The Committee on Commerce and Labor was called to order at 2:00 p.m., on Friday, April 2, 1999. Chairman Barbara Buckley presided in Room 4100 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All Exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

COMMITTEE MEMBERS PRESENT:

COMMITTEE MEMBERS ABSENT:

GUEST LEGISLATORS PRESENT:

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Following roll call, Chairman Buckley addressed A.B. 383.

Ms. Buckley stated the bill’s sponsor advised her the subject matter of A.B. 383 would be considered within another bill and asked for a motion to indefinitely postpone it.

ASSEMBLYMAN HUMKE MOVED TO INDEFINITELY POSTPONE A.B. 383.

Chairman Buckley opened the hearing on A.B. 491.

Assemblywoman Vivian Freeman, District 24, provided a summary of A.B. 491 (Exhibit C) and explained the bill considered the issue of external reviews for coverage disputes for people who had been in managed health care. Ms. Freeman and Marla Williams, Senior Research Analyst, Legislative Counsel Bureau, Research Division, researched the matter extensively and tried to select what would best fit the question in the State of Nevada. The bill was well written, reasonable, and sought to strengthen the consumer protection efforts of the Commissioner of Insurance. In the 1997 session, a compromise was reached on similar legislation, and a bill was passed establishing a toll free telephone line to assist customers with negotiating the benefits of their health care plans. The bill also helped formalize the role of the division and its consumer protection efforts.

The bill's provisions were, in part, as follows:

• The first review was a review of benefits and established whether an insured person was eligible for denied benefits.

• The second review was a medical review, which was not currently performed on a formal level. Under the provisions of A.B. 491, managed care organizations (MCOs) and insurers would be protected from liability lawsuits because the review determined whether existing medical protocol warranted a procedure requested by an insured person.

Ms. Freeman explained the first nine sections of the bill included definitions. The composition of the external review panel began in section 10, on page 2. The combination of a medical director, primary care physician, and division staff member allowed for a comprehensive review of issues insured persons might bring forward. The conditions were specified in section 11, on page 2.

• Section 11, subsection 2, stated the measure specified an appeal may be requested by the insured person, legal guardian, legal representative, or health care provider. There was a nonrefundable filing fee of $25 that might be waived if necessary. The fee was not to support the efforts of the commissioner but rather the fee was there as a deterrent to frivolous appeals.

• Section 12 required an insurer notify an insured person of their right to appeal to the external review panel.

• Section 13 specified the process the Commissioner of Insurance, the external review panel, the insured, and the insurer must follow. All items in the section were subject to discussion.

• Section 14 required the insurer pay for the cost of an appeal if a decision was rendered against the insurer. The section served as an additional incentive for an insurer not to arbitrarily deny a benefit or treatment to an insured.

• Section 15 provided for both parties involved in an appeal to recognize their right to an attorney, but the external review panel would not award either party attorney's fees regardless of the outcome of the appeal.

Mrs. Freeman advised the committee there was a bill at the federal level called the "Managed Care Reform Act of 1999." A provision within the act allowed for an external appeal body, and much of the language within A.B. 491 was found in pending federal legislation. She noted being advised Congressman Jim Gibbons supported the bill and hoped the legislation would be achieved at both the federal and state level.

She stated many people expressed an interest in testifying on behalf of the bill, but the shortened session and time constraints prevented their appearing. Among those who were interested were providers, physicians, physical therapists, and patients who thought A.B. 491 was a good idea.

Guy Perkins, Supervisor, Department of Business and Industry, Division of Insurance, Life and Health, offered suggestions for consideration. It was unknown as to how many individuals would be involved in an external review, particularly at the beginning of the function. In checking with other states with similar legislation, the numbers seemed extremely large. It was also unknown as to how much general fund money would be available to fund the panel. He therefore suggested the $100 threshold be raised to $500.

Mr. Perkins said instead of stopping the process at the decision of the panel, consumers, who were not satisfied with the outcome, would be able to take the panel’s decision, which was approved by the commissioner to a final result being the courts. As the bill now stood, the final resolution rested with the panel and the Commissioner of Insurance.

Chairman Buckley noted she reviewed the National Association of Insurance Commissioners Model Act on External Review and believed it to be a excellent document. She said she would make the document available to any committee member who desired to read it. One section of the document was devoted to who made the review. It was suggested to Chairman Buckley that the best composition of a review panel would be volunteers, doctors, or insurance companies instead of employees of the Division of Insurance who might not have medical experience. The review panel could be modeled similarly to the medical legal screening panel where both doctors and lawyers reviewed medical malpractice cases. Chairman Buckley thought the panel could serve on an uncompensated basis, especially in a year with budget barriers.

Mrs. Freeman agreed with the approach.

Assemblywoman Evans questioned Mr. Perkins on section 10, subsection 2, which said, "the division may enter into a contract with (a) A medical director of a managed care organization in this state; and (b) A primary care physician. . ." She asked if costs would be absorbed into the division’s budget or offset by the fee.

Mr. Perkins explained if costs were involved and actions of the panel were not carried out on a voluntary basis, both positions would be absorbed in the budget. The $25 fee would not be used to offset any costs.

Ms. Evans referenced section 11, subsection (b), which said, "Except as otherwise provided in this paragraph, the insured has exhausted the grievance procedures established by the insurer to challenge the denial of benefits or treatment. The commissioner may waive this requirement if life of the insured is in imminent or emergent jeopardy." She asked if the commissioner could judge whether an individual’s life was in imminent jeopardy.

Mr. Perkins believed such a decision would be made before it got to the external review process. A provision coming out of A.B. 156 of the 69^th Session was the review of emergency cases that said an MCO had 72 hours to make a decision in life threatening cases.

Ms. Williams explained she and Ms. Freeman reviewed bills from other states, and Ms. Freeman recommended if the insurer lost a decision, the insurer was responsible for the payment of the review panel. Another envisioned consideration was the commissioner compiling a list of participants who would be responsible for medical reviews. It would not be a joint review where the staff of the Division of Insurance, the medical director, and the primary care physician reviewed the same case, each would have different responsibilities in the review.

Ms. Freeman said A.B. 156 from the 69^th Session was the foundation of A.B. 491, and Mr. Perkins recommended language could be offered amending the bill to specify the agency decision was subject to judicial review. She asked Chairman Buckley for her legal opinion.

Chairman Buckley explained generally there were three enforcement mechanisms to managed care decisions, which were an ombudsman, a right to sue, and an external review. The benefit of an external review was the review allowed someone an opportunity to have a decision overturned if need be, and if the decision was affirmed, the consumer learned. There were advantages to an external review versus a judicial review. The judicial review, in addition to the external review, depended on whether the decision was an agency decision, which made it a little more complicated.

Mrs. Freeman agreed and did not want to complicate the issue. She said there would probably be the usual opposition to the bill from the industry noting A.B. 491 was reasonable and offered a great deal to consumers in the state who were on managed care. There should be no fiscal note attached to the bill so it would not have to go to the Assembly Committee on Ways and Means.

Mathew Sharp, representing the Nevada Trial Lawyers Association, came forward in support of A.B. 491. As the association interpreted the bill, it would not interfere with the consumer's right to bring a lawsuit. The purpose of the bill was to protect individuals for whom a lawsuit would not be an appropriate remedy for economic or other reasons, but in other situations where a lawsuit would be appropriate, the right would be retained. The proposed amendment presented by Mr. Perkins would not clarify the issue but could cloud it. As he understood the amendment, there would be a right to bring an action, and Mr. Sharp did not think following the appeal process would prohibit a consumer's right to bring an action if the appeal process did not work. A.B. 491 was a preventative measure encouraging the consumer and the insurance company to talk. The bill benefited the "little guy" who had a small claim for which a lawsuit would not be appropriate.

Dr. David Edwards, representing the Nevada Homeopathic Physicians Associations, supported A.B. 491. However, he presented an amendment for consideration seeking to define primary care physicians (Exhibit D). Nevada Revised Statutes (NRS) defined three types of primary care physicians as osteopathic, homeopathic, and allopathic. He informed the committee he served as a volunteer on the medical legal screening panel and believed physicians probably would volunteer to do external review if it were available to them.

Bobbie Gang, representing the Nevada Women's Lobby and the National Association of Social Workers, testified in support of A.B. 491 and specifically supported external reviews for medical care.

Janice C. Pine, representing the Nevada Association of Health Plans, stated she was not opposed to A.B. 491. However, if there was a desire to move forward with such an appeals board, the board needed to be well designed and well developed. It needed to be easy for the consumer, patient, and health plan as well as produce high quality, fair, and binding decisions based on medical evidence. In addition, the board needed to be free of conflicts of interest and able to render decisions quickly and efficiently. Additionally, a single consistent set of independent review rules for all individuals needed to be in place thus avoiding duplicative review systems. Decisions needed to be based on the terms and conditions of health plans. As stated in the bill, the review needed to be the process used after all internal grievance procedures were followed. Moreover, it had to be binding on both the health plan and consumers and allow for common sense.

Ms. Pine was not sure establishing a panel of volunteers would accomplish consistency and follow the same set of rules for all decisions. Those issues concerned her greatly.

Fred Hillerby, representing Hometown Health Plan and the Nevada Association of Health Plans, spoke in opposition to A.B. 419. He said Janice Pine expressed his concerns as well. The notion of external review was getting national attention, and there were many issues being discussed. Certain quality standards were at issue so as to allow for fairness for both parties.

He referenced feuds between different factions within managed care and was concerned about the motives of those who wanted to serve on a voluntary panel. It was necessary to ensure evidence-based medicine where good criteria was followed using the best experts available. In some states, it came under the auspice of the Division of Insurance to ensure programs were accredited and standards met. At least one heath plan embarked on the road of having voluntary external reviews and others were considering the issue based on the size of their company and their ability to afford it.

Mr. Hillerby was concerned about the fiscal note pointing out the number was $336,000 the first year and $302,000 the next. In the 70^th Session, time was an issue, and lack of time could affect the ability to examine how an external review process could work and work effectively for the consumer and the health plan. Mr. Hillerby was not opposed to the bill, but the process was being considered nationally, and he thought the issue needed careful consideration. Mr. Hillerby did not believe giving the Division of Insurance total responsibility with the above mentioned fiscal note was the appropriate way of dealing with the issue. He was concerned about handling the issues in the bill and doing so in a manner to avoid the fiscal note bothered him.

Chairman Buckley was intrigued that Mr. Hillerby did not "flat-out" oppose the bill if it was constructed carefully and there were no conflicts of interest on the part of reviewers.

Mr. Hillerby said many health plans were looking at the process and more plans were moving in the direction taken by the bill. He noted the issues were individuals who were denied care for a medical necessity, debates over experimental medicine, and whether experimental medicine was important for a particular patient. The panel needed true medical experts who looked at available medical evidence. Mr. Hillerby did not know if the Division of Insurance had such specialties. He further noted if the panel was to be established, it needed to be done correctly.

Chairman Buckley stated the only criticism she had of the industry’s attempt to initiate the panel was reviewer qualifications. She explained when someone was paid to review denials of benefits or treatment, there was no confidence the decision would be impartial. The same was true for the MCOs; they too wanted the reviewer to be fair.

Mr. Hillerby agreed with Ms. Buckley’s statement and noted there were national organizations being accredited who were contracted to act in such a fashion. They were national experts in medical fields. Once consumers saw the layout, there would be greater consumer confidence. The frustration was the bias would be in the direction of who paid for the service. If the right individuals with the right credentials were hired, such would encourage consumer confidence. The burden of cost should not be put on the member. If the job was done by health plans, the cost was spread throughout the total cost of operations of the business.

As there was no further testimony, Chairman Buckley closed the hearing on A.B. 491 and opened the hearing A.B. 551.

Assemblywoman Marcia de Braga, Assembly District 35, presented A.B. 515 (Exhibit E). The bill considered phenylketonuria (PKU), which was an inherited metabolic disorder causing affected individuals to improperly metabolize phenylalanine, a part of protein. The disorder was usually detected within the first few days of life and affected 1 out of every 10,000 to 20,000 births.

Ms. de Braga introduced Linda and Jess Tews noting Jess was the subject of the bill, as he had PKU. Chronologically high levels of phenylalaqnine and some of its breakdown products could cause significant brain damage. For such a reason, individuals with the disorder would have to drink a special formula and eat special foods all of their lives, which were not easily obtained in northern Nevada.

The food and formula were costly, and during the 69^th Session of the Nevada Legislature, a bill was introduced by Assemblywoman Evans to require insurance companies to pay $2500 per year for the special products. A.B. 551 asked the amount insurance companies were required to pay be increased to $5000.

Ms. de Braga noted the bill did not address the issue of availability of formula, which could not be purchased in a drugstore or a regular store. The formula could be purchased in the Special Children’s Clinic in Reno, Nevada, and individuals on the federally funded Women, Infants & Children USDA Special Supplemental Food Program (WIC) could get the food, but the program could not stock extra formula even to allow someone not on the WIC program the ability to purchase it.

Ms. de Braga hoped the passage of the bill would help solve the problem whether it be through a public health nurse or through a resolution urging the U.S. Congress to expand their service to allow parents the ability to obtain the foods. She thought there was a need to create a resolution letter to encourage congress to speed up research.

Linda Tews introduced her husband Wes Tews and their son Jess. Ms. Tews relayed her story about Jess and their concerns with PKU (Exhibit F) and reiterated some of Ms. de Braga’s testimony on PKU and A.B. 551.

Chairman Buckley stated the committee would consider sending a letter to Congress concerning research, to the Department of Agriculture, who supervised the WIC programs, and to the public health community to consider the needs of those in the rural areas. She referenced the increase of $2500 to $5000 and asked how the increase would help meet the needs in the rural communities.

Ms. de Braga noted the tremendous cost of the foods and thought insurance companies might be prompted to help find a solution. The money was never the focus; it was the vehicle to move the bill.

Chairman Buckley asked if the real interest was in the delivery system as opposed to the amount and benefit.

Ms. de Braga affirmed Ms. Buckley’s statement pointing out the interest was in availability and encouraging congress to speed up research on PKU noting there might be a solution on the horizon.

Mr. Hettrick asked if there was a way the Special Children’s Clinic in Reno could be authorized to ship the product to the rural areas.

Ms. de Braga said time and cost were the issue. She explained she contacted the Special Children’s Clinic, and a staff member was scheduled to testify but was forbidden by the governor from testifying under an order stating anyone who was not a head of an agency was not to be in the building.

Mr. Hettrick explained the issue was policy not a specific prohibition against the staff member. He knew the state delivered items all over and wondered why the formula or foods could not be put on the truck. He desired the issue of how the product could be made available to the rural areas be researched.

Ms. de Braga explained a doctor wrote a prescription for the powdered formula, and she thought a pharmacy could stock it.

Ms. Evans pointed out she introduced a bill in the 69^th Session, which was similar. She noted extensive testimony from numerous families with PKU babies and thanked Ms. de Braga and Ms. Tews for bringing the issue back to the attention of the legislators.

Chairman Buckley stated the committee would like to help in any way possible in an attempt to make the formula available.

Ms. de Braga wondered if the foods could be distributed through the public health nurse.

Chairman Buckley though such a manner of distribution made a lot of sense.

Mr. Hettrick suggested the bill be amended to read, "by request, the public health nurse had to supply, obtain, or make available."

Ms. de Braga asked if every county had a public health nurse; she was not sure if they did.

Mr. Beers asked if the powdered formula was perishable. He thought if the committee endorsed the amendment, a statement might be added making the amendment applicable only to rural counties that had a PKU baby.

Ms. Tews noted some of the special foods were perishable, but the formula was like any other formula; it was sealed and had a shelf life.

Mr. Beers asked if the foods were obtained at the same place as the formula. Ms. Tews affirmed his statement.

Mr. Hillerby noted the industry he represented supported the bill brought forth by Ms. Evans in the 69^th Session. During hearings, testimony was provided stating there were 55 to 60 children in the state who had PKU, and A.B. 551 would affect about one third of those children. The consequences of not taking care of all PKU children was emotionally, financially, and socially unacceptable. The dollars involved were not great, and he noted the possibility of the state purchasing necessary items, having a distribution system, and ensuring every child diagnosed with the condition have access to the foods. The issue was a public policy issue. Mr. Hillerby thought the issue of distribution was the easiest to satisfy and noted a willingness to cooperate in achieving the goal of helping all PKU children, not just the children who had insurance.

Chairman Buckley noted Mr. Hughey would contact those working in the public health capacity as well as individuals involved with the Special Children’s Clinic and obtain information. The committee would then determine whether a letter of intent should be written or if they should act in a stronger fashion and amend language into the bill.

There being no further testimony, Chairman Buckley closed the hearing on A.B. 551 and opened the hearing on A.B. 515.

Ms. de Braga presented A.B. 515 to the committee noting the bill required any type of insurer, in a timely manner, to provide an estimate of the rate at which a provider of health care would be reimbursed for providing a health care service. Currently when an individual received authorization for a procedure, they did not necessarily receive the rate with which they would be reimbursed, although there was a set list of criteria to follow. Ms. de Braga desired "usual and customary" based charges be provided to an insured or provider of health care upon request. She did not believe what she desired was well communicated in the bill. In order for individuals to make intelligent health care decisions, it was vital they know the "usual and customary" charges. A patient needed to be able to opt out of treatment if the financial burden was too great and they chose to do so.

Ms. de Braga referenced section 19 noting self funded insurance was not regulated at the present time nor was it under the Employment Retirement Income Security Act (ERISA) or Title 57. The intent of section 19 was to put self funded insurance under Title 57, which would allow for a review panel and timely treatment in an emergency situation. Ms. de Braga noted what was missing was every insurance company needed to let patients know in a timely manner whether a procedure would be authorized or denied.

Ms. de Braga proposed amendments to A.B. 515 noting provisions requiring a timely authorization or denial of health care treatment and a provision providing upon request an estimate as to "usual and customary" charges. Ms. de Braga presented Exhibit G, which was an additional amendment requiring an insurer include a provision authorizing a woman the ability to obtain covered health care services without first receiving authorization or referral from her primary care physician, and she be able to designate an obstetrician or gynecologist as her primary care physician.

Mr. Goldwater asked if it was feasible to receive information as to "usual and customary" charges.

Ms. de Braga explained payments were denied on the "usual and customary" basis, so information must be available for base reimbursement costs. The information was available for Medicare patients.

Mrs. Segerblom asked why a patient could not shop around for a good price.

Ms. de Braga explained the problem was not being able to receive information as to cost. An additional problem was not every specialty was on the list.

Alison Gaulden, Associate Vice President of Public Affairs, Planned Parenthood, Mar Monte, offered written support for A.B. 515, (Exhibit H) and the amendment, which included direct access to obstetric and gynecological (ob/gyn) care. Ms. Gaulden highlighted that women often thought of their gynecologist as their doctor, and they needed better direct access to them.

Ms. Gaulden read Exhibit I into the record, which was testimony provided by Cookie Bible, Nurse Practitioner, Planned Parenthood. The testimony noted, "An advanced practitioner of nursing who has specialized skills and training in ob/gyn should be able to see a woman through a managed care plan; advanced practitioners of nursing are very cost effective and give excellent care. It would be important for clinics, (nonprofit, state and county) to be able to serve these women. Women often want to see a woman for their care; most ob/gyn, women’s health Advanced Practitioners of Nursing are women. Advanced Practitioners of Nursing have a very good working relationship with their female patients."

Ms. Gaulden read Exhibit J into the record, which was testimony provided by Dr. Richard Stratton, MD. The testimony explained that generally the first time a woman sought medical care it was for a reproductive health issue. As it stood, the ob/gyn was usually the primary physician for a woman with a longevity relationship of often 30 years. Because of such longevity, the ob/gyn had complete medical histories of their patients. In order for an ob/gyn to help a woman with her reproductive health, they must know their general health.

According to Dr. Stratton, it made economic sense to eliminate an unnecessary referral system. The elimination of a gatekeeper would save money for the patient and the insurance company by not having to pay for an extraneous visit. A.B. 515 supported the reality of patient’s use of health care.

Bobbie Gang representing Planned Parenthood of Southern Nevada, offered written testimony (Exhibit K) in support of A.B. 515 and the amendments, which related to direct access and selection of an ob/gyn as a primary care provider. Ms. Gang referenced Exhibit K, page 2, noting there were 24 states requiring direct access to ob/gyns and 16 states mandating ob/gyns be permitted to be selected as primary care providers. Presently in Nevada, a woman was permitted to obtain an annual cytological exam.

Ms. Gang read into the record Exhibit L, which offered support for A.B. 515 on behalf of the Nevada Nurses Association. She explained the mission statement of the association was to educate and advocate for accessible and affordable quality care for clients. They believed the implementation of the amendment to A.B. 515 would allow an advanced practice nurse, with specialized skills and training in obstetrics or gynecology, to directly provide health services for women without a physician referral. Such was a quality of care and cost effective measure.

Matthew Sharp, representing the Nevada Trial Lawyers, supported A.B. 515. The Nevada Trial Lawyers thought the bill was good for access and quality of care, as well as consumer care.

Mr. Sharp referenced section 3 and addressed Mr. Goldwater’s concern as to "usual and customary" charges. He noted how information was provided to a consumer as to what a physician would charge and what the insurance company would approve before a patient saw the physician. Mr. Sharp thought insurance companies had the information as to "usual and customary" charges, and it was important consumers were provided with such information.

It was important to take into account the interest of the consumer. Mr. Sharp thought the consumer could take the managed care negotiated prebilled amount, present the amount to his or her choice of physician, and see if the doctor would see the consumer for such amount. Such an arrangement would benefit the consumer and not harm the managed care organization. He thought the bill supported consumer rights noting there could be problems with respect to "usual and customary."

Mr. Sharp noted section 4 and the other provisions relating to providing care within the 75-mile radius. What had occurred as a result of an attempt by specialists to provide health care to the rural communities was some specialty groups contracted with various hospitals within the rural community to fly staff people out to areas to see patients. As a matter of fairness, if the specialty group contracted with a county to provide its residents with specialists, those in the rural area should not be penalized if the specialists did not contract with the right managed care organization. Mr. Sharp thought the bill would encourage physicians to go out to rural areas.

Fred Hillerby, representing Home Town Health Plan and the Nevada Association of Health Plans, explained his health plan had a number of primary care physicians who were capitated, and under such a situation, it was difficult to tell an inquirer what they would pay. In the case of "usual and customary," methodology had to be filed and approved by the division. He noted there was also a confidentially problem. He thought the bill, as written, was tough to manage, particularly for health maintenance organizations (HMOs), and it did not get at some of the concerns of Ms. de Braga.

Mr. Hillerby referenced the 75-mile issue and noted the Division of Insurance required HMOs have adequate specialists. He was unsure how the 75-mile issue would work in rural areas. In such areas, there were not many specialists, and a patient would have to go the urban areas for care, which had to be provided. Mr. Hillerby explained the service of some specialists was taken to patients in the rural areas and some patients were sent out-of-state.

Janice Pine, representing the Nevada Association of Health Plans, addressed the

proposed amendment about the issue of the ob/gyn. She noted the medical director of her health plan testified to the fact the issue was quality of care. In health maintenance organizations, a woman had very quick access to an ob/gyn without having to go through a primary care physician. The ob/gyn was generally considered the secondary person. The primary care physician had the responsibility for the quality of care and continuum of care for the patient and there were immunization, throat, and other issues. It was not in the best interest of patients to have anyone other than a true primary care physician designated as such.

Chairman Buckley asked if Ms. Pine’s position would change if the bill or amendment did not include the provision to designate an ob/gyn as a primary care physician but instead said if a woman wanted to receive ob/gyn care, they could do so without first receiving authorization.

Ms. Pine, representing Saint Mary’s Health Plan, said when a patient signed up with the company, the patient designated a primary care physician and a secondary care physician. The secondary care physician was the ob/gyn. She explained the patient would then follow the rules set forth in the health plan allowing for direct access. In some plans, access would be once a year, and in other plans, there would be no designation. She thought a patient would still want to go through their primary care physician so as to not overuse or thwart the primary care physician process. Ms. Pine offered an example of a patient going to an ob/gyn for a sore throat rather than going through the primary care physician. A condition may be more than a sore throat, and a patient needed to go through the doctor who had the responsibility to see the patient got to the right place at the right time. Unless there was a problem, a patient did not need to see an ob/gyn more than once a year.

Ms. Evans said part of the issue was a patient going directly to an ob/gyn. She explained she was in an HMO and was entitled to see the ob/gyn once a year. If something would occur of a gynecological nature after the yearly examine, she could not directly contact her ob/gyn without having a fee for service charge. She would be required to see her primary care physician who would have to authorize her seeing the ob/gyn physician.

Ms. Pine said she did not know what the process was in the other health plans. She thought the referral would be quick, but there could be a hurdle of which she was unaware.

Chairman Buckley explained many primary care physicians on lists were part of major clinics where the woman never saw the same doctor twice. If a woman had a condition, such as a bladder infection, she could be required to wait for many hours at such a clinic and then be rereferred. There was an additional cost because there was more than one visit. In addition, Chairman Buckley did not know of many women who would go to a gynecologist for a sore throat.

Ms. Pine referenced Ms. Buckley’s comment about a bladder infection noting it might be more appropriate for the patient to see an urologist rather than a gynecologist. Such would be the decision a primary care physician would make because of the division of specialties.

Chairman Buckley said the issue was a woman’s health care issue, and most women would know if the issue was a serious urological problem or whether the issue required an ob/gyn.

Ms. Giunchigliani noted Ms. Pine’s comments and asked if there were any ob/gyn physicians within her health plan on the primary care list.

Ms. Pine stated there were no ob/gyn physicians on Saint Mary’s Health Network list as primary care physicians. The primary care list contained family practitioners, internists, or pediatricians. An ob/gyn would be on the secondary care list.

Ms. Giunchigliani noted the company recognized there were special needs for children by allowing a pediatric doctor to be on a primary care list, but the company did not recognize gynecological needs as a specialty area.

Ms. Pine said Ms. Giunchigliani was correct. A primary care physician was the gatekeeper, but with Saint Mary’s Health Network, every woman was asked to name an ob/gyn physician and then had access to the physician.

Ms. Giunchigliani said what the bill brought to light was many of the health care plans, as they moved to managed care, did not take into consideration at least 30 years of a woman’s life dealt with gynecological issues. Women did not have direct access to an ob/gyn, and A.B. 515 recognized ob/gyn was an area of specialty just as pediatrics and should be considered as a primary care.

Mr. Hillerby noted by regulation, an HMO had to capitate their primary care. It became problematic when an ob/gyn was designated a primary care physician, and the ob/gyn did not want to do all that was required of a primary care physician, such as treat a sore throat.

Chairman Buckley explained for the purposes of the discussion it was being explored not having an ob/gyn as a primary care provider but rather allowing a woman to see her ob/gyn without prior authorization.

Mr. Hillerby recognized prior authorization was another issue and noted discussions on yearly exams with an ob/gyn.

Ms. Berman did not believe a gynecologist should be a primary care provider but believed a woman had the right to go to her gynecologist. She thought the 1 yearly visit could be extended to three visits, if necessary, which could be determined by a telephone call with the woman’s primary care physician. The woman did not have to make two trips to two different physicians. It was time to open up an opportunity for women to take their own medical health into their own hands.

Mr. Goldwater said there were three different models being discussed. There was the staff model HMO, which was pure capitation. Primary care physicians did not always like doing all of the work and desired to refer patients to specialists. The second model was the primary care case management model, which had inherent weaknesses, and the third element was managed care, which was different than primary care case management. He noted what needed to be done was remove ob/gyn from the primary care case management and place it into managed care where a specialist had a presumption they were not going to get paid under primary care case management. In addition, what was needed were ob/gyns with an automatic presumption that they were going to get paid, and then the burden would be on another to prove that they would not get paid. Currently the burden was on the specialist because they did not have the referral form.

Mr. Hillerby agreed with Mr. Goldwater with one exception. He noted they did not have a true staff model. When primary care was used, by regulation, they had to use capitation. He noted the issues were continuously being piecemealed. There would be no rational response to major problems being raised if the different issues were addressed in different bills.

Mr. Dini referenced section 9, which said, "A society shall." He asked if the language referred to a fraternal order. He thought the issue could present a problem for smaller societies.

Chairman Buckley affirmed his question noting (NRS) 695A. She explained NRS 695A was the fraternal benefit society chapter. She pointed out discussion with committee research staff as to whether the bill was placed in the chapter of the NRS. The bill addressed NRS 689A, 689B, 695A, 695B, and 695C. There was also a managed care chapter.

Dana R. Bennett, representing the Nevada State Medical Association, submitted written testimony in support of A. B. 491, A.B. 515, and A.B. 551 (Exhibit M).

There being no further testimony or questions, Chairman Buckley closed the hearing on A.B. 515 and called the committee’s attention to the work session document. Chairman Buckley explained she would not hold the work session on A.B. 470, as information was not fully prepared on the bill.

Chairman Buckley called the committee’s attention to A.B. 532, which was presented by Vance Hughey, Committee Policy Analyst (Exhibit N).

Mr. Hughey noted there were no amendments to A.B. 532.

Chairman Buckley explained when the bill was originally heard, there were questions about the differences of categories of peace officer status. She noted the bill would go to the Assembly Committee on Ways and Means because of the fiscal note. The note amount was $7800 in fiscal year 1999 and $7800 the following year.

ASSEMBLYMAN DINI MOVED TO DO PASS AND REREFER A.B. 532.

ASSEMBLYWOMAN GIUNCHIGLIANI SECONDED THE MOTION.

THE MOTION CARRIED.

Mr. Hughey recounted A.B. 616.

Mr. Hughey noted Joseph Guild, representing the International Anticounterfeiting Coalition, proposed an amendment, which added a new subsection to section 1 of the bill defining the term retail value for: (a) items that were components of a counterfeit finished product; and (b) for all other counterfeit items (Exhibit M).

Chairman Buckley said the bill was fairly straightforward dealing with trademark infringement and counterfeit goods. The amendment clarified the one definition.

Mr. Goldwater asked how many prison beds would be taken up with nonviolent offenders. He inquired as to the fiscal note on the bill.

Chairman Buckley said there was an affect on the state budget, but there was no fiscal note in the book.

Ms. Berman asked if the arrest could be a house arrest.

Mr. Dini thought it best the bill be sent to the Assembly Committee on Ways and Means.

Ms. Giunchigliani wondered as to dialogue that required a large fine versus a felony. The process could progress from a misdemeanor to a large fine or from a misdemeanor to a gross misdemeanor to a large fine.

Chairman Buckley thought the bill could go back to Mr. Guild noting the committee supported the concept but was concerned about creating new classes of felonies with the current prison bed situation. The committee could ask him to work further and consider gross misdemeanor and enhanced penalties.

Mr. Humke thought if the bill was passed it would fit into the fabric of federal prosecution. There were certain efforts by the Department of Commerce, to stop counterfeiting abroad. A felony provision in state law would serve as a hammer whereby through plea bargains they affected bargained settlements to payback victims. He strongly suggested the bill be passed along to the Assembly Committee on Ways and Means because he did not believe the result would ever be an additional used prison bed in Nevada.

Mr. Hettrick agreed with Mr. Humke and noted looking at the category E Felony, which said at first it was a misdemeanor and then a category E. In category D, it took two prior convictions. It was not a first-time offense but a bargaining tool.

Chairman Buckley thought the only exception was the category E kicked in not only for the one-strike but also if the goods cost $1001 to $10,000. She noted it was generally used as a plea-bargain chip.

Mr. Goldwater said he just raised a concern; he was not opposed to the bill.

ASSEMBLYMAN DINI MOVED TO AMEND AND DO PASS A.B. 616.

ASSEMBLYMAN GOLDWATER SECONDED THE MOTION.

THE MOTION CARRIED.

There being no further business to come before the committee, Chairman Buckley adjourned the meeting at 3:50.

RESPECTFULLY SUBMITTED:

______________________________

Jane Baughman

Committee Secretary

APPROVED BY:

Assemblywoman Barbara Buckley, Chairman

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