cda j ournal , vol 37 , n

5
may 2009333
Environmental Drift in
Health Center Dental
Practice Management
bob russell, dds, mph
abstractFederally qualied health centers, FQHCs, face a
number of challenges providing low-cost health services and meeting
their primary mission of being available to all users regardless of
their ability to pay. In eect, health centers must provide services
that border on free to minimal revenue-generating potential. This is
especially challenging for health centers providing dental services
that are ofen more costly on a case-by-case visit encounter than
primary care services. .
ommunity hcalth ccntcrs acc
many challcngcs attcmpting
to providc hcalth scrviccs
to lowincomc populations.
As a major considcration
in succcssul practicc managcmcnt, a
hcalth ccntcr dcntal clinic must managc
thc inow o ncw paticnts cntcring thc
dcntal practicc. \hilc it is customary to
allow opcn acccss and simply trcat all
potcntial paticnts as thcy walk into thc
clinic, a succcssul practicc must moni
tor and managc ncw paticnt activitics.
Tis includcs such practicc paramctcrs
as dcntal scrvicc timc allocation, rcv
cnuc gcncration ratios o uninsurcd to
insurcd paticnts, thc ratio o cmcrgcncy
walkins vcrsus comprchcnsivc rcgular
carc scckcrs, atcrhours and cxtcndcd
occ hours covcragc, and paticnt ow.
A hcalth ccntcr dcntal clinic that simply
allows a passivc opcn acccss policy without
c h a l l e n g e s
managcmcnt is playing a gamc o dicc
and accs thc risk o poor pcrormancc duc
to cnvironmcntal changcs. Tis can thrcat
cn thc longcvity o thc dcntal program.
According to guidclincs cstablishcd
by thc Hcalth Rcsourccs and Scrviccs
Administration, HRSA, Burcau o Pri
mary Hcalth Carc, hcalth ccntcrs arc
to providc broad and comprchcnsivc
hcalth scrviccs to thcir scrvicc arcas
rcgardlcss o ability to pay, yct maxi
mizc all rcvcnucs rom all sourccs.
r
Tis
includcs thc provision o dcntal scrvic
cs.
.
In addition, hcalth ccntcrs must bc
ablc to monitor intcrnal and cxtcrnal
changcs that may impact thcir ability
to continuc opcrations. Tis cntails thc
ability to prcdict changcs within thc
cnvironmcnt that impact uturc rcvcnuc
strcams and takc appropriatc action
in advancc o such changcs. Tis drit
in cnvironmcntal actors can prcscnt a
author
Bob Russell, dds, mph, is
with the Iowa Department
of Public Health in Des
Moines.
C
334may 2009
cda j ournal , vol 37 , n

5
ccntcrs targct community and a nccds
analysis that can projcct proportions
o potcntial paycr typcs and rcsourccs.
Tis inormation should includc gcncral
agc, gcndcr, racc, disabilitics, spccial
nccds, and cthniccultural makcup.
Population hcalth nccds data can
dcmonstratc and support thc hcalth
ccntcrs acccss policy and thc gcncral
mix o paticnts sccn. By combining thc
population nancial prolc and dcmo
graphic data with thc hcalth ccntcrs
nancial bottomlinc indicators, thc
hcalth ccntcr can managc paticnt acccss
by matching clinic acccss pattcrns with
thc combincd prolc data. Tc data
hclps thc hcalth ccntcr dcntal clinic
avoid appcaring arbitrarily sclcctivc or
chcrrypicking practiccs. HRSA Burcau
o Primary Hcalth Carc cxpccts initial
and ongoing rcgular community as
scssmcnts in ordcr to cvaluatc nccds,
rcsourccs, and program scrvicc potcntial.
Tc primary oral hcalth carc plan
is an intcgral componcnt o thc ovcrall
primary hcalth carc plan, bascd upon
what is casiblc, taking into considcr
ation thc programs projcctcd rcvcnuc,
othcr rcsourccs, and grant support.

Tc primary clcmcnts o a hcalth ccntcr

community nccds analysis should includc
projcct plans, prcvcntion scrvicc mix, orga
nization o carc, and stang rcquircmcnts.
A brcakout cxamplc o a community nccds
analyst includcs thc ollowing clcmcnts.
r. Fstimatcs o thc numbcr o uscrs
(spcciy critical mass o dcntal paticnts or
thc program),
.. Lcscription o cxisting provid
crs and rcsourccs in thc community as
wcll as an asscssmcnt o unmct nccds,
. Prcdominant charactcristics o scr
vicc population such as racc, gcndcr, agc,
cthnicity, primary languagc, incomc, ctc.,
. Oral hcalth status, prcvcntion,
and trcatmcnt nccds o thc population,
to cxist bascd on prcvious nccds asscss
mcnt o thc scrvicc arca has changcd.
A statc may cxcludc rom covcragc
ccrtain cdcral classicd clcctivc addi
tions to Mcdicaid, such as thc provision
o dcntal scrviccs to all adults ovcr agc
.c. Such a changc would havc a dcvas
tating impact on a hcalth ccntcr with
an opcn acccss policy or all agc groups.
A hcalth ccntcr may changc thc scopc
o practicc to targct primarily childrcn
and cxcludc adult paticnts. Tis dcci
sion can bc bascd on thc dcmographic
nccd to targct spccic population
subgroups that sustain thc ability o thc
hcalth ccntcr to continuc opcrations.
scrious challcngc to hcalth ccntcrs, and,
unlcss accountcd or, can doom a wcll
mcaning program to nancial ailurc.
Fnvironmcntal drit signics that
conditions changc ovcr timc. Com
munitics as vital cntitics in motion,
also acc constant and otcn prcdict
ablc changcs ovcr timc. Such drit can
somctimcs occur rapidly in actors such
as dcmographic makcup, cmploymcnt,
rcsourccs, and hcalth carc dcmand. A
hcalth ccntcrs projcct scopc and thc
initial population nccds asscssmcnt may
not rccct thc rcality o hcalth scrvicc
dcmand, uturc trcnds, and projcctcd
rcvcnuc strcams oncc thc hcalth ccntcr
is up and running. Unlcss thc asscss
mcnt o thc community is thorough,
accuratc, ongoing, and takcn rom rcli
ablc sourccs, thc rcal opcrating condi
tions accd by thc hcalth ccntcr whcn
comparcd to thc projcctcd scopc o
practicc may not bc or rcmain rcalistic.
It is a HRSA Burcau o Primary
Hcalth Carc program cxpcctation that
hcalth ccntcrs cstablish comprchcnsivc
primary oral hcalth carc as an intcgral
componcnt o primary hcalth carc
scrviccs providcd whcn rcsourccs arc
availablc to support such a program.
Acccss to scrviccs dcncd within that
scopc must bc madc availablc to all hcalth
ccntcr uscrs rcgardlcss o ability to pay.

Acccss to carc must bc availablc

rcgardlcss o ability to pay, unlcss thc
hcalth ccntcr is ablc to justiy limits
in carc, scopc, or spccic popula
tion targcts. For cxamplc, a hcalth
ccntcr may limit scrvicc to spccial
nccds populations or childrcn only.
An cxamplc o an cnvironmcntal drit
that could bc uscd to justiy a scopc o
scrvicc changc or targctcd subgroup would
bc a suddcn loss o a largc portion o Mcd
icaid covcrcd scrviccs, or thc numbcr o
cnrollcd or cligiblc population dctcrmincd
c h a l l e n g e s
Hcalth ccntcrs must bc ablc to
justiy why scrviccs andor populations
arc cxcludcd rom thc scopc o prac
ticc, i thc scopc o scrviccs is limitcd
andor lcss than comprchcnsivc.
,
Tc kcy principlc is to justiy ncccs
sary subgroup targcting bascd on an
acccptablc standard according to cdcral
rulcs and quality ovcrsight. ustica
tion can consist o cxtrcmc nancial
diculty bascd on unusual shits in
cnvironmcntal changcs or population.
To support justication, a hcalth ccntcr
must collcct appropriatc data to provc
thcir casc. Such data must includc
changcs in dcmographics o thc hcalth
access to care
must be available regardless
of ability to pay, unless
the health center is able
to justify limits in care, scope,
or specic population targets.
cda j ournal , vol 37 , n

5
may 2009335
Community Hcalth Ccntcrs rccommcnds
thc ollowing or hcalth ccntcrs whcn
cvaluating budgctary constraints.
rr
n
Hcalth ccntcr administrators should
strivc to know and undcrstand currcnt
costs and paticnt utilization pattcrns in as
much dctail as possiblc. Tis is ncccssary
in ordcr to know whcthcr participation
at dicrcnt ratcs o rcimburscmcnt and
all associatcd nancial risks is prudcnt.
n
Bc surc thc scopc o rcquircd scr
viccs is clcarly dcncd in ordcr to dctcr
minc whcthcr paymcnt will bc adcquatc.
n
Lo not assumc risk or scrviccs that
cannot bc controllcd dircctly by thc hcalth
ccntcr, a mcmbcr o thc hcalth ccntcr
nctwork, or managcd carc organization
working on bchal o thc hcalth ccntcr.
A mcthod to hclp urthcr control
nancial losscs within thc hcalth ccntcr
dcntal program would bc to adjust thc
ratios o dcntal chairtimc slots or thc
dcntal scrvicc mix availablc to thc targct
population. Such dccisions can bc bascd
on shiting dcmographic data and paticnt
catcgorics such as agc, typc o scrvicc,
paycr sourcc, and thc pcrccntagc thc
practicc can absorb and rcmain viablc.
Tc ocus o a hcalth ccntcr is to bc
availablc to all potcntial uscrs within thc
community at compctitivc priccs and
standards o carc availablc with othcr
hcalth scrvicc providcrs within thc com
munity. Hcalth ccntcrs providc aordablc
good carc standards at lcss costly ratcs
to thc undcrscrvcd lowincomc uscrs. To
accomplish this, dcmographic changcs
and population prolc data can bc uscd
to solicit othcr unding rcsourccs rom
local charitics, statc, rcgional, and na
tional grants targcting spccic nccdbascd
groups. A hcalth ccntcr dcntal dircctor
and hcalth ccntcr program administrator
should rst scck thcsc typcs o rcvcnuc
cnhanccrs rathcr than rcsorting to
limiting paticnt scrviccs or cxclusions.
ing rcvcnuc strcams, rising costs, and
rapid dcplction o cdcral grant unds.
It is important that thc hcalth ccntcrs
administrativc lcadcrship dctcrminc
thc undcrlying rcason or thc ncgativc
cash ow and accommodatc or this
trcnd. It should not bc assumcd that a
hcalth ccntcrs cdcral grant will covcr
all costs i scvcrc ncgativc cash ow
situations arisc. \hilc cdcral grant
unds assist a hcalth ccntcr to covcr
somc o its opcrational costs providing
scrviccs to lowincomc and indigcnt
populations, thc avcragc cdcral grant
only providcs an avcragc o .. pcrccnt o
thc ccntcrs total opcrational budgct.
8

. Barricrs to acccssavailability to
comprchcnsivc oral hcalth carc scrviccs, and
. Lcscription o nccds and trcatmcnt
o spccial populations (c.g., HIV, homc
lcss, migrants).
Sincc oral hcalth carc nccds in
undcrscrvcd communitics arc cxtcn
sivc and cannot bc ully addrcsscd by
any onc organization, it is important
that programs activcly solicit collabora
tion and linkagcs with dcntists, dcntal
schools, dcntal socictics, and othcr hcalth
carc providcrs in thc community.
/
An cxamplc o a typc o cnviron
mcntal drit that ncgativcly impacts
a hcalth ccntcrs ability to scrvc thosc
most in nccd and rcmain nancially vi
ablc is a community acing a sharp risc
in ovcrall uncmploymcnt and a subsc
qucnt risc in uninsurcd and indigcnt
clicnts. \hilc thc numbcr o Mcdicaid
paticnts in this community may still
bc substantial, thc immcdiatc crisis o
incrcasing dcmand by rising uninsurcd
paticnts bcgin to outnumbcr and crowd
out othcr rcvcnuc gcncrating paticnts.
I thc hcalth ccntcr dcntal program
maintains an opcn acccss policy, thc
dcntal clinic will soon nd thc major
ity o paticnts sccking cntrancc into
thc practicc arc uninsurcd and unablc
to pay or scrviccs rcsulting in a scal
crisis. Howcvcr, in this sccnario, thcrc
arc still viablc Mcdicaid cnrollcd cli
cnts and othcr rcvcnuc gcncrating carc
scckcrs within thc community. Yct, thc
dcmand or scrviccs is highcst among
thc growing population o indigcnt and
uninsurcd clicnts. Bcttcr managcmcnt
o all rcsourccs including scrvicc ap
pointmcnts could improvc thc hcalth
ccntcrs viability in thcsc situations.
Unrcstrictcd opcn acccss during
ncgativc community dcmographic and
cnvironmcntal changcs rcsult in hcalth
ccntcr dcntal programs acing dcclin
A hcalth ccntcr cannot sustain itscl
dcpcnding on grant dollars alonc. Na
tional data rccct that Mcdicaid rcvcnucs
rcprcscnt / pcrccnt or morc o a hcalth
ccntcrs rcvcnuc strcam and or a hcalth
ccntcrbascd dcntal program, Mcdicaid
is thc largcst singlc paymcnt sourcc.
,,rc
Tc hcalth ccntcrs budgctary goal
should bc to anticipatc a uturc impact
on program viability and dcvclop an
intcrvcntion to stop potcntial ncgativc
cash ow i dccmcd ncccssary. How
cvcr, this cort must bc consistcnt with
thc hcalth ccntcrs mission and ovcrall
cdcral guidclincs or hcalth ccntcr
programs. Tc National Association o
it should not be
assumed that a health
centers federal grant
will cover all costs if
severe negative cash
ow situations arise.
336may 2 009
cda j ournal , vol 37 , n

5
ccntcrs must bc supportcd by good,
datadrivcn cvidcncc. \hilc dccisions
to rcducc programmatic scrviccs can bc
madc, hcalth ccntcrs should strivc to
usc ncgativc trcnd data to support thc
nccd or additional rcsourccs. A casc
should bc madc that i ncw rcsourccs
wcrc availablc how thcsc rcsourccs would
incrcasc thc hcalth ccntcrs ability to
mcct thc scrvicc populations nccds.
Tis kind o planning is urthcr il
lustratcd in BPHC rcgulations, Hcalth
ccntcrs arc rcquircd to maximizc rcvcnuc
rom all sourccs o incomc to mcct thc
nccds o thc paticnt population scrvcd.
Hcalth ccntcrs arc rcquircd to assurc
that scrviccs shall bc availablc to thc
scrvicc population without rcgard to
mcthod o paymcnt or hcalth status.
At thc samc timc, hcalth ccntcrs arc
cxpcctcd to maximizc rcvcnuc rom
thirdparty paycrs and rom paticnts
to thc cxtcnt thcy arc ablc to pay.
r.,r

Hcalth ccntcrs should dcvclop a
nancial plan or oral hcalth dclivcry.
Tc program should opcratc and bc
trackcd as a cost ccntcr or analysis o
cash ow, rcvcnuc gcncration, program
costs, and utilization. Tc data should
rccct thc dcgrcc to which thc budgct
and nancial plan assurcs appropriatc
utilization o rcsourccs, mccts scrvicc
objcctivcs, and projccts a likclihood
that thc program will rcmain viablc.
Principle Elements of a Financial Plan
Should:
n
Iink thc budgct with thc goals and
objcctivcs spccicd in thc oral hcalth pro
gram plan and ovcrall hcalth ccntcr plan.
n
Idcntiy spccic cost such as
salarics, cquipmcnt, supplics, rcnt, ctc.
n
Providc a budgct orccast or uturc
ycars which dcmonstratcs incrcasing
potcntial or program succcss.
n
Apply cdcral grant rcsourccs to
all cost ccntcrs within thc hcalth
ulcd appointmcnt timc, and paticnt
ow consistcnt with mission objcctivcs
and nancial limitations. Such dcci
sions must bc bascd on data that justi
cs cxclusions and scrvicc limitations.
It must bc cmphasizcd that tar
gctcd schcduling is not justication or
churning, or shortcning paticnt visits,
or thc amount o trcatmcnt pcrormcd.
Fcctivc and quality quadrant dcntistry
within thc ull cld o ancsthcsia is
thc prccrrcd standard o carc. Sclcc
tivc targctcd schcduling simply scrvcs
as a mcthod or cstablishing appoint
mcnt prioritics by targcting all availablc
paycr catcgorics within thc scrvicc arca.
As an cxamplc, a ccrtain hcalth
ccntcr atcr a scal analysis rcquircs
avcragc monthly rcvcnuc proportions o
c pcrccnt Mcdicaid, c pcrccnt sliding
cc scrviccs, rc pcrccnt insurcd, and .c
pcrccnt uncompcnsatcd carc writcos
or minimum program viability. I thc cn
vironmcntal asscssmcnt closcly matchcs
this proportion o rcvcnuc gcncrators
nccdcd or minimum program viability,
chairtimc appointmcnt slots can bc sct
up to targct thcsc paycr catcgorics.
Targctcd rcstrictions in schcdul
ing must closcly match thc population
nccds prolc and bc assigncd by callins
and appointmcnts. Chair appointmcnt
control mcthods work bcst whcn a
practicc utilizcs clcctronic schcduling and
intcgratcd billing sotwarc, along with
closc monitoring by thc hcalth ccntcrs
nancial tcam. Oncc availablc paticnt
typc catcgoricsratio slots arc llcd, all
othcrs arc placcd on standby or ncxt day
llin with thc cxccption o cmcrgcncics.
Fmcrgcncy carc should ncvcr bc
rcstrictcd by this mcthodology. Fmcr
gcncy acccss is limitcd only by thc clinics
cxccss volumc limitations pcr day bascd
on thc numbcr o providcrs availablc,
noshows, and unschcdulcd chair capac
ity. Indigcnt cmcrgcncy carc is applicd
against thc .c pcrccnt uncompcnsatcd
carc proportion i uninsurcd and uncol
lcctiblc. Tc FQHC cdcral grant autho
rizcd undcr Hcalth Scrvicc Act, Scction
c, should bc uscd to assist thc hcalth
ccntcr covcr thcsc rcvcnuc losscs.
Tis typc o chair managcmcnt systcm
or targctcd schcduling works bcst with
a minimum o thrcc dcntal chairs pcr
ulltimc cquivalcnt dcntist. Onc chair is
unschcdulcd or cmcrgcncics and walk
ins whilc two chairs utilizc a targctcd
schcduling systcm. Tc kcy in addrcssing
cnvironmcntal drit in hcalth ccntcrs is
to managc all practicc rcsourccs, schcd
A hcalth ccntcr dcntal program must
bc rcalistic in tcrms o rcsourccs and
ability to mcct thc nccds o thcir scr
vicc population. Lccisions must not bc
limitcd to cxpcnsivc idcalistic trcatmcnt
outcomcs or scal bottomlinc conccrns
alonc. A balanccd pcrspcctivc must bc
dcvclopcd with ocus on community
and individual paticnt carc nccds, s
cal, and mission objcctivcs consistcnt
with cdcral FQHC policy guidclincs.
Fcdcral grants that support somc
portion o FQHC opcrations arc limitcd.
Tcy arc xcd at spccic ratcs ovcr scvcral
ycars without guarantccs in adjustmcnts.
Administrativc dccisions within hcalth
c h a l l e n g e s
a health center
dental program must
be realistic in terms of
resources and ability to
meet the needs of their
service population.
cda j ournal , vol 37 , n

5
may 2009337
ccntcrs budgct to osct lowrcvcnuc
gcncrating scrviccs.
Hcalth ccntcr dcntal clinics arc in c
cct hybridmanagcd carc programs that
primarily bcnct rom hcalth maintc
nancc and prcvcntionbascd activitics
morc than timc intcnsivc and costly
rcstorativc or rcpair scrviccs unlikc most
privatc practiccs. Rcvcnuc gcncration in
thcsc ccntcrs is not proportional to thc
ull cost o providing carc or bascd on
thc cxpcnsc or complcxity o scrviccs.
Tis orccs rcstrictions on what hcalth
ccntcrs can do whcn acing ovcrwhclm
ing dcmand and limitcd rcsourccs.
references
1. HRSA Bureau of Primary Health Care Policy Information
Notice 98-23, bphc.hrsa.gov/policy/pin9823/managemen-
tandnance.htm. August, 1998. Accessed March 2, 2009.
2. Ruddy G, Health centers role in addressing the oral health
needs of the medically underserved. National Association of
Community Health Centers. Washington, D.C., August 2007.
3. BPHC Dental Policy PIN 97, Midwest Clinicians Network,
December 2003.
4. Takach M, Federal community health centers and state
health policy: A primer for policymakers. National academy for
state health policy, Washington, D.C., June 2008, nashp.org/
Files/health_centers_primer.pdf. Accessed March 2, 2009.
5. So you want to start a health center? A practical guide for
starting a federally qualied health center. National associa-
tion of community health centers, Washington, D.C., January
2005, nachc.com. Accessed March 2, 2009.
to request a printed copy of this article, please
contact Bob Russell, DDS, MPH, Lucas State Oce Building,
321 E. 12th St., Des Moines, Iowa, 50319.