Expanding Access to Dental Care Through C A L I FOR N I A California’s Community Health Centers H EALTH C ARE F OU NDATION Introduction resources to difficulties in hiring high-quality Access to dental care for low-income Californians professional staff and a patient-payer mix that is quite limited. Only 26 percent of the does not allow for adequate reimbursement. The 8.5 million eligible for Medi-Cal dental benefits, interviews also produced recommendations for Issue Brief commonly known as Denti-Cal, receive treatment overcoming these barriers, including: every year.1 Few facilities will offer treatment to K Creation of a peer networking program patients who rely on publicly funded insurance that would allow clinic dental directors and programs or are uninsured. Low reimbursement executives to discuss clinical, operational, rates for Denti-Cal enrollees and the threat of administrative, financial, and policy issues; further cuts discourage dentists in private practice from treating such patients. K Wider dissemination of “best practices” for clinic efficiency and cost savings, such as bulk Federally qualified health centers (FQHCs) offer purchasing of supplies and services; dental care to a small percentage of low-income K Clarification of reimbursement policies for Californians and could potentially take on more FQHCs on allowable services, billing rules patients. However, FQHCs, also referred to and procedures, and location of services; as community health centers, face numerous obstacles to establishing or expanding dental K Greater funding for capital funds and start-up services. costs; K Support for programs which encourage dental In an effort to better understand these obstacles, students and professionals to practice in clinic the California HealthCare Foundation settings, such as externships, residencies, and commissioned a field survey of FQHC’s. loan repayment; and Researchers interviewed dental directors, executive directors, clinicians and other staff at K Further research on the ability of health six community health centers in California with centers to provide inducements to attract dental practices that treat a limited number of qualified dentists, reduce operating costs patients. The researchers also interviewed staff through partnerships with other health members at organizations that collaborate with centers, use expanded-scope dental and provide support to community health centers professionals, and streamline licensing and in California, Arizona, and Ohio. regulatory requirements for expanding or opening new clinics. The survey findings show that while FQHCs are willing to start or expand dental care for While some clinics that provide dental services low-income Californians, they face a common set have experience in finding ways to solve common A ugust of impediments, ranging from insufficient capital problems such as schedule-balancing and 2008 no-shows, all said they could benefit from technical K Participation in school or community-based services, assistance and peer-to-peer networking to address or other outside activities; persistent reimbursement and operations issues. In K Competing providers and primary sources for patient addition, the interviews suggested that the full support referrals; of the health center’s chief executive appeared crucial to K Needs of the target population; ensuring the success of dental services. K Major impediments for expanding dental capacity; A companion report, The Good Practice: Treating K Opportunities or incentives to expand dental Underserved Dental Patients While Staying Afloat, capacity; examines the broader problem of how community dental K What has been tried that worked, and what didn’t practices — both large and small, public and private —  work; and can design or improve the efficiency and effectiveness of K How to share best practices data so that clinics can the dental services they deliver. The report is available on and will use it. the California HealthCare Foundation’s Web site at www.chcf.org/topics/medi-cal/index.cfm?itemID=133706. Figure 1 provides general information on the six community health centers that participated in the survey Methodology and a visual reference of their geographic locations. To obtain information for this issue brief, a team of researchers made site visits in early 2008 to six California Findings federally qualified health centers which provide a low or Although the community health centers interviewed had moderate volume of dental services and interviewed the substantial differences in terms of their location, staffing dental directors and executive directors. (The researchers and patient mix, all agreed on one thing: they do not defined low-volume clinics as those with fewer than have the capacity to meet the dental care needs of their 5,000 dental encounters per year; “moderate” volume as patient populations. 5,000 to 15,000 per year; and “high” volume as those with over 15,000 annual encounters per clinic site.) Fewer than 2 percent of Denti-Cal services are now Clinics were selected for the diversity of their geographic provided by community health centers.2 Of the location, patient mix, and staffing patterns. Additional 857 licensed community clinics in the state, only 245 interviews were conducted with clinics that have yet to (29 percent) reported treating dental patients in 2006. Of provide any dental services, as well as with regional clinic these, 34 (14 percent) reported more than 10,000 dental consortia. Lastly, the researchers interviewed people and encounters, a volume that accounted for nearly two-thirds organizations that collaborate with and provide support (63 percent) of all such visits. By contrast, the 164 clinic to community health centers in the states of California, sites that provided low volumes of dental care (between Arizona, and Ohio. To ensure the maximum degree of 1,000 and 10,000 per year) accounted for an average of candor, interview subjects were offered anonymity both 4,200 encounters. for themselves and their clinics. The field research conducted for this issue brief shows The interviews focused on nine key areas: that there is no single barrier impeding the expansion K Dental capacity and operating model; of dental care at community clinics; rather there is a set K Past, present, or future plans to either expand or scale of barriers that proved common to the health centers back dental services; which participated in this study. These fall into four 2  |  California HealthCare Foundation Figure 1. Characteristics of Six Participating California Community Health Centers, by Region d e n ta l d e n ta l F TE E n cou n t e rs Num b e r of Num b e r Del Norte Siskiyou Modoc Region Geographic type pat i e n t s e n cou n t e rs dentists per dentist op e r a t or i e s of S i t e s 1 Southern CA Urban 11,755 32,688 7.9 4,138 22 3 Shasta Lassen Trinity Humboldt 2 Southern CA Suburban/Agricultural 4,138* 11,960 3.3 3,624 7 1 Tehama Plumas Glenn Butte Sierra 3 Los Angeles Urban 940 2,565 1.4 1,832 7 (using 4) 1 Mendocino Nevada Lake Colusa Yuba Sutter Placer 4 Bay Area Suburban/Urban 2,143 4,749 1.6 2,968 3+mobile 1+mobile El Dorado Yolo Sacramento Napa 5 5 Bay Area Agricultural 4,802* 10,759 4.0 2,689 10 2 Sonoma Alpine Amador Solano Calaveras Marin San Contra 4 Joaquin Tuolumne Mono 6 Central Coast Rural/Agricultural 6,685 18154 5.2 3,491 9+mobile 2+mobile Costa San Francisco Alameda Stanislaus Mariposa San Mateo Santa Clara Merced Madera Santa Cruz *2006 data. San Benito Inyo Fresno Tulare Monterey Kings San Luis Obispo 6 Kern San Bernardino Santa Barbara Ventura 3 Los Angeles Riverside Orange 1&2 San Diego Imperial In addition to construction costs, dental clinics spend main categories: start-up and operating costs; payer $50,000 to $75,000 per operatory for large equipment mix, reimbursement, and uncompensated care; staff (patient chairs, x-ray units, operating lights, computers, recruitment, retention and training; and issues related etc.), instruments, non-disposable supplies, and small to leadership and management, including measures for equipment. In some cases, equipment such as patient quality and efficiency. chairs and dental units — the chair-side utility station that supplies water, compressed air, electricity, and Start-up and Operating Costs vacuum — were donated to the clinics. More commonly, For a dentist to maximize the number of patients treated money to pay for equipment was obtained through per day there needs to be at least two, and preferably public or private grants, or collected as part of general three, treatment rooms assigned to each dentist. Because fundraising. such rooms, formally known as dental operatories, are very specialized and require plumbing for water, While construction and equipment costs are a major compressed air, and suction, the capital cost for a dental deterrent to expansion for most clinics, dental directors clinic (without equipment) is substantially higher than all voiced greater concern regarding their annual budget that for a medical clinic. The estimated average capital for disposable supplies — approximately $25,000 for a construction cost for a three-operatory dental clinic is three-operatory clinic. Many pointed out that although $375,900, or $209 per square foot.3 All but one of the grants can be obtained to cover the cost of construction clinics interviewed for this issue brief needed to expand and major equipment, there are few funds available their clinic space before they could add additional dental to underwrite daily operations, including disposable staff. Some were interested in expanding the dental supplies. clinic space at their primary location, while others were interested in opening new clinics at additional sites. One Payer Mix, Reimbursement, and clinic had sufficient space but lacked equipment, supplies, Uncompensated Care and staff. The sustainability of a dental clinic depends on (1) the mix of payment sources (e.g., Denti-Cal, self-pay), (2) the size of practice, (3) the types of services provided, and Expanding Access to Dental Care Through California’s Community Health Centers  |  3 (4) the efficiency of the practice. Managing and clinics reported high success in collecting payments from deciphering different reimbursement methods, including uninsured patients, due in large part to the fact that the the process of identifying means of payment for the patients recognize that the community health centers’ fees uninsured, is often overwhelming for management and are much lower than those of private providers. staff at FQHCs. Staff Recruitment, Retention, and Training For private-pay patients and those enrolled in Healthy Families and Healthy Kids, the clinics bill at a fee-for- Dentists service rate. For Medi-Cal patients, reimbursements for All of the clinics reported problems with recruiting, each visit are fixed at a rate negotiated with the federal training, and retaining dentists. One clinic, assuming that and state government, an arrangement known as the it would be unable to recruit a dentist, reported that it Prospective Payment System (PPS). For these patients, had never tried; the others stated that they had difficulty clinics do not bill for individual procedures, but submit recruiting dentists with the desired qualifications. a single charge for each visit. The PPS rate is set at a baseline, with annual adjustments tied to the Medicare Compared to patients seen in private practice, those Economic Index (MEI), which does not necessarily served by public dental clinics have substantially more cover the actual increases in costs. A community health complex dental treatment needs, are more likely to be center may apply for a rate increase based upon a change medically compromised, and have poorer compliance to in scope of services, e.g., adding a new operatory, adult recommended self-care. In addition, public health clinics dental care, or other additional services. generally lack the ability to refer patients to specialists, which means that their dentists must be proficient in The Prospective Payment System rate for community complex procedures, such as oral surgery and root canals. health centers is an all-inclusive rate designed to reimburse the facility for the overall costs of providing The community health centers reported that they pay services to Medi-Cal patients, with each visit billed new dentists between $52 and $62 per hour. This at the average cost. Most FQHCs have a single PPS is substantially less than the $84 average hourly net reimbursement rate which covers both medical and dental income of a general dentist who owns, or is a partner visits. Because the size of the PPS rate depends on a in, a private practice.4 At least one community health community health centers’ patient mix and what services center interviewed for this survey has lost dental staff to they provide, careful attention needs to be paid to these the California prison system, where annual salaries for factors if a clinic is to cover its costs. dentists have reportedly reached $180,000, far beyond what clinics can pay. As a result, a large portion of those For the uninsured, FQHCs have sliding-scale fee who apply for FQHC positions are recent dental school schedules along with some direct payment funding graduates, who typically do not have the clinical skills from public and private sources. They also attempt to or speed to provide the comprehensive care needed by a determine whether uninsured patients qualify for available clinic’s complex patient population. programs such as Medi-Cal and Healthy Families, and, if so, help them to enroll. Uninsured patients are Hiring such graduates is a long-term investment which advised of the cost of the initial visit. Afterwards, when a requires training in a public health setting. This typically treatment plan is developed, clinic staff discuss the costs means that the dental director must spend a large portion and payment options with the patient. In interviews, the of clinical time mentoring new dentists, instead of 4  |  California HealthCare Foundation treating patients. Taking advantage of external training Dental Hygienists opportunities poses a different sort of problem, since it The primary service provided by dental hygienists, requires dentists to leave work. The California Dental which cannot be performed by an expanded-function Association Foundation’s Pediatric Oral Health Access dental assistant, is the removal of tartar deposits below Program, which provides free training to general dentists the gum line as part of the prevention and treatment in treating younger children, reports that some clinic of periodontal disease in adults. The treatment of dentists find it difficult to attend since they aren’t able to periodontal disease, which requires patient compliance secure the necessary time. with recommended self-care and regular dental visits, is generally not a high priority for FQHCs, for several Most of the clinic dental directors stated that they look reasons. Dental hygienist time is expensive ($45 per hour) for dentists who (1) are interested in practicing in a and production is low. Only one or two patients can be community setting, (2) have a strong commitment to booked per hour. Double-booking patients to account public service, and (3) were trained in the United States. for no-shows is not feasible because if both patients show Only one U.S. dental school has a teaching model up, the hygienist can only treat one. On the other hand, specifically designed to meet the needs of public dental dentist time is only slightly more expensive; dentists can clinics — the Arizona School and Dentistry and Oral see three or more patients per hour, and they are not Health. During their fourth year, students spend a large limited in the services they can perform. Also, Denti-Cal portion of time practicing in public clinics throughout does not pay for all of the dental hygiene visits required the country. For a clinic to host a student, however, it to treat periodontal disease, and the state has not yet must supply housing and other support, which most implemented independent billing procedures for dental FQHCs cannot afford. hygienist services. Dental Assistants Leadership and Management The community health centers interviewed for this survey Findings from the survey indicate that two of the reported fewer problems with recruiting and training elements of a successful clinic are the leadership of a dental assistants, although retention was sometimes an skilled and committed dental director and the support of issue. Relationships with local dental assistant training an engaged chief executive officer (or executive director). programs at community colleges were an asset in The dental director takes on many roles: manager, highly recruiting qualified dental assistants. Such efforts focus skilled clinician, mentor and trainer, recruiter, office primarily on RDAs — registered dental assistants — rather planner, and cheerleader. While the dental directors do than the more highly trained registered dental assistants not seem to be directly engaged in fundraising, they are in expanded functions, or RDAEFs, who are authorized responsible for their budgets and act in a cost-efficient to take impressions, apply pit and fissure sealants, remove manner so as to maximize their available resources. excess cement from subgingival tooth surfaces, and apply etchant for bonding restorative materials.5 Although The support of the chief executive officer cannot be RADEFs can provide these routine treatments at a lower underestimated. With the myriad issues facing clinic cost, most of the clinics do not use them, making it CEOs, dental services often take a back seat. They are necessary for dentists to do such work. expensive services with high demand and high overhead. Dental care is new territory for some clinic executives, but with the recent push from the Bureau of Primary Health Care to ensure access to dental services, FQHCs Expanding Access to Dental Care Through California’s Community Health Centers  |  5 are taking greater initiative in providing them. The Dental Clinic Efficiency higher-volume clinics were those where the CEO had an Community health centers’ fixed overhead and personnel understanding of the need for dental services, grasped costs require that they keep patients flowing through the operational issues, and was in close contact with the their dental clinics. While some of the surveyed clinics dental director. When the CEO was not paying close had a dentist rotating through three operatories, which attention to the dental component, operations and is considered the most efficient model, most had two efficiencies seemed to slip, with a resulting drain on the operatories for each dentist, primarily because of space clinic’s operating budget. considerations. Due to the significant increase in efficiency when moving from two to three operatories, Dental directors often work in isolation, both within clinics should make such an expansion a key priority. the operation of the FQHC and from their professional peers. They often lack the opportunity to interact with Having the right patient mix and flow are key to a dental directors from other clinics or the time and successful clinic operation. Patient mix involves the resources to attend outside meetings. However, survey age of patients, their payment sources, and the types of results indicated that many of the problems that were services that are provided. Those clinics that were doing raised in one clinic had been solved in another, and that better financially saw many more children than adults, techniques that worked in one clinic could be shared with and more Denti-Cal patients than private-pay patients. others. Unfortunately, a statewide venue in which dental The financially successful clinics also had a balance of directors could discuss clinical, financial, recruitment, and preventive, restorative, and surgical procedures that administrative issues does not as yet exist. optimized revenue and clinician time. Quality of Care Clinic directors were concerned, however, that in focusing One issue raised by several dental directors was the lack on the more profitable exams and preventive services, they of a consensus on the definition of quality in community were not actually completing treatment plans or providing clinic settings. FQHCs are rated on the number of visits, necessary restorative services. Also, by concentrating on both in total and per practitioner, rather than the type patients with preferred revenue sources, e.g., Denti-Cal, of care provided or the clinical outcomes. Based on this some clinics were not always able to serve their broader metric, the incentive is to perform more exams and patient population, which includes the uninsured. As a preventive services while minimizing restorative services. condition of their federal status, FQHCs are required to While a treatment plan should be included in a patient’s serve the uninsured. Often, due to the lack of preventive chart, there is no standard mechanism for reviewing and regular care, patients with no insurance have a higher whether the course of treatment is completed. Also, it is need for complex and costly procedures. While children difficult to measure outcomes in dentistry, because unlike require substantial preventive and some restorative medical care, there is no dental diagnosis noted on a services, it is the adult population — with its greater patient’s chart. proportion of uninsured — that generally accounts for the most expensive treatments. As one clinic director said, The dental directors suggested that one of the purposes of “Twenty percent of the patients incur much more than convening clinic dental professionals would be to establish 20 percent of the costs.” a consensus view on quality standards and develop measures that FQHC’s could implement. Patient scheduling and flow has long been a source of concern for clinics. No-show rates for dental 6  |  California HealthCare Foundation appointments are often 20 to 40 percent of scheduled These approaches are already in use to some degree patients. Each clinic interviewed for the survey had across California and their expansion to all dental developed strategies to keep the clinic full. Most double- clinics would help offset some costs of operation. One or even triple-booked their patients. The majority also well-established group-purchasing program is organized placed reminder calls to patients at various intervals, as by the San Diego Council of Community Clinics well as keeping a waiting list. Some tried patient contracts (www.councilconnections.com). Several clinics suggested to ensure compliance with a treatment plan, but this met the creation of a “340b drug pricing program” for with limited success. The most successful strategy proved purchasing equipment and supplies at highly reduced to be allowing walk-ins to fill the holes left by no-shows. costs, using the model of the drug pricing programs FQHCs already use to purchase drugs at the lowest To maintain good patient flow in clinics with multiple established rate paid by the federal government. dentists, the dental directors have also worked on managing dentists’ schedules. Rather than scheduling Payer Mix, Reimbursement, and individual patients for dentists, they schedule operatories, Uncompensated Care and the dentist treats whichever patient is ready to be Below is a list of policy issues related to payer mix and seen. A similar strategy is for all the dentists to take a reimbursement produced by the interviews. Some may team approach, continually treating patients as they are be resolved through clarification for community health ready, sometimes dividing assignments according to their center executive directors and dental directors, while particular skills and expertise. others would require a major shift in policy by public and private institutions. Recommendations K Clinics’ efforts to expand services by using off-site providers are hampered by confusing Startup and Operating Costs rules and regulations. For example, it is not clear To meet the needs of their patient population and fulfill if school-based services (e.g., sealant programs) their public mission, FQHCs need to expand their dental or services provided at private dental clinics on capacity. Grants and low-interest loans for capital and behalf of the FQHC (e.g., dental specialists) are equipment costs were of primary interest to clinics. While reimbursable. There is also confusion concerning the federal government has recently made additional the ability to bill for dental hygienists as a separate funds available for clinic expansion, these grants are FQHC-reimbursable visit. Although SB 238 competitive in nature and insufficient to meet the patient was enacted in 2007 (Chapter 638) to allow for needs nationally. Given the high cost of building and independent billing of hygienist services, it has not equipping a dental clinic, only a small part of the need yet been implemented. The state and the clinics are can be met. Expanded public and philanthropic programs working on a mechanism for recalculating clinics’ would enhance the ability of clinics to expand. PPS rates for those health centers that use hygienists. To reduce the cost of disposable supplies, community K Payments for oral surgery also are a source of health centers recommended that dental clinics adopt confusion. Some clinics reported that the costs for bulk or joint ordering and use their non-profit status to oral surgery and anesthesia were not reimbursable. obtain discounts and donations from their suppliers. For hospital-based cases, Denti-Cal only covers the dentist’s charges, while reimbursement for other Expanding Access to Dental Care Through California’s Community Health Centers  |  7 services (e.g., operating room and anesthesia) must be K Allow state institutions (e.g., prisons) to hire dentists sought from the medical side of Medi-Cal. with licenses in other states so that they can recruit from a larger national pool and alleviate hiring K Although FQHCs are not reimbursed on a fee-for- competition with California clinics. service basis, they still must show that they provided a covered service for an eligible patient and met the K Create more opportunities for student externships necessary billing requirements. Clinics complained in clinics through the provision of funds to support that adjudication of their Medi-Cal claims was not training and hosting. always clear or consistent. They felt that claim denials K Amend the California Dental Practice Act to allow or deferrals should be explained by citing specific FQHCs to operate as a federal facility, similar to reasons and include any corrective action that clinics Indian Health Service clinics, which would permit could take. expanded-function dental assistants to take on tasks that must now be performed solely by dentists. Community health centers interviewed for this survey also suggested that the reimbursement system be changed K Provide training for dental directors in administrative so that billing for outside services, such as laboratory and financial skills necessary to operate a successful work (e.g., for dentures and crowns), can be separated clinic. from PPS encounter billing. This would allow a clinic to K Create mentoring and continuing education cover the cost of complex cases requiring outside vendors. programs for dental assistants and front-desk staff FQHCs can apply for a change in their baseline PPS rate geared specifically toward public clinics, rather than under Section 14132.100 of the Welfare and Institutions private-practice staff. Code if there has been a change in their scope of services. Leadership and Management Staff Recruitment, Retention, and Training In the area of professional staffing, clinics underlined the Peer Networking, Technical Assistance need to create incentives for dentists (particularly new To improve overall management and efficiency of their dentists) to practice in community settings. Suggestions clinics, dental directors suggested establishing a regular included: venue for discussing issues with other dental directors. K Expand loan repayment programs for new dentists The California Primary Care Association (CPCA) is also who choose to practice in clinics. interested in regular meetings with community health centers’ dental directors, possibly through a joint effort K Increase the availability of general practice residencies between the regional community clinic consortia and in community clinics. the statewide association. Several regional consortia have K Train more community oriented, bi-lingual dentists periodic meetings of dental directors. The CPCA has a to work in clinics. medical clinicians network that meets quarterly to discuss strategic and policy issues and could be a model for a K Remove the state board requirement for dentists dental directors’ network. Another potential partner is who have successfully completed a general practice the Oral Health Access Council, which already has joint residency. This would provide additional incentives to meetings with the CPCA and is attended by a range of enter a residency program. people interested in oral health and policy issues. 8  |  California HealthCare Foundation Some participants in the survey recommended that a K The Arizona Association of Community Health network of technical assistance providers work directly Care (www.aachc.org), the state’s primary care with the clinics to improve operational efficiency, and association, convenes its dental directors on a that the network include providers who are independent semi-annual basis. These one-day meetings are of FQHCs’ funding sources. This approach would hosted by various agencies throughout the state and avoid any potential conflicts of interest and encourage are attended by a majority of the state’s 14 FQHCs. open communication and the willingness to identify Agendas include clinical, administrative, and policy inefficiencies. issues. AACHC also hosts an annual Region IX management training conference, which combines Models for this type of technical assistance include: the disciplines of health care administration, clinical services, and financial operations. K The Dental Pipeline project, a collaborative of California and U.S. dental schools to reduce oral Interviewees suggested meetings with dental directors health disparities by preparing students to work in that would combine the administrative discussions with community settings. As part of its partnerships with clinical education and provide continuing education community clinics, the Dental Pipeline will provide credits. Quarterly or even semi-annual meetings, technical assistance to program clinics on practice perhaps alternating between in-person meetings, video management. conferences, and Web-based seminars, would provide K The Catalyst Institute (www.catalystinstitute.org), the opportunity for dental directors to learn from each a non-profit Massachusetts-based offshoot of other, as well as from other outside experts. Given the Delta Dental, that provides practice management similar types of issues faced by each of the clinics, which technical assistance to safety-net clinics. Their serve similar populations, peer-to-peer networking has Safety Net Solutions program assesses a wide range the ability to develop solutions from within the clinics of operational elements, including financial and and implement them throughout California. Survey productivity data, revenue and expenses, services, participants also recommended that meetings among payer mix, program leadership, billing, operations, dentists be coordinated with the clinics’ CEOs and CFOs policies, equipment, workflow, and culture.  so these executives can share their perspectives on dental services. Funding for travel expenses and time away from K The Dental Clinic Manual work would encourage more participation in clinician (www.dentalclinicmanual.com) was developed as meetings. a collaboration between the Ohio Department of Health, the Indian Health Service, and the FQHCs and Dental Clinic Licensure Association of State and Territorial Dental Directors. The amount of red tape involved in licensing dental This comprehensive manual highlights all aspects of clinics was identified as a barrier to expanding services. dental clinic development as well as daily operations. FQHCs cited unclear and inconsistent regulations It is designed to assist beginners and includes a from multiple agencies at the state and local level, as series of steps for starting a dental clinic, along with well as their frustration in obtaining operating licenses information for those interested in improving an in a timely manner. The clinics recommended that existing dental facility or services. efforts be made to standardize and streamline licensing processes. Alternatively, clinics supported the possibility of Expanding Access to Dental Care Through California’s Community Health Centers  |  9 developing manuals and checklists that would help them Endnotes navigate the maze of clinic licensure. 1.California HealthCare Foundation, Denti-Cal Facts and Figures, May 2007. Summary 2.Ibid. Field interviews show that California’s federally qualified health centers are very interested in expanding their 3.Safety Net Dental Clinic Manual, Chapter 2 Facilities dental clinics. However, clinic directors are cautious and Staffing, www.dentalclinicmanual.com, accessed about doing so until they have sufficient start up funds, April 14, 2008. can reasonably expect to attract high quality professional 4.According to the American Dental Association the average staff, and are able to sustain their operations over the independent general practitioner’s net income from long term with a patient mix that allows for adequate primary private practice in 2002 was about $175,000 reimbursements. ($175,000/year 4 2,080 working hours/year 5 $84.13/hour) . 5.California Code Of Regulations, Title 16. Professional and Some of the barriers to expansion can be overcome with Vocational Regulations, Division 10. Dental Board of more funding for capital and start-up costs. Staffing California. Dental Practice Act, Chapter 3, Article 5. issues can be overcome through increased training of community dentists and opportunities for fellowships and loan repayment. Other barriers can be addressed through a more formalized network of technical assistance providers and a peer network of clinic dental and executive directors to share best practices and successful strategies for tackling operational and efficiency issues. Authors Diringer and Associates: Joel Diringer, J.D., M.P.H., founder and principal Kathy Phipps, Dr.P.H., R.D.H., director of research About the F o u n d at i o n The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information on CHCF, visit us online at www.chcf.org. 10  |  California HealthCare Foundation