BILL ANALYSIS Ó AB 1174 Page 1 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: AB 1174 Page 2 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 AB 1174 Page 3 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 AB 1174 Page 4 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