There is general agreement that the field of Dentistry is undergoing significant change, whether one looks at the education system, the delivery system, the payment system, or the population served. Far from being a Doom and Gloom situation, members of the American Association of Dental Consultants (AADC) feel these changes may offer opportunities for our membership. In this paper we will provide a look at the fields of change, what opportunities the changes may offer, and how one might best prepare for future opportunities available.
We have listed eight fields of interest:
- Quality Management
- Dental Products Industry
- Political Appointments
- Community Health
The Committee has interviewed more than a dozen acknowledged experts in these fields and we will present a forecast of the change and opportunities for each field, what skill sets make a person attractive, and how or where one can obtain further education or training.
Changes: Tort Reform remains a contentious issue in several states and the financial implications from Liability Insurance costs to unnecessary treatment provide an opportunity for someone with a history in litigation / Risk Management to be of value to several entities. In addition, there remains the need for Expert Witnesses in the traditional court system. Topics that have taken over the spotlight in litigation include, but are not limited to: failure to diagnose periodontal disease, failure to obtain proper informed consent for all types of treatment, placement of implants, lack of documented treatment planning, failure to deliver properly constructed crown and bridge restorations on natural teeth and implants, and failure of cosmetic procedures.
There is also a need for expert consultants to assist dentists who have been challenged by state boards or other administrative agencies. These dentists may need assistance/representation along with legal counsel.
Skill Sets: The primary skill set for both consulting on legal manners as well as providing Expert Witness advice and testimony is experience, and the primary filter for selection is networking. Experience can begin by getting involved with Peer Review and Grievance resolution. A knowledge of Record Keeping and Coding is mandatory. Dental training to expert level for many treatment protocols as well as the latest scientific basis for treatments and materials are essential. Review of court decisions will help with understanding “standard of care”. Some legal knowledge is also necessary; i.e., statute of limitations; continuous care doctrine; methods of ‘examinations’. Office safety, OSHA regulations, CDC roles also offer opportunities for qualified dentists to audit / teach compliance. Personal appearance is extremely important in court cases, as is general demeanor and self-confidence. Familiarity with Office Management software and billing practices enhances one’s reputation. Expert witnesses must have practiced within 5 years of the time a suit is commenced. His / her reputation must be above reproach or conflicts, absent of state Department of Health actions, or of any other healthcare entity.
Handwriting analysis is another tool that can become important in either validating or invalidating treatment notes since a majority of notes are handwritten or transcribed later into computer notes, dates
It is important to know that general dentists usually can be experts in general dentistry issues, while cases involving dental specialists will need to be reviewed/ opined by consultants who are board certified or eligible in that specialty.
3D radiography (CBCT) has enabled a more sophisticated diagnostic approach to implant, periodontal, oral surgical, and endodontic treatments. These advancements have also given malpractice attorneys additional ways of proving dental care that has breached the standard. Malpractice insurers are also using advanced techniques for defending their clients’ care. Staying current with dental procedures and diagnostic tools gives dental consultants the credentials needed to provide services to the legal profession.
Where to Go, What to Do: Involvement with local component societies or with the American Dental Association (ADA) Peer Review process is a good place to start as are maintaining affiliation with the Academy of General Dentistry (AGD), Specialty Organizations and other certifications such as AADC and Certified Fraud Examiner (CFE), which allow for unbiased review of records in enough detail so presentation of opinions have credibility in court proceedings and depositions.
There is a two-day course available in California four times a year by the California Association of Dental Plans (CADP) that is an excellent resource for office assessment and regulatory requirements. The cost varies from $700 to $900 depending on membership in the CADP. Several states have office assessment evaluations as part of the regulatory process. The Dentists Insurance Company (TDIC) as do other Dental Liability Insurance Companies, offer Risk Assessment courses throughout the country. These are half-day courses, modestly priced for members of TDIC, and some companies offer premium discounts for attendance. Courses in Evidence-based Dentistry are available through the ADA, again, very modestly priced. Educational materials for training for OSHA and CDC rules and regulations are also available online.
There are some additional, independent ways to increase your knowledge and marketability: Attend court proceedings in malpractice cases. The court “docket” is posted on a daily / weekly basis online at your local county courthouse. On the web: dictionary www.law.com has a Legal Dictionary: American Legal (ALM’'s) online Real Life Dictionary of the Law. The easiest-to-read, most user-friendly guide to legal terms. You might also contact a local law school and inquire into courses in court procedure Handwriting analysis can be established through the International Graphoanalyis Society (IGAS): www.igas.com .
Contact a local Bar association and ask if it is possible to “shadow” a malpractice attorney or whether the association offers courses in expert witness testimony, and risk management law. If there is enough interest AADC, may start a course in Expert Witness Testimony.
Changes: Probably few of the topics selected for this paper provide more variety or opportunity than the field of Quality Management and its sister-topics: Quality Assessment and Quality Improvement. The Affordable Care Act (ACA), in particular with the Essential Healthcare definition for children’s oral health requires accountability where little or none existed before. Nationally, standards are being developed by the National Quality Forum. The ADA is involved in the Dental Quality Alliance. Several states are setting National Committee on Quality Assurance (NCQA)-type standards for dentistry. The National Association of Dental Plans (NADP) has been a major player in defining quality for dental services. Dental “reason” codes are now incorporated in International Classification of Diseases (ICD)-10 and Systematized Nomenclature of Dentistry (SNODENT) for use in filing electronic claims. EZ codes Dental Diagnostic Terminology, which accomplish the same thing are part of the reporting software used in almost every US Dental School. Testing of the Virtual Dental Office is incorporating outcome analysis and relating treatment to cost effectiveness. More and more dentists and dental staff are becoming familiar with rubrics, which use quality measures
Skill Sets: Interviews with experts in this field suggest desired skill sets might include a background in Public Health, a background in business, corporate experience, awareness of patterns of care and standards of care, an interest in providing dental services to large numbers effectively, scientific method and analysis, well read, inter-activity with Regional Dental Directors, Dental Commissions, and Regulators. A background in Clinical Dentistry (in contrast to academia) is helpful. Actuarial skills are a plus.
Where to Go, What to Do: Get involved with work groups through regulators and Trade Associations, including AADC. Public Health and Business courses are available through educational institutions.
Dental Products Industry
Changes: The explosion in dental technology is anticipated to continue at a rapid pace for the foreseeable future. Not only will there be new devices but products related to new fields such as patient risk assessment, genetics and nano-technology to name a few. Sophisticated developers of these new “products” are cognizant that the dentist adaptation rate for their product can be significantly impacted by dental plan cove rage (or lack thereof). Guidance along the often arduous and tortuous path of obtaining dental plan coverage can be extremely valuable to these industries.
Skill Sets: The primary skill for consulting to the dental products industry is a thorough knowledge of dental benefit plans and how they work. This includes understanding the perspective of all the potential parties of interest including but not limited to: dental plans, dental directors, purchasers, consulting entities, brokers, patients, labor unions, organized dentistry, and the practicing dentists who will use these new technologies. Also the consultant should have strong capabilities in new technology assessment, cost effectiveness, and cost benefit analysis, relevant governmental regulations (including state dental boards, licensing issues, FDA clearance) and evidence based dentistry. Thorough knowledge of the ADA coding process is also necessary. Finally, strong communication skills and the ability to work with groups often with conflicting interests is necessary.
Where to Go, What to Do: Experience in working with a dental carrier is paramount. Involvement with organizations such as the American Association of Dental Consultants (AADC) can provide contacts that may be useful in seeking employment opportunities in the field of dental benefits AADC also provides educational opportunities through their journal and workshop. The American Dental Association offers both an evidence based dentistry course and a management leadership training course. Formal education in public health or business administration although not required will provide many of the skills required as well as make the candidate more attractive.
Changes: The field of Dental Forensics changed dramatically after 9/11, when dentists and the dental team were identified as a primary source of body identification. While the field of Dental Forensics still is involved in body identification, missing person identification, legal testimony in rape, assault and murder cases, it increasingly assumes a role in mass casualties. Dental Forensics also is becoming part of the DNA identification, with applications for refined bite-mark analysis in at least one Dental School.
Skill Sets: An interest in Pathology is helpful as well as skills taught in Dental School about anatomy, reading and evaluating x-rays, and maturation of the dentition. Clinical experience is useful, but not necessary. Flexibility in schedule and ability to travel on short notice are almost a necessity. As with many of these fields, passion for the subject is the greatest skill set needed. With so many dedicated, qualified experts and so few occasions of need, there is virtually no financial opportunity in the field. Most experts have skills honed from military service or academia.
Where to Go, What to Do: The training and experience required to become Board Certified in the field of Forensic Odontology is arduous and expensive. There are currently about 100 dentists so trained and certified. Short of Board certification, www.ABFO.org there is membership in the American Association of Forensic Sciences, www.AAFS.org , for not only dentists but also students or staff interested in the field. Membership is modestly priced. You might also do some individual searching on the National Missing and Unidentified Persons website, www.namus.gov to see if the field has interest for you.
Changes: Several changes have occurred in the area of Political Appointments, not the least of which is the subject of a recent Supreme Court case, alleging that the North Carolina Dental Board may have acted in its own interest (and those of practicing dentists) rather than the interest of consumers, when they declared teeth whitening at a mall kiosk the practice of dentistry. This case is expected to be decided in June 2015. More than thirty states may be looking at how their Dental Boards are constituted. There are other political appointments than Dental Boards, however. Several states have a state Dental Director, for instance, and many offer appointments of dentists to Community and Federally Qualified Health Centers. While not exactly a political appointment, working within organized dentistry is very much a political process and provides a means for improving name recognition for advancement.
Skill Sets: Fortunately most of the skill sets necessary to be considered for political appointments are learned after graduation from school. They would include: organizational and communications skills, time management, ability to work with others towards consensus, knowledge of current affairs, and congeniality. One of the truths of political appointments is that there is great value in past successes; i.e., better and greater appointments follow success in lower and smaller appointments.
Where to go, What to Do: Although problematic for older dentists, the best avenue to start is within organized dentistry. An alternative method is to volunteer in community projects. Standard Executive training is available from several sources. Networking through Service organizations is useful in building name recognition within a community. Committee work in trade associations, such as NADP and AADC is useful in staying knowledgeable about current issues, both nationally and locally. Several websites are available that could be helpful, including those for the above mentioned trade associations. Establishing your own website is a good way to increase your name recognition but is quite expensive. Other social media, such as LinkedIn, Facebook, and Plaxo, if used effectively, provide easy ways to network. Study Clubs have pretty-much disappeared, but some communities may offer opportunities to publish or participate on radio or television to establish credentials. Advanced degrees; e.g. MBA, MPA, are available at many colleges and universities on a part-time basis.
Changes: Even the terms Monitoring and Mentoring have changed their connotation in recent times. As defined in this paper Monitoring will be activities to evaluate Quality and effectiveness of care, and Mentoring will be activities to improve those same measures. The Affordable Care Act, particularly the Children’s Oral Health Essential Benefit already is offering opportunities to define Quality Measures and establish Standards of Care, and Risk Assessment. As the Accountable Care Organization concept becomes applied to Dental Benefits, both Monitors and Mentors will be needed. It is important to note that “standard of care” is a concept, defined individually, based on expert testimony, published articles, dental school teaching and Board or court rulings. There is no written actual standard which can be applied for all cases. Acceptability of care provided is based on that care given by the average dentist of similar training in similar situation in the community.
Skill Sets: Knowledge of what constitutes Quality dental services, the components thereof, and the metrics involved in evaluation are of paramount importance. Much of this knowledge is in the formative stages; e.g., Quality Measures, Code Sets, Outcome Analysis, Legislative and Regulatory Standards, and Optimum Outcomes. There is also a need to accept quality as a continuum, rather than a pass/fail component of service delivery. Finally, there is a need to accept that quality may be defined differently across socio-economic and cultural boundaries.
Where to Go, What to Do: Again, involvement in committee work, whether through organized dentistry, Public Health, Educational Institutions or Trade Associations is an excellent training ground. Current literature on topics relating to Quality Assessment for Dentistry are also good sources, as are websites such as www.nadp.org, www.ada.org and www.caldentalplans.org. CADP provides an excellent course on Quality Evaluation four times a year in California for about $500. One of AADC’s member, P&R, has initiated a service to delineate dentists on the basis of quality. Information on that program can be found at: email@example.com.
Changes: Faced with the rising costs of education, especially in the field of dentistry, and the scarcity of traditional educational staff, more and more schools are going to a modular program staffed by part-time faculty with no tenure, sick days, or retirement. We also are seeing more dental education become virtual and self-paced. Dentists who have the skill sets and reputation are attractive as part of this pool. Also, more and more schools are integrating their dental programs with medical programs, emphasizing oral health as a component of overall health. Finally, as the profession addresses care to the underserved there exists an opportunity for education in Public Health.
Skill Sets: A knowledge of current delivery systems, the materials available, and more importantly the technology available are absolute necessities to separate oneself from the pack. As with many of the above fields, networking is a major factor in selection. There also should be a dedication to teach and a reward system that treasures education and respect. Computer skills are a must.
Where to Go, What to Do: Almost all of the newest 12 dental schools and those on the horizon use or will use some part-time faculty. A check with those schools as to the criteria they will use in hiring would be valuable. Again, stay current with topical literature and concepts. Computer skills are a must and courses are available from many sources.
Changes: There was a time when Military Service, Education and Community Health were the only salaried areas in the field of dentistry. Today, with group practice accounting for almost 50% of opportunities, which is no longer the case. Another change of consequence is the huge debt of most recent graduates. In searching for ways to pay off or reduce the debt, many Federal, state and local community health positions offer the most attractive opportunity. Finally, as the generation of Millennials enters the dental work force, many adjust their priorities in ways that make community health a more attractive option, at least for a period of time.
Skill Sets: The most important skill set is a change in perspective of what is meaningful in the practice of dentistry. Most of us were taught that dental services should be tailored to an ideal oral health conclusion and treatment plans were designed to achieve that ideal. The world of practicality suggests otherwise. Personal factors, such as patients assuming responsibility for continuing care, return on investment of time and dollars, access to care and limited resources to provide care, and measurable favorable outcomes may play an increasing role in how dentistry is practiced and by whom. In addition to the change of perspective there is a need to have exceptional technological skills, a statistics background, Business Administration skills, Managerial skills, including delegation and supervision, and practical experience.
Where to Go, What to Do: Most Masters of Business Administration (MBA) programs would be helpful, as would formal Public Health programs. Short of that, volunteer internship in programs that are in Beta-testing would serve several positive functions including: networking, current program knowledge, where to find funding, etc. The ADA is sponsoring ways to volunteer for existing Federally-Qualified Health Clinics (FQHC)s, all of which are compensated, and this offers a way to get involved on your own time schedule at the local level. Many community health programs have room for dentists on their advisory boards, although consumer membership of a majority is a requirement and lessens the opportunity for dentists to serve. Committee work in the above-mentioned organizations also will allow knowledge of possible opportunities.
More than a dozen persons with richly diverse backgrounds were interviewed for this paper. The most obvious common trait they possess is that they had a passion for the field they settled in. Almost all said that the job came to them rather than the other way around. Most were approached by someone who either mentored them or saw in them a commonality for the passion they held. While this paper was originally designed to identify opportunities for Dental Consultants in the changing texture of dentistry, it has become obvious that unless there is a sincere, existing interest in one or more aspects of what is developing, the dentist who sees his or her opportunities to review claims may have to move into volunteer work and follow these pathways to learn new skills. Dental Consultants can advance their skills, use knowledge gained in claim review to expand their ability to act in some of the fields as noted above. Some areas can provide significant income, while others will not.
SKILLS / ABILITY TO EVALUATE
EXPERT WITNESS (legal forensic dentistry)
Professional Liability case
Whether for the Defense or Plaintiff there are criteria for the consultant to apply:
1. Evaluate the written records for
c. signatures of treating staff member/doctor
d. tooth numbering system
e. registration form filled out by patient
f. health history form filled out by the patient
g. dates on all forms that are part of the patient record
h. patient signatures on all forms and treatment letters or in charts where discussions or decisions are made
i. cross outs/deletions/whiteout/ missing pages of record
j. changes in handwriting or initials
k. when records are not legible, ask for a typewritten transcription of all documents
2. Review radiographs
a. correlate with treatment records
b. note the quality of developing or digital image
c. note the diagnostic image quality-are images purposely distorted to hide critical information?
d. correlate with insurance submission dates as to type, quantity, location of the teeth numbers imaged
e. for traditional films-determine how they are mounted –button out or in to eliminate errors of judgment
3. Correlate billing records with treatment and match to insurance submissions
4. Evaluate the clarity of the complaint by the plaintiff and any response from the defendant or the reverse.
5. Develop a time line of the course of treatment
6. Determine what and the way treatment was provided relates to standard of care.
7. Describe the way and the point at which during treatment a violation of the standard of care occurred.
8. Evaluate appropriateness of treatment
9. Learn the definition of Standard of Care and then how it relates to your case
10. Understand the doctrine of continuous care, Informed consent, Informed refusal, abandonment, state statute of limitations
11. Understand the state dental practice statutes of the state in which the case is placed in motion.
HOW TO TESTIFY
1. Learn the procedures of depositions, court testimony, and the mechanics and sequencing of the proceedings
2. Learn the process of examination and cross-examination, questioning techniques and techniques of reply
Interviewees in Alphabetical Order
Emil Capetta, DDS
Michel E. Coret, DDS
Jack Dillenberg, DDS, MPH
Fred Horowitz, DMD
Leeann Glassaway, MPH
L. Thomas Johnson, DDS
Henry Lotsof, DDS
Howard Pactovis, DMD
Amber Riley, RDH, MS
Tom Ruffio, MBA
Harriet Seldin, DMD. MBA
Cathye Smithwick, RDH
Positions Committee Members
Michael DL Weisenfeld, DDS, Chair
Dee FitzGerald, DDS, Primary Author
Andrew Mogelof, DDS
Marc Zweig, DDS, MS
Scott Navarro, DDS
Cary Sun, DDS
Pam Chung, DDS
Robert Rosenthal, DDS