BILL ANALYSIS Ó AB 1174 Page 1 ASSEMBLY THIRD READING AB 1174 (Bocanegra and Logue) As Amended January 6, 2014 Majority vote BUSINESS & PROFESSIONS 12-0 HEALTH 17-0 ----------------------------------------------------------------- |Ayes:|Gordon, Jones, Bocanegra, |Ayes:|Pan, Maienschein, | | |Campos, Dickinson, | |Ammiano, Atkins, Bonilla, | | |Eggman, Hagman, | |Bonta, Chesbro, Gomez, | | |Maienschein, Mullin, | |Gonzalez, Roger | | |Skinner, Ting, Wilk | |Hernández, Logue, | | | | |Mansoor, Nazarian, | | | | |Ridley-Thomas, Wagner, | | | | |Wieckowski, | | | | |V. Manuel Pérez | |-----+--------------------------+-----+--------------------------| | | | | | ----------------------------------------------------------------- APPROPRIATIONS 16-0 -------------------------------- |Ayes:|Gatto, Bigelow, Allen, | | |Bocanegra, Bradford, Ian | | |Calderon, Campos, Eggman, | | |Gomez, Holden, Linder, | | |Pan, Quirk, | | |Ridley-Thomas, Wagner, | | |Weber | | | | | | | -------------------------------- SUMMARY : This bill expands the scope of practice for a registered dental assistant (RDA), registered dental assistant in extended functions (RDAEF), registered dental hygienist (RDH), and registered dental hygienist in alternative practice (RDHAP) to better enable the practice of teledentistry in accordance with the findings of a Health Workforce Pilot Program (HWPP), and authorizes Medi-Cal payments for teledentistry services provided to individuals participating in the Medi-Cal program. Specifically, this bill : 1)Authorizes an RDA to determine which radiographs to perform if he or she completes a Dental Board of California (DBC)-approved RDA educational program in those duties or provides evidence to the AB 1174 Page 2 board of having completed a DBC-approved course in those duties. 2)Authorizes an RDAEF licensed on or after January 1, 2010, an RDH, and an RDHAP, pursuant to the order, control, and full professional responsibility of a supervising dentist, to perform, only in a dental office setting or public health setting and under the supervision of a dentist, as specified, both of the following duties: a) Choose radiographs without the supervising dentist having first examined the patient for the purpose of diagnosis and treatment planning by the dentist, as specified; and, b) Place protective restorations, through interim therapeutic restorations (ITR) that remove soft material from the tooth using only hand instrumentation, without the use of rotary instrumentation, and subsequent placement of an adhesive restorative material, without the use of local anesthesia, after diagnosis and treatment plan by a dentist, as specified. 3)Requires an RDAEF, RDH, and an RDHAP, in order to perform the functions described in paragraph 2), to complete a program that includes training in those functions or to provide evidence satisfactory to the DBC or the Dental Hygiene Committee (DHC) of having completed a DBC- or DHC-approved course in those functions. 4)Requires, until January 1, 2018, a program to perform the duties described in paragraph 2) to contain a course that is established at the postsecondary educational level and to have faculty responsible for clinical evaluation complete a course in clinical evaluation or have a faculty appointment at an accredited dental education program. 5)Defines, until January 1, 2018, the terms "clinical instruction," "course," "didactic instruction," "interim therapeutic restoration," "laboratory instruction," "preclinical instruction," and "program." 6)Requires, until January 1, 2018, the program or course required to choose radiographs to contain all of the following instructional components: a) A program of sufficient duration for the student to develop minimum competency making decisions about which radiographs to take, as specified; AB 1174 Page 3 b) Didactic instruction on guidelines for radiographic decisionmaking and specific decisionmaking protocols that incorporate prescribed information; c) Laboratory instruction that includes simulated decisionmaking using case studies, and there must be at least one instructor for every 14 students, as specified; and, d) Examinations using decisionmaking where students make decisions and demonstrate competency to faculty on case studies containing specified elements. 7)Requires, until January 1, 2018, the program or course required to place protective restorations to contain all of the following instructional components: a) A program of sufficient duration for the student to develop minimum competency in the application of protective restorations, including ITRs, as specified; b) Didactic instruction on topics including pulpal anatomy, theory of adhesive restorative materials, and criteria that dentists use to make decisions about placement of adhesive protective restorations; c) Laboratory instruction that includes placement of adhesive protective restorations where students demonstrate competency in this technique on typodont teeth; and, d) Clinical instruction that includes experiences where students demonstrate placement of adhesive protective restorations under direct supervision of faculty. 8)Deems, until January 1, 2018, an RDAEF, RDH, or RDHAP who has completed the prescribed training in the HWPP to have satisfied the requirement for completion of a DBC- or DHC- approved course. 9)Provides that, to the extent federal financial participation (FFP) is available, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for teledentistry by store and forward. Defines "teledentistry by store and forward" as an asynchronous transmission of dental information to be reviewed at a later time by a dentist at a distant site who reviews the dental information without the AB 1174 Page 4 patient being present in real time. FISCAL EFFECT : According to the Assembly Appropriations Committee: 1)Annual fee-supported special fund costs to the Dental Hygiene Committee of California (DHCC) and the DBC to approve training courses and to oversee the expanded scope of dental personnel would be incurred as follows: a) $150,000 to the DBC, which regulates RDAs (State Dental Assistant Fund). b) $80,000 to the DHCC (State Dental Hygiene Fund). 2)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. 3)Potential unknown future cost savings from avoiding costly dental diseases and emergencies. COMMENTS : 1)Purpose of this bill . This bill expands the scope of practice for RDAs, RDAEFs, RDHs [and RDHAPs] 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. "This bill incorporates the prevention and early intervention duties authorized by the HWPP into the scope of practice of allied AB 1174 Page 5 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 HWPP 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. Upon approval, OSHPD conducts periodic site visits and continuous evaluations of the pilot project based on specified criteria. 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 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)Virtual dental homes . 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. AB 1174 Page 6 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 Web site 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, 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, creating a true community-based "dental home." 5)Medi-Cal . The VDH treatment model is 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. Analysis Prepared by : Eunie Linden / B., P. & C.P. / (916) 319-3301 FN: AB 1174 Page 7 0003006