1. No category

Charting the Course for Success!
Dental Operations in the FQHC
Bob Russell, DDS, MPH
Iowa Department of Public Health
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
• 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!!!
 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
 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.
• 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
• 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
• 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!!!
“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
• 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%)
• 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
• 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.
• 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
• 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
• 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
Productivity

Many factors are involved with productivity,
and no single measure will provide an
accurate view.

Sites should be reviewing productivity from
many perspectives.
• 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
• 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
• 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
• 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
• 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, nonsurgical 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
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).
• 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….
• 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
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.
 “Community health dental programs provide highquality 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
• 2500-3200 encounters/year/FTE dentist
• 1300-1600 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
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.
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
• 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
• 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
• 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
• 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
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.
• 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…)
• 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)
36
How to evaluate your finances to determine effectiveness
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
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 loss = ($23,750)
Operating surplus = $55,000
 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 lowincome clients in your clinic
 Use patient-population growth to adjust PPS rates
 Watch for incremental changes (monthly) on budget
Example: Monthly Financial Statement
REVENUE:
GROSS CHARGES
INSURANCE ADJUSTMENTS
GRANT REVENUE
CAPITATION PAYMENTS
INTEREST/OTHER INCOME
TOTAL REVENUE
Jan-12
Feb-12
Mar-12
451,392
404,048
626,948
(170,175)
(152,326)
(236,359)
22,917
22,917
22,916
5,366
5,186
5,224
-
-
-
279,825
418,729
EXPENSES:
SALARIES & BENEFITS
235,182
221,523
COMMISSIONS
RENT, BUILDING EXPENSE, OFFICE EQUIPMENT
13,542
13,542
PRINTING & ADVERTISING
250
250
POSTAGE & SUPPLIES
35,808
35,808
TELEPHONE
1,715
1,708
OPERATIONAL EXPENSE
1,542
1,542
PROFESSIONAL SERVICES & CONSULTING
18,417
18,417
INITIATIVES
COMPANY INSURANCE
TRAVEL
67
67
MISCELLANEOUS
993
993
DEPRECIATION
32,223
32,223
Total Expenses
339,738
326,071
247,372
13,542
250
35,808
1,708
1,542
18,417
2,900
67
3,193
32,223
357,021
NET INCOME
309,500
(30,238)
(46,247)
61,708
• 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