BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AB 648
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|AUTHOR: |Low |
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|VERSION: |June 11, 2015 |
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|HEARING DATE: |June 24, 2015 | | |
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|CONSULTANT: |Teri Boughton |
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SUBJECT : Community-based services: Virtual Dental Home program.
SUMMARY : Establishes the Virtual Dental Home (VDH) grant program at the
California Department of Public Health and appropriates $4
million from the General Fund to expand the VDH model of
community-based delivery of dental care to California residents.
Existing law:
1)Establishes the Dental Practice Act (DPA), administered by the
Dental Board of California (DBC).
2)Permits the DBC to license as a registered dental assistant in
extended functions (RDAEF) a person who submits satisfactory
written evidence of specified eligibility requirements, such
as a current licensure as a registered dental assistant (RDA)
or completion of the requirements for licensure as an RDA;
successful completion of a DBC-approved course in the
application of pit and fissure sealants; successful completion
of DBA-approved extended functions post-secondary programs, as
specified; and, passage of a written examination and a
clinical or practical examination administered by the DBC or
by a DBC-approved extended functions program.
3)Establishes within the jurisdiction of DBC a Dental Hygiene
Committee of California (DHCC), and states legislative intent
to permit the full utilization of RDAs, 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.
AB 648 (Low) Page 2 of ?
4)Permits the Office of Statewide Health Planning and
Development (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.
5)Requires, no later than January 1, 2018, regulations to be
promulgated related to establishing criteria for approval of
courses of instruction for the procedures 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 DHCC proposed regulations related to the
curriculum required for protective restorations.
6)Requires OSHPD to extend 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.
This bill:
1)Establishes the VDH grant program, administered by the dentist
of the Oral Health Unit of the State Department of Public
Health (DPH), to expand the VDH model of community-based
delivery of dental care to California residents.
2)Requires the grant program to facilitate, coordinate, and
encourage development and expansion of the delivery of dental
health services through the use of the VDH model by providing
grants to:
a) Develop training modules and Web-based
technical assistance;
b) Establish community-based learning
collaboratives;
AB 648 (Low) Page 3 of ?
c) Fund essential VDH technology and equipment;
and,
d) Develop and fund other services, as determined
by the grant administrator, as required by this bill.
3)Authorizes the program administrator to seek additional
private or public funds to expand access to the VDH program.
4)Requires the VDH program to be focused on providing needed
services in geographic areas of highest need, as determined by
the program administrator.
5)Authorizes the program administrator to grant funds directly
to the public and private educational institutions or
nonprofit entities as required to meet the requirements of
this bill.
6)Appropriates $4 million from the General Fund (GF) to DPH for
purposes of the VDH program.
FISCAL
EFFECT : According to the Assembly Appropriations Committee:
1)$4 million GF to DPH to establish the program. DPH would
scale the effort, including number of sites, individuals
trained, and individuals served, to the available funding.
Supporters, who are familiar with the VDH model, project the
funding could be used to support training and equipment in 20
communities over a three-year grant period.
2)To the extent this model is successful in promoting access to
preventive and diagnostic dental services and more children
are able to receive such services through its widespread
adoption, there could be commensurate cost pressure on
Medi-Cal dental services to reimburse for additional services
(GF/federal funds). However, any increased costs would likely
be offset to some extent by reductions in emergency dental
procedures or complications from untreated dental disease.
The magnitude and likelihood of such costs or savings is
unknown.
AB 648 (Low) Page 4 of ?
PRIOR
VOTES :
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|Assembly Floor: |79 - 0 |
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|Assembly Appropriations Committee: |17 - 0 |
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|Assembly Health Committee: |19 - 0 |
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COMMENTS :
1)Author's statement. According to the author, in 2014, the VDH
pilot project was made permanent as a sustainable and scalable
model for delivering dental care in California. The project
demonstrated that early dental disease prevention can be
provided safely and effectively in community-based sites by
allied dental team members who are connected to a dentist at
an off-site location via "teledentisty." Patients served by
VDH systems have access to comprehensive dental care,
including diagnosis, treatment planning and restorative care,
as well as other complex care as needed. Through the project,
nearly 3,000 patients have been seen at more than 50 sites
around California with overwhelmingly positive results and
approximately two-thirds of the patients seen were able to
receive the care they needed at the community site. Good
dental health is critical to a child's ability to grow up
healthy. Yet, tooth decay is the most common chronic disease
and unmet health care need of children in California.
California has identified 341 Dental Health Professional
Shortage Areas (DHPSA), areas so designated because the
dentist-to-population ratio is below the threshold set by the
federal government. By their very nature, DHPSA's identify
areas throughout the state where patients frequently
experience barriers to comprehensive dental care. This bill
is an innovative and cost-effective model for providing dental
services to the residents of this state who are in need of
receiving dental care.
2)HWPP No. 172 and VDH. The HWPP No. 172 was approved by OSHPD
in December 2010, and patient care with the new HWPP No. 172
duties began in January of 2011. The purpose of the pilot was
to test two new duties to be performed by allied dental
AB 648 (Low) Page 5 of ?
personnel to demonstrate that these duties could be performed
safely and effectively and contribute to the development of a
community-based oral health delivery system using
telehealth-connected teams in a system called the VDH. The
system was designed to reach and improve the oral health of
underserved and vulnerable populations not fully participating
in the current dental care delivery system. HWPP No. 172 was
funded by public and private grants and was sponsored by the
Pacific Center for Special Care at the University of the
Pacific (UOP) School of Dentistry.
The HWPP No. 172 provided dental services to approximately 3,000
patients in 13 California communities, operating at more than
50 sites, including in elementary school-based facilities,
Head Start Preschools, a nursing home, residential care
facilities and a community center. Ninety percent of patients
seen were eligible for Denti-Cal. There were a total of 12
trainees licensed and experienced as RDAs, RDHs, or RDHAPs.
In addition to the allied dental personnel, there were 23
dentists that participated, serving as "collaborating
dentists" in the various community sites.
Under the VDH and HWPP 172, RDA, RDH or RDHAPs use portable
imaging equipment and an internet-based dental record system
to collect electronic dental records such as X-rays,
photographs, charts of dental findings, and dental and medical
histories, and upload 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. As of 4/30/15 there were 2,858 patients seen,
2,083 radiographs taken, and 994 interim therapeutic
restorations placed. All procedures were rated as acceptable
and there were no reports of adverse outcomes. With regard to
patient satisfaction 86% who responded to the survey were very
satisfied with the overall dental care received.
AB 648 (Low) Page 6 of ?
3)Dental Access. According to OSHPD's Health Care Atlas,
approximately five percent of Californians live in a DHPSA;
DHPSAs are Medical Service Study Areas that meet federally
mandated criteria to qualify facilities for benefit programs,
such as loan repayment programs. The designation is based on
the availability of dentists and dental auxiliaries. A July
2010 article published in Health Affairs, indicates, children
in Medicaid, especially Latinos and African Americans,
experience high rates of tooth decay, yet they visit dentists
less often than privately insured children. Even Latino and
African American children with private insurance are less
likely than white children to visit dentists and have longer
intervals between dental visits. Furthermore, Latino and
African American children in Medicaid are more likely than
white children in Medicaid to have longer intervals between
visits. According to a 2008 publication from the California
HealthCare Foundation, the burden of oral disease continues to
fall more heavily on children from poor, minority households.
And despite growing awareness of the lifelong effects of poor
oral care, nearly one quarter of California children have
never been to a dentist, including half of all children under
the age of five.
4)State Audit. The California State Auditor published audit
results in December 2014 of an audit conducted on the
Department of Health Care Services (DHCS) administration of
dental services for children on Medi-Cal which raises issues
with access to services. According to the audit, although the
proportion of children who had at least one dental procedure
performed during the year increased by as much as 1.2
percentage points each year from 2011 to 2013, annual
utilization rates are still lower than those of many other
states. Data from the federal Centers for Medicare and
Medicaid Services (CMS) indicate that nearly 56% of the 5.1
million children enrolled in Medi-Cal in federal fiscal year
2013 (October 1, 2012, through September 30, 2013) did not
receive dental care through the program. The CMS data indicate
that the national average utilization rate was 47.6% and
ranged from a low of 23.7% in Ohio to a high of 63.4% in Texas
for that same federal fiscal year. CMS's data also indicate
that California's utilization rate of 43.9% was the 12th worst
among the states that submitted data. The auditor's review of
DHCS' data for 2011 through 2013 found similar results.
Studies reviewed suggested several reasons for low utilization
rates, including an uneven distribution of dentists nationwide
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and a relatively small number of dentists who participate in
Medicaid.
5)State Budget. SB 75 (Committee on Budget and Fiscal Review)
eliminates the 10% Medi-Cal payment reductions pursuant to AB
97 (Committee on Budget, Chapter 3, Statutes of 2011) for
dental providers effective July 1, 2015. SB 75 is awaiting
action by the Governor.
6)VDH Grant Program. According to a representative of UOP, the
grant funds anticipated in this bill might include funding to
cover the following start-up costs: The equipment and
instrument cost is about $35,000 - $40,000 as a one-time
expense; there are supported salaries, decreasing over time,
during the ramp up to a fully billable and sustainable model
at a total of around $70,000 - $80,000, spread over 3 years;
and, the costs for site selection and enrollment, program
planning, system training, procedure training, monitoring,
technical assistance and evaluation could be expected to be
around a total of $80,000 - $90,000 spread over 3 years.
7)Related legislation. AB 502 (Chau) would require insurance
companies to reimburse registered RDHAPs for dental hygiene
care legally provided and covered by insurance, and clarifies
that RDHAPs are authorized to establish corporations.
8)Prior legislation. AB 1174 (Bocanegra, Chapter 662, Statutes
of 2014), expands the scope of practice for a RDAEF, RDH, and
RDHAP to better enable the practice of teledentistry in
accordance with the findings of a HWPP 172, and authorizes
Medi-Cal payments for teledentistry services provided to
individuals participating in the Medi-Cal program.
9)Support. Proponents support this bill because it would
provide upfront investment necessary for the VDH to become a
sustainable and scalable model for dental care delivery.
Without an upfront investment in training, equipment,
technical assistance, and other support that providers need to
get started, the system will not be able to develop a critical
mass needed to spread statewide and truly be integrated into
California's dental delivery system. The Children's
Partnership cosponsors this bill to ensure the VDH - an
innovative and cost-effective system for providing dental care
to California's most vulnerable children and adults in
community settings- can spread across the state. The
AB 648 (Low) Page 8 of ?
California Dental Association also cosponsors this bill,
because the VDH model of dental care uses technology to
connect allied dental team members located at community sites
with dentists in offices or clinics, facilitating the
provision of comprehensive dental care to underserved children
and adults.
10)Suggested Amendment. The committee may wish to require an
evaluation of the grant program in order to measure the extent
to which it meets the stated objectives. Evaluation
provisions could include the following:
(g) The program administrator shall develop a method for
evaluating each grantee's progress toward meeting the
objective to expand the virtual dental home model of
community-based delivery of dental care to residents in
geographic areas of highest need. Upon completion of the
grantee evaluations, the program administrator shall post a
grant program evaluation summary associated with expenditure
of the General Fund appropriation contained in this bill.
SUPPORT AND OPPOSITION :
Support: California Dental Association (co-sponsor)
Children's Partnership (co-sponsor)
Alameda County Board of Supervisors
Alameda County Developmental Disabilities Council
California Chronic Care Coalition
California Dental Hygienists' Association
California Society of Pediatric Dentistry
Children Now
Community Clinic Association of Los Angeles County
Community Health Systems, Inc.
Delta Dental
Dental Hygiene Committee of California
East Bay Developmental Disabilities Legislative
Coalition
First 5 Sonoma County
Liberty Dental Plan of California, Inc.
Maternal and Child Health Access
Mendocino Community Health Clinic, Inc.
Neighborhood Mobile Dental Van Prevention Program
Shasta Community Health Center
State Council on Developmental Disabilities
United Ways of California
AB 648 (Low) Page 9 of ?
Venice Family Clinic
2 individuals
Oppose: None received
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