HOUSE BILL NO. 111 "An Act relating to the practice of dental hygiene; relating to advanced practice permits for dental hygienists; relating to dental assistants; 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." 10:25:39 AM REPRESENTATIVE IVY SPOHNHOLZ, SPONSOR, introduced the bill with a prepared statement as follows: House Bill 111 creates an Advanced Practice Permit which will allow experienced, licensed dental hygienists to provide preventative oral health care to underserved populations at senior centers, health care facilities, day cares, and schools, and for Alaskans who are eligible for public assistance, are homebound, or who live in underserved rural communities. • Oral health care plays a crucial role in the overall health and well-being of Alaskans. Poor oral health care contributes to poor overall health. • This is problem is worst amongst our state's most vulnerable populations: • Many low income individuals and families in Alaska don't regularly seek oral healthcare due to cost, apprehension of dental work, access, and trouble finding a provider. • Bad oral health is linked to cardiovascular disease, Alzheimer's, osteoporosis, as well as poor nutrition and other serious health issues. • So, increasing access to preventative dental healthcare will save and improve Alaskan's health. • HB 111 aims to increase access to oral healthcare to underserved populations, specifically children, seniors, and individuals with disabilities. • By expanding access, HB 111 creates an advanced practice permit for dental hygienists. • Currently, dental hygienists can practice in a dentist's practice or practice semi-independently if they have a collaborative agreement with a dentistsimilar to what Physicians Assistants do. HB 111 creates an Advanced Practice Permit which will allow dental hygienists to care for underserved populations at senior centers, health care facilities, day cares, and schools, and for Alaskans who are eligible for public assistance, are homebound, or who live in an underserved community. If they have the following: 1. minimum of 4,000 hours of clinical experience and 2. are approved by the Alaska Board of Dental Examiners. • The bill lays out the specific services allowed under the permit and the specific populations that a licensed dental hygienist can provide services to without the supervision or physical presence of a licensed dentist. This list has been developed in consultation with the Alaska Dental Society, Board of Dental Examiners, and Alaska Dental Hygienists Association. • The Advanced Practice Permit-holder will have to maintain malpractice insurance, provide a written notice of their service limitations, and make a referral to a licensed dentist nearby if further dental treatment is needed (Section 2(d)). • This will allow dental hygienists to practice to the full scope of their training, credentials, and professional experience. • Alaska won't be the first state to make these changes. Dental hygienists are able to practice under advance practice permits or similar permits in six other states (Colorado, Washington, Montana, Maine, Connecticut, and California) and 40 other states are considered "direct access" states, meaning that dental hygienists can initiate treatment based on their assessment of a patient's needs without the authorization or presence of a dentist. • Lastly, I'll note that we have already made important changes to this bill at the recommendation of the Board of Dental Examiners and the Alaska Dental Society, including: • requiring permit-holders to maintain patient records for at least 7 years, • making sure that the Board of Dental Examiners has separately certified a dental hygienist to administer local anesthesia, and • empowering the Department of Health and Social Services to make regulations related to the bill. 10:28:58 AM Representative Spohnholz listed individuals available to testify. Representative Thompson asked how many advanced hygiene practice permits were expected to be issued at the start. Representative Spohnholz answered that there were currently 659 registered dental hygienists in the state and roughly 10 percent of dental hygienists in Alaska would be eligible. She reiterated that the candidates needed 4,000 hours of experience and would have to be approved by the Board of Dental Examiners. Therefore, roughly 65 dental hygienists would be eligible. Representative Wool asked for verification that the bill did not expand the scope of practice and that hygienist were currently allowed to give local anesthesia. Representative Spohnholz answered affirmatively. She elaborated that hygienist were currently allowed to give local anesthesia on a limited basis. She determined that if the bill did expand the scope of practice, dentists would oppose the legislation. She related that dentists were in full support of the bill. 10:31:22 AM Vice-Chair Ortiz spoke to the issuance of an advanced practice permit and wondered whether it would allow the hygienist to practice independently and open a clinic anywhere, if they felt the market would be supportive. Representative Spohnholz answered that the intent of the bill was to increase access to preventative dental care, not to increase competition with dentists. She furthered that the intent of the bill was that hygienists would meet the needs of underserved populations. PAKAK SOPHIE BOERNER, STAFF, REPRESENTATIVE IVY SPOHNHOLZ, interjected and directed members attention to a document in the members files titled Frequently Asked Questions (FAQs) (copy on file). She noted that in the document Vice-Chair Ortizs question was addressed. She relayed that in other states the advanced practitioners worked part-time in dental shortage areas as well as continuing to work part-time in traditional private or public health dental offices. 10:33:56 AM Representative Josephson asked if a dental hygienist sometimes worked less than 40 hours per week due to the strenuous work. He wondered whether the advanced practice work would be supplemental in nature. Representative Spohnholz deferred the answer. ROYANN ROYER, CERTIFIED DENTAL ASSISTANT, ANCHORAGE (via teleconference), shared that she worked in the field as a practitioner and educator for 35 years. She answered that she expected most people to engage in the advanced license as a primary practice. She thought that others may do the work as an extra job. Representative Josephson wondered how the practitioner's typical day would change. Ms. Royer answered that the individuals would be doing the work in underserved areas without a dentist as their primary practice and it may be supplemental or not. Representative Josephson asked for verification that the individuals would remain connected to a dental practice. Ms. Royer answered that the practitioner would not necessarily have to be associated with a specific private practice. Representative Spohnholz clarified that the bill would create a new standard of licensure for dental hygienists that would allow them to practice independently without a dentists supervision to practice in a very narrow scope, in communities without access to dental care like senior centers and nursing homes. She furthered that the advanced practitioner could still practice under a dentist, but it was anticipated that it would become a specialty of certain practitioners. She reminded the committee that the licensing process was very rigorous. She concluded that there would be a very high bar set for the licensee and the individuals would be providing services to a small population of underserved individuals. She characterized the service as niche. 10:38:46 AM Ms. Royer interjected that currently she was working under a Collaborative Practice Agreement that allowed a hygienist to work independently under the general supervision of a dentist. She currently worked at Prestige Rehabilitation Center Long-Term Care, and the Alaska Pioneer Homes. She furthered that the bill would allow an advanced hygienist to work independently and refer a patient to a dentist in the area. Ms. Boerner provided a PowerPoint presentation titled "HB 111: Dental Hygiene Advanced Practice Permit" (copy on file). She began with slide 2 titled Why is HB 111 Important? She relayed that according to the American Dental Association Health Policy Institute 2015 document titled "Oral Health and Well-Being in the Alaska, 62 percent of Alaskan elementary students have a high rate of tooth decay rate. In addition, 43 percent of low-income Alaskans have difficulty biting and chewing. Pain is the top oral health problem for young adults and low-income adults in America. Low-income families in Alaska don't regularly seek oral health care due to cost, access, or trouble finding a provider. 10:40:37 AM Ms. Boerner moved to slide 3 titled titled "Why is HB 111 Important? Dental diseases disproportionately affect our state's most vulnerable people. Dental hygienists are the front line for preventative dental care and education about the critical link between oral health and overall, wellbeing. HB 111 increases access to oral health care for underserved populations: ? Children ? Seniors ? Alaskans with disabilities ? Alaskans in correctional facilities 10:41:40 AM Ms. Boerner reviewed the sectional analysis of the bill in lieu of slide 4 (copy on file): Section 1 Ability of practice of dental hygienists. (e) Amends AS 08.32.110. to allow a licensed dental hygienist who holds an advanced practice permit issued by the board to perform duties allowed by the permit. Section 2 Advanced practice permits. Adds a new section under AS 08.32.125. creating the advanced practice permit and providing requirements as follows: (a) The Board of Dental Examiners may issue an advanced practice permit to a licensed dental hygienist with a minimum 4,000 documented hours of clinical experience. This subsection lists what duties fall under advanced practice permits: general oral health & cleaning, providing treatment plans, screenings, taking radiographs, and/or delegating to dental assistants. (b) A licensed dental hygienist holding an advanced practice permit may provide services to a patient who is not able to receive dental treatment because of age, infirmity, or disability. The patient may be a resident of a senior center, residential health facility, or held in a local correctional facility. The patient may also be enrolled in certain schools, receiving benefits under the Special Supplemental Food Program (WIC), homebound, or a resident of a community that has a shortage of dental health professionals. (c) A licensed dental hygienist holding an advanced practice permit can provide appropriate services to a patient without the presence, authorization, and supervision of a licensed dentist and without an examination from a licensed dentist. (d) Licensed dental hygienists with an advanced practice permits must maintain professional liability insurance. They must also give the patient, parent, or legal guardian written notice that the treatment provided will be limited to those allowed by the permit, a written recommendation that the patient be examined by a licensed dentist for comprehensive oral care, and assistance in receiving a referral to a licensed dentist for further oral treatment. (e) 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. Section 3 Grounds for discipline, suspension, or revocation of license. Amends AS 08.32.160 to exempt a licensed dental hygienist as permitted under an advanced practice permit from supervision requirements for clinical procedures. Licenses may be revoked if a dental hygienist allows a dental assistant to perform a prohibited procedure, or if the licensee falsified, destroyed, or failed to maintain a patient or facility record for the last seven years. Section 4 Allows a dental hygienist holding an advance practice permit to delegate to a dental assistant the exposure/development of radiographs, the application of preventative agents, and other tasks as specified by the board in regulations. Section 5 Prohibits insurance providers from discriminating against dental hygienists holding advanced practice permits. Section 6 This section is amended to include dental hygienist services in the optional services 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. The regulations may not take effect before the effective date of this bill. Section 8 Section 7 on regulations takes effective immediately. Section 9 Effective date for sections 1-6 is July 1, 2022. 10:45:44 AM Ms. Boerner turned to slide 5 that listed the Dental Health Professional Shortage Areas (DHPSA) in Alaska and concluded her presentation. She noted that the shortage areas were in geographic DHPSAs, Alaskan Native Tribal populations, state provided situations such as correctional facilities, and federally qualified health centers. Representative Spohnholz suggested that the invited testifiers be heard. Ms. Royer provided further invited testimony. She emphasized that she worked under a Collaborative Practice Agreement, which she currently practiced under at two long- term care facilities. She began the non-profit organization 5 years ago and hoped to expand beyond the two facilities. The agreement allowed a hygienist to practice independently under the general supervision of a dentist. The legislation would expand access to dental care by allowing hygienists to work independently to provide services, be able to bill for services provided, and refer to a dentist when needed. The collaborative practice had improved access to care. However, many hygienists who want to work in underserved areas cannot find a dentist who will work in a collaborative agreement. She reported that a dental hygienist in Fairbanks initiated the legislation due to that scenario. She believed that new ways of bringing oral health care to underserved populations were needed and was the reason dental practitioners supported HB 111. The legislation would foster an opportunity to revise efficiency and cost-saving methods to assist the underserved populations. She emphasized that routine exams and cleanings were less expensive than waiting for the patient to notice problems or experience pain before seeking out a dentist. A hygienist could assess minor issues and refer the patient to the dentist prior to it turning into a larger more costly problem. She pointed out the many correlations recognized between oral health, overall health, and systemic conditions such as pneumonia, heart disease, and diabetes. 10:48:30 AM Vice-Chair Ortiz appreciated the intent of the bill. He was unclear whether someone who received the advanced practice permit was responsible for deciding where they could open a clinic to offer services or were limited to the DHPSAs. Ms. Royer replied that the bill specified that the practice could only be in underserved areas and the hygienist could decide which underserved area she would prefer to work in. She ascertained that it would likely be in consultation with a dentist working in the underserved area and would still work collaboratively with the dentists in the area. Vice-Chair Ortiz asked for clarification that the underserved areas were clearly defined. Ms. Royer answered in the affirmative. Representative Spohnholz directed attention to the areas in the bill where the permitted hygienist could practice; Section 2, subsection (b) on page 3, line 1. She stressed that the bill clearly lists the underserved areas of the state. 10:51:17 AM Representative Wool noted that Ms. Royer had stated she had a collaborative agreement allowing her to work in underserved areas. He asked if her job would change much if she received the advanced licensure. Ms. Royer stated that she personally would not change licensure and her collaborative agreement was working well. She viewed the collaborative agreement, and the advanced practice permits separately. She would continue working under the collaborative agreement with a dentist. She provided a scenario where dentists in the area did not want to work with a collaborative agreement; the advanced practice permits would fill the gap. Representative Wool asked if there was an advantage to a collaborative agreement versus an advanced practice permit. He asked what she would be required to do if she chose to become an advanced practitioner. Ms. Royer answered that she would need to fill out an application and appear before the board. Representative Spohnholz noted there was a member of the Board of Dental examiners on the invited testifier list. Representative Wool restated his question regarding an advantage to remain in a collaborative agreement versus holding an advanced permit. 10:54:05 AM Ms. Royer answered that it was an advantage to her to have a collaborative agreement because she worked with the same dentists that provided care at the facilities, she provided care in. Representative Wool asked if it was a common agreement. Ms. Royer answered there had only been collaborative agreements for about 10 years and it was working well. She did not know the number of hygienists working under a collaborative agreement. Representative Spohnholz interjected that there were five hygienists in the state that practiced under collaborative agreements. She asked to hear from the Department of Commerce, Community and Economic Development (DCCED). SARA CHAMBERS, DIRECTOR, DIVISION OF CORPORATIONS, BUSINESS AND PROFESSIONAL LICENSING, DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT (via teleconference), agreed with Representative Spohnholz. She responded that there were 5 hygienists working under a collaborative agreement. Representative Thompson thought the permit would allow a dental hygienist to practice independently. He asked if there would be an additional fee for the permit. Ms. Chambers replied in the affirmative. The hygienist was required to be registered as a hygienist before applying for the advanced permit. The certification would likely be an endorsement to a dental hygiene license. She related that she worked with the board and discussed the fee setting process. It was currently difficult to assess the amount of an additional fee since the number of applicants were unknown. 10:57:02 AM Representative Thompson asked if the advanced practitioner did anything out of their scope of practice would it warrant an investigation. Ms. Chambers responded that the advanced practice permit would fall under the Board of Dental Examiners authority to review and revoke permits. The permit would be exactly like all other types of licenses issued - a fee would be paid to practice and hopefully they would practice lawfully. In the event of a complaint or some other triggering event, investigators would investigate an individual and the board would ultimately decide if a violation took place and how to remediate it. She reminded the committee that by statute the license had to be self-funding; if there were investigations the increased fees would be covered by all the dental licensees. Representative Thompson asked about a scenario where there were extensive investigations of advanced practice permit holders. He wondered whether all licensees under the licensure would be liable for the investigative costs or only the advanced practice permit holders. Ms. Chambers answered that she did not anticipate many and likely not any additional investigations. She elucidated that statute required each license program to pay for itself. The division considered investigative fees the same as administrative fees therefore, the program was required to cover the costs via discussions with the dental board. Investigations were not linked by license type so it was possible all license holders would be liable. 11:01:23 AM Co-Chair Merrick asked to hear from the additional invited testimony. GREG JOHNSON, MEMBER, BOARD OF DENTAL EXAMINERS, FAIRBANKS (via teleconference), shared that he practiced pediatric dentistry in Alaska since 1987. He noted that the questions being asked by the committee were spot on. He reported that during the prior legislative session, the board had contemplated the introduction of the bill. The board was in unanimous support of the advanced practice permit. He elaborated that the advanced practice and the collaborative agreement were similar. He estimated that that the number of advance practice permit holders would be less than 10. He indicated that the permit holders would be able to practice independently and there would be a bit more skin in the game in terms of carrying liability insurance, paying staff, and overhead. The board would watch the advanced practitioners very carefully over the next few years. He was reassured that there were some guard rails in the bill. He suggested that preventative and maintenance care was essential for positive outcomes. The board endorsed the bill because it put the right people with the right training with the right oversight in the right places. He was available for questions. Co-Chair Merrick appreciated the doctor calling in. 11:06:18 AM Representative Josephson referenced subsection (b) on page 3 of the bill. He wondered if the practice would be Medicaid eligible. Representative Spohnholz answered in the affirmative and indicated it was a critical element of the bill. Representative Josephson asked whether patients with private insurance and were not Medicaid eligible would have the service covered. Representative Spohnholz responded that the bill applied only to underserved areas, if someone was in the underserved population private insurers were required to cover the services. She did not expect a large utilization in the private insurance market because the bill targeted an underserved population that was typically in a rural community and covered by tribal health or economically underserved and would be covered by Medicaid. She did not expect a large amount of insurance pay. 11:08:23 AM Representative LeBon thanked Dr. Johnson for calling in on a Saturday and recognized that he was recently confirmed by the legislature for his board appointment. Mr. Johnson affirmed that he was recently named to the Board of Dental Examiners. Representative Wool echoed Representative LeBon's comments to Dr. Johnson. He provided a scenario where a hygienist was under collaborative agreement, and it was determined that a patient needed medication. He guessed that it would be filled by the collaborating dentist. He assumed hygienists did not have prescription power. He asked if the advanced hygienist would refer the patient to a dentist. 11:10:54 AM Representative Spohnholz replied that if a dental hygienist identified something out of the scope of their training and practice, they were required to refer patients to a dentist. She pointed to page 3, line 29, Section 2, Subsection (d) in the bill, requiring a referral to a dentist for anything outside the scope of their licensure. She voiced that an advanced practitioner would uphold the statute. Representative Wool concluded that the advanced permit holder could not prescribe drugs. Representative Spohnholz affirmed the statement. HB 111 was HEARD and HELD in committee for further consideration. Co-Chair Merrick announced that amendments were due by Tuesday at noon. She reviewed the schedule for the following meeting.