When a 100-year pandemic emerged in March 2020, most healthcare professionals knew it would be severe. Now, several years later, its long-term effects are becoming more evident.
The pandemic had a catastrophic impact on the global economy, especially in the U.S., which had the most infections. COVID-19 hit dentistry hard, as well. According to the Central Valley Health Policy Institute at Fresno State University, experts at the American Dental Association (ADA) and state dental authorities recommended early on that dental practices cease elective procedures and focus on urgent care.
By mid-May 2020, most states allowed dentists to perform elective treatments. But consumer fear of catching COVID-19 at their dental office significantly lowered demand. According to ADA's Health Policy Institute, by September 7, 2020, 48.3% of U.S. practices were operating normally. However, 50.5% were seeing lower-than-expected patient volume. Plus, for 60% of participating practices, total office revenues for the week of September 7 were only 76% or more than average. Meanwhile, 23% posted only 26% of their regular income 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'll discuss some high-level changes dental-industry experts have witnessed, organized in terms of dental workflow, practice finances 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 future.
Dental Workflow Changes
COVID-19 has sparked radical changes to almost every element of dental patient care. Following are some major examples. Revised practices include:
- Issuing communications regarding preventive measures and suggesting patients return for preventive care.
- Pre-visit screening to make sure patients don't have the virus or haven't been exposed to someone who's currently sick.
- Requiring patients to wear masks, limit guests and be prepared for a temperature screen.
- At arrival, administering another screening. A positive answer to any item should prompt discussion with the dentist before beginning elective treatments.
- Sending a post-procedure reminder to flag COVID-19 signs or symptoms within the next 48 hours.
- Instituting infection-control measures in the waiting room. This involves providing hand sanitation and a notice requesting people also wear masks.
- Making bathrooms and patient consultation rooms appropriate for social distancing. Remove or frequently clean items such as magazines, TV remotes and other shared objects. Also, regularly clean chair arms, doorknobs, light switches and hangers.
- Revising chair-side behavior to reduce infection risk. Take steps such as reducing paperwork in the operatory and using clear barriers on computers. Also, limit office areas open to the public, reduce staff presence and refrain from physical patient contact.
- During treatments, complying with ADA mask and face shield rules.
- Using low aerosol-producing methods and armamentarium when providing care. Also, consider transferring high-risk procedures to a different facility.
- Using a disposable nasal hood to administer nitrous oxide and disposable or sterilized reusable tubing.
- Correctly wearing and removing personal protective equipment (PPE).
- Protecting staff from patients and other staff. This involves providing training on hand hygiene, PPE and COVID-19 screening and testing. Read ADA document mentioned earlier for further details.
Note: Some dental practices have installed new technology to serve their patients safely during the pandemic. One example is air filtration systems that remove COVID-19 particles and aerosol from office air.
Financial Modifications
Falling patient demand damaged dental-industry finances. Reopening, but conducting fewer procedures, decreased practice revenue. Offices also invested heavily in COVID-19 safety measures. According to the Fresno State University study, 28% of dental providers had a 20% increase in overhead; 35% had a 30% uptick and 25% saw a 40% increase. With less revenue coming in and more money going out, many dental businesses resorted to harsh measures to remain in business.
The biggest problem was adjusting labor expenses with income shortfalls. In most practices, wages are about 25% to 30% of expenses. The other overhead categories — rent, office supplies and lab materials — are variable expenses, rising and falling based on the number of procedures. Not surprisingly, those categories declined when practices closed. To adjust wages, many dental practice owners laid off staff; the Fresno State study revealed that 64% of independent private-practice owners said they were unlikely to retain all staff. Meanwhile, 50% of dental corporations, 40% of mobile clinics and 23% of federally qualified health centers said they planned to reduce headcount.
In addition to terminating staff to adjust a practice's cost structure, some dentists elected to hire only temporary personnel when they reopened. They hoped this would allow their practice to respond to future revenue shortfalls.
With lower income, practices considered adjusting their desired patient profiles. For example, according to the Fresno State study, 40% of dentists said they were likely to stop treating Medicaid patients. Reconsidering fee levels was also a possible tactic for cash-short practices, as was charging extra to recoup higher PPE costs.
PPE surcharges have become common since the onset of the pandemic. The ADA agrees with their use, as do many dental insurers. If you're considering increasing your fees or instituting a PPE surcharge, think about the legal and insurance impact. Dental insurers may decline them for not being "reasonable and customary" charges.
Malpractice Risk and Insurance
COVID-19 legal liability depends on how well you execute infection control. Drop the ball and you will face added litigation risk.
To safeguard your practice, adhere to regulatory protocols from the CDC, OSHA, the ADA and individual state governments and dental boards. But don't just review and implement these measures once; check them often and update your COVID-19 practices as needed.
Equally important is explaining the risk of catching COVID-19 while receiving in-person dental care. Ask your attorney to draft a COVID-19 disclaimer statement for patients to acknowledge the chance of getting sick after a visit to your office. However, this practice won't provide legal immunity if you were negligent in implementing COVID-19 infection control.
Signed COVID-19 disclaimer forms should go in each patient's medical record. Also, document discussion of international travel, COVID-19 symptoms and possible viral exposures.
Then determine whether your malpractice insurance policy excludes pandemics. If not, it likely will cover your legal costs and settlements or judgments following a patient's successful COVID-19 claim against you. However, whether it covers your actual claim costs depends on the specifics of your case. If you suspect a patient might sue you, notify your malpractice insurer. This will allow the firm to hire a defense attorney and begin preparing your claim file.
Finally, ask your insurer to verify coverage for virtual dentistry. If it does cover you — and the patient you're treating virtually lives in a state where you're licensed to practice — your policy should shield you against malpractice claims following a virtual dental visit.
The COVID-19 pandemic has sparked many other clinical, business and insurance changes in the dental profession. More will arrive as the outbreak continues to evolve and public health policy responds. Will the changes be permanent? It's hard to know. One thing is sure, though: Practicing dentistry during a pandemic will be something you'll tell your children and grandchildren about.