MINUTES OF MEETING
ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES
Sixty-seventh Session
March 2, 1993
The Assembly Committee on Health and Human Services was called to order by Chairman Jan Evans at 1:33 p.m., Tuesday, March 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:
Mrs. 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
Mrs. 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:
Suzanne Ernst, Division of Aging Services; Sharon Ezell, Health Division; Cynthia Pyzel, Deputy Attorney General; William Offutt, Les Bradshaw, Arthur Wehrmeister, and Pat Christensen, Nye County; May Shelton, Washoe County Social Services; Michael McMahon, Churchill County; Michelle Bero, NACO; John Schaper and Dr. T. Brian Callister, Nye Regional Medical Center; Kirby Burgess, Clark County; Bill Welch, Nevada Rural Hospital Project; and James Wadhams, Nevada Hospital Association.
ASSEMBLY BILL 169 - Allows state board of health to authorize county health officers to supply abstracted birth certificates under certain circumstances.
Mrs. Evans called attention to the proposed amendment to AB 169 which was submitted to the committee for consideration by the State Health Division (EXHIBIT C).
ASSEMBLYMAN TOOMIN MOVED TO ACCEPT THE AMENDMENT.
ASSEMBLYMAN FREEMAN SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
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ASSEMBLYMAN SMITH MOVED TO AMEND AND DO PASS ON AB 169.
ASSEMBLYMAN DE BRAGA SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
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ASSEMBLY BILL 182 - Prohibits bureau of services to the blind of rehabilitation division of department of human resources from guaranteeing loans to blind persons who are under contract with bureau.
ASSEMBLYMAN FREEMAN MOVED DO PASS ON AB 182.
ASSEMBLYMAN HELLER SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
Mrs. Evans opened the hearing on Assembly Bill 193.
ASSEMBLY BILL 193 - Revises definition of "residential facility for groups" for purposes of licensure and regulation.
Suzanne Ernst, Division of Aging Services, indicated AB 193 was recommended by the Division of Mental Hygiene and Mental Retardation for the purpose of making it possible to license individuals who were being paid to care for one or more persons in a group care facility. Problems with the current statute were discussed.
Sharon Ezell, Health Division, read her prepared statement and submitted a copy of amendments proposed by the Bureau of Licensure and Certification (EXHIBIT D).
Mrs. Evans asked for clarification of section 2(D). Ms. Ernst explained MH/MR did not want to be exempt.
Cynthia Pyzel, Deputy Attorney General, passed out the recommended amendment from the Division of MH/MR and offered an explanation for the proposed changes (EXHIBIT E).
Mrs. Freeman inquired if previous legislation regarding ombudsmen related to this bill. Ms. Ernst responded community ombudsmen had nothing to do with group care facilities.
Mr. Toomin requested information on the fiscal impact of the bill. Ms. Ezell explained the fiscal note referred to the cost of one additional surveyor.
Mrs. Segerblom asked how many people were involved in an intermediate facility for the mentally retarded. Ms. Pyzel noted the term refers to the level of care and not the size of the facility.
Mr. Petrak wondered how long an individual could be confined to an intermediate care facility. Ms. Pyzel said it was important to define intermediate care facility for the mentally retarded because it was not measured by days but rather by diagnosis.
Mrs. Evans referred AB 193 to subcommittee for further work on the proposed amendments.
Mrs. Evans opened the hearing on Assembly Bill 197.
ASSEMBLY BILL 197 - Limits liability of county under certain circumstances for medical services provided to indigent persons.
William Offutt, Nye County Manager, introduced staff members Pat Christensen, Arthur Wehrmeister, and Les Bradshaw. Mr. Offutt indicated his concern with the way the bill had been drafted and offered amendments which would clarify the intent of the law (EXHIBIT F).
Mrs. Evans asked Mr. Offutt to discuss the background of the bill. Mr. Offutt responded NRS 450.400 set forth the liability of the county to provide for the care of indigents. As currently written the statute left room for ambiguity and misinterpretation. Nye County had received a ruling from the State Supreme Court in regard to this statute.
Les Bradshaw, Deputy District Attorney, discussed the ruling received from the Supreme Court in the Delapeza case (EXHIBIT G). Attention was drawn to the requested amendments (EXHIBIT H).
Mrs. Freeman asked if the word "reasonable" was defined in statute. Mr. Wehrmeister indicated he was not aware of a specific statutory definition of reasonable as it related to hospital costs; however, NRS 428 related reasonableness to Medicaid/Medicare standards.
Mrs. Evans inquired if the rendering hospital could institute a lawsuit if the resident county refused to accept responsibility under current statute. Mr. Bradshaw said yes, current statute makes reference to a collection action by a hospital against a county. Mr. Wehrmeister added Nye County had been involved in 17 lawsuits with Washoe Medical Center in the last two years. Nye County would like to eliminate the need for litigation by simplifying the rules so everyone understood who was responsible for payment.
Mrs. Evans asked if Nye County had the ability to use the indigent accident fund. Mr. Wehrmeister explained that AB 197 did not pertain at all to the indigent accident fund. These were general fund monies appropriated by the Board of County Commissioners. Mrs. Evans inquired if the time frame for notification was 3 working days. Mr. Wehrmeister maintained Nye County was not objectionable to notification within 3 working days; however, the board must make a determination within 7 days which was totally unreasonable.
Ms. Augustine asked if this was a means to move funds out of indigent care. Mr. Wehrmeister indicated these funds could only be used for indigent care. Appropriation was set by state law. Ms. Christensen clarified once funds were appropriated for medical care they could not be used for any other purpose.
Mr. Toomin asked what the admittance policy was for the hospital with regard to indigents. Mr. Offutt said the hospital had no choice but to provide treatment. The problem was identification and determination of eligibility.
Mrs. Segerblom inquired about the amount of money paid out. Mr. Offutt responded Nye County had paid very large sums of money to the hospital for anyone treated in the emergency room. Under the proposed language Nye County would have enough money to pay for indigents.
Mr. Petrak inquired about responsibility with regard to residents of other counties. Mr. Bradshaw clarified within the state of Nevada the hospital could ask the county of residence to accept responsibility for medical bills.
Mrs. Freeman asked if the county could impose a tax override for indigent care and what percent of the county budget went toward write-offs of unpaid bills. Mr. Offutt did not respond to the first question but said the hospital would have to address the second question. Mr. Wehrmeister added these were not only Nye County issues, the problem existed in all rural and urban counties.
May Shelton, Director, Washoe County Social Services, addressed the committee. Ms. Shelton indicated initially AB 197 was not acceptable to Washoe County; however, Washoe County would support the bill with the proposed amendments.
Michael McMahon, Director, Churchill County Welfare, spoke in support of AB 197. The language in NRS 450 was confusing. Litigation served as an attempt to gain understanding of the statute. Mr. McMahon recommended the proposed language suggested by Nye County be sent back to bill draft. Then the counties and the hospitals could work together to resolve the issues.
Michelle Bero, representing the Nevada Association of Counties, indicated support for clarification of NRS 450. Mr. Toomin asked if every county was in agreement with the changes to NRS 450. Ms. Bero said that was the understanding of the NACO board of directors.
John Schaper, Administrator, Nye Regional Medical Center, commented on his concerns. According to federal mandate hospitals could not turn patients away. The determination of indigency was a difficult process. The hospital was concerned with how long they would be able to continue service. The last time they received payment from Nye County was in September. Eighty percent of unpaid emergency room bills were Nye County residents.
Dr. T. Brian Callister, Chief of Medicine, Nye Regional Medical Center, addressed the issues and practical implication of the bill from his perspective. The question of indigency and the county's obligation to support the emergency room were discussed. The way the statute read, if the hospital made a diligent effort but could not collect from a patient, the county was responsible. The Supreme Court opinion in the Delapeza case put the burden of proof on the hospital. Changing the law would affect the standard of care. The Nye County emergency room was loosing $30,000 to $50,000 a month. Ability to collect small bills from people who lived far away was extremely limited.
Mr. Petrak wanted to know if indigency must be proven before the county would accept responsibility for payment. Mr. Schaper explained it took the hospital 6 months to prove due diligence. Dr. Callister added the hospital had to provide proof a person was indigent.
Mrs. Evans asked what Nye Regional Medical Center would offer as an alternative. Dr. Callister said the statute as it pertained to emergency care should not be changed. Mr. Schaper said the Medicaid reimbursement rate would be reasonable.
Mrs. Evans noted the Supreme Court decision was an important variable to be considered and she had asked the LCB legal division to work with the committee on this issue. The bill would be referred to subcommittee and redrafted.
Ms. Augustine clarified the hospital had been able to break even prior to September when the payments ceased.
Mr. Toomin asked what Clark County's stance was on AB 197. Kirby Burgess indicated Clark County took a neutral position with regard to AB 197. Initially, there was some concern regarding the 7-day eligibility requirement. Clark County had not had the same problems other counties had. He noted it took up to 90 days to determine patient eligibility. The bill would benefit Clark County.
Bill Welch, Executive Director, Nevada Rural Hospital Project, supported the initiative of Nye County to clarify the language. However, he did not necessarily support the outcome Nye County was trying to accomplish; i.e., shifting responsibility for indigents to the hospital. He was supportive of working out a compromise. Identification of indigent patients was a very difficult process. Criteria for eligibility needed to be addressed.
Jim Wadhams, Nevada Hospital Association, pointed out there were two issues which needed to be addressed. One was the counties' responsibility for the cost of indigent care. A separate issue was what level of emergency room availability should be made accessible to the public. These were public policy issues which deserved very serious consideration.
Mrs. Freeman noted the problem with patients being shuttled from hospital to hospital because of indigency status had been previously addressed and wondered if this was still a concern. Mr. Wadhams said he would ask Mr. Ash to address the question at a later time.
There being no further business to come before committee, the meeting was adjourned at 3:12 p.m.
RESPECTFULLY SUBMITTED:
CONNIE CAMPBELL
Committee Secretary
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Assembly Committee on Health and Human Services
March 2, 1993
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