MINUTES OF MEETING
ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES
Sixty-seventh Session
February 4, 1993
The Assembly Committee on Health and Human Services was called to order by Chairman Jan Evans at 1:30 p.m., Thursday, February 4, 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:
Yvonne Sylva and Martin Atherton, Nevada State Health Division; Chris Thorne and Patricia Raetz, Nevada Health Information Management Association; Dr. John Kelly, American Cancer Society; Elaine Speegle and Faye McNamee, Nevada Cancer Data System; Dr. Roger Miercort; Fred Hillerby, Washoe Medical Center; Jerry Ash, Nevada Hospital Association, Captain Randy Oaks, Las Vegas Metropolitan Police Department; Jerry Zadny, Dr. John Marino, Dr. Michael Fitting, and Dr. Carlos Brandenberg, Mental Health/Mental Retardation; Kevin Christensen, Office of Protection and Advocacy; Mary Henderson and Brian Mirch, Washoe County.
Mrs. Evans opened the hearing on Assembly Bill 131.
ASSEMBLY BILL 131 - Revises provisions relating to reporting information on certain cases of cancer.
Yvonne Sylva, Acting Administrator, Nevada State Health Division testified in favor of AB 131 with two proposed amendments (EXHIBIT C). Ms. Sylva introduced Mr. Martin Atherton, Bureau Chief of Health Information Data Management, Nevada State Health Division, and responded to questions.
Mrs. Freeman requested Ms. Sylva to clarify why only freestanding plastic reconstructive surgery, and oral and maxillofacial types of cancer were included. Ms. Sylva clarified these facilities would be additions. She stated information was currently abstracted from all the hospitals in Nevada. The proposed amendment would allow cancer data from other facilities to be included. Ms. Sylva asserted other types of cancer could be included if the committee would entertain a motion before Ways and Means or Senate Finance.
She explained current law did not permit hospitals to do their own abstracting even though in some cases hospitals felt they could do abstracting for less money than Nevada State Health Division would charge. Ms. Sylva pointed out some facilities had chosen to do their own abstracting, and the Nevada Health Division had historically allowed certain facilities to do so and charged them a reduced fee. Ms. Sylva commented by amending the statutes, hospitals could do their own abstracting possibly at a lower cost which would allow the Health Division to assess a smaller fee for only processing data.
Mrs. Freeman commented on communications received from physicians who were concerned by the proposed statute. Ms. Evans explained all the committee members received the same communications, and shared the information with Ms. Sylva for her response (EXHIBIT D).
Mr. Gibbons expressed his concern for the confidentiality of the information and asked how confidentiality could be preserved in the facilities mentioned in Ms. Sylva's amendment. Ms. Sylva replied the same confidentiality would be preserved regardless of the facility, and stated all medical records were treated as confidential.
Mr. Atherton assured the committee information was maintained by the Nevada statewide cancer registry to the highest degree of completeness and accuracy which could be provided with staffing available. He explained the Nevada statewide cancer registry collected information on the number of new cases of cancer which came into existence within a specified period of time. He further stated the function and goal was to track those cases. Follow up, once cases were identified, was an ancillary function to cancer registration in the United States. He added the follow-up component to determine how long people survived after diagnosis had been revised over the past year as a result of budget cutbacks and staff reduction in the cancer registry. He said the Nevada statewide cancer registry had the number of new cases which came to medical attention during a specified period of time, but information on survival patterns was being maintained by hospitals.
Ms. Sylva addressed the issue regarding the abstraction fee. The original bill was unclear and the amendment offered would better define the bill. Ms. Sylva confirmed a charge associated with the State Health Division handling abstractions when the abstractions were received. She acknowledged a charge of $2.15 to $2.45 per record by the Rocky Mountain Data Cancer System. She explained when abstractions were done by a source outside the division, the State Health Division would review the medical records and visit facilities to make sure information was abstracted in the proper manner. She commented fees would be associated.
Mrs. Evans asked Ms. Sylva to identify the Rocky Mountain Data System, its fee structure, how they interface with the Health Division and what the Health Division was trying to achieve.
Mr. Atherton explained Rocky Mountain Data Cancer System is a consortium of statewide cancer registries located primarily in the intermountain states. Data is also shared with the California registry which has its own system. Nevada shares data with California through the Rocky Mountain Cancer Data System. Mr. Atherton elaborated on the $2.15 per case charge and stated when the Cancer Registry made those cases available to the Rocky Mountain System, the Nevada Health Division is billed, and the billing charge becomes part of the Nevada Health Division budget.
Mrs. Evans asked why collection of data was important for Nevada. Mr. Atherton pointed out Nevada had the highest rate of cancer mortality for women, particularly lung cancer, which far exceeded any experience in the country. He stated cancer of certain sites and certain varieties was a major problem in Nevada's overall health status. To determine the level of excess mortality attributed to lung cancer, he stressed the importance of identifying groups which should be targeted for health education and intervention. Mr. Atherton stressed the large costs incurred for treatment by victims of lung cancer. He felt information provided by the Cancer Registry to the medical community at large was providing an important service to Nevada. He remarked the Nevada Health Division was active with the U.S. Department of Justice in assisting victims of radiation exposure to receive compensation. He added the Nevada Cancer Registry in many cases had served as the primary source of first record validation of those cases of cancer.
Mrs. Evans referred to the letter received from UNLV and asked what changes had been made to the system. Mr. Atherton responded he did not know what changes were instituted in the cancer registry which would affect research. Mrs. Evans inquired if hard copies of the information were maintained. Mr. Atherton said yes.
Ms. Sylva indicated Dr. Shield's concern appeared to relate to fees charged to facilities doing their own abstractions. Two separate fee structures were being proposed. The current charge for an abstraction done by the State Health Division was $20.
Mr. Atherton explained the abstraction process involved a thorough review of medical records, then the information collected must be coded.
Ms. Smith asked what benefit was derived the individual who is paying the abstraction fee. Mr. Atherton indicated this information was not only helpful to researchers, but data was made available in newsletter format so physicians could gain insight regarding cancer patterns.
Ms. Augustine asked how the registry interfaced with the American Cancer Society. Mr. Atherton explained the American Cancer Society had been very interested in the Nevada Cancer Registry, and they collaborated on the radiation exposure program.
Mr. Toomin asked if the cancer registry had kept any figures with regard to how long cancer patients had lived in the state. Mr. Atherton commented, due to Nevada's growth and the influx of people into the state, maintaining an accurate record was very difficult. However, a number of research groups were interested in this information. Mr. Atherton agreed Nevada's health trends were important and needed to be maintained.
Mr. Petrak asked how laboratory test results were transferred to the cancer registry and who paid the associated costs. Mr. Atherton explained labs were not charged a fee for providing information.
Mrs. Freeman asked if there were sufficient funds and manpower available to perform the goals and objectives of the cancer registry. Mr. Atherton said long-term follow up was no longer a central component of the cancer registry.
Mrs. Segerblom asked why the long-term studies were abandoned. Mr. Atherton verified this information was being maintained by several hospitals in Nevada which diagnose and treat three-fourths of the cancer patients. It was felt incidence and surveillance should be done at a minimum and follow up would be done when another means of support becomes available. Ms. Sylva added long-term follow up was eliminated due to staff reductions.
Mr. Toomin asked if results of tests conducted by a physician were reported to the registry. Ms. Sylva said the only results received were from hospitals.
Ms. de Braga asked if outpatient data was reported. Ms. Sylva said any information associated with a hospital would be reported.
Chris Thorne and Patricia Raetz, Nevada Health Information Management Association, spoke in favor of AB 131 with one additional amendment (EXHIBIT E).
Dr. John Kelly, American Cancer Society, encouraged use of the term "health care facility" rather than "hospital" in drafting the language of the bill.
Elaine Speegle and Faye McNamee, Nevada Cancer Data System, spoke in opposition to AB 131 (EXHIBIT F). Ms. McNamee indicated the benefits of hospitals being able to develop their own programs. These programs were patient oriented and required lifetime follow-up. She further indicated all hard copy documents in the state cancer registry were being shredded and abstracted documents must be retained indefinitely.
Dr. Roger Miercort, discussed his experience with tumor registries. He indicated Nevada previously had a tumor registry which was quite complete. However, the state tumor registry was now being forced to simply gather data.
Mr. Gibbons asked if there was a difference in the information obtained from the various hospitals or did they use a standard format. Dr. Miercort indicated some basic information was required, however, completeness of the information could vary.
Ms. de Braga asked how much data was being missed. Dr. Miercort said Nevada previously shared information with other registries although Nevada might no longer have the same capability.
Mrs. Freeman noted it appeared the Nevada cancer registry was no longer funded adequately.
Mrs. Segerblom asked if the information abstracted was shared between hospitals. Dr. Miercort said no.
Mr. Petrak indicted up-to-date information was going to be vital for future planning, and Dr. Miercort agreed.
Fred Hillerby, Washoe Medical Center, reiterated the hospital did its own abstractions and follow-up. He called attention to the fee structure. The statistical data being collected by the state no longer had any value. There should be a limitation on the amount of fees charged.
Jerry Ash, Nevada Hospital Association, acknowledged this was a confusing and controversial issue. It was not just a matter of fee but a matter of value. He encouraged the committee to look deeper into the issue. The Hospital Association would like to support a superior cancer registry, not simply spend more money for less service.
Ms. Augustine entered into a discussion with Mr. Ash and concurred the proposed legislation would not do anything to increase the value of the information.
Mrs. Evans indicated no vote would be taken. The bill would be reconsidered again after the proposed amendments were drafted.
Mr. Toomin directed a final question to Ms. Sylva regarding the cost of one additional position. Ms. Sylva responded she would have to get back to Mr. Toomin with an exact figure. She clarified the cancer registry was not totally self funded, 28 percent came from general fund support. Last year there were over 6,000 records abstracted. She estimated another staff person would probably cost between $35,000 and $40,000 per year. Ms. Sylva believed if the additional position were funded the former level of service could be restored, however, the executive budget office had not recommended approval of the position. Ms. Sylva commented the Nevada cancer registry would still share data with other states in the Rocky Mountain region.
Mrs. Evans opened the hearing on Assembly Bill 168.
ASSEMBLY BILL 168 - Makes various changes relating to preliminary medical examination of allegedly mentally ill person before transportation to mental health facility.
Captain Randy Oaks, Las Vegas Metropolitan Police Department, testified in support of AB 168. Captain Oaks explained the requirement to have an individual examined by a licensed hospital before transport to a mental health facility and discussed the associated costs involved. Captain Oaks indicated there was a physician on staff in the county jail qualified to make this examination. Further, the mental health facility was requesting full diagnostic testing to determine if the person had a medical problem rather than a psychiatric problem. He expressed his concern this was not necessary in every case. Captain Oaks indicated language was deleted in lines 21 and 22 which caused concern for county social services, and he requested the language be restored. Captain Oaks noted other agencies would be in opposition also and he recommended the bill be referred to subcommittee for further study.
Jerry Zadny, Administrator, Mental Health/Mental Retardation, testified in opposition to AB 168. He drew attention to language in lines 16 through 19.
Dr. John Marino, Mental Health/Mental Retardation, discussed the physicians point of view in regard to AB 168. He indicated a number of patients have become ill or died unnecessarily because of medical problems while in the custody of the mental health facility. He affirmed the need for full diagnostic screening to rule out any medical conditions before individuals were admitted to the mental health facility.
Ms. Augustine asked Captain Oaks if the staff physician at the county jail had the necessary diagnostic equipment to perform a complete screening. Captain Oaks explained he could draw samples which would then be sent to a laboratory.
Mr. Petrak asked if Metro police brought all psychiatric patients to the mental hospital or just incarcerated individuals. Dr. Marino indicated he believed any patient who was assumed to need psychiatric attention after completion of the physical exam was brought to the mental hospital.
Dr. Michael Fitting, Mental Health/Mental Retardation, testified the two problems with the bill were standardization and scope. He discussed concerns regarding inappropriate admission of medically ill patients to the mental health facility and the inability to provide care to these individuals.
Mr. Toomin asked Captain Oaks if this bill referred to the transportation of arrestees. Captain Oaks explained it was both persons incarcerated as well as admissions directly from the field.
Dr. Carlos Brandenberg, Director Forensic Services, Lakes Crossing Center, spoke in opposition to AB 168, section 2, lines 14-19. He indicated all clients/inmates referred to the facility should be medically cleared and free of acute illness. The facility had no means of diagnosing or treating individuals with medical problems.
Mrs. Freeman asked what would happen if a patient in the facility contracted a communicable disease. Dr. Brandenberg said the only recourse would be to try to have the patient admitted to a medical hospital.
Mrs. Evans acknowledged this was a very complex issue and indicated the bill would be referred to subcommittee.
Kevin Christensen, Director, Office of Protection and Advocacy, Department of Commerce, spoke in opposition to AB 168. Mr. Christensen discussed the purpose and history of the bill. Essentially, the bill attempts to evaluate indigent persons with medical problems which might present psychological symptoms. He cited several examples of such cases.
Mary Henderson and Brian Mirch, Administrative Analysts, Washoe County, indicated this bill represented one facet of a larger issue. Mr. Mirch summarized the county's concerns (EXHIBIT H). It was inappropriate to hold mentally ill persons in the county jail. County staff was in the process of working with area hospitals and law enforcement personnel to develop a solution.
Mrs. Freeman asked if Washoe County would provide the committee with feedback from their meetings with the Board of County Commissioners and Mr. Griepentrog-Carlin.
Mrs. Evans indicated the hearing on Assembly Bill 169 would be rescheduled.
There being no further business to come before committee, the meeting was adjourned at 3:38 p.m.
RESPECTFULLY SUBMITTED:
CONNIE CAMPBELL
Committee Secretary
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Assembly Committee on Health and Human Services
February 4, 1993
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