Learn more about the ongoing collaborative work between WSDA and Delta Dental of Washington following the organizations' Memorandum of Understanding (MOU).
QUICK BITES
- Delta Dental of Washington (DDWA) and WSDA negotiated a memorandum of understanding as part of a settlement to the lawsuit WSDA and member dentists had brought against DDWA.
- Two joint workgroups have been operating under the MOU: Hygienist and Assistant Workforce Shortages, and DDWA Policies and Plans.
- The collaboration is already producing results, including changes in Explanation of Benefit language and a proposal to change how radiograph coverage is determined.
- The two organizations are also coordinating advocacy efforts on select workforce and dental benefits issues in Olympia and beyond.
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History and the arts are littered with famous feuds and rivalries: the Hatfields and the McCoys; the Montagues and the Capulets; the Jets and the Sharks.
Not so long ago, Delta Dental of Washington and the Washington State Dental Association might have felt right at home on that list. But that was before the two organizations negotiated a Memorandum of Understanding (MOU) to help settle a lawsuit WSDA and some of its member dentists had brought against DDWA. Since then, the two organizations have found themselves working together more collaboratively.
“By the time we signed the MOU, we had spent enough time together to develop a working relationship that allowed us to quickly jump into these important topics,” said Cindy Snyder, Delta Dental’s Chief Operating Officer, who has been one of the company’s lead representatives in the process. “Working together has provided opportunities to build stronger relationships on both sides. There will always be some issues that we differ on, but there are far more where we are aligned and can make a greater impact together.”
Snyder said that one benefit of implementing the MOU agreement is that it has helped build personal relationships between those who are involved. “It’s been a pleasure to get to know the WSDA leadership team and dentists participating with the MOU workgroups. Many I knew only by name but had never met. We’re getting to know them as individuals and they’re getting to know us.”
“The biggest surprise is how much we have in common. We are all passionate about solving the big issues facing dentistry and positively impacting oral health in Washington. The workgroup members are generous with their time, typically meeting after a long day of patient care,” she added.
As those personal relationships grow, there are new opportunities to develop a better understanding of the challenges facing each organization, according to Snyder.
“We’re trying to build dentists’ understanding of the complexities and competitiveness of the dental benefits market and how plans are developed and negotiated. At the same time, the WSDA representatives are giving us a better understanding of the concerns they have as a dental community and the complexities they face in their practices,” Snyder said.
“One thing that’s clear is that we’re all trying to do the right thing for better oral health.”
WSDA leadership agrees with this assessment. “Getting to know the leadership of DDWA has been very helpful in building a more robust understanding of the dental benefits marketplace and how Delta sees itself in that system,” said Bracken Killpack, WSDA Executive Director. “By talking and working together, we have been able to develop detailed proposals that will improve patient care in our state and beyond.”
PRIMARY FOCUS AREAS
The MOU identified many critical areas for the two organizations to focus on through the formation of joint workgroups. In 2021, the first two of these workgroups were established: Hygienist and Assistant Workforce and DDWA Policies and Plans. A third joint workgroup on Medicaid will be launched later in 2023.
The Workforce Shortages workgroup is focusing on identifying strategies to help close the serious gaps in the dental hygiene and dental assisting ranks that are plaguing dental practices and clinics across the state. While the group will pursue short-term strategies that will make a difference, it recognizes that creating lasting change will require longer-term efforts, such as expanding existing training programs, launching new schools, and changing state licensing requirements through legislation.
Diane Oakes, DDWA’s Chief Mission Officer, said the Workforce group has created a forum for collaborative efforts to solve a common problem.
“It’s such a big issue and this is our opportunity to think big about solutions,” she said. “It’s a true partnership. Our task force meets every month, but we are talking weekly — if not more frequently than that. On some issues, WSDA takes the lead. On some, Delta is leading. And on some, we are working completely in tandem.”
“The first challenge was getting good data so we could all look at the situation objectively,” added Oakes. “So the early stages of our partnership were spent mining the existing data to confirm the size and scope of the problem.”
Oakes said that WSDA and DDWA jointly supported state funding to match Dental Dental’s grants to the UW Center for Health Workforce Studies to launch a dental professional workforce data dashboard. Now WSDA and DDWA are supporting continued state funding to continue this public-private partnership to develop additional data collection and management tools to inform both organizations and policymakers in addressing workforce issues.
The group has been developing strategies to transform hygiene education programs to create multiple pathways into the workforce.
“We’re not going to take away from what currently exists,” Oakes said. “But we need to offer more options for populations that historically have not accessed hygiene education to enter the field, earn a salary, and support their families.”
“We are jointly supporting the creation and expansion of associate-level hygiene programs. Bachelor-level degree programs have some advantages, but they can be challenging for some populations due to the cost and time involved.”
The workgroup is supporting continued growth in the Shoreline Community College hygiene program now located at the UW School of Dentistry; creation of a new hygiene program at Peninsula College that is currently pursuing CODA accreditation; and resumption of the dental assistant program at Lake Washington Technical College, now an evening program offered on campus and in conjunction with a local high school skills center, among others.
BUILDING DIVERSITY
More than just increasing the size of the dental workforce, DDWA and WSDA are also working to help make that workforce more diverse and reflective of the patient population. Recruiting a more diverse field of candidates for these positions will require a comprehensive and strategic approach.
In addition to creating more training slots in general, there is a real need to make the hygiene profession more accessible to candidates facing cost and time constraints, many of whom come from diverse communities. That could also create a career path for current dental assistants that want to become hygienists, but can’t take four years away from work to do it.
For this reason, the group is reaching out to various governing bodies to advocate for changes that would make programs more accessible. It is advocating for CODA to rethink some of their current program requirements that may be barriers to some student populations. They are also partnering with the State Board for Community and Technical Colleges to take a statewide look at changes needed in hygiene education to increase diversity, increase class sizes, and improve the sustainability of these programs.
But growing diversity will require more than increasing the supply of accessible training slots; it also will require generating more demand for those slots among diverse communities of potential students. To build interest in dental careers, DDWA has taken the lead on a curriculum that can be shared with school-aged children from Historically Underrepresented Groups (HUGs). The first iteration of this curriculum has been presented to students in King, Pierce, and Spokane Counties by Lolinda Turner, Delta Dental’s Program Manager for Dental Workforce Diversity and Inclusion, volunteer dentists, and DDWA and WSDA staff. DDWA will be training other organizations in Washington on the program later this year to increase the number of youth reached.
“While I am very excited about many aspects of our workforce-related projects with Delta, I am probably most excited about the work Lolinda is doing to lead us in raising interest and awareness about the dental professions with HUGs,” said Killpack. “We need to see our lower-than-desired representation amongst these groups as an opportunity and challenge when recruiting our future workforce.”
“We need to focus on the time when children start to think of themselves in different professional roles and show them that they can be successful and welcome in dentistry, dental hygiene, and assisting,” he added. “Many dentists have an ‘origin story’ about when they decided to become a dentist that starts at a pretty young age; this work will help generate more ‘origin stories’ across a wider swath of our population.”
DDWA POLICIES AND PLANS
The second established task force is addressing DDWA Policies and Plans. This group includes a leadership representative from each organization along with Delta’s dental director, provider relations manager, and six dentists — three of whom are members of Delta’s Member Advisory Panel and three of whom are members of WSDA leadership.
Among other things, the task force is addressing how best to communicate information regarding Delta Dental of Washington’s benefit plan values and policies; provide ideas on potential new benefit products and services that improve oral health and better support dentists, patients, and groups; serve as advisors on policy and explanation-of-benefits (EOB) language; evaluate cost of care and treatment utilization trends in Washington; and make recommendations on streamlining claims processing and claims attachments.
“These DDWA Policy and Plans workgroup meetings have helped grow relationships. Listening and trust are the basis for understanding and change,” said Dr. John Gibbons, WSDA President and a member of the workgroup.
The effort is already bearing fruit.
According to Delta’s Dental Director, Dr. Kyle Dosch, one of the first issues raised by participating dentists related to benefits coverage and payments for radiographs. The issue arose because Delta’s payment policy prohibits a member dentist from charging a Delta-covered patient above the approved fee for a full mouth series of radiographs on the same day of service. If four bitewings and a panoramic radiograph are prescribed on the same day, a portion of the approved fee is determined to be not billable to the patient, because the combined fees for that array often exceed what is approved for a comprehensive, full mouth series of images.
“If the patient were to come back the next day to have the panoramic radiograph taken separately, then their benefits would cover both types to their maximum allowable amount. But that’s not an efficient use of the patient’s or the dentist’s time,” Gibbons said. “We found that nationwide, there were tens of thousands of times a year that dentists were taking both types of radiographs on the same day and writing off some of what they would normally be able to charge to the patient.”
“We know that the two types of radiographs are used primarily to diagnose different conditions,” Dosch said. He explained that bitewing and periapical radiographs are most often prescribed to help diagnose oral disease, while panoramic radiographs are used to monitor dentofacial growth and development, as well as in identifying cysts or other boney lesions, evaluating bone density, and aiding in diagnosis of TMJ disorders.
“Because quality diagnostic information is fundamental to making appropriate treatment decisions, we agreed that billing for different types of images to help diagnose diverse conditions should not be limited by policy,” Dosch said.
Accordingly, after reviewing this issue with the group, Delta Dental of Washington submitted a request to its parent organization, the Delta Dental Plans Association (DDPA), to allow the benefit determination for the panoramic radiographic as a separate diagnostic image and not subject to the comprehensive radiograph series limitation. Resolution of that request is pending, according to Dosch.
Another meaningful change could be made locally without application to DDPA. Dentists were concerned with language on EOB forms that included the phrase “Participating dentists have agreed …” in conjunction with determinations that a submitted procedure was not billable.
“Our member dentists understand that, by participating in a plan, they agree to its policies and provisions,” Dosch said. “But they may not always agree with a specific determination and this language was a point of friction.”
The solution to reducing that friction was straightforward. The EOB language on approximately 80 dental codes was changed to read, “The amount indicated is the patient’s responsibility under the plan.”
“We requested the EOB language be changed to more accurately reflect the dentist role in the policies of the plan that the patient has purchased,” WSDA’s Gibbons said. “The language of the EOBs no longer references the dentist as part of the explanation.”
“The new language didn’t change the payment result in any specific policy, but it created messaging that our MOU group felt would better serve both patients and providers,” Dosch said.
The impact of the workgroup in bringing about these changes hasn’t been lost on Dr. Elissa Maynard, a WSDA member dentist who also served nine years on the DDWA Member Advisory Panel (MAP).
“I have worked with Delta Dental as a MAP member for a number of years, but this workgroup structure is the best way I’ve seen to enable collaboration and proactively address issues,” Maynard said. “DDWA representatives are showing up to meetings, and listening to dentists’ concerns, and this collaborative space is genuinely helpful.”
“One of the things we’ve found is that many of the issues that have been the biggest problems for dentists aren’t Delta Dental of Washington policies, but are policies of the national association of Delta Dental plans. That’s an important distinction to understand,” she added.
“The nearly monthly meetings that the DWWA Policies and Plans task force has held have been informative and provided WSDA members and staff with a stronger baseline understanding of DDWA operations,” said Killpack. “With deeper understanding comes the ability to have more meaningful conversations about changes that reduce barriers and improve patient care.”
WORKING TOGETHER IN OLYMPIA
The spirit of collaboration and cooperation brought on by the MOU has extended beyond Zoom meeting rooms. Delta and WSDA are teaming up in Olympia this legislative session to deliver the message that the dental workforce shortages are real and they are serious, and that steps must be taken to increase the supply of qualified hygienists and assistants — especially among diverse communities — in Washington.
Some of the issues being jointly addressed include support for the University of Washington’s budget request to expand the RIDE rural dental education program, as well as increased funding for the State Board for Community and Technical Colleges to address general workforce needs, including increasing their schools’ capacity to train new hygienists and assistants. Other legislation would authorize Washington’s participation in an interstate hygienist licensure compact, making it easier for trained hygienists practicing in other states to begin work when they move to Washington. The two organizations are also jointly supporting a bill to allow collection of health care provider demographic data at the time of license application or renewal to allow reporting of diversity in Delta Dental’s network and encourage better health outcomes for diverse patient populations.
Sean Pickard, Delta Dental’s Director of Government Relations, said it’s still too early to predict the final outcome, but the collaboration is opening a few eyes. “Legislators who have been around for a while and have seen the tension, and the two of us not being on the same side of the table, are taking notice,” said Pickard. “It’s a welcome change.”
The DDWA/WSDA cooperation isn’t the only thing that’s new in the capitol this session. Pickard says that having a new chair of the House Health Care Committee, Rep. Marcus Riccelli (D-Spokane), has created a new dynamic.
“The chair is very interested in bringing folks together to talk about a broad set of issues. He seems to want to hear from everyone before setting a direction for the committee, which creates an opportunity for us to present our shared vision.”
“Our message really dovetails with WSDA’s messaging,” Pickard added. “We’re both talking about reducing barriers to entering the dental workforce — the financial and time requirements — for everyone, but especially among diverse communities.”
WHAT LIES AHEAD
The signed MOU is a three-year agreement that will expire at the end of 2023. Given the positive results to date, Snyder is confident that the collaboration will continue.
“We haven’t tackled everything that was contained in the MOU, and working together we are continuing to identify more issues,” she said. “I’m confident that we will either extend the MOU or just keep working together without a formal agreement. Either way, we will be continuing the work.”
WORKGROUP MEMBERSHIP ENABLES COLLABORATION
Here are the representatives of WSDA and DDWA serving on the current workgroups:
MOU Policies & Plans Joint Workgroup
Cindy Snyder, DDWA Chief Operating Officer
Marie Rizzuto, DDWA Senior Manager Utilization Management
Dr. Kyle Dosch, DDWA Dental Director
Siobhan Whitney, DDWA Director of Provider Relations
Dr. CR Anderegg, DDWA MAP Member
Dr. Elissa Maynard, former DDWA Map Member
Dr. Katie Hakes, DDWA Board Member
Bracken Killpack, WSDA Executive Director
Dr. Todd Irwin, former WSDA Board Member
Dr. John Gibbons, WSDA President
Dr. Kim Nordberg, WSDA Board Member
Megan Bartol, WSDA Policy Project Coordinator
Workforce Joint Workgroup
Dr. Katie Hakes (Co-Chair), DDWA Board Member
Dr. Chris Delecki (Co-Chair), former WSDA President and Board Member
Dr. Elissa Maynard, former DDWA Map Member
Cindy Snyder, DDWA Chief Operating Officer
Diane Oakes, DDWA Chief Mission Officer
Sean Pickard, DDWA Director of Government Relations
Brittney Arneson, DDWA Provider Relations Ambassador
Lolinda Turner, DDWA Program Manager for Dental Workforce Diversity Equity and Inclusion
Dr. Lisa Egbert, WSDA Board Member
Dr. Christine Kirchner, WSDA Board Member
Bracken Killpack, WSDA Executive Director
Emily Lovell, WSDA Director of Government Affairs
Megan Bartol, WSDA Policy Project Coordinator
This article originally appeared in 2023 Issue 1 of the WSDA News magazine.