in order to succeed in a dental practice set-up. Community-based health practice offers unique challenges in each category not generally experienced in a traditional private dental practice model.

4. Issues of Concern for Health Centers
Environmental/financial challenges
Federal/state regulations
Payer mix
Competition for patients
Competition for staff
Bottom line: success depends on healthy revenue sources. Various differences exists in payer mix and rates per community. It is possible to lack sufficient revenue sources to sustain a viable stand alone dental clinic. Other options like mobile/portable dental equipped rotating site practices or school based dental programs may be necessary.
Many community-based practices develop a mixture of insured patients consisting of both public and private plans. Local private practices may compete with the clinic for private insured patients. This may sour relationships with local dental society members and private practice dentists. Establishing a line of open communications with other dental providers within the community is vital for a successful clinic start-up.
Another important concern is the availability of trained potential dental employees. Some communities may lack sufficient training programs to cover the needs of both local private practices and a new clinic set-up. This may require out of locality recruiting or acceptance of less qualified staffing. Both will increase the cost of doing business through lost productivity and recruitment advertising costs.
Federal/state regulations will also increase operations costs. Regional regulation variances should be evaluated and the potential practice impact determined before planning a dental clinic set-up.

5. Environment is Important!
Dentists aren’t dropping from the skies. Not that urban dentists are any more eager to treat children or Medicaid recipients, but you have enough providers crammed in an urban area, that you are eventually able to find someone to work with you.
In a rural area, you’re often lucky just to have a dentist and/or a county health department that appreciates its commitment to oral health.
Make the most of what you’ve got!
Stretch those boundaries!
Start with yourself…educate your own personal dentist. Does he/she know what you do and why oral health is important to Head Start kids?
Use that relationship to get invited to the local dental society meeting and get on the agenda.
Be introduced by your local dentist
Give relevant statistics and cite real numbers.
State the need and “make the ASK.” What do you want these oral health professionals to do for you?
How will you “make it worth their while?”
Good Public Relations
Media coverage
Proper acknowledgement and thanks
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:
“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!
Nobody said it was going to be easy!
Feel like you’re being pulled in opposite directions?
You’re at your wits’ end?
Ready to pull your hair out…or someone is ready to do it for you?
You’re in the right place! Welcome to Reality!
For coming this far…you get an “A” for effort!
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
A unique challenge faced by community-based “safety net” practices is how do you provide both “ideal” care and cost effective care to a large volume of individuals facing the worst possible dental related diseases in generally unhealthy environments? All of this on a restrictive budget. In addition, how do you effectively change behavioral and cultural patterns that negatively impact on oral health? The sad reality is that unless the target population’s behavioral practice both support and maintain the outcome of intensive treatment the results will quickly fail. A spiral of treatment failure and high maintenance will develop that rapidly depletes resources. This results in over-utilization of care or a “super- consumer” pattern of behavior that will defeat the mission of the health center in the long run.
Creative methods aimed at avoiding the “super-consumer” pattern of behavior must be included in the practice plan in order to develop a successful health center dental clinic. Both quality and quantity of dental care intervention depend on curbing over-utilization of resources by individual patients.
How to avoid super- consumerism? Hint: focus on education/prevention/cultural competencies.

13. 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

14. Working with Health Center Administration
Sometimes you’ll feel caught in the middle and all tied up. Patient service verses productivity will place you between the ropes.
The goal is to provide good quality care and meet the productivity needs of the health center. This may require less emphasis on long extensive procedures for those that are clinically sound, but less expensive and timely to perform.
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.
A diverse community partnership should not be restricted to only dental professionals but include civic, social, educational, business and various other professionals of all backgrounds and cultures that reflect the community population.
Effort to obtain input concerning the community’s needs, assets, and resources should be made through the partnership. The partnership will also provide influence within the community in order to foster support and political buy-in among other community members. This will help decrease resistance to the planned clinic start-up within the community and serve to market the services of the clinic within the target population.
Key to the survival of a dental start-up is the identification of referral networks within or near the target community. Essential services like hospital based outpatient sedation services for very young children and severely mentally challenged adults, oral surgery specialists, endodontists, orthodontists, and periodontal specialty service providers must be identified depending on the scope of practice provided by the clinic.
Additional service support including a dental prosthetics laboratory, equipment suppliers and local transportation providers must be identified as well.
Local grants and charity based donations may be obtained through partnerships with business leaders within the community.

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.
Prevention based dental services and cultural competent education are key elements in addressing “super-consumerism” within the target population. Only through prevention can the cycle of high maintenance treatment and repeat treatment costs be controlled.
Prevention is not a short term solution. Prevention and education will yield results over time as many of the target population become more aware of proper oral health care and service utilization.
Services provided by the new community dental clinic should emphasize less expensive options within therapeutically acceptable outcomes. This allows treatment to be extended over a wider range among the target population at less cost. Contrary to popular belief, brand B is acceptable in a cost conscious public health environment where resources must be spread out in order to impact a large population unable to access traditional routes of oral health care.
Clinical designs that are too small attempting to restrict initial start-up costs will increase staff tension and turnover rates, restrict traffic flow, increase waiting time and thereby actually increase operations costs in the long run. Good initial planning saves costs and frustration in the long run.

24. Good Equipment and Appropriate Clinical Procedures are Important!
Basic or “discounted” dental services in population-based settings doesn’t mean bad dentistry. Procedures should focus on correcting dental disease within the financial restrictions of a public health practice; yet clinically good quality of care.

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.
Large-volume practices need equipment that can withstand heavy duty use and require less maintenance. This can save the clinic money and less down time for repairs.
Larger waiting areas promote less patient irritation and conflict potential. This goes a long way in promoting patient satisfaction and cooperation when high patient volume results in longer waiting time.
While the initial hiring of a dental hygienist may not seem productive due to higher than expected no-show patterns in preventive services. However, the long term results will generate increased efficiency as patient treatment requirements decrease and better oral health behavior patterns set in.
An extra chair in addition to the 2 per FTE dentist and 2 FTE assistants/dentist could serve walk-in emergency patients without restricting access to scheduled longer treatment cases. This will also increase encounters for the clinic. The extra chair will also help accommodate non-billable encounters and patient consultation visits without interrupting regular billable visits.

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.
Good planning requires thinking of future growth opportunities while developing the start-up.
Multi-site locations and mobile equipment allows even greater opportunities to target need in large geographic areas where transportation options may be lacking.
The number of uninsured families are rising and not expected to end anytime soon. Expect increasing demand on services over time.

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
Operatory 1 2 3 4
8:00 exam
8:30 treat
Insurance
Sliding Fee
Emerg/Walk-in
9:00 exam
9:30 treat
Medicaid
10:00 exam
10:30 treat
11:00 exam
11:30 treat

35. Prior conditions in your Health Center may be less than Ideal
Old equipments, less than idea staffing, poor scheduling systems, ancient practice models, poor clinic structure and traffic control, uncooperative staff, less than optimum fee schedule and billing practices, - all of these may produce less than idea conditions within a health center and limit success.
You’ll have to adapt, advocate, and educate for change!

36. Jedi Master or House Elf?
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: encounters/yr. X FTE Dentist.
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.
Hygienists RVUs may vary depending if periodontal services provided.
Dentists have more variability and greater number of potential procedures per encounters – each with differing RVU rates.

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.
3.5 vs. 5 for a dentist

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
Cost per RVU is the key to this calculation.

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 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.
Do not undermine collections by discounting full fee charges – do that with the sliding fee scale.

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 % of overall cost center operational charges within the health center

51. Realistic Fiscal Policy
All non-clinical revenue resources should be allocated proportionately for dental as a cost center within the health center

52. 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.

53. 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.

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

55. “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 can’t be or give all things to all people.

56. With so many patients needing so much, you’ll feel rushed
Keep your cool, there is always another day!

57. The Need Can Be Extensive and Sometimes Overwhelming!
You are certainly needed; and you’ll know you’re making a difference!!