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Dentist

County dental clinic slated for closure

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Coconino County dentist

Dr. Thomas Cardwell, who has been the county's public health dentist since September, has announced he will be resigning from the position, effective Sept. 30. Cardwell's departure spurred the Coconino County Board of Supervisors to consider the dental clinic's future and on Tuesday the board decided to close the clinic's doors at the end of September. The county will instead pursue a voucher and preventive dental services program. 

The dental clinic that Coconino County has run for decades -- and the only one of its kind in the state -- will be no more after Sept. 30.

After learning of the resignation of public health dentist Thomas Cardwell last month, the county Board of Supervisors on Tuesday decided to close the clinic’s doors at the end of September, when Cardwell departs.  Costs to run the clinic, difficulty in finding and recruiting dentists and low utilization rates were a few of the factors that led to the decision.

The clinic charges patients on a sliding fee scale based on income. About 850 people have been seen in the last 18 months.

The county will likely transition to a voucher system to pay for people to seek services elsewhere and put more of a focus on a prevention program centered on children, said officials with the county’s public health services district.

It was a move that several supervisors said was hard to make.

“I am convinced there is a tremendous need out there for dental clinic services. That is why it is difficult for me to break away from the more historical mode (of the dental clinic),” Coconino County Supervisor Liz Archuleta said on Tuesday.

A new way to provide services

In lieu of the dental clinic, the county is proposing a voucher program that would cover the cost for eligible residents to receive preventive and emergency services at other providers. It's also looking at expanding an already existing preventive care program to serve children from birth through elementary school with services like education, screenings and fluoride varnish applications.

The health district still has a lot to figure out with the new offerings, said Denise Burley, clinical services manager at the Coconino County Public Health Services District.

One is determining exactly what emergent services would be covered by vouchers. It also needs to establish relationships with various providers willing to accept the vouchers. Northern Arizona University's Dental Hygiene Clinic, for example, will likely provide preventive services like cleaning, exams and x-rays under the voucher program, Burley said.

There are upsides and downsides to the new model. Vouchers might not cover all of the services that are now offered under a sliding scale fee model at the county clinic, Burley said. Dentures and ongoing care like filling replacements likely would no longer be covered, she said.

She also said it's not guaranteed the voucher program would be in place by the time the clinic closes Sept. 30.

There are also benefits, including an ability to provide expanded access to dental services outside of Flagstaff by partnering with agencies in places like Williams or Page that would accept the vouchers, Coconino County Supervisor Art Babbott said.

The current arrangement forces residents from across the county, the second largest in the nation, to travel to Flagstaff to access county dental care, Babbott said.

The district’s goal would be to serve at least as many people as the clinic serves now, Burley said. The county also would likely adopt a structure that would reduce the costs of its dental program. In fiscal year 2015 the clinic’s expenditures are estimated to exceed revenues by $332,000.

"We're estimating (the new program) will be a cost savings in the long run," Burley said.

Mounting challenges

A confluence of factors led to the decision to close the dental clinic, county officials said. Perhaps the biggest, several people said, is the difficulty in finding and retaining a dentist to staff the clinic. Dental students graduate with an average of $200,000 to $300,000 in debt, and the county isn’t able to offer the salary or the debt repayment benefits to attract those people, Burley said.

The county currently offers a salary of $109,333 for the 32-hour-per-week clinic dentist position.

Underutilization is another issue, Burley said. According to clinic data, just 50 to 60 percent of people who made appointments actually showed up for them.

“We have empty chairs at too high of a frequency,” Babbott said.

That no-show rate has much to do with the population the clinic is serving, 60 percent of whom are uninsured, Burley said.

“Most of these people are living paycheck to paycheck so if they have a need it really is emergent. If we are unable to get them in very quickly and we are booking a week out they may not come because they no longer have the money,” she said.

The clinic’s financial structure was another challenge, Burley said. Expenditures consistently exceed revenues by tens of thousands of dollars. In fiscal year 2012, the clinic was $280,000 in the red. In fiscal year 2016 it is expected to run a deficit of $312,343.

Because the clinic’s patients are either uninsured or underinsured and its services are offered on a sliding fee scale based on income, it rarely gets paid or reimbursed the full cost of the service provided.

Meanwhile, the cost of providing services, including supplies and employee salaries, is rising, Burley said. On top of that, the health district faces a structural deficit of about $80,000, according to a May presentation.

Tough decision

Bryan Shanahan, a longtime dentist in town who served on a committee that tried to make the clinic sustainable, said it is hard to see the dental clinic go.

“If you talk to local dentists in Flagstaff a lot of us have worked in the county dental clinic and a lot of us wanted it to be saved,” Shanahan said.

The clinic is one of the only places for low-income residents to access affordable dental care, he said. At the same time, Shanahan said it was hard to imagine that the clinic would ever be financially sustainable on its own.

Babbott described the transition to a voucher system and expanded prevention program as an effort to better meet the dental needs of the county's low and middle-income residents.

"As a primary clinical provider, it does not seem that (the dental clinic) has been the most effective use of our resources," he said.

He also reaffirmed the county's longstanding commitment to providing dental services in a state where most counties don't take on that responsibility, at least on the same level as Coconino.

"Coconino County tries to put resources where there is a compelling need and I think as a county we have much higher rates of dental challenges," Babbott said. "We have a bigger problem so we have to take a bit more proactive involvement in finding a solution to that problem."

Emery Cowan can be reached at (928) 556-2250 or ecowan@azdailysun.com

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