CDA Journal - July 2022: Facing the Challenges of Dental Benefit Plans

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D E N TA L

A S S O C I AT I O N

July 2022 Commercial Dental Benefits Medi-Cal Dental Program Medicare Coding and Reimbursing for Teledentistry

FACING THE CHALLENGES OF

dental benefit plans VIREN R. PATEL, DDS

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Nº 7

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d e pa r t m e n t s

383 The Editor/A Little Bit Normal 385 Impressions 421 RM Matters/Minimize Risk of Bloodborne Pathogen Exposure Through Education and Planning

427 Regulatory Compliance/ Infection Control Do’s and Don’ts

429 Tech Trends

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f e at u r e s

389 Facing the Challenge of Dental Benefit Plans An introduction to the issue.

Viren R. Patel, DDS

C.E. Credit

393 Commercial Dental Benefit Plans This article discusses the history and status of the commercial dental coverage industry as well as the associated benefits, shortcomings and potential for the future.

Charles D. Stewart, DMD

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Reshaping the Medi-Cal Dental Program — Evolving Oral Health Care in California This article discusses the challenges faced and substantive improvements made to California’s Medi-Cal Dental Program over the last five to six years and the potential to continue moving the program forward.

Jennifer Kent, MPA

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One More Look at Medicare and Why a Dental Benefit Is Still Needed for All This article discusses how the failure to realize a dental benefit in Medicare remains a missed and elusive opportunity for the profession to join the rest of health care.

Elisa M. Chávez, DDS

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Benefit Design and Reimbursement Considerations for Teledentistry This manuscript explores some of the ways that policymakers and payers can facilitate a digital transformation of care and allow teledentistry to enhance the way dental practitioners develop systems of care for both today and the future of dentistry.

Nathan Suter, DDS

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Journa C A L I F O R N I A

published by the California Dental Association 1201 K St., 14th Floor Sacramento, CA 95814 800.232.7645 cda.org

CDA Officers Ariane R. Terlet, DDS President president@cda.org John L. Blake, DDS President-Elect presidentelect@cda.org

D E N TA L

Management Peter A. DuBois Executive Director Carrie E. Gordon Chief Strategy Officer Alicia Malaby Communications Director

Editorial Kerry K. Carney, DDS, CDE Editor-in-Chief Kerry.Carney@cda.org Ruchi K. Sahota, DDS, CDE Associate Editor

Carliza Marcos, DDS Vice President vicepresident@cda.org

Marisa K. Watanabe, DDS, MS Associate Editor

Max Martinez, DDS Secretary secretary@cda.org

Gayle Mathe, RDH Senior Editor

Steven J. Kend, DDS Treasurer treasurer@cda.org Debra S. Finney, MS, DDS Speaker of the House speaker@cda.org Judee Tippett-Whyte, DDS Immediate Past President pastpresident@cda.org

Volume 50 Number 7 July 2022

A S S O C I AT I O N

Jack F. Conley, DDS Editor Emeritus Robert E. Horseman, DDS Humorist Emeritus

Production Danielle Foster Senior Visual Designer

Upcoming Topics August/Precision Medicine September/Dental Radiology October/Diversity in Dentistry

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Viren R. Patel, DDS Guest Editor Andrea LaMattina, CDE Publications Manager Kristi Parker Johnson Communications Manager Blake Ellington Tech Trends Editor

The Journal of the California Dental Association (ISSN 1942-4396) is published monthly by the California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. The California Dental Association holds the copyright for all articles and artwork published herein.

The Journal of the California Dental Association is published under the supervision of CDA’s editorial staff. Neither the editorial staff, the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority of the author whose name is indicated. The association reserves the right to illustrate, reduce, revise or reject any manuscript submitted. Articles are considered for publication on condition that they are contributed solely to the Journal of the California Dental Association. The association does not assume liability for the content of advertisements, nor do advertisements constitute endorsement or approval of advertised products or services.

Copyright 2022 by the California Dental Association. All rights reserved.

Journal of the California Dental Association Editorial Board Charles N. Bertolami, DDS, DMedSc, Herman Robert Fox dean, NYU College of Dentistry, New York Steven W. Friedrichsen, DDS, professor and dean, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Mina Habibian, DMD, MSc, PhD, associate professor of clinical dentistry, Herman Ostrow School of Dentistry of USC, Los Angeles Robert Handysides, DDS, dean and associate professor, department of endodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.

Bradley Henson, DDS, PhD , interim vice president research & biotechnology, associate dean for research and biomedical sciences and associate professor, Western University of Health Sciences College of Dental Medicine, Pomona, Calif.

Paul Krebsbach, DDS, PhD, dean and professor, section of periodontics, University of California, Los Angeles, School of Dentistry Jayanth Kumar, DDS, MPH, state dental director, Sacramento, Calif.

Lucinda J. Lyon, BSDH, DDS, EdD, associate dean, oral health education, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Nader A. Nadershahi, DDS, MBA, EdD, dean, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco Francisco Ramos-Gomez, DDS, MS, MPH, professor, section of pediatric dentistry and director, UCLA Center for Children’s Oral Health, University of California, Los Angeles, School of Dentistry Michael Reddy, DMD, DMSc, dean, University of California, San Francisco, School of Dentistry Avishai Sadan, DMD, dean, Herman Ostrow School of Dentistry of USC, Los Angeles Harold Slavkin, DDS, dean and professor emeritus, division of biomedical sciences, Center for Craniofacial Molecular Biology, Herman Ostrow School of Dentistry of USC, Los Angeles

Visit cda.org/journal for the Journal of the California Dental Association’s policies and procedures, author instructions and aims and scope statement.

Brian J. Swann, DDS, MPH, chief, oral health services, Cambridge Health Alliance; assistant professor, oral health policy and epidemiology, Harvard School of Dental Medicine, Boston

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Editor

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A Little Bit of Normal Kerry K. Carney, DDS, CDE

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here are a lot of nice things about being a dentist. That is why it continues to show up on the top 10 best jobs list.

There is the return on investment. I read one commentary after another explaining that the cost of a professional education does not matter until it negatively impacts the number of applicants for matriculation into dental schools. Education is monetized. The idea is as long as you can earn enough over the lifetime of your career to pay back the loans for your education, everything is rosy.

There is the freedom to locate where you will. When my husband and I started planning our practice, I did reconnaissance in the areas we preferred. Of course, my scouting skills proved questionable. (I reported that one town would be good because I spotted a factory with a lot of new cars parked in the lot. I thought the workers had parked their cars in the lot. I reasoned that the per capita income must have been pretty high in order for so many of the factory workers to own new cars. As it happened, I had mistaken a Toyota importer’s lot for a factory parking lot. It still turned out to be a good place to live and establish a practice. But as a professional investigator, I was a dud.)

There is the freedom to set your hours. And by that, I mean for the first few years out of school, we worked 10-hour days, six days a week. But as time passed, we could cut back on hours at work to improve our life/work balance.

Dentistry is fairly family friendly. If you are self-employed, you can make working schedules fit parenting and child-rearing needs.

There is the continual stimulation of

Our work provides a little bit of normal in crisis times for those who need it.

new techniques and new science. Digital technology adds a dimension to dentistry that was unimaginable decades ago. As most dentists are gadget freaks, there is a never-ending supply of new things to try.

But the best part of dentistry is the patients. Of course, there are bad days, but most every day, you can, through your knowledge and skill, help an old friend or aid a new friend.

When you practice in the same small town where you live, you become part of the community. You can encourage the young, congratulate the adults on family and individual achievements and commiserate with the elderly. Through our profession, we hold a special place in our community.

There is a recurring bittersweet role that we play in the lives of our patients. I was reminded of this when a long-time patient and friend, I will call him Dan, was reviewing his medical history with me. Dan told me he had been diagnosed with cancer.

He proceeded to tell me about all that he had gone through physically and emotionally since he received the news.

He told me that he felt safe coming into our office and was glad to be able to devote his attention to his oral health for a while. He told me he was so tired of talking about the cancer treatment with his family and friends. He was relieved to talk about his dental health, a normal part of

everyone’s life.

That made me consider the other instances that a routine dental visit had been a chance to have a brief return to normal for some patients. There was the young woman who had a life-threatening diagnosis who really wanted to complete the restoration of an endodontically treated tooth with a crown. She was the first person who actually articulated to me how going through the dental procedure made her feel normal. She looked forward to our appointments, as it was a reminder of her life before her diagnosis.

In reviewing their medical histories, I have had men break down as they tell me about the bad outcomes of biopsies or blood tests. One very sweet person confided his very serious diagnosis at the beginning of a cleaning and exam appointment.

When I told him that his oral health was good and that we looked forward to seeing him again in six months, he took my hand and told me that was the best news he had heard in months.

Familiar structure and predictable routine can be so reassuring in a time of crisis. When my father was struggling at the end of his life, being a dentist, working with our team in our practice and providing care for our patients was a constant emotional aid for me. It was the still water in the storm. It allowed me to accept what could not be avoided and help myself by helping JULY 2 0 2 2

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others. This is a part of our profession for which I am truly grateful.

Our work provides a little bit of normal in crisis times for those who need it.

Before dismissing Dan at the end of his appointment, I asked when he was going to get to go fly-fishing again. I knew that this was his favorite sport. His face lit up as he proceeded to tell me all about where he wanted to fish next. As he left, he told me it was always a pleasure to come see me and my staff but that day it was a positive joy.

His comments reminded me of what a rewarding profession dentistry can be. n

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The Journal welcomes letters We reserve the right to edit all communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/ jcaldentassoc. By sending the letter, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

Impressions

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Periodontitis May Exacerbate Other Inflammatory Conditions

(Credit: Katie Vicari.)

Researchers from the University of Pennsylvania discovered the mechanism by which innate immune memory can cause one type of inflammatory condition — in this example, periodontitis — to increase susceptibility to another — arthritis — through alterations to immune cell precursors in the bone marrow. In a mouse model, the research team demonstrated that recipients of a bone marrow transplant were predisposed to more severe arthritis if their donor had periodontitis. The research was published in the journal Cell.

Previously, the researchers explored the role of innate immune memory and found that the innate immune system’s myeloid cells could “remember” past encounters, becoming more responsive when exposed to a new threat, just like the adaptive immune system’s T cells and B cells. The research also pinpointed how this memory was encoded, tracing it to the bone marrow, and showed that this “trained immunity” could be transferred from one organism to another through a bone marrow transplant, protecting recipients from cancer through an innate immune response.

To trace the source of the association between comorbidities to the innate immune training in the bone marrow, the research team first showed that within a week of inducing periodontal disease in a mouse, the animal’s myeloid cells and their progenitor cells expanded in the bone marrow. Examining these cells weeks later, after periodontitis was intentionally resolved, the researchers did not notice significant changes in how the cells looked or behaved.

However, these progenitor cells appeared to have memorized the inflammation they were exposed to, as they harbored important epigenetic changes: alterations in molecular markers that affect the ways genes are turned on and off but do not alter the actual DNA sequence. The researchers found that these alterations, triggered by inflammation, could alter the manner in which the genes would be expressed after a future challenge. The overall pattern of epigenetic changes, the researchers noted, was associated with known signatures of the inflammatory response. Mice with induced periodontal disease also had more severe responses to a later immune system challenge, which was evidence of trained immunity.

To demonstrate the link between inflammatory conditions, the “critical experiment” was a bone marrow transplant. Two hundred stem cells from the bone marrow of mice with periodontitis were transplanted into mice that never had gum disease and that had their own bone marrow irradiated. A few months later, these mice were exposed to collagen antibodies, which trigger arthritis.

Mice that received the transplant from mice with periodontitis developed more severe arthritis than mice that received a donation of stem cells from periodontally healthy mice. And higher joint inflammation in recipient mice was due to inflammatory cells deriving from the periodontitis-trained stem cells, according to the authors. n JULY 2 0 2 2

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Blocking a Protein Could Prevent Common Oral Cancers Researchers at Boston University’s Henry M. Goldman School of Dental Medicine have found that dialing back or even genetically deleting a protein that seems to spur the growth of oral squamous cell carcinoma — the most common head and neck cancer — might help limit a tumor’s development and spread. They say their findings make the protein, an enzyme called lysine-specific demethylase 1 (LSD1), a potential “druggable target” — something that doctors could aim chemo and immuno-oncology therapies at to take down a tumor. The study was published in the journal Molecular Cancer Research.

In previous work, the researchers found that lysine-specific demethylase 1 (LSD1) — an enzyme that typically plays a crucial role in normal cell and embryo development — goes out of control or is “inappropriately upregulated” in a range of cancers, including in the head and neck, as well as those in the brain, esophagus, liver and lung. The expression of this enzyme goes up with each tumor stage. The worse the tumor, the higher the expression of this protein.

The researchers began testing what would happen to tumors in the tongue if LSD1 was blocked. To restrict the enzyme, the researchers knocked it out by manipulating genes so LSD1 was effectively switched off or by using a type of drug called a small molecule inhibitor, which enters a cell and impedes its normal function. Already in clinical trials for treating other cancers, small molecule inhibitors haven’t previously been tested against oral cancer. The research team found that disrupting LSD1 curbed the tumor’s growth.

Given that at least one-third of Americans don’t visit a dentist regularly, according to the CDC, the discovery could be a future lifesaver for those who miss out on preventive care. Patients who see a dentist before things take a nasty turn have a shot at preventing the lesions from turning cancerous or can at least make sure treatment starts when it’s most effective.

Study Analyzes Tooth Survival After Root Canal A recent study of root canal longevity using electronic dental record data from 46,000 root canal patients treated in community dental practices found geographic and procedure disparities, providing real-world insight that can be used to inform dental practice. The study, published in the Journal of Dental Research, also found that teeth survive about 11 years after a root canal. The groundbreaking research from the Regenstrief Institute and the Indiana University School of Dentistry is the first to analyze records from community dental practices, where most Americans receive dental care.

For this study, the research team gathered deidentified electronic dental records from the National Dental PracticeBased Research Network consisting of 99 small group and solo dentistry practices from around the country. The data covered more than 46,000 patients who received root canals.

Data analysis revealed that the median survival time of a tooth after a root canal is 11.1 years. However, several factors can impact that, including follow-up treatments: ■ Teeth that receive a root canal and a subsequent filling and crown last out 20 years.

■ Teeth that receive either a filling or a crown after a root canal last around 11 years.

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Teeth that receive no restorative work after a root canal only last about 6.5 years.

There were also wide disparities in longevity among geographic regions, and insurance status also played a significant role in tooth survival time.

This study provides more representative data of the overall population than previous ■

studies. It also demonstrates that meaningful insights can be gained through analysis of existing data from routine dental care.

“This data could also inform dental insurance coverage by demonstrating the value of crowns and permanent restoration options,” said Thankam Thyvalikakath, DMD, MDS, PhD, first author of the study.

C D A J O U R N A L , V O L 5 0 , Nº 7

Researchers Develop Biological Dental Enamel A research team from KU Leuven and Hasselt University in Belgium has developed a 3D model of enamel from human dental stem cells that could change how caries and enamel damage are repaired by dentists. The results of the research were published in the journal Cellular and Molecular Life Sciences.

“The advantage of this type of 3D model is that it reliably reproduces

Experimental overview of the scRNA-seq analysis. (Hemeryck L et al., licensed under Creative Commons CC BY-NC 4.0.)

the stem cells’ original properties. We can recreate a small piece of our body in the lab, so to speak, and use it as a research model,” said Hugo Vankelecom, PhD, KU Leaven research director.

In the new model, the researchers

Wearing Dentures May Affect Nutrition Dentures may have a potentially negative impact on a person’s overall nutrition, according to new research from the Regenstrief Institute and the Indiana University School of Dentistry and published in the Journal of Prosthodontics.

The research team leveraged electronic dental and health records to gain a better understanding of how oral health treatments affect individuals’ overall health over time.

This is believed to be the first study to report the results of utilizing lab values of nutritional biomarkers and linking them with dental records.

For the study, the research team matched the dental records of more than 10,000 patients in Indiana with medical laboratory data, specifically markers for malnutrition.

The laboratory tests included complete blood count, basic metabolic profile and lipid and thyroid panel tests, among others. They compared lab results from two years before a patient received dentures to lab results two years after.

Researchers found that people with dentures had a significant decline in certain nutrition markers over those two years. People who did not wear dentures did not experience this decline. The marker levels were still within normal range, but researchers say the levels could potentially continue to fall as more time passes.

“Dentures are a significant change for a person. They do not provide the same chewing efficiency, which may alter eating habits,” said senior author Thankam Thyvalikakath, DMD, MDS, PhD. “Dentists need to be aware of this and provide advice or a referral for nutrition counseling. These patients need support during the transition and possible continued monitoring.”

The next steps in this research area are to look at other factors that may influence nutrition, including insurance status and dental clinic characteristics.

turned dental stem cells into ameloblasts that produce enamel components, which can eventually lead to biological enamel.

That enamel could be used as a natural filling material to repair dental enamel.

“The advantage is that in this way, the physiology and function of the dental tissue is repaired naturally, while this is not the case for synthetic materials. Furthermore, there would be less risk of tooth necrosis, which can occur at the contact surface when using synthetic materials,” said doctoral student Lara Hemeryck.

Not just dentists would be able to help their patients with this biological filling material. The 3D cell model can have applications in other sectors as well. For example, it could help the food industry to examine the effect of particular food products on dental enamel or toothpaste manufacturers to optimize protection and care.

“In addition, we want to combine this model with other types of dental stem cells to develop still other tooth structures and eventually an entire biological tooth. Now, we focused on ameloblasts, but our new model clearly opens up various possibilities for further research and countless applications,” Dr. Vankelecom said.

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introduction C D A J O U R N A L , V O L 5 0 , Nº 7

Facing the Challenge of Dental Benefit Plans Viren R. Patel, DDS

AUTHORS Viren R. Patel, DDS, received his dental degree from the University of London in England and is also a licentiate in dental surgery from the Royal College of Surgeons of England. He was an active member of the British Dental Association during his U.K. practice years. Dr. Patel moved to California in 1992 and has been active in the dental community ever since, volunteering at all levels of organized dentistry. He is the president of the Sacramento District Dental Foundation and serves on the California Dental Association Board of Directors. He maintains a private practice in Folsom, California, and serves as faculty at the California Northstate University, College of Dental Medicine.

Conflict of Interest Disclosure: None reported.

W

hen surveying our members and asking what concerns them most in their practices, the challenges related to dental benefit plan reimbursement is at the top of the list, followed by the increasing cost of dental school and staffing shortages. It’s clear that the range of concerns about dental plans varies as much as the types of dental plans that exist in the market, with fluctuating nuances and coverage shifts.

Just as the dental profession has witnessed advances in clinical techniques and shifting business models, the dental benefits marketplace also continues to evolve. The pressures in the dental benefits industry are comparable to those felt in thousands of industries and professions around the world — how to offer valued products and services while addressing the needs of their customers and containing costs. For dental benefit plans, employers are their primary customer. Employers are challenged with offering competitive benefit packages to retain and attract talent, as medical benefits take up a larger and larger part of the available health care benefit dollars. Dental coverage is a highly valued benefit by employees, falling right behind medical coverage and retirement benefits. In order to retain a dental benefit, many employers have shifted the cost of dental coverage to their employees, along with increased copays, something we’re witnessing firsthand in our practices.

The world of dental benefits is broad and encompasses many types of coverage. Commercial employer-based or individually acquired plans are common and well known, if not well understood, by the majority. The history and current offerings are presented by Dr. Charles Stewart with a discussion of the benefits and challenges of the differing types of commercial plans. Additionally, the author offers a perspective of what the future may bring in this area and how that may impact all those who participate in these types of plans.

Benefits provided by the government also exist for those who are unable to find care through other means. The reader will get insight into the unenviable task of the management of one of these programs from Jennifer Kent, the former director of the California Department of Health Care Services. The author discusses the barriers to change and the methodology as well as the avenues used to affect significant improvement in utilization of the Medi-Cal dental benefit.

The provision of health care to the elderly has been administered through the JULY 2 0 2 2

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Medicare program. Historically, dental care has been excluded from that area and currently continues to be. However, in the past year or so policymakers on Capitol Hill attempted to address this by proposing a dental benefit in Medicare as part of the 2021 federal spending plan. It was ultimately removed from the bill that passed, but a need remains that has yet to be met.

Dr. Elisa Chávez is well-versed in this topic and offers perspective on a dental benefit in Medicare, addressing points for and against the proposed benefit.

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The pandemic and concomitant response had a vast number of unintended sequelae. One area that saw accelerated change was the provision of dental care through teledentistry. Benefit plan design will need to look to this area since it is quickly evolving. Those needs are discussed in this edition by an author with significant experience in this area, Dr. Nathan Suter. He brings to our attention the methods available for appropriate reporting and billing of these teledentistry visits as well as what we can expect in this arena as we move forward.

My personal journey with regard to dental benefits was influenced greatly by my time as chair of the CDA Dental Benefits and Economics Task Force in 2018-2019. I found that more information and a greater understanding of the differing perspectives allowed me to feel more at ease with the subject. Even though the thought of dental benefits often elicits an emotional response in some, it is my hope that after reading this issue of the CDA Journal, the reader will find this to be a more understandable and less frustrating subject. n

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commentary C D A J O U R N A L , V O L 5 0 , Nº 7

C.E. Credit

Commercial Dental Benefit Plans Charles D. Stewart, DMD AUTHOR Charles D. Stewart, DMD, is the president, CEO and chairman of the board of directors for Aetna Dental of California Inc. and the senior dental director for Aetna Inc., both CVS Health companies. He is also the chairman of the California Association of Dental Plan’s (CADP) quality management committee, a member of the CADP board of directors and the lead instructor for the CADP’s quality assurance consultant certification courses. Dr. Stewart is credited with the development and implementation of the CADP computerized shared quality assurance assessment warehouse program. He is the 2021 recipient of the NADP Gabryl award for lifetime achievement in the dental benefits industry.

Conflict of Interest Disclosure: None reported.

C

ommercial dental benefit coverage has been identified by many terms, including dental insurance, dental benefits, private dental insurance and dental plans. The model refers to dental benefits offered through an arrangement with an employer or employer group or individually purchased coverage. The plans offered through an employer or employer group are standardized for that employer and may have varied coverages, benefits, exclusions and limitations. Individual plans are more standardized and structured with specific benefit levels and coverages. These individual plans rarely permit any options or changes to the standard offering.

Dental coverage as we know it today began because of the International Longshoreman’s Union/Pacific Maritime Association’s (ILWU-PMA) desire to add a dental plan as an employee or member benefit. In 1954, these organizations consulted with the California, Oregon and Washington dental associations to work on developing some type of dental coverage.1 The result of this collaborative effort was the development of a benefit model where certain dental benefits were prepaid in the form of capitation to the dentist and other dental benefits were reimbursed by an established patient copayment that was paid by the patient directly to the dental office. This effort resulted in the formation

of a subsidiary of the Washington Dental Association, named Washington Dental Service (WDS), later to become a Delta Dental plan, to administer this new prepaid dental benefit. Though many would suggest the Delta Dental plans are an indemnity plan, they do share many characteristics of that model, differing by their regulatory oversight. This regulatory oversight has associated requirements for benefits, quality and oversight.

In 1959, the Continental Casualty Company (CCC) became the first commercial insurer to offer dental insurance.2 The indemnity or private model of commercial dental benefits grew dramatically following the development by the CCC. The early model had rich coverages with specific annual maximums.

A common complaint today is that the annual maximum appears seemingly frozen at a level close to what it was at the inception of the benefit model.

The early dental health maintenance organization (DHMO) model worked well and provided valuable experience and learning opportunities for WDS. Today’s DHMO model resulted from evolution of this early WDS model of dental coverage.

Some of the experiences learned proved that “dental is different” and that a traditional medical HMO model and operation did not fit or work well in a dental office setting. The dental HMO JULY 2 0 2 2

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model grew in acceptance from both providers and patients, and by 1966, 2 million patients were covered by a dental HMO (prepaid dental). The explosive growth of this segment of the dental benefits industry continued, and in 1970, 12 million patients were covered.1 The Knox-Keene Act was written in 1975 as state legislators in California recognized the growth of this industry and required that regulations be established to set standards that assured compliance and consumer protections. In addition to the regulations, the Knox-Keene Act established governmental oversight for the prepaid medical and dental benefits industry. Initially, the oversight fell to the California Department of Corporations. The current regulator, the California Department of Managed Healthcare (DMHC), was established in 1999. The DMHC has oversight of and regulates all DHMOs in California as well as the products of Delta Dental of California. The dental preferred provider organizations (DPPO) began in the mid-1990s.1 Most dental PPOs are regulated by the California Department of Insurance. The oversight by the two different regulators in California differ in scope, magnitude and engagement.

In 1981, 82 million patients were covered by a dental HMO1 and growth seemed to continue unchecked. As the millennium approached, the dental benefits industry continued this growth pattern, and reportedly, over 150 million Americans had some type of dental benefit.1 By 2015, roughly 64% of the U.S. population had dental benefits. This number, when reviewed, showed about 170 million patients had some form of commercial dental benefit and about 50 million patients had benefits through a governmental program, such as Medicaid, Medicare or the Children’s Health Insurance Program (CHIP).3 394

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Today

In 2022, the standard commercial models of benefits described previously continue to exist, though the market share proportion of each of these models differs substantially from the market shares reported previously. Today, the DPPO product accounts for 86% of the dental benefit policies issued, according to the National Association of Dental Plans. The mechanics of the PPO model involve a network of contracted providers for patients to choose from.

These network dentists agree to accept

The dental indemnity model makes up slightly over 5% of 2022 dental benefit policies issued.

a discounted fee schedule in return for the referral of patients covered by the dental benefits plan. Most PPOs offer out-of-network (OON) benefits, with the OON benefit having the patient bear higher out-of-pocket costs. Some benefit plans even have lower annual maximums and higher deductibles than that which would exist by the patient being treated by an in-network dentist. Most PPO plans provide full coverage for diagnostic and preventive procedures, and some plans do not apply a deductible for these categories of procedures. For all the other categories of CDT codes and procedures, most PPOs pay either a percentage of or flat fee for the specific procedure. PPOs use a claim-based model of benefits and reimbursement. Specialists and general dentists are contracted to become

participating providers.

The National Association of Dental Plans

The DHMO plans use a closed network of providers, requiring the patient to select a primary care dentist. The primary care dentist is paid a fixed amount per month to provide a prepaid set of procedures to the assigned patient. Other procedures may have assigned copayments if performed. The DHMO model has prepaid benefits, meaning that claims are not required for reimbursement, though most DHMO’s require the submission of encounter claims. The reference to closed network infers that there are not out-of-network benefits available for the patient with the DHMO model.

Specialty care and services are available from the panel of contracted specialists.

The dental indemnity model makes up slightly over 5% of 2022 dental benefit policies issued. This claims-based model’s market share has been impacted by the strength and growth of the DPPOs and DHMOs. Dental indemnity plans are similar in structure to a PPO, without the network of providers. The California Department of Insurance provides oversight of and regulates dental indemnity plans. The level of benefits on these plans is highly variable, based on the purchasing employer’s desires.

Some additional factors contributing to the decline of the dental indemnity model are premium costs that are associated with no network providers and high utilization with patients desiring to maximize their benefits used.

The other significant model of commercial dental benefits is the discount dental plan. Roughly 6% of the 20204 products issued were discount dental plans.

Discount dental plans are not insurance but are designed where a dentist agrees to accept a discounted fee for procedures.

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The patient pays the dentist directly for all services performed based on the plan.

No claims or encounters are required for the discount plan model. Many dentists sell this type of plan directly to their patients. The DMHC regulates discount dental plans in California.

Governmental programs such as Medicaid (Medi-Cal Dental), CHIP and Medicare may follow a PPO or DHMO model. In addition, these government-sponsored programs may use a commercial dental benefit company to administer the program.

Admittedly, not all the described models of dental benefits would be acceptable to all dentists; some dentists may accept some, some may accept all and some might not accept any form of reimbursement, preferring a cash-only dental practice model. Frustrations may exist with any of these models.

For DHMOs, the structure of benefits and reimbursements may be simple or complex. Rules of what is or what is not a covered benefit complicate a practice’s ability to understand and communicate dental benefits to their patients. Dental benefit design lends itself to dentists and dental staff negotiating with and educating patients. Many dentists have expressed the concern that the DHMO-covered benefits are “free” when they are prepaid monthly. This structure where negotiation is required could lend itself to the high level of consumer complaints regarding balance billing and covered benefits. Most DHMO plans allow a dentist to provide an alternative or upgraded procedure if the covered benefit has been presented to the patient. When looking deeper at the design of the DHMO plans, the most common financial frustration is with the fixed copayment design of the DHMO plan. This design defines the maximum fee that can be charged for a specific CDT code. These fixed copayments

rarely, if ever, are changed, as any change in fixed copayment is embedded in the plan design and requires a filing with the DMHC before being permitted. This difficulty to update the fixed copayment creates a “stale” or outdated fee structure.

The PPO model has similar frustrations regarding the “staleness” of fees expressed about the DHMO model.

Some dental benefit plans allow providers of the DPPO model to negotiate fee schedules. Negotiating fees, if permitted, provides some control over the amount of payment received on a per-procedure

Dentists need to determine if the benefit of contracting with a DPPO fits within their individual practice model.

basis. Some dental benefit companies do not negotiate fees and use standard geographic fee schedules. Dentists need to determine if the benefit of contracting with a DPPO fits within their individual practice model; this selection is key to a mutually beneficial relationship between the dentist and the dental benefit plan.

Another concern is with the annual maximum. Many DPPO plans have the same annual maximum in place as they did in the early 1990s.5 The National Association of Dental Plans 2021 Dental Benefits Report from October 2021 stated that the percentage of PPO (in-network) patients who reached their annual maximum declined 2.4%. This is best explained as most dental benefit plans will provide a benefit level to an employer or company based on the desire

of that employer or company, though only a small percentage of patients ever reach that amount. In 2022, many dental benefit plans offer $2,500 or more as an annual maximum. Some rare plans do not have an annual maximum at all. Some traditional plans still have the $1,000 annual maximum that was common with the inception of the PPO concept. In a nutshell, the annual maximum should not be generalized to a dental benefit plan, as variants can and do exist in every benefit company. Tiered benefit levels based on the participation status of the dentist are another source of confusion for the PPOs. These tiers may provide a higher level of reimbursement, coverage and/or annual maximum when treated by an in-network dentist. Consumer complaints do exist with this product, however, the number of complaints on the PPO plans are much smaller compared to the DHMOs. There are positive aspects to the different models of dental benefit designs.

The DHMO model is viewed as an affordable benefit plan by employers and employer groups. This delivery model does not fit for every dentist or every dental office. There are dentists who prefer the stability of this model, with the predictable monthly capitation payment, viewing this as a guaranteed monthly income. During the 2020 COVID-19 pandemic and shutdown, dental benefit plans continued to pay providers their monthly capitation uninterrupted. This provided income to dental practices when dental care was restricted to emergency appointments only. The future of this benefit model appears uncertain. Enrollment in DHMOs has dropped reflective of the current employment situation in California. Growth and recovery of this market is flat, with pre-pandemic enrollment numbers remaining illusive.

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regarding the DHMO does not apply to the DPPO market. The DPPO is a claims-based, patient-based model. During the COVID-19 pandemic, patient visits were restricted to emergency services only, which allowed no financial stability or guaranteed income for PPO providers.

Patients were limited in their ability to see the dentist for dental care other than emergency services. No treatment means no claims, which leads to no income.

The driver or influencer over change in plan design and premium costs is the plan purchaser. As previously noted, employers influenced the early development of dental benefit coverage and have continued to play a significant role in sponsoring dental coverage and driving change in benefit models and coverage levels. However, significant shifts have occurred in the last few decades on the employer’s role in paying for dental coverage by markedly shifting the premium costs to their employees.

In the early WDS model discussed previously, all premiums were paid by the ILWU-PMA, likely from dues.

Employer-sponsored plans paid the entire premium in these early models. Under today’s dental benefit model, the patient can select different products during their open enrollment, with the employer contributing a specific amount toward the monthly premium. Most dental benefit companies are willing to design a benefit package with different coverage levels, annual maximums and benefits. Some employer groups today want higher annual maximums, coverage for implants and implant prosthetics, coverage for sleep appliances, coverage for TMJ treatments and enhanced benefits for dental/ medical conditions. Providing a more comprehensive and integrated benefit demonstrates some hope for change for the future of the dental benefit industry.

The correlation between oral health 396

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and overall health has prompted dental benefit plans to offer programs that enhance benefits for those patients with qualifying medical conditions.

Cardiovascular disease, cerebrovascular disease, diabetes and pregnancy are the most common medical conditions linked by dental benefit plans to be eligible for enhanced dental benefits.

The specific enriched dental benefits vary by plan, but generally are an allowance for an additional prophylaxis or other periodontal procedures. Research has shown true savings in medical costs for

Changes to the industry are starting to happen with the use and integration of artificial intelligence (AI).

those with the medical conditions who access their enhanced dental benefits.6 Some full-service benefit plans (medical and dental) can review medical claim data to determine eligibility for the enhanced dental benefits. Standalone dental benefit plans rely on the patient to self-report the medical condition for consideration of any enhanced dental benefits.

Improved access to care is a beneficial aspect of having a dental benefit plan for the patient.7,8 Plan regulators require that dental benefit plans have filed access standards or requirements that all providers are expected to meet to ensure patient appointment access.

These access requirements vary from benefit plan to benefit plan and even product to product. The goal of the

access standards is to provide consistent and guaranteed access to care. In 2022, many dental benefit plans are exploring expanding their product scope into the individual marketplace, thus, there is the potential for more insured individuals.

More insured individuals means increased demand for dental treatment and access, but also means the potential for increased patient flow. It’s a win-winwin for enrollees, providers and plans.

Looking Ahead

The future looks bright for the dental benefits industry. While more Americans are retaining their natural teeth into their later years, dental caries and other diseases remain a constant threat to good oral health. The foods consumed, the delivery of that food (fast food), sugary snacks and lax home care regimens can assure that the need for dental care will continue into the future. The dental benefits industry serves as a conduit for enrollees to receive needed dental treatment.

Changes to the industry are starting to happen with the use and integration of artificial intelligence (AI). AI is the practice and development of automated systems and processes using computer systems to perform tasks that historically required human intervention or human intelligence. The world is experiencing speech recognition, visual recognition, decision-making and analysis and language capabilities all moving to some form of AI. Dental plans are also implementing some of these capabilities in the customer service departments as well as claims and utilization management processes to improve efficiencies and identify anomalies in claim submission.

All dental benefit plans have extensive and comprehensive programs to address fraud, waste and abuse (FWA) in the dental insurance claims process. These programs addressing FWA are required

C D A J O U R N A L , V O L 5 0 , Nº 7

by law. Several private companies offer AI as a tool to assist in the identification of FWA. Using AI, the detection and follow-through on potential FWA have become more sophisticated. Historic FWA programs were generally internal to a dental benefits company and used algorithms to analyze and select claims, claim patterns and develop practice profiles used to identify, curtail and prosecute FWA, but these internal programs were limited to internal claims and claims processes. With AI, analysis of claims does occur, but the analysis can identify additional patterns and concerns, such as the same duplicate radiographic or photographic images used for different patients as well as upcoding of restorative surfaces.

AI is being used to expedite claim review and claim processing, with a higher level of accuracy than with the traditional or historic models of manually handling claims. With AI, all claims are addressed using an automated process that provides a faster, fairer and more consistent outcome for the patient, the provider and the dental benefits plan. Kyle Stanley, DDS, an international lecturer known for his work in the field of dental AI, says “Like it or not, insurance is the dental industry’s financial engine. Anything that makes that engine more efficient is going to benefit dentistry as a whole.”9 AI shows the potential of streamlining the claims review process. With increased acceptance of AI, the result will be less human intervention, more automation, centralized information resources, standardized professional reviews and elimination of human errors and bias. These changes ultimately benefit the dental providers and dental staff by eliminating the burdens and concerns that exist today regarding the claims review process.

AI implementation is not limited in

scope to the dental benefit plans. AI can be used in the dental office as well. In 2022, many dentists use digital imaging systems or CAD/CAM technology for restorations or prosthetics. Newer applications can be used to aid in the detection of soft tissue abnormalities, bone loss, calculus and caries from the various images obtained in the examination process. Other applications could be used to develop a treatment plan. The potential expansion of the capabilities of AI provides a bright future that will enhance the dental experience for patients, providers and plans alike.

insurance.

4. National Association of Dental Plans. 2021 Dental Benefits Report: Enrollment. December 2021.

5. National Association of Dental Plans. 2021 Dental Benefits Report: Enrollment. October 2021.

6. Center for Integration of Primary Care and Oral Health and Harvard School of Dental Medicine Initiative. The Challenge of Medical Dental Integration.

7. American Dental Association. Oral health and well-being in the United States.

8. Manski RJ, Moeller JF, Chen H. Dental Care Coverage and Use: Modeling Limitations and Opportunities. Am J Public Health 2014 February; 104(2): e80–e87. Published online 2014 February. doi: 10.2105/AJPH.2013.301693.

9. Stanley K. AI set to fix dental insurance. Dent Econ Feb. 29, 2020.

T HE AU T HOR , Charles D. Stewart, DMD, can be reached at stewartc@cvshealth.com.

Conclusion

In the 70 years since the initial concept of a dental benefit plan was developed, many changes have occurred.

Unfortunately, some things such as basic benefit design, annual maximums, exclusions and limitations remain unchanged, much to the dismay of the dental professionals of 2022. As dental benefit plans provide many patients with a financial means and incentive to achieve and maintain dental health, they too cause frustration for dental patients, dental providers and their office staff.

Today’s dental benefit plan is much more flexible and willing to offer and design a product based on the request of an employer group than in the earlier years of the industry, but this acceptance is dictated by the willingness of the employer groups that purchase the product to make changes to their employees’ package of dental benefits. Artificial intelligence provides hope for the future to apply the processes necessary to continue easing the frustrations expressed by many users of the dental benefit plans. n RE FE RE N C E S 1. National Association of Dental Plans. Dental benefits history.

2. Encyclopedia.com. Dental insurance.

3. American Student Dental Association. Understanding dental JULY 2 0 2 2

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C .E. CREDIT QUESTIONS

July 2022 Continuing Education Worksheet This worksheet provides readers an opportunity to review C.E. questions for the article “Commercial Dental Benefit Plans” before taking the C.E. test online. You must first be registered at cdapresents360.com. To take the test online, please click here. This activity counts as 0.5 of Core C.E. 1. Which of the following statements is false: a. The first known dental plan, instigated by the International Longshoremen’s Union/Pacific Maritime Association’s desire to provide dental benefits to employees was a collaboration between California, Oregon and Washington in 1954. b. The plan that resulted was a subsidiary of the California Dental Association and was named the California Dental Service (CDS). c. That first plan eventually became known as Delta Dental. d. In 1959, the Continental Casualty Company (CCC) became the first commercial insurer to offer dental insurance.

2. True or False: The Knox-Keene Act, written in 1975, established national governmental oversight for the prepaid medical and dental benefits industry.

3. In 2022, according to the National Association of Dental Plans, what percentage of dental plans utilizes the PPO model? a. 68% b. 72% c. 78% d. 86% 4. Which of these are true statements regarding PPO plans (mark all that apply)? a. They utilize a network of contracted providers. b. Network providers accept a discounted fee schedule in return for the referral of patients. c. Most plans do not cover out-of-network services. d. Often diagnostic and preventive services are fully covered.

5. Which statement about DMHO plans is false? a. Patients must select a single, primary care dentist. b. Dentists receive a capitated monthly rate for a predetermined set of services for each assigned patient. c. The DMHO model does not utilize a claims-based payment model. d. Dentists can perform and bill patients for services that are not part of the predetermined set of benefits if in their judgement the patient needs a noncovered service. e. DMHOs are generally viewed as an affordable benefit plan by employers and employer groups.

6. Which statement about dental indemnity plans is false? a. In 2022, just slightly over 5% of the dental policies issued were indemnity plans.

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b. One of the main differences between a PPO and indemnity plan is that the indemnity plan does not use a network of providers. c. The level of benefits offered in an indemnity plan is determined by the purchasing employer. d. In California, indemnity plans are regulated by the California Department of Managed Healthcare.

7. True or False: The DMHO model of prepaid benefits often leads to confusion among patients about what is covered and what they must pay for, which results in billing complaints.

8. Which of the following are common frustrations with dental benefit plans (mark all that apply)? a. Fixed copayment design in the DMHO model. b. Stale annual maximums. c. Difficulty updating dentists’ fee schedules. d. Plan complexities and coverage variations require dentists and dental office staff to spend time educating patients. e. All of the above.

9. Which of the follow statements accurately describes artificial intelligence (AI) and its use in the dental sector (mark all that apply)? a. AI is the practice and development of automated systems and processes using computer systems to perform tasks that historically required human intervention or human intelligence. b. All dental benefit plans use AI to address fraud, waste and abuse in the dental insurance claims process. c. AI analysis can identify such concerns as the same duplicate radiographic or photographic images used for different patients as well as upcoding of restorative surfaces. d. AI can expedite claim review and claim processing, with a higher level of accuracy than with the traditional or historic models of manually handling claims. e. Newer AI applications can be used in-office to aid in the detection of soft tissue abnormalities, bone loss, calculus and caries from the various images obtained in the examination process. f. All of the above.

10. True or False: Today’s dental benefits plan is more flexible and willing to offer and design a product based on the request of an employer group than in the earlier years, but this acceptance is dictated by the willingness of the employer groups that purchase the product to make changes to their employees’ package of dental benefits.

C D A J O U R N A L , V O L 5 0 , Nº 7

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Reshaping the Medi-Cal Dental Program — Evolving Oral Health Care in California Jennifer Kent, MPA AUTHOR Jennifer Kent, MPA, has more than 15 years of extensive health administration and policy experience in California that spans over three gubernatorial administrations and encompasses both private and public delivery systems. As director of the Department of Health Care Services, Ms. Kent oversaw the second largest public health care system in the nation with an annual budget of over $100 billion and serving approximately 13 million Californians. She also has experience in the private sector as a lobbyist, consultant and association executive.

Conflict of Interest Disclosure: None reported.

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alifornia’s Medicaid program, Medi-Cal, is the largest in the nation with over 14 million low-income Californians currently enrolled as of June 2021.1 For perspective, the next largest Medicaid program is the state of New York, with 7.2 million beneficiaries as of September 2021.2 With such a large population and complicated program, enacting meaningful, direct and notable change is often difficult. When I became director of the Department of Health Care Services (DHCS) in February 2015, I often said that running the Medi-Cal program was like steering a cargo ship: The program was slow and built to travel long distances and carry a heavy load — it was not a speedboat. Given the vulnerable populations served by MediCal, it is also a management challenge to spend dedicated, focused time on a single element of the program when it spans eligibility, fiscal, information technology, legal and policy areas. There is often not a lot of flexibility or luxury to choose the area of the department that a director wants to work on. Rather, a single issue or public headline can dominate a department for weeks, if not months. Advocates, providers, counties, policymakers, federal agencies and state oversight agencies also have significant input into the priorities of the department, which creates a distinctly unique set of balancing these oftenoppositional demands. It was hard to

satisfy anyone, much less everyone.

As a new director, one of the very first issues to catch my attention was the Medi-Cal Dental Program. But then again, it was not hard to miss! I walked into a department that had already received one extremely critical external report, with another one pending, on the failure of the program to provide basic dental care to millions of low-income Californians, especially children. Between the California state auditor’s December 2014 report “California Department of Health Care Services: Weaknesses in its Medi-Cal Dental Program Limit Children’s Access to Dental Care” and the Little Hoover Commission’s April 2016 report “Fixing Denti-Cal,” the department was under a lot of pressure to make quick improvements in a program that had been largely ignored for years. Those problems included an unacceptable utilization of preventive services, diminishing provider participation rates, lagging reimbursement rates and general staff apathy. An example in the auditor’s report noted that a federal Centers for Medicare & Medicaid Services (CMS) report had indicated that California’s utilization rate of 43.9% was the 12th worst among states in fiscal year 2013. And one of the most telling data points was our own DHCS data: 11 counties had no providers willing to accept new Medi-Cal patients and 16 counties had provider-to-patient ratios above 1:2,000. We also knew that there was at least one county without a single JULY 2 0 2 2

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participating dentist. Based on all of these facts, I knew I had problem that needed a variety of solutions, each of which would require time, patience and persistence.

What To Fix First?

Money

As the audits and external reports pointed out, the dental rates in MediCal were low. But simply throwing money at the program is not as easy as it sounds. Most notably, I worked for a governor who was famously (and proudly) tightfisted. At some point, Gov. Jerry Brown had given a placard to one of his senior staff that stated: “Responsibility is a form of compensation.” We liked to joke that we were highly compensated in his administration. Due to the governor’s perspective on this issue, DHCS could not get rate increases by simply asking.

Rather, DHCS had to demonstrate to the Department of Finance that there were legal ramifications (such as federal disallowances or sanctions) that required such a rate increase. And a “demonstration” of this magnitude was often still rejected after multiple meetings and documents. Adding to the governor’s general opposition to rate increases in Medi-Cal, the state of California was also bolstered by its recent U.S. Supreme Court victory in Douglas v. Independent Living Centers3 (2012) regarding the ability of a state to reduce Medicaid rates and the inability of providers to challenge those reductions. Due to the legal and fiscal environment in 2015-16, it was clear that a straightforward rate increase would not be successful. Lastly, we knew that a rate increase, even if provided, would be so small as to be almost unnoticed by providers and would not correct years of static funding in the program.

Administration

Given the fiscal situation of the state

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budget and the reluctance of the governor to approve across-the-board rate increases, we also focused on the other aspects of the program that were not budget related. We heard loud and clear from dentists about the administrative burden of participating in the Medi-Cal Dental Program, including the length of the provider application and the unnecessary or overly burdensome treatment authorization process for several procedures. These changes were easier (although not as easy as it sounds) to address. The program staff worked with representatives from the

We heard loud and clear from dentists about the administrative burden of participating in the Medi-Cal Dental Program.

California Dental Association (CDA) and individual providers to understand the barriers to participation and suggestions on improvements. Based on these meetings, the dental provider application was dramatically shortened to the “bare essentials” as required by federal law and a number of prior authorizations were removed. A longer-term initiative was also started to add dental providers into the DHCS provider enrollment portal (PAVE) so that new and renewing dental providers could more easily apply electronically.

Management

John C. Maxwell has a favorite quote that perfectly describes how I approached changes to the Medi-Cal Dental Program: The pessimist complains about the wind. The optimist expects it

to change. The leader adjusts the sails.

When I first met with the dental division staff shortly after I became DHCS director, I distinctly remember one staff member who fell asleep during our meeting, and the acting division chief spent the better part of our time together explaining all the reasons why the program could not change, mostly because “it had always been done that way.” I left that meeting and promptly decided that a significant staff overhaul was warranted.

Within a week, that acting division chief had been reassigned to another part of DHCS — which ultimately led to their decision to retire a week later.

We had a few dental consultants who were not meeting expectations and those contracts were ended. Other staff decided that perhaps their future was in a different program or state agency.

All of these changes were expected and part of the necessary change that would lead to a better program — and while I knew it was going to be a little bumpy in the interim, I felt it would ultimately be successful as long as a solid team was being established in its place. Thankfully, we were able to recruit a dynamic and thoughtful division chief, and we were able to attract other individuals who are still working in the program and are as committed to improving the program as when they started.

Location

The Medi-Cal Dental Program had been located in Rancho Cordova, California, for many years near the location of Delta Dental’s headquarters.

Given the cost and availability of office space for state agencies in downtown Sacramento, this remote location was not necessarily unusual. However, based on a variety of issues, it became clear that a relocation of the program to the DHCS headquarters would be an important

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factor in changing the culture of the division and ensuring that executive leadership was able to help support the new division chief. While this change was in development, one event helped expedite the move: a box of cash.

Fraud is not new to Medi-Cal. Unfortunately, when a program as large as California’s exists, there are always a few individuals who look to take financial advantage. Former directors of DHCS have appeared on “60 Minutes” and CNN defending the department after extremely damaging fraud investigations and explaining how they would change the program to better protect public funds from fraud and corruption. DHCS has had employees led out of the department in handcuffs, and the FBI has seized documents from our own offices. While there is always a lot of bad publicity around fraud in public programs, the increasing use of technology, including data analytics and more sophisticated claims systems, has reduced fraud, especially when coupled with aggressive state and federal prosecutions.4 As you can imagine, it is one of the most disappointing and disheartening events that can happen to a director to see unscrupulous individuals abusing a program that has so many reputable providers and deserving beneficiaries. The final straw about relocating the Medi-Cal Dental Program was when I got a call late one night reporting that a box of cash had been found in the program’s mailroom stacked next to other boxes containing dental molds and other packages for the program staff. This box, however, had no mailing address and no return address — and contained over $18,000 in cash ($50s and $100s all wrapped in plastic). It is not surprising that to this day, all these years later, the individual “mailing” this package and the individual “expecting” this package have never come

forward looking for their lost parcel. Thus, the dental program was expeditiously moved into the main headquarters of DHCS, and we moved onward.

Opportunity Knocks

State Medicaid programs have a series of authorities and mechanisms to operate their programs, and California has traditionally used a variety of these methods to accomplish initiatives that would otherwise not be possible or fiscally allowable using a more traditional Medicaid authority. Dating back to the

DHCS has had employees led out of the department in handcuffs, and the FBI has seized documents from our own offices.

early 2000s, California has employed the use of a Section 1115 Demonstration (1115) Waiver authority to make significant changes in its Medi-Cal program. Without being overly technical, a state can make a series of calculations to demonstrate to the federal government that the 1115 waiver will either be budget neutral or save the federal government funds. This waiver calculation allows for a state to use these “savings” to otherwise support a state’s waiver initiative and fund items that would not otherwise be eligible for Medicaid funding. While the state’s initial 1115 waiver in 2005 was primarily used to support California’s designated public hospitals, it also contained the first of many coverage expansions for individuals otherwise not eligible for Medi-Cal. With each five-year waiver

period, California has increasingly used these 1115 waiver funds to expand coverage, transform public hospital systems and fund innovative programs such as the Dental Transformation Initiative.

As the state was negotiating its 1115 waiver in 2015, we were mindful of the fact that substantial Medi-Cal provider rate increases would not be forthcoming in the state budget. So, when the federal government indicated that it was rejecting earlier waiver concepts but that a small portion of funding was available over the five-year waiver period ($750 million), we seized the opportunity and created the Dental Transformation Initiative (DTI). I still remember sitting next to the state Medicaid director as we were on a call with the federal officials from the Centers for Medicare & Medicaid Services and nodding together as they explained the limited items they would consider acceptable. We immediately said in unison, “We want it for dental, please.” This infusion of cash was not only important to lift the dental program into a place where it could demonstrate new ways of delivering care, such as the local dental pilot programs and the caries risk assessment, but it also signaled to both DHCS staff and providers that we were collectively aligned in our goals to bring better quality dental care to California patients. I considered this the first important building block that showed we were truly committed to improving the dental program and were not on the defensive and merely responding to audits and negative reports.

Once DHCS realized that funds were going to be available to help restore the dental program, it quickly became necessary to establish an advisory group of external experts to help the program set goals and desired outcomes. CDA was quick to provide both staff and clinical expertise to the DHCS staff as we JULY 2 0 2 2

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developed utilization goals and worked through the details of the structure of the DTI. While there was pressure from the Little Hoover Commission, the California state auditor and state policymakers about the need to set ambitious goals for utilization, the state has traditionally relied on a mix of federal targets or benchmarking against other state Medicaid programs as a way to ascertain the success of a program benefit or modification. In this particular instance, the state also worked closely with CDA to pull research from other academic sources, especially for the pediatric dental standards. Ultimately, the state relies on a compilation of material to set program goals, targets and benchmarks.

Getting a Seat at the Table

As part of the DHCS official stakeholder process, there is a committee known as the “Stakeholder Advisory Committee,” which was originally composed of a small number of providers, health plans, advocates and counties. The original committee was created as part of the state’s 1115 waiver process in 2010 and met quarterly with DHCS executives.

While the meetings were public, there was very little input that members of the public could participate in, including attendees from CDA. As part of the effort to improve the Medi-Cal Dental Program and build a stronger relationship with organized dentistry, DHCS offered a designated seat to CDA so the issues of oral health would be more prominently heard and included when it came to the overall administration of the Medi-Cal program. This seat continues to be held by a representative from CDA, which has led to an overall more responsive relationship between the association and the program staff. It has also been an important reminder to everyone, both DHCS staff and other interested parties, 404

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to not forget the role that oral health plays in the overall health of a beneficiary.

Restoration of Adult Dental and Restoration of Rates

Data play an important role in the Medicaid program, and the abundance of such data finally allowed the DHCS to successfully advocate within the administration to the Department of Finance and the governor’s office that the 10% provider rate reduction as enacted via AB 975 be restored in the dental program. While a few services such as

As with all program changes in Medi-Cal, it often takes many years for the full impact of the change to be seen.

the rates paid to dental pediatric surgery centers were exempt from these rate cuts, most were not. This rate restoration, as indicated earlier, was not necessarily significant enough on its own or large enough to increase provider participation in any meaningful way, but it was part of a larger package of improvements to the program that signaled positive changes.

The Game Changer Proposition 56

On Nov. 8, 2016, the efforts of CDA (along with the California Medical Association and other key organizations) were successful in convincing a majority of California voters to approve Proposition 56 — the California Healthcare, Research and Prevention Tobacco Tax Act. A portion of the additional

$2 tax on tobacco products made a once impossible goal possible, and this dedicated piece of Proposition 56 has enabled supplemental payments for restorative, endodontic, prosthodontic, oral and maxillofacial, adjunctive and preventive services, which generally equaled a 40% increase in the established base Medi-Cal rate. For certain codes or procedures, DHCS made a specific dollar increase that equaled a 100% or greater increase in the service code. As dental providers saw this increase in their reimbursements, it became exceedingly important to ensure the stability of the Proposition 56 supplemental rates in order to retain the existing providers but also attract new providers in the program.

Growing a Medi-Cal Dental Workforce

As with all program changes in Medi-Cal, it often takes many years for the full impact of the change to be seen.

Even with positive changes such as the Proposition 56 supplemental payments, we knew it would take several years for utilization to increase to levels that fully reflected provider acceptance and participation in the program. After the first year of Proposition 56 rate increases, DHCS was faced with leftover funds that had not been earmarked. Rather than allow the funds to be “swept” back into the state general fund (which was definitely the preference of the Department of Finance), we reached out to the California Medical Association and CDA. We proposed to use the leftover $220 million for physician and dental loan repayment. And this loan repayment program was not just any loan repayment program — the CalHealthCares program was designed in a way to fundamentally alter the career path of physicians and dentists when starting out. We suspected that many providers wanted to serve

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in underserved areas or work with underserved populations, but simply could not because the economics of that kind of population could not support them as they established their practice, paid off their student loans and looked to their future home and life. CalHealthCares will pay up to $300,000 in qualified student loans for providers who have graduated within the past five years and are willing to commit to a third of their patient caseload being Medi-Cal patients. To date, almost 80 dentists have been awarded loan repayments from CalHealthCares, and it is expected that several more cohorts will be announced in the next few years.

To Summarize: Change Is Hard

As this brief article demonstrates, the myriad changes that have been made in the Medi-Cal Dental Program over the past five to six years have taken time to fully come to fruition and may continue to evolve in future years. Given the exciting changes that continue to be on the horizon, including an integrated dental benefit in cooperation with the Health Plan of San Mateo, I believe that the audits and negative reports were actually helpful in bringing attention to a program that had been largely ignored and not prioritized for improvement. While there are still plenty of issues that could

be addressed, I think the department, in cooperation with CDA, can be proud of the progress that was made and the progress that remains to be achieved. n RE F E RE N C E S 1. Department of Health Care Services, September 2021.

Medi-Cal Monthly Eligible Fast Facts.

2. New York State Department of Health. Medicaid enrollment by county.

3. The Supreme Court of the United States. Douglas v.

Independent Living Centers.

4. State of California Department of Justice, Office of the Attorney General. Medi-Cal fraud.

5. California State Assembly, Committee on Budget. 2011 Assembly budget committee reports.

T HE AU T HOR , Jennifer Kent, MPA, can be reached at jennifer@thekentgroup.org.

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One More Look at Medicare and Why a Dental Benefit Is Still Needed for All Elisa M. Chávez, DDS

abstract Medicare was originally envisioned to include oral health care. But the opposition to its inclusion prevailed, and nearly 60 years since its enactment, older Americans struggle to afford needed dental care. An opportunity came and went to include provisions for oral health care in Medicare with the Affordable Care Act and most recently in the Build Back Better Act. The need and benefit of regular oral health care for older adults has been demonstrated time and again. There has been strong support from advocates for older adults and their families, including many medical and dental professional groups and patients themselves. Yet, there was not enough support to surmount resistance to the financial, social and professional investment that is required to get older and disabled Americans the resources they need to improve their access to care and maintain good oral health. And so there remains a known gap in our health care system that will continue to present a barrier to achieving the best outcomes for patients in both dentistry and medicine.

Keywords: Aging, dentistry, oral health, health policy, disparities, Medicare, vulnerable patients

AUTHOR Elisa M. Chávez, DDS, is a professor in the department of diagnostic sciences at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco and the director of the Pacific Center for Equity in Oral Health Care. She graduated from the University of California, San Francisco, School of Dentistry and earned her certificate in geriatric dentistry from the University of Michigan, Ann Arbor. Dr. Chávez has practiced in private, community health center, skilled nursing, hospital

and PACE (program for all-inclusive care for elders) settings. She recently served on the California Dental Association Medicare task force and as a founder’s fellow and scholar with the Santa Fe Group advocating for the oral health needs of older adults nationwide.

Conflict of Interest Disclosure: None reported.

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he concept of integrating medical and dental care in America is not novel. In 1932, the inclusion of dental care as part of a comprehensive health plan was considered by then Secretary of the Interior Ray L. Wilbur, MD.1 President Harry Truman sought a national health plan in 1945 that would provide for routine health care such as doctor and hospital visits, laboratory services, nursing and even dental care. Then in the early 1960s, President John F. Kennedy called for a health program specifically to support seniors after a study revealed more than half were without health insurance at

the time.2 This is interesting in light of 2016 data showing 62.7% of adults aged 65 and older lacked dental insurance.3 In 1965 under President Lyndon B. Johnson, Medicare was enacted, but without dental benefits. Both the American Medical Association (AMA) and the American Dental Association (ADA) were opposed to Medicare. The ADA prevailed, and ultimately oral health care was left out of Medicare.4 In 1966, some 19 million older adults signed up for Medicare in the first year. In 1972, Medicare was extended to individuals under age 65 if they had a long-term disability or end-stage renal disease. The 1980s saw expansion in home JULY 2 0 2 2

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health and hospice care benefits. Medicare Part C or Medicare Advantage (MA) plans introduced in the 90s offered addon benefit coverage through a managed care program, rather than the traditional Medicare fee for service. Now about 42% of all Medicare enrollees are in an MA plan. These MA plans take the place of both Part A and Part B for people who choose to enroll. In 2003, Medicare Part D was added as an option to purchase in addition to Medicare or integrated with an MA plan to help cover prescription drug costs. Prior to this time, only about a quarter of older American’s had insurance to cover drug costs. By 2019, nearly threequarters of enrollees had a drug benefit and about 90% of MA plans included Part D.2 The Patient Protection and Affordable Care Act of 2010 implemented many reforms in Medicare aimed at reducing costs and improving outcomes, but provisions for dental care for older adults were not among these reforms.2,5,6

adults. California is one of only 19 states that provide extensive dental coverage for adults who qualify for Medicaid, but these benefits are also vulnerable each year as the annual state budget is established.8 Medicare is paid for through two trust fund accounts held by the U.S. Treasury. These funds can only be used for Medicare.9 ■ Part A is funded by the Social Security’s Federal Hospital Insurance (HI) Trust Fund and helps cover inpatient hospital stays, stays in skilled nursing facilities, hospice and

California is one of only 19 states that provide extensive dental coverage for adults who qualify for Medicaid.

What Medicare Covers and How

Medicare is primarily funded by federal dollars and is available to all Americans age 65 and older and some adults younger than 65 who are disabled. There are 6.4 million enrollees in California, the most of any state. Medicare is administered on a federal level and income is not a consideration for enrollment.

Medicaid uses means testing to determine eligibility and is funded by federal and state funds but is administered by each state. As such, states can determine if or what benefits they will provide as well as reimbursement structures and rates.

Rates for Medicare tend to be higher than rates for Medicaid, and there is a higher physician enrollment as a result.7 While some states provide adult dental benefits in Medicaid, these benefits are not guaranteed and are not a reliable source of oral health care coverage for older 408

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home health care as well as program administration costs. Part A is funded by payroll taxes, income taxes paid on Social Security benefits and interest earned on the trust fund investments, so enrollees do not pay a premium for this coverage. Medicare spending projections fluctuate with time. It has been projected that the Medicare Part A trust fund asset level was expected to be depleted by 2026 and that future claims would have to be covered predominantly by payroll taxes, which may be inadequate.9,10 Part B is funded by the Supplementary Medical Insurance (SMI) Trust Fund. These funds come from general revenue authorized

by Congress and enrollee monthly premiums. Part B helps cover the

costs for outpatient care, including some preventive services and tests, physician’s services, medical equipment, clinical laboratory services and some other services for all enrollees. Medicare beneficiaries pay a Part B premium to the Social Security Administration. Although Part B services are the same for all beneficiaries regardless of income, low-income beneficiaries who qualify for Medicaid receive subsidies for Part B at no extra cost ($0 premium). For most services, Medicare pays 80% of the cost (using an established fee schedule) and patients have a 20% copay. There are no limits on outof-pocket payments for enrollees.8 However, enrollees can purchase supplemental health insurance (Medigap) to traditional Part A and Part B to help reduce the out-ofpocket costs for copays, coinsurance and previously for deductibles. These Medigap plans are different from MA plans and they are not available for persons with MA plans, only traditional Medicare. For persons who qualify for Medicaid, Medicaid covers those gaps in traditional Medicare coverage. States can use Medicaid funds to cover Medicare premiums and cost sharing for beneficiaries whose income is ≤ 100% of the federal poverty level (FPL). Some states have expanded Medicaid eligibility to include individuals and families up to 138% of the FPL. The FPL in 2020 was an annual income of $12,880 for one person and $17,420 for a family of two. In 2019, ~12% of Medicare beneficiaries were at 100% or below the FPL and another ~20% were below 200%.11 The average out-of-pocket costs in 2016 were $5,806 for supplemental insurance and uncovered medical

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and long-term care costs, but they could be much higher for persons without this Medigap insurance.10 Part C allows Medicare recipients to select to receive their Part A and Part B covered services via a managed health care plan (known as Medicare Advantage) rather than accessing them through the traditional fee-for-service providers who participate in Medicare. o MA enrollees usually pay the Part B premium in addition to their MA premium. o MA plans must provide at a minimum the same benefits provided under traditional Medicare, but they can offer additional coverage at additional cost. The plans may charge beneficiaries a premium in addition to their Part B premium and can establish different copay arrangements with patients.

They may offer extra coverage above what is required under Part A and Part B such as prescription drug coverage, dental, vision, hearing and wellness programs, but they are not required to provide a specific package of benefits beyond what is currently provided through traditional Medicare. Federal regulation requires MA plans to establish a limit on out-of-pocket spending for beneficiaries. In 2021, this limit was $7,550 for in-network care and $11,300 for out-of-network care. This out-of-pocket limit does not exist in traditional Medicare and thus the availability of Medigap (supplemental plans) to traditional Medicare. These

o

limits do not apply to Part D, which is discussed below.11 While dental plans are now widely available in MA plans, they also vary widely. In 2020, ~74% of MA enrollees paid for a dental plan, some of which included only preventive care. Every MA plan can establish its own set of benefits and rates and most plans mirror traditional dental plans, including an annual dollar cap on the benefit. If a

Plans must provide at a minimum the same benefits provided under traditional Medicare.

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dental benefit were provided in Part B, MA plans would need to include at least the same benefit for anyone who chooses an MA plan.10 Part D is also funded by SMI and provides prescription drug coverage to both traditional and MA enrollees who wish to enroll. Part D is offered by distinct Medicare Prescription Drug Plans or MA plans, each of which establishes their own drug formulary and enrollees’ cost-sharing like premiums and deductibles, but they must provide at least a standard benefit that is established by Medicare.10 States must use Medicaid funds to cover Medicare Part A and Part B premiums and cost sharing for beneficiaries whose income is

at or below 100% of the FPL.

Dental Benefits in Medicare Now12

The exclusion of dental care in Medicare is specified in Section 1862 (a)(12) of the Social Security Act: “where such expenses are for services in connection with the care, treatment, filling, removal or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.” This provides only for the cost of the hospital services, not the providers or any dental procedures that are provided in the hospital.

The Centers for Medicare & Medicaid Services (CMS) acknowledges that the exclusion is not based on value nor necessity of the care but is limited by the structures, in this case: “Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, cementum of the teeth and the alveolar bone (i.e., alveolar process and tooth sockets).” Even in cases where another procedure is covered, such as surgery to excise a tumor, any subsequent dental care, such as replacement of dentition that was removed at the same time the tumor was removed, is not covered. There are two exceptions to the dental exclusions: ■ The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

■ An oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a rural health center JULY 2 0 2 2

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Medicare enrollees 70 (RHC) or federally qualified health center (FQHC) prior to a heart valve replacement. Note that this refers to just the examination, not the subsequent dental treatment.

MA plans currently serve about 45% of Medicare beneficiaries in California and about 39% nationally.14 These plans voluntarily offer dental benefits to attract patients to their plans and there are no requirements for what these plans must provide.13,14 Benefits provided through Part B in the fee-forservice traditional Medicare program would establish a minimum level of coverage that MA programs must include in their policies.13 If dental benefits were added to Part B, MA plans could provide more extensive coverage at an additional cost for persons who want more coverage, but they could not provide less than Part B, which would establish it as a basic benefit for all enrollees.

The Legislative Road So Far

There has been much discussion and anticipation of a dental benefit in Medicare in recent years and months.

Even before the pandemic, recognition was growing about the disparities in oral health care for older adults as a group with additional disparities related to race, ethnicity, income and disability.14 Approximately half of Medicare enrollees did not have a dental visit prior to the pandemic — often skipping care due to cost.15 And disparities exist along racial and ethnic lines as well; 68% of Black beneficiaries and 61% of Hispanic beneficiaries did not have a dental visit in 2018.15 Individuals with disabilities experience an additional level of risk for oral disease and difficulty accessing care.

Fourteen percent of enrollees are under age 65 with a disability that qualifies them to receive Medicare.11 A third of all enrollees require help with one or more 410

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60 50 40 30 20 10 0 Long-term care

85+

Under 65

Functional 2 or more limitation chronic conditions

FIGURE 1. Enrollee characteristics.15 (Source: KFF Medicare enrollee data 2016.)

activities of daily living such as eating, bathing, dressing, walking, doing chores or managing their money or medications.

Three percent require assistance to the extent that they are in long-term care.

And 12% of enrollees are age 85 and older, a population that continues to grow rapidly. Approximately two-thirds of all enrollees live with two or more chronic conditions such as diabetes and cardiovascular and pulmonary diseases, all of which have been associated with poor oral health15 (FIGURE 1 ). Persistent and chronic poor oral health poses a risk to overall health and well-being.16–19 And further, the conditions themselves and the medications used to manage diseases such as these that are common in older adults also place oral health at risk, becoming a circular issue. In the absence of regular preventive oral health care, dentition and oral health can break down with both chronic and acute consequences.20 Since 2015, 26 legislative bills were drafted with the aim of including a dental

benefit in Medicare. Some of the most recent and most widely known bills are H.R.3, the Elijah E. Cummings Lower Drug Costs Now Act, and H.R.5376, the Build Back Better Act of 2021.

The Build Back Better plan called for dental, vision and hearing coverage to be added to Medicare at an estimated cost of $238 billion over 10 years to include preventive and screening services such as oral exams, cleanings and X-rays, major treatments such as crowns and root canals and dentures. The savings from the other provision of this bill to reduce the cost of prescription medications were projected to pay for the cost of these added benefits, along with patient premiums and co-pays.21 The plan would provide coverage to all enrollees through Part B — alongside other outpatient health care services such as primary and specialty physicians, physician assistants, nurse practitioners, chiropractors, clinical social workers, physical therapists, occupational therapists, speech language pathologists,

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clinical psychologists and others.13,22 As noted by a letter to legislators from the Medicare Oral Health Coalition (established through advocacy efforts of Families USA), this legislation to include dental care in Medicare had the support of many diverse organizations including formal coalition member groups and others such as dental professional organizations, advocacy groups for older adults, consumer groups, social service and social justice groups and older adults themselves. (Letter: Medicare Oral Health Coalition, September 2021.)

Some groups that signed support were American Association of Retired Persons, American Association for Dental, Oral and Craniofacial Research, American Association of Public Health Dentistry, American Board of Dental Public Health, American Dental Hygienists’ Association, American Geriatrics Society, American Heart Association, American Medical Student Association, Association of State and Territory Dental Directors (ASTDD), CareQuest Institute for Oral Health, Center for Medicare Advocacy, Families USA, Justice in Aging, National Association of Chronic Disease Directors, National Council on Aging, National Dental Association, National Interprofessional Initiative on Oral Health, National Kidney Foundation and many other national, state and grassroots groups.

They were among many supporters and an estimated 9 in 10 voters who support a Part B dental benefit to be included with the rest of their health care benefits. These groups collectively advocated for full coverage of preventive benefits and 20% copay and 80% coverage for more complex services, except for those in poverty whose copays would be covered by Medicaid.

Opposition to a Benefit in Part B

There were also several groups and individuals opposed to adding a Medicare

dental benefit to Part B for a variety of political, financial, ideological and professional reasons. Just as in 1965, the ADA was an important and ardent voice in opposition to the proposed Part B benefit for all enrollees in 2021.

The leadership also voiced its position in a letter to legislators that included concurrence from the Academy of General Dentistry, American Academy of Oral and Maxillofacial Pathology, American Academy of Oral and Maxillofacial Radiology, American Academy of Periodontology, American Association for Women Dentists, American Association of Endodontists, American Association of Oral and Maxillofacial Surgeons (AAOMS), American Dental Education Association (has since clarified their position in support of a Part B benefit), American Student Dental Association and Society of American Indian Dentists. (Letter Sept. 1, 2021.) This was followed by a letter in which most of the state dental associations, though notably not the California Dental Association, also expressed agreement with the ADA’s position and suggested that most dentists would be unlikely to enroll as providers.

The concerns expressed included the potential for low reimbursement rates that would not adequately address the high overhead costs of dental practice, deterirng dentists from enrolling and resulting in inadequate access to care, such as occurs in many state Medicaid programs that provide dental benefits.

Further, there was concern that there would be an “undue burden on dentists” to meet the administrative, regulatory and compliance issues that would be required

by Medicare in order to participate as part of a national system of care and that most dentists are not currently prepared to meet the requirements.

In response to these concerns, the

ADA proposed a dental benefit outside of Part B — “Part T” — and also proposed restricting coverage to persons who live below 300% of the FPL ($38,640 for one person). (Letter Sept. 9, 2021, Klemmedson and O’Loughlin.) Using income to determine benefit qualification, which is known as means testing, as proposed by the ADA, is how Medicare is structured. However, benefits in Medicare are not determined or restricted based on income status; everyone who receives Medicare is eligible for the same set of benefits. Where the Medicare Part B framework does consider income is to determine premiums; some people pay no premiums and people who earn more pay a higher Part B premium.14 Some concerns that have been expressed about the ADA proposal include: A new administrative structure would need to be created within Medicare, possibly extending the time to implementation in addition to additional cost to administer the program; a new Part T with new rules could potentially cause confusion among beneficiaries who are already accustomed to managing Part B; a benefit outside Part B could perpetuate coverage gaps, much like occurred with Medicare Part D for prescription drugs; a Part T would not result in establishing any minimum of required benefits that are available through MA plans for an additional cost to older adults; and if dental care is not included along with all other outpatient medical services for all Medicare enrollees, it reinforces the perception that oral health care is not as important as other health care services that are provided for older and disabled adults through Medicare.13 While persons with higher incomes may have certain advantages in access to care, it is important to remember that Medicare was enacted to protect older adults and adults who are disabled by JULY 2 0 2 2

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making sure they have adequate resources to meet their health care needs. Financial resources do not prevent neglect and financial abuse by individuals caring for them.24 In the absence of guaranteed benefits through Medicare, older adults who become cognitively or physically disabled and rely on others to help them access appropriate care may be denied even basic medical and dental care as well as necessary care. Caregivers could be seeking to preserve financial resources that would otherwise be available for their own expenses or passed on to them after the death of the individual, or they could deplete the resources that the dependent adult might have otherwise used for health care.25 Some basic level of guaranteed dental benefits for all Medicare enrollees is an important safeguard for older Americans who are most at risk.

Some stakeholders have also expressed concerns that reimbursements will be inadequate or will be set and controlled by physicians rather than dentists. Part B already includes fee-setting schedules to accommodate a wide range of outpatient services and could presumably accommodate a distinct and separate process for dentistry, setting adequate reimbursement levels based on dentists’ input.26 Adequate reimbursement will be needed for a large proportion of dentists to accept Medicare and for patients to receive the care they need.

If dentists don’t enroll, then access will not have been improved. Therefore, the profession must be engaged and included to ensure that appropriate rates are established to encourage dentist participation and good experiences for both providers and patients.

In 2019, CDA formed a Medicare task force, of which I am a member, to examine these issues and concerns and develop educational resources for its members as well as prepare the organization to 412

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respond should congress become active on this issue. The task force acknowledged that adequate reimbursement will be needed for a large proportion of dentists to accept Medicare and for patients to receive the care they need, noting that if dentists don’t enroll, then access will not have been improved. The task force concluded that the profession must be engaged and included to ensure that appropriate rates are established to encourage dentist participation and that the program is designed so it works well for both patients and providers.21

Some basic level of guaranteed dental benefits for all Medicare enrollees is an important safeguard for older Americans who are most at risk.

Some dental providers, such as oral and maxillofacial surgeons, are already enrolled as Medicare providers. The ADA and the AAOMS have recently expressed concern not for the reimbursement amounts but that claims for biopsies required for diagnosis in the oral region may have been denied altogether on the basis of the pre-existing exclusion for dental care. (Letter Sept. 21, 2021, Klemmedson and Tiner.) The removal of the express exclusion of dental care in Medicare Part B could immediately resolve the potential for issues such as these for those who are already Medicare providers and open the door for other general and specialty providers to provide and be reimbursed for similar procedures, improving access to care and early diagnosis of diseases and conditions that

can range from issues related to quality of life to those that are life threatening.14

The Argument for a Benefit in Part B

As noted above, the addition of a dental benefit is highly popular among older Americans themselves and organizations who advocate on behalf of older adults, adults with disabilities and their families. Grassroots and professional organizations have been vocal and persistent supporters of a robust dental benefit in Medicare Part B since the first bills to include a benefit were drafted.

These groups support the elements contained in the legislative framework that was under consideration in the Build Back Better bill. AARP’s letter supporting a Part B dental benefit stated that Medicare Advantage dental coverage is “inconsistent, and not nearly robust enough,” adding that, “Medicare should cover the entire person — from head to toe … People want these services and are often surprised when they learn Medicare does not cover them.”23 A universal dental benefit would cross all socioeconomic, racial and ethnic lines and immediately create the potential to reduce the disparities in care that became so apparent during COVID-19. These disparities have been repeatedly demonstrated in regard to oral health and access to care for older adults in particular during the pandemic but also pre-pandemic.14 This broad-based advocacy set the table for oral health care to be included in Medicare.

Older adults have at once diverse and distinctive oral health needs that must be addressed in health care. Even before there is a benefit, there has already been much speculation that the coverage would be inadequate and that persons who most need care won’t be served. But individuals who need care are not getting it now; coverage as it currently stands in Medicare and options for coverage outside

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FIGURE 2

Scenarios Highlighting the Need12 The frail or not so frail elder who takes a fall and fractures her front teeth needing extractions and wants them replaced in order to maintain some sense of dignity and to maintain social contacts.

of Medicare are inadequate to meet even the basic oral health needs of most older adults who rely on Medicare.14 Not only are they lacking financial resources, but they are also lacking important cues about the importance of oral health care as a component of successful aging.

Other health care providers may not consider the importance of oral health care if they are not prompted to make a referral as part a comprehensive health program. Patients who get referrals can’t follow up if they don’t have the financial means. They are missing one more opportunity for an encounter with another health professional who can reinforce healthy habits that preserve oral health as well as general health.

Common risk factors in areas such as nutrition, preventive behaviors and self-care are relevant to both oral and systemic chronic diseases. One more touchpoint in the system through dentistry can mean improved access to vaccinations and reminders to see health care providers for routine examination and diagnostic procedures. Medicare enrollees are missing opportunities to receive treatment for diseases — oral and systemic — at early stages, because they are missing out on basic and routine preventive and restorative oral health care that is currently disjointed from the rest of primary care.27 A dental benefit in Medicare that is accessible to all and stands alongside other preventive care provided through Medicare is an important step toward increasing public awareness of the importance of oral health, addressing the oral health needs of older adults and deconstructing long-held ageist views that associate deteriorating oral health as inevitable in old age. While persons with higher incomes tend to have better health literacy, that is still not a guarantee that their oral health literacy is adequate

The 70-year-old man who has smoked since he was 15 now has a rough red and white patch on the side of his tongue that will not been seen until it’s too late because he cannot afford regular dental check-ups.

The 80-year-old woman, who has lived just above the poverty line her entire life and managed to maintain some dentition and acquire partial dentures at some point, accidentally throws her partial away and with it her last remaining functional chewing pairs of teeth.

The 67-year-old who has been depressed since retiring and takes a host of medications that dry his mouth, leaving him at an extreme risk for caries, especially since he brushes less and drinks alcohol more now that he is in retirement and home most of the time.

The 60-something who suffers a stroke that has left him paralyzed on one side and in addition to a host of other drugs is taking a calcium channel blocker that combined with inadequate oral hygiene has left him with gingival enlargement that even further complicates his attempts to keep his mouth clean and healthy.

The 89-year-old woman with Alzheimer’s disease whose daughter says her mother is old, eats soft food all the time and never says her teeth hurt and she sees no need to take her mother for dental care that will be expensive and unnecessary since no one ever mentions her mother needs to see the dentist when she goes to see her doctor.

The 80-year-old who retired at 65 with decent oral health but lost his dental insurance and has no “extra” money for dental care leading to an absence of care for 15 years, who is now noticing his teeth breaking off at the gumline.

The patient in their late 60s with Parkinson’s disease, now with dysphagia, who is aware her dexterity and oral hygiene are in decline but is unaware of an increased risk for aspiration pneumonia in the presence of heavy plaque and calculus and a concomitant absence of regular dental care.

The 70-something who has lived with diabetes since his mid-50s and has a periodontium that has slowly been destroyed in the absence of regular dental care and poor control of his diabetes.

and that they understand the full value of oral health as a part of health and wellbeing. By failing to include a universal dental benefit in Medicare, not only are opportunities for direct care lost, but also opportunities to signal and reinforce the importance of oral health care. A dental benefit in Part B would raise oral health care to the same level of importance as the other health needs that are included.

Inclusion of a meaningful benefit available to all enrollees would also create an opportunity for oral health measures to be included in a national health care system and develop best practices that advance both dentistry and medicine.27

Who Is in Need and What Kind of Care Is Needed

A dental benefit package must meet the unique oral health needs of older adults. From individuals with good oral health and low risk to others with extreme risk of oral disease and poor oral health, appropriate preventive and

restorative care can reduce inflammation, treat disease, stabilize oral health, restore basic function or maybe save a life.20,27 FIGURE 2 represents just a few scenarios in which health and oral health collide in older adults in a way that can be disfiguring, debilitating and disheartening for the millions without resources and access to appropriate dental care.

These are common scenarios that describe the people who lack adequate resources and access to oral health care. This is the kind of care that is needed and the conditions that will go untreated because they are expressly excluded from Medicare benefits. Left untreated, an eminent decline in oral health looms along with a broad range of implications for the health and well-being of such individuals.20,27

The Road Ahead

Since 2015, seven bills have been put forth in the Senate and 19 in the House aimed at adding a dental benefit in JULY 2 0 2 2

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Medicare. In this moment, it is difficult to know if this represents inevitability or futility. Now it appears this effort is on a path toward nothing as an element of the Build Back Better Act, except for some provisions for oral health literacy initiatives as the proverbial and nominal nod to the importance of oral health. A national oral health literacy campaign is important, but it cannot take the place of direct care for persons who have been without and are in need or at risk. Much can and should be done at home and in the community to preserve oral health, but this is not enough to ensure that older Americans can age successfully, with grace and dignity, and to mitigate the impact of such widespread neglect on public health.

As a profession, dentistry has long espoused that oral health is integral to general health and more recently hailed oral health care as essential care.

Yet, nearly 60 years after the advent of Medicare, dentistry has not collectively and definitively said “yes, oral health is important enough that every older adult should receive oral health benefits through Medicare.” The failure to say these words and to agree on this point — as the primary advocates for oral health and oral health care — must have some impact on what the public and legislators think is important and how they will ultimately advocate and legislate. Dentistry can’t continue to have it both ways when 64 million older and disabled Americans are lucky to have it any way at all when it comes to oral health care. Numerous studies have shown that for older adults in particular, oral health is inextricably linked to systemic health.28 Yet once again we are poised to wait for the next opportunity, for the next fiscal projection and proposal, for the social, political and professional will to remedy the nextto-nothing in essential oral health care coverage that exists now for older adults.

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Whether we view Medicare favorably or unfavorably, as individuals, as professionals or as organizations, Medicare has made a positive difference to older Americans for decades, across the country and across class, race, ethnicity and gender. Yet in this moment, the failure to realize a dental benefit in Medicare remains a missed and elusive opportunity for the profession to join the rest of health care and lend our expertise from the inside, rather than from the sidelines, in an integrated effort toward successful aging for older Americans. n RE FE RE N CE S 1. Viseltear AJ. Medical Care for the American People. The Final Report of the Committee on the Costs of Medical Care.

Adopted October 31, 1932. Am J Public Health 1974 Jan;64(1):82.

2. Medicareresources.org. A brief history of Medicare in America. Accessed Nov. 9, 2021.

3. Yarbrough C, Vujicic M. Oral health trends for older Americans. J Am Dent Assoc 2019 Aug;150(8):714–716. doi: 10.1016/j.adaj.2019.05.026. PMID: 31352967.

4. Simon L, Giannobile WV. Is it finally time for a Medicare dental benefit? N Engl J Med 2021 Dec 2;385(23):e80. doi: 10.1056/NEJMp2115048. Epub 2021 Oct 20. PMID: 34670037.

5. Palay C. Dental care: Unmet oral needs of patients with cancer and survivors. Clin J Oncol Nurs 2017 Oct 1;21(5):629–632. doi: 10.1188/17.CJON.629-632. PMID: 28945715.

6. Chernew ME, Conway PH, Frakt AB. Transforming Medicare’s payment systems: Progress shaped by the ACA. Health Aff (Millwood) 2020 Mar;39(3):413–420. doi: 10.1377/hlthaff.2019.01410. PMID: 32119623.

7. Zuckerman S, Skopec L, Aarons J. Medicaid physician fees remained substantially below fees paid by Medicare in 2019. Health Aff (Millwood) 2021 Feb;40(2):343–348. doi: 10.1377/hlthaff.2020.00611. PMID: 33523743.

8. Centers for Health Care Strategies. Medicaid adult dental benefits: An overview. Accessed Nov. 9, 2021.

9. Medicare.gov. How is Medicare funded? Accessed Nov. 9, 2021.

10. Kaiser Family Foundation. An overview of Medicare.

February 2019 Issue Brief. Accessed Nov. 9, 2021.

11. Kaiser Family Foundation. Medicare and dental coverage: A closer look. Accessed May 13, 2022.

12. Kaiser Family Foundation. Distribution of Medicare beneficiaries by federal poverty level. Accessed Nov. 9, 2021.

13. Centers for Medicare & Medicaid Services. Medicare dental coverage. Accessed Nov. 9, 2021.

14. California Dental Association. Congress is pursuing a Medicare dental benefit: Here’s what you need to know. Sept.

20, 2021.

15. Henshaw MM, Karpas S. Oral health disparities and inequities in older adults. Dent Clin North Am 2021 Apr;65(2):257–273. doi: 10.1016/j.cden.2020.11.004.

Epub 2021 Jan 22. PMID: 33641752.

16. Freed M, Ochieng N , Sroczynski N, Damico A, Amin K. Medicare and dental coverage: a closer look. Kaiser Family Foundation July 28, 2021. Accessed Nov. 9, 2021.

17. Hung M, Moffat R, Gill G, et al. Oral health as a gateway to overall health and well-being: Surveillance of the geriatric population in the United States. Spec Care Dentist 2019 Jul;39(4):354–361. doi: 10.1111/scd.12385. Epub 2019 May 14. PMID: 31087569.

18. Strait RH, Barnes S, Smith DK. Associations between oral health and general health: A surveywide association study of the NHANES. Community Dent Health 2021 May 28;38(2):83–88. doi: 10.1922/CDH_00121Strait06.

19. Bui FQ, Almeida-da-Silva CLC, Huynh B, Trinh A, Liu J, Woodward J, Asadi H, Ojcius DM. Association between periodontal pathogens and systemic disease. Biomed J 2019 Feb;42(1):27–35. doi: 10.1016/j.bj.2018.12.001. Epub 2019 Mar 2. PMID: 30987702; PMCID: PMC6468093.

20. Carrizales-Sepúlveda EF, Ordaz-Farías A, Vera-Pineda R, Flores-Ramírez R. Periodontal disease, systemic inflammation and the risk of cardiovascular disease. Heart Lung Circ 2018 Nov;27(11):1327–1334. doi: 10.1016/j.hlc.2018.05.102.

Epub 2018 Jun 2. PMID: 29903685.

21. Yellowitz JA, Schneiderman MT. Elder’s oral health crisis.

J Evid Based Dent Pract 2014 Jun;14 Suppl:191–200. doi: 10.1016/j.jebdp.2014.04.011. Epub 2014 Apr 13.

22. Cox C, Rudowitz R, Cubanski J, et al. Potential Costs and Impact of Health Provisions in the Build Back Better Act. Accessed Nov. 9, 2021.

23. Centers for Medicare & Medicaid Services. CMS fast facts.

24. Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, Kilpatrick DG. Prevalence and correlates of emotional, physical, sexual and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. Am J Public Health 2010 Feb;100(2):292–7. doi: 10.2105/AJPH.2009.163089. Epub 2009 Dec 17. PMID: 20019303; PMCID: PMC2804623.

25. Moon A, Lawson K, Carpiac M, Spaziano E. Elder abuse and neglect among veterans in Greater Los Angeles: Prevalence, types and intervention outcomes. J Gerontol Soc Work 2006;46(3–4):187–204. doi: 10.1300/ J083v46n03_11. PMID: 16803784.

26. Cubansji J, Neuman T, Freed M. The facts on Medicare spending and financing. August 2019 Issue Brief, Kaiser Family Foundation. Accessed Nov. 9, 2021.

27. Simon L, Giannobile WV. Is it finally time for a Medicare dental benefit? N Engl J Med 2021 Dec 2;385(23):e80. doi: 10.1056/NEJMp2115048. Epub 2021 Oct 20.

28. Slavkin HC, Santa Fe Group. A national imperative: Oral health services in Medicare. J Am Dent Assoc 2017 May;148(5):281–283. doi: 10.1016/j.adaj.2017.03.004.

PMID: 28449740.

T HE AU T HOR , Elisa M. Chávez, DDS, can be reached at echavez@pacific.edu.

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Benefit Design and Reimbursement Considerations for Teledentistry Nathan Suter, DDS

abstract Teledentistry is a broad term that allows for patient care to be digitized and delivered through multiple modalities. Teledentistry can be facilitated via many innovative technologies, thus allowing patients to engage in dental care regardless of physical and structural constraints of the dentist’s availability, creating equity through the availability of auxiliary dental team members. This manuscript lays out some of the ways that policymakers and payers can facilitate a digital transformation of care and allow teledentistry to enhance the way dental practitioners can develop systems of care for both today and the future of dentistry.

Keywords: Teledentistry, dental insurance, dental benefits

AUTHOR Nathan Suter, DDS, is the chief innovation officer at Enable Dental. He is a leading expert in consulting with provider groups, state boards and payers on how teledentistry can expand access to quality dental care. Dr. Suter has served on the board of directors of Enable Dental since 2020 and is the co-founder of Healier, a teledentistryfocused software platform.

He was named the 2019 Missouri Dentist of the Year by the Missouri Dental Association and was awarded the American Dental Association’s 2020

Top 10 Under 10 award, which honors dentists who have made an impact in the profession less than 10 years after graduating from dental school. Dr. Suter practices in House Springs, Missouri.

Conflict of Interest Disclosure: None reported.

T

eledentistry is a broad term that allows for patient care to be digitized and delivered through multiple modalities.

Teledentistry can be facilitated via many innovative technologies, thus allowing patients to engage in dental care regardless of physical and structural constraints of the dentist’s availability, creating equity through the availability of auxiliary dental team members.

This manuscript explores some of the ways that policymakers and payers can facilitate a digital transformation of care and allow teledentistry to enhance the way dental practitioners can develop systems of care for both today and the future of dentistry.

Providers have used teledentistry to deliver care to the most vulnerable

and underserved patients, both rural and urban, for more than a decade.

This initial concept was illustrated with success in California by the University of the Pacific, Arthur A Dugoni Dental School’s virtual dental home model.1 The initial success in California was replicated in many states prior to the pandemic in a model utilizing dental hygienists to send data to be reviewed by a dentist for remote diagnosis and treatment planning. In many states, teledentistry was not allowed as a reimbursable service, which limited the utilization among providers to implement this model of care.

During the COVID-19 outbreak, many states changed scope-of-practice guidelines to allow the reimbursement and utilization of teledentistry, seeing it as an effective way to assess and triage JULY 2 0 2 2

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Is your clinic/health center’s dental program currently using teledentistry as part of its reopening protocols?

patients while limiting in-office visits except for those in need of urgent or emergency care. One issue facing both patients and their potential dental home are stop-gap partnerships with dental insurance companies and national teledentistry mobile platforms that were announced during the pandemic.2 Many insurance companies quickly partnered3 with national teledentistry companies to provide near on-demand dental consults between a patient and a dentist who is licensed in multiple states. The insurance companies found a way to make their products relevant and accessible to employers and their employees during the pandemic. However, the dilemma is that these teledentistry visits often require the copay to be met and count as one of the oral evaluations a patient or member may use in a calendar year, unlike 24-hour nurse lines or telehealth visits in a major health insurance plan.

Through these services, a patient gets access to dental care that is very limited in what services may be provided. In most cases, a referral and an antibiotic prescription can be provided. These teleprovider visits can often be a detour to care that sometimes refers patients to a dentist who is in network. Continuity of care would be delivered in a more holistic way if the direct-to-consumer options were an additional benefit outside the members’ plan or if the teledentistry visit was delivered by the treating dental provider.

Over the course of the pandemic, there has been a surge in utilization of teledentistry. The American Dental Association (ADA) Health Policy Institute (HPI) surveyed providers and found initially that providers quickly adopted the ability to remotely triage their patients, but remote triaging waned as offices started to open again.4 A follow-up survey done by HPI revealed that while teledentistry triage declined from 24% in 416

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YES 57% Yes (57%)

No (41%)

NO 41%

Dentists in public health settings — week of June 29

Not sure (3%)

Insight: Dentists in public health settings have been far more likely to embrace teledentistry

Is your practice currently using virtual technology/telecommunications to conduct remote problem-focused evaluations (CDT Code D0140)?

Dentists in private practice 24.8% 12.2%

71.2%

Week of April 20

86.2%

Week of July 13

FIGURE 1. Questions of the Week: Teledentistry. (Source: ADA Health Policy Institute. © 2022 American Dental Association.)

April 2020 to 12% by July 2020, dentists were providing a number of other services via teledentistry (FIGURE 1 ). In a February 2021 survey,5 HPI delved deeper into teledentistry adoption and found that over 36% of private practice dentists and over 60% of public health dentists were using some form of teledentistry in their practices (FIGURE 2). The application of teledentistry was broad and included triage, consults, postop, aligner checks, hygiene recall, patient education and more.

Based on the rapid increase in teledentistry utilization, it is very important that the profession revisit how and when a provider is reimbursed for teledentistry services. The existing structure for reimbursement is exclusively based on procedures or services provided in person by a dentist or a dental hygienist. Many valuable services can be rendered remotely by a provider. The entire dental industry will have to be motivated to make this type of system change. Many providers will only change their clinical workflow when they see reimbursement change from insurance benefit plans.6,7 These services can be convenient for a patient as well as delegated to an allied team member under appropriate credentials and supervision.

In a time when many states are increasing the number of citizens enrolled in expanded Medicaid as well as the possible addition of dental benefits to Medicare, we should revisit how the dental industry can meet all of this demand. Part of the solution is through teledentistry and the digitization of dental care.

Four Pillars of Teledentistry Reimbursement

In order to understand how teledentistry can be properly funded by both policymakers and insurance companies, the dental industry can learn a lot from the medical industry.

Teledentistry fits under the umbrella of telehealth, which includes professions like dermatology, post-acute care, cardiology, pulmonology and others that have similar challenges and have offered telemedicine for over a decade. Telehealth (including teledentistry) reimbursement is currently broken down into four components, which many states or insurance companies decide and include in their policies.

One: Service

The list of services that can be delivered via teledentistry usually includes diagnostic services such as

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Questions of the Week Is your practice using virtual technology/telecommunications to conduct any of the following?

Private practice dentists Triaging emergencies Consults Post-ops and follow-up care Patient education Orthodontic checkups Other, please specify Any of the above

24.7% 17.5% 21.0% 12.4% 3.7% 2.6% 36.2%

Public health dentists Triaging emergencies Consults Post-ops and follow-up care Patient education Orthodontic checkups Other, please specify Any of the above

46.6% 35.2% 35.2% 28.4% 1.1% 6.8% 61.4%

Insight: Dentists are using virtual technology in various ways, especially in public health settings.

FIGURE 2 . ADA survey results during COVID-19. (Source: ADA Health Policy Institute. © 2021 American Dental Association.)

limited, comprehensive and periodic oral evaluations as well as imaging captured through either radiographs or photographs. The location of the patient usually determines the level of diagnostic data that is available for the services to be delivered. For example, a patient at home using a secured videoconference tool may only receive a consultation or limited exam, while a patient seen in a clinical setting may have a full scope of diagnostic images and radiographs captured that allows a dentist to complete a more thorough evaluation. As technology advances, it is important to revisit the services that are covered by policies and dental plans.

We can learn from our medical peers and see that the use of connected devices can allow for a new way to reach, educate, intervene and create targeted treatment plans for patients’ specific needs.

hardware and software due to new ways to encrypt data and communicate with mobile devices. An example of location reimbursement restrictions would be that for years a provider office to a hospital was reimbursable, but in many states, a provider’s office to a patient’s home was not reimbursable. Many states temporarily enacted workarounds due to the pandemic, and a more holistic and permanent solution needs to be enacted.

Two: Location

Synchronous refers to video communication between a patient and a provider happening in real time. In many situations, the patient is accompanied by a provider such as a dental assistant or dental hygienist. Patients and providers may communicate directly using a smartphone or computer with videoconferencing software. Synchronous is usually what most patients and even providers imagine when first hearing about teledentistry. This is a common

For decades, telehealth has had a location component tied to reimbursement. In many policies, a list of approved sites or facility types have dictated when a service can be reimbursed.

This component is still in place in many state and federal policies. However, modern alternatives are emerging with the significant change in technology and because a point-to-point connection of a “secure” line is not needed with modern

Three: Modality

Telehealth service can be delivered in multiple ways. Two mainstream categories, or modalities, are billable for teledentistry services. The ADA has updated guidance on these two modalities based on its current policy toward teledentistry.8 The modality relates to how a provider engages in the care of the patient.

Synchronous or ‘Real Time’

starting point, but one-on-one interactive modality limits the potential impact that other modalities and technologies can provide. This form of teledentistry still requires the provider and the patient to align their availability and creates a potential bottleneck to reaching preventive and diagnostic services.

Asynchronous or ‘Store and Forward’

Asynchronous is the transmission of images and/or data taken at a separate time from when the assessment or initial visit took place. This can be facilitated with a digital health form. Data may be stored directly into an existing practice management or electronic dental record to review at a later time when the provider is available. How data is collected is changing as technology improves. Many dental offices have added digital forms and ways to send images directly from the patient, and depending on the data collected, this can be enough for a limiteduse case. The transmission of data, notes and images from hygienist to dentist was the most common form of teledentistry prior to the pandemic, mainly for public health settings. Another area of growing interest is the ability of patient monitoring and how data can be sent directly to a dentist to provide services to patients.

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Four: Provider

The last pillar of telehealth policy and plans is the specific list of providers who can provide services and submit claims for reimbursement. This is usually a state-by-state law, regulation or rule.

States typically add dentist, hygienist, oral surgeon, dental assistant and others to a list that includes all health care providers under overarching telehealth legislation.

Many states during the pandemic added dentists and hygienists temporarily, due to executive orders. Stakeholders should review any provider list and ensure that oral health care providers are represented in any permanent telehealth legislation or regulations.

An additional regulatory aspect of telehealth is each state’s dental or dental hygiene practice act. Dental boards have the responsibility to maintain patient safety through enforcement and oversight of regulations and standards of care.

Teledentistry requires the same standard of care as in-person care. Technology allows for some of that care to be digitized and delivered in new and innovative ways.

A state dental board has an influence on all of the pillars of teledentistry. The burden of the dental boards is to create regulations that allow for patient safety without unnecessary restrictions, limiting access to care or restrictions that become obsolete as the technology improves.

Benefit Considerations

Coding and submitting for teledentistry is as important to dental insurance companies and state governments as it is for dentists. Many states, including California, made adjustments to their reimbursement models in response to the pandemic.9 Historically, teledentistry is a process of providing current diagnostic procedure codes using technology. The teledentistry codes for synchronous (D9995) and 418

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asynchronous (D9996) are generally used in order to label the visit as a telehealth encounter. These codes are completed in conjunction with the initial diagnostic procedure code. An example would be when a dental hygienist is collecting diagnostic data and forwards it to a dentist or when a dentist is providing a live consultation with a patient. A few state Medicaid agencies10,11 and insurance companies have provided an additional benefit for the adjunctive teledentistry visit codes in addition to the preventive and diagnostic codes.

Many states, including California, made adjustments to their reimbursement models in response to the pandemic.

Going forward, the industry should consider how technology could enhance new ways to see patients and expand the utilization of oral health in new ways focused on earlier interventions. There are some additional use cases that need to be researched by insurance carriers and implemented as teledentistry allows for innovative ways to care for patients.

The ‘Digital Front Door’

Telehealth, including teledentistry, saw a 38x increase in adoption and has been sustained at that level year over year from February 2020 to 2021.12 There is a significant increase in these new ways to access care through what is being called the “digital front door.”

Medical insurance companies are even creating plans that exclusively start

with a virtual or near-virtual visit. The potential here is a more efficient way to both triage care and deliver preventive care. Some of the issues of dental insurance companies’ initial offerings for teledentistry are important but could be improved in at least a couple of ways: ■ Offer in-network dentists a platform that allows patients searching for a dentist via teledentistry to connect directly with the treating dentist and team. This would require a significant number of network dentists to adopt teledentistry referrals as well as an upgrade from the traditional “directory” of network providers that a patient uses to search for a dentist near them.

■ Change these virtual-only third-party consults from national teledentistry platforms to an added benefit that would not count as one of the annual examination benefits and not require a copay. This is essentially what medical plans have offered for almost a decade to help triage care. The current system for these third-party teledentistry providers is causing confusion for the patient and the network provider when the patient finds a dental home and is needing diagnostics in addition to treatment.

Risk Stratification of Care Through Teledentistry

Risk stratification is a medical term for a standard process of assigning all patients in a practice a particular risk status. In a traditional dental practice, every patient with a recall visit is seen by the dentist in person along with the patients in treatment throughout the day.

The dentist is ultimately the “gatekeeper of care.” If a practice offers hygiene care under general supervision, it can remedy some of this bottleneck. If payers and providers would begin to risk stratify their

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patients, teledentistry may offer a more sustainable delivery model. The dentist in the traditional practice has to interrupt their treatment appointments in order to check all of the hygiene patients regardless if they are a high-risk or a low-risk patient.

With risk stratification, all low- and even moderate-risk patients could see the hygienist. These lower-risk patients can receive all preventive care, diagnostic records and an asynchronous teledentistry visit. This can free the practice to offer more convenient hours for care outside of the dentist’s schedule while also offering shorter hygiene visits.13 In a practice that adopts this model, a dentist could increase the capacity of the schedule and focus on quality of treatment by only seeing treatment patients and high-risk patients in person while reviewing the patient records for the low- or moderate-risk patients through teledentistry recall visits.

Teledentistry Enabled Provider to Provider Consultations

The traditional patient referral from a general dentist to a specialist is a piece of paper or online form submission to a nearby dental specialist. These patient referrals can be very dependent on the patient’s own follow-through, and the general dentist and team have no direct incentive to coordinate the care of the patient. Some primary care doctors are incentivized to close the “referral loop” through contracts with some government and insurance companies.14 These types of visits are sometimes called eConsults and have seen positive findings by both patients and providers, although the relationship with the general practitioner is noted as a key to a successful referral via eConsult.15 Dental insurance companies would need to either add new codes to their covered benefits, such as D9310 Consultation (diagnostic service provided by dentist or physician other

than practitioner providing treatment) or incentivize a digitally enhanced method of teledentistry and care coordination.

If these types of benefits are not added, there will not be an incentive to encourage a business decision to invest in new technology or workflows.

Patient Monitoring

The final piece of the teledentistry puzzle is the growing area of patient monitoring through connected health care devices or applications. The majority of these services have not seen the

Some primary care doctors are incentivized to close the “referral loop” through contracts with some government and insurance companies.

adoption in dentistry as they have in medicine. Devices like wearable devices, smartphones and tablets have facilitated a growth in patient monitoring in telehealth. In dentistry, there is earlystage research in areas of connected toothbrushes, mobile device cameras, pH monitoring, sleep monitoring, microbiome testing and more. Recent financial success like French company Dental Monitoring getting a valuation of over $1 billion shows that some of these companies are showing value for orthodontists and dentists for even nonbillable visits like monitoring the progression of orthodontic cases.16 Patient monitoring in dentistry has the potential to learn from the medical industry that has made patient monitoring work for multiple specialties through multiple different technologies.

In medicine, this has added value for preventive care compliance, postoperative follow-up, patient education and early interventions.17 A dental practice with patients utilizing connected devices could allow a dentist and the rest of the care team to maintain more patients at a lower cost while focusing the dentist’s time on higher-need patients needing surgical interventions.

Summary

The health care industry is in a period of transformation due to the COVID-19 pandemic, and there has been an increase in demand and adoption for a more digitized delivery of care.18 Dentistry has a pre-pandemic history of utilizing teledentistry to deliver care in innovative ways. The pandemic has brought heightened interest and opportunity for patients, providers and payers. There are many opportunities to adopt these new technologies and incorporate them into the practice of dentistry. The burden is on both providers and insurance carriers to facilitate the transformation that is taking place. This can be through state and federal policymaking, educating members/patients on the value of teledentistry, investing in the modernization of dental practices, training teledentistry in continuing education and academic settings and adjusting reimbursement models. As technology advances, many of these new systems will have to adapt. The way health care is being delivered is changing rapidly, and it will take the entire dental industry to meet this challenge. n RE F E RE N C E S 1. Namakian M, Subar P, Glassman P, Quade R, Harrington M. In-person versus “virtual” dental examination: Congruence between decision-making modalities. J Calif Dent Assoc 2012 Jul;40(7):587–95. PMID: 22916380.

2. Toothpic.com Toothpic to offer virtual dental care access to Delta Dental of California members. (2021, February 23).

Accessed Nov. 2, 2021.

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3. Teledentistry.com. Delta Dental – Emergency Missouri Virtual Visits. Accessed Nov. 2, 2021.

4. ADA Health Policy Institute. COVID 19 Economic Impact on Dental Practices Week of April 20 Results. Surveys.ada.org.

Accessed Nov. 3, 2021.

5. ADA Health Policy Institute. COVID 19 Economic Impact on Dental Practices Week of February 15 Results. Accessed Nov. 3, 2021.

6. HealthPayerIntelligence.com. Key considerations for permanently integrating telehealth coverage. Accessed Nov. 3, 2021.

7. American Dental Association. D9995 and D9996 — ADA Guide to Understanding and Documenting Teledentistry Events.

Accessed Nov. 2, 2021.

8. California Dental Association. 7 things to know about using telehealth during the COVID-19 pandemic. Accessed Nov. 2, 2021.

9. State of Missouri, MoHealthNet. Dental Provider Manual.

Accessed Nov. 2, 2021.

10. Washington State Healthcare Authority. Billers, providers, and partners: Providing billing and fee schedules. Accessed Nov. 3, 2021.

11. Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: A quarter-trillion-dollar post-COVID-19 reality? McKinsey & Company. Accessed Nov. 3, 2021.

12. Suter N. Teledentistry applications for mitigating risk and balancing the clinical schedule. J Public Health Dent 2020 Sep;80 Suppl 2:S126–S131. doi: 10.1111/jphd.12421.

13. U.S. Centers for Medicaid & Medicare Services. Quality Payment Program Overview. Accessed Nov. 2, 2021.

14. Ackerman SL, Gleason N, Shipman SA. Comparing patients’ experiences with electronic and traditional consultation: Results from a multisite survey. J Gen Intern Med 2020 Apr;35(4):1135–1142. doi:10.1007/s11606-02005703-7. Epub 2020 Feb 19.

15. Business Wire. DentalMonitoring, the leading AI-based dental software company, announces a $150 million growth financing, reaching a valuation over $1 billion. Accessed Nov. 3, 2021.

16. Broderick A, Steinmetz V, Benzinou M, et al. Remote Patient Monitoring in the Safety Net: What Payers and Providers Need to Know. California Health Care Foundation.

Accessed Nov. 3, 2021.

17. Weigel G, Ramaswamy A, Sobel L, et al. Opportunities and barriers for telemedicine in the U.S. during the COVID-19 emergency and beyond. Kaiser Family Foundation. Accessed Nov. 3, 2021.

THE AU THO R , Nathan Suter, DDS, can be reached at nsuter@accessteledent.com.

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RM Matters

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Minimize Risk of Bloodborne Pathogen Exposure Through Education and Planning TDIC Risk Management Staff

D

ental professionals may be at risk of exposure to numerous workplace hazards. The federal Occupational Safety and Health Administration (OSHA) and the state of California have legal requirements for employers to create and maintain safe workplaces.

California dental offices must meet infection control and safety standards, including those that address bloodborne pathogens and biological agents, for both federal and state agencies.

OSHA’s Bloodborne Pathogen Standard applies to all employers with employees who have occupational exposure to blood or other potentially infectious materials, regardless of how many workers are employed.

The Dentists Insurance Company handles workers’ compensation claims related to a wide range of workplace incidents, but the most common reported injuries are from needlesticks. These injuries can put health care workers at risk of exposure to bloodborne pathogens, including hepatitis B, hepatitis C and HIV. It is no surprise then, that to be compliant with Cal/OSHA standards, California dental practices are required to train any team member who may be exposed to bloodborne pathogens. What might come as a surprise to practice leaders is that this training is required by both federal and Cal/OSHA on a yearly basis. Confusion exists because many assume the standards for bloodborne pathogen training are the same as those for infection control training, which is required by the Dental Board of California to be completed every two years.

When a sharps injury does occur, practice owners are responsible for managing the possible exposure to bloodborne pathogens. The Dentists Insurance Company’s Advice Line often receives calls regarding how to handle exposures and mitigate liabilities.

A Common Scenario

In one case reported to TDIC’s Advice Line, a full-time dental assistant

had just completed assisting a dentist with a root canal procedure. In a rush to prepare the operatory for the next patient, the assistant failed to notice that the needle was not capped. While hurrying to gather the instruments, she punctured her right thumb with the needle, then reported the incident to the dentist.

When the dentist called the Advice Line for guidance, the TDIC analyst

answers

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reminded the dentist that wounds that have been in contact with blood or bodily fluids should be washed with soap and water. Additionally, the dentist must properly document the needlestick incident in a sharps injury log, which is required by law in most jurisdictions.

The dentist inquired if it would be acceptable to contact the source patient and request that she undergo testing. He also inquired about his responsibility to cover any cost associated with patient testing. The analyst advised the dentist that it is a best practice to send the source patient for testing and discussed opening a claim to cover the source testing under his TDIC Professional & Dental Business Liability policy.

Mitigating Risks Through Exposure Plans

Due to the potentially serious consequences of a needlestick incident, the Cal/OSHA Bloodborne Pathogens Standard requires dental practices of every size to have post-exposure plans in place. Essential plan components include: ■ Immediate reporting of a needlestick injury to the dentist.

■ Forms documenting the exposure and, when necessary, employee or source patient refusal of medical evaluation or testing.

■ A sharps injury log.

■ A preselected physician from the medical provider network (MPN), the referral list provided by the workers’ compensation carrier, who can evaluate the exposed dental professional within 24 hours.

TDIC advises dentists to report any sharps or needlestick incidents to their workers’ compensation and professional liability insurance carriers for coverage of employee testing and source patient testing. Employers are required 422

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to pay for any medical treatment related to the bloodborne pathogen exposure. However, all workers’ compensation policies, including TDIC’s, cover this for employees in the event of a needlestick injury.

Needlesticks: Prevalent but Preventable

While employee needlestick injuries in the dental setting are common, training and safety protocols can help prevent them.

“I typically see needlestick injuries arising from employees moving too quickly as they

TDIC advises dentists to report any sharps or needlestick incidents to their workers’ compensation and professional liability insurance carriers. are recapping used needles,” notes Karen Schaffner, workers’ compensation manager for TDIC. The injuries frequently occur when breaking down instrument trays following a procedure, in a recurring pattern of hurrying to clean up and prepare for the next patient.

Your Safety Obligations

To help reduce the risk of needlestick accidents and exposure to bloodborne pathogens, dentists are required to use “standard precautions” and to have a pre-exposure control plan with details on employee protection measures. This plan must specify the use of a combination of engineering and work practice controls.

Work practice controls include: ■ Personal protective clothing.

■ Training on sharps use and disposal,

■

■

including not bending or breaking needles prior to disposal.

Medical surveillance and hepatitis B vaccinations.

Signs and labels.

Engineering controls include: ■ Safety syringes designed to eliminate recapping and removing the needle after use.

■ Sharps containers.

■ Strict observance of the “full” line on sharps containers.

Other Resources To Support Your Practice

In the state of California, employers are required to provide form DWC-1 to an employee for completion within one business day of becoming aware of a work-related injury or illness. Both TDIC and CDA offer additional resources for education, training and information about compliance with Cal/ OSHA requirements for bloodborne pathogen exposure management.

TDIC policyholders can sign in to tdicinsurance.com to access: ■ A downloadable form to document an employee’s refusal of post-exposure evaluation.

■ Straightforward ways to initiate a quote or request assistance with workers’ compensation insurance designed for dental practices.

■ A workers’ compensation claims kit, which includes important required forms and postings such as DWC-1, DWC-7 and Form 5020.

Policyholders who have not yet created an online access account may do so at tdicinsurance.com/AccountOverview.

CDA members can log in to cda.org to access downloadable resources: ■ Bloodborne pathogens exposure management protocol.

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A list of safety sharps providers compiled by CDA Practice Support.

■ Sets of required posters about safety and employee rights, regularly updated with the latest information.

Members also have access to affordable online training: ■ CDA’s Bloodborne Pathogens Online Training Program is a convenient way to earn C.E. and meet requirements while training ■

your team and working together to build your exposure control plan.

Take time to explore the tools and expertise available through organized dentistry. Then, develop your exposure plan with your team and pursue the bloodborne pathogens training that protects you and your practice team. Any time TDIC policyholders or CDA members have questions about bloodborne pathogen exposure or other

compliance concerns, TDIC’s Risk Management Advice Line is ready to offer expert guidance. n The Dentists Insurance Company’s Risk Management Advice Line is a benefit available at no cost to CDA members, as well as to policyholders protected

by TDIC. To schedule a consultation, visit tdicinsurance.com/RMconsult or call 877.269.8844.

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Regulatory Compliance

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Infection Control Do’s and Don’ts CDA Practice Support This article reviews some of the infection control topics about which CDA members have contacted Practice Support.

DO’s

Screen patients for aerosol-transmissible diseases. California dental practices have been required to conduct this screening since Cal/OSHA approved the aerosoltransmissible diseases regulation in 2009.

The screening is one of four conditions dental practices must meet to be exempt from the majority of ATD regulation requirements. The other three conditions are: A written procedure for screening patients that is consistent with current CDC guidelines must be included in a practice’s injury and illness prevention plan; employees must be trained in the procedure; and aerosol-generating procedures may not be performed on a patient who is identified by the screening procedure as a possible ATD exposure risk.

Provide timely training. Provide a new employee with bloodborne pathogens exposure control training before or at the time of assignment to tasks that can expose them to blood, saliva or other potentially infectious material. An experienced staff member can provide the required training by using training materials such as the dental practice’s exposure control plan, online training and relevant articles like those on the CDC website or in professional journals.

The trainer must address the 14 topics required in the Cal/OSHA regulation.

Offer required vaccination. Offer a new employee the hepatitis B vaccination series if their job potentially exposes them to blood, saliva or other potentially

infectious materials (OPIM). Cal/OSHA requires employers to offer the vaccination after providing the required bloodborne pathogens training and within 10 working days of the initial work assignment. The offer need not be made if the employee has previously received the vaccination series, antibody testing reveals the employee is immune or the vaccine is contraindicated for medical reasons. For more information on the requirement, see “Hepatitis B Vaccination: Requirement and

Recommendations.”

Have required written protocols. Have written protocols for instrument processing, operatory cleanliness and injury management as required by the dental board in its infection control regulation. Dental plan auditors are known to request the protocols when auditing a practice. Sample protocols are included in CDA’s “Regulatory Compliance Manual.”

Designate an infection control coordinator. This is a leadership role. A

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key staff member can ensure consistent application of infection control protocols, train staff and maintain necessary and required documentation.

DONT’S

Avoid an employer’s responsibility. Job applicants and new employees may not be required by an employer to undergo a prescreening as a prerequisite for receiving the hepatitis B vaccination series.

Confuse “uniforms” with “personal protective equipment.” The bloodborne pathogens regulation does not include the terms “scrubs” or “uniforms.” It requires the use of “personal protective equipment” (PPE).

The question “who is responsible for laundering scrubs” cannot be answered by looking at the regulation. Scrubs may be worn in the practice because they are comfortable and can provide a uniform look for the staff. However, scrubs cannot be used as PPE because they do not fit the following description provided

by Cal/OSHA: PPE will be considered “appropriate” only if it does not permit blood or other potentially infectious material (OPIM) to pass through employees’ underlying garments or to reach the skin, eyes, mouth or other mucous membranes under normal conditions of use. PPE must retain this capability during the entire course of its use by the employee. This allows the employer to select PPE based on the type of exposure and the quantity of blood or OPIM reasonably anticipated to be encountered during performance of a task or procedure.1 A gown that covers the arms to the wrist, the neck and covers an individual’s lap while sitting is appropriate PPE in a dental practice.

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Incorrectly believe the dental boardrequired infection control continuing education to be the same as annual bloodborne pathogens training. Both Cal/ OSHA and the dental board have regulations governing infection control in dental settings. Both agencies require training that cover similar subjects, but each has slightly different requirements.

The dental board requires licensed professionals to take a two-hour infection control course every license renewal period. The course must be approved by the dental board and must be provided by a dental board-approved continuing education provider. The course content must relate to the dental board’s infection control regulations.

Cal/OSHA requires employers to provide bloodborne pathogens training to occupationally exposed employees upon hire, whenever a change in procedures may lead to increased exposure and at least annually. The training must be offered during work hours, at no cost to the employee, and be provided by a knowledgeable trainer.

There is no minimum time requirement for the training, but it must cover: ■ Epidemiology and symptoms of bloodborne diseases.

■ Modes of transmission of bloodborne pathogens.

■ The dental practice’s exposure control plan, the bloodborne pathogens regulation and means to obtain a copy of both.

■ How to recognize tasks that may involve exposure.

■ Use and limitations of engineering controls, work practices and PPE. ■ Type, use, location, handling, decontamination and disposal of PPE. ■ Explanation of basis for selection of PPE. ■ HBV vaccine information:

■

■

■

■

efficacy, safety, method of administration, benefits, offered at no cost to employees.

Actions to take and who to contact in an emergency involving infectious materials.

Postexposure procedures including reporting, medical follow-up and sharps injury log recording.

Employer’s requirements for postexposure evaluation and follow-up.

Signs and labels.

RE F E RE N C E 1. California Department of Industrial Relations Cal/OSHA. Frequently asked questions about the bloodborne pathogens standard. Accessed April 22, 2022.

Regulatory Compliance appears monthly and features resources about laws that impact dental practices. Visit cda.org/ practicesupport for more than 600 practice support resources, including practice management, employment practices, dental benefit plans and regulatory compliance.

Tech Trends

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A look into the latest dental and general technology on the market

Anker 100W USB-C Charger, 736 Charger ($75.99, Anker) Many chargers for laptops and mobile devices use the same USB connections and cables but may not be created equal. It is especially important for owners to take note that when purchasing additional chargers, certain ones may not be able to provide enough power for their devices. Larger and heavier charger “bricks” supply more power but can be misleading when there are multiple ports to charge several devices simultaneously. The Anker 736 Charger provides a premium balance between portability and capability that will satisfy even the hungriest of power users.

The Anker 736 Charger is remarkably small and can charge up to 100W through either one of its two USB-C ports. The latest Gallium Nitride (GaN) II technology makes it 34% smaller compared to an Apple 96W charger. It has two USB-C ports and one USB-A port, and the power prongs can fold into the charger for a sleek compact profile. When a single USB-C port is used, the charger provides a full 100W of power to the connected device. When two or three ports are used, the charger provides various power profiles that deliver up to a total of 100W simultaneously to devices. The charger can provide full power to a single 14-inch MacBook Pro or a combination of a 13-inch MacBook Pro, 12.9-inch iPad Pro and iPhone 13 Pro Max at the same time. The build quality is solid and remains cool to the touch while in use. This charger can also be used for devices requiring more power through a single USB-C port but will supply up to a maximum of 100W. Anker’s PowerIQ 3.0 technology is built-in and ensures that every device connected receives the fastest charging speed possible. Currently, there is no comparison for a charger that provides this amount of versatility in a portable form factor.

When looking to purchase additional device chargers , users must choose the right one for their needs. It is common for users to carry separate charging bricks that travel with multiple devices. Those looking to maximize charging capabilities while minimizing bulk will be amazingly satisfied with the Anker 736 Charger.

Poly Blackwire 8225 USB Headset ($189.95, Poly)

Headsets have been an office staple for decades. Innumerable innovations have been incorporated into this technology so that users can clearly and comfortably communicate even in the most disruptive of environments. With an ever-increasing reliance on conferencing and a shift to open concept offices, practitioners and their staff are motivated to seek out reliable headsets that can filter out environmental noise, isolate their voices from others in the room and “just work” when needed. Poly — the amalgamation of audio communication mainstays Plantronics and Polycom — has a host of solutions, one of the most popular being the Blackwire 8225 headset. This review focuses on the USB-A, Microsoft Team compatible version of the 8225.

Poly describes the Blackwire 8225 as a “headset designed to blow minds.” From a comfort perspective, it reaches this lofty goal by being lightweight (144 g), fully adjustable with pivoting speakers and sporting a pair of soft ear covers. Construction feels flimsy due to the pivoting speakers and the USB cable length hovers in an in-between of too long and not long enough (7 feet), but neither quality detract significantly from the device. The 8225 utilizes two forms of active noise canceling: first on the speakers to block out unwanted noise for the user, then second on the microphone to form an “acoustic fence” that stops conversations from bleeding into the microphone. Both features are adjustable via the Poly application, and even without adjustment, they do an excellent job of isolating sound. Two people can have a spirited conversation directly next to the 8225 user and none of their voices will distract from the call in any way. The 8225 has a dongle that controls volume, noise canceling, muting and disconnecting. For practitioners considering a headset either for themselves or their staff, Poly’s Blackwire 8225 represents an excellent option owing to its impeccable sound quality, comfort and price point.

— Alexander Lee, DMD

— Hubert Chan, DDS

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Is your practice fully in compliance?

Bloodborne pathogen and infection control are not the same.

Did you know that Cal/OHSA requires annual bloodborne pathogen training for dental professionals, as well as annual review for practices’ exposure control plans?

CDA has developed convenient, flexible and affordable training — available only to members and their practice teams.

NEW! BLOODBORNE PATHOGENS AND EXPOSURE CONTROL PLAN PROGRAM • • • • •

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