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Stateline
The latest legislative news in oral health
from coast to coast
Stateline is prepared by the ADHA Division
of Governmental Affairs
January 2008 | February 2008 | March
2008 | April | May-June
| May-June 2008 |
| Direct access initiatives have taken
center stage in the 2008 state legislatures. In Alaska, a bill for
collaborative practice was sent to the governor. In Maine, the governor
has signed a new law permitting dental hygienists to practice independently.
And in Minnesota, steps are being taken to launch advanced dental
hygiene practice. Alaska
dentists and dental hygienists agreed to the merger into one bill
of a dental association initiated bill (allowing dental assistants
to polish and provide restorative services) with a dental hygienists’
association proposal (for collaborative practice and general supervision
for local anesthesia). Dental hygienists would also be able to qualify
to perform restorative services.
Now on the governor’s desk, House
Bill 319 would allow dental hygienists with at least 4,000 hours
of experience in the last five years to practice according to a
written collaborative agreement with a dentist. The board would
need to approve the collaborative agreement, which could allow the
dental hygienist to initiate services without the dentist’s
individual diagnosis and treatment plan at settings other than the
dentist’s usual place of practice. The collaborative hygienist
could perform virtually any traditional dental hygiene service,
including local anesthesia, pursuant to the terms of the agreement,
whether or not the dentist was present.
The Minnesota State Senate
overwhelming passed an amended Omnibus Higher Education Bill that
contained a provision to put language in statute that creates the
Oral Health Practitioner (OHP) and convenes a workgroup to make
recommendations and propose legislation to define the scope, supervision
and education of the provider. The amendment codifies that the OHP
will be a licensed, educated provider who works under the supervision
of a dentist via a collaborative management agreement. The amendment
stipulates that OHPs must practice in underserved areas and cannot
begin lawful practice prior to 2011.
The scope of practice the workgroup is directed
to design for the provider includes primary diagnostic, educational,
palliative, therapeutic and restorative (cavity preps, restoration
of permanent teeth, temporary crowns, placement of preformed crowns,
pulpotomies on primary teeth, pulp capping) services, as well as
extractions of primary and permanent teeth, placing and removing
sutures and prescriptive authority (anti-infective, non-narcotic
pain management and prevention).
The various stakeholders including representatives
from Metropolitan State University, the University of Minnesota,
the Minnesota Dental Hygienists’ Association, the Minnesota
Dental Association, the state board of dentistry, Safety Net Coalition
and several other dentists representing various public health and
special interest groups, as well as two state agency representatives,
will populate the workgroup. The majority of dentists on the workgroup
will have to have specific public health experience. The workgroup
is charged with completing its work by December 15, 2008, and draft
legislation to enact specific recommendations will be required by
January 15, 2009.
Dental hygienists in Maine
can practice independently in all settings, thanks to a proposal
submitted by a denturist. Independent practice for dental hygienists
was among the four proposals under consideration by the state’s
Department of Professional and Financial Regulation during their
sunrise review. The other three were licensure of graduates of foreign
dental schools, creation of a separate licensing board for denturists
and hygienists, creation of an advanced practice dental hygiene
practitioner, and independent practice. The Joint Committee in Business,
Regulation and Economic Development released its recommendation
from the sunrise review in late February. Their recommendation:independent
practice. Facing no opposition by organized dentistry, the bill
sailed through the Maine legislature and was signed into law by
the governor in mid-April.
Independent practice dental hygienists are
required to possess a bachelor’s degree from a dental hygiene
program accredited by the Commission on Dental Accreditation (CODA)
and 2,000 work hours of clinical practice in a private dental practice;
or possess an associate degree from a CODA-accredited dental hygiene
program and 6,000 work hours of clinical practice in a private dental
practice. They are also required to provide a referral plan to patients
in need of additional care by a dentist.
Indiana
became the 41st state, including Washington, D.C., to allow dental
hygienists to administer local anesthesia. Under the new law, dental
hygienists who have completed a board-approved course and received
a board-issued dental hygiene anesthetic permit may administer local
anesthesia under direct supervision. The bill also contained a provision
to expand the current law to allow prescriptive supervision in hospitals,
clinics, fixed charitable institutions, public health settings and
correctional institutions. Under prescriptive supervision, a licensed
dentist is not required to be physically present but needs to have
examined the patient and prescribed the patient care within the
previous 45 days. As a trade-off with the Indiana Dental Association,
dental assistants who have completed a board-approved curriculum
are allowed to polish coronally and apply fluoride under the direct
supervision of the dentist. The Indiana State Board of Dentistry
must finalize the rules and regulations for the law to take effect.
The Virginia Board of Dentistry established
guidelines, criteria and regulations to enable licensed hygienists
to practice local anesthesia and administer nitrous oxide. A dental
hygienist who completed a 36-hour course and successfully passed
a CODA-accredited exam is certified to administer nitrous oxide
and local anesthesia to patients 18 years of age or older under
the direction of a dentist. |
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| April 2008 |
ADHP
News The Minnesota
state legislature made history earlier this year by introducing
legislation to establish an Advanced Dental Hygiene Practitioner.
House File 3247 (HF 3247) and the Senate companion bill, Senate
File 2895 (SF 2895), direct that the new provider will be a licensed
dental hygienist, educated at the master’s level and permitted
to practice an advanced scope by the state board of dentistry. The
ADHP will have an expanded role in treating patients by providing
basic oral health primary care services including diagnostic, preventive,
prescriptive, therapeutic and restorative services directly to the
public. The new provider will be focused on practice in public health
settings and will enter into a collaborative management agreement
with a licensed dentist in the state, which will lay out protocol
for patient referral, provider communication and guidelines for
emergency situations.
Since
introduction in February, the ADHP legislative efforts are progressing
quickly. On March 13, the Senate Health and Human Services Budget
Division voted in favor of passing SF 2895 on to the full Senate
Finance Committee. The house companion bill, HF 3247, was scheduled
for a hearing in the full House Committee on Health and Human Services
but was later pulled due to lack of votes.
There is a great deal of support for the
concept within the state, but certainly, there are those who are
not in favor. The Minnesota Dental Hygienists’ Association,
Minnesota State Colleges and Universities, and the Safety Net Coalition
will continue their hard work to advocate in favor of the legislation
in coming months. The three groups have been working heartily for
months to generate support and educate legislators about the need
for the new provider.
In other ADHP news, the New Hampshire
State House recently passed legislation that establishes a commission
to study the creation of an Advanced Dental Hygiene Practitioner
to increase access to oral health care. House Bill 1487 passed on
a voice vote by the full house and will now move onto the senate
for consideration.
Workforce Model Update
On February 25, legislation in Minnesota,
SF 3122 and HF 3254, was introduced that included a provision to
study the Community Dental Health Coordinator model. Both bills
passed through a number of committees and are currently awaiting
hearings in the House and Senate Finance Committees respectively.
Missouri House Bill 1976,
scheduled for a committee hearing in late March, would explicitly
add “removal of hard and soft deposits from teeth” to
duties permitted to all dental assistants. Although the board would
be allowed to set conditions for dental assistants to scale, they
would not be required to mandate any additional education or special
regulation for scaling assistants.
Public Health Hygienist
Florida dental hygienists
have expressed strong support for Governor Crist’s "Access
to Oral Health Act" proposal, sent to the legislature in March
as one of his top priorities for this session. The proposal (companion
bills Senate Bill 2760/House Bill 1367), begins with a preamble
that recognizes the importance of preventive services and the fact
that in Florida dental care for low-income and other underserved
patients is provided primarily through publicly funded programs.
There are three major public health related
components of the measure. The initial section revises the composition
of the dental board to require that two of the seven dentist members
of the 11-person board must either have practiced in the public
health sector in two of the last five years or hold an advanced
degree in public health.
Second, although Florida has been one of
the handful of states with no provision for any kind of licensure
by endorsement or reciprocity, this measure would allow licensed
dentists from other states to obtain a license without retaking
the clinical examination for practice in public health facilities.
A dentist holding such a public health license could apply to convert
it to a general license after a minimum of 3,000 hours of public
health service.
Finally, the proposal would allow dental
hygienists to practice under public health supervision in public
health settings. They could provide a full range of services without
the prior examination or presence of a dentist in public health
programs, institutions of the Department of Children and Family
Services, the Department of Juvenile Justice, non-profit community
health centers, a Head Start center, or a federally qualified health
center.
In addition, the bills would allow physicians
and nurses to be reimbursed by Medicaid for applying fluoride varnish
for children up to three years old during Well Child visits and
fund increased community dental services in rural areas for disabled
people.
The Maryland General Assembly
introduced the Public Health Dental Hygiene Act in early February.
House Bill 1280 and its senate companion, Senate Bill 818, are a
direct response to the state’s access-to-care crisis that
claimed the life of 12-year-old Deamonte Driver last February. Secretary
Colmer of the Maryland State Department of Health and Mental Hygiene
formulated the Dental Action committee to study this problem. The
Public Health Hygienist was a priority of this committee.
The Public Health Dental Hygiene Act seeks
to increase access by allowing the Public Health Dental Hygienist
to work in a variety of public health settings including facilities
owned and operated by federal, state or local governments; schools;
Head Start programs; and facilities that provide Dental care to
the poor, elderly or handicapped. The Public Health Hygienist would
be able to work under general supervision to the full scope of dental
hygiene practice to include sealants and fluoride agents.
With bipartisan support in the house and
senate as well as backing from the Maryland Dental Hygienists’
Association and the Maryland State Dental Society, the bill is expected
to easily pass both chambers. |
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March 2008
| ADHP Update
The Minnesota Dental
Hygienists’ Association (MNDHA) announces that
H.F. No. 3247, a bill calling for the creation of an
Advanced Dental Hygiene Practitioner (ADHP) in the state
of Minnesota, has successfully advanced from the House
Licensing Committee to a full House Health Care Committee
hearing. The legislation is a direct response to recent
events and research that highlight the difficulties
Minnesotans and Americans – particularly children,
the elderly, and minority populations – face in
accessing oral health care services.
The Senate Health, Housing
and Family Security Committee is holding a hearing on
the companion bill S.F. 2895 during the first week of
March. |
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While a number of states authorize a dental
hygienist to assess and/or treatment plan, if proposed rules are
finalized at the next board meeting, Montana will
have the distinction of becoming the second state to specifically
recognize the dental hygiene diagnosis. The rule proposal, issued
by the dental board in early January, states that laws restricting
diagnosis to a dentist do not apply to “dental hygiene diagnosis
and treatment planning” necessary to provide dental hygiene
procedures. Oregon rules four years ago were the first to authorize
dental hygiene diagnosis in a similar fashion by specifying that
dental hygiene diagnosis was not included in the general prohibition
against diagnosis.
The New Hampshire House
Committee on Health, Human Services and Elderly Affairs passed HR
1487, a bill that directs the study of the Advanced Dental Hygiene
Practitioner (ADHP) model to increase access to oral health. After
a series of hearings and an executive session, the committee recognized
the need for a mid-level provider and voted 13-4 in favor of establishing
a study committee to examine the various workforce models, particularly
ADHP, as a solution to the state’s access to care problem.
The bill awaits action in the Senate.
The South Dakota Board of Dentistry
issued a “Fluoride Varnish Declaratory Ruling” in January,
which allows health professionals other than licensed dental providers
to apply fluoride varnish when “prescribed by an appropriately
licensed practitioner.” The board, voting unanimously, noted
the efficacy of fluoride varnish, the fact that no dental instruments
are needed and that at least seven other states permit non-dental
providers to apply varnish in making its determination. This declaratory
ruling is expected to allow dental hygienists to provide fluoride
varnish in a variety of settings, including nursing homes, day cares,
outreach programs and nursing homes under the prescription of a
physician, physician’s assistant or nurse practitioner as
well as a dentist.
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The
Pennsylvania Dental Hygienists’ Association presented
State Senator Patricia Vance with the Certificate of
Recognition Award for her efforts to increase access
to oral health care. The presentation ceremony took
place at Harrisburg Area Community College in November.
Senator Vance was the primary
sponsor of a bill that amended Pennsylvania’s
dental law to allow public health dental hygiene practitioners
to provide preventive health care to individuals in
a variety of public health settings without dental supervision.
The governor signed the bill into law last summer.
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Februry 2008
The defeat of two sets of proposed
rules in late 2007—in Florida and Nebraska—illustrate
that the agency rulemaking process is also subject to strict guidelines.
The first principle of rulemaking is that the rules cannot contradict
statutory law, and that rulemaking agencies such as dental/dental
hygiene boards have only as much authority to make rules as the
statutory practice act delegates to them.
On December 6, 2007, the Florida Dental Board
rejected a request from the Florida Dental Association to add supragingival
scaling and periodontal probing to the list of duties permitted
to dental assistants. The request was part of a large package asking
the board to include some additional restoration-related duties
and relax some supervision requirements for dental hygienists and
assistants, as well as approval for dentists to provide “dermal
fillers” and “injectable botulism toxin.”
The Florida Dental Hygiene Association (FDHA)
had strongly opposed allowing unlicensed persons to either scale
or probe, pointing out the obvious concerns about supragingival
scaling alone being a non-therapeutic procedure and the possibility
for physical harm to the patient from either probing or scaling
performed by inadequately trained persons.
However, in this case, as FDHA also pointed
out, these proposed rules were in conflict with the dental practice
act. The Florida statute says that the removal of calculus and accretions
can be delegated only to a dental hygienist.
Nebraska rules concerning dental assistant
duties were approved by the board of dentistry and the board of
health but were rejected for lack of statutory authority—in
this case, following a mandatory review by the state attorney general.
The board had proposed a new and longer laundry list of duties for
dental assistants. The widely ranging duties would have included
application of sealants, performing a brush biopsy, placing retraction
material and placing amalgam. In addition, there would have been
greatly expanded educational requirements for exposing X-rays, as
well as detailed course requirements for several of the newly added
duties. The Nebraska Dental Hygienists’ Association consistently
opposed the proposed rules but advocated for accredited education
and credentialing for dental assistants prior to the delegation
of expanded duties.
In addition, the attorney general also rejected
the rules on procedural grounds. Nebraska, like other states, has
a requirement for regulatory boards to hold public hearings to accept
comment on proposed rules. The board may amend the proposed rules
based on public input before approving them. However, if the amended
rules differ too much from those presented at the first hearing,
a second hearing on the new version of the rules is required. In
this case, the attorney general found “a number of changes
in the text made between the time of newspaper notice and the adoption
of the amended regulations, including several deletions and additions
to the list of allowable duties for dental assistants,” resulting
in regulations “substantially different from” the rules
proposed and noticed.
Although registered dental hygienists in
alternative practice (RDHAPs) have been California Medicaid providers
for a decade, it was not until California Senate Bill 238 was signed
in October, 2007, that they were recognized as reimbursable providers
in federally qualified health centers (FQHCs). FQHCs, often referred
to as “safety net clinics,” are non-profit, privately
run community health centers open to anyone regardless of ability
to pay, which obtain federal public health funding reimbursement.
However, payment is based on a fixed fee per patient “encounter”
with an approved provider rather than fee for service.
Both the California Dental Hygienists’
Association and the California Dental Association threw their support
behind this measure. Implementation of rules adding both dental
hygienists and RDHAPs to the list of approved providers is pending.
FQHC patients should be able to access dental hygiene services directly
later this year.
Stateline is prepared by the
ADHA Division of Governmental Affairs. |
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January 2008
Prepare for Upcoming Legislative Sessions
State legislatures are just beginning to
convene for 2008, and with that will come a flurry of legislative
activity. If you enjoy following the lawmaking process, here are
some resources to get acquainted with before the activity gets heavy.
Check out these sites for interesting background
information:
- Curious about when the legislature in
your state meets? StateNet, a well known tracking service, has
a 2008_Legislative_Session_Calendar available at: http://www.statenet.com/resources/
Note that Arkansas, Montana, Nevada, North Dakota, Oregon
and Texas meet only every other year and will not be in session
in 2008.
- Interested in the partisan make-up of
each legislature? See http://www.ncsl.org/statevote/partycomptable2008.htm.
This is the site of the National Conference of State Legislatures,
an organization that gathers information for legislators and their
staff.
- Want information about a particular legislator?
Visit www.votesmart.org to see a full page of data including committees
served on, voting records and positions on a variety of issues.
For
really comprehensive information on what is happening during the
session in any state, go directly to the state legislature’s
Web site. Most state legislature Web sites are easy to navigate.
Typically there is a section labeled “bills” or “legislation”
where you can search for bills by number or by key words. The full
text of the legislation is virtually always available, plus generally
there is information about the progression of legislation through
various committees and legislative chambers. Some other typical
features of a legislature’s site are links to existing state
statutes, how to find and contact your representatives, and information
on bills that were considered in previous sessions.
Although, for the most part, state level
dental hygiene practice laws determine how you practice every day,
federal laws are important too. ADHA is active in Washington, D.C.
to advocate on behalf of efforts that advance the practice of dental
hygiene and make oral health care more accessible to patients. You
are probably aware of recent efforts to obtain federal funding for
an advanced dental hygiene practitioner pilot project, as well as
work to include mandatory dental benefits in the State Children’s
Health Insurance Program (SCHIP).
The place to go for up–to-date information
on bills in Congress is “Thomas”– the Library
of Congress Web site named for Thomas Jefferson at http://thomas.loc.gov/.
Again, you can search by bill number, by topic or by key words.
You can also link to federal legislators, the Congressional Record
and much more. |
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