Defining Advocacy Through Successful Representation

By Srini Varadarajan​, J.D.

“If you could change one thing about AAE membership, what would it be?”

That was a question that the American Association of Endodontists (AAE) asked you – our members – as part of its 2017 Membership Satisfaction and Needs Survey.

You answered with a call for more aggressive advocacy.

Specifically, AAE members urged the association to promote the value of the profession as a specialty, fight for the ethical and financial interests of the professional, and uplift and uphold standards of care for the patient.

Defining Advocacy: A Strategy for Growth

The AAE heard the voice of its members in developing its 2017-2020 AAE Strategic Plan. The plan laid the groundwork for the Worth Saving campaign, the white papers on treatment standards and endodontic competency, and more.

The plan also embraced advocacy for the profession and the professional. This included increased partnerships with other dental specialties to promote the training and expertise of specialists as well as interacting with third party stakeholders, including governmental entities and the insurance industry, to advance the interests of the professional. Notably, only 37% of survey respondents to the 2017 survey were satisfied with the AAE’s advocacy to these stakeholders.

In April 2019, the AAE Board expanded the plan, not only in duration to include a fourth year, but also in content. In addition to adding an outcome related to clinical research, the revised plan defined the scope of advocacy, to include successful representation before the Code Maintenance Committee (CMC), governmental entities, and the insurance industry.

Success in Representation

In the first half of 2019, the AAE has represented the profession before the Dental Specialties Group (DSG), Commission on Dental Accreditation (CODA), Code Maintenance Committee (CMC), American Association of Dental Boards (AADB), American Dental Education Association (ADEA), ADA Standards Committee on Dental Informatics (SCDI), ADA Standards Committee on Dental Products (SCDP), American Association of Dental Consultants (AADC), American Dental Political Action Committee (ADPAC), ADA Dentist and Student Lobby Day, Dental Quality Alliance (DQA), Organization for Safety, Asepsis and Prevention (OSAP), National Commission on Recognition of Dental Specialties and Certifying Boards (NCRDSCB) and Organized Dentistry Coalition (ODC).

However, representation is sometimes merely an alphabet soup of acronyms and initialisms, without the tonic of success. So, how do we define success?

Voices in the Vote:

Many have heard the expression, “If you’re not at the table, you’re on the menu.” It suggests that one’s interests shall be adversely affected by the very virtue of one’s absence. Yet, for this phrase to be more than just a cliché in non-sequitur, the context must be one in which an advocate has a clear position that might otherwise be insufficiently represented and in which representatives with opposing points of view may carry such weight as to cause decisions adverse to the advocate’s position.

Committees before which the AAE has a voting seat often provide such context.

For example, thanks to the AAE’s efforts, proposed revisions to Standard 4-8e of the Accreditation Standards for Advanced Dental Education Programs in Endodontics were adopted by vote of the CODA commissioners at the February 2019 CODA meeting and will go into effect on July 1, 2019. The revisions added the words, “including use of Limited Field of View (LFOV) Cone Beam Computed Tomography (CBCT),” to the competency requirement in radiographic and other diagnostic imaging technologies. The proposed revisions had been submitted to CODA by the CODA Review Committee on Endodontics Education, and CODA had sought comments on the proposed revisions from communities of interest. The AAE Educational Affairs Committee (EAC) and Board had also supported the proposed revision. Dr. Bradford Johnson serves the AAE as its voting representative on the Commission.

Similarly, the AAE appreciates the hard work and voting representation of Dr. Neill Luebke and Dr. Gary Goodell on SCDP and SCDI, respectively, Dr. Maria Maranga on ADPAC, Dr. Brian Bergeron on DQA, and Dr. Kenneth Wiltbank and Dr. Elizabeth Perry on CMC.

Standards committees of the ADA address multiple issues, some of which demand the attention and the unique position of the endodontist. Issues of relevance for endodontists include whether synthetic bone and mineral trioxide aggregate (MTA) fit within the definition of an implant, as well as development of cleaning protocols that may meet guidelines of the U.S. Food and Drug Administration (FDA) for instruments that transcend single use. Accordingly, the standards committees provide the AAE an opportunity for collaboration prior to vote.

The CMC provides a similar opportunity. On March 14, 2019, the CMC held its annual meeting. The CMC meets in the spring of each year to deliberate upon requests for revision to the Current Dental Terminology (CDT) Dental Procedures Codes. Requests must be submitted by Nov. 1 of the prior year to be considered by the CMC for the subsequent year’s CDT. For example, requests submitted by Nov. 1, 2018, were considered at the March 2019 CMC meeting for implementation on Jan. 1, 2020, as part of the 2020 CDT.

The AAE holds one of 21 voting seats on the CMC. The other voting seats are held by each of the NCRDSCB recognized specialties, the AGD, the ADA (holding five seats), ADEA, and five payer organizations (Centers for Medicare & Medicaid Services (CMS), America’s Health Insurance Plans (AHIP), Blue Cross Blue Shield Association (BCBSA), National Association of Dental Plans (NADP), and Delta Dental Plans Association (DDPA).

At the March 2019 CMC meeting, the AAE voted on all 146 submissions to revise the CDT. The AAE is pleased to report that 100% of submissions upon which the AAE voted affirmatively were also voted affirmatively by the entire CMC, and 100% of the submissions upon which the AAE voted to defeat or abstain were also defeated by the CMC.

The CMC meeting is often a culmination of various conversations that have transpired between representatives prior to the meeting. The ADA representatives hold separate informal telephone meetings with the representatives of each specialty organization including the AAE, as well as other voting representatives, to discuss specific submissions of interest. Representatives of the specialties and the AGD also hold an informal non-voting meeting the day prior to the CMC meeting to discuss the submissions. In 2020, the AAE will host this meeting at its new headquarters offices in Chicago.

That meeting underscores the importance of the AAE building relationships and serving as an effective voice even where there is no vote to be had at that moment.

Building Relationships, Establishing Influence:

At the ADEA Annual Session & Exhibition, AAE President-Elect Dr. Alan Gluskin presented before dental school deans, loudly and clearly voicing the AAE’s concerns about poor endodontic care as a result of inadequate predoctoral education and calling for greater consistency and competency.

Current AAE President Dr. Keith Krell similarly engaged other dental specialties at the February 2019 DSG meeting to explore how other specialty organizations address gaps in predoctoral education.

At the AADC Annual Workshop in May 2019, where the AAE also does not have a vote, Dr. Elizabeth Perry was an active voice, rising to the podium to ask poignant questions of speakers and provide endodontic guidance where appropriate. In one instance, Dr. Perry’s contribution resulted in the speaker’s subsequently reaching back to the AAE as a go-to resource to help him provide accurate and thorough information in his future presentations. For May 2020, in addition to its biennial meeting with dental directors, the AAE has requested to present before the AADC on dental benefits design to support preserving natural teeth; this request is pending the approval of the AADC.

As you may know, the AAE also established May as Save Your Tooth Month. In a crossover to state advocacy, AAE Marketing-Communications staff and local members worked with contacts in state government to recognize Save Your Tooth Month in Illinois and Iowa, respectively.

In the governmental arena, the AAE has also worked with numerous specialty organizations, the AGD, and the ADA through the ODC to influence federal legislation. The AAE joined the ODC in letters to various legislators in support of bills to repeal protections from antitrust laws for insurance companies under the McCarran-Ferguson Act, pass the RAISE Health Benefits Act, pass the Resident Education Deferred Interest (REDI) Act, pass the Protect Medical Innovation Act, and amend the United States-Mexico Tourism Improvement Act to protect the patient from adverse consequences of dental tourism.

Further, Dr. Maria Maranga, AAE’s ADPAC representative, joined two members of the AAE Practice Affairs Committee, Dr. Magdalena Holz and Dr. Beth Damas, to meet with legislative offices at the ADA Dentist and Student Lobby Day in April of this year. In addition to addressing many of the bills described above, the AAE representatives were pleased to join the ADA to address the value of loan forgiveness programs as well the Ensuring Lasting Smiles Act.

Grassroots Engagement

The representation by committee members at ADA’s Lobby Day underscores the value of grassroots engagement. As an extension of the AAE’s advocacy for partial repeal of the McCarran-Ferguson Act, the AAE also provided an advocacy booth at AAE 2019 to enable attendees to contact their legislators through the ADA’s site.

Grassroots engagement is often even more important for successful representation at the state level. While 2019 has been relatively silent with regard to new constitutional challenges to state laws addressing recognition and advertising of specialties, the AAE understands that this is a matter that will require continued vigilance and will benefit from a more proactive approach. Meanwhile, 2019 has witnessed various state laws affecting endodontists – from Arizona’s consideration of bills to provide dentists the same exclusion as physicians to have concierge dental plans, to California’s implementation of a law that makes it unprofessional conduct for a dentist to “use water, or other methods used for irrigation, that are not sterile or that do not contain recognized disinfecting or antibacterial properties when performing dental procedures on exposed dental pulp.” The AAE is presently working on educational guidance on the latter.

However, successful representation of endodontists at the state legislative or regulatory level prior to passage of laws demands the use of the proper tools to make grassroots advocacy more effective and accessible to members. As such, the AAE Board has approved funding to establish online legislative tracking and action alert tools to enable AAE members to communicate directly with offices of both their state and federal legislators with messaging provided by the AAE. This tool will be available to AAE members later this year.

Grassroots engagement also extends beyond the legislative arena. Specifically, the AAE strives to work with individual members on coding and insurance matters. In addition to this one on one assistance, the AAE shall solicit its membership for revisions to the CDT as well as for issues to raise before insurers. While the insurance industry has the dollars to exert great influence, the AAE understands and appreciates that the dental benefits and insurance administration challenges faced by endodontists can have significant adverse impacts on their practice. The AAE shall continue to explore innovative but legally-permissible ways to help the profession in this area.

Unified Philosophy through Divergent Efforts

This article has provided a glimpse into various efforts of the AAE in several key areas of advocacy – from education to insurance to governmental relations to other dental organizations – with a focus on success through representation.

Additional advocacy efforts, beyond representation, include ongoing work to build a core outcome set in endodontics to guide endodontic research and ultimately improve care quality, a webinar held May 23, 2019, presenting the AAE’s treatment standards and endodontic competencies to both endodontists and general dentists, and provision of input as part of communities of interest on review of policies and guidelines of the ADA and other organizations.

These various divergent efforts beg for a unified theme. That is, what are we trying to achieve here?

AAE’s advocacy efforts strive to enable endodontists to engage in financially successful and satisfying practice to provide the best of endodontic care to patients. In doing so, advocacy efforts recognize that endodontists have the specialized training to practice at the pinnacle of endodontics, but also that endodontists comprise less than three percent of dentists.

Accordingly, the unified philosophy is captured by Goal 2 of the AAE Strategic Plan, which reads: “The dental profession will value endodontists as partners with advanced expertise in providing patient care.”

What’s Next?

The key sentiment of advocacy moving forward is to strive not only for effective reactivity but also for proactivity. Proactive representation will include not only the efforts described above, but also a proactive approach to developing new policies and updating our current ones.

Moreover, engagement of new tools to collect practice data as well as enable grassroots advocacy will empower the AAE to continue to grow in an effort to better advocate for its members’ interests.

However, we would like to know what you think. What else would you like to see? How do you see the unified philosophy of advocacy for endodontists? How can the AAE better advocate for you? Please send ideas and comments to advocacy@aae.org.

Srini Varadarajan​ is the AAE’s associate executive director for advocacy and professional relations. He can be reached at svaradarajan@aae.org.