BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                AB 1174
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        ASSEMBLY THIRD READING
        AB 1174 (Bocanegra and Logue)
        As Amended  January 6, 2014
        Majority vote 

         BUSINESS & PROFESSIONS       12-0                   HEALTH    17-0
         
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        |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  








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          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; 








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           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  








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          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  








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          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.








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          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:  








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