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April 2004

Chapter 6. Access to Care

This chapter summarizes the findings of the study relating the impact of the professional practice index of DHs on access to health care in the U.S. It includes the following subsections:

Introduction
Discussion

Introduction

Of primary interest to this study is the question of the effects of the legal scope of practice for dental hygienists on access to care for underserved populations. Traditionally, these oral health professionals have provided services through gatekeeper dentists who supervise hygienists and manage provision of care to the patient. The roles of dentists in the management of oral health care are described in the dental practice acts and the dental hygiene acts that govern the licensure and the practice of oral health professions. The statutes in each State are augmented by the regulations promulgated by Boards of Dentistry and Boards of Dental Examiners who regulate the services which may be provided, the locations in which practice may occur, and the circumstances (including supervision requirements and patient affiliation with the dentist) under which care may be provided.

Of particular interest is the effect of legislative and regulatory controls on access to oral health care by populations with marginal or no access to regular dental services. As discussed in this report, the DHPPI was created to provide a numerical indicator to be used in analysis of this question. Initially, it was hoped that a statistical index for the profession could be developed for the year 1992 as well as for the year 2001. Composing an index that accurately reflected the legal conditions of practice for dental hygienists in 1992 proved to be beyond the scope of this study. Statutes are dynamic documents that change incrementally over time and ascertaining the prevailing legal conditions for hygienists in 1992 would require significant expert legal research. In the absence of comprehensive historical documents to inform the creation of an index for 1992, researchers examined available sources to support the investigation into changes over the decade in supervision requirements, tasks allowed to the hygienist, and permission to provide services in a variety of non-traditional settings. This chapter will detail the findings from this investigation. Each of the areas examined in the index are addressed below. Although this overview of practice across the decade is not as comprehensive as the detailed index for 2001, the thrust of changes that have occurred is clearly evident. In fact, this overview further supports the researchers’ conclusion that change for the profession has been slow. Change has occurred in increments with more change in the later years of the decade than in the earlier ones.

There have been many ongoing legislative initiatives in more recent years (the later years of the 90s and the first years of the new century) that address supervision, settings, and tasks.

In an effort to understand how scope of practice has changed over the decade, researchers examined historical documents published by constituent organizations including the American Dental Hygienists’ Association and the American Dental Association. These documents provide a picture of changing conditions and permit several observations about the quality and quantity of change that has occurred over the decade.

Regulation of the Dental Hygiene Profession

In most States, Boards of Dentistry or Boards of Dental Examiners oversee the regulation of the profession. The hygiene profession has been well established for many decades. Since 1951, hygienists are licensed in every State and the District of Columbia.^[50] The profession is also universally title protected meaning that States define and protect the use of the title “dental hygienist”. This protection establishes legal recognition for the profession. Presently, the profession enjoys self-regulation in only a few States. Over the past decade several States have passed legislation that has moved the profession towards self-regulation but there are still only a handful of States that permit hygienists any autonomy in professional regulation. Self-regulation is emerging as a particularly cogent issue for the profession as hygienists consider future practice for the profession. The following list details the slow progression to professional regulatory autonomy.

From the early 1980’s, a Dental Hygiene Advisory Committee that is composed of three hygienists and one public member has governed hygienists in the State of Washington. The committee was originally invested with limited authority that has evolved to full regulation of hygienists in the State.^[51]
In the 1990’s, Florida passed legislation creating a Council on Dental Hygiene and a Council on Dental Assisting with advisory capacity to the Florida Board of Dentistry.^[52]
In 1992, Maryland created a Committee on Dental Hygiene as a result of a sunset review of the Board of Dental Examiners. The committee operates in an advisory capacity.^[53]
Since 1993, hygienists in the State of Connecticut have been regulated directly by the Department of Health. The profession is enabled in statute but only minimal regulations exist which relate to continuing education requirements for the profession. Regulation of the profession occurs in a more diffuse form. For instance, there are social service regulations that pertain to the provision of oral health care by hygienists in the schools and to reimbursement for those services.^[54]
In 1994, the New Mexico legislature established a Dental Hygienists Committee that has the power to make mandatory recommendations regarding practice by hygienists to the Board of Dental Health Care. The board may decline to ratify the recommendations that pertain to hygiene practice only under very specific circumstances.^[55]
In 1994, Texas created a Dental Hygiene Advisory Committee to provide advice to the Board of Dental Examiners pertaining to practice by hygienists.^[56]
In 1996, Arizona legislated a five-member dental hygiene committee including three hygienists, one dental assistant and one dentist to advise the board or matters pertaining to dental hygiene.^[57]
Effective in 1997, the Delaware legislature further empowered an already existing Dental Hygiene Committee with power to advise the Board of Dental Examiners on dental hygiene policy, practice and licensure.^[58]
In 1999, the Iowa Legislature created a Dental Hygiene Committee within the State Board of Dental Examiners. The committee is empowered to make rules for the practice of dental hygiene. It is mandated that committee recommendations be passed unless a reasonable impediment can be demonstrated.^[59]
In 2001, the State of Missouri established a five member Advisory Commission for Dental Hygienists to make recommendations to the Dental Board.^[60]
In 2002,a sunset review by the Committee on Dental Auxiliaries in California in October 2002 resulted in the passage by the legislature of a bill expressing legislative intent to create an independent Board of Dental Hygiene in the State.^[61]

Self-regulation provides a profession with the autonomy to govern licensed professionals within the boundaries of patient safety while maintaining or elevating the profession by encouraging expertise in professional practice. The regulation of hygienists by the profession of dentistry limits the hygienist profession to practice consistent with the prerogatives of another profession. This situation is at variance with the prevailing standard of self-regulation for most health professions.

Supervision of Hygienists

The required level of supervision for hygienists is a central aspect of access to care. If hygienists are required by law or rule to be directly supervised, hygienists are limited in the circumstances in which they can provide service. Direct supervision confines the hygienist to situations where the dentist is physically present. Two decades ago, direct supervision was more prevalent than it is today. Two decades ago, only 23 States permitted general supervision of hygienists. By 2001, that number has increased to 35 States with a total of 43 States permitting general supervision in at least some settings.^[62] Less restrictive supervision requirements most often apply in public settings where dental services are not traditionally offered such as schools and long-term care facilities.

Table 1 demonstrates the change in supervisory requirements from 1993 to 2000 in all fifty States and the District of Columbia in the following locations:

in dental offices,
in long-term care facilities,
in schools,
in homes,
and in State institutions.

This information was obtained from publications of the American Dental Association that detail legal provisions for supervision of dental hygienists and assistants across States in 1993, 1998, and 2000.^[63] The published material was obtained by survey of the Executive Secretary or Administrator of each State Board of Dentistry in each year. Table 6-1 was created from Chart E-1 in Appendix E of this report which details the actual level of supervision required by year by State by setting. In Chart E-1, in cases where supervision in a setting is not addressed or where the information was not available, a blank space occurs. It is of interest, that in some States, there has been some regression in the amount of supervision required in certain settings. States that might have had less direct supervision in the early part of the decade may now require more direct supervision.

Table 6-1 of this report provides an illustration of the net change in supervision over the seven-year period. In scoring the change in level of supervision the following scores were applied to the level of supervision detailed in Chart E-1:

Direct Supervision, 0
Indirect Supervision, 1
General Supervision, 2
No Supervision, 3

To create Table 6-1, a numerical score was assigned to the level of supervision (see Chart E-1) required in each year in each setting. After that assignment was complete, the level of supervision applicable in the year 1993 in a setting was subtracted from the level of supervision required in that same setting in the year 2000. The results are presented here in tabular form (Table 6-1).

State	Original Index			New Index for 2000	Rating Based on New Index
Table 6-1 Professional Practice Indices for CNMs in the 50 States and District of Columbia
State	1992	2000	Change	New Index for 2000	Rating Based on New Index
Washington	62	100	38	92	Excellent Environment
New York	67	90	23	92
Maine	90	90	0	91
Utah	73	88	15	89
Rhode Island	84	90	6	88
New Mexico	78	90	12	88
Alaska	84	90	6	88
Connecticut	93	90	-3	86
Oregon	80	90	10	85
Minnesota	100	100	0	84	Favorable Environment
Iowa	55	97	42	84
Delaware	60	100	40	83
Colorado	50	100	50	82
New Hampshire	70	95	25	82
Montana	98	98	0	82
Idaho	54	100	46	81
Maryland	69	90	21	80
Arizona	76	96	20	79
South Dakota	70	89	19	78
Wyoming	60	90	30	77
Kansas	68	83	15	76.5
Massachusetts	57	90	33	74
Indiana	25	98	73	73.5
West Virginia	80	90	10	73
North Carolina	90	90	0	73
District of Columbia	60	80	20	72	Acceptable Environment
Ohio	60	90	30	71
North Dakota	55	97	42	70.5
Michigan	70	70	0	69
Kentucky	68	68	0	68.5
Vermont	57	80	23	64
Arkansas	35	78	43	64
Texas	54	67	13	62
California	80	70	-10	60
Oklahoma	54	60	6	60
Virginia	47	67	20	59
Tennessee	56	59	3	59
Missouri	27	60	33	59
Florida	98	58	-40	58
Hawaii	42	67	25	57.5
Wisconsin	62	78	16	57	Limiting Environment
Louisiana	37	70	33	56
New Jersey	54	47	-7	55
Mississippi	59	59	0	54
Nevada	30	58.5	28.5	52.5
Pennsylvania	34	50	16	52
Nebraska	50	50	0	44
Illinois	31	71	40	43
Georgia	70	59	-11	43	Restrictive Environment
South Carolina	59	59	0	39
Alabama	32	50	18	38

In several States, negative change is noted in one, some or all settings. For those States, according to informants, the mandated level of supervision required for hygienists actually increased over the decade. Although the net change across States was positive, change was relatively small and net gains in more autonomous practice for hygienists were negligible. The chart evidences that the most significant change occurred in dental office settings indicating a decrease in the level of supervision required in private practice locations.

This chart does not accommodate the required level of supervision for extended function hygienists. In a few States, this category of hygienist may work with little or no supervision in some or all settings. Practice by extended function hygienists is addressed in a further section of this chapter. Rather, this particular evaluation addresses supervision by licensed dental hygienists in the State. There are several interesting observations about changes in required supervision over the past decade:

In a large number of States, no change has occurred in the level of supervision required in any of the five settings during the seven year period. (25 of 51).
Change occurred in 26 of the 51 jurisdictions. Net change was negative in 10 of those States indicating that supervision requirements are more restrictive now than in the early part of the decade.
In 9 of the 26 States in which some change in required supervision occurred, the change happened only in a single setting. In the other 17 jurisdictions, change in required supervision occurred across multiple settings.
Importantly, there has been comparatively little net change over the decade in required levels of supervision in the five settings examined.
The level of supervision required is generally less restrictive in non-traditional dental settings. That is to say that the supervision required in dental offices is generally more restrictive than the incumbent level in other health settings.
Some States provide the opportunity for multiple levels of supervision in a particular setting. The applicable supervision may be dependent on the task that is being performed (e.g. prophylaxis or administration of anesthesia) or may be at the discretion of the supervising dentist who determines the level of supervision depending on the skill or experience of the performing hygienist. In cases where several levels of supervision apply, for purposes of tabulation, the most restrictive supervision was scored.

0 = No Change
+1 to + 16 = Degree of Easing of Supervision Requirements
-1 to –10 = Degree of Increase in More Restrictive Supervision Requirements

Tasks Permitted to Dental Hygienists

A review of documents from the American Dental Association provided a longitudinal history of the level of required supervision required for selected tasks by dental hygienists across the fifty States and the District of Columbia from 1993 to 2000.^[64] In order to assess change over the seven year period, once again, a chart was created from Chart E-2 in Appendix E titled Dental Hygiene Required Supervision by Task by Year which details the supervision required for selected hygiene services.

In order to examine the range of allowable services, the chart includes some fundamental preventive services and some extended functions. If the service was permitted to a hygienist in the jurisdiction, the required level of supervision was indicated. If a service was not permitted to hygienists, not permitted was placed in the chart. If the respondent had not provided information to the surveyors and supervision could not be noted or permission to perform the task was in question, the notation N/A was inserted.

To quantify the chart, a scoring system was applied:

Not Permitted or N/A = 0
Direct Supervision = 1
Indirect Supervision = 2
General Supervision = 3
None or No Supervision = 4

If an informant indicated only that the task was “permitted”, it was assumed that the level of supervision remained the same from the previous reported year. In cases where the task was permitted but the level of supervision was not indicated (permitted/none specified), it was assumed that no supervision applied and therefore, a score of 4 was applied.

The net scores for each State for each task are presented here in Table 6-2. The net score was achieved by subtracting the score for the level of supervision by task in 1993 from the score for the level of supervision by task in 2000. This was assumed to represent net change. In some States, negative change occurred suggesting that either the level of supervision required increased over the seven year period or that a particular task permitted to hygienists in 1993 was no longer permitted in 2000.

Table 6-2

Overall, positive change has occurred in the tasks that are permitted to hygienists over the seven year period. Some conclusions about change in tasks permitted to hygienists are evident:

Overall, positive change occurred indicating that permitted tasks have increased and the incumbent level of supervision is more permissive.
Change occurred in 48 of the 51 jurisdictions examined. Change was positive in 37 States, with negative change occurring in the other 11 jurisdictions.
Most change occurred in the period between 1993 and 1998. However, there has been significant change between 2000 and 2003 in several States. There are a number of legislative initiatives or pending bills in States addressing both supervision and permitted services by hygienists. The reader is directed to the footnotes in Appendix C of this report that document by State impending change in operative supervision, permitted services, and locations where services may be provided.
As would be expected, the most change occurred in expanded functions for dental hygienists including monitoring of nitrous oxide, administration of local anesthesia, and administration of nitrous oxide. Most health professions have experienced expansion in scope of practice due to increased educational levels, increased technology available to perform and monitor services, and increased recognition of the skill of the profession.
The least change occurred in coronal polishing and application of sealants. This would be anticipated since these tasks are fundamental to the hygiene profession and are staple services provided to patients. In most States, the level of supervision required would be the most liberal for these prophylactic services so a measure of change would be minimal.
A small change measure would also be expected for restorative services such as placing amalgam restorations. Since this is outside the traditional scope of practice for the profession, permission to perform the service would be less frequent and it would be expected that supervision would be restrictive.
It is of interest (refer to Chart 2 in Appendix E) to note that although supervision by task does differ within States, each State seems to adopt a prevailing level of supervision that applies to prophylactic and preventive services. When direct supervision applies to the basic services performed by the hygienist, it is reasonable to expect that direct supervision will apply to more expanded functions. In States, that permit general supervision, more permissive practice is apparent. However, it is also not surprising that in States where general supervision prevails, there is often a requirement for direct or indirect supervision when anesthesia is administered. Patient safety guides the degree of regulation/supervision for these more complicated tasks when provided by hygienists.
When positive change has occurred in the level of supervision required, it often applies across the tasks permitted. Delaware, Nevada, New Mexico, Pennsylvania, and Oklahoma are examples of States where prevailing supervision changed substantially over the seven year period.

The following Chart 6-3 is a graphical representation of the number of States that permitted hygienists to perform a variety of tasks in 1993, 1998, and 2000. The chart demonstrates expansion of practice in a number of areas for dental hygienists over the last decade. This chart was created from Table E-3 in Appendix E.

[D]

Expanded Functions for Dental Hygienists

An increase in the number of expanded functions permitted to dental hygienists is noted across the decade. Chart 4 in Appendix E, which documents this expansion, is a compilation from various sources. The chart provides a visual overview of change through the past decade.

In 1993, only 12 States provided for the provision of expanded services by dental hygienist.
In 2001, 35 States permit some form of expanded function to dental hygienists.
The greatest change in permission for expanded functions has occurred in the period between 1998 and 2001.
There has been notable change across States in permission to administer both nitrous oxide and local anesthesia over recent years. In 1985, only 14 States permitted a hygienist to administer local anesthesia and only 5 States permitted administration of nitrous oxide. In 2001, 28 States permited administration of local anesthesia with 18 States permitting administration of nitrous oxide by hygienists.^[65]
In 2001, hygienists are permitted unsupervised practice for certain services in designated settings in 14 States.^[66]
Expanded functions are permitted to hygienists in a variety of settings in order to meet designated public health and legislative prerogatives. For instance, Connecticut has mandated school based oral health services. Hygienists are permitted to provide those services unsupervised in schools and to receive direct reimbursement for those services. South Carolina is another example of a State that has focused on a school based sealant program that permits hygienists to provide services to school age children with permission of the parent.
California has created an expanded function license that requires extensive education and experience of the hygienist. A hygienist providing services under that license may do so unsupervised by a dentist. New Mexico has legislated that a hygienist may perform services as long as a collaborative agreement with a dentist is in place. This is much like the nursing model for advanced practice.

Direct Reimbursement for Dental Hygienists

The ability to be reimbursed for services is essential to the provision of any service by a health professional. Almost universally, oral health services are billed by dentists to public and private payers. Dentists, therefore, receive the professional reimbursement for the prophylactic and preventive services provided by the hygienists in their employ. Since reimbursement is generally contingent on an arrangement with a dentist, hygienists are limited to providing services to locations and patients with whom their employing dentists are engaged. The ability to be reimbursed directly for services would provide hygienists some autonomy in practice and would permit some self-determination about work locations and patients served. However, in only seven States is any direct reimbursement available to hygienists:

In California, registered dental hygienists in alternative practice are permitted to submit insurance or other third party claims for direct reimbursement.
In Colorado, unsupervised hygienists providing services in public settings are permitted to submit claims to Colorado Medicaid for direct reimbursement to the hygienist.
In Connecticut, hygienists working in a variety of public health settings including nursing facilities, intermediate care facilities for the mentally retarded or developmentally disabled, in group homes, schools, and community based clinics may be directly reimbursed for services by Connecticut Medicaid or by Medicaid Managed Care Programs in the State.
In Missouri, Medicaid is required to directly reimburse any eligible provider including dental hygienists who provides certain health services to a Medicaid eligible child.
In New Mexico, collaborative practice dental hygienists are eligible to participate as Medicaid oral health providers.
In Oregon, limited access dental hygienists practicing in State licensed facilities are entitled to direct reimbursement for services provided to patients.
In Washington, dental hygienists are eligible to enroll as a provider with the Medical Assistance Administration for direct reimbursement for oral health services provided to Medicaid eligible patients.
Utah insurance law enumerates dental hygienists as eligible health care providers but as yet, not direct reimbursement is in place for the profession.

Access to care is directly affected by the reimbursement policies mandated in law and regulation. More autonomous practice would require some mechanism for direct reimbursement for these professionals to provide care.

Conclusions

The dental hygiene profession has made slow progress over the decade in some areas:

The number of States that permit self-regulation by the dental hygiene profession remains small. A few States have created advisory committees for the profession that have some power to effect the conditions for practice by hygienists in the State.
- The level of supervision required for hygienists has decreased, but only marginally, in office settings and in public health settings in the majority of States.
- Direct reimbursement to hygienists as a mechanism for increasing access to services is only recently receiving attention. In most States, hygienists are required to be employed by or contracted to a dentist who receives reimbursement for preventive and prophylactic services of hygienists and then pays the hygienists through a salary or stipend.
Moderate progress has occurred in other areas which directly affect access by underserved populations:
- The settings in which hygienists are permitted to practice have been expanded to include other than the traditional dental office settings. Hygienists are now permitted in most States to practice without the direct supervision of a dentist in one or another public health setting.
- There has been an expansion in the tasks allowed to hygienists in a number of States beyond traditional prophylaxis and education including some basic restorative and treatment services.
- Expanded functions are permitted in many more States than in the early part of the decade. These privileges enable the hygienist to provide multiple points of entry to oral health services in locations that expand access to care.
Progress in self-regulation, in scope of practice, in supervision, and in reimbursement has occurred incrementally in most States. Some States (e.g. New Mexico) have undertaken substantive change in regulation of the profession, in settings and tasks permitted, and in reimbursement policy driven by a vision to increase access for underserved populations. Global change for the profession is, however, still the exception rather than the rule.
The dental hygiene profession has progressed less quickly than most other health professions. This is largely due to the regulation of the profession by dentistry, a condition that is unusual in health regulation since most other professions are provided with autonomy in governing their constituents.