BILL ANALYSIS �
SB 694
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Date of Hearing: June 26, 2012
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
SB 694 (Padilla) - As Amended: June 20, 2012
SENATE VOTE : 34-2
SUBJECT : Dental care.
SUMMARY : Establishes the Statewide Office of Oral Health
(Office) within the Department of Public Health (DPH) to consist
of a licensed dentist to serve as Dental Director and authorizes
the Dental Director, or the Secretary of the California Health
and Human Services Agency (Secretary of CHHSA) or his or her
designee, to design and implement a study to assess the safety,
quality, cost-effectiveness, and patient satisfaction of
expanded dental procedures performed by dental care providers,
as specified. Specifically, this bill :
1)Establishes a Dental Director within the Office who is a
licensed dentist.
2)Provides that the Dental Director and his or her staff shall
have all, but are not limited to, the following
responsibilities:
a) Advance and protect the oral health of all Californians;
b) Develop a comprehensive and sustainable state oral
health action plan to address the State's unmet oral health
needs;
c) Encourage private and public collaboration to meet the
oral health needs of Californians;
d) Secure funds to support infrastructure, and State and
local programs;
e) Promote evidence-based approaches to increase oral
health literacy; and,
f) Establish a system for surveillance and oral health
reporting.
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3)Authorizes the State to accept public and private funds for
the purpose of implementing this bill.
4)Provides that no General Fund (GF) moneys shall be used for
the Office, and moneys to fund the office shall be secured
from other public or private sources. Requires the Department
of Finance (DOF) on January 1, 2014, and annually thereafter,
to make a determination regarding the funding status of the
Office. Provides that moneys needed to sufficiently fund and
commence the study specified in item 9) below shall not be
considered for purposes of determining the funding status of
the Office, as specified.
5)Provides that the Office shall be established only after a
determination has been made by the DOF that public or private
funds in an amount sufficient to fully support the activities
of the Office, including staffing the Office, have been
deposited with the State. States that if the DOF makes a
determination that sufficient funding has been secured to
establish the office, it shall file a written statement with
the Secretary of the Senate, the Chief Clerk of the Assembly,
and the Legislative Counsel memorializing that this
determination has been made.
6)Indicates that if the Office is established, it shall assume
responsibility for identifying and securing funding sources in
order to maintain the functions of the Office.
7)Provides that if the DOF makes a determination that the Office
has not secured sustainable funding sources, as specified, the
DOF shall file a written statement with the Secretary of the
Senate, the Chief Clerk of the Assembly, and the Legislative
Counsel memorializing that this determination has been made.
8)Provides that items1) through 7) above shall become
inoperative on January 1, 2016.
9)Authorizes the Dental Director or, in the absence of a Dental
Director, the Secretary of CHHSA or his or her designee, to
design and implement a scientifically rigorous study to assess
the safety, quality, cost-effectiveness, and patient
satisfaction of expanded dental procedures performed by dental
care providers for the purpose of informing future decisions
about how to meet the State's unmet oral health need for
California's children. Requires the research parameters of
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the study to include public health settings, multiple models
of dentist supervision, multiple pathways of education and
training, and multiple dental providers. Requires that
procedures performed during the study be performed only by
dental care providers within the confines of a
university-based study.
10)Requires the Dental Director or, in the absence of a Dental
Director, the Secretary of California Health and Human
Services or his or her designee to do all of the following:
a) Convene an advisory group on study design and
implementation. Requires the advisory group to be
comprised of representatives of all dental practices,
including traditional and nontraditional, as well as
nondentists and consumer advocates.
b) Provide input regarding study design and implementation,
receive all study data and reports, and develop a report
and recommendations to be submitted to the Legislature
based on the study findings.
c) Consult with the Legislative Analyst's Office in
designing the study and selecting any contractors.
11)Limits the study to a dentist licensed by the Dental Board of
California (DBC), and at least two of each of the following
dental care providers:
a) A registered dental hygienist who is educated in a
limited number of additional dental procedures, as
specified.
b) A registered dental assistant in extended function who
is educated in a limited number of additional dental
procedures, as specified.
12)Limits the dental procedures that may be examined to the
following:
a) Administration of local anesthesia;
b) Tooth preparation for, and the placement and finishing
of, direct restorations;
c) Placement of interim therapeutic restorations;
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d) Stainless steel crown placement;
e) Therapeutic pulpotomy;
f) Pulp cap placement, direct and indirect; and,
g) Extraction of primary teeth.
13)Requires the study to examine and compare the procedures
described in item 12) above as performed under the following
types of supervision:
a) Direct supervision, as defined;
b) General supervision, as defined; and,
c) Remote supervision by a dentist where the supervising
dentist is not onsite while a dental care provider is
practicing, as authorized, and shall be facilitated by
"standing orders" as an agreement between the dental care
provider and supervising dentist. Prohibits the dental
care provider from performing duties beyond what is agreed
upon in the standing orders. Provides that remote
supervision may:
i) Incorporate the use of technology, such as
telehealth, to facilitate dentists providing remote
supervision to the provider, where the provider does not
have to be in the same location as the supervising
dentist;
ii) Include a mechanism for the provider to seek and
receive additional professional advice in a timely manner
as needed; and,
iii) Include a mechanism for the provider to make
referrals to a qualified dentist as needed.
14)Requires the study to examine dental care providers in public
health settings that represent the racial, ethnic, urban, and
rural diversity of California's child population. Indicates
that settings may include, but not be limited to, community
health clinics, Head Start, and schools with greater than 50%
participation in the federal free and reduced-price lunch
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program.
15)Requires the study to be conducted through a dental school at
an institution of higher learning within the State.
16)Provides that no GF moneys shall be used to implement the
study provisions of this bill. Requires moneys to fund the
study, including analysis and findings, and all procedures
administered by dental care providers during the study, to be
secured from other public or private sources. Indicates that
no one provider group or interest group may provide more than
half the private funding for the study.
17)Makes the provisions relating to the study inoperative by
January 1, 2014 if the study is not sufficiently funded and
commenced by that date.
18)Sunsets the provisions of this bill on January 1, 2017,
unless a later enacted statute, enacted before January 1, 2017
deletes or extends that date.
19)Provides that the current Oral Health Program (Oral Health
Unit) within DPH shall become inoperative on the date that the
DOF memorializes in writing, as specified, that sufficient
funds have been deposited with the state to establish the
Office, and shall become operative again on the date that DOF
memorializes in writing, as specified, that the Office has not
secured sustainable funding sources to maintain the activities
of the Office, or on January 1, 2016, whichever occurs first.
20)Finds and declares that to address unmet dental needs, a
comprehensive coordinated dental strategy is necessary, at the
foundation of which is a strong state oral health
infrastructure to coordinate essential public dental health
functions, including assessing need and capacity to address
the need.
21)Finds and declares that as part of a comprehensive integrated
system of dental care, with the dentist as the head of that
system, additional dental care providers who provide basic
preventive and restorative oral health care to underserved
children, located at or near where children live or go to
school, may have the potential to reduce the oral health
disease burden in the population most in need.
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EXISTING LAW :
1)Requires DPH to maintain a dental program to do specified
functions, including but not limited to, the following:
a) Develop comprehensive dental health plans within the
framework of the State Plan for Health to maximize
utilization of all resources;
b) Provide the consultation necessary to coordinate
federal, state, county, and city agency programs concerned
with dental health;
c) Encourage, support, and augment the efforts of city and
county health departments in the implementation of a dental
health component in their program plans;
d) Provide evaluation of these programs in terms of
preventive services; and,
e) Provide consultation and program information to the
health professions, health professional educational
institutions, and volunteer agencies.
2)Requires a pupil attending a public school while in
kindergarten or first grade to present proof by May 31st of
each year of having received an oral health assessment by a
licensed dentist or other licensed or registered dental health
professional no earlier than 12 months prior to the date of
the initial enrollment.
3)Establishes the Office of Statewide Health Planning and
Development (OSHPD) to, among other functions, collect data
and disseminate information about California's health care
infrastructure, promote equitable distribution of health care
outcomes, and publish information about health care outcomes.
Establishes within OSHPD the Health Workforce Pilot Projects
Program (HWPP) 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.
4)Establishes the DBC to license and regulate the practice of
dentistry.
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5)Establishes functions for dental hygienist, and various
categories of registered dental assistants.
6)Defines, under the Dental Practice Act the following:
a) Direct Supervision means 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 procedures.
b) General Supervision means the supervision of dental
procedures based on instruction given by a licensed dentist
who is not required to be physically present in the
treatment facility during the performance of procedures.
7)Establishes the Patient Protection and Affordable Care Act
(ACA), which imposes various requirements, some of which take
effect on January 1, 2014, on states, insurance carriers,
employers, and individuals to expand health care coverage.
Establishes essential health benefits which include pediatric
oral care.
8)Establishes the California Health Benefit Exchange, pursuant
to the ACA, to facilitate the purchase of qualified health
plans by qualified individuals and qualified small employers
by January 1, 2014.
FISCAL EFFECT : According to the Senate Appropriations
Committee:
Fiscal Impact (in thousands)
Major Provisions 2012-13 2013-14 2014-15 Fund
Creation of new Statewide Office of Oral Health
- personnel Up to $1,000 initially, up to $500
ongoing Private/
- information technology system Up to $2,000 one time,
minor ongoing Federal
Study of dental procedures $100 $100 Private
Increase in Unknown, potentially
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significantGeneral/
Denti-Cal Benefits utilization cost
increase annually Federal
COMMENTS :
1)PURPOSE OF THIS BILL . The Children's Partnership is the
sponsor of this bill. According to the author, this bill is
intended to address the dental health access dilemma in
California, especially its impact on children. Tooth decay is
the most common chronic disease and unmet health care need of
children in California, and about 71% of California's children
experience tooth decay by the time they reach the third grade.
Additionally, about one million children live in federal
dental health professional shortage areas or areas where there
are shortages of dental providers. The access problem is only
expected to get worse with the implementation of the ACA as
approximately 1.2 million additional children are expected to
gain dental coverage over time, leading to an even greater
mismatch between the number and location of available
providers and their ability to provide services for the
increasing number of children needing dental care. To address
unmet need, a comprehensive solution is necessary. As part of
this solution, we must study innovative policies to determine
the best way to bring basic oral health care to underserved
children in California. The comprehensive solution must also
be based on State oral health leadership that can draw down
federal dollars and that can coordinate essential dental
public health functions, including assessing need and capacity
to address that need.
2)BACKGROUND .
a) Dental Health Needs of Children . A 2008 report by the
University of California, Los Angeles (UCLA) Center for
Health Policy Research indicates that nearly one-third of
young children 11 years of age or younger have never
visited a dental provider in more than a year. According
to Children NOW, common problems such as tooth decay become
debilitating for children when left untreated because it is
progressive and can undermine long-term health, educational
achievements, self-image, and overall success. For every
dollar spent on preventive oral health care, as much as $50
is saved on restorative and emergency oral health
procedures. Preventable oral health problems in children
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are also a considerable cost to the education system. In
California, students miss an estimated 874,000 school days
annually due to dental problems. These absences cost local
school districts approximately $28.8 million. California's
poor and low-income children, in particular, lack needed
access to quality oral health care. For example, only 59%
of children covered by Healthy Families (California's
Children's Health Insurance Program) visit a dentist each
year. African American and Latino children access dental
services less frequently than white children, and in 13 of
California's 58 counties, no dentists accept Medi-Cal
affecting access for low-income children.
b) Federal Health Care Reform. On March 23, 2010,
President Obama signed the ACA, Public Law (P. L.) 111-148,
as amended by the Health Care and Education Reconciliation
Act of 2010, P. L. 111-152. It is estimated that 4.7
million California children and adults who were uninsured
during some part of 2009 will be eligible for health
coverage under the ACA. Among its many provisions, the
ACA:
i) Requires that insurance plans offered under the
Exchange include oral care for children;
ii) Expands school-based sealant programs;
iii) Authorizes $30 million for fiscal year 2010 to train
oral health workforce;
iv) Establishes five-year, $4 million demonstration
projects to test alternative dental health care
providers;
v) Establishes a public health workforce track,
including funding for scholarships and loan repayment
programs for dental students and grants to dental
schools;
vi) Establishes three-year, $500,000 grants to establish
new primary care residency programs, including dental
programs, and,
vii) Provides funding for new and expanded graduate
medical education, including dental education.
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c) Dental Workforce Capacity . In 2011, the Senate
Business, Professions and Economic Development Committee
conducted a sunset review of the DBC. One of the issues
raised by the background paper for the sunset process is
whether California will be able to meet the increased
demand for dental services with the enactment of ACA. A
brief summary of the dentist workforce was included in the
background paper, specifically, a June 2009 Health Policy
Fact Sheet by the UCLA Center for Health Policy Research
which indicated that California has about 14% of the total
number of dentists nationwide (the largest percentage of
any state). The dentist-to-population ratio in California
is estimated as 3.5 dentists per 5,000 or a dentist for
every 1,440 persons. This ratio is higher than the
national estimate of three dentists per 5,000, or a dentist
for every 1,660 persons. However, the Health Policy Fact
Sheet revealed that although there is a large number of
practicing dentists in California, many areas in the state
continue to have a shortage of dentists, and these areas
are mostly located in rural areas, including Yuba, Alpine,
Colusa, Mariposa, Mono, and San Benito Counties.
Additionally, according to the United States Health and
Human Services Agency, there are 333 dental health
professional shortage areas statewide. These designated
areas generally have a dentist-to-population ratio of one
per 5,000 or lower; a high population need with a ratio of
at least 1.25 dentists per 5,000 (or 1 per 4,000); and, a
public or non-profit health center that provides dental
services to shortage areas or populations. Additionally,
the Health Policy Fact Sheet indicated that the percentage
of dentists who may be nearing retirement age is greater
than the percentage of newly licensed dentists. In some
counties, far fewer are newly licensed and many more are
nearing retirement age. As the background paper indicated,
these shortages could potentially impact the implementation
of the ACA.
d) Oral Health Unit within DPH . The Oral Health Unit
within DPH (formerly the Office of Oral Health), currently
has one staff and among other functions, is charged with
maintaining a dental program that develops a comprehensive
dental health plans, coordinates federal, state, county,
and city agency programs related to dental health, and
encourages, supports, and augments the efforts of city and
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county health departments in the implementation of a dental
health component.
e) OSHPD Health Workforce Pilot Project . The HWPP at OSHPD
allows organizations to test, demonstrate, and evaluate new
or expanded roles for health care professionals, or new
health care delivery alternatives before changes in
licensing laws are made by the Legislature. For example,
in 2010, a pilot project proposal was submitted to HWPP
entitled "Training Current Allied Dental Personnel For New
Duties in Community Settings." This pilot proposed the
involvement of eight to 10 trainees, three supervisors, and
nine sites, and included two new duties that will be
performed that require an expanded scope of practice for
community-based registered dental assistants (RDAs),
registered dental hygienists (RDHs) working in public
health programs, and registered dental hygienists in
alternative practice (RDHAPs). The new duties to be
evaluated under the pilot are: (1) RDAs will make the
decision about which radiographs to take, if any, to
facilitate an initial oral evaluation by a dentist. RDHs
can already make these decisions, and, (2) allow RDAs,
RDHs, and RDHAPs to place "interim therapeutic
restorations" (ITR). According to the American Academy of
Pediatric Dentistry, an ITR is a restoration placed on
teeth to prevent the progression of caries. ITR may be
used to restore and prevent dental caries in young
patients, uncooperative patients, patients with special
health care needs, and situations in which traditional
cavity preparation and/or placement of traditional dental
restorations are not feasible.
The objectives of the pilot include: Allowing RDAs, RDHs, and
RDHAPs working in community settings with underserved
populations to facilitate collaboration with a dentist and
the development of an appropriate plan of care for the
patient. The placement of ITRs when directed to do so by a
collaborating dentist will allow RDAs, RDHs, and RDHAPs to
stabilize patients' teeth from further deterioration until
they can be seen by a dentist in an appropriate setting;
and, facilitate the development of new models of care
designed to improve the oral health status of underserved
populations.
3)SUPPORT . The Children's Partnership (CP) states that the goal
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of this bill is to improve children's oral health, and
strengthen California's leadership in oral health by ensuring
that the State has a robust Office, led by a Dental Director.
CP states that addressing the dental access problem requires a
comprehensive approach. An essential element of that approach
is to test different workforce models that include providers
whose scope of practice is narrower than that of dentists but
who can effectively deliver urgently needed, high-quality
preventive and routine restorative dental care in places where
children who would otherwise go without dental care are
located. The California Coverage and Health Initiatives
states that California's current dental workforce does not
have the capacity to meet the dental care needs of children,
especially underserved children. The California Dental
Association states they support establishing the Office as
long as sufficient federal and private funds are secured, and
points out that a study as specified in the bill is the
appropriate next step in building the necessary evidence base
prior to any consideration of expanded or increased scope of
practice.
4)OPPOSITION . The Hispanic Dental Association, California
Academy of General Dentists, and individual dentists oppose
the provision in this bill relating to the workforce study
because the study would include non-dentists doing surgical or
irreversible procedures. The California Academy of General
Dentistry (CAGD) states that because dental auxiliaries
already have the ability to complete virtually every dental
restorative procedure except drilling on teeth, extraction of
teeth, and treating the nerve tissue inside a tooth, the only
significant expanded procedures likely to be considered would
be surgical and irreversible procedures. CAGD does not
believe that non-dentists should be performing surgical and
irreversible procedures because unexpected outcomes from such
procedures could put children at risk of complications and
developing poor attitude towards future dental care. The
California Nurses Association states that this bill allows
non-dentist providers to provide care outside of their scope
of licensure, and this is a dangerous precedent for our health
care delivery system and for our educational system which is
set up to train appropriately licensed practitioners.
5)POLICY COMMENTS .
a) Appointment of the Dental Director . This bill does not
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specify who appoints the Dental Director. Staff recommends
that this bill be amended to indicate that the director is
appointed by the Governor, subject to Senate confirmation,
and serves at the pleasure of the Governor. Additionally,
this bill should also state that all applicable laws
contained in the Government Code relating to appointees
should apply to the Dental Director.
b) Qualifications of the Dental Director . The only
qualification of the Dental Director specified in the bill
is that he or she is a licensed dentist in good standing.
Staff recommends that the Dental Director be a licensed
dentist, and who has demonstrated dental and management
experience, and at least five years of experience in public
dental health.
c) Should the Study go through OSHPD ? Since OSHPD,
specifically HWPP has experience designating pilot projects
on health workforce, should the study proposed in this bill
go through OSHPD?
6)SUGGESTED TECHNICAL AMENDMENTS .
a) On page 3, line 21, delete "The Dental Director and his
or her staff" and replace with "The Office."
b) On page 4, line23, delete "2016" and replace with "2017"
c) On page 5, line 4, after "Services," add "Agency"
d) On page 5, line 10, after "Services," add "Agency"
e) On page 5, line 15, after "Services, add "Agency"
REGISTERED SUPPORT / OPPOSITION :
Support
Children's Partnership (sponsor)
American Federation of State, County, and Municipal Employees
California Coverage & Health Initiatives
California Dental Association
California Primary Care Association
California School Health Centers Association
Center for Oral Health
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Children's Defense Fund-California
Children NOW
Regional Economic Association Leaders
United Ways of California
100% Campaign
Opposition
California Academy of General Dentists
California Nurses Association
Hispanic Dental Association
Individual dentists
Analysis Prepared by : Rosielyn Pulmano / HEALTH / (916)
319-2097