Coming Back from Covid-19: The Effects of PPE on American Dental Practices By Kate Willeford, CPA of The Willeford Group During the week of May 10, 2020, The Willeford Group conducted an online survey of American dental practices. The 300 survey respondents were located across the United States and answered questions related to reopening practices and the steps being taken to ensure the safety of their patients and their teams. Their responses give insight into how our industry is coping with the new requirements for PPE and social distancing as well as some of the ways in which dental offices will attempt to reopen their practices and recover their financial stability as the nation recovers from the pandemic. Who is Concerned about PPE expenses? More than 85% of those who completed the survey were General Dentists, however other specialty practices were also represented. Because the practices sampled are located across the United States, they were in many different states of the reconfiguration and reopening process. More than a third of them had already opened when they took the survey and more than half expected to be open by May 15. However, 14% of offices were looking at June or beyond before they could reopen the practice. Because most of the country has been shut down since Mid-March, practices forced to open in June or after face an even higher loss of income. What Types of PPE requirements are practices implementing? Most practices, nearly 90%, plan on changing how they implement face masks. A higher use of hand sanitizer is also nearly universal. Meanwhile more than half expect to add plexiglass to reception areas to protect their front desk team and, in an attempt to minimize disease spread, more than a third expect to use different attire for team members. (Note: These figures reflect how practices are changing in response to Coronavirus. For instance, a practice that already had glass or plexiglass to reduce exposure for the office team would not have an added expense for that feature.) N95 Masks An overwhelming majority of practices surveyed plan to supply clinical teams with N95 masks instead of regular surgical masks in the wake of the Coronavirus outbreak. Face Shields Most practices surveyed are also adding reusable face shields to their PPE budgets. Face shields have the benefit of protecting the eyes, and when they’re combined with a mask they can greatly reduce the risk to the clinical team. Gowns Some practices are adding disposable or washable gowns to their PPE in order to add an extra layer of protection between patients. When gowns are used, they are generally discarded between patient encounters. Of the 277 practices adding gowns, 25% plan on using a mix of disposable and reusable gowns. The cost of gowns per patient is highly variable, since there are multiple types of gown and laundry expenses for reusable gowns vary by region. Laundry Expenses 67% of survey respondents expect to change how they do practice laundry in response to the pandemic. And, 5 dentists said they are now using a laundry service such as Aramark. How are Supply Chain Issues Affecting PPE Purchases? Supply chain issues continue to present a challenge for dentists. While more than half of the practices are already open, many essential items are still on backorder. 92% of survey respondents reported that one or more of the PPE items that they require are on backorder. 83% of the practices who responded to our survey (248 out of the 300) reported that the N95 masks they had ordered are on backorder. Meanwhile, 50% of practices are still having difficulty sourcing surgical masks and face shields for their teams. With so many practices reopening, these PPE shortages represent a real challenge for clinical teams. How Many Masks Will Each Patient Visit Use? The Median practice that responded to the survey expects to use 2-3 masks per patient encounter. Of note, there is a shift in the type of mask being used as nearly 16% of practices will use 4-5 masks per patient visit. The majority of practices plan to use N95 masks to reduce the spread of Covid-19 and other infectious diseases. How are Clinical Teams Responding to Covid-19? Many practices are changing the way in which they care for patients as a result of Covid-19. In particular, some practices are eliminating tools and techniques that might increase the risk to their clinical teams when used on asymptomatic Coronavirus carriers. Nearly 18% of practices are discontinuing the use of high-speed handpieces for the duration of the Covid-19 crisis. Meanwhile, nearly 48% are discontinuing the use of ultrasonic scalers. While this move may decrease the risk of infection for the clinical team, it could result in longer appointment times and reduced production. What are Practices Spending to Ensure the Safety of Their Patients and Teams? The new requirements in the wake of the Coronavirus pandemic mean that all our practices are seeing an increase in PPE expenses. The independent practice is at a competitive disadvantage compared to large corporate dental groups when it purchases this equipment. However, most dental practices are not teaming up with other groups to complete bulk purchases. In the future, practices in any part of the Country may want to work together to reduce their PPE expenses, or even approach local supply providers about buying in bulk to reduce the expenses for individual practices. One-time Expenses Many practices are doing permanent upgrades in order to reduce disease transmission and increase patient and team safety. These include: UV-C lights HVAC upgrades Ozone units Foggers Infrared thermometers for checking temperature before patients are allowed in the building Oral vacuums Enclosing patient bays to reduce droplet spread The costs of these upgrades vary by practice and region. Air Purification 238 of the 300 practices purchased new Air Purification equipment for their offices. The one-time expenditures on this item ranged from $300 to more than $4000, with the median practice spending between $1,200 – $2,500 on new air purification devices. N95 Masks Most practices surveyed are planning on incorporating N95 masks into their patient care protocols. The median practice will be spending $4.00 – $5.00 per N95 mask, and will be supplying them to all hygienists, assistants, and doctors. In situations where the masks will be discarded after each patient visit, the average office will be spending a minimum of $8.00 per patient on N95 masks. Surgical Masks To comply with re-opening guidelines, most members of the practice’s team will need to at least wear surgical masks at work. In addition, if patients are allowed to wait in the office, as opposed to in their cars, they may be given masks in the reception area. The median office is spending between $1 and $1.25 per surgical mask. This is nearly double the price of surgical masks before the pandemic. Face Shields 278 of the practices in our study plan on buying plastic face shields for their teams. Face shields range in cost from less than $10 to more than $20, depending on the supplier. 49% of practices surveyed are spending $12 or less on each face shield, while $39% are spending more than $15 a face shield. How will Practices Cope with Increased Expenses? While every practice is facing increased PPE expenses and decreased production from the Coronavirus pandemic, many dentists are pessimistic about the ability of the insurance industry to respond to their increased per-patient costs. Less than 10% of our respondents believe that insurance reimbursements will increase in response to their new precautions. However, the majority of the practices do intend to list the per-patient PPE expenses as a line item on invoices, so that insurers and patients will understand the degree to which safety has increased their costs and with the hopes of reimbursement. How will practices recoup PPE expenses? According to the free-response portion of the study, some dentists plan on an across-the-board fee increase of 10% to recoup PPE expenses while others are charging $10-12 per patient, with one practice charging $30. Given the median costs associated with Covid-19 precautions, these increases represent an attempt to break even on PPE costs. The increased expenses have also affected insurance networks. Some respondents are considering dropping Delta Dental now that they are limited to seeing fewer patients and higher costs stating they believe the write-offs are too high to stay in-network. What does this mean going forward? For the foreseeable future, dental offices are looking at increased PPE expenses and decreased patient visits per day due to social distancing and cleaning precautions. While this represents a potential loss for the industry, dentists who can successfully redesign their schedule, days worked and processes, and technologically adapt, may be able to find ways to increase production and patient counts even in this challenging environment. In the long-term, the same precautions that protect teams against the coronavirus will also protect teams against familiar illnesses like colds, the flu, and norovirus. This could reduce sick days and improve the overall health and wellness of our office teams. Insurers who refuse to acknowledge the increased costs may face shrinking networks. While corporate practices may be able to ‘make it up on volume,’ independent practices are facing significant daily and annual costs from coronavirus compliance. Practices that can create alternatives to insurance, such as in-house membership plans and patient financing, may be able to recoup these expenses more easily than practices that rely on insurance reimbursements. Over time, practice owners may want to consider the best ways to reconfigure their office space and their schedules in order to respond to both the current and future pandemics. Coronavirus represents a major, ongoing challenge to the American dental industry, however, by careful planning and creative problem solving, many practices will be able to continue to grow and thrive.