SB 68-DENTAL HYGIENIST ADVANCED PRAC PERMIT  2:03:32 PM CHAIR BISHOP reconvened the meeting and announced the consideration of SPONSOR SUBSTITUTE FOR SENATE BILL NO. 68, "An Act relating to the practice of dental hygiene; establishing an advanced practice permit; prohibiting unfair discrimination under group health insurance against a dental hygienist who holds an advanced practice permit; and relating to medical assistance for dental hygiene services." He said this is the first hearing, but the companion has made significant progress in the other body. He noted there was a proposed committee substitute that would be addressed after the sponsor makes opening remarks. 2:03:57 PM SENATOR CATHY GIESSEL, Alaska State Legislature, Juneau, Alaska, sponsor of SB 68, stated that this bill will create a dental hygienist advanced practice permit. She explained that some dental conditions can predispose a person to heart disease and if they are missing teeth, their nutritional status falls significantly, which affects their health. In Alaska, the most vulnerable populations are children, seniors and those with disabilities. She said the state has an enormous unmet need for dental care in Alaska and dental costs are high. Many states allow dental hygienists to hold advanced practice permits that allow them to provide dental services to underserved populations who are at risk. These patients may not have access to a dental office, there may not be a dental office in their community, or the patients may have transportation issues getting to a dentist. She explained that SB 68 would establish an advanced practice permit for Alaska-licensed dental hygienists to expand access to dental care. She highlighted that in 2019 there were 703 licensed dental hygienists in Alaska. These are skilled dental health professionals whose focus is preventing and treating oral diseases. SENATOR GIESSEL said the lack of access to dental care in Alaska has created enormous need in populations and communities that are underserved by the traditional system of care and the cost of obtaining treatment is high. Many states have addressed similar challenges by allowing non-dentist oral healthcare practitioners the freedom and flexibility to reach out to patients in new and creative ways to help improve access to basic oral care. Alaska would benefit from replicating such innovative oral health care delivery models. SENATOR GIESSEL related that dental hygienists have graduated from nationally accredited dental hygiene education programs and have successfully passed a national written and state clinical examination. Given their comprehensive education and clinical preparation, dental hygienists are well prepared to deliver preventative oral health care and other services to the public, safely and effectively, she said. She listed the identified underserved areas in Alaska, which includes nursing homes, K-12 schools, senior centers, residential treatment centers, assisted living centers, nursing homes, nursery schools, and day care centers. SENATOR GIESSEL stated that licensed dental hygienists holding advanced practice permits could provide early preventive treatment thus reducing the number of acute dental care visits, which can be very costly. Additionally, these advanced practice dental hygienists could identify more acute dental issues early on and refer patients needing definitive restorative treatment to dentists. She pointed out that 62 percent of Alaska's children have higher than normal tooth decay rates, so having access to care at a day care center, nursery school, or K-12 school could help to reduce dental issues. SB 68 would create new consumer choices for preventive oral health, and help to educate individuals, families, caregivers, and health providers on the basics of oral health and dental hygiene. It has support from the Alaska Board of Dental Examiners, the Alaska Dental Hygienists Association, the American Dental Hygienists Association, the Alaska Dental Society, and dental hygienists. 2:07:37 PM SENATOR STEVENS asked for an estimate of the cost savings if the underserved dental care is met. SENATOR GIESSEL replied it is difficult to estimate preventative dental care savings, but the dental health aides that Alaska now has have had a significant positive impact. She added that the advanced practice dental hygienists could help seniors with dementia some of the disruptive and disorienting experiences of going to a dentist. An advanced practice dental hygienist could go into the Pioneer Home, for example, and meet the needs of many of those seniors. CHAIR BISHOP noted that he and the sponsor recently heard an overview on the Medicaid costs for dental care. He suggested that this bill could help drive down those costs. 2:10:01 PM SENATOR STEVENS moved to adopt the proposed committee substitute (CS) for SSSB 68, work order 31-LS0224\R, as the working document. CHAIR BISHOP found no objection and Version R was adopted. 2:10:23 PM JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State Legislature, Juneau, Alaska, provided the following sectional analysis for the CS for SSSB 68, Version R: Section 1 AS 08.32.110. Scope of practice of dental hygienists Amends section (e) of dental hygienists' scope of practice to allow a licensed dental hygienist who holds an advanced practice permit issued by the board to perform the duties allowed by the permit. Section 2 Adds a new section to AS 08.32: AS 08.32.125. Advanced practice permits. Outlines the advanced practice permit requirements and privileges. (a) The Board of Dental Examiners may issue an advanced practice permit to a licensed dental hygienist with a minimum of 4,000 documented hours of clinical experience. A licensed dental hygienist with an advanced practice permit may perform the specific services listed in this section (1) (12) (b) Describes patients a licensed dental hygienist who holds an advanced practice permit may provide services to, including: • A patient not able to receive dental treatment due to age, infirmity, or disability, and is • A resident of a senior center, hospital, long- term care, residential care facility, adult foster home, adult congregate living facility, an inmate in a local correctional facility a healthcare facility, residential treatment center or facility for those with disabilities, nursery school, day care, vocational training program, secondary school, private school, or charter school • A patient receiving benefits under the Special Supplemental Food Program (WIC), homebound, or a resident where there's a shortage of dental health professionals. (1) (7) (c) A licensed dental hygienist holding an advanced practice permit can provide services listed in subsection (a) to a patient described in subsection (b) without the presence, authorization, or supervision of a licensed dentist and without an examination from a licensed dentist. (d) A licensed dental hygienist with an advanced practice permit who provides services must do the following: ~ maintain professional liability insurance. ~ give the patient, parent, or legal guardian written notice that the treatment provided will be limited to services listed under subsection (a) ~ provide a written recommendation that the patient be examined by a licensed dentist for comprehensive oral care ~ provide assistance for a referral to a licensed dentist for further oral treatment. (e) A licensed dental hygienist with an advanced practice permit may practice as an independent contractor. (f) An advanced practice permit is valid until the license of the dental hygienist expires. A licensed dental hygienist can renew their advanced practice permit at the same time they renew their license. 2:14:24 PM CHAIR BISHOP noted that a dental hygienist with an advanced practice permit who provides services must maintain professional liability insurance. He asked if she agreed that these individuals could work in a practice or set up their own shop. MS. CONWAY answered that is correct but the expectation is that most of these dental hygienists will work for a dentist and also go out to underserved areas to provide services. CHAIR BISHOP asked if the dental office as the primary employer would maintain the professional liability insurance for these dental hygienists who also go out on their own to provide services in other settings. 2:15:29 PM SENATOR GIESSEL answered that in her experience with advanced practice nurses, employers will offer liability insurance as a benefit, but it is typically up to the clinician to maintain that liability insurance and pay the premiums. 2:16:01 PM MS. CONWAY continued the sectional analysis for CSSSSB 68: Section 3 Amends 08.32.160 Grounds for discipline, suspension or revocation of license. Outlines and amends grounds for discipline; allows the Board of Dental Examiners to discipline, suspend, or revoke the license of an advanced practice permit-holder who: o Knowingly commits fraud or misrepresentation to obtain a license o Knowingly commits fraud/misrepresentation in providing services or billing procedures o False advertises or misleads o Been convicted of a felony or other crime that would affect ability to practice competently o Failed to comply to statute or regulations or board order o Practices if unfit due to incompetence, addiction or dependence on drugs or alcohol, is physically or mentally disabled, engaged in immoral conduct while in practice o performs procedures outside scope of practice or without supervision of a dentist o allows a dental assistant to perform duties outside their scope o Falsifies or destroys a patient or facility record or fails to maintain a patient or facility record for at least seven years after the date the record was created. MS. CONWAY emphasized that when a dental hygienist with an advanced practice permit is supervising a dental assistant, it is mandatory that they make sure that the dental assistant only operates within the advanced practice permit holder's scope of practice. The provision related to falsifying or maintaining a patient or facility record is the same requirement as for dentists, she said. SENATOR STEVENS asked what types of procedures would fall outside the scope of practice. MS. CONWAY answered that a dental hygienist would not do invasive procedures such as pulling teeth. Those patients would be referred to a dentist. 2:18:06 PM MS. CONWAY continued the sectional analysis for CSSSSB 68: Section 4 Adds a new subsection to AS 08.36.346. (Delegation to dental assistant.) Allows delegation of the following tasks to a dental assistant: a. The exposure and development of radiographs, b. Application of topical preventative agents or pit and fissure sealants, and c. Other tasks specified by the board in regulations. The dental assistant must be supervised at a level specified by Board of Dental Examiners in regulation. Section 5 AS 21.36.090. Unfair discrimination. Adds "dental hygienist holding an advanced practice permit" to the list of providers who may not be discriminated against in subsection (d). Section 6 AS 47.07.030. Medical services to be provided. (Medicaid) Adds dental hygiene services to the list of services which may be provided by the Department of Health & Social Services. Section 7 This new section allows the Department of Commerce, Community, and Economic Development (DCCED), the Department of Health and Social Services, and the Board of Dental Examiners to adopt regulations necessary to implement the changes made in this bill. The regulations may not take effect before the effective date of this bill. Section 8 Section 7 takes effect immediately. Section 9 The effective date of this bill (not including Section 7) is July 1, 2021. 2:19:38 PM CHAIR BISHOP noted who was available to answer questions. 2:20:45 PM KATRINA VIRGIN, President, Alaska Dental Hygienist Association, Kodiak, Alaska, stated support for SB 68 and offered to answer questions. 2:21:31 PM DOMINIC WENZELL, DMD, Member, Alaska Board of Dental Examiners, Girdwood, Alaska, stated support for Version R of SB 68 and offered to answer questions. 2:22:02 PM SENATOR REVAK asked Dr. Wenzell if he was back practicing dentistry. DR. WENZELL answered that the orthopedic surgeon just released him to work one-half day per week. 2:22:35 PM ANN LYNCH, Director of Advocacy and Education, American Dental Hygienists Association (ADHA), Chicago, Illinois, spoke in support of SB 68. She stated that she has been with ADHA for eight years. Before that she served as a state senator in Minnesota. She said ADHA is the largest national organization representing dental hygienists in the nation. She related that in 1995, only five states allowed dental hygienists to practice without the presence and authorization of a dentist. Now there are 42 states, including Alaska, that permit dental hygienists to work in communities to provide preventive oral health services without the presence or direct supervision of a dentist. This will further utilize the dental hygienist workforce in Alaska. She said there are national standards for dental hygienist education programs that are accredited throughout the country, including Alaska and this advanced practice permit will allow dental hygienists to meet clients where they live and receive service. As a former lawmaker, she said SB 68 provides an opportunity to provide leadership and support a change that will make a difference in the lives of many people across Alaska for years to come. She thanked members for their service and the leadership members provide. 2:26:27 PM CHAIR BISHOP asked if there was any data on the number of hygienists who go on to become dentists. MS. LYNCH answered that it is far more common for dental hygienists to seek the ability to practice at the top of their scope of practice based on their education. SENATOR REVAK asked about the scope of the practice and whether advance practice dental hygienists can administer local anesthesia. MS. LYNCH directed attention to page 2, lines [9-29] of SB 68, Version R, which lays out the scope of practice for an advanced practice dental hygienist. The question about administering local anesthesia is addressed on page 2, lines 24-27. SENATOR REVAK asked for a description of nonsurgical periodontal therapy, with or without local anesthesia. MS. LYNCH answered that she is not a dental hygienist. She suggested the question be posed to the dental hygienist online. CHAIR BISHOP said he'd hold the question. 2:29:56 PM SENATOR STEVENS referenced her earlier statement that in some settings dental hygienists can work without a dentist being present. He asked what that setting would be. MS. LYNCH responded that 42 states have direct access, such that in at least in one setting in each of those states, dental hygienists can provide those services to patients without the presence or authorization of a dentist. She said most commonly that occurs in schools and that is the case in Alaska. Since 2008, dental hygienists in Alaska have been able to provide services under a collaborative practice agreement. SB 68 creates the advanced practice permit system, which will allow increased access for dental hygienists to work in more settings. 2:32:18 PM At ease 2:32:37 PM CHAIR BISHOP reconvened the meeting and asked Senator Revak to pose his earlier question to Dr. Wenzell. SENATOR REVAK asked for help understanding the scope of practice that includes nonsurgical periodontal surgery, with or without anesthesia. DR. WENZELL referred to page 2, lines 21-22 of SB 68, Version R. He explained that if a patient has [gumline] probings that are deeper than four millimeters and tenacious sublingual calculus, the dental hygienist is not able to scale the root plane without numbing the area so the patient is comfortable. Dental hygienists currently are able to administer local anesthetic under the general supervision of a dentist and the dental board supports allowing dental hygienists to administer local anesthetic in settings like a nursing home. 2:34:22 PM CHAIR BISHOP opened public testimony on SB 68. 2:34:34 PM VIVIAN STIVER, representing self, Fairbanks, Alaska, spoke in support of SB 68. She said she has worked with the senior population for nine years and has witnessed the oral health problems low-income seniors experience due to cost and transportation barriers. She said having bad teeth can be painful, cause eating difficulty, and affect a person's overall health. Sometimes seniors will opt for tooth extractions because they cannot afford the other types of services. She said SB 68 will help with this situation by allowing dental hygienists to screen, clean, and encourage seniors to address problems as they crop up. This has the potential to improve the quality of life for seniors. She summarized that she was pleased to see the advanced practice permit system since it can help provide services to those communities that are currently underserved. 2:36:46 PM CHAIR BISHOP closed public testimony on SB 68 and held the bill for future consideration.