MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-Second Session
February 17, 2003
The Committee on Health and Human Serviceswas called to order at 1:35 p.m., on Monday, February 17, 2003. Chairwoman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
COMMITTEE MEMBERS PRESENT:
Mrs. Ellen Koivisto, Chairwoman
Ms. Kathy McClain, Vice Chairwoman
Mrs. Sharron Angle
Mr. Joe Hardy
Mr. William Horne
Ms. Sheila Leslie
Mr. Garn Mabey
Ms. Peggy Pierce
Ms. Valerie Weber
Mr. Wendell P. Williams
COMMITTEE MEMBERS ABSENT:
None
GUEST LEGISLATORS PRESENT:
None
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Terry Horgan, Committee Secretary
OTHERS PRESENT:
Robin Keith, President, Nevada Rural Hospital Partners
Roger Volker, Executive Director, Great Basin Primary Care Association
Steven Hansen, Chief Executive Officer, Nevada Health Centers
Chairwoman Koivisto opened the meeting by explaining the Committee would be hearing presentations from rural health care delivery and safety net providers.
Robin Keith, President, Nevada Rural Hospital Partners (NRHP), explained that she was also president of the Nevada Rural Hospital Partners Foundation and of the Liability Cooperative of Nevada, a self-funded professional liability insurance trust through which malpractice insurance was provided to their members. Ms. Keith also served during the interim as Chair of the Governor’s Task Force for the Development of a Strategic Plan for Rural Healthcare.
Ms. Keith’s testimony was accompanied by a Power Point presentation (Exhibit C). She explained that the purpose of NRHP and its associated entities was to maintain access to hospital-based healthcare services for rural residents and to improve the viability of rural hospitals through shared services, resources, and advocacy. Members, she elaborated, included all of Nevada’s small, rural, frontier, public, and private not-for-profit hospitals, serving approximately 350,000 residents spread over an area almost as large as New England. Access, Ms. Keith noted, was the perspective from which NRHP viewed rural healthcare: access to what and for whom, how much was enough, and who would pay for it.
Ms. Keith explained that rural hospitals were providers of basic hospital and clinic services that included emergency rooms, diagnostic services, in-patient services, and long-term care. Ms. Keith noted that some services were paid for, some were partially paid for, and some were not paid for at all. She clarified that government programs such as Medicare, Medicaid, and county indigent programs were among the partially paid programs. Ms. Keith explained that the underinsured and uninsured generally provided partial payment, but Nevada hospitals were still owed about $125 million per year for uncompensated care.
Ms. Keith stated that Nevada hospitals provided community services free of charge, including community health education and health screening programs. They also participated in business development in rural communities and were anchors for health care practitioners and were actively working at recruitment and retention, bringing permanent staff into their own facilities, bringing visiting specialists into the communities, and providing for mobile services when they could not provide those services on a permanent basis.
Ms. Keith emphasized that rural hospitals had far-reaching effects because bringing health care professionals into a community had ripple effects that benefited the community as a whole. Rural hospitals, she observed, were major employers and contributed to local economies. Quoting a University of Nevada, Reno study updated in 2000, Ms. Keith announced that Nevada’s rural healthcare system accounted for 3,000 jobs and $95 million in annual payroll. She pointed out that the mere existence of a hospital in a rural community assisted with local economic development because the two things businesses always wanted were schools and healthcare.
Ms. Keith mentioned that rural hospitals were advocates for rural healthcare, were active coordinators of services for providers and patients and moved their communities forward in terms of the quality and variety of healthcare available.
Ms. Keith explained that rural hospitals operated in an environment of scarce financial and human resources, and one in which the older population and its demand for services was rapidly growing. Ms. Keith noted that the population in rural Nevada aged 65 and over was projected to grow 78 percent in the next 10 years. Ms. Keith added that rural hospitals operated in an environment with increasing numbers of uninsured people, but lacked the critical mass to achieve real economic efficiency because they served small, geographically isolated population centers.
Assemblyman Horne, noting increases in the numbers of uninsured in Washoe and Clark Counties, inquired what the increase in the uninsured in the rural areas was.
Ms. Keith answered that she did not have that specific information, but mentioned that the Great Basin Primary Care Association had analyzed the issue of Nevada’s uninsured and might have that information.
Assemblyman Horne restated the question, hypothesizing that if there had been a 2 percent increase in the uninsured in Clark County over a certain period of time, what percentage increase would there have been in the uninsured in the rural counties over the same period of time.
Roger Volker, Director, Great Basin Primary Care Association, answered that he could only make an estimate about the rural areas because national census data was on a county-wide basis. He noted that increases in the uninsured appeared to be mostly stable across the entire state. Mr. Volker added that a comprehensive trend analysis for the uninsured study would be published in approximately two weeks, and he would be happy to share it with the Committee when it was available.
Ms. Keith noted that the Rural Strategic Planning Task Force had forecast that the impact of the numbers of uninsured had not been felt yet. She pointed out the incredible increases in the cost of medical insurance faced by employers, adding that hospitals, as employers, had been faced with 15 to 20 percent increases in the costs of insuring their employees. She warned that not all employers would be able to absorb those costs.
Ms. Keith explained that transportation was a significant issue in accessing healthcare in rural Nevada because public transportation was limited, if available at all.
Inadequate infrastructure was another environment Nevada’s rural hospitals operated within, Ms. Keith explained, stating that most of Nevada’s rural hospitals had been built with Hill-Burton funds in the mid-1950’s and 1960’s. Some, she noted, had been able to get enough community support to be able to make major improvements in their facilities, so they had modern, up-to-date physical plants. Other hospitals were not so fortunate and were greatly in need of capital improvements, Ms. Keith added, and, in addition, sagging rural economies and shrinking tax bases were not helping.
On a positive note, Ms. Keith explained there had been movement toward integrating the systems. She noted that in the past, the healthcare systems had been very disparate; however, she recognized that there had been significant movement toward cooperation and collaboration and therefore greater efficiency. As examples, Ms. Keith mentioned “one-stop-shopping” ideas and the co-location of providers, as well as new types of providers who had more flexibility in their scope of practice, and who could bring their skills into facilities and communities, enabling one person to do the work of two. She also mentioned improving productivity through technology. Ms. Keith noted the NHRP had been working on tele-health capacity for 15 years, so usage had been greatly increased within Nevada because compressed video was statewide and tele-health transmission facilities were in all the hospitals. Ms. Keith indicated that the next step would be to work on the panel of providers who would use all that infrastructure.
Ms. Keith indicated that the federal access program, intended to support the viability of the smallest and most critical hospitals in the country, had been an incredible boon to Nevada’s rural hospitals. The program allowed a hospital to use its staff more flexibly and also put the hospital on cost-based reimbursement, which had turned some member hospitals around financially. Ms. Keith said there were six critical access hospitals within Nevada.
Ms. Keith stated that a lack of coherent articulated public policy about rural healthcare at the state or federal level had produced conflicting policies. As an example, Ms. Keith explained Medicare reduced reimbursement with one hand and increased it with the other. Nevada, Ms. Keith emphasized, was quite supportive of its rural healthcare network, a fact for which the NRHP was most grateful.
Rural hospitals needed fair reimbursement, Ms. Keith emphasized, saying they needed costs reimbursed, an allowance for capital improvements, and a margin. They also needed access to capital at affordable rates through a reasonable process and they needed implementation of the interim study recommendations concerning the distribution of disproportionate share dollars.
Ms. Keith stated that specific healthcare services needed in the rural areas included pre-natal care, pediatrics, geriatrics, dental care, long term care, and home health/independent living services. Addressing the emergency medical system (EMS), Ms. Keith stated they needed salaried paramedics, noting that almost the entire EMS in rural Nevada was volunteer-based. She acknowledged that was a thrifty way to operate, but noted that it led to a system with a lot of turnover. Ms. Keith also indicated a need to access behavioral and mental health services.
Discussing the workforce issue, Ms, Keith pointed out that Committee members were already aware of the nursing shortage within the state, but she added that shortages also included physicians, “mid-levels,” practitioners, pharmacists, lab and radiology technicians, licensed practical nurses, certified nursing assistants, dentists, and hygienists. Workforce costs, which included wages, benefits, recruitment, and temporary staffing, she counseled, were rising dramatically. Ms. Keith expressed support for a national mutual recognition pact and funding for the university to double its capacity to graduate nurses.
Ms. Keith explained that hospital costs for labor, pharmaceuticals, technology, and regulation were increasing at an alarming rate. She noted that a recent American Hospital Association study had demonstrated that, for every hour of patient care, there were one and a half to two hours of paperwork.
Mentioning tax policy, Ms. Keith noted that hospitals needed to benefit from a better tax structure; however, she warned, if healthcare were taxed, about half of the people healthcare was provided to, the insured and the uninsured/indigent, would wind up being responsible for those increased costs. That would result in continued erosion in the numbers of employers that provide healthcare insurance.
Ms. Keith stressed the importance of resolving the professional liability insurance issue, saying the crisis in malpractice insurance had resulted in the loss of medical providers in Nevada. She also indicated the importance of maintaining the Certificate of Need process in rural Nevada.
Ms. Keith concluded her testimony by reiterating points she had made previously:
Ms. Keith indicated that there was a very irrational reimbursement system in the healthcare industry driven by Medicare and Medicaid regulations that had little connection between what services were provided and what, or how, the provider was paid.
Ms. Keith repeated once again that the rural hospitals needed healthcare professionals, public policy that supported social well-being, adequate reimbursement, disproportionate share funding, maintenance of the Certificate of Need process, and commitment to the policy statement in the rural strategic plan that said rural residents had the same right to healthcare as urban residents and that there should be reasonable access to healthcare services for the great majority of Nevada residents. Ms. Keith emphasized that sustaining a viable system was impossible without the commitment of public resources. She pointed out that there was an economic component added to the impact of rural health, because with the economic multipliers added in, 47,000 jobs and $145 million in income were attached to the rural healthcare industry.
The underlying message of the policy statement contained within the rural strategic plan, Ms. Keith stressed, was the need to adopt a consistently supportive context for policy decisions.
Roger Volker, Executive Director, Great Basin Primary Care Association, explained that he also served as chair of Nevada’s Maternal and Child Health Advisory Board and as chair of the Board of Trustees of Nevada’s Public Health Trust Fund. The Great Basin Primary Care Association, he announced, was comprised of many of Nevada’s safety net providers, providers who provided healthcare to everyone, regardless of their ability to pay. Mr. Volker explained that their clients included those with insurance, those covered by HMOs, those who had Medicaid or Nevada Check Up, those with no insurance but who could pay, and those who had no insurance and could not pay.
Mr. Volker explained that the primary care system was not just a system for the poor; it was a system for everyone, regardless of ability to pay. Because of that, it was able to sustain itself and as a result, Mr. Volker added, thousands of people in rural Nevada were receiving quality affordable healthcare because of a network of primary care clinics and rural hospitals. Mr. Volker warned that the infrastructure sustaining the network was extremely fragile.
Mr. Volker said that creating a stable funding base for that infrastructure was a recurring issue. He noted that currently, the healthcare industry and healthcare access fluctuated with the economy, and therefore was not stable. He indicated that public dollars to sustain care were still needed by the infrastructure. Referencing his handout (Exhibit D), Mr. Volker explained it listed some of the benefits that would accrue by creating a stable funding base for the safety net infrastructure.
Mr. Volker, referencing Ms. Keith’s discussion about provider shortages, noted those providers also needed some place to practice, so new, adequate facilities were needed.
The next issue Mr. Volker addressed was reducing barriers to low-cost health insurance coverage for children and families. He anticipated that Nevada Check Up would be maintained, noting there were now almost 26,000 children covered by that program. Those children, he explained, were receiving preventative care and early diagnosis of diseases such as diabetes. In addition, Mr. Volker noted, outreach programs to children had been more successful in the rural areas of Nevada than in the urban areas. He credited school nurses, commissioners, social workers, and other caring people in those communities who had seen to it that the children were enrolled. Citing his study of the uninsured, Mr. Volker indicated that as of July 2002 there were approximately 38,000 children who fell into the Nevada Check Up income range.
Chairwoman Koivisto inquired whether there were 38,000 total children uninsured, or if there were 38,000 children in addition to the 26,000 currently enrolled.
Mr. Volker replied that there continued to be 38,000 uninsured children in that income range, in addition to the 26,000 currently enrolled.
Assemblywoman Pierce inquired whether the totals were for all of Nevada or just for rural Nevada.
Mr. Volker answered that the figures were for all of Nevada, but could be broken out by county.
Mr. Volker mentioned that there was a bill to create an office of minority health currently within the Legislature. He said it was important because a great percentage of the clients who accessed the primary care system in both the urban and rural areas were minorities, and, by not having an office of minority health in Nevada, Nevada had failed to qualify for some federal resources that could help the infrastructure of its primary care system.
Another issue paramount to the rural areas and the primary care system was emergency medical services, Mr. Volker continued. Stating that the primary care system in the rural areas was, for the most part, an emergency medical care system, Mr. Volker stressed it was even more essential that those services be maintained. That part of the infrastructure was in very great need, he emphasized, and mentioned ambulances that needed tires, and a shortage of radios and repeater towers that kept emergency responders from being able to communicate with providers. Mr. Volker indicated the Nevada Office of Rural Health had made some recommendations on ways to upgrade the EMS, and that one recommendation had been to support a state emergency medical services director.
Mr. Volker testified he had supporting data that indicated 80 percent of all the patients who accessed the primary care clinics had some form of diagnosable mental health or substance abuse problem, and there was a severe shortage of mental health resources in the primary care setting to address this. He noted the existence of two pilot programs, one in Wendover and one in Carson City, where the mental health coalition was looking into integrating mental health services into a primary care setting. Mr. Volker stated he hoped to be able to gather federal, state, and foundation resources to make the pilot programs more available around the state.
Another issue referenced by Mr. Volker was oral health access. He indicated access had improved as a result of a bill passed during the last legislative session that had allowed recruitment of oral health professionals under limited, restricted licensure, so that they would serve in parts of the state where previous recruitment efforts had not been successful. In addition, Mr. Volker stated money had been received from the Fund For A Healthy Nevada to open dental sites, and his handout listed several counties in which service was now improved.
Chairwoman Koivisto said she understood there had been difficulty establishing regulations after passage of the prior session’s legislation, and asked if those were now in place.
Mr. Volker replied that it continued to be a very cumbersome process and that there had been some difficulty with the Board of Dental Examiners. Mr. Volker indicated his desire to continue working with the dental board to resolve outstanding issues.
Mr. Volker explained that another issue effecting primary care in Nevada was a lack of specialists, including obstetricians and oncologists. Mr. Volker thanked the Committee for allowing him to make his presentation about rural healthcare issues and indicated his willingness to work with the Committee throughout the Session. He also mentioned his willingness to provide any specific research the Committee wanted, or answers to specific questions.
Steve Hansen, CEO, Nevada Health Centers, made a Power Point presentation of his testimony to the Committee (Exhibit E) and stressed the importance of community health centers in Nevada. President Bush’s goal, he noted, was to double the number of community health centers across the United States over the next five years.
Mr. Hansen explained that in Nevada there were two community health centers, Health Access Washoe County (HAWC), which operated both a clinic and a homeless clinic in Reno, and his organization, which operated in the rural areas and in Las Vegas.
Mr. Hansen explained his centers provided access to health care for all individuals without regard for their ability to pay. Nevada Health Centers, he said, had been operating for over 25 years, first as a public entity from 1977 and then from 1995 as a private, non-profit 501c3 corporation. Mr. Hansen noted that Nevada Health Centers had received its status as a federally qualified health center in 1977 through the Public Health Service Act. He indicated that governance was through a volunteer board of directors made up of community members from all the locations they served. He added that there were two administrative sites, one in Carson City and one in Las Vegas, and that the centers employed approximately 125 people, 25 of whom were primary care providers. Mr. Hansen noted the center’s liability was covered under the Federal Tort Claims Act, so the federal government provided their liability insurance because the employees were deemed to be federal employees, even though they were not. That really had helped the centers during the current malpractice insurance situation, he emphasized.
Mr. Hansen explained that the clinics were spread throughout Nevada, and that three primary care clinics and one clinic specifically focused on the homeless population were located in Las Vegas. Mr. Hansen indicated that last year the clinics had 70,000 visits from 35,000 to 40,000 individuals. The majority of revenue received by the clinics was paid by the patients, he explained, who paid based on a sliding fee scale provided by the federal government that was related to income and family size. Thirty percent of their budget was provided by federal grant, 23 percent was provided through local and county contributions, and Mr. Hansen noted that every year his organization broke even. It was a very fragile financial situation, and without all those partners the clinics would not exist, he commented.
Referencing the clinic in Beatty, Mr. Hansen said it was representative of the rural clinics and had one physician, one physician’s assistant, and regular support staff. Noting that his clinics were basically a family practice model, Mr. Hansen added that they cared for many categories of illness and injury, including occupational health issues. Mr. Hansen explained that some clinic equipment had been provided by local employers, such as the mines, and some had been provided by local communities. Because of the clinics, some rural areas were able to access x-rays and 24-hour coverage, Mr. Hansen reported. He mentioned that there was also a centralized pharmacy in Carson City that provided medicines to the clinics.
Assemblywoman McClain inquired whether the clinics’ centralized pharmacy was utilizing the state’s bulk purchasing contracts.
Mr. Hansen replied that they were and that they also utilized the federally qualified 340b program, which was how they were able to provide medicine to Medicare patients as well as to their uninsured patients.
Assemblywoman McClain asked about the cost to the uninsured.
Mr. Hansen explained that the co-pay was on a sliding scale and that it could be as low as ten dollars, if the person could afford it.
Mr. Hansen next discussed the clinic at Amargosa Valley, where the county had provided the building, as it had the Beatty clinic. He indicated that clinic provided similar services, including rooms with defibrillating and other equipment used to stabilize a patient.
Mr. Hansen said they also operated a mobile mammography unit, which traveled throughout the state about 20 percent of the time and was in Las Vegas the remainder of the time. Those services were provided to all comers, whether insured or uninsured, he noted.
Mr. Hansen indicated that even though Nevada did not provide direct financial support, indirect support, such as that from Medicaid and Nevada Check Up, was also considered patient revenue. He explained that if those programs were cut back, it would have an effect on his health centers.
Noting that liability concerns did not directly affect Nevada Health Centers, Mr. Hansen stressed that they were a big issue indirectly because it was to many of the affected specialists that they referred their patients. He repeated how closely all the various entities needed to work together as partners to make the safety net work in rural Nevada.
Assemblywoman McClain asked about the Nevada Health Centers clinics in southern Nevada.
Mr. Hansen explained Nevada Health Centers had been asked by the federal government to take over in Las Vegas on an interim basis about three years ago. The move had been so successful, he enthused, that they had asked to stay on permanently. Mr. Hansen noted they operated four clinics in Las Vegas utilizing five providers and serving an uninsured population of approximately 230,000. Providers saw about 25 patients a day, 70 percent of whom were uninsured. The ability to grow in Las Vegas, he added, was based on their generation of enough revenue to hire a new doctor for which the need was huge. He also stated that the federal government was willing to put money into projects as long as local or state governments were willing to participate. He stressed that partnerships were the way to have a bigger impact.
Assemblywoman McClain remarked that what was great about little community-based clinics was that people used them to get the help they needed. She indicated that she was impressed with the clinics.
Chairwoman Koivisto, mentioning the shortage of dentists and lack of dental care, inquired whether Mr. Hansen was working with the dental school, perhaps to partner with it to provide some care.
Mr. Hansen replied that there were five clinics operating within the University of Nevada, Las Vegas dental program, and noted that his organization referred a number of people to those clinics. Mr. Hansen said he hoped some day his organization would be able to operate a dental facility, adding that dental operatories were very expensive to equip.
Assemblyman Mabey commented that he had grown up in a rural community and that his father and grandfather had been physicians serving that area. He asked whether doctors could volunteer their time and services but not be liable or have to worry about being sued.
Mr. Hansen replied that under current law there was no way to volunteer. He explained that to be covered under the Federal Tort Claims Act, the provider must be paid as an employee; however, he added, the provider could choose to donate that payment back to the organization.
Assemblyman Mabey inquired whether one could be paid just one dollar in salary.
Mr. Hansen replied that his attorneys had recommended against it; he noted, however, that HAWC in Washoe County did that.
Chairwoman Koivisto, thanking Mr. Mabey for the question, indicated she had asked Marla McDade Williams, Committee Policy Analyst, to investigate available options.
Mr. Hansen clarified that HAWC also had volunteer physicians who were paid a small amount of money.
Chairwoman Koivisto thanked the panel for their presentations. With no further business to come before the Committee, the meeting was adjourned at 2:45 p.m.
RESPECTFULLY SUBMITTED:
Terry Horgan
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairwoman
DATE: