BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 1174
AUTHOR: Bocanegra
AMENDED: May 21, 2014 (and As Proposed to be Amended)
HEARING DATE: June 25, 2014
CONSULTANT: Bain
SUBJECT : Dental professionals.
SUMMARY : Allows registered dental assistants in extended
functions (RDAEF) and registered dental hygienists (RDH), using
telehealth, to determine which radiographs to perform on a
patient who has not received an initial examination by the
supervising dentist for the purpose of the dentist making a
diagnosis and treatment plan for the patient, and to place
interim therapeutic restorations (ITRs are defined as a direct
provisional restoration placed to stabilize the tooth until a
dentist diagnoses the need for further definitive treatment).
Requires the Office of Statewide Health Planning and Development
to extend the duration of the health workforce project known as
Health Workforce Pilot Project Number 172 until January 1, 2016
(HWPP 172 authorized the performance of these procedures by
RDAEF and RDHs). Prohibits in Medi-Cal, to the extent that
federal financial participation is available, face-to-face
contact between a health care provider and a patient from being
required under the Denti-Cal program for teledentistry by store
and forward.
Existing law:
Dental Practice Act
1.Establishes the Dental Practice Act (DPA), administered by the
Dental Board of California (DBC).
2.Makes it unprofessional conduct under the DBC for any dentist
to perform, or allow to be performed, any treatment on a
patient who is not a patient of record of that dentist.
Permits a dentist, after conducting a preliminary oral
examination, to require or permit any dental auxiliary to
perform procedures necessary for diagnostic purposes, provided
that the procedures are permitted under the auxiliary's
authorized scope of practice.
3.Allows a dentist to require or permit a dental auxiliary, upon
the direction of the dentist, to perform all of the following
Continued---
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duties prior to any examination of the patient by the dentist,
provided that the duties are authorized for the particular
classification of dental auxiliary under existing law:
a. To expose emergency radiographs upon direction of the
dentist;
b. Perform extra-oral duties or functions specified by the
dentist; and,
c. Perform mouth-mirror inspections of the oral cavity, to
include charting of obvious lesions, malocclusions,
existing restorations, and missing teeth.
Registered Dental Assistant in Extended Function (RDAEF)
4.Permits the DBC to license as a RDAEF a person who submits
satisfactory written evidence to DBC of all of the following
eligibility requirements:
a. Current licensure as a registered dental assistant (RDA)
or completion of the requirements for licensure as an RDA;
b. Successful completion of a DBC-approved course in the
application of pit and fissure sealants; and,
c. Successful completion of either of the following:
i. An extended functions postsecondary program
approved by the DBC board in specified procedures; or,
ii. An extended functions postsecondary program
approved by the DBC to teach the duties that RDAEF
were allowed to perform pursuant to board regulations
prior to January 1, 2010, and a course approved by the
DBC in specified procedures.
d. Passage of a written examination and a clinical or
practical examination administered by the DBC or by a
DBC-approved extended functions program.
Dental Hygiene Committee and RDH and RDH in Extended Functions
5.Establishes within the jurisdiction of DBC a Dental Hygiene
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Committee of California (DHCC), and states legislative intent
to permit the full utilization of RDH, registered dental
hygienists in alternative practice (RDHAP), and registered
dental hygienists in extended functions (RDHEF) in order to
meet the dental care needs of all of the state's citizens.
Requires the DHCC to perform specified functions, including
making recommendations to the DBC regarding dental hygiene
scope of practice issues.
6.Specifies the scope of practice of dental hygiene and what it
does and does not include and what services can be performed
under direct supervision, without direct supervision and under
general supervision. The practice of dental hygiene includes
dental hygiene assessment and development, planning,
implementation of a dental hygiene care plan, oral health
education, counseling, and health screenings. The practice of
dental hygiene excludes placing, condensing, carving or
removal of permanent restorations, and diagnosis and
comprehensive treatment planning.
7.Defines "direct supervision" as the supervision of dental
procedures based on instructions given by a licensed dentist
who is required to be physically present in the treatment
facility during the performance of those procedures.
8.Defines "general supervision" as the supervision of dental
procedures based on instructions given by a licensed dentist
who is not required to be physically present in the treatment
facility during the performance of those procedures.
9.Permits, unless otherwise specified, an RDH to perform any
procedure or provide any service within the scope of his or
her practice in any setting, so long as the procedure is
performed or the service is provided under the appropriate
level of supervision required under the RDH body of law.
Health Workforce Pilot Projects
10.Permits the Office of Statewide Health Planning and
Development (OSHPD) to designate experimental health workforce
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projects as approved projects where the projects are sponsored
by community hospitals or clinics, nonprofit educational
institutions, or government agencies engaged in health or
education activities. Permits, notwithstanding any other
provision of law, a trainee in an approved project to perform
health care services under the supervision of a supervisor
where the general scope of the services has been approved by
OSHPD.
11.Prohibits OSHPD from approving a project for a period lasting
more than two training cycles plus a preceptorship of more
than 24 months, unless OSHPD determines that the project is
likely to contribute substantially to the availability of
high-quality health services in the state or a region.
Medi-Cal Reimbursement of Teleophthalmology and Teledermatology
12.Prohibits, to the extent that federal financial participation
is available, face-to-face contact between a health care
provider and a patient from being required under the Medi-Cal
program for teleophthalmology and teledermatology by store and
forward. Requires services appropriately provided through the
store and forward process to be subject to billing and
reimbursement policies developed by the Department of Health
Care Services (DHCS).
Definition of Telehealth
13.Defines "telehealth" as the mode of delivering health care
services and public health via information and communication
technologies to facilitate the diagnosis, consultation,
treatment, education, care management, and self-management of
a patient's health care while the patient is at the
originating site and the health care provider is at a distant
site. States that telehealth facilitates patient
self-management and caregiver support for patients and
includes synchronous interactions and asynchronous store and
forward transfers.
This bill:
1.Amends a DPA unprofessional conduct section of law to allow a
dentist to require or permit, prior to any examination of the
patient by the dentist, an RDAEF, an RDH or an RDHAP to
determine and perform radiographs for the specific purpose of
aiding a dentist in completing a comprehensive diagnosis and
treatment plan for a patient using telehealth under this bill.
2.Requires it to be the responsibility of the authorizing
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dentist that the patient or the patient's representative
receive written notification that the care was provided at the
direction of the authorizing dentist and that the notification
include the authorizing dentist's name, practice location
address, and telephone number if dental treatment is provided
to a patient by a RDAEF, a RDH or a RDHAP pursuant to the
diagnosis treatment plan authorized by a supervising dentist,
at a location other than the dentist practice location.
Prohibits this provision from requiring patient notification
for dental hygiene preventive services provided in public
health programs authorized under existing law, or for dental
hygiene care when provided as authorized by existing law.
3.Prohibits a dentist from concurrently supervising more than a
total of five RDAEF, RDH or RDHAP under this bill.
4.Allows a RDAEF and RDH, using telehealth for the purpose of
communication with the supervising dentist, to:
a. Determine which radiographs to perform on a patient who
has not received an initial examination by the supervising
dentist for the specific purpose of the dentist making a
diagnosis and treatment plan for the patient. Requires the
RDAEF and RDH to follow protocols established by the
supervising dentist. Limits, for RDAEF, this expansion to a
dental office setting and to a public health settings.
Defines public health settings to include, but not limited
to, schools, head start, preschool programs, and community
clinics.
b. Place protective restorations, identified as ITR, and
defined as a direct provisional restoration placed to
stabilize the tooth until a licensed dentist diagnoses the
need for further definitive treatment. States an ITR
consists of the removal of soft material from the tooth
using only hand instrumentation, without the use of rotary
instrumentation, and subsequent placement of an adhesive
restorative material where local anesthesia is not
necessary for ITR placement. Requires ITRs to be placed
after a diagnosis and treatment by plan by a dentist in
either of the following settings:
i. In a dental office setting, under the direct
or general supervision of a dentist as determined by
the dentist for a RDAEF, and under general supervision
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for a RDH; and,
ii. In public health settings. Public health
settings including, but not limited to, schools, head
start preschool programs, and community clinics.
5.Permits a RDHAP to provide the telehealth duty (determining
which radiographs to perform and placing ITRs) in residential
facilities, institutions, and residences of the homebound.
6.Permits the additional functions to be performed by a RDAEF or
RDH only after completion of a program that includes training
in performing those functions, or after providing satisfactory
evidence of having completed an approved course in those
functions.
7.Requires, no later than January 1, 2018, regulations to be
promulgated related to establishing criteria for approval of
courses of instruction for the procedures under this bill
using the competency-based training protocols established by
Health Workforce Pilot Project No. 172 (HWPP No. 172) through
OSHPD. Requires, in developing regulations and any subsequent
proposed amendments to promulgated regulations, the DBC to
provide to the DHC proposed regulations related to the
curriculum required for protective restorations.
8.Requires a program, in addition to the instructional
components described in this bill, to contain both of the
instructional components:
a. Requires the course to be established at the
postsecondary educational level; and,
b. Requires all faculty responsible for clinical
evaluation to have completed a one-hour methodology
course in clinical evaluation or have a faculty
appointment at an accredited dental education program
prior to conducting evaluations of students.
9.Permits the DBC to issue a permit to a RDAEF to provide the
duties specified in this bill after the DBC has determined the
RDAEF has completed the required coursework.
10.Prohibits in Medi-Cal, to the extent that federal financial
participation is available, face-to-face contact between a
health care provider and a patient from being required under
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the Denti-Cal program for teledentistry by store and forward.
Defines "teledentistry" as an asynchronous transmission of
dental information to be reviewed at a later time by a dentist
at the distant site without the patient being present in real
time.
11.Requires OSHPD to extend the duration of the health workforce
project known as HWPP No. 172 until January 1, 2016, in order
to maintain the competence of the clinicians trained during
the course of the project, and to authorize training of
additional clinicians in the duties specified in HWPP No. 172.
Sunsets this provision January 1, 2016.
FISCAL EFFECT : According to the Assembly Appropriations
Committee:
1.Annual fee-supported special fund costs to the 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); and,
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.
PRIOR VOTES :
Assembly Business, Professions, and Consumer Protections:12- 0
Assembly Health: 17- 0
Assembly Appropriations: 16- 0
Assembly Floor: 76- 0
Senate Business, Professions, and Economic Development: 8- 0
COMMENTS :
1.Author's statement. According to the author, this bill will
codify the Virtual Dental Home (VDH), as tested through a HWPP
since 2010. This bill would allow the VDH model to be employed
statewide, opening up access to dental care for the state's
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underserved populations. Using telehealth to allow dentistry
services, the VDH allows RDHs and RDAEFs out in the field to
collaborate with a dentist who is not onsite but back at his
or her office. Through a process called "store and forward,"
RDHs and RDAEF take x-rays, as well as take pictures of the
teeth and perform a preliminary exam in a school or community
setting. They then send the results through a secure web cloud
to the dentist for review. Using the data provided, the
dentist performs a dental exam and determines a treatment plan
for the patient, to be performed by the RDH, if appropriate.
This combination of telehealth and expanded duties, allows for
effective and safe services in communities that currently lack
access to dental care.
2.HWPP No. 172 and VDH. The HWPP 172 was approved by OSHPD in
December 2010, and patient care with the new HWPP duties began
in January of 2011. The purpose of the pilot program was to
teach new skills to existing categories of health care
personnel and to improve the oral health of underserved
populations by expanding duties of RDA, and RDHs working in
community settings, and to permit temporary legal waivers of
certain practice restrictions or educational requirements to
test expanded roles and accelerated training programs for
health care professionals. HWPP was funded by public and
private grants and was sponsored by the Pacific Center for
Special Care at the University of the Pacific School of
Dentistry.
A policy brief describes the VDH, which included HWPP 172.
Allied dental professionals in the HWPP 172 demonstration
project were allowed to place ITRs under general supervision
of dentists. In addition to testing the ability of allied
dental personnel to place ITRs, this pilot project tested the
ability of these allied dental personnel to decide which
radiographs to take in order to facilitate an oral evaluation
by a dentist. These procedures have expanded the ability to
create telehealth-enabled, geographically distributed teams
and to improve the oral health of the vulnerable and
underserved populations participating in the VDH
demonstration. Thirteen allied dental health providers
participated (1 dental assistant, 4 RDHs working in public
health programs, and 8 RDHAPs) at 14 pilot program locations.
Under the VDH and HWPP 172, an RDA, RDH or RDHAP uses portable
imaging equipment and an internet-based dental record system
to collect electronic dental records such as X-rays,
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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 RDHAP, RDH or RDA then
carries out the aspects of the treatment plan that can be
conducted in the community setting. After the dentist reviews
the electronic dental records, the RDHAP, RDH or RDA refers
patients to dental offices for procedures that require the
skills of a dentist. When these visits occur, the patient
arrives with health history and consent arrangements
completed, a diagnosis and treatment plan already determined,
preventive practices in place and preventive procedures having
been performed.
3.Double referral. This bill was previously heard in the Senate
Business, Professions and Economic Development Committee,
where it passed on an 8-0 vote.
4. Support. Children's health groups write in support of this
bill, arguing this bill will increase access to dental care
for underserved children and adults who currently go without
needed care by enacting policies that would sustain the VDH.
Supporters argue the VDH is a proven and cost-effective
system for providing dental care to California's most
vulnerable children and adults. This bill will ensure the VDH
could become a sustainable model and be implemented in sites
throughout California. Supporters also argue the expanded
functions authorized in this bill, and the Denti-Cal
store-and-forward benefit will reach many individuals in
Medi-Cal with diagnostic and interim stabilizing procedures,
but more importantly, as a bridge to entering into the
full-scope of treatment services available under our existing
dental delivery system.
5.Opposition. The California Dental Hygienists' Association
(CDHA) writes in opposition to this bill, arguing it will
impede access to dental care. CDHA states that, by requiring
general supervision for RDHAPs, this bill denies the patients
currently being served by RDHAPs access to provisional
fillings that are temporary and prevent tooth pain until the
patients can get to a dentist for a permanent filling. CDHA
states RDHAPs have practiced independently in schools, skilled
nursing facilities, residences of the homebound, institutions
and dental health shortage areas for over twelve years, and it
AB 1174 | Page 10
does not make sense to force RDHAPs into a business
relationship with a dentist just to provide the services in
this bill. CDHA argues this bill directly benefits dentists at
the expense of RDHAPs, who will lose an opportunity to expand
the preventive services that they are now providing to
patients in settings where dentists do not practice. CDHA
states RDHAPs have been able to provide much needed services
to populations because they did not have to be employed by a
dentist to do so. By refusing to allow the RDHAP to provide
the services tested in the pilot project unsupervised, the
bill will benefit dentistry, but not the public, and the RDHAP
will have no means to continue to provide services that they
are no longer going to be paid for.
6.Oppose unless amended. DHCC writes asking this bill be amended
to reflect only ITR and not the determination of radiographs
or settings for RDHs as DHCC argues existing law establishes
the settings for RDHs. DHCC also argues that having the RDHAP
under general supervision for the ITR is a step backwards
rather than forward. Third, DHCC believes RDH and RDHAP are
educated and trained to determine which radiographic
projections should be taken on patients, and proposes language
to allow RDH and RDHAPs to determine which radiographs to
perform on a patient, including patients who have not received
an initial examination by a dentist. DHCC writes that the
language is overly restrictive for RDHs and differs from how
the DHCC views the current scope of practice, and it opposes
the need for additional training for RDHs and RDHAPs to
determine which radiographs to perform. Finally, DHCC objects
to the regulation language in the version of this bill that is
in print.
7.Support if amended. The DBC writes seeking amendments, arguing
the additional allowable duties of a RDAEF should be
authorized in the form of a permit once requirements are
successfully completed so that consumers and dental health
care professionals are able to discern between the varied
allowable duties that RDAEFs are allowed to perform. In
addition, DBC indicates it has a concern that the current
language does not provide the authority for DBC to assess an
application or renewal fee for the issuance of this new
permit. The mock-up language authorizes the issuance of a
permit but not a new fee related to the permit. DBC also seeks
a deletion in a provision of the regulation language in this
bill, and the latest mock-up makes this deletion.
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8.Policy questions:
a. Should there be general supervision of registered
dental hygienists in alternative practice performing the
radiographs and ITR authorized by this bill? RDHAPs are
individuals licensed as an RDH who have been engaged in
dental hygiene practice for a minimum of 2,000 hours
during the preceding 36 months, and have a bachelor's
degree or its equivalent from an accredited institution.
RDHAPs can practice as an independent contractor or as a
sole proprietor of an alternative dental hygiene
practice, in addition to being employees of a dentist,
another RDHAP, or a primary care or specialty care
clinic. RDHAPs can also operate a mobile dental hygiene
clinic.
This bill amends the RDH body of law to authorize these
additional functions, so an RDHAP could only perform
these procedures under his or her RDH license. One of the
issues in dispute is whether RDHAP can perform an ITR
without general supervision. Under this bill, a RDH
(RDHAPs are also RDHs) can perform an ITR, but only under
general supervision as an RDH. Under HWPP No. 172, the
project director indicates the placement of ITRs in the
pilot was tested as a general supervision duty, meaning
the dentist provided instructions for the allied dental
personnel in the project to perform the duty (place the
ITR) at a time and place when the dentist was not
present.
The other additional function authorized by this bill is
allowing RDH and RDAEF to determine which radiographs to
perform on a patient who has not received an initial
examination by the supervising dentist for the specific
purpose of the dentist making a diagnosis and treatment
plan for the patient. One of the other areas in dispute
in this bill is whether RDHs are already allowed to
determine which radiographs to perform.
The amendments in the latest mock-up attempt to address
these issues by requiring the use of telehealth for the
extended functions in this bill, and to require the
radiographs to be for the specific purpose of the dentist
making a diagnosis and treatment plan for the patient.
Diagnosis and comprehensive treatment planning are
excluded under existing law from the scope of practice of
an RDH.
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CDHA has instead proposed this bill be amended to delete
the phrase "general supervision" as the existing RDH body
of law this bill amends already requires general
supervision. CDHA also requests moving the locations in
which RDHAP can perform these duties to the RDHAP
provisions of law (discussed below), and to allow RDHAPs
to perform the radiographs and ITRs under their current
practice settings, which can include as a sole proprietor
of an independent alternative dental hygiene practice.
b. Which entity should adopt regulations under this
bill? DHCC is charged with administering the body of law
regulating RDHs and RDHAPs. Included in DHCC duties are
making recommendations to the DBC regarding dental
hygiene scope of practice issues, and adopting, amending
and revoking regulations to implement the requirements of
the dental hygiene body of law.
This bill requires, no later than January 1, 2018,
regulations to be promulgated using the competency-based
training protocols established by the HWPP No. 172 to
establish criteria for approval of courses of instruction
for the procedures authorized to be performed by a RDH
under this bill. However, this language is silent on
which entity is promulgating these regulations, although
it would presumably be the DHCC under its existing law
authority.
In addition, the mock-up requires, in developing
regulations and any subsequent proposed amendments to
promulgated regulations, the DBC to provide to the DHCC
proposed regulations related to the curriculum required
for ITR-related duties. DBC is charged with developing
regulations for RDAEF, but it is unclear why DBC is
providing DHCC the proposed regulations related to the
ITR curriculum, and whether the DBC-provided regulations
are required to be adopted by DHCC.
1.Drafting issues:
a. This bill permits a RDHAP to provide the
telehealth duty (determining which radiographs to
perform and placing ITRs) in residential facilities,
institutions, and residences of the homebound.
However, in the mock-up, this provision of law is
being added in the provisions of law dealing with
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RDHs, not RDHAP. Staff recommends this provision be
moved to the RDHAP body of law.
b. Section 2 and 3 of this bill both establish a
new Section 1753.55 of the Business and Professions
Code, with Section 2 "sunsetting" January 1, 2018 and
being replaced by Section 3. Subdivision (a) of
Section Section 2 has a cross reference to Section
1753.6 which is not in Section 3, and Section 2. In
addition, Section defines public health settings to
include residential facilities, while Section 2 does
not. Amendments are needed to conform these two
provisions.
SUPPORT AND OPPOSITION :
(Support and Opposition is not based on the mock-up)
Support: AgeTech West
California Academy of Physician Assistants
California Coverage and Health Initiatives
California Dental Association
California Society of Pediatric Dentistry
Children Now
Community Clinic Association of Los Angeles
Connecting to Care
Delta Dental of California
Liberty Dental Plan of California
Los Angeles Area Chamber of Commerce
Los Angeles Unified School District
Los Angles Trust for Children's Health
Maternal and Child Health Access
Mendocino Community Health Clinic, Inc.
Peninsula Family Service
Rural County Representatives of California
The Children's Partnership
United Ways of California
Worksite Wellness LA
Several individuals
Oppose: California Dental Hygienists' Association
Dental Hygiene Committee of California (unless
amended)
Union of American Physicians and Dentists (unless
amended)
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