BILL ANALYSIS Ó
AB 1174
Page 1
Date of Hearing: April 16, 2013
ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER
PROTECTION
Richard S. Gordon, Chair
AB 1174 (Bocanegra and Logue) - As Amended: April 9, 2013
SUBJECT : Dental professionals: teledentistry under Medi-Cal.
SUMMARY : This bill expands the scope of practice for
registered dental assistants (RDA), registered dental assistant
in extended functions (RDAEF), and registered dental hygienists
(RDH) to better enable the practice of teledentistry in
accordance with the findings of a Health Workforce Pilot Program
(HWPP), and enables reimbursement by Medi-Cal for Virtual Dental
Home (VDH) treatment. Specifically, this bill :
1)Authorizes an RDA, after completing a Dental Board of
California (DBC) -approved educational program or course to
that effect, to determine which radiographs to perform.
2)Authorizes an RDAEF licensed on or after January 1, 2010 to
place an interim therapeutic restoration (ITR) if he or she:
a) Places the ITR upon the order of the supervising
[licensed] dentist under general supervision;
b) Places the ITR pursuant to the order, control, and full
professional responsibility of a licensed dentist, either
under direct or general supervision, as determined by the
supervising licensed dentist; and,
c) Has taken a DBC-approved RDAEF education program or
course to that effect in placing an ITR.
3)Authorizes a RDAEF licensed before January 1, 2010 to place an
ITR if he or she:
a) Places the ITR upon the order of the supervising
[licensed] dentist under general supervision;
b) Places the ITR pursuant to the order, control, and full
professional responsibility of a licensed dentist, either
under direct or general supervision, as determined by the
supervising licensed dentist; and,
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c) Provides evidence of having completed a DBC-approved
course in placing an ITR and passed an examination.
4)Authorizes an RDH, after submitting to the Dental Hygiene
Committee (DHC) evidence of satisfactory completion of a DHC-
approved course of instruction, to do the following:
a) Determine which radiographs to perform; and,
b) Place an ITR upon the order of a licensed dentist.
5)Defines the following terms:
a) "Asynchronous store and forward" means the transmission
of a patient's dental information from an originating site
to the health care provider at a distant site without the
presence of the patient;
b) "Distant site" means a site where a health care provider
who provides health care services is located while
providing these services via a telecommunications system;
c) "Health care provider" means a person who is licensed by
the DBC;
d) "Interim therapeutic restoration" (ITR) as the removal
of caries using hand instruments and placement of an
adhesive restorative material.
e) "Originating site" means a site where a patient is
located at the time health care services are provided via a
telecommunications system or where the asynchronous store
and forward service originates;
f) "Synchronous interaction" means a real-time interaction
between a patient and a health care provider located at a
distant site;
g) "Teledentistry" means the mode of delivering dental
health care services and public dental health via
information and communication technologies to facilitate
the diagnosis, consultation, treatment, education, care
management, and self-management of a patient's dental
health care while the patient is at the originating site
AB 1174
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and the dental health care provider is at a distant site.
Teledentistry includes synchronous interactions and
asynchronous store and forward transfers; and,
h) "Teledentistry by store and forward" means an
asynchronous transmission of dental information to be
reviewed at a later time by a licensed dentist at a distant
site, where the dentist at the distant site reviews the
dental information without the patient being present in
real time.
6)Prohibits the requirement of face-to-face contact between a
health care provider and a patient under the Medi-Cal program
for teledentistry by store and forward, to the extent that
federal financial participation is available.
7)States that services appropriately provided through the
teledentistry store and forward process are subject to billing
and reimbursement policies developed by the Department of
Health Care Services (DHCS).
8)Requires a patient receiving teledentistry by store and
forward to be notified of the right to receive interactive
communication with the distant dentist and receive an
interactive communication with the distant dentist upon
request.
9)Requires, if requested, communication with the distant dentist
to occur either at the time of the consultation, or within 30
days of the patient's notification of the results of the
consultation.
10)Requires that dentist participation in services provided at
an intermittent clinic through the use of telehealth be
considered a billable encounter under Medi-Cal.
11)Permits DHCS to implement, interpret, and make specific these
provisions regarding Medi-Cal teledentistry by means of
all-county letters, provider bulletins, and similar
instructions.
12)Requires DHCS to report to the Legislature the number and
type of services provided, and the Medi-Cal payments made
related to the application of store and forward teledentistry
by January 1, 2017.
AB 1174
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EXISTING LAW :
1) Establishes the Dental Board of California (DBC) to license
and regulate the practice of dentistry. (Business and
Professions Code (BPC) Section 1600 et seq.)
2) Establishes the Dental Hygiene Committee within DBC. (BPC
1900 et seq.)
3) Establishes the Telemedicine Development Act of 1996 for the
purpose of addressing significant barriers to access to
health services in medically underserved rural and urban
areas, and defines "telemedicine" as the practice of health
care delivery, diagnosis, consultation, treatment, transfer
of medical data, and education using interactive audio, video
or data communications. Neither a phone conversation nor an
electronic mail message between a health care practitioner
and patient constitutes telemedicine. (BPC 2290.5)
4) Provides that for the purpose of practicing telemedicine,
provides that the term "health care practitioner" includes a
physician and surgeon, podiatrist, clinical psychologist,
marriage and family therapist, licensed clinical social
worker, dentist, or optometrist. (BPC 2290.5)
5) Requires, prior to the delivery of health care via
telemedicine, a health care practitioner who has ultimate
authority over the care or primary diagnosis of the patient
to obtain verbal and written informed consent from the
patient or the patient's legal representative. Specifies
that the informed consent procedure must include certain
information to be given to the patient or the patient's legal
representative verbally or in writing. Specifies that
failure of a health care provider to comply with these
requirements constitutes unprofessional conduct. Provides
for exemptions to the application of telemedicine. (BPC
2290.5)
6) States that no health care service plan contract that is
issued, amended, or renewed shall require face-to-face
contact between a health care provider and a patient for
services appropriately provided through telemedicine, as
specified. Provides that this requirement applies to health
care service plan contracts with the Medi-Cal managed care
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program only if certain requirements are met. (Health and
Safety Code (HSC) 1374.13)
7) Establishes the Medi-Cal program, administered by Department
of Health Care Services (DHCS), under which health care
services are provided to qualified low-income persons.
(Welfare and Institutions Code (WIC) 14000 et seq.)
8) Provides that face-to-face contact between a health care
provider and a patient shall not be required under the
Medi-Cal program for services appropriately provided through
telemedicine, subject to reimbursement policies developed by
the Medi-Cal program, as specified. (WIC 14000 et seq.,
14132.72)
9) Defines an "intermittent clinic" as a clinic that is operated
by a primary care community or a free clinic and that is
operated on separate premises from the licensed clinic and is
only open for limited services of no more than 20 hours a
week. (HSC 1206 (h))
FISCAL EFFECT : Unknown
COMMENTS :
1)Purpose of this bill . This bill expands the scope of practice
for RDAs, RDAEFs, and RDHs to better enable the practice of
teledentistry and fully realize the concept of the Virtual
Dental Home (VDH), consistent with the findings of successful
pilot program, and enables reimbursement by Medi-Cal for VDH
treatment. This bill is author sponsored.
2)Author's statement . According to the author, "A three year
demonstration, directed by the Pacific Center for Special Care
at the University of the Pacific School of Dentistry, has
established the ability of the VDH system to reach underserved
children in Head Start centers and schools, people with
disabilities in residential care facilities, seniors in
nursing homes, and others who do not access dental care in the
traditional office and clinic-based delivery system.
"AB 1174 expands the existing VDH system, as authorized
through a HWPP under the Office of Statewide Health Planning
and Development (OSHPD), and allows these systems to be used
statewide.
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"This bill incorporates the prevention and early intervention
duties authorized by the HWPP into the scope of practice of
allied dental personnel. It will also create parity between
telehealth-facilitated diagnostic and preventive dental
services and traditional in-person services by allowing
telehealth-enabled teams to be able to bill the Medi-Cal
program for providing dental care to enrolled individuals."
3)OSHPD pilot project . OSHPD was created in 1978 to provide
California with an enhanced understanding of the structure and
function of its healthcare delivery systems. OSHPD considers
itself the leader in collecting data and disseminating
information about California's healthcare infrastructure,
promoting an equitably distributed healthcare workforce and
publishing valuable information about healthcare outcomes.
The Health Workforce Pilot Program within OSHPD allows
organizations to test, demonstrate, and evaluate new or
expanded roles for healthcare professionals, or new healthcare
delivery alternatives before changes in licensing laws are
made by the Legislature. An OSHPD pilot project is authorized
to waive laws that would otherwise bar clinicians from
learning and performing procedures outside their current scope
of practice.
OSHPD establishes minimum standards, guidelines, and
instructions for approved pilot projects after one or more
public hearings. Pilot projects must be sponsored by
community hospitals or clinics, nonprofit educational
institutions, or government agencies engaged in health or
education activities.
Upon approval, OSHPD conducts periodic site visits and
continuous evaluations of the pilot project based on specified
criteria. All data collected by OSHPD and by the pilot
projects are public information, with due regard for the
confidentiality of individual patient information. The raw
data on which projects' reports and OSHPD's evaluation are
based is available for public review.
The Pacific Center for Special Care at the University of the
Pacific, Arthur A. Dugoni School of Dentistry applied for and
was approved to conduct a pilot project, HWPP 172, to teach
new skills to health care personnel and improve the oral
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health of underserved populations by expanding duties of RDAs,
RDAEF, and RDHs working in VDHs.
The goal of HWPP 172 was to demonstrate that RDAs, RDAEFs, and
RDHs can keep people healthy in community settings by
providing education, preventive care, interim therapeutic
restorations triage, and case management. Where more complex
dental treatment is needed, the VDH connects patients with
dentists in the area.
Since January 2011, 1,514 patients have been seen under HWPP
172. 1,514 radiographic decisions were made and 324 ITRs were
placed by RDAs, RDAEFs, and RDHs with no adverse outcomes.
4)VDH . Virtual Dental Homes create a community-based oral health
delivery system in which people receive preventive and basic
therapeutic services in community settings where they live or
receive educational, social or general health services. It
utilizes technology to link practitioners in the community
with dentists at remote office sites.
Equipped with portable imaging equipment and an Internet-based
dental record system, the RDA, RDAEF, or RDH collects
electronic dental records such as X-rays, photographs, charts
of dental findings, and dental and medical histories, and
uploads the information to a secure website where they are
reviewed by a collaborating dentist. The dentist reviews the
patient's information and creates a tentative dental treatment
plan. The RDA, RDAEF, or RDH then carries out the aspects of
the treatment plan that can be conducted in the community
setting. These services include:
a) Health promotion and prevention education;
b) Dental disease risk assessment;
c) Preventive procedures such as application of fluoride
varnish, dental sealants and, for dental hygienists, dental
prophylaxis and periodontal scaling;
d) Placing carious teeth in a holding pattern using ITRs to
stabilize patients until they can be seen by a dentist for
definitive care; and,
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e) Tracking and supporting the individual's need for and
compliance with recommendations for additional and
follow-up dental services;
The RDA, RDAEF, or RDH refers patients to dental offices for
procedures that require the skills of a dentist. When such
visits occur, the patient arrives with a diagnosis and
treatment plan already determined, preventive practices in
place and preventive procedures having been performed.
Presumably, the patient is more likely to receive a successful
first visit with the dentist as the patient's dental records
and images have already been reviewed. All of this adds up to
a more successful dentist visit.
In some cases the dentist may come to the community site and
use portable equipment to provide restorations or other
services that only a dentist can provide. In either case, the
majority of patient interactions and efforts to keep people
healthy are performed by the RDA, RDAEF, or RDH in the
community setting, thus creating a true community-based
'dental home'.
5)Medi-Cal . The VDH treatment model is currently not
reimbursable by Medi-Cal because existing law requires
face-to-face contact between a health care provider and a
patient. This bill would delete that provision and allow
practitioners to receive payment for these services. This
bill also provides patient protections by ensuring contact
with the remote dentist upon request.
6)Arguments in support . The Children's Partnership writes, "The
VDH is currently being implemented on a pilot basis and is
grant-funded. Therefore, it is not sustainable, as is. Two
of the procedures that the dental hygienists and assistants
are performing are currently authorized under a Health
Workforce Pilot Project (HWPP) program?.Under the HWPP, the
dental hygienists and assistants who are participating in the
VDH are deciding which x-rays to take and are allowed to place
interim therapeutic restorations (temporary fillings). These
two duties are not within these professionals' current scope
of practice, but the HWPP has shown that dental hygienists and
assistants can safely and effectively perform them.
"Legislation is needed to ensure dental hygienists and
assistants can continue to perform the duties they are
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performing under the HWPP and to ensure Medi-Cal pays dentists
to provide store-and-forward teledentistry. We are strongly
supporting AB 1174 because the VDH is a proven, successful
model for bringing dental care to large numbers of children
and other underserved populations in their communities."
7)Related legislation . AB 318 (Logue) would provide that, to
the extent that federal financial participation is available,
face-to-face contact between a health care provider and a
patient shall not be required under the Medi-Cal program for
"teledentistry by store and forward" and shall be considered a
billable encounter. This bill is currently in Assembly Health
Committee and its provisions have been incorporated into AB
1174.
AB 1231 (V.Manuel Pérez) would permit, until January 1, 2019,
the treatment of a pervasive developmental disorder or autism
through the use of telehealth, and that dentistry may be
provided through the use of teledentistry. The bill would
require the Department of Developmental Services to provide
technical assistance to regional centers on the use of
telehealth and teledentistry. AB 1231 is in the Assembly
Human Services Committee.
8)Previous legislation . AB 415 (Logue), Chapter 547, Statutes
of 2011, enacted the Telehealth Advancement Act of 2011. This
bill repeals and recasts existing laws related to the delivery
of health care services via telemedicine and replaces the term
telemedicine with telehealth.
9)Double-referral . This bill is double-referred, and if passed
by this Committee, it will be referred to the Assembly
Committee on Health.
REGISTERED SUPPORT / OPPOSITION :
Support
California Coverage and Health Initiatives
California School Health Centers Association
California Primary Care Association
Children Now
Children's Defense Fund - California
Connecting to Care
Community Clinic Association of Los Angeles County
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Golden Gate Regional Center
Los Angeles Trust for Children's Health
Shasta Community Health Center
The Children's Partnership
United Ways of California
Venice Family Clinic
Westside Children's Center
Worksite Wellness LA
1 private individual
Opposition
None on file.
Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916)
319-3301