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A conversation with the president-elect: Part 2

‘The work is never completed in advocacy’

Editor’s note: This is the second part of a conversation about the issues facing the profession with Dr. Robert A. Faiella, ADA president-elect, who will take office Oct. 23 during Annual Session in San Francisco. Part 1 was printed in the Sept. 17 ADA News. ADA News Editor Judy Jakush interviewed Dr. Faiella.

ADA News: The Board of Trustees approved the formation of the new Code Advisory Committee to handle maintenance, changes and deletions to the Code on Procedures and Nomenclature. This replaces the Code Revision Committee. How do you define the CAC’s role for the profession?

Dr. Faiella: To provide some historical context, initially the Code Revision Committee was created through the ADA-Delta settlement agreement approximately 10 years ago. That agreement has moved into an expiration phase, but we still need to maintain the Code, especially with the technological changes in the current electronic transmissions environment. With the development of the Code Advisory Committee, the Council on Dental Benefit Programs is taking the responsibility for maintenance of the Code, in which a greater number of stakeholders will now be involved in an open, transparent process. They will vote by simple majority whether to accept new codes, modify existing codes or delete outdated or redundant codes. The Code may expand to include procedural, diagnostic and administrative codes. It must be granular enough to capture the workflow in the office for the electronic record, but also must be basic enough to allow for reporting out for adjudication of insurance claims. These are two separate, but related, uses. For the patient health record, you need input codes for all that you do; but for payment, you only need to report out a single procedure code, and not every step you took to perform it. The procedural codes needed for insurance submissions are a small subset of the larger code needed to capture what dentists do in providing care.

Image: Dr. Faiella: “We know that advocacy is the No. 1 reason members cite for being a member of the Association. Our Washington Office is working very hard in a difficult political environment, particularly with an election coming. They have been successful in achieving many of our goals, but other goals are a little more elusive in this environment.”
Dr. Faiella: “We know that advocacy is the No. 1 reason members cite for being a member of the Association. Our Washington Office is working very hard in a difficult political environment, particularly with an election coming. They have been successful in achieving many of our goals, but other goals are a little more elusive in this environment.”

The CAC is a 21-member voting body with representation from a wide range of dental stakeholders. As was the case under the former code revision process, the CAC actively engages the payer community to help us maintain the code. The major difference is that the new process will provide for the dental community with a better way to make the appropriate recommendations consistent with developing codes for the electronic health record in dentistry. It’s really important for dentists to understand that the CAC’s mission is to make the Code reflect what we do in the office, but also to keep it relevant for the adjudication of claims. It is a very complex topic within the Bylaws responsibility of CDBP, and the council has embraced it.  CDBP’s continued work on the Code is reflected in the latest release, CDT 2013: Dental Procedure Codes.

ADA News: You’ve taken a lead role in helping the ADA develop standards for electronic health records, providing education about what’s coming and advocating for the profession within the process. What’s the status of this transition? Do you think dentists are ready to move from paper to electronic? Do you think even those who aren’t required to move to an EHR system by 2014 will do so anyway?

Dr. Faiella: People concerned about moving to an EHR are already doing many of their business transactions through an electronic environment. This is usually through their practice management software, which submits claims electronically with attachments for adjudication. The question is whether dentists can find certified electronic record systems that meet the needs in their practices. As for the EHR, the first point is that it is clearly the way of the future. For some in the baby boom generation, it can be a struggle to transition from paper to electronic transactions. But if you ask the new generation of dentists, they cannot imagine doing it another way. We know that the adoption of technology changes from generation to generation, and that will drive the transition to a paperless environment.

The second point is related to interoperability, which few understand. Right now, you can buy an electronic health record system as a standalone product. You capture the data, but another system can’t read it because the information fields don’t match between systems. Someday, with the work we are doing on the development of standards, they will.

Some people may think an electronic record is merely an electronic PDF of a paper file. That’s not it. A true electronic record means that fields match up from one record to another. Consider the field for patient marital status. In some software programs marital status is given as married/not married; in some it’s married, separated, divorced or single. That’s two choices in one program, and four in another. If I transfer a record to you, how do you map that and set parameters that allow for accurate communication of information? Field mapping can get very complicated. It has to be standardized to work.

For the EHR, it is not going to be one finish line for every area in medicine and dentistry in 2014. There will be sectors like hospitals and ambulatory centers, and certain government program providers, like Medicare, that will be required to hit that goal first. Eventually dentistry will be part of it, but we don’t know exactly when that is: there is no deadline for EHR implementation in dentistry at this time. Along the way we are making sure we are involved in the certification of compliant systems, developing standards specific to dentistry, educating our members as the process moves along, and keeping liaison relationships with other standards organizations so we have input as things develop. Certification is an important piece, and assures the standard will lead to interoperability. We have a dentist on the Certification Commission for Health Information Technology for the first time ever. We are working with the Office of the National Coordinator in Washington to advocate for dentistry in the EHR development process, which is still evolving.

ADA News: Third-party payers like Delta Dental continue to cut reimbursement fees for dentists in various states. What is the ADA’s role in these situations? As Delta says, are the cuts simply just another reflection of the economy?

Dr. Faiella: Our role in third-party issues is through the Council on Dental Benefit Programs and its Dental Benefit Information Service. The ADA has no direct control over third-party policy decisions. We can only engage them in dialogue, monitor what they are doing and inform our members on matters related to third-party issues. Each dentist has to look at his or her relationship with third parties individually. Federal law restricts our ability to negotiate or act on behalf of our members in this regard. We cannot give dentists advice on how to react, but we can keep them informed about how we communicate with insurers, and hopefully our continued communication with third parties on behalf of our members can result in favorable changes.

ADA News: What other third-party payer issues are on the forefront for members?

Dr. Faiella: The legislative challenge to the noncovered services issue started in Rhode Island, which was the first state to pass a law prohibiting a cap on noncovered services. Basically, it prevents capping by any insurance plan. Twenty-eight states now have legislation preventing capping of fees of noncovered services. That is a huge achievement on this issue. And there are more states with similar, pending legislation. Obviously this is a state-based issue, and the wording of the proposed legislation varies by state. Our Department of State Government Affairs provides advice and shares information about what other states are doing. This is an important benefit for our members and the state dental societies trying to achieve legislative traction on this and other state-based issues.

ADA News: The ADA’s GKAS program has reached the milestone of a decade of providing education and messaging about the importance of dental care and a dental home, as well as advocating with policymakers for better access to care for all. How do you see the program moving ahead? Does it need some retooling or redirection? Are there ways to measure the impact it has had on the profession and on access to care for patients? How will the recent collaboration with NASCAR open new avenues for GKAS, from bringing dental care and messages to kids and families in need to drawing more attention from policymakers?

Dr. Faiella: GKAS started as a local program by Dr. Jeff Dalin in St. Louis, whom I met when I went to the GKAS event in Virginia earlier this year. It provides a white-hot spotlight on the needs of a very vulnerable children’s population for oral health services. It is astonishing that we have 16 million children in the U.S. with untreated caries, and 80 percent of untreated caries is in 25 percent of the children. That’s an incredible statistic. According to the U.S. surgeon general’s report on oral health, it accounts for 51 million hours of lost school time. But charity alone is not a solution, so obviously we need to hold these events to continue to drive home the importance of oral health to policymakers and legislators so they can see what a difference it makes when you remove the barriers to access to care in these vulnerable children.

The ADA took the local St. Louis program national in 2003, which leads us to the ADA’s 10th GKAS anniversary. It’s tremendous the way it has evolved to include NASCAR through 3M ESPE’s relationship with them, which brings even a greater spotlight on the effort. We are happy to be partnered with 3M ESPE, NASCAR and Henry Schein and to work with Greg Biffle and the No. 16 car. We appreciate how having these partners come together brings more attention to oral health.

ADA News: The ADA Foundation has been fast evolving in the past few years. Has its role changed? What message do you want to convey about the role of the ADAF to members?

Dr. Faiella: After restructuring ADAF to make it the truly independent charitable arm of our Association, the Foundation has been evolving. From the leadership of Dr. Arthur Dugoni, who did a tremendous job, through that of the current president Dr. David Whiston and executive director Gene Wurth, who joined ADAF last year, the Foundation is poised to continue in a strong and positive direction. Dr. Whiston has been absolutely tireless in his efforts to revitalize the Foundation. The Association is excited by the future of the Foundation to fulfill its mission. We are looking forward to having the corpus of the Foundation continue to grow and to provide funding for what ADAF determines is appropriate to support oral health outcomes and programs benefiting patients.

ADA News: The ADA Center for Evidence-Based Dentistry is increasing efforts to tailor EBD workshops and teaching opportunities to audiences beyond the ADA’s annual EBD Champions Conference. What is your assessment of how the ADA needs to proceed in further bringing attention to EBD and the related resources that the ADA offers?

Image: Periodontist: Dr. Faiella has two offices for his periodontology practice, one in Osterville on Cape Cod, and a second in Duxbury, Mass. He is past president of the Massachusetts Dental Society and will become the 149th president of the ADA this month.
Periodontist: Dr. Faiella has two offices for his periodontology practice, one in Osterville on Cape Cod, and a second in Duxbury, Mass. He is past president of the Massachusetts Dental Society and will become the 149th president of the ADA this month.

Dr. Faiella: I think people are excited by the notion that evidence-based dentistry provides a scientific basis for what we do, rather than relying solely on an anecdotal history. That said, what we are learning when we carefully evaluate the existing literature is that many anecdotal reports predominate in the search results. Different topics have different levels of information in the literature, so this becomes a challenge. Clearly, EBD helps us understand what needs to be done for future research so we can have the appropriate evidence as a translational basis for making decisions about treatment and provision of care. It will be an integral part of our future both in medicine and dentistry, but it is shining a glaring light on our research needs and research agenda to assure a rigorous scientific basis for clinical decisions.

I spoke at one of the EBD workshops and was impressed by the enthusiasm of the attendees, and with good reason. Once you are engaged in it, you realize the power of the process. We will do as much as we can to make sure all of our members have the opportunity to understand how important it is, not only for the present but also for the future of our profession.

ADA News: In the past 10 years, eight new dental schools have opened and two more are in the works. Most are private institutions. The schools vary in philosophy and approach. What should members know about this expansion of dental education? How are competency and licensure issues addressed with respect to newly graduated dentists?

Dr. Faiella: The Commission on Dental Accreditation writes standards for accreditation of dental schools and their curricula. That is an important role CODA plays as authorized by the U.S. Department of Education through a process that involves intense scrutiny of CODA activities. We support that role because we feel committed as an Association to the best educational process possible. Even so, the delivery of education is something that should always be evolving. While most of the new schools are private, I don’t think the new school models will escape the economic pressures that the traditional schools have faced.

Here is the meaningful question: Who is ultimately responsible for the competency of the graduate? The accreditation community? The dental schools? Or the examining community? I would suggest all three play a very critical role in developing and assessing competencies. CODA, in developing the accreditation standards, doesn’t set the bar, it sets the floor. You have to meet the standard—but you can certainly go beyond that.

How much beyond is really left to each school. If a model is based on community delivery of services, is that sustainable? There are some dental school models that have had success with that, but that approach may not necessarily find success in every community. How the community accepts those new school models is yet to be determined.

Time will tell how this trend impacts the profession from a provider distribution base. It’s hard to predict because, as we have seen in the past, there are periodic expansions and contractions of educational institutions. I suspect we will probably see a similar pendulum swing in the future. That is yet to be determined as we continue our efforts to understand the impact of the new school models.

ADA News: You participated this summer in the Multicultural Oral Health Summit, held in July, which marked the first joint annual session between the Hispanic Dental Association, National Dental Association and Society of American Indian Dentists. Have you seen any changes in the ADA’s relationship with dentists who represent diverse groups over the past 10 years?

Dr. Faiella: The Multicultural Summit was very exciting. The relationship among the diversity groups has been growing positively over the past several years and this year for first time, NDA, HDA, SAID and the ADA had a chance for members from each of their respective boards to participate in a joint leadership education program in connection with the summit. It was an opportunity to share ideas regarding where we are headed collectively in the future, and to recognize our common goals and concerns about the oral health of the nation. Working together is the key to progress. The more understanding we have about each other, the more we can share, and the better it will be for the profession and the patients we serve. This was a really important, landmark meeting.

ADA News: Can you talk about what the ADA is doing to be relevant to specific groups in which there are opportunities for membership growth? These groups include women dentists, dentists who were internationally trained and racially/ethnically diverse dentists. Have you seen any impact from the Membership Program for Growth (which is the tripartite marketing collaborative approach that provides constituent and component societies with marketing expertise and customized resources) or know of other efforts?

Dr. Faiella: Absolutely there has been an impact. Obviously, our population is ever more diverse, and our profession is evolving to express that diversity as a reflection of society. I think the Council on Membership is focusing on certain very important groups for engagement. Women dentists, dentists of diverse backgrounds, non-U.S.-trained dentists living and practicing in the U.S., and the urban components are where we are seeing the greatest opportunity for membership growth. The council is working very hard for outreach to these groups.

ADA News: Do you think most members understand or are concerned about the need to seek new members? Why does the ADA exist?

Dr. Faiella: I believe this comes down to being part of a profession. Going to dental school is a huge commitment, and I believe with it comes the opportunity to live and practice a profession to the fullest. That includes becoming directly involved with the group that represents all dentists and their efforts to improve the oral health of our patients. The Association works continuously to help society understand the importance of oral health. The ADA is not a trade group. It is a professional association with a goal of improving oral health measures and doing so in appropriate ways, allowing the dentist to exercise his or her clinical judgment. Entities or agencies with legislative, regulatory or other authority may act in ways that may limit the individual dentist’s ability to deliver that care. The ADA is the voice that speaks on behalf of the profession and works to protect it from undue interference in the doctor-patient relationship. That’s the message about membership. It’s not about growing for the sake of growth, or increasing revenue for revenue’s sake; it’s about having the people in the profession doing the good work the Association has been doing for 150 years.

The work is never completed in advocacy. We know that advocacy is the No. 1 reason members cite for being a member of the Association. Our Washington Office is working very hard in a difficult political environment, particularly with an election coming. They have been successful in achieving many of our goals, but other goals are a little more elusive in this environment. We support them fully and appreciate all our members engaging their legislators at not only the state level but also the federal level to advance oral health initiatives which safeguard the profession and the public’s health. Our governmental affairs efforts include the Council on Government Affairs, the Department of State Government Affairs, the State Public Affairs program and the Council on Access, Prevention and Interprofessional Relations, which have provided some states with support they could never garner on their own.

ADA News: The Association has been going through an extensive financial review the past few years, facing many of the same challenges all businesses have during the recession. The 2013 budget proposal the Board is advancing to the House during Annual Session Oct. 19-23 calls for a dues increase of $30 and a special assessment of $50 in 2013 and 2014 to establish a capital improvement fund to cover deferred maintenance and improvements on the ADA buildings in Chicago and Washington. How do you see 2013 unfolding from a financial perspective?

Dr. Faiella: The Board’s budget proposal is designed to align with the four major goals of the ADA Strategic Plan, with particular emphasis in 2013 on the first goal, to help dentists succeed in their careers and the fourth goal, to ensure the ADA is a financially stable organization.

Projected 2013 revenue is $118.6 million. Pretax operating expenses are projected at $120.2 million. Specifics about the plan are in Board Report 2 to the 2012 House of Delegates, which is posted on ADA.org.

I can’t emphasize enough how critical it is for us to align our appropriations with our strategic and operational initiatives. Our strategic plan drives what we do as an Association.

The decision to request a dues increase and establish a capital fund was made after extensive deliberations and a thorough review of Association finances. Last year, we overhauled the ADA employee pensions to bring them into alignment with current practice and economic conditions. For 2013, it is the first time that we have used universal assessment criteria to give us some basis to evaluate programs for return on investment, return on objective, alignment with the Strategic Plan and mandates from the House of Delegates. Those criteria will continue to evolve as we continue to inform the new budget process and make appropriate decisions as fiduciaries.

ADA News: The Commission on Dental Accreditation voted to develop standards for dental therapy programs in 2011. There has been some comment on this from the House. Will CODA continue to move forward with this plan? What do members need to know about this issue, both from an accreditation viewpoint and a legislative one?

Dr. Faiella: Right now, CODA is authorized by the U.S. Department of Education to write standards for dental education and allied dental education programs in the United States. The House of Delegates has made it very clear to CODA that it has concerns with some of the criteria regarding these programs. There are five criteria, which include economic viability and whether there is a market need for that model. CODA agrees that it needs to answer the questions on those two criteria specifically. CODA is going to continue its work in developing those standards, but those standards will not be promulgated until the issues relating to those criteria are resolved. Legislatively, there are activities across the country and the models that are being proposed vary. In September, the Washington State Dental Association’s delegates agreed to support a very specific type of model in response to the direction of the Washington state legislature on this issue.

The groups that are focused exclusively on a specific workforce model are, I believe, concentrating too much on trying to be innovative and are not really looking at the potential to change disease rates in a population. We know that the access issue and, more importantly, the delivery of care issue are much more broadly defined. It’s a combination of factors, including cultural, language, geography, oral health literacy, funding and to a limited degree, workforce distribution. I don’t think we’ve fully explored using the current workforce to our advantage. We are working to move the discussion away from a very narrowly focused discussion on a single solution.

ADA News: The Association instituted a study this year of its governance structure. What is the outcome?

Dr. Faiella: The outcome will be determined at the House. A firm recognized for its expertise in this area gathered data and input from all levels of the Association. Its report, along with the Board’s recommendations, has been shared with delegates (and is posted on ADA.org under 2012 Board Reports & Resolutions). We have seen significant dialogue in the states already, and several amendments and resolutions are being put forward in addition to those suggested by the Board. The point of the effort is to make the Association a more effective organization, utilizing best practices while at the same time keeping the governance relevant and ensuring meaningful representation of our members in the development of ADA policy.