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$: #190309 v1 - MAINE STUDY OF ALTERNATIVE DENTAL PROVIDERS (WORD) · PDF file · 2012-07-19Study of Alternative Dental Providers – Maine April 9, 2012 . 1920\01\190309(docx)-E2 i$
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Study of Alternative Dental Providers –Maine

April 9, 2012

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T A B L E O F C O N T E N T S

Page

I. Executive Summary ....................................................................... 1

II. Introduction .................................................................................. 3

III. Approach ....................................................................................... 6

IV. Results – The Economic Viability of Alternative Providers ........... 10

V. Conclusion ................................................................................... 12

Appendix A – Overview of Methodological Approach Appendix B – Practice Economics – Revenue Calculations Appendix C – Estimated Revenue for DHAT Appendix D – Estimated Revenue for DT Appendix E – Estimated Revenue for ADHP Appendix F – Reimbursement Appendix G – Reimbursement Rates Appendix H – Productivity Calculations Appendix I – Provider Scope of Practice Appendix J – Estimated Production – DHAT Appendix K – Estimated Production – DT Appendix L – Estimated Production – ADHP Appendix M – Salaries and Benefits Calculations Appendix N – Dentist Supervision Expense Calculations Appendix O – Depreciation Calculations Appendix P – Equipment List – Low-Range Operatory Option Appendix Q – Finance Expense Calculations Appendix R – Rent/Lease Calculations Appendix S – Other Operating Expenses Calculations Appendix T – Tuition Appendix U – Cost of Living Appendix V – Cost-of-Living Estimates by School Appendix W – Student Loan Calculations Appendix X – Salary Requirements and Tuition Subsidies

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I. Executive Summary

ECG Management Consultants, Inc., was engaged by the American Dental Association (ADA) to assist in assessing the economic viability of alternative mid-level provider models for the provision of dental care to the underserved in five selected states – Connecticut, Kansas, Maine, New Hampshire, and Washington. The three alternative mid-level providers were dental therapists (DTs), dental health aide therapists (DHATs), and advanced dental hygiene providers (ADHPs) based on existing models and those in proposed legislation. The assessment of these mid-level provider types included evaluating compensation levels, cost of training, operating expenses, estimated productivity, and potential revenue. The feasibility of each alternative provider was evaluated for three payor mix scenarios. See Table 1 below for the composition of each payor mix. Furthermore, the attractiveness of the career was evaluated through an analysis of educational debt levels relative to compensation levels.

Table 1 – Payor Mix Composition

Payor Mix Public Fee Schedule Sliding Fee Schedule Private Fee Schedule

A 75% 25% 0%

B 50% 25% 25%

C 50% 0% 50%

To prepare these analyses for Maine, ECG obtained data from the ADA, Maine Dental Association (MDA), tertiary dental educational programs, community dental health centers, and online sources. ECG also interviewed MDA leaders, dentists in public practice clinics and clinic administrators, and representatives from dentist and dental provider educational institutions familiar with tuition and program finances. As shown in Table 2 below, only under the most generous payor mix, Payor Mix C, is the DHAT model economically viable. Under all other payor mixes, none of the three models are economically viable. The ADHP model is less favorable than the DT and DHAT models, primarily due to significantly higher expenses (higher provider salaries). Of all the payor mixes (see Table 1), C generates the largest revenue due to its higher concentration of private dental beneficiaries. With the exception of the DHAT model with Payor Mix C, the practice is likely to operate at a loss. Integrating mid-level providers into an existing clinic would lower equipment, finance and rent expenses, but even under this scenario, the practice is still likely to operate at a loss under all three payor mixes (the only exception being the DHAT in Payor Mix C noted above).

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Table 2 – Practice Economics – Annual Income (in thousands of dollars)

DHAT DT ADHP

Payor Mix A B C A B C A B C

Total Revenue $136 $181 $239 $ 128 $174 $231 $ 124 $173 $231

Total Expenses 212 212 212 261 261 261 267 267 267

Net Income/(Loss) $ (76) $ (31) $ 27 $(133) $ (87) $ (30) $(143) $(94) $ (36)

Table 3 below indicates that the debt burden for all the provider models is much greater than the sustainable range of a 15 percent debt load.1 The DHAT provider model is closest to the 15 percent debt load range at 20 percent, which suggests that there could be sufficient interest in this occupation to attract applicants. In order for the DHAT, DT, and ADHP models to be sustainable, significant tuition subsidies or loan repayment programs would be necessary.

Table 3 – Mid-Level Provider Economics – Debt Burden

DHAT DT ADHP

Provider Salary $54,000 $93,000 $110,000

Educational Debt (annual, over 25 years) $11,000 $22,000 $28,000

Debt as a Percentage of Salary 20% 24% 25%

Based on an analysis for the state of Maine, with the exception of the DHAT model with Payor Mix C, none of the three alternative mid-level providers are economically viable. The inadequacy of current public reimbursement levels for dental providers is highlighted by the results of the practice economics. If serving patients at the public reimbursement level is not economically feasible for providers with salaries below 50 percent of those of a dentist, then one of the limitations of greater access to dental treatment is clearly that existing fee schedules in public settings do not cover the cost of treating these patients. In Maine, the DHAT salary is less than 50 percent of a public dentist’s salary, while the DT salary is 76 percent and the ADHP salary is 90 percent of a public dentist’s salary. The ADHP salary is 54 percent of a private dentist’s salary. The introduction of additional providers does nothing to address this issue. The educational debt burden for all the mid-level providers relative to projected salaries was found to be unsustainable. In order to attract candidates into these careers, tuition subsidies or loan repayment programs will be needed.

1 U.S. Department of Education, Federal Student Aid, Administrative Wage Garnishment. Available at:

www2.ed.gov/offices/OSFAP/DCS/awg.html.

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II. Introduction

Oral health is vital to the general health and well-being of all Americans. As stated in the 2011 Institute of Medicine report, “In recent decades, advances in oral health science broadened understanding not just of healthy teeth but of the health of the entire craniofacial-oral dental complex and its relation to overall health.”2 The nation’s overall oral health is improving (as shown by decreases in caries prevalence and edentulism, as well as increases in the delivery of preventive services such as sealants), and the U.S. population’s access to dental care is excellent. Most Americans today receive the oral health care services that they need and want. Near-term and long-term outlooks for the affordability and accessibility of dental care for the majority of Americans remain excellent, a situation due in no small part to dentistry’s outstanding record of prevention, efficiency, and cost-control.3 Amidst an abundance of dental services for the huge majority of Americans, pockets of our citizens do not access dental services commensurate with the overall population. For individuals with meager incomes, especially those who live in areas with few dental personnel, access is more difficult. For individuals who have disabilities and other special problems, access to care can be exceedingly difficult.2,3 There are many components to attempt to address the oral healthcare needs of the economically disadvantaged: charity care provided by private practice dentists, the dental safety net system, and Medicaid. Results of these efforts have shown some success. For example, national estimates from the Centers for Medicare and Medicaid Services (CMS)4 show that the percentage of children enrolled in Medicaid with a dental visit during the past year rose from 27 percent in 2000 to 40 percent in 2009. The national trends, however, mask significant variation in progress among states. In Maine, for example, in 2000 the utilization rate for Medicaid children4 was 35 percent compared to 52 percent for privately insured children5 in the U.S. – a 17 percentage point utilization gap. Between 2000 and 2009, the utilization rate for Medicaid children in Maine increased to 37 percent while the utilization rate among privately insured children in the U.S. increased to 57 percent – resulting in a widening of the utilization gap to 20 percentage points in 2009. Among adults, the utilization rate in 2010 was 68.7 percent in Maine compared to 69.7 percent in the U.S. as a whole.6

2 Institute of Medicine of the National Academies, “Advancing Oral Health in America,” The National

Academies Press, Washington, D.C., 2011. 3 L.J. Brown, Adequacy of Current and Future Dental Workforce: Theory and Analysis, Chicago, ADA,

Health Policy Resources Center; 2005. 4 CMS. Available at: www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-

Care/Quality-of-Care.html. 5 U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality, “Medical

Expenditure Panel Survey” (MEPS). Available at: http://meps.ahrq.gov/mepsweb/. 6 Centers for Disease Control and Prevention; Office of Surveillance, Epidemiology, and Laboratory

Services; Behavioral Risk Factor Surveillance System (RFSS). Available at: http://apps.nccd.cdc.gov/nohss/ListV.asp?qkey=5&DataSet=2.

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As part of their efforts to improve the oral health of the economically disadvantaged population, some states are considering the addition of a mid-level provider to the dental workforce. Efforts to add a mid-level provider are taking place during a time when several new dental schools have opened and the number of dental school graduates has dramatically increased. When assessing various policy options in the state of Maine, it is important to perform a cost-benefit analysis of any proposed solution. ECG was engaged by the ADA to conduct a study to explore the economics of three types of mid-level providers currently being considered in several states. This economic feasibility assessment consists of two elements:

● Whether the DHAT, DT, and ADHP are financially viable in practice conditions that enhance dental care access to the underserved.

● Estimation of whether provider compensation can sustain the debt load associated with the cost of training programs.

This report summarizes the analysis for Maine. Table 4 below lists the general characteristics of the DHAT, DT, and ADHP as they have been introduced into legislation to provide increased access to dental care for the underserved, as well as locations where a similar model is currently deployed.

Table 4 – Comparison of Provider Models

Characteristic DHAT DT ADHP

Currently Active Alaska. Minnesota. No states.

Prerequisite High school. High school. Bachelor’s degree in dental hygiene.

Education/Training An 18- to 24-month community college/ technical school program and preceptorship. Modeled as a 24-month program.

A 48-month university-based program after high school.

A 24-month university-based master’s degree program that follows a 48-month university-based bachelor’s degree program in dental hygiene.

Practice Setting Predominantly public health setting.

Predominantly public health setting.

Predominantly public health setting.

Billing Practice Procedural-based billing (done by employing entity).

Procedural-based billing (done by employing entity).

Procedural-based billing. Can bill independently (may be done by employing entity).

Dental Supervision Dental supervision on site or remotely using teledentistry technology.

Dental supervision on site or remotely using teledentistry technology.

Not required.

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Characteristic DHAT DT ADHP

Expected Patient Population Served

Underserved children and adults (50% or more of the patients are on public insurance or are uninsured).



Table 5 broadly defines the scope of practice for each mid-level provider. Note that there are differences in scope within each procedure category for the various providers. The DHAT is the most limited in scope, and the ADHP has the broadest scope of practice of the three models examined.

Table 5 – Scope of Practice for Provider Models

Procedure Category DHAT DT ADHP

Diagnostic None None Moderate

Radiographs Extensive Limited Interpretation Extensive

Preventive Limited Extensive Extensive

Restorative Some Extensive Direct Restorations

Extensive Direct Restorations

Endodontics Limited Limited Limited

Periodontics None None Nonsurgical

Prosthodontics None Limited Limited

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III. Approach

Economic viability is determined by modeling expected revenues and expenses in the simplest practice model – one chair and a dental assistant (DA). This approach ensures the greatest flexibility to provide dental care in underserved settings and applicability of results, whether the setting is school-based, rural, mobile, or a larger dental and/or medical clinic. The detailed methodology is described in APPENDIX A. Revenue is based on the three key elements illustrated in the figure below and is detailed in APPENDICES B through E:

● Blended procedural-based reimbursement scenarios from 0 percent of private payor fee schedules to a maximum of 50 percent of the ADA Survey of Dental Fees. See Table 1 for the exact composition of each payor mix. The sliding fee is calculated as 30 percent of the private fee schedule. The public reimbursement source is the most recent MaineCare fee schedule. See APPENDICES F through G for more detail.

● Volumes derived from estimated time to perform procedures in a public health clinic setting and adjusted for productivity in the one operatory setting. See APPENDIX H for more detail.

● Procedure and patient mix based on an average public dental clinic and within each provider’s scope of practice. See APPENDICES I through L for more detail.

As a result of using procedures performed in a generic public health clinic, the results are not biased by available coverage and more accurately represent the care that would be provided to the underserved. To ensure that reimbursement is recorded for all work, when a procedure is within the scope of practice and not covered, the sliding fee schedule is applied.

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Figure – Derivation of Provider Revenues

% Public Payor% Private Payor (Medicaid)% Sliding Fee

Type of Procedures Performed

Public Clinic Patient/

Procedure Mix

Provider Scope of Practice

Productivity(Time to Complete

Procedures)

Payor Mix (Reimbursement Level)

Volumes Reimbursement

Revenues

Table 6 – Payor Mix Composition


A 75% 25% 0%

B 50% 25% 25%

C 50% 0% 50%

The following expenses are included in the income statement for the public dental practice:

● Provider Salary – The salary for each provider is derived from actual salaries paid to the Alaska DHAT and Minnesota DT, as well as a projected salary for the ADHP, and is adjust-ed for income differentials between those states and Maine. See APPENDIX M for more detail.

● Staff Salary – Based on the average salary of a DA in a Maine public dental clinic. Assumed that the staff assisting the mid-level provider is a DA. See APPENDIX M for more detail.

● Benefits – A 27.5 percent benefits rate is applied to all providers, except for dental supervision below. See APPENDIX M for more detail.

● Dentist Compensation – This is a salary estimate to meet the supervision requirement for the DHAT and DT only. It assumes 65 minutes a day for oversight. See APPENDIX N for more detail.

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● Depreciation (Computer and Equipment) – Depreciation based on the purchase of new, low-end operatory equipment to permit practicing independent of a larger clinic setting. In addi-tion to basic operatory equipment to practice, this requires sterilization, lab, X-ray, and other machinery. Equipment cost includes a laptop. These expenses are identical for all provid-ers, with the exception of intraoral cameras to be used for teledentistry and supervision ex-cluded from the ADHP costs. See APPENDICES O and P for more detail.

● Finance Expense – Financing of the previously described equipment at current market rates for 10 years. See APPENDIX Q for more detail.

● Rent/Lease – Rent costs are based on square footage required for the operatory and equipment. Other areas are omitted, as they are not required in a mobile setting or common to a larger facility, such as a school or clinic setting. See APPENDIX R for more detail.

● Operating Expenses – Operating expenses include dental supplies and maintenance costs, lab services, office supplies, and other miscellaneous expenses for cleaning and so forth and are based on average practice expenses from multiple public dental clinics normalized for provider FTEs and productivity. See APPENDIX S for more detail.

The economic sustainability of a career as a DHAT, DT, or ADHP is determined by the cost of training (APPENDIX T) and associated debt load relative to the expected earnings in the context of other alternatives. In addition to the salary derivation described above, the cost of training was calculated using unsubsidized tuition and the average cost of living (e.g., room, board, books, transportation, personal expenses) (APPENDICES U and V) for the respective program durations (see Table 4). To determine the annual debt expense of each provider, standard student loan terms and current interest rates were applied. See APPENDIX W for more detail. There are three key features of this approach:

1. Identifying the unsubsidized or actual program cost per student provides decision makers with the true cost of the training per provider.

2. Including post-high school training costs for all providers:

● Ensures an equal basis for comparison of educational costs.

● Permits assessment of the cost of increasing the supply of providers rather than poaching from existing dental workers that may pursue additional training.

3. Assuming that 100 percent of the educational costs are borrowed, this approach ensures that the analysis is not biased by the socioeconomic limitations of potential applicants. It represents the full cost of the education, unsubsidized by the financial means available to some candidates.

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Unsubsidized tuition is based on the actual training cost of the Alaska DHAT students for a class size of 30 – approximately $51,000 per year. It is expected that annual educational expenses for the other programs would be similar, as they require the same clinical equipment, facilities, and salary level for educators. Costs specific to the Alaska setting were excluded.

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IV. Results – The Economic Viability of Alternative Providers

Estimated revenue for each provider and for each payor mix is detailed in EXHIBIT I. As expected, Payor Mix C produces the highest revenue, due to a larger percentage (50 percent) of privately insured beneficiaries. Comparing across the providers, DT and ADHP revenues are similar. There is a maximum revenue variability across providers of approximately $12,000 within a given payor mix, with the DHAT generating the most revenue. This indicates that for the same expected productivity level, the DHAT is able to generate the most revenue due to a higher volume of shorter procedures. The practice variability has little effect on the expenses – the DHAT and DT only differ in their salaries. In addition to the salary differential, the ADHP has no costs associated with supervision requirements such as dentist compensation and teledentistry equipment. This results in $5,000 less in expenses. Salaries are the primary driver of the varying practice expense. The resulting margins show a net loss for each provider model in a public health practice setting, with the exception of the DHAT model with Payor Mix C. Even assuming that the equipment is paid off, thereby reducing annual costs by approximately $32,000, only the DHAT model with Payor Mix B and the DT model with Payor Mix C generate positive net income. This demonstrates that subsidies would be necessary to sustain most of these models. The magnitude of the practice loss for each margin is large and, with the exception of an increase in reimbursement, few realistic scenarios would change this considerably. However, two scenarios should be considered. The first scenario is to vary reimbursement. This model assumes that all mid-level providers are reimbursed, similar to a dentist, at 100 percent of the fee schedule for all procedures within their scope of practice. However, there is precedent for reimbursement to be a percentage of the dentists’ reimbursement, similar to how physician assistants (PAs) and advanced registered nurse practitioners (ARNPs) are currently reimbursed by some payors. For example, PAs are reimbursed at either 75 or 85 percent (depending on the service) of the Medicare Physician Fee Schedule, and ARNPs are reimbursed at 85 percent of the Medicare Physician Fee Schedule.7 Were this to be the case for dental care, the loss per practice would be far greater than modeled in this study. The second scenario is to vary equipment expenses. DTs, DHATs, and ADHPs are expected to practice in public health settings. These can either be freestanding or integrated clinics. Integrated into an existing clinic, the equipment expenses could be reduced by approximately half, as the mechanical, lab, and sterilization equipment could be shared. Furthermore, this would reduce rent/lease costs equivalent to the space required for this equipment. The impact on the operating expenses would be approximately $9,000, which would be insufficient to change the outcome of the analysis.

7 CMS, Medicare Claims Processing Manual.

EXHIBIT I

AMERICAN DENTAL ASSOCIATIONSTUDY OF ALTERNATIVE DENTAL PROVIDERS

INCOME STATEMENT – PRACTICEMaine

Payor Mix A B C A B C A B C

REVENUEClinic Revenue 1,2,3

136,000$ 181,000$ 239,000$ 128,000$ 174,000$ 231,000$ 124,000$ 173,000$ 231,000$ Total Revenue 136,000$ 181,000$ 239,000$ 128,000$ 174,000$ 231,000$ 124,000$ 173,000$ 231,000$

EXPENSES

Practitioner Salary & Benefits 4 69,000$ 69,000$ 69,000$ 118,000$ 118,000$ 118,000$ 141,000$ 141,000$ 141,000$ Staff Salaries & Benefits 4,5 45,000 45,000 45,000 45,000 45,000 45,000 45,000 45,000 45,000 Dentist Compensation 6 15,000 15,000 15,000 15,000 15,000 15,000 - - - Depreciation (Computer & Equipment) 7 16,000 16,000 16,000 16,000 16,000 16,000 15,000 15,000 15,000 Finance Expense 8 16,000 16,000 16,000 16,000 16,000 16,000 15,000 15,000 15,000 Rent/Lease 9 5,000$ 5,000$ 5,000$ 5,000$ 5,000$ 5,000$ 5,000$ 5,000$ 5,000$ Operating Expenses 10

46,000 46,000 46,000 46,000 46,000 46,000 46,000 46,000 46,000 Total Expenses 212,000$ 212,000$ 212,000$ 261,000$ 261,000$ 261,000$ 267,000$ 267,000$ 267,000$

NET INCOME/(LOSS) (76,000)$ (31,000)$ 27,000$ (133,000)$ (87,000)$ (30,000)$ (143,000)$ (94,000)$ (36,000)$

Expenses as a Percentage of Clinical Revenue 156% 117% 89% 204% 150% 113% 215% 154% 116%

NOTE: Totals have been rounded to the nearest thousand.

1

2

3

4

5

6

7

8

9

10

DHAT DT ADHP

Depreciation cost in Year 1. In accordance with IRS Publication 946, computer depreciation is based on a 5-year useful life, and office equipment and other nonspecified equipment depreciation is based on a 7-year useful life. Furthermore, the straight-line depreciation method is applied. Annual financing payment based on an interest rate of 7.5% for a 10-year term.Based on an average square foot estimate of 397 based on a mix of locations from Ms. Charmen Brummer, Patterson Dental. Includes space for sterilization, laboratory, gas storage, X-ray, and other areas.Operating expenses include dental supplies and maintenance costs, any contractual services, office supplies, and other miscellaneous expenses.

Payor Mix A: 75% Public Fee Schedule, 25% Sliding Fee Schedule, and 0% Private Fee Schedule.Payor Mix B: 50% Public Fee Schedule, 25% Sliding Fee Schedule, and 25% Private Fee Schedule.Payor Mix C: 50% Public Fee Schedule, 0% Sliding Fee Schedule, and 50% Private Fee Schedule.Salary and benefit estimates based on data from Alaska DHAT program, public dental clinic in Minnesota, and U.S. Bureau of Labor Statistics.Salary based on average annual compensation for a dental assistant. Source: U.S. Bureau of Labor Statistics. Benefits are applied at a rate of 27.5%This includes a salary for supervision. Salary based on dentist in public health setting.

1920\01\190312(xlsx)||PRACTICE

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As a first test of appeal, the alternative provider compensation has to be greater than that of existing providers with similar education levels. All pass this test.

Table 7 – Salary Comparison

Salary DA DH DHAT DT ADHP Dentist

Public $29,120 $55,120 $54,483 $92,733 $110,396 $122,720

Private $35,670 $67,660 $205,050

Based on debt levels, both the DT and the ADHP are less attractive career options than the DHAT. As shown in Table 3, the debt burden for the DHAT is 20 percent, for the DT is 24 percent, and for the ADHP is 25 percent, all of which exceed the 15 percent of salary threshold considered sustainable for educational loans.8 Now that the emerging Minnesota providers have established earning expectations, students are unlikely to choose DT or ADHP as careers unless salaries increase or their tuition cost is subsidized, as at the University of Minnesota. To achieve a 15 percent debt-to-salary ratio, the DHAT, DT, and ADHP will require the tuition subsidies shown in Table 8. This subsidy should be $17,000 per year for the DHAT, $23,000 per year for the DT, and $21,000 per year for the ADHP. The total supplemental tuition funding for the program’s duration is $34,000 for the 2-year DHAT, $92,000 for the 4-year DT, and up to $126,000 for the 6-year ADHP. See APPENDIX X for calculation details.

Table 8 – Tuition Subsidy Required to Maintain 15 Percent Debt-to-Salary Ratio

DHAT DT ADHP

Debt-to-Salary Ratio and Salary Required

Provider Salary $54,000 $ 93,000 $110,000

Annual Debt Expense (Actual) 11,000 22,000 28,000

Debt Percentage of Salary (Actual) 20% 24% 25%

Salary Required Each Year of Loan for 15% Ratio $73,000 $147,000 $187,000

Tuition Subsidy Required

Total Loan Amount $95,000 $166,000 $202,000

Average Annual Unsubsidized Tuition (Per Student) 51,000 51,000 41,000

Required Tuition to Meet Debt Ratio (Annual) 34,000 28,000 20,000

Tuition Subsidy (Annual Per Student) $17,000 $ 23,000 $ 21,000

Total Subsidy for Duration of Training (Per Student) $34,000 $ 92,000 $126,000

8 U.S. Department of Education, Federal Student Aid, Administrative Wage Garnishment. Available at:

www2.ed.gov/offices/OSFAP/DCS/awg.html.

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V. Conclusion

Financially, the only provider model that is independently sustainable is the DHAT, with a 50 percent private payor patient mix. Addressing the access issue will require more public subsidies for practices as a result of the following factors:

1. Dental care in Dental Health Professional Shortage Areas (DHPSAs) is impacted by the economics of remote locations and small populations. Bringing care into these areas is less efficient. Costs increase when practices must be small scale because the population cannot support the more productive large clinic-based multi-operatory and provider model.

2. Public procedural-based reimbursement and sliding fees are too low. Although mid-level providers are likely to require lower salaries than dentists, available reimbursement through Medicaid is insufficient. At a 75 percent minimum, Medicaid patient mix reimbursement does not cover salary and benefits for any of the mid-level provider types. Medicaid and sliding fee payments are insufficient to cover direct salaries, benefits, and operating ex-penses. These are covered only for the DHAT and assuming a 50 percent private payor patient mix (Payor Mix C) and no overhead for administrative salaries or lease.

Based on an analysis for the state of Maine, only the DHAT model with Payor Mix C is economically viable. The educational debt burden for all mid-level providers relative to projected salaries was found to be unsustainable at the projected salaries. The DHAT, DT, and ADHP would not be viable without considerable tuition subsidies. However, it is important to note that this analysis is based on the very lean expense structure of the Alaska DHAT program. Does the introduction of these providers increase access? The inadequacy of current public payor and indigent reimbursement levels for dental providers is highlighted by the results of the practice economics. If serving patients at the public reimbursement level is not economically feasible for providers with salaries below 50 percent of the dentists’, then one of the limitations of greater access to dental treatment is clearly that existing fee schedules do not cover the cost of treating these patients. The introduction of additional providers does nothing to address this issue.

APPENDIX A

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AMERICAN DENTAL ASSOCIATION STUDY OF ALTERNATIVE DENTAL PROVIDERS – MAINE

OVERVIEW OF METHODOLOGICAL APPROACH

The figure below presents a summary of our approach to deriving net income for each provider. The details of each sub-calculation, as well as assumptions, are provided in the subsections that follow. A guide to the appendices is provided in the table below.

Figure – Calculation of Net Income

Net Income = Revenue – Expenses = ∑FiQi – [Salaries and Benefits + Supervision + Depreciation

+ Finance Expense + Rent/Lease + Other Operat-ing Expenses]

Table – Location of Detailed Methodology

Appendix Description

B Practice Economics – Revenue Calculations

C Estimated Revenue for DHAT

D Estimated Revenue for DT

E Estimated Revenue for ADHP

F Reimbursement

G Reimbursement Rates

H Productivity Calculations

I Provider Scope of Practice

J Estimated Production – DHAT

K Estimated Production – DT

L Estimated Production – ADHP

M Salaries and Benefits Calculations

N Dentist Supervision Expense Calculations

O Depreciation Calculations

P Equipment List – Low-Range Operatory Option

Q Finance Expense Calculations

R Rent/Lease Calculations

S Other Operating Expenses Calculations

T Tuition

U Cost of Living

V Cost-of-Living Estimates by School

W Student Loan Calculations

X Salary Requirements and Tuition Subsidies

APPENDIX B

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PRACTICE ECONOMICS – REVENUE CALCULATIONS

Revenue is calculated for each provider based on his/her annual volume of procedures. Reim-bursement is on a procedural basis; thus, the reimbursement results from one of three payor mix scenarios. The table below demonstrates the calculation for an adult patient of the DHAT provider applying Payor Mix B. Each element in this calculation is detailed in the subsequent appendices. Total revenues for each provider are in APPENDICES C, D, and E.

Revenue Calculation Example

Calculation Public Fee Schedule1

Sliding Fee

Private Fee Schedule2

Weighted Average

CDT: D0210 A $44 $39 $130

Percentage Payor Option B: Adult

B 50% 25% 25%

Payment C = A × B $22 $10 $33 $65

Production D 80

Revenue Option B E = C × D $5,200

1 Source: MaineCare. 2 Source: American Dental Association, 2009 Survey of Dental Fees.

APPENDIX CPage 1 of 4

CDT

Code Pediatric Adult Total

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor Mix

C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C

D0120 - - - -$ -$ -$ -$ -$ -$ -$ -$ -$ D0140 - - - - - - - - - - - - D0145 - - - - - - - - - - - - D0150 - - - - - - - - - - - - D0210 35 80 115 1,465 2,160 2,914 3,390 5,120 6,940 4,855 7,280 9,854 D0220 143 311 454 1,137 1,780 2,431 2,496 3,973 5,443 3,633 5,753 7,874 D0230 55 106 161 359 572 784 692 1,102 1,511 1,051 1,674 2,294 D0272 92 84 176 1,318 1,916 2,576 1,229 1,859 2,520 2,546 3,774 5,096 D0274 78 146 224 1,521 2,301 3,120 2,847 4,307 5,840 4,368 6,608 8,960 D0277 - - - - - - - - - - - - D0350 - - - - - - - - - - - - D0460 - - - - - - - - - - - - D1110 6 327 333 214 266 345 12,017 16,105 21,255 12,231 16,371 21,600 D1120 408 - 408 10,924 13,678 17,748 - - - 10,924 13,678 17,748 D1230 - - - - - - - - - - - - D1204 - 3 3 - - - 33 53 72 33 53 72 D1206 119 - 119 1,383 2,068 2,797 - - - 1,383 2,068 2,797 D1310 - - - - - - - - - - - - D1330 - - - - - - - - - - - - D1351 223 62 285 3,512 5,408 7,359 930 1,473 2,015 4,442 6,880 9,374 D1510 - - - - - - - - - - - - D1515 - - - - - - - - - - - -

Procedures 1 Payor Mix – Child 2 Payor Mix – Adult 2 Total Revenue


ESTIMATED REVENUE FOR DHATMaine

1920\01\190313(xlsx)||APPENDIX C


CDT


Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor Mix

C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C




D1520 - - - - - - - - - - - - D1525 - - - - - - - - - - - - D1555 - - - - - - - - - - - - D2140 24 38 62 884 1,322 1,788 1,439 2,266 3,097 2,323 3,588 4,885 D2150 51 84 135 2,383 3,594 4,871 4,007 6,275 8,568 6,390 9,869 13,439 D2160 24 37 61 1,775 2,345 3,084 2,778 3,795 5,032 4,553 6,140 8,116 D2161 2 7 9 176 230 302 626 847 1,120 803 1,077 1,422 D2330 29 55 84 1,773 2,258 2,944 3,416 4,516 5,940 5,188 6,774 8,884 D2331 16 36 52 1,291 1,591 2,056 2,921 3,650 4,734 4,213 5,242 6,790 D2332 9 24 33 871 1,078 1,395 2,340 2,946 3,828 3,211 4,024 5,223 D2335 7 21 28 717 969 1,281 2,172 3,001 3,990 2,889 3,970 5,271 D2391 58 98 156 3,589 4,705 6,177 6,189 8,492 11,270 9,777 13,197 17,447 D2392 39 75 114 3,188 4,163 5,460 6,244 8,494 11,250 9,432 12,657 16,710 D2393 9 22 31 852 1,142 1,508 2,129 2,992 3,993 2,980 4,134 5,501 D2394 2 7 9 208 290 386 745 1,091 1,470 953 1,381 1,856 D2920 - - - - - - - - - - - - D2930 6 - 6 651 842 1,101 - - - 651 842 1,101 D2931 - 8 8 - - - 720 480 480 720 480 480 D2932 - - - - - - - - - - - - D2933 - - - - - - - - - - - - D2934 - - - - - - - - - - - - D2940 11 26 37 322 487 660 798 1,311 1,807 1,119 1,798 2,467



CDT


Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor Mix

C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C




D2970 - - - - - - - - - - - - D3110 - - - - - - - - - - - - D3120 - - - - - - - - - - - - D3220 13 1 14 649 1,026 1,404 51 84 115 700 1,110 1,519 D4341 - - - - - - - - - - - - D4342 - - - - - - - - - - - - D4355 - - - - - - - - - - - - D4381 - - - - - - - - - - - - D4910 - - - - - - - - - - - - D5520 - - - - - - - - - - - - D5640 - - - - - - - - - - - - D5730 - - - - - - - - - - - - D5731 - - - - - - - - - - - - D5850 - - - - - - - - - - - - D5851 - - - - - - - - - - - - D7111 2 3 5 97 119 153 149 191 249 246 309 402 D7140 133 286 419 10,364 11,628 14,630 22,866 27,513 35,321 33,230 39,141 49,951 D7270 - - - - - - - - - - - - D7288 - - - - - - - - - - - - D9110 1 25 26 34 49 66 853 1,291 1,750 887 1,340 1,816 D9210 - - - - - - - - - - - - D9211 - - - - - - - - - - - -



CDT


Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor Mix

C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C




D9212 - - - - - - - - - - - - D9215 - - - - - - - - - - - - D9230 - - - - - - - - - - - - D9630 - - - - - - - - - - - - D9910 - - - - - - - - - - - - D9911 - - - - - - - - - - - - D9940 - - - - - - - - - - - - D9941 - - - - - - - - - - - -

Total 1,595 1,972 3,567 51,656$ 67,988$ 89,338$ 84,074$ 113,225$ 149,609$ 135,731$ 181,212$ 238,947$

1

2

3

4

5

Procedure volume and time data obtained from public health clinics in various states and averaged. Volumes adjusted by 60% productivity when converting two operatories to one operatory. Data was also adjusted to reflect 1.00 FTE (1,920 hours of provider time).Public reimbursement is based on the Medicaid fee schedule. Private reimbursement is based on the ADA 2009 Survey of Dental Fees. Sliding fee is 30% of private reimbursement.Payor Mix A: 75% Public Fee Schedule, 25% Sliding Fee Schedule, and 0% Private Fee Schedule.Payor Mix B: 50% Public Fee Schedule, 25% Sliding Fee Schedule, and 25% Private Fee Schedule.Payor Mix C: 50% Public Fee Schedule, 0% Sliding Fee Schedule, and 50% Private Fee Schedule.


APPENDIX DPage 1 of 3

CDT


Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C

D0120 - - - -$ -$ -$ -$ -$ -$ -$ -$ -$ D0140 - - - - - - - - - - - - D0145 - - - - - - - - - - - - D0150 - - - - - - - - - - - - D0210 38 87 125 1,590 2,346 3,164 3,687 5,568 7,547 5,277 7,914 10,711 D0220 157 340 497 1,248 1,955 2,669 2,729 4,344 5,950 3,977 6,298 8,619 D0230 60 116 176 392 624 855 757 1,206 1,653 1,148 1,830 2,508 D0272 101 92 193 1,447 2,103 2,828 1,346 2,036 2,760 2,792 4,139 5,588 D0274 85 160 245 1,658 2,508 3,400 3,120 4,720 6,400 4,778 7,228 9,800 D0277 - - - - - - - - - - - - D0350 - - - - - - - - - - - - D0460 - - - - - - - - - - - - D1110 6 358 364 214 266 345 13,157 17,632 23,270 13,370 17,898 23,615 D1120 447 - 447 11,968 14,986 19,445 - - - 11,968 14,986 19,445 D1230 - - - - - - - - - - - - D1204 - 3 3 - - - 33 53 72 33 53 72 D1206 119 - 119 1,383 2,068 2,797 - - - 1,383 2,068 2,797 D1310 - - - - - - - - - - - - D1330 21 40 61 233 259 326 120 190 260 353 449 586 D1351 244 62 306 3,843 5,917 8,052 930 1,473 2,015 4,773 7,390 10,067 D1510 15 - 15 1,424 2,253 3,083 - - - 1,424 2,253 3,083 D1515 6 - 6 1,193 1,539 2,013 - - - 1,193 1,539 2,013 D1520 - - - - - - - - - - - - D1525 - - - - - - - - - - - - D1555 - - - - - - - - - - - - D2140 26 41 67 957 1,432 1,937 1,553 2,445 3,342 2,510 3,877 5,279 D2150 56 92 148 2,617 3,947 5,348 4,388 6,872 9,384 7,005 10,819 14,732 D2160 26 40 66 1,923 2,540 3,341 3,003 4,103 5,440 4,926 6,643 8,781 D2161 2 8 10 176 230 302 716 968 1,280 892 1,198 1,582



ESTIMATED REVENUE FOR DTMaine

1920\01\190313(xlsx)||APPENDIX D


CDT


Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C




D2330 31 60 91 1,895 2,414 3,147 3,726 4,926 6,480 5,621 7,340 9,627 D2331 18 39 57 1,453 1,790 2,313 3,165 3,955 5,129 4,617 5,745 7,442 D2332 10 26 36 968 1,198 1,550 2,535 3,192 4,147 3,503 4,390 5,697 D2335 8 24 32 819 1,107 1,464 2,482 3,430 4,560 3,301 4,537 6,024 D2391 64 108 172 3,960 5,192 6,816 6,820 9,358 12,420 10,780 14,550 19,236 D2392 43 82 125 3,515 4,590 6,020 6,827 9,287 12,300 10,342 13,877 18,320 D2393 10 25 35 947 1,269 1,675 2,419 3,400 4,538 3,365 4,669 6,213 D2394 2 8 10 208 290 386 851 1,247 1,680 1,059 1,537 2,066 D2920 - 2 2 - - - 60 95 130 60 95 130 D2930 7 - 7 760 982 1,285 - - - 760 982 1,285 D2931 - 9 9 - - - 810 540 540 810 540 540 D2932 - - - - - - - - - - - - D2933 - - - - - - - - - - - - D2934 - - - - - - - - - - - - D2940 12 28 40 351 531 720 859 1,412 1,946 1,210 1,943 2,666 D2970 - 1 1 - - - 54 122 178 54 122 178 D3110 1 2 3 10 25 36 21 54 80 32 79 116 D3120 1 2 3 19 31 42 39 64 88 58 94 130 D3220 15 1 16 749 1,184 1,620 51 84 115 800 1,268 1,735 D4341 - - - - - - - - - - - - D4342 - - - - - - - - - - - - D4355 - - - - - - - - - - - - D4381 - - - - - - - - - - - - D4910 - - - - - - - - - - - - D5520 - - - - - - - - - - - - D5640 - 1 1 - - - 50 77 105 50 77 105 D5730 1 1 2 59 39 39 80 134 185 139 173 224 D5731 - 1 1 - - - 81 135 187 81 135 187 D5850 - - - - - - - - - - - -



CDT


Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5

Payor

Mix A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C




D5851 - - - - - - - - - - - - D7111 2 3 5 97 119 153 149 191 249 246 309 402 D7140 146 - 146 11,377 12,764 16,060 - - - 11,377 12,764 16,060 D7270 - - - - - - - - - - - - D7288 - - - - - - - - - - - - D9110 1 27 28 34 49 66 921 1,394 1,890 955 1,443 1,956 D9210 - - - - - - - - - - - - D9211 - - - - - - - - - - - - D9212 - - - - - - - - - - - - D9215 - - - - - - - - - - - - D9230 4 9 13 72 103 138 128 86 86 200 189 224 D9630 - - - - - - - - - - - - D9910 - - - - - - - - - - - - D9911 - - - - - - - - - - - - D9940 1 2 3 112 181 250 232 402 559 344 583 809 D9941 - - - - - - - - - - - -

Total 1,786 1,900 3,686 59,669$ 78,830$ 103,681$ 67,897$ 95,191$ 126,963$ 127,567$ 174,022$ 230,644$

1

2

3

4

5



APPENDIX EPage 1 of 3

CDT


Payor

Mix A –

75/25/0 3Payor Mix B –

50/25/25 4

Payor Mix

C –

50/0/50 5

Payor Mix

A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C

D0120 116 197 313 3,010$ 3,474$ 4,408$ 2,482$ 3,930$ 5,378$ 5,492$ 7,404$ 9,786$ D0140 56 152 208 1,100 1,688 2,296 3,112 5,126 7,068 4,213 6,815 9,364 D0145 23 - 23 449 679 920 - - - 449 679 920 D0150 85 151 236 3,933 4,188 5,185 3,624 5,738 7,852 7,557 9,926 13,037 D0210 27 61 88 1,130 1,667 2,248 2,585 3,904 5,292 3,715 5,571 7,540 D0220 110 239 349 875 1,370 1,870 1,918 3,053 4,183 2,792 4,423 6,053 D0230 42 82 124 274 437 599 535 853 1,169 809 1,290 1,767 D0272 71 64 135 1,017 1,479 1,988 936 1,416 1,920 1,953 2,895 3,908 D0274 60 112 172 1,170 1,770 2,400 2,184 3,304 4,480 3,354 5,074 6,880 D0277 - - - - - - - - - - - - D0350 - - - - - - - - - - - - D0460 - - - - - - - - - - - - D1110 6 251 257 214 266 345 9,224 12,362 16,315 9,438 12,628 16,660 D1120 313 - 313 8,381 10,493 13,616 - - - 8,381 10,493 13,616 D1230 - - - - - - - - - - - - D1204 - 2 2 - - - 22 35 48 22 35 48 D1206 119 - 119 1,383 2,068 2,797 - - - 1,383 2,068 2,797 D1310 - - - - - - - - - - - - D1330 15 28 43 167 185 233 84 133 182 251 318 415 D1351 171 62 233 2,693 4,147 5,643 930 1,473 2,015 3,623 5,619 7,658 D1510 10 - 10 950 1,502 2,055 - - - 950 1,502 2,055 D1515 4 - 4 795 1,026 1,342 - - - 795 1,026 1,342 D1520 - - - - - - - - - - - - D1525 - - - - - - - - - - - - D1555 - - - - - - - - - - - - D2140 18 29 47 663 991 1,341 1,098 1,729 2,364 1,761 2,720 3,705 D2150 39 64 103 1,822 2,749 3,725 3,053 4,781 6,528 4,875 7,529 10,253 D2160 18 28 46 1,331 1,759 2,313 2,102 2,872 3,808 3,433 4,631 6,121 D2161 2 5 7 176 230 302 447 605 800 624 835 1,102



ESTIMATED REVENUE FOR ADHPMaine

1920\01\190313(xlsx)||APPENDIX E


CDT


Payor

Mix A –


50/25/25 4

Payor Mix

C –

50/0/50 5

Payor Mix

A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C




D2330 22 42 64 1,345 1,713 2,233 2,608 3,448 4,536 3,953 5,161 6,769 D2331 13 27 40 1,049 1,293 1,671 2,191 2,738 3,551 3,240 4,031 5,221 D2332 7 18 25 678 839 1,085 1,755 2,210 2,871 2,433 3,048 3,956 D2335 5 16 21 512 692 915 1,655 2,287 3,040 2,167 2,979 3,955 D2391 45 75 120 2,784 3,651 4,793 4,736 6,499 8,625 7,521 10,149 13,418 D2392 30 57 87 2,453 3,203 4,200 4,745 6,455 8,550 7,198 9,658 12,750 D2393 7 17 24 663 888 1,173 1,645 2,312 3,086 2,307 3,200 4,258 D2394 2 5 7 208 290 386 532 780 1,050 740 1,069 1,436 D2920 - 2 2 - - - 60 95 130 60 95 130 D2930 5 - 5 543 701 918 - - - 543 701 918 D2931 - 6 6 - - - 540 360 360 540 360 360 D2932 - - - - - - - - - - - - D2933 - - - - - - - - - - - - D2934 - - - - - - - - - - - - D2940 9 20 29 263 398 540 614 1,009 1,390 877 1,407 1,930 D2970 - 1 1 - - - 54 122 178 54 122 178 D3110 1 2 3 10 25 36 21 54 80 32 79 116 D3120 1 2 3 19 31 42 39 64 88 58 94 130 D3220 10 1 11 500 790 1,080 51 84 115 551 873 1,195 D4341 10 140 150 465 915 1,300 6,720 13,720 19,600 7,185 14,635 20,900 D4342 2 5 7 97 154 211 252 399 546 349 553 757 D4355 6 31 37 522 612 780 2,709 3,212 4,108 3,231 3,824 4,888 D4381 - 1 1 - - - 23 36 49 23 36 49 D4910 - - - - - - - - - - - - D5520 - - - - - - - - - - - - D5640 - 1 1 - - - 50 77 105 50 77 105 D5730 1 1 2 59 39 39 80 134 185 139 173 224 D5731 - 1 1 - - - 81 135 187 81 135 187 D5850 - - - - - - - - - - - -



CDT


Payor

Mix A –


50/25/25 4

Payor Mix

C –

50/0/50 5

Payor Mix

A –

75/25/0 3

Payor Mix

B –

50/25/25 4

Payor

Mix C –

50/0/50 5Payor Mix

A

Payor Mix

B

Payor Mix

C




D5851 - - - - - - - - - - - - D7111 2 3 5 97 119 153 149 191 249 246 309 402 D7140 102 66 168 7,948 8,917 11,220 5,277 6,349 8,151 13,225 15,267 19,371 D7270 - - - - - - - - - - - - D7288 - - - - - - - - - - - - D9110 1 19 20 34 49 66 648 981 1,330 682 1,030 1,396 D9210 - - - - - - - - - - - - D9211 - - - - - - - - - - - - D9212 - - - - - - - - - - - - D9215 - - - - - - - - - - - - D9230 3 6 9 54 77 104 86 57 57 140 134 161 D9630 - - - - - - - - - - - - D9910 - - - - - - - - - - - - D9911 - - - - - - - - - - - - D9940 1 2 3 112 181 250 232 402 559 344 583 809 D9941 - - - - - - - - - - - -

Total 1,590 2,094 3,684 51,946$ 67,743$ 88,815$ 71,889$ 105,522$ 142,174$ 123,834$ 173,265$ 230,989$

1

2

3

4

5



APPENDIX F

1920\01\190309(docx)-E2


REIMBURSEMENT

Payment per procedure is calculated based on three payor mix scenarios (shown in the table below) intended to signify a blend of payors that represent the provider’s expanding access to care for the underinsured. Thus, the payor mix ranges from a 100 percent underinsured population in Payor Mix A (i.e., 25 percent qualifying for sliding fee and 75 percent Medicaid) to a maximum of 50 percent privately insured population in Payor Mix C. Pediatric and adult fees for each payor and the resulting reimbursement for each code are provided in APPENDIX G.

Payor Mix Composition


A 75% 25% 0%

B 50% 25% 25%

C 50% 0% 50%

Assumptions

● Sliding fee is 30 percent of the private fee schedule.

● It is assumed that the provider collects 100 percent of the stated reimbursement.

● In cases where the public fee schedule does not reimburse for a procedure, the default is the sliding fee.

APPENDIX GPage 1 of 4

Codes 1

Pediatric Adult Pediatric Adult Pediatric Adult

Payor MixA –

75/25/0 5

Payor MixB –

50/25/25 6

Payor MixC –

50/0/50 7

Payor MixA –

75/25/0 5

Payor Mix B –

50/25/25 6

Payor MixC –

50/0/50 7

D0120 $30.00 $12.60 $46.00 $42.00 $13.80 $12.60 $25.95 $29.95 $38.00 $12.60 $19.95 $27.30D0140 $20.00 $20.00 $62.00 $73.00 $18.60 $21.90 $19.65 $30.15 $41.00 $20.48 $33.73 $46.50D0145 $20.00 $0.00 $60.00 $0.00 $18.00 $0.00 $19.50 $29.50 $40.00 $0.00 $0.00 $0.00D0150 $55.00 $24.00 $67.00 $80.00 $20.10 $24.00 $46.28 $49.28 $61.00 $24.00 $38.00 $52.00D0210 $43.50 $43.50 $123.00 $130.00 $36.90 $39.00 $41.85 $61.73 $83.25 $42.38 $64.00 $86.75D0220 $8.00 $8.00 $26.00 $27.00 $7.80 $8.10 $7.95 $12.45 $17.00 $8.03 $12.78 $17.50D0230 $6.50 $6.50 $22.00 $22.00 $6.60 $6.60 $6.53 $10.40 $14.25 $6.53 $10.40 $14.25D0272 $15.00 $15.00 $41.00 $45.00 $12.30 $13.50 $14.33 $20.83 $28.00 $14.63 $22.13 $30.00D0274 $20.00 $20.00 $60.00 $60.00 $18.00 $18.00 $19.50 $29.50 $40.00 $19.50 $29.50 $40.00D0277 $30.00 $30.00 $0.00 $0.00 $0.00 $0.00 $22.50 $15.00 $15.00 $22.50 $15.00 $15.00D0350 $15.00 $0.00 $50.00 $0.00 $15.00 $0.00 $15.00 $23.75 $32.50 $0.00 $0.00 $0.00D0460 $10.00 $10.00 $0.00 $0.00 $0.00 $0.00 $7.50 $5.00 $5.00 $7.50 $5.00 $5.00D1110 $40.00 $40.00 $75.00 $90.00 $22.50 $27.00 $35.63 $44.38 $57.50 $36.75 $49.25 $65.00D1120 $30.00 $20.40 $57.00 $68.00 $17.10 $20.40 $26.78 $33.53 $43.50 $20.40 $32.30 $44.20D1230 $0.00 $0.00 0.00 $0.00 0.00 $0.00 0.00 0.00 0.00 0.00 0.00 0.00D1204 $9.60 $11.10 32.00 $37.00 9.60 $11.10 9.60 15.20 20.80 11.10 17.58 24.05D1206 $12.00 $11.10 $35.00 $37.00 $10.50 $11.10 $11.63 $17.38 $23.50 $11.10 $17.58 $24.05D1310 $0.00 $0.00 $0.00 $0.00 0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00D1330 $13.00 $3.00 $18.00 $10.00 $5.40 $3.00 $11.10 $12.35 $15.50 $3.00 $4.75 $6.50D1351 $16.00 $15.00 $50.00 $50.00 $15.00 $15.00 $15.75 $24.25 $33.00 $15.00 $23.75 $32.50D1510 $95.00 $91.20 $316.00 $304.00 $94.80 $91.20 $94.95 $150.20 $205.50 $91.20 $144.40 $197.60D1515 $220.00 $128.70 $451.00 $429.00 $135.30 $128.70 $198.83 $256.58 $335.50 $128.70 $203.78 $278.85D1520 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00


REIMBURSEMENT RATESMaine

Public

Reimbursement 2Private Practice

Plan 3 Sliding Scale 4 Collections – Child Collections – Adult

1920\01\190313(xlsx)||APPENDIX G


Codes 1


Payor MixA –

75/25/0 5

Payor MixB –

50/25/25 6

Payor MixC –

50/0/50 7

Payor MixA –

75/25/0 5

Payor Mix B –

50/25/25 6

Payor MixC –

50/0/50 7



Public



D1525 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.50 $55.00 $55.00 $0.00 $0.00 $0.00D1555 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.50 $25.00 $25.00 $0.00 $0.00 $0.00D2140 $38.00 $38.00 $111.00 $125.00 $33.30 $37.50 $36.83 $55.08 $74.50 $37.88 $59.63 $81.50D2150 $48.00 $48.00 $143.00 $156.00 $42.90 $46.80 $46.73 $70.48 $95.50 $47.70 $74.70 $102.00D2160 $81.00 $81.00 $176.00 $191.00 $52.80 $57.30 $73.95 $97.70 $128.50 $75.08 $102.58 $136.00D2161 $97.00 $97.00 $205.00 $223.00 $61.50 $66.90 $88.13 $115.13 $151.00 $89.48 $120.98 $160.00D2330 $68.00 $68.00 $135.00 $148.00 $40.50 $44.40 $61.13 $77.88 $101.50 $62.10 $82.10 $108.00D2331 $91.00 $91.00 $166.00 $172.00 $49.80 $51.60 $80.70 $99.45 $128.50 $81.15 $101.40 $131.50D2332 $109.00 $109.00 $201.00 $210.00 $60.30 $63.00 $96.83 $119.83 $155.00 $97.50 $122.75 $159.50D2335 $111.00 $111.00 $255.00 $269.00 $76.50 $80.70 $102.38 $138.38 $183.00 $103.43 $142.93 $190.00D2391 $68.00 $68.00 $145.00 $162.00 $43.50 $48.60 $61.88 $81.13 $106.50 $63.15 $86.65 $115.00D2392 $90.00 $90.00 $190.00 $210.00 $57.00 $63.00 $81.75 $106.75 $140.00 $83.25 $113.25 $150.00D2393 $103.00 $103.00 $232.00 $260.00 $69.60 $78.00 $94.65 $126.90 $167.50 $96.75 $136.00 $181.50D2394 $111.00 $111.00 $275.00 $309.00 $82.50 $92.70 $103.88 $144.88 $193.00 $106.43 $155.93 $210.00D2920 $30.00 $30.00 $75.00 $100.00 $22.50 $30.00 $28.13 $39.38 $52.50 $30.00 $47.50 $65.00D2930 $120.00 $78.90 $247.00 $263.00 $74.10 $78.90 $108.53 $140.28 $183.50 $78.90 $124.93 $170.95D2931 $120.00 $120.00 $294.00 $0.00 $88.20 $0.00 $112.05 $155.55 $207.00 $90.00 $60.00 $60.00D2932 $120.00 $120.00 $0.00 $0.00 $0.00 $0.00 $90.00 $60.00 $60.00 $90.00 $60.00 $60.00D2933 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00D2934 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0.00 0.00 0.00 $0.00 $0.00 $0.00D2940 $30.00 $30.00 $90.00 $109.00 $27.00 $32.70 $29.25 $44.25 $60.00 $30.68 $50.43 $69.50D2970 $40.00 $40.00 $0.00 $315.00 $0.00 $94.50 30.00 20.00 20.00 $53.63 $122.38 $177.50D3110 $7.00 $7.00 $65.00 $73.00 $19.50 $21.90 $10.13 $24.63 $36.00 $10.73 $27.23 $40.00



Codes 1


Payor MixA –

75/25/0 5

Payor MixB –

50/25/25 6

Payor MixC –

50/0/50 7

Payor MixA –

75/25/0 5

Payor Mix B –

50/25/25 6

Payor MixC –

50/0/50 7



Public



D3120 $19.00 $19.00 $65.00 $69.00 $19.50 $20.70 19.13 30.63 42.00 $19.43 $31.93 $44.00D3220 $50.00 $50.00 $166.00 $180.00 $49.80 $54.00 $49.95 $78.95 $108.00 $51.00 $83.50 $115.00D4341 $40.00 $40.00 $220.00 $240.00 $66.00 $72.00 46.50 91.50 130.00 $48.00 $98.00 $140.00D4342 $48.60 $50.40 $162.00 $168.00 $48.60 $50.40 $48.60 $76.95 $105.30 $50.40 $79.80 $109.20D4355 $100.00 $100.00 $160.00 $165.00 $48.00 $49.50 87.00 102.00 130.00 $87.38 $103.63 $132.50D4381 $0.00 $22.50 $0.00 $75.00 $0.00 $22.50 $0.00 $0.00 $0.00 $22.50 $35.63 $48.75D4910 $39.00 $36.60 $0.00 $122.00 $0.00 $36.60 29.25 19.50 19.50 $36.60 $57.95 $79.30D5520 $50.00 $50.00 $0.00 $155.00 $0.00 $46.50 $37.50 $25.00 $25.00 $49.13 $75.38 $102.50D5640 $50.00 $50.00 $0.00 $160.00 $0.00 $48.00 37.50 25.00 25.00 $49.50 $77.00 $105.00D5730 $78.00 $78.00 $0.00 $292.00 $0.00 $87.60 $58.50 $39.00 $39.00 $80.40 $133.90 $185.00D5731 $78.00 $78.00 $0.00 $296.00 $0.00 $88.80 58.50 39.00 39.00 $80.70 $135.20 $187.00D5850 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00D5851 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0.00 0.00 0.00 $0.00 $0.00 $0.00D7111 $55.00 $55.00 $98.00 $111.00 $29.40 $33.30 $48.60 $59.35 $76.50 $49.58 $63.58 $83.00D7140 $91.00 $91.00 $129.00 $156.00 $38.70 $46.80 77.93 87.43 110.00 $79.95 $96.20 $123.50D7270 $175.00 $175.00 $0.00 $0.00 $0.00 $0.00 $131.25 $87.50 $87.50 $131.25 $87.50 $87.50D7288 By Report By Report $0.00 $0.00 $0.00 $0.00 NA NA NA NA NA NAD9110 $35.00 $35.00 $97.00 $105.00 $29.10 $31.50 $33.53 $49.03 $66.00 $34.13 $51.63 $70.00D9210 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0.00 0.00 0.00 $0.00 $0.00 $0.00D9211 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00D9212 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0.00 0.00 0.00 $0.00 $0.00 $0.00D9215 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00D9230 $19.00 $19.00 $50.00 $0.00 $15.00 $0.00 18.00 25.75 34.50 $14.25 $9.50 $9.50



Codes 1


Payor MixA –

75/25/0 5

Payor MixB –

50/25/25 6

Payor MixC –

50/0/50 7

Payor MixA –

75/25/0 5

Payor Mix B –

50/25/25 6

Payor MixC –

50/0/50 7



Public



D9630 By Report By Report $0.00 $0.00 $0.00 $0.00 NA NA NA NA NA NAD9910 $13.50 $17.70 $45.00 $59.00 $13.50 $17.70 13.50 21.38 29.25 $17.70 $28.03 $38.35D9911 $0.00 $17.10 $0.00 $57.00 $0.00 $17.10 $0.00 $0.00 $0.00 $17.10 $27.08 $37.05D9940 $110.00 $110.00 $389.00 $449.00 $116.70 $134.70 111.68 181.43 249.50 $116.18 $200.93 $279.50D9941 $45.60 $45.00 $152.00 $150.00 $45.60 $45.00 $45.60 $72.20 $98.80 $45.00 $71.25 $97.50

1

2

3

4

5

6

7Payor Mix C: 50% Public Fee Schedule, 0% Sliding Fee Schedule, and 50% Private Fee Schedule.

Codes provided by the ADA to define scope of practice.

Based on the state's Medicaid dental fee schedule.

Based on the ADA 2009 Survey of Dental Fees . Child private dental plan reimbursement is based on median values for national pediatric dentists. Adult dental plan reimbursement is based on the median values for general practitioners in the region.

Sliding scale is the collection rate based on 50% of private dental plan reimbursement.

Payor Mix A: 75% Public Fee Schedule, 25% Sliding Fee Schedule, and 0% Private Fee Schedule.

Payor Mix B: 50% Public Fee Schedule, 25% Sliding Fee Schedule, and 25% Private Fee Schedule.


APPENDIX H Page 1 of 2

1920\01\190309(docx)-E2


PRODUCTIVITY CALCULATIONS

Procedural volumes are based on typical adult and pediatric procedures performed in the public health setting. These are modified by the scope of practice for each provider as defined by the ADA based on existing providers and/or as defined in pending legislation. The number of procedures is based on dentist productivity in the public health setting and is normalized for the practice structure of the alternative dental provider assisted by a DA. Annual procedural data performed by dentists was collected from public health settings. It is assumed that the mix of procedures performed in a public health practice setting is different from that in a private health practice setting. For example, the latter may include cosmetic procedures. Furthermore, in a private practice, the patient population may have more regular access to care and prevention, thus reducing the acuity and complexity of treatment provided. Furthermore, as procedures performed for patients may vary due to practice location and associated demographics (a greater pediatric or elderly population) as well as public reimbursement (e.g., where there is only reimbursement for emergent procedures, these may be overrepresented relative to states that pay for more comprehensive and preventive treatments). In order to adjust for these variations, a blend of procedures and mix of pediatric and adult patients was developed based on a variety of public clinic locations across several states. To calculate reimbursement of the DHAT, DT, and ADHP, the public health procedural codes are modified by the scope of each provider. APPENDIX I defines the procedural codes within each provider’s range. Productivity assumptions are based on an average number of minutes per procedure as provided by dentists practicing in public health settings. Table 1 provides an example of how productivity was normalized and adjusted to the scope of each provider up to his/her hours of clinical activity. APPENDICES J, K, and L present the productivity calculation for the DHAT, DT, and ADHP.

APPENDIX H Page 2 of 2

1920\01\190309(docx)-E2

Table 1 – Productivity Calculation Example

Calculation Example

Average Production Public Health Setting1 A 78

Adjusted Minutes Per Procedure (See Table 2) B 25

Total Minutes C = A × B 1,954

Multiplier (See Table 3) D 0.02

Increase/Decrease Minutes E = D × C 46

Increase/Decrease Procedures F = E ÷ B 2

Total Procedures G = A + F 80

Table 2 – Adjusted Minutes Per Procedure Calculation

Calculation Example

Minutes Per Procedure A 15

Increased Procedure Time Adjustment for Fewer Operatories (From Two to One Operatory in This Example)

B 0.6

Minutes Per Procedure (Adjusted) C = A ÷ B 25

Table 3 – Multiplier for Hours Needed to Be 1.0 FTE Calculation Example

Calculation Example

Total Time Converted to Hours A 1,876

1.0 FTE Defined Hours B 1,920

Multiplier C = (B ÷ A) – 1 0.02

Assumptions

● The production for each provider is determined by his/her scope. The total volume in a year is based on practicing for 1,920 hours each year. The total procedure times for the year will add up to 1,920 hours. This assumes 1.0 FTE works 48 weeks per year and has a total of 4 weeks’ vacation, holidays, and sick leave.

● Productivity data from each clinic is normalized based on the number of dentists and operatories on the basis that one operatory per provider rather than two (one dental assis-tant [DA] rather than two DAs) adjusts productivity by 60 percent.

1 Source: Public dental clinics in California, Connecticut, and New Hampshire.

APPENDIX IPage 1 of 2

Procedure Codes Procedure Description DHAT* DT ADHP

D0120 Periodic Oral Evaluation and Assessment XD0140 Limited Oral Evaluation and Assessment XD0145 Oral Evaluation for a Patient Under 3 Years of Age and Counseling With Primary Caregiver XD0150 Comprehensive Oral Evaluation – New or Established Patient XD0210 Intraoral Complete Series (Including Bitewings) X X XD0220 Intraoral Periapical – First Film X X XD0230 Intraoral- Periapical Each Additional Film X X XD0272 Bitewings – Two Films X X XD0274 Bitewings – 4 Films X X XD0277 Vertical Bitewings X X XD0350 Oral/Facial Photographic Images XD0460 Pulp Vitality Tests X XD1110 Prophylaxis – Adult X X XD1120 Prophylaxis – Child X X XD1230 Topical Application of Fluoride – Child X X XD1204 Topical Application of Fluoride – Adult X X XD1206 Topical Fluoride Varnish; Therapeutic Application for Moderate to High Caries Risk Patients X X XD1310 Nutritional Counseling for Control of Dental Disease X XD1330 Oral Hygiene Instructions X XD1351 Sealant Per Tooth X X XD1510 Space Maintainer – Fixed Unilateral X XD1515 Space Maintainer – Fixed Bilateral X XD1520 Space Maintainer – Removable Unilateral X XD1525 Space Maintainer – Removable – Bilateral X XD1555 Removal of Fixed Space Maintainer X XD2140 Amalgam – One Surface X X XD2150 Amalgam – Two Surfaces X X XD2160 Amalgam – Three Surfaces X X XD2161 Amalgam – Four or More Surfaces X X XD2330 Resin-Based Composite – One Surface, Anterior X X XD2331 Resin-Based Composite – Two Surfaces, Anterior X X XD2332 Resin-Based Composite – Three Surfaces, Anterior X X XD2335 Resin-Based Composite – Four or More Surfaces Involving Incisal Angle, Anterior X X XD2391 Resin-Based Composite – One Surface, Posterior X X XD2392 Resin-Based Composite – Two Surfaces, Posterior X X XD2393 Resin-Based Composite – Three Surfaces, Posterior X X XD2394 Resin-Based Composite – Four or More Surfaces, Posterior X X XD2920 Recement Crown X XD2930 Prefabricated Stainless Steel Crown – Primary Tooth X X XD2931 Prefabricated Stainless Steel Crown – Permanent Tooth X X XD2932 Prefabricated Resin Crown X XD2933 Prefabricated Resin Crown With Resin Window X XD2934 Prefabricated Esthetic Coated Stainless Steel Crown – Primary Tooth X XD2940 Protective Restoration X X XD2970 Temporary Crown X XD3110 Pulp Cap – Direct X XD3120 Pulp Cap – Indirect X XD3220 Therapeutic Pulpotomy – Primary Teeth X X XD4341 Periodontal Scaling and Root Planing – 4 or More Teeth Per Quadrant XD4342 Periodontal Scaling and Root Planing – 1-3 Teeth Per Quadrant XD4355 Full Mouth Debridement XD4381 Localized Delivery of Antimicrobial Agents XD4910 Periodontal Maintenance XD5520 Replace Missing or Broken Teeth – Complete Denture (Each Tooth) X XD5640 Replace Broken Teeth – Per Tooth X XD5730 Reline Complete Maxillary Denture (Chairside) X XD5731 Reline Complete Mandibular Denture (Chairside) X XD5850 Tissue Conditioning Maxillary X XD5851 Tissue Conditioning Mandibular X XD7111 Extraction, Coronal Remnants Deciduous Tooth X X XD7140 Extraction, Erupted Tooth or Exposed Root, Primary Tooth X X XD7270 Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth X XD7288 Brush Biopsy – Transepithelial Sample Collection X XD9110 Palliative (Emergency) Treatment of Dental Pain – Minor Procedure X X X


PROVIDER SCOPE OF PRACTICE

1920\01\190313(xlsx)||APPENDIX I

APPENDIX IPage 2 of 2

Procedure Codes Procedure Description DHAT* DT ADHP


PROVIDER SCOPE OF PRACTICE

D9210 Local Anesthesia not in Conjunction With Operative or Surgical Procedure X X XD9211 Regional Block Anesthesia X X XD9212 Trigeminal Division Block Anesthesia X X XD9215 Local Anesthesia X X XD9230 Analgesia, Inhalation of Nitrous Oxide X XD9630 Other Drugs and/or Medicaments, By Report X XD9910 Application of Desensitizing Medicament X XD9911 Application of Desensitizing Resin for Cervical or Root Surface Per Tooth X XD9940 Occlusal Guard Soft X XD9941 Fabrication of Athletic Mouthguard X Xno code Atraumatic Restorative Therapy X X Xno code Cavity Preparation X X Xno code Suture Removal X Xno code Mechanical Polish X Xno code Charting Oral Cavity X X Xno code Oral Evaluation and Assessment of Oral Disease X X Xno code Dressing Change X Xno code Place Sutures X Xno code Formalization of Treatment Plans X Xno code Supervision of EFDAs and Dental Assistants X Xno code Dispensation of Drugs X Xno code Prevent, Identify and Manage Dental and Medical Emergencies X X

* DHAT procedures based on recertification checklist** No panorex machine listed in equipment*** Procedure code nomenclature changed. May be used to relieve pain.

1920\01\190313(xlsx)||APPENDIX I

APPENDIX JPage 1 of 2

CDT

Code Pediatric Adult Total Pediatric Adult Pediatric Adult Total Multiplier Time Procedures Time Procedures Pediatric Adult Pediatric Adult Total

D0120 - - - 25 25 - - - 0.02 - - - - - - - - - D0140 - - - 25 33 - - - 0.02 - - - - - - - - - D0145 - - - 8 - - - - 0.02 - - - - - - - - - D0150 - - - 25 33 - - - 0.02 - - - - - - - - - D0210 34 78 112 25 25 850 1,950 2,800 0.02 19 1 44 2 35 80 875 2,000 2,875 D0220 140 304 444 17 17 2,333 5,067 7,400 0.02 53 3 115 7 143 311 2,383 5,183 7,567 D0230 54 104 158 17 17 900 1,733 2,633 0.02 20 1 39 2 55 106 917 1,767 2,683 D0272 90 82 172 17 17 1,500 1,367 2,867 0.02 34 2 31 2 92 84 1,533 1,400 2,933 D0274 76 143 219 17 17 1,267 2,383 3,650 0.02 29 2 54 3 78 146 1,300 2,433 3,733 D0277 - - - - - - - - 0.02 - - - - - - - - - D0350 - - - - - - - - 0.02 - - - - - - - - - D0460 - - - - - - - - 0.02 - - - - - - - - - D1110 6 320 326 - 58 - 18,667 18,667 0.02 - - 424 7 6 327 - 19,075 19,075 D1120 399 - 399 33 - 13,300 - 13,300 0.02 302 9 - - 408 - 13,600 - 13,600 D1230 - - - - - - - - 0.02 - - - - - - - - - D1204 - 3 3 - 8 - 25 25 0.02 - - 1 - - 3 - 25 25 D1206 119 - 119 - - - - - 0.02 - - - - 119 - - - - D1310 - - - - - - - - 0.02 - - - - - - - - - D1330 - - - 8 8 - - - 0.02 - - - - - - - - - D1351 218 62 280 17 - 3,633 - 3,633 0.02 82 5 - - 223 62 3,717 - 3,717 D1510 - - - 50 - - - - 0.02 - - - - - - - - - D1515 - - - 50 - - - - 0.02 - - - - - - - - - D1520 - - - - - - - - 0.02 - - - - - - - - - D1525 - - - - - - - - 0.02 - - - - - - - - - D1555 - - - - - - - - 0.02 - - - - - - - - - D2140 23 37 60 50 33 1,150 1,233 2,383 0.02 26 1 28 1 24 38 1,200 1,267 2,467 D2150 50 82 132 42 50 2,083 4,100 6,183 0.02 47 1 93 2 51 84 2,125 4,200 6,325 D2160 23 36 59 42 50 958 1,800 2,758 0.02 22 1 41 1 24 37 1,000 1,850 2,850 D2161 2 7 9 42 58 83 408 492 0.02 2 - 9 - 2 7 83 408 492 D2330 28 54 82 42 50 1,167 2,700 3,867 0.02 26 1 61 1 29 55 1,208 2,750 3,958 D2331 16 35 51 42 50 667 1,750 2,417 0.02 15 - 40 1 16 36 667 1,800 2,467 D2332 9 23 32 42 50 375 1,150 1,525 0.02 9 - 26 1 9 24 375 1,200 1,575 D2335 7 21 28 42 67 292 1,400 1,692 0.02 7 - 32 - 7 21 292 1,400 1,692 D2391 57 96 153 42 50 2,375 4,800 7,175 0.02 54 1 109 2 58 98 2,417 4,900 7,317 D2392 38 73 111 50 67 1,900 4,867 6,767 0.02 43 1 110 2 39 75 1,950 5,000 6,950 D2393 9 22 31 50 50 450 1,100 1,550 0.02 10 - 25 - 9 22 450 1,100 1,550 D2394 2 7 9 67 67 133 467 600 0.02 3 - 11 - 2 7 133 467 600 D2920 - - - - - - - - 0.02 - - - - - - - - - D2930 6 - 6 50 - 300 - 300 0.02 7 - - - 6 - 300 - 300 D2931 - 8 8 50 67 - 533 533 0.02 - - 12 - - 8 - 533 533 D2932 - - - 50 - - - - 0.02 - - - - - - - - - D2933 - - - - - - - - 0.02 - - - - - - - - - D2934 - - - - - - - - 0.02 - - - - - - - - - D2940 11 25 36 33 50 367 1,250 1,617 0.02 8 - 28 1 11 26 367 1,300 1,667


ESTIMATED PRODUCTION – DHAT

Average Production 2Minutes Per

Procedure 3 Total Time (Minutes)

Increase/(Decrease)

Pediatric 4Increase/(Decrease)

Adult 4 Total Procedures Total Time for 1.0 FTE 5

1920\01\190313(xlsx)||APPENDIX J

APPENDIX JPage 2 of 2

CDT

Code Pediatric Adult Total Pediatric Adult Pediatric Adult Total Multiplier Time Procedures Time Procedures Pediatric Adult Pediatric Adult Total


ESTIMATED PRODUCTION – DHAT



Increase/(Decrease)



D2970 - - - - 50 - - - 0.02 - - - - - - - - - D3110 - - - - - - - - 0.02 - - - - - - - - - D3120 - - - - - - - - 0.02 - - - - - - - - - D3220 13 1 14 42 - 542 - 542 0.02 12 - - - 13 1 542 - 542 D4341 - - - 50 50 - - - 0.02 - - - - - - - - - D4342 - - - 17 17 - - - 0.02 - - - - - - - - - D4355 - - - 50 67 - - - 0.02 - - - - - - - - - D4381 - - - - 50 - - - 0.02 - - - - - - - - - D4910 - - - - - - - - 0.02 - - - - - - - - - D5520 - - - - - - - - 0.02 - - - - - - - - - D5640 - - - 17 17 - - - 0.02 - - - - - - - - - D5730 - - - 100 100 - - - 0.02 - - - - - - - - - D5731 - - - - - - - - 0.02 - - - - - - - - - D5850 - - - - - - - - 0.02 - - - - - - - - - D5851 - - - - - - - - 0.02 - - - - - - - - - D7111 2 3 5 17 - 33 - 33 0.02 1 - - - 2 3 33 - 33 D7140 130 280 410 33 42 4,333 11,667 16,000 0.02 98 3 265 6 133 286 4,433 11,917 16,350 D7270 - - - - - - - - 0.02 - - - - - - - - - D7288 - - - - - - - - 0.02 - - - - - - - - - D9110 1 24 25 33 50 33 1,200 1,233 0.02 1 - 27 1 1 25 33 1,250 1,283 D9210 - - - - - - - - 0.02 - - - - - - - - - D9211 - - - - - - - - 0.02 - - - - - - - - - D9212 - - - - - - - - 0.02 - - - - - - - - - D9215 - - - - - - - - 0.02 - - - - - - - - - D9230 - - - 17 17 - - - 0.02 - - - - - - - - - D9630 - - - - - - - - 0.02 - - - - - - - - - D9910 - - - - - - - - 0.02 - - - - - - - - - D9911 - - - - - - - - 0.02 - - - - - - - - - D9940 - - - 17 17 - - - 0.02 - - - - - - - - - D9941 - - - - - - - - 0.02 - - - - - - - - -

Total 1,563 1,930 3,493 41,025 71,617 112,642 931 32 1,625 42 1,595 1,972 41,933 73,225 115,158

Time in Hours 6 684 1,194 1,877 16 27 699 1,220 1,919

1

2

3

4

5

6

Mix of annual procedures within the DHAT scope of practice performed by one provider with two operatories. Total hours of 1877 reflect the time required for the DHAT procedures when the average public health dentist's annual practice is reduced to one operatory and assistant.

Estimated per FTE productivity for one DA and operatory, based on average provider procedural mix and productivity.

Procedure time has been discounted by 0.6 from the original data set to reflect the adjustment from two operatories and assistants to one.Increase or decrease in procedures performed to reach 1.00 FTE (1920 hours of provider time). Rounded to the nearest whole.Total time to perform all procedures (in minutes). Minutes converted into hours. Total time may be slightly less or greater than 1920 hours due to rounding of procedures.

1920\01\190313(xlsx)||APPENDIX J

APPENDIX KPage 1 of 2

CDT

Code Pediatric Adult Total Pediatric Adult Pediatric Adult Total Time Procedures Time Procedures Pediatric Adult Pediatric Adult Total

D0120 - - - 25 25 - - - - - - - - - - - - D0140 - - - 25 33 - - - - - - - - - - - - D0145 - - - 8 - - - - - - - - - - - - - D0150 - - - 25 33 - - - - - - - - - - - - D0210 34 78 112 25 25 850 1,950 2,800 102 4 234 9 38 87 950 2,175 3,125 D0220 140 304 444 17 17 2,333 5,067 7,400 280 17 608 36 157 340 2,617 5,667 8,283 D0230 54 104 158 17 17 900 1,733 2,633 108 6 208 12 60 116 1,000 1,933 2,933 D0272 90 82 172 17 17 1,500 1,367 2,867 180 11 164 10 101 92 1,683 1,533 3,217 D0274 76 143 219 17 17 1,267 2,383 3,650 152 9 286 17 85 160 1,417 2,667 4,083 D0277 - - - - - - - - - - - - - - - - - D0350 - - - - - - - - - - - - - - - - - D0460 - - - - - - - - - - - - - - - - - D1110 6 320 326 - 58 - 18,667 18,667 - - 2,241 38 6 358 - 20,883 20,883 D1120 399 - 399 33 - 13,300 - 13,300 1,597 48 - - 447 - 14,900 - 14,900 D1230 - - - - - - - - - - - - - - - - - D1204 - 3 3 - 8 - 25 25 - - 3 - - 3 - 25 25 D1206 119 - 119 - - - - - - - - - 119 - - - - D1310 - - - - - - - - - - - - - - - - - D1330 19 36 55 8 8 158 300 458 19 2 36 4 21 40 175 333 508 D1351 218 62 280 17 - 3,633 - 3,633 436 26 - - 244 62 4,067 - 4,067 D1510 13 - 13 50 - 650 - 650 78 2 - - 15 - 750 - 750 D1515 5 - 5 50 - 250 - 250 30 1 - - 6 - 300 - 300 D1520 - - - - - - - - - - - - - - - - - D1525 - - - - - - - - - - - - - - - - - D1555 - - - - - - - - - - - - - - - - - D2140 23 37 60 50 33 1,150 1,233 2,383 138 3 148 4 26 41 1,300 1,367 2,667 D2150 50 82 132 42 50 2,083 4,100 6,183 250 6 492 10 56 92 2,333 4,600 6,933 D2160 23 36 59 42 50 958 1,800 2,758 115 3 216 4 26 40 1,083 2,000 3,083 D2161 2 7 9 42 58 83 408 492 10 - 49 1 2 8 83 467 550 D2330 28 54 82 42 50 1,167 2,700 3,867 140 3 324 6 31 60 1,292 3,000 4,292 D2331 16 35 51 42 50 667 1,750 2,417 80 2 210 4 18 39 750 1,950 2,700 D2332 9 23 32 42 50 375 1,150 1,525 45 1 138 3 10 26 417 1,300 1,717 D2335 7 21 28 42 67 292 1,400 1,692 35 1 168 3 8 24 333 1,600 1,933 D2391 57 96 153 42 50 2,375 4,800 7,175 285 7 576 12 64 108 2,667 5,400 8,067 D2392 38 73 111 50 67 1,900 4,867 6,767 228 5 584 9 43 82 2,150 5,467 7,617 D2393 9 22 31 50 50 450 1,100 1,550 54 1 132 3 10 25 500 1,250 1,750 D2394 2 7 9 67 67 133 467 600 16 - 56 1 2 8 133 533 667 D2920 - 2 2 - - - - - - - - - - 2 - - - D2930 6 - 6 50 - 300 - 300 36 1 - - 7 - 350 - 350 D2931 - 8 8 50 67 - 533 533 - - 64 1 - 9 - 600 600 D2932 - - - 50 - - - - - - - - - - - - - D2933 - - - - - - - - - - - - - - - - - D2934 - - - - - - - - - - - - - - - - - D2940 11 25 36 33 50 367 1,250 1,617 44 1 150 3 12 28 400 1,400 1,800


ESTIMATED PRODUCTION – DT



Increase/(Decrease)



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APPENDIX KPage 2 of 2

CDT



ESTIMATED PRODUCTION – DT



Increase/(Decrease)



D2970 - 1 1 - 50 - 50 50 - - 6 - - 1 - 50 50 D3110 1 2 3 - - - - - - - - - 1 2 - - - D3120 1 2 3 - - - - - - - - - 1 2 - - - D3220 13 1 14 42 - 542 - 542 65 2 - - 15 1 625 - 625 D4341 - - - 50 50 - - - - - - - - - - - - D4342 - - - 17 17 - - - - - - - - - - - - D4355 - - - 50 67 - - - - - - - - - - - - D4381 - - - - 50 - - - - - - - - - - - - D4910 - - - - - - - - - - - - - - - - - D5520 - - - - - - - - - - - - - - - - - D5640 - 1 1 17 17 - 17 17 - - 2 - - 1 - 17 17 D5730 1 1 2 100 100 100 100 200 12 - 12 - 1 1 100 100 200 D5731 - 1 1 - - - - - - - - - - 1 - - - D5850 - - - - - - - - - - - - - - - - - D5851 - - - - - - - - - - - - - - - - - D7111 2 3 5 17 - 33 - 33 4 - - - 2 3 33 - 33 D7140 130 130 33 42 4,333 - 4,333 520 16 - - 146 - 4,867 - 4,867 D7270 - - - - - - - - - - - - - - - - - D7288 - - - - - - - - - - - - - - - - - D9110 1 24 25 33 50 33 1,200 1,233 4 - 144 3 1 27 33 1,350 1,383 D9210 - - - - - - - - - - - - - - - - - D9211 - - - - - - - - - - - - - - - - - D9212 - - - - - - - - - - - - - - - - - D9215 - - - - - - - - - - - - - - - - - D9230 4 8 12 17 17 67 133 200 8 - 16 1 4 9 67 150 217 D9630 - - - - - - - - - - - - - - - - - D9910 - - - - - - - - - - - - - - - - - D9911 - - - - - - - - - - - - - - - - - D9940 1 2 3 17 17 17 33 50 2 - 4 - 1 2 17 33 50 D9941 - - - - - - - - - - - - - - - - -

Total 1,608 1,706 3,314 42,267 60,583 102,850 5,074 178 7,273 194 1,786 1,900 47,392 67,850 115,242

Time in Hours 6 704 1,010 1,714 85 121 790 1,131 1,921

1

2

3

4

5

6

Mix of annual procedures within the DT scope of practice performed by one provider with two operatories. Total hours of 1714 reflect the time required for the DT procedures when the average public health dentist's annual practice is reduced to one operatory and assistant.

Estimated per FTE productivity for one DA and operatory, based on average provider procedural mix and productivity.

Procedure time has been discounted by 0.6 from the original data set to reflect the adjustment from two operatories and assistants to one.

Increase or decrease in procedures performed to reach 1.00 FTE (1920 hours of provider time). Rounded to the nearest whole.

Total time to perform all procedures (in minutes).

Minutes converted into hours. Total time may be slightly less or greater than 1920 hours due to rounding of procedures.

1920\01\190313(xlsx)||APPENDIX K

APPENDIX LPage 1 of 3

CDT


D0120 148 251 399 25 25 3,700 6,275 9,975 (796) (32) (1,350) (54) 116 197 2,900 4,925 7,825 D0140 71 194 265 25 33 1,775 6,467 8,242 (382) (15) (1,392) (42) 56 152 1,400 5,067 6,467 D0145 29 - 29 8 - 242 - 242 (52) (6) - - 23 - 192 - 192 D0150 108 192 300 25 33 2,700 6,400 9,100 (581) (23) (1,377) (41) 85 151 2,125 5,033 7,158 D0210 34 78 112 25 25 850 1,950 2,800 (183) (7) (420) (17) 27 61 675 1,525 2,200 D0220 140 304 444 17 17 2,333 5,067 7,400 (502) (30) (1,090) (65) 110 239 1,833 3,983 5,817 D0230 54 104 158 17 17 900 1,733 2,633 (194) (12) (373) (22) 42 82 700 1,367 2,067 D0272 90 82 172 17 17 1,500 1,367 2,867 (323) (19) (294) (18) 71 64 1,183 1,067 2,250 D0274 76 143 219 17 17 1,267 2,383 3,650 (273) (16) (513) (31) 60 112 1,000 1,867 2,867 D0277 - - - - - - - - - - - - - - - - - D0350 - - - - - - - - - - - - - - - - - D0460 - - - - - - - - - - - - - - - - - D1110 6 320 326 - 58 - 18,667 18,667 - - (4,017) (69) 6 251 - 14,642 14,642 D1120 399 - 399 33 - 13,300 - 13,300 (2,862) (86) - - 313 - 10,433 - 10,433 D1230 - - - - - - - - - - - - - - - - - D1204 - 3 3 - 8 - 25 25 - - (5) (1) - 2 - 17 17 D1206 119 - 119 - - - - - - - - - 119 - - - - D1310 - - - - - - - - - - - - - - - - - D1330 19 36 55 8 8 158 300 458 (34) (4) (65) (8) 15 28 125 233 358 D1351 218 62 280 17 - 3,633 - 3,633 (782) (47) - - 171 62 2,850 - 2,850 D1510 13 - 13 50 - 650 - 650 (140) (3) - - 10 - 500 - 500 D1515 5 - 5 50 - 250 - 250 (54) (1) - - 4 - 200 - 200 D1520 - - - - - - - - - - - - - - - - - D1525 - - - - - - - - - - - - - - - - - D1555 - - - - - - - - - - - - - - - - - D2140 23 37 60 50 33 1,150 1,233 2,383 (247) (5) (265) (8) 18 29 900 967 1,867 D2150 50 82 132 42 50 2,083 4,100 6,183 (448) (11) (882) (18) 39 64 1,625 3,200 4,825 D2160 23 36 59 42 50 958 1,800 2,758 (206) (5) (387) (8) 18 28 750 1,400 2,150 D2161 2 7 9 42 58 83 408 492 (18) - (88) (2) 2 5 83 292 375 D2330 28 54 82 42 50 1,167 2,700 3,867 (251) (6) (581) (12) 22 42 917 2,100 3,017 D2331 16 35 51 42 50 667 1,750 2,417 (143) (3) (377) (8) 13 27 542 1,350 1,892 D2332 9 23 32 42 50 375 1,150 1,525 (81) (2) (247) (5) 7 18 292 900 1,192 D2335 7 21 28 42 67 292 1,400 1,692 (63) (2) (301) (5) 5 16 208 1,067 1,275 D2391 57 96 153 42 50 2,375 4,800 7,175 (511) (12) (1,033) (21) 45 75 1,875 3,750 5,625 D2392 38 73 111 50 67 1,900 4,867 6,767 (409) (8) (1,047) (16) 30 57 1,500 3,800 5,300 D2393 9 22 31 50 50 450 1,100 1,550 (97) (2) (237) (5) 7 17 350 850 1,200 D2394 2 7 9 67 67 133 467 600 (29) - (100) (2) 2 5 133 333 467


ESTIMATED PRODUCTION – ADHP

Total Procedures Total Time for 1.0 FTE 5Average Production 2Minutes Per


Increase/(Decrease)


Adult 4

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CDT






Increase/(Decrease)


Adult 4

D2920 - 2 2 - - - - - - - - - - 2 - - - D2930 6 - 6 50 - 300 - 300 (65) (1) - - 5 - 250 - 250 D2931 - 8 8 50 67 - 533 533 - - (115) (2) - 6 - 400 400 D2932 - - - 50 - - - - - - - - - - - - - D2933 - - - - - - - - - - - - - - - - - D2934 - - - - - - - - - - - - - - - - - D2940 11 25 36 33 50 367 1,250 1,617 (79) (2) (269) (5) 9 20 300 1,000 1,300 D2970 - 1 1 - 50 - 50 50 - - (11) - - 1 - 50 50 D3110 1 2 3 - - - - - - - - - 1 2 - - - D3120 1 2 3 - - - - - - - - - 1 2 - - - D3220 13 1 14 42 - 542 - 542 (117) (3) - - 10 1 417 - 417 D4341 13 179 192 50 50 650 8,950 9,600 (140) (3) (1,926) (39) 10 140 500 7,000 7,500 D4342 3 7 10 17 17 50 117 167 (11) (1) (25) (2) 2 5 33 83 117 D4355 8 40 48 50 67 400 2,667 3,067 (86) (2) (574) (9) 6 31 300 2,067 2,367 D4381 - 1 1 - 50 - 50 50 - - (11) - - 1 - 50 50 D4910 - - - - - - - - - - - - - - - - - D5520 - - - - - - - - - - - - - - - - - D5640 - 1 1 17 17 - 17 17 - - (4) - - 1 - 17 17 D5730 1 1 2 100 100 100 100 200 (22) - (22) - 1 1 100 100 200 D5731 - 1 1 - - - - - - - - - - 1 - - - D5850 - - - - - - - - - - - - - - - - - D5851 - - - - - - - - - - - - - - - - - D7111 2 3 5 17 - 33 - 33 (7) - - - 2 3 33 - 33 D7140 130 84 214 33 42 4,333 3,500 7,833 (933) (28) (753) (18) 102 66 3,400 2,750 6,150 D7270 - - - - - - - - - - - - - - - - - D7288 - - - - - - - - - - - - - - - - - D9110 1 24 25 33 50 33 1,200 1,233 (7) - (258) (5) 1 19 33 950 983 D9210 - - - - - - - - - - - - - - - - - D9211 - - - - - - - - - - - - - - - - - D9212 - - - - - - - - - - - - - - - - - D9215 - - - - - - - - - - - - - - - - - D9230 4 8 12 17 17 67 133 200 (14) (1) (29) (2) 3 6 50 100 150 D9630 - - - - - - - - - - - - - - - - - D9910 - - - - - - - - - - - - - - - - - D9911 - - - - - - - - - - - - - - - - -



CDT






Increase/(Decrease)


Adult 4

D9940 1 2 3 17 17 17 33 50 (4) - (7) - 1 2 17 33 50 D9941 - - - - - - - - - - - - - - - - -

Total 1,988 2,654 4,642 51,783 95,008 146,792 (11,144) (398) (20,446) (560) 1,590 2,094 40,725 74,333 115,058

Time in Hours 6 863 1,583 2,447 (186) (341) 679 1,239 1,918

1

2

3

4

5

6 Minutes converted into hours. Total time may be slightly less or greater than 1920 hours due to rounding of procedures.

Estimated per FTE productivity for one DA and operatory, based on average provider procedural mix and productivity. Mix of annual procedures within the ADHP scope of practice performed by one provider with two operatories. Total hours of 2447 reflect the time required for the ADHP procedures when the average public health dentist's annual practice is reduced to one operatory and assistant.Procedure time has been discounted by 0.6 from the original data set to reflect the adjustment from two operatories and assistants to one.Increase or decrease in procedures performed to reach 1.00 FTE (1920 hours of provider time). Rounded to the nearest whole.Total time to perform all procedures (in minutes).


APPENDIX M Page 1 of 3

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SALARIES AND BENEFITS CALCULATIONS

Salary estimates for alternative providers in Maine are based on the existing salaries for the DHAT in Alaska, the DT in Minnesota and the ADHP model (projected salary). The salaries of the practicing providers are used to develop a salary adjustment ratio relative to the salaries reported by the Bureau of Labor Statistics (BLS) in their existing states. This salary adjustment is also based on salary data for DAs, dental hygienists (DHs), and dentists. The calculation of an example salary adjustment is shown in Table 1. According to Alaska DHAT program sources, DHATs in Alaska earn between $60,000 and $80,000. The mean is applied to the average of the Alaska BLS DH and DA salaries to derive a factor by which to adjust the average BLS DA and DH salaries for Maine to estimate the potential earnings of the DHAT in Maine. A similar methodology is followed to calculate the salary adjustment factor for the Minnesota DT model and the ADHP model to estimate the Maine earnings of these provider types (Tables 2 and 3).

Table 1 – Sample Calculation – DHAT Salary Adjustment

Calculation Example

Alaska DH Salary1 A $90,740

Alaska DA Salary1 B $42,020

Average (DHAT Estimate) C = (A + B) ÷ 2 $66,380

Alaska DHAT Salary (Actual)2 D $70,000

Salary Estimate Percentage E = D ÷ C 105%

DHAT Salary Adjustment F = E – 1 5%

Table 2 – Sample Calculation – DT Salary Adjustment

Calculation Example

Minnesota DH Salary1 A $70,560

Minnesota Dentist Salary1 B $186,350

Average (DT Estimate) C = (A + B) ÷ 2 $128,455

1 Source: Bureau of Labor Statistics, Occupational Employment Statistics, 291021 – Dentists, 292021 –

Dental Hygienists, and 319091 – Dental Assistants, May 2010. 2 Source: Alaska DHAT program.


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Calculation Example

Minnesota DT Salary (Actual)3 D $87,360


DT Salary Adjustment F = E – 1 -32%

Table 3 – Sample Calculation – ADHP Salary Adjustment

Calculation Example

Minnesota DH Salary1 A $70,560

Minnesota Dentist Salary1 B $186,350

Average (ADHP Estimate) C = (A + B) ÷ 2 $128,455

ADHP Salary (Projected) 3 D $104,000


ADHP Salary Adjustment F = E – 1 -19%

Alternative provider salaries were determined by applying the adjustments to the appropriate and existing Maine position (Table 4). A public dentist “cap” salary is applied to ensure that the calculated provider salaries are reasonable, given current salary levels of public dental providers with the broadest scope.

Table 4 – Provider and Staff Salary and Benefit Calculations

Calculation DHAT DT ADHP Staff

DA1 Benchmark $ 35,670 N/A N/A $ 35,670

DH1 Benchmark $ 67,660 $ 67,660 $ 67,660 N/A

Dentist1 Benchmark N/A $205,050 $205,050 N/A

Average A $ 51,665 $136,355 $136,355 $ 35,670

Salary Adjustment B 5% -32% -19% 0%

Salary Cap (Maine Public Health Dentist Salary)4

$122,720 $122,720 $122,720 $122,720

Salary Estimate C = A × (1 + B) $ 54,483 $ 92,733 $110,396 $ 35,670

Benefits Percentage D 27.5% 27.5% 27.5% 27.5%

Benefits Estimate E = C × D $ 14,983 $ 25,501 $ 30,359 $ 9,809

Salary and Benefits Estimate F = E + C $ 69,465 $118,234 $140,755 $ 45,479

3 Source: Public dental clinic in Minnesota. 4 Source: Public dental clinic in Maine.


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Assumptions

● The DHAT salary was assumed to lie between the DA and DH salaries, based on existing Alaska salaries and the provider’s scope of practice. The ratio of the known Alaska DHAT salary to the average of the DH and DA salary (105 percent) is applied to estimate the po-tential salary requirements for the DHAT.

● The DT and ADHP salaries were assumed to lie between the DH and dentist salaries, based on their scope of practice. The ratio of the Minnesota DT salary to the average of the DH and dentist salaries (68 percent) is applied to estimate the potential salary requirements for the DT. The ratio of the ADHP salary to the average of the DH and dentist salary (81 percent) is applied to estimate the potential salary requirements for the ADHP.

● The benefits rate was assumed to be 27.5 percent of the salary for all providers and staff, based on typical public clinic settings.

● The staff support is limited to one DA. The salary level is estimated based on the average DA in a Maine public health setting.

APPENDIX N

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DENTIST SUPERVISION EXPENSE CALCULATIONS

This expense factors in the amount of time that a dentist would need to supervise a DHAT or DT. Once the annual supervision requirement is determined, it is applied to the average Maine public dentist salary.

Dentist Supervision Expense Calculations

Daily Time Requirement Calculation DHAT DT ADHP

Minutes A 65 65 -

Hours Conversion B = A ÷ 60 1.08 1.08 -

Days Per Year C 240 240 -

Daily Time (Hours) D = B × C 260 260 -

Accreditation (Hours) E - - -

Total Time Required F = D + E 260 260 -

FTE (Conversion) G = F ÷ 2,080 0.13 0.13 -

Dentist Salary H $122,720 $122,720 -

Supervisory Expense I = G × H $ 15,340 $ 15,340 N/A

Assumptions

● Daily supervision of DHATs and DTs is expected to be 65 minutes, per the MDA.

● The ADHP will not need to be supervised; no supervision expense is estimated.

● Unlike the Alaska DHATs, no dentist time is assumed to be required for supervision of a biannual accreditation process.

● The dentist salary is based on average public health dentist salaries provided for Maine.

● This estimate does not include dentist benefits.

APPENDIX O

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DEPRECIATION CALCULATIONS

Depreciation is based on the equipment list in APPENDIX P as well as purchase of a laptop. This was calculated based on guidelines from the Internal Revenue Service (IRS). Accordingly, computer depreciation is based on a 5-year useful life, while office and other equipment are based on a 7-year useful life. The annual depreciation expense was calculated by taking the equipment cost divided by its useful life.

Depreciation Calculations

DHAT DT ADHP

Laptop Cost F $ 1,500 $ 1,500 $ 1,500

Useful Life (In Years) G 5 5 5

Depreciation Expense (Year 1) H = F ÷ G $ 300 $ 300 $ 300

Equipment Cost1 A $108,712 $108,712 $103,934

Useful Life (In Years) I 7 7 7

Depreciation Expense (Year 1) J = A ÷ I $ 15,530 $ 15,530 $ 14,848

Total Depreciation Expense K = H + J $ 15,830 $ 15,830 $ 15,148

Assumptions

● Due to similarities in practice scope, it is assumed all providers require the same equipment, with one exception. The ADHP will not need the USBCam Camera Kit and thus will incur equipment costs approximately $5,000 less than that of the DHAT and the DT, who are ex-pected to reuse this for teledentistry purposes in lieu of more elaborate and expensive equipment.

● The estimate provided in APPENDIX P is based on installation of one low-end operatory with the equipment required to function independently of another dental clinic (e.g., lab, sterilizing equipment).

● Installation costs are included, as is shipping.

● Per IRS, computer depreciation is for 5 years.

● Per IRS, equipment depreciation is for 7 years.

● A quality laptop is estimated to cost $1,500.

1 Source: Ms. Charmen Brummer of Patterson Dental.

APPENDIX PPage 1 of 3

Equipment Manufacturer Quantity Cost/Unit DHAT DT ADHP

VACUUMPowerVac G, Single 3 User (208-230V) MIDMARK 1 9,231$ 9,231$ 9,231$ 9,231$ COMPRESSORAirStar 30C Oil Free Air Compressor w/ Sound Reducing AIR 1 6,616 6,616 6,616 6,616 Remote Control Panel 3 Switch (24V) AIR 1 231 231 231 231 Remote Water Control Valve w/ Filter (24V) AIR 1 1,054 1,054 1,054 1,054

PLANMECA Intraoral Wall Mount w/ Special Arm (74") PLANMECA 1 4,424 4,424 4,424 4,424

M11 UltraClave Sterilizer w/ Automatic Door MIDMARK 1 5,495 5,495 5,495 5,495 XRAY SCICAN 1 4,411 4,411 4,411 4,411

Hydrim L Instrument Washer SCICAN 1 7,942 7,942 7,942 7,942 Equipment Package #1 MIELE 1 9,292 9,292 9,292 9,292

MINERAL MIZER II: DI Water for Sterilizer w/ Dispensing, Gun - Makes 2+ GPH

O-SO PURE 1 2,119 2,119 2,119 2,119

BIOSONIC UC125 1.25 GAL WHALED 1 701 701 701 701

Model 26A Red Wing Lathe HANDLER 1 280 280 280 280 Model Trimmer 10" w/ Solenoid PATTERSON 1 637 637 637 637 VACUUM FORMER PATTER 1 300 300 300 300 LABORATORY VIBRATOR PATTER 1 89 89 89 89 PLASTER TRAP GLECO 1 100 100 100 100


EQUIPMENT LIST – LOW-RANGE OPERATORY OPTION 1

XRAY

STERILIZATION

THERMAL DISINFECTORS/WASHERS

WATER DISTILLERS

ULTRASONIC CLEANER

LAB

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Portable Oxygen System – Demand Valve ACCUTRON 1 856 856 856 856

Miniature Head Handpiece PATTERSON 1 476 476 476 476 6-Pin Fiber Optic Coupler PATTERSON 1 136 136 136 136

PD20 BC/RM AIRMOTOR PATTERSON 1 185 185 185 185 High-Speed Handpiece, 4-Hole Mini Head, PB PATTERSON 3 168 504 504 504 PD58 CONTRA ANGLE PATTERSON 3 157 471 471 471 PD43 STR NOSE CONE PATTERSON 3 85 255 255 255 HALOGEN CURING LIGHT PATTER 1 399 399 399 399 AMALGAMATOR PATTER 1 409 409 409 409 Engle 360 (Left-Right) Package ENGLE 1 10,732 10,732 10,732 10,732

6-Pin Handpiece Illumination System ENGLE 1 265 265 265 265 Doctor`s Stool – Deluxe ENGLE 1 519 519 519 519 Assistant`s Stool ENGLE 1 445 445 445 445

INPUT DEVICE - 1 X 5 TOPAZ SIGNATURE PAD PDTECH 1 475 475 475 475

CDR Elite Size 1 Sensor 6` SCHICK 1 10,476 10,476 10,476 10,476 CDR Elite Size 2 Sensor 6` SCHICK 1 12,204 12,204 12,204 12,204 CDR Elite Remote Module SCHICK 1 2,128 2,128 2,128 2,128 USB Remote HS Cable (2 meter) SCHICK 1 54 54 54 54

Universal Starter Kit – Size 2 SCHICK 1 180 180 180 180 Universal Starter Kit – Size 1 SCHICK 1 180 180 180 180

USBCAM4 CAMERA KIT – DT/DHAT ONLY SCHICK 1 4,266 4,266 4,266 -

OXYGEN

OPERATORY

SOFTWARE

ELITE SENSORS AND REMOTES

ACCESSORIES

CAMERA

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USBCam Cable – DT/DHAT ONLY SCHICK 1 68 68 68 - Subtotal 98,605$ 98,605$ 94,271$

Freight 2.00% 1,972 1,972 1,885 Sales Tax 8.25% 8,135 8,135 7,777

Total 108,712$ 108,712$ 103,934$

1 Costs include installation. Quote provided by Ms. Charmen Brummer of Patterson Dental, February 2012.

1920\01\190313(xls)||APPENDIX P

APPENDIX Q

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FINANCE EXPENSE CALCULATIONS

Equipment finance costs are based on the equipment costs stated in the previous section.

Equipment Finance Calculation

Calculation DHAT DT ADHP

Equipment Cost1 A $108,712 $108,712 $103,934

Percentage Borrowed B 100% 100% 100%

Loan Amount C = A × B $108,712 $108,712 $103,934

Annual Expense D = Payment for Loan Amount C

$ 15,838 $ 15,838 $ 15,142

Total Loan Cost E = D × 10 Years $158,378 $158,378 $151,417

Assumptions

● Equipment is financed at a rate of 7.5 percent over 10 years.

● The entire cost of equipment is being financed.

1 Source: Ms. Brummer of Patterson Dental.

APPENDIX R Page 1 of 2

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RENT/LEASE CALCULATIONS

To estimate the rent/lease expense, the average annual lease rate in Maine’s Dental Health Professional Shortage Areas (DHPSAs) was obtained. This was then multiplied by the minimum office square footage necessary for an independently functioning one-chair operatory dental facility to yield the lease cost.

Table 1 – Rent/Lease Calculation

Calculation Example

Average Annual Lease Per Square Foot1,2 A $13

Office Square Footage3 B 397

Lease Cost C = A × B $5,260

Assumptions

● The minimum clinic space per dental provider is 397 square feet.

● The required space includes both the operatory and additional room for the lab, sterilization, and other equipment required to support the practice (Table 2).

● It is expected that additional amenities and facilities will either not be required or be provided in an adjacent or larger, associated facility (e.g., bathrooms or waiting area would be availa-ble within a school or medical clinic).

● Rent/lease would not be applicable in a mobile setting. It is expected that this setting would have equivalent annual costs for gas, vehicle maintenance, insurance, and so forth.

Table 2 – Dental Office Size Standards3

Room Dimensions Square

Feet Quantity Total

Square Feet

Required Space

Sterilization 10’ × 10’ 100 1 100

Laboratory 8’ × 10’ 80 1 80

Panoramic X-Ray 5’ × 6’ (With Ceph, Add 10 Square Feet)

30 1 30

1 Source: Health Resources and Services Administration Web site. 2 Source: LoopNet Web site. 3 Source: Ms. Brummer of Patterson Dental.

APPENDIX R Page 2 of 2

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Room Dimensions Square

Feet Quantity Total

Square Feet

Treatment Rooms 10’ × 11’ = 110 Square Feet Per Room

110 1 110

Mechanical Room 6’ × 10’ 60 1 60

O2-N2O Storage 2’ × 4’ 8 1 8

Washer/Dryer Area 3’ × 3’ 9 1 9

Total Square Feet Required

397 397

Calculations of office leases by county with DHPSAs and office square footage are in Table 3.

Table 3 – Office Lease by DHPSA County2

Annual Lease Per Square Feet

County Low High Average Square Footage Lease Cost

Kennebec $7 $12 $9.50 397 $3,772

Penobscot $12 $22 $17.00 397 $6,749

Average $10 $17 $13.00 397 $5,260

APPENDIX S

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OTHER OPERATING EXPENSES CALCULATIONS

Operating expenses include dental supplies, maintenance, office supplies, and other overhead and lab services. These expenses are averaged based on data from public dental clinics in various states and normalized to reflect amounts per dentist FTE per operatory.

Other Operating Expenses Calculation

Calculation Example

Average Number of Dentist FTEs A 1.4

Average Number of Operatories Per Dentist FTE B 3.0

Average Dental Supplies and Maintenance C $ 69,115

Average Office Supplies and Other Overhead D 124,743

Average Lab Services E $ 28,935

Average Total Per FTE F = (C + D + E) ÷ A $122,224

Average Total Per FTE Per Operatory (Adjusted for 60% Productivity)

G = F × (2 ÷ B) × 0.6 $ 45,538

Assumptions

● It is assumed that the DA may perform some administrative duties, such as scheduling, and that the practice exists within a larger public health or other administrative structure that per-forms the billing and accounting for the practice.

● Other operating expenses do not include costs of ongoing education and training.

● Productivity is 60 percent when two operatories are reduced to one operatory in a public clinic, based on six to eight visits a day per provider.

APPENDIX T Page 1 of 3

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TUITION

In order to fully consider the economics of the new provider types, this model estimates the unsubsidized annual per student cost of educating each student. Understanding the full cost allows for decisions about whether it is necessary to subsidize the programs for any given provider and, if so, how much is required to keep tuition sustainable for the prospective student. Table 1 begins to illustrate the challenge of identifying the true educational costs based on published tuition rates. It is evident that resident tuition for public schools falls far below the nonresident tuition. One can assume that state subsidies for public schools may account for some of the difference between resident and nonresident tuition. However, in comparing nonresident tuition across schools, it was noted that class sizes varied considerably regardless of public or private institution, suggesting that tuition may be modified by adjusting the class size. Adjusting for class size, we found that for a class size of 30, per student costs could be as high as $130,000 a year. We also reviewed expenditures for academic institutions; however, large academic institutions typically have complex funds flows that consist of several sources of revenue in which tuition represents a low percentage of these; accordingly, distinguishing unsubsidized costs for one program can be challenging. Again, our estimates yielded per student costs upwards of $100,000. A conversation with a finance administrator at the University of Washington confirmed that the estimated per student costs at $90,000 per year. This number is very high and would not be sustainable for the modeled providers. However, based on discussions with the Alaska DHAT program, in which we were able to review line item expenditures and identify educational costs that would be required of any comparable training, we derived a per student cost of approximately $51,000 for a class size of 30. This cost excludes any Alaska-specific costs for travel and so forth.

Table 1 – Tuition/Program Cost Per Student Comparison

Resident Average Tuition/Cost Per Year

Nonresident Average Tuition/Cost Per Year

Private Dental Hygiene Program Tuition1 $31,168 $31,168

Public Dental School Tuition2 $21,722 $43,059

Private Dental School Tuition2 $46,436 $48,155

DHAT Program Cost Per Student3 $50,645 $50,645

1 Sources: University of Bridgeport, University of New Haven, University of New England. 2 Source: American Dental Association, 2009–10 Survey of Dental Education Tuition, Admission, and

Attrition, Volume 2. 3 Source: Alaska DHAT program.


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Resident Average Tuition/Cost Per Year

Nonresident Average Tuition/Cost Per Year

University of Washington School of Dentistry Tuition4

$30,641 $58,619

University of Washington Dental Program Cost Per Student4

$90,000 $90,000

Based on requirements to train these providers, it is assumed that educational expenses would be comparable to the annual cost of dental school or other existing programs. The Alaska DHAT program cost per student was used as annual tuition for the DHAT, DT, and the last 3 years of the ADHP program, as this is understood to be equivalent to unsubsidized tuition and reflects the true cost of educating a student. It was difficult to obtain comparably reliable data for other dental schools and the existing Minnesota program. The DHAT annual program cost per student was multiplied by the number of years to reflect the tuition expenses for the DHAT, DT, and the last 3 years of the ADHP program. We assumed that the first 3 years of the ADHP program are comparable to a dental hygiene program, with costs less than that of the DHAT or dentistry programs. We also assumed that class size during the first 3 years is greater than 30, which is typical of dental hygiene programs. Using private tuition, which is closer to unsubsidized tuition than public tuition, this was multiplied by the first 3 years to obtain a portion of the ADHP program tuition.

Table 2 – Estimated Tuition Costs By Program

DHAT DT ADHP

Private Dental Hygiene Program Tuition1

A $31,168 $31,168 $31,168

Years of Post-Secondary Education

B 0 0 3

Alaska DHAT Program Cost Per Student (Annual)3

C $50,645 $50,645 $50,645

Years of Post-Secondary Education

D 2 4 3

Total Program Tuition E = (A × B) + (C × D) $101,290 $202,580 $245,440

Assumptions

● Training for these providers may take place in a university-based or private technical college setting; however, tuition assumptions are for program costs only and do not reflect other ac-ademic costs of the institution.

● Unsubsidized tuition per year for the DHAT, DT, and the last 3 years of the ADHP program will be equivalent to the current Alaska DHAT annual program cost per student.

4 Source: University of Washington School of Dentistry.


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● The first 3 years of the ADHP program will be equivalent to the tuition at a private dental hygiene program.

● The DHAT program takes 2 years of post-secondary education; the DT program takes 4 years post-secondary; and the ADHP program takes 6 years post-secondary.

● Class size is assumed to be 30, with a 1:8 instructor ratio in the clinical setting for the DHAT, DT, and the last 3 years of the ADHP program.

● Class size is assumed to be greater than 30 for the first 3 years of the ADHP program.

● Instructors are all dentists.

● The tuition estimate includes program supplies.

● $51,000 is a reasonable minimum annual cost for these programs.

● Tuition estimates and program duration account for any prerequisites that could not have been completed in high school.

APPENDIX U

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COST OF LIVING

A student’s cost of living consists of room and board, books, transportation, and personal expenses. To determine the annual cost of living, an average was taken across schools in the states that offered dental programs. See APPENDIX V for school-specific living expenses. This annual amount was then multiplied by the program length to yield the total cost of living.

Estimated Cost of Living

DHAT DT ADHP

Annual Cost of Living1 $13,927 $13,927 $13,927

Years of Post-Secondary Education 2 4 6

Total Cost of Living $27,854 $55,708 $83,562

Assumptions

● Based on 12 months per year.

● Student lives away from home.

1 Sources: University of Maine – Augusta and University of New England.

APPENDIX V


COST OF LIVING ESTIMATES BY SCHOOL

University of Maine-

Augusta 1University of New

England 2 Average

State Maine Maine

Room/Board (Annual) 6,034$ 12,020$ 9,027$

Books (Annual) 1,300 1,400 1,350

Transportation (Annual) 2,100 1,350 1,725

Personal Expenses (Annual) 2,250$ 1,400 1,825

Total Cost of Living (Annual) 3 11,684$ 16,170$ 13,927$

NOTE: Figures may not be exact due to rounding.

1

2

3

Source: University of Maine-Augusta Web site. Estimated costs for room/board, books, transportation and personal expenses for student away from home by Ms. Sherry McCollett, Director of Financial Aid, University of Maine, Augusta.

Source: University of New England Web site.Total cost of living includes room and board, books, transportation and personal expenses. Assumes that student will be living away from home. The amount is an estimated cost per student per year.

1920\01\190313(xlsx)||APPENDIX V

APPENDIX W Page 1 of 2

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STUDENT LOAN CALCULATIONS

The student enrolled in a mid-level provider program will assume to borrow 100 percent of tuition and cost-of-living expenses. It is a reasonable assumption that the intensive and short-term nature of this program will not permit students to work at the same time. This is the case for the Alaska DHAT program. Secondly, given the assumption that these students have only a high school education upon entering these programs, they likely have limited earning potential. Finally, in order to standardize the model across all socioeconomic levels, it is assumed that the entering students and their families do not have significant savings to contribute to the cost of education. Based on a loan at a rate of 6.80 percent for 25 years, the student can expect to incur the annual and total loan costs shown in the table below. Based on loan terms and rates available at this time, private loans are a better option than government loans, as they have comparable rates but a longer term, thereby reducing the annual cost of the loan.

Annual Loan Expense and Total Loan Cost Calculation

DHAT DT ADHP

Tuition Costs A $101,000 $203,000 $245,000

Living Expenses B 28,000 56,000 84,000

Total Cost of Study C = A + B $129,000 $259,000 $329,000

Percentage Borrowed D 100% 100% 100%

Loan Amount E = C × D $129,000 $259,000 $329,000

Annual Expense F = Payment for Loan Amount E

$ 11,000 $ 22,000 $ 28,000

Total Loan Cost G = F × 25 Years $275,000 $550,000 $700,000

NOTE: Amounts have been rounded to the nearest thousand.

Assumptions

● Student borrows 100 percent of tuition and cost-of-living expenses.

● The student does not have an adverse credit score that would increase the available interest rate.

● Student has a private loan at a rate of 6.80 percent, since this is comparable to current government loan rates. Also, unlike government loans, some private loans do not have a borrowing limit. Since most private student loans have a maximum repayment period rang-ing from 15 to 25 years, it was assumed that the student would take out a loan of 25 years, the maximum possible, in order to minimize his/her debt burden.1

1 Sources: Citibank, Sallie Mae, Inc., Chase, and Wells Fargo.

APPENDIX W Page 2 of 2

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● Preceptorship requirements do not impact the loan amount, as this takes place within the time frame of the program duration, and regardless of whether income is earned during the preceptorship, it is assumed that there are no incremental expenses incurred.

APPENDIX X Page 1 of 2

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SALARY REQUIREMENTS AND TUITION SUBSIDIES

It is recommended that an individual spend no more than 15 percent of his/her salary on student loans.1 Detailed below are salary requirements and tuition subsidies for each provider to maintain a 15 percent debt-to-salary ratio. To calculate the tuition subsidy required, the loan amount equivalent to 15 percent of salary is determined. The total loan amount is then calculated based on a rate of 6.80 percent for 25 years. The cost of living is factored out before calculating the tuition subsidy.

Tuition Subsidy and Salary Requirement Required to Maintain a 15 Percent Debt-to-Salary Ratio


Student Loan Expense

Tuition A $101,000 $203,000 $245,000

Living Expenses B 28,000 56,000 84,000

Total Cost to Study C= A + B $129,000 $259,000 $329,000

Percentage Borrowed D 100% 100% 100%

Loan Amount E = C × D $129,000 $259,000 $329,000

Annual Debt Expense (Actual) F = Annual Payment for Loan Amount “E”

$11,000 $22,000 $28,000

Total Loan Cost G = F × 25 Years $275,000 $550,000 $700,000

Salary Requirement

Provider Salary H $54,000 $93,000 $110,000

Debt Percentage of Salary (Actual)

I = F ÷ H 20% 24% 25%

Desired Debt Percentage of Salary

J 15% 15% 15%

Salary Required Each Year of Loan

K = F ÷ J $73,000 $147,000 $187,000

Tuition Subsidy Requirement

Annual Debt Expense (With Subsidy to Meet 15% Debt-to-Salary Ratio)

L = H × J $8,000 $14,000 $ 17,000

Total Loan Amount M = Present Value of L 95,000 166,000 202,000

1 Source: U.S. Department of Education, Federal Student Aid, Administrative Wage Garnishment.

Available at: www2.ed.gov/offices/OSFAP/DCS/awg.html.

APPENDIX X Page 2 of 2

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Years of School N 2 4 6

Average Annual Tuition O = A ÷ N $51,000 $51,000 $ 41,000

Cost of Living P $28,000 $56,000 $ 84,000

Required Tuition to Meet Debt Ratio (Annual)

Q = (M – P) ÷ N $34,000 $28,000 $ 20,000

Tuition Subsidy (Annual Per Student)

R = O – Q $17,000 $23,000 $ 21,000

Total Subsidy for Duration of Training (Per Student)

S = R × N $34,000 $92,000 $126,000

NOTE: Amounts have been rounded to the nearest thousand.

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