MINUTES OF THE
SENATE COMMITTEE ON HUMAN RESOURCES AND FACILITIES
Sixty-seventh Session
February 22, 1993
The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 1:30 p.m., on Monday, February 22, 1993, in Room 226 of the Legislative Building, Carson City, Nevada. Exhibit A is the Meeting Agenda. Exhibit B is the Attendance Roster.
COMMITTEE MEMBERS PRESENT:
Senator Raymond D. Rawson, Chairman
Senator William R. O'Donnell, Vice Chairman
Senator Randolph J. Townsend
Senator Joseph M. Neal, Jr.
Senator Diana M. Glomb
Senator Lori L. Brown
COMMITTEE MEMBERS ABSENT:
Senator Bob Coffin (Excused)
STAFF MEMBERS PRESENT:
Pepper Sturm, Research Analyst
Judy Alexander, Committee Secretary
OTHERS PRESENT:
Bertha J. Warrick, Division Manager, Clark County Social Service
Myla C. Florence, Administrator, Nevada State Welfare Division
Kirby Burgess, Clark County
Mary Lynne Evans, Administrator, Office of Narcotics Control Assistance, Department of Motor Vehicles and Public Safety
Donald S. Kwalick, M.D., M.P.H., State Health Officer, State of Nevada
David Rowles, Director, Administrative Services, Clark County Health District
Sharon M. Ezell, Chief, Bureau of Licensure and Certification, State Health Division
Jerry Ash, President, Nevada Hospital Association
Larry Matheis, Executive Director, Nevada State Medical Association
Fred Hillerby, Lobbyist, State Board of Pharmacy
Jan Davidson, Director, Contracts Management, University Medical Center
Chairman Rawson opened the hearing on Senate Bill (S.B.) 58.
SENATE BILL 58: Excludes financial resources of certain incapacitated persons in determining eligibility for assistance to medically indigent persons.
Bertha J. Warrick, Division Manager, Clark County Social Service testified in support of S.B. 58 in her summary (Exhibit C).
Chairman Rawson noted the cost in the first year of $2.3 million and $2.6 million in the second year and asked Ms. Warrick if she had seen the fiscal note on this?
Ms. Warrick, responded those were initial expenditures.
Chairman Rawson asked, "What your are indicating is that even though there may be an initial outlay, you expect the recovery of that amount?"
Ms. Warrick responded that the law indicates that Medicaid can lien any of those assets.
Ms. Warrick responded to a question by Senator Neal and advised that the amount of money or resources a person is allowed to have is $2,000 by federal Supplemental Security Income (S.S.I).
Senator O'Donnell referenced S.B. 58, subsection 1, and asked if a person does not have a legal guardian, then can you lien their assets?
Ms. Warrick responded yes, and stated that a legal guardian can liquidate the estate.
Senator O'Donnell, referred to subsection 5 and said, "It says you cannot enforce this unless they have a legal guardian."
Ms. Warrick answered yes, and stated that these people at that point will be coming in for public guardianship. We are trying to get a coverage period until we can get guardianship through the public administrator's office. She advised you can lien the property, but you cannot enforce the lien as far as collection purposes until there is someone who can legally represent that person.
Ms. Warrick stated that when a guardian is appointed for the incapacitated person, a form is submitted to the public guardian's office. The form then goes through the court process, before the probate judge, and then the public administrator becomes the public guardian. She advised they cannot liquidate any of the assets if the process runs over 4 months which is the allowable time to file for Medicaid.
Myla C. Florence, Administrator, Nevada State Welfare Division, opposed S.B. 58 as referenced in her summary (Exhibit D).
Senator Glomb stated that either county or state tax dollars will have to cover the cost of medical care of that person until those resources can be tapped and asked, "Is that a fair assumption or deduction?"
Ms. Florence answered yes.
Senator Glomb, asked, aren't we obligated to find a way to obtain federal money to pay half of that cost?
Ms. Florence stated federal funds are currently paying half of those costs once the eligibility determination is made.
Senator Glomb questioned who is picking up the tab in the meantime.
Ms. Florence stated it varies by the situation. In some cases when resources are determined, the county or an authorized representative on behalf of the individual will assist that person to draw down resources to the allowable level. During that interim period, the county guarantees payment, should they be found ineligible. In many cases no payment is made since the person's case is pending. Federal rules will not permit states to carve out one category of eligibles. In other words, the provisions of this bill would have to apply to all aged, blind and disabled individuals in an institution. You would have to support their initial placement with state funds and if that person were determined not to be eligible, then the state would be liable for the total cost of the care. There would be no recovery in that case.
Senator Glomb asked, "So are you saying hypothetically, if we passed this bill the way it is written, it would not hold up because it would be in violation of federal codes and guidelines?"
Ms. Florence answered, that is correct.
Ms. Florence advised the federal rules provide that you cannot disregard assets in determining one as eligible under Title 19 in the Social Security Act, in section 3. During that period of determination of assets, the state will be liable for whatever expenses they are paying up-front.
Senator Neal asked can the state deny service to this incapacitated person? Ms. Florence answered yes, they can deny payment to the provider of medical services, because the person has not been deemed eligible for Medicaid reimbursement.
In response to a question by Senator Neal, Ms. Florence advised the state cannot deny treatment, but can deny payment based upon a finding of eligibility. She stated what S.B. 58 intends to correct are cases of incapacitated individuals where the assets are not necessarily known. The county is at risk for guaranteed payment to the provider during the period, pending verification of eligibility. The county would want the state to guaranteed that payment up-front and assume full state responsibility for those who are not eligible.
Ms. Florence advised the problem is the unknown cost impact on the state at a time when the state is cutting back on services.
Senator Brown noted it seems that a better way to deal with this problem would be to require emergency guardianship for individuals in this situation.
Senator Glomb asked is the new plan to leverage the county money to pay for the indigent care going to help offset any of this?
Ms. Florence advised because of the change in federal rules, it is going to result in fewer dollars becoming available under the new rules.
Senator Glomb, addressed Chairman Rawson and declared, "There is merit in this bill, and maybe we are going about this the wrong way, at the time when we need to leverage as much federal dollars as we can, it would seem to be to our benefit to do that."
Senator Brown, asked would the cost of litigating the liens and collecting the money be collectable from the estate as part of the collection process?
Kirby Burgess of Clark County agreed with Senator Glomb, there is merit in this bill.
Chairman Rawson asked Senator Glomb to chair a subcommittee to work out those details and will wait to hear a report from that sub-committee before rescheduling the bill.
Chairman Rawson closed the hearing on S.B. 58.
Chairman Rawson opened the hearing on Senate Bill 60.
SENATE BILL 60: Provides for certain assistance to victims of sexual assault regarding exposure to sexually transmitted diseases.
Mary Lynne Evans, Administrator, Office of Narcotics Control Assistance Formula Grant Program, Department of Motor Vehicles and Public Safety testified on S.B. 60 as referenced in her summary (Exhibit E).
Chairman Rawson referred to past legislation that required testing of a person not convicted, but of a person arrested, and advised that S.B. 60 appears to be lessening the standards.
Ms. Evans responded that the statute that was passed in 1989 is not being enforced unless there is actually a court order issued to demand that the testing be done.
Chairman Rawson asked is that because of state health department rules, or lack of rules?
Ms. Evans said she has been informed that it is because of lack of funding . She explained that when a person is convicted and imprisoned, they actually go through a HIV (Human Immuno Virus) and syphilis test. The way the law is written, the offender does not have the right to know. The Attorney General's Office can be solicited for that information for the victim and so it is on a case-by-case basis. She advised what they would like to do is to place the victim notification provisions into the Nevada Revised Statutes (NRS) chapters dealing with convictions. She suggested leaving NRS 441 the way it is, on arrest, so that if money comes available, the testing can be done.
In response, to Chairman Rawson's question of lowering the current standard, we suggest retaining NRS 441 and adding this language to the conviction .
Chairman Rawson asked if there would be a fiscal note? Ms. Evans advised there would be a large fiscal note if the provisions of the bill applied to treatment and testing on arrest. As for just putting this under the conviction, she advised there would not be any fiscal note since they are doing this at present.
Senator Neal asked since this is not presently being enforced, how would this change. Ms. Evans advised that presently it is not being enforced on an arrest. However, on conviction when a person is imprisoned, they are automatically given a HIV test as well as the syphilis test. The only thing lacking is the victim does not have the automatic right to know and has to petition for the right to know. The administration are the only ones who have the right to know the results.
Chairman Rawson asked Ms. Evans was she responsible for S.B. 60
Ms. Evans answered yes.
Dr. Donald S. Kwalick, M.D., M.P.H., State Health Officer, presented to the committee a handout (Exhibit F) that showed recommended changes on S.B. 60. Dr. Kwalick advised page 1 (Exhibit F) was a copy of the existing bill showing recommended changes. He referred to section 1 and advised that area is too broad and should be deleted. Section 2 would then become section 1 and he recommended rewording of the existing section 2, which is shown on page 3 of Exhibit F. He advised the way the bill is now written, the health authority cannot get a specimen from a minor without parental consent. They feel that if a minor is the perpetrator of a crime, the victim does have the right to know the results of the test and that the test be obtained from that individual.
Chairman Rawson asked is there any reason why you would limit it to HIV and syphilis? Dr. Kwalick responded, there are general testing for all STDs (Sexually Transmitted Disease), not just HIV and syphilis.
Chairman Rawson stated a victim would want information from the test on all STDs.
Mr. David Rowles, Director, Administrative Services, Clark County Health District, advised they do not oppose broadening the term to include any sexually transmitted disease.
Mr. Rowles, read from his summary (Exhibit G) advising that the Clark County Health District supports the provisions of the bill with the recommended changes as noted. He addressed concern for the language in the bill that talks about testing and treatment. There is no treatment for HIV positive at the present time. The bill will leave uncertain the length of treatment and could be of significant fiscal impact.
Dr. Kwalick advised the examination and treatment section was in the existing legislation and the language treatment should stay in the bill. He added, that if treatment becomes available in the future, this treatment should be made available to prevent the spread of disease or just on humanitarian grounds, even though it will have a significant fiscal impact.
Mr. Rowles clarified that the treatment of HIV does not end the disease but simply prolongs the terminal effect of the disease and is a very expensive treatment. There should be perhaps some further discussion if treatment for HIV is left in the language, as to the fiscal resources. Their reading of it, in Clark County, with a sizable population base and significant impact on fiscal resources is that this could be extremely costly and they do not see how this could be retrieved.
Chairman Rawson asked is that existing language at this point? Dr. Kwalick answered, yes.
Senator Neal asked could you tell me what is the cost of AZT (Azidothymidine)?
Dr. Kwalick, answered $250 to $300 per month, pricing from the University Medical Center. The recommended dose on a daily basis per year is between $2500 and $3000 per year for an adult patient. For pediatric patients the cost would be a little bit less due to smaller dosage.
Chairman Rawson asked the staff to put these suggested changes together and bring it back to the committee to consider.
Chairman Rawson closed the hearing on S.B. 60.
Chairman Rawson opened the hearing on Senate Bill 64.
SENATE BILL 64: Redefines "surgical center for ambulatory patients" for purposes of licensure and regulation.
Sharon M. Ezell, Chief, Bureau of Licensure and Certification, State Health Division, advised the intent of S.B. 64 in her summary (Exhibit H).
Chairman Rawson asked is just certification the problem here? Ms. Ezell answered yes, just one that is not certified.
Chairman Rawson asked what change does this put on the practice of medicine?
Ms. Ezell answered, that approximately 11 of the 20 centers would not be required to go through the licensure process.
Chairman Rawson, asked is the only reason we go through the examination, for the Medicaid designation and not the quality per se?
Ms. Ezell, answered, there is no indication in their records of any complaints with the quality of care being provided in these types of facilities.
Senator Neal advised you have taken out anesthesia and asked who would administer anesthesia in one of these centers?
Ms. Ezell, responded the surgeon could administer, or he could use a nurse practitioner certified in anesthesia, or he could bring a physician in that was a anesthesiologist. It would not change any requirements with the scope of the practice.
Senator Neal asked are you able to get payment for the services rendered by the state by not having a surgeon, having surgery performed on these patients while they are under anesthesia?
Ms. Ezell, answered she did not think the change would affect that.
Senator Neal asked if it is not going to affect anything then why do you need the change?
Ms. Ezell, because as it is, you could not do any ambulatory surgery without an anesthesiologist present.
Chairman Rawson, advised that is pertinent to a discussion or contest that is developing between the nurse anesthetist and the anesthesiologist. He questioned are we changing some definition of the practice and stated he understood now that from your standpoint that isn't the intention. Chairman Rawson advised one reason for developing the anesthesiologist, was a feeling that there was more risk to a patient if the primary surgeon was also responsible for the patient's anesthesia. This does leave some question, if there are extensive procedures being done.
Senator Glomb, referred to the last sentence and asked if the wording means that these offices, physician, podiatrist or dentist do not fall under any regulatory guidelines?
Ms. Ezell responded that typically a individual practitioner does not, but if they were to do surgery in the office, they would not come under regulatory guideline. They are regulated by the medical examiners, as physicians.
Senator Glomb asked, then the physician, podiatrist or dentist do not pay the $500 fee that ambulatory centers pay.
Ms. Ezell, answered correct.
Senator Neal asked would it do damage to this bill if it would be amended to exclude nurse practitioners from administering anesthesia?
Ms. Ezell responded she did not see this would do damage because that was not their concern.
Jerry Ash, President, Nevada Hospital Association, expressed concern in the wording of the last sentence of S.B. 64. His concern is that it could be construed to mean that a group of surgeons might develop a surgical center. He advised we must be careful we do not create the ability for some unlicensed and unregulated true surgical centers, that would involve several physicians, whose primary responsibility would be to provide surgical services.
Larry Matheis, Executive Director, Nevada State Medical Association, testified they do not have any particular problem with the bill. It is their understanding that all the requirements of Medicare certification, quality assurance and all of those requirements are maintained. So what this does is acknowledge that the need for anesthesia is not always there anymore. He reminded that these were outgrowths of hospital outpatient surgery centers when the federal government wanted to encourage outpatient surgery in a less costly setting.
Dr. Kwalick, advised that to put in the last sentence is superfluous because there is no regulation of the private practice of any of these professions.
Fred Hillerby, Lobbyist, representing several insurance companies advised deleting the last line is important because you have created a new facility, a surgical center that isn't defined.
Chairman Rawson, asked who is responsible for this bill. Dr. Don Kwalick, advised he is responsible for the bill and does not have a problem with removing the last line.
Chairman Rawson, closed the hearing on S.B 64.
Chairman Rawson, opened the hearing on Senate Bill 69.
SENATE BILL 69: Authorizes sale of controlled substances or dangerous drugs to certain persons and agencies that provide emergency care in order to stock ambulances and other authorized vehicles.
Fred Hillerby, Lobbyist, Nevada State Board of Pharmacy, stated that he understood the intent of the bill was to alleviate the problem the trauma centers have when out-of-state emergency vehicles needed to be restocked with drugs. The hospital pharmacy would be in violation of federal law, the way the bill is written, if they were to restock the out-of-state emergency vehicles. This leaves the vehicle short of supplies for their return trip home.
Dr. Kwalick advised, S.B. 69 is language that would allow the ambulance, whether they are a urban or rural setting, to fill up on the drugs that have been utilized in the transit of the patient to the facility. He offered Exhibit I for clarification of the language.
Senator Rawson, added that he would see this also as drugs out of date, damaged, where sterility is lost or any of those kinds of issues that require drugs be replaced.
Mr. Hillerby advised he did not see a problem with this direction and some language still needs to be corrected in reference to who the pharmacy can sell to.
Jan Davidson, Director, Contracts Management, University Medical Center advised this is their bill. She stated the reason they put in this bill is the fact they have received several patients from out-of-state by ambulance and had experienced the problem of replenishing undangerous drugs. She advised she had given Mr. Hillerby some proposed language from their director of pharmacy.
Chairman Rawson asked Senator Brown to chair a subcommittee to resolve the wording of S.B. 69.
Chairman Rawson closed the hearing on S.B. 69.
Chairman Rawson introduced the following BILL DRAFT REQUESTS (BDRs)
BDR R-1314 - Urges President and Congress to increase amount of financial assistance allotted to research chronic fatigue syndrome.
SENATOR NEAL MOVED TO INTRODUCE BDR R-1314.
SENATOR TOWNSEND SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR COFFIN WAS ABSENT FOR THE VOTE)
BDR 40-58 - Requires establishment of toll-free telephone service for dissemination of information about effects of exposure to teratogenic agents during pregnancy.
SENATOR O'DONNELL MOVED TO INTRODUCE BDR 40-58.
SENATOR GLOMB SECONDED THE MOTION
THE MOTION CARRIED. (SENATOR COFFIN WAS ABSENT FOR THE VOTE.)
BDR 38-526 - Requires advocates for residents of facilities for long-term care and ombudsman for aging persons to perform each other's duties on temporary basis.
SENATOR NEAL MOVED TO INTRODUCE BDR 38-526.
SENATOR BROWN SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR COFFIN WAS ABSENT FOR THE VOTE.)
There being no further business, Chairman Rawson adjourned the meeting at 3:10 p.m.
RESPECTFULLY SUBMITTED:
Judy Alexander,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE:
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Senate Committee on Human Resources and Facilities
February 22, 1993
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