Californias sweet taste of freedom

May 1, 1999
The road to independent practice has been a long struggle. From the start, when hygienists were first licensed, there has been a growing momentum to practice independently. As a groundbreaking state, the California legislature in 1972 identified a need to improve the effectiveness of health-care delivery systems, enacting the Health Manpower Pilot Projects Act (HMPP) as part of the California Health and Safety Code.

`HAP` is either a nickname for someone named Happy or a hygienist happily practicing independently.

Frances Dean Wolfe

The road to independent practice has been a long struggle. From the start, when hygienists were first licensed, there has been a growing momentum to practice independently. As a groundbreaking state, the California legislature in 1972 identified a need to improve the effectiveness of health-care delivery systems, enacting the Health Manpower Pilot Projects Act (HMPP) as part of the California Health and Safety Code.

Since that time, the HMPP program has contributed significantly to the state`s health care by providing "... a systematic, planned approach to alternative health-care methods." Some of the successful pilot programs focused on nurse practitioners, certified nurse midwives, emergency medical technicians, and physician assistants. The dental profession has also benefited from the HMPP program - first by establishing the designation of registered dental assistant; secondly, by legally allowing hygienists to administer local anesthesia.

Health Manpower Pilot Project #139, the Dental Hygiene Independent Practice Prototype project, was developed to create awareness about the increased value of registered dental hygienists practicing independently. The project`s intent was to increase access to preventive dental services, as well as access to the general dental health-care system.

The timetable about how California resolved the issue of independent practice by dental hygienists can be summarized as:

- The initial application for the HMPP #139 was submitted in 1980.

- In 1981, the project was approved by the Office of Statewide Planning and Development under the sponsorship of the California State University-Northridge.

- Maxine Waters, a state assembly member, introduced two bills in 1985. The legislation addressed issues of access to preventive dental hygiene services in California. The wording of this bill allowed hygienists to practice without the supervision of a dentist in institutions and healthcare facilities.

- Funding was acquired for the project in 1986, and the first class of participants was certified to practice independently.

- In 1987, the California Dental Association initiated a lawsuit against the California Office of Statewide Health Planning and Development, the first 15 HMPP hygienists, and the Trustees of the California State University system.

- The second class of participants was certified and entered independent practice in 1988.

- The CDA lawsuit terminated HMPP #139 in 1990. In the same year, HMPP #155 was approved after submission of a new application, public hearing, and public meeting.

- Assemblyman Rusty Areias, a Democrat from Los Banos, introduced AB 2353 in 1992. While there were no limitations to the location of practice sites for HMPP participants, the CDHA and Areias agreed to incorporate limitation(s) in practice settings. The bill failed to pass committee by only one vote because of a tardy report about HMPP #139.

- In 1993, the Dental Hygiene Access to Care Bill was written by Areias. The final report about HMPP #139 advised members of the California Legislature: "Seemed to be evidence of the potential for increased access to dental care associated with independent practice by hygienists." Areias` bill, though, failed to pass the full Senate vote, and a multi-million dollar campaign waged by the state`s dental association was given credit for the bill`s defeat.

- State Senator Hershel Rosenthal introduced SB 560 in 1995. It was co-sponsored by the American Association for Retired Persons (AARP) and the California Dental Hygienists` Association.

- The governor signed AB 560 in 1997.

- AB 560 resulted in a new category of dental auxiliary in 1998: RDHAP (Registered Dental Hygienist in Alternative Practice). RDHAPs are licensed to practice in California, providing authorized services under the prescription of a licensed dentist, physician, or surgeon.

Still bumpy for the independents

At least 11 California hygienists work in some type of independent practice. The new designation reads "HAP" on the actual license. RDHAP is what the new law calls the certification. Under AB 560, an RDHAP may perform duties authorized in the following settings:

* Residences of homebound patients

* Schools

* Residential facilities and other institutions

* Areas certified by the Office of Statewide Health Planning and Development as having a shortage of dental health professionals.

According to "independent" hygienists contacted by RDH, the road to independent practice remains a struggle. According to Diane Azavedo Rocklin, "Hygienists have been victimized by male supremacy, and they continue to be cash cows for dentists who offer virtually zero supervision, but at the same time use the regulations to profit from their hygienists` work."

According to Rocklin, a new regulation has capped free-standing offices, limiting the establishment of independent practices unless approved by the Office of Statewide Planning and Development. Rocklin also believes the regulations constitute restriction of trade, referring to recent discussion of the phrases "inner city" rather than "rural" to describe the underserved population that qualifies for treatment by an RDHAP.

She also says the requirement for a prescription from a dentist or physician is also a serious restriction of trade issue. Many of her prospective patients, according to Rocklin, do not have a family physician or dentist, and many are finding they can`t obtain an appointment to see their dentist for a prescription for hygiene services.

The California Dental Association, Rocklin asserts, is lobbying furiously against physicians being allowed to write prescriptions for hygiene visits. She also says, "A rewarding result of the three courses of HMPP studies directly responsible for the act permitting the RDHAP certification is that Canada requested the data collected for the act, reviewed it, and immediately enacted its own alternative practice certification."

She continues, "[We] fought so long and hard (more than 20 years) in California, but one result was a very quick and easy transition in Canada."

Barbara Sklar of San Rafael took a slightly different road. She`s been an independent practitioner for five years, focusing on dental hypnosis and other holistic therapies. She sees independent practice as an avenue for approaching wellness in a less clinical, more spiritual context. Sklar practices out of her home, treating phobics, trauma victims, and women of domestic abuse.

"My downside is isolation," she says. Sklar said she feels uncomfortably alone in her ideology and even in her clinic. She longs for support.

Sklar has not been able to secure a dentist to whom she can comfortably refer her patients. Most patients arrive at her home, according to Sklar, because they don`t trust the ADA team-player type [of dentist] who overdiagnoses, overcharges, overcontrols, and overbooks.

A provider of continuing education programs, Sklar has presented seminars at New York University on dental hypnosis and published the article, "Mind Over Matter," in RDH in 1997. She offers clinical seminars in her San Rafael practice, as well as in Montana and Colorado; she also facilitates Spiritual Partnerships at Cal Berkeley.

Sklar notes, "Even the professional organizations of registered dental hygienists are not unilaterally in favor of independent practice."

She continues, "Most RDHs are very conservative. They are content in their current roles, earning $300 per day in my area, without much responsibility for management or for start-up costs." But for her and the other RDHAPs, Sklar adds, "Independent practice is a dream come true; a dream no one believed possible 20 years ago when it first surfaced in California."

The queenpin who watched it all

Toby Segal, described by others as "the true originator of HMPP" and the "queenpin" of independent practice, chaired the 1978 committee that was tasked with investigating several hygienists who set up shop in kiosks in shopping malls. The committee`s job, at the time, was simply to research the concept of independent practice.

"The issue," says Segal, "is not so much that the hygienists hung out their shingles and treated patients, rather that they were being fired for it (independent practice) by their dentist/employers." Her committee eventually submitted a report to the Board of Dental Examiners. An interested bystander was the Federal Trade Commission, which was investigating restraint of trade.

Segal says, "Hygienists could almost certainly have won their case for illegal restraint of trade in court, but decided to fight the other way - by changing the wording of the laws governing direct and indirect supervision via the Health Manpower Project laws. In those days, dentists assumed awful things would result from unsupervised hygiene practices, but no one had any hard evidence."

She believes that many dentists who are supportive of the movement would not belong to the California Dental Association (because of ideological and political differences), except for the benefit of group-subsidized malpractice insurance.

"I can`t think of anything I would rather have done with my life," says Segal.

Judy Boothby claims independent practice is booming in Sacramento. According to Boothby, dentists are referring to RDHAPs, RDHAPs are referring to dentists, and she`s buried under her patient load. Ironically, she was asked to write the tests for independent practitioners for the state board after independent practice came into being.

Boothby believes that women have helped the independent practice effort because many of them are nurturing and selfless by nature. "It`s these qualities that have contributed to the wide acceptance of independent practice," she says. By RDHAPs` willingness to practice in environments that are "underserved" (meaning, by extrapolation, "not profitable"), they showed the profession that they did not aspire to undermine the economics of dentistry, but only to offer the care they had been trained to provide.

In 1986, Boothby put everything she stood for on the line in trying to meet the needs of an underserved population. She formed, under the Health Manpower Pilot Project #139 and later #155, her company, Dental Hygienist Out and About. For more than 12 years she has worked and invested in a vision to serve those who would not otherwise receive the care they needed. She notes that many elderly people are being removed from institutions and cared for by family members in their homes.

"This is a societal trend to which independent practice has had the privilege of contributing," she says. She sees preventive care of the future moving away from the "high tech" orientation of the 1980s toward more of a focus on the quality of healing.

Boothby earned her bachelor`s degree in gerontology in 1993 at California State University, Sacramento, and completed her graduate education in Dental Care for the Disabled and Elderly in 1987 from the University of Washington School of Dentistry in Seattle. In 1993, her home-based practice received the first Annual Profiles in Excellence Award for the fastest growing home-based business for Sacramento.

-n a typical day, Boothby packs her dental hygiene equipment into her van. Her clients vary from nursing homebound patients where she shares space with a cosmetologist, to visiting residential care and home-bound clients.

A mission for creative patient education

Laurlyn Borst, another RDHAP, states, "The long road to independence featured the intertwined issues of economics, gender, control, and power. Hygienists can`t afford the political fight that the CDA is so well-funded to wage. They were able to outlast the hygienists who had to pay their own way to Sacramento and forego the fees for each day`s work lost." She adds that dentists who opposed them hired lobbying groups to protect their financial and emotional turf.

Borst says the next step, that of making it legal for any consumer to go directly to independent practitioners without a prescription [from a dentist], is still being fought and facing the same political and economic barriers as before. She credits Don Perata, a state senator from Alameda, as the champion of the original legislation and the ongoing motion to soften the prescription laws.

Perata, according to Borst, backed the independent Ounderserved or institutionalizedO practice act because his own mother was housed in a convalescent home and could not find trained personnel to perform her maintenance hygiene, even though it was a contractual medical service promised by her facility and covered by her long-term care insurance.

The RDHAP certification, Borst says, has empowered her to run her own little shop. ONo one is on my back or looking over my shoulder,O she says. OThis is why I went to school.O The autonomy, she says, has fulfilled her to implement her own spin on health.

She enjoys being able to present her own philosophy to her patients and believes prevention and maintenance are the most obvious and least-touted ways to sustain excellent health. OWe have learned that chemicals don?t work,O she says. OThey may deliver the promised clinical result, but always with a backlash. Dentists perform appropriate therapies, but hygienists facilitate the educational process that creates health.O

Some other comments from California RDHAPs include:

Y OEach of our practices is run differently and uniquely to our own satisfaction. All California dental hygienists have the opportunity to expand their horizons and provide access to care.O ? Charlotte Burroso.

Y OAlthough many of the original independent hygienists trained through the Cal State Northridge-based program ... have moved back to traditional hygiene roles, we have paved the road for training hygienists with a method of practice that will allow them to reach out to individuals in areas ... that traditional practice cannot and does not viably serve.O? Ginger Koshay.

Y OI?m glad I did it even though it?s been hard work. I have control over the patient care I provide to a much greater extent than I did before.O? Shirley Thompson.

The success of RDHAP in California marks a significant historical turning point in dental hygiene. Long-term, the outlook for alternative/independent practice in other states grows more promising as the millennium draws near. More involvement from hygienists is needed to get manpower bills passed in other states.

Frances Dean Wolfe is the pen name of a dental professional who has written articles for many dental journals since the early 1980s.