MINUTES OF MEETING
ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES
Sixty-seventh Session
February 2, 1993
The Assembly Committee on Health and Human Services was called to order by Chairman Jan Evans at 1:15 p.m., Tuesday, February 2, 1993, in Room 330 of the Legislative Building, Carson City, Nevada. Exhibit A is the Meeting Agenda, Exhibit B is the Attendance Roster.
COMMITTEE MEMBERS PRESENT:
Ms. Jan Evans, Chairman
Mrs. Vivian L. Freeman, Vice Chairman
Ms. Kathy M. Augustine
Ms. Marcia de Braga
Mr. James A. Gibbons
Mr. Dean A. Heller
Mr. William A. Petrak
Ms. Gene W. Segerblom
Ms. Stephanie Smith
Mr. Louis A. Toomin
Mr. Wendell P. Williams
COMMITTEE MEMBERS ABSENT:
None
GUEST LEGISLATORS PRESENT:
None
STAFF MEMBERS PRESENT:
Kerry Carroll Davis, Research Analyst
OTHERS PRESENT:
Mary Ellen McCarthy, Attorney, Nevada Legal Services;
Dr. Robert Daugherty, Dean, University of Nevada School of Medicine;
Frances Doherty, Attorney, Washoe Legal Services;
Tim Fuetsch, Principal, Glenn Duncan Elementary School;
Dr. Jeffrey Wrightson, Chairman of the Department of Obstetrics and Gynecology, University of Nevada School of Medicine;
Caroline Ford, Director, Office of Rural Health, University of Nevada School of Medicine;
T. Brian Callister, Chief of Medicine, Nye Regional Medical Center;
Bill Welch, Executive Director, Nevada Rural Hospital Project;
Robert Hadfield, Executive Director, Nevada Association of Counties.
Chairman Evans requested committee introduction of BDR 40-803.
BDR 40-803 - An act relating to health care; revising the definition of "residential facility for groups" for the purposes of licensure and regulation; and providing other matters properly relating thereto.
ASSEMBLYMAN FREEMAN MOVED FOR COMMITTEE INTRODUCTION OF BDR 40-803.
MS. DEBRAGA SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
Mrs. Evans offered two alternative dates for a joint meeting with the Senate Committee on Human Resources and Facilities. It was the consensus of the committee to hold the joint meeting on Monday, February 22 at 5:00 p.m.
Ms. Davis, Research Analyst, distributed an issue brief and indicated its purpose was to summarize the issues and bills which came before the committee during the last session as well as present some topics which might come before the committee during the current session.
Mary Ellen McCarthy, Attorney, Nevada Legal Services, discussed the effect of some of the state's policies in regard to health care (EXHIBIT C).
Mr. Heller commented on his frustration in dealing with people who were unable to obtain housing. If someone had a medical emergency there would be nowhere for them to go because rural housing had a waiting list of one year to 18 months.
Mrs. Segerblom asked what kind of resistance was received from Nevada health professionals. Ms. McCarthy responded there was resistance, although people educated in the medical field had a moral obligation to the citizens of the community.
Dr. Robert Daugherty, Dean, University of Nevada School of Medicine, described the health care services and educational outreach programs of the school (EXHIBIT D).
Mrs. Freeman asked if it was still necessary to supplement the rural areas with obstetricians.
Dr. Daugherty explained due to the increase in malpractice insurance, physicians in small rural communities had to stop giving prenatal care. He noted the University did not have the resources to provide any help and this continued to be a problem.
Mr. Petrak commended the Medical School for initiating a bone marrow transplant unit.
Frances Doherty, Staff Attorney, Washoe Legal Services, expressed her concerns regarding access to health care. She related an instance where a couple utilized the services of the hospital emergency room to treat health conditions. She indicated indigent care and Medicaid programs were insufficient to meet the needs of very low income individuals and urged expansion of these programs. Ms. Doherty also commented on the Truckee Meadows Human Services Plan. The greatest human service needs in the county were identified as access to affordable housing and access to health care.
Mrs. Freeman asked why the couple went to the hospital emergency room and not the county clinic. Ms. Doherty responded they were subsequently referred to the clinic but she did not feel they could meet the eligibility guidelines. Mrs. Freeman commented on the Washoe County Truckee Meadows Human Services Plan. It was so successful it became a model for all other counties in the state.
Tim Fuetsch, Principal, Glenn Duncan Elementary School, familiarized the committee with a pilot program entitled Family Focus Center (EXHIBIT E). The program was a multi-disciplinary approach to solving family problems. Many families qualified for Medicaid and Food Stamp programs but were unable to take advantage of them due to language barriers and transportation problems. The program worked with a number of different agencies to address the problems the children were facing.
Mrs. Freeman explained the Glenn Duncan School was in her district and asked Mr. Fuetsch to describe the demographics of the school. Mr. Fuetsch responded 85 percent of the students qualify as being at the poverty level, 78 percent were minorities and 50 percent were Hispanic and had a language barrier.
Mrs. Freeman said she was drafting a bill in support of the program. This was the type of project where help could be provided to a community which was helping itself.
Mrs. Segerblom asked if the program was dealing just with children. Mr. Fuetsch said the proposal was limited to children between the ages of 3 and 12.
Dr. Jeffrey Wrightson, Chairman of the Department of Obstetrics and Gynecology, University of Nevada School of Medicine, spoke on behalf of the School of Medicine and as a member of the Maternal and Child Health Advisory Board (EXHIBIT F). Dr. Wrightson outlined new programs and indicated in order for growth to continue an alliance between the University and State Medicaid should be considered so money spent would flow back into Nevada's health care system. Dr. Wrightson highlighted the concerns of the Maternal and Child Health Advisory Board.
Mrs. Freeman pointed out bills had already been drafted to address some concerns.
Mrs. Evans asked Dr. Wrightson if he could expand on the number of fetal alcohol syndrome and crack babies. Dr. Wrightson said the numbers have been rising dramatically and stressed early intervention into prenatal care as a means of prevention.
Caroline Ford, Center for Education and Health Services Outreach, University of Nevada School of Medicine, discussed rural health issues (EXHIBIT G). Ms. Ford indicated 16 percent of Nevada's population lives in rural settings. Because of problems of geography, i.e., vast distances which were crucial to emergency situations, made it extremely difficult to recruit and train qualified personnel to serve in these areas. Provision of obstetrical services was in crisis, and facilities were in need of modernization.
Mrs. Freeman asked if malpractice premiums had gone down for obstetrians in outlying areas. Ms. Ford indicated there was some fluctuation depending on the physician's experience rating; however, it had not changed dramatically.
Mrs. Evans asked Ms. Ford to discuss certified nurse midwives, nurse practitioners and physician assistants as they relate to better health care in remote areas. Ms. Ford said they would be referred to as mid-level practitioners or position extenders. They operated under protocols, diagnosed and treated primary health care problems and worked with some independence. There was a nurse practitioner training program beginning in Las Vegas.
Dr. Brian Callister, M.D., discussed health care issues in rural Nevada from a practitioner's viewpoint (EXHIBIT H). The biggest problem was from burnout due to hours worked, poor facilities, and lack of backup personnel.
Mrs. Freeman asked if the $20,000 being offered by Elko to find a physician would be adequate. Dr. Callister explained when a finder's fee was being offered, the physician did not get the money. The money would go to the recruiter. Mrs. Freeman asked if Nye Regional Medical Center was publically or privately owned. Dr. Callister said it was a county hospital district. For example, anyone who could not pay his emergency room bill was no longer being funded by the county. Mrs. Freeman inquired if "care flight" service was available. Dr. Callister indicated air transportation was usually available to Reno but transportation to Las Vegas was difficult if the patient did not have insurance. Mrs. Freeman asked what kind of backup support was offered by physician assistants. Dr. Callister said they were extremely efficient. Mrs. Freeman asked if the mine at Round Mountain provided any assistance. Dr. Callister said they actually employed the physician assistant and had a clinic. Mrs. Freeman asked if a cross training program was in place. Dr. Callister explained the hospital in Tonopah did its own cross training.
Mrs. Segerblom asked if Tonopah took care of patients in Gabbs and Pahrump. Dr. Callister indicated the hospital covered Austin, Eureka, Round Mountain, Manhattan, Bellmont, Mina, Fish Lake Valley, Goldfield, and Beatty.
Ms. Augustine asked if firefighters were also volunteers. Dr. Callister said they were all the same people. He was teaching EMT recertification courses as well as fire rescue.
Mr. Petrak asked if the high cost of malpractice insurance was a factor in retaining physicians. Dr. Callister said insurance coverage was a problem; however, rural areas had a much lower rate of lawsuits.
Bill Welch, Executive Director, Nevada Rural Hospital Project, provided an overview of key legislative issues (EXHIBIT I). Mr. Welch clarified several questions regarding malpractice insurance. Insurance premiums were lower when a physician first entered practice. The premiums increased 25 percent each year for four years. There was a reduced malpractice insurance premium available for practitioners who delivered less than 100 babies per year. Although Elko was paying $20,000 to a placement company to find a physician, there was no support to maintain the position and the guaranteed salary was only good for one year.
Mr. Gibbons asked if Mr. Welch had noticed a decrease in malpractice insurance premiums due to the activities of the medical screening panel enacted in 1987. Mr. Welch indicated the decrease was a result of the panel, and rural hospitals had created their own malpractice insurance pool. Experience tended to be lower in the rural areas.
Mrs. Freeman asked if the insurance premium was based on experience. Mr. Welch said it was a combination of experience and number of clients. Mrs. Freeman stated the Nursing Foundation Board identified the need for faculty as the biggest problem with regard to Nurses' training. Mr. Welch agreed and indicated when a training program was being taught through an existing program provisions were made to have it videotaped. Mrs. Freeman asked for an explanation in regard to the broadening of revenue sources. Mr. Welch explained current statutes prohibit a public hospital from providing certain services in the community. Mrs. Freeman commented on board composition being appointed rather than elected. Mr. Welch explained the majority of the board members would be elected with an additional two members appointed. Mrs. Freeman asked who would be the advocate of indigent eligibility for hospital emergency rooms. Mr. Welch believed the bill would be introduced by Nye County.
Mr. Heller asked how quickly the loan program would be utilized. Mr. Welch indicated the bulk of the money would be utilized in the next 18 to 24 months. Then access to funds would be limited due to repayment of the RWJ grant.
Mrs. Segerblom asked if the Boulder City loan was being repaid within 5 years. Mr. Welch said it was a newly acquired loan and payments began two months ago.
Mr. Welch noted rural hospitals were limited in their ability to acquire loans from banking institutions. Security was required on all loans granted under the program.
Robert Hadfield, Executive Director, Nevada Association of Counties, commented on county participation in the health care system. The RWF loan fund was made possible in part by city/county relief tax money. In addition NACO administers an indigent accident fund and a supplemental fund. Mr. Hadfield urged continued support of the AHEC program which provided training to health care professionals in rural Nevada.
There being no further business to come before committee, the meeting was adjourned at 3:30 p.m.
RESPECTFULLY SUBMITTED:
CONNIE CAMPBELL
Committee Secretary
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Assembly Committee on Health and Human Services
February 2, 1993
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