1. IV. CALCULATING POPULATION TO PROVIDER RATIOS Dental IV-1

2. CALCULATING POPULATION TO PROVIDER RATIOS PROVIDER RATIOS (DENTAL) Objective: Participants will understand how to: 1) Identify all dental providers, 2) Calculate Full-Time-Equivalency (FTE) rates, and 3) Determine the population to provider ratios for dental geographic and population designations IV-2

3. Population to Provider Ratios Needed for Designation (DENTAL) Geographic Area: > 5,000:1 A rational service area - sub-county (MSSA) Geographic Area w/Unusually High Needs: > 4,000:1 A rational service area plus one of the following: a) More than 20% of the population has incomes at or below 100% of the Federal poverty level; or b) More than 50% of the population has no fluoridated water; or c) Meets insufficient capacity criteria Population Groups: > 4,000:1 A rational service area plus meets the requirements of the specific designation category (e.g. low-income, homeless, etc.) Contiguous Areas are overutilized if: > 3,000:1 IV-3

4. POPULATION SIDE OF THE RATIO (Same as Primary Health Care) IV-4  ________________ :

5. PROVIDER SIDE OF THE RATIO : IV-5 ___________ 

6. STEPS 1)Identify all general practice dentists in the area to be designated. 2)Determine the number of hours each dentist works in direct patient care office serving the population to be designated. 3)Calculate the FTE for each dentist serving the population to be designated. 4)Calculate the population to provider ratio. IV-6

7. STEP 1 Identify all general practice dentists in the area to be designated. Identify all general practice dentists in the area to be designated. IV-7

8. List all dentists (D.D.S. or D.M.D.) who: 1) Provide direct patient care in the service area, and 2) Practice principally in general dentistry or pedodontics (pediatric dentistry) Do not include:  Oral surgeons, orthodontists, or other specialists Include in your list:  Dentists who serve in the NHSC Scholarship or Federal Loan Repayment Programs (exclude their FTEs)  Dentists who serve in the State Loan Repayment Program  Dentists who are Federal providers (e.g., Commissioned Officers at Indian Health Services or Bureau of Prisons)  Dentists who are planning on retiring but are still seeing patients  Dentists engaged solely in administration, research, or teaching  Locum tenens serving less than 1 year IV-8

9.  Dentists who serve in the NHSC Scholarship or Loan Repayment Programs.  Dentists who serve under a J-1 or H-1B waiver  Dentists who are Federal providers (e.g., Commissioned Officers at Indian Health Services or Bureau of Prisons)  Dentists who are planning on retiring within six months, but are still seeing patients Include in Survey but reduce FTE to zero III-9

10. Include the following provider’s FTE: All Dentists who provide direct patient care in the service area, including those who:  Serve in State Scholarship or Loan Repayment Programs  Serve at Indian Health Clinics and are not Federal providers  Plan on retiring (> 6 months) but are still seeing patients III-10

11. Sources of Provider Data  State Licensure Lists: http://www2.dca.ca.gov/pls/wllpub/wllqryna$lcev2.startup?p_qte_c ode=DDS&p_qte_pgm_code=3610 http://www2.dca.ca.gov/pls/wllpub/wllqryna$lcev2.startup?p_qte_c ode=DDS&p_qte_pgm_code=3610  National, State, and Local Dental Association Directories  Local Telephone Directory/Yellow Pages  Commercially Developed Listings IV-11

12. STEP 2 Determine each dentist’s age, number of auxiliaries 1, and number of hours serving the population to be designated. IV-10 1 Auxiliaries are non-dentists assisting in dental care such as dental assistants, hygienists, etc. They do not include receptionists and other support staff.

13. Designation Types and Whom to Include in the Provider Count COUNT ALL DENTAL PROVIDERS WHO SERVE ALL PERSONS: Geographicin the service area Low-Income Populationin the service area that have incomes < 200% of the Federal poverty level (Medicaid and Posted Sliding Fee) DESIGNATION TYPE: IV-13

14. Providers Dentist NameAgeLocation of Practice # of Auxiliaries Hours of Direct Pt. Care/Week M. Incisor, D.D.S.29789 Crown Street Tooth Fairy, CA 99864 145 R. Wisdom, D.D.S.78789 Crown Street Tooth Fairy, CA 99864 115 A. Canine, D.D.S.4033 Halitosis Road Smile City, CA 99918 337 B. Crown, D.D.S.39103 Molar Lane Chompers, CA 99918 224 C. Buck, D.D.S.3266 Cavity Place Mouthtown, CA 99918 225 Total Dentists: 5 IV-14

15. STEP 3 Calculate the FTE for each dentist serving the population to be designated. IV-15

16. Equivalency Weights by Number of Auxiliaries and Age Auxiliaries are non-dentists assisting in dental care such as dental assistants, hygienists, etc. Auxiliaries<5555-59 60-6465+ 00.8 0.7 0.6 0.5 1 1.0 0.9 0.8 0.7 2 1.2 1.0 1.0 0.8 3 1.4 1.2 1.0 1.0 > 4 1.5 1.5 1.3 1.2 If an auxiliary is less than full-time, round to nearest whole number (0.4 = 0, 0.5 = 1). If more than one auxiliary works less than full time, add total hours, divide by 40, and round if not a whole number [(16 +20 + 32/40) = 1.7 = 2]. If number of auxiliaries is not available, use these weights: < 55 = 1.2 55 - 59 = 0.9 60 - 64 = 0.8 > 65 = 0.6 If dentist’s age and the number of auxiliaries are not available: Use weight of 1.2 IV-16

17. FTE Calculation 40 hours = 1.0 FTE (There are no provisions to reduce the FTE of a dentist in residency.) Every 4 hours (½ day) is counted as 0.1 FTE Adjust FTE based on actual hours, age, and auxiliaries A dentist’s FTE can exceed 1.0 due to auxiliaries Only the Total (or Total Low-Income) FTE is rounded to the nearest tenth of a percent: Examples:0.875= 0.9 0.817= 0.8 0.83 = 0.8 0.85 = 0.9 Note: The FTE for low-income population designations is based on the average number of hours per week spent with Medicaid and SFS patients. It is not based on whether the provider is accepting new Medicaid patients. IV-17

18. FTEs - Geographic Designation Dentist NameAgeLocation of Practice # of Auxiliaries Hours of Direct Pt. Care/Week FTE Based on Hours Total FTE M. Incisor, D.D.S.29789 Crown St. Tooth Fairy, CA 99864 1451.0 (45/40= 1.1=1) 1.0 (1.0x1.0=1.0) R. Wisdom, D.D.S. 1 78789 Crown St. Tooth Fairy, CA 99864 115.375 (15/40=.375) 0.26 (.375x0.7=.26) A. Canine, D.D.S. 2 4033 Halitosis Rd. Smile City, CA 99918 337.925 (37/40=.925) 1.29 (.925x1.4=1.29) B. Crown, D.D.S. 3 39103 Molar Lane Chompers, CA 99918 225.625 (25/40=.625) 0.75 (.625x1.2=.75) C. Buck, D.D.S. 4 3266 Cavity Place Mouthtown, CA 99918 225.625 (25/40=.625) 0.75 (.625x1.2 =.75) Total Dentists: 5 Total FTEs: 4.05 = 4.1 1 – Dr. Wisdom works 25 hours/week in another location 2 – Dr. Canine spends 2 hours/week in administrative activities 3 – Dr. Crown chooses to work 25 hours/week 4 – Dr. Buck spends 15 hours/week in childcare activities IV-18

19. FTEs - Low-Income Designation Dentist NameHours of Direct Pt. Care/Week FTE Based on Hours Total FTE% Medi- Cal * % SFS % of Low- Income Total Low- Income FTE M. Incisor, D.D.S. 45 (45/40= 1.1=1) 1.0 (1x1= 1) 10%2%12% (10%+02%=12%) 0.12 (.12 x 1 =.12) R. Wisdom, D.D.S. 15 (15/40=.375).3750.262 (.375x.0.7=.262) 0.0% 0% 0.0 (0 x.262 = 0) A. Canine, D.D.S. 37 (37/40=.925).9251.29 (.925x1.4=1.29) 50%10%60% (50%+10%=60%) 0.774 (.6 x 1.29 =.774) B. Crown, D.D.S. 25 (25/40=.625).6250.75 (.625x1.2=.75) 20% 40% (20%+20%=40%) 0.3 (.4 x.75 =.3) C. Buck, D.D.S. 25 (25/40=.625).6250.75 (.625x1.2 =.75) 60%15%75% (60%+15%=75%) 0.5625 (.75 x.75 =.5625) Total Low-Inc FTEs: 1.7565 = 1.8 IV-19

20. Survey Dentists to Determine Their FTE  Survey all dentists in service area  Minimum two-thirds response rate required Calculation of Non-Responders Use survey average Ex: Galt, California - 6 providers 4 - respond to survey 2 - no response after repeated telephone calls Response rate: 4/6 = 66.6% Total FTE for the 4 responders= 3.5 1)Divide FTE of responders (3.5) by the number of responders (4) for the average FTE of responders (.87) 2)Multiply number of non-responders (2) by the average FTE of responders (.87) for FTE of non-responders (1.75) 3) Add FTE of responders (3.5) and non-responders (1.75) for total FTE = 5.3 IV-20

21. STEP 4 Calculate the population to provider ratio. Calculate the population to provider ratio. IV-21

22. Population to Provider Ratios Civilian Population Ratio: Civilian Population = 20,900 Dentist FTE = 4.1 (20,900/4.1 = 5,098:1) Civilian Population (High Needs) Ratio: Civilian Population = 20,900 Dentist FTE = 5.2 (20,900/5.2 = 4,019:1) (100% Federal poverty level at 18.9%) Low-Income Population (200% Poverty): Low-Income Population = 10,137 (49.47%) FTE of Dentists Serving that Population = 1.8 (10,137/1.8 = 5,632:1) IV-22

23. Calculating the Maximum FTE IV-23

24. Calculating the Maximum FTE To determine the maximum allowable FTE divide the Civilian Population by the Ratio.Example: Geographic Designation: Civilian Population = 70,000 Population to Provider Ratio: 5000:1 Maximum FTE (70,000/5000) = 14.0 Geographic Designation (High Needs) : Civilian Population = 80,000 Population to Provider Ratio: 4000:1 Maximum FTE (80,000/4000) = 20.0 Contiguous Area: Civilian Population = 75,000 Population to Provider Ratio: 3000:1 Maximum FTE (75,000/3000) = 25.0 IV-24

25. What to Include in the Population to Provider Ratio Dental Section of Your Application Population  Cover letter with summary findings  Total adjusted population  Source of data List of Dentists Include the Following for Each Dentist:  Name  Age  Location: Non-metro areas - name of town Metro areas – complete address with zip code, and CT if available  Specialty (general dentistry and pedodontics)  Number of auxiliaries  Equivalent weights  Number of hours/week of patient care in area  Percentage of practice Medicaid (for low-income and Medicaid-eligible designations)  Percentage of practice Sliding Fee Scale (for low-income designations)  FTE total for each provider rounded to the nearest tenth of a percent  Description of how information was obtained (sources, methods of gathering data) Totals and Ratio  Total number of providers  Total FTE  Population to provider ratio  Explanation of any high need indicators IV-25

26. Contiguous Area Resources IV-26

27. Contiguous Area Resources Objective: Participants will understand how to identify contiguous areas, determine if they have resources, and if the resources are excessively distant, overutilized, or inaccessible to the population of the area proposed for designation. Purpose of Contiguous Area Analysis: To identify nearby sources of care and determine if they are inaccessible to the population in the proposed service area IV-27

28. STEPS 1) Identify the boundaries of each contiguous area 2)Evaluate each area to determine availability of resources IV-28

29. Identify the Boundaries of Each Contiguous Area A.Identify on a map the boundaries and population center of the proposed service area. B.Determine the contiguous areas in all directions within 40 minutes from the proposed area’s population center. C.Map the boundaries of each contiguous area in all directions (North, East, South, & West). Boundaries The boundaries of each contiguous area may be based on: Travel time (40 minutes) Socio-economic/demographic characteristics Established neighborhoods Physical barriers Designated HPSA The boundaries of contiguous areas are often (not always) based on the same census delineation as the proposed area: Proposed service area = whole county Contiguous areas = whole counties Proposed service area = census tracts (MSSA) Contiguous areas = census tracts (MSSA) IV-29

30. Determine Availability of Resources A.Check the HPSA list to determine if any of the contiguous areas are designated as HPSA and therefore considered inaccessible. If it is not inaccessible HPSA, then B.Determine if there are significant socio-economic/demographic disparities or physical barriers. (A 2 * N or plus 15% for percentages below 15 to determine disparity between the population in the service area and the population in the contiguous area) If there are not significant socio-economic/demographic disparities or physical barriers, then C.Determine if the contiguous area’s providers are located > 40 minutes away from the population center of the proposed area and are therefore inaccessible due to excessive distance. If they are not excessively distant, then D.Determine if the resources in the contiguous area exceed the population-to- provider ratio and are therefore overutilized. If they are not overutilized, this area cannot be designated. (Consider a different kind of designation.) IV-30

31. Check the HPSA Status of Each Contiguous Area and Determine if This Type of HPSA Is Inaccessible to the Proposed Area Geographic without high needsGeographic HPSA Geographic with high needsGeographic HPSA, Low-Income HPSA (based on 100% poverty indicator) Low-Income HPSAGeographic HPSA, Low-Income HPSA IV-31 If the proposed service Then the contiguous area area is: is inaccessible if it is a:

32. Determine if Providers Are Excessively Distant 1) Develop a list of providers in the contiguous area 2) Map their office locations 3) Determine the travel time from the proposed area’s population center to the contiguous area Providers > 40 minutes from the population center are excessively distant IV-32 Dental : > 40 minutes Interstate Roads - 30 miles X 1.33 = 40 minutes Primary Roads - 25 miles X 1.6 = 40 minutes Secondary Roads - 20 miles X 2.0 = 40 minutes

33. Service Area Travel Calculation Primary Health Care Interstate Roads: 25 miles X 1.2 = 30 minutes Primary Roads (include surface streets): 20 miles X 1.5 = 30 minutes Secondary Roads (mountainous terrain or unpaved road): 15 miles X 2.0 = 30 minutes Dental and Mental Health Care Interstate Roads: 30 miles X 1.33 = 40 minutes Primary Roads (include surface streets): 25 miles X 1.6 = 40 minutes Secondary Roads (mountainous terrain or unpaved road) 20 miles X 2.0 = 40 minutes III-33

34. Determine if Providers Are Excessively Distant (continued) Inner Portions of Metropolitan Areas: Distance is based on time using public transportation * during non- rush hour. Bus routes and schedules must be described (provide narrative Description and include bus schedule if possible). *Public Transportation can be used only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate. IV-34

35. Determine if Contiguous Areas Are Overutilized  Calculate FTE - use same method as used for the proposed service area.  If needed, survey providers and determine FTE serving the population. Use same surveying method as used for the proposed service area.  Explain how the information was obtained and calculated, and include population, total FTE, and population to provider ratio. Population to Provider Ratios: DENTAL: > 3,000:1 dentist IV-35

36. Examples Survey IV-36

37. IV-37

38. Determine the Nearest Source of Non-Designated Care Needed for HPSA score: Geographic Designation: Can be in a Low-Income HPSA Population Designation: Cannot be a HPSA (of any type) Cannot have significant socio-economic/demographic differences or physical barriers Can be excessively distant Can be overutilized For all applications:  Provide a road map with the proposed service area and contiguous areas outlined.  On the map, indicate the population center of the proposed service area, the nearest source of care, and the route between these points.  Provide the name and address of the nearest source of care, route, miles, and minutes. For inner portions of metropolitan areas, include:  Bus route information from the population center of the proposed area to the nearest source of care, and  Miles and minutes of travel time IV-38

39. Time Saving Tips Survey providers only if necessary:  In contiguous areas, calculate the population to provider ratio counting each provider as 1.2 FTE. If area meets ratio of > 3,000:1, do not survey. (Geographic only)  Collect all possible information in one survey (e.g. Medicaid and sliding fee scale even for a Geographic designation).  Work with State licensing department to obtain information on providers.  Use claims data for Denti-Cal FTE (works only in fee-for-service). IV-39

40. What to Include in the Contiguous Area Resources Section of Your Application Map with Census Delineations  Name and boundaries of proposed service area  Name and boundaries of contiguous areas  Population center for the proposed service Knowledge of designation status of each of the contiguous areas is helpful. Road Map  Outline of proposed area boundaries  Location of nearest source of non-designated care  For automobile transportation - start, end, and route  For public transportation - start and end points of route IV-40

41. For Contiguous Areas that are not Excluded with Current Designations and Whose Providers are Excessively Distant  Travel time to closest provider from population center of service area, including miles, route, and type of road; or public transportation information, including bus routes, start/end points, miles, minutes, and source; include bus schedule if available For Contiguous Areas that are not Excluded with Current Designations and have Access Barriers  Description of any significant socio-economic/demographic disparities (e.g., demographic data on racial/ethnic composition or income levels comparing proposed service area population to population in the contiguous area, and source of data), or  Description of any significant physical barrier For Contiguous Areas that are not Excluded with Current Designations and are Overutilized  Population to provider ratios, and  Description of how information was obtained IV-41 What to Include in the Contiguous Area Resources Section of Your Application (continued)

42. For All Designation Requests: For Public Transportation Routes*:  Travel time, based on non-rush hour bus schedules  Start/End point of route  Include time waiting for transfers while in route  Map showing proposed area boundaries, start and end points of bus route  Bus schedules, if available  Cite source of information * Public Transportation can be used only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate.  Address of nearest source of non-designated, accessible care, including address, miles and minutes via public transportation if metropolitan area  Location of nearest source on road map IV-42 What to Include in the Contiguous Area Resources Section of Your Application (continued)

43. Websites California Public Transit Information and Maps: http://maps.google.com 2010 CT Locator: http://www.ffiec.gov/Geocode/default.aspx U.S. Census Bureau – American Factfinder: http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml IV-43

44. APPLY FOR DESIGNATION No Contiguous Area Conditions Met 1or more Contiguous Area Conditions Met for EACH Contiguous Area Evaluate Contiguous Area STOP: Area Not Qualified For Designation Calculate Population-to- Dentist Ratio Define Rational Service Area Determine Dental FTEs Determine Service Area Population Evaluate Service Area for High- Need Indicators STOP: Area Not Qualified For Designation STOP: Area Not Qualified For Designation No High Need Indicators Present 1 or more High- Need Indicators Present Process Model for Geographic Dental Health (Professional Shortage Area Designation) To Use: Follow arrows. Numbers are reference citations only. Refer to correspondingly numbered pages following for additional information on steps in numbered boxes 2 3 46 9 1 5 98 IV-44 Ratio < 3999 9 Ratio 4000-4999 Evaluate Contiguous Area 5 1 or less Insufficient Capacity Indicators Present 2 or more Insufficient Capacity Indicators Present 1 or more Contiguous Area Conditions Met for EACH Contiguous Area No Contiguous Area Conditions Met STOP: Area Not Qualified For Designation 9 APPLY FOR DESIGNATION 8 Ratio > 5000 Evaluate for Insufficient Capacity 7