The Joint Subcommittee on Human Resources/K-12 of the Senate Committee on Finance and the Assembly Committee on Ways and Means was called to order by Chairman Jan Evans, at 8:15 a.m., on Wednesday, April 14, 1999, in Room 3137 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

SENATE COMMITTEE MEMBERS PRESENT:

Senator Raymond D. Rawson, Chairman

Senator William J. Raggio

Senator Bob Coffin

Senator Bernice Mathews

ASSEMBLY COMMITTEE MEMBERS PRESENT:

Mrs. Jan Evans, Chairman

Mr. Joseph (Joe) E. Dini, Jr.

Mr. David E. Goldwater

Mr. Lynn C. Hettrick

Mr. David R. Parks

STAFF MEMBERS PRESENT:

Steve Abba, Senior Program Analyst

Ginny Wiswell, Program Analyst

Jean Laird, Committee Secretary

OTHERS PRESENT:

Mrs. Evans said there were three budget areas for the committee to cover. She explained that, typically, testimony is not taken during budget closings, which are work sessions for the committee. She noted that as the committee goes through the budgets there are occasionally issues or questions raised by committee members to which persons in the audience may be called on to speak.

DEPARTMENT OF HUMAN RESOURCES

HR, Assistance to Aged and Blind – Budget Page WELFARE-39 (Volume 2)

Budget Account 101-3232

Steve Abba, Senior Program Analyst, Fiscal Analysis Division, Legislative Counsel Bureau, did not recommend changes to this budget but said there were two issues the committee needed to consider.

Mr. Abba pointed out this decision unit provides for anticipated caseload growth as well as the additional administrative fees the Social Security Administration (SSA) will charge the Welfare Division for processing the monthly SSA checks for aged and blind individuals.

Mr. Abba said there is also a 3 percent rate increase built into decision unit M-200 for Adult Group Care Facility (AGCF) operators effective July 1, 1999. He explained the 3 percent rate increase is recommended because the 6 percent increase scheduled for January 1999 could not be implemented. He noted that a 3 percent increase was implemented in March 1999 and the additional 3 percent recommended in M-200 for July 1999 will make whole the 6 percent increase approved by the 1997 Legislature.

Senator Raggio asked whether the AGCF operators had received the 6 percent increase. Mr. Abba said that in total the operators will receive the 6 percent, but it will be a few months late. He explained that instead of getting 6 percent in January 1999 they will get 3 percent in March 1999 and 3 percent in July 1999.

Mr. Abba also called attention to an issue regarding the federal Supplemental Security Income (SSI) payment increase that is provided every January. He recalled there was misunderstanding about the federal rate increase provided to the aged and blind as well as the AGCF operators during this past biennium. He said the Welfare Division currently has the discretion to determine how that annual increase is implemented. Mr. Abba explained the division usually makes the decision, based on past practices, whether to pass along that federal increase to the AGCF operators, increase the client’s personal needs allowance, or implement some combination of both. He noted that in years during which there has been a fiscal crisis, the division has reduced the state supplement to reduce the General Fund expenditures in this account. He mentioned that concerns were expressed by the AGCF operators this past fiscal year regarding the federal increase.

Mr. Abba indicated the joint subcommittee may want to provide direction to the Welfare Division regarding how the annual federal SSI payment increases are implemented. He referenced page 60 of the closing sheets, "Subcommittee on K-12, Human Services, Closing List for Wednesday, April 14, 1999." (Exhibit C.)

Mr. Abba explained there were four options for the committee to consider. He said the first option is splitting the federal SSI increase evenly between the AGCF operator and the client’s personal needs allowance. The second option is designating the entire increase to the AGCF operator. He noted that currently the state supplement paid to the operators is $340 per person per month, increasing to about $350 on July 1, 1999, with the 3 percent increase. The third, and maybe the best, option is for the Welfare Division to report to the Interim Finance Committee (IFC) in December of each year on how the division plans to implement the federal SSI payment increase. At least by December of each year, he noted, the division would have information on what the federal SSI increase will be. At that time the division can discuss with IFC their plans to implement the increase and open it up for discussion. The final option is to maintain the current practice of allowing the Welfare Division to implement the SSI increase in the manner the division deems appropriate.

Senator Raggio asked when the Welfare Division would know the amount of the increase. Michael Willden, Deputy Administrator for Program and Field Operations, Welfare Division, Department of Human Resources, responded the division is usually notified in mid-October of each year. Senator Raggio asked what kind of increase the division anticipates. Mr. Willden said the increases are usually between 2 and 4 percent, depending on the consumer price index (CPI).

Referencing the chart depicting the historical federal and state SSI payments on page 16 of the closing sheets (Exhibit C), Mrs. Evans noted there are long historical periods where the personal needs allowance has been static. She pointed out that although Nevada has done better in recent times, it is "the kind of thing that can fall behind." She said the Legislature would like to see the clients get an increase whenever possible. Mrs. Evans said it is important the Welfare Division understand the committee’s concerns.

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MENTAL HYGIENE & MENTAL RETARDATION DIVISION

Mrs. Evans explained the committee would not review the Mental Hygiene and Mental Retardation (MH/MR) Administration budget since there are several pending issues on that budget.

HR, Mental Health Information System – Budget Page MH/MR-50 (Volume 2)

Budget Account 101-3164

Bob Guernsey, Principal Deputy Fiscal Analyst, Fiscal Analysis Division, Legislative Counsel Bureau, referenced page 12 of the closing sheets (Exhibit C). He explained this budget provides statewide management information systems support for mental health agencies. He said it includes the statewide Advanced Information Management System (AIMS) computer system and supports 4 staff. Mr. Guernsey recommended closing the budget with no changes to The Executive Budget.

HR, Nevada Mental Health Institute – Budget Page MH/MR-5 (Volume 2)

Budget Account 101-3162

Mr. Guernsey referenced page 13 of the closing sheets (Exhibit C). He recommended revenues be annualized for the Program for Assertive Community Treatment (PACT) and the Residential Treatment Program (RTP) added by the 1997 Legislature. He explained this has the effect of reducing the General Fund obligation by $203,697 each year. He noted he worked closely with the MH/MR staff, who have been extremely cooperative in reexamining revenues and reducing the General Fund obligation as much as possible. He explained that implementation of these programs occurred later on in the year and, when the budget was constructed, the expenses for those programs were annualized, but revenues were not.

Mr. Guernsey recalled there was considerable concern and discussion at prior committee meetings regarding inpatient census. He directed attention to page 14 of the closing sheets (Exhibit C), on which there is a chart showing budgeted and actual inpatient census for Fiscal Year (FY) 1998 and FY 1999. He pointed out the facility is currently budgeted for 52 inpatient beds. If the committee has concerns regarding budgeted levels for inpatient services, the cost of adding four additional beds would increase the General Fund need by $83,686 the first year and $103,940 the second year.

Mr. Guernsey pointed out that many of the programs added by the 1997 Legislature, which MH/MR Division testimony had indicated would reduce inpatient census, have not been fully implemented. He said the PACT program is not fully operational and the 8-bed RTP, although now fully operational, was delayed significantly. He said the committee may wish to issue a Letter of Intent requiring the division to continue to report inpatient census to IFC and to consider approaching the State Board of Examiners and IFC if the inpatient census rises above the budgeted level and cannot be handled with existing resources. He indicated he did not believe the census warrants adding staff at this time.

Mr. Guernsey pointed out the Psychiatric Emergency Services (PES) program has not been recommended for funding. He said the new hospital building will include space for a 10-bed PES program. The 1997 Legislature added approximately $117,000 to renovate Building 7 on the institute campus and that will probably be completed in September 1999. He said the Legislature may want to add a PES program and noted the division has reexamined this program configuration, trying to reduce the General Fund amount while maintaining adequate staffing levels. The latest discussions have been to increase the nonstate revenue in support of the PES program above the earlier estimates, to $165,000 each year. The General Fund cost would be $533,000 in FY 2000 and $752,000 in FY 2001.

Mr. Guernsey informed the committee he had requested the division reconsider what impact the additional 10 PES beds would have on inpatient census. He explained the PES program allows for a "72-hour hold" without actually admitting the patient through the inpatient hospital. He asked the division to consider whether the budgeted level could be reduced from 52 beds to another number if the PES program is funded. He said the division responded it is currently uncomfortable coming in with any lower estimate.

Mrs. Evans indicated psychiatric emergency service is one of the chief concerns of this committee. She recalled earlier testimony that Building 7 renovation is expected to be completed in the fall of 1999. Carlos Brandenburg, Ph.D., Administrator, Mental Hygiene and Mental Retardation Division, Department of Human Resources, informed the committee that is correct. Ms. Evans pointed out the PES program will need funding if it is going to operate. She said the chief issue is whether the PES program, by triaging patients more quickly and effectively, would reduce the inpatient census, which is budgeted for 52. She asked Dr. Brandenburg whether the budget could safely be set at something less than 52, such as 46 or 48 beds. She said the committee is looking for General Fund savings so the PES can be funded. She reiterated the committee clearly has concerns and wants to support the PES.

Dr. Brandenburg replied that when the division discussed the issue with Mr. Guernsey, the division’s concern was that a budget census be arrived at that Dr. Brandenburg felt reasonably certain would be safe. He said he believed the census would decline somewhat but felt uncomfortable removing staff from the acute inpatient hospital until he knew for certain what the reduced census would be. He said he proposed to Mr. Guernsey the PES be funded for 16 positions rather than the original request of 29 positions. He proposed the Legislature give the division the opportunity to achieve the reduced census during the coming biennium. Then, for the next legislative session, the division would know exactly what that number would be and could reduce staff in the inpatient hospital to make up the additional staff needed in the PES.

Dr. Brandenburg informed the committee he had indicated to Mr. Guernsey he could support reducing the budget level from 52 to 50 but that he felt uncomfortable reducing it any further. He pointed out it will take some time to bring up the PES program. He said that in the past it has taken longer than expected to bring up new programs at the Nevada Mental Health Institute (NMHI), to get them running efficiently and effectively. He cautioned that if the hospital staff is reduced, the division is "placed between a rock and a hard spot." He stressed that his needs are to provide a safe environment for clients and staff at the hospital.

Mrs. Evans asked whether the new PACT program has reduced or will reduce census. Dr. Brandenburg said there are many factors in reducing hospital census, including the PACT, the RTP, and the newer and safer medications funded by the Legislature. He said the problem is that he does not have solid data to determine what that number is going to be and he feels uncomfortable with a number less than 50. He said his goal is to reduce the inpatient beds and he wants to be able to do that in a very deliberate and solid manner, but right now he does not have the necessary data to determine "where the census will go." He explained that by the next legislative session he will have more than a year’s data and if the program is successful in reducing inpatient census, the division could safely reduce the budgeted number of hospital beds.

Mrs. Evans pointed out it may come down to a trade-off position on whether or not the Legislature will be able to fund the PES. Certainly, she said, if a somewhat lower projection would be possible, it would allow some "wiggle room." Dr. Brandenburg said he could feel comfortable with a census of 50 but it appeared as though the committee would need it to be 48 to fund the PES program. He said he could agree to a reduction in staff to 48 beds but added that he prefers making important decisions based on good solid data and right now he does not have that.

Mr. Guernsey recommended reductions in decision unit E-710 based on updated cost information for computer hardware and software.

Mr. Guernsey pointed out that, for the first time, the budget office, at the request of the division, supported a preventive maintenance category for NMHI. He noted the budget office recommended $68,500, but only for the first year. Mr. Guernsey recommended the funding be split between the 2 years of the biennium so the maintenance on the many buildings can be done over a 2-year period. He said maintenance funding has been placed in the operating category in the past, and when the operating category must be reduced for any reason, preventive maintenance is the first thing to be cut. He mentioned the "sad" condition of a number of the buildings at the Nevada Mental Health Institute and said this will be a small step towards giving the division the ability to keep those buildings in acceptable condition.

Mr. Guernsey referred to a memorandum from Mike Torvinen, Administrative Services Officer IV, Mental Hygiene and Mental Retardation Division, Department of Human Resources, sent through Charlotte Crawford, Director, Department of Human Resources, addressed to Mr. Guernsey (Exhibit D). He said the subject of the memorandum is "Funding for Opening New Hospital at NMHI." In the memorandum, Mr. Torvinen raised concerns that if construction of the new hospital is substantially completed during the biennium the division would be required to pay utility costs, with nothing allocated for this item in the budget at this time. Mr. Guernsey recommended that if the building is substantially completed as scheduled in January 2001, the division request a supplemental appropriation through the budget office for the 2001 Legislative Session.

Senator Raggio pointed out this budget is a crucial one and staff is recommending increasing revenue collections and reducing General Fund appropriations as a result of the PACT and RTP programs. Regarding the inpatient census, Senator Raggio indicated he would be uncomfortable, after having seen the census chart, "pushing that down too far." He pointed out that although the hospital was budgeted for a census of 52, there were several months in which the census averaged over 58. He agreed with Dr. Brandenburg that reducing the number too far would be an artificial and troublesome thing to do. He suggested a Letter of Intent to continue the census report as staff have recommended.

Senator Raggio asked Dr. Brandenburg whether budgeting for a census of 50 would be acceptable and Dr. Brandenburg said it would be. Senator Raggio suggested the committee reduce the budgeted census to 50, providing the opportunity for the division to approach IFC if adjustments need to be made. He emphasized he did not want there to be a limitation that would cause a problem.

Senator Raggio also stated it would be irresponsible to renovate the building for PES and then "mothball" it for the remainder of the biennium. He asked Dr. Brandenburg whether the revised cost estimate for the PES is $533,000 the first year and $752,000 the second year. Dr. Brandenburg responded that is correct. Senator Raggio recommended the committee add the PES program and pointed out there will be "some new money" as a result of the Economic Forum projections and this should be one of the high priorities on that list. He called attention to the success of the similar operation at Southern Nevada Adult Mental Health Services and said it is certainly worthy of the committee’s consideration for the north. He also recommended that, if the hospital is completed, the division approach IFC for funding for utilities.

• TO ACCEPT STAFF RECOMMENDATIONS INDICATED IN THE CLOSING SHEETS FOR THIS BUDGET,
• THAT FUNDING BE AUTHORIZED AT 50 HOSPITAL BEDS, WITH A LETTER OF INTENT TO REQUEST ADDITIONAL FUNDING IF CENSUS EXCEEDS 50 AND EXISTING RESOURCES ARE NOT OTHERWISE AVAILABLE,
• THE COMMITTEE ISSUE A LETTER OF INTENT THAT IF THE HOSPITAL BECOMES OPERATIONAL DURING THE BIENNIUM THE AGENCY REQUEST ADDITIONAL FUNDING FOR UTILITIES, AND
• THAT ADDITIONAL FUNDING BE PROVIDED FOR THE PSYCHIATRIC EMERGENCY SERVICES PROGRAM TO COME FROM A HIGH PRIORITY RANKING ON ADDITIONAL REVENUES THAT MAY BE DISCLOSED AS A RESULT OF ECONOMIC FORUM PROJECTIONS.

Mrs. Evans pointed out the committee is expecting the division to continue to report census information for all residential facilities of the division. She noted the motion includes additional funding, but also includes an adjustment from funding for 52 hospital beds to funding for 50 hospital beds.

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HR, Southern Nevada Adult Mental Health Services – Budget Page MH/MR-20 (Volume 2) Budget Account 101-3161

Mr. Guernsey directed attention to page 29 of the closing sheets (Exhibit C).

Mr. Guernsey pointed out The Executive Budget recommends an increase in decision unit M-200 of approximately $1.8 million the first year and $2.8 million the second year for caseload growth, medications, and 8.78 FTE (full-time equivalency) new positions to support the four medication clinic sites in Clark County. The increased funding for medications in this decision unit alone is $1.4 million the first year and over $2 million the second year. He noted these increases are already built into the budget.

Mr. Guernsey recommended adjustments in revenues to reflect additional billing for the existing 10-bed PES unit. He said that when the division considered adding a 10-bed PES at NMHI, division staff thoroughly reviewed and analyzed billing procedures for the PES in the south and determined additional revenues could be collected through improved billing of physician time for inpatient services. He said this has the effect of reducing the General Fund obligation by $145,000 each year.

Mr. Guernsey recommended the addition of 2 new Accountant Technicians initially requested from General Fund support, but not recommended in The Executive Budget. He said the division had requested reconsideration of these 2 new positions in prior committee meetings and indicated revenues generated from billings could support the positions. He said that with the additional demands at the clinic sites, the caseload growth, and the additional amount of billing responsibilities being placed on the agency, many of the billing positions are probably truly overworked. He suggested the committee give strong consideration to adding those 2 new positions since there is no cost to the General Fund. He noted the addition of the 2 positions is built into the recommendations in the closing sheets.

Mr. Guernsey explained that the Mojave Mental Health Program (Mojave) provides mental health services to Medicaid-eligible clients in southern Nevada and was established after the budget cuts in FY 1992 and FY 1993 to assure continuation of services to Medicaid clients. He pointed out the numbers reflecting state support for MH/MR do not include these dollars which flow directly from Medicaid to Mojave and are not included in the MH/MR Division total. He said this is additional funding the state provides for mental health services and it is anticipated to be $4.1 million this year for adults and $190,000 for children.

Mr. Guernsey said the Assembly members of the subcommittee were able to tour the Mojave facility and the comments were very favorable. Mr. Guernsey said he had also toured it a number of times in the past. He pointed out there is some thought by the Mojave Mental Health Program to expand services to northern Nevada. He explained these dollars are not captured in any way for the committee to easily track, because they are buried in the Medicaid budget. Therefore, the MH/MR division has been reporting on a quarterly basis the Mojave caseload and amounts paid to Mojave from Medicaid, so the committee will be aware of the additional money spent for mental health services in southern Nevada. Mr. Guernsey recommended the committee continue that reporting through a Letter of Intent. Also, if Mojave is giving strong consideration to expanding to the north, he recommended the Letter of Intent request that Mojave work cooperatively with MH/MR. He also recommended MH/MR and Mojave keep IFC aware of the status for possible future cost implications.

Mr. Guernsey referred to a possible move of the medication clinic located on East Sahara Boulevard. He said he has visited this full-blown clinic site and it is extremely busy and crowded. He recalled that at an earlier committee meeting the division included an item of $70,000 for remodeling. He said the division’s latest proposal on page 32 of the closing sheets (Exhibit C) removes that $70,000 for remodeling, but it still includes an additional General Fund cost of $16,000 the first year and $35,000 the second year. He said the committee may wish to ask the division for comment regarding this. He opined that with the additional billing staff and additional space in which to provide services to more clients, it might be realistic for the division to increase revenues to offset that cost. If that were the case, the clinic could be expanded at no cost to the General Fund.

Mrs. Evans asked whether Dr. Brandenburg was comfortable with the recommendation that 2 additional accounting positions be supported by increases in non-General Fund revenues. Dr. Brandenburg said he was and noted the division’s original request for the positions included the assumption the positions would be funded by nonstate revenues.

Mrs. Evans asked Dr. Brandenburg to comment on the possibility of expansion of the "Mojave model" to the north. She noted what was impressive about the Mojave Mental Health Program was the case management that occurs in dealing with the client and the program’s ability to individualize services. She pointed out no two clients are exactly alike in their needs.

Dr. Brandenburg agreed the program is an excellent model. He said one of the things the Mojave Mental Health Program does very well that he wished his staff in the north could do better is to collect Medicaid revenues. He indicated a Letter of Intent may be called for in this situation to direct the division to look into the prospects of a "Mojave model" in the north. He cautioned that if that model were to be implemented in the north, the 14 case managers at NMHI would probably be reduced by 8 or 9 state employees. If those positions were moved to the hospital and PES, he said it would minimize or eliminate the possibility of employees losing their jobs.

Dr. Brandenburg said the Letter of Intent could direct the division to determine what can be done to maximize Medicaid billings. If the division is unable to maximize that billing and is unable to provide the same level of treatment as exists in the "Mojave model," then the division would present a proposal to the Legislature at the next session to develop a "Mojave model" Medicaid program. He explained this program would be for Medicaid clients at the Nevada Mental Health Institute. The division would then primarily serve persons who are not Medicaid-eligible.

Mrs. Evans urged the committee to consider Dr. Brandenburg’s suggestion on this because it is better for the clients and more cost-effective. She said this could be done with a Letter of Intent to maximize billing and service levels while at the same time providing a roadmap for adopting the "Mojave model" in the north.

Mrs. Evans asked for the division’s comments on the East Sahara Clinic issues. Mr. Torvinen said the revenue issue is not as clear-cut for southern Nevada as it is for Rural Clinics. He pointed out the "Mojave factor" is part of that. The Mojave Mental Health Program serves approximately 85 percent of the Medicaid clients in the south. He said Medicaid is the largest revenue source for billings for outpatient services. In the south, he noted, the division’s clinics would only be getting 15 percent of the Medicaid clients. He said he would not be comfortable increasing non-General Fund revenues as much as if the clinic were serving and billing for 100 percent of the Medicaid clients.

Continuing, Mr. Torvinen added that the division "squeezed" the General Fund revenue request as much as possible before submitting the request to the Budget Division in August. He reiterated Dr. Brandenburg’s statement that the 2 accounting positions were intermingled in the M-200 decision unit but were fully supported by nonstate revenues in the agency request. He pointed out that Mr. Guernsey is proposing just over $375,000 additional nonstate revenues in this budget. However, Mr. Torvinen said, the amounts for moving the East Sahara Clinic are small and if the committee’s wish is to allow the agency to make that move, but fund it with nonstate revenues, the division will do it’s best to accomplish that.

Mr. Hettrick pointed out this budget includes 100 percent of the agency’s request for medications in decision unit M-100 and an increase over and above what the agency requested in decision unit M-200, and the committee is now discussing additional funding. He indicated concern that the needs in the Rural Clinics budget have not been funded and suggested the committee consider using some of this money for Rural Clinics.

Dr. Brandenburg indicated he understood Mr. Hettrick’s concern but said "there is one variable with Rural Clinics." He said he had been able to increase staff productivity in the northern and southern agencies. Although some rural clinics are very effective in meeting the productivity standards, he continued, there are other rural clinics that are not. He explained this is one of the reasons there are not increases in the Rural Clinics budget and he had proposed to the budget office the division improve productivity in Rural Clinics as had been done in the north and south before significantly increasing the budget. He noted he had only been able to start effectively changing productivity in Rural Clinics in the last few months and said there is no doubt Rural Clinics could be more productive. He said he would first like to maximize existing resources and exercise the option to transfer positions from less productive sites to more productive sites, such as the Douglas or Silver Springs Clinics. Once that is accomplished, he added, it would be appropriate to request additional resources.

Senator Raggio asked why the amount recommended by the Governor in decision unit M-200 is so much higher than the agency request and asked whether that money could be used elsewhere. Dr. Brandenburg responded that the additional amount is for medications, which is driven by caseload growth and increased compliance. He explained that with newer and safer medications, more clients are willing to comply with medication regimes. He added now that outpatient services are decentralized, there are very productive clinics in North Las Vegas, eastern Las Vegas, and Henderson, so the agency is serving more people.

Senator Raggio pointed out that if this budget is approved, there will be $5.3 million for medications in FY 2000 and $6.1 million in FY 2001. That is about $400,000 each year in excess of what the agency requested and he assumed the agency request included the caseload factor. Mr. Torvinen responded the original request was based on caseload information available in June 1998. By the time the Governor’s recommendation was prepared, it was clear the caseloads had been underestimated for southern Nevada and decision unit M-200 would have to be increased to meet the needs.

Mrs. Evans outlined several items to consider for the Letter of Intent. First would be to continue to have the division report quarterly to IFC concerning caseload data and Medicaid payments to Mojave Mental Health Services. Second would be to continue to have the division report to IFC concerning the utilization and effectiveness of the newer and safer medications approved by the 1997 Legislature. Third would be to have the division take steps to maximize Medicaid billing revenues and to assess the feasibility of a "Mojave model" in the north.

Mrs. Evans said the committee may want to consider authorizing additional non-General Funds to add 2 Accounting Specialists and to move the East Sahara clinic site.

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Budget Account 101-3645

Mr. Guernsey reminded the committee there was a 12-bed addition authorized by the 1997 Legislature, increasing the 36-bed facility to 48 beds. He said the construction was anticipated to be completed during the current biennium. He informed the committee that date has been pushed back and it is not likely to be completed until sometime after the start of the new fiscal year. He said the staff and operating costs were built into the current budget, but the new positions are currently "frozen" and the operating costs for FY 1999 have been reserved for reversion, since the 12 beds are not completed. He pointed out the positions and operating funds are included in the budget for the next biennium.

Mr. Guernsey recommended reductions in E-710 based on updated price information for computers and software.

Mr. Guernsey cautioned he might need to make adjustments in the budgeted amount for client meals. He explained that a single contract covers meal preparation costs for all northern MH/MR agencies and if adjustments are made in the number of meals purchased by the mental retardation program, the price per meal in this budget will be affected.

Dr. Brandenburg informed the committee he had met with the State Public Works Board, which projected that the 12-bed addition would be completed in August 1999.

Mrs. Evans asked whether there are position vacancies in this budget. Dr. Brandenburg responded there are. Mrs. Evans asked whether the vacancies were due to the hiring freeze or to other factors. Dr. Brandenburg responded they were due to both. Mrs. Evans asked how many positions are vacant. Dr. Brandenburg answered "Probably 6." Mrs. Evans asked to what the division attributed the vacancies, other than the hiring freeze. Dr. Brandenburg responded, "Required vacancy savings." Mrs. Evans asked whether the agency would be staffed and ready for the new addition. Dr. Brandenburg replied the agency would be and indicated he would need to bring the staff on board in time to get them trained for P.O.S.T. (Peace Officers Standards and Training) certification, which is required for forensic positions.

Mrs. Evans asked Dr. Brandenburg whether, with this budget, he felt secure about client and staff safety. He replied that he did, in part because of policies and procedures in place. Dr. Brandenburg also testified that if the State Public Works Board is not able to complete the addition by the projected date, he would delay the hiring of staff. Mrs. Evans expressed concern that required vacancy savings might create a situation which is unsafe. Dr. Brandenburg responded that to protect client, community, and staff safety, when positions must be left vacant to generate vacancy savings he would leave clinical positions vacant, rather than forensic positions.

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HR, Rural Clinics – Budget Page MH/MR-15 (Volume 2)

Budget Account 101-3648

Mr. Guernsey informed the committee he had requested the division to reexamine revenues in all budget accounts. He said the business manager for Rural Clinics, in conjunction with division administrative staff, reexamined revenues and identified an additional $67,302 each year. Mr. Guernsey said this has the effect of lowering the General Fund obligation by that same amount and recommended revenues be adjusted accordingly.

Mr. Guernsey recommended reductions be made in decision unit E-710 based on updated prices for computers.

Mr. Guernsey mentioned that an issue discussed extensively at the last committee meeting was the overcrowding at the Douglas Mental Health Clinic and the limitations of that facility to providing adequate levels of service to clients. He said the division has submitted information on costs to expand services and move the clinic to a larger facility, delineated on page 36 of the closing sheets (Exhibit C). He pointed out the division has identified non-General Fund revenue generated from billings for additional services that could be provided to fund the expansion and the move.

Mr. Guernsey directed attention to page 37 of the closing sheets (Exhibit C). He said that at the last meeting the committee asked the division to develop a budget proposal to add a Clinical Social Worker for support to the Silver Springs Juvenile Facility. He pointed out the cost is estimated at $60,861 the first year and $66,870 the second year and that is not built into the budget. He noted it is not known whether non-General Fund revenue could be generated for that position.

Mrs. Evans summarized the issues for this budget, which include revenue adjustments, computer cost adjustments, Douglas Mental Health Clinic expansion, and the clinical social worker in Silver Springs to support the new Silver Springs Juvenile Facility.

Mr. Dini indicated he supported the additional Clinical Social Worker position in the Silver Springs Mental Health Clinic. He explained the juvenile facility was built next door to the clinic and there is also a medical clinic in the complex. He said the two judges in Lyon and Churchill Counties indicated that if there were an additional worker at the mental health clinic it would help this juvenile facility get started. He said the juvenile facility will have social workers for their programs for children. However, there will be an increase in the number of people at the clinic, which is already too busy and has a 4-month waiting period. The mental health clinic needs the worker just to address that, but it also needs to be able to give immediate assistance for problems the juvenile facility might have on a short-term basis. Mr. Dini said the juvenile facility will be a treatment center for alcohol and drug abuse problems and it is a short-term program, but there will be times when the rural clinic will be called in to assist the juvenile facility. He declared it would be money well-spent and would help build a solid program.

Senator Raggio asked whether the juvenile facility is a county facility. Mr. Dini responded that it is. He said the state built it and five counties will operate it. Senator Raggio indicated concern regarding establishing a precedent of state employees working in a county facility. Mr. Dini responded the clinic is right next door to the juvenile center. He asked, "Why duplicate the service in case the juvenile facility needs to go to that level?" He asserted there is enough need in Silver Springs now for an additional social worker in the mental health clinic, without even considering the juvenile facility. He said that is an area with a lot of problems and the last he heard there was a 4-month wait to get an appointment. Mr. Dini added that notwithstanding the fact the juvenile center will bring some problems with it, the need is there for the additional position now. Senator Raggio said he did not disagree with that but was concerned about the precedent of putting state positions into the operation of county juvenile facilities, "because then all counties will step forward with similar requests." Mr. Dini said this person would not be placed in the Silver Springs Juvenile Facility but in the rural mental health clinic.

Mrs. Evans said she was hearing in this discussion that there is currently a backlog in the mental health clinic, and with the addition of the juvenile facility when it opens there will be additional caseload on top of that. Senator Raggio said the decision would have to rest on whether there is a demonstrated need for this position apart from the county facility. He said he was not sure he heard there was such a need and asked whether there is.

Mr. Dini clarified the division was requested to estimate the cost to fund a Clinical Social Worker for the Silver Springs Mental Health Clinic because of the increased load from the juvenile facility. Mrs. Evans asked Dr. Brandenburg whether this position would be located at the mental health clinic. Dr. Brandenburg responded it would be. Mrs. Evans said it was her understanding a mental health position is needed to reduce the existing 4-month backlog, which would be exacerbated by the addition of the juvenile facility.

Mr. Dini asked the chairman to outline the possibilities for a motion. Mrs. Evans said the key issues are the reduction of General Fund revenue to be offset by Medicaid and client charge revenue, the expansion and move of the Douglas Mental Health Clinic funded by increased billing revenues, and the addition of a clinical social worker for the Silver Springs Mental Health Clinic.

Mrs. Evans asked Dr. Brandenburg what flexibility is needed by the division to move staff around. She said the committee has heard about the mental health clinics in Silver Springs and Douglas County at this meeting and in Carson City at a prior meeting.

Dr. Brandenburg said he can move positions as long as he keeps the budget office and Legislative staff informed and he is meeting legislative intent. If a position were authorized for a specific site for a specific purpose the division would like to be able seek approval to move the position to another site or another purpose if justified. Mrs. Evans said that would be worth clarifying in a Letter of Intent from this committee. She added that, of course, the committee does not speak for the budget office. She said that from documents provided earlier by the division it can be seen there is some real "unevenness" among the rural clinics. She observed that some clinics seem to be okay and others have heavy caseloads and waiting lists. She said that providing flexibility so the division can make decisions accordingly would be a consideration for this committee. She pointed out it is very hard to budget 2 years out and project caseloads and service needs.

Dr. Brandenburg agreed and suggested the committee consider including in the Letter of Intent that the division provide quarterly reports on the waiting lists for Rural Clinics in the various sites. He said the division will be doing this anyway and it would keep the committee informed on the current waiting list and what the division is doing to manage those lists.

Mr. Dini said the Rural Clinics agency requested 18 new positions and zero positions are recommended. He asked how the budget office plans to take care of the problems in rural Nevada. Dr. Brandenburg responded that the budget office expects the division to maximize productivity, determine which sites have the highest true need, and employ the flexibility discussed to meet those needs. Mr. Dini asked Dr. Brandenburg whether he believed he could do that with the additional flexibility. Dr. Brandenburg responded that he thought he could. Mrs. Evans noted that if the agency had requested 18 new positions, it was based on some reality of need. She said the fact that there is an identified need and nothing additional is budgeted is very troubling.

Mrs. Evans reiterated that the issues for the committee to address are revenue adjustments, adjustments for computer prices, the Douglas County clinic, the social worker position at Silver Springs, and a Letter of Intent for flexibility and quarterly reports on caseloads and waiting lists.

Mr. Hettrick indicated he could support adding the social worker at the Silver Springs Clinic and asked whether that is one of the positions with which the division would exercise flexibility. In other words, he inquired, if the position is not needed in Silver Springs, could it be moved elsewhere either temporarily or permanently?

Dr. Brandenburg informed the committee this particular position was not requested by the division. He said if the position were added, he could see the division using the position at the Silver Springs Juvenile Facility, but also providing services at the Silver Springs Mental Health Clinic, the Yerington Mental Health Clinic, and throughout Lyon County. He added he could see the division using this position with flexibility.

*****

HR, Maternal Child Heath Services – Budget Page HEALTH-48 (Volume 2)

Budget Account 101-3222

Ginny Wiswell, Program Analyst, Fiscal Analysis Division, Legislative Counsel Bureau, directed attention to page 44 of the closing sheets (Exhibit C). She explained the Maternal Child Health Services (MCH) program is responsible for improving the health of families, pregnant women, infants and children. She said there are two issues to address regarding this budget.

She pointed out the adjusted base budget mistakenly included the costs associated with the expansion of dental care services for children. This was in the amount of $220,787 in each year of the biennium. She said budget amendment No. 49 was processed by the Budget Division requesting removal of the funds from the base, but without identifying how the funding would be used. The division developed three options for the committee to consider based on questions from the committee.

Ms. Wiswell explained the first option is to use the funds to offset the General Fund obligation in the MCH budget. She said the division has indicated these funds could be used as a onetime reduction to the General Fund, the only restriction being to keep the same percentage of dedication to services as required by the MCH block grant.

The second option is to redirect the funds towards a preventive dental care initiative in the MCH budget, Ms. Wiswell continued. The Health Division has indicated it would like to explore using the MCH block grant funding to provide preventive dental care services for children. The division is working with the MCH advisory committee to determine the need and, if there is a need, how best to develop that oral health initiative. The recommendation from the MCH advisory committee is expected in June 1999. The division believes the undefined oral health initiative would cost about $200,000 each year. The initiative would include approximately $100,000 for a statewide public awareness media campaign. Ms. Wiswell said if the committee has interest in pursuing this option, she recommends a Letter of Intent requiring the division to receive approval of the IFC for the expenditure plan once it is known.

Senator Rawson said there is "a serious shortfall" in meeting the dental needs of children in this state and said the idea of simply cutting out this dental program and using the money for public relations or some nondefined program is unconscionable. He said there were 2,400 children admitted to the University Medical Center last year for dental pain. He suggested the committee direct the division to contract with the University and Community College System of Nevada to specifically provide statewide dental care, "not public relations or anything else." He said one of the issues the Legislature will decide is whether to proceed with a dental school, but even if there is no dental school, there are other dental programs in the state. He pointed out there is a dental hygiene program developing at Truckee Meadows Community College, there is one in southern Nevada, there are faculty practice programs, and there is a dental bus operated through Saint Mary’s Hospital. He said the options exist to start a statewide dental care program right now and the university system could contract out the services.

Mr. Goldwater asked Senator Rawson how the dental proposal would work regarding the dental school. Senator Rawson said he would recommend the money be transferred to the Special Children’s Clinic budget with a Letter of Intent for the clinics to contract with the dental program at the University of Nevada system to see that there is dental care provided.

Senator Raggio said the problem with this may be that there are waiting lists in the Special Children’s Clinic budget for general medical services which have high priority. He said diagnostic and treatment services are "underfunded." In Las Vegas alone there are 117 children waiting, and meeting their needs would be a higher priority than redirecting the money elsewhere. He agreed with Senator Rawson that the money should not be used for advertising campaigns because the effect of those programs is not really proven.

Senator Rawson said that by picking the third option, directing the money to the Special Children’s Clinic budget and issuing a Letter of Intent to use existing or developing facilities, comprehensive care can immediately be acquired for the children involved. The Special Children’s Clinic can develop contracts with oral surgeons, for example.

Mr. Dini indicated interest in option 2 for dental care because "about 4 months ago there were only two dentists in western Nevada, both in Reno, who would accept Medicaid patients." He said Medicaid has increased the payment level since then, so more dentists may be willing to serve Medicaid patients now. He emphasized that Nevada needs to reach the people who need that care. The dental issue is a serious one and this option should be given serious consideration in this debate, Mr. Dini said.

Continuing her outlining of the options available, Ms. Wiswell explained the third option is to transfer the unobligated MCH funds to the Special Children’s Clinics budgets to address the backlog in diagnostic and treatment services. She said if this option were selected by the committee, the division has indicated the funds could be used to pay for hiring additional staff or to pay for contract services. She reminded the committee the division has also provided a longer-term solution to address the waiting lists in the clinics. She said it goes beyond the use of onetime unobligated funding.

Alex Haartz, Administrative Services Officer III, Fiscal, Services and Personnel, Health Division, Department of Human Resources, offered clarification regarding option 2 and Senator Rawson’s suggestion to use the money to pay for dental treatment services. He said the division’s suggestion was to use the funds for a preventive campaign that would include public awareness regarding proper ways to maintain oral hygiene, information on the process of referral to Nevada Medicaid programs, and the Nevada Check-Up Program. Potential messages would not necessarily be a public relations campaign. Mr. Haartz said that if it were the committee’s direction, the division would also use funding for other preventive treatment services. He said the key is that the MCH block grant funds need to focus on preventive services from a public health standpoint and the MCH block grant funds are "payment of last resort." He added MCH funds are at the end of the line when it comes to paying for treatment services.

Mr. Haartz said that, unfortunately, one of the impacts of Nevada Check-Up was that children who were not eligible for Medicaid are eligible for Nevada Check-Up. Once Nevada Check-Up went into effect, dental treatment services that the MCH funds were paying for had to be "ramped down." He noted this information has been provided to legislative fiscal staff. Essentially, he said, these dollars may not be used to pay for treatment services. He explained Nevada might be able to do something as a "demonstration and data-collection-type-project" that may allow payment for treatment services, but it would have to be examined closely regarding whether it would create a problem with block grant restrictions.

Mr. Hettrick pointed out the committee had heard testimony regarding advertising to get people to sign up for Nevada Check-Up. He suggested that if MCH block grant funds are appropriately used for advertising campaigns they could be used for the advertising campaign for Nevada Check-Up, with the General Fund money from that program then being moved to this budget for treatment services.

Mark Stevens, Assembly Fiscal Analyst, said he believed there would be a restriction upon the use of federal MCH money to match federal Title XXI dollars in the Nevada Check-Up Program.

Mr. Hettrick suggested, in that case, the MCH money be used to reduce General Fund obligations or to provide services, but not to advertise.

Senator Rawson stated the committee is "looking at the trees rather than the forest." He said a number of comments have come up that need to be addressed. He pointed out there may appear to be need to advertise for the Nevada Check-Up Program, but Nevada is limited to 10,000 children and 7,500 are already enrolled. He said it is a "nonissue" because if the Nevada Check-Up Program is advertised, "there will be 20,000 children [enrolled] tomorrow."

Senator Rawson said the committee needs to look at a comprehensive dental plan because there are "little bits of money all over the state" going out to such things as sealant programs and fluoride programs. He stated Nevada spent $13 million last year in Medicaid on dentistry and 60 percent of it went for nothing – X rays, exams and no treatment. He opined it was wasted money. He said checkups and exams are important, but Nevada did not get any services for 60 percent of that $13 million. He reiterated Nevada needs a comprehensive plan and this MCH money should be part of that plan.

Senator Rawson said if MCH restrictions require the money be used for prevention or diagnostic services, that can be worked out. As part of a comprehensive plan this $200,000 can be included in the diagnostic part of that comprehensive plan. He said if Nevada "just piece-meals this out in individual little programs," it is wasted effort and there will be no prevention and no change in the health status of children in this state. According to Senator Rawson, before money is pulled out of dentistry and other money is "scattered among little programs," Nevada needs to make decisions on a comprehensive plan and consolidate money into one budget. He said he does not know which single budget would be the best one but suggested the Medicaid budget. He recommended the committee direct all the money spent on dental services in this budget towards that comprehensive use. Senator Rawson said it would be an absolute wrong move to pull money that has been dedicated to dentistry out for another purpose, because Nevada is woefully short of covering the needs. He said he must resist very hard any attempts to pull money out of dentistry and reiterated that "it should go into a comprehensive plan."

Mrs. Evans indicated the committee would review other issues in this budget, vote on those issues alone, close that portion of the budget, and hold the issue of the three options until the committee is discussing the Special Children’s Clinic budget, when committee members can hear all the testimony and information on the Special Children’s Clinics.

Ms. Wiswell directed attention to the second issue on page 46 of the closing sheets (Exhibit C). She said that during the hearing of March 30, 1999, the committee briefly reviewed these decision units. She reminded the committee decision units M-200 and M-201 recommend three new Public Health Nutrition Specialist positions.

Ms. Wiswell said decision unit M-200 recommends a contract be converted to a classified position. She explained the position will work closely with the schools and provide support and evaluations for children with nutritional disorders. The funding source would continue to be the MCH grant, as the contract was.

Decision unit M-201 recommends 2 Public Health Nutrition Specialists. One is a contract conversion currently located in the Las Vegas clinic. The second would be located in the Reno clinic and is a new position. She said these positions would be located in the Special Children’s Clinic, but would not address the existing waiting list because they would serve a different population. These positions would serve children who have nutritional disorders, rather than children who are developmentally delayed.

Ms. Wiswell also called the committee’s attention to a potential technical adjustment that may need to be made. She explained that medical payment rates in this budget are kept the same as Medicaid payment rates. She said when the Medicaid payment rates are determined later in the month, payment rates in this budget will need to be adjusted to duplicate Medicaid rates. Mr. Goldwater asked whether this is a fee issue and whether it meets with the Governor’s approval. Senator Raggio responded it is not an issue because it is already in the budget.

*****

HR, Special Children’s Clinic – Budget Page HEALTH-54 (Volume 2)

Budget Account 101-3208

Ms. Wiswell explained the Special Children’s Clinics in Las Vegas and Reno serve as regional centers for services to families with children aged birth to 3, who have been or may be diagnosed as developmentally delayed. She said there are two primary issues for the committee’s consideration.

Ms. Wiswell said the first issue is whether to reduce the waiting lists for diagnostic and treatment services. She reminded the committee that during the January budget hearing the division provided information that funds would be made available through a reallocation of resources from the MCH budget. She said the division anticipates client caseloads in the MCH program will decrease as more children enroll in the Nevada Check-Up Program and as additional age groups become eligible for the Medicaid CHAP (Children’s Health Assistance Program). She said these anticipated reductions would free up staff resources that could be earmarked for the Special Children’s Clinics to address the waiting list.

Ms. Wiswell explained this is the option that represents the division’s long-term plan for reducing the waiting list at the clinics. She pointed out it involves an internal reallocation of resources. According to the information provided by the division, 7 of the 11 positions in the MCH budget could be transferred to this budget. According to the division’s proposal, these positions would be reclassified in accordance with the clinic needs to reduce the waiting list for diagnostic and treatment services at the Las Vegas clinic. Since the Las Vegas clinic has the most significant waiting list the division has targeted that clinic for this portion of the proposal.

Ms. Wiswell pointed out that only two of the positions identified for transfer are currently vacant and incumbents in the remaining positions do not meet the qualifications of the proposed reclassifications. The division proposes to maintain the same funding source for the positions after completion of the transfer. Those persons who are currently MCH block-grant-funded would continue to be MCH block-grant-funded. Those persons who are General-Funded would continue to be General-Funded. Therefore, she said, the proposal would be revenue-neutral, except for the additional funding necessary for the reclassifications.

Ms. Wiswell explained that to reduce the waiting list for diagnostic and treatment services at the Reno clinic, the division estimates 2.5 FTE positions would be necessary. She said the division has indicated that because of the multi-disciplinary approach to working with children, these positions would include a Child Development Specialist/Speech Pathologist, a Child Development Specialist, and a part-time Public Service Intern. She noted the division has indicated the MCH block grant funds currently used for treatment services in the medical expense category of the MCH budget could ultimately be available for transfer to the Reno clinic. As with the other proposal, the MCH block grant funds could be transferred to the clinic and used to fund the new positions. The division would propose to maintain the same source of funding for these new positions after the reallocation.

Ms. Wiswell recommended that if the committee pursued this proposal, a Letter of Intent require the division to appear before the IFC as the plan is clarified. Additionally, Ms. Wiswell said, the committee may wish to approve the transfer and reclassification of the two vacant positions from the MCH budget to this budget.

Mrs. Evans noted that as part of the long-range plan the committee could consider adding language to the General Appropriations Act to allow transfers between budget accounts.

Senator Raggio said there are 117 children on the waiting list in Las Vegas and there is a 12-week wait. He asked what that waiting list and waiting time would be reduced to if this plan were implemented. He pointed out these are children up to 3 years old who have severe developmental problems. He asked how transferring 7 positions would reduce the waiting list of 117 children from 12 weeks to 2 weeks.

Mr. Haartz responded that children wait different lengths of time depending on their treatment or diagnostic needs. Currently the waiting list to start receiving services runs from 12 to 14 weeks. He agreed that by transferring 7 positions the division is not going to be able to take 117 children off the waiting list. The division’s plan is to reclassify the transferred positions to those classifications that provide the biggest "bang for the buck" and allow the division to reduce those waiting lists by discipline. For example, with a newly classified speech pathologist, 15 children who are waiting for speech pathology services would immediately be removed from the waiting list for that discipline; with a newly classified child development specialist, 20 children who are waiting for child development services would immediately be removed from the waiting list. Mr. Haartz said the division does not believe it can get it down to zero, so there would still be a waiting list.

Senator Raggio asked how this would be done in Reno and pointed out the waiting list of 75 is not an insignificant number. Mr. Haartz agreed. He informed the committee the waiting time is not as long as in Las Vegas. Depending on discipline, he said, the wait is 2 to 6 weeks, with an average of 4 weeks. He said the longest wait would be for speech pathology services. He added the division’s priority is to address the Las Vegas situation first.

Senator Raggio said he did not understand how this plan would be a solution for the parent who is told to come back in 6 weeks, whether the family is in Reno or Las Vegas. He asked whether there is a better solution because "transferring a few positions back and forth does not impress the parent with a child sitting at home waiting for services."

Mr. Haartz responded the division was seeking a solution with available dollars which would continue to be available.

Senator Raggio asked whether transferring positions back and forth is the real solution or if the solution is adding new positions to meet the needs.

Agreeing with Senator Raggio, Mrs. Evans asked the budget office why the 20.5 new positions requested by the division were not included in The Executive Budget. She said Mr. Haartz has probably given the best answer he can from the agency perspective. Senator Raggio indicated that so far he had not gotten an answer. He said he was being told that a long-term solution was suggested to deal with this. He said he could not understand how this plan deals with the problem.

Mr. Haartz explained that under this proposal more staff would be available if two positions were transferred immediately to reduce the waiting. As additional positions become vacant they would also be transferred to further reduce the waiting list.

Senator Raggio asked whether transferring the $220,000 in MCH block grant funds in the MCH budget to this budget (Special Children’s Clinic) would add new positions to help address the waiting list. Mr. Haartz responded it would if the committee chose to direct those dollars for that purpose. Senator Raggio asked whether the 20.5 positions originally requested by the agency, but not recommended by the budget office, were intended to address the waiting list. Mr. Haartz responded that they were and said that when the budgets were developed in June and July of 1998 the division anticipated the 20.5 positions would reduce the waiting time to 2 or 3 weeks. He said it would not have taken care of future growth but would have brought the program to where it needs to be today. Senator Raggio said this problem was discussed in February and said he continues to ask questions because this plan does not satisfy the need and leaves an unacceptable wait list.

Mrs. Evans said Senator Raggio’s characterization was appropriate because the plan partially addresses, but does not solve, the problem. She asked whether the budget office was made aware of the heavy caseloads and the backlog when the positions were denied. Don Hataway, Deputy Director, Budget Division, Department of Administration, responded the reason for not funding the positions "boiled down to" available resources. He said the Department of Human Resources has caseload issues and waiting lists throughout the entire department, as well as other departments. He said it was a matter of priorities. He explained the budget office has no quarrel with the need for additional resources in this budget, but it was a matter of using available resources for the highest priorities. He noted that as additional funding may become available and if this is a high priority for the Legislature, the budget office would not oppose placing additional staff in this budget, this division, or this department.

Mr. Dini asked whether the Health Division had ever referred cases to the Scottish Rite Language Disorders Clinics and noted there are three in Nevada: one in Carson City, one at the University of Nevada, Reno and one in Las Vegas. He also asked whether the division had referred clients to the Shrine Hospital. He pointed out there is a new one in Sacramento where orthopedic and spinal cases can be treated at no cost to the parents or the state. He added transportation is also provided for the parents when the child receives services at one of those clinics. Mr. Haartz responded the Health Division does work closely with the Shriner’s organizations, tries to provide appropriate referrals, and makes sure families are aware those services are available. He said he could not speak to the question regarding the Scottish Rite Language Disorder Clinics but said he would look into the matter.

Senator Raggio indicated legislative fiscal staff are maintaining a list of items the committee designates as high-priority. He stated it is essential that a plan to reduce these waiting lists be included on that priority list. He said he did not believe additional funding could be added at this meeting, other than the transfer of block grant funds from the MCH budget. He said the Special Children’s Clinics are a high priority for him and have been for a long time. He suggested adding to the high-priority list this issue of addressing the waiting list in Las Vegas and in Reno clinics. He explained this budget can be tentatively closed, with a note to that effect.

Mrs. Evans asked the Health Division to review the originally requested 20.5 positions. She said it is highly unlikely that enough money would become available to fund that many positions. She asked for two or three options, adding positions at different increments, prioritizing the position types based on highest need. She said that will be helpful when the Economic Forum projections become available. Mr. Haartz said the Health Division will provide that information. He asked whether the 7 positions suggested to be transferred from the MCH budget would be among those 20.5 positions. Mrs. Evans said the committee needs the division to lay out the position issue so the committee can evaluate the best solutions.

Mrs. Evans directed attention to the issue brought up during discussions of the MCH budget regarding the use of the $220,000 MCH block grant funds. She asked whether the block grant money could be used for dental treatment for children and asked what the restrictions are. Senator Rawson pointed out the Special Children’s Clinic has a cranial/facial program that deals with cleft palates and so forth.

Senator Raggio said his question would be whether MCH block grant funds can be used for that purpose and if so whether that would help reduce the waiting list. He added that reducing the waiting list is the primary concern.

Mr. Haartz said MCH block grant funds cannot be used for typical dental treatment and restorative services. He added the funds can be used for services for a child with a special health care need such as a cranial/facial cleft palate condition, which falls outside the typical dental restorative treatment. Mrs. Evans asked what the level of need is for such treatment. Mr. Haartz said he did not know the number of children that would be involved. Mrs. Evans said that to decide whether to pursue this option, the committee would need to know the number of children needing this service and how much of the available money would be needed.

Mrs. Evans said that with so many unanswered questions, the committee will postpone closing the MCH budget and the Special Children’s Clinic budget until the committee can sort out these issues.

HR, Emergency Medical Services – Budget Page HEALTH-62 (Volume 2)

Budget Account 101-3235

Ms. Wiswell directed attention to page 53 of the closing sheets (Exhibit C). She explained the mission of this program is to ensure access to prompt, efficient, and appropriate ambulance transportation and medical trauma care throughout Nevada, except Clark County. She reminded the committee that issues had been identified during the March 30, 1999, hearing. Some concern was expressed over the adequacy of funds budgeted for training Emergency Medical Services (EMS) staff in the rural areas. In response to those concerns, the Health Division developed four options on how additional levels of funding could be utilized if the committee elected to approve additional funding.

Ms. Wiswell said the first option would add $20,000 over the biennium, the second option would add $40,000 over the biennium, the third option would add $80,000 over the biennium, and the fourth option included consideration for upgrading two data management systems used by the EMS program.

Ms. Wiswell explained the first option, estimated at $20,000, would allow purchase of three training mannequins for the Carson City, Elko, and Tonopah field offices. The mannequins allow training on airway maintenance, cardiac resuscitation, and intravenous (IV) access. The Health Division has worked closely with EMS advocates throughout rural Nevada and the EMS advocates have indicated this option would be acceptable.

Ms. Wiswell explained the second option, estimated at $40,000, would establish two mobile testing team units for the EMS program. They would be based in Elko and Tonopah and would travel to the rural communities on a rotating basis. Each unit would be a travel trailer, housing a variety of equipment including the training mannequin to train and evaluate skills. Each unit would cost just over $14,000. In addition to the purchase of the two units, this option would provide approximately $10,000 over the biennium for additional evaluator training. Ms. Wiswell noted EMS staff per diem and conference travel would also be provided. She indicated the EMS advocates suggested this option be modified to purchase just one mobile unit and use the remaining funds to support the EMS advisory committee. She said the EMS advocates also suggested any remaining funds could be used to supplement the training grants issued to EMS volunteers through the EMS self-supported training fund.

Ms. Wiswell explained the third option, estimated at $80,000, would establish four mobile training units, two in each year of the biennium. During the first year of the biennium, Tonopah and Elko would receive the units and during the second year, Carson City and Reno would receive units. In addition to the purchase of the four units, this option would provide $20,000 over the biennium to support evaluator training as well as staff per diem and conference travel. She said EMS advocates have indicated this option should be modified to purchase two units, using the remaining funds to support the EMS advisory board and the EMS self-supported training fund.

Ms. Wiswell explained the fourth option provides for upgrading two EMS data management systems. The first system is the licensure and certification program. She indicated this system is not Year 2000 (Y2K) compliant according to the division. She said the division indicated this system will lose functionality on all date-relational processes, which would include the ability to recognize renewal dates for certifications, licenses, and permits. The program would not have the ability to recognize dates beyond the end of this calendar year. She said an application definition study was completed in June 1998 and the Department of Information Technology (DoIT) indicated that $24,360 for additional programming would be necessary to rewrite this program and an additional $4,800 would be needed for ongoing maintenance in the second year.

Senator Raggio asked whether the approximately $24,000 for initial programming and $4,800 ongoing maintenance are already in the budget or whether it would need to be added. Ms. Wiswell said those amounts would need to be added.

Senator Raggio requested clarification that option 4 is not in lieu of the other three options but is an additional item for consideration. Ms. Wiswell affirmed that is correct.

Senator Coffin asked how many licensed personnel there are. Ms. Wiswell replied about 3,000. Senator Coffin asked, "If these systems are not Y2K-compliant, what kind of platform they are maintained on now?" Ms. Wiswell said the platform is basically a stand-alone type. Senator Coffin pointed out, "That is not very many records in today’s PC [personal computer] environment." He asked whether there is any reason this system could not just be transferred to and maintained on a good-sized PC. Mr. Haartz replied the system is currently maintained in a PC environment. He said the current software is proprietary because that was what was available. He explained the division requested DoIT study the problem, which DoIT has done. He added the estimates provided are for DoIT to provide a new system in a PC Windows environment that is Y2K-compliant and could be maintained by DoIT.

Senator Coffin asked how much the Health Division paid DoIT for the study. Mr. Haartz replied the division paid $4,111. Senator Coffin asked why the division is not able to just set up the application themselves. Mr. Haartz said the division could buy a new PC, set it up in a database, such as Microsoft Access, but someone still needs to do the programming to create the data base to transfer the data into. Mr. Hettrick indicated that based on that description, this should have cost $4,000 total, not $4,000 to study, $24,000 to set up, and $4,800 for annual maintenance.

Mr. Haartz said the study performed by DoIT addressed all the functionality issues for the EMS program. For example, at present the field offices are not networked and do not have access to information. Part of the programming was to provide that functionality to allow staff in the field offices to call up and use a record. Mr. Haartz said the estimate does not assume new hardware is needed but covers programming time based on DoIT’s recommendation. He said the $4,800 annual maintenance was recommended to meet changing needs in the future.

Mr. Hettrick asked whether the field offices currently have computers. Mr. Haartz replied they do. Mr. Hettrick suggested a method other than a full-blown network be used to transmit files. He added he believed this need can be met for a lot less money and suggested the division consider purchasing a stand-alone program purchased from a vendor. Mr. Haartz pointed out the division had searched for such a program and was unable to find one; hence, the request for DoIT to conduct a study. Mr. Hettrick said that is probably true if the division searched for a program that would allow common access to one database from all outlying districts. He said that is why he suggested changing the plan and building it for one location, then sending a copy of the file to the field offices on a regular basis. He said that although it would not provide the network, the entire system could be set up for a onetime cost of $4,800 (without the ongoing $4,800 annual maintenance costs) and accomplish the same thing.

Ms. Wiswell pointed out there was an additional data management issue. She explained the Pre-hospital Emergency Care Program is Y2K-compliant, but technical support for the proprietary program will be reduced by the vendor in the future. The division has suggested an application definition study be done by DoIT to analyze the activities. She noted the study would also explore the potential for a cooperative effort with the Trauma Institute at the University of Nevada School of Medicine to coordinate a statewide database. The division estimates approximately $4,115 would be needed to conduct that study.

Mrs. Evans asked the committee to consider the two data management issues separately from the remaining issues in this budget. She summarized the two issues to be upgrading the Licensure and Certification Program for an initial $24,360 and $4,800 for subsequent years for maintenance, and conducting a study for the Pre-hospital Emergency Care Program for $4,115.

Mr. Hettrick asked whether anyone other than DoIT was asked for a proposal to conduct the study on the Pre-hospital Emergency Care Program. Ms. Wiswell responded, "not at this time."

*****

Mr. Goldwater said the total funding requested for this budget is not a large amount of money and the program should be given what is needed. He noted it was interesting the EMS advocates would give up the mobile units for funding for the EMS advisory board.

Mrs. Evans asked the committee to first address the remaining data management question, relating to upgrading the Licensure and Certification Program. Mr. Parks said he has been told much of the current data is in some disarray and is not fully updated. This upgrade would bring the data fully into compliance with the needs of the program as well as make the system Y2K-compliant. He indicated that is part of the reason for the large cost estimate. Senator Coffin said that even if a system is made Y2K-compliant it will still be in disarray and the process of transferring to a different platform can solve many of the problems.

*****

Senator Raggio called attention to Budget Page HEALTH-62. He pointed out that The Executive Budget already includes $34,215 each year for EMS training and $15,984 each year for trauma training and suggested the budget be closed without additional funding. He pointed out that legislative action on S.B. 365 will determine whether an EMS advisory board is required.

Mr. Dini directed attention to page 53 of the closing sheets (Exhibit C), which reduces training by $21,895 and transfers $15,984 to Vital Statistics. He said the reason S.B. 365 was introduced is that the 2,500 to 3,000 volunteer firemen throughout the state have said they are unable to get the necessary training to comply with federal law. He said the division has not been able to provide the services and that is why they need to get the mobile units "out there." He pointed out if all of the emergency medical technicians (EMTs) are in Carson City for training, nobody is available for emergency services.

Mrs. Evans asked for clarification whether the adjustments in the closing sheets are for realignment only or result in actual reductions. Mr. Haartz explained modifications are outlined to segregate self-funded training. He said the purpose is to assure the self-funded training fund is used only for the intended purposes. He reminded the committee this recommendation is a result of concerns expressed at the February 11, 1999, committee hearing. He said the change does not reduce training resources.

Mrs. Evans reminded the committee that at the two previous hearings on Health Division budgets, EMS representatives testified in support of additional funding for training. She said that is why these three options have been presented at this hearing.

Senator Raggio stated he opposes the motion, "not that it is not worthwhile, but because the committee needs to draw the line somewhere." He said this issue does not rank as high as waiting lists in mental health programs and other areas, especially since the Governor has recommended training amounts above the actual expenses in FY 1998. He pointed out the actual expenses for FY 1998 for EMS training were $12,825, although the work program for FY 1998 was $44,000. He said the Governor has recommended $34,120 a year in addition to the amounts for trauma training. He said if S.B. 365 is passed, it will include an appropriation. He reiterated The Executive Budget has adequately provided for EMS training.

Mrs. Evans asked about federal funding for EMS training that may be available through the Office of Traffic Safety, Department of Motor Vehicles and Public Safety. Mr. Haartz replied that the Office of Traffic Safety has indicated there is funding available for traffic safety on an annual grant basis. He said that apparently funding was secured many years ago from the Office of Traffic Safety for this budget. He said there may be funding available for which Nevada would have to compete. Mrs. Evans asked what the application deadlines are and whether Nevada might be eligible this year. Mr. Haartz responded that a grant application would need to be submitted to the state Office of Traffic Safety by April 19, 1999. He said the Health Division met with the state Office of Traffic Safety, but there was not enough time to prepare and submit the application.

Senator Rawson informed the committee the emergency management bill provides interest from the budget stabilization fund to be used by first responders for replacement of equipment, training, and travel. He said emergency medical technicians are considered first responders. He added that starting in the year 2000 there will be up to $500,000 available, some of which could be available for EMS training.

Mrs. Evans called for separate votes on the motion that was made and seconded, first from Senate committee members and second from Assembly committee members.

*****

Mr. Dini requested clarification whether there is adequate training money available and why the EMS advocates testified more money was needed for training.

*****

Mrs. Evans adjourned the meeting at 11 a.m.

RESPECTFULLY SUBMITTED:

Jean Laird,

Committee Secretary

APPROVED BY:

Senator Raymond Rawson, Chairman

DATE:

Assemblywoman Jan Evans, Chairman

DATE: