In Managing an Efficient and Effective Safety Net Dental Program - Part 1, I discussed "Managing for Success" and "Key practice Data." Today, I'll cover "Evaluating the Dental Program" and "Creating a Culture of Accountability."
Evaluating the Dental Program
Cost/Visit vs. Revenue/Visit
Cost per visit is calculated by dividing total expenses (direct and indirect) by the overall number of visits for the reporting period. Revenue per visit is calculated by dividing net revenue by the overall number of visits. It can be useful to determine net revenue per visit both with and without grants. The difference between cost per visit and revenue per visit is the amount the dental practice needs to make up to break even both with and without grant support.
Payer mix has a huge impact on financial sustainability and can be a significant challenge to manage. To understand the impact payer mix is having on the dental program, the manager needs to determine the average revenue per visit for each payer type (eg, Medicaid, Medicaid Managed Care, Commercial and Self-Pay/Sliding Fee scale patients). This is an easy process if this information can be generated electronically (net revenue per payer type divided by number of visits per payer type). With average revenue per visit per payer type in hand, the manager can identify a payer mix that ensures financial sustainability while preserving access for all patients.
No-Shows and Last-Minute Cancellations
No-shows and last-minute cancellations should be calculated as a percentage of scheduled appointments for which the patient failed to show or cancelled with less than 24 hours notice. In calculating their no-show rate, many programs subtract open slots in the schedule caused by no-shows/late cancellations that staff was able to fill with walk-ins/emergencies, but that masks the true nature of the problem. When staff has to scramble to fill sudden and unexpected holes in the schedule due to patients who failed to keep their appointments, they are not thinking about the potential these “fill in” patients have to contribute financially to their care. All staff cares about is getting a warm body in the chair to fill the sudden opening. In addition to elevating the risk to financial sustainability, this scramble to fill chairs adds to overall chaos within the program and can disrupt the care of regularly scheduled patients.
Providing emergency care is a crucial part of the safety net dental program’s mission. However, emergencies add to overall chaos, stress and unpredictability in the practice. Emergency visits tend to reimburse poorly, and they can interfere with the care of regularly scheduled patients. Safety net dental programs that are swamped with emergencies often have great difficulty providing the definitive care and prevention that leads to improved oral health for patients. There are many different ways to manage emergencies effectively, depending on the daily demand, number, type and skill of providers and number of available operatories. What matters most is determining the average daily demand for care and developing a system for accommodating emergencies in a way that preserves the care of regularly scheduled patients and enables the practice to meet its financial goals.
Transactions are dental procedures (services) with ADA codes attached to them. The total number of procedures divided by the total number of visits will reveal how many services are being provided per visit, which can be an important indicator of provider productivity. Breaking out the procedures by type (diagnostic, preventive, restorative, specialty, prosthodontics, oral surgery and emergency) and calculating the percentage for each type reveals the scope of service for the practice. Is the practice mainly providing exams and x-rays or are they working hard to prevent and eliminate disease? Are they doing mostly emergencies and extractions? Or is there a balance that demonstrates that they are focused on improving the oral health status of their patients?
Tracking quality outcomes enables safety net dental programs to measure the meaningful impact of their work. Being able to demonstrate meaningful impact shows public and private funders and other key stakeholders that the practice is operating on the cutting edge of community health dentistry. But perhaps more importantly, it enables practices to evaluate the quality of their work. Is it the right work for our patients? Is the work actually improving the health and well-being of our patients? Quality outcomes need to be both meaningful and measurable. Completion of Phase I treatment plans and dental sealants are two examples of outcomes that are both meaningful and measurable. Phase I treatment is defined as diagnosis, prevention, elimination of disease, non-surgical periodontal disease and extraction of hopeless teeth. The measure is the number of patients who received comprehensive or periodic exams whose Phase I treatment plans were completed within a 12-month period. This demonstrates the practice’s ability to identify, prevent and eliminate dental disease in its patients in a timely manner, thus restoring them to a baseline of optimum oral health. For dental sealants, the measures are the number of children who needed sealants that got them and the overall number of sealants that were applied. These quality outcome indicators can be tracked easily using dummy codes.
The amount of money owed to the practice past 90 days can be a marker for how well the billing and collection processes are working. Are reception/registration staff consistently collecting co-pays from patients at the time of the visit? Are they documenting the eligibility of patients with 3rd party dental coverage? If accounts receivable is high for Medicaid or commercial insurance, the entire billing process should be reviewed to determine the source(s) of the problems, which can be related to the determination of eligibility, registration issues, provider issues, submission of claims and management of denials. If accounts receivable is high for self-pay/sliding fee scale patients, the practice should review its systems and processes for managing these patients. Is there a policy defining all aspects of payment for dental care services? Do patients understand why payment is required at the time of the visit? Have we given front desk staff the tools they need to feel comfortable communicating with patients around payment for dental care? Are we holding staff accountable for collecting at the time of the visit? The dental manager should set a ceiling for accounts receivable past 90 days, use the aging report to monitor status, provide feedback on a regular basis to staff and actively manage performance failures.
Creating a Culture of Accountability
The keys to creating a culture of accountability within the dental program are to:
Continuously monitor and analyze performance.
Provide regular feedback to staff.
Get all staff at the table and engage them in establishing solutions and goals.
Reward success and coach setbacks.
Always lead by example.
Make it fun!
Dori Bingham is the Program Manager for the DentaQuest Institute’s Safety Net Solutions (SNS) initiative, which provides technical assistance and practice management consulting to safety net dental programs nationwide. Since its inception in 2006, Safety Net Solutions has worked with over 300 safety net dental programs in 30 states. Prior to joining the DentaQuest Institute in 2006, Dori served as Associate Vice President for External Affairs at Morton Hospital and Medical Center in Taunton, MA.
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