HB 111-DENTAL HYGIENIST ADVANCED PRAC PERMIT  3:21:10 PM CO-CHAIR FIELDS announced that the next order of business would be 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." 3:21:24 PM CO-CHAIR SPOHNHOLZ, as prime sponsor, introduced HB 111. She explained that the advanced practice permit created under HB 111 would allow experienced, licensed dental hygienists to provide preventative oral care to underserved populations at senior centers, healthcare facilities, daycares, and schools, as well as to those who are eligible for public assistance, are homebound, or who live in an underserved community. Pointing out that 62 percent of Alaska's elementary-aged children have tooth decay, and many low income families don't regularly seek dental care due to cost and difficulty in finding a provider, she explained that HB 111 would create a permit for dental hygienists similar to one used by nurse practitioners. Currently, she said, dental hygienists can either practice in a dental office or collaboratively with a supervising dentist; HB 111 would allow hygienists who have at least 4,000 hours of clinical experience and have been approved by the Alaska Board of Dental Examiners to work independently via a direct care agreement with a dentist. CO-CHAIR SPOHNHOLZ noted that the proposed legislation was developed in consultation with the Alaska Dental Society, the Board of Dental Examiners, and the Alaska Dental Hygienist Association. The advanced practice permit holders would have to maintain malpractice insurance, she said, provide written notice of their service limitations, and make referrals to dentists for cases in which treatment is needed. Co-Chair Spohnholz noted that Colorado, Washington, Montana, Maine, Connecticut, and California allow dental hygienists to practice under a similar permit, with 40 other states allowing dental hygienists the latitude to initiate treatment based on their patients' needs without prior authorization from, or presence of, a dentist. At the recommendation of the Board of Dental Examiners and the Alaska Dental Society, she said, HB 111 includes the requirement that dental hygienists operating under the advanced practice permit maintain patient records for at least seven years, as well as be certified separately by the Board of Dental Examiners to administer local anesthesia. 3:25:05 PM PAKAK BOERNER, Staff, Representative Ivy Spohnholz, Alaska State Legislature, presented a PowerPoint [hard copy included in the committee packet] titled "HB 111: Dental Hygiene Advanced Practice Permit," on behalf of Co-Chair Spohnholz, prime sponsor. She began the presentation on page 2, "Why is HB 111 Important?", which read as follows [original punctuation provided]: 43% of low-income Alaskans have difficulty biting and 1 chewing. Low-income families in Alaska don't regularly seek oral health care due to cost, access, or trouble 1 finding a provider. 62% of Alaskan elementary students have a high tooth 2 decay rate . Pain is the top oral health problem for young adults 3 and low-income adults in America. 1 American Dental Association Health Policy Institute 2015: "Oral Health and Well-Being in the Alaska" 2 Alaska Department of Health & Social Services 2012- 2016: " Alaska Oral Health Plan" 3 American Dental Association Health Policy Institute 2015: "Oral Health and Well-Being in the United States" MR. BOERNER presented slide 3, "Why is HB 111 Important?", which read as follows [original punctuation provided]: ? Dental diseases disproportionately affect our state's most vulnerable people. ? Dental hygienists work on the front line for preventative dental care and education about the critical link between oral health and overall well- being. ? HB 111 increases access to oral health care for underserved populations: ? Children ? Seniors ? Alaskans with disabilities ? Alaskans in correctional facilities MS. BOERNER presented slide 4, "What Does HB 111 Do?", which read as follows [original punctuation provided]: HB 111 creates an advanced practice permit. ? This permit allows experienced, licensed dental hygienists to work independently without on-site supervision when providing dental care. 3:26:55 PM MS. BOERNER paused the PowerPoint to detail the sectional analysis, which read as follows [original punctuation provided]: 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) Licensed dental hygienists with advanced practice permits may practice as independent contractors. (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. 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 licensee 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. 3:32:13 PM MS. BOERNER resumed the PowerPoint presentation with slide 5, "Dental Health Professional Shortage Areas (DHPSA) in Alaska," which read as follows [original punctuation provided]: In 2021 there are 679 licensed dental hygienists in Alaska Geographic DHPSAs (e.g. Aleutians East Borough, North Slope Borough, Yukon-Koyukuk Census Area) Alaskan Native Tribal Populations (e.g. SEARHC/Mt. Edgecumbe Hospital, Norton Sound Health Corporation Outpatient Primary Care, Kana Clinic Native Village of Karluk, . Chief Andrew Isaac Health Center, Eklutna Health Clinic, Upper Tanana Health Center,Dena' Nena' Henash) Correctional Facilities (e.g. Lemon Creek Correctional Facility, Yukon Kuskokwim Correctional Facility, Anvil Mountain Correctional Facility ) Federally Qualified Health Centers (e.g. Bethel Family Clinic, Mat-Su Health Services, Southeast Alaska Region Health Consortium) Full index of all Dental Health Professional Shortage Areas here: https://data.hrsa.gov/tools/shortage- area/hpsa-find 3:32:37 PM CO-CHAIR SPOHNHOLZ noted that in attendance via teleconference were representatives of the Alaska Dental Hygienists' Association, Alaska Primary Care Association, and HyLife Oral Health Alliance. Also in attendance via teleconference, she said, is a former state senator from Minnesota who worked on similar statutes. 3:33:06 PM CO-CHAIR FIELDS referred to the language of HB 111, page 3, line 31 through page 4, line 1, which read, "(e) A licensed dental hygienist holding an advanced practice permit may practice as an independent contractor." He then asked for explanation of that subsection. CO-CHAIR SPOHNHOLZ responded that a dental hygienist holding an advanced practice permit ("advanced practice dental hygienist"), and who is in a collaborative agreement with a dentist, would be able to have an independent practice similar to that of a physician's assistant (PA). She said that many of the urgent care centers in Southcentral Alaska are owned and operated by PAs who have direct care agreements with doctors; under HB 111, dental hygienists with an advanced practice permit may operate in a similar manner. CO-CHAIR FIELDS said that the term "independent contractor" usually has other implications in terms of labor law, workers' compensation, and minimum wage. He expressed that he did not want to unintentionally exclude someone from workers' compensation coverage through the language of the bill, and asked for testimony from Legislative Legal Services at the next meeting. CO-CHAIR SPOHNHOLZ said that she would follow up. CO-CHAIR FIELDS pointed out that pediatrics is an area in which advanced practice dental hygienist could practice, and he asked whether there is data on accessibility for pediatric dentistry in Anchorage, and how pediatric dentistry would be addressed by HB 111. He said, "My sense is there are lots of pediatric dentists, so the supply is there in terms of the practitioners, but what are the barriers in terms of kids who don't actually have pediatric care?" CO-CHAIR SPOHNHOLZ replied that the populations proposed to be served by the creation of the advanced practice permit are underserved populations, such as low income families and those who lack access to adequate dental health care. She explained that underserved populations also include those who receive services through federally-qualified health centers (FQHCs) like Anchorage Neighborhood Health, which could hire an advanced practice dental hygienist to provide dental care for the population it serves. CO-CHAIR FIELDS asked Ms. Menkens what percentage of kids are not receiving adequate dental care and, should HB 111 pass, how she envisions care reaching the kids. 3:36:06 PM JESSIE MENKENS, Policy & Partnerships Manager, Alaska Primary Care Association, replied that she doesn't have data on pediatric dental care accessibility but that she would be happy to follow up. She referred to Co-Chair Spohnholz's description of the FQHCs and said that those facilities have a mandate to provide "safety net" care regardless of an individual's ability to pay. Within the FQHCs, she said, families rely on pediatric dental health care. She stated the Alaska Primary Care Association's support of HB 111 and said that its provisions are becoming a national "best practice" with positive impact. 3:37:21 PM REPRESENTATIVE MCCARTY referred to page 2, lines 5-8, of HB 111, which read as follows: Sec. 08.32.125. Advanced practice permits. (a) The board 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 holding an advanced practice permit may REPRESENTATIVE MCCARTY asked whether there is a definition for "hours of clinical experience." CO-CHAIR SPOHNHOLZ deferred to Ms. Bryant. 3:37:58 PM LISA BRYANT, Legislative Co-Chair, Alaska Dental Hygienists' Association, explained that 4,000 hours of clinical experience equates to approximately two to three years' experience, which is the same amount of time required by the state to have a collaborative agreement with a dentist. REPRESENTATIVE MCCARTY asked whether there is a difference between hours providing direct patient care versus hours working on notes or reviewing charts. MS. BRYANT responded that there is no differentiation between those tasks because every time care is provided to a patient, the dental hygienist is performing tasks such as reviewing the patient's health history, assessing patient needs, or reviewing radiographs. REPRESENTATIVE MCCARTY asked whether other states differentiate between hours providing direct patient care versus hours reviewing patient charts or notes. MS. BRYANT replied that she has not experienced any such differentiation. 3:39:46 PM CO-CHAIR SPOHNHOLZ interjected that Ms. Reetz, who has earned the equivalent of the advanced practice permit in Oregon, may be able to provide more details. 3:40:04 PM LORI REETZ, President, Alaska Dental Hygienists' Association, clarified that she has only practiced dental hygiene in Alaska; however, she graduated with a bachelor's degree in dental hygiene in Oregon, where the curriculum includes practice to obtain an Oregon license similar to the advanced practice permit as proposed under HB 111. 3:41:35 PM REPRESENTATIVE MCCARTY stated that one of his concerns is ensuring that a practitioner has experience with patient care instead of only paperwork experience. CO-CHAIR SPOHNHOLZ said that the intention of the proposed legislation is to make the licensure available only to a practicing dental hygienist who has 4,000 hours of experience prior to seeking licensure. REPRESENTATIVE MCCARTY stated his understanding that in order to receive the advanced practice permit, one must be a dental hygienist with 4,000 hours of practice. CO-CHAIR SPOHNHOLZ replied, "Yes, sir." REPRESENTATIVE MCCARTY referred to the text of HB 111, page 4, lines 2-4, which read as follows: (f) An advanced practice permit is valid until the expiration of the dental hygienist's license to practice. A licensed dental hygienist may renew an advanced practice permit at the time of license renewal under AS 08.32.071. REPRESENTATIVE MCCARTY said, "Did I overhear that a person, as an advanced practitioner, has to have two licenses, not just one?" CO-CHAIR SPOHNHOLZ replied that one must have received approval and licensure in order to become a dental hygienist, and subsequently seek the additional licensure in order to become an advanced practice dental hygienist. REPRESENTATIVE MCCARTY asked whether the same process is followed for a nurse practitioner. CO-CHAIR SPOHNHOLZ explained that a nurse practitioner may go all the way through school to achieve that licensure without independent practice, with clinical hours as part of the training; for example, a biology degree, followed by a master's or doctoral degree, would include clinical experience, with independent practice thereafter. She said that this licensure is different because one would do clinical training to become a dental hygienist, followed by additional training to get the advanced practice permit. REPRESENTATIVE MCCARTY stated his understanding that a dental hygienist with an advanced practice permit would, under HB 111, have to have two licenses: a dental hygienist license, and an advanced practice permit. He asked why two licenses are necessary for a dental hygienist to operate under an advanced practice permit, when the same thing is not required for nurse practitioners. CO-CHAIR SPOHNHOLZ responded that the advanced practice permit is designed to build onto a dental hygienist license after they've gotten the requisite clinical experience. She explained that a nurse practitioner can proceed forward through their training and, after graduating with a master's degree or doctorate, go directly into practice. She pointed out that a nurse practitioner has a much wider scope of practice and isn't required to have a direct care agreement with a doctor. She said that a better comparison in training and licensure would be the process of becoming a physician's assistant: a medical professional who has practiced in their field, returns to school to receive additional training, and then practices in partnership with a direct care agreement under a supervising physician. REPRESENTATIVE MCCARTY referenced Co-Chair Fields' earlier questions about page 3, line 31 through page 4, line 1, of the proposed legislation, which read, "(e) A licensed dental hygienist holding an advanced practice permit may practice as an independent contractor." He stated the understanding that this subsection would give the advanced dental hygienist the ability to have their own practice. Co-Chair Spohnholz stated her agreement, and he said, "So they would not be under a dentist, if that's the case." He then surmised that in the scenario described by Co-Chair Spohnholz, advanced practice dental hygienists "would actually have their own practice, and they'd have people working for them, even potentially a dental hygienist under the advanced [practice permit]." CO-CHAIR SPOHNHOLZ responded, "Both of those things are sort of true." A physician's assistant, she explained, has a direct care agreement with a physician, yet can still have an independent practice. An advanced dental hygienist would have a direct care agreement with a dentist but would be able to operate their own practice. 3:47:17 PM CO-CHAIR FIELDS asked for input from Legislative Legal Services. 3:47:26 PM REPRESENTATIVE KAUFMAN asked whether the proposed legislation includes provisions for radiography such as what would be found in a dental office. CO-CHAIR SPOHNHOLZ deferred to Ms. Bryant. 3:48:03 PM MS. BRYANT explained that dental hygienists are highly trained in radiography and, as advanced dental hygienists, could use portable radiography units in their treatment plans and assessments. She offered clarification on the collaborative agreements and said that the advanced practice permit would allow a dental hygienist to work without a dentist's authorization. REPRESENTATIVE KAUFMAN asked how an advanced practice hygienist would manage radiation safety. He said that he wants to ensure that radiation safety requirements would match what is required of a dentist office. MS. BRYANT responded that radiation safety devices such as lead aprons and thyroid collars are employed. She said that dental hygienists practice the radiation safety training given during their education. 3:50:45 PM CO-CHAIR SPOHNHOLZ interjected to point out that it was an earlier version of HB 111 that included the direct care agreement; the current version does not include that provision. She then pointed out that the issue of all regulations associated with radiography are determined by the Board of Dental Examiners, and that an advanced practice hygienist would be required to follow all rules and regulations set forth by the board. CO-CHAIR FIELDS asked to hear testimony from representatives of the Board of Dental Examiners and the Alaska Dental Association during the next meeting. 3:51:26 PM REPRESENTATIVE KAUFMAN asked whether professional liability would be commensurate with that faced by dentists. MS. BRYANT responded that professional liability would be covering practices performed as dental hygienists. CO-CHAIR SPOHNHOLZ explained that a dental hygienist's scope of practice is much narrower than that of a dentist. She also noted that a representative from the Board of Dental Examiners is expected to provide testimony at the next hearing. REPRESENTATIVE KAUFMAN said, "I appreciate that their scope is different, but there's a little bit of convergence with the expanded scope." He then asked whether the intent of HB 111 is to limit services provided by an advanced dental hygienist to underserved populations, or to make care available to anyone. CO-CHAIR SPOHNHOLZ clarified that the advanced practice permit would not expand the scope of practice for dental hygienists, it would simply allow them to practice independently. She said, "What dental hygienists do will not change, and I think that's a very important distinction." She described HB 111 as a "carefully crafted compromise" between dental hygienists and dentists, and she expressed the belief that, if HB 111 proposed expanding the dental hygienists' scope of practice, the dental society might not be supportive of the proposed legislation. She said that the intention is to increase access to dental health care for underserved communities. She noted that there are many communities throughout the state with economies that don't support dental health care; there are also people who live in facilities that don't get access to regular dental health care. Communities to which dentists won't travel could benefit from the dental health care provided by advanced dental hygienists. She stressed that the dental society has been supportive of the proposed legislation for the past three years. REPRESENTATIVE KAUFMAN asked whether Anchorage, with its adequate level of dental health care access, could expect to see businesses opening to practice the scope of work as described in the proposed legislation. CO-CHAIR SPOHNHOLZ replied that nothing in the proposed legislation prohibits an advanced dental hygienist from opening a business in Anchorage, given that the hygienist operate within their limited scope of training and authorization by the Board of Dental Examiners. 3:55:12 PM CO-CHAIR FIELDS asked whether a dental company could lay off all of their dentists and hire dental hygienists instead. CO-CHAIR SPOHNHOLZ responded that dentists do not provide the preventative care that dental hygienists do. Typically, she said, when one goes to the dentist's office, it's only the dental hygienist providing the care. A dentist may do a brief exam, but it's the dental hygienist taking any x-rays, cleaning, and doing the screening. She said that HB 111 wouldn't necessarily change that practice. 3:56:26 PM REPRESENTATIVE NELSON asked whether there is a rough estimate of how many people are in the underserved categories described in the proposed legislation. CO-CHAIR SPOHNHOLZ replied that she doesn't have an immediate answer to that question. "What we do know," she said, "is that there is a shortage of dental health care access in correctional facilities, federally-qualified health centers for low income folks, and in many parts of rural Alaska where dental hygienists would be able to practice using this advanced practice permit." She stressed that HB 111 would increase access to dental health care in underserved communities. REPRESENTATIVE NELSON said that he wanted to know the number of people in the "underserved" category. CO-CHAIR SPOHNHOLZ said that Ms. Menkens, who works with federally-qualified health centers, may be able to address the question. 3:57:37 PM REPRESENTATIVE NELSON noted that the fiscal note is calculated with a 75 percent federal match. He asked for further explanation of the 25 percent for which the state is responsible. CO-CHAIR SPOHNHOLZ responded that the amount in question is the state's contribution for the increased amount of dental health care that could be provided if a certain percentage of dental hygienists were to become advanced practice providers. REPRESENTATIVE NELSON asked, "And what's that percentage?" CO-CHAIR SPOHNHOLZ replied that she doesn't have the number immediately accessible. 3:58:31 PM CO-CHAIR FIELDS opened invited testimony on HB 111. 3:58:42 PM MS. MENKENS, having previously provided answers to committee questions, now gave her testimony in support of HB 111. She read a letter from Joe Zasada, Policy Integration Director of the Alaska Primary Care Association, which read as follows [original punctuation provided]: The Alaska Primary Care Association (APCA) supports the operations and development of Alaska's 29 Federally Qualified Health Centers (FQHCs and Look Alikes). Alaska Health Centers voted to support health workforce development initiatives that introduce new provider types to the market and increase access to care in their 2021 Policy Priorities. All of Alaska's Community Health Centers are required to provide oral health services as a component of the comprehensive medical, dental, behavioral, pharmacy and care coordination services they offer. Dental services and overall oral health are vital components in the whole person care that Community Health Centers provide their patients. Many Health Centers offer on- site dental services provided by staff or contracted dental health professionals. Other more rural and smaller sites rely on sending patients to larger hub health facilities or neighboring urban Health Centers for dental care. One frequently cited reason for the shortage of dental services is the lack of providers. In 2019, almost one third of Alaska Health Centers' 113,000 patients received dental care at their Community Health Center through over 96,796 visits provided by 77 full-time equivalent dentists, hygienists, and dental therapists. Persistent shortages of providers at all levels in Community Health Center dental clinics result in providers not working at their highest level of licensure; creating inefficiencies, decreased provider satisfaction, and barriers to patient care. The addition of Advanced Hygienists to practices would add an additional valuable layer of staffing between dentists and other hygienists and dental therapists to provide comprehensive services and support integration with other Health Center services, including chronic disease management, and behavioral health/substance use disorder services. Community Health Centers have been pioneers in the past in supporting and incorporating expansion of health professional provider types into their care settings. Community Health Centers are ready to embrace this new provider type as they continue to grow and expand the increasing need of integrated dental care in primary care settings. We urge passage of House Bill 111. 4:00:52 PM CO-CHAIR FIELDS asked Ms. Menkens what percentage of children are served under Medicaid versus private insurance. MS. MENKENS responded that she would follow up with that information. CO-CHAIR FIELDS opined that there seems to be an oversupply of dentists and an undersupply of affordable care in Anchorage. He wondered whether parents know where to get dental health care for their children, or whether pediatric dentists don't accept Medicaid. He then asked whether schools have dental screenings and how families can access services. 4:02:28 PM CO-CHAIR SPOHNHOLZ pointed out that Co-Chair Fields identified that while there are many dentists in Anchorage, that is not the situation for the entire state of Alaska. She said that she mentioned Anchorage Neighborhood Health because Anchorage is the home community of the majority of committee members; however, rural Alaska does not have the supply of dentists that Anchorage has. She stressed that it's not only the tribal communities but also communities on the road system with shortages in dental health care providers. She recalled the inception of the Dental Health Aide Therapist program, intended to help communities in rural Alaska, and said that the belief among dentists was that those therapists may not provide adequate care; however, those dentists weren't travelling to rural Alaska to provide that care. She said, "[In] urban Alaska, particularly in Anchorage, we don't have an access problem when it comes to dental health care. But we're not the rest of the state, we're just 40 percent of the population." CO-CHAIR FIELDS said he wants to understand what percentage of kids in Anchorage don't have adequate dental care, and why. 4:04:31 PM MS. BRYANT, having previously responded to committee questions, now gave testimony in support of HB 111. She stated that she is a registered dental hygienist (RDH), as well as a U.S. Air Force veteran. She said that as of March 8, 2021, there are approximately 679 RDHs in Alaska, with only a few with a collaborative agreement with a dentist. The factor limiting collaborative agreements, she said, is believed to be the number of licensed dentists in Alaska interested in entering into such an agreement. A collaborative agreement allows an RDH with 4,000 hours of experience to work under the authorization of a licensed dentist without the dentist being onsite, in an area other than the usual place of practice of the licensed dentist, and without the dentist's diagnosis and treatment plan, unless otherwise specified in the collaborative agreement. The provisions under HB 111 would break down barriers and bridge the gap in access to dental health care. Based on feedback from RDHs in meetings pertaining to this bill, approximately 5 percent have expressed interest in seeking an advanced practice permit. Advanced practice for dental hygienists is not a new concept, she said; many states have implemented legislation for RDHs to provide varying degrees of direct patient care since 1995, with many states advancing legislation as lawmakers, dental associations, and medical professionals recognize the benefits of utilizing RDHs to safely provide services while increasing access to oral health care and education. MS. BRYANT pointed out that there are no legal cases regarding treatment issues, and RDHs in Alaska have had a longstanding safety record. She explained that care provided by RDHs includes oral cancer screenings, blood pressure assessment, providing tobacco cessation information, and educating the public about oral health and its systemic connection. Routine dental health care, she said, correlates to decreased emergency dental care, thereby decreasing medical costs. She expressed witnessing the suffering caused by oral diseases among those who live remotely and have experienced challenges accessing dental health care services. She implored the committee members to not let Alaska be known as the "Last Frontier" for passing legislation that could help increase access to care, and urged them to support HB 111. She stressed that the Alaska Dental Hygienists' Association, American Dental Hygienists' Association, Alaska Dental Society, and the Alaska Board of Dental Examiners support HB 111. 4:08:52 PM CO-CHAIR FIELDS asked Ms. Bryant what being an independent contractor means. MS. BRYANT replied that it means a dental hygienist would practice on their own, creating their own assessment and treatment plans for the patient, and if necessary, referring the patient to a licensed dentist for further care. CO-CHAIR FIELDS interjected and asked Mr. Fisher why language allowing advanced practice dental hygienists to be classified as independent contractors is in the proposed legislation. 4:10:10 PM SANDON FISHER, Legislative Counsel, Legislative Legal Services, Legislative Affairs Agency, explained that the term "independent contractor" is a commonly used term in the employment context, with ramifications for the relationship between the party contracting for the services and the independent contractor themselves. A person or business using an independent contractor would generally not withhold employment taxes or cover the contractor by workers' compensation insurance. CO-CHAIR FIELDS thanked Mr. Fisher for the explanation. 4:11:39 PM LORI REETZ, President, Alaska Dental Hygienists' Association, testified in support of HB 111 on behalf of the Alaska Dental Hygienists' Association. She said that she obtained her associate degree in dental hygiene from the University of Alaska Anchorage in 1997, and has been practicing as an RDH in Alaska for 24 years. In 2015 she obtained her bachelor's degree in dental hygiene from the Oregon Institute of Technology where, she explained, part of the curriculum is training to successfully become Oregon's version of an advanced practice dental hygienist. She described learning how to provide care to people in limited access populations, and to those with limited mobility, without the supervision of a dentist. She expressed concern about her aging parents' ability to access dental health care if they're not able to leave their house, and said that with an expanded practice permit she could provide care to those with limited mobility. 4:15:13 PM ANGIE STONE, Founder and CEO, HyLife Oral Health Alliance, testified in support of HB 111. She said that she first became aware of the problems faced by the elder population in accessing dental health care when a family member entered a nursing home which had no dental health care. She said, "As a Wisconsin dental hygienist, I was not allowed to provide dental hygiene treatment without the involvement of a dentist, which is currently the situation in Alaska." With no dentist wanting to provide care at the facility, she said, her family member was left with no treatment for periodontal disease and subsequently had recurrent lung infections. Ms. Stone told of another family member who, within two years of entering a nursing home, lost 60 percent of the teeth that she had kept for 90 years. She said that the surgeon general has reported that elderly nursing home residents have extensive oral disease, poor oral hygiene, and suffer the worst oral health of any population. She said that nursing home oral health surveys around the country reflect this, reporting that 42 percent of residents have untreated tooth decay, 31 percent have root tips in their mouths, 35 percent have substantial oral debris, 22 percent have severe inflammation of the gum tissues, and 20 percent have a need for periodontal care. All of the observed conditions, she said, are things that dental hygienists are trained to prevent. On March 30, 2017, Wisconsin passed a law allowing dental hygienists to practice without the presence of a dentist. She asked the committee to ensure vulnerable nursing home residents in Alaska have access to dental health care. 4:19:50 PM CO-CHAIR FIELDS asked whether dental hygienists in Alaska could sign up as independent contractors with HyLife Oral Health Alliance. He also asked what the business model is. MS. STONE responded that clinical services had ceased due to the COVID-19 restrictions, with the dental hygienists not able to enter nursing homes. She said that dental hygienists in Alaska could register through HyLife Oral Health Alliance, allowing the company to handle billing. She said that in Wisconsin she is able to bill Medicaid, but she doesn't know how billing would work in Alaska. She said that she was of the opinion that the language of HB 111 would be most beneficial if the hygienist could be either an employee or an independent contractor, as there are several different models with varying levels of appropriateness for situations. 4:22:04 PM ANN LYNCH, Director of Advocacy and Education, American Dental Hygienists' Association, testified in support of HB 111 on behalf of the American Dental Hygienists' Association (ADHA). She read excerpts from her written testimony, which read as follows [original punctuation provided]: ADHA advocates that dental hygiene and/or dental practice acts be amended so that the services of dental hygienists can be fully utilized in all settings. Furthermore, ADHA supports oral health care workforce models that culminate in graduation from an accredited institution; professional licensure; and direct access to patient care. ADHA defines direct access as the ability of a dental hygienist to initiate treatment based on their assessment of a patient's needs without the specific authorization of a dentist, treat the patient without the presence of a dentist, and maintain a provider-patient relationship. In 1995, five states allowed direct access. Currently, 42 states, including Alaska, have policies that allow dental hygienists to work in community-based settings to provide preventive oral health services without the presence or direct supervision of a dentist. Allowing dental hygienists to practice under an advanced practice permit will further improve upon Alaska's direct access and provide additional opportunities for the safe and effective care provided by dental hygienists in order to reach patients in need. MS. LYNCH explained that HB 111 would further the impact of dental hygienists by allowing them to work to the full extent of their education and license. She expressed gratitude to Co- Chair Spohnholz for carrying the bill, as well as to the committee for hearing it. She continued reading excerpts from her written testimony, which read as follows [original punctuation provided]: The policies cited above are further supported by research demonstrating the impact dental hygienists have on access to care and public policy recommendations supporting dental hygienists providing care in direct access settings, including: ? In December 2018, the U.S. Departments of Health and Human Services (HHS), Treasury, and Labor in collaboration with the U.S. Federal Trade Commission (FTC) and White House offices, made policy recommendations on state and federal policies to improve choice and competition in the health care markets. The report says dental hygienists can safely and effectively provide some services offered by dentists, as well as complementary services. It goes on to recommend states should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set. It also recommends that States eliminate requirements for rigid collaborative practice and supervision agreements between dentists and hygienists that are not justified by legitimate health and safety concerns. ? The National Governor's Association specifically says, "the rationale that state dental boards most commonly used for restricting hygienists from practicing in unsupervised settings focuses on concerns about quality and safety, even though no clear evidence exists to support such restrictions. ? The FTC previously wrote to the Georgia Board of Dentistry regarding regulation of dental hygiene supervision. In the letter, FTC staff stated "sound competition policy calls for competition to be restricted only when necessary to protect the public from significant harm. Here, we are aware of no evidence of past or future harm from current practices." ? The Oral Health Workforce Research Center concluded in 2016 that "Scopes of practice which allow dental hygienists to provide services to patients in public health settings without burdensome supervision or prescriptive requirements appear to increase access to educational and preventive care." MS. LYNCH said, "Simply put, House Bill 111 is good public policy." 4:28:37 PM CO-CHAIR FIELDS opened public testimony on HB 111. There being no one who wished to testify, he closed public testimony. [HB 111 was held over.]