Managing for Success. A User s Guide to Dental Program Sustainability. Dori Bingham SNS Program Manager

Transcription

1 Managing for Success A User s Guide to Dental Program Sustainability Dori Bingham SNS Program Manager

2 The Key Concepts to Managing for Success You need good data to evaluate and measure dental s performance Use this data to create a business plan for the dental department This business plan is a road map that shows the department how to achieve and maintain financial sustainability, maximize patient access and achieve meaningful and measurable quality outcomes Dental program performance evaluation should be part of a formal continuous quality improvement focus Dental program performance should also be regularly shared with staff to create a culture of accountability

3 Key Data Number of visits Number of unduplicated patients Number of new patients Gross charges Net revenue (including all sources of revenue) Payer and patient mix Total expenses (direct and indirect) No-show rate Emergency rate Transactions (procedures by ADA code) Percentage of completed treatments Percentage of children needing sealants who received sealants Number of FTE providers (dentists and hygienists) Aging report

4 The Business Plan What the dental practice needs to accomplish to be financially sustainable, maximize patient access and provide meaningful quality outcomes Target population to be served Numbers and types of patients to be seen Numbers, types and lengths of appointments Scope of service for the practice Staffing model

5 The Business Plan (cont.) Service delivery model Hours of operation Financial, productivity and quality goals to be met Optimal payer mix Evaluation plan

6 Evaluating Dental Program Performance

7 Cost/Visit vs. Revenue/Visit Determine the cost per visit (total expenses 3 visits) Determine the revenue per visit (total net revenue 3 visits) If revenue/visit is higher than cost/visit, pat yourself on the back and keep up the good work If you re like the majority of community health dental programs, cost/visit is higher than revenue/visit The difference is what the dental practice needs to make up in each visit to reach sustainability

8 Determining Potential Visit Capacity Potential capacity is based on number of FTE providers, hours of operation and standard productivity benchmarks Benchmarks are different for dentists vs. hygienists Potential visit capacity is impacted by factors affecting provider productivity

9 Determining Potential Visit Capacity (Dentists) # of FTE Providers X 1.7 Visits/FTE/Clinical Hour X # of Clinical Hours Potential Visit Capacity Mon Tues Wed Thurs Fri

10 Evaluating Potential Capacity vs. Actual Visits Potential weekly visit capacity in example was x 46 weeks = annual potential capacity of 8,924 Actual annual visits was 7,520 84% of potential capacity was achieved Not bad, but what could we do to make this better?

11 Common Factors Impacting Provider Productivity No-shows and last-minute cancellations Scheduling issues Insufficient support staff (dental assistants) Lack of goals and accountability Individual provider issues (unmotivated, inexperienced, health problems, life issues, etc.) Insufficient instruments, supplies Equipment issues (outdated, missing, broken) Lack of EDR/PMS (or not being used maximally)

12 Payer Mix Huge impact on financial sustainability Big challenge to manage Determine the average revenue per visit per payer type Use that information to create a payer mix that ensures financial sustainability while preserving access for all patients

13 Impact of Payer Mix on Sustainability Now (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 visits x $100 = $262,500 4,125 visits x $30 = $123, visits x $120 = $90,000 Total revenue = $476,250 Total expenses = $500,000 Operating loss = ($23,750) Better (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 Operating surplus = $55,000

14 Tweaking Payer Mix Designate priority populations and work to get them in the practice Women and children first! Pregnant women and children are more likely to have Medicaid coverage More Medicaid means less uninsured, yes, but no margin, no mission Goal to preserve as much access for uninsured patients as possible while maintaining financial sustainability Being financially sustainable lays the groundwork for expansion, which increases access for all payer types

15 No-Shows Calculate no-shows as percentage of scheduled appointments for which the patient failed to show or cancelled at the last minute Don t subtract open slots caused by no-shows/last minute cancellations that staff were able to fill with walkins/emergencies Example: 8,000 scheduled appointments, 2,400 noshows/last minute cancellations (even if the practice managed to fill 1,800 of those open slots with emergencies/walk-ins) = 30% No-Show Rate Use dummy codes to track no-shows

16 Strong policy Managing No-Shows Consistent enforcement Social marketing to patients about the value of practice and importance of keeping appointments Establishing culture of accountability Lots of best practices to try!

17 Emergencies Calculate emergencies using D0140 and/or D9110 (or create a dummy code to track emergencies) Use one of these codes in every emergency visit, even if definitive treatment is provided (eg, extraction) (or 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

18 Managing Emergencies Providing emergency care is a crucial part of our mission, BUT Emergencies add to overall chaos, stress and unpredictability in the practice Emergency visits tend to reimburse poorly Emergencies can interfere with the care of regularly scheduled patients Key is to develop a system and policy for managing emergencies that provides sufficient access while preserving the care of regularly scheduled patients, minimizing disruption to the practice and maintaining financial sustainability

19 Transactions Transactions are procedures with ADA codes attached to them Transaction reports reveal the scope of service for the practice, as well as what is happening at the visit level Look at number and types of procedures that are non- Medicaid covered Total number of procedures 3total number of visits = procedures/visit (important measure of productivity and ability to complete treatment plans in a timely manner) Break out procedures by type (diagnostic, preventive, restorative, specialty, prosthodontics, oral surgery and emergency) Calculate percentage of each type to reveal scope of service

20 Scope of Service FY2010 Diagnostic 37.5% Preventive 6.9% Restorative 16.4% Specialty (endo/perio) 3.0% Oral Surgery 16.1% Prostho 0.0% Emergencies 20.1% Total: 11,242 procedures

21 Quality Outcomes Tracking quality outcomes enables us to measure the meaningful impact of our work Is the work we re doing the right work for our patients? Is our work improving the health and well-being of our patients? Quality outcomes need to be both meaningful and measurable

22 Quality Outcomes (cont.) Two outcomes that are both meaningful and measurable: Completion of Phase I Treatment Plans Phase I treatment is diagnosis, prevention, elimination of disease, non-surgical periodontal disease and extraction of hopeless teeth Dental sealants How many children who needed sealants got them and how many overall sealants were applied

23 Tracking Quality Outcomes Create dummy codes for completed treatments (eg, TXComp) Start point is a visit with D0150 or D0120 (comprehensive or periodic exam) treatment plan is created at that visit, and when final service in that plan is completed, provider checks off dummy code Goal is to complete treatment within 12 months of the exam Create dummy codes for child needs sealants (eg, D1351N) and received sealants (eg, D1351R) Run reports to determine the percentage of children needing sealants who got them Divide total number of sealants done by number of children who got them to determine average number of sealants per child

24 Aging Report Accounts receivable past 90 days broken out by payer type (Medicaid, commercial, self-pay/sliding fee scale) Marker for how well the billing process is working Marker for whether the dental staff is consistently collecting co-pays from patients at the time of the visit If A/R is high in Medicaid or commercial, look at entire billing process to determine source(s) of problems (eg, determination of eligibility process, registration issues, provider issues, submission of claims, management of denials)

25 Aging Report (cont.) If A/R is high for self-pay/sfs patients, review systems and processes Review/create policy defining all aspects of payment for dental care Educate patients about why payment is required at the time of the visit Develop scripting for staff to use in communicating with patients Alert front desk staff that A/R past 90 days from self-pay/sfs patients is a measure used to evaluate their performance Set ceiling targets for A/R, monitor, provide feedback to staff and manage performance failures

26 Setting Goals Access --Total number of visits --Number of unduplicated patients --Number of new patients Provider Productivity --Visits/day --Procedures/visit --Revenue/day Quality Outcomes --Percentage of completed treatments --Percentage of children who needed sealants and got them Financial Outcomes --Gross charges --Net revenue --Bottom line

27 Setting Goals: Access Determine annual potential capacity (total visits) Total visits 32.5 = number of unduplicated patients per year Total number of completed treatments = number of new patients

28 Setting Goals: Provider Productivity Use benchmarks (1.7 visits/hour for dentists, 1.25 visits/hour for 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

29 Setting Goals: Provider Productivity Example: Total operating costs = $1,000,000 Grants = $100,000 Breakeven costs to cover from patient care = $900,000 5 FTE providers (all general dentists); each FTE dentist needs to generate $180,000/year in net revenue $180, clinical days = $783 in net revenue per dentist per day to break even Assumes each provider sees the same types of patients and provides same types of services Revenue goals would be different for dentists vs. hygienists

30 Setting Goals: Quality Outcomes No national benchmarks at this time Completed treatments: 35% in year 1, 50% in year 2, 75% in year 3 and beyond Sealants: 50% in year 1, 75% in year 2 and 90% in year 3 and beyond Quality goals should be lofty, but achievable

31 Setting Goals: Financial Decision: break even okay or go for surplus? Surplus if possible to build reserves for future growth and upgrading of facilities/equipment Determine total costs Look at payer mix, average revenue per payer type, number of FTE providers, clinical hours of operation, total visit capacity First goal, reach break-even Second goal, into the black

32 Example: Setting Goals: Financial Total operating costs = $1,000,000 Grants = $100,000 Breakeven costs to cover from patient care = $900,000 $900, clinical days = practice needs to achieve $3,913 in net revenue per day to break even Practice historically nets 65% of gross charges; thus, daily gross needs to be $6,020 Profitability goal = $1,300,000 (minus $100,000 grant) = $1,200,000 $1,200, clinical days = $5,217 in net revenue per day; gross charges per day need to be $8,026 Practice needs to continuously monitor actual performance against goals

33 Our Major Strategic Tool: The Daily Schedule Scheduling is an art Done properly, it supports maximum access, quality outcomes and financial sustainability Done improperly, all of these areas suffer First step: create a formal policy Second step: create a scheduling template with goals and designated access for priority populations Third step: make sure staff who schedule know how it needs to be done Final step: monitor how well things are working and provide regular feedback to schedulers

34 Creating a Culture of Accountability Monitor and analyze performance Provide regular feedback to staff Get everyone at the table and engage them in establishing solutions and goals Reward success, coach setbacks Lead by example Make it fun!

35 Partnering to Strengthen and Preserve the Oral Health Safety Net A PROGRAM OF THE 2400 Computer Drive, Westborough, MA Tel: Fax: