BILL ANALYSIS Ó
AB 1174
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB 1174 (Bocanegra and Logue)
As Amended August 22, 2014
Majority vote
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|ASSEMBLY: |76-0 |(January 27, |SENATE: |36-0 |(August 27, |
| | |2014) | | |2014) |
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Original Committee Reference: B., P. & C.P.
SUMMARY : Expands the scope of practice for a 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 RDAEF licensed on or after January 1, 2010, or
who completes a course in specified procedures approved by the
Dental Board of California (DBC) and passes the same
examination as someone licensed on or after January 1, 2010,
and an RDH to perform the following additional duties:
a) Determine, following protocols established by the
supervising dentist, 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; and
b) Place protective restorations, after the diagnosis,
treatment plan, and instruction to perform the procedure is
provided by a dentist.
2)Identifies a protective restoration as an interim therapeutic
restorations (ITR), which is defined as a direct provisional
restoration placed to stabilize the tooth until a licensed
dentist diagnoses the need for further definitive treatment
3)Authorizes the performance of those duties in a dental office
setting or public health setting using telehealth, and
pursuant to the order, control, and full professional
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responsibility of a supervising dentist, as specified.
4)Authorizes an RDHAP to perform these additional duties in
residences of the homebound, schools, and residential
facilities and other institutions, and to place protective
restorations only under the general supervision of a dentist.
5)Provides that ITRs consist 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, without the use of local
anesthesia, after diagnosis and treatment plan by a dentist.
6)Requires an RDAEF and RDH, in order to perform the functions
described above, to complete a program that includes training
in performing those functions or to provide evidence
satisfactory of having a DBC- or Dental Hygiene Committee of
California (DHCC)-approved course in those functions.
7)Requires DBC and DHCC to adopt, by January 1, 2018,
regulations to establish requirements for courses of
instruction for these procedures using the competency-based
training protocols established by HWPP.
8)Requires DBC to submit to DHCC proposed regulatory language
for approval of courses for instruction for ITRs for purposes
of promulgating regulations for RDHs and RDHAPs, and requires
DBC to submit any subsequent amendments to those regulations
to DHCC.
9)Requires DHCC to use the curriculum submitted by DBC to adopt
regulatory language for approval of courses of instruction for
ITRs, and requires any subsequent amendments to those
regulations to be agreed on by DBC and DHCC.
10)Requires, until January 1, 2018, a program to perform these
duties 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.
11)Deems, until January 1, 2018, an RDAEF or RDH who has
completed the prescribed training in the HWPP to have
satisfied the requirement for completion of a DBC- or
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DHC-approved course.
12)Requires DBC to issue a permit to an RDAEF who files a
completed application, including the fee, to provide these
duties after it has determined he or she has completed the
required coursework.
13)For RDHs and RDHAPs, increases to $750 the fee for each
review or approval of course requirements for licensure or
procedures that require additional training that are not
accredited by a DHCC-approved agency.
14)Until January 1, 2016, requires the Office of Statewide
Health Planning and Development (OSHPD) to extend the duration
of the HWPP 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 the HWPP.
15)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.
16)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 patient being present in real
time.
17)Provides that it is not unprofessional conduct for a dentist
to require or permit, prior to any examination of the patient,
an RDAEF, RDH, or 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, as defined, under these provisions.
18)Provides that a dentist is not required to review patient
records or make a diagnosis using telehealth.
19)Makes it the responsibility of the authorizing dentist, if
dental treatment is provided to a patient pursuant to the
diagnosis and treatment plan authorized by a supervising
dentist at a location other than the dentist's practice
location, that the patient, or the patient's representative,
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receive written notification that the care was provided at the
direction of the authorizing dentist and that includes the
authorizing dentist's name, practice location address, and
telephone number, except as specified.
20)Prohibits a dentist from concurrently supervising more than a
total of five RDAEFs, RDHs, or RDHAPs under these provisions.
The Senate amendments :
1)Delete provisions that authorized a registered dental
assistant (RDA) to determine which radiographs to perform if
he or she completed a DBC-approved educational program in
those duties.
2)Delete provisions that require an RDHAP to complete specified
coursework in order to determine which radiographs to perform
or place protective restorations.
3)Delete provisions that define the following terms: "clinical
instruction," "course," "didactic instruction," "interim
therapeutic restoration," "laboratory instruction,"
"preclinical instruction," and "program."
4)Delete the requirement that a program or course required to
choose radiographs to contain specified instructional
components, including didactic and clinical instruction,
laboratory instruction, and examinations.
5)Require DBC and DHCC to promulgate, by January 1, 2018,
regulations to establish requirements for courses of
instruction for the additional procedures using the
competency-based training protocols established by the HWPP.
6)Require DBC to submit to DHCC proposed regulatory language for
approval of courses for instruction for ITRs for purposes of
promulgating regulations for RDHs and RDHAPs, and requires DBC
to submit any subsequent amendments to those regulations to
DHCC.
7)Requires DHCC to use the curriculum submitted by DBC to adopt
regulatory language for approval of courses of instruction for
ITRs, and requires any subsequent amendments to those
regulations to be agreed on by DBC and DHCC.
AB 1174
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8)Require DBC to issue a permit to an RDAEF who files a
completed application, including the fee, to provide these
duties after it has determined he or she has completed the
required coursework.
9)For RDHs and RDHAPs, increases to $750 the fee for each review
or approval of course requirements for licensure or procedures
that require additional training that are not accredited by a
DHCC-approved agency.
10)Until January 1, 2016, require OSHPD to extend the duration
of the HWPP 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 the HWPP.
11)Provides that it is not unprofessional conduct for a dentist
to require or permit, prior to any examination of the patient,
an RDAEF, RDH, or 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, as defined, under these provisions.
12)Provides that a dentist is not required to review patient
records or make a diagnosis using telehealth.
13)Make it the responsibility of the authorizing dentist, if
dental treatment is provided to a patient pursuant to the
diagnosis and treatment plan authorized by a supervising
dentist at a location other than the dentist's practice
location, 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 includes the
authorizing dentist's name, practice location address, and
telephone number, except as specified.
14)Prohibit a dentist from concurrently supervising more than a
total of five RDAEFs, RDHs, or RDHAPs under these provisions.
15)Make conforming changes.
FISCAL EFFECT : According to the Senate Appropriations
Committee:
1)One-time costs of about $50,000 for the development of
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regulations and information technology upgrades and ongoing
costs of $200,000 per year for licensing and enforcement by
the Dental Board of California (State Dentistry Fund).
2)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 the Dental Hygiene
Committee of California (State Dental Hygiene Fund).
3)Minor costs to continue the operation of Health Workforce
Pilot Project #172 (private funds).
4)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.
The Department 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.
COMMENTS :
1)Purpose of this bill. This bill expands the scope of practice
for 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 a
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
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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 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.
In 2010, 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
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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.
The project has been extended through November 30, 2014.
4)Virtual Dental Homes. 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. It 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, 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
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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.
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: 0005518