Dental Business Strategies During the National State of Emergency

We are all affected by the COVID-19 state of emergency. The latest mandates for the Dental Industry's clinical practice is to provide emergency treatment only for the next 14 or 21 days depending on the state. The ADA defined the term "emergency" last week, see below. As a business owner, we needed to make a difficult decision whether or not to stay open for emergency patients. Then we needed to make another difficult decision on what to do with the expense of payroll during a time of reduced workload of the dental team. Working with so many offices nationwide and having helpful resources, I wanted to share with you some information that will be helpful during this desperate time.

We have a sense of responsibility to contribute to the containment of the spread of the pandemic and abide by the state guidelines. I have been personally in contact with many of my colleagues to see what decisions they are making. Half of the offices decided to completely close for 3 weeks and a half are open for emergency treatment. Either decision leaves the team with a significantly reduced workload. I wanted to share this information with you so that it will be helpful in your decision making and ensure you prepare for the next 60 days.

 Business Decisions:

Obviously due to the discontinuation of routine dental care and the spread of the virus via areasol, offices were forced to shut down their hygiene department and the overall manpower is working maybe 3% of the normal business, if it stays open at all for emergencies. As business owners we have the following options

1. Completely shut down

         a. place the team on unemployment

         b. payout the PTO until it is used up then place the team on unemployment

2. Stay open for emergencies only

         a. put hygiene on unemployment, and reduce the rest of the team hours and payout PTO to match the reduced hours until the PTO is used, then unemployment

          b. In New York, the Labor Department started the Shared Work Program. Other states have similar programs developed by their labor Department. This program was designed to reduce the unemployment rates and help employees keep their jobs and benefits, as well as, spring back quickly once the mandate of limited clinical work is lifted. The business can keep the team employed, but reduce their work by 20-60%, employer pays benefits as usual, the state will supplement 80% of the reduced hours up to the State’s maximum allowable unemployment pay.

3. Telemedicine Dentistry for emergencies. Office is shut down, but the Dentist goes in as needed, team is handled as one of the options from above. Zoom conference is a HIPAA compliant app and desktop software that can be used for Telemedicine. It is free or with minimal service fee depending on the options you choose.       

If you stay open for emergencies, the recommendation is to use the N95 with another mask over it to prevent the soiling of the N95 mask. A face shield, surgical cap, disposable gowns need to be used. Please look at the extended use and reuse of the N95 masks below.

Business Expenses

It is very important that you take advantage of the deferments, and waivers that are in place right now to ensure that you lower your expenses immediately and over the next 60 days. Run your detailed profit and loss report and checks paid to vendors. Here is a list of ideas to lower your expenses during this time of decreased income. Preserve your liquid cash to avoid tapping into your savings.

1.     Marketing: suspend any marketing services and firms for 30 days. Decrease your social media ads budgets like GoogleAds, Yelp, Facebook, and Instagram. Currently you are not able to see those patients anyway so this money is wasted.

2.     Bank Mortgage loans: there are executive orders by State Governors to suspend fees for ATMs, overdraft fees, credit card late fees. In addition, the federal government gave an executive order and informed the public 1 week ago that the public can delay payments of mortgage, medical bills, and utilities. Banks are on high alert and you need to contact your bank and request a deferment of any loans for 3 months. The way it works is that the bank will suspend the monthly payment and add 3 additional months to the tail end of the loan term.

3.     Equipment loans: you can ask for a deferment for 3 months (until June/2020) and ask the bank to add the total amount deferred to be spread over the remaining months until December 2020.

4.     Get a Loan if Needed: There are Economic Injury Disaster Loans available for small businesses. Contact your county to see what is available and if you need cash to carry you through this period of time you may need to take a loan out.

5.     Hold of on Sending Patient Statements. There is also in New York State, Nevada, Illinois, and maybe other states, a national temporary Suspension of Debt Collection. Check your state’s guidelines. We advise our clients to prepare the patient statements but hold on to them until 4/6/2020. The reason is that the public will ignore these statement since the government is telling them to delay paying medical bills. Also, you will incur the expense of postage if you send them out right now.

6.     Taxes: request a deferment to file your personal and corporate taxes. The new deadline without any penalties or late charges is July 15, 2020, but you still need to ask for the extension at no additional charge.

7.     Families First Coronavirus Response Act and Emergency Family and Medical Leave Expansion Act. Effective 4/2/2020 Federal Act: Very Important act to employers and for employees who are employed by you on as of 4/2/20. Read below or follow the link on the Federal Act. In a nutshell, if the employee falls under one of the criteria, you will need to pay their salaries for an extended period of time and hold their position. The childcare is probably the most important and impactful criteria under this act as schools are closed of the remainder of the year. In Coronavirus epicenters, there is a concern about dental employees getting infected or having to take care of a family member that was infected.

8.     Monthly Reoccurring Services: review your credit cards, and profit and loss reports to see who you pay monthly. Here is a list of services you can suspend for 30 or 60 days until you are open for regular business

a.      Lawncare/snow plowing

b.     Office cleaning service

c.      Dental equipment support services

d.     Auto reorder of materials or supplies

e.      Ask for an extension on lab bills for 30 days

f.      Suspend the sharps an medical waste pickup

g.     If you have a linens service suspend it

h.     Pandora music or other digital services like Neflix, cable

i.       Postage meter rental: you should not mail any statement for at least 3 weeks

j.       Credit card processing equipment

k. Utility companies will still send you a bill but they are suspending any collection and not disconnecting service until the end of April. Therefore, do not be hasty to pay your bill.

9.     Personal expenses:

a.      Your mortgage: you can do the same thing as with the business loans. Defer payment for 3 months and ask for it to be added to extend the loan term by 3 months.

b.     Car loans. You can ask for a deferment for 3 months and ask for the 3 months amount to be spread across the remainder of the loan payments

c.      Services: review your services and see who you cannot live without for 2 months and suspend other services for at least 30 days.

Ideas to increase Income

1.     Sell products online with mail delivery or “at the door” pickup

2.     Social media: ramp up your social media posts and work on recording now for future posts

3.     Teledentistry exams: encourage consults and schedule in-office exams 3 weeks out

4.     Sell gift cards for whitening: secure price now, schedule the appointment in 30 days

5.     Prepay for service now at a discounted rate and schedule the appointment in 30 days

6.     Work on accounts receivable claims recovery. Insurances are still paying out claims and if you fell behind in claims management this is the time to increase the cash flow. If your team is not experienced or you had to let your team go on unemployment or layoff, we can step in and work on the aging claims during this difficult time. 

With the right planning for the next 60 days, your business should survive. We are here to help. Please contact me if you need more clarification of any information in this email.

In Better Dental Health,

Dr. Dorothy Kassab

1810 Erie Blvd

Syracuse, NY 13210

contact@dentalclaimscleanup.com

(800) 652-3431

Emergency or Non Emergency? ADA Offers Guidance for Determining Dental Procedures

In a statement issued on March 16, the American Dental Association (ADA) called upon dentists nationwide to postpone elective dental procedures for three weeks in order for dentistry to do its part to mitigate the spread of COVID-19. Concentrating on emergency dental care only during this time period will allow dentists and their teams to care for emergency patients and alleviate the burden that dental emergencies would place on hospital emergency departments.

The ADA recognizes that state governments and state dental associations may be best positioned to recommend to the dentists in their regions the amount of time to keep their offices closed to all but emergency care. This is a fluid situation, and those closest to the issue may best understand the local challenges being faced.

The following should be helpful in determining what is considered “emergency” versus “non emergency.” This guidance may change as the COVID-19 pandemic progresses, and dentists should use their professional judgment in determining a patient’s need for urgent or emergency care.

1. Dental emergency

Dental emergencies are potentially life threatening and require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain or infection, and include:

· Uncontrolled bleeding

· Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient’s airway

· Trauma involving facial bones, potentially compromising the patient’s airway

Urgent dental care focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These should be treated as minimally invasively as possible.

· Severe dental pain from pulpal inflammation

· Pericoronitis or third-molar pain

· Surgical post-operative osteitis, dry socket dressing changes

· Abscess, or localized bacterial infection resulting in localized pain and swelling.

· Tooth fracture resulting in pain or causing soft tissue trauma

· Dental trauma with avulsion/luxation

· Dental treatment required prior to critical medical procedures

· Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation 

Other urgent dental care:

· Extensive dental caries or defective restorations causing pain

· Manage with interim restorative techniques when possible (silver diamine fluoride, glass ionomers)

· Suture removal

· Denture adjustment on radiation/oncology patients

· Denture adjustments or repairs when function impeded

· Replacing temporary filling on endo access openings in patients experiencing pain

· Snipping or adjustment of an orthodontic wire or appliances piercing or ulcerating the oral mucosa

2. Dental non emergency procedures

Routine or non-urgent dental procedures include but are not limited to:

· Initial or periodic oral examinations and recall visits, including routine radiographs

· Routine dental cleaning and preventive therapies

· Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma)

· Extraction of asymptomatic teeth

· Restorative dentistry including treatment of asymptomatic carious lesions

· Aesthetic dental procedures

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JB Pritzker, Governor Ngozi O. Ezike, MD, Director

Respirator Reuse Recommendations

As recent as February 29, 2020, CDC and NIOSH provided guidance and recommendations regarding extended use and reuse of n95 respirators. This guidance is for any healthcare provider or first responder providing care to a person suspected of having COVID-19 positive or confirmed to be positive for COVID-19. There is no way of determining the maximum possible number of safe reuses for an N95 respirator as a generic number to be applied in all cases. Safe N95 reuse is affected by a number of variables that impact respirator function and contamination over time. (18, 19) However, manufacturers of N95 respirators may have specific guidance regarding the reuse of their product. The recommendations below are designed to provide practical advice so that N95 respirators are discarded before they become a significant risk for contact transmission or their functionality is reduced. If reuse of N95 respirators is permitted, respiratory protection program administrators should ensure adherence to administrative and engineering controls to limit potential N95 respirator surface contamination (e.g., use of barriers to prevent droplet spray contamination) and consider additional training and/or reminders (e.g., posters) for staff to reinforce the need to minimize unnecessary contact with the respirator surface, strict adherence to hand hygiene practices, and proper PPE donning and doffing technique, including physical inspection and performing a user seal check. (16) Healthcare facilities should develop clearly written procedures to advise staff to take the following steps to reduce contact transmission:

• Discard N95 respirators following use during aerosol generating procedures.

• Discard N95 respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.

• Discard N95 respirators following close contact with any patient co-infected with an infectious disease requiring contact precautions.

• Use a cleanable face shield (preferred) or a surgical mask over an N95 respirator and/or other steps (e.g., masking patients, use of engineering controls), when feasible to reduce surface contamination of the respirator.

• Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly.

• Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if necessary, for comfort or to maintain fit).

• Avoid touching the inside of the respirator. If inadvertent contact is made with the inside of the respirator, perform hand hygiene as described above.

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• Use a pair of clean (non-sterile) gloves when donning a used N95 respirator and performing a user seal check. Discard gloves after the N95 respirator is donned and any adjustments are made to ensure the respirator is sitting comfortably on your face with a good seal.

To reduce the chances of decreased protection caused by a loss of respirator functionality, respiratory protection program managers should consult with the respirator manufacturer regarding the maximum number of donnings or viruses they recommend for the N95 respirator model(s) used in that facility. If no manufacturer guidance is available, preliminary data(19, 20) suggests limiting the number of reuses to no more than five uses per device to ensure an adequate safety margin. Management should consider additional training and/or reminders for users to reinforce the need for proper respirator donning techniques including inspection of the device for physical damage (e.g., Are the straps stretched out so much that they no longer

provide enough tension for the respirator to seal to the face?, Is the nosepiece or other fit enhancements broken?, etc.). Healthcare facilities should provide staff clearly written procedures to:

• Follow the manufacturer’s user instructions, including conducting a user seal check.

• Follow the employer’s maximum number of donnings (or up to five if the manufacturer does not provide a recommendation) and recommended inspection procedures.

• Discard any respirator that is obviously damaged or becomes hard to breathe through.

• Pack or store respirators between uses so that they do not become damaged or deformed.

Secondary exposures can occur from respirator reuse if respirators are shared among users and at least one of the users is infectious (symptomatic or asymptomatic). Thus, N95 respirators must only be used by a single wearer. To prevent inadvertent sharing of respirators, healthcare facilities should develop clearly written procedures to inform users to:

• Label containers used for storing respirators or label the respirator itself (e.g., on the straps(11))

between uses with the user’s name to reduce accidental usage of another person’s respirator.

Risks of Extended Use and Reuse of Respirators

Although extended use and reuse of respirators have the potential benefit of conserving limited supplies of disposable N95 respirators, concerns about these practices have been raised. Some devices have not been FDA-cleared for reuse (21). Some manufacturers’ product user instructions recommend discard after each use (i.e., “for single use only”), while others allow reuse if permitted by infection control policy of the facility.(19)

The most significant risk is of contact transmission from touching the surface of the contaminated respirator. One study found that nurses averaged 25 touches per shift to their face, eyes, or N95 respirator during extended use. (15)Contact transmission occurs through direct contact with others as well as through indirect contact by touching and contaminating surfaces that are then touched by other people.

Respiratory pathogens on the respirator surface can potentially be transferred by touch to the wearer’s hands and thus risk causing infection through subsequent touching of the mucous membranes of the face (i.e., self-inoculation). While studies have shown that some respiratory pathogens (22-24) remain infectious on respirator surfaces for extended periods of time, in microbial transfer (25-27) and re-aerosolization studies (28-32) more than ~99.8% have remained trapped on the respirator after handling or following simulated cough or sneeze.

Respirators might also become contaminated with other pathogens acquired from patients who are co-infected with common healthcare pathogens that have prolonged environmental survival (e.g., methicillin-Version 1.0 (03.13.2020) 3 resistant Staphylococcus aureas, vancomycin-resistant enterococci, Clostridium difficile, norovirus, etc.). These

organisms could then contaminate the hands of the wearer, and in turn be transmitted via self-inoculation or to others via direct or indirect contact transmission.

The risks of contact transmission when implementing extended use and reuse can be affected by the types of medical procedures being performed and the use of effective engineering and administrative controls, which affect how much a respirator becomes contaminated by droplet sprays or deposition of aerosolized particles.

For example, aerosol generating medical procedures such as bronchoscopies, sputum induction, or endotracheal intubation, are likely to cause higher levels of respirator surface contamination, while source control of patients (e.g. asking patients to wear facemasks), use of a face shield over the disposable N95 respirator, or use of engineering controls such as local exhaust ventilation are likely to reduce the levels of respirator surface contamination.(18)

While contact transmission caused by touching a contaminated respirator has been identified as the primary hazard of extended use and reuse of respirators, other concerns have been assessed, such as a reduction in the respirator’s ability to protect the wearer caused by rough handling or excessive reuse.(19, 20) Extended use can cause additional discomfort to wearers from wearing the respirator longer than usual.(14, 15)

However, this practice should be tolerable and should not be a health risk to medically cleared respirator users.(19)

Families First Coronavirus Response Act

FEDERAL LAW

President Trump signed legislation designed to provide American workers with relief as Coronavirus continues to spread. Among other things, the Families First Coronavirus Response Act (H.R. 6201) requires all employers with fewer than 500 employees to provide paid sick leave related to Coronavirus. With the paid leave protections under this new law set to go into effect April 2, 2020.

The Emergency Paid Sick Leave Act

Through December 31, 2020, the Emergency Paid Sick Leave Act requires employers with fewer than 500 employees to provide their employees with two (2) weeks of paid sick leave to employees who are unable to work in the workplace or remotely for the following reasons:

1. The employee is subject to a quarantine or isolation order from a federal, state, or local governmental authority related to Coronavirus;

2. The employee has been advised by a healthcare provider to self-quarantine as a result of Coronavirus concerns;

3. The employee is experiencing symptoms of Coronavirus and is also seeking a medical diagnosis/testing;

4. To care for an individual who is self-isolating due to any government authority’s order or where the individual has been advised by a healthcare provider to do so;. 

5. To care for the employee’s minor son or daughter in the event that the child’s school or place of care has been closed, or if the child care provider of such child is unavailable due to Coronavirus; or

6. The employee is experiencing any other substantially similar condition specified by the Secretary of Health and Human Services in consultation with the Secretary of the Treasury and the Secretary of Labor – likely to occur in regulations to be codified as soon as possible.

Importantly, the new law prohibits employers from requiring an employee to use other paid leave before using the sick leave provided under this new law.

Notably, employers with fewer than 50 employees may seek a waiver from the Department of Labor where these requirements would jeopardize the viability of their business. However, the process for seeking a waiver have not been drafted and are not yet in effect at the time of this advisory.

The required paid sick leave must be paid at the employee’s full regular rate of pay when it is used by employees to quarantine or to seek a diagnosis or preventive care for COVID-19. However, the paid sick leave is reduced to two-thirds the employee’s regular rate when it is used to care for a family member, to take care of a child whose school has closed, or where a child care provider is unavailable.

While full-time employees are entitled to the full two (2) weeks of leave (i.e., 80 hours), part-time employees are entitled to the “typical number of hours that they work in a typical two-week period.”

The paid sick leave is capped at different amounts based on the reason the leave is taken: (a) $511 per day and $5,110 in the aggregate for any employee who takes leave for reasons 1 through 3 above; and (b) $200 per day and $2,000 in the aggregate for any employee who takes leave for reasons 4 through 6 above.

Once this law goes into effect, employers will be required to make their employees aware of the new legislation by posting a notice created by the Department of Labor in a conspicuous location. Staff Leasing will provide the required notice once available.

The Emergency Family and Medical Leave Expansion Act

The law also amends the Family and Medical Leave Act (“FMLA”) to account for the ongoing outbreak (up and until December 31, 2020). This amendment provides eligible employees with up to 12 weeks of FMLA-protected leave (10 days unpaid and the remainder paid) for certain reasons related to Coronavirus.

Notably, this portion of the Act drastically changes who is eligible to take FMLA leave and what employers are covered. Any employee – both full and part-time – who has been employed for at least 30 calendar days by the employer would be eligible for FMLA leave due to Coronavirus. This expanded definition would replace the FMLA’s typical language, which requires that an employee work for an employer for 12 months and have worked at least 1,250 hours for the employer in the 12 months prior to taking leave. Further, this new FMLA leave applies to employers with fewer than 500 employees – replacing the previous cut off of 50 or more employees – but exempts employers with 500 or more employees.

However, these amendments are limited. Eligible employees are only permitted to take emergency FMLA leave to care for the minor son or daughter of the employee in the event that the child’s school or place of care has been closed, or if the child care provider of the son or daughter is unavailable due to Coronavirus.

Importantly, whether an employee’s covered leave is paid or not depends on the length of their leave:

·     First 10 Days: An employee’s first 10 days of eligible Coronavirus-related FMLA leave may be unpaid. However, an employee can choose to substitute accrued vacation leave, personal leave, or other medical or sick leave for unpaid leave (including the emergency sick leave described in reason 5 above). Employers cannot force an employee to use their accrued paid leave under existing vacation, sick, or PTO policies.

·      After 10 Days: After the initial 10 days of unpaid leave have passed, employers must then provide paid Coronavirus-related FMLA leave (for the few reasons provided above) at no less than two-thirds the employee’s regular rate of pay for the number of hours the employee would have been normally scheduled. Importantly, the monetary amount of paid FMLA leave an employee can receive is capped at $200 per day and $10,000 in the aggregate.

As is the case under traditional FMLA leave, an employee’s Coronavirus-related leave is job-protected. Specifically, employees taking Coronavirus-related FMLA leave must be restored to their same or equivalent position when they return to work. However, there is an exception for employers with fewer than 25 employees if the employee’s position does not exist after taking Coronavirus-related FMLA leave due to either: (a) an economic downturn; or (b) any other operating conditions that affect employment caused by a public health emergency during the period of leave. This exception is subject to certain conditions, however, including reasonable attempts by the employer to return the employee to an equivalent position, and efforts to contact the displaced employee for up to a year after they are displaced. Therefore, employers should use this exception very cautiously as the risk of litigation when not returning an employee to work is high and costly.

Importantly, the law exempts employers with fewer than 50 employees from civil FMLA damages in an FMLA lawsuit brought by employees, but it is important to note the Secretary of Labor retains the ability to bring an action to recover damages against employers with fewer than 50 employees for violations of this law.

Tax Implications

The new law does provide some financial relief to employers required to pay sick leave. For example, it provides a refundable tax credit equal to 100 percent of the qualified paid sick leave wages paid by an employer under the Emergency Paid Sick Leave Act for each calendar quarter. Employers are also provided a similar refundable tax credit equal to 100 percent of qualified family leave wages under the Emergency Family and Medical Leave Expansion Act. Both credits are allowed against the tax imposed by the employer portion of Social Security taxes.

The benefits provided under the new law, however, are not permitted to exceed the tax credit employers may receive under the law. For paid sick leave, this amount is limited to $511 per day, or $5,110 in total. Payment under the amended FMLA, meanwhile, is capped at $200 per day, or $10,000 in total.

Background:

COVID-19, originally known as 2019-nCoV, is a strain of a large family of coronaviruses that can be transmitted from animals to humans. It was first identified as the cause of a respiratory illness outbreak in Wuhan, China in late 2019.

Symptoms:

COVID-19 symptoms are similar to the cold or flu, and may take up to 14 days to appear after exposure to the virus. Be vigilant as severe cases may lead to pneumonia, kidney failure or death.

Mild symptoms may include:

• Fever
• Headache
• Runny Nose & Sneezing
• Cough & Sore Throat
• Difficulty Breathing
• Muscle Pain & Weakness
• Chills & Fatigue
• Impaired Liver & Kidney Function

Prevention:

A few preventative tips from The World Health Organization (WHO) advises the following prevention methods:

• Wash Hands Frequently: Use soap and water for visibly dirty hands or an alcohol-based hand rub frequently for non-visibly dirty hands.
• Practice Respiratory Hygiene: When coughing and sneezing, cover mouth and nose with flexed elbow or tissue – discard tissue immediately into a closed bin and clean your hands with alcohol-based hand rub or soap and water.
• Maintain Social Distancing: Maintain at least 3 feet distance between yourself and other people, particularly those who are coughing, sneezing and have a fever. If you are too close, you can breathe in the virus.
• Avoid Touching Eyes, Nose & Mouth: Hands touch many surfaces that can be contaminated with the virus. If you touch your eyes, nose or mouth with your contaminated hands, you can transfer the virus from the surface to yourself.
• Seek Medical Care Early: If you have fever, cough and difficulty breathing, seek medical care early and tell your health care provider if you have traveled in an area in China where the virus has been reported, or if you have been in close contact with someone with who has traveled from China and has respiratory symptoms.
• Mild Symptoms: If you have mild respiratory symptoms and no travel history to or within China, still seek medical care and be sure to carefully practice basic respiratory and hand hygiene and stay home until you are recovered, if possible.
• Animal Proximity Precautions: Practice general hygiene measures when visiting farms, live animal markets, wet markets, animal product markets or contact with wild animals. Ensure regular hand washing with soap and potable water after touching animals and animal products.
• Animal Consumption: Avoid eating raw or undercooked animal products. Handle raw meat, milk or animal organs with care, to avoid cross-contamination with uncooked foods, as per good food safety practices.

More Information:

For the most up-to-date information on possible vaccines, treatments, FAQs, news and more, please visit the following official health organizations:

Centers for Disease Control & Prevention (CDC)

www.CDC.gov

World Health Organization (WHO)

www.WHO.int