BILL ANALYSIS Ó
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | AB 1174|
|Office of Senate Floor Analyses | |
|1020 N Street, Suite 524 | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
THIRD READING
Bill No: AB 1174
Author: Bocanegra (D) and Logue (R)
Amended: 7/2/14 in Senate
Vote: 21
SENATE BUSINESS, PROF. & ECON. DEV. COMM. : 8-0, 6/16/14
AYES: Lieu, Wyland, Berryhill, Block, Corbett, Galgiani, Hill,
Torres
NO VOTE RECORDED: Hernandez
SENATE HEALTH COMMITTEE : 8-0, 6/25/14
AYES: Hernandez, Morrell, Beall, De León, DeSaulnier, Evans,
Monning, Nielsen
NO VOTE RECORDED: Wolk
SENATE APPROPRIATIONS COMMITTEE : 6-0, 8/14/14
AYES: De León, Gaines, Hill, Lara, Padilla, Steinberg
NO VOTE RECORDED: Walters
ASSEMBLY FLOOR : 76-0, 1/27/14 - See last page for vote
SUBJECT : Dental professionals: teledentistry under Medi-Cal
SOURCE : Author
DIGEST : This bill authorizes certain allied dental
professionals to perform additional activities using telehealth;
extends the duration of the Health Workforce Pilot Project No.
172 (HWPP No. 172) until January 1, 2016; and prohibits Medi-Cal
from requiring a face-to-face visit between a patient and
CONTINUED
AB 1174
Page
2
provider before allowing for teledentistry services.
ANALYSIS :
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 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
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.
RDAEFs
1.Permits DBC to license as an RDAEF a person who submits
satisfactory written evidence to DBC all the following
eligibility requirements:
A. Current licensure as a registered dental assistant (RDA)
or completion of the requirements for licensure as an RDA;
CONTINUED
AB 1174
Page
3
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:
(1) An extended functions postsecondary program
approved by DBC in specified procedures; or
(2) An extended functions postsecondary program
approved by DBC to teach the duties that RDAEFs were
allowed to perform pursuant to DBC regulations prior to
January 1, 2010, and a course approved by DBC in
specified procedures.
A. Passage of a written examination and a clinical or
practical examination administered by DBC or by a
DBC-approved extended functions program.
Dental Hygiene Committee of California (DHCC) and RDHs
1.Establishes within the jurisdiction of DBC a DHCC, and states
legislative intent to permit the full utilization of RDHs,
registered dental hygienists in alternative practice (RDHAPs),
and registered dental hygienists in extended functions
(RDHEFs) in order to meet the dental care needs of all of the
state's citizens. Requires DHCC to perform specified
functions, including making recommendations to DBC regarding
dental hygiene scope of practice issues.
2.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.
3.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
CONTINUED
AB 1174
Page
4
facility during the performance of those procedures; and
"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.
4.Permits, unless otherwise specified, an RDH to perform any
procedure or provide any service within the scope of his/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.
5.Requires DHCC to establish by resolution the amount of the
fees that relate to the licensing of RDHs, RDHAPs, and RDHEFs.
Limits the fee for each review of courses required for
licensure that are not accredited to $300. Limits those fees
to the reasonable regulatory cost incurred by DHCC.
HWPPs
6.Permits OSHPD to designate experimental health workforce
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.
7.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: store and forward
8.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
CONTINUED
AB 1174
Page
5
reimbursement policies developed by the Department of Health
Care Services (DHCS).
Telehealth
9.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
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 an RDAEF, RDH, or 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 RDAEFs, RDHs, or RDHAPs.
4.Allows an RDAEF and RDH, using telehealth for the purpose of
communication with the supervising dentist, to:
CONTINUED
AB 1174
Page
6
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 RDAEFs, this expansion to
a dental office setting and to public health settings.
Defines public health settings to include, but not be
limited to, schools, head start and preschool programs, and
community clinics.
B. Place protective restorations, identified as interim
therapeutic restorations (ITRs), and defined as a direct
provisional restoration placed to stabilize the tooth until
a licensed dentist diagnoses the need for further
definitive treatment. States that 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 plan by a dentist in either of the following
settings:
(1) In a dental office setting, under the direct or
general supervision of a dentist as determined by the
dentist for an RDAEF, and under general supervision for
an RDH; and
(2) In public health settings, including, but not
limited to, schools, head start and preschool programs,
and community clinics.
1.Permits an RDHAP to provide the telehealth duty (determining
which radiographs to perform and placing ITRs) in residential
facilities, and other institutions, schools, and residences of
the homebound, upon completion of specified courses.
2.Permits the additional functions to be performed by an 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.
CONTINUED
AB 1174
Page
7
3.Requires DBC, no later than January 1, 2018, to promulgate
regulations establishing criteria for approval of courses of
instruction for the procedures under this bill using the
competency-based training protocols established by HWPP No.
172 through OSHPD. Requires DBC, in developing regulations
and any subsequent proposed amendments to promulgated
regulations, to provide to DHCC proposed regulations related
to the curriculum required for ITR.
4.Requires a program, in addition to the instructional
components described in this bill, to contain both of the
following 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.
1.Permits DBC to issue a permit to an RDAEF to provide the
duties specified in this bill after DBC has determined the
RDAEF has completed the required coursework.
2.Limits the fee, for each review or approval of course
requirements for licensure or procedures that require
additional training that are not accredited to $750, for RDHs,
RDHAPs, and RDHEFs.
3.Requires OSHPD to extend the duration of 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 on January
1, 2016.
4.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.
Defines "teledentistry" as an asynchronous transmission of
CONTINUED
AB 1174
Page
8
dental information to be reviewed at a later time by a dentist
at the distant site without the patient being present in real
time.
Background
Oral health statistics . According to an article published in
the Journal of the California Dental Association (JCDA, 2012),
"The Virtual Dental Home: Bringing Oral Health to Vulnerable
and Underserved Populations," the traditional office and
clinic-based oral health delivery system is failing to reach a
large and increasing segment of the population. The JCDA
article indicates that, in California, oral health disparities
are more severe than the national average, particularly among
low-income and disabled populations. Almost one-quarter of
children in California have never seen a dentist, and
approximately 40% of California's black, Latino, and Asian
preschoolers and approximately 65% of elementary school children
in these groups need dental care. In 2011, only 22% of the
total number of people eligible for Medi-Cal dental services
received any service, a decrease of 8% from 2009. A decrease
was expected for adults since most adult dental benefits were
eliminated in 2009. However, there was also a decrease for
children. In 2011, only 27% of eligible children received any
dental service compared to 34% in 2009. In California,
approximately 6.3 million children, or two-thirds of all
children in the state, suffer needlessly from poor oral health
by the time they reach the third grade.
Virtual dental homes (VDHs) . VDHs 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. The
VDH utilizes technology to link practitioners in the community
with dentists at remote office sites.
Equipped with portable imaging equipment and an Internet-based
dental record system, an RDA, RDAEF, or RDH collects electronic
dental records such as X-rays, photographs, charts of dental
findings, dental and medical histories and uploads the
information to a secure Internet 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
CONTINUED
AB 1174
Page
9
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.
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,
thus creating a true community-based dental home.
HWPP No. 172 . The HWPP at OSHPD permits temporary legal waivers
of certain practice restrictions or educational requirements to
test expanded roles and accelerated training programs for health
care professionals. In December 2010, OSHPD approved HWPP No.
172 which allowed RDAs and RDHs to perform an expanded scope of
practice. The project has been extended twice, with the second
extension running from December 1, 2012, to December 1, 2013.
Funding for HWPP No. 172 comes from various sources including
the California Health Care Foundation (CHCF), American Dental
Hygiene Association, American Dental Association, Paradise
Foundation, and Verizon Foundation. Evaluation of the project
is also funded by CHCF. The long-term objective of the project
is to facilitate the development of new models of care designed
to improve the oral health status of underserved populations.
HWPP No. 172 is a project at the University of Pacific, School
of Dentistry which creates a VDH and is testing a concept where
patients interact with RDAs and RDHs after a telehealth
consultation with a collaborating dentist who makes diagnostic
and treatment decisions and determines the best location for
CONTINUED
AB 1174
Page
10
treatment. There are nine sites currently operating this model
of care in California. Preventive and early intervention care
is being provided in the community (two elementary schools in
Sacramento and San Diego counties, a consortium of Head Start
centers in San Francisco and San Diego, residential facilities
associated with three regional centers for persons with
developmental disabilities, four long-term care facilities, and
one community clinic). Patients with advanced disease requiring
the service of a dentist are being referred to dental offices
and clinics.
A policy brief describing the model and the results of the
current project indicates that under HWPP No. 172, allied dental
personnel completed the following types of procedures:
collecting patient information (including medical and dental
history, consent forms, and caries risk assessment); charting
pre-existing conditions; taking digital radiographs; taking
digital intra and extra-oral photographs; prophylaxis; fluoride
varnish; sealants; ITRs; patient, parent, and staff oral health
education; nutritional counseling; oral hygiene instructions;
case management; referrals; and communicating with collaborating
dentists. As of March 31, 2013, a total of 1,494 patients have
been seen: Head Start centers (797); elementary schools (212);
long-term care facilities (176); multifunction community centers
(197); and, regional centers (112). The policy brief also
indicates that 110 ITRs were placed during the training phase of
the program in addition to the 295 placed in the utilization
phase for a total of 405.
ITR . According to the American Academy of Pediatric Dentistry,
an ITR may be used to restore and prevent further
decalcification and caries in young patients, uncooperative
patients, patients with special health care needs or when
traditional cavity preparation and/or placement of traditional
dental restorations are not feasible and need to be postponed.
Additionally, an ITR may be used for step-wise excavation in
children with multiple open carious lesions prior to definitive
restoration of the teeth. The use of an ITR has been shown to
reduce the levels of cariogenic oral bacteria (e.g., mutans
streptococci, lactobacilli) in the oral cavity. The ITR
procedure involves removal of caries using hand or slow speed
rotary instruments with caution not to expose the pulp. Leakage
of the restoration can be minimized with maximum caries removal
from the periphery of the lesion. Following preparation, the
CONTINUED
AB 1174
Page
11
tooth is restored with an adhesive restorative material such as
self-setting or resin-modified glass ionomer cement. ITR has
the greatest success when applied to single surface or small two
surface restorations. Inadequate cavity preparation with
subsequent lack of retention and insufficient bulk can lead to
failure. Follow-up care with topical fluorides and oral hygiene
instruction may improve the treatment outcome in high
caries-risk dental populations.
Medi-Cal . The VDH treatment model is currently not reimbursable
by Medi-Cal because existing law requires face-to-face contact
between a health care provider and a patient. This bill deletes
that provision and allows practitioners to receive payment for
these services. This bill also provides patient protections by
ensuring contact with the remote dentist upon request.
Comments
According to the author's office, this bill will codify the VDH,
as tested through an HWPP since 2010. This bill allows the VDH
model to be employed statewide opening up access to dental care
for the state's 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/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.
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: No
According to the Senate Appropriations Committee:
One-time costs of about $50,000 for the development of
regulations and information technology upgrades and ongoing
costs of $200,000 per year for licensing and enforcement by
DBC (State Dentistry Fund).
CONTINUED
AB 1174
Page
12
One-time costs of about $50,000 for the development of
regulations and information technology upgrades and ongoing
costs of $80,000 per year for licensing by DHCC (State Dental
Hygiene Fund).
Minor costs to continue the operation of HWPP No.172 (private
funds).
Unknown impact on Medi-Cal costs for dental procedures
(General Fund and federal funds). Under current practice, the
Medi-Cal program does not provide reimbursement for dental
services provided through telehealth. By specifically
authorizing such reimbursement and making changes to scope of
practice laws that will increase the potential use of
telehealth, this bill will likely increase utilization to some
degree. The size of that impact is unknown.
DBC has indicated that the cost of setting up the required
information technology systems to facilitate dental telehealth
will limit implementation. This may be particularly significant
for the Denti-Cal program, in which reimbursement rates are
generally low. On the other hand, utilization rates in the
Denti-Cal program are very low (in 2011, only 27% of eligible
children received dental care). Therefore, there is significant
scope for increasing utilization of services in the Denti-Cal
program. Finally, it may be the case that more early
intervention will reduce long-run costs to provide dental care
in the Medi-Cal program.
SUPPORT : (Verified 8/13/14)
Age Tech West
California Academy of Physician Assistants
California Coverage & Health Initiatives
California Dental Association
California Dental Hygienists' Association
California Primary Care Association
California Society of Pediatric Dentistry
California Telehealth Network
Children Now
Community Clinic Association of Los Angeles
Connecting to Care
Delta Dental of California
CONTINUED
AB 1174
Page
13
First 5 Los Angeles
First 5 Yolo Children and Families Commission
Liberty Dental Plan of California
Los Angeles Area Chamber of Commerce
Los Angeles Trust for Children's Health
Los Angeles Unified School District
Maternal and Child Health Access
Mendocino Community Health Clinic, Inc.
Peninsula Family Service
Roseland Pediatrics
Rural County Representatives of California
Shasta Community Health Center
The Children's Partnership
The L.A. Trust
The Pew Charitable Trusts Children's Dental Campaign
Union of American Physicians and Dentists
United Ways of California
Worksite Wellness L.A.
OPPOSITION : (Verified 8/13/14)
Dental Hygiene Committee of California
Union of American Physicians and Dentists
ARGUMENTS IN SUPPORT : Children's health groups state that
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.
ARGUMENTS IN OPPOSITION : No letters on file.
ASSEMBLY FLOOR : 76-0, 1/27/14
AYES: Achadjian, Alejo, Allen, Ammiano, Atkins, Bigelow, Bloom,
Bocanegra, Bonilla, Bonta, Bradford, Brown, Buchanan, Ian
CONTINUED
AB 1174
Page
14
Calderon, Campos, Chau, Chávez, Chesbro, Conway, Cooley,
Dababneh, Dahle, Daly, Dickinson, Eggman, Fong, Fox, Frazier,
Beth Gaines, Garcia, Gatto, Gomez, Gonzalez, Gordon, Gorell,
Gray, Grove, Hagman, Hall, Harkey, Roger Hernández, Holden,
Jones, Jones-Sawyer, Levine, Linder, Lowenthal, Maienschein,
Mansoor, Medina, Melendez, Morrell, Mullin, Muratsuchi,
Nazarian, Olsen,
Pan, Patterson, Perea, Quirk, Quirk-Silva, Rendon,
Ridley-Thomas, Rodriguez, Salas, Skinner, Stone, Ting, Wagner,
Waldron, Weber, Wieckowski, Wilk, Williams, Yamada, John A.
Pérez
NO VOTE RECORDED: Donnelly, Logue, Nestande, V. Manuel Pérez
MW:e 8/16/14 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****
CONTINUED