This issue's policy forum focuses on initiatives that promote oral health and on challenges the state currently faces. Commentaries discuss new practice models and trends in dental practice, dentist workforce numbers, the East Carolina University School of Dental Medicine education model, and insurance innovation in dental coverage. Several articles focus on access to oral health care in specific populations including children, adult Medicaid recipients, and people with special needs. Original articles examine reasons for tanning bed use among community college students and evaluate the effectiveness of mailed interventions to increase colon cancer screening.
Strengthening the Oral Health Safety Net: Increasing Access and Improving Financial Sustainability
The Blue Cross and Blue Shield of North Carolina (BCBSNC) Foundation has invested more than $2 million in grants over the last 3 years to increase North Carolinians’ access to oral health care. One of the most promising strategies we have identified to improve access for low-income communities across the state is to build capacity at existing clinics that make it their mission to provide care to underserved populations.
While these safety net clinics provide a great deal of care to both Medicaid-covered and uninsured patients, many have struggled to keep their doors open and provide adequate access to meet the need in their local communities. Historically, these clinics have operated at large deficits, putting them at great risk during lean economic times, and many have not maximized capacity of their staff and infrastructure.
Improving Access by Improving Operations
In 2009, to help provide existing clinics with support to increase access, the BCBSNC Foundation made a 3-year investment in Safety Net Solutions, a program of the DentaQuest Institute, to provide practice management consulting to safety net dental practices across the state. Since then, Safety Net Solutions and a national team of expert advisors, including 2 based in North Carolina, have provided support to 21 clinics that sought to both improve their bottom line and increase access to care. These clinics, shown in Table 1, have varied by type (federally qualified health centers, health departments, and hospital-based programs), size, geography, and patient mix (serving only children or a mix of children and adults). Safety Net Solutions and its advisors are grounded in a community-based approach, and their mission-driven philosophy has been critical to the success of this program and to participants’ engagement in the work.
In evaluating the impact of this work, Safety Net Solutions and the BCBSNC Foundation consider several aspects — financial improvement (charges, revenue, and bottom line), improvement in access to care (number of unduplicated patients, visits, and procedures) and operational improvement (change in no-show rates). Sample results are shown in Table 2. The 21 participating clinics are at different stages in their work and each faces unique challenges in their daily operations; as a result they have experienced varying levels of success. Likewise, it is important to recognize that some individual patients have benefited from the resulting changes, while others have not — as clinics have increased their fees, for example, some patients have had to pay more for services. However, based on the first full year of operational improvements in 10 clinics, we have noted that even modest changes to fee schedules, patient mix, and scheduling practices have a substantial impact on both solvency and access to care.
In the first cohort of 10 participating clinics, the net bottom line improved from an aggregate deficit of just under $3.5 million to under $2.5 million over the course of a year, with the bulk of this change occurring in the last 6 months of the time period. Each of the clinics engaged in this process started in the red, with deficits ranging from $80,000 to $1 million. Today, many are inching toward the black while increasing access to care for more North Carolinians — the unduplicated patient count among them went up by 5,000 and the number of procedures went up by 25,000 in the same timeframe.
To achieve these gains, clinics made specific policy changes and operational improvements recommended by Safety Net Solutions. These included increasing integration of medical and dental practices and improving cooperation with prenatal and WIC providers to bring more patients into care; reducing no-shows and improving continuity by scheduling out no more than 45 days; maximizing treatment provided at each visit; and improving patient flow and scheduling practices to reduce chaos in the office. Additional changes included increasing the top range of sliding fee schedules to the 80th percentile of usual and customary, documenting Medicaid eligibility prior to service, monitoring billing performance, establishing productivity goals (and accountability to them), and initiating quality improvement both in billing and in the practice of dentistry. Several participating clinics have been supported by subsequent grants from the BCBSNC Foundation and others to secure digital radiography and practice management software, further increasing their efficiency and ability to monitor and deliver quality care.
Participating clinics have been very positive about their engagement in this work. Several have described the change in their clinic as going from an anecdotal understanding of need, no-shows, and productivity, to a more data-driven approach. But at the root of any change is altering the culture of the organization — from the way the front desk interacts with patients, to the way providers are compensated for their work, to the collection and dissemination of data, to the level of integration with other services at the agency. Perhaps most important is the empowerment of all staff to suggest and make changes that improve access and care. The critical lessons of this work for the BCBSNC Foundation and other participating organizations are the critical lessons of the changes going on across the health care sector. Among these lessons: buy in from executive leadership (CEOs, CFOs, and health directors) is critical as is an organizational culture that embraces change.
Barriers to Success
While the BCBSNC Foundation marks this project as a success, some clinics have achieved at a higher level than others. Predictably, clinics that changed the way they do business and deliver care achieved at the highest levels. A persistent challenge for many clinics, even those that have embraced change, has been recruitment and retention of dentists. Some clinics, despite implementing significant and positive changes, did not improve their bottom line or access to care because they struggled over periods of months to fill vacant positions. This has proven to be a critical limiting factor and one we fear will continue to impact access to care for vulnerable populations across the state over the long term. At one participating health department, it took 8 months to fill a position vacated by a retiring dentist. While large clinics can keep their doors open despite isolated staff vacancies, clinics with only one dentist may be forced to cease operations while they recruit and hire.
To support safety net clinics in the work they do to recruit and hire dental professionals, and to provide more consistent access to a consultant specializing in the dental safety net, the BCBSNC Foundation recently provided grant support to the North Carolina Office of Rural Health and Community Care for a full-time staff person to provide technical assistance relating to practice management in the dental practice and recruitment and retention of dentists in the safety net. We believe that more functional, productive, and financially stable safety net practices will be more conducive to retaining skilled and caring dental professionals and that we can support many more clinics through this local resource.
A second challenge in this work has been shifting scope of practice to focus on a quality measure, namely completion of the phase one treatment plan including diagnosis, prevention, elimination of disease; addressing non-surgical periodontal disease; and extraction of hopeless teeth. Completing the treatment plan not only eliminates disease, but also allows for new patients to enter the practice as others move into a more routine schedule of dental hygiene appointments. Only one clinic in the first cohort of 10 was tracking completion of treatment prior to their work with Safety Net Solutions. A year later, 8 clinics were tracking this data, but as a group, they were completing treatment plans on only 19% of patients. This speaks to both the administrative challenges of getting patients into care in a timely manner and the social and economic factors that inhibit patients from returning for follow-up care. However, we are confident that with continued improvements in clinic efficiency and patient education, the number will rise over the next year.
Making a Difference
Through our engagement in this project we have met many local heroes — dental professionals who are providing compassionate quality care, and practice managers and other administrators who are able to sustain their programs in an unforgiving fiscal environment. These individuals recognize that there is a productive balance between their mission to provide care and their financial stability. They provide daily proof that safety net clinics can deliver quality care across a broad scope of practice and within the framework of a Medicaid and sliding scale fee structure without sacrificing access. Dr. Rob Doherty of Greene County Health Care, who is profiled in the Tar Heel Footprint of this issue, is one such hero.
The oral health care Greene County Health Care clinic and other safety net clinics deliver to North Carolinians from all walks of life is making a difference in oral health and ultimately overall health. Going forward, we believe that safety net clinics have a tremendous and unique opportunity not only to demonstrate and improve quality of care, but also to further integrate oral health care delivery with other primary care. Their IT infrastructure and the co-location of dental and medical services provide opportunities that aren’t as accessible to private providers, opportunities that are increasingly valued in an era where care is integrated more broadly. At the BCBSNC Foundation, where our mission is to improve the health and well-being of all North Carolinians, we salute the dental and administrative leadership at all of the participating clinics who opened their doors, and their books, to Safety Net Solutions as part of this process and then took bold steps within their own practices to improve local access to care.
Technical assistance was provided to grantees by Safety Net Solutions, a program of the DentaQuest Institute, with financial support from the BCBSNC Foundation.
Potential conflicts of interest. K.H and K.E. have no relevant conflicts of interest. M.J.D. is the project director for Safety Net Solutions and served as consultant to several of the participating clinics.
Kathy Higgins, MS president, Blue Cross and Blue Shield of
North Carolina Foundation, Chapel Hill, North Carolina.
Katie Eyes, MSW program officer, Blue Cross and Blue Shield
of North Carolina Foundation, Chapel Hill, North Carolina.
Mark J. Doherty, DMD, MPH, CCHP Safety Net Solutions
project director, DentaQuest Institute, Westborough,
Address correspondence to Katie Eyes, Program Officer, BCBSNC Foundation, PO Box 2291, Durham, NC 27702 (Katie.firstname.lastname@example.org).