MINUTES OF THE meeting

of the

ASSEMBLY SUBCommittee on Health and Human Services

 

Seventy-First Session

March 27, 2001

 

 

The Subcommittee on Health and Human Serviceswas called to order at 3:30 p.m., on Tuesday, March 27, 2001.  Chairman Sheila Leslie 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:

 

Ms.                     Sheila Leslie, Chairman

Ms.                     Kathy McClain

Mrs.                     Dawn Gibbons

 

STAFF MEMBERS PRESENT:

 

Marla McDade Williams, Committee Policy Analyst

Darlene Rubin, Committee Secretary

 

OTHERS PRESENT:

 

Richard Spain, Registered Technologist, Carson-Tahoe Hospital

Bill Welch, President, Nevada Hospital Association

Helen Foley, Lobbyist, PacifiCare

Yvonne Sylva, Administrator, State Health Division

Jean Irwin, Teacher for the Deaf

Janice Pine, Director of Government Affairs, Saint Mary’s Health Network

 

Chairman Sheila Leslie opened the subcommittee work session on A.B. 250.

 

Assembly Bill 250:  Requires screening of certain newborn children for hearing impairments. (BDR 40-155)

 

Ms. Leslie asked if anyone in the audience required the services of the sign language interpreter who was present; no one did.

 

Ms. Leslie said the subcommittee would work through the amendments that had been suggested at the last subcommittee hearing, as outlined on the documents “Amendments to A.B. 250 as Suggested During March 20, 2001, Subcommittee Hearing” (Exhibit C).  Testimony would not be taken unless time permitted.

 

Marla McDade Williams, Committee Policy Analyst, informed she had prepared the amendments document based on testimony that had been received before the subcommittee and the full committee had two substantive amendments; one was from Bill Welch, Nevada Hospital Association, the other was from Yvonne Sylva, Administrator, State Health Division.  The document incorporated the changes that Ms. Sylva provided to the committee so the sections that were lined out in the previous document could be seen. 

 

Ms. Williams discussed some of the key concerns:

 

• One of the primary changes was the term “newborn child” which was replaced with “newborns.” 

 

• Another suggestion was to add clarification that hospitals be certified for obstetrical services.  Ms. Williams felt the subcommittee needed to decide whether to add that amendment to the bill.

 

• Concerning infants, Mr. Welch was concerned that every time an infant was admitted to a hospital that the hospital would be required to conduct a hearing screening.  His concerns could be taken care of by the term “newborn.” 

 

• The issue of adding the definition for “obstetric center,” which was already included in Nevada Revised Statutes (NRS) 449.0155, and that was something the bill drafter could ultimately decide, however, the committee could suggest they consider adding that.

 

• There had been some discussion about the certified technologist, who actually conducted the hearing screening at the hospital, and who actually did the diagnosis.  Ms. Williams looked through the NRS and the Nevada Administrative Code (NAC) but did not find any reference to certified technologist or ear, nose, and throat specialist, discussed further on in the document.  However, the definition in Section 8 was broad enough to say that the term included a licensed audiologist, a licensed physician, or an appropriately supervised person who had documentation that demonstrated to the State Board of Health that he had completed training specifically for conducting hearing screenings of newborns.  Ultimately, the responsibility was with the State Board of Health to determine who was qualified to conduct the hearing screenings.  Further along in the document there would be discussion about who was qualified to conduct the hearing screening and who would be qualified to make the diagnosis.

 

• Public testimony also indicated that it was necessary to distinguish between the providers that were able to conduct screenings and those that were qualified to make a diagnosis of a hearing loss. 

 

• Section 10 provided the first substantive information regarding how the entire process would work.

 

• Subsection 10, No. 2(d) referred to the hospital being required to have someone on staff who would ultimately coordinate follow-up services for a newborn who had been screened for a hearing loss.  Ms. Williams presumed that the follow-up would be necessary when there had been some type of determination that the child might have a hearing loss.

 

• New language for subsection 10, No. 3 and No. 4 was adapted from the amendment by Ms. Sylva.

 

• Line 122, in the right-hand column, Mr. Welch indicated his desire that facilities only be required to report annually.  That would be language that would have to be amended into the bill, or, alternately, direct a legislative Letter of Intent to the State Board of Health expressing that preference and that it be drafted in the regulation.

 

• Subsection 10, No. 4 was renumbered as subsection 10, No. 5 to accommodate the previous changes.

 

• Section 11, a significant portion was deleted.

 

• Section 12 returned to the issue of screenings.  Committee members might consider amending that section even further than what had been suggested by Ms. Sylva.  A suggestion was to replace the term “diagnostic screening” with the term “diagnostic evaluation,” which was the term referenced in Section 4 under the definition “hearing screening.”  There was additional discussion about what “failed” actually meant.  The other consideration for that section came from Janice Pine, who suggested that providers of hearing screenings be allowed to make referrals to ear, nose, and throat specialists.             Ms. Williams felt that the State Board of Health could determine who was appropriately qualified to make the ultimate diagnosis.  At line 99, right-hand column, there was suggested language for Section 12, which would replace the three lines in Section 12 to read “If a hearing screening that is performed at a licensed hospital or a licensed obstetric center indicates that a newborn may have a hearing loss, the hospital or obstetric center shall refer the child to a provider of hearing screenings for a follow-up diagnostic evaluation.”  The definition for a provider of hearing screenings was contained in Section 8.

 

• Line 110, Mr. Welch suggested that the State Board of Health adopt a uniform brochure that contained the information required in Section 15.  Ms. Williams said if members concurred with that recommendation the bill should be amended to reflect that preference.  Suggested language started at line 117, “The State Board of Health shall be responsible for developing a brochure that used terms easily understandable to parents and legal guardians of a newborn, and that included information about the importance of screening the hearing of a newborn.  The brochure shall include a description of the normal development of the auditory processes, speech, and language in children.  A licensed hospital or licensed obstetric center shall provide this information to the parents or legal guardians of a newborn.”  That language would replace the entire Section 16.

 

• Delete all of Section 16, No. 2 and treat anyone who provided obstetric services equally, with no exceptions for any of those facilities.

 

• A suggested amendment to Section 17, described on page 4 of the document, came from Terry Pittman, Northern Nevada Center for Independent Living, which would require that parents or legal guardians of a child determined to have a permanent hearing loss be referred to a panel of professionals that included an audiologist, teacher of the deaf, other parents of children with hearing loss, a speech and language pathologist, and a representative of the deaf community.  The purpose of that referral would be to insure that parents or legal guardians of the child were fully informed of all their options concerning the habilitation of their child.  The primary consideration was that there might be some medical bias that a hearing loss could always be treated by some medical procedure, and that was what Mr. Pittman wanted to avoid in that section.  Members might consider Section 17 and inserting new language into the bill that required the State Board of Health to identify the available options for parents or legal guardians concerning the habilitation of a child with permanent hearing loss.  If members agreed to Mr. Welch’s previous suggestion concerning a brochure, that information may be able to be included in that document.

 

• The final issues concerned whether to require health insurers to pay for the hearing screenings in hospitals and licensed obstetric centers, and how to deal with privacy concerns and personally identifiable information. 

 

• If subcommittee members agreed to retain the language in the bill concerning the required coverage by health insurers, there was an amendment that was submitted by Helen Foley, representing PacifiCare.  That amendment was included on page 10 of the document (Exhibit C).  Also included was the letter from Bill Welch, on page 9 (Exhibit C), that he submitted to the subcommittee at the last hearing.

 

Chairman Leslie thanked Ms. Williams for doing a good job in putting the material together in a way that made it easier to work through.

 

• Ms. Leslie dealt first with the suggestion made by several people to amend throughout the bill the language that stated “newborn child or infant” to “newborn.”  The subcommittee members agreed that was clearer.

 

• Also on the first page, it had been discussed whether to add the definition of an obstetric center to the bill, however, it was already defined in NRS and the issue was whether to repeat it in the appropriate section or make reference to it.  Mrs. McClain and Mrs. Gibbons felt it best to make reference to it.

 

• The next issue on page 1 was clarifying whether hospitals and obstetric centers were certified for obstetrical services, and whether that should be added to the definition.  Ms. Leslie asked if it was necessary to add “certified.”  Bill Welch, Nevada Hospital Association, came forward to state that not every hospital in Nevada was licensed to provide obstetrical services.  The majority might provide a delivery in an emergent situation.  Ms. Leslie concluded the word “certified” should be added.  The other members agreed.

 

• On page 2, concerning the term “certified technologist” for people who conducted hearing screenings, Ms. Williams had said earlier that only audiologists were licensed hearing practitioners in the state.  If the members wanted to add that it would go into Section 8 under the definition of a provider of hearing screenings.  Mrs. Gibbons said she liked the way Ms. Williams had broadened the definition.  She asked if “diagnostic screening” or “diagnostic follow-up” should be defined.  Jean Irwin, a teacher of the deaf, came forward to comment that Ms. Williams’ suggestion on line 80, page 3, was to change that to “diagnostic evaluation.”  Once the screen was failed it was necessary to determine why the child had the hearing loss.  In that case a “more licensed” person would be needed, and the language in Section 8 covered anybody that the State Board of Health would approve to screen.  The diagnosis would have to be done by someone who was certified.  Ms. Irwin felt the word “evaluation” was a good choice because it delineated between screening and diagnosis.

 

Ms. Irwin next referred to page 3, Section 12, line 17, and suggested adding an “s” to “screening,” because often it was more than one screening.  Ms. Williams interjected that on page 1, at Section 4, a hearing screening was defined as: “a hearing screening means a test or battery of tests administered to determine the need for an in depth hearing diagnostic evaluation” and that would probably accommodate what Ms. Irwin said in terms of having multiple screenings.

 

Ms. Leslie said she was leaning toward leaving out the idea of the certified technologist, because the hospital made a good point at the last hearing that they needed to have some flexibility in terms of conducting the screening.  The diagnostic evaluation, she noted, was a different discussion.

 

• Regarding Section 9, Chairman Leslie asked why there were deletions.  Ms. Williams said it was decided not to treat those facilities differently.  “Obstetric center” was added to 9 (a), and that took care of all the lines through line 23.  Mrs. Gibbons wondered about line 24, where “State Board of Health” appeared, and line 55, where “Health Division” had been substituted.  Ms. Leslie said it was because the Health Division would do the report, while the State Board of Health set the regulations.

 

• Section 10, Ms. Williams stated, was to set out the responsibilities of the hospital and the obstetric center in terms of having the entire program and the providers available.  Line 46, Ms. Leslie recalled, began the language Janine Hansen, Nevada Eagle Forum, had been concerned about, but in speaking to her before the meeting Ms. Hansen said the language now covered her concerns regarding privacy.  The committee also was in agreement.

 

• Section 10, subsection 5, stated the Health Division, not the Board of Health, annually prepared the written report to the Governor, which would enable the state to keep track of Nevada’s progress.  That section also addressed Bill Welch’s concern.  Ms. Williams said it stated the Health Division’s responsibility, however, did not clearly state what the hospital’s responsibility was in getting the data to the Health Division.  What Mr. Welch preferred was that it be submitted annually.  Ultimately, the State Board of Health could adopt regulations concerning that, but the committee needed to tell them they needed to adopt the regulations.

 

            Ms. Leslie said the subcommittee might want to consider a             recommendation to the full committee to have a legislative Letter of             Intent to the State Board of Health.  Ms. Leslie then asked if anyone in             the audience cared to comment on that.  Mr. Welch stated that in Section             4, lines 51-52, inserting the word “annually” after “shall report” would             address his concern.  Ms. Leslie said that with the insertion it would not be necessary to send the Letter of Intent.  Ms. Leslie commented that      the committee would make the recommendations to the bill drafters who             would clean up the language in the best way. 

 

• Page 3, Section 11, Ms. Williams recalled there had not been too much testimony on that point.  Language suggested by Yvonne Sylva, State Health Division, essentially said no distinction would be made between newborns born at home, because there were so few, and the Health Division felt there was not a need to have language that addressed that issue.  Mrs. Gibbons asked if that covered those facilities in rural Nevada.  Ms. Leslie said it covered only those licensed facilities, not unlicensed centers that might deliver a baby in an emergency situation, which had been agreed to.

 

• Section 12 differentiated between the screening and the diagnostic evaluation. What needed to be done was to change the wording from a “follow-up diagnostic screening” to a “follow-up diagnostic evaluation.”  Ms. Williams said the new language was stated at line 100 of the document, “If a hearing screening that is performed at a licensed hospital or licensed obstetric center indicates that a newborn may have a hearing loss, the hospital or obstetric center shall refer the child to a provider of hearing screenings for a follow-up diagnostic evaluation.”

 

Richard Spain, Carson-Tahoe Hospital, questioned that change in that it sounded to him like the hearing screening would be provided by the hospital, and then any diagnostic evaluation would be done by an audiologist.  Ms. Williams said it was not limited to an audiologist but to a provider of hearing screenings that would be further defined by the State Board of Health.  Mr. Spain said after the screening had been performed the hospital conducted a diagnostic test, called a brain-stem auditory evoked response.  Thereafter, the hospital referred to an audiologist.  Ms. Leslie asked for further clarification.  Mr. Spain said the screening was done first; if the child failed, the screening was repeated.  If the child failed the screening the second time, there would be a follow-up with the diagnostic test, a brain-stem auditory evoked response.  Ms. Leslie asked if that test was commonly called a diagnostic test, or would some hospitals use that test as a screening.  Mr. Spain said that test would never be used as a screening.  He added they sometimes performed a “hearing latency curve,” which was also a diagnostic, and thereafter performed another diagnostic, checking for brain tumors and so on. If the child failed that test they were then referred to an audiologist.  Ms. Leslie asked if what he wanted was to do the same test without sending it out, but ultimately he would send out to an audiologist to do an evaluation of the actual hearing loss.  He said that was correct, and that audiologists would not be checking for brain tumors.  Ms. Leslie asked for his suggested wording.  Mr. Spain said after the hearing screening had been performed, the addition of “and other hospital-provided diagnostic tests as necessary.”

 

Ms. Williams suggested Yvonne Sylva might be able to help decide whether or not it was necessary to specify language in the NRS accommodating that, or was it something that could be left to the State Board of Health to determine.  There was some discussion about whether the suggested language was too specific in the NRS.  The intent was not to prohibit hospitals from doing those tests.  Ms. Williams suggested either doing a Letter of Intent to the State Board of Health, saying it was not the intention to prohibit the hospital from conducting a diagnostic test if it was part of their policy and procedure, or, if the subcommittee agreed, bill drafting could work out the language. 

 

Mrs. Gibbons had some question about the individual performing the testing, whether it was a technologist or certified technician.  Ms. Leslie felt that had been covered, that the audiologist was whom the referral would be made to outside the hospital.

 

Helen Foley, PacifiCare, said, for MCO coverage, once past the original screening work, anything then referred to someone outside the hospital setting must be done through the primary care physician and be referred out.  It was important not to circumvent that process.  Ms. Leslie believed that had been covered by the wording beginning on line 100, page 3, of the document, “shall refer the child to a provider of hearing screenings for a follow-up diagnostic evaluation”; that left it up to the managed care organization.  Ms. Foley said the wording was the “hospital or obstetric center shall refer,” and she would prefer it said the “insurer” could make that referral.  Ms. Williams said, as now written, it shall refer the child “to a provider of hearing screenings” had to be considered in conjunction with Section 8, which said that “a provider of hearing screenings,” followed by a list of those providers, and the final portion of that language stated “that demonstrates to the State Board of Health that he has completed training specifically for conducting hearing screenings of newborns.”  Within that process the State Board of Health would have the flexibility to allow for those types of referrals.  Ms. Foley said there were many things a hospital did with newborns that was covered in their per diem package.  Once referrals were made to outside facilities after the child left the hospital, it became a new area.  There could be professionals who performed that testing as part of the original package and continued on to do the diagnostic work, in order to clearly identify who had a problem and what it might be.  Ms. Foley agreed with Mr. Spain that once referrals were made outside the hospital it should be under the care of their managed care organization, if they had one.

 

Mr. Welch came forward to comment that neither hospitals nor obstetric centers referred patients; it was the patient’s clinician who would make the referral.  In a previous suggested amendment Mr. Welch had said “the provider of the diagnostic screening who evaluates the newborn hearing impairment would be required to refer the patient.”  In that event, it would be the primary care physician that Ms. Foley referred to, or the diagnostic service that was being contracted if not provided within the hospital.  Mr. Welch also pointed out that medical indicators drove patient care in the hospital.   Medical indicators suggested the patient, based upon a certain level of evaluated medical condition, would require something additional.  Ms. Leslie agreed that determination should be left to the medical professionals.  Ms. Williams believed it was implied within the language that some person was actually going to be conducting the hearing screening and making an ultimate recommendation that the child needed to be seen by someone else.

 

Ms. McClain asked if there was a way to refer to the primary caregiver, which meant insurance, doctor, and so on.  Mr. Spain said that at Carson-Tahoe they gathered the results from all the tests and gave them to the pediatrician who was in charge of that patient.  It was up to that pediatrician to refer them to the health care insurance, and so on.  Ms. Leslie asked how that could be accomplished.  Ms. Williams summed it up with the scenario:  A provider has screened the child and made a determination that the child needed an additional assessment.  The state could not tell the parent they had to take their child to the audiologist down the street.  It was not realistic, once the parent left the hospital they would take their child wherever they wanted, or even not take them.  The state could not force them.  Ms. Williams said perhaps the brochure the State Board of Health would develop for parents could indicate that the hospital or obstetric center shall provide information to the parents about additional diagnostic workups or testing.  The hospital or obstetric center could be required to provide the information to the parents.  Ms. Leslie wondered if Section 12 was even needed.  Ms. McClain suggested leaving out the word “refer” and use “recommend.”  She reasoned that if the facility had done the screening they could send the results to the primary care physician, who in turn could make the recommendation to the parents, the insurance company, and whomever else was in that “loop,” that the child needed further testing.  Mr. Spain agreed with that recommendation.  The hospital technologist had to report the information to the patient’s physician and at that point the hospital should be released of responsibility.  The subcommittee was in agreement. 

 

• Section 13 was basically cleanup language, based on decisions reached earlier.

 

• Section 14 had no changes.

 

• Section 15 had no changes.

 

• Section 16 was the first section that affected insurers.  Based on the testimony in the committee and in the subcommittee, Ms. Leslie suggested to the subcommittee that all insurance mandates be removed, particularly as so many HMOs covered the hearing screening, and the hospitals could be depended upon to negotiate their contracts to include insurance provision for the service.  The subcommittee agreed.  Ms. Leslie believed all insurance companies in the state should provide the coverage and she encouraged parents to look for that provision in insurance policies when making a decision.  She felt removal of the mandates would aid in helping the bill to pass.  Mrs. Gibbons added it would also help those people who did not have insurance because it would put the responsibility on the hospitals.

 

• Section 15.  Ms. Leslie felt the Health Division would be the appropriate division to do the brochure, not the Board of Health.  She was concerned about the cost of the brochure because she wanted to keep the fiscal note as minimal as possible, but she said someone needed to develop it.    Mrs. Gibbons believed the primary objective of the bill was to make sure every newborn was tested.  If a brochure had to be done, she did not know where the money would come from.  Perhaps, Mrs. Gibbons said, the brochure should be dropped for now.  Ms. Leslie said she was wavering on that as well, however, felt it was important.  She explained she had received feedback from women who had recently given birth in a Reno hospital and the issue of the hearing screen had not been handled well.  Therefore, a better job of educating new parents was needed.

 

Mrs. Gibbons felt that could be the subject of another bill, meanwhile it was best to get A.B. 250 passed.  Ms. Leslie agreed.  Mr. Welch’s concern about the brochure amendment was to make sure there was consistency in the information provided to the parents.  Instead of having the state develop such a brochure, possibly the American Speech, Language, Hearing Association, or some other association might already have a brochure on the value and benefits of the follow-up screening and studies that might be accessed through the state.  Ms. Leslie liked that suggestion.  Ms. McClain said a state agency could apply for grants from United Way, or some other organization, also.  Ms. Leslie wondered about a Letter of Intent.  She asked Yvonne Sylva to come forward to address what role the Health Division could play in the matter.

 

Ms. Sylva said it was indeed important to have consistent information, and the Health Division probably would have to pay for it, even if it could be obtained from another source.  She reported that when newborn screenings were done they did provide information.  In the Newborn Screening Program they had a brochure that was given to all new parents so they understood the purpose of the screening.  The cost of the brochure was included in the cost of the screening and paid to the State Health Division by the hospitals for the number of newborns born in those hospitals.  Ms. Leslie asked if the State Health Division was the proper division to develop the brochure.  Ms. Sylva thought there might be some organizations who would be interested in developing a brochure in a voluntary capacity, for example, March of Dimes.  There were approximately 30,000 births a year in the state so it would be an ongoing expense.  Ms. McClain felt certain the Gaudet University in the east would contribute something to the brochure effort.

 

Ms. Leslie summed up the point saying the policy issue for the committee was to determine if the brochure was an appropriate expense for the state to incur through the State Health Division to ensure that every baby in Nevada was screened.  It was, after all, the number one birth defect and perhaps March of Dimes would make a donation, if not however, should the state be responsible for producing it.  Ms. McClain felt it was the logical choice.  Mrs. Gibbons felt the brochure could be done, but she reiterated her desire to see the bill passed.  Ms. Leslie agreed with her desire, however, wanted to leave in the brochure amendment and if it had to come out later in order to get the bill passed then she would take it out.

 

• Helen Foley asked if Section 16, subsection 2, was being deleted.  Ms. Leslie said it was. 

 

• In Section 17, line 57, Mrs. Foley said she would like the words “and to an audiologist for diagnostic testing” deleted, as that could be included in the “medical management, treatment and follow-up.”  There was no objection to that.

 

• Also in Section 17, the suggested amendment that the child diagnosed as hearing impaired be seen by a panel of experts, Jean Irwin suggested in place of a panel, a second brochure be made available that described the options available to the parents.  As 4 in 1,000 newborns had a hearing impairment it would not be necessary to have as many of those brochures.   Ms. Irwin said there were many groups who already had brochures. The state would not have to develop anything.  Ms. Leslie confirmed that Ms. Irwin was not in agreement with Terry Pittman’s suggestion for having a panel; it was not practical.   Ms. Irwin said two brochures would be best.  The first would explain the necessity of newborn hearing screening; that would be available for every newborn in the state.    The second, as outlined above, explained what options were available.  Mrs. Gibbons suggested inserting the word “may” in line 117 on page 3, instead of “shall.”  Ms. Leslie wanted to leave it “shall” for the present.

 

On page 4 of the document, Terry Pittman’s suggested amendment regarding a professional panel was deemed not practical.  Ms. Leslie felt it was the role of whoever conducted the diagnostic evaluation to speak to the parents about available options.  Ms. McClain agreed, and thought whoever performed that diagnostic test might have brochures available.

 

• Janice Pine, Saint Mary’s Health Network, referred back to Section 14 and Richard Spain’s testimony about doing one or two screenings, followed by a brain-stem evoked response, which he said was never a screening but a diagnostic test.  Section 14 discussed a hearing screening including that diagnostic test.  Saint Mary’s health plan talked about those auditory brain-stem responses as being for ICN babies or babies with a medical history that would indicate a need for that level of test to be performed.  Ms. Pine said she had written down what Mr. Spain had said, because of her concern, and then noticed in Section 14 that it did include that test.  Ms. Williams interjected that Section 4 on page 1 gave a definition of a hearing screening as being “a test or battery of tests.”  With that in mind, Ms. Williams suggested deleting Section 14.

 

Ms. Leslie asked if everyone was satisfied with the amendments.  Everyone said yes.  Ms. Williams, however, asked to go over Section 15 once again.  She asked if the decision was to leave it as written, or was it amended with the new language on the right-hand column, requiring the development of a brochure.  Ms. Leslie liked the new language.

 

The subcommittee then unanimously agreed to make a recommendation to the full committee to insert the above-described amendments into A.B. 250. 

 

Ms. Leslie thanked all participants for their effort in working out the problems on that very difficult bill.  She then adjourned the meeting at 4:35 p.m.

 

RESPECTFULLY SUBMITTED:

Darlene Rubin

Committee Secretary

APPROVED BY:

                       

Assemblywoman Sheila Leslie, Chairman

DATE: