The COVID-19 pandemic has changed everyone’s life as we know it. Dental practices have certainly not been immune and have also experienced disruption in their office and chairsidepractices, their finances and their malpractice liability risks. How has your practice or job evolved?
When a 100-year pandemic—COVID-19—closed the world beginning in March 2020, most scientists and public-health experts knew it would be bad. Now, several months later, its far reaching effects are coming into sharp focus. According to the Johns Hopkins Coronavirus Resource Center, the U.S. has experienced 7.1 million COVID-19 cases as of September 28, 2020, suffered 204,800 deaths, and is adding some 37,000 new cases a day.
The pandemic has had catastrophic consequences on the world economy, especially in the U.S., which has been the epicenter of global infection. The field of dentistry has been no exception. According to a study from the Central Valley Health Policy Institute at Fresno State University, the American Dental Association and state authorities issued guidelines early in the pandemic that dental practices should stop doing elective procedures and focus instead on patients needing urgent and emergency care.
By mid-May, most states had allowed dental practices to reopen for elective procedures. But public concern over catching the virus during a dental procedure sharply reduced demand. According to a tracking study from the American Dental Association’s Health Policy Institute, by the week of September 7, 2020, 48.3% of U.S. practices were open and doing business as usual. However, 50.5% were open, but experiencing lower than normal patient volume. Plus, total collections for the week of September 7 were only 76% or more of the norm for 60% of reporting practices. Meanwhile, 23 percent of practices were collecting only 26% of their normal fees during that week.
Given the severity of the pandemic and its resulting financial devastation, one wonders how the dental industry has changed. A topic this big might take a book to answer. But for the sake of this article, we will discuss some of the broad changes dental-industry experts have witnessed, organized in terms of dental workflow, practice financial and malpractice risk and insurance. Considering where the industry is today will help you determine where to take your dental practice (or job) in the post-COVID-19 future.
Dental Workflow Changes
The threat of getting infected during a dental procedure has ushered in sweeping changes to virtually every aspect of patient care. The following are some of the major ones. For a full list, refer to the ADA’s Return to Work Interim Guidance and Toolkit. Today, dentists in the post-Covid world are:
- Sending out communications explaining their practices’ infection-control measures and encouraging patients to return for normal preventive care.
- Screening patients before their office visit to make sure they don’t have COVID-19 or haven’t been exposed to someone who has it.
- Advising patients with appointments to wear a mask, limit guests and be prepared to have their temperature taken prior to receiving care.
- If possible, asking patients to wait in their cars before being texted to enter the lobby.
- When patients arrive, administering the COVID-19 screening form again. A positive response to any item should trigger a deeper discussion with the dentist before proceeding with elective treatments.
- Providing a post-procedure reminder to report any signs or symptoms of COVID-19 within the next two days.
- Preparing the reception area to minimize infection. This involves providing a hand sanitation station at the entry and a notice asking people to use it before entering. A mask notice should also be posted.
- Setting up bathrooms and patient consultation rooms to allow for social distancing. Toys, reading materials, remote controls and other communal objects should either be removed or cleaned frequently. Also, all other touchable surfaces such as chair arms, doorknobs, light switches and hangers should be cleaned regularly.
- Adjusting all chair-side activities to minimize infection. This involves things like limiting paperwork in the operatory, covering computer keyboards with a disposable clear barrier that can be changed between patients, limiting patient accessible areas if possible, reducing staff presence as much as possible and engaging in no social physical contact with patients.
- During the procedure, complying with all ADA interim mask and face shield guidelines.
- Striving to use the lowest aerosol-generating procedures and armamentarium when conducting care. Also, some procedures might be more appropriately done in a different care setting (example: hospital).
- Using a disposable nasal hood when administering nitrous oxide and disposable or sterilized reusable tubing.
- Properly using and removing PPE (outside the operatory).
- Taking steps to protect staff from patients and each other. This is a complicated process that involves training on hand hygiene, proper PPE, employee COVID-19 screening and testing. Consult the ADA document mentioned earlier for a full discussion.
In addition to the above changes, some dental practices have adopted new technology to serve their patients safely during this challenging time. One is the installation of advanced air filtration systems to cleanse office air of COVID-19 particles and aerosol. Another is the use of virtual patient consults, which allows practices to continue seeing patients despite legal restrictions on office visits.
Financial Changes
Plummeting consumer demand has affected industry finances. Seeing fewer patients, even after reopening, means revenue is lower. Practices have also had to invest heavily in safety measures. According to the Fresno State University study, 28% of the surveyed dentists experienced a 20% overhead-expense increase; 35%, a 30% increase; and 25%, a 40% increase. With less money coming in and more going out, dental practices have had to implement harsh measures to stay afloat.
The biggest challenge is to align labor expense with lower revenue. Wages account for some 25% to 30% of practice expenses. The other expense categories—rent, supplies and lab—are typically lower expense items linked to the volume of dental procedures completed. So those expense categories have a natural fall-off during practice closures. To deal with wages, dental practice owners commonly laid off staff. Sixty-four percent of standalone private practice owners said they were unlikely to keep their staff, the Fresno State study reported. This compared with 50% of dental corporations, 40% of mobile dental clinics and 23% of federally qualified health centers.
In addition to laying off workers in order to reduce a practice’s cost structure, some practices have decided to hire only temporary staff upon re-opening to give their practice flexibility to address future revenue shortfalls.
With constrained income, more practices are reevaluating the types of patients they wish to treat. For example, according to the Fresno State study, 40% of responding dentists said they were unlikely to keep treating Medicaid patients. For self-pay patients and those with private insurance, that number was 18% and 11%, respectively. Reconsidering fee levels is also an option for practices short of cash, as is adding a surcharge for providing patients with extra PPE.
PPE surcharges have become increasingly common in the post-COVID-19 world. The American Dental Association (ADA) supports their use, as do a growing number of dental insurers. But at least one state—Maryland—has objected to them on the grounds they violate consumer protection laws. Though Whether you’re considering higher fees or a PPE surcharge, don’t proceed without assessing the legal and insurance impact of such moves. caution should be taken if considering these measures– when increasing your fees, dental insurers may not consider them to be “reasonable and customary” and thus refuse to pay for your patient’s dental insurance claims.
Malpractice Risk and Insurance
Does COVID-19 increase your risk of getting sued for malpractice? Yes and no. Yes, it increases your risks if you fail to screen out a sick patient who ends up infecting other patients in your office with COVID-19. But COVID-19 per se isn’t a new risk to your practice. Just as you might get sued for not adhering to industry care standards during a poorly executed root canal, you will likely face litigation if a patient catches the virus because you failed to follow industry best practices for infection control. When it comes to COVID-19 legal liability, it’s all about how well you execute the standard of care. Drop the ball and you will face greater litigation risk.
To safeguard your practice against COVID-19 litigation, be sure to follow all relevant regulatory protocols from the CDC, OSHA, the ADA and individual state governments and state dental boards. But don’t just review and respond to these guidelines once; continuously refer to them so you can update your practices when standards evolve.
Equally important is disclosing to patients the risk of catching COVID-19 during a dental visit. Completed COVID-19 risk forms should become part of each patient’s medical record. Documentation of all discussions about international travel, coronavirus symptoms and potential exposures should also become part of the patient’s file. Also consider having your attorney draw up a COVID-19 disclaimer statement in which patients acknowledge the risk of catching the virus during a visit to your office. However, keep in mind that such disclaimers do not provide immunity in cases where you were negligent in preventing the spread of the virus.
Another thing to check: whether your malpractice insurance policy has a pandemic exclusion. If it doesn’t, then it likely will provide coverage for legal costs and settlements or judgments relating to a patient’s COVID-19 claim against you. However, whether it will cover your specific claim costs depends on your case’s fact pattern. Always provide a prompt notice of claim to your insurer so it can begin reviewing the legal dispute and provide coverage, if warranted.
Finally, be sure to check with your insurer to verify that it considers virtual dentistry a covered professional service. If it does and the patient you’re serving virtually is located in a jurisdiction in which you are licensed to practice dentistry, then your policy should shield you against any claims of professional negligence arising from a virtual dental consult.
Many other dental workflow, financial and risk and insurance changes have swept across the profession due to the Covid-19 pandemic. More are sure to come as the outbreak evolves and public health policy responds in turn. How long will these changes last (example: strict infection control)? It’s impossible to say. Only once a vaccine becomes available and millions of Americans are inoculated, the long-term impact will become clear. Until then one thing is certain: practicing dentistry during the time of COVID will likely be something you tell your children and grandchildren about. Let’s continue to do our part to ensure these stories have happy endings.