SENATE COMMITTEE ON COMMERCE AND LABOR

MINUTES OF THE

SENATE Committee on Commerce and Labor

Seventy-First Session

February 16, 2001

The Senate Committee on Commerce and Laborwas called to order by Chairman Randolph J. Townsend, at 8:05 a.m., on Friday, February 16, 2001, in Room 2135 of the Legislative Building, Carson City, Nevada. The meeting was video conferenced to the Grant Sawyer Office Building, Room 4412, Las Vegas, 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 Randolph J. Townsend, Chairman

Senator Ann O’Connell, Vice Chairman

Senator Dean A. Rhoads

Senator Mark Amodei

Senator Raymond C. Shaffer

Senator Michael A. (Mike) Schneider

Senator Maggie Carlton

GUEST LEGISLATORS PRESENT:

Senator Raymond (Ray) D. Rawson, Clark County Senatorial District No. 6

STAFF MEMBERS PRESENT:

Scott Young, Committee Policy Analyst

Lydia Lee, Committee Secretary

OTHERS PRESENT:

Mark Tratos, Attorney

K. Neena Laxalt, Lobbyist, Nevada Nurses Association

Donna L. Dominguez, Lobbyist, Nevada Nurses Association

Cynthia Bunch, Lobbyist, Nevada Nurses Association

Phyllis A. Suiter, Lobbyist, Advanced Practitioners of Nursing Special Practice Group of Nevada Nurses Association

Sue E. Meiner, Assistant Professor of Nursing, College of Health Sciences, Department of Nursing, University of Nevada, Las Vegas

Steven Phillips, M.D., Geriatric Care of Nevada

Keith W. Macdonald, Executive Secretary, State Board of Pharmacy

Kathy Apple, Lobbyist, Executive Director, Nevada State Board of Nursing

Sean G. Nebeker, Lobbyist, Clark County Health District

Bill M. Welch, Lobbyist, President, Nevada Hospital Association

Lawrence P. Matheis, Lobbyist, Nevada State Medical Association

Chairman Townsend opened the hearing by introducing Bill Draft Request

(BDR) 35-932.

BILL DRAFT REQUEST (BDR) 35-932: Revises provisions governing issuance ofcertain permits to occupy or encroach upon state highways or rights of way. (Later introduced as Senate Bill 195.)

Senator O’Connell moved to introduce BDR 35-932.

SENATOR shaffer SECONDED THE MOTION.

tHE MOTION CARRIED UNANIMOUSLY.

*****

Chairman Townsend opened the hearing on Senate Bill (S.B.) 45 and Senate Bill (S.B.) 50.

SENATE BILL 45: Provides remedy for dilution of marks. (BDR 52-256)

SENATE BILL 50: Revises provisions governing trade secrets. (BDR 52-257)

Chairman Townsend pointed out that S.B. 45 and S.B. 50 have been introduced due to the Senate Concurrent Resolution 19 of the Sixty-ninth Session committee findings.

SENATE CONCURRENT RESOLUTION 19: Directs Legislative Commission to conduct interim study of methods to encourage corporations and other business entities to organize and conduct business in this state. (BDR R-534)

Mark Tratos, Attorney, Las Vegas, stated these bills address unique problems in Nevada. He first addressed Senate Bill (S.B.) 45 regarding a dilution provision in the trademark laws. Mr. Tratos provided a memorandum (Exhibit C) documenting the rationale for his proposed changes to S.B. 45 and S.B 50. He noted similar dilution provisions in New York and California, as well as some other states and follows provisions in the federal Lanham Patent Act (Title 15 of the United States Code). Mr. Tratos made reference to the millions of dollars the Mirage Hotel and Casino spends annually on advertising. He added that since Nevada did not have an “anti-dilution provision,” the Mirage trademark was easily victimized. Mr. Tratos noted some instances of businesses, which were not competitive with the Mirage Hotel and Casino, benefiting from the use of the Mirage trademark. He said that Senate Bill (S.B.) 45 resembles legislation which has been enacted in California and New York as well as in the federal Lanham Patent Act. Mr. Tratos concluded by stating, S.B. 45 is intended provide protection of individual trademarks and to allow for prosecution when violations occur in Nevada.

Mr. Tratos addressed S.B. 50. He stated the various types of trade secrets, such as important formula, data lists, customer lists, supplier lists and special know-how, are protected in Nevada under the “Uniform Trade Secrets Act.” Mr. Tratos added that S.B. 50 will provide, by court order, for an injunction preventing the further dissemination on the worldwide web, and should keep the secret intact. That knowledge should be kept as “trade secrets” and not allowed to become public domain. He indicated S.B. 50 will be an encouraging factor for companies deciding to move to Nevada and will portray our state as a progressive leader by addressing the new internet trademark issues. Mr. Tratos invited questions.

Regarding S.B. 45, Senator Carlton inquired as to the actual definition of a “trademark.”

Mr. Tratos responded that Nevada’s definition, which resembles the definition contained in the federal Lanham Patent Act, “A trademark is any easily recognized word, symbol or combination of words or symbols that constitute the device by which a company identifies itself to the public.” Senator Carlton asked if that definition would also apply to organizations, such as labor unions, that have a distinctive mark.

Mr. Tratos said the same definition would indeed apply, but, he said, in Nevada a different statute applies to organizations, insignias and governmental insignias. He said, in Nevada, labor unions would be covered under the typical trademark provisions covered in S.B. 45.

Senator Carlton questioned the definition of the word “famous” and at what level the mark becomes “famous.”

Mr. Tratos responded that definition is a matter of years of case law development. He explained the way it developed in California and New York and federally under the Lanham Patent Act, on a case-by-case basis. He added that fame is hard to ascribe, but essentially it is when the court determines whether or not a mark has become so broadly recognized, if it is so inherently distinctive that when heard, people immediately identify the source of origin. Mr. Tratos related examples within the gaming industry, like MGM, Mirage or Caesar’s Palace as trademark names that would qualify as famous. He gave an example of someone opening a business called “Caesar’s Palace Shoeshine,” which the public would expect to be affiliated with, or associated with, “Caesar’s Palace,” or it would “dilute the mark.” He added that famous marks are those the court determines to have achieved “distinctiveness” or to have a “secondary meaning.”

Chairman Townsend closed the hearings on S.B. 45 and S.B. 50 and opened the hearing on S.B. 52.

SENATE BILL 52: Authorizes advanced practitioner of nursing to prescribe controlled substances under certain circumstances. (BDR 54-291)

Senator Raymond (Ray) D. Rawson, Clark County Senatorial District No. 6, started his testimony:

Good morning, Mr. Chairman and members of the Committee. My major concern, as we have worked in the Legislature, has been access to various kinds of medical care. I have brought many issues before your committee on everything from dentistry to whatever fields. The problem really developed in Nevada because we have a half million people who are not insured, and another 300,000 to 400,000 people in the rural areas, where there is difficult access to adequate medical care. We have worked very extensively to try to develop the rural networks and ways to handle many of these problems. Physician extenders see many of these people now, and it is the only way we are able to get modern health care to them. When the medical condition is serious enough, the patient must travel to areas where they can obtain more sophisticated care.

Senator Rawson continued:

We’ll never have enough physicians to extend into all these niches. It is not economically prudent for many people to set up practice in the rural areas or to treat, exclusively, indigent patients. This has led to the development of certain groups of people with limited access to medical care. The system with physician extender’s, like advanced practitioners of nursing, works well, but not as well as it could, because of some limitations of their ability to prescribe controlled substances. They are able to handle a number of medications right now, some are very dangerous medications, but we’ve always been very careful about giving the right to prescribe controlled substances, just by their name, they are “controlled.” These are drugs or medications that have the potential to be habit forming. We are very careful with those privileges. When an antidiarrheal, which may have a codeine or morphine derivative in it, that puts it into this controlled substance class, when it is needed by someone in the rural areas or one of these difficult groups to treat, they can now be seen by an advanced practitioner of nursing and need to make a trip to a physician’s office to obtain a signed prescription. It simply doesn’t work for many people. It is not just an issue of inconvenience, but many of the people in these groups simply don’t have transportation to do that for the numerous kinds of prescriptions they might need in a year, all for minor ailments or issues that could be treated well by an APN (advanced practitioner of nursing). We could go through a long list of things, cough medicines, antidiarrheals and many psychotropic medications. I think this committee is aware that over the years we’ve turned our mental health [service] into a community service type of delivery, rather than centralizing everything in the state. As those people go to the streets, being on their medication is critical. When they get off of their medication, we see them enter the criminal justice system. We see them really endanger themselves and other people. There are a lot of needs out there and the advanced practitioner of nursing is one way to extend into this group and to be able to get the care to those desperately needing it in this state. This isn’t just another encroachment on a physician’s scope of practice. I think it’s important to go into that. I’m very sensitive about protecting the practice of physicians, or dentists, or other groups of professionals. They have gone through extensive training, and have earned the right to do some of the things they do, they have very strict controls and licensure and continuing education. This is one of those issues where the advanced practitioner of nursing works with the physician. They are well trained, they are subject to protocols and in fact they work under the authorization of a physician. We are not talking about turning someone loose out there that is going to compete with a physician. The physician, in fact, bills for the services that are provided by an advanced practitioner of nursing.

Senator Rawson continued:

This is something that is really needed in our state, simply to be able to improve the flow of care that gets to people at every level of our society. I’m confident, as I have queried very carefully to see where this is heading, whether this is part of a national movement or is this part of a “we’ll get our nose under the tent first, we’ll try to do this and then next session we’ll be back for something else?” I am satisfied that this is what they want. It’s not [they are] trying to become independent practitioners that compete directly with a physician. I think as the rest of the people discuss this issue they are willing to give you the assurances of that. You all know that we can’t bind any future session of the Legislature. Yes, we could leave here today and next session a group might be back asking for extended privileges, but I think they are willing to give you assurances in writing, that speak to the legislative intent of what’s being done here. They are willing to live by that, and I’ve asked them very seriously, “As you put these kinds of things in writing, are you willing to live with this for a decade or more, because that’s what will be required of you, if you say these things?” Absolutely, they have no reservation about giving those assurances. I would just recommend your careful consideration on this. I think it is needed. I know there will be concerns. Anytime that you have large professions that feel that someone may be encroaching on them, they get very concerned, they are jeopardized by that. I have lived through those situations myself, and I understand that. I am satisfied that this is not a serious encroachment on the medical profession. It’s really an adjunct to it. Thank you. If you have questions of me, fine. There are other people, I’m sure, that would like to proceed with comments.

Senator Shaffer asked where the advanced practitioners of nursing would be performing services, whether it would be statewide or just in the rural areas of Nevada.

Senator Rawson replied that they would have statewide jurisdiction. He added that there are 26 federally identified “underserved areas.” Most of these areas or “pockets of need” are in Las Vegas, Reno, and Elko.

Senator Shaffer inquired whether a physician’s malpractice insurance coverage would also apply to an advanced practitioner of nursing who encounters a problem.

Senator Rawson stated that he did not know the answer, but that would be answered by forthcoming testifiers.

Senator Shaffer related his personal experience of having been seen by an advanced practitioner of nursing during a visit to his HMO (Health Maintenance Organization) physician’s office. He said he prefers to be seen by his physician,

especially when he is really ill and not feeling well. He asked if this is commonly the case.

Senator Rawson stated that the advanced practitioner of nursing is usually the initial care provider. He added that when a person is not responding to treatment, the advanced practitioner of nursing has an obligation to refer the patient to a physician. He said he believes that a person should have the right to request to be seen by a physician.

Senator Shaffer asked if there are limitations of how many advanced practitioners of nursing can provide services under authorization of one physician.

Senator Rawson stated he did not know if there are such limitations.

K. Neena Laxalt, Lobbyist, Nevada Nurses Association, introduced Donna L. Dominguez, Lobbyist, Nevada Nurses Association, and Cynthia Bunch, Lobbyist, Nevada Nurses Association.

Ms. Dominguez volunteered to answer several questions posed by Senator Shaffer earlier in the meeting. She assured him that advanced practitioners of nursing are required to carry their own malpractice insurance. She added that patients always have the option of seeing a physician. She also stated there is a ratio limit of three advanced nurse practitioners per one physician.

Senator Shaffer asked Ms. Dominguez if she identifies herself as being a advanced practitioner of nursing. He also asked if Ms. Dominguez has referred patients, who requested to see a physician, to a physician.

Ms. Dominguez replied that advanced practitioners of nursing are required by law to identify themselves as such, and she has on many occasions referred patients to a physician. She said it is the patient’s right to choose either care provider.

Ms. Dominguez prepared a Microsoft PowerPoint presentation for the committee. She identified materials distributed to the committee, which included: Microsoft PowerPoint presentation document (Exhibit D), a pamphlet “The Nurse Practitioner APN and Primary Care Professional” (Exhibit E), an example of a protocol (Exhibit F), and (Exhibit G. Original is on file in the Research Library), “Letters of Support BDR 291.” She explained the presentation would give the committee an idea of what advanced practitioners of nursing do, some national and state statistics and proposed bill language.

Ms. Dominguez began the Microsoft PowerPoint presentation (Exhibit D). While giving the presentation, she said advanced practitioners of nursing obtain medical histories of patients and perform physical examinations as well as diagnose acute and chronic illnesses. She added they order, perform, and interpret diagnostic tests, such as laboratory work and x-rays. Ms. Dominguez said they prescribe medications and other treatments, provide prenatal care and family planning services and provide well-child care including screening and immunizations. She continued saying advanced practitioners of nursing provide health maintenance for adults including physicals. She said advanced practitioners of nursing also promote positive health behaviors through education and counseling and they collaborate with physicians and other health care professionals.

Ms. Dominguez stated that, presently, in the United States, there are about 78,000 advanced practicing nurses. Her projections show an anticipated increase of 106,000 by 2005. All states currently allow some type of prescribing authority to advanced practicing nurses. She defined the three levels of practice in the United States. The first level is “Independent Practice,” whereby the advanced practicing nurse, conducts the practice independently without a physician. She said the second level is “Collaborative Practice.” She described it as “a synergistic alliance of the two professions, the physicians and the advanced practitioners of nursing.” She added that it brings the best of both worlds into promoting the most optimal health care for the population. This level is driven by protocols that direct patient care. She defined the third level, “Supervisory Practice,” as having a greater intensity of oversight by the physician and said it is legally more restricted. She also said the physician in this level has complete authority regarding the practice of the advanced practicing nurse.

Ms. Dominguez referenced a chart listing examples of controlled substances from Schedules 1 through 5 (Exhibit D). Schedule 1 controlled substances are the illegal drugs. Schedule 2 controlled substances have a high potential for abuse and dependence. She continued to give examples of the other three categories of controlled substance schedules as listed.

She testified that 320 APNs (advanced practitioners of nursing) are practicing in the state of Nevada, under the “Collaborative Method.” She added this method has worked well in Nevada since 1983, when APNs received prescribing authority, excluding controlled substances. She explained mandatory courses are required to receive prescribing authority. The physician and the APN must also review protocol annually. Ms. Dominguez explained further, APNs, in Nevada, are regulated by the State Board of Nursing, State Board of Pharmacy, and a collaborating physician. Ms. Dominguez stated that if this bill passes, the federal government through the United States Drug Enforcement Administration would also regulate APNs. She added that without being granted the privilege to prescribe controlled substances, they could not apply for a DEA (Drug Enforcement Administration) license.

Ms. Dominguez continued the presentation with “Proposed Bill Language” section (Exhibit D). She stated the proposed bill language would add “controlled substances” to the current prescribing authority of APNs, in chapter 632 of Nevada Revised Statutes (NRS) (Nursing), chapter 639 of Nevada RevisedStatutes (NRS) (Pharmacists and Pharmacy), and chapter 453 ofNevadaRevised Statutes(NRS) (Controlled Substances). She added that no other changes to the bill language would be requested.

Ms. Dominguez stated several reasons why the Nevada Nurses Association requests approval of S.B. 52. She acknowledged that representatives for the following associations advocate passage of S.B. 52: Nevada Nurses Association, Nevada State Board of Pharmacy, Nevada State Board of Nursing, Nevada Hospital Association, Sierra Health Services Incorporated, Nevada Association of Physician Assistants, Nevada Dental Association, Nevada Assisted Living Association, and American Association of Retired Persons. Ms. Dominguez concluded by referring to letters of support from the community (Exhibit G).

Chairman Townsend inquired how psychotropic drugs are categorized.

Ms. Dominguez answered most are in Schedule 4 or Schedule 3.

Chairman Townsend clarified the fact that APNs are currently prohibited from prescribing psychotropic drugs.

Ms. Dominguez concurred.

Senator Rhoads inquired how many of the 350 APNs in Nevada are located in the rural areas.

Ms. Dominguez offered to obtain that answer.

Kathy Apple, Lobbyist, Executive Director, Nevada State Board of Nursing, speaking from the audience, said approximately 116 APNs are located in the rural areas.

Senator Schneider asked Ms. Dominguez to describe the collaboration feature, in prescribing various medications, under S.B. 52.

Ms. Dominguez explained several scenarios depicting the APN in collaboration with a physician. She indicated that a physician is not always notified when the APN has prescribed medications which are within the previously agreed upon protocols. She said in cases where protocols do not apply the physician would indeed be involved.

Cynthia Bunch, Lobbyist, Nevada Nurses Association, indicated the Nevada Nurses Association support for passage of S.B. 52. She asked for the committee’s support for S.B. 52, stating the benefits and improved access to patient care in Nevada, with passage of the bill.

Senator O’Connell inquired how many APNs in Nevada have independent practices, and how many are associated with HMOs.

Ms. Bunch stated that currently, in Nevada, law does not permit APNs to practice independently. She added that results of a survey, conducted in Nevada, showed APNs have no desire to practice independently, and prefer a collaborative relationship with a physician.

Senator O’Connell requested clarification of the three categories of APNs in Nevada.

Ms. Dominguez clarified that the three categories are used nationwide, but Nevada recognizes only one method, “collaborative practice.”

Senator O’Connell asked if they are all associated with HMOs or if some are involved with independent physician practices.

Ms. Bunch said APNs practice in a variety of settings such as with HMO clinics, inner-city federally-funded centers, and independent physicians’ practices.

Senator O’Connell asked if any breakdowns in the numbers of APNs currently practicing in each of those venues are available.

Ms. Bunch replied that none are available.

Senator Carlton asked for clarification of the one to three ratio of physician to APN. She asked if it is part of the protocol or a voluntary standard.

Ms. Dominguez clarified the ratio is a regulation of the state Board of Medical Examiners.

Senator Carlton noted the state Board of Medical Examiners would need to enact any change to that regulation. She further clarified that an HMO could not arbitrarily decide the ratio to vary from the regulation. Senator Carlton added that, under proposed S.B. 52, the physician will still retain final option regarding prescribing authority of the APN.

Chairman Townsend revisited Senator Shaffer’s question as to how many APNs currently work for an HMO, and how many practice with an independent physician.

Ms. Dominguez answered that she does not work for an HMO. She said she works for an independent physician in a group, but she does see HMO patients there.

Chairman Townsend inquired how much time might pass, until a physician sees a patient, when a patient decides to do so.

Ms. Dominguez responded that a patient could be seen the same day, if the physician is present. She said when a physician is not available the patient must make an appointment. Ms. Dominguez added that prospective patients are given the choice to see either a physician or an APN.

Senator O’Connell questioned the difference of billing amounts for physicians’ services versus services of APNs.

Ms. Dominguez explained the billing variations, with assistance from an unidentified person in the audience. She said a physician is paid 100 percent while an APN is paid about 80 percent. She added that with Medicare, a physician is paid about 60 percent and an APN would get a lesser percentage of that. All accounts receivable go directly to the practice, not to the APN.

Phyllis A. Suiter, Lobbyist, Advanced Practitioners of Nursing Special Practice Group of Nevada Nurses Association, via video conferencing in Las Vegas, stated that many rural areas and inner-city clinics in Las Vegas are served by APNs as primary health providers. She said eight APNs are with her in support of S.B. 52. Ms. Suiter introduced Sue E. Meiner who is on the faculty at the University of Nevada, Las Vegas (UNLV).

Sue E. Meiner, Assistant Professor of Nursing, College of Health Sciences, Department of Nursing, University of Nevada, Las Vegas, via video conferencing, explained that while she has earned her doctorate degree, she is not a physician. Dr. Meiner is on faculty at the University of Nevada, Las Vegas, in the College of Health Sciences, Department of Nursing. She is chairwoman of a new program, Geriatric Nurse Practitioner Education. Dr. Meiner stated APNs, currently, must complete a master of nursing degree, and a specialty degree in a specific area of practice. She continued saying APNs gain hundreds of hours of practical experience, before being granted prescribing authority.

Steven Phillips, M.D., Geriatric Care of Nevada, added that he represents the American Geriatric Society which has 600 health care providers nationally. He stated that he has written several nationally published position statements on the role of care management, emphasizing collaborative care, by APNs and physicians, of senior citizens. He stated approval of S.B. 52 would enhance ongoing care provided by the APNs in the geriatric community.

Senator Shaffer questioned the billing if seen by a physician then an APN during same office visit.

Dr. Phillips explained the CPT (current procedural terminology) coding system only allows billing for one visit, no matter how many professionals see the patient during that encounter.

Senator Shaffer mentioned that four hospital visits were billed to him on 1 day.

Dr. Phillips clarified the Senators’ situation, in comparison to the patient visit to a physician’s office.

Keith W. Macdonald, Executive Secretary, State Board of Pharmacy, stated the board maintains public neutrality in allowing APNs to prescribe controlled substances. He explained a law exists in Nevada to allow prescriptions issued by APNs with controlled substance prescribing authority in other states to be filled here. Mr. Macdonald continued by saying Nevada statutes authorize pharmacists in other states to fill prescriptions issued by APNs practicing in Nevada, who do not have controlled-substance prescribing authority. He added that an unusual circumstance exists in Nevada in that pharmacists in Nevada are permitted to fill prescriptions issued by out-of-state APNs with controlled- substance prescribing authority, but are not permitted to fill them for Nevada- practicing APNs. He stated no problems have been identified since 1983 when Nevada APNs were originally granted prescribing authority. He added Nevada APNs are required to register with the State Board of Pharmacy per the Uniform Controlled Substance Act, Sixty-seventh Legislative Session, Nevada RevisedStatutes 453.226. He concluded stating the substance abuse task force developed the controlled substance tracking program which retrospectively tracks prescribing practices.

Kathy Apple, Lobbyist, Executive Director, State Board of Nursing, stated her support of S.B. 52. She clarified previous testimony by Ms. Dominguez regarding the various venues where Nevada APNs practice, and cited an 18-year safety record as her rationale in favor of passage of S.B. 52.

Sean G. Nebeker, Lobbyist, Clark County Health District, stated support for the passage of S.B. 52, and that it is not only a rural-Nevada issue. She pointed out the need for quality health care especially in the “at-risk” schools in Clark County. She concluded that a controlled substance would not be prescribed to a child by an APN without prior parental consent.

Senator O’Connell inquired about the method of obtaining parental permission to prescribe a controlled substance to a child.

Ms. Nebeker stated that she would obtain an answer, but added that clinic-type practices where the APN’s practices are open 1 p.m. until 7 p.m., Monday through Friday. She said it is her belief that most often a parent would accompany a child to the clinic, during those hours, simplifying the process of gaining parental consent.

Bill M. Welch, Lobbyist, President, Nevada Hospital Association, stated support of S.B. 52, saying the Nevada APNs play a very important part in providing quality care in Nevada.

Lawrence P. Matheis, Nevada State Medical Association, stated opposition of some parts of S.B. 52. He credited the APNs practicing in Nevada with improving availability of quality health care for residents. He said the Nevada State Medical Association recommends that physicians provide increased accountability for APNs prescribing controlled substances, especially those drugs included on Schedule 2. He added that protocols be put in place specifying exactly what drugs could be prescribed by APNs.

Senator Shaffer asked for clarification regarding the percent of billing amounts charged for the services of APNs.

Mr. Matheis provided justification of the amounts charged for services of the APNS. He explained the APNs are trained professionals in positive relationships with physicians. Mr. Matheis conveyed APNs are necessary to provide quality health care in the community.

Senator Shaffer acknowledged the letters of support (Exhibit G) and noted that only about 16 are members of the Nevada State Medical Association.

Senator Schneider called attention to the fact that Nevada is the only Western State that does not allow APNs to prescribe controlled substances. He asked whether the controlled-substance prescribing privilege for APNs could be written into the protocol, with the physician providing additional accountability.

Mr. Matheis agreed that privilege should be explicitly included into the practice protocol. He suggested the physician would then assume supervisory duties for APNs who prescribe controlled substances. He expressed that the Nevada State Medical Association stands by its strongly held recommendations for increasing physician accountability if S.B. 52 is passed.

Senator Shaffer asked whether there is a system for monitoring the physicians who collaborate with APNs.

Mr. Matheis stated physicians collaborating with APNs are required to identify themselves and the APNs to the state Board of Medical Examiners. He added that the protocol for their practice is also on file.

Senator Carlton requested a definition of “supervisory.” She also requested a hard copy for her future reference. She said she wants to be sure she understands the difference between “collaborative” and “supervisory” practices.

Mr. Matheis agreed to provide Senator Carlton with the printed statute regarding those definitions. He said in a supervisory relationship, the physician has a higher level of scrutiny, and requires a more direct participation both in the decision-making and the over all direction of the practice decisions. He described the collaborative relationship requires less-frequent communication and is imprecise.

Senator Carlton asked for additional clarification regarding whether supervision meant supervision of the physician, or supervision of the APN.

Mr. Matheis clarified that the physician would supervise the APN who prescribes controlled substances under the protocols.

Senator Carlton agreed to wait for printed copies of the definitions to make certain she understands them. She added she would like to talk about the problems and possible resolutions with Mr. Matheis at a later date.

Chairman Townsend summarized the differences of opinions of the language of S.B. 52, between the Nevada Nurses Association and the Nevada Board of Medical Examiners. He invited representatives of both opinions to the testifying table. He asked for clarification of which controlled-substance schedule includes “natural growth hormone.”

Mr. Matheis explained that he is a practicing physician and offered his assistance. He said “natural growth hormone” is an anabolic (steroid) drug in Schedule 3, like testosterone, for example. Mr. Matheis said he feels the physician in the supervisory role over the APN who prescribes controlled substances, is repressive and regressive. He stated it undermines the relationship between a physician and an APN. He said he believes the collaborative practice relationship to be preferable to all parties.

Chairman Townsend emphasized the importance of rapport and trust in APNs. He concluded by stating that a work session has been scheduled for next week.

The meeting was adjourned at 9:50 a.m.

RESPECTFULLY SUBMITTED:

Lydia Lee,

Committee Secretary

APPROVED BY:

Senator Randolph J. Townsend, Chairman

DATE: