The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 3:25 p.m., on Wednesday, March 31, 1999, in Room 2135 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.

COMMITTEE MEMBERS PRESENT:

Senator Raymond D. Rawson, Chairman

Senator Maurice Washington, Vice Chairman

Senator Mark Amodei

Senator Bernice Mathews

Senator Michael Schneider

Senator Valerie Wiener

COMMITTEE MEMBERS ABSENT:

Senator Randolph J. Townsend (Excused)

GUEST LEGISLATORS PRESENT:

Assemblyman Joseph (Joe) E. Dini, Jr., Lyon County, Storey County, and Carson City Assembly District No. 38

Senator Alice Costandina (Dina) Titus, Clark County Senatorial District No. 7

STAFF MEMBERS PRESENT:

Patricia Di Domenico, Committee Secretary

OTHERS PRESENT:

Senator Bernice Mathews, Washoe County Senatorial District No. 1, stated Senate Bill 412 was a bill to help children. Senator Mathews explained that Senate Bill 412 proposes changes to the child custody laws in cases where a child’s parent is killed in an act of domestic violence. Continuing, Senator Mathews told the committee that there are rules and procedures in place in chapter 432B of the Nevada Revised Statutes, but the statutes do not provide specific directions governing when a child’s parent is killed by an act of domestic violence. She submitted her written testimony (Exhibit C) for the record. Senator Mathews introduced Janet J. Berry, District Judge, Department 1, Second Judicial District Court, and stated Judge Berry was the primary influence behind S.B. 412.

Judge Berry testified that S.B. 412 came from the Washoe County Domestic Violence Fatality Review Committee of which she is the chairperson. She said the committee’s responsibility was to autopsy domestic violence murders. Judge Berry indicated that the committee discovered a gap in the law while reviewing a domestic violence case. She explained the procedure law enforcement officers follow in a domestic violence situation where a child’s parent is murdered by the other parent. Judge Berry noted one of law enforcement’s responsibilities is to place the child. Continuing with her testimony, Judge Berry stated that at this point often a blood relative will offer to take the child and the relative is given custody of the child. She stressed there is no venue, forum, court, or agency that determines what is in the best interest of the child. Judge Berry related the results of a case where children were placed in the custody of their paternal grandparents after their father murdered their mother. She emphasized that the children were now in the custody of the parents who had raised the murderer of their mother. Judge Berry stated there was no mechanism for the children to have a voice in their placement. Concluding her remarks, Judge Berry told the committee of two other instances where children were placed in the care of individuals without a voice and the consequences of those placements.

District Judge Berry referring to the proposed amendments of S.B. 412 (Exhibit D) and the verbiage "… by the other parent …" said this would allow the natural parent who is, for example, in another state take custody of the child.

May S. Shelton, Lobbyist, Director, Social Services, Washoe County, testified that the Washoe County Social Services and Division of Child and Family Services are in support of S.B. 412.

James F. Nadeau, Lobbyist, Captain, Washoe County Sheriff’s Office, voiced support of S.B. 412. He expressed concern about hindering instead of helping the children in these situations. Captain Nadeau stated this legislation will give police officers direction in these circumstances.

Stan R. Olsen, Lobbyist, Lieutenant, Las Vegas Metropolitan Police Department, and Nevada Sheriffs & Chiefs Association, averred their support of S.B. 412.

Susan Meuschke, Lobbyist, Nevada Network Against Domestic Violence, voiced support of S.B. 412.

A letter (Exhibit E) supporting S.B. 412 was received from the attorney general’s office and distributed to the members of the Senate Committee on Human Resources and Facilities.

Chairman Rawson closed the hearing on S.B. 412 and asked the committee if the October 1, 1999, effective date of S.B. 412 was a concern. Ms. Shelton replied that Assembly Bill (A.B.) 158 addresses Nevada Revised Statutes chapter 432B and has a July 1, 1999, effective date.

Chairman Rawson queried the intent of A.B. 158. Ms. Shelton responded the bill brings the state law into conformance with the federal Adoptions and Safe Families Act.

Chairman Rawson clarified the motion S.B. 412 would be amended with the amendments presented to the committee and the effective date of July 1, 1999.

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Chairman Rawson opened the hearing and invited testimony on Senate Bill 382

Peter Barcus, Chief Executive Officer of Nathan Adelson Hospice, and President, Hospice Association of Nevada, read from prepared testimony (Exhibit F) on the benefits of hospice care. He pointed out three major points in S.B. 382 to benefit citizens:

Continuing, Mr. Barcus elaborated on each of the three points. In conclusion, he encouraged the committee to vote in favor of S.B. 382.

Chairman Rawson introduced Senator Alice Costandina (Dina) Titus, Clark County Senatorial District No. 7. Senator Titus stated hospice care is a humane and economical approach to help people at the end of their life. She urged the committee’s support of S.B. 382. Chairman Rawson asked if Medicaid coverage is permitted. Senator Titus replied in the affirmative. She stated that there had been consideration to make hospice a mandated benefit for all insurance companies at the same level that is provided through Medicaid, but because there is such an emphasis on mandated benefits at this time it was decided to just do technical revisions at this time. Senator Titus added that if in the future there is a study of benefits, hospice should be a part of that study because it will save money. Chairman Rawson concurred and said that the economic advantage to hospice should be evident without it being mandated.

Chairman Rawson questioned why the verbiage "freestanding" was included in the original Nevada Revised Statutes. Mr. Barcus opined the original facility was a freestanding structure that was used as a model when the licensing rules were developed in 1989. Senator Wiener queried how hospices presently adhere to the mandate of naming the nurse who will pronounce the death of a patient. Mr. Barcus replied there is a conflict between the Nevada Administrative Code and the Nevada Revised Statutes. He added, in February the board of health modified their language to conform to S.B. 382. Mr. Barcus indicated the mandate is not strictly followed. Chairman Rawson asked if a physician must authorize the death pronouncement within a specific period of time. Mr. Barcus responded that the nurse notifies the physician but the physician does not have to be on-site. He added, the administrative code calls for the county officer to be notified if the patient has not been seen by a physician within 10 days. Chairman Rawson asked if the reference to "nurse" in the bill meant a registered nurse. Mr. Barcus answered in the affirmative.

Janice C. Pine, Lobbyist, Saint Mary’s Health Network, testified that at the present time the Saint Mary’s Hospice of Northern Nevada does not have a facility but supports S.B. 382 for the future.

Chairman Rawson closed the hearing on S.B. 382 and opened the hearing on Senate Bill (S.B.) 365.

Senator Mark E. Amodei, Capital Senatorial District, testified that S.B. 365 was requested by Steve L. Tognoli, District Chief, Mason Valley Fire District. Senator Amodei referred to section 5, of S.B. 365 as the duties of the committee. He said the bill seeks to amend chapter 450B of the Nevada Revised Statutes (NRS). Senator Amodei stated NRS 450B.077 defines a health authority in Nevada as the county or district board of health in a population that is 400,000 or more (Clark County); for the rest of the state the health authority is the state Health Division. He added, this legislation seeks to affect the state Health Division’s jurisdiction in this area but does not seek to affect the county board of health in Clark County. Senator Amodei pointed out that on page 1 of S.B. 365, a "yes" is indicted after, "Effect on the State or on Industrial Insurance:" under fiscal note. Senator Amodei noted for the record, Caroline Ford, Assistant Dean/Director, Center for Education and Health Services Outreach, School of Medicine, University of Nevada, Reno, is in support of S.B. 365, and can assist on the fiscal note.

Joseph (Joe) E. Dini, Jr., Lyon County, Storey County, and Carson City Assembly District No. 38, testified the establishment of committee on emergency medical services (EMS) will accomplish important objectives. One, it will review and revise the Health Division regarding management and performance of emergency medical services in the state. Two, it will advise the Health Division on the following matters: policy relating to emergency care; preparation and adoption of regulations; and reviewing the budget of the Health Division as it relates to emergency medical services. Three, it will encourage the training and education of emergency medical service personnel. Assemblyman Dini emphasized the State of Nevada needs to manage emergency medical services more effectively. He urged the passage of S.B. 365 because it will help everyone in the state.

Steve L. Tognoli, District Chief, Mason Valley Fire District, gave a summation of the history of S.B. 365. He referred to proposed amendments of S.B. 365 (Exhibit G). District Chief Tognoli stated the emergency medical services committee will discuss EMS issues and make recommendations to the Health Division so that the gap between Nevada and other states will disappear as it relates to EMS. Chairman Rawson asked if Clark County was providing emergency medical services separate from the state. District Chief Tognoli answered in the affirmative. Chairman Rawson questioned if Washoe County and Reno would be under the auspices of the EMS committee. District Chief Tognoli answered in the affirmative. Chairman Rawson queried whether there was a representative from an urban group. District Chief Tognoli replied that there were representatives from all areas including Clark County, Elko, and Winnemucca. Chairman Rawson asked if there is a Clark County representative on the EMS committee. District Chief Tognoli responded that by having someone from Clark County, the committee will have an informational resource and also the communications throughout the state will remain open. Chairman Rawson asked if there was an EMS person in the Health Division. Responding to the question District Chief Tognoli said that the Department of Human Resources Health Division, Bureau of Licensure and Certification, has an EMS section.

Senator Amodei pointed out that NRS chapter 450B.830 is an extensive chapter on Emergency Medical Services. He indicated the key to S.B. 365 is to bring a priority in focus to the issues in the 16 counties that are under the jurisdiction of the Health Division. Senator Amodei reiterated that S.B. 365 establishes a committee that will address EMS issues. Chairman Rawson commented that the concept of S.B. 365 was clear but there were proposed amendments to the bill. Chairman Rawson initiated a dialog to clarify the proposed amendments (Exhibit G). Chairman Rawson asked about the fiscal note. District Chief Tognoli replied that the costs would include paying per diem for nine members of the EMS committee. He explained the approximate costs would be between $13,000 to $15,000 for nine members of the committee to attend four meetings a year. Chairman Rawson said that during the last session the emergency assistance account was created and might be a financial source to provide training to personnel related to emergency management.

Senator Amodei noted page 2, line 41 of S.B. 365 designates: "The committee shall meet at the call of the chairman at least four times each year." He indicated the number could be reduced if it was problematic. Senator Mathews commented that she had extensive experience teaching EMS. She opined that there should be a minimum of four meetings a year particularly for the rural areas. Chairman Rawson drew attention to the verbage "… at least four times a year" and explained that language will add a fiscal note to S.B. 365 but "… at the call of the chair …" leaves room to dispute whether it effectuates a fiscal note.

Chairman Rawson acknowledged the importance of replacing "fireman" with "firefighter" in the statute. He indicated that a reviser’s bill might be needed to accommodate the change.

Senator Amodei referred to page 2, line 31, and said changing the word "county" to "entity" would afford the Governor flexibility. Chairman Rawson duly noted the change. Chairman Rawson stated the Health Division will be consulted as to their position on the verbiage on page 3, line 18. Assemblyman Dini remarked that volunteers from rural areas need classes in their region instead of Reno or Las Vegas. He emphasized the necessity to train the volunteers close to their home areas. Chairman Rawson iterated the emergency assistance account might be used to provide training to personnel related to emergency management. Chairman Rawson requested Senator Amodei research the issue in the Nevada Revised Statutes.

Chairman Rawson asked if there was anyone in the audience from Clark County and if they would state their position on S.B. 365. La Rue Scull, Emergency Medical Services Coordinator, Clark County Health District, indicated support for S.B. 365 as amended.

Jim Gubbels, Vice President, Regional Emergency Medical Services Authority (REMSA), testified that REMSA supports S.B. 365 as amended. He stated a combined board can effectively have input into the EMS protocols and regulatory process.

Scott Huntley, Vice President, Nevada Emergency Medical Association (NEMA), stated he was the EMS task force chairman. He indicated that the emergency medical technicians throughout the state met this year. Mr. Huntley said in EMS there is an expression "the golden hour" which is the time a patient needs critical care. He said EMS in Nevada is at that critical level and S.B. 365 will be a start to addressing that problem. Mr. Huntley pointed out that federal regulations need to be addressed as well as the statewide structure that will provide services for communities as well as travelers.

John T. Magruder, Emergency Medical Services Coordinator, Humboldt General Hospital, testified on behalf of the hospital and EMS. He said that current administration in the EMS division solicits unofficial advice from the providers or individuals that have EMS experience. The concern of employees providing EMS service is that the expert advice might not be available in the future. Mr. Magruder stressed the need for a formal structure to share information in the future. He related a previous experience when a budgeted EMS class could not be held because the travel budget was cut and therefore no one could test the class. Mr. Madgruder stressed the need to have a budget review and the importance of the proposed amendments would benefit the providers and the community at large.

Richard Schwall, Director, Ambulance Service, Churchill Community Hospital, voiced support of S.B. 365.

William Z. Webb, Elko County Ambulance Service, testified that S.B. 365 is a start to putting the system together and having the system work for all the people of Nevada.

Guy Gansert, M.D., Washoe Medical Center, averred support of S.B. 365 as written and read a proposed amendment (Exhibit H) to S.B. 365 for the committee’s consideration. He explained EMS cannot function independently of the medical system. The medical community must agree with the care that is being provided in the pre-hospital setting. According to Dr. Gansert, the public must feel comfortable that the physicians treating them have agreed to the treatment that is being provided. Chairman Rawson commented that due to the 120-day legislative session there were tight guidelines on bill drafting and amending bills. Chairman Rawson defined the proposed amendment as establishing a separate policy for Washoe County that is not germane to the bill.

Wayne Hardwick, M.D., Washoe County Medical Society, averred support for the concept of independent medical control of all the EMS agencies in Washoe County.

Myron Gomez, M.D., Director, Trauma Services and Intensive Care, Washoe Medical Center, stated that the Washoe Medical Center is the designated trauma center for northern Nevada. He said that in order for the center to maintain its designation the state requires trauma-center and trauma-systems standards outlined by the American College of Surgeons to be maintained. Dr. Dr. Gomez stated support of re-establishing the medical control board under the Washoe County District Health Department. He explained that it would fulfill and correct the oversight deficiency, which was recognized by the American College of Surgeons in their review. Chairman Rawson asked if the Washoe Medical Center was in support of S.B. 365. Dr. Gomez answered in the affirmative.

James L. Allen, M.D., Medical Director, Regional Emergency Medical Services Authority (REMSA), voiced support of S.B. 365 with the proposed amendments from the Mason Valley Fire Department. He stated opposition to the amendment proposed by Dr. Gansert.

Discussion ensued regarding the amendment proposed by Dr. Gansert. Chairman Rawson indicated that the amendment may not fit the criteria for a single subject bill therefore it might be a moot point.

Mr. Magruder stated consistency in emergency medical care is important in a large system such as Washoe County but should be addressed as a separate issue. He opined the inclusion of this amendment to S.B. 365 could defeat the bill. Mr. Magruder stated opposition to the amendment proposed by Dr. Gansert.

Chairman Rawson closed the hearing on S.B. 365 and opened the hearing on Senate Bill (S.B.) 370.

Senator Maurice E. Washington, Washoe County Senatorial District No. 2, testified that the genesis for S.B. 370 came from looking at other state’s alternatives to providing long-term care. He said the issue of long-term care is crucial because of the increase in the elderly population of our state. Senator Washington mentioned California, Kentucky, and Illinois, among other states that have already entered into long-term care partnerships between insurance companies and the Medicaid population. Chairman Rawson noted there are two bills that address long-term studies in the current legislative session.

Chairman Rawson said because of the waiver specified in S.B. 370 the concern is with Nevada Operations Multi-Automated Data Systems (NOMADS) and not having certification. Chairman Rawson commented that depending on the outcome of the bill this issue should be part of the studies that come out of the session. Senator Washington stated that there are significant concerns about the fiscal note attached to S.B. 370. He identified expenditures as: personnel; out-of-state travel; operating equipment; information services; and restructuring NOMADS to include the Medicaid population. Senator Washington pointed out that the cost would be $1.8 million over the biennium.

Senator Washington defined the intent of S.B. 370 and provided the committee with an exhibit titled "CA Partnership for Long Term Care" (Exhibit I) for their review. Senator Rawson opined the issue is a good idea and suggested that the plans of all the states that have implemented this procedure be studied.

Myla C. Florence, Administrator, Welfare Division, Department of Human Resources, read from prepared testimony (Exhibit J), regarding changes proposed in S.B. 370 which impact the Welfare Division’s Medicaid Estate Recovery Program. She testified that to avoid conflict between the federal regulation and state statute, the Welfare Division suggests modified language as contained in the proposed amendments to S.B. 370 on page 3 of Exhibit J. Ms. Florence referred to section 1, subsection 2 of S.B. 370; on line 10, insert the verbiage "… to the extent not prohibited by federal law …" and in section 3, subsection 2, on line 31, preface the existing language with "To the extent allowed by federal law …." Ms. Florence stated a fiscal note had been prepared which reflects the impact to the Welfare Division with the new category of eligible recipients. She acknowledged that this would impact the welfare’s automated system. Ms. Florence offered to review the information Senator Washington has on the subject. She agreed that the issue is appropriate for a long-term care study coming out of the session.

Chairman Rawson asked if long-term care for state employees would be a pilot project worth exploring. Ms. Florence responded that individuals typically do not access long-term care insurance in their younger years nor is it attractive to the senior community. Chairman Rawson commented that New York Life Insurance Company quoted a premium of $230.00 per employee, per year if all state employees were enrolled. He continued, retired state employees cannot purchase a policy for $2000 to $2500; therefore, it is a way to cover individuals that have the most need of long-term care insurance. Senator Rawson noted that the cost to provide long-term care for state employees would be $56 million. Continuing he said, compared to a 1-percent wage increase, at the cost of $40 million that equates to a 1.5-percent employee benefit. Senator Wiener questioned what happens to the benefit when a long-time employee leaves state service. Chariman Rawson explained that an individual could continue the coverage on their own or sacrifice the benefit. There was general discussion on the importance of long-term care insurance and the urgency to address the issue.

Chairman Rawson closed the hearing on S.B. 370 and opened the hearing on Senate Bill (S.B.)520.

Gary E. Milliken, Lobbyist, University Medical Center, introduced Dana R. Bennett, Lobbyist, University Medical Center, and William R. Hale, Lobbyist, University Medical Center of Southern Nevada. Mr. Hale noted S.B. 520 only impacts Clark County but, if successful, could be utilized by other counties. He reported that numerous organizations have endorsed the County Organized Health System (COHS). Mr. Milliken called the committee’s attention to the report entitled, "Formation of a County Organized Health System" (Exhibit K. Original is on file in the Research Library.), and pointed out the following: section 2, highlights the success of COHS in other states; section 3, organizational charts and graphs showing how the system works; section 4, depicts the estimated costs to establish the program; and section 1, page 11, answers questions about COHS. He elucidated that their intent was to receive permission from the Legislature to obtain the necessary federal waivers to provide services under this concept and to return next session with the mechanisms to move the necessary money between the state and federal governments. Mr. Milliken said the only concern brought to his attention was from the Division of Insurance. They will be providing an amendment to exclude them from being the oversight of this program.

Chairman Rawson asked if COHS would be establishing a program for the medically needy, whether or not they were participants in Medicaid. Mr. Milliken answered in the affirmative. Chairman Rawson mentioned that an issue under consideration was the funding of a dental school that would use a component of Medicaid and Nevada Children’s Health Insurance Program to provide for indigent care. He questioned whether providing dental services were a concern of COHS. Mr. Milliken replied that, because of the dental deficiencies in Clark County, it was a concern. Chairman Rawson pointed out that this issue required further consideration.

Glen G. Arnodo, Lobbyist, Culinary Workers Union, testified that the union has a health and welfare plan with 108,000 participants. He said the union and employers jointly administer the fund, but the employers make contributions on behalf of the employees. Mr. Arnodo remarked service sector workers are at the bottom of the economic ladder including their health care. He stated dishwashers, maids and other culinary workers in the union have complete health care coverage, and commended the employers for working with the union to provide health care coverage.

Mr. Arnodo indicated that the working poor are those individuals who do not have health insurance but get medical treatment at places such as the University Medical Center (UMC). He explained that workers with no insurance testified before the Clark County Board of Commissioners and admitted not paying their medical bills because they do not have the money to do so. According to Mr. Arnodo, the one thing that is common among the working poor is that their employers do not offer affordable health insurance. He gave an example of a worker who received two paychecks for 91 hours of work, one for $0 and the other for $1.63. The reason this occurred was because this worker receives the minimum wage and his employer deducted for family health insurance. Mr. Arnodo stressed most employees in that situation will opt not to have health insurance. He explained that a study was initiated by the Clark County Board of Commissioners to determine the usage of the UMC by workers who do not have health insurance. The results revealed that $10 million a year of uncompensated care went to cover working people whose employers do not provide affordable health insurance. Mr. Arnodo pointed out that Nevada has one of the lowest unemployment rates in the country and the highest rate of uninsured workers. Ultimately, the taxpayers subsidize health care for large companies such as Wal-mart. He urged support of S.B. 520.

Timothy (Tim) Fries, Lobbyist, Nevada Nurses Association, averred support for the concept of a county organized health system and provided written text (Exhibit L). He said that as patient advocates we believe it delivers better patient care, reduces the risk to the state, and gives local discretion.

Lawrence P. Matheis, Lobbyist, Nevada State Medical Association, voiced the association’s support of S.B. 520. Providing written testimony (Exhibit M), Mr. Matheis expounded on the necessity to provide help for the "medically needy." He emphasized that S.B. 520 is the first step towards a significant expansion of the Medicaid program and its better integration with other indigent care services. He urged the Legislature and Clark County to commit to this future step. Senator Mathews asked if S.B. 520 could be a model for the state. Mr. Matheis replied if there is a commitment from Clark County then S.B. 520 will work for southern Nevada, but he opined that it was not a state approach to the problem. Continuing, he said if this program works in Clark County then a significant part of the problem would be addressed and the rest of the state would be manageable. Senator Mathews elucidated that the intent of her question was not to imply the bill should not be passed unless it addressed the entire state.

Keith Beagle, Chairman, Nevada Association of Health Plans, stated their support of the concept of a community health system. Mr. Beagle noted that one of the association’s concerns was freedom of choice. He said that based on the testimony of William R. Hale that concern might be alleviated. Mr. Beagle pointed out that Mr. Hale referred to County Organized Health System as a health maintenance organization (HMO), which requires licensure through the Division of Insurance. He remarked, if that is the case then the association urges that the same rigorous requirements of all HMOs be imposed.

Chairman Rawson closed the hearing on S.B. 520.

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Chairman Rawson inquired about the progress of the research on S.B. 365. Senator Amodei requested to defer action until Friday, April 12, 1999.

Chairman Rawson adjourned the meeting at 5:22 p.m.

RESPECTFULLY SUBMITTED:

Patricia Di Domenico,

Committee Secretary

APPROVED BY:

Senator Raymond D. Rawson, Chairman

DATE: