A Fine Balance: Mitigating the Financial Challenges Faced by Safety Net Dental Clinics

Transcription

1 A Fine Balance: Mitigating the Financial Challenges Faced by Safety Net Dental Clinics Findings from an Evaluation of the Strengthening Community Dental Practices Demonstration Project January 2011 Prepared by Clare Nolan Fontane Lo Katherine Lee

2 table of contents Executive Summary i 1. Introduction 1 The Strengthening Community Dental Practices Demonstration Project 2 Evaluating the Success of SCDP 3 2. Participating Clinics 7 3. Implementation and Results 8 Overall Success of Practice Management Consulting 8 Satisfaction with Consulting 10 Strategies for Clinic Impact Consulting Model 18 Strengths and Weaknesses of the Consulting Model 18 Factors that Influenced Success 20 Improving the Design of Consulting Model Considerations for Future Work Discussion and Recommendations 27 Consultant Characteristics 27 Appendix A: Clinic Case Studies 30 Clinicas de Salud del Pueblo 31 Community Oral Health Services 34 County of Marin Dental Services 37 Del Norte Clinics 40 Inland Behavioral and Health Services 43 La Clínica de la Raza 46 Mission Community Hospital Dental Clinic 49 Native American Health Center 52 Vista Community Clinic 55 Appendix B: Clinic Attributes and Data 58 Appendix C: Clinic Goals and Outcomes 60 Appendix D: Clinic Communities 62 Appendix E: Interview Participants 63

3 Executive Summary Strengthening Community Dental Practices The primary mission of community dental practices is to serve to low-income, underserved populations who could not otherwise afford care. However, the recent economic downturn and fiscal crisis have made it increasingly difficult for community dental practices to both uphold this mission and keep their doors open. California s fiscal crisis has led to significant cuts to public dental benefits for adults, and has reduced local and private funding factors which have only exacerbated these difficulties. Strengthening Community Dental Practices (SCDP) was a joint project by the California HealthCare Foundation (CHCF) and the California Pipeline Program. The purpose of this pilot project was to ascertain the effectiveness of practice management consulting, an intensive year-long engagement of individualized assistance aimed at improving the long-term sustainability of safety net dental clinics. Harder+Company Community Research ( a California-based consulting firm specializing in research and planning for the health and social service sectors, was commissioned to independently evaluate the potential of practice management consulting to strengthen community dental practices. Participating Clinics Nine pilot clinics were selected for participation, broadly representing the diversity of safety net dental clinics in California. Clinics varied by type (federally qualified health centers, public health clinics, nonprofit clinics), size and structure (mobile, single-site, multi-site), setting (urban and rural), tenure (start-up and more established practices), and patient mix (serving primarily adults or primarily children). Management Consulting Providers Safety Net Solutions (SNS) and Pride Institute were contracted to provide practice management consulting services. SNS is a program of Dentaquest Institute, a Massachusetts-based oral health organization that specializes in consulting services for safety net dental clinics. SNS s model is rooted in their consultants deep experience in community dental practice, and they work with clinics to implement specific operational improvements. Pride Institute is a California-based consulting firm that provides consultation primarily to private dental practices. Pride Institute s model is rooted in clinic education, organizational development, and an internal culture of change. Pride Institute consultants worked with clinics to develop a vision, and they rely on the self-direction of clinic leadership to implement changes. Summary of Findings Each clinic faced unique challenges and limitations in their daily operations, and therefore experienced varying levels of success from the consulting engagement. This section discusses the overall success of practice management consulting, identifies strategies that the participating clinics found most helpful, and outlines considerations for future work. Prepared by Harder+Company for the California HealthCare Foundation January 2011 i

4 Overall Success of Practice Management Consulting In this evaluation, success is defined as the added value of consulting services to clinic management and operations. In other words, this evaluation does not aim to assess the clinic, but the effectivenessness of practice management consulting on clinic operations. While the data available does not permit a rigorous comparison across clinics, * Exhibit ES1 provides a framework with rankings of relative success based on a review of clinic staff interviews and self-reported financial and operational measures. Three of the clinics realized a high degree of success, three experienced moderate success, and three experienced low success with practice management consulting. Clinic success is ranked along four dimensions: (1) breadth of implementation, or the degree to which clinics implemented the consultant s recommendations, (2) financial improvement (e.g., changes in revenue, patient load, or patient mix), (3) operational improvement as indicated by no-show rates, wait time for appointments, and clinic staff reports, and (4) anticipated longevity of improvements over time. With regard to the last dimension, improvements were judged as long-lasting if clinic staff buy-in was high and improvements aligned with clinic mission and values. Exhibit ES1: Assessment of Consulting Success Clinic Overall Success Breadth of Implementation Improved Finances* Changes to Operations Longevity of Improvements Vista Community Clinic High High High High High Community Oral Health High High High High Moderate Services Inland Behavioral & Health High High Moderate High High Services County of Marin Dental Moderate Moderate High Moderate Moderate Services Mission Community Hospital Moderate Moderate Moderate Moderate Moderate Native American Health Moderate High Low Moderate High Center Clinicas de Salud del Pueblo Low Moderate Low Moderate Low Del Norte Clinics Low Low Low Moderate Low La Clínica de la Raza Low Low Low Moderate Low * All financial calculations exclude grant funding. Despite varying degrees of success, all nine clinics reported satisfaction with the consulting services they received through SCDP. The clinic expressing the least satisfaction ( somewhat satisfied ) discontinued their involvement with SCDP half-way through the project year due to changes in dental clinic leadership. Clinics reporting lower levels of satisfaction tended to have no internal champion for the project and minimal buy-in from clinic staff and management. Strategies for Clinic Improvement Of the strategies recommended by the consultants, four areas seemed to help clinics make the greatest strides toward sustainability. However, findings also suggest that there is no one-size-fits-all recipe, * Available data includes interviews with key informants at two points in time and quarterly practice-related measures. While consistent with standard practices in evaluation, the available data only captures snapshots in time with select informants. Prepared by Harder+Company for the California HealthCare Foundation January 2011 ii

5 and what worked well for some clinics did not work well for others. The unique qualities and characteristics of each clinic therefore necessitate a tailored approach. Adjusting fee schedules. Given their mission to serve low-income and uninsured patients, many clinics charged fees well below the usual rates for the area. Consultants suggested fee increases coupled with a steeper sliding scale such that patients at the highest tier would pay more while relieving the financial burden for patients at the lowest tier. As a result, clinics would collect higher fees from those who could afford it while providing larger subsidies for those at the lowest income levels. Some clinics saw significant increases in revenue (such as Vista Community Clinic). Other clinics (such as Mission Community Hospital), however, felt the fee increases conflicted with their mission and purpose. Modifying patient mix. Due to significant cuts to adult public dental benefits, consultants advised clinics to focus their efforts on pediatric patients. Patient mix modification is a strategy that enables struggling clinics to maintain financial solvency while meeting their goal of serving uninsured adults. While uninsured adult patients would not be turned away, they may have to wait longer for non-emergent care (up to 30 days at most clinics). Many clinics took this strategy to heart and successfully recruited pediatric patients into their practices through active outreach (such as those instituted by Inland Behavioral and Health Services) and portable clinics at schools (such as Native American Health Center). However, clinic data reveal that modifying patient mix may not guarantee more patients with dental insurance. Altering scheduling practices. Though sometimes seen as a peripheral function in clinics, scheduling practices are a cornerstone of clinic efficiency and financial viability. A clinic s schedule sets the pace and flow for clinic staff and determines which patients will have access to services. Scheduling practices have considerable potential to reduce the sense of chaos in daily operations while maximizing the use of each dentist s time, not only with regard to the number of patients served but also to the quality of care provided. While altering scheduling practices helped reduce stress levels at some clinics (such as County of Marin Dental Services), it also created greater stress and anxiety at others (such as Clinicas de Salud del Pueblo). Establishing policies and procedures. Policies and procedures help standardize and bring greater transparency to how staff members respond to patients in daily interactions. While policies and procedures entail a broad range of strategies, this section focuses on the most noteworthy: no-show policy, triage process, proof of income, follow-up on account receivables, and clarification of internal policies. Many clinics reported success in reducing no-show rates, reducing clinic stress levels, and improving their ability to collect payments from patients. One clinic (La Clínica de la Raza) focused on building a stronger foundation for change by clarifying staff responsibilities, billing policies, and management practices. Clinics appreciated that consultants were able to identify what they needed and then bring in policies and procedures that clinics could tailor to their needs. In each of these strategy areas, it is important to recognize that some people benefit from changes, and others do not. When clinics increase fees, some patients must pay more for services. When clinics elect to enforce a no-show policy, some patients may have to wait longer for care. These are the tradeoffs with which clinics struggle in order to keep their doors open and maintain services for underserved populations. Prepared by Harder+Company for the California HealthCare Foundation January 2011 iii

6 Consulting Model Practice management consulting is a relatively new model for strengthening the financial viability of safety net dental practices. SCDP has shown that the results of practice management consulting may vary across clinics, as shown in Exhibit ES1. The experiences of the nine clinics point to several factors that create an environment for success. By understanding these factors and addressing them prior to the engagement, clinics may experience greater and more predictable success with practice management consulting. Successful clinics reported that the consultants brought deep knowledge as practicing community dentists, and understood the legal mandates and strict reimbursement guidelines under which safety net clinics operate. Furthermore, clinics appreciated consultants who approached them as collaborative partners rather than simply telling them what to do. As one staff member relayed, They worked with us to develop recommendations and strategies. They didn t tell us what to do. It was a collaborative effort and they spoke with authority, knowledge, and experience. From the experiences of the nine pilot clinics, six factors arose as key elements of success: Buy-in from executive leadership and clinic staff. Buy-in, defined as a strong sense of ownership in the work and a drive to advocate for change, is critical for establishing openness to change and strengthening follow-through in the implementation phase. In particular, it is important to determine whether the executive leadership is fully committed to the project and will provide the leadership, resources, and support necessary for successful implementation. Project champions. Strong project leaders have a vital role in gaining buy-in at all levels and helps clinic staff to maintain focus on the task at hand. It is important that project champions exist at both the executive and clinic levels. At the executive level, the project champion should be able to effectively communicate progress and obtain resources. At the clinic level, the project champion should have a deep understanding of day-to-day clinic operations, and should be wellpositioned to communicate clinic concerns upward to the executive leadership. A culture that supports change. Cultural norms at the executive and clinic levels can either support or inhibit change. It is important to determine whether it is safe and encouraged to speak up, and whether the organization s culture nurtures, rather than stifles, change and innovative thinking. Clear and compelling project goals. Clear goals help staff at all levels understand why changes are necessary and maintain focus on the work. With the hectic schedules and high stress levels typical of safety net clinics, clear goals ensure more follow-through in the implementation phase. Availability of resources for consulting work. A successful consulting engagement not only requires the dedication and commitment of clinic staff, but also concrete resources in terms of release time for staff members to do the work, data capacity to diagnose and monitor clinic needs, and adequate technological resources to support change. Consultation customized to address clinic needs. New clinics and established clinics face different barriers and concerns in the consulting process. New clinics seek an infusion of knowledge and expertise, and often have a high level of buy-in and commitment at the start. On Prepared by Harder+Company for the California HealthCare Foundation January 2011 iv

7 the other hand, established clinics often need someone to help push them beyond old habits and adopt best practices. Exhibit ES2 offers a potential typology for considering clinic needs and the possible implications for the consulting approach. Exhibit ES2: A Potential Typology of Clinic Needs Clinic attributes High Stress High Resistance Positioned for Change Chaotic and stressful clinic operations. Limited staff time and data capacity to participate. Champion sees need for change but faces resistance. Needs third party to help prioritize resources. Well-positioned for change, but needs tools and/or buyin to move forward. Consulting approach Coach. Clinic has minimal culture of change. Help managers see why operations are stressful so they recognize need for change. Facilitator. Clinic is ready to expand culture of change. Extend buy-in to clinic staff and executive leadership to enable implementation. Catalyst. Clinic already has culture of change. Help identify final pieces required to put ideas into action. Case examples Del Norte Clinics, La Clínica de la Raza Clinicas de Salud, Native American Health Center Vista Community Clinics, Inland Behavioral & Health Services Lessons and Considerations for Future Work Interviews with oral health care stakeholders and potential partners reveal that there is a clear need for practice management consulting among safety net dental clinics. Interview participants expressed that many clinics are too overwhelmed to think about practice management, and they typically lack the financial resources to pay for this type of assistance on their own. A number of clinics outside of this study expressed that they could definitely benefit from practice management consulting. However, this demonstration reveals that successful implementation requires key elements such as buy-in at the executive and clinic levels, project champions within the clinic and in the administration, a culture that supports change, clear and compelling project goals, and the availability of resources for the consulting work. Some clinics may require support in addressing these requisite elements in order to support an effective change process. In considering future work, oral health care stakeholders and potential partners agree that it would be important to capture the long-term impact of practice management consulting. Areas of impact should include not only financial viability, but also quality of care and prevention in the long term. Recommendations Findings from the evaluation thus far suggest that, while practice management consulting is not a cure-all, it shows great promise for helping clinics achieve a productive balance between their public health missions and fiscal solvency. Case studies of the nine pilot clinics revealed several key elements that create an environment for success. Clinics were more likely to experience success if a number of key elements were in place prior to the engagement: executive and clinic-level support for the work, strong project leadership, a culture that supports change, compelling project goals, and the availability of resources for the consulting work. By helping clinics to address these factors prior to the consulting engagement, practice management consulting projects will be more well-positioned for success and for maximizing social impact. Prepared by Harder+Company for the California HealthCare Foundation January 2011 v

8 Successful clinics were more likely to describe their consultant as having two key characteristics: significant credibility as practicing community dentists and a collaborative approach in which clinics were viewed as partners in change. Credibility and a collaborative approach made clinic staff more receptive to suggestions and more open to change. For some clinics, there may be alternative modes of assistance that more directly address their needs. For example, public policy may be a better tool for addressing the scarcity of public funding for adult dental services, and leadership training may be a better tool to help executive level leadership and clinic managers develop the foundational skills needed in order to push for greater change in the future. Overall, clinics expressed a high level of satisfaction with the consulting model. However, findings also point to potential refinements to the model. Some clinics felt overwhelmed by the long list of recommendations, and suggested that the work could be divided into modules so that they could focus on one operational area at a time. Furthermore, increasing hands-on assistance from consultants during implementation and with facilitating buy-in may lead to greater follow-through of the recommended improvements. Conclusion Safety net dental clinics strive to maintain a fine balance between upholding their mission and maintaining financial viability. Serving those most in need regardless of ability to pay while also collecting enough revenue to keep clinic doors open can be quite a challenge. It is especially difficult to achieve this balance during a time of declining resources, high unemployment, and growing patient need. The nine demonstration clinics illustrate some of the difficult decisions and uncomfortable tradeoffs that safety net clinics must make. Findings from the evaluation suggest that practice management consulting, while not a cure-all, shows promise for helping clinics achieve a productive balance between their public health missions and fiscal solvency. Prepared by Harder+Company for the California HealthCare Foundation January 2011 vi

9 1. Introduction California s community dental practices work hard to achieve a productive balance between meeting their public health missions and maintaining financial viability. 1 However, a statewide fiscal crisis compounded by the recent economic downturn has created unprecedented challenges for community dental practices across the state. These trends threaten the sustainability of safety net dental clinics and may ultimately reduce access to care for many low-income and uninsured Californians: The California Legislature eliminated most Medi-Cal dental benefits for adults effective July This public program had been the primary payer source for most safety net dental clinics in California and was a vital source of coverage for more than three million Californians. 3 As resources are waning, the demand for safety net services is rising. California s high unemployment rate (12.4 percent as of December 2010) speaks to the rising uninsured population. Many dental practices are faced with declines in funding from private foundations and local agencies. Without these funds, clinics are less able to subsidize care for the uninsured. Even as challenges mount, there are still opportunities for growth through the Patient Protection and Affordable Care Act of 2010 (PPACA) and the American Recovery and Reinvestment Act of 2009 (ARRA). The implications of PPACA remain uncertain. Safety net clinics have the potential to either thrive or become marginalized by the new reforms. Still, PPACA presents an opportunity for clinics to strengthen their services, networks, and infrastructure provided they can contain costs. 4 ARRA allotted $1.5 billion of infrastructure improvement funding and $500 million of operations funding for federally qualified health care centers nationwide. 5 ARRA s implications for community clinics include: Many health centers are moving toward electronic record systems, which have the potential to greatly improve the operational efficiency of safety net dental clinics. Federally qualified health care centers have additional funding at their disposal, some of which could be directed toward improving efficiency and quality of safety net dental services. 1 For further context regarding challenges faced by safety net clinics, please refer to: California HealthCare Foundation. California s Safety Net Clinics: A Primer, 2009; California HealthCare Foundation. The Good Practice: Treating Underserved Dental Patients While Staying Afloat, The cuts did not affect federally-required adult dental services (primarily emergency services), pregnancy-related services, and dental services for persons living in nursing facilities were not cut. 3 Oral Health Access Council, California Primary Care Association, and the Dental Health Foundation. Eliminating Medi-Cal Adult Dental: Costs and Consequences, Katz, Mitchell H. Future of the Safety Net Under Health Reform. JAMA. 2010; 304(6): National Association of Community Health Centers. The American Recovery and Reinvestment Act of 2009: Frequently Asked Questions, Prepared by Harder+Company for the California HealthCare Foundation January

10 The Strengthening Community Dental Practices Demonstration Project The Strengthening Community Dental Practices (SCDP) demonstration is a joint project between the California HealthCare Foundation (CHCF) and the California Pipeline Program. 6 While the goals of each entity are unique, both have an interest in the management and sustainability of safety net clinics. SCDP is a pilot project to ascertain the effectiveness of practice management consulting, an intensive year-long engagement of individualized assistance aimed at improving the long-term sustainability of safety net dental clinics. The goals of CHCF s Innovations for the Underserved program are to promote lower-cost models of care, improve access to care for under-served populations, increase patient enrollment and retention in public health care programs, and improve operational efficiency of the safety net. California Pipeline Program partners with community clinics to provide training for dental students. The program aims to help dental students build greater competency in serving diverse populations while also providing needed services in community clinics and encouraging more students from low-income and under-represented communities to join the dental profession. CHCF and the California Pipeline Program saw a synergistic partnership clinics need dentists who are committed to community dentistry, and operationally strong clinics provide better learning opportunities for dental students. Clinic selection. Nine California dental clinics serving low-income and uninsured populations participated. Clinics varied by type (federally qualified health centers, public health clinics, nonprofit clinics), size and structure (mobile, single-site, multi-site), setting (urban and rural), tenure (start-up and more established practices), and patient mix (serving primarily adults or primarily children). Five of the clinics were recruited by CHCF through a formal application process. Clinics were selected for participation based on four criteria: (1) demonstrated community need for greater access to oral health care, (2) willingness to participate in all phases of the assessment, implementation, and evaluation process, (3) evidence of support for participation from executive and clinical leadership, and (4) demonstrated need to Exhibit 1: Participating Clinics Clinic Sponsor Consultant improve fiscal operations. The California Pipeline Program recruited the remaining four clinics from their community clinic partners. Clinics were selected for SCDP participation based on Clinicas de Salud del Pueblo Community Oral Health Services County of Marin Dental Clinic Del Norte Clinics, Oroville Inland Behavioral & Health Services CHCF CHCF CHCF Pipeline CHCF SNS SNS SNS Pride SNS interest and the need to improve clinic La Clínica de la Raza Pipeline Pride management and fiscal capacity. Mission Community Hospital Pipeline SNS Management consulting providers. Over the course of one year, the nine clinics received practice management consulting Native American Health Center Vista Community Clinic Pipeline CHCF SNS SNS 6 The California Pipeline Program is funded by the Robert Wood Johnson Foundation and the California Endowment and administered by the University of the Pacific. Prepared by Harder+Company for the California HealthCare Foundation January

11 from one of two consulting groups: Safety Net Solutions and Pride Institute (Exhibit 1). Safety Net Solutions (SNS) is a program of Dentaquest Institute, a Massachusetts-based oral health organization, that specializes in providing practice management consulting to safety net dental clinics. SNS s approach can be summarized as follows: (1) diagnostic assessment based on analysis of practice data, (2) discussion of findings with clinic staff, (3) development of an improvement plan, and (4) supported implementation of improvement strategies. SNS worked with seven of the nine participating clinics. Pride Institute is a California-based consulting firm that provides practice management consulting primarily to private dental practices. Pride uses a two-year consulting model: the first year focuses on information gathering and systems building, and the second year focuses on implementation. Pride modified their approach for SCDP s one-year duration. The approach includes: (1) diagnostic assessment and creation of vision based on a site visit, (2) a one-day course based on the findings and vision, (3) self-directed implementation based on the new vision, and (4) ongoing consultant support via phone and periodic visits. Pride worked with two of the participating clinics. Evaluating the Success of SCDP The goal of SCDP is to understand the potential of practice management consulting in strengthening community dental practices statewide. Harder+Company Community Research, a California-based consulting firm specializing in research and planning for the health and social service sectors, was commissioned to conduct an independent evaluation of the pilot. The evaluation addressed the following questions identified by CHCF and the California Pipeline Program: 1. What kinds of organizational changes have been made at the pilot sites as a result of participating in practice management consulting? 2. How successful are the nine pilot community dental practices in improving efficiency according to key practice-related measures related to clinical and financial productivity (such as net revenue, expenses, number of visits, wait time to next available appointment, and noshow rate)? 3. How successful are the practice management consulting models delivered to the community dental practices? 4. What are the long-term prospects for implementing the practice management consulting model for safety net dental clinics throughout California? Practice management consulting is designed to improve clinical productivity and financial viability within dental practices, thereby strengthening their capacity and long-term sustainability. However, safety net dental clinics operate within a larger context comprised of factors at multiple levels. Harder+Company developed a conceptual framework (Exhibit 2) that maps the influence of practice management consulting within this larger context. This framework informed the study design as well as interpretation of findings. Safety net dental practices are influenced not only by internal management practices, but also by factors at the health care organization and health care system levels. Clinics operate within a larger Prepared by Harder+Company for the California HealthCare Foundation January

12 health care organization such as a federally qualified health center (FQHC), a county health clinic, or a nonprofit. These health care organizations in turn operate within a larger system of health care resources, policies, actors, and institutions. Practice management consulting targets practice-level factors such as patient policies, scheduling, and billing procedures. While practice management consulting may influence some organization-level factors such as executive leadership and support, it cannot reach factors at the systems and economy levels. The goal of this discussion is not to minimize the potential of practice management consulting in improving long-term sustainability, but to recognize that sustainability is a result of action and change at multiple levels. Each clinic operates within a unique set of constraints and supports at each level, and therefore the outcomes of practice management consulting may be varied. Exhibit 2: Clinic capacity and sustainability are influenced by factors at multiple levels Economy Practice level factors Policies and procedures, operational efficiency, director and line staff support. Health Care System Health Care Organization Dental Practice Organization level factors Patient population, executive leadership and support for oral health as a priority. Systems level factors Policies prioritizing community oral health as a medical need, leadership and networks between community oral health partners. Economy level factors Availability of public and private funding to subsidize cost of care. A Fine Balance: Tradeoffs between Mission and Margin Safety net clinics are defined by a common mission: to provide health care services to individuals and their families regardless of a patient s ability to pay. 7 Safety net clinics have, therefore, a double bottom-line. Long-term sustainability requires a fine balance between mission and financial viability. Restrictive reimbursement structures and tough economic times have forced some clinics to make decisions that are not necessarily reflective of their own values or the interest of public health. It is within this uncomfortable reality that SCDP operates and this reality that SCDP seeks to alleviate. Research Methods The findings of this report are primarily based on a deep analysis of qualitative data using a multi-case study design. The evaluation team conducted a structured analysis of qualitative and quantitative data from nine SCDP clinics (see Appendices A and B) to examine cross-cutting themes, as well as situational influences and constraints. Data included: (1) site visits incorporating in-person interviews with dental practice directors, clinic staff, and clinic leadership at project launch, (2) telephone 7 California HealthCare Foundation. California s Safety Net Clinics: A Primer, Prepared by Harder+Company for the California HealthCare Foundation January

13 interviews with dental directors (or other key staff member) at project completion, (3) review of documents generated through the consulting process (i.e., practice assessments, clinic enhancement plans, progress reports, and final reports provided by the consultants), (4) interviews with the consultants, and (5) quarterly quantitative measures specific to each clinic s dental practice. With respect to item (5), clinics provided quarterly data specific to their dental practice at baseline and for the following three quarters. Measures included net revenue, expenses, patient mix, payer mix, and productivity. While the case study analysis provides a glimpse into what happened and how it happened, quantitative measures add an important dimension by speaking to the degree of change. These measures are central to understanding changes in financial viability and clinic productivity. To understand the model s long-term prospects (Question 4), the cross-case analysis was supplemented by interviews with CHCF and California Pipeline Program staff, potential partnering agencies and other stakeholders, and dental clinics outside of the demonstration project. These interviews went beyond the experience and results of pilot sites to examine the perspectives of key stakeholders. All told, more than 60 interviews informed this report. The full list of interview participants is available in Appendix E. As with any evaluation, certain study limitations must be considered when interpreting findings. The qualitative nature of the study, the clinic selection process, the small sample size, and variation in participating clinics prevent the generalization of findings to the larger population of California community health dental practices. A number of factors influence clinic operations and outcomes, making it impossible to isolate the influence of practice management consulting in the context of this study. Two areas in particular merit specific discussion. 1. At the start of SCDP, the recession and statewide fiscal crisis were already in full swing and some clinics had already set a number of changes in motion prior to SCDP. While the consultant may have facilitated substantial change at some clinics, the impact is less clear at others even from the clinic s own perspective. 2. Also, two clinics (County of Marin Dental Services and Del Norte Clinics) experienced a change in dental director during the project. The leadership change not only disrupted the consulting work, but also created a gap in knowledge and data. While practice measures add an important dimension to the evaluation, they are not the primary determinant of success. Three important limitations exist: 1. It can take a year (and often longer) before implemented improvements are fully reflected in performance data. The final practice measures reported for SCDP reflect only three quarters of implementation time. 2. Clinics reported practice measures to the best of their ability based on their patient records and billing systems. However, data quality may vary from clinic to clinic depending on how easily customized reports can be created and the time lags between service date and payer reimbursement date. Prepared by Harder+Company for the California HealthCare Foundation January

14 3. Baseline net revenue data for Native American Health Center was unavailable. As a result, net revenue analyses for Native American Health Center compare first and third quarters of implementation rather than baseline and third quarter. 4. Practice measures were unavailable for two of the nine clinics Del Norte Clinics and La Clínica de la Raza. Assessment of success relied primarily on qualitative data for these two clinics. In spite of these limitations, the evaluation team believes this study provides valuable insights regarding the potential efficacy of practice management consulting as a strategy for mitigating current challenges faced by safety net dental practices, the strengths and weaknesses of the consulting model, and long-term prospects for such a model. Prepared by Harder+Company for the California HealthCare Foundation January

15 2. Participating Clinics Nine safety net dental clinics throughout California were chosen to participate in the Strengthening Community Dental Practices (SCDP) demonstration. This section provides an overview of these nine clinics, which were selected to represent the diversity of clinics across California. Appendices A and B provide more detailed information on clinic type and size, patient mix, baseline practice measures, and payer mix. Clinic type. Six of the clinics are FQHCs. Due to their focus on serving high-need communities, FQHCs receive higher reimbursement rates under Medi-Cal than other safety net dental clinics. Three clinics fall outside of the FQHC category County of Marin Dental Services (CMDS) is a county-funded public clinic, Mission Community Hospital Dental Clinic (Mission) is a hospitalaffiliated nonprofit clinic, and Community Oral Health Services (COHS) is a nonprofit mobile dental clinic. These clinics receive substantial funding from county government, private foundations, and program grants respectively. Mission and COHS were particularly hard-hit by losses in grant funding, and may face a harder and longer journey to financial viability. Clinic size and structure. The nine participating clinics are diverse in terms of both size and structure. At the smaller end of the spectrum is COHS, the only mobile dental clinic in the group. On the other end of the spectrum, Clinicas de Salud del Pueblo (Clinicas de Salud) encompasses three participating sites, fourteen operatories, and five FTE dentists on staff. All other clinics fall in between in terms of size. While there are additional multi-site clinics in the group, Clinicas de Salud is the only clinic with more than one site participating in the study. Other clinics chose one site to be the focal point with hopes of later adopting successful practices at other sites. Setting. Clinics are located in different regions and represent rural (Brawley, Monterey County, Yuba City) and urban (Oakland, San Bernardino, San Fernando, San Francisco, San Rafael, Vista) practices. Tenure. While most of the participating dental practices are well-established, two practices are relatively new Vista Community Clinic (Vista) and COHS. For over thirty 30 years, Vista has provided a wide range of medical services, but only recently started its dental program. COHS similarly found itself in new territory. Founded with a primary focus in prevention and oral health education, the budget crisis has forced it to move to a revenue-generating, treatment-focused model. Payer mix. For many of the clinics, SCDP started just in time. Six of the nine clinics mostly served adults and faced significant funding difficulties due to the elimination of Medi-Cal adult dental coverage. These clinics looked to practice management consulting to cope with a difficult financial situation and help build a stronger foundation for financial stability. This summary highlights the uniqueness of individual clinics. Despite variation, common across all clinics was their dedication to providing quality dental care to low-income communities. Prepared by Harder+Company for the California HealthCare Foundation January

16 3. Implementation and Results The goal of the Strengthening Community Dental Practices (SCDP) demonstration is to help clinics build a foundation for long-term financial solvency. This chapter describes the overall success of practice management consulting, clinic satisfaction with consulting services, and strategies that have facilitated the greatest strides toward financial viability. The experience of individual clinics can be found in the case studies in Appendix A, and summary tables of these experiences are available in Appendices B and C. Overall Success of Practice Management Consulting Each of the nine demonstration clinics faces unique challenges and limitations in its daily operations. For the purposes of this evaluation, success is defined as the added value of consulting services to clinic operations. In other words, this evaluation does not aim to assess the clinic, but the effectivenessness of practice management consulting on clinic operations. While the available data does not permit a rigorous comparison across clinics, 9 Exhibit 3 provides a helpful framework that ranks relative success based on a review of clinic staff interviews and self-reported financial and operational measures. Three of the clinics realized a high degree of success, three experienced moderate success, and three experienced low success with practice management consulting. Clinic success is ranked along four dimensions: (1) breadth of implementation, or the degree to which clinics implemented the consultant s recommendations, (2) financial improvements (e.g., changes in revenue, patient load, or patient mix), (3) operational improvements as indicated by no-show rate, wait time for appointments, and clinic staff reports, and (4) anticipated longevity of improvements over time. With regard to the last dimension, improvements were judged as long-lasting only if clinic staff buy-in was high and improvements aligned closely with clinic mission and values. Exhibit 3: Assessment of Consulting Success Overall Breadth of Improved Changes to Longevity Clinic Success Implementation Finances* Operations of Improvements Vista Community Clinic High High High High High Community Oral Health High High High High Moderate Services Inland Behavioral & Health High High Moderate High High Services County of Marin Dental Moderate Moderate High Moderate Moderate Services Mission Community Hospital Moderate Moderate Moderate Moderate Moderate Native American Health Moderate High Low Moderate High Center Clinicas de Salud del Pueblo Low Moderate Low Moderate Low Del Norte Clinics Low Low Low Moderate Low La Clínica de la Raza Low Low Low Moderate Low * All financial calculations exclude grant funding. A more detailed discussion is available on page 9. 9 Available data includes interviews with key informants at two points in time and quarterly practice-related measures. While consistent with standard practices in evaluation, the available data only captures snapshots in time with select informants. Prepared by Harder+Company for the California HealthCare Foundation January

17 Financial Viability Beyond Net Revenue and Margin As illustrated in Exhibit 2, safety net dental clinics operate within multiple tiers of constraint and influence. In particular, it is difficult to isolate the effect of practice management consulting from the effects of a fiscal crisis. For some clinics, success may take the form of a tangible improvement in the margin between the dental clinic s net revenue and expenses ( margin ). For others, holding steady may be a significant feat in itself since patients are losing dental coverage and therefore require subsidized care. The rationale behind each clinic s Improved Finances score in Exhibit 3 is described below, including a detailed comparison between clinic-reported measures at baseline and after three quarters of implementation. Vista Community Clinics scored high for raising the margin from -$42,131 to $118,464, which was a result of increased net revenue coupled with reduced expenses. Expense reduction was quite a success given the growth Vista experienced in patient visits (23 percent). Community Oral Health Services scored high for improving their margin from -$113,181 to -$91,516 despite having to transition from a prevention and education clinic to a treatment clinic. COHS also increased their patient visit count by 29 percent. Inland Behavioral & Health Services experienced a margin decline from -$34,776 to -$63,516. Although this would have scored as low financial improvement, IBHS scored moderate due to the increasing proportion of self-pay patients (19 percentage-point increase). County of Marin Dental Services scored high due to reduced expenses and increases in selfpay patients. CMDS s margin improved from -$595,016 to -$335,979 despite fewer patient visits and a patient population that is primarily self-pay (20 percentage-point increase). The clinic was able to reduce expenses in anticipation of drops in patient visits. Mission Community Hospital experienced a decline in margin from -$21,355 to -$27,193 despite growth in patient visits and revenue. This was due to expenses that grew faster than revenue. Mission scored moderate for being able to hold steady with a very large population of self-pay patients (88 percent, a one percentage-point increase). Native American Health Center scored low for the significant decline in margin from $56,008* to -$188,193 due to operating expenses that rose more than net revenue. The clinic experienced growth in patient visits (17 percent growth) as well as self-pay patients (13 percentage-point increase compared to baseline). Clinicas de Salud del Pueblo scored low because the clinic experienced increased losses, with the margin declining from $80,260 to -$30,749. Net revenue decreased quite a bit due to fewer patient visits, but margin suffered because expenses remained unchanged. * Baseline (Q0) net revenue for Native American Health Center is unavailable. Therefore, the baseline margin reported is from the first quarter of implementation (Q1). All other measures reported are from baseline (Q0). Prepared by Harder+Company for the California HealthCare Foundation January

18 To shed light on how clinic experiences vary across domains, examples of clinics experiencing high, moderate, and low success with practice management consulting are described below: High success case. As a newly established clinic, Vista looked to consultants for guidance on how to create an organized, efficient, and financially stable clinic. With support from the executive director and clinic staff, Vista adopted nearly all of the consultant s recommendations to strengthen their foundation for the future. By the end of the engagement, Vista lifted clinic finances out of the red and cut its no-show rate from 41 percent to 20 percent. Moderate success case. As a clinic founded to be the safety net of safety nets for uninsured adults, Mission relied heavily on private foundation funding. Mission s funding deteriorated with the downturn of the economy, and the clinic turned to practice management consulting to streamline operations and strengthen financial viability. As a result, Mission realized success in implementing new fee schedules and scheduling practices. However, many of the consultant s recommendations were not implemented due to conflicts with the clinic s mission and purpose. Low success case. Although Clinicas de Salud implemented many of the recommendations, the clinic did not experience as much success. Clinicas de Salud s main focus was to improve scheduling, which has been a source of significant frustration for staff at all levels. Despite high hopes, Clinicas de Salud experienced significant drops in productivity after implementing new scheduling practices, leading them to go back to past ways of doing business. Satisfaction with Consulting Despite varying success rates, all nine clinics reported satisfaction with the consulting services they received through SCDP. The one clinic expressing the least satisfaction ( somewhat satisfied ) discontinued their involvement with SCDP half-way through the project year due to changes in dental leadership. Clinics reporting lower levels of satisfaction often did not have certain success factors in place, such as internal champions for the work and buy-in from clinic staff and management. Exhibit 4 summarizes overall success, satisfaction, and key challenges as reported by each clinic. Exhibit 4: Clinic Success, Satisfaction, and Challenges Clinic Overall Success Satisfaction Challenges Vista Community Clinic High Very satisfied Would have liked more customization to maximize potential Community Oral Health Services Inland Behavioral & Health Services County of Marin Dental Services High Very satisfied Overhaul in scope of service from prevention to treatment High Very satisfied None reported Moderate Very satisfied Goal for project unclear Mission Community Hospital Moderate Satisfied Did not feel their mission to serve adults was thoroughly understood Native American Health Center Moderate Very satisfied Internal resistance to change from executive administration Clinicas de Salud del Pueblo Low Very satisfied Frustration with scheduling practices, high anxiety in a tough economy Del Norte Clinics Low Somewhat satisfied Needed strong champion and buy-in La Clínica de la Raza Low Satisfied Needed strong champion and buy-in Prepared by Harder+Company for the California HealthCare Foundation January

19 Strategies for Clinic Impact Of the many strategies recommended by the consultants, four areas seemed to help clinics make the greatest strides toward sustainability. These included adjusting fee schedules, modifying patient mix, altering scheduling practices, and establishing policies and procedures. The first two strategies helped many of the clinics increase revenue, while the latter two were commonly used to improve operational efficiency. The results across the nine demonstration clinics indicate that there is no one-size-fits-all recipe for success, and what worked well for some clinics did not work well for others. The unique qualities and characteristics of each clinic therefore necessitate a more tailored approach. In each of the strategy areas, it is important to recognize that some people benefit from changes, and others do not. When clinics increase fees, some patients must pay more for services. When clinics elect to enforce a no-show policy, patients may have to wait longer for care. These are just some of the tradeoffs with which clinics struggle in order to keep their doors open and maintain services for underserved populations. Adjusting Fee Schedules In their mission to serve low-income and uninsured patients, many clinics charged fees well below usual rates for their area. Consultants typically suggested fee increases coupled with steeper sliding scales such that patients at the highest tier would pay more while relieving the financial burden for patients at the lowest tier. By collecting higher fees from those more able to afford it, the clinics could provide larger subsidies for patients at the lowest income levels. Five clinics chose to institute new fee schedules: COHS, IBHS, Mission, Native American Health Center (NAHC), and Vista. Although adjustments in fee increases and sliding scales are not the only strategies affecting revenue, Exhibit 5 shows that these five clinics have managed to maintain or increase their net revenue despite cuts to Medi-Cal adult dental benefits. Three clinics in particular reported high success: NAHC, Exhibit 5: Percent Change in Net Revenue Percent Change Baseline Clinic from Baseline Net Revenue* Clinicas de Salud del Pueblo -24% $516,827 Community Oral Health Services +7% $86,709 County of Marin Dental Services -47% $1,154,806 Del Norte Clinics - Unavailable Inland Behavioral & Health Services +7% $127,808 La Clínica de la Raza - Unavailable Mission Community Hospital +5% $44,729 Native American Health Center +8% $370,483** Vista Community Clinic +36% $338,354 * Net revenue excludes grant funding. ** Baseline (Q0) net revenue for Native American Health Center is unavailable. Therefore, the baseline net revenue reported is from the first quarter of implementation (Q1). IBHS and COHS. Together with improvements in billing and collections, the new fee schedules enabled NAHC to eventually triple their cash and insurance collections from $5,000 to $18,000 per month. NAHC was very happy with the results from both financial and community perspectives. Staff members felt that the steeper sliding scale allowed greater access to care for patients at the lowest income levels, although this was achieved at the expense of patients at the higher income levels. Prepared by Harder+Company for the California HealthCare Foundation January

20 At IBHS, educating patients about the value of services proved to be a key strategy for successful implementation. In the past, the clinic experienced a drop in patient volume after increasing fees. With the consultant s help, IBHS was able prevent patient attrition by educating patients on the value of the clinic s services. For example, the cost of a root canal is typically about $1,500 but a patient may only pay $600 due to the clinic s lower prices and sliding scale. Patient education was crucial to keeping patients satisfied despite fee increases. For COHS, the new fee schedules generated similar success, and this clinic felt that the continued loyalty of their patients was a testament to the quality of their services. As their executive director explained, Patients stayed. I m convinced that it s because they feel like they are getting quality services. While fee schedule adjustments proved successful for some clinics, this may not be a viable solution for others. Three clinics struggled with adjusting fee schedules: CMDS, Clinicas de Salud and Mission. As a county clinic, CMDS had greater difficulty adjusting their fee schedules since any fee increases must be approved by Marin s Board of Supervisors and the public. In light of the recent economic downturn, Marin County is considering fee increases but is conflicted because higher fees may turn some patients away. Clinicas de Salud and Mission felt the fee increases and steep sliding scale were not financially viable. Clinicas de Salud did not implement new fee schedules because of their proximity to the Mexican border. They explained that, if faced with higher fees, many patients would opt for the cheaper clinics in Mexico. The clinic administrator at Mission was similarly wary, stating that everybody somehow manages to find a piece of paper that says they fall within that lower income range. As a result, Mission did not implement as steep of a sliding scale as recommended by the consultants. Both Clinicas de Salud and Mission saw fee adjustments as a risky strategy. Modifying Patient Mix Due to significant cuts to adult public dental benefits, consultants advised clinics to give priority to patients with coverage: children and pregnant women. Patient mix modification is a strategy that enables struggling clinics to both maintain financial solvency while meeting the goal of serving uninsured adults. While uninsured adult patients would not be turned away, they may have to wait longer for non-emergent care (up to 30 days at most clinics). Many clinics took this strategy to heart and actively recruited pediatric patients into their practices. However, clinic data reveal that modifying patient mix may not guarantee more patients with dental insurance. Outreach to pediatric patients. Among the seven clinics that were advised to modify patient mix, two clinics (Vista and COHS) were already serving mostly children. One clinic (Mission) chose not to follow this strategy because alternate resources existed for children in their community, but not for adults. As shown in Exhibit 6, many clinics were successful in reaching more pediatric patients. Clinicas de Salud, IBHS, NAHC, and Vista all increased the pediatric patient population in their practices. Most clinics tried to recruit pediatric patients implicitly through their scheduling practices, which will be discussed in the next section. However, some clinics worked proactively to engage pediatric patients by developing new partnerships and starting portable on-site services at schools. IBHS and Del Norte Clinics implemented active outreach to the families in their communities. Prior to SCDP, IBHS already recognized the need to reach out to patients and they began to engage families in the medical clinic waiting room. If a child had not received a dental check-up in the preceding six Prepared by Harder+Company for the California HealthCare Foundation January