MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-First Session
March 5, 2001
The Committee on Health and Human Serviceswas called to order at 1:30 p.m., on Monday, March 5, 2001. Chairman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
COMMITTEE MEMBERS PRESENT:
Mrs. Ellen Koivisto, Chairman
Ms. Kathy McClain, Vice Chairman
Ms. Sharron Angle
Ms. Merle Berman
Ms. Dawn Gibbons
Ms. Sheila Leslie
Mr. Mark Manendo
Ms. Bonnie Parnell
Ms. Debbie Smith
Ms. Sandra Tiffany
Mr. Wendell Williams
COMMITTEE MEMBERS ABSENT:
Mrs. Vivian Freeman
GUEST LEGISLATORS PRESENT:
Assemblyman Lynn Hettrick, District 39
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Darlene Rubin, Committee Secretary
OTHERS PRESENT:
Steve Smith, Carson-Tahoe Hospital
Greg McAninch, Chief of Staff, Carson-Tahoe Hospital
Tom Metcalf, Trustee, Carson-Tahoe Hospital
Jon Smith, Regional Chief Financial Officer, Nevada Rural Hospital Project
Joan S. Hall, R.N., Administrator, South Lyon Medical Center
Mary Walker, Lobbyist, Carson-Tahoe Hospital
Chairman Koivisto invited Assemblywoman Parnell to introduce her bill, A.B. 13.
Assembly Bill 13: Revises provisions governing membership of boards of hospital trustees in certain counties. (BDR 40-436)
Assemblywoman Bonnie Parnell, District 40, introduced A.B. 13 which would enable legislation to allow the Board of County Commissioners to appoint the hospital chief of staff to serve as a voting member of the hospital board of trustees. The bill affected only counties with a population of less than 100,000 and only affected public hospitals.
Assemblyman Lynn Hettrick, District 39, added his support for A.B. 13. He believed it made sense to allow those boards to be able to make some of the appointments they needed to fill vacancies.
Assemblywoman Parnell introduced several other witnesses: Tom Metcalf, Chairman, Carson-Tahoe Hospital Board of Trustees, Dr. Greg McAninch, Chief of Staff, Carson-Tahoe Hospital, and Steve Smith, Chief Executive Officer, Carson-Tahoe Hospital.
Steve Smith, CEO and Administrator at Carson-Tahoe Hospital, announced his support for A.B. 13. He pointed out several benefits of the measure. First, many times in the rural communities physicians were involved with the hospital even longer than the elected trustees on the board. Many of those trustees might have been involved with the board slightly before they were elected, but the doctors had been there for 10, 20, sometimes 30 years; they had a vested interest in the health care of that community and the success of the hospital. Many times they were not asked their opinion nor could they vote on what was best for the hospital. Mr. Smith believed the community would be better served to have, in addition to the elected officials, the chance to appoint the chief of staff as a voting member of the board of hospital trustees to make a better decision for the success of the hospital.
Chairman Koivisto asked if the board of trustees ran for election as trustees for the hospital. Mr. Smith said at the Carson-Tahoe Hospital they had six members; five ran for that position and one was appointed as a representative from the county commissioners.
Assemblywoman Leslie asked if that meant the bill called for the appointment of a seventh member, who would be the chief of staff. Mr. Smith confirmed that was correct. Mrs. Leslie asked how the chief of staff at the hospital was selected. Mr. Smith responded that the medical staff, the physicians, selected the chiefs of staff in all hospitals and it could be every year or every other year.
Dr. Greg McAninch, Chief of Staff, Carson-Tahoe Hospital, said the medical staff elected the chief of staff for a one-year term with the option to extend for one year. Mrs. Leslie asked why, in his view, it should be done. She noted Mr. Hettrick talked about filling vacancies, which she did not quite understand, and Mr. Smith talked about them bringing history and needed expertise. Dr. McAninch said the chief of staff’s ability to participate in the meeting was certainly welcomed. Also he attended all the board meetings and participated in answering questions, and provided as much information as possible from a physician and medical staff perspective. However, he did not have the opportunity to vote on any crucial matter. The medical staff, he said, was the best patient advocate in the setting and had the best understanding of medical economics relative to a learned-but-lay board.
Mrs. Leslie understood the doctors would like to have a voting seat on the board. Dr. McAninch said that was correct. She asked if other hospitals had that kind of arrangement. Mr. Smith responded that almost all hospitals that were not county or district hospitals had at least one-third to one-half of their board composed of physicians. Mrs. Leslie asked why he was not asking for that. Mr. Smith said he would like it to be one-third or one-half, but doubted it would pass. Mrs. Leslie asked if the community wanted the measure to pass. What was the impetus; was it coming from the medical community. Mr. Smith said it came from the medical staff and administration of the hospitals, but nothing from the public as yet, either in favor or opposition.
Tom Metcalf, Chairman, Board of Trustees, Carson-Tahoe Hospital, reported it was his third year as trustee and second year as chairman. Adding to what Mr. Smith and Dr. McAninch stated, it had been a unanimous decision by the board of trustees in January 2000. The move to have a voting seat on the board had been instigated by administration, the doctors, and the trustees, not one group marketing another group. The board at Carson-Tahoe was the definition of a lay board. There were five elected members throughout the different ward districts in Carson. There was also one appointed supervisor. One of the things specifically for Carson-Tahoe Hospital was that they were a six-member board. The advantage of adding a seventh member would be to help break ties. But also, because Carson City was a small community, they valued the physician’s input. As Dr. McAninch said, they were invaluable for technical advances, the medicine as delivered then and in the future, and finally patient needs. The physician was at the forefront in patient needs and their input for the hospital and how it was run was valuable. In the last ten years the number of physicians at Carson-Tahoe had increased from 60 to 165 presently. The medical community in Carson City had tripled in that same period. Mr. Metcalf said he had no opposition from the public; it was a community where people loved their doctors, ran into them in the grocery store, at the swim meets, and school plays.
Assemblywoman Gibbons asked for clarification from Marla McDade Williams, Committee Policy Analyst, regarding page 2, line 28: should the word “may” be changed to “in addition” otherwise it appeared to her as though the physician who was the chief of staff could be appointed, or could not be appointed. Ms. Williams said the inclusion of the “or” after number b., in the a., b., or c. series, gave the flexibility to choose any of the categories, they were not required to choose all of them or any of them, but had the option of choosing any of the three or all three.
Next to speak was Joan Hall, Administrator, South Line Hospital, Yerington. Ms. Hall explained the governance at her hospital was different than most rural hospitals. They were tax-supported so they had a district board who was elected, much like Mr. Smith had spoken about. South Line’s district board chose to lease the operations of the hospital to a nonprofit corporation. Therefore, they had another board who managed the governance and day-to-day operations of the hospital. In 1994, she said, Mrs. Jeanne Dini was the chairman of that board and it voted to amend their current bylaws to allow the chief of staff as a regular voting member of the board. They had done that because they saw many of the benefits mentioned by the previous witness. Without being allowed to vote, however, they did not feel empowered. Having the board made up of one-third to one-half of medical staff would be wonderful, Ms. Hall stated, except in most rural areas they had only five physicians. Most probably that would never happen.
Ms. Hall said she saw the issue as a real benefit for rural areas for recruitment and retention. It was an empowerment issue. The physicians did have patient advocacy in mind at all times, and they viewed the finances differently. She emphasized the importance of the issue.
Jon Smith, Chief Financial Officer, Nevada Rural Hospital Project, explained the group was an alliance of 11 other rural hospitals in Nevada, of which Carson-Tahoe Hospital and South Line Hospital were members. Mr. Smith echoed Ms. Hall’s sentiments. The board of the Nevada Rural Hospital Project was comprised of the 11 CEO’s who ran the facilities and membership, and when the issue came before them for a vote they were unanimously in favor of it. The number of physicians at hospitals in rural communities was as few as two up to five. It was an issue of recruitment and retention. The physicians wanted to know that their voice was being heard. As a CEO one heard their voice through the medical staff, but to enable them to have a voting membership on the hospital board would help insure that their voice was heard on a continuing basis.
Chairman Koivisto asked Ms. Hall who in Yerington had authorized a physician to be a voting member on the board. Ms. Hall said it was the governing board, all lay people. Since that had been done in 1994 they looked to the leadership the medical staff provided them.
Mrs. Koivisto asked Ms. Williams if the South Line Hospital had been able to do that, why was the legislation needed. Ms. Hall responded it was because their district board, who were the elected officials, leased the operation to another board to govern. Thus, it was not the district board who had the chief of staff on their board, it was the nonprofit governing board.
Mary Walker, representing Carson-Tahoe Hospital, presented Exhibit C, an amendment to A.B. 13. She said the original legislation was supposed to have included all rural hospitals, both the county hospitals in the rural areas as well as the district hospitals. Unfortunately, she said, she had only put that in one section of NRS 450.640. Assemblyman Dini had asked her if she was sure that met the requirements of the district hospital. She subsequently spoke to Brenda Erdoes, Legal Research, Legislative Counsel Bureau, who told her where she needed to mirror the language in the other section of NRS 450.640. The amendment would allow the physicians to be appointed on district hospitals as well as the rural county hospitals.
Ms. Walker added that in any community it was the physicians who provided the direct service to the patients while the hospitals provided the tools for the physicians to do their jobs. In rural Nevada, she explained, attracting and retaining physicians in their communities was a very difficult task. Often physicians from other areas made visits to the rural communities in order to provide health care or, more typically, the patient had to travel long distances to see a physician simply because there were no physicians in their community. That exacerbated the financial problems of rural hospitals since they were losing their patients due to the lack of physicians in their communities. Ms. Walker said the bill recognized the vital partnership hospitals shared with their community physicians. By allowing the Board of County Commissioners to appoint the chief of staff of the hospital to the board of trustees, physicians would have a greater partnership interest in the hospital. It would provide more coordination of interest and a better quality of care to the community.
Ms. Walker added that in private hospitals physicians typically made up, as Mr. Smith stated, one-third to one-half of the board of trustees. Since public hospitals were much like public enterprise where charges for service paid for the cost of the service provided, A.B. 13 would allow rural hospitals to be run more like a business. It was important, she said, for those rural hospitals to survive; several in Nevada were having severe financial difficulty often caused by the lack of physicians being attracted and retained in their communities. The bill would elevate the importance of the physicians working in the rural communities as being a full partner in the operation of the rural hospital.
Assemblywoman Leslie asked Ms. Walker to clarify the term of office for both the board of trustees and the chief of staff. There had been a discrepancy in the original bill that, if not changed, would permit someone on the board who was no longer the chief of staff. Ms. Walker said it was dependent upon the hospital, whether the chief of staff was a one or two-year term. She referenced Section 2 on page 3, regarding the vacancy, where it was stated: “An appointee shall hold office until the next following general election in the usual manner if it was an elected member, or 2. if the appointee was a physician appointed to fill the vacancy of a member appointed pursuant to the provisions of paragraph b. for the unexpired term of that member.” What would happen, Ms. Walker explained, was that if it was only one year then the board could then select the chief of staff that had been elected to fill the term if the need arose.
Mrs. Leslie asked if they could also choose not to do that, in which case that situation could arise where the physician who was the board of trustees member was no longer chief of staff. Ms. Walker said “no.” Only the chief of staff could be on the board, so if he was no longer the chief of staff he was no longer on the board. She added they had been very careful in that area because they had not wanted to have just any physician be able to be on the governing board. At Carson-Tahoe, for example, 165 physicians elected their chief of staff. Therefore, she felt it had to be a person who had standing in the physician community. Mrs. Leslie summed up that issue stating that if the chief of staff position was not renewed for the second time, they would automatically be off the board and the vacancy provision went into effect. Ms. Walker added there would be a new chief of staff, and the board could choose that physician to be on the board. Mrs. Leslie said it seemed awkward. It might be better to appoint the chief of staff for two years and be done with it. Ms. Walker said that with the above-discussed provision in the bill the hospitals might choose to do that.
Chairman Koivisto asked for questions; there were none.
ASSEMBLYWOMAN SMITH MOVED TO AMEND AND DO PASS A.B. 13.
VICE CHAIRMAN MCCLAIN SECONDED THE MOTION.
THE MOTION PASSED UNANIMOUSLY.
Chairman Koivisto said when the amendment was received Assemblywoman Parnell could introduce the bill on the floor.
Chairman Koivisto opened the hearing on A.B. 14.
Assembly Bill 14: Increases compensation of members of certain boards of hospital trustees for rural county hospitals. (BDR 40-845)
Assemblyman Lynn Hettrick, District 39, introduced A.B. 14 and explained it applied only to counties of less than 100,000. It mandated that the hospital trustees be paid an increased salary, it also applied separately to the chairman and secretary which was in the law. Under current law the sum of $60 was to be paid to the secretary and chairman for two meetings, which totaled $120 a month.
Mr. Hettrick informed the bill had been brought to him because as things became more complex there were more meetings, people devoted more and more time, and they should be compensated for those meetings. He noted the bill contained an unfunded mandate at the top of the page, but, it had also been requested by the local governments. They wanted to be able to pay the trustees more money. There were two categories: chairman and secretary and the other trustees. It allowed them to pay up to six meetings a month. In addition, Section 1 (2) (b), allowed, in addition to the salary, to provide the members with insurance just as it provided to its employees.
Assemblywoman Tiffany asked who paid the compensation. Mr. Hettrick presumed it came from the hospital, from its earnings. Ms. Tiffany clarified the hospitals wanted to offer its board members salary and benefits to attract a more desirable board. Mr. Hettrick said it was to compensate the board for the work they already did. Currently the hospital was limited to paying for only two meetings; under the bill they could pay for up to six meetings. Where previously it was $120 per month maximum, the bill raised it to $510 maximum and the per meeting rate to $85. The bill further allowed for the committee appointed by the board; sometimes they worked in subcommittees and could not be paid. Ms. Tiffany asked if that would bring them up to the standard of other boards. Mr. Hettrick said it would make them consistent with school districts and other boards.
Assemblywoman Leslie felt the real benefit was in the health insurance. She wondered about the rationale behind it and if it would really make a difference to people serving. Mr. Hettrick said the rationale was unknown to him, however he agreed it was a tremendous benefit and should attract people particularly in the smaller communities where it was difficult to get people to serve. Mrs. Leslie asked the body in general if an individual on the board would be entitled to the Consolidated Omnibus Budget Reconciliation Act (COBRA) when they left the board. The answer came back that it was a federal law. Mrs. Leslie acknowledged the hospital had made a huge commitment. Mr. Hettrick reiterated it was an attempt by the rural hospitals, at their request, to be able to attract quality people.
Assemblywoman Smith asked if the bill mandated the hospital pay for those benefits. She felt the wording meant the hospitals simply had to provide the coverage. Mr. Hettrick felt the word “provide” implied the hospital paid for it. It was enabling; they did not have to do it. Further, he felt since it was enabling there would be nothing to prohibit the hospital from saying “we’ll pay half of it, if you like.” They could negotiate with someone if they chose to. Ms. Smith said that was her point; the wording said they offered the coverage but not necessarily that the hospital would pay 100 percent of the cost. Mr. Hettrick said they could negotiate anything, and noted the wording was “may provide” so it was completely enabling, they did not have to offer it at all if they chose not to.
Assemblywoman Leslie said Mr. Hettrick’s mention of “negotiate” caught her attention, consequently, she wanted to know if the hospital would provide the same access to everybody on the board. She hoped it would not be a case where the hospital was negotiating with one person and not another. Where, she asked, did the bill state it had to be the same for everyone. Mr. Hettrick referred to line 14 of the bill, “may provide to each.” Mrs. Leslie asked if a member chose not to have it because they were covered elsewhere, they would not have to take the insurance. Mr. Hettrick said that was correct, the hospital simply had to offer the same to all.
Assemblywoman Parnell joined with Mr. Hettrick in support of A.B. 14 and acknowledged the rural counties had some special problems in getting people to serve on boards and she wanted to encourage consideration for anything that would help.
Tom Metcalf, Chairman, Board of Trustees, Carson-Tahoe Hospital, reported the bill was a joint effort of all parties involved. He brought up, by way of example, that Carson City employs 400 people. The supervisors met at two published meetings a month and were paid $18,000 a year. As chairman of the board for the hospital, Mr. Metcalf signed 950 paychecks per week and was paid $120 a month. He added the service area was not only Carson City; there were 250,000 potential patients in the gross service area. He echoed Assemblyman Hettrick and Assemblywoman Parnell that the provisions of the bill would enable the hospital to attract a wider variety of people to run for those board positions. Mr. Metcalf reported he owned a business and was not too affected by the measure as he had his own insurance, however, there were individuals to whom it might make a huge difference; such as retirees who had a wealth of knowledge and who might share some of that with the hospital. He added that the board wanted community representation; the last three elections he and two other trustees had run unopposed. He summed it up by stating that anything that could be done to attract a greater variety of quality individuals to assist the hospitals was well worth it.
Dr. Greg McAninch, Chief of Staff, Carson-Tahoe Hospital, offered support for A.B. 14. He acknowledged his service as an non-voting member of the board as a wonderful opportunity where all the members invested countless hours to serving the hospital’s needs. Accordingly, the bill was entirely appropriate and he urged the committee’s support.
Steve Smith, CEO, Carson-Tahoe Hospital, urged passage of A.B. 14. The dollar amounts were similar to what the school district’s board members received, and, regarding the insurance, as a health care provider, he wished everyone had insurance. Moreover, he asked to go on record as believing the State Assembly and Senate should have health care insurance or that option. He felt he could bring the full weight of the hospital association and the rural hospitals to support introducing that measure. He offered his support in any way.
Mrs. Leslie said she also believed that people needed health insurance and applauded his efforts in trying to get it for the board members. She noted that in the remainder of the bill, those hospital boards in counties over 100,000 would not be receiving an increase or offered coverage. She wondered if that had been addressed or if those larger counties would come before the legislature to ask for a similar measure. Mr. Smith thought the only hospital that would apply to would be University Medical Center (UMC). If they chose to do that he would wholeheartedly support it. He felt the county commissioners already had that benefit.
Jon Smith, CFO, Nevada Rural Hospital Project, and a former administrator of the hospital in Lovelock, Nevada, attested to the amount of time and effort that his board members in Lovelock spent and the lack of compensation received. The bill simply brought the smaller counties’ hospital boards up to the level of the larger counties. As with A.B. 13, A.B. 14 also received the unanimous vote of the 11 rural hospitals.
Joan Hall, Administrator, South Line Hospital, reiterated the sentiments of other speakers who urged support and passage of A.B. 14.
Mary Walker added that the stipend for rural hospitals board of trustees had been raised only once in 20 years.
Chairman Koivisto brought the bill back to the committee for action.
ASSEMBLYWOMAN GIBBONS MOVED DO PASS ON A.B. 14.
ASSEMBLYWOMAN TIFFANY SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
There being no further business before the committee, Chairman Koivisto adjourned the meeting at 2:13 p.m.
RESPECTFULLY SUBMITTED:
Darlene Rubin
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairman
DATE: