1. Charting the Course for Success!
Dental Operations in the FQHC
Bob Russell, DDS, MPH
Iowa Department of Public Health

2. Challenge of a changing health system and culture
We don’t work in a vacuum…
Environmental/financial challenges
Federal/state regulations
Auxiliary supervision and scope of service
Reimbursement scenarios
Payer mix
Competition for patients
Competition for staff
Challenge of a changing health system and culture
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.

3. Setting Priorities in the Safety Net as Public Health Dental Programs
A Population-based focus; individual patient treatment planning and surveillance of the total population must be part of an efficient public health care dental program
Data Driven!!!

4. Specific Data Driven Advantages
Monitoring quality of care –basic outcome measures
Peer Review protocols
Patient satisfaction surveys
Community needs assessment
Efficiencies in treatment applications
Financial Management
Cost control and supply utilization
Revenue and service cost tracking
Provider productivity tracking

5. Setting Priorities in Safety Net Dental Programs
Service and treatment option priorities that impact productivity must be based on:
availability of resources,
space and design of clinic,
service prioritization,
size of the target population,
dental disease prevalence and types,
demand of the population,
all providers calibrated on a reasonable concept and path towards creating dental health verses highest cost = ideal restoration.

6. Make Patients Responsible
When scheduling assure that the patient knows they are responsible for notifying the office 24 hours before breaking an appointment OR confirming an appointment.
No call or notification, the booked block is cancelled and reassigned to another patient.
3 No-shows, patient loses booking privileges and assigned to walk –in status
Measure variances in no-show ratios to schedule appointments using predictability in overbooking situations

7. Good Data Helps Meet Fiscal and Operational Challenges
Differing Medicaid payment structures
CBR, PPS, FFS
Balancing revenues and expenses
Increases the Safety Net clinic’s value in the public health system
Increases competitiveness for public dollars

8. New Danger Signs Ahead!
Electronic health records produce traceable data that reveal trends in care
Medicaid is now monitoring for “churning” or minimizing treatment per encounter
National outcomes measures are being implemented
Risk Management required
Health centers have received large dollars for expansion
The nation’s eyes are on FQHCs!!!

9. “The refinements of productivity measurements will
require more intensive, real-time data collection,
but will yield significant payoff in improved
understanding of dental practice and its
contributions to oral health.”
Conrad, Douglas A. Shuk-Yin Lee, Rosanna. Milgrom, Peter. Huebner, Colleen E. “Estimating Determinants of Dentist Productivity: New Evidence.” Journal of Public Health Dentistry, Vol. 70, No. 4; Fall 2010, pg. 267

10. Specific Data Driven Productivity Determinants – Quality Outcomes
Clinical Advantages
Needs and Risk Assessment Protocols
Patient satisfaction
Pre and Post treatment outcomes monitoring
Electronic record reviews
Adverse outcomes tracking
Monitoring treatment ratios: Phase one levels of care (75%)
Treatment levels 1,2,3 up to 60 percent of total dental treatment ratios = Phase one federal standard for levels of care.
Emergency, prevention, and secondary restorative

11. Why Should Health Centers Assess Quality?
Section 330 of Public Health Service Act requires every Health Center to have ongoing QI/QA program.
Federal Tort Claim Act (FTCA) deeming application process requires submission of Health Center QI/QA plan and QI/QA committee minutes
Provides accountability to Board of Directors, community members, and funding entities

12. Risk Assessment: what is it?
Risk Assessment is the identification, assessment, and prioritization of risks (the effect of uncertainty).
Risk Management is the application of resources to minimize, monitor, and control the probability or impact of adverse events.
It specifies information needed by providers, leaders, and staff to minimize risks for their oral health programs, and next steps if an error occurs.

13. Components of Risk Assessment Planning: Know the Regulations!
Regulatory Requirements (examples)
Health Insurance Portability and Accountability Act (HIPAA), American Disabilities Act (ADA), Culturally and Linguistically Appropriate Services (CLAS), Federal Tort Claim Act (FTCA), Occupational Safety and Health Administration (OSHA), The National Institute for Occupational Safety and Health (NIOSH) …most are applied health center wide, but may have dental specific applications
Clinical (examples)
CDC Infection Control Guidelines
State Licensing Regulatory Standards of Care
ADA Principles of Ethical Standard and Conduct
The Joint Commission (TJC formerly JCAHO) or other ambulatory certification authority

14. Set Goals Based On Realistic Expectations
Use environmental data from your health center’s fiscal, historical mission, population needs, and outcome expectations to set goals
Make determinants for measurement in easy descriptive terms, i.e. cost per encounter
Use national recognized benchmarks based on best practices as a foundation

15. Measures are the Key
Allow you to individualize for your patient populations and their needs
Allow you to collect data to show delivery of proven health care interventions
Enable you to show improved health care outcomes

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

17. Patient Care: HRSA Scope of Service Requirements
REQUIRED
Pediatric Dental Screenings
Preventive Dental Care & Diagnosis
Emergency Services
EXPECTED
Treatment of Dental Disease \ Early Intervention Services
Basic Restorations Services
Services for Special Needs Patients
Additional primary oral health care services identified in a needs assessment of the population & the availability of resources to meet those needs.
Comprehensive primary oral health care as an integral component of primary health care services
RECOMENDED
Rehabilitative Services
Recommended are resource dependant

18. New Requirements in Dental Productivity Measures
Output to be measured in terms of contributions to oral health, not visits
Use of dental auxiliaries and their skill level be measured, not just their availability
Utilization of dental technology and space utilization be measured more precisely
Patient mix (demographics and oral health) be included in production models
Risk management protocols in place

19. Productivity
Four interrelated economic determinants that a public health clinical program should focus on:
productivity rate or units produced per time period
revenue generated per production unit
cost for service per unit generated
Quality outcome impact on client’s health

20. Productivity
There are several outcomes that have to drive the program’s expectations:
improved oral health status of the patient population served
a financially viable delivery system
physical size of clinic, staffing efficiencies in skill sets and abilities, and equipped for maximum productivity

21. Productivity Outcomes (Basic)
Outcomes are a measure of the dental program’s success in improving the health of its patients and the communities it serves
Phase I treatment completion focuses on the diagnosis, prevention and elimination of dental disease, non-surgical periodontal care and elimination of hopeless teeth
Goal to complete Phase I treatment on 50-75% of patients within 12 months of dental exam and formulation of treatment plan

22. Set Realistic Financial and Productivity Goals
Service costs provided (average) should be less than actual rate per patient/encounter.
Comprehensive mix of services should emphasize basic therapeutically acceptable care options. More “bang for the buck.”
Productivity goals based on practice objectives: services vs. time (encounters).

23. THE FQHC Payment System
Self Pay
Sliding Fee Scale (From100% to 200% Federal Poverty Guidelines)
Private Dental Insurance (new ACA Benefit Exchange combinations med-dent, dental only)
Medicaid:
Managed Care Organizations
Fee For Services
PPS (Perspective Payment System = Encounter Rate)
CBR (Cost Based Reimbursement = end of year cost settlement)
CHIP (Children’s Health Insurance program)
Various grants, endowments, subsidies, etc….

24. Future Payment structures
Pay for Performance – Quality Outcome Indicators Enforced!
Accountable Care Organizations
Multiple Practice Conglomerations
Single billing core entity for efficiencies
Multi-discipline and multiple locations
Many FQHCs will merge into existing or new ACOs

25. Vision
Creation of a high-quality, affordable, oral health program that documents the improvement of the oral health status of the patients we treat while being financially responsible.

26. Ensuring Financial Sustainability
“Community health dental programs provide high-quality clinical care to our nation’s most vulnerable residents. However, without a balance between mission focused-care and robust business practices, community health dental programs may jeopardize their own sustainability”
Mark Doherty, DDS
DentaQuest Institute/Safety Net Solutions

27. 2500-3200 encounters/year/FTE dentist
Benchmarks
encounters/year/FTE dentist
encounters/year/FTE hygienist
2700 encounters/year with 1100 patient base (dentists)
1.7 patients/hour or 13.6 patients per day per dentist
1.2 patients/hour or 8-10 patients/day for hygienist
Gross Charges = >$400K per dentist per year
Benchmarks are for comparison only and are not precisely relative to each program. They demonstrate a national average with which to compare ourselves but can vary markedly based upon variables within our programs.

28. Performance Indicators
Relative Value Units (RVUs) per Hour – A minimum of 5 RVUs for a dentist, 3.5 RVUs for a dental hygienist.
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.
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.

29. Productivity
Sites should calculate the gross productivity utilizing full fee charges as one measure of productivity.
Full Fee Schedule should be 85% or higher of local charges of UCR
(average gross charges) presuming that the fees are market rate
UCR – Usual and Customary Rate

30. Setting Goals: Provider Productivity
Use benchmarks (1.7 visits/hour for dentists, 1.25 visits/hour for dental hygienists, 1 visit/hour for externs and new residents)
Benchmark x number of daily clinical time = total number of visits/day/provider (eg, 1.7 x 8 hours = 14 visits)
Goal for procedures per visit: 2-5 (for basic dental program serving mix adults and children)
Revenue goals need to be based on overall costs of running program
Everyone loves benchmarks since they demonstrate where the bar is set for whichever cohort they apply to. In FQHCs we are very fortunate to have several benchmarks to utilize in the sharing of information and in business planning. The danger with them is to make sure that they properly apply to your practice and your particular environment of care. Numbers of visits in a primarily pediatric practice would be different then those expected in an adult practice. Numbers of visits in a practice where dentists work out of one operatory would be different from a practice where a dentist might work out of three operatories, etc. The next two slides demonstrate a simple method of determining financial productivity goals for a program and for the dentists and dental hygienists working within it.

31. Determining Potential Visit Capacity
Potential capacity is based on number of FTE providers, hours of operation, chairs and standard productivity benchmarks
Benchmarks are different for dentists vs. hygienists
Potential visit capacity is impacted by factors affecting provider productivity
Remember, What happens in the visit determines your quality and your quantity. Mission and Margin

32. Productivity
Poor clinic design and less than optimal chair numbers per provider will lower productivity
Lack of sufficient clinical space for traffic will lower productivity
Less trained staff or less than optimal staff numbers and will lower productivity
Higher ratios of patients with complete treatment plans and receiving comprehensive care will lower encounter productivity
Meeting the mission objective of FQHCs to improve the population’s health lowers the productivity ceiling

33. Productivity
Higher proportions of patients with medical compromised status, advanced mental or physical disabilities, disruptive behavior, and very young with extensive treatment needs will lower productivity
Productivity has a ceiling and cannot be exceeded without lowering quality and burning out staff
This ceiling varies among clinics and is based on that site’s particular environment

34. Productivity
A dentist should utilize three chairs and 1 dental assistant per chair to achieve good productivity aims.
This is for optimum efficiency.
Use of additional operatories and expanded function dental assistants (EFDAs) significantly increase the marginal rate of return on investment as well as productivity.

35. Set Realistic Goals
Do not set productivity levels so high resulting in a decrease in quality and ability of providers to meet the needs of patients.
Attempt to standardize encounter time increments that allow sufficient time to provide reasonable service
Document all conditions that force encounter time changes to less than scheduled – or prolongs encounter time beyond what is scheduled.
Be prepared to address complaints of churning or producing lower than expected encounter numbers over a specific time (i.e. quarters, semi-annual, etc…)

36. Key Data to Evaluate Program Performance
Number of visits
Gross charges
Total expenses (direct and indirect)
Net revenue (including all sources of revenue)
Expense/visit
Revenue/visit
Transactions (procedures by ADA code)
Transactions /visit
Aging report past 90 days
Payer and patient mix
No-show rate
Emergency rate
Number of unduplicated patients
Number of new patients
Percentage of completed treatments
Percentage of children needing sealants who received sealants
Number of FTE providers (dentists, hygienists, other providers with chargeable services)

37. What is Financial Success?
How to evaluate your finances to determine effectiveness

39. Impact of Payer Mix on Sustainability
Now (7,500 visits)
35% Medicaid (avg. revenue/visit = $100)
55% Self-Pay/SFS (avg. revenue/visit = $30)
10% Commercial (avg. revenue/visit = $120)
2,625 visits x $100 = $262,500
4,125 visits x $30 = $123,750
750 visits x $120 = $90,000
Total revenue = $476,250
Total expenses = $500,000
Operating loss = ($23,750)
Better (7,500 visits)
50% Medicaid (avg. revenue/visit = $100)
40% Self-Pay/SFS (avg. revenue/visit = $30)
10% Commercial (avg. revenue/visit = $120)
3,750 visits x 100 = $375,000
3,000 visits x $30 = $90,000
750 visits x $120 = $90,000
Total revenue = $555,000
Total expenses = $500,000
Operating surplus = $55,000
This slide demonstrates the impact that tweaking payer mix can have on a practice. In this practice it was determined that operating at a deficit was no longer acceptable and that they also wanted to treat more young children and perinatal females. Changing the number of children and pregnant females seen changed the payer mix from 35% Medicaid to 50% Medicaid, which moved a loss of $23, to a gain of $55, in twelve months. Incidentally , they also determined going forward that this would allow them to open more hours and treat more self-pay patients with the profit realized by the payer shift.

40. Adjust Fees Annually! To compensate for rising costs!
Assurance your program remains profitable
Use standard local/regional Usual Customary Rates (UCR)
Stay within 85+ percentile of local fee scale
Remember: you have a sliding scale to assist the low-income clients in your clinic
Use patient-population growth to adjust PPS rates
Watch for incremental changes (monthly) on budget

41. Example: Monthly Financial Statement

42. Financial Success
Practice incurs $800,000 in direct and indirect expenses for the year
To break-even (without grant support), practice must generate that much in net patient-generated revenue
To achieve surplus, practice sets a goal of $900,000 in net patient-generated revenue
$900,000 ÷ 230 days = $3913 in net patient revenue per day; $19,565 in net patient revenue per week = Practice Goals
Practice collects 50% of what it charges; therefore, gross production goals need to be $7,826 per day and $39,130 per week

43. Bob Russell, DDS, MPH State of Iowa Public Health Dental Director