HOUSE BILL NO. 127 "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; relating to medical assistance for dental hygiene services; and providing for an effective date." 2:38:59 PM Co-Chair Johnston invited the testifiers to the table. 2:39:18 PM REPRESENTATIVE IVY SPOHNHOLZ, BILL SPONSOR, introduced herself. She thanked the committee for hearing her bill which would establish advanced practice permits for dental hygienists. She explained that oral health was an important part to an individual's overall health and wellbeing. Poor oral health attributed to poor physical health. It was a problem amongst some of the state's most vulnerable populations. She reported that 62 percent of elementary students had tooth decay. Low income individuals and families that did not regularly seek oral health care due to cost, apprehension of dental care, access, and trouble finding a provider contributed to bad health outcomes. She noted several negative health outcomes including heart disease, Alzheimer's, osteoporosis, and poor nutrition. Representative Spohnholz continued that HB 127 aimed to increase access to oral healthcare to underserved populations, specifically children, seniors, and individuals with disabilities. The legislation created an advanced practice permit for dental hygienists similar to the certificate advanced nurse practitioners had which was created in 1981 and implemented in 1984. Currently, dental hygienists were able to practice in a dentist's practice or semi-independently if they had a collaborative agreement with a dentist similar to what physician's assistants did. House Bill 127 created an advanced practice permit which allowed dental hygienists to care for underserved populations in senior centers, healthcare facilities, daycares, schools, and for Alaskans who were eligible for public assistance, homebound, or lived in an underserved community. Dental hygienists who had a minimum of 4000 hours of clinical experience and who were approved by the Alaska Board of Dental Examiners could be advanced practice dental hygienists. Representative Spohnholz indicated the bill laid out very specific services that could be provided by permit holders and the specific populations that licensed dental hygienists could serve without supervision or the physical presence of a licensed dentist. The permit was not a cart blanch permit for practicing independently. The list of services had been developed in consultation with the Alaska Dental Society, the Board of Dental Examiners, and the Alaska Dental Hygienists Association. Advanced practice dental hygienists would have to maintain malpractice insurance, provide a written notice of their service limitations, and make a referral to a licensed dentist nearby for a patient's dental treatment. The permit would allow dental hygienists to practice to the full scope of their training, credentials, and professional experience. She noted that Alaska would not be the first state to make such changes. Dental Hygienists were able to practice under advanced practice permits or similar permits in six other states: Colorado, Montana, Maine, Connecticut, and California. She indicated 40 other states were considered direct access states. The bill would mean that dental hygienists could initiate treatment based on their assessment of a patient's need without authorization or the presence of a dentist. Alaska would not be breaking new trail; it was something done in many other states. She noted that since the prior year she had made some important changes to the bill at the recommendation of the Board of Dental Examiners and the Alaska Dental Association including requiring permit holders to maintain patient records for at least 7 years. It would ensure that the Board of Dental Examiners had separately certified a dental hygienist to administer anesthesia, and empowering DHSS to make regulations related to the bill. She reported that her aide had a PowerPoint Presentation and relayed the names of available testifiers. Co-Chair Johnston indicated Co-Chair Foster and Representative Knopp had joined the meeting. 2:43:28 PM KASEY CASORT, STAFF, REPRESENTATIVE IVY SPOHNHOLZ, introduced the PowerPoint: HB 127: Dental Hygiene Advance Practice Permit. She began with slide 2 to review the importance of the bill. She spoke of there being many unique barriers to accessing health care including dental care in Alaska. She noted that 62 percent of Alaskan elementary students had a high rate of tooth decay and, 43 percent of low-income Alaskans had trouble biting or chewing. Both young adults and low-income adults across American cited pain as their top oral health problem and, low-income families in Alaska did not regularly seek oral health care due to cost, access, or trouble finding a provider. She asserted that Alaska needed all of its qualified health professionals operating to the full scope of their training, especially when it came to caring for Alaskans with the greatest need. 2:44:27 PM Ms. Casort continued to explain the importance of HB 127 turning to slide 3. Dental hygienists were state- licensed health professionals who were trained to provide education and care that focused on preventing and treating oral diseases. However, under current statute, dental hygienists were required to work under the direct supervision of a licensed dentist or enter a collaborative agreement where they remained under general supervision. The requirements limited where and when dental hygienists could practice and was a barrier to preventative dental care for Alaskas seniors, children, and adults living with disabilities. Ms. Casort relayed with slide 4 that HB 127 created an advanced practice permit that would allow experienced, licensed dental hygienists to work independently to the full scope of their credentials and professional experience when they were caring for underserved populations. Ms. Casort turned to slide 5. She indicated that underserved populations were defined in U.S. Code under the term "dental health shortage areas," which were "geographic areas, populations, and facilities with too few dental providers and services." In Alaska, it meant an area with more than 5000 patients per 1 provider. Ms. Casort continued that dental health shortage areas in Alaska where an advanced practice permit-holder could serve included geographic areas like the North Slope Borough; facilities which primarily serve tribal populations like Mt. Edgecumbe Hospital or Chief Andrew Isaac Health Center; correctional centers like Goose Creek Correctional Center; and federally qualified health centers like the Bethel Family Clinic or Mat-Su Health Services. House Bill 127 would allow hygienists to care for Alaskans in need like elders living in senior centers, underserved children in schools, Alaskans who were eligible for public assistance, and Alaskans with disabilities for whom oral care could be a scary, uncomfortable experience. Increasing the number of underserved Alaskans receiving preventative care also meant that dental hygienists could catch more acute problems earlier on when care was less costly, painful, and inconvenient. Ms. Casort concluded that HB 127 was the next step in allowing dental hygienists to provide preventative care to patients with the greatest need. Should would be walking through the bill section-by-section. 2:46:35 PM Ms. Casort presented a sectional analysis in a prepared statement: Section 1 amends the dental hygienists' scope of practice to allow advanced practice permit holders to provide specific services independently. Section 2(a) allows the State of Alaska Board of Dental Examiners to issue advanced practice permits to hygienists with at least 4000 hours of clinical experience. Section 2(b) enumerates the services an advanced practice permit-holder can perform without the presence, authorization, supervision, or prior examination of a licensed dentist (section 2(c)), including • providing oral health education, • removing stains and deposits from the surface of the teeth, • applying preventative agents and sealants, • taking and developing x-rays, • screening for oral cancer, • using local anesthesia if separately licensed to do so by the Board, • and performing preliminary charting and triage to formulate a dental hygiene assessment and dental hygiene treatment plan. Section 2(d) requires an advanced practice permit- holder to maintain liability insurance and provide their patients or the patient's parent or legal guardian with a written notice of the services the permit allows them to perform. They must also help the patient with referrals to see licensed dentists in the area for more comprehensive dental care. Section 2(e) allows an advanced practice permit-holder to practice as an independent contractor. Section 2(f) establishes that the advanced practice permit is valid until the dental hygienist's license expires and allows the permit to be renewed at the same time as the license. Section 3 amends the grounds for discipline, suspension, or revocation of a dental hygienist's license to allow them to provide the services listed in section 2 independently without being punished. Section 3 also empowers the Board to discipline permit-holders who • allow a dental assistant under their supervision to perform procedures outside their scope of practice, • falsify or destroy a patient or facility record, • or fail to maintain a patient or facility record for at least 7 years, which is similar to the requirement for dentists. o This was added into the bill in House Labor & Commerce, at the request of the Alaska Board of Dental Examiners and the Alaska Dental Society. Section 4 amends Alaska Statue 08.36.346, Delegation to dental assistants, to allow permit-holders to delegate x-rays, application of topical preventative agents or sealants, and other tasks specified by the Board of Dental Examiners in regulation to dental assistants under their supervision. The Board is also tasked with specifying in regulation the level of supervision required over the dental assistants. Section 5 adds dental hygienists holding an advanced practice permit to the list of providers who may not be discriminated against. This prevents an insurer from refusing to reimburse the appropriately licensed provider on the basis of cost or on the basis of race, religion, gender, etc. Section 6 adds dental hygiene services to the list of services which may be provided by the Department of Health and Social Services. Section 7 allows the Department of Commerce, Community, and Economic Development, 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. Finally, Sections 8 and 9 set an effective date of July 1, 2020. Ms. Casort indicated Katrina Virgin, President of the Alaska Dental Hygienists' Association, was online as well as others to answer any questions. 2:50:02 PM Representative Sullivan-Leonard asked for information regarding the educational requirements for dental hygienists. She was seeing a correlation between a nurse practitioner and an advanced dental hygienist. Representative Spohnholz deferred to Ms. Virgin to answer the question about education. 2:50:52 PM KATRINA VIRGIN, PRESIDENT, ALASKA DENTAL HYGIENISTS ASSOCIATION (via teleconference), responded that the requirements for a dental hygienist to become licensed in any state within the lower 48 and Alaska were that they must graduate from an accredited dental hygiene school that was a CODA [Commission on Dental Accreditation] accreditation. School was typically 4 years. There were some programs that were still in existence that were 2 years. However, even the University of Alaska Anchorage had moved to a 4-year baccalaureate type program. It would take about 3 to 4 years working consecutively under the supervision of a dentist for a dental hygienist to meet the 4000 clinical hours requirement. Representative Sullivan-Leonard asked for a comparison of the requirements for an advanced nurse practitioner versus an advanced dental hygienist. Representative Spohnholz responded that a nurse practitioner had more training than a dental hygienist. However, a nurse practitioner had more authority. Nurse practitioners in Alaska had full prescriptive authority whereas, a dental hygienist would not. The training for a dental hygienist was in line with the services they would be providing. Representative Sullivan-Leonard asked for the number of years of training for an advanced nurse practitioner versus an advanced practice dental hygienist. Representative Spohnholz responded that a nurse practitioner would have a 4-year undergraduate degree and either a 2-year or 4-year graduate degree. 2:52:50 PM Representative Tilton asked if the services could be billed through Medicaid and whether a new category would be created in Medicaid. She also asked if there would be an increase or decrease in Medicaid services, overall. Representative Spohnholz responded that a dental hygienist would be able to bill Medicaid. Currently, they already did under the supervision of a dentist or through a collaborative agreement with a dentist. The legislation would allow dental hygienists to practice independently. Theoretically, there might be an increase in the number of people receiving services. However, it was unclear because eligibility or the number of services available would not change. There was a finite number of people eligible for Medicaid in the State of Alaska and a finite number of services that could be provided. House Bill 127 would make it easier and more cost effective for people to receive the preventative care that dental hygienists provided as opposed to the treatment options that dentists provided. Frequently, people stated they were going to the dentist when they were really going to a dental hygienist for a routine cleaning or other prophylactic treatments used for cavity prevention and the prevention of other more expensive care. 2:54:25 PM Representative Tilton asked if the bill sponsor thought there was confidence in allowing a new category of advanced practice hygienists. She wondered if people would be more comfortable about getting preventative dental care. She noted there were existing challenges in getting people to receive preventative dental care. Representative Spohnholz responded that the proposal was structured to allow people to receive care where they lived. They might be able to avoid going to an office to receive dental care. They might be able to have a dental hygienist go onsite to places such as nursing homes, day care centers, elementary schools, and senior centers. She thought some of the barriers would be reduced to getting needed preventative care. She also thought the legislation would increase access for people who were physically challenged in going to the dentist's office. 2:55:49 PM Co-Chair Foster asked if the bill sponsor had reached out to any of the hospitals in rural areas. He wondered if she had received any feedback from any folks from the rural areas of Alaska. Representative Spohnholz responded that she had not received any feedback from providers or hospitals in the rural areas. She surmised that the bill would be viewed very favorably by the people in the rural areas, as the bill would increase access to care. She was aware of huge challenges in getting access to dental care in rural Alaska which precipitated the creation of the dental health aide therapist. They did amazing work in rural Alaska and dramatically increased access to dental care. The bill before the committee would be adding another level of possible provider care in rural Alaska. Dental hygienists would also be more affordable than would dentists, as they had few university bills to pay off. 2:56:56 PM Vice-Chair Ortiz referred to slide 4 and noted that in order for a dental hygienist to receive an advance practice permit they could only do so in underserved areas. He asked how extensive the list was that was mentioned on the slide. Ms. Casort noted she could provide the extensive list which included many facilities across Alaska, but specifically underserved areas. She could also provide how the information was calculated which factored in the patient-to-provider ratio, whether water was fluoridated, and how long it took to access a dentist. She had outlined the factors which were considered in scoring between 0 and 26. She would provide more detail to the committee. 2:58:15 PM Representative Tilton asked if it was an appropriate time to discuss the fiscal note. Co-Chair Johnston indicated there would be another time available for fiscal note questions. Representative Wool had a couple of questions related to the list of underserved populations. He had a letter from Mary Cerney from Fairbanks which mentioned that the bill would eliminate barriers to accessing care desperately needed by many people. He thought one of the barriers to care was that some people could not afford it. He wondered if, by approving an advanced practice certificate for dental hygienists, low-income people would have more access just on the basis of being low-income as opposed to being in a geographical area where the ratio was not as high as in urban centers. Representative Spohnholz responded that a person would have to be low-income and receiving services in a dental professional shortage area or in one of the facilities listed on page 3 starting on line 2. The list included a senior center, a hospital long-term care facility, an adult foster home, and a residential care facility. The list was long. The list continued to page 3, line 12 of the bill. She informed the committee that the word "and" was stipulated. A person had to meet the first 3 criteria and receive services in one of the centers or live in a dental health professional shortage area. The bill was not designed to allow a dramatic expansion of those people that would be providing services. The bill targeted a very, specific, and under-served population. Representative Wool noted that there were 703 dental hygienists in Alaska. He supposed there were shortages in some areas around the state. He asked if the bill sponsor envisioned dental hygienists leaving their current workplace to become an advanced dental hygienist and exacerbating any shortages. Representative Spohnholz reported that there was a shortage of dental healthcare in Alaska, particularly in the underserved populations. She did not believe creating the advanced practice license would exacerbate the shortage. She thought it would help redistribute access to dental hygiene care, which was really important. Many of the places where advanced practice dental hygienists would practice would be in locations currently without appropriate care. She reported that the Alaska Dental Hygiene Association estimated that of the 703 dental hygienists, approximately 5 percent would explore an advanced practice license in order to practice independently, which was on par with nurses. She indicated there were about 5.5 percent of nurses in the State of Alaska that were advanced practice nurses. She did not think the legislation would change the total number. Rather she thought it would help reallocate the resource to get it to the people that needed it most. Representative Wool suggested that 5 percent of hygienists would equal about 3500 hygienists. The current population of hygienists would go into advanced practice. He suspected the model would be such that a practitioner would leave the office they were currently in to go to an undeserved area. He wondered about the potential for a practitioner to continue working in their current office a couple of days and on their own another couple of days per week. Ms. Virgin offered that it was common for dental hygienists to work in several facilities in a week. The goal would not be to work in one location. The bill would allow for a practitioner to work at multiple facilities and would open up what services hygienists could provide. Representative Wool asked if there was a dental hygienist program currently in Alaska. Representative Spohnholz responded affirmatively. Ms. Virgin added that there was a degree program for dental hygienists through the University of Alaska Anchorage. The University offered a 4-year degree, a CODA approved dental program. The University focused on public health initiatives and going out to different rural areas to provide treatment. The University wanted to see equal access to care. Co-Chair Johnston set the bill aside. HB 127 was HEARD and HELD in committee for further consideration.