BILL ANALYSIS �
SB 694
Page 1
Date of Hearing: July 3, 2012
ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER
PROTECTION
Mary Hayashi, Chair
SB 694 (Padilla) - As Amended: June 28, 2012
SENATE VOTE : 34-2
SUBJECT : Dental care.
SUMMARY : Establishes the Statewide Office of Oral Health
(Office) within the State Department of Public Health (DPH) and
authorizes the Office to conduct a study to assess the safety,
quality, cost-effectiveness, and patient satisfaction of
expanded dental procedures performed by specified dental health
care providers. Specifically, this bill :
1)Establishes the Office within DPH and requires there to be
within the office a licensed dentist who serves as the dental
director. The dental director shall be appointed by the
Governor, subject to confirmation by the Senate, and shall
serve at the pleasure of the Governor. The dental director
shall be a licensed dentist in good standing who has
demonstrated dental and management experience, including at
least five years of experience in public dental health.
2)Vests the Office with all of, but not limited to, the
following responsibilities:
a) Advancing and protecting the oral health of all
Californians;
b) Developing a comprehensive and sustainable state oral
health action plan to address the state's unmet oral health
needs;
c) Encouraging private and public collaboration to meet the
oral health needs of Californians;
d) Securing funds to support infrastructure and statewide
and local programs;
e) Promoting evidence-based approaches to increase oral
health literacy; and,
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f) Establishing a system for surveillance and oral health
reporting.
3)Allows the state to accept public and private funds for the
purpose of implementing this bill, prohibits General Fund (GF)
moneys from being used for purposes of the Office, and
requires moneys to fund the Office to be secured from other
public or private sources.
4)Requires the Department of Finance (DOF) to make a
determination on January 1, 2014, and annually thereafter
regarding the funding status of the Office, and prohibits
moneys needed to sufficiently fund and commence the study
authorized by this bill from being considered for purposes of
determining the funding status of the Office.
5)Provides that the Office shall be established only after a
determination has been made by DOF that public or private
funds in an amount sufficient to fully support the activities
of the Office, including staffing, have been deposited with
the state. If DOF makes a determination that sufficient
funding has been secured to establish the Office, 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.
6)Provides that, if the Office is established pursuant to this
bill, the Office shall assume responsibility for identifying
and securing funding sources in order to maintain its
functions.
7)Provides that, if DOF makes a determination that the Office
has not secured sustainable funding sources to maintain its
activities, 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)Makes 1) through 8), above, inoperative on January 1, 2016.
9)Allows the Office 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
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purpose of informing future decisions about how to meet the
state's unmet oral health need for the state's children. The
research parameters of the study shall include public health
settings, multiple models of dentist supervision, multiple
pathways of education and training, and multiple dental
providers. Procedures performed during the study shall 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 (HHS) or his or her designee to convene an advisory
group on study design and implementation. The advisory group
shall be comprised of representatives of all dental practices,
including traditional and nontraditional, as well as
non-dentists and consumer advocates.
11) Requires the dental director or, in the absence of a
dental director, the Secretary of HHS or his or her designee
to 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. The dental director or, in the absence of
a dental director, the Secretary of HHS or his or her designee
shall also consult with the Legislative Analyst's Office in
designing the study and selecting any contractors.
12) Limits the study to a California licensed dentist, and
at least two registered dental hygienists (RDHs) and
registered dental assistants (RDAs) in extended functions
educated in a limited number of additional dental procedures.
13) Limits the dental procedures that may be examined in
the study to the following: administration of local
anesthesia; tooth preparation for, and the placement and
finishing of, direct restorations; placement of interim
therapeutic restorations; stainless steel crown placement;
therapeutic pulpotomy; pulp cap placement, direct and
indirect; and, extraction of primary teeth.
14) Requires the study to examine and compare the
procedures described above, as performed under the following
types of supervision:
a) Direct supervision, as specified;
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b) General supervision, as specified; and,
c) Remote supervision by a dentist where the supervising
dentist is not onsite while a dental care provider is
practicing as authorized by the study and shall be
facilitated by "standing orders" as an agreement between
the dental care provider and supervising dentist. The
dental care provider shall not perform duties beyond what
is agreed upon in the standing orders. Remote supervision
may:
i) Incorporate the use of technology, such as
telehealth, to facilitate dentists providing remote
supervision to the dental care provider, where the dental
care provider does not have to be in the same location as
the supervising dentist;
ii) Include a mechanism for the dental care provider to
seek and receive additional professional advice in a
timely manner as needed; and,
iii) Include a mechanism for the dental care provider to
make referrals to a qualified dentist, as needed.
15) 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.
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
program.
16) Requires the study to be conducted through a dental
school at an institution of higher education within the state.
17) Prohibits any GF moneys from being used to carry out
the study. Moneys to fund the study, including analysis and
findings, and all procedures administered by dental care
providers during the study, shall be secured from other public
or private sources. No one provider group or interest group
may provide more than half the private funding for the study.
18) Makes this bill's provisions authorizing the study
inoperative on January 1, 2014, if the study is not
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sufficiently funded and commenced by that date, and repeals
this bill's provisions authorizing the study on January 1,
2017, as specified.
19) Makes inoperative existing statutes requiring DPH to
maintain a dental program on the date DOF memorializes in
writing, pursuant this bill, that sufficient funds have been
deposited with the state to establish the Office, and makes
them operative again on the date DOF memorializes in writing,
pursuant to this bill, that the Office has not secured
sustainable funding sources to maintain its activities, or on
January 1, 2016, whichever occurs first.
20) States legislative findings and declarations.
EXISTING LAW :
1)Requires DPH to maintain a dental program including, but not
limited to, the following:
a) Development of 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)Establishes the Dental Board of California to license and
regulate the practice of dentistry.
3)Establishes functions for RDHs, and various categories of
RDAs.
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4)Provides various definitions under the Dental Practice Act,
including:
a) Direct Supervision, which 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;
and,
b) General Supervision, which 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.
5)Establishes, under federal law, the Patient Protection and
Affordable Care Act (PPACA), 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 dental care.
FISCAL EFFECT : Unknown
COMMENTS :
Purpose of this bill . According to the author, "Oral health is
a critical component of overall health. According to the
National Maternal and Child Oral Health Resource Center, poor
dental health can disrupt normal childhood development,
seriously damage overall health, and impair a child's ability to
learn, concentrate, and perform well in school.
"The Dental Health Foundation reports that both nationally and
in California, tooth decay ranks as the most common chronic
disease and unmet health care need of children?The California
Healthcare Foundation found that in 2007, more than 83,000
Californians visited the emergency room for dental problems at a
cost of more than $55 million?Additionally, in 2007, California
children missed 874,000 school days due to dental problems.
According to the UCLA Center for Health Policy Research, this
resulted in the loss of nearly $30 million in attendance based
school funding.
"Throughout California there is a mismatch of providers and
services needed. The United States (U.S.) Department of Health
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and Human Services reports that the state has 333 federally
designated dental health professional shortage areas?With the
passage of PPACA, children are entitled to dental coverage.
Starting in 2014, approximately 1.2 million additional
Californian children are expected to gain dental coverage over
time, leading to an even greater need to address the dental
health access crisis in our state.
"To address unmet need, a comprehensive solution is necessary.
As part of the 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."
Background . The Center for Health Policy Research at the
University of California, Los Angeles, reports in a June 2009
health policy fact sheet 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 at 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, 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. In addition, according to the U.S. 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.
Furthermore, 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. These shortages could
potentially impact the implementation of PPACA.
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In California, implementation of PPACA is underway with the
establishment of the California Health Benefits Exchange
(Exchange) within HHS. According to advocates, an estimated 1.2
million California children will soon gain dental coverage due
to the recent enactment of PPACA. Advocates argue that
California will not be able to fulfill the promise of improving
children's dental health if there are not enough dental
providers to meet this growing demand.
PPACA requires a number of things that will likely impact the
dental workforce in California, including:
Requiring that insurance plans offered under the Exchange
include oral care for children;
Expanding school-based sealant programs;
Authorizing $30 million for fiscal year 2010 to train the oral
health workforce;
Establishing five-year, $4 million demonstration projects to
test alternative dental health care providers;
Establishing a public health workforce track, including
funding for scholarships and loan repayment programs for
dental students and grants to dental schools;
Establishing three-year, $500,000 grants to establish new
primary care residency programs, including dental programs;
and,
Providing funding for new and expanded graduate medical
education, including dental education.
The Oral Health Unit (formerly the Office of Oral Health) within
DPH has one staff member and, among other functions, is charged
with maintaining a dental program that: develops a comprehensive
dental health plan; coordinates federal, state, county, and city
agency programs related to dental health; and, encourages,
supports, and augments the efforts of city and county health
departments in the implementation of a dental health component.
Support . The Children's Partnership writes, "Addressing the
dental access problem requires a comprehensive approach. An
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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. More than 50
other countries and native communities in Alaska have seen
significant increases in access to dental care and improved
dental health among children as the result of the deployment of
new workforce models. The results of the study authorized by SB
694 will inform how to shape California's dental workforce so
that children get the preventive care they need, while saving
the State money in the long run.
"In addition, SB 694 strengthens California's Statewide Office
of Oral Health. A key role of the office will be to draw down
federal dollars for oral health programs. These are dollars
that the State is currently foregoing because it does not have a
structure in place to apply for and manage federal dollars for
oral health programs. Many of the programs funded by the
federal program focus on preventive care for children, such as
school sealant programs."
Opposition . The California Nurses Association (CNA) states, "SB
694 seeks to study the efficacy of dentist and non-dental
providers to practice very serious procedures like triage care,
infection, fillings, tooth extractions, baby root canals and
anesthesia. AB 694 is an unnecessary and dangerous piece of
legislation.
"The skill and maturity that's acquired through four years of
undergraduate plus four years of dental school is the minimum
required to safely treat our children. Anything less would be
unconscionable. California has the best dentist patient ratio
in the country; there is no shortage in the workforce. It's a
provider distribution problem and lack of funding in our state
budgets. Dental and other health programs are on the chopping
block every budget cycle. Dentistry is a well evolved and
established practice. We know what works and what is safe for
children. CNA would support alternative ways to incentivize
dentist providers to fill the gaps in our state's geography to
ensure every child is covered. We oppose any legislation that
would subject our patients to a sub-standard, two-tiered system
of health care."
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Related legislation . SB 540 (Price) Chapter 385, Statutes of
2011, extends the sunset date of the Dental Board of California,
among other provisions.
Double referred . This bill is double-referred to Assembly
Health Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
The Children's Partnership (sponsor)
California Dental Association
California District of the American Academy of Pediatrics
California Primary Care Association
California School Health Centers Association
California Society of Pediatric Dentistry
Center for Oral Health
Children Now
First 5 Los Angeles
First 5 Marin Children and Families Commission
First 5 Trinity County
Los Angeles Area Chamber of Commerce
Regional Economic Association Leaders Coalition
Santa Barbara County Children's Oral Health Collaborative
Executive Committee
Shasta Community Health Center
The Arc and United Cerebral Palsy in California
Worksite Wellness Los Angeles
One individual
Opposition
California Nurses Association
Numerous individuals
Analysis Prepared by : Angela Mapp / B.,P. & C.P. / (916)
319-3301