FQHC Dental "Balancing Act": Establishing Productivity in CHCs


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  • If dental represents 20% of the health centers over-all operational costs then dental should be allocated 20% of base 330 grant revenues on average.
  • Revenue forecasts should not be limited to patient service collections but all revenue sources available to the health center: grants and subsidies.
  • Other: Bonuses, gifts, etc…
  • Other: local subsidies, awards
  • Cost center must allocate a proportion of health center grant subsidies toward dental operations in proportion to over-all operational costs.
  • 2700 is not the upper limit of an efficiently managed dental program – this value may serve as the minimum benchmark in some optimally equipped and designed operations.
  • For financial solvency a health center must be able to sustain operational margins in their service area.
  • This provides further reason for proportional non-productivity revenue allocations toward dental services: to cover unexpected uncompensated emergency care.
  • The more non-patient service revenue available the less restrictive the health center’s admissions policies. Active promotions of services to all service population will assure adequate payer mix in each category. General Rule: Patients with less resources will demand services disproportionately to their demographic numbers (higher) – this is why managed appointments and resource allocation is critical.
  • FQHC Dental "Balancing Act": Establishing Productivity in CHCs

    1. 1. “ The FQHC Balancing Act ” Establishing Dental Encounters and Productivity in a Community Health Center Bob Russell, DDS,MPH
    2. 2. <ul><li>HRSA Bureau of Primary Health Care 2003 Recommended Dentist Productivity: </li></ul><ul><ul><li>1.7 encounters per hour </li></ul></ul><ul><ul><li>13.5 encounters per day minimum </li></ul></ul><ul><ul><li>2006 Average cost per dental encounter: $139 </li></ul></ul>
    3. 3. Moving Target <ul><li>National 2003 cost per encounter: $124 </li></ul><ul><li>2003 cost per user: $293 </li></ul><ul><li>2006 cost per encounter: $139 </li></ul><ul><li>2006 cost per user: $333 </li></ul><ul><li>A rise in cost of over 11% in three years nationally! </li></ul><ul><li>Bottom-line : Costs are a moving target! </li></ul>
    4. 4. <ul><li>State (MI) cost per encounter: $127 </li></ul><ul><li>State cost per user: $294 </li></ul><ul><li>National 2006 cost per encounter: $139 </li></ul><ul><li>National 2006 cost per user: $333 </li></ul>
    5. 5. Goal #1 Establish a Bottom-line cost per encounter for providing dental care services
    6. 6. Goal #2 Monitor your Bottom-line cost per encounter annually
    7. 7. Goal #3 Allocate a proportion of total base 330 grant for dental operations
    8. 8. What to do? <ul><li>Link the budget with the goals and objectives specified in the oral health project plan and overall Health Center mission. </li></ul><ul><li>Identify specific cost such as salaries, equipment, supplies, rent, etc. </li></ul><ul><li>Provide a budget forecast for future years which demonstrates increasing potential for program success.” </li></ul>
    9. 9. Components of Cost per Encounters <ul><li>Total fixed and variable costs of running a dental program </li></ul><ul><ul><li>Including Administrative overhead </li></ul></ul><ul><li>Estimated total annual expected encounters </li></ul><ul><li>Projection of annual revenue sources </li></ul><ul><ul><li>Including proportion of 330 allocated for dental within overall FQHC cost centers </li></ul></ul><ul><li>Estimated projected total collections </li></ul>
    10. 12. Set Realistic Financial and Productivity Goals <ul><li>Service costs provided ( average ) should be less than actual rate per patient/encounter. </li></ul><ul><li>Comprehensive mix of services should emphasize basic therapeutically acceptable care options. More “bang for the buck.” </li></ul><ul><li>Productivity goals based on practice objectives: services vs. time (encounters). </li></ul><ul><li>2500 to 2700 encounters/yr. X FTE Dentist </li></ul><ul><li>1300 encounter/yr. X FTE Hygienist </li></ul>
    11. 13. Productivity <ul><li>Based on 2003 UDS Data a health center program with one-dentist needs to collect approximately $300,000 to break even (~$356,396 in 2006). </li></ul><ul><li>It should be noted that this sum includes funds collected from patient care services as well as grant subsidies to cover uninsured and underinsured patients. </li></ul>
    12. 14. Total Dental Operational Revenues Should Not Be Only Revenues Generated By Patient Service Collections Dental Cost Centers must include a proportion of all grant and other revenue resources allocated to the health center.
    13. 15. Productivity Sites should calculate the gross productivity, utilizing full fee charges as one measure of productivity. Average gross charges, presuming that the fees are market rate fees, should exceed $400,000/dentist/year
    14. 16. Productivity = Encounters <ul><li>“ 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). </li></ul><ul><li>Assuming roughly 200 work days per year (or 1600 work hrs per year after holidays and vacations).  </li></ul>
    15. 17. Productivity = Encounters <ul><li>Based on 2005 UDS stats Nationwide, the average number of encounters per full time dentist were 2700 per year or 1100 patients . </li></ul><ul><li>The average number of encounters per Dentist FTE per hour would be 1.7 patients per hour or 13.5 patients per day for 2700 encounters/200days/yr. </li></ul>
    16. 18. Productivity = Encounters Many sites have 220 days of care/FTE , so the math would be 1.54 patients per hour (8 hour day) or 12.3 patients/day . You may want to benchmark the productivity of your current program to see if greater efficiency can occur that would allow you to see new patients.
    17. 19. Productivity <ul><li>A dentist should utilize a minimum of two chairs and 1.5 dental assists to achieve these productivity aims. </li></ul><ul><li>This is for minimum efficiency. </li></ul><ul><li>Use of additional operatories and assistant staff significantly increase the marginal rate of return on investment and increase productivity. </li></ul>
    18. 20. Fiscal Policy Management <ul><li>A financial analysis and formula should: </li></ul><ul><ul><li>be developed by the health center’s financial management with guidance for the dental director </li></ul></ul><ul><ul><li>Establish minimum ratios or percentage of payer mix needed to maintain operations. </li></ul></ul>
    19. 22. Example: <ul><li>Health Center “X” average projected revenue proportions for minimum program viability must be 40% Medicaid , 30% SFS , 10% insured and 20% uncompensated care uninsured write-offs . </li></ul>
    20. 23. EXAMPLE: <ul><li>In addition – Health Center X allocates 20% of its annual $800,000 federal 330 grant toward dental operations to cover estimated 20% uncompensated care: $160,000 </li></ul><ul><li>Dental operations is roughly 20% of overall cost center operational charges within the health center </li></ul><ul><li>Other revenue resources should be allocated proportionately for dental as a cost center within the health center </li></ul>
    21. 24. Example: <ul><li>Service Area Population: </li></ul><ul><ul><li>Demographic data reflect a similar ratio: 40% Medicaid; 30% low-income employed; 10% insured; and 20% uninsured. </li></ul></ul><ul><ul><li>Both demographic and minimal bottom-line financial restraints should match or exceed expectations. </li></ul></ul>
    22. 25. Example: Practical Application <ul><li>In this scenario, the clinic can assign available appointment slots to match financial demographic expectations : </li></ul><ul><ul><li>40% Medicaid </li></ul></ul><ul><ul><li>30% Sliding Fee Scale discount </li></ul></ul><ul><ul><li>10% Insurance </li></ul></ul><ul><ul><li>20% write-off at zero% </li></ul></ul>
    23. 26. WHY? Matching available resources to population demographics is considered adequate justification . Good data helps the dental clinic avoid the potential of appearing selective or “cherry picking” for the sake of financial gain only.
    24. 27. Bureau of Primary Health Care Policy <ul><li>Access to services defined within their scope must be made available to all health center users regardless of ability to pay . </li></ul><ul><li>Health centers must be able to justify why services and/or populations are excluded from the scope of practice, if the scope of services are limited and/or less than comprehensive. </li></ul>
    25. 28. Justification <ul><li>Combine population financial profile and demographic data with the health center’s financial “ bottom line ” indicators necessary to sustain the facility; </li></ul><ul><li>Manage patient access by essentially matching clinic access patterns with the combined profile data. </li></ul>
    26. 29. Justification <ul><li>Key points: </li></ul><ul><ul><li>Manage all practice resources, scheduling , chair time and patient flow consistent with practice mission objectives; </li></ul></ul><ul><ul><li>Base financial limitations on support data that provides justification for exclusions and service limitations. </li></ul></ul>
    27. 30. Application Limitations <ul><li>Do not restrict emergency access </li></ul><ul><ul><li>based on payer category or patient type. </li></ul></ul><ul><li>Only appointment slots, new patient routine care and comprehensive exams can be managed chair time. </li></ul>
    28. 31. Managing Clinic Appointments <ul><li>Emergency access is managed by limiting the total numbers seen per day </li></ul><ul><li>Emergencies can be absorbed in your uncompensated care appointment ratio or “write- offs” if revenue collections for these types of services are minimal </li></ul>
    29. 32. Rationale The FQHC is “still” available to all users within the centers fiscal and physical capacity
    30. 33. Active Promotions <ul><li>Health Centers must actively promote their services to target population to assure adequate patient flow in all demographic and payer categories. </li></ul><ul><li>Promotions must be culturally relevant and focused toward major social outlets utilized by target population. </li></ul>
    31. 34. Questions?