BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                  AB 1174
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          Date of Hearing:   January 23, 2014

                        ASSEMBLY COMMITTEE ON APPROPRIATIONS
                                  Mike Gatto, Chair

            AB 1174 (Bocanegra and Logue) - As Amended:  January 6, 2014 

          Policy Committee:                             Business and  
          Professions  Vote:                            12-0
                       Health                           Vote: 17-0    

          Urgency:     No                   State Mandated Local Program:  
          No     Reimbursable:              No

           SUMMARY  

          This bill allows certain allied dental professionals to perform  
          additional functions, and addresses Medi-Cal reimbursement for  
          teledentistry services that are otherwise covered by the  
          program.  Specifically, this bill:

          1)Allows registered dental assistants (RDAs) in extended  
            functions (RDA-EF), registered dental hygienists (RDH), and  
            registered dental hygienists in alternative practice (RDH-AP)  
            to place interim therapeutic restorations (ITRs) and choose  
            which x-rays to take for purposes of diagnosis by a dentist.  

          2)Allows RDAs to choose which x-rays to take.

          3)Prescribes, until 2018, training requirements for dental  
            personnel who perform the additional functions.  

          4)Adds teledentristy to a list of specialty health care services  
            for which face-to-face contact is not required in order to  
            claim reimbursement from Medi-Cal.  Subjects such  
            reimbursement to billing and reimbursement policies developed  
            by the Department of Health Care Services (DHCS).

           FISCAL EFFECT  

          1)Annual fee-supported special fund costs to the Dental Hygiene  
            Committee of California (DHCC) and the Dental Board of  
            California (DBC) to approve training courses and to oversee  
            the expanded scope of dental personnel would be incurred as  
            follows:








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               a.     $150,000 to the DBC, which regulates RDAs (State  
                 Dental Assistant Fund).
               b.     $80,000 to the DHCC (State Dental Hygiene Fund).

          2)Minor one-time Information Technology (IT) costs to  
            incorporate changes to the licensing system (State Dental  
            Assistant Fund/State Dental Hygiene Fund).

          3)Denti-Cal, the dental program within Medi-Cal, may incur  
            additional costs, potentially in the hundreds of thousands of  
            dollars, as a result of increased utilization of dental  
            services.  Increased costs are more likely if personnel  
            performing the expanded functions, and/or using teledentistry,  
            reach populations that may otherwise forgo dental care.  Given  
            utilization rates of Denti-Cal services are extremely low,  
            there appears to be ample opportunity to increase utilization,  
            leading to commensurate cost increases.  

            Any additional costs would likely be relatively small at first  
            and could grow with time, as the expanded functions and  
            reimbursement for teledentistry became the norm.  A credible  
            fiscal estimate for initial years developed by the principal  
            investigators of Health Workforce Pilot Project (HWPP) #172,  
            based upon the number of participants in the project, pegged  
            increased Denti-Cal costs at about $300,000 annually, likely  
            growing slowly over time (GF/federal funds, majority federal  
            funds).  This estimate may overstate costs directly resulting  
            from this bill, as existing law authorizes DHCS to reimburse  
            for teledentistry services. 

            In practice, however, it appears as though ambiguity as to  
            whether providers are allowed to bill Medi-Cal for  
            teledentistry services has limited provider interest in  
            developing these systems and billing Medi-Cal.

          4)If this bill leads to greater utilization of relatively  
            low-cost preventive interventions such as ITRs, the state may  
            eventually experience some level of future cost savings by  
            avoiding more costly dental diseases and emergencies. However,  
            an estimate of the magnitude and likelihood of any such  
            savings are beyond the scope of this analysis.

           COMMENTS









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          1)Purpose  . The intent of this bill is to expand, statewide,  
            components of a pilot program that has allowed allied dental  
            professionals to provide additional functions in community  
            settings as part of a telehealth-enabled dental care team.   
            The author hopes this bill will expand the development of the  
            piloted model of community dental care, termed the "Virtual  
            Dental Home," and that the deployment of this model will  
            improve access for hard-to-reach populations such as  
            low-income children, individuals living in institutions, and  
            the developmentally disabled. This may help address extremely  
            low utilization of Denti-Cal.  

          2)Background  . The Office of Statewide Health Planning and  
            Development (OSHPD) oversees health workforce programs in the  
            state. The HWPP program within OSHPD allows organizations to  
            test and evaluate new or expanded roles for health care  
            professionals. Because HWPPs allow small-scale testing of  
            changes to a health care professional's scope in a safe and  
            controlled manner, they can provide a reasonable basis to  
            guide statutory changes that affect an entire licensure  
            category.  

            HWPP #172 piloted the "Virtual Dental Home" model by  
            implementing the expanded scope, along with technology that  
            enables the allied dental professionals to provide services in  
            a community setting.  The pilot ran for three one-year  
            periods, ending December 31, 2013.  A number of reports have  
            evaluated various aspects of the pilot.  Approximately 2,000  
            patients were seen in settings ranging from preschools to  
            long-term care facilities. University of the Pacific, which  
            conducted the project, reported no adverse occurrences and  
            reported that individuals served were generally satisfied with  
            the service.  They also found equipment and overheard costs  
            for the services were relatively low, and thus project this  
            model can be deployed economically even if providers rely  
            largely on Denti-Cal reimbursement.

           3)Related Budget Proposal  .  To address low utilization of  
            Denti-Cal services among children, the governor's 2014-15  
            budget proposes $17.5 million (California Children and  
            Families Commission Proposition 10 funds /federal funds) to  
            increase dental outreach activities.

           4)Concern  .  The California Association of Oral and Maxillofacial  
            Surgeons has concerns with the provisions allowing mid-level  








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            professionals to place ITRs, and would support this bill if  
            these provisions were amended out.  

            The California Dental Association indicates it has been  
            working with the author on several of the details of the bill,  
            including supervision and settings for the new duties, and  
            would be in support if these issues are addressed.  

            The California Dental Hygienists Association opposes the bill  
            unless amended to remove certain provisions related to x-rays,  
            contending their scope already allows them to perform  
            procedures explicitly authorized by this bill.

           Analysis Prepared by  :    Lisa Murawski / APPR. / (916) 319-2081