CS FOR HOUSE BILL NO. 111(FIN) "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." 1:19:01 PM CHELSEA WARD-WALLER, STAFF, REPRESENTATIVE IVY SPOHNHOLZ, introduced herself. She believed Representative Spohnholz was available online to introduce the legislation. REPRESENTATIVE IVY SPOHNHOLZ, SPONSOR, ANCHORAGE (via teleconference), introduced the legislation with prepared remarks: House Bill 111 creates an advanced practice permit, which would allow experienced and licensed dental hygienists to provide preventative oral healthcare to underserved populations at senior centers, healthcare facilities, daycares, and schools for Alaskans who are eligible for public assistance, are homebound, or who live in a rural underserved community. We know that oral health plays a really critical role in the overall health and well-being of Alaskans and poor oral health contributes to poor health. In fact, bad oral health is linked to cardiovascular disease, Alzheimer's, osteoporosis, as well as poor nutrition and other serious health issues and this is more acute for low income individuals and those who are physically immobile. Currently, dental hygienists can practice in a dentist office or they can practice semi-independently if they have a collaborative agreement with a dentist, which is similar to what physician's assistants do already. An advance practice permit that's proposed by House Bill 111 would allow dental hygienists to care for these underserved populations at senior centers, healthcare facilities, daycare, schools, and those that are eligible for public assistance, are homebound, or live in underserved communities if they have a minimum of 4,000 hours of clinical experience and are approved by the board of dental examiners, which includes both dentists and dental hygienists. The bill lays out specific services allowed under the permit and specific populations that a licensed dental hygienist can provide those services to without the supervision and physical presence of a licensed dentist. Unlike some licensing bills in the past where there was competing license types that had different perspectives, this bill has been developed in consultation with the Alaska Dental Society, the Board of Dental Examiners, and the Alaska Dental Hygienists Association. The advanced practice permit holder will have to maintain malpractice insurance, provide written notice of their service limitations, and make a referral to a licensed dentist if further treatment is necessary. This bill would allow dental hygienists who are experienced to practice to the full scope of their training credentials and professional experience. Importantly, 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 and 40 other states are considered direct access states for dental hygienists, which means that dental hygienists can initiate treatment based on their assessment of a patient's needs without the authorization or presence of a dentist. Finally, I will note that we have 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 seven years, making sure that the Board of Dental Examiners has a separately certified hygienist to administer local anesthesia, and then empowering the Department of Health and Social Services (DHSS) to make regulations related to this bill. We may need to update the DHSS language to confirm with the recent split of the Department of Health and Social Services. Representative Spohnholz listed individuals available to speak to the bill. 1:23:31 PM Senator Olson asked if the bill allowed prescriptive authority to the advanced dental hygienists. Representative Spohnholz replied there was very narrow prescriptive authority regarding topical, preventative, and prophylactic agents that dental hygienists were already allowed to provide. She deferred the question to Royann Royer [with the Alaska Dental Hygiene Association] for further detail. Senator Olson asked if advanced dental hygienists had to participate in the Prescription Drug Monitoring Program (PDMP) that other prescriptive practitioners were required to abide by. Representative Sponholz answered that dental hygienists did not prescribe controlled substances and therefore, did not have DEA [Drug Enforcement Administration] certification and did not have to participate in the PDMP. Senator Olson asked if the permit enabled advanced dental hygienists to perform advanced dental procedures. Representative Sponholz responded that the bill did not allow dental hygienists to practice beyond the scope of their current practice in any way. The bill simply enabled dental hygienists to do what they had already been doing safely for a very long time and without the supervision of a dentist if they had 4,000 hours of experience in addition to a previous dental hygienist license and were approved by the Board of Dental Examiners. 1:25:27 PM Ms. Ward-Waller discussed the Sectional Analysis (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) A licensed dental hygienist with an advanced practice permit 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. 1:29:31 PM ROYANN ROYER, ALASKA DENTAL HYGIENE ASSOCIATION, ANCHORAGE (via teleconference), spoke in support of the legislation. She shared information about her work in dentistry for many years in Alaska. She shared that approximately six years back she had seen a significant need that was not being addressed in Alaska. She had started a nonprofit organization that served residents in long-term care facilities. She spoke to the importance of the legislation. She currently practiced under a collaborative practice agreement, which allowed dental hygienists to provide treatment under the general supervision of a dentist. She was able to see a patient prior to the dentist. She was lucky to have several dentists to collaborate with on the project and would continue as long as possible. However, if the bill went through, it would provide another option to continue the program if needed. For example, if she did not have a dentist to work with, she would be able to continue seeing the long-term residents and provide assessments, radiographs, preventative services, and oral health education. The patients could then see a dentist either in or outside the facility as needed. Ms. Royer relayed that many hygienists wanted to work in underserved areas, but they could not find a dentist who would work in a collaborative agreement. The legislation had been brought forward by a hygienist in Fairbanks who wanted to find a way to provide services. She shared that assessment and treatment done routinely were less expensive than waiting for a person to notice problems, which necessitated more extensive and expensive procedures. She highlighted that preventative treatment helped to prevent systemic conditions such as pneumonia, diabetes complications, and heart disease. She stated that Alaska needed more providers in underserved areas and the registered dental hygienist advanced practitioner would help decrease the disparity. 1:32:54 PM DAVID NIELSON, CHAIR, ALASKA BOARD OF DENTAL EXAMINERS, ANCHORAGE (via teleconference), shared that discussion about the advanced dental hygiene permit had come up several times over the past couple of years and the support had always been good. He shared that the bill sponsor had been receptive to board comments and had made a couple of changes to the original bill. He relayed that the board supported the bill in its current form. He highlighted that Section 4 specified that the dental board would draft regulations to clarify what additional tasks, if any, would be delegated dental assistants by the advanced hygiene permit holder and under what level of supervision. Co-Chair Bishop looked at Section 2 (a) and wondered how the 4,000 hours was documented. He asked if students or individuals had a logbook. Mr. Nielson replied that there was typically an affidavit where someone attested to the fact that a person had 4,000 hours of practice. He stated that it would likely be a person's employer. 1:35:24 PM JOHN ZASADA, POLICY DIRECTOR, ALASKA PRIMARY CARE ASSOCIATION, ANCHORAGE (via teleconference), spoke in support of the legislation. He detailed that the association supported the operations and development of Alaska's 29 non-tribal and tribal federally qualified health centers. He provided detail about the association. He stressed that dental services and oral health were vital components of the whole person care that community health centers provided patients. He detailed that many health centers offered on-site dental services provided by staff or contracts with other dental health professionals. Smaller sites relied on sending patients to larger hub facilities or neighboring urban health centers for dental care. One frequently cited reason for the shortage of dental services was the lack of providers. He stated that persistent provider shortages at all levels in the community healthcare dental system resulted in providers not working at their highest level of licensure, which created inefficiencies, decreased provider satisfaction, and barriers to patient care. The bill would add a valuable layer of staffing between dentists and other hygienists to provide comprehensive services. He spoke to further attributes of the program. The new provider type would lead to an adjustment of the overall health spend, potentially lessening the reliance on higher cost dentists to lower cost hygiene. He urged the passage of the bill. 1:37:44 PM Co-Chair Bishop OPENED and CLOSED public testimony. 1:38:03 PM AT EASE 1:38:43 PM RECONVENED CSHB 111(FIN) was HEARD and HELD in committee for further consideration.