BILL ANALYSIS �
AB 1174
Page 1
ASSEMBLY THIRD READING
AB 1174 (Bocanegra and Logue)
As Amended January 6, 2014
Majority vote
BUSINESS & PROFESSIONS 12-0 HEALTH 17-0
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|Ayes:|Gordon, Jones, Bocanegra, |Ayes:|Pan, Maienschein, |
| |Campos, Dickinson, | |Ammiano, Atkins, Bonilla, |
| |Eggman, Hagman, | |Bonta, Chesbro, Gomez, |
| |Maienschein, Mullin, | |Gonzalez, Roger |
| |Skinner, Ting, Wilk | |Hern�ndez, Logue, |
| | | |Mansoor, Nazarian, |
| | | |Ridley-Thomas, Wagner, |
| | | |Wieckowski, |
| | | |V. Manuel P�rez |
|-----+--------------------------+-----+--------------------------|
| | | | |
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APPROPRIATIONS 16-0
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|Ayes:|Gatto, Bigelow, Allen, |
| |Bocanegra, Bradford, Ian |
| |Calderon, Campos, Eggman, |
| |Gomez, Holden, Linder, |
| |Pan, Quirk, |
| |Ridley-Thomas, Wagner, |
| |Weber |
| | |
| | |
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SUMMARY : This bill expands the scope of practice for a registered
dental assistant (RDA), 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 RDA to determine which radiographs to perform if he
or she completes a Dental Board of California (DBC)-approved RDA
educational program in those duties or provides evidence to the
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board of having completed a DBC-approved course in those duties.
2)Authorizes an RDAEF licensed on or after January 1, 2010, an RDH,
and an RDHAP, pursuant to the order, control, and full
professional responsibility of a supervising dentist, to perform,
only in a dental office setting or public health setting and under
the supervision of a dentist, as specified, both of the following
duties:
a) Choose radiographs without the supervising dentist having
first examined the patient for the purpose of diagnosis and
treatment planning by the dentist, as specified; and,
b) Place protective restorations, through interim therapeutic
restorations (ITR) that remove 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, as specified.
3)Requires an RDAEF, RDH, and an RDHAP, in order to perform the
functions described in paragraph 2), to complete a program that
includes training in those functions or to provide evidence
satisfactory to the DBC or the Dental Hygiene Committee (DHC) of
having completed a DBC- or DHC-approved course in those functions.
4)Requires, until January 1, 2018, a program to perform the duties
described in paragraph 2) 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.
5)Defines, until January 1, 2018, the terms "clinical instruction,"
"course," "didactic instruction," "interim therapeutic
restoration," "laboratory instruction," "preclinical instruction,"
and "program."
6)Requires, until January 1, 2018, the program or course required to
choose radiographs to contain all of the following instructional
components:
a) A program of sufficient duration for the student to develop
minimum competency making decisions about which radiographs to
take, as specified;
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b) Didactic instruction on guidelines for radiographic
decisionmaking and specific decisionmaking protocols that
incorporate prescribed information;
c) Laboratory instruction that includes simulated
decisionmaking using case studies, and there must be at least
one instructor for every 14 students, as specified; and,
d) Examinations using decisionmaking where students make
decisions and demonstrate competency to faculty on case studies
containing specified elements.
7)Requires, until January 1, 2018, the program or course required to
place protective restorations to contain all of the following
instructional components:
a) A program of sufficient duration for the student to develop
minimum competency in the application of protective
restorations, including ITRs, as specified;
b) Didactic instruction on topics including pulpal anatomy,
theory of adhesive restorative materials, and criteria that
dentists use to make decisions about placement of adhesive
protective restorations;
c) Laboratory instruction that includes placement of adhesive
protective restorations where students demonstrate competency
in this technique on typodont teeth; and,
d) Clinical instruction that includes experiences where
students demonstrate placement of adhesive protective
restorations under direct supervision of faculty.
8)Deems, until January 1, 2018, an RDAEF, RDH, or RDHAP who has
completed the prescribed training in the HWPP to have satisfied
the requirement for completion of a DBC- or DHC- approved course.
9)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. 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
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patient being present in real time.
FISCAL EFFECT : According to the Assembly Appropriations Committee:
1)Annual fee-supported special fund costs to the Dental Hygiene
Committee of California (DHCC) and the DBC to approve training
courses and to oversee the expanded scope of dental personnel
would be incurred as follows:
a) $150,000 to the DBC, which regulates RDAs (State Dental
Assistant Fund).
b) $80,000 to the DHCC (State Dental Hygiene Fund).
2)Denti-Cal, the dental program within Medi-Cal, may incur
additional costs, potentially in the hundreds of thousands of
dollars, as a result of increased utilization of dental services.
3)Potential unknown future cost savings from avoiding costly dental
diseases and emergencies.
COMMENTS :
1)Purpose of this bill . This bill expands the scope of practice for
RDAs, 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 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
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
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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.
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 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.
4)Virtual dental homes . Virtual Dental Homes 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.
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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 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, creating a true
community-based "dental home."
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:
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