SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Steven Glazer, Chair

2019 - 2020 Regular

Bill No: SB 653 Hearing Date: April 22, 2019

Author:	Chang
Version:	April 22, 2019
Urgency:	No	Fiscal:	Yes
Consultant:	Sarah Huchel

Subject: Dental hygienists: registered dental hygienist in alternative practice: scope of practice

SUMMARY:

Revises the scopes of practice for a registered dental hygienist (RDH) and a registered dental hygienist in alternative practice (RDHAP), including allowing a RDHAP to remain in a dental health professional shortage area (shortage area) if that area loses that designation.

Existing law:

Establishes the Dental Hygiene Board of California (DHB) within the Department of Consumer Affairs to regulate the practice of RDHs, RDHAP, and registered dental hygienist in extended functions (RDHEF). (Business and Professions Code (BPC) Sections 1901, 1905)
Requires the DHB to make recommendations to the Dental Board of California regarding dental hygiene scope of practice issues. (BPC § 1905 (a)(8))
Defines the practice of dental hygiene to include dental hygiene assessment and development, planning, and implementation of a dental hygiene care plan. It also includes oral health education, counseling, and health screenings. It does not include any of the following procedures:
1. Diagnosis and comprehensive treatment planning.
2. Placing, condensing, carving, or removal of permanent restorations.
3. Surgery or cutting on hard and soft tissue including, but not limited to, the removal of teeth and the cutting and suturing of soft tissue.
4. Prescribing medication.
5. Administering local or general anesthesia or oral or parenteral conscious sedation, except for the administration of nitrous oxide and oxygen, whether administered alone or in combination with each other, or local anesthesia.
  (BPC § 1908)
States that any procedure performed or service provided by a RDH that does not specifically require direct supervision shall require general supervision, so long as it does not give rise to a situation in the dentist’s office requiring immediate services for alleviation of severe pain, or immediate diagnosis and treatment of unforeseeable dental conditions that, if not immediately diagnosed and treated, would lead to serious disability or death. (BPC §1912)
Authorizes anyone to apply topical fluoride, including fluoride varnish, to the teeth of individuals who are being served in a public health setting or a public health program that is created or administered by a federal, state, or local governmental entity, according to the prescription and protocol issued and established by a physician or dentist. (Health and Safety Code § 104762)
Authorizes a RDH to perform soft-tissue curettage and administer local anesthesia under the direct supervision of a licensed dentist, after submitting to the DHB evidence of satisfactory completion of an approved course of instruction in the procedures. (BPC § 1909 (a-b))
Authorizes a RDHAP to perform all the functions that may be performed by a registered dental assistant; dental hygiene assessment and development; planning and implementation of a dental hygiene care plan; oral health education, counseling, and health screenings; preventive and therapeutic interventions, including oral prophylaxis, root planning and scaling; and application of topical, therapeutic, and subgingival agents used for the control of caries and periodontal disease in the following settings:
1. Residences of the homebound.
2. Schools.
3. Residential facilities and other institutions.
4. Shortage areas, as certified by the Office of Statewide Health Planning and Development (OSHPD), as specified. (BPC §1926)
Defines the following terms:
1. “Sponsored event” is an event, not to exceed 10 calendar days, administered by a sponsoring entity or a local governmental entity, or both, through which health care is provided to the public without compensation, or expectation of compensation. (BPC § 1626.6 (b)(4))
2. “Sponsoring entity” means a nonprofit organization pursuant to Section 501(c)(3) of the Internal Revenue Code, or a community-based organization.
  (BPC § 1626.6 (b)(6))
3. “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 those procedures. (BPC § 1902 (c))
4. “General supervision” means the supervision of dental procedures based on instructions given by a licensed dentist who is not required to be physically present in the treatment facility during the performance of those procedures. (BPC § 1902 (d))

This bill:

Authorizes a RDH to provide oral screenings and dental hygiene preventive services including, but not limited to, the application of fluorides and pit and fissure sealants unsupervised at a sponsored event by a sponsoring entity or at a nonprofit organization.
Defines a “nonprofit organization” as a tax-exempt nonprofit corporation supported and maintained in whole or in substantial part by donations, bequests, gifts, grants, government funds, or contributions, in the form of money, goods, or services, where dental hygiene services are performed. A nonprofit organization shall not be construed to be engaging in the unlicensed practice of dentistry if all of the following apply:
1. The nonprofit organization obtains the DHB’s approval to offer dental hygiene services pursuant to regulations adopted by the DHB.
2. The nonprofit organization does nothing to interfere with, control, or otherwise direct the professional judgment of, or the services performed by, a RDH acting within their scope of practice.
3. The licensees providing the services for or at the nonprofit organization comply with all applicable rules.
4. The nonprofit organization operating the event is in compliance with the dental hygiene practice act and all other applicable provisions of state and federal law.
Authorizes a RDH to provide fluoride varnish to a patient without supervision.
Removes the requirement that an RDHAP must be an employee of a primary care clinic, specialty clinic, or professional corporation in order to practice in those settings, as specified.
Authorizes an RDHAP to perform soft-tissue curettage and administer local anesthesia with emergency protocols in the following settings:
1. Residences of the homebound.
2. Residential facilities and other institutions.
3. Dental health professional shortage areas, as certified by OSHPD.
4. Dental or medical settings.
Authorizes a RDHAP to: 1) determine which radiographs to perform on a patient who has not received an initial examination by the supervising dentist making a diagnosis and treatment plan for the patient, and 2) place interim therapeutic restorations on a patient in shortage areas and in dental or medical settings.
Replaces the requirement of general supervision for a RDHAP placing interim therapeutic restorations on a patient with “prior authorization of a collaborating dentist”, as specified.
Authorizes a RDHAP to continue to practice in a shortage area after the designation is removed if the RDHAP established the practice prior to the designation’s removal.
Makes technical changes.

FISCAL EFFECT:

Unknown. This bill is keyed fiscal by Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by California Dental Hygienists’ Association. According to the Author’s office, “RDHAPs provide patients the same type of professional preventive care they would receive in a dental office, but allows patients to receive this care conveniently in schools, skilled nursing facilities, hospitals, private homes and in some instances in an RDHAP’s own office.

“RDHs and RDHAPs comprise a workforce that is underutilized, yet standing ready to provide more care to more people in more places. Unnecessary restrictions on the services they are skilled and educated to provide should be removed.”

Background. The DHB regulates three categories of mid-level dental professionals: RDH, RDHAP, and RDHEF:

A RDH is a dental professional who is authorized to perform all duties assigned to dental assistants (DAs) and registered dental assistants (RDA), plus those additionally enumerated in statute and regulation, under the supervision of a licensed dentist. There are presently over 30,000 RDHs in California.
A RDHAP may perform all the functions of a DA, RDA, and RDH under general supervision, and certain RDH duties independently, if prescribed by a dentist or physician and under other qualifying conditions. There are presently 703 RDHAPs in California
A RDHEF may perform all the functions of a DA, RDA, and RDH under general supervision, and other procedures specified in regulation under the direct supervision of a dentist. There are presently 32 RDHEFs in California.

RDHAPs. Currently, an RDHAP may set up practice in a dental health professional shortage area, but the RDHAP must relocate their practice once that shortage is deemed to no longer exist. AB 502 (Chau, Chapter 516, Statutes of 2015) originally contained provisions that would have allowed a RDHAP to continue practicing. This language was later removed, but not before the California Health Benefits Review Program performed an independent, evidence-based analysis of the legislation. It determined that the services RDHAPs provide are largely effective in improving oral health and that “The reductions in administrative barriers associated with RDHAP practice may result in increasing numbers of RDHAP licensees. Thus, the long-term effects would likely increase access to dental health services and improve dental health for patient populations in RDHAP practice settings.” Essentially, CHBRP stated that RDHAPs improve oral health where they practice, and if there were fewer barriers to expanded practice, more people would benefit from their care.

This bill would allow RDHAPs to remain in their practice settings if the shortage area designation changes. Provisions in this bill also remove the requirement that an RDHAP be an employee to provide services in a primary care clinic, specialty clinic, or professional corporation. This change will allow RDHAPs to partner with additional service providers. This bill also deletes references to general supervision for RDHAPs when placing interim therapeutic restorations, but requires collaboration with a dentist.

RDHs. The DHB’s 2018 Sunset Background Paper addressed the concern that RDHs are allowed to provide care at public health programs, but not at sponsored events run by nonprofit organizations.

It was indicated in the Background Paper that there does not appear to be any evidence that public settings have greater support services for an RDH, that patients tend to be lower-risk, or that RDHs have been shown professionally incapable of unsupervised preventive practices in other settings. This bill amends current law to allow RDHs to perform certain services unsupervised at a sponsored event by a sponsoring entity or at a nonprofit organization.

This bill also allows an RDH to provide fluoride varnish to a patient without supervision; current law authorizes any person to provide this service in a public health setting when following a prescription or protocols provided by a dentist or physician.

Previous Related Legislation. SB 1482 (Hill, Chapter 858, Statutes of 2018) renamed the Dental Hygiene Committee of California as the DHB and made other technical and substantive changes.

AB 502 (Chau, Chapter 516, Statutes of 2015) authorized the creation of and established rules of governance for a RDHAP corporation.

Arguments in Support. The California Dental Hygienists Association writes, “A January 2018 California Health Report indicated that per Department of Health Care Services data, 13 counties out of California’s 58 counties had no participating Denti-Cal dentist, 7 counties only had 1 participating dentist, and even San Francisco only had 20 dentists and orthodontists serving 150,000 Denti-Cal enrollees.

“The inability to obtain proper dental care, particularly preventative care, can have significant long-term impacts. Research continues to show that poor oral health negatively impacts overall health and quality of life, including the ability to obtain and maintain a job. “…SB 653 makes several changes to the dental hygiene practice act that significantly improve patients’ access to preventive dental hygiene care.”

Arguments in Opposition. The California Dental Association (CDA) expresses an “oppose unless amended” position, stating “CDA appreciates the time and effort the author’s office and bill sponsor, California Dental Hygiene Association (CDHA) have spent working with our organization to address many of the issues that CDA conveyed over the bill’s initial language. Since then, CDA and CDHA have come to agreement on language for a number of provisions in the bill.

“… [C]onsistent with the creation of RDHAP licensure to increase access to dental hygiene services for underserved populations, the purpose of the RDHAP should remain in order to increase access to underserved areas and populations. The RDHAP licensure was created to allow a hygienist to provide preventive and periodontal dental services outside of a traditional office setting and the usual supervision of a dentist. The focus of the RDHAP licensure is to increase access for populations who cannot access a traditional dental office, either because they are unable to travel (populations including the homebound, children in schools, and residents of nursing homes) or because there is a shortage of dentists available nearby. Although there are no examples of a DHPSA losing its designation, CDA recognizes the concerns raised by CDHA if an RDHAP where to lose their brick and mortar practice if the federal [shortage area] designation was not renewed.

“CDA believes that if an RDHAP is permitted to continue practicing in an area that has lost the [shortage area] designation, it would be important for the state to ensure that the practice continues to provide access to care for underserved populations. As one third of all Californians, including nearly 50 percent of all children in the state are covered by Medi-Cal, a 30 percent Medi-Cal patient mix seems a reasonable minimum to ensure continued access by an RHDAP practice, while respecting the need for a balanced patient mix for sustainable practice. CDHA’s opposition to any threshold to provide care to the underserved populations the RDHAP licensure category was intended to serve, even a 15 percent Medi-Cal patient mix, makes it clear that this bill is not about expanding access to care but is actually about expanding the opportunity for increased profitability in hygienist practices.”

Author’s amendment. The author wishes to propose the following amendment:

On page 7, delete lines 33-37 and insert the following:

1926.5. A registered dental hygienist in alternative practice may continue practice in a DHPSA if:

1. The registered dental hygienist in alternative practice had established his or her practice in a qualified DHPSA, and
2. The registered dental hygienist in alternative practice continues to practice within the DHPSA after the DHPSA designation was lifted if a minimum of 15% of the annual visits at his or her practice are for persons with Medi-Cal benefits.

SUPPORT AND OPPOSITION:

Support:

California Dental Hygienists Association (Sponsor)

Opposition:

California Dental Association

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SB 653: Dental hygienists: registered dental hygienist in alternative practice: scope of practice.

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