Michigan Community Dental Clinics, Inc Michigan Community Dental Clinics, Inc. Dental Care for the Under-served Medicaid Eligible and the Low Income Uninsured The Dental Clinics North “Social Entrepreneur” Model adapted for the State of Michigan Gregory P. Heintschel, DDS Dental Director _______ Patti Ulrich Director of Community Programs and Outreach 2

MCDC Mission Statement Why we exist … Our Mission is to increase access to oral healthcare and provide health education to Medicaid recipients and to low-income uninsured persons in Michigan. Our care is delivered in a fashion that upholds and respects the dignity of those served, with the ultimate goal of improving their quality of life with improved health and wellbeing. Our focus is on those we serve. We are changing lives – one life at a time. 3

MCDC Vision Statement What we hope to accomplish … Our vision is a healthy Michigan population, who assume responsibility for their own wellness, with our staff’s guidance and proper intervention. This is accomplished by providing appropriate oral healthcare, delivered efficiently and with assured quality, to meet the needs of those who seek care. 4

MCDC Action Statement How we succeed We assist in the development of dental clinics and other dental models to increase access to oral healthcare for those on Medicaid and the Low-income Uninsured. We also provide the Staff and Management Services that allow the clinics to maximize efficiency and productivity, thereby leveraging limited resources for the greater good. 5

What is Dental Clinics North? A partnership of 6 LHDs that serve 21 Cos from M-55 to the Mackinac Bridge Created and operated by NW Michigan Community Health Agency – Charlevoix (DCN is a division of NWMCHA) Health Dept for CHX, Emmet, Antrim, and Otsego counties 5 other LHDs partner with NWMCHA to coordinate care with other LPH programs – WIC, etc. To be the LHD presence for the dental clinic(s) in their service area Ten Clinics located in TC, Manistee, Cadillac, West Branch, Mancelona, East Jordan, Gaylord, Alpena, Petoskey, Cheboygan - with Manistee joining in Jan ‘08 34 Dentists, 22 RDHs, 61 dental assistants Central Staff of seven dedicated to Dental with backup from more in Finance and IT 6

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Dental Clinics North Programs Current Programs: Ten Clinics serving 21 rural northern lower MI counties 25,000 clients served with over 50,000 visits annually Electronically connected with Electronic patient record using the DXOne version of Dentrix (as of October 1, 2004) The Northern Dental Plan Training Program for University of Michigan Dental Students Hospital care provided in 3 regional hospitals For children < 4 with severe dental disease (ECC) or medical necessity For those Developmentally Disabled (DD) Adults who cannot be treated in the clinic setting Programs on the “Drawing Board” Nursing Home Program for the 85% of residents who are covered by Medicaid and cannot access care Expansion of the Hospital Program to more hospitals Newly Created MI Community Dental Clinics, Inc, (MCDC) to increase access to care throughout MI New clinic buildings for our Gaylord and Manistee operations 8

Essential Changes that allow DCN to efficiently provide care to the underserved in Northern MI April, 2004, we initiated the Northern Dental Plan (NDP) to provide access to care for low-income uninsured adults. October, 2004, we implemented Dentrix Enterprise® - dental practice management computer system Increased efficiency of scheduling, delivery of care, and billing Reduction in errors, and electronic patient charts 1st Step toward “paperless” patient records August, 2005, a new reimbursement program to encourage productivity and control costs – an efficient private sector model for delivery of public health services DDS and RDH paid a flat per diem + % of production – using the NDP fee schedule as RVU schedule Assistants and RDH paid a gain-share bonus if achieve daily production goals, based on the cost of their clinic that day March, 2006, SPA approved by the Feds (CMS) – allowing an increased Medicaid FFS rate for LPH dental clinics in MI A rate that covers our cost and allows for surplus funds to improve clinic infrastructure and support the cost of un-insured care for the underserved - if the clinics are cost efficient and productive June, 2006 – Present, adding capacity in many of our current clinics December, 2006, digital x-rays – both Panoramic and intra-oral Further reduces daily operating cost, and increases clinic productivity The next necessary step to becoming “paperless” December, 2006, MCDC was incorporated as a not-for-profit dental services corp. 9

Results from the Changes in Reimbursement Method Dental Clinics North - July 05 versus July 06 *Income expressed in RVU’s. Actual income may be more or less depending on payer mix. Expense is actual dollars spent. 10

Coordinated Prevention & Education Programs Work! 11

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The Northern Dental Plan (NDP) A Reduced Fee Program for Uninsured Adults Implemented April 1, 2004 Eligible Adults - up to 200% of the Poverty Level Using a fee schedule that covers DCN’s costs All area Dentists can participate – if willing to accept the fee schedule Comprehensive dental services available at more affordable fees Allows access to care for those not eligible for Medicaid (the working poor and retirees subsisting on SS alone) Patients will pay for services as they are rendered using cash, check, money order or credit card 13

The Northern Dental Plan A Reduced Fee Program for Uninsured Adults How it works… Interested patients contact our Clinics to join the plan – cost is $50 per person to enroll In return for the $50, the patient receives a Comprehensive Oral Exam w FMX & TXT Plan In addition, the patient now has access to our reduced fee schedule, which is ~ 35-40% below UCR Those persons on Medicaid can receive services not covered by Medicaid at these fees without enrolling in the plan We allocate 15-20% of our schedule to accommodate the NDP patient pool. 14

Funds in Excess of Costs will be used to Continually expand, update, repair and replace dental equipment and clinic infrastructure Create a Dental Assistance Fund dedicated to supporting the cost of care in our clinics Using the NDP fee schedule…. Provide essential services not covered by Medicaid Provide services to low-income uninsured adults Have patients pay a portion of the cost, with the Fund paying the balance. 15

New Equipment and Clinic Expansion (18 additional dental chairs ~ 3-4 clinics) Mancelona –added 2 chairs and now have 2 DDS Cadillac- added 2 chairs and now have 2 DDS East Jordan – added 2 chairs and now have 1.5 DDS Traverse City – adding 3 ops – and will have 3 DDS West Branch – added 1 op and now have 1.5 DDS Alpena – added 2 new chairs and now have 2 DDS Petoskey – added 3 new chairs and have 1.5 DDS Gaylord – will build new clinic with 8 ops (net gain 4) & will have 3 DDS Manistee – will build new clinic with 8 ops (net gain 4) and will have 2 DDS Cheboygan – will re-model/refurbish – 1 DDS Digital Radiography for all clinics 16

Quality Assurance Patient Satisfaction Surveys 2. Director of Quality Assurance at DCN David Murphy, DDS – UMSD, 1969 25 yrs of dental practice experience 5 yrs teaching clinical dentistry at UMSD as a clinical assistant professor Currently teaching at Kalamazoo Valley CC dental hygiene program, and resides in Otsego, MI. Electronic Chart reviews to determine Appropriateness of Care Before and after quality effects of txt, using digital x-ray images Consistency of Care and billing practices Rx prescribing practices 3. Group practice Working with other professionals in a group encourages conformity and assures quality of care. Continual peer pressure to provide optimal care. Outliers from the norm are easily identified and corrected. 17

Dental Clinics North Providing Access to Comprehensive Dentistry delivered in an Efficient Fashion with Outcomes that are of Assured Quality and Appropriateness of Care 18

Michigan Community Dental Clinics, Inc (MCDC) A Vehicle to allow the efficient Dental Clinics North practice model to become the Norm to increase Access to Dental Care for Medicaid and Low-income Uninsured via Public Health Dental Clinics throughout Michigan Mission Statement Provide the Management Services that allow LPH Depts. in Michigan to increase access to Oral Healthcare to persons who are Medicaid eligible and the low-income uninsured. 19

Michigan Community Dental Clinics Why do it? There is a need to “Normalize” the DCN clinic model, so that LPH dental clinics can operate without loosing money – a private-sector approach to public healthcare delivery. Assures continued funding for all LHD dental clinics in MI. Allows LHD dental clinics to increase the level of dental care for more people. To expand the dental clinic network and take further advantage of the economies of scale. To share the expertise and path to success of DCN with others. To be able to attract and retain dental professionals… This model creates a viable career alternative to owning a private practice. To significantly increase the access to care for more folks in need. Both adults and children on Medicaid currently have difficulty accessing dental care. Most adults under 200% of the Federal Poverty level have poor access to dental services. Because it’s the right thing to do. 20

Michigan Community Dental Clinics, Inc A 501C(3) non-profit Dental Services Corporation Provides Dental Services on behalf of Local Health Depts. Services include: Design of new clinic facilities or remodel of existing facilities Providing specifications for equipment and supplies Management of the Clinic Facilities by: Providing the Electronic Patient Record using Dentrix® Enterprise software Billing Medicaid for services rendered, collecting fees, paying op costs Hiring all clinic personnel Direction for operation of all clinics to equal the Dental Clinics North model Assisting LHDs with integration of Oral Health Education and Prevention programs with WIC, Head Start and other services Allows for expanded economies of scale with administrative costs distributed over more clinics 21

What does MCDC look like? Michigan Community Dental Clinics, Inc. (MCDC) DCN Admin Staff Affiliated Groups of Dental Clinics (Anchor LHD) Dental Clinics North (NWMCHA) Dental Clinics of Southwest MI (Van Buren / Cass DHD) Thumb Area Dental Clinics (St. Clair Co HD) Dental Clinics Mid-Michigan ( Mid MI HD). Detroit Community Dental Clinics (DHD) Host Health Departments (where clinics reside)

Current, Planned, & Proposed Clinics Dental Clinics North Petoskey East Jordan Mancelona Gaylord Cheboygan Alpena West Branch Cadillac Manistee Traverse City Marquette (1/1/08) Mid MI Dental Clinics Stanton (6/08) Big Rapids (6/08) Hart (6/08) Mt. Pleasant (08) Dental Clinics of SW MI Hartford Dowagiac Three Rivers (12/1/07) Berrien Springs (09) Coldwater (08) Hillsdale (1/01/08) (Kalamazoo in ’08 ??) Thumb Area Dental Clinics Port Huron (5/01/08) Caro (09) Algonac (09) Detroit Community Dental Clinics Children’s Hospital (CHM) (08) Herman Keiffer (08) Samaritan Center (08) 23

Board of Directors includes: Gerald Chase, MPH, Chair Jeffrey Elliott, BBA James Young, JD Patrick Shannon, JD, MPH, EdD Daniel Briskie, DDS, MS Daniel Sarya, DDS, MPH, MS Lonnie Stevens 24

MCDC Management Team Executive Director: Tom Veryser, DDS, MHSA Dental Director: Greg Heintschel, DDS Operations Director: Sandy Kilmer Human Resources Director: Sindy Karaptian Oral Health Promotion & Community Services Coordinator: Patti Ulrich, RDH Quality Assurance Director: David Murphy, DDS MCDC contracts with NWMCHA for accounting services 25

Michigan Community Dental Clinics In general terms, How will it work? Groups of Dental Clinics that are owned and operated by Local Health Depts. (LHDs) will contract for dental services with MCDC Dental Clinics North Dental Clinics of SW Michigan Dental Clinics of Mid Michigan Dental Clinics SE MI/Thumb Detroit Community Dental Clinics The Model Each Dental Clinic and equipment is owned by or partnered with a LHD MCDC provides dental services on behalf of LHDs, will bill and collect fees, pay all bills on behalf of LHDs LHDs will provide the cash required for the Medicaid Match for the SPA fees. MCDC will pay rent for the space and equipment . MCDC will compensate the LHD for Outreach and other LHD services that coordinate with oral health services or prevention. 26

Duties of the Anchor HDs (VB/Cass HD & NWMCHA, etc.) Provide a Dental Director, employed by MCDC To oversee clinical operations and supervise the professional staff (DDS and RDH) Provide a Clinic Supervisor, employed by MCDC To oversee and coordinate the auxiliary staff of the Division Clinics To coordinate purchasing of supplies, equipment, etc. Purchase and Own or Lease the equipment, instruments and supplies in each clinic Provide the space for each clinic Provide Outreach and other LHD services coordinated with dental. 27

Duties of the Host HDs (Where the Dental Clinics are located Provide space for lease to Anchor HD for dental clinics. Provide Outreach and Health Promotion activities within its service area. Coordination of other H.D. Functions and Services that impact Oral health. Provide the funds for IGT drawdown of funds if the Anchor HD has insufficient funds available in any quarter. 28

The MCDC Model allows… LHD to separate dental staff from other LHD staff and provide unique Staffing reimbursement for the Dental Network Staff that rewards performance and controls cost. LHDs to provide dental services to persons-in-need, without the cost or “hassle” of managing the clinic. Regionalization of network clinics to address local issues locally with local health department recognition for doing so. For increased leverage in purchasing supplies and services via coordination by MCDC. A cost-efficient method of expanding access to dental services to the underserved throughout Michigan. A method to create a Fund to support the cost of uninsured care in other regions of the State. Empowerment of individual clinics to provide care in an efficient fashion, and for the employees to be rewarded for extraordinary performance. 29

DCN Nursing Home Initiative Based upon information obtained in a survey by the Michigan Department of Community Health only 63% of Michigan dentists provide nursing home services in their office. Only 16% of all dentists provide for care in the nursing home. Currently 46,826 residents, 35,119 on Medicaid. Medicaid paid 567,622 in dental services for the elderly in 2006, and 56% of that was payment to mobile services. Leaving only 249,753 paid on behalf of the elderly by 4500 active licensed dentists in the state. Resulting in only $16.16 spent per resident annually, and only $55.50 per dentist.

Huge Unmet Need For The Medicaid Nursing Home Resident! Consequence Huge Unmet Need For The Medicaid Nursing Home Resident!

DCN Nursing Home Initiative as a Proposal. What We Provide. Annual in house exam by a dentist All dental equipment and materials Ease of referral to DCN clinics In-service training at no expense to home Individual consultations for residents on oral healthcare issues Billing, scheduling, and other administrative functions Reduced set up fees for care Access to the Dental Assistance Fund (DAF)

Our proposal to facilities requires 2 year agreement for services minimum 500 residents to initiate $75 per resident “dental director” first year fee $50 annual “dental director” per resident adequate facility (beauty shop) dedicated aid for assistance and transportation consent for treatment health history IT support through a broad band connection dedicated but minimal storage for supplies

What Outcomes We Expect Help facilities meet federal care mandates Reduced transportation fees for residents Reduced staffing costs Increased consciousness of oral hygiene Healthier residents Improved quality of life for residents Marketing advantage to the facility

Pilot Program: Meadow Brook, Bellaire, MI 36% of resident population seen Avg. 50 min per appointment. 4% of residents seen at accelerated re-care 70% of hygienists salary for direct care and 30% for admin, education, and in-service training. 50% of residents referred for further treatment

A unique model funded by local tax dollars Northern Dental Clinics entered into an agreement with the Lelanau County Commission on Aging to provide diagnostic and preventative treatment to county residents age 60 and above at 200% of poverty or below. Each eligible resident will receive a voucher valid for a initial exam, full x-rays, and a prophylaxis, a complete treatment plan, opportunity for the DAF, and entrance into the NDC clinics through the NDP. County may pay for additional services upon review.