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Keeping Communities Smiling: A DSO Addresses Dental Care Inequities Exacerbated by COVID-19

Diamond Braces orthodontist Dr. Douglas consults with a patient on the company's virtual telehealth platform, which they built to better serve their community during the pandemic.

When COVID-19 first began to spread across the U.S. this past March, some initially referred to the virus as “the great equalizer.” Contagion, after all, knows no national borders, and does not rely on prejudices or stereotypes to decide which humans to infect.

As the pandemic worsened, however, it quickly became obvious that despite its biological origins, the COVID-19 pandemic was no equalizer. Instead, the scale of its health impacts and the consequences of its spread have fallen along pre-existing fault-lines in our communities. The pandemic has highlighted our society’s many inequities across a spectrum of outcomes, health and income chief among them. As dental providers, we are tasked with providing quality dental care to families in our communities, and it has never been more critical that we adapt to this crisis to ensure our patients don’t lose access to critical dental care.

Like most healthcare companies, my dental practice, Diamond Braces, raced to adjust to the rapid changes we all faced this year. We are a large orthodontics company with 34 office locations across New York, New Jersey, and Connecticut. Our key mission is to make orthodontic care affordable and accessible to all families in our community; the choices we make are always informed by those values. When our leadership team adapted our operating procedures to this new reality, therefore, it was imperative that we assist our patients in staying in treatment, regardless of their economic circumstances.

Below, I offer some insights into addressing and overcoming the social inequalities presented by the COVID-19 pandemic, and advice for helping your patients achieve excellent oral health outcomes, through this crisis and beyond.

Supporting Patients Through Loss of Employment, Housing, and Health & Dental Insurance

 Nationwide shutdowns to slow transmission of the COVID-19 virus, though critical from a public health perspective, nonetheless created financial upheaval for millions of families. According to the Bureau of Labor Statistics, at the unemployment crisis’ peak in April 2020, 18.4 million Americans were without employment. Today, the BLS reports an unemployment rate of 6.7%, still nearly twice the pre-pandemic levels.

In a national health system where health insurance is often tied to employment, this precipitous nationwide job loss has created significant disruptions for Americans’ ability to pay for health care. The Commonwealth Fund found 2 in 5 people who lost a job or whose partner lost a job were dependent on health insurance coverage through that job. Research from the W.E. Upjohn Institute for Employment Research estimated that as many as 7.7 million workers lost jobs with Employer Sponsored Insurance (ESI) as of June, 2020, which has affected as many as 6.9 million dependents.

The consequences of such financial upheaval can often extend to housing: in addition to serving patients who lost income or ESI, our business also worked with families who had moved during the pandemic, some as close as a nearby neighborhood, and some across the entire country.

At Diamond Braces, part of our early adaptation plan for the COVID-19 pandemic was a strategy to help patients stay in treatment, regardless of the family’s financial, insurance, or housing situation. Our plans were immediately put to the test: the bulk of our locations are in the New York City region, which felt the effects of both the pandemic and the ensuing shutdowns early and intensely. Over the spring and summer, we helped hundreds of patients struggling with financial hardship, loss of health insurance, and or housing displacement continue treatment uninterrupted.

We immediately set to work ensuring that patients whose families were paying for orthodontic care with private insurance would be able to stay in treatment. We provided a hotline for patients whose financial situations had changed to adjust their payments and make changes.

We worked with each patient’s family to assess their new financial reality and develop a working solution. Patients who had lost insurance were migrated to zero-interest, flexible monthly payment plans tailored to their financial capacity. If out-of-pocket financing was not possible, we helped families apply for third-party financing to assist in payments.

For those patients whose families moved during treatment, we worked closely to provide virtual assistant or help them find alternative treatment. We found local orthodontists to scan patients and virtually transferred the records so we could receive aligners in the office and ship directly to their home; we built a virtual teledentistry platform (described below) to provide remote care, which serves patients who have temporarily moved, are away from home, or cannot make it to the practice. For those moving out of the region, we helped refer patients’ families to local orthodontists in their new area, sending over records and consulting with doctors for the patient file handover.

Because our business model is dedicated to making orthodontic care affordable for low- and middle-income families, Diamond Braces was in fact well-prepared to maintain continuity of care for patients whose financial situation had abruptly changed. Offering no-interest payment plans and providing third-party financial resources are both critical to supporting families through financial hardship. In a specialty like orthodontics, where consistent doctor supervision throughout treatment is critical to effective outcomes, having plans in place for patients’ changing financial realities is paramount.

Addressing Disparities in Access to High-Speed Internet for Teledentistry

As an adaptation to pandemic health and safety protocols, our business built a teledentistry arm of the practice from scratch. Over the course of three months, we introduced a host of virtual care options on our secure, HIPAA-compliant telehealth platform, including emergency appointments, new patient consultation, retainer checks, and braces and Invisalign progress checks.

These virtual services have provided invaluable in keeping our staff and patients safe and healthy during the pandemic, and have allowed us to limit patient traffic in our physical offices by resolving certain orthodontic issues entirely remotely (a July 2020 article in Oral Diseases on teledentistry found that a Brazilian diagnostic teledentistry platform resulted in a recommendation for medical prescription or in-person follow-up in only 25% of cases).

Here, too, America’s social inequalities rear their heads: access to high-speed internet, while a requisite for effective teledentistry, varies widely depending on region, income, and demographic. The Federal Communication Commission’s 2020 Broadband Development Report found that as many as 18 million Americans lack access to broadband internet. Meanwhile, a study this year in Population Health Management found that tele-health users tended to be younger and more urban, suggesting that a wide swath of Americans are missing out on a critical health option when they most need it.

To provide telehealth services to patients with unreliable internet service, we devised a multi-prong virtual platform that includes both video call services and no-call photo upload, which simply requires the patient to upload photos for the doctors to review. Patients and doctor are then able to communicate via email or text.  This service requires less internet usage, providing high-impact virtual care requiring less internet usage. Our virtual platform also provides text, email, and phone call options, so patients have the option of discussing their treatment using these more traditional methods, while still avoiding in-person visits whenever possible for the patient.

COVID-19 and Oral Health: Addressing Comorbidities

 Much research in the last year has confirmed the disproportionate impact on low-income communities and communities of color; studies have also found that those same communities suffer oral health disparities that are magnified by the pandemic shutdowns. As a 2020 sturdy in the Prevention of Chronic Disease notes, “COVID-19 has led to closure and reduced hours of dental practices except for emergency and urgent services, limiting routine care and prevention.”

These closures and reduced hours have had a disparate impact on lower-income and minority communities, which already suffer from fewer dental providers, thanks to insurance restrictions, as noted in a 2006 analysis in BMC Oral Health on oral health and inequality.

Though the New York State Governor shuttered all dental clinics beginning in March 2020, Diamond Braces was committed to finding methods to support our patients and wider community. We established several emergency orthodontic care sites, which accepted patients from across our locations for in-office care from our own expert doctors. We also opened these services to anyone in need of emergency orthodontic caret, regardless of patient status, offering assistance for those whose orthodontic providers were closed.

Our development team also worked to tirelessly to build a HIPAA-compliant, secure telehealth platform, which went online quickly to support our patients, and continues to provide a safe, private orthodontic care solution for patients. When our offices reopened in May, 2020, we did so under stringent new health and safety measures and enhanced infection control procedures to keep patients and staff alike safe throughout the pandemic.

Thanks to the tireless efforts of our team members, Diamond Braces was able to provide uninterrupted access to affordable orthodontic care throughout this past year.

The comorbidities of COVID-19 and poor oral health are not easily remedied: the social determinants of health that lead certain communities to suffer from higher infection rates, higher hospitalization rates, and higher death rates are the same factors that lead to higher rates of dental caries, lack of orthodontic treatment, incidence of periodontal disease, premature tooth loss, and more in those same communities.

While addressing such issues cannot be done overnight, acknowledging the complex factors that produce and widen inequalities in income, employment, insurance, dental care, and COVID-19 health incomes can all help us to provide better access to quality care for everyone in our communities.

With solutions-driven approaches, creative strategies, and a provider model that adjusts for the socioeconomic realities of our patients, I believe we can all rise to the occasion to provide quality, affordable, effective dental care for all Americans.

Written by Dr. Oleg Drut
Dr. Drut is the founder, owner, and Chief Clinical Officer of Diamond Braces, an orthodontics practice with locations across New York, New Jersey, and Connecticut. A graduate of NYU College of Dentistry, Dr. Drut opened a single practice in Hackensack in 2000 with the goal of making orthodontic care accessible and affordable for more families in his community. Since then, Diamond Braces has helped over 100,000 patients achieve healthy, beautiful smiles. Dr. Drut has 20 years of experience in management, office set-up, workflow supervision, and training and mentorship of new orthodontists. His work has been featured in The New York Times, Elle Magazine, Reader’s Digest, Star Tribune, and more. He lives in New Jersey with his wife and five children. He can be reached for comment at [email protected].

 


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