IV. CALCULATING POPULATION TO PROVIDER RATIOS Dental

IV. CALCULATING POPULATION TO PROVIDER RATIOS Dental

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IV. CALCULATING POPULATION TO PROVIDER RATIOS Dental

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1. IV. CALCULATING POPULATION TO PROVIDER RATIOS Dental -------------------------------------------------- IV-1

2. CALCULATING POPULATION TO PROVIDER RATIOS (DENTAL) -------------------------------------------------- Objective: Participants will understand how to: 1) Identify all dental providers, 2) Calculate Full-Time-Equivalency (FTE) rates, and 3) Determine the population to provider ratios for dental geographic and population designations IV-2

3. Population to Provider Ratios Needed for Designation (DENTAL) -------------------------------------------------- Geographic Area:> 5,000:1 A rational service area - sub-county (MSSA) Geographic Area w/Unusually High Needs:> 4,000:1 A rational service area plus: a) More than 20% of the population has incomes at or below 100% of the Federal poverty level; or b) More than 50% of the population has no fluoridated water; or c) Meets insufficient capacity criteria Population Groups:> 4,000:1 A rational service area plus meets the requirements of the specific designation category (e.g. low-income, homeless, etc.) Contiguous Areas are overutilized if: > 3,000:1 IV-3

4. POPULATION SIDE OF THE RATIO (Same as Primary Health Care) -------------------------------------------------- : ________________ IV-4

5. PROVIDER SIDE OF THE RATIO -------------------------------------------------- : ____ IV-5

6. STEPS -------------------------------------------------- • 1) Identify all general practice dentists in the area tobe designated. • 2) Determine the number of hours each dentist works in direct patient care office serving the population to be designated. • 3) Calculate the FTE for each dentist serving the population to be designated. • 4) Calculate the population to provider ratio. IV-6

7. STEP 1 -------------------------------------------------- Identify all general practice dentists in the area to be designated. IV-7

8. -------------------------------------------------- List all dentists (D.D.S. or D.M.D.) who: 1) Provide direct patient care in the service area, and 2) Practice principally in general dentistry or pedodontics (pediatric dentistry) • Include in your list: • Dentists who serve in the NHSC Scholarship or Federal Loan Repayment • Programs (exclude their FTEs) • Dentists who serve in the State Loan Repayment Program • Dentists who are Federal providers (e.g., Commissioned Officers at Indian Health Services or Bureau of Prisons) • Dentists who are planning on retiring but are still seeing patients • Dentists engaged solely in administration, research, or teaching • Locum tenens serving less than 1 year Do not include: • Oral surgeons, orthodontists, or other specialists IV-8

9. Sources of Provider Data • State Licensure Lists:http://www2.dca.ca.gov/pls/wllpub/wllquery\$.startup • National, State, and Local Dental Association Directories • Local Telephone Directory/Yellow Pages • Commercially Developed Listings -------------------------------------------------- IV-9

10. STEP 2 -------------------------------------------------- Determine each dentist’s age, number of auxiliaries1, and number of hours serving the population to be designated. 1 Auxiliaries are non-dentists assisting in dental care such as dental assistants, hygienists, etc. They do not include receptionists and other support staff. IV-10

11. Designation Types and Whom to Include in the Provider Count -------------------------------------------------- DESIGNATION TYPE: IV-11

12. -------------------------------------------------- For each dentist, include the number of hours of direct patient care provided in the service area: Include: All dentists who provide direct patient care in the service area, including those who: • Serve in the State Loan Repayment Program • Serve at Indian Health Clinics and are not Federal providers • Plan on retiring but are still seeing patients Include in the Survey but list their FTE at 0: • Dentists under contract with the NHSC Federal Scholarship or Loan Repayment Programs (this does not apply to dentists in the State Loan Repayment Program). • Other Federal providers (e.g., Commissioned Officers at Indian Health • Services or Bureau of Prison sites, etc.) • Dentists engaged solely in administration, research, or teaching • Locum tenens serving less than 1 year IV-12

13. Providers -------------------------------------------------- Total Dentists: 5 IV-13

14. STEP 3 -------------------------------------------------- • Calculate the FTE for each dentist serving the population to be designated. IV-14

15. Equivalency Weights by Number of Auxiliaries and Age -------------------------------------------------- Auxiliaries are non-dentists assisting in dental care such as dental assistants, hygienists, etc. Auxiliaries<5555-5960-6465+ 0 0.8 0.7 0.6 0.5 1 1.0 0.9 0.8 0.7 2 1.2 1.0 1.0 0.8 3 1.4 1.2 1.0 1.0 > 4 1.5 1.5 1.3 1.2 If an auxiliary is less than full-time, round to nearest whole number (0.4 = 0, 0.5 = 1). If more than one auxiliary works less than full time, add total hours, divide by 40, and round if not a whole number [(16 +20 + 32/40) = 1.7 = 2]. • If number of auxiliaries is not available, use these weights: • <55 = 1.2 • 55 - 59 = 0.9 • 60 - 64 = 0.8 • > 65 = 0.6 If dentist’s age and the number of auxiliaries are not available: Use weight of 1.2 IV-15

16. FTE Calculation -------------------------------------------------- 40 hours = 1.0 FTE (There are no provisions to reduce the FTE of a dentist in residency.) Every 4 hours (½ day) is counted as 0.1 FTE Adjust FTE based on actual hours, age, and auxiliaries A dentist’s FTE can exceed 1.0 due to auxiliaries Only the Total (or Low-Income) FTE is rounded to the nearest tenth of a percent: • Examples: 0.875= 0.9 0.817= 0.8 • 0.83 = 0.8 0.85 = 0.9 Note: The FTE for low-income population designations is based on the average number of hours per week spent with Medicaid and SFS patients. It is notbased on whether the provider is accepting new Medicaid patients. IV-16

17. FTEs - Geographic Designation -------------------------------------------------- Total Dentists: 5 Total FTEs: 4.05 = 4.1 1 – Dr. Wisdom works 25 hours/week in another location 2 – Dr. Canine spends 2 hours/week in administrative activities 3 – Dr. Crown chooses to work 25 hours/week 4 – Dr. Buck spends 15 hours/week in childcare activities IV-17

18. FTEs - Low-Income Designation -------------------------------------------------- Total Low-Inc FTEs: 1.7565 = 1.8 *As of March 2011 due to State budget cuts, Denti-Cal is primarily for Children (most adult Denti-Cal has ceased) IV-18

19. Survey Dentists to Determine Their FTE -------------------------------------------------- • Survey all dentists in service area • Minimum two-thirds response rate required Calculation of Non-Responders • Use survey average • Ex: Galt, California - 6 providers • 4 - respond to survey • 2 - no response after repeated telephone calls • Response rate: 4/6 = 66.6% • Total FTE for the 4 responders= 3.5 • Divide FTE of responders (3.5) by the number of responders (4) for the average FTE of responders (.87) • Multiply number of non-responders (2) by the average FTE of responders (.87) for FTE of non-responders (1.75) • 3) Add FTE of responders (3.5) and non-responders (1.75) for total FTE = 5.3 IV-19

20. STEP 4 -------------------------------------------------- Calculate the population to provider ratio. IV-20

21. Population to Provider Ratios -------------------------------------------------- Civilian Population Ratio: Civilian Population = 20,900 Dentist FTE = 4.1 (20,900/4.1 = 5,098:1) Civilian Population (High Needs) Ratio: Civilian Population = 20,900 Dentist FTE = 5.2 (20,900/5.2 = 4,019:1) (100% Federal poverty level at 18.9%) Low-Income Population (200% Poverty): Low-Income Population = 10,137 (49.47%) FTE of Dentists Serving that Population = 1.8 (10,137/1.8 = 5,632:1) IV-21

22. What to Include in the Population to Provider Ratio Dental Section of Your Application -------------------------------------------------- • Population • Cover letter with summary findings • Total adjusted population • Source of data List of Dentists • Include the Following for Each Dentist: • Name • Age • Location: Non-metro areas - name of town Metro areas – complete address with zip code, and CT if available • Specialty (general dentistry and pedodontics) • Number of auxiliaries • Equivalent weights • Number of hours/week of patient care in area • Percentage of practice Medicaid (for low-income and Medicaid-eligible designations) • Percentage of practice Sliding Fee Scale (for low-income designations) • FTE total for each provider rounded to the nearest tenth of a percent • Description of how information was obtained (sources, methods of gathering data) • Totals and Ratio • Total number of providers • Total FTE • Population to provider ratio • Explanation of any high need indicators IV-22

23. What Not to Include in Your Application -------------------------------------------------- • Information on the weather or climate • Information on road conditions, construction, or number of avalanches • Personal statements of driving time • Average number of funerals • History of the early settlers of the area • Newspaper articles • Pictures of the mayor • General information on access issues that is not specific to the area or population • Copies of old applications IV-23

24. Contiguous Area Resources -------------------------------------------------- IV-24

25. Contiguous Area Resources -------------------------------------------------- Objective: Participants will understand how to identify contiguous areas, determine if they have resources, and if the resources are excessively distant, overutilized, or inaccessible to the population of the area proposed for designation. Purpose of Contiguous Area Analysis: To identify nearby sources of care and determine if they are inaccessible to the population in the proposed service area IV-25

26. STEPS -------------------------------------------------- 1) Identify the boundaries of eachcontiguous area 2) Evaluate each area to determine availability of resources IV-26

27. Identify the Boundaries of Each Contiguous Area -------------------------------------------------- • Identify on a map the boundaries and population center of theproposed service area. • Determine the contiguous areas in all directions within 40 minutes from the proposed area’s population center. • Map the boundaries of each contiguous area in all directions (North, East, South, & West). Boundaries The boundaries of each contiguous area may be based on: • Travel time (40 minutes) • Socio-economic/demographic characteristics • Established neighborhoods • Physical barriers • Designated HPSA • The boundaries of contiguous areas are often (not always) based on the same census delineation as the proposed area: • Proposed service area = whole county • Contiguous areas = whole counties • Proposed service area = census tracts (MSSA) • Contiguous areas = census tracts (MSSA) IV-27

28. Determine Availability of Resources -------------------------------------------------- A. Check the HPSA list to determine if any of the contiguous areas are designated as HPSA and therefore considered inaccessible. If it is not inaccessible HPSA, then B. Determine if there are significant socio-economic/demographic disparities or physical barriers. If there are not significant socio-economic/demographic disparities or physical barriers, then C. Determine if the contiguous area’s providers are located > 40 minutes away from the population center of the proposed area and are therefore inaccessibledue to excessive distance. (30% or more disparity between the service area and the contiguous area) If they are not excessively distant, then D. Determine if the resources in the contiguous area exceed the population-to-provider ratio and are therefore overutilized. If they are not overutilized, this area cannot be designated. (Consider a different kind of designation.) IV-28

29. Check the HPSA Status of Each Contiguous Area and Determine if This Type of HPSA Is Inaccessible to the Proposed Area -------------------------------------------------- If the proposed service Then the contiguous area area is: is inaccessible if it is a: IV-29

30. Determine if Providers Are Excessively Distant -------------------------------------------------- 1) Develop a list of providers in the contiguous area 2) Map their office locations 3) Determine the travel time from the proposed area’s population center to the contiguous area Providers > 40 minutes from the population center are excessively distant Dental : > 40 minutes Interstate Roads - 30 miles X 1.33 = 40 minutes Primary Roads - 25 miles X 1.6 = 40 minutes Secondary Roads - 20 miles X 2.0 = 40 minutes IV-30

31. Determine if Providers Are Excessively Distant (continued) -------------------------------------------------- Inner Portions of Metropolitan Areas: Distance is based on time using public transportation* during non- rush hour. Bus routes and schedules must be described (provide narrative Description and include bus schedule if possible). *Public Transportation can be used only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate. IV-31

32. Determine if Contiguous Areas Are Overutilized -------------------------------------------------- • Calculate FTE - use same method as used for the proposed service area. • If needed, survey providers and determine FTE serving the population. Use same surveying method as used for the proposed service area. • Explain how the information was obtained and calculated, and include population, total FTE, and population to provider ratio. • Population to Provider Ratios: • DENTAL:> 3,000:1 dentist IV-32

33. Example -------------------------------------------------- ASAPS Maps IV-33

34. The proposed area is MSSA 61- Arvin-Lamont in Kern county. The black polygon represents the 40 minute travel time. IV-34

35. Sub-County -------------------------------------------------- A) Determine the contiguous areas in all directions within 40 minutes from the proposed area’s population center, for MSSA 61 Geographic Designation: Area 1 MSSA 66a - Bakersfield Northeast Area 2 MSSA 66b - Bakersfield East Area 3 MSSA 57.2 - Taft Area 4 MSSA 62 - Tehachapi Area 5 MSSA 66c - Bakersfield Downtown Area 6 MSSA 66d - Bakersfield Northwest IV-35

36. Sub-County -------------------------------------------------- B) Examine the contiguous areas using the factors previously mentioned to determine if they can be ruled out: Area 1 MSSA 66a - Bakersfield Northeast Area HPSA, ruled out Area 2 MSSA 66b - Bakersfield East Pop. HPSA, ruled out (proposed area Geo. with High needs) Area 3 MSSA 57.2 - Taft Pop. HPSA, ruled out (proposed area Geo. with High needs) Area 4 MSSA 62 - Tehachapi Pop. HPSA, ruled out (proposed area Geo. with High needs) Area 5 MSSA 66c - Bakersfield Downtown Significant socio-economic difference, 200% at 32.39 % for CA, 72.52% for proposed area Area 6 MSSA 66d - Bakersfield Northwest Significant socio-economic difference, 200% at 15.93 % for CA, 72.52% for proposed area IV-36

37. The proposed area is MSSA 189.2- Redding in Shasta county. When applying for the low-income designation the black polygon represents the 7 mile (40 minutes for public transportation) travel time. The green polygon is the 40 minute travel time if public transportation is not used. IV-37

38. Sub-County -------------------------------------------------- A) Determine the contiguous areas in all directions within 40 minutes from the proposed area’s population center: Area 1 MSSA 189.3 - City of Shasta Lake Area 2 MSSA 189.1 - Palo Cedro Area 3 MSSA 188.1 - Big Bend/Round Mountain IV-38

39. Sub-County -------------------------------------------------- B) Examine the contiguous areas using the factors previously mentioned to determine if they can be ruled out: Area 1 MSSA 189.3 - City of Shasta Lake Low-income HPSA, ruled out Area 2 MSSA 189.1 - Palo Cedro Low-income HPSA, ruled out Area 3 MSSA 188.1 - Big Bend/Round Mountain Area HPSA, ruled out IV-39

40. Examples -------------------------------------------------- Survey IV-40

41. IV-41

42. Determine the Nearest Source ofNon-Designated Care -------------------------------------------------- Needed for HPSA score: • Cannot be a HPSA (of any type) • Cannot have significant socio-economic/demographic differences or physical barriers • Can be excessively distant • Can be overutilized For all applications: • Provide a road map with the proposed service area and contiguous areas outlined. • On the map, indicate the population center of the proposed service area, the nearest source of care, and the route between these points. • Provide the name and address of the nearest source of care, route, miles, and minutes. For inner portions of metropolitan areas, include: • Bus route information from the population center of the proposed area to the nearest source of care, and • Miles and minutes of travel time IV-42

43. Time Saving TipsSurvey providers only if necessary: -------------------------------------------------- • In contiguous areas, calculate the population to provider ratio counting each provider as 1.2 FTE. If area meets ratio of > 3,000:1, do not survey. • Collect all possible information in one survey (e.g. Medicaid and sliding fee scale even for an area designation). • Work with State licensing department to obtain information on providers. • Use claims data for Medicaid FTE (works only in fee-for-service Medicaid). IV-43

44. What to Include in the Contiguous Area Resources Section of Your Application -------------------------------------------------- Map with Census Delineations • Name and boundaries of proposed service area • Name and boundaries of contiguous areas • Population center for the proposed service Knowledge of designation status of each of the contiguous areas is helpful. Road Map • Outline of proposed area boundaries • Location of nearest source of non-designated care • For automobile transportation - start, end, and route • For public transportation - start and end points of route IV-44

45. What to Include in the Contiguous Area Resources Section of Your Application (continued) -------------------------------------------------- For Contiguous Areas that are not Excluded with Current Designations and Whose Providers are Excessively Distant • Travel time to closest provider from population center of service area, including miles, route, and type of road; or public transportation information, including bus routes, start/end points, miles, minutes, and source; include bus schedule if available For Contiguous Areas that are not Excluded with Current Designations and have Access Barriers • Description of any significant socio-economic/demographic disparities (e.g.,demographic data on racial/ethnic composition or income levels comparingproposed service area population to population in the contiguous area, andsource of data), or • Description of any significant physical barrier For Contiguous Areas that are not Excluded with Current Designations and are Overutilized • Population to provider ratios, and • Description of how information was obtained IV-45

46. What to Include in the Contiguous Area Resources Section of Your Application (continued) For All Designation Requests: -------------------------------------------------- For Public Transportation Routes*: • Travel time, based on non-rush hour bus schedules • Start/End point of route • Include time waiting for transfers while in route • Map showing proposed area boundaries, start and end points of bus route • Bus schedules, if available • Cite source of information *Public Transportation can be used only in Inner City/Metro areas for Geographic designations, where the 100% poverty rate is ≥ 20%, or for Population designations regardless of the 100% poverty rate. • Address of nearest source of non-designated, accessible care, including address, miles and minutes via public transportation if metropolitan area • Location of nearest source on road map IV-46

47. Websites -------------------------------------------------- Bay Area Public Transit (San Francisco): http://tripplanner.transit.511.org/mtc/XSLT_TRIP_REQUEST2?language=en Southern California Public Transit (San Diego): http://www.sdcommute.com/ Los Angeles County Metropolitan Transportation Authority: http://www.metro.net/default.asp 2000 CT Locator: http://www.ffiec.gov/Geocode/default.aspx U.S. Census Bureau – American Factfinder: http://factfinder.census.gov/home/saff/main.html?_lang=en Google Maps: http://maps.google.com/maps IV-47

48. Process Model for Geographic Dental Health (Professional Shortage Area Designation) To Use: Follow arrows. Numbers are reference citations only. Refer to correspondingly numbered pages following for additional information on steps in numbered boxes Define Rational Service Area 1 Determine Service Area Population 2 Determine Dental FTEs 3 Calculate Population-to- Dentist Ratio Evaluate Contiguous Area Evaluate Service Area for High- Need Indicators Ratio > 5000 Ratio 4000-4999 5 4 6 1or more Contiguous Area Conditions Met for EACH Contiguous Area No Contiguous Area Conditions Met Ratio < 3999 No High Need Indicators Present 1 or more High- Need Indicators Present STOP: Area Not Qualified For Designation STOP: Area Not Qualified For Designation Evaluate Contiguous Area Evaluate for Insufficient Capacity APPLY FOR DESIGNATION 9 8 9 5 7 1 or less Insufficient Capacity Indicators Present 2 or more Insufficient Capacity Indicators Present 1 or more Contiguous Area Conditions Met for EACH Contiguous Area No Contiguous Area Conditions Met APPLY FOR DESIGNATION STOP: Area Not Qualified For Designation STOP: Area Not Qualified For Designation 8 IV-48 9 9