In this month’s letter, ADEA President and CEO Dr. Rick Valachovic shares lessons from a 2014 ADEA Dean’s Conference presentation on ways that innovative dental schools are devising financially strong and educationally sound clinical education programs.
As promised last month, this Charting Progress will look at emerging practices that are helping schools maximize clinic revenue, improve their overall financial pictures and enhance clinical education in the process. Once again, we have a speaker at the 2014 ADEA Dean’s Conference last November to thank for the information I am about to share. John Reinhardt, D.D.S., who recently stepped down from his deanship at the University of Nebraska Medical Center College of Dentistry to rejoin the dental school faculty, told us what he learned from the research he conducted during his experience as the 2014 ADEA William J. Gies Foundation Education Fellow.
Using his connections with other dental school deans in the Big Ten athletic conference, John collected and compiled the kind of data that dental schools use to measure the financial health of their clinical programs. Dental schools generally do not share this type of data with other dental schools. However, these Big Ten schools have a history of sharing data with one another while maintaining confidentiality, which, John says, gives each institution strong evidence on which to chart its own individual path to improvement. Why might other dental schools want to share data? In John’s view, “Unless schools know how their clinical programs compare to others financially, those schools don’t know whether or where to seek improvements.”
John was surprised by the remarkable differences among schools his survey revealed, and so were those of us who heard his presentation. His survey looked at both dental residents and D3 and D4 students and asked about the number of clinic hours assigned, the average annual and hourly revenue collected per student and the fees for 20 key procedures. Here is a sample of what he learned about the nine schools.
- Annual clinic hours for D3 and D4 students (combined) ranged from 1,500 hours to 2,700 hours, a difference of 80%.
- Average hourly collections for D3 students ranged from $9 to $23, even though overall the fees charged by all schools were similar.
- The highest fees charged for seven procedures commonly performed by dental students were more than double the fees at the schools that charged the least; for example, a complete removable maxillary denture ranged from $393 to $999.
- Annual revenues per dental resident ranged from $29,000 to $194,000 for advanced education programs in pediatric dentistry and from $53,000 to $290,000 for advanced education programs in oral and maxillofacial surgery.
While there may be good explanations for the magnitude of these differences, they seem extreme given how much the Big Ten dental schools—all large, research-focused public universities—have in common. As John put it, “There’s something happening here that we need to explore.”
Fortunately for us, John plans to continue his research. This year he will invite all of our dental schools to participate in a survey to collect revenue-related data on a broader scale. Given adequate participation, the results should provide compelling evidence about which practices are effective and should help dental schools make informed decisions about clinical education and clinic management.
In the meantime, John has already gathered information on five innovative dental schools that others can look to as they contemplate how best to shape clinical education in the future. You can learn more from looking at John’s slides, but here, in a nutshell, are some of the lessons John learned about maximizing dental clinic revenue.
MOSDOH has eliminated its reliance on an in-school dental clinic by establishing a novel public–private partnership with Grace Hill Health Centers, a federally qualified health center (FQHC). MOSDOH, which just opened its doors to students in 2013, assumed responsibility for constructing a new dental education and oral health clinic in an area of high dental need in St. Louis and will retain ownership of the building. Grace Hill will be responsible for maintenance, supplies and clinical operations, with the two partners sharing revenue and risk.
Students will complete their initial didactic education in Kirksville, MO before relocating in their junior years to pursue clinical education at the Grace Hill facility. Senior students will spend about six months in externships at other community health clinics. The MOSDOH model has many advantages, including shared financing, access to enhanced Medicaid reimbursements and additional financial support under the Public Health Service Act. The facility also gives MOSDOH access to clinical faculty and helps the school fulfill the university’s mission to serve the community.
ECU SDM has retained its use of a campus clinic, but like MOSDOH, ECU SDM has transferred a large portion of clinical education to the community. The school has built eight 16-chair Community Service Learning Centers in underserved areas across the state, where each senior dental student spends three rotations of two months duration. Each center has a local partner, such as an FQHC, public health department, hospital or community college. To reduce costs and simplify management, all eight buildings have the same floor plan and use axiUm software. In addition, because ECU is a public school, it received state support for the construction, equipping and maintenance of the new clinical facilities.
The model also offers several educational advantages. Students gain experience managing business operations at a small multi-dentist clinic, and ease of data collection through axiUm creates opportunities for community-based research. The ability to collect and compare data will also allow ECU SDM to examine financial performance, productivity and health outcomes across the eight sites to further refine the school’s clinical education model.
The University of Maryland modified its approach to clinical education without building independent facilities. In 1985, the dental school spun off its clinic operations as a tax-exempt professional corporation, or a 501(c)(3). Although named the University of Maryland Faculty Dental Service Plan, the nonprofit encompasses all of the school’s clinics whether staffed by students, faculty and/or residents. Separating clinic operations from the university allows for greater business flexibility, making it easier for managers to hire, adjust work assignments, revise job descriptions, modify work hours and reward outstanding employees. The corporate model also encourages fiscal responsibility and streamlines purchasing by bypassing state approval for some purchases and bidding processes. Departments are allowed to retain half of the net revenues they generate, creating an incentive for clinics to increase income.
VCU SOD also uses a 501(c)(3), VCU Dental Care, to manage its clinical operations and market its services to the public. VCU Dental Care was first formed in 1995 to oversee its faculty practice but has since evolved, incorporating residents in 2001 and dental and hygiene students in 2009. Like the University of Maryland, VCU Dental Care has more flexibility in handling business challenges. For example, the ability to hire outside state salary requirements and offer employee incentives makes VCU Dental Care a more competitive employer. The corporate system’s financial data reporting system also simplified VCU Dental Care’s ability to gather information needed to apply for federal Electronic Health Record incentive payments, which the clinics received. The corporation’s separate 501(c)(3) status has also allowed VCU Dental Care to earn money for its clinics by investing its reserve funds. Perhaps most impressive, VCU SOD has established a system of clinical performance incentives. Through its Variable Clinic Earnings incentive plan, VCU Dental Care contributed $2 million to faculty salaries in 2014.
Midwestern University’s Arizona campus has taken, to my knowledge, a unique approach to clinical education that appears to be enhancing learning, patient care and the clinic’s bottom line. The school pairs its D3 and D4 students to work together side by side for a year with one serving as dental care provider and the other as a chairside assistant. The students switch roles as the complexity of their work dictates. When the D4 student graduates, his or her D3 partner is paired with a new student, and the team continues to serve the same cohort of patients in the year ahead.
This arrangement has multiple advantages over more traditional clinics in which students often operate without dental assistants. Patients benefit from continuity of care and receive more efficient service. Patients feel more secure since treatment is overseen by three sets of eyes (those of the student provider, the student assistant and the faculty supervisor). Students benefit from constant peer review, collaborative learning and the steady presence of a dental assistant. And finally, the clinic can operate more efficiently because it requires fewer chairs, fewer faculty and (since more treatment can be provided per visit) fewer disposable supplies to educate its students.
In comparison to the Big Ten schools, Midwestern-Arizona does well financially. Its fees fall in the average range for the Big Ten, yet they collect $62,000 per D3-D4 student pair annually on average, far more than the comparable Big Ten average of roughly $40,000. This amounts to $10 more collected per hour at Midwestern—no small accomplishment.
Each of these models is tailored to the specific needs, circumstances and goals of five very different dental schools.
“It always comes back to this: Is clinical education a byproduct of patient care, or is patient care a byproduct of clinical education?” John noted during his presentation. “It has to be a little bit of both, but how you look at that issue is what really determines clinical models, how dental care is delivered, and how dentistry is taught.”
It’s exciting to realize there are so many creative strategies available to dental schools looking to enhance clinical revenue and make changes to their curricula in ways that will improve the long-term financial prospects and educational strength of their programs. The willingness of the Big Ten schools and these five innovators to share information about their programs gives other dental schools an excellent basis for evaluating the many approaches to improving clinical revenue. Although each school will pursue its own unique course, the dental education community benefits from the availability of information on how other schools have tackled common challenges, and we appreciate John’s efforts to collect and share it.
John’s 2015 ADEA survey will provide us with a much larger evidence base that we can use to pinpoint problems and identify best practices. This may be critical if we are to overcome the economic challenges discussed in last month’s Charting Progress.