The joint subcommittee meeting on Human Resources/K-12 was called to order at 8:17a.m., on Thursday, February 11, 1999. Chairwoman Jan Evans presided in Room 3137 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List.

ASSEMBLY SUBCOMMITTEE MEMBERS PRESENT:

Ms. Jan Evans, Chairwoman

Mr. Joseph Dini, Jr.

Mr. David Goldwater

Mr. Lynn Hettrick

Mr. David Parks

SENATE SUBCOMMITTEE MEMBERS PRESENT:

Senator Bob Coffin

Senator Bernice Mathews

Senator William Raggio

Senator Raymond Rawson

SUBCOMMITTEE MEMBERS ABSENT:

None

STAFF MEMBERS PRESENT:

Chairwoman Evans asked Yvonne Sylva, Administrator for the Nevada State Health Division, Human Resources Department, to present budgets for the Health Division.

Ms. Sylva said the budget of the Office of Health Administration, Budget Account 3223, provided for overall agency administration which included fiscal and grant management, personnel, health planning, and funding for the State Board of Health. The account was funded through federal grants plus indirect costs, and included a transfer from the Department of Human Resources for health planning functions.

Ms. Sylva explained there were two enhancements within the budget, E-125 and E-710. E-125 would provide funds for the recommended Auditor II position to assist the state in fiscal accountability through internal program review funded by indirect costs. The division was responsible for passing through large amounts of money to local persons and she felt the division, as well as other agencies, needed to be accountable for the funds. Ms. Sylva indicated she envisioned the auditor would conduct approximately 18 audits of community-based organizations. Ms. Sylva stated E-710 would provide funds for the recommended replacement of six computers used by financial management personnel, and noted the current computers were not Y2K compliant, nor did they meet the minimum standards for the state’s information system. She advised those were the only two enhancements included in the budget.

Chairwoman Evans inquired if the auditor position would be involved in internal work, as well as working with sub-grantees, and instructed Ms. Sylva to provide a more complete job description. Ms. Sylva responded the auditor would perform both internal and external functions. Administration was attempting to build the Financial Management Section in order to exert greater control over the operation of the agencies, and she envisioned the auditor assisting the Health Division to ensure the timely deposit of the agency’s fees.

Was the division currently able to audit its sub-grantees, asked Chairwoman Evans. Ms. Sylva answered that it was not, other than the monitoring done at the programmatic level. Chairwoman Evans stated the auditor position was included in the Administration budget, and inquired if the position would work throughout all the budget accounts within the Health Division. Ms. Sylva answered in the affirmative.

Chairwoman Evans then asked Ms. Sylva to address the Safe Drinking Water Revolving Account, and explain its operation. Ms. Sylva informed the subcommittee that the Safe Drinking Water Revolving Loan Fund, Budget Account 3211, was not included in the Health Division budget, and was administered through the Municipal Bond Fund in order to allocate funds to community water suppliers around the state. Ms. Sylva stated communities applied for the low interest loans to become compliant with the Safe Drinking Water Act.

Chairwoman Evans asked if funding for the Safe Drinking Water Revolving Account would be included in the indirect cost plan, to which Ms. Sylva responded the Safe Drinking Water grant was included in that plan. In order to clarify the matter for the committee, Chairwoman Evans inquired if Ms. Sylva was referring to the Capitalization Grant as being included in the indirect cost plan. Electing to respond was Alex Haartz, Administrative Services Officer, who advised the division was eligible to draw from the indirect cost plan against Capitalization Grant funds, and would use that option.

Ms. Sylva explained in Budget Account 3190, the State Office of Vital Records and Statistics provided for the registration of all births and deaths, furnished certified copies of records, filed corrections or other legal amendments to records, and maintained computerized files of all abortions, marriages, and divorces for statistical purposes. The office served as the custodian of all original documents. She noted that the state General Fund and the Social Security Administration supported funding for the Vital Statistics budget.

Ms. Sylva stated the division received $1.70 per birth for families choosing to have a Social Security card issued for their child. She said funds were also received from the National Center for Health Statistics (NCHS) for providing birth and death data. Ms. Sylva said Maternal and Child Health (MCH) block grant funds were used to cover costs of the state’s Bio-statistician position. She added charges from surrounding states were being reviewed in order to determine an increase of division fees.

With regard to the State Office of Vital Records and Statistics, Chairwoman Evans commented the division had a grant of $180,000 for reporting, which has remained unchanged since FY 1998, and asked if the amount budgeted was adequate. Chairwoman Evans remarked there was a concern this amount was understated. Mr. Haartz replied the grant to which Chairwoman Evans referred was a contract from the National Center for Health Statistics. He did not believe the amount was understated; however, if it were determined to be so, the division would come before the Interim Finance Subcommittee (IFC). The indication the division presently had was $180,000 was correct, and additional revenue was not anticipated.

Chairwoman Evans asked when the division would receive notification if there was a change in grant awards. Mr. Haartz responded the National Center for Health Statistics had been developing an ongoing contract amendment process with the Health Division but did not traditionally notify the division of grants. He said as soon as the Health Division knew they could safely project more revenue, it would present the findings to the subcommittee.

Ms. Sylva stated the Cancer Control Registry Program was initiated in 1979 and mandated through Nevada Revised Statutes (NRS) Chapter 457 and was funded with a federal grant as well as fees. She stated the division chose over the past biennium not to fund the Cancer Control Registry with General Fund support. Looking at performance indicators, Ms. Sylva stated the division projected the ability for case reporting within 6 months of diagnosis and at a level of 85 percent. She remarked the division achieved only a reporting level of 65 percent in 1998 when data collected regarding cancer abstractions was not remitted to the Health Division on a timely basis. After health care facilities worked with their individual contractors, the division reported increased data reporting. Ms. Sylva added the division was working with medical laboratories to develop electronic linkage for the expeditious transfer of data.

Senator Coffin noted the Cancer Control Registry was a program the legislature had fought to keep alive over the 20 years of its existence, actually fighting opposition from other legislators, some of whom were afflicted with cancer. Upon review of the budget, he noted that General Fund revenue had been eliminated, and asked why that was done and was there a guarantee the money would be available should federal funding cease. Senator Coffin noted the registry now relied on increased fees, and inquired if that would be a disincentive for institutions to report because of the higher fee requirement.

Ms. Sylva responded the division had not experienced reluctance on the part of institutions to report data to the Health Division because of the fee increase. She advised the Cancer Control Registry had been a troubled budget over the years, with the division internally questioning the value. According to Ms. Sylva, the addition of federal grand funds, and by placing the registry in a position within the Health Division had actually put the program on the right track and moving in the right direction. The division was no longer just looking at numbers, and would soon be publishing a 2-year cancer report. Ms. Sylva felt that report would be unique because it would deal with trending data, which would give the division an opportunity to target programs around the state. She emphasized institutions were reporting as required, and the division was now receiving useful data.

Senator Coffin commented he had always felt the data was useful and added in some cases the state was able to rely on the registry knowing the Federal Government was unable to provide the data. Due to the increase of cancer cases in Nevada in the past, Senator Coffin said he was concerned the elimination of General Fund support was indicative of lack of support for the program; he was looking forward to the report. Ms. Sylva remarked the Health Division was appreciative of the support and the Cancer Control Registry was a priority. She added if there were issues or concerns they would be presented to the subcommittee.

Addressing M-200, Mr. Hettrick requested clarification of the $43,535, which would be used to fund increases in travel and operating costs for the Cancer Registry’s five employees. Mr. Haartz answered that decision unit was placed in the budget to reflect the difference between funds the Health Division was notified they were to receive from the granting agency versus actual expenditure in FY 1998; the basic premise behind the $43,535 was the anticipated increase in revenue. The decision unit reflected increased travel and operating expenses because of the division’s concerted effort to contact every hospital or entity that data would be abstracted from and also to ensure quality control was being done.

Mr. Hettrick observed in-state travel and operating expenses noted outside the Cancer Registry were $16,000 for all years within the budget and projected figures would reflect an increase of 50 percent. He was concerned that federal funds were going where they were budgeted. Mr. Haartz stated federal funds were budgeted for grant-supported activities, and other operating expenses were based on fees.

With regard to fees, Chairwoman Evans asked on what basis the fee increases were developed and by how much, and if the revenues budgeted for collection via abstraction fees were obtainable. Ms. Sylva stated she believed the Health Division would be able to generate the amount of revenue projected, and added when the legislature met last session, the Health Division indicated that fees would be increased within the Cancer Control Registry budget. She said when the Health Division performed an abstraction, the per-abstraction fee increased by $12 from $20 to $32. When health facilities chose to perform their own abstractions the division increased the per-abstraction fee by $2 from $6 to $8. The increase was based upon the division’s cost for data entry and quality assurance.

Chairwoman Evans asked if, in addition to hospitals, there were other providers that had information relevant to the Cancer Registry Program. Ms. Sylva responded other providers having information included medical laboratories and outpatient surgery centers. Did the fee increase apply to all providers, asked Chairwoman Evans. Ms. Sylva responded the fee applied to all facilities where records were being abstracted.

Regarding performance indicators, Chairwoman Evans stated in the Cancer Registry budget those could be strengthened. As an example, she noted the performance indicators contained in the Vital Statistics budget, and further advised that overall, the Health Division budgets contained good performance indicators, and she would commend the division overall in that area. Ms. Sylva advised her staff had worked diligently on those performance measures.

Ms. Sylva stated the Health Aid to Counties, Budget Account 3209, identified flow-through funds to Clark and Washoe County Health Districts in return for the districts’ support in providing public health services. The funds provided support for nursing services, maternal and child health, emergency medical services, air pollution control, and communicable diseases. The amount of funding included in the budget was based on a per capita rate of 55 cents per county resident. That rate was established in conjunction with the legislature during the 1991session due to budget shortfalls. Ms. Sylva stated the counties would approach the legislature this session regarding funding.

Chairwoman Evans remarked it appeared increases were based upon population increases, but not in the rate structure. She asked Ms. Sylva if the Health Division had considered adjusting the per capita rate since the 1991 reduction was implemented. Ms. Sylva responded since she had been with the division, the Health Aid to Counties budget account was always increased or decreased at the will of the legislature, not necessarily upon the recommendation of the Health Division itself. Clearly, she noted, the public health responsibilities in Washoe and Clark were tremendous, and also in the remaining 15 counties. Increases were based on population, and Ms. Sylva reiterated an increase in the rate would need to be approved by the legislature. Chairwoman Evans remarked the legislature looked toward the Health Division for assessment of needs when rate increases could be justified.

David Rowles, Director of Administrative Services, Clark County Health District, reported for almost two decades the legislature had allocated a per capita formula to the two health districts that encompassed Washoe and Clark Counties, where 85 percent of the state’s population resided. Mr. Rowles said Clark County had a rapidly growing, nationally recognized, population growth, that continued to require and demand essential and core public health services. The original Health Aid to Counties allocation had been in the form of revenue sharing, to help extend public health services within the two counties, to meet population growth, and to perform mandated state or federal health services. Those mandated services would encompass a far greater dollar expenditure by the state if it was required to provide those services without the county’s assistance.

Referring to the Clark County Health District handout (Exhibit C), Mr. Rowles explained the allocation of funds. He stressed no funds had been diverted to administrative or overhead costs, but funds were directed at providing services to the citizens. In 1991, the state experienced fiscal challenges, at which time the county health districts were asked to voluntarily reduce their existing legislatively funded per capita rate of $1.10 by 50 percent, in order to eliminate the need to reduce staff at the Health Division. Mr. Rowles noted in a spirit of cooperation, and with the understanding that it would be a temporary contribution by the counties, the districts agreed to the reduction.

Turning to page 3 of Exhibit C, Funding Per Capita – Clark County, Mr. Rowles indicated the per capita rate had essentially been "flat-lined" since FY 1991-92. During subsequent bienniums, when funding issues were not as critical as those faced in FY 1991-92, there had been no reply regarding the counties request to increase the per capita funding. Mr. Rowles stated he was not necessarily requesting a return to the per capita rate of $1.10, but if the legislature would approve even a 10 cent to 25 cent raise in the per capita formula, the counties would be able to extend additional services to residents. Those services would include immunization, maternal and childcare, and other programs normally funded by federal dollars. He explained the Clark County Health District made every attempt to manage its funds in a responsible manner, and were audited every year, with those reports available for state review.

Mr. Rowles indicated one of the impacts felt by the county health districts was the mandated shift to Health Maintenance Organization (HMO) managed care. Referring to Exhibit C, Medicaid Funding by Fiscal Year, he explained the graph identified the impact of the shift to HMO managed care and the decrease experienced in Medicare recapture funding. Mr. Rowles explained the Clark County Health District was concerned about the allocation and recommendation from the legislature, and would certainly use any additional allocations in the effort to keep pace with the need for public services within the growing population.

Mr. Rowles concluded by stating local health districts were responsible for the air its population breathed, the water it drank, the food it ate, the garbage thrown out; the immunizations for diseases, and the ambulances used in emergencies. Aid to County Funds were virtually used in all of those programs, and county health districts tried to make the "buck" go farther by being conservative in its actions, and in its staff allocated from year-to-year to those services.

Jim Begbie, Acting District Health Officer, Washoe County, echoed the sentiments expressed by Mr. Rowles, and called the committee’s attention to the information contained in Exhibit D, which would be addressed by one of his staff members, Ms. Coulombe.

Eileen Coulombe, Acting Director of Administrative Health Services, Washoe County District Health Department, said the concerns of Washoe County echoed those of Clark County although on a much smaller scale. Referring to page 1 of Exhibit D, she explained the Washoe County District Health Department’s Health Aid to Counties allocation of funds was represented in terms of percentages:

• Administration Division (departmental support, payroll, purchasing, personnel activities), 6 percent;
• Emergency Medical Services (REMSA ambulance services, Emergency Management Planning and Preparedness), 11 percent;
• Child Health (well-children exams), 1 percent;
• Community & Clinical Services (public health field visits for child abuse and neglect, domestic violence), 21 percent;
• Wellness Program (development of public health report card), 7 percent;
• AIDS Program (education and prevention), 3 percent;
• Sexually Transmitted Diseases Program (education, testing, treatment), 12 percent;
• Air Quality Management (permitting, monitoring, enforcement activities), 10 percent;
• Environmental Health Services (permitting, enforcement, and land use), 22 percent; and,
• Immunization, 7 percent.

Turning to page 2 of Exhibit D, Ms. Coulombe indicated the graph represented the dollar allocations to the different areas. She said page 3 showed the decrease in funds beginning with 1992, and the graph on page 4 depicted the ratio of Aid to Counties funding to population. Ms. Coulombe said the Washoe County District Health Department proposed the Aid to Counties per capita rate be reinstated to $1.10. The reinstated allocations would enable the department to address regulatory enforcement permitting facilities within Environmental Health Services Program by adding two staff members to complete inspections. She explained an increase in the rate within the arena of immunizations would address the grant revenue shortfall.

Mr. Begbie commented the letter provided to the subcommittee (Exhibit E), written by Donald S. Kwalick, Chief Health Officer, Clark County Health District, summarized both County District Health Departments’ concerns and interests. Mr. Begbie added any increase in the per capita rate would enable both districts to increase public health services. He requested the subcommittee consider restoring the per capita rate from $.55 to $1.10, but would be grateful for any increase that could be provided.

Comparing handouts from each of the County District Health Departments, Chairwoman Evans noticed funds were allocated quite differently, i.e., in Clark County, 22 percent was allocated for immunization and Washoe County utilized 7 percent in the same category; she noted the two counties also focused on different categories. Chairwoman Evans stated it appeared the counties had complete discretion in terms of use of the funds, and asked if there were any guidelines provided by the state regarding the use of funds. Mr. Rowles responded that the health district reported every biennium to the legislature, and were audited on an annual basis.

According to Mr. Rowles, the district believed it was the legislature’s intent that local options and needs be met, which were at times divergent between the two health districts. He explained that resulted in the different use of the allocation in different categories. As far as Washoe County was concerned, the Children’s Cabinet worked very closely with the health district regarding immunizations. He remarked Clark County had a substantial challenge with regard to appropriately immunizing children before the age of 2. Clark County Health District had made strides in immunization, but requested funding assistance to expand the effort to achieve compliance in immunizing children 2 years of age and younger.

Mr. Begbie stated the Washoe County Health District had a budgeting process involving the local Board of Health, which reviewed staff recommendations on distributions of Health Aid to Counties appropriations. He said the distribution of funds depicted in Exhibit E represented long-standing agreements with the local Board of Health and how they chose to allocate Health Aid to Counties funds across the program areas. Mr. Begbie explained Washoe County also received external audits and that information was always available to the State Health Division. While he could not speak for the Board of Health specifically, he would recommend that it continue to allocate the funds across the broad-based programs, as that had worked well in the past. The district would be presenting its budget to the Board of Health in the near future, and Mr. Begbie stated he would make the recommendation that funding be allowed to continue in the same program areas.

Karl Munninger, Administrative Services Manager, Clark County Health District, said Clark County could be losing up to $500,000 Medicaid dollars due to the mandated shift to HMO managed care in Clark County. As a result of the cutback of the per capita rate in 1991, the Clark County District Health Department sought out Medicaid dollars to replace state dollars lost. He remarked that strategy had been adequate in the past, but presently the department faced the loss of Medicaid funding and requested the restoration of the per capita rate to offset the shortfall.

Continuing, Mr. Munninger called attention to NRS 441A.370 that stated the State Health Division shall provide for care of patients with tuberculosis (TB). He added the health district maintained a large tuberculosis program and direct costs for providing services to TB patients was projected at $842,000 in the current fiscal year. Out of $842,000, only $235,000 or 28 percent would be state-funded resulting in a deficit of $607,000 in the TB program. Mr. Munninger commented on the legislature only providing 28 percent of the legislatively mandated support for the care of TB patients. He added with the restoration of the per capita rate, $750,000 in costs could be defrayed.

In regard to increasing the per capita rate, Chairwoman Evans asked if the Clark County Health District had calculated what the dollar amounts would for and increase such as 10 cents. Mr. Munninger responded even a 10 percent increase of the per capita rate amounted to $73,500 in the forthcoming fiscal year and $76,600 in the succeeding year.

Mr. Parks requested both health districts provide the committee with a perspective as to the percentage of their overall budgets the Health Aid to Counties funding represented. Mr. Munninger responded the funding represented approximately 2 percent of the Clark County District Health Department’s budget. He added the budget had increased substantially due to Ryan White Title I funding. Mr. Begbie added Health Aid to Counties represented 1 percent of Washoe County District Health Department’s budget.

Senator Coffin remarked he understood the legislature had pushed both the districts into an unfunded mandate, but he also understood the administration’s problem with trying to balance the budget and hoped something could be worked out with both the agency’s requests.

With regard to the Cancer Registry, Senator Coffin asked Mr. Rowles if, in his opinion, the increase in fees would be a disincentive toward honest, thorough reporting. Mr. Rowles responded local districts were not involved in the Cancer Registry, but did receive occasional reports. He reported the health district did hear from individuals who thought it was part of the state’s effort in collecting the data, however, the only contact was the result of complaints.

Mr. Rowles stated when things were going well with the program, people did not call, and the complaints the health district did receive were aimed at the insensitivity of the questions asked by the registry. He felt the state had made every attempt to resolve those complaints as best it could, in order to make the registry a viable reporting program. At one point in time, he stated, the legislature, along with other agencies, was concerned that the data from the Cancer Registry was at least 2 years behind, but collecting that data was not an easy task. Any improvement that could be made in the procedure would help give a better profile of those things that could be done on the local level to address some of the cancer agents. Mr. Rowles went on to explain the health district had just hired a health education person to address the tobacco issues.

Senator Coffin stated the county health district knew the issues and knew no other agency was collecting data except the state. Senator Coffin stated he wanted to make sure the legislature was getting straightforward information, and that the registry was not headed for trouble by increasing fees which added disincentives to reporting. Mr. Rowles responded the health district was well aware of the legislature’s concern over the past two decades regarding the Cancer Registry.

Mr. Begbie advised Washoe County was very interested in information and data acquired from the Cancer Registry for use in targeting areas for improvement in community wellness. He added Washoe County was interested in developing a "report card" for Washoe County on the wellness of the community. He stressed the information from the Cancer Registry would be a very essential and critical addition to the report card.

In the area of air pollution control, Mr. Dini asked if the state passed through money from the Federal Government and was that the only contribution. Mr. Rowles responded revenue was transferred from the Department of Motor Vehicles/Public Safety (DMV/PS) which did not come out of the state’s budget. Some years ago, he stated those funds were included in the Aid to Counties fund. He said the funds were earmarked strictly for air-pollution control efforts.

Mr. Dini inquired how large the budget was regarding air-pollution control. Mr. Munninger replied the total budget for the Clark County Health District in the current fiscal year for the air-pollution control program was $4.1 million, funded two-thirds by regulatory revenue, one-sixth by federal grants, and one-sixth by DMV/PS and State Health Aid to Counties funding. Mr. Begbie stated Washoe County Health District operated under a similar situation with pass through funds from DMV/PS and the total budget amount targeted for air-pollution control was approximately $1.1 million funded through federal contributions, permit fees, Health Aid to Counties funding, and local sales tax.

Mr. Dini then asked if adequate funding was being received from the state, and if the program was proceeding according to federal requirements. Mr. Begbie responded the Washoe Health District was in a very favorable position, and received funds from DMV/PS. He reminded the committee that a portion of the smog certificate fee for residents of Washoe and Clark was returned to both health districts to support and fund air quality management services. That was a very important revenue source for the health district, and helped to solidify its funding base in air quality management. Mr. Begbie explained the Washoe County Health District had made significant improvements in air quality as a result of the legislature’s action in allocating a portion of those smog check fees back to the district.

Ms. Sylva stated Budget Account 3194, Consumer Health Protection, provided regulatory and professional engineering services in the area of public health, including engineering plan review, public health sanitation, and administered the Federal Safe Drinking Water Program. She said activities also included plan review of commercial developments, sewage disposal systems, and investigation of incidents involving transmission of disease. Staff was involved in the enforcement of NRS, Chapter 585, which she explained was the manufacture of drugs and cosmetics.

The Consumer Health Protection budget also provided for inspections, as related to permitting of food establishments, hotels, motels, institutions, schools, correctional facilities, recreational vehicle parks, milk plants and dairies. Further, Ms. Sylva stated staff was on call on weekends and completed inspections when fires or accidents involved food or drugs. She stated the Consumer Health Protection budget was funded with General Fund support, the Safe Drinking Water grant, and fees, plus funding from the Department of Energy (DOE).

Continuing, Ms. Sylva stated during the Health Division’s previous budget overview hearing, Chairwoman Evans asked specific questions relating to the frequency of inspections. Those inspections were tied specifically to the fact that the last legislative session authorized 1 full-time position, based on the fact the Health Division had not met required inspections of food establishments. Ms. Sylva reported in 1996, 81 percent of food establishments were inspected; in 1997, when the division requested the additional position from the legislature, the inspection rate was 85 percent. In 1998, Ms. Sylva advised, records indicated the division was able to inspect 97 percent of all food establishments which fell under its jurisdiction. In 1999, the division estimated a 100 percent inspection rate; the reason the 100 percent rate was not reached in 1998, was because of the regulatory process.

Ms. Sylva advised two enhancements, E-710 and E-130 were included in the Consumer Health Protection budget. E-710 was a one-shot General Fund appropriation in the amount of $20,630, which would be used to replace 10 computers in rural areas. The computers would enable environmental engineers to utilize tracking databases, along with other software, in order to comply with the mandatory inspection schedules. She anticipated the ability for electronic transference of inspection reports and violation letters to the central office in Carson City, and the ability to follow-up on documented deficiencies in a timely fashion.

Senator Rawson commented on the Family-to-Family budget and noted there were $427,000 worth of computers that were purchased by the state. He said an accounting of those computers was requested to determine where the computers were placed, and he wondered if the environmental engineers could perhaps utilize some of that equipment. Senator Rawson requested that the division check out the possibility of transfer of equipment for its use.

Addressing E-130, Mr. Haartz remarked the decision unit addressed the projected decline of base revenue in the upcoming biennium. The Health Division determined part of the decision unit had been recommended twice and, therefore, that decision unit needed to be amended. Mr. Haartz recalled the 1997 Legislative Session provided $55,000 in General Fund revenue to compensate for the projected revenue loss in the Division of Environmental Protection (DEP) for landfill and public sewage system inspections. After submitting the budget, the Health Division determined that part of the decision unit which dealt with revenue GL3803, requesting $700,450, should be removed; the balance of the decision unit would remain. Mr. Haartz advised a shortfall was still projected in revenue from licensure of drug manufacturing plants and requested $9,700 in the General Fund support be provided within E-130.

Continuing, Mr. Haartz pointed out a mistake in the budget which was the inclusion of state owned renting in operating expenses. The budget still reflected that the program rented state-owned space and that was not the case. Information had been submitted recommending a reduction in expenditures and an accompanying federal revenue reduction.

Chairwoman Evans expressed her interest in knowing whether the fees generated were adequate in covering additional staff and their support, and voiced the subcommittees’ concern regarding the rate of inspections for the upcoming biennium, and if computer utilization would improve the rate of inspections. Ms. Sylva responded the computers would be placed in Fallon, Winnemucca, Elko, Ely, Tonopah, Las Vegas, and two in Carson City, and would serve primarily out-station workers, allowing them to process inspection data in an expeditious manner. She explained in some instances, staff in many rural areas were located with other Health Division Staff, and in some cases were totally isolated. For that staff to have no computer access was a hindrance to the program. Consumer Health Protection had a network in place that ran well, and out-station staff needed easy access to computers for data input. She stated she believed the fees established in the budget would be generated; however, there were always exceptions to every rule and unforeseen circumstances could create a problem. Ms. Sylva stated the Health Division believed the fees would be met.

Chairwoman Evans asked if the Consumer Health Protection Program staff administered the Safe Drinking Water Fund. Ms. Sylva answered affirmatively. Chairwoman Evans remarked she would like the division to advise the subcommittee where those funds would be expended. Ms. Sylva said she would provide the requested information.

Mr. Hettrick remarked on the performance indicators and expressed his desire to have a comparison of inspections completed next to the indicators. Ms. Sylva responded the Health Division had workload indicators that were not reported in The Executive Budget document, and would provide the information next session.

Ms. Sylva stated the Health Facilities Hospital Licensing budget, Budget Account 3216, was often referred to as Licensure and Certification. The Health Facilities Hospital Licensing budget was responsible for certifying and/or licensing health facilities for the dependent, medical laboratories, laboratory personnel, and environmental laboratories. Ms. Sylva said the Health Facilities Hospital Licensing budget was also responsible for registering group homes that served less than three persons.

Ms. Sylva went on to explain the budget was under contract with the Federal Government to certify agencies participating in Medicare/Medicaid health care reimbursement programs. She advised there were more than 30 regulations that the budget operated under, actually developed and keeping current some of those regulations, in order for the Health Division to determine compliance with established laws, investigate complaints, and provide training and education to those agencies it regulated.

Continuing, Ms. Sylva addressed questions subcommittee members had at the budget overview. She stated the Health Division’s reserve balance of $800,000 was reviewed from 1993 to 1998, to determine why such a large reserve was maintained. The 1995 Legislature approved 11 new positions for the Health Division. Nine positions were surveyors who would work in various statewide locations. The contributing factor that led to the large reserve was the difficulty in filling those positions. Ms. Sylva noted during that same time period, the division went from General Fund funding to being totally funded by federal monies and fee-based revenue.

Ms. Sylva explained in order to ensure that the division could continue to pay for the new positions, it had to ensure there were fees in place which would generate the necessary revenues. The difficulty the division experienced when attempting to fill the positions was complex, and in some cases it took almost a year to recruit persons for the vacancies. Most of the surveyors were nurses and there was a great deal of competition from the private sector. Many nurses sought private sector positions where they were paid more for fewer hours.

At the same time the division raised its fees, the facility growth continued, stated Ms. Sylva, and staff was continually conducting new inspections. Quite frankly, the division did not have professional administrators or managers, and its highest level of staff was classified as surveyors for positions, and actually did the group type of management. The division did not have dedicated staff to rewrite regulations or recruit new staff, and those functions were handled by the surveyors. Further, she reported, the division underwent an occupational study of the surveyor classification, and that report contained a wrong word, which caused the division to struggle during the last biennium because it was unable to fill positions because of that error. Ms. Sylva advised for the first time, the division was at full staff.

In review of the first few months of FY 1999, with the current expenditure rates, the division found itself utilizing a portion of the $800,000 reserve, and anticipated by FY 2001, the reserve balance would be $400,000. At that point in time, advised Ms. Sylva, the division would then need to increase fee revenues because it needed a $400,000 cushion to move forward to the first quarter of each state fiscal year, along with the $400,000 General Fund load that it received in order to cover expenses. She further explained the revenues from licensure of facilities was not realized by the division until November and December of each year.

Ms. Sylva said the Health Division had originally intended to present before the subcommittee the request for new full-time positions. She said in reviewing staff allocation of federal surveys versus state surveys, the Health Division had determined staff was disproportionately assigned to the federal side, and was not generating enough revenue due to lack of federal reimbursements for initial certifications of facilities for Medicare/Medicaid. The new facilities coming into Nevada deserved to have an initial inspection performed and receive certification for Medicare/Medicaid to bring in those revenues. State staff had been assigned to ensure new facilities were able to come in and meet certification requirements.

Ms. Sylva noted, due to the growth, the Health Division had been unable to meet the required annual surveys for licensure, and stressed that although the division had been unable to perform annual surveys, the quality of service and care received in the facilities remained the same. Unless the state received complaints, the Health Division did not review facilities accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Ms. Sylva said the Health Division had surveyed 100 percent of the facilities that were Medicare/Medicaid certified to ensure revenue was generated and residents received quality care.

With regard to issues within the budget, Ms. Sylva reviewed several of the Health Division’s successes. She remarked during the 1995 session, the survey and certification of environmental laboratories was located within the State Public Health Laboratory, and there was legislation introduced which almost put the state laboratory out of business. The question at that time was how the state laboratory could be asked to regulate other laboratories when there was not much incentive to do so. The Health Division made the calculated decision to transfer the Environmental Laboratory Certification Program to the Consumer Health Protection budget. The Health Division was able to perform timely certification of all environmental laboratories.

Regarding performance indicators, Ms. Sylva noted that in 1998 out of the 30 sets of regulations, only 33 percent were current. As of February 1, 1999, 88 percent of the regulations were current, which meant division surveyors had the opportunity to regulate facilities with some degree of quality. Investigations of serious complaints at facilities were completed within a 24-hour period and necessary action was taken which could include a ban on admissions. Over the past biennium the Health Division had two facilities in which a ban on admissions was placed, which meant the Health Division believed a potential for serious harm existed at the facilities and, therefore, they should be prohibited from admitting new patients. The division had been told that Nevada had the worst deficiency rate in the nation. Ms. Sylva stated it was very difficult for any facility in the state to pass its initial survey with no deficiencies. One facility, Fallon Convalescent Center, after having a ban on admissions, passed the survey with no deficiencies. She remarked staff had worked very hard with the facility to bring it into compliance, and was proud that they had a part in assisting it, so the persons residing in that facility were now receiving quality care.

Originally, advised Ms. Sylva, the division felt additional staff would provide the answer, however, she did not believe that was the case, and felt the division needed to review its function and complete a fundamental review of the program in order to make decisions that were accurate. Growth was a major issue and did impact the budget.

Mr. Dini asked how many positions were vacant at the Health Division. Ms. Sylva answered there was one vacant position, but it was not a surveyor position.

Ms. Sylva remarked Budget Account 3224, Community Health Services, was the Rural Community Health Nursing Program. She stated there were currently 22 nurses in addition to the bureau chief and a health education staff member, who provided services from 18 primary locations and 52 satellite offices within the state. Staff members provided services in all counties in Nevada except Washoe and Clark Counties. Through cooperative agreements with the Health Division, rural counties provided financial support equal to 40 to 50 percent of the community health nurses’ salaries. Additional financial support was provided through provision of facilities and administrative support.

Ms. Sylva stated approximately $1.3 million was provided from the counties in FY 1998 and $1.4 million in FY 1999. Approximately $400,000 or 20 percent of the overall Community Health Services budget was cash from the counties. She shared with the subcommittee the Health Division had sent a letter to each county requesting contributions for the Community Health Services budget be increased. Ms. Sylva advised she did not know what the increase would be, however, the percentages requested were based upon the population growth in each county. Generally speaking, she stated, counties provided some support, if not in dollars, in other methods of support. The county commissioners in general and the persons who lived in the rural counties were extremely appreciative of the work done by the community health nurses.

Chairwoman Evans voiced her concern about the decline of county participation in the second year of the biennium, from $417,253 in FY 2000 to $405,335 in FY 2001. Mr. Haartz responded part of the reason for the decline was in FY 1999, the state entered into a contractual agreement with Eureka County, which had originally provided $5,000 in county participation. He expected the amount would increase once notification from the Eureka County Board of Commissioners was received.

Mr. Goldwater inquired about $2,940 in the unfunded decision unit. Ms. Sylva replied E-175 would add warehouse space for the Community Health Nursing Program for medical supplies and materials for the rural community health offices. Mr. Goldwater asked if these funds were needed. Ms. Sylva advised, based upon limited warehouse space, the Health Division would be able to make do with the space through reorganization.

Mr. Hettrick requested clarification on Performance Indicator Number 3 "Number of pregnancies among girls aged 17 and younger in rural counties with a goal of no more than 51 per 1000 adolescents," and Performance Indicator Number 5, "Number of sexual offense crimes reported." He asked if the Health Division could relate some of the performance indicators to the number of dollars expended for prevention of offenses to determine if expenditure per incident reported was beneficial. Addressing Performance Indicator Number 3, Ms. Sylva explained the goal of the Health Division for FY 2000 was that no more than 51 per 1,000 youths would become pregnant. She acknowledged there was a higher teen pregnancy rate in the rural areas, and that was perhaps not the best indicator to use, because populations were small. That indicator would require some adjustment, and she advised that would be done.

Mr. Dini asked if the Health Division increased Lyon County’s health nurses. Ms. Sylva replied the division would request funds for an additional nurse in Yerington in Budget Account 3219 rather than the Community Health Services budget.

With regard to M-200 in the Community Health Services budget, Chairwoman Evans asked for the physical location of the nursing position recommended for Nye County. Ms. Sylva responded the Nye County Community Health Nurse would be located in Pahrump. Chairwoman Evans then asked if the Health Division anticipated that nursing position providing additional hours of direct client service. Ms. Sylva answered the position was a contract conversion determined to be less expensive if converted to a state position. She explained nurses providing services in rural areas had gone to the Health Division saying they would no longer provide those services to rural areas unless they were paid more per hour.

Chairwoman Evans requested that Ms. Sylva inform the subcommittee about the position cost and if costs for the position would be covered. Mr. Haartz responded the state’s share of the money was previously expended from category 04 and was adjusted-out in hopes the position change would be approved. Additional funding from Nye County had been requested so no fiscal problems were anticipated by the Health Division in terms of continuing services.

Chairwoman Evans asked if the requested funds were part of the budget. Mr. Haartz replied additional funds from Nye County had not yet been received, but letters had been sent to the counties. He added the subcommittee would be informed as soon as the notification of funds was received.

Ms. Sylva stated the Health Communicable Disease Control Program included the administration of three major programs: tuberculosis (TB), breast and cervical cancer, and diabetes. The major function of the TB program was to prevent the spread of communicable diseases through a comprehensive program of case identification, education, treatment, and intervention. Ms. Sylva said the program included surveillance of all non-sexually transmitted communicable diseases, and all refugees entering Nevada were registered and referred for health assessment. The scope of services included diagnosis and inpatient care.

Continuing, Ms. Sylva addressed the breast and cervical cancer program, known in Nevada as the Women’s Health Connection. The program was federally funded through the Centers for Disease Control and Prevention, and provided a comprehensive public health approach to reduce breast and cervical cancer morbidity and mortality through screening, referral, follow up, public education and outreach. She said the Breast and Cervical Cancer Early Detection Program Grant had increased from $250,000 in 1996 to $2 million presently. The grant had transitioned from a capacity-building grant into a grant which implemented the actual screening for breast and cervical cancer.

Ms. Sylva stated the Diabetes Control Grant started at $250,000 and an increase was anticipated. The goal of the program was to reduce occurrences of diabetes through statewide education and prevention. Two maintenance units were included in the Health Communicable Disease Control budget, but she would not review them unless it was so wished by the subcommittee.

Chairwoman Evans asked if there was an increase in the incidence of TB. Ms. Sylva answered the TB level for 1998 was 7.6 per 100,000 persons. She believed that the TB rate was currently stable in Nevada.

Chairwoman Evans asked if the Health Division was experiencing difficulty in attaining providers to address breast and cervical cancer issues. Ms. Sylva said presently there were 67 providers across the state. She added the Health Division had experienced a great deal of difficulty with providers when the screening program was first implemented.

Mr. Goldwater asked why the Health Division was experiencing problems, and asked if it was due to low reimbursement rates. Ms. Sylva explained the federal grant only allowed a reimbursement rate set at levels equal to Medicare allowable amounts.

Ms. Sylva addressed Budget Account 3215 and said Nevada’s Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS), and sexually transmitted disease programs were designed to reduce the incidence and prevalence of all sexually transmitted diseases through screening of persons engaged in high risk activities, identification, and treatment. There were three major target areas within the program:

1. Prevention;
2. Surveillance; and,
3. Treatment.

Ms. Sylva stated she would address the committee’s question related to the Ryan White Title II care guidelines for receipt of drugs and protease inhibitors through that program. If a person did not meet those guidelines, where would they go to receive services, or would they have to do without medication. In researching that question, the Health Division ascertained that individuals who did not meet any income guidelines would be eligible through the Patient Assistance Program offered by various pharmaceutical companies.

According to Ms. Sylva, the process for applying for the program was at times very difficult and required staff assistance in application completion. Only one pharmaceutical company had an income guideline of 400 percent of poverty, other companies based qualifications merely on the individual’s ability to pay and if the individual had been turned down by other payment sources. In some cases, the Health Division found there were individuals who did not participate in the program who were eligible for county assistance and social service programs. Ms. Sylva stated when the division spoke with Hope’s Clinic and the University Medical Center (UMC) Wellness Clinic it was determined that no one they knew to be in need of drugs was doing without. Chairwoman Evans noted that was the crux of the matter, whether persons would fall into a "gap" because of lack of coverage or income levels and not receiving necessary medication was frightening. Ms. Sylva stated the Health Division certainly agreed with that.

Ms. Sylva stated the Sexually Transmitted Disease Control budget did provide some General Fund support to other sexually transmitted disease programs, such as programs for Syphilis and Gonorrhea, which sometimes were lost in the budget process because so much of the funding was expended on HIV/AIDS. The federal grant had increased from $1 million in 1996 to $5 million in 1999, and she stressed if not for the support of the community and community planning groups, the Health Division would have experienced difficulty implementing the program.

Chairwoman Evans asked for the status of anticipated increases in the Ryan White Title II funds. Ms. Sylva answered the current grant award was $3.9 million. The Health Division had been instructed by the CDC to request approximately $4.7 million, which represented an increase of $800,000. The funds would be earmarked for the Aids Drug Assistance Program (ADAP). Chairwoman Evans asked if those funds were distributed statewide. Ms. Sylva responded the division had been distributing funds for medication geographically, however, had changed its methodology during the past year. Funds were now distributed based upon need in ADAP so there was no waiting list.

Chairwoman Evans asked if local jurisdictions were able to directly access Ryan White grant funds or any other funding sources. Ms. Sylva remarked Clark County had been able to access Ryan White Title I funds based on the incidents of HIV reaching a required level in Clark County. Chairwoman Evans then asked if Clark County was eligible for funding through the State Health Division. Ms. Sylva answered Clark County was eligible to receive funding from the state agency and any monies received from Ryan White Title I funds were taken into account and factored-in by the community planning groups who then made distribution decisions.

Senator Rawson remarked there was supposed to be significant Ryan White grant funds for dentistry and for research, and asked if those funds would be accessed through the Health Division or directly through the county. Ms. Sylva replied she was not aware of how those funds would be accessed, but would research the matter.

Mr. Goldwater remarked there was a state AIDS director who had since vacated his position, and that position was very attentive to Ryan White Title funding issues. Since the position was federally funded a waiver had to be applied for. He hoped the Governor would grant the waiver in order to fill the position with someone as attentive to the Ryan White funding issues.

Ms. Sylva indicated the long-term goal of the Immunization Program, Budget Account 3213, was the prevention, control, and eventual eradication of vaccine-preventable disease in Nevada. In order to attain the goal, public and private health care providers statewide were supplied with vaccines. Ms. Sylva stated children entering school were 96 percent immunized, children who participated in licensed childcare were over 90 percent immunized, and 2-year-olds were assessed annually to determine immunization levels. Currently 72 percent of 2-year-olds in Nevada were immunized.

Ms. Sylva said when she last appeared before the subcommittee there were some issues related to the addition of new vaccines, specifically Rotavirus. The Rotavirus vaccine was recommended by the Academy on Immunization Practices to be included as part of the childhood immunization package. She added President Clinton’s budget would include funding for the federal portion of the Rotavirus Program. She reminded the subcommittee that the Health Department operated under a Letter of Intent from the Legislature, which stated before any new vaccine could be added, it needed to conduct a study in order to determine the cost-effectiveness of the action, and present the information to the Legislature. The cost of Rotavirus would be $30 per dose for a required total of three doses. Ms. Sylva said the Health Division was researching the addition of the new vaccine and the expansion of Hepatitis B to evaluate cost-effectiveness in human and monetary terms, and would report to the IFC. If the vaccine was added, the estimated state share in FY 2000 would be $224,737, and $471,947 in FY 2001.

Ms. Sylva directed the subcommittee members’ attention to the performance indicators for projected vaccine doses and indicated they were "way-off." She explained during the first 6 months of FY 1999, 300,000 doses had been administered, and the division would exceed the projected doses if, in fact, that figure doubled by the end of the year. She advised the division normally administered more vaccines from July through December due to the start of the school year. Ms. Sylva stressed the Health Division would closely monitor vaccine doses. A reversion of unexpended funds within the Immunization Program budget had been completed; therefore, those funds would not carry forward to the FY 2000-2001 budget, which might impact the Immunization Program.

Turning to the Immunization Program performance indicators, Ms. Sylva indicated there were discrepancies in actual FY 1998 doses of vaccines administered. An earlier figure showed administered doses at 477,162, and actual doses totaled 538,628. She said the Health Division would be revising the projected FY 2000-2001 numbers downward to approximately 600,000 for FY 2000 and 626,000 for FY 2001. The original projected numbers initially included the addition of vaccine that the division did not have approval to add from the legislature.

Chairwoman Evans commented that to add the Rotavirus to the vaccination program, the state-match totaled $700,000 for the upcoming biennium. She asked Ms. Sylva to clarify the timetable for the cost-benefit analysis and anticipated need for a federal match. Ms. Sylva replied the cost-benefit analysis would be complete in a couple of weeks, and at that time, the division would make the determination of whether or not it would benefit Nevada to add the Rotavirus. Ms. Sylva advised that information would be provided, and would include a better estimate of dollar amounts. The ultimate decision of whether or not to add the Rotavirus would lie with the legislature.

Chairwoman Evans commented Ms. Sylva had not referred to Pneumo-7 vaccine

mentioned during the budget overview in January. Ms. Sylva replied the addition of Pneumo-7 vaccine was not anticipated, therefore not addressed.

Ms. Sylva introduced Budget Account 3222, Maternal Child Health (MCH) Services, and stated the program included children with special health care needs, children and adolescent services, and perinatal/obstetrical services. She explained the primary source of funding was Title V of the Social Security Act, which was commonly referred to as the Maternal and Child Health Block Grant. Funding was targeted to improve the health of families, women, pregnant women, infants, children and adolescents, as well as to provide monies for the development of a system of community-based, family-centered services for children with special health care needs.

Ms. Sylva advised the Children With Special Health Care Needs Program (CSHCN) provided for diagnoses, evaluation, and treatment of children with specified handicapping conditions. While providing financial assistance to families, the program was the payer of last resort. Prior to authorizing services under the Children With Special Health Care Needs Program, referrals were made to Nevada Medicaid and Nevada Check-up. A key component of the program was newborn screening. The program was also responsible for tracking of abnormal test results for seven metabolic disorders and hemoglobinopathy for which all infants in Nevada were screened twice. In 1998, 24 infants were identified with a metabolic disorder, and 7 with hemoglobinopathy. She remarked the MCH budget would be impacted as a result of the implementation of Nevada Check-up Program.

When Ms. Sylva appeared before the subcommittee in January, she advised it was the intent of the Health Division to reallocate any savings within the budget toward the reduction of waiting lists at special children’s clinics. Waiting lists for initial appointments and treatment services represented waits of 1 to 5 weeks for an initial appointment, and 4 to 6 months for treatment. Ms. Sylva said in order to reduce both waiting lists to 2 weeks, it would be necessary to add in excess of 20 staff members. The cost of such an expansion would be approximately $1 million. Since the revenue was not available to fund the needed additions to the Special Children’s Clinic budget, nor was it expected to be available in the future, the Health Division proposed to take advantage of the opportunity to redirect a portion of the funds from the MCH budget to the Special Children’s Clinics, which would reduce waiting lists.

Continuing, Ms. Sylva said 240 children eligible for services through the CSHCN program had been referred to the Nevada Check-up Program for enrollment, as well as 348 children who were receiving dental services. The MCH Block Grant mandated that at least 30 percent of its grant, and associated match, be expended on programs targeting children and adolescents, and at least 30 percent of the grant and associated match be expended on programs for children with special health care needs. Given those mandates, the children’s dental program would become a prevention model and a portion of the medical payments for CSHCN, along with associated staff reductions, would be redirected to the Special Children’s Clinics in Reno and Las Vegas to reduce waiting lists for initial intake and treatment. According to Ms. Sylva, it was anticipated that between the reduction in full-time positions, and savings from medical payments, there would be funds available for redirect to the Special Children’s Clinics. Ms. Sylva could not give specific amounts or how the Health Division would accomplish redirection of funds at that time. Impacts within the MCH budget were just beginning to be felt, but the full impact would not be felt until FY 2000.

Ms. Sylva said it was the intent of the Health Division to redirect any funds in an incremental manner throughout the biennium, which would require a great deal of visits to the IFC. Ms. Sylva advised she did not believe sufficient funds were available to reduce the waiting list for treatment services to 2 weeks; however, she did believe the Health Division would be able to provide assurances to families that the wait would be no longer than 2 weeks for an initial appointment, and waiting lists would be reduced by one-third.

Ms. Sylva went on to explain the MCH budget account was also home to the Baby-Your-Baby program, as well as prenatal substance abuse program. She added she chose to address the issue of the Special Children’s Clinics in the MCH budget and would address the issue again in the next budget presentation.

Chairwoman Evans requested clarification on the term "redirect" as it related to the transference of funds from the MCH budget to the Special Children’s Clinics budget. Ms. Sylva responded the Health Division had not transferred funds, but were trying to determine how the redirection of funds would be utilized. She said that information would be presented to the IFC.

With regard to Consumer Price Index (CPI) increase for MCH providers, Chairwoman Evans requested clarification on which provider groups were recommended to receive the rate increase. Ms. Sylva answered the rate was based on the formula for medical providers that came from the budget office. Mr. Haartz added the increase covered providers of services to children with special health care needs.

Referring to M-200, Chairwoman Evans requested the rationale for converting services provided by contractors to classified positions. Mr. Haartz replied M-200 proposed to convert existing nutritional services that were being provided to the various school districts within the state. He said part of the mandate under the Title V funding source was to provide infrastructure development and coordination of services. The recommended position would be responsible for providing evaluations on children who were diagnosed with nutritional disorders. When a child with special needs entered school, it would be the responsibility of the new position to ensure the staff at the school were trained in, and understood, the nutritional needs of the child.

Chairwoman Evans asked how many positions would be providing that type of service. Mr. Haartz answered there was currently one contractor. The Health Division proposed to convert the contract position to one full-time state employee. Chairwoman Evans then inquired if that full-time employee would provide service to all the school districts. Mr. Haartz replied in the affirmative.

Ms. Sylva presented to the subcommittee Budget Account 3208, Special Children’s Clinics. She stated the Special Children’s Clinics in Reno and Las Vegas served as regional centers providing comprehensive family-centered, community-based, multi-disciplinary, early intervention diagnostic and treatment services to families with children with known or suspected developmental delays in the areas of cognition, communication, physical development, social/emotional development and adaptive skills. In addition, the clinics provided assessment and follow-up services through contractual agreement with all Level III Neonatal Intensive Care Units in the state, and served as primary providers of early childhood intervention services. Clinic staff included pediatricians, social workers, psychologists, speech pathologists, audiologists, nutritionists, occupational therapists, along with child development specialists.

In FY 1998, the clinics received approval from the IFC to use $110,000 in available MCH Block Grant funds to alleviate a projected shortfall in the collection of medical charges. Ms. Sylva stated a recent review of revenues in FY 1999 showed the Health Division was "on-track" for collecting budgeted revenues. She said she felt secure that the revenue budgeted for FY 2000-2001 would be realized given no unforeseen occurrences. The Special Children’s Clinics budget was funded with General Fund revenue, along with insurance recoveries and a small transfer from the Child Care Block Grant of $31,799. Two enhancements were included in the budget:

• E-710 for recommended replacement of equipment to allow the upgrade of network servers in the Reno and Las Vegas offices, plus allow the replacement of outdated desktop computers; and,

• E-720 recommended funding to purchase new equipment complete the network in Reno and Las Vegas.

Referring to the Unfunded Decision Unit category, Mr. Parks asked for what program the Health Division requested the substantial amount of $1,011,654 in FY 1999-2000 and $1,074,181 in FY 2000-01. Ms. Sylva replied she addressed the amount and program when she spoke of Budget Account 3222, Maternal Child Health Services. She noted $1 million was needed to reduce the initial and treatment waiting lists to 2 weeks for the Special Children’s Clinics.

Chairwoman Evans expressed an interest in knowing how the following performance indicators were determined:

• Indicators 1 and 9 for Reno and Las Vegas - Percentage of families satisfied with services based upon periodic surveys.

• Indicator 12 – Lagtime for availability of initial appointment.

• Indicator 13 – Appropriate, comprehensive diagnostic services were offered to child and family.

Ms. Sylva clarified Indicator 13 as meaning for every child in which there was an individual family service plan developed, the child’s treatment needs were determined at that time. Based upon that plan, the Health Division would determine whether those services were offered and completed. Ms. Sylva addressed Indicators 1 and 9 by stating the Health Division had implemented a behavior scale developed by the University of Kansas measuring client satisfaction. In the first month of implementation, the Health Division determined a 95 percent satisfaction rate from parents completing the survey.

Mr. Hettrick requested the status of revenue collections and if they were improving. Mr. Haartz replied revenue collections were improving, and referred to the shortfall of fee collection experienced in FY 1998. The division was able to address issues in-house by notifying staff to remind parents when an insurance situation changed in order to appropriately bill insurance. Last fiscal year, the Health Division was averaging a combined per-month revenue of $26,400 from the two clinics, and revenues averaged $34,100 per month during the current fiscal year.

Mr. Hettrick remarked the Clinics received $110,000 from IFC to alleviate the shortfall, but even recouping $8,000 per month totaling $96,000 would still leave a shortfall. When Mr. Hettrick inquired about the bad debt rate, Mr. Haartz responded when the Health Division appeared before the IFC, the $110,000 was originally the amount placed in the work program request, and the division ended up with a shortage of $56,000 in revenue at the end of the year. Mr. Haartz explained "bad debt" was a bad choice of wording, but it referred to the Medicare-allowable reimbursement rate that primary payers used as guidelines, and the Health Division trying to maximize revenue.

Mr. Hettrick remarked he realized what the division tried to accomplish, but the Health Division should re-categorize using "Uncollected Fees" based on fees charged, and another as true "Bad Debt." Mr. Haartz said the division would be pleased to implement the new categories and identify them as such. Mr. Hettrick also suggested the Health Division rewrite performance indicators so they could be understood.

Chairwoman Evans remarked the subcommittee appreciated Mr. Haartz’s assurances regarding goals to improve revenue collection, and requested a listing of the proactive measures the Health Division anticipated undertaking for improving revenue collections.

Chairwoman Evans noted in E-710 and E-720, new equipment was requested, and asked Mr. Haartz if that would help the division with the billing system, and was revenue collection tied to billing issues. Mr. Haartz stated the division’s revenue collection and billing system would not necessarily be impacted by those enhancement units, as they represented a continuation of a program from the 1997 session, which would ensure that professional and clerical staff had the computerized infrastructure necessary for report-writing, as well as documentation of services. Chairwoman Evans asked if the billing system was adequate. Mr. Haartz replied he believed the billing system was efficient.

WIC FOOD SUPPLEMENT – BUDGET PAGE HEALTH-48

Ms. Sylva presented Budget Account 3214, WIC Food Supplement. She said the Women, Infants, and Children (WIC) Program was a 100 percent federally funded rebate program that served approximately 38,000 women, infants, and children on a monthly basis.

Ms. Sylva said the source of funding came from the United States Department of Agriculture (USDA) and had remained stable. The WIC program currently served 64 percent of the eligible client population at, or below, 185 percent of poverty and were medically or nutritionally at-risk. The Health Division projected being able to serve 40,800 or 78 percent of women, infants, and children on a monthly basis under the WIC Program in FY 2000-2001. Ms. Sylva advised she did not envision waiting lists, but if that was the case there were policies and procedures in determining the highest priorities.

Continuing, Ms. Sylva advised the Health Division had been working on the proposed Electronic Benefit Transfer (EBT) program with the Western Governor’s Association (WGA) to implement the "Health Passport" project. That project would allow the division to implement a pilot project in Washoe County through agreements with eight northern Nevada retail chains. The Health Division anticipated the pilot project startup date at the end of summer. She said the only retailers that would be able to participate in the WIC Program were those who had a participation agreement in the EBT Program.

Chairwoman Evans asked if she was accurate in assuming no eligible person was turned away from the WIC Program. Ms. Sylva responded that was correct.

Chairwoman Evans noted the total funding recommended for the WIC Program for the upcoming biennium was less than that of FY 1998, and asked the Health Division to explain how more clients could be served with less funding. Mr. Haartz indicated some of the strategies allowed by the Federal WIC program allowed the change from brand name food products to generic or store labels, thereby, allowing for the maximization of the food dollar. That would also allow the division to revisit the amount of benefit an individual would receive, and move individuals around on the priority list as well.

Budget Account 3235 was presented and Ms. Sylva said a question had arisen regarding a request for a part-time medical director during the Health Division’s last appearance before the subcommittee. At the time the position for medical director was budgeted there was a bill before the legislature allowing the transfer of the responsibilities of the Emergency Medical Services (EMS) from Washoe County back to the Health Division. Because the Health Division’s priority was for the timely implementation of the EMS Program, and there was a state health officer and an advisory group that the Health Division felt could answer medical questions, the division chose not to fill the position for the medical director. The position was not filled and subsequently the funding for the position was lost.

Ms. Sylva stated a self-funded training fund was approved by the 1997 Legislature. During FY 1998, the training fund was established in regulation through the collection of a $5 incremental fee for each new or renewed certification. Funds were then transferred back to the counties for use in volunteer services. She said the Health Division had placed caveats on the funds that indicated the division would only provide counties with 75 percent of the funds and the counties had to provide 25 percent in cash or in-kind. Ms. Sylva said the Health Division established an administrative policy in June of 1998 to determine how funds would be allocated. The Health Division had implemented the policy and a Request For Proposal (RFP) had been sent to those counties. The Health Division received nine returned applications for training grants, but because a full year of certification fees had not been generated, the Health Division only had $5,125 to allocate, with requests of $13,156. Ms. Sylva noted the Health Division awarded $4,520, and remaining funds would carry forward to the next allocation in July. EMS and fire district volunteers could then utilize the funds for refresher courses. She anticipated the next allocation of funds would be distributed in FY 2000.

Mr. Haartz stated Category 10 was the training category that included both the self-funded training funds, as well as General Fund support. He said when the EMS budget was developed and finalized, it had inadvertently double counted carry-forward revenue. Mr. Haartz stated the Health Division, along with Budget Office and LCB staff, was in the process of backing out the funds. Funds would be available based on the self-funded training fund to continue training activities.

Chairwoman Evans asked what factors contributed to the long periods of vacant positions, and if the division faced any "hurdles" with the EMS budget such as those faced in prior budgets with filling positions. She noted in one area difficulty arose when competitive salary rates became an issue. Ms. Sylva explained the Health Division had experienced difficulties in filling positions over the years, in particular the position of supervisor. Due to the grade level and the requirements of the position, it was difficult to recruit an individual with an Emergency Medical Technician (EMT) certificate. Ms. Sylva remarked the last time the Health Division had recruited for a supervisor the recruitment period lasted 8 months. The Health Division had a person acting in the supervisor capacity who had since retired, leaving the position vacant. Ms. Sylva noted recruitment for the position had recently closed and interviews were beginning.

Chairwoman Evans requested comments from Ms. Sylva regarding the Pre-Hospital Emergency Care Data Registry. Ms. Sylva responded the Pre-Hospital Registry was operated by the state and maintained all centralized data. The Health Division had been working with the University of Nevada School of Medicine Trauma Institute in identifying standardized data sets, and in developing a central repository for collection and analyses. Ms. Sylva believed standardization of data sets would enable the Health Division to receive more meaningful information and commitment from the larger participating counties.

Chairwoman Evans asked if the standardization and upgrade of the data system was being pursued. Ms. Sylva replied the upgrade was not being pursued in the EMS budget, and the division believed federal funding could be used to enable the Health Division to perform an upgrade. Chairwoman Evans inquired if the new data system was reflected in the budget as anticipated revenue. Ms. Sylva replied it was not.

Chairwoman Evans requested comments on transferring the oversight for the Trauma Registry to Vital Statistics. Ms. Sylva responded the Trauma Registry was transferred because of the inability to produce reports in a timely manner. The division was attempting to locate all registries in one location enabling a greater responsiveness from the Health Division. Ms. Sylva said since transferring the Trauma Registry to the Office of Vital Records for oversight, the Health Division anticipated developing an interim trauma trending report for the last 2 years. She anticipated the Health Division would have that report accomplished by the end of the fiscal year. Ms. Sylva said the University of Nevada School of Medicine Trauma Institute would serve as the central repository for the data, and furnish reports to the Health Division.

Chairwoman Evans asked within which budget the expenditures associated with the Trauma Registry belonged. Ms. Sylva answered the expenditures belonged in the EMS budget and a change in location was not anticipated. Chairwoman Evans then asked if Ms. Sylva thought the expenditures should be transferred into the Vital Statistics budget. Ms. Sylva responded the expenditures could be separated from the EMS budget if that was so wished by the subcommittee members.

In regard to the certification fees, Chairwoman Evans commented the state-support and $5 fee for training activities were commingled. She remarked it would be helpful to the subcommittee if the fees were separated for easy tracking. Mr. Haartz answered the division would work with the subcommittee on resolving the issue.

Mr. Dini asked if there were adequate funds in the budget to cover licensing attendants and ambulances, ambulance inspections, and EMT certification in rural areas. Mr. Dini advised there were approximately 5,000 volunteer fireman, and at least 1,200 to 1,500 were EMT’s that provided a tremendous service to the state. He wanted to be sure the EMT’s received needed training and safe equipment. Ms. Sylva responded the Health Division was working to make EMS a priority. She believed that given the infrastructure, the Health Division could maintain the EMS budget, and funding was sufficient in order to do what needed to be done. Ms. Sylva thanked Mr. Dini for calling the issues to her attention, and added the Health Division needed to serve rural area residents in a much better manner.

Chairwoman Evans thanked Ms. Sylva and Mr. Haartz for their presentation and called for public testimony.

Steve Tognoli, District Chief, Mason Valley Fire District, Yerington Volunteer Fire Department, remarked the purpose of his appearance was to ensure EMS increased in priority throughout the state.

Scott Huntley, Division Training Chief, Mason Valley Fire District, and President, Nevada Emergency Medical Association (N.E.M.A.), remarked the reason he appeared before the subcommittee again, in addition to echoing remarks made by Mr. Tognoli, was to inform the subcommittee of his meeting with the Nevada State Firefighters Association. The Nevada State Firefighters Association was very concerned about EMS, and supported the N.E.M.A. in developing a Bill Draft Request (BDR) that proposed a Board of Emergency Medical Services outlined in (Exhibit F). Mr. Huntley felt the board might help in resolving problems. He stated issues with the EMS budget needed to be addressed, and action had to be taken in support of EMS. In closing, Mr. Huntley reminded the subcommittee of his correspondence to various agencies and legislators.

Senator Rawson remarked the hospital in Tonopah was reorganizing and may close, and the hospital in Caliente was in serious condition. He wondered how a unified system or trauma network would be developed and implemented in rural areas if Tonopah and Caliente hospitals closed. Mr. Tognoli made the following remarks:

Senator Rawson commented he would like to leave the session with a comfortable feeling about EMS. The program needed to be dealt with and it did not matter what the budget considerations were. Senator Rawson asked to which house the Bill Draft Request was going. Mr. Tognoli answered both houses, and added Mr. Dini and Senator Amodei sponsored the bill.

Mr. Tognoli said establishing a board would assist the Health Division in addressing concerns in a timely fashion.

Mr. Huntley noted it was not only the rural areas, but all areas involved with EMS were concerned that those issues needed to be addressed.

Chairwoman Evans thanked Mr. Tognoli and Mr. Huntley for the packet presented to the subcommittee and for their presentation.

Mr. Dini remarked on the amount of work performed by EMS, and added just the number of cases generated in Yerington that needed to be transported to Reno and Carson-Tahoe was impossible to imagine. He reported helicopters would come to Yerington on a daily basis for patient transfer, and he requested a figure on ambulance transports to Reno and Carson City. Mr. Tognoli responded 128 inter-hospital transports were made. He remarked ground transports included labors, trauma, or a transport for basic surgery; however, he could not comment on the number of Careflight transports but said ground and air was split 50-50.

Mr. Dini asked Mr. Tognoli if he had delivered any babies last year. Mr. Tognoli answered he had delivered one and hoped it was his last. Mr. Dini remarked babies were not normally delivered in the Yerington hospital because there was not a surgeon or an anesthesiologist.

Chairwoman Evans commented the services provided by the EMS were appreciated and thanked everyone for their participation.

There being no further business, the meeting adjourned at 10:50 a.m.

RESPECTFULLY SUBMITTED:

Rachel Baker,

Subcommittee Secretary

APPROVED BY:

_____________________________________________

Assemblywoman Jan Evans, Chairwoman

Date:________________________________________

____________________________________________

Senator Raymond Rawson, Chairman

Date:_______________________________________