TELEDENTISTRY: PROVIDING ALTERNATIVE CARE ......Barriers drive up costs and worsen the chronic disease burden Vanderbilt Univ. Medical Center, Lack of oral care can lead to lifethreatening

TELEDENTISTRY:PROVIDING ALTERNATIVE CARE DURING APUBLIC HEALTH CRISISDentaQuest Partnership Continuing Education WebinarApril 6 & 8, 2020

DOI: 10.35565/DQP.2020.3003

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Learning Objectives

By the end of this webinar, participants will be able to:1. Recognize Teledentistry as a mode to increase access to dental care in

urgent situations.2. Describe policy issues around Teledentistry and the potential solutions for

policymakers.3. Understand examples of how Teledentistry has been used to improve access

to care.

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Housekeeping

• All lines will remain muted to avoid background noise.• A copy of the slides and a link to the recording will be shared after the webinar

concludes. • In order to receive CE credit you must fill out the webinar evaluation, which

will be shared at the end of the presentation. The evaluation must be completed by EOD Friday, April 17 to receive CE credit. CE certificates will be distributed a few days after the webinar takes place.

The DentaQuest Partnership is an ADA CERP Recognized Provider. This presentation has been planned and implemented in accordance with the standards of the ADA CERP.

*Full disclosures available upon request

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Q&A Logistics

After the presentations we hope to have some time for Q&AWe will be monitoring the chat box through the entire presentation and we will do our best to answer all questions.• Type your question in the chat box

and make sure you send it to allpanelists.

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Presenters:

TELEDENTISTRYProviding access to care during the COVID-19 crisis April 6, 2020

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• New HHS policy statement allows for reductions or waivers of cost-sharing obligations by people enrolled in Medicare and Medicaid

• Many governors have issued executive orders promoting telehealth

• In this crisis, dental providers can use telehealth to consult with patients, triage their needs and offer limited emergency services

As the COVID-19 pandemic intensifiedFederal and state leaders have taken steps advancing telehealth

Office of Inspector General, U.S. Dept. of Health and Human Services, policy statement regarding telehealth services during the coronavirus (COVID-19) outbreak, March 17, 2020; IL Executive Order No. 2020-09, KS Executive Order No. 20-08, NH Emergency Order No. 8, and TX statement on payment parity posted on gov.texas.gov, March 17, 2020.

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Some states’ executive orders (EOs) are fairly limited in scope:• The Arkansas EO no longer requires a “real time” patient encounter to

establish a professional relationship

• The Florida EO enables state employees to receive free telehealth services during the COVID-19 crisis but covers less than 1% of Floridians

• The Maryland EO allows health director to permit “real time” audio-only remote consultation between patients and providers

• The Texas EO focused on payment parity and it covers 16% of Texans

State executive orders vary in their scopeGovernors were focused on the immediate COVID-19 crisis

Arkansas Governor’s Exec. Order 20-05; Florida Governor’s Exec. Order 20-85; Texas Governor’s Statement issued March 17, 2020; Maryland Governor’s Executive Order No. 20-03-20-01;

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The duration of these EOs is limited:• Kansas EO expires no later than May 1

• Massachusetts EO expires whenever its “state of emergency” ends

• New Hampshire EO expires when its “state of emergency” ends

• North Dakota EO expires when its “state of emergency” ends

• Rhode Island EO expires on April 17

State executive orders vary in their durationGovernors were focused on the immediate COVID-19 crisis

Kansas Governor’s Exec. Order 20-08; Massachusetts Governor’s Exec. Order on Telehealth Services, March 15, 2020; New Hampshire’s Emergency Order No. 8; North Dakota Governor’s Exec. Order 2020-05.01; Rhode Island Governor’s Exec. Order 20-06.

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Where states stand on teledentistryOnly a few states have a truly supportive policy environment

Data from three interactive maps on the Scope of Practice Policy website, designed by NCSL and ASTHO, was used to gauge state-based environments on teledentistry based on three parameters: 1) dental hygienists with direct access, 2) status of dental therapists as part of the oral health team, and 3) states allowing the practice of teledentistry. Information provided in the maps was used to evaluate each state on these parameters on a scale of 1-5, with 1 = the most unsupportive environment and 5 = the most supportive environment.

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Both documents can be accessed at https://bit.ly/Teledentistry2020Access DQP’s Communications Brief and White Paper

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States have a unique opportunity to:• Enable dental providers and patients to

connect remotely in compliance with social-distancing and other guidance

• Help people with important oral health needs consult with providers, deterring them from visiting hospital EDs, which are overwhelmed

• Build a more accessible and connected system that remains after the immediate crisis ends

As COVID-19 cases continue to growTeledentistry gives states a chance to improve access

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Over 56 million people live in a dental professional shortage area

Even outside shortage areas, many people face barriers, including:• Seniors with limited mobility

• People with complex medical issues

• People facing transportation barriers

• People on the autism spectrum

Barriers to care are persistent, even for many who are insuredDental access is much more than a rural problem

OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak March 17, 2020

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Oral health access also impacts overall healthGrowing research links oral health with chronic health conditions

Teeuw, WJ et al., Diabetes Care, Feb 2010; Sen S, Sumner R, Hardin J, et al., Journal of Stroke and Cerebrovascular Diseases, 2013; Wang C-W, McCauley LK. Current Osteoporosis Reports, Dec 2016; Müller F, Journal of Dental Research, Oct 2014.

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• These ED visits are very costly for consumers, insurers and states

• These ED visits can disrupt more urgent needs at a time when COVID-19 has overwhelmed many hospitals

Most of the 2 million annual ED dental visits could be handled in dental offices and/or through teledentistry

Slow progress on teledentistry hurts efforts to improve accessBarriers drive up costs and worsen the chronic disease burden

Vanderbilt Univ. Medical Center, Lack of oral care can lead to life-threatening situation, VUMC Reporter, Sept 2016; Wall T, Nasseh K, and Vujicic M, Majority of Dental-Related Emergency Department Visits Lack Urgency and Can Be Diverted to Dental Offices, Aug 2014, Health Policy Institute, American Dental Association.

A lack of access can lead to untreated tooth decay or other infections, leaving people with no viable options other than visiting hospital EDs

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• During the COVID-19 crisis, it’s crucial for EDs to be free for patients who are acutely ill

• This is an added concern for states with high percentages of seniors — and teledentistry can allow older adults to access providers while safely at home

The numbers in Florida:

Dental-related visits to Florida’s hospital EDsThese visits can disrupt or delay care for more urgent conditions

489,000+ Number of dental-related hospital ED visits in Florida over a three-year period

1 in 4

Serna CA, Arevalo O, and Tomar SL. Dental-Related Use of Hospital Emergency Departments by Hispanics and Non-Hispanics in Florida. American Journal of Public Health. 2017.

The share of these Florida hospital ED visits that were billed to Medicaid

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The 4 modalities of teledentistry

Live video (synchronous): Two-way, real-time interaction between two or more people

Store-and-forward (asynchronous): Photos, X-rays or other patient info are transmitted through a secure system to a dental provider

Remote patient monitoring (RPM): Personal health or medical data are gathered from a person in a different location, allowing a provider to monitor blood pressure or another vital sign or condition

Mobile health (mHealth): Making health data or education accessible to smartphones or other mobile devices

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• Medicaid reimburses live video services for telehealth in all 50 states

• 2/3 of Americans say they are open to using telehealth

• Experts: Oral health is “lagging behind” other health disciplines in utilizing telehealth

Telehealth initiatives are steadily growingHowever, teledentistry is expanding more slowly

Center for Connected Health Policy, State Telehealth Laws & Reimbursement Policies, Fall 2019; American Well’s Telehealth Index: 2019 Consumer Survey, July 2019; Teledentistry: How Technology Can Facilitate Access To Care, a white paper by the Association of State and Territorial Dental Directors, March 2019.

19American Hospital Association. Telehealth Use Surges in Rapidly Changing Market, April 4, 2019; Minemyer P, article in FierceHealthcare, Dec 5, 2018.

Telehealth use is accelerating in medical and behavioral healthOral health is trailing behind these efforts

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• California’s Virtual Dental Home (VDH) delivered much more preventive and early intervention services at a lower cost per patient than the Medicaid program

• 2/3 of children and 1/2 of adults in VDH with complex health conditions were able to obtain all the care they needed at the community site

Teledentistry: Promising initiatives in a variety of statesThese programs demonstrate the ability to improve access

Univ. of the Pacific. “Virtual dental homes” prove safe, effective in six-year statewide study. Aug 2, 2016; Glassman P, Teledentistry Improving Oral Health Using Telehealth-Connected Teams, Pacific Center for Special Care, Aug 2016.

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Teledentistry: A promising impact on improving access

Pelto I. A Reason to SMILE(S): Dental Care for Thousands of Coloradans, Colorado Health Institute, 2018; Minemyer P. The missing piece in telemedicine? Dentistry. FierceHealthcare. 2018 Dec 5.

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Teledentistry: A promising impact on improving access

Pelto I. A Reason to SMILE(S): Dental Care for Thousands of Coloradans, Colorado Health Institute, 2018; Minemyer P. The missing piece in telemedicine? Dentistry. FierceHealthcare. 2018 Dec 5.

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1. Dental workforce

2. Reimbursement policies

What can states do to seize the opportunity of teledentistryHere are the 4 key areas that need to be addressed

As of 2019, all states have Medicaid policies that reimburse live video services for medical or behavioral health encounters.

State Practice Acts should allow care in community settings by non-dentists while having appropriate regulations to ensure oversight, instead of imposing direct supervision rules.

Both public and private insurers should reimbursement teledentistry provided via live video or a store-and-forward mechanism. In addition to payment parity, there should be no discrimination based on the type of dental provider.

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3. Legal clarity

4. Sharing patient information

What can states do to seize the opportunity of teledentistryHere are the 4 key areas that need to be addressed

NOTE: Health Level 7 is an international network of experts developing consensus standards for the exchange, integration, retrieval or sharing of electronic health records (EHRs). The ADA is among the key stakeholders lending their expertise to these efforts to achieve interoperability.

States should help to bring clarity to legal issues that discourage providers and health systems from engaging in teledentistry. These issues include liability coverage for dental providers, getting “credentialed,” data security, and rules of HIPAA compliance.

Experts and key stakeholders are working to make electronic health records (EHRs) “interoperable” or shareable. States should support efforts to achieve interoperability and mandate that certified health IT products adopt the dental exchange standard.

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• Creating telehealth-friendly policies now can ensure that patients are able to receive oral health and other services away from settings where potential for contracting COVID-19 is higher

• States can leverage the federal CARES Act, which includes telehealth provisions

This is an ideal time for states to act States can address immediate and long-term health care needs

National Consortium of Telehealth Resource Centers, COVID-19 Telehealth Toolkit, March 18, 2020. The Coronavirus Aid, Relief and Economic Security Act (CARES) was enacted by Congress and signed by the President in March 2020.

• Making permanent changes to laws and policies that promote teledentistry would better prepare states for similar crises in the future

California Northstate University College of Dental Medicine

Paul Glassman DDS, MA, MBAProfessor and Associate Dean for Research and Community EngagementCalifornia Northstate UniversityElk Grove, [email protected]

mailto:[email protected]


Disclosures

The presenter has consulting arrangements with the following entities:• DentaQuest Partnership, Inc.• Virtual Dental Care• Idaho Department of Health• Rhode Island Department of Health• Multiple dental care providers



DeliverySystems

Measurement and Payment

Systems

Preventionand Behavior

Science


Preventionand Behavior

Support Science


The Declining Role for the Dental Drill


Behavior Change Principles

• Messages delivered by trusted members of the community• Multiple people delivering the same message• Small incremental behavior changes• Ongoing reinforcement, coaching• Peer support


DeliverySystems


Teledentistry

Dentist to dentist interactions: share records, patients

Real time video surgical support

Real time video consultation – dentist to dentist/patient

Store-and-forward record review

Patient to dentist interactions

mHealth data collection

Telehealth-connected team delivery systems



Space and Equipment


EHR: Radiographs


EHR: Photographs




Community-based Prevention and Early Intervention Procedures




The Virtual Dental Home Sites


• Reach people, emphasize prevention, and lower costs• Majority of people kept and verified healthy on-site

– About 2/3 of children had all needed services completed by dental hygienist

• Continuous presence• Community organization integration• Dentist integration


The Virtual Dental Home Current Trainees8- DentalQuestLearning Collaborative

19- DHCS DentalTransformation Initiative

1- Delta Dental

5- HRSA

1 – CA Wellness

2 – Regional Centers

2 – Hawaii3 – Oregon5 - Colorado

Total = 46 entities


States Adopting Virtual Dental Home Systems2010

VDH Funded Projects

VDH Systems

VDH Discussions


States Adopting Virtual Dental Home Systems2020

VDH Funded Projects

VDH Systems

VDH Discussions


Community EngagedOral Health Systems


California Northstate University College of Dental Medicine 52

Maintaining Services and Contact with Patients During the time of COVID‐19 Physical Distancing

Using Teledentistry Tools and Strategies


• People cut off from sources of dental care• Practices trying to limit services to emergent/urgent services• Need to:

– Establish communications– Provide advice, consultation, triage– Provide limited and efficient in-person services when needed.

necessary• Must keep people from seeking care for oral health concerns in

other components of health care system – Emergency Rooms

Physical Distancing


1. Optimized systems: Integrated teledentistry systems that include all needed tools

2. Combining available tools:– Email and text + patient generated photographs– Off-the shelf/low-cost/free separate tools:

• scheduling/video/forms/payment– Copy and paste all activity into one record/EDR

Solutions for current physical distancing environment


• Notify• Plan• Advice/Consultation/Triage• In-person – minimal interventions• Secure complete record of all components of the patient

interactions

Optimized System: Components


• Notify• Plan• Advice/Consultation/Triage• In-person – minimal interventions• Secure complete record of all components of the patient

interactions

Optimized System: Components



Patient:• Notify• Register – create patient portal• Choose level of response• Pay or enter insurance/Medicaid number• Fill out forms• Upload – photos, text, records• Schedule – type, urgency

Optimized System: Workflow


Provider:• Notified of patient registration and uploads• Respond via message –portal/chat• Secure videoconference• Advice/consultation/triage• Next steps:

– Advice– Prescription– Follow-up appointment– In-person treatment

Optimized System: Workflow



Provider:• Telehealth system

– Notifications/Appointments– Consent/signatures/explanations/instructions

• In-person– No waiting room– Text or call when ready– No paperwork, no explanations, no signatures– Short visit – in and out

• Follow-up: Teledentistry system

Optimized System: In-person visit



• Patient– Secure, one-stop access to provider

• Oral health provider– Maintain contact with patients– Full ability to provide advice, consultation, triage– Plan for in-person visits if needed– Complete record of images, forms, consent, payment all in one record

tied to practice EDR• Health care system

– Help people with dental conditions to receive advise or care outside of other components of the health care system – especially ER

Optimized System: Advantages


Live Video

Schedule

PatientInformation

Forms

ConsentExplanation/Information

Integrated Permanent

Record

Registration

Messaging

Chat

Optimized Systems for COVID-19 ERA: All-in-One


Paul Glassman DDS, MA, MBAProfessor and Associate Dean for Research and Community EngagementCollege of Dental Medicine, California Northstate [email protected]

Maintaining Services and Contact with Patients During the time of COVID‐19 Physical Distancing

Using Teledentistry Tools and Strategies

A COVID-19 SNAPSHOT OF TELEHEALTH AND ORAL HEALTHSean G. Boynes, DMD, MSVice President, Health ImprovementDentaQuest Partnership for Oral Health Advancement

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Emergent and Urgent Care, Reducing Exposure, & Finding Health

The covid-19 pandemic is accelerating the transition to a new model of remotely delivered health care that embraces the benefits of digital and data technologies.

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Proportion of All Dental Encounters that are Unplanned

DQ Partnership Preliminary Analysis - NHANES

14%

5%

17% 17%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Total Children (<21) Adults (21-64) Elderly (65+)

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Proportion of All Dental Encounters that are Unplanned, by Insurance Type

16%

19%

29%

10%

16%

12%

24%

0%

5%

10%

15%

20%

25%

30%

35%

Medicaid only Medicare only Dual Eligibles PrivateInsurance only

Other insurers Multipleinsurers

Uninsured

DQ Partnership Preliminary Analysis - NHANES

70

10%

6%

19%

0%

5%

10%

15%

20%

25%

Total Children Adults

2017

Proportion of All Dental Encounters that are due to a Emergency

Truven IBM –Marketscan – DQ Partnership Preliminary Analysis

9% 9% 10% 10% 10%

6% 6% 6% 6% 6%

20% 20% 20% 20% 19%

0%

5%

10%

15%

20%

25%

2013 2014 2015 2016 2017

2013-2017 Trend

Total Children Adults

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# of Days Between Dental Emergency Visit and Next Dental Visit

32%

15% 15%

9%

15% 14%

44%

20%17%

7% 8%4%

16%

11%14%

11%

27%

20%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1-15 16-30 31-60 61-90 91-180 181-365Number of Days

Emergency Dental Treatment Routine Dental

Truven IBM –Marketscan – DQ Partnership Preliminary Analysis

72

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Fragmented guidance…

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Emergency BundleTeledentistry CDT Codes Variations of the following CDT Codes:D9995 teledentistry – synchronous; real-time encounter Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

-or-

D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service.

D0140 - Limited oral evaluation, problem focused

D0160 - Detailed and extensive oral evaluation

D0170 - Re-evaluation - limited, problem focused (established patient; not post-operative visit)

D0171 - Re-evaluation – post-operative office visit

D0190 - screening of a patient

D0191 - assessment of a patient

D9992 - Dental case management – care coordination.

D9994 - Dental Case Management – patient education to improve oral health literacy.

D9311 - Consultation with a medical health care professional.

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Follow Current State Orders & CDC / ADA Recommendations

Initiate Patient-DMD/DDS/RDH

Teledental Encounter

Patient Self-Help

OTC or Rx Medication

In DMD/DDS Office-Follow current CDC/ADA

guidance to minimize need for aerosol producing procedures

Access, Review,

Update and/or create pt.

record, med hx

Initiate triage protocol

(ADA, CDC, etc.)

Collect records via interview,

patient photos/video

Document and treat

Virtual care

Urgent +

Emergency

Patient Education

Use most current ADA Guidance for Triaging and Screening Patients

Refer to Medical Professional or ED

only if warranted

include COVID-19 Screening

Consultation with medical

professional

Bill Codes:

D1330,D9992, D9994, and/or D9311

Bill Code:

D0140, D0160D0170

D0171, orD0190

Dental Professional Follow-Up:Decide If Follow-up Contact Needed

Notate definitive treatment priority once business and

operations have returned to normal

Constant monitor community and state

recommendations related to COVID-19

By phone, telehealth, video as approved

Teledental Emergency Flowchart for COVID-19 Impacted Dental Coverage

Bill for procedures

provided

Bill Code:

D0995(D0996 only if asynchronous)

Bill Code:Limited use:

D0350

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A few things to ponder….

• Limited teledental or virtual visit services for new patients only• “My dentists phone is just ringing and no one is picking up, can you help me?”

– 19% closed and not seeing any patients (ADA HPI: N≈11,000 ADA Members)

– State level reports of dentists closing offices permanently due to loss of lease

• Requiring patients to activate the tele-visit • Limitations of cold calling for a billable procedure

• Telehealth is not applicable to dentistry because it is a surgical sub-specialty only• In Medicaid (2017), 25% of all dental claims and 43% of all costs were for surgical

procedures (restorative care, oral surgeries, periodontal care, and anesthesia)

• In Commercial Insurance (2017), 24% of all dental claims and 49% of all costs were for surgical procedures

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Re-designing the pathway to oral surgical intervention

Grocott et al. Perioperative Medicine 2017; 6:9

Encounter. An interaction between a patient and a healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

HEALTH

DISEASE

Opportunities of health-oriented patient engagement

Traditional focus on disease-oriented patient engagement

What gets done to the patient?What gets done

with the patient?

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Re-designing the pathway to oral surgical intervention

Grocott et al. Perioperative Medicine 2017; 6:9

Encounter. An interaction between a patient and a healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

HEALTH

DISEASE

Opportunities of health-oriented patient engagement

• Collaborative (shared) decision-making

• Collaborative behavioral change (lifestyle modification)

• Comorbidity and risk management

• Expectation management and psychological preparedness

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Re-designing to Assess Health and Risk of Disease

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Risk Stratified Annual Surgical Dental Intervention Costs

MORE Care: Preliminary Analysis

0

10

20

30

40

50

60

70

High Risk Moderate Risk Low Risk

Surgical Intervention Rate by Risk

Surgical Intervention Rate

Medicaid, 2017 – 0.33% CRA reportsCommercial, 2017 – 0.28% CRA reports

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14% 13%

88%

29%

24%

78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Emergency Dental Visit Surgical Intervention Preventive Procedure

Patie

nts

Rec

ievi

ng S

ervi

ce

Relationship between “Oral Health Visit” in 2018 on Oral Health in 2019

Had Oral Health Visit in 2018 No Oral Health Visit in 2018

MORE Care: Preliminary Analysis

QUESTIONS?

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Webinar Evaluation

https://www.dentaquestpartnership.org/node/193990*Must complete by EOD Friday, April 17 in order to receive CE credit

Upcoming Webinar:• Wednesday, April 8th at 1:00 PM – Teledentistry: Providing Alternative Care

During a Public Health Crisis

Sign up to receive our newsletter to get more information on future webinars!

https://www.dentaquestpartnership.org/node/193990

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Documents

TELEDENTISTRY: PROVIDING ALTERNATIVE CARE ......Barriers drive up costs and worsen the chronic disease burden Vanderbilt Univ. Medical Center, Lack of oral care can lead to lifethreatening