Crisis and Opportunity: COVID-19 Pandemic Kick Starts Changes for Dental Community
By LaShell Stratton-Childers, ADEA Senior Editor
The COVID-19 pandemic’s impact has been and continues to be wide-ranging, influencing legislation and regulations on both a national and state level. Several of those changes have been relevant to the dental and dental education community, from the expansion of telehealth in some states, to the approval by the Biden administration of dentists and dental students becoming COVID-19 vaccinators, to greater movement in licensure portability and licensure examinations. ADEA and other dental organizations advocated for many of these improvements with the hope they will last well beyond the pandemic, but whether these changes will be long-lasting is the prime question of several observers.
States Expand Teledentistry
Telehealth—health care attained from the safety of the patient’s home—became even more prevalent during the pandemic because of lockdown mandates and safety concerns of those who feared risking their health with in-person visits.
“COVID-19 spurred unprecedented need for telehealth nationally and globally,” said Erik Skinner, M.P.H., a Policy Associate in the National Conference of State Legislatures’ Health Program, during the educational session, Federal and State Update: Teledentistry and COVID-19, at the 2021 ADEA Annual Session & Exhibition.
“Both the Health and Human Services Secretary and Medicaid temporarily loosened restrictions on telehealth,” Mr. Skinner said in a follow-up interview. “We saw states either build on these actions by further loosening restrictions or by applying these new telehealth policies to different patient populations, for example, teledentistry.”
This expansion of teledentistry at a state level included both synchronous and asynchronous services. Synchronous teledentistry takes place in real-time with a telephone and/or video component. Asynchronous teledentistry is traditionally done with another technician. It can include acquiring images secured by a clinician and sending them to a dentist remotely for evaluation.
“More states are beginning to add a clear definition of teledentistry to their statutes,” said Phillip Mauller, M.P.S., ADEA Director of State Relations and Advocacy. “These definitions help by clarifying practices that are permitted. States are also beginning to allow for new methods of communication. Many states once required real-time interaction and are now allowing for store-and-forward methods of communication that allow for the transmission of documents through secure e-mail connections.”
Mr. Skinner said during the ADEA Annual Session & Exhibition that, in 2020, Oregon, Hawaii and Tennessee passed laws related to teledentistry.
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This year in March, the North Carolina Senate passed a bill that would define and establish standards for the practice of teledentistry. That same month, the New Mexico House of Representatives expanded the scope of teledentistry in the state. Under the state’s current law, a dentist may only engage in teledentistry in real-time in cooperation with another oral health professional to provide limited diagnostic and treatment planning services. The new law would redefine teledentistry to mean “the use of electronic information, imaging and communication technologies, including interactive audio, video and data communications as well as store-and-forward technologies, to provide and support health care delivery, diagnosis, consultation, treatment, transfer of medical data and education.” And finally, in Maryland, the General Assembly has sent a hefty bill to Gov. Larry Hogan (R) that rewrites many of the state’s telehealth policies and redefines telehealth to include medically necessary dental services.
Medicaid Reimbursement of Telehealth
Some state bills have included a reimbursement component for telehealth services, an important part of this legislation.
“Many of them do, and some of the states, at least on a temporary basis, passed emergency regulations that allowed for or increased reimbursement through state Medicaid systems,” Mr. Mauller said. “I do think reimbursement is an important component that will allow oral health providers to be fairly compensated for their time, expertise and care provided.”
But Mr. Skinner said the reimbursement component can be complex, with its pros and cons, depending on the perspective. “Requiring reimbursement for telehealth, especially reimbursement equal to in-person care, is often a controversial topic,” he said. “Some providers and advocates argue requiring reimbursement offers a financial incentive for providers to use telehealth, and payment parity laws ensure payers do not reimburse for telehealth at lower rates. However, certain payers and other policy experts maintain virtual services are not equivalent to in-person care—and requiring payment parity may negate the cost-savings of using telehealth.”
Mr. Mauller said he believes that states will continue the momentum of adopting telehealth legislation after the COVID-19 pandemic. “Telehealth in general is providing more convenient ways for practitioners to treat their patients and for patients to see practitioners,” he said. “Most health professions, including dentistry, were incorporating telehealth into their practices before the pandemic, but social distancing requirements created by the pandemic increased their use and importance. While oral health practitioners will still need to see patients in person for many services, I believe that after experiencing increased convenience and efficiency teledentistry provides, both patients and providers may call for increased access through teledentistry.”
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“We have certainly heard a wide range of health care stakeholders advocate to make these changes permanent on both the state and federal level,” Mr. Skinner said. “On the state level, the policy views of legislative leadership, the governor/state health agencies, as well as other health care stakeholders will shape the outcome. Cost considerations may also factor into some policymakers’ plans to make permanent changes or pursue a return to pre-pandemic telehealth policies.”
Dentists and the COVID-19 Vaccine
Within 48 hours of the Pfizer/BioNTech COVID-19 vaccine receiving Emergency Use Authorization (EUA) from the U.S. Food and Drug and Administration (FDA) in December 2020, the federal government shipped almost 3 million doses of the vaccine throughout the country. It was left largely to the states to prioritize who would first receive the vaccine.
Though many health care professions were considered top tier recipients, in several states dentists and allied dental professionals were not included in this category, even though dentists, dental hygienists and dental assistants are three of the top five professions with the highest risk of infection from COVID-19, according to the World Economic Forum.
The Trump administration would eventually include dentists in phase 1 for the COVID-19 vaccine, said Bridgette Dehart, ADEA Director of Federal Government Relations. “The decision was part of the national vaccine prioritization plan that the Centers for Disease Control and Prevention put out,” Ms. Dehart explained. “However, the plan only offered guidance to the states. The CDC didn’t have the power to make states follow the guidance. States ultimately prioritized the order in which vaccine would be distributed in their state.”
So, it was left to many in the dental profession to advocate on the ground at the state level.
“Dentists were in the fourth priority group in Oregon’s initial COVID-19 vaccine rollout plan, which began with frontline health care workers,” said Brad Hester, D.M.D., President of the Oregon Dental Association in the ADEA Jan. 21 article, “A Shot Worth Taking: Dentists in Several States Join the Fight Against COVID-19 by Giving Vaccinations.” “We advocated successfully to ensure dentists are considered a high priority in the first phase of vaccine distribution in Oregon as well, because dentists are also essential health care workers. Dentists and their teams are now eligible to receive the vaccine in Oregon as supply becomes available.”
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The National Vaccine Rollout
In addition to wanting dentists prioritized to receive the COVID-19 vaccine, ADEA and other dental organizations also pushed for dentists to be able to administer the vaccine.
“If dentists are going to give a vaccine, they need to be vaccinated,” said Judee Tippett-Whyte, D.D.S., California Dental Association President in the same Jan. 21 article.
The ADEA Council of Deans Administrative Board drafted a resolution showing that ADEA supports and encourages the education of dental students, residents and oral health care providers in the administration of vaccinations. The ADEA House of Delegates voted in favor of the resolution at the 2021 ADEA Annual Session & Exhibition. Also, the American Dental Association (ADA) passed a resolution at its virtual annual meeting in October 2020, showing support for dentists who choose to administer critical vaccines to help during declared local, state or federal public health emergencies.
Ms. Dehart said ADEA reached out to both the Trump and Biden administrations in an effort to amend the Public Readiness and Emergency Preparedness (PREP) Act to include dentists and dental students as vaccinators. “The amendment would have allowed dentists and dental students to give the COVID-19 vaccine,” she said.
Recently, the Biden administration granted ADEA’s request and amended the PREP Act to include dentists and dental students. Ms. Dehart said this inclusion may be largely due to the administration’s goal of 200 million vaccine doses within the first 100 days of Biden’s presidency, requiring even more health care professionals. Additionally, 12 states have allowed dental hygienists to administer the vaccines.
Licensure Portability Sees an Uptick
Two other areas that have seen movement because of the pandemic are the increase of licensure portability and the end of single encounter, procedure-based clinical examinations on patients. These are the goals of the Coalition for Modernizing Dental Licensure. The Coalition’s establishment was the culmination of years of work to improve the dental licensure process.
In a collaborative effort, ADEA, ADA and the American Student Dental Association (ASDA) formed the Task Force on Assessment of Readiness for Practice. This group authored what is often referred to as the TARP report, which issued a call for change, provided an analysis of the current licensure process and, most importantly, proposed a way forward. The report recommended that a coalition of like-minded organizations and agencies be established, and this is what led to founding the Coalition for Modernizing Dental Licensure in October 2018. Coalition membership includes more than 35 dental schools, in addition to state dental societies, dental specialty organizations and national and non-profit organizations.
Dean Cecile A. Feldman, D.M.D., M.B.A., of Rutgers, The State University of New Jersey, School of Dental Medicine and a member of the Coalition, said there is no logical justification for states to continue to restrict licensure portability. “We have a national accrediting system for dental schools,” Dr. Feldman said. “So, if you graduate from an accredited program, and if you passed an exam and got a license from one state, why shouldn’t you be able to practice in another state?”
She also noted there are some states “that allow individuals from other states to come in and provide care as long as it’s in a low-income, underserved area. Again, that doesn’t make any sense. Either someone is qualified to provide patient care, or they’re not qualified to provide patient care.”
Prior to the pandemic, Arizona became the first—and at that time—only state to grant licensure portability to any state resident who had held a license in another jurisdiction that is in good standing for at least one year. Since then, more states have embraced licensure portability.
On Jan. 27, 2020, Ohio Gov. Mike DeWine (R), signed a bill to grant temporary licensure to members of the military and their spouses who held licenses in other jurisdictions. Similarly, in Iowa on June 25, 2020, Gov. Kim Reynolds (R) signed a new law that requires licensing boards in the state to issue an Iowa license to any resident or spouse of an active-duty member of the military stationed in the state, who has held a license issued by another jurisdiction that is in good standing for at least one year. The Iowa law does allow licensing boards to require applicants to pass an examination specific to the laws of the state and establishes some minimum requirements to qualify for portability.
On July 6, 2020, Missouri Gov. Mike Parson (R) signed a bill that required licensing boards to waive any examination, educational or experience requirements for individuals who have held a license in another jurisdiction for at least one year, and if the license is in good standing, only if the licensing board determines there were minimum education, work experience and clinical supervision requirements in the other jurisdiction and the jurisdiction verifies the person met those requirements. The bill’s sponsor, Missouri Rep. Derek Grier (R), told The Missouri Times in a March 15, 2020 article that he put forward the legislation because he thought it could help the state mitigate potential medical professional shortages due to the COVID-19 pandemic.
So far this year, Mississippi and Kansas have also joined the fold. On March 25, Mississippi Gov. Tate Reeves (R) signed a bill that would require licensing boards to grant a license to numerous licensed professionals, including dentists and dental hygienists, who establish residency in the state and who have held licenses that are in good standing in another jurisdiction for at least one year. (Current Mississippi law already extends this courtesy to members of the military, military spouses and their dependents.) In addition to establishing residency, an applicant for licensure by reciprocity cannot have faced or be facing specified discipline or complaints.
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And finally, on April 21, Kansas Gov. Laura Kelly (D) signed a law that requires licensing boards in the state, including the Kansas Dental Board, to grant licenses to individuals who establish residency in the state or intend to establish residency, hold a license that is in good standing from another jurisdiction that authorizes a similar scope of practice and have worked for at least on year in the profession in which the license is sought. Applicants who meet the requirements would be given a probationary license at least 45 days after submitting a complete application that will allow them to practice. (The period is 15 days for a member of the military or a military spouse.) Additionally, when an applicant has not worked in their occupation for the preceding two years, licensing bodies are permitted to require applicants to complete additional testing, training, monitoring or continuing education to establish the applicant’s ability to practice in a manner that protects the public’s health and safety.
Manikin-based Exams Gain Support
According to the Dental Licensure by State Map on the Coalition for Modernizing Dental Licensure website, as of April 21, 11 states currently accept alternative pathways to licensure (Alaska, California, Oregon, Washington, Colorado, Minnesota, Iowa, Indiana, Ohio, New York and Connecticut) while the remaining states still require single encounter, procedure-based clinical examinations on patients. These alternative pathways can include, but are not limited to, manikin-based exams.
Dr. Feldman said she believes more states will move away from single encounter, procedure-based clinical examinations on patients.
“As there are more experiences with states using alternative pathways and there are no adverse events that occur because of that, I think it’s going to harder and harder to keep justifying restrictive pathways to licensure,” Dr. Feldman said. She also said she believes that some of the other methods, such as the Dental Licensure Objective Structured Clinical Examination (DLOSCE), which is administered by the Joint Commission on National Dental Examinations, have stronger validity and reliability, “so again it’s going to be harder to not accept those alternative pathways.”
Dr. Feldman also pointed out that because of the pandemic, almost all states have made “some accommodations to enable students who were graduating to get licensed.”
Those accommodations sometimes included manikin-based exams. This was the case with the emergency rules issued by the District of Columbia’s Department of Health in September 2020 that amended city regulations to allow the acceptance of nonpatient-based clinical examinations for initial licensure for both dentists and dental hygienists. The rules limit acceptance of nonpatient-based exams to those administered by the American Board of Dental Examiners, and eliminate a mandate requiring dentists to complete a periodontal examination.
Later that year, in November 2020, the Montana’s Board of Dentistry published a regulatory proposal that would extend a decision to allow manikin-based exams beyond 2020 for both dentists and dental hygienists. That same month, the Iowa Dental Board recently filed a proposed rule change that would allow candidates for dental licensure to complete manikin-based exams to fulfill clinical testing requirements needed for licensure. Candidates could pass either the Central Regional Dental Testing Service, Inc. (CRDTS), a manikin-based examination as administered by CRDTS, or the American Board of Dental Examiners, Inc., a manikin-based examination as administered by the Commission on Dental Competency Assessments.
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Dr. Feldman acknowledged there was definitely “forward momentum that occurred as a result of COVID, and we certainly want to make sure we can maintain those changes because I think it was for the better.”