Session 6: Dental Program Performance. Presenter: Danielle Apostolon, Senior Project Manager, Safety Net Solutions

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1 Session 6: Dental Program Performance Presenter: Danielle Apostolon, Senior Project Manager, Safety Net Solutions

2 Key Objectives Overview of the important key data to track dental program performance Discuss how to analyze the data to improve dental program performance Discuss how to use data to make informed decisions about your dental program The goal is to transform data into information and information into insight

3 Rule #1 Keep It Simple!

4 Rule #2: Make Clean Data a Priority Dirty data is misleading & incorrect. Data must be accurate in order to be meaningful Detect it, remove it or correct it! Establish Data protocols Make clean data a priority

Rule # 3: Use Data to Manage for Success Define success- Creating the business plan Establish a Baseline - Where you are now Set realistic goals -where you want to be

5 Rule # 3: Use Data to Manage for Success Define success- Creating the business plan Establish a Baseline - Where you are now Set realistic goals -where you want to be Measure performance in meeting those goals- take the pulse of the practice Identify areas in need of improvement Hold everyone accountable for working towards success Repeat!

6 Metrics to Measure: Gross Charges Net Revenue Expenses Number of visits Revenue per visit Cost per visit A/R past 90 days # of Unduplicated Patients # of New Patients # of Transactions Scope of Service Treatment Plan Completion Rate # of children ages 6-9 at moderate or high risk receiving sealants # of sealants applied Broken Appointment Rate Emergency Rate Payer Mix Percentages # FTE Providers # FTE Support Staff

7 Metrics that Shed Light on Access/Productivity Number of visits # of Unduplicated Patients # of New Patients

8 Benchmarks encounters/year/fte dentist encounters/year/fte hygienist 1.7 patients/hour or 13.6 patients per 8-hour day per dentist (At least two operatories and 1.5 dental assistants) 1.2 patients/hour or 8-10 patients per 8-hour day per hygienist Panel Size 1,100-1,200 unduplicated patients per FTE General Dentist

9 Example A health center s 2014 UDS report documents 2,900 dental visits What does that mean in terms of productivity: 2,900 visits 230 clinic days (5 days/week x 46 weeks) = 13 visits/clinic day 900 Hygiene Visits 1 FTE= 900 visits per FTE Hygienist per year 900 visits/1,656 hours = 0.5 visits per clinical hour 2,000 Dental Visits 2 FTE = 1,000 visits per FTE Dentist per year 2,000 visits /1,656 hours = 1.2 visits per clinical hour 800 unduplicated patients per FTE Dentist

10 What Should it Look Like? 1 FTE Hygienist working 36 hours per week = 36 hours x 1.2 x 46 weeks= 1,987 visits per year 2 FTE Dentists working a total of 72 hours per week= 72 hours x 1.7 x 46 weeks= 5,630 visits per year Total visits = 7,617 2,200-2,400 unduplicated patients per FTE dentist

11 Comparison Example Potential 85% Utilization Rate Hygiene Visits 900 1,987 1,689 Dentist Visits 2,000 5,630 4,786 Total Visits 2,900 7,617 6,475 Unduplicated Visits 1,600 2,200-2,400

12 Areas to Investigate Broken appointments Scheduling issues Insufficient dental assistants & front desk Broken, outdated equipment Insufficient number of instruments No EDR Provider skill level Unmotivated staff Lack of goals, roles and accountability Patient experience of care = patient satisfaction

13 Potential vs. Actual Capacity based on FTE Dentists # of Providers # of total clinical hours worked x recommended # of visits/ clinical hour Potential Visit Capacity Actual Visits % of Capacity Achieved Mon % Tues % Wed % Thurs % Fri % Potential Weekly Capacity = 135 Dentist Visits

14 Potential vs. Actual Capacity based on FTE Hygienists # of Providers # of total clinical hours worked x recommended # of visits/ clinical hour Potential Visit Capacity Actual Visits % of Capacity Achieved Mon % Tues % Wed % Thurs % Fri % Potential Weekly Capacity = 45 Hygiene Visits

15 Determine Daily Visit Capacity (Example) Monday: 27 dentist visits + 9 hygienist visits = 36 visits Tuesday: 27 dentist visits + 9 hygienist visits = 36 visits Wednesday: 27 dentist visits + 9 hygienist visits = 36 visits Thursday: 27 dentist visits + 9 hygienist visits = 36 visits Friday: 27 dentist visits + 9 hygienist visits = 36 visits Total weekly visit capacity = 180 Total annual visit capacity (180 x 46 weeks) = 8,280

16 New Patients: What the Data Reveals Measured by the number of comprehensive dental exams (D0150) The number of new patients = the number of patients we completed treatment on Need to determine the number of new patients the practice can manage Too many or too few are both problematic Indicators that you may be bringing in too many new patients: Increased length of time between exams (treatment plan creation) and the completion of phase one treatment Decrease in the % of completed treatments plans The dental schedule is booked out past 2 months Increase in the broken appointment rate

17 Take Another Look at Productivity: Not Just Visits! The number of and types of procedures being done Generate a productivity report Total the number of procedures by ADA code and divide that by the total number of yearly visits Red flag if the average is below 2 procedures per visit The target is 2-4 procedures per visit with 2.5 the ideal target

18 Example Total annual visits = 3,600 Total procedures by ADA/CDT code = 4,000 4,000/3,600 = 1.1 procedures per visit

19 What Should the Data Look Like? Total annual visits = 3,600 3,600 x 2.5 = 9,000 CDT procedures codes What information is missing: Patient mix Types of services

20 Scope of Service Productivity report also reveals the types of services being provided to patients What percentage is diagnostic, preventive, restorative, etc. Does the scope of service match our patients need and capacity? Majority need phase 1 services: prevention, diagnosis and elimination of disease Rehabilitative and complex (specialty services) make an informed decision What is the patient mix? Example: If your dental program has a majority of uninsured adult patients that will often result in less prevention, more emergencies, and more extractions

21 Scope of Service, Example Service Type CHC Sample Scope Benchmarks Diagnostic 50% 35% Preventive 10% 33% Restorative 12% 20% Specialty 0% 2-6% Prosthodontics 1% 0-2% Oral Surgery 13% 5-10% Emergencies 14% 2-6%

22 Areas to Investigate How many new patients are coming into the practice Appointment lengths are too short Lack of policy and protocol for managing emergencies Fall behind and impact patients with scheduled appointments Scheduling issues i.e. staff not familiar with appointment type and length Lack of documented & sequenced treatment plans Communication issues between providers and front desk Intentional or unintentional decision to churn visits Can be related to types of services being provided (e.g. crown prep, molar root canal) Unrealistic encounter goals

23 Metrics that Shed Light on Finance Gross Charges Total Revenue Collection Rate Total Expenses Bottom Line

24 Benchmarks Gross charges: $450-$500K per FTE Dentist; $150-$200K per FTE Hygienist Administrative overhead allocation: 10-15% of dentals overall budget Cost per visit: $172 (UDS 2014)

25 Gross Charges If my dental program provided $1 million worth of services and collected $500,000; that means $500,000 dollars worth of care was subsidized. Communicate the value of care Does not hurt to increase your fees

26 Example A dental program incurs $800,000 of direct and indirect expenses for the year To break-even (without grant support), practice must generate that much in net patient-generated revenue The dental program generated $650,000 in patient revenue Bottom line = $150,000 deficit Gross charges = $1.6 million Collection rate = 50%

27 What Should it Look Like $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 Yearly Revenue Goal = $800,000 in patient revenue $800, days = $3,478 in net patient revenue per day; $17,390 in net patient revenue per week Aim to collect 60% of gross charges. Therefore gross (charges) production goals: Per day = $5,797 Per week = $28,985

28 Comparison CHC Sample Goal to Break Even Expenses $800,000 $800,000 Yearly Net Revenue $650,000 $800,000 Bottom Line ($150,000) $0 Revenue per Day $2,826 $3,478 Revenue per Week $14,130 $17,390 Gross Charges per Day $4,710 $5,797 Gross Charges per Week $23,550 $28,985

29 Cost/Visit vs. Revenue/Visit Determine the cost per visit (total expenses visits) Determine the revenue per visit (total net revenue visits) If the cost/visit exceeds revenue/visit, the difference is the average additional dollar amount that needs to be generated at each visit Everyone in the dental program should be aware of what it costs to seat a patient and know the goals for daily revenue & gross charges

30 Provider FTE Gross Charge s Net Revenue (60%) Annual Days Worked Charges/Day Dr. D 1.0 $541,667 $325, $2,355 $1,413 Dr. G 1.0 $541,667 $325, $2,355 $1,413 Revenue/Day Total Dentist 2.0 $1,083,333 $650, $4,710 $2,826 RDH 1.O $291,667 $175, $1,268 $761 RDH 1.0 $291,667 $175, $1,268 $761 Total RDH 2.0 $583,333 $350, $2,536 $1,522 TOTAL $1,666,666 $1,000,000

31 Areas to Investigate Billing & Collections: Are we getting paid for the services provided? Productivity: Generating enough visits? Empty chairs = missed opportunities Expenses: Did we budget appropriately, where are there variances? Reimbursement environment: What is our PPS rate? Are there limited Medicaid benefits for adults? Patient/Payer Mix: Who are our patients? Scope of services: Are there too many high end complex services with limited reimbursement potential while not being aware of the impact or planning how to subsidize this care? Fee schedules & SFDS/Nominal fee: Are fees below market rates? Is the SFDS reasonable? Is the nominal fee affordable?

32 Metrics that Shed Light on Other Aspects of Dental Program Performance Broken Appointment Rate Emergency Rate Payer Mix Percentages Accounts Receivable/Collections

33 Broken Appointments GOAL: Strive for 15%-18% broken appointment rate Calculate no-shows as percentage of scheduled appointments for which the patient failed to show or cancelled at the last minute (<24 hours notice) Don t subtract open slots caused by no-shows/last minute cancellations that staff were able to fill with walk-ins/emergencies Example: 8,000 scheduled appointments, 2,400 no-shows/last minute cancellations (even if the practice managed to fill 1,800 of those open slots with emergencies/walk-ins; these were not scheduled appointments ) = 30% No-Show Rate Use new CDT codes to track no-shows and last-minute cancellations (D9986 = missed appointment; D9987 = cancelled appointment)

34 Emergencies Calculate emergencies using D0140 and/or D9110 (or create a dummy code to track emergencies) Use one of these codes at every emergency visit (e.g. If definitive treatment is provided, such as an extraction, use a no-charge dummy code) Calculate emergency rate as percentage of overall visits Example: 8,000 visits; 1,500 visits were coded as emergencies = 18.8% emergency rate One size does not fit all the key is understanding the impact on your dental program

35 Payer/Patient Mix It is important to know the payer and patient mix for dental Capture the average reimbursement by payer type This data reveals billing and collection issues Used to project yearly revenue

36 Payer Mix Projections Fiscal Year Projection Tool Financial Projections Projected Visits 6500 Actual Visits Difference Patient/Insurance mix: Yearly visits Percent Medicaid 60% 3,900 Percent Self Pay 30% 1,950 Percent Commercial Insurance 5% 325 Percent Other 5% 325 Total 100% 6,175 Reimbursement Rate (per visit): Yearly Revenue Medicaid $ $ 507, Self Pay $ $ 97, Commercial Insurance $ $ 52, Other $ $ 40, Total Projected Revenue $ 656,500.00

37 Impact of Payer Mix on Sustainability (7,500 visits) 35% Medicaid (avg. revenue/visit = $100) 55% Self-Pay/SFS (avg. revenue/visit = $30) 10% Commercial (avg. revenue/visit = $125) 2,625 Med. visits x $100 = $262,500 4,125 S.P. visits x $30 = $123, Com. visits x $120 = $90,000 Total revenue = $476,250 Total expenses = $500,000 Operational deficit = ($23,750) (7,500 visits) 50% Medicaid (avg. revenue/visit = $100) 40% Self-Pay/SFS (avg. revenue/visit = $30) 10% Commercial (avg. revenue/visit = $125) 3,750 visits x 100 = $375,000 3,000 visits x $30 = $90, visits x $120 = $90,000 Total revenue = $555,000 Total expenses = $500,000 Operational surplus = $55,000

38 Metrics that Shed Light on Billing and Collections Accounts receivable past 90 days broken out by payer type Marker for how well the billing and collection process is working Marker whether the dental staff are consistently collecting co-pays at the time of the visit If A/R is high for Medicaid or Commercial, look at entire billing process to determine source or sources of the problem (e.g. eligibility, registration issues, provider issues, submission of claims, management of denials, etc) Example of a Collection Rate by Payer type: Gross charges Medicaid = $500,000 Total net revenue Medicaid = $300,000 Collection rate = $300,000 $500,000 = 60%

39 Metrics that Shed Light on Outcomes Phase One Treatment Plan Completion Rate: Documents improvements in oral health status of the population and helps identify the number of new patients that can be accommodated # of high and moderate risk children ages 6-9 who received sealants # of sealants applied Health centers may identify many other outcomes to track depending on specific grant requirements, etc. More on Quality Outcomes in the next session!

40 Dental Leadership s Role in Measuring Performance Run daily, weekly, and monthly reports on all of the performance metrics Analyze the data, compare against goals, identify problem areas, develop potential solutions to address problem areas, and then implement strategies and evaluate results (PDSA) Educate dental staff so they understand what it costs the practice to see patients and what they need to do on a consistent basis to at least cover these costs Establish a clear chain of accountability from senior management to dental staff Provide ongoing, regular feedback and guidance to dental staff to ensure productivity and financial goals are met make this a part of everyday life in the clinic

41 Executive Leadership Role in Measuring Performance Actively review dental program performance Remove barriers to success (e.g. resolving staff issues, policies and procedures, effective communication, resources) Support dental improvement initiatives (understand what they are doing, why they are doing it, be a dental champion and a change agent) Celebrate successes and coach setbacks Include dental leadership in key decisions, operations design, and budget development. Medical and dental leadership both need a seat at the table

42 Tools for Tracking Performance

43 Interactive Pro Forma Fiscal Year Profit & Loss - Budget Variance Projections Actual Variance Gross Charges: $ - Revenue: Section 330 Revenue/Grants $ - Medicaid 507,000 - $ 507, Self Pay 97,500 - $ 97, Commercial Insurance 52,000 - $ 52, Other 40,625 $ 40, Total Revenue $ 656,500 $ - $ 656, Direct Expenses: Salaries $ - $ - Benefits $ - $ - Total Salaries $ - $ - $ - Support Costs: Rental Cost $ - $ - Lab Fees $ - $ - Education, Training, Conferences $ - $ - Maintenance and repair $ - Dues $ - $ - Bad Debt $ - Office Supplies $ - Depreciation $ - Printing, Postage $ - $ - Total Support Costs - $ - $ - Total Direct Expenses - $ - $ - Indirect Expenses: Administrative costs $ - Total Direct and Indirect Expenses: $ - $ - $ - Net Income or (Loss) $ 656, $ - $ 656,500.00

44 Dr. X Visits # of Days Worked Monthly Provider Performance Avg. # of Visits per Day # Procedures Procedures per Visit Gross Charges Net Revenue Revenue Per Visit Example: $17, $13, $ Month 1 #DIV/0! #DIV/0! #DIV/0! Month 2 #DIV/0! #DIV/0! #DIV/0! Month 3 #DIV/0! #DIV/0! #DIV/0! Month 4 #DIV/0! #DIV/0! #DIV/0! Month 5 #DIV/0! #DIV/0! #DIV/0! Month 6 #DIV/0! #DIV/0! #DIV/0! Month 7 #DIV/0! #DIV/0! #DIV/0! Month 8 #DIV/0! #DIV/0! #DIV/0! Month 9 #DIV/0! #DIV/0! #DIV/0! Month 10 #DIV/0! #DIV/0! #DIV/0! Month 11 #DIV/0! #DIV/0! #DIV/0! Month 12 #DIV/0! #DIV/0! #DIV/0! 253

45 Interactive Performance Evaluation Tool Dental Department Performance Quarter 1 Quarter 2 Quarter 3 Quarter 4 Gross Charges Net Revenue Expenses # of Visits Revenue per Visit #DIV/0! #DIV/0! #DIV/0! #DIV/0! Cost per Visit #DIV/0! #DIV/0! #DIV/0! #DIV/0! Unduplicated Patients New Patients # of Procedures Procedures per Visit #DIV/0! #DIV/0! #DIV/0! #DIV/0! Broken Appointment Rate #DIV/0! #DIV/0! #DIV/0! #DIV/0! Emergency Rate #DIV/0! #DIV/0! #DIV/0! #DIV/0! # of FTE Providers Treatment Completion Rate #DIV/0! #DIV/0! #DIV/0! #DIV/0! # Under 21 Receiving Sealants # of Sealants

46 Broken Appointments Actual Visits No-Shows Cancellations Walk-Ins Scheduled Appointments Broken Appointment Rate Example % Month 1 0 #DIV/0! Month 2 0 #DIV/0! Month 3 0 #DIV/0! Month 4 0 #DIV/0! Month 5 0 #DIV/0! Month 6 0 #DIV/0! Month 7 0 #DIV/0! Month 8 0 #DIV/0! Month 9 0 #DIV/0! Month 10 0 #DIV/0! Month 11 0 #DIV/0! Month 12 0 #DIV/0!

47 FTE Clinic Days Per Year Clinic Hours Per Day Total Provider Hours Visits Per Hour* Total Visits Dental Visits 0 0 Hygiene Visits 0 0 TOTAL VISITS 0 Projecting Gross Charges Utilizing Last Fiscal Year Profit and Loss Statement Step 1: Most Recent FY Gross Charges Most Recent FY Net Revenue Collection Rate #DIV/0! Step 2: Projected Net Revenue Collection Rate Projected Gross Charges #DIV/0!

48 Payer Mix and Collections Quarter 1 # of Visits % Gross Charges Revenue Collected Medicaid #DIV/0! Self Pay #DIV/0! Sliding Fee #DIV/0! Commercial Ins. #DIV/0! Managed Care #DIV/0! Other #DIV/0! Q1 Totals 0 #DIV/0! $0.00 $0.00 Quarter 1 # of Procedures % Diagnostic #DIV/0! Preventive #DIV/0! Restorative #DIV/0! Endodontics #DIV/0! Periodontics #DIV/0! Prosthodontics #DIV/0! Emergency #DIV/0! Oral Surgery #DIV/0! Orthodontics #DIV/0! Adj. Services #DIV/0! Totals 0 #DIV/0!

Scheduling by Design. Dori Bingham Danielle Goldsmith. Strategies to Enhance Financial Sustainability, Access and the Completion of Phase 1 Treatments

Scheduling by Design. Dori Bingham Danielle Goldsmith. Strategies to Enhance Financial Sustainability, Access and the Completion of Phase 1 Treatments Scheduling by Design Strategies to Enhance Financial Sustainability, Access and the Completion of Phase 1 Treatments Dori Bingham Danielle Goldsmith Use of the dental schedule to achieve three key strategic