MINUTES OF THE
SENATE Committee on Commerce and Labor
Seventy-First Session
March 30, 2001
The Senate Committee on Commerce and Laborwas called to order by Chairman Randolph J. Townsend, at 7:03 a.m., on Friday, March 30, 2001, in Room 2135 of the Legislative Building, Carson City, Nevada. The meeting was video conferenced to the Grant Sawyer Office Building, Room 4406, 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 Mark Amodei
Senator Raymond C. Shaffer
Senator Michael A. (Mike) Schneider
Senator Maggie Carlton
COMMITTEE MEMBERS ABSENT:
Senator Dean A. Rhoads (Excused)
STAFF MEMBERS PRESENT:
Scott Young, Committee Policy Analyst
Laura Adler, Committee Secretary
OTHERS PRESENT:
James T. Russell, Lobbyist, Nevada State Board of Accountancy
Fred L. Hillerby, Lobbyist, Nevada Association of Health Plans, and State Board of Nursing
Marie H. Soldo, Lobbyist, Sierra Health Services
Christine Petersen, M.D., Vice President of Medical Affairs and Chief Medical Officer, Sierra Health Services Incorporated
Helen A. Foley, Lobbyist, PacifiCare Secure Horizons
H. Bard Coats, M.D., President and Chief Medical Officer, PacifiCare Secure Horizons
Robert A. Ostrovsky, Lobbyist, Nevadans for Affordable Health Care
Lawrence P. Matheis, Lobbyist, Nevada State Medical Association
Ruth Mills, President, Nevada Health Care Reform Project
Kami L. Dempsey, Lobbyist, Las Vegas Chamber of Commerce
Kimberly Everett, Associate Actuary, Division of Insurance, Department of Business and Industry
Bobbie Gang, Lobbyist, Nevada Women’s Lobby
Christine Sawyer, Registered Nurse, Service Employees International Union, Nurse Alliance, Nevada Health Care Reform Project
Matthew Sharp, Lobbyist, Nevada Trial Lawyers Association
Janice C. Pine, Lobbyist, Saint Mary’s Health Network
Norma Brown, Nurse Executive, Saint Mary’s Health Network
Kathy Apple, Lobbyist, Nevada State Board of Nursing
Jon L. Sasser, Lobbyist, Washoe County Senior Law Project
Ruth Paxton, President, National Alliance for the Mentally Ill
James L. Wadhams, Lobbyist, Nevada Hospital Association
Bill M. Welch, Lobbyist, Nevada Hospital Association
Doreen Begley, Lobbyist, Nevada Hospital Association
Robin Keith, Lobbyist, Nevada Rural Hospital Project Foundation
Theresa Morrow, Registered Nurse
Carin R. Franklin, Lobbyist, Operating Engineers Local 3
Richard Schlegel, Executive Director, Nevada Nurses Association
Danny L. Burress, D.C., Concerned Citizen
Gwen Barkman, Concerned Citizen
Terri Lynn Van Ostrand, D.D.S., Concerned Citizen
Kathy Stone, Concerned Citizen
Mickie Enniss, Concerned Citizen
Kim Paulsen, Concerned Citizen
Bill J. Bailey, D.C., Secretary, Chiropractic Physicians’ Board of Nevada,
Michael D. Kirk, D.V.M., Concerned Citizen
Beverly Willard, Nevada State Board of Veterinary Medical Examiners
Chris Ferrari, Representing Nevada Chiropractic Association
Senator Townsend opened the meeting asking for a motion to suspend the 3-day agenda-posting rule to accommodate only the Assembly bill on divestiture. He explained this would speed the process of divestiture because of the impending sale.
SENATOR AMODEI MOVED TO SUSPEND THE THREE-DAY AGENDA POSTING RULE WITH REGARD TO THE ANTICIPATED ASSEMBLY BILL ON UTILITY DIVESTITURE.
SENATOR O’CONNELL SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR RHOADS WAS ABSENT FOR THE VOTE.)
*****
Senator Townsend opened the hearing on Senate Bill (S.B.) 512.
SENATE BILL 512: Revises provisions relating to accountants. (BDR 54-1208)
Senator Amodei disclosed, as of February 5, 2001, Todd Russell became a partner in the law firm in which Senator Amodei is an attorney.
James T. Russell, Lobbyist, Nevada State Board of Accountancy, stated S.B. 512 is a housekeeping bill. He said section 1 allows the board to proctor out-of-state candidates for the Certified Public Accountant (CPA) examination. He commented, these candidates are merely coming to Nevada to take the examination, not to be licensed in Nevada. He said section 2 allows greater discretion for the board in granting reciprocity licenses. He noted section 3 had an unintended language change and he offered an amendment to clarify the wording. He said that section sets the fee for a fictitious name filing as a one-time fee. He continued, section 4 also has an unintended language change and wanted clarification so the 30-day license renewal period is understood. Finally, he said, under section 5, a license could be revoked after 60 days if the applicant has not submitted a new licensing application. He added it also allows the board to discipline those who cheat on the certified public accountant (CPA) examination.
Senator Townsend closed the hearing on S.B. 512 and opened the hearing on S.B. 320.
SENATE BILL 320: Requires managed care organizations to establish system for independent review of final adverse determinations of medical necessity. (BDR 57-676)
Senator O'Connell expressed her thanks to Fred Hillerby and Marie Soldo for all their work on the bill. She voiced her thanks to Assemblywoman Barbara E. Buckley, Clark County Assembly District No. 8, who has a similar bill in the Assembly. She emphasized the bill is important to patients’ rights, and in case of family catastrophes. She explained the bill requires all state regulated insurers, health maintenance organizations, and health benefit plans adopt binding independent review programs allowing patients to challenge health plan coverage decisions based on medical necessities. She noted this type of legislation has been adopted in more than 39 states and the District of Columbia, and she said she understood, nationally, this would be a part of the movement.
Fred L. Hillerby, Lobbyist, Nevada Association of Health Plans, stated he also wanted to acknowledge another person who worked hard on the bill, Jack Kim. Mr. Hillerby explained, section 6 of S.B. 320 has a new fee of $250. He emphasized, section 7 was the most important part of the bill, and explained it defines what the external organization has to do to be certified by the insurance commissioner, including conflict of interest guidelines. He added, to avoid confusion, this bill reflects the criteria of national organizations. He elucidated sections 11-18 is the process by which this patients’ bill of rights will be implemented into all the various health plans in Nevada. He recognized other sections in the bill as providing definitions. He emphasized, section 25 explains the managed care companies must enter into contracts with at least two managed care organizations. He said other sections describe the patients’ options and the timeframe when requesting reviews. Additionally, it requires managed care organizations have in place an external review process.
Senator Shaffer queried as to the makeup of the external review panel. Mr. Hillerby answered, typically they use what is termed “centers of excellence,” such as, Johns Hopkins Medical Institutions, Massachusetts General Hospital, the Mayo Clinic, and others “with people who have incredible credentials in their fields.”
Senator Carlton wanted to know if there was anyone to whom the program in this bill would not apply. Mr. Hillerby stated, unfortunately, there is. He elucidated it would not apply to self-funded programs qualified under the Employee Retirement Income Security Act (ERISA) or under the Taft-Hartley Labor Act (1947, U.S. Code: Title 29, Chapter 7), and the labor unions. He added, the hope is when the federal law passes, these exceptions will also qualify.
Marie H. Soldo, Lobbyist, Sierra Health Services, stated she supported S.B. 320. She said the bill is the final piece to complete the Patient’s Bill of Rights which passed in 1997.
Christine Petersen, M.D., Vice President of Medical Affairs and Chief Medical Officer, Sierra Health Services, stated she is in support of the bill and the process it fosters. She emphasized when something is sent out for review, they actually receive a biography of the person doing the reviewing. The reviewers also sign a conflict of interest statement on every case they review, and a support documentation is supplied along with the review. Dr. Petersen pointed out, generally, the cases being reviewed are very serious, very rare, and unusual. Review of these cases is done on a rotation basis. She stated from experience, she is very supportive of the external review process. She thinks it is very valuable for the patients, it is efficient, effective, independent of the health plan and the provider, it provides clinical expertise not always available in other formats, and above all, it protects the health of the patient.
Helen A. Foley, Lobbyist, PacifiCare Secure Horizons, stated S.B. 320 is the final piece to the patient protection act, which is vitally important.
H. Bard Coats, M.D., President and Chief Medical Officer, PacifiCare Secure Horizons, stated PacifiCare serves over 68,000 enrollees throughout Nevada. He said the parent company, PacifiCare Health Systems, serves over 4 million members in eight states. He said he supports the bill because it offers patients a fair process, and consistency in the process, as well as, access to independent experts. He added they have been using external review for the past 8 years, and have a lot of experience with it, and he thinks it works to the benefit of all involved. He continued, PacificCare pays a per-case fee for their commercial cases to the contracted review company, and the health plan pays no part of the fee. Dr. Coats commented on the pitfalls of not having consistent external review when dealing within a framework of coordinating managed care, especially when legal action is taken, because time delays can interfere with the quality of a patient’s care.
Senator Shaffer noted the examples were all in support of decisions made by the health care provider. He queried if this was a rubber-stamp review process.
Mr. Hillerby responded, in one example, the provider denied a liver transplant because the patient had two types of hepatitis, but the external review said to give the patient the liver, and the provider did. He noted the process has been about 50/50.
Dr. Christensen confirmed the 50/50 ratio is about right regarding the external review process.
Dr. Coats stated the external review process has reversed the providers’ decisions a number of times, and has also provided insight into alternatives not originally considered for the patient.
Mr. Hillerby agreed with Dr. Coats this method is a preferred alternative to litigation, but the external review process is binding only on the health plan, the patient still has the opportunity to pursue legal remedies. He added, everyone, including Assemblywoman Buckley, is working on bringing the two bills together for consistency.
Robert A. Ostrovsky, Lobbyist, Nevadans for Affordable Health Care (NAHC), stated NAHC represents about 50,000 employees from various companies, who see the bill as an opportunity for quick resolution of health care issues. He submitted testimony supporting passage of S.B. 320 (Exhibit C).
Lawrence P. Matheis, Lobbyist, Nevada State Medical Association, stated he was in support of S.B. 320.
Ruth Mills, President, Nevada Health Care Reform Project (NHCRP), stated the NHCRP is a coalition of consumers, organized labor, seniors, disability groups, religious organizations, and health care professionals, and represents over a half million Nevadans who are part of the 94 member organizations. She conveyed the NHCRP’s mission is to assure all Nevadans comprehensive and affordable health care coverage and to improve the quality of health care. She stated S.B. 320 is the insurance industry’s version of external review. She said the NHCRP is working to resolve the final point between S.B. 320 and Assembly Bill 422 so they can be incorporated into one document.
ASSEMBLY BILL 422: Provides for external review of certain determinations made by managed care organizations and health maintenance organizations. (BDR 57-1092)
Ms. Mills continued, the last point of disagreement has to do with placement of external review. She opined external review must be placed in the office of consumer health assistance, which was created to advocate for people who have problems with their health insurance. She asserted to allow an insurance company to have its own external review process would defeat the purpose of this legislation. In response to the insurance industry’s argument this would impose an additional bureaucratic burden on them, she stated the role of the Governor’s Office of Consumer Health Assistance is limited. She explained it would only take two telephone calls for the ombudsman to set the process in motion, and the office of consumer health assistance said it would require no additional funds to handle external review. She pointed out Medicare uses an independent external review. Concluding her remarks, she asked for the committee’s support of the bill.
Responding to Senator Shaffer’s question, Mr. Matheis stated, as long as the external review organizations are acting in good faith, they are not directly liable, however, if there is gross negligence, then it would be analogous to the standard generally used in malpractice.
Adding to Mr. Matheis’ statement, Mr. Hillerby said he wanted to point out, A.B. 422 also offers protection for the consumer. He stressed it is important the state acts to assure the bona fides of these organizations through licensing or registration, or some other means of verification for accountability, to give the public a sense of trust, and not rely solely on a voluntary system.
Senator O'Connell stated it had been indicated to her, the office of health care assistance may need up to eight more ombudsmen to provide meaningful and timely responses to the public’s complaints, and she said she wanted to know if that was the case.
Mr. Matheis commented he did not know about the personnel, but stated the health plans and the medical association have worked together to voluntarily adopt a single prior authorization form for use throughout Nevada. He mentioned, now they are working on a standard, single-credentialing form for providers.
Mr. Hillerby stated the bill would move from voluntary to mandatory and the Division of Insurance would certify these independent review organizations. He added there is an omission in the bill, a requirement the activities of the external review be reported to the insurance division, a process he noted as key to the effectiveness of the program.
Kami L. Dempsey, Lobbyist, Las Vegas Chamber of Commerce, stated the chamber’s 6500 members support S.B. 320, and see it as a means to help control costs by reducing the amount of potential legal action.
Kimberly Everett, Associate Actuary, Division of Insurance, Department of Business and Industry, stated the division anticipates the bill would somewhat reduce the number of health insurance complaints to the division and the office of consumer health assistance. She conveyed, both groups would have to advise consumers about their external review rights. She stated there will be a fiscal impact to the division, and a fiscal note was prepared and submitted on March 27, 2001. Continuing, Ms. Everett stated a new licensee category would be created involving up to 10 existing independent review organization companies; and up to 300 utilization review entities as licensees. She said this would impact the division budget, requiring anywhere from $5000 up to $30,000 the first year from the General Fund; and after the first year, the fees should then be able to sustain the division’s budget. The money would be used to develop the certification criteria and forms; a new licensing category; and associated support materials, including printed information for the public.
Mr. Hillerby remarked there was no intent to create a problem for the division of insurance. He stated the $250 fee specified in the bill could be raised to provide the needed revenue, and the companies would come because they would see this as good business for them. He articulated the 10 existing companies are already certified nationally, so they do not have to be recertified by Nevada; they only have to pay the fee.
Senator O'Connell wanted to know what information Ms. Everett could give on another bill addressing the payment of doctor bills by Medicaid. Ms. Everett responded she did not know of any audits of Medicaid, but would check on it and supply the committee with whatever information is gleaned.
Senator Townsend added, according to testimony by physicians, the number-one, on-time bill payer was Medicare. The bad news was no one else paid, whether on time or late, including Medicaid.
Senator O'Connell stated the task force was not addressing this particular area, and the committee needed to know why. Ms. Everett remarked she had heard the task force was looking into that area, and she would check on it and make sure the right department responds.
Bobbie Gang, Lobbyist, Nevada Women’s Lobby (NWL), stated the NWL strongly thinks an external review is necessary, and they support S.B. 320. She pointed out the health care system is difficult for anyone to negotiate, especially for low-income families. She stressed it is very important to consider what agency would be handling the external reviews.
Christine Sawyer, Registered Nurse, Service Employees International Union (SEIU), Nurse Alliance, Nevada Health Care Reform Project, stated they are in support of S.B. 320. She presented written testimony (Exhibit D).
Matthew Sharp, Lobbyist, Nevada Trial Lawyers Association (NTLA), stated the NTLA is generally in favor of the bill, but has a few concerns. First, he noted, managed care organizations could be absolved of their responsibility to treat customers fairly in their reviews. Second, they should have a truly independent process, he noted, for example, one of the largest disability insurance companies in the country created a subsidiary to conduct external reviews. They advertised to doctors and insurance companies they could cut claims and did not disclose the affiliation to the insurance commissioner or the public. And, third, the process should not interfere with the legitimate ability to get to court, if needed.
Senator Townsend closed the hearing on S.B. 320, and opened the hearing on S.B. 394.
SENATE BILL 394: Prohibits state board of nursing or employer of nurse from requiring inclusion of certain information on badge or other form of identification worn by nurse while on duty. (BDR 54-1136)
Janice C. Pine, Lobbyist, Saint Mary’s Health Network, said she would like to introduce Norma Brown.
Norma Brown, Nurse Executive, Saint Mary’s Health Network, stated although the bill is short, full name disclosure is a very important issue to all nurses and other medical staff personnel in Nevada. She pointed out, many nurses cited incidences of harassment, stalking, and threats of all kinds, including death. She said at one point, the State Board of Nursing indicated an unwillingness to compromise on the issue because of its concern over patient advocacy. She added, it was a mutual concern of nurses.
Senator Townsend requested clarification of the board’s requirement nurses’ identification badges display the wearer’s full name. Ms. Brown explained, the Board of Nursing requires the first name, last name, and classification of the caregiver be clearly identified and readable from 3 feet away.
Kathy Apple, Lobbyist, Nevada State Board of Nursing, explained it was not a case of the board’s unwillingness to compromise, but the requirement was set in statute in 1996. She stated the board had indicated their willingness to look at the issue and consider alternatives. She conveyed, the only way for the board to identify a caregiver when a patient has a complaint is for the patient to provide the name of the caregiver in question.
Senator Townsend surmised if a patient gave a first name and last initial, the hospital, the room number, and approximate time, then it should be easy to identify the nurse.
Ms. Apple responded, it would, except, when the patient is sent to the hospital for the name, the hospital has refused to provide information. She emphasized she fully understood the concern regarding harassment, since for security they had to have their last board meeting in Las Vegas in the Capitol Police conference room of the Grant Sawyer Building, because of a disgruntled out-of-state applicant who sexually harassed a staff member and threatened the board. She stressed there is increasing violence nowadays which was not a consideration before.
Mr. Hillerby, Lobbyist, State Board of Nursing, stated he was sure there was a compromise that could address the nurses’ concerns, while hospitals and others could maintain the types of records needed for the board to identify a caregiver when a complaint is filed against them. He reminded everyone part of the patient’s bill of rights states a patient has the right to know who is taking care of him or her. He pointed out there are visiting nurses, and the patients must be sure of the proper identity of whoever takes care of them. He acknowledged the concerns of all sides, and stated all concerned would be able to draft language for the bill, which would protect the nurses and the consumers.
Ms. Brown conveyed characterizations of the hospitals’ lack of cooperation were not entirely accurate. She expressed, as she understood the process, if a consumer files a complaint with the board and only has a first name and last initial, the consumer is sent back to the hospital to obtain the full name. She stressed, if a stranger, claiming to have been a patient, asked her to identify a nurse, it would be difficult for her to justify providing information because she did not know what was really going to be done with it. She added, if the board made the request, she would willingly supply information, and so would any other provider in the state.
Senator Townsend emphasized there is very little time remaining to introduce new language for the bill and vote in time to clear the Senate and go to the Assembly, and urged the parties involved to work on the bill quickly.
Danny L. Thompson, Lobbyist, Nevada State American Federation of Labor Congress of Industrial Organizations (AFL-CIO), stated they support the S.B. 394. He pointed out, lobbyists wear a badge with an identifying number, and offered instituting such a practice is a possible solution.
Jon L. Sasser, Lobbyist, Washoe County Senior Law Project, stated the seniors have some concern with nurses from home health agencies having proper identification. He emphasized they understand the problem the nurses are experiencing, but they do not want the patients’ safety and care compromised.
Senator Townsend queried how 3 feet became the standard for readability of a name badge. Ms. Apple responded it was determined 3 feet was the distance seniors, who needed larger print, would be able to read the nametag.
Ruth Paxton, President, National Alliance for the Mentally Ill, stated the consumers she represents want to know the name of the person treating them. She expounded, as a former home health nurse, she was always careful to properly identify herself. She explained the visiting nurse was breaching the patient’s safe territory when he or she entered the home. She continued when her mother was hospitalized, there was a problem with wrong medication, and she, personally, experienced difficulty in finding the responsible nurses. She stated the hospital board and the State Board of Nursing were uncooperative. She added, this negative experience resulted from not having the nurses’ names. She pointed out, at this time, the hospitals and others do not have to give the names, but if they were compelled to provide information to the board of nursing, and the board would follow through, she would be satisfied.
Senator Townsend closed the hearing on S.B. 394 and opened the hearing on S.B. 423.
SENATE BILL 423: Revises provisions governing issuance of license to practice as professional nurse or practical nurse or certificate to practice as nursing assistant to person who has been issued corresponding license or certificate in another jurisdiction. (BDR 54-1081)
James L. Wadhams, Lobbyist, Nevada Hospital Association, pointed out, S.B. 423 was one of the bills coming from bill drafting “not the way it was intended,” and presented proposed amendments (Exhibit E). He stated there was current statutory authority for the board to deal with nurses who are licensed and qualified in other states. He maintained the purpose of the bill was to identify the other jurisdictions with substantially equivalent licensure to Nevada’s and facilitate the practice in Nevada. He averred the evaluation of quality was not affected, but the process time would be shorter. He noted the shortage of nurses in Nevada puts the state at the bottom of the nurse-to-patient ratio. He emphasized the bill was just one of the steps towards bringing nurses to the state while maintaining quality of skills.
Bill M. Welch, Lobbyist, Nevada Hospital Association (NHA), testified from prepared text (Exhibit F), according to the Nurse Shortage Report commissioned by the NHA, Nevada has the worst availability of registered nurses per population in the nation. He stated population growth and attrition are aggravating the shortage, plus Nevada’s educational system today produces 262 registered nurses per year to fill the current demand for 600 nurses per year. He emphasized the nursing shortage was affecting the public’s ability to access health care. He stressed S.B. 423 will not solve the problem, but it will help to narrow the gap in health care services.
Senator O'Connell wanted to know whether the nursing shortage was national or unique to Nevada, and why was it so difficult to get and keep nurses.
Mr. Welch acknowledged, not only is it a national problem, but also an international problem. He expounded, outside recruiters are wooing Nevada nurses; even Canada is trying to get their Canadian-trained nurses back. As for the reasons behind the nursing shortage, Mr. Welch stated, it is complex; although the study does address it on a limited basis. He explained it is a difficult work environment with a lot of stress. He pointed out there are many more career opportunities for women these days, as compared to 30 years ago when teacher or nurse was the prime career choice.
Doreen Begley, Lobbyist, Nevada Hospital Association (NHA), stated there is a letter of support for mutual recognition from the Regional Emergency Medical Services Authority (REMSA) and Care Flight, as well as from the Air & Surface Transport Nurses Association (Exhibit G). She pointed out, the Nevada State Board of Nursing supports mutual recognition to simplify the governmental process, remove regulatory barriers, and increase consumer access to quality nursing care.
Continuing, Ms. Begley stated she had been hired by NHA specifically to address nurse shortage issues and actively seek positive solutions to what has now been described as a threat to public health. To further this goal of more nurses, the Nevada Task Force was formed in spring 2000. As the task force progressed in their work, they realized more time and effort was required. In addition to expanding the task force, they hired her to give full-time attention to the issue. She said one issue identified by the task force was mutual recognition, and they found statewide support from many individuals and organizations. She noted this is becoming a trend across the country in which 13 states have already enacted mutual recognition legislation; and five others are considering it, including Georgia, New Jersey, North Dakota, our neighbor Arizona, and Nevada (Exhibit G). She emphasized being a member of the mutual recognition pact between states will help give Nevada a competitive edge to recruit and retain qualified nurses, which will benefit nurses, employers, and the public.
Commenting further, Ms. Begley explained mutual recognition is similar to a driver’s license, allowing a person to operate a vehicle in another state so long as the driver abides by its vehicle codes. She said nurses would be able to move to member states of the mutual recognition pact without having the time delay of requalifying and the added cost of yet another license.
Senator Townsend inquired how it now works when REMSA or Care Flight crosses the border into another state. Ms. Begley explained the nurses and other medical professionals must carry licenses from each state their work requires them to enter.
Robin Keith, Lobbyist, Nevada Rural Hospital Project Foundation (NRHP), stated the project is a consortium of all 11 small rural public and not-for-profit hospitals in Nevada who support S.B. 423. She testified, often in a rural setting, one nurse may wear many hats in a day: from emergency room, to medicine, to geriatrics. She voiced, limited finances and limited populations add to the shortage problem in rural communities so the absence of just one nurse can mean all services are cut in half.
Ms. Apple stated the board of nursing supports the bill. She conveyed the board’s adoption of mutual recognition was based primarily on their 3-year review of the needs of licensure for the turn-of-the-century. She elucidated the amended language contains safeguards the board supports. She stressed they would only enter a compact that supports the Legislature’s mission for the board to ensure the health, safety, and welfare of the public; and the licensure requirements of other compact states are substantially equivalent to Nevada’s licensure requirements. She averred the bill is explicit about the board’s authority to take action related to practice privilege; i.e., a nurse from another state working in Nevada would be considered privileged to practice here.
Theresa Morrow, Registered Nurse, testified from Las Vegas she had practiced nursing in Nevada from 1982 until retirement in 2000. She stated her opposition to S.B. 423 was it deregulates licensure and puts the public at risk. She told of trying to verify licensure of a head nurse where she had once worked. She said she called the various agencies and the board of nursing many times without a response. Finally, she resorted to the attorney general’s office, which she noted, responded within an hour with the information the nurse was not licensed in Nevada and had penalties against her in another state. Ms. Morrow said the hospital was fined $100, and the nurse fined $500. Continuing, she added, the hospital changed the job title to disguise that the nurse is still working there. When she inquired why there was a difference when in another incident, a nurse was fined $5000, Ms. Morrow stated she was told by the licensing board they were only authorized to fine out-of-state licensees $500, but in-state license infraction fines were authorized up to $5000.
Ms. Morrow noted other problems such as states not even taking fingerprints or doing background checks on nurses. She asserted mutual recognition would not help with the nursing shortage in Nevada. She maintained, a nurse from another state can easily get a temporary license within 10 days. She said she knows of nurses who also have California licenses so they can work there on their days off. She expounded all a patient has to do to find out who was involved in their care is to request their medical records. She averred everyone’s name appears on those records, some many times.
Carin R. Franklin, Lobbyist, Operating Engineers Local 3, stated they are in opposition to S.B. 423. She stated, although Nevada ranks fiftieth among the states in nurse-to-population ratio, it does not mean Nevada should lower its standards. She pointed out, each state has its own standard of nurse practice acts, and by the time a nurse gets his or her license, the time allows that individual the time to read and understand the state’s requirements. She emphasized the lack of tracking allows nurses with violations and nurses who have lost their licenses to practice elsewhere, to the detriment of the patients.
Mr. Thompson maintained the AFL-CIO has long fought for equity. He voiced the nursing shortage had more to do with staffing standards than with licensing. He explained, if a nurse is put in charge of more patients than can be properly attended to, it is the nurse whose reputation and license are put in jeopardy, not the facility’s. He said, for example, some hospitals are on “divert” (diverting to another facility) 7 days a week; so even though a patient is closest to that hospital, he would automatically be taken to another hospital, adding extra time, which could be life-threatening to the patient. He surmised mutual recognition could also be used as a “strikebreaker” against Nevada’s own nurses.
Richard Schlegel, Executive Director, Nevada Nurses Association, stated, since the move for implementation of an interstate compact by the National Council of State Boards of Nursing in 1998, the Nevada Nurses Association, the American Nurses Association, and other nursing associations and organizations have expressed a number of concerns. He maintained many nursing organizations concur the interstate compact will have little to no effect, as the limited number of practicing nurses nationwide would remain the same. He elucidated the main concerns are a lack of demonstrated need, only 2 to 3 percent of nurses in Nevada would be affected. He asserted there is disproportionate funding of compact implementation, since the board has stated it would seek a significant increase in nurse licensure fees to fund participation in the national database, and there would also be the potential revenue loss of licensure fees from nurses who would no longer be required to hold a Nevada license while living in another state. Additionally, he opined, there would be increased administrative costs for investigation and discipline of nurses working in Nevada while being licensed in another compact state. He claimed, currently, nurses could only be disciplined in the state in which they are licensed. Mr. Schlegel pointed out, under the compact, any member state could discipline a nurse, even if the nurse is not working in that state. He expounded, multiple disciplinary actions would create undo burdens for nurses legally, financially, and emotionally. He also noted, the compact would allow a nurse to practice in a state without the knowledge of the state board. He conveyed the NNA recommends nurses practicing in a compact state be required to register with that state’s board. He noted, not having registration establishes a loose system by which oversight would be weakened, and complicates the reporting by patients of nurse malpractice. He added, registration would enhance communication of board practices and policy updates. He remarked Maryland and Illinois require registration including the employer’s name. Further, he stated, it does not allow for a process to verify a nurse’s education meets Nevada’s standards.
Mr. Schlegel stated the NNA recommended the bill and its amendments be referred to an interim health care committee to study the impact of the newly implemented compact in other states, and its effects, if enacted, in Nevada. The compact portends a great impact on health care for everyone in Nevada, and warrants careful study. He urged the committee to give careful consideration to an interim committee for a legislative, not regulatory, process.
Ms. Sawyer stated the members of the NSEU Nurse Alliance are opposed to S.B. 423. She stated the compact would allow nurses from other states to work in Nevada without accountability. She said front-line nurse opposition to mutual recognition as proposed by the National Council of State Boards of Nursing caused NSEU, Nurse Alliance to not adopt the proposal. She pointed out adoption of the bill could turn over regulatory functions to the National Council of State Boards of Nursing, which is not regulated by any state or the federal government, thus creating a new level of bureaucracy and depleting Nevada’s authority. Ms. Sawyer said, with the loss of authority, Nevada could not protect its patients from out-of-state nurses who are not fit to practice in Nevada. She pointed out, the bill does not provide a process by which the board can communicate Nevada’s nurse practice act, provide updates to continuing education units (CEU) requirements, or notice of changes in the law.
Continuing, Ms. Sawyer stated no other professionals she knows about, especially in the medical field, have a mutual licensure arrangement as proposed in S.B. 423. She claimed the State Board of Nursing indicated the nursing licensure fee would have to be increased by $50 to subsidize the licensing of out-of-state nurses. She remarked there could be a flight of nurses away from the profession, thus causing more problems than the bill would solve, and it could even threaten Nevada’s standard of patient care. She concluded she has been licensed in four states, and is currently also licensed in California. She posited it is not difficult or time consuming to be licensed in any state.
Senator Townsend closed the hearing on S.B. 423 and opened the hearing on S.B. 510.
SENATE BILL 510: Authorizes certain chiropractors to engage in practice of animal chiropractic. (BDR 54-1209)
Danny L. Burress, D.C., Concerned Citizen, stated he has been a licensed chiropractor since 1983. He said in 1991 a patient asked him to look at her horse, as nothing else was working, and he decided to placate her by at least looking at the horse. He said it was obvious what the problem was and proceeded to treat the problem as he would a regular patient. The next day the horse’s owner was on the telephone, excited because the horse was running for the first time in quite a while. As a result, he said he decided to find out more about animal chiropractic and enrolled at the American Veterinary Chiropractic Association (AVCA) in Illinois, and has now completed one-third of the advanced course of study. He articulated since 1995, when he entered the field fulltime, he has built a practice and a reputation in animal chiropractic.
Dr. Burress continued in 1998, he and Dr. Edy Rooke responded to a complaint from the attorney general’s office, and they demonstrated what they were doing was legal according to veterinary statute. The matter was referred to the chiropractic board, which had no issue. The matter was then referred to the veterinary board, which also had no issue, but decided to adopt regulations to protect the public. He testified he, Dr. Rooke, Dr. Mike Gleason from California, and Dr. Bill Bailey participated in a series of discussions to establish regulations they could live with. However, the final regulations the veterinary board adopted were so restrictive to chiropractors, basically, nothing can be done without a veterinarian present, placing an additional financial burden on the animal’s owner and creating a major scheduling and logistics problem. He voiced, those regulations are, obviously, slanted towards the veterinarian without regard for the public or the cost.
Dr. Burress pointed out people are afforded the opportunity of choosing medical care and do not have to have the referring doctor accompany them to the other doctor. He elucidated having a veterinarian present implies they have superior knowledge, which often they do not. The regulations require the chiropractor to have continuing education of 12 hours yearly, but there is no such requirement of the veterinarian who can legally offer chiropractic service without any training.
Dr. Burress stressed, S.B. 510 is more about a certified chiropractor having the rights and freedoms to practice. He expounded a similar bill has passed in Oklahoma, and similar bills are being considered in New Jersey, New Hampshire, and Maryland. He said Colorado is pursuing establishing animal chiropractic as a separate profession. He continued nationally the profession is on the rise, and the rights of people are being protected. He implored that animal owners’ rights and freedoms not be abrogated to protect the interest of just the veterinary profession. He averred a survey was taken, and the chiropractic profession was definitely in favor of the bill (Exhibit H).
In response to Senator Townsend’s query, Dr. Burress stated the veterinary board regulations are so punitive as to make it almost impossible to pursue his practice. For example, he noted, there is a 3-year requirement of being in practice as a chiropractor before an application can be submitted to the veterinary board, and requirements to be registered with the board, to have a written referral from a veterinarian with a prior history with the horse, to have the veterinarian present when treating the animal, and to have the veterinarian collect the fees. He said he would provide the list of regulations to Senator Townsend.
Gwen Barkman, Concerned Citizen, stated she was a past president of the Nevada Paint Horse Club and sits on the board for Washoe Horseman’s Association. She said as a highly competitive horseperson, she thinks it is the responsibility of owners to check the credibility of the person who works on their horses, and it is also the owners’ right to choose whom they would like to care for their horses, therefore, she is in favor of the bill.
Terri Lynn Van Ostrand, D.D.S., Concerned Citizen, stated she is a dentist for humans. She said she has performance horses, and has had them adjusted by different chiropractors in California, Nevada, Utah, Arizona, and Montana, as she makes the performance circuit. She explained, since her horses are performance horses, she has them adjusted so they can perform at their peak; however, it is very difficult to have the adjustments done legally when other doctors are opposing it, and the board strictly regulates who can and cannot see her horses. She elucidated when she has paid for the horse and is the rider, and the horse is part of her lifeline to the money she makes, then why is it they can tell her who can adjust her horse. Dr. Van Ostrand stressed, in her dental practice, patients have a choice to see her, regardless of whether insurance covers the visit or not, and asked why it cannot be the same for her horses. She concluded, she supports S.B. 510.
Kathy Stone, Concerned Citizen, stated she is in favor of the bill. She communicated she is a team roper, which is a rodeo event, and owns five horses used in team roping competitions. She conveyed team roping can be very taxing on a horse. She stressed team roping can result in a lot of pain and suffering for some horses not properly prepared. In fact, she said she has seen a lot of horses sold because no one could address the issue of pain. She explained, team roping requires a lot of travel, meaning her veterinarian is not in the area, and if getting a chiropractor to adjust her horse is not allowable, her horse suffers. She emphasized she should not have to have permission from her veterinarian to have her horses adjusted.
Mickie Enniss, Concerned Citizen, stated she is the mother of four children who are all active in horse-oriented activities, and she owns six horses and various other animals. She told of having a horse injured during team roping, and said among the recommendations the veterinarian made, one was to call the chiropractor. She said the adjustments made by Dr. Burress cut down the recovery time of her horse by almost a year. She expounded one of her dogs was not moving well, and since Dr. Burress was present to adjust one of her horses, she asked him to look at the dog. She said Dr. Burress, instead, recommended the veterinarian, who found an underlying health problem, see the dog. She claimed both incidents demonstrated responsible action on the part of both doctors, and she is in favor of S.B. 510. She emphasized no veterinarian or veterinary board has the right to determine her choices in health care for her animals or the way she spends her money. She pointed out there is no board or particular doctor telling her where she should take her children for medical care, and that should also apply to her animals.
Kim Paulsen, Concerned Citizen, stated she was in favor of the bill, and she was speaking for her right to choose the appropriate care for her horses. She voiced it should be her decision as to the care for her animals without restrictive regulations limiting control and making it an economic and logistic hardship. She noted the requirement of a veterinarian’s presence and prior knowledge of the animal provides no added benefit or safety, because of the veterinarian’s limited or lack of formal training in chiropractic care. She emphasized the added burden on the animal’s owner included the added expense of a veterinarian’s presence and the logistical arrangements of getting the animal, the owner, the veterinarian, and chiropractor in the same place at the same time. She stressed, any person rendering chiropractic care for animals should be licensed and certified by the AVCA, which the bill requires. She pointed out there are people representing themselves as qualified animal chiropractors, and the requirements in this bill would reduce the problem. She surmised, those who oppose the bill do so only because of financial gain.
Bill J. Bailey, D.C., Secretary, Chiropractic Physicians’ Board of Nevada, stated the board opposes S.B. 510. He pointed out, the present definition of chiropractor would have to be changed by statute. He stated the chiropractic board understands the veterinary board is the only board dealing with the treatment of animals. Therefore, should animal chiropractic come under their statute, the chiropractic board would feel compelled to test those doctors in a state board examination. He pointed out, since there is no undergraduate training for animal chiropractic, it would not be practical to administer an examination to doctors coming to Nevada. Further, he stated, it would be virtually impossible to pursue a complaint, since no one has the type of training to adequately assess the validity of the complaint.
Dr. Bailey claimed the board feels strongly there are benefits to animal manipulation by a chiropractor, and would work closely with the veterinary board to provide regulations to allow for adequately trained chiropractors to work under the direction of a veterinarian. He opined both boards understand the frustration with the current regulations, but explained, all parties are in a learning curve. He explained, the boards think the current status of the regulations is the preferable one, rather than changing current law to allow for animal chiropractics. He pointed out the chiropractic board has a problem with the term “chiropractic” being used in veterinary law, because in the Nevada Revised Statutes the definition refers to the human spine, and the public’s view is it pertains to humans.
Senator Townsend, requested clarification of the American Veterinary Chiropractic Association (AVCA), and which was their basis, chiropractic or veterinary. Dr. Bailey answered he understood the AVCA included both disciplines.
Dr. Burress responded the AVCA is an agency established as a union between veterinarians and chiropractors to bring the two professions together. He said the AVCA is the only such agency in the United States able to train and certify doctors, and attendees must either be a licensed veterinarian or chiropractor to qualify for the school.
Senator Townsend wanted to know how the national boards of the two disciplines view the AVCA. Dr. Burress explained the national boards seem to be participating, because Nevada’s veterinary board has acknowledged the AVCA and stated only chiropractors trained by the AVCA should render animal chiropractic care; and the veterinarians in Nevada who are also trained and certified in chiropractic have to be certified through the same agency, so the veterinary board is, obviously recognizing the AVCA.
Michael D. Kirk, D.V.M., Concerned Citizen, stated he was in his third term as member of the State Board of Veterinary Medical Examiners. He said he came before the committee as a veterinarian who has practiced large equine medicine in Nevada for 31 years. He stressed the veterinary board exists primarily to protect the public and to protect animals. He posited, the ability of the board to do its job depends on licensure of any individuals practicing animal medicine. He noted the number of veterinarians licensed in animal chiropractic is increasing. He stated chiropractors who are not veterinary-trained individuals, who only hold certificates of veterinary chiropractic technique from AVCA, want to practice veterinary medicine with no restrictions and free of administrative remedy. He said passage of the bill would absolve the animal chiropractor of any liability and accountability for harm to an animal patient.
Dr. Kirk pointed out, the concept is contrary to the veterinary practice act, and inconsistent with the American Veterinary Medical Association (AVMA) position on chiropractic procedures, which are considered the practice of veterinary medicine (Exhibit I). He stressed, chiropractors are, basically, practicing veterinary medicine without a license, and it goes back to the 1995 Legislature allowing this to be put in the veterinary practice act. He said animals with acute injuries that could recover with veterinary care, could be become chronic with no hope of recovery by delaying treatment due to misdiagnosis and inappropriate therapy. He noted the regulations do have a sunset clause and will be revisited in May 2001.
Commenting further, Dr Kirk stated the regulations were designed to protect the public by defining veterinary chiropractic, providing requirements to practice, providing standards of practice, and providing for disciplinary action in the case of chiropractic error. He stressed, the board is not dictating to anyone or infringing on their freedom of choice; the pet owners do have the freedom to take their animals to anyone they want. He conveyed, the problem results when the horse is damaged and the owner seeks an outlet to rectify the situation, and there is no place to go. He explained, the veterinary board’s power lies in licensure, and they cannot license chiropractors, and the chiropractic board can only license chiropractors who work on humans.
Senator Townsend stated the primary concern of the committee is discipline and recourse. Dr. Burress responded, currently the statute says human, and you only need to add the word animal. He said a request was made of the board to have the change made through the Legislature, but members were split in their decision and decided not to. He stated animal chiropractors are held accountable by the chiropractic board. He reiterated the chiropractic board’s position of not being trained chiropractics is unfounded, because not all the board members are trained as chiropractic orthopedists or chiropractic radiologists, yet they respond to complaints in those fields.
Senator Townsend reiterated the problem is who issues the license and how do they monitor performance and qualifications. He stated the committee will study the issue between now and the work session next week to help them decide which is the better way to go. He stressed, a major concern is not to open the floodgates to allow every medical discipline to now be able to practice on animals, too.
Beverly Willard, Nevada State Board of Veterinary Medical Examiners, stated the question is the difference between humans and animals. She expounded if something is done incorrectly by a chiropractor who is not familiar with animals, the animal cannot speak for itself as to whether it feels better or worse, like humans can. She said she has horses, dogs, and cats; and her concern is for the animals.
Chris Ferrari, Lobbyist, representing Nevada Chiropractic Association, communicated he is neutral on S.B. 510, but offered to work with all the parties.
There being no further testimony, the meeting was adjourned at 10:34 a.m.
RESPECTFULLY SUBMITTED:
Laura Adler,
Committee Secretary
APPROVED BY:
Senator Randolph J. Townsend, Chairman
DATE: