MINUTES OF THE
SENATE Committee on Finance
Seventy-second Session
March 5, 2003
The Senate Committee on Finance was called to order by Chairman William J. Raggio at 8:09 a.m. on Wednesday, March 5, 2003, in Room 2134 of the Legislative Building, Carson City, 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 William J. Raggio, Chairman
Senator Raymond D. Rawson, Vice Chairman
Senator Dean A. Rhoads
Senator Barbara K. Cegavske
Senator Bob Coffin
Senator Bernice Mathews
COMMITTEE MEMBERS ABSENT:
Senator Sandra J. Tiffany (Excused)
GUEST LEGISLATORS PRESENT:
Senator Maurice E. Washington, Washoe County Senatorial District No. 2
Senator Warren B. Hardy II, Clark County Senatorial District No. 12
Senator Mike McGinness, Central Nevada Senatorial District
Assemblyman Joseph Hardy, Clark County Assembly District No. 20
STAFF MEMBERS PRESENT:
Gary L. Ghiggeri, Senate Fiscal Analyst
Bob Guernsey, Principal Deputy Fiscal Analyst
Denise Davis, Committee Secretary
OTHERS PRESENT:
Rick Bennett, Lobbyist, University of Nevada, Las Vegas
Dr. Ronald Remington, President, Community College of Southern Nevada, University and Community College System of Nevada
Deborah Ballard-Reisch, Coordinator, Bioterrorism Risk Communication Project
Noel Tiano, Director, Nevada Center for Ethics and Health Policy, University of Nevada, Reno
Gerald Ackerman, Assistant Director, Office of Rural Health, School of Medicine, University of Nevada
Linda L. Sheldon, Lobbyist, Great Basin Primary Care Association
Craig Kadlub, Lobbyist, Clark County School District
Terry L. Hickman, Lobbyist, Nevada State Education Association
Senator Raggio:
We will open the hearing on Senate Bill (S.B.) 101.
SENATE BILL 101: Makes appropriations to Department of Administration for allocation to Board of Regents of University of Nevada to provide scholarships for certain students enrolled in medical and dental schools. (BDR S-925)
Senator Maurice E. Washington, Washoe County Senatorial District No. 2:
Today, I ask the committee to look past the financial request and see the benefits and dividends this bill might pay to those young people who have a dream or aspiration to serve in the medical or dental profession, but may not have any means or resources to reach that dream. This request would give those hardworking students hope and encouragement, and maybe an incentive to stay in Nevada and enter its great institutions. It would also help us stop exporting our talent to neighboring states. Lastly, after completion of their education, they might choose to stay in Nevada and serve its citizens by participating in its economy, as well as contributing to the State coffers. I feel the content and intent of this request is self-explanatory.
Senator Rawson:
We do not have as much diversity in our professions as we should. We face the issue of how many minority students are enrolled in our medical school every session. Other programs actively seek them, and it has been hard for our system to attract them. This small amount of money would go a long way towards bringing more minority students into our programs. The dental school has 19 minority students in its first class.
Senator Raggio:
This bill would provide each school $200,000 over a period of 4 years, at a rate of $50,000 a year.
Senator Washington:
That is correct.
Senator Raggio:
The language in the bill is “disadvantaged and underrepresented.” Are we talking about minorities?
Senator Washington:
The intent is to reach minority students.
Senator Mathews:
I have found, in the past, “disadvantaged” always takes precedence over “underrepresented.” You end up not getting the result you intended. If this bill passes, we are going to have to state clearly in a letter of intent what we are seeking. Otherwise, we will end up with a bunch of females.
Senator Washington:
I understand your concern, and I want to explicitly state for the record this is not a set-aside. This is for those students who have an aspiration and a dream, they are doing well and working hard in their academics to enter the School of Medicine or Dentistry, but may not have the resources or means because of family or financial situations. This could provide the opportunity to achieve their dream.
Senator Mathews:
Ask me to be on the committee. When I took over the program at the community college, we had very few minority students in the program because they said they did not qualify. I can tell you how to qualify. There was not a year during my time there that there were less than five minority students of the twenty students in the program.
Senator Raggio:
What criteria do you anticipate the Board of Regents will set and the Interim Finance Committee will approve? What criteria would you suggest?
Senator Washington:
I would say the criteria will be maintained at current levels. I do not expect it to change.
Senator Raggio:
Would this in any way create a quota system?
Senator Washington:
I would hope not. We are not seeking a quota system. We are seeking opportunities for those students who are disadvantaged, not based solely on their ethnicity, gender, financial resources, or socioeconomic status.
Senator Raggio:
I do not think $50,000 a year will pay for too many students’ registration fees, books, and living expenses.
Senator Washington:
No, it will not. The medical and dental schools are looking for the best and brightest. The minority students who have achieved a high academic standard are who we really want to target.
Senator Raggio:
Do you anticipate academics will be included in the criteria?
Senator Washington:
Yes.
Rick Bennett, Lobbyist, University of Nevada, Las Vegas:
I would like to submit a letter (Exhibit C) from Dr. Patrick Ferrillo, dean of the dentistry school at the University of Nevada, Las Vegas (UNLV). I would add competition is strong for these students. They have their choice of schools because they are accepted at several schools. Scholarship packages help in attracting and admitting students we have accepted.
Senator Coffin:
The University of Michigan is going through turmoil in the courts on the question of apportioning scholarships and placements. Would you expect this or other programs to be in trouble if the U.S. Supreme Court rules against Michigan?
Senator Washington:
Absolutely not, because this is not a quota or set-aside. There is no specified percent or number of students who have to enter into the School of Medicine or Dentistry. This is a scholarship fund.
Senator Coffin:
Michigan actually set a numerical quota?
Senator Washington:
Yes. It was based on affirmative action. Students were given a certain amount of points based on factors such as ethnicity. This bill does not do that.
Senator Raggio:
We will now open the hearing on S.B. 152.
SENATE BILL 152: Makes appropriation to University and Community College System of Nevada for renovation of former Mesquite High School for use as part of Community College System. (BDR S-1063)
Senator Rawson:
This issue was brought to me as chairman of the Senate Committee on Human Resources and Facilities. For several sessions, Mesquite has been on the priority list with a $5 million project for a community college. They have never made the cut with the available money. They now have 250 students in a storefront property. The people of Mesquite decided they would try to help the process, so they purchased the old high school. Parts of the school are relatively modern and in good shape, but they need $1.2 million to renovate the building to be able to offer their programs. This bill asks for $970,000. The community has committed to paying the rest. They have essentially cut this from a $5 million project to a $1 million project. I think that is responsible on their part, and I wanted you to know that.
Senator Warren B. Hardy II, Clark County Senatorial District No. 12:
Mesquite is the fastest-growing community in the fastest-growing State in the nation. It has gone from about 2200 residents in 1991 to just over 17,000 today. Education is very important to the people of Mesquite. In 1997, the Legislature awarded money to begin planning a community college facility. At that time, the community college had it on their priority list and felt it was going to be desperately needed in the future. It is my understanding the person assigned by the community college to shepherd this through the process died. We brought it back in the 70th Legislative Session, but there was no money available at that time. We did not quite make the cut in terms of need.
The councilmen explained to the community that a project requiring construction costs of $5 million to $8 million was not feasible, considering economic conditions. In the mid‑80s, there was significant renovation to the school. The community realized, with additional renovation money, they could use the existing facility and provide for the needs of the community college for the next 15 to 20 years, and not return to the Legislature for capital funds. On their initiative, they made arrangements to acquire the property. Through exchanges, the city basically purchased the school and is making it available. I believe they have shown a great deal of initiative. This kind of thinking in tough economic times certainly should be rewarded.
Senator Mike McGinness, Central Nevada Senatorial District:
One of the issues Mesquite is serious about is establishing a campus for the community college. They have worked on this for a number of years. They have been disappointed, but they have decided to embark on a program to help themselves. The city has committed about $350,000 annually to the operation and maintenance of this joint facility. They have $1.1 million to purchase the site from the Clark County School District. The city has a proposed lease agreement with the community college and has worked closely with the college to develop a plan for expansion. The first community college class I ever took was held in the Churchill County high school. I think the sharing of community college classes with local school facilities is a great partnership.
Senator Raggio:
So, the college is functioning there with about 250 students, but in a storefront property.
Senator McGinness:
That is correct.
Senator Raggio:
If this was constructed or renovated, is there a potential for a larger number of students than there are presently?
Senator Hardy:
We believe there is significant potential.
Senator Rawson:
Mesquite is only 30 or 40 miles from southern Utah, so many of the kids go to Dixie State College of Utah, which is a loss to Nevada.
Assemblyman Joseph Hardy, Clark County Assembly District No. 20:
My district includes the new Mesa View Hospital, which is scheduled to open in 2004. At the groundbreaking ceremony about a month ago, 500 citizens attended. There is a need for medical care in Mesquite and the surrounding area, and there will be programs in this college for nursing, telemedicine, and other medical fields. There will also be more vocational facilities, which will improve our workforce and allow our children to stay in Nevada.
Senator Raggio:
Any of these bills containing appropriations not included in the Executive Budget are probably not feasible, unless there are additional revenues at the State level. Do you think the people in the district will support this? Without additional revenue, and possibly new taxes, these kinds of projects are not going to be considered.
Assemblyman Hardy:
If we look at the history of what Mesquite has already done, they have put their wallets on the line. They have recognized the need. This is the kind of thing we need to seriously look at to allow our State to continue to grow. We need to provide nursing education and other vocational training so we can.
Senator Hardy:
I have never heard anything from my constituents other than they want us to act responsibly. They want us to cut where we can and look at the budget line item by line item. When we have done that, they are prepared to pay additional monies. I am prepared to vote for additional taxes.
Senator Raggio:
The taxation committees are the key to all this. We have a number of bills from members of the Legislature for very worthy purposes, each of which has a price tag. We are also trying to balance a budget and act responsibly. We all need to keep that in mind.
Senator Hardy:
We have had extensive meetings with Dr. Jane Nichols and Dr. Ronald Remington to discuss finding money to do this outside of the legislative process. They have committed to doing everything they can to make this happen, regardless of appropriations. We are committed to doing everything we can.
Senator Raggio:
My question to Dr. Remington concerns the interest and priority of the Board of Regents in this project.
Dr. Ronald Remington, President, Community College of Southern Nevada, University and Community College System of Nevada:
We have not been able to give the attention we should to our outlying centers. I believe the bill you are considering is a very responsible way to help us grow the community college in Mesquite.
Senator Raggio:
Why is this not on the list of capital improvement projects recommended by the Board of Regents?
Dr. Remington:
I believe this strategy came up after we pulled our list together. The timing was not as it should have been.
Senator Raggio:
Ordinarily, we would not look at something like this unless it was on the capital improvement projects list recommended by the Board of Regents. What, if anything, has a higher priority than this in your system?
Dr. Remington:
We have a health science facility that is critical to meeting needs in Nevada. We have to go forward with it. The people representing Mesquite are really asking that we allow them the opportunity to grow the enrollment. I believe we could quadruple the enrollment if we had the facilities to handle it.
Senator Raggio:
Why will a renovated facility do that?
Dr. Remington:
We will have access to more classroom space than we currently have.
Senator Hardy:
We believe this will more than triple the room available. I think we, the people of Mesquite, bear a large part of the responsibility for this not being higher on the priority list. We did not communicate with the community college as well as we should have. We were thinking in terms of how we could do this locally. We cut back significantly on our request, but we realized we were going to be $1.2 million short. At that point, we brought it to the attention of the community college.
Senator Raggio:
How much have they raised in Mesquite?
Senator Hardy:
If you include the land, we will be contributing about $1.5 million locally.
Senator Raggio:
They bought the school.
Senator Hardy:
That is correct.
Senator Raggio:
Who owns the school?
Senator Hardy:
The city of Mesquite owns the school.
Senator Raggio:
If it were renovated, you have the additional cost of staffing, plus furniture, fixtures, and equipment. Are you prepared to invest that?
Dr. Remington:
We are willing to meet the people in Mesquite halfway.
Senator Raggio:
What does halfway mean? Staffing is a considerable expense, and you would have to bear the cost of staffing.
Dr. Remington:
It is an expense, but this is a reasonable way of assessing what we can do in Mesquite.
Senator Raggio:
Are you prepared to do the staffing and whatever is necessary for the operation and maintenance of this facility?
Dr. Remington:
Absolutely.
Senator Mathews:
How far from Las Vegas is Mesquite?
Senator Hardy:
It is 78 miles. This could also serve Moapa Valley, which is about 24 miles from Mesquite, versus 45 miles to Las Vegas.
Senator Mathews:
And Dixie Valley is about 44 miles away?
Senator Hardy:
That is correct. We are losing a considerable number of students to Utah.
Senator Mathews:
There is a new high school in Mesquite now. Is there some way the school district can help with this project? I am just thinking about marrying the two.
Senator Raggio:
They sold the high school.
Senator Hardy:
I believe Senator Mathews is referring to the existing high school.
Senator Raggio:
Yes, but they sold the old high school to the city.
Senator Hardy:
Yes. It has been operating as an elementary school for several years. We considered that possibility, but the problem is we need to provide daytime classes. We are at the limit of nighttime classes, so that arrangement does not work in this situation. I want to emphasize the city tried to find a way to do this without asking the Legislature for help. We are $1.2 million short.
Senator Mathews:
Can you move the Henderson faculty out there if we pass this? If so, you would not have faculty expense.
Dr. Remington:
We will rely on part-time faculty for some time. When enrollment grows, we can locate full-time faculty there, just as we have done with some of the outlying centers elsewhere.
Senator Raggio:
We will now open the hearing on S.B. 153. This is a requested appropriation for $150,000 each year.
SENATE BILL 153: Makes appropriation to Nevada Center for Ethics and Health Policy for training of state and local leaders and health care providers regarding human and ethical aspects of bioterrorism. (BDR S-1060)
Deborah Ballard-Reisch, Coordinator, Bioterrorism Risk Communication Project:
I am not the author of this proposal, but I want to speak in support of it from the perspective of what the State is already being funded to do through the federal government with respect to bioterrorism preparedness. Last July, the federal government gave Nevada almost $10 million through the Health Division to address the creation of a public health infrastructure prepared to meet bioterrorism needs, as well as other public health issues. That money does not address any of the psychosocial, ethical, and personal issues that affect the public as a result of having to manage reality within the context of the potential for bioterrorism.
To illustrate, at a conference a few weeks ago, one of the speakers decided to use duct tape and plastic sheeting as visual aids for his presentation. This was less than 24 hours after the speech regarding emergency preparedness by the federal government. There was no plastic sheeting or duct tape anywhere in Reno or Sparks. This indicates to us there are significant pressures on the public at this point that federal money is not earmarked for or addressing. This proposal by the Nevada Center for Ethics and Health Policy goes a long way in starting that dialog and bringing our attention to issues that are fundamental from the people perspective in regard to bioterrorism. Ethical questions have emerged in every focus group during training, and there is no mechanism at this time to pay for development of that training. I speak in favor of this proposal because I believe it compliments what the federal government will give us in terms of revenues to support the public health infrastructure. It brings to our attention issues such as civil liberties versus national security, individual rights versus public health, and will allow us to develop mechanisms for helping those who must make decisions to do so effectively.
Senator Raggio:
How is the Nevada Center for Ethics and Health Policy funded?
Noel Tiano, Director, Nevada Center for Ethics and Health Policy, University of Nevada, Reno:
The center is funded through a statewide enhancement through the University of Nevada, Reno (UNR).
Senator Raggio:
Is there any federal funding available for this?
Dr. Tiano:
Not for this particular project or the center.
Senator Raggio:
Your “Proposal to Provide Ethical and Health Policy Information and Training Regarding the Human Aspects of Bioterrorism” (Exhibit D) shows a budget for the use of this potential funding over a 2-year period.
Dr. Tiano:
That is correct. In summary, our proposal is for the Nevada Center for Ethics and Health Policy to train State leaders, local leaders, and health care providers about the human and ethical aspects of bioterrorism. Our center has a statewide program focusing on ethics and policy throughout a person’s lifespan. Within that context, we propose a contracting project utilizing our coalition consisting of 70 organizations throughout the State, as well as Nevada’s existing disaster preparedness resources. Our proposal is to convene a statewide forum for federal, State, and local leaders and stakeholders to address major human and ethically-related issues, such as confidentiality, privacy, civil liberties, and how this impacts the frail, the chronically ill, the elderly, and people with disabilities. Health care workers and providers must be prepared for death and dying issues, such as grief and bereavement, and how cultural and spiritual issues of a diverse population can be addressed during such emergency situations.
Senator Rawson:
I have distributed pages (Exhibit E) from magazines, which highlight some of these issues. Some things can be stockpiled and securitized, and we can take care of most of these issues, but there is an ethical aspect tied to each of them. For example, during the anthrax scare, there was a run on antibiotics. There was concern they would be depleted. Questions arise, such as who should receive the antibiotics: should it be distributed just to the people exposed, the elderly, the young, people on Medicaid, or only to the people who can afford it. During the interim, we struggled with all of the issues of the Model State Emergency Health Powers Act. We had dramatic hearings. Six meetings were filled with people concerned about their civil liberties and religious exemptions.
In a serious bioterrorism incident, the worst-case scenario is there could be up to 3 million fatalities. Millions of people would be restricted, quarantined, or detained. Are families allowed to be with other family members? Will children be separated from parents? Will they have access to telephones? There will be a bill on the Senate floor regarding the granting of public health powers in the State, but the ethical issues remain. There is no one to train the health care workers, the police, or fire departments on all of these issues. I understand the problems we are facing in this session, but our awareness of the potential for these situations has been heightened in the last year or so. It would be irresponsible for us to ignore this. We present this for consideration and realize it will be some time before a decision can be made.
Senator Coffin:
I believe I now understand why this bill has been directed toward the center as opposed to the State emergency preparedness group. However, if there are contagious diseases introduced into society, either intentionally or by accident, you sometimes have to forcibly do what you need to do to protect the greater good of society.
I believe the last country where smallpox existed was India. The army had to go in and forcibly inject people with the vaccine, against their religion, to prevent it from spreading. Will there be time for ethical studies or the consequences of it at that point?
Dr. Ballard-Reisch:
We do not have time to develop an ethical plan once something has happened. One of the reasons this is so compelling now is we still have the opportunity to preplan. We can be proactive instead of reactive. We will be able to develop a strategy and a plan to determine how people will be treated, and create a system to consider ethical issues. That is the most valuable piece of this possibility, the opportunity to step forward now to develop guidelines and structures that allow us to figure out how to negotiate these situations, so when they emerge, we can move quickly and efficiently.
My particular issue with respect to this plan is federal guidelines and money have nothing addressing psychosocial and ethical aspects. They are still geared toward developing public health infrastructure, such as hospital preparedness, surveillance, epidemiology and lab capacity, as well as training providers in issues such as identification of smallpox, because most providers have not seen an actual case of smallpox.
Senator Coffin:
I challenged you on this because I think we have already fought this battle. It was only about two generations ago when we decided it was our policy as a country, and, through the United Nations, forced other countries to inoculate their citizens, as we had forced our own population to undergo inoculations. I do not know of a new religious objection to this that did not exist then.
Senator Rawson:
With the passage of time, a lot of attitudes have been rethought in this country. We see the states writing consensual medical treatment and quarantines into their laws. For example, if there was an exposure to smallpox today and you did not want to be vaccinated, you could be isolated in your home or somewhere else. Whether we approve of that or not is the ethical issue.
More importantly, people have to be trained in dealing with death and dying in large numbers of people. Our nursing students have a seminar in death and dying, but only concerning one person at a time. None of us are prepared for a mass casualty in this country. From my own experience, I helped in the identification of 111 victims from the Sioux City crash, and it took me 2 years to recover from it. There is tremendous emotional pressure from dealing with that much tragedy. We are talking about something much bigger than my experience.
Dr. Tiano:
The Nevada Center for Ethics and Health Policy began in 1999 through a grant from the Robert Wood Johnson Foundation specifically to improve care at the end of life in Nevada. We have had a lot of experience with regard to training professionals, as well as individuals, in addressing death and dying, grief, and bereavement issues. We see this as a need in our State.
Senator Mathews:
What connection do you have with the State homeland security department? Is there any dialog between you and that department?
Dr. Ballard-Reisch:
I have been coordinating the risk communication focus area of the grant. I have done focus groups with stakeholders throughout the State, who will be talking with Legislators in the next couple of weeks. I have worked with Karen Seale from the Area Health Education Center, who does the training and education component of the grant, and Jim Najima, who is coordinator of the public health preparedness project for the State. I am involved in their project, and they have been informed of this proposal. We have talked about the possibilities for collaboration. This effort is related, but it would not be under them because they have no money to do it. This is not a priority.
Senator Mathews:
Do they have any money yet?
Dr. Ballard-Reisch:
Yes.
Senator Raggio:
I am personally acquainted with the Nevada Center for Ethics and Health Policy and its programs dealing with death and dying. I compliment you on your efforts over the years.
We will now open the hearing on S.B. 154. It requests $200,000 a year in the next biennium.
SENATE BILL 154: Makes appropriation to Great Basin College of University and Community College System of Nevada for establishment of oral health clinic in Elko. (BDR S-304)
Senator Rhoads:
Senate Bill 154 appropriates $200,000 each year for the next 2 years for start‑up costs to establish an oral dental clinic at the Great Basin College in Elko. It would serve Medicaid recipients, indigents, and handicapped people. Of 51 dentists surveyed in Elko, White Pine, Eureka, Lander, and Humboldt counties, only 10 accepted Medicaid, and only 5 are active. The Office of Rural Health surveyed the rural areas and recognized the need for such a program.
Senator Raggio:
As you are aware, this appropriation is not included in the Executive Budget. It will require additional revenue at the State level to accommodate these kinds of requests.
Senator Rhoads:
I have served in the Legislature for 25 years. I have never signed a no‑tax pledge. I recognize we need to broaden the tax base.
Senator Raggio:
I bring this up because I believe you serve on the Senate Committee on Taxation.
Gerald Ackerman, Assistant Director, Office of Rural Health, School of Medicine, University of Nevada:
When Winnemucca requested we study dental access in the community, I found dentists in Humboldt County were trying to retire, but could not because other dentists did not want to come in and take over their practices. A dentist actually offered to give his practice to anyone at the meeting who would take it. I believe he was one of the few dentists at that time who accepted Medicaid children, which is why the hospital did not want to see him retire.
Senator Raggio:
Why do more dentists not take Medicaid?
Mr. Ackerman:
I think there are several reasons.
Senator Raggio:
Is failure to pay promptly one of them? Reimbursement amounts? Things of that nature?
Mr. Ackerman:
One of my observations is Elko has enough private‑pay patients to keep the dentists busy.
Senator Raggio:
How would the establishment of an oral health clinic address that issue?
Mr. Ackerman:
According to data at the time, there are about 7000 Medicaid kids in the area.
Senator Raggio:
But you are only reimbursed a certain amount of money from Medicaid. If the dentists are not willing to take these patients now, how will an oral health clinic change that?
Mr. Ackerman:
This will not only be a clinic, but it will also have dental students and dental residents rotating from UNLV’s School of Dentistry. One of the problems we face is many of these patients are very young, and we have no pediatric dentists in Elko or rural Nevada. Currently, we are participating in a project which brings in a pediatric dental resident just to do screening clinics in Elko. To date, we have done 92 screenings; of those, about 25 percent need immediate oral surgery. We are already scheduled through May or June for oral surgeries. Access to pediatric dentists is an issue because general dentists do not like to see those little kids squirming around in the chair. I drive my own children to Reno or Salt Lake City to see a dentist. We have a commitment from pediatric dental residency, and we are working on hospital privileges for faculty from UNLV, so surgeries can be performed at the hospital in Elko. The hospital has agreed to make arrangements for that to happen. The other problem is a shortage of dentists, period.
Senator Coffin:
Does Elko have fluoridated water to help prevent cavities in youngsters?
Mr. Ackerman:
It does not.
Senator Coffin:
Has that become a controversial issue in town?
Mr. Ackerman:
I would say it is an issue that no one has pushed very hard. There are 17,000 people in outlying areas who are not on city water. You are only going to reach a small portion of the population.
Senator Coffin:
The majority of the population of Elko is not on city water?
Mr. Ackerman:
The city of Spring Creek, with a population of about 15,000 people, is on the other side of the hill. We have several people on the outskirts who are on well water.
Senator Rawson:
The “Crackdown on Cancer” program went to Elko this last year and did a good survey of the kids and their oral health. They found the carries rate in Elko is twice the rate of the rest of the State. There is twice the number of filled teeth, but there is also twice the number of unfilled teeth. The kids are underserved. They have more dental disease, and there are not enough dentists to take care of it.
Senator Raggio:
Why, out of 51 dentists, are only 5 actively taking Medicaid patients?
Senator Rawson:
There are six or eight issues we can see. Probably the most important is Medicaid actually pays 37 percent of the usual and customary office fee. There is a high no-show rate, typically 30 percent. The dental school has actually found it to be 40 percent this year. If a dentist is not even being paid his or her overhead, and gives that time up to a patient who does not show up, he or she is taking a loss. They will only do it a few times before taking the attitude they do not want to deal with it. Beyond that, there has been a fair amount of difficulty in getting paid. We have tried to work through all these things. There has been fee realignment, but in reality, there is just not enough money.
Linda L. Sheldon, Lobbyist, Great Basin Primary Care Association:
I am here to support this project. Great Basin Primary Care Association received a grant from the Fund for a Healthy Nevada for $855,000 over a 2-year period to establish dental facilities in rural Nevada, and to expand Health Access Washoe County, which is seeing most of the dental patients on the western side of Nevada and has a huge backlog. We partnered with the School of Medicine Office of Rural Health to establish a clinic in Elko, and to serve the patients in Winnemucca. Seed money of about $94,000 was given over a 2‑year period, which is a minimal amount of money to establish a dental clinic. This seed money has produced other partners.
We are also in the process of serving patients and establishing dental clinics in Fallon, Yerington, and Silver Springs. We are partnering with Health Access Washoe County and the Washoe Tribal Health Clinic. The tribal clinic is seeing non‑Indian children and disabled adults. The School of Medicine has been very innovative in putting this project together, using donated equipment and donated space from Great Basin College. The money they are requesting for this project is necessary for the families.
We are pursuing as many grants as possible in order to augment services, provider salaries, and other items. We have a grant out right now for salaries for dentists, which would pay for a full-time dentist in Elko and a full-time dentist in Silver Springs. We are trying to establish clinics throughout Nevada and give them enough seed money so they can continue to operate. Medicaid has been an issue. Most of the dentists practicing in rural Nevada have enough full‑pay patients that they do not need to take Medicaid. Because of the reimbursement rates and the no‑show rate, combined with the fact they are not required to see Medicaid patients, they choose not to. We have been to the point of begging dentists to see these kids, but they do not want to participate. We are using S.B. 133 to bring in dentists.
SENATE BILL 133: Revises requirements for certain licenses to practice medicine if applicant intends to practice medicine at certain mental health centers under certain circumstances. (BDR 54-508)
The grant pays for Dr. Ryan Johanssen to be in Elko part time to screen these kids, then take them to Salt Lake City. We are using Western Interstate Commission for Higher Education (WICHE) dentists who are required to do their loan repayment either through the Health Care Access Program or the pro bono program, and we pay them a travel stipend to come and work for 2 days at a time. We are exhausting as many possibilities as we can to establish these clinics. It has been a long road. We are beginning to see services being provided to children.
Senator Raggio:
Do you have a clinic in Fallon?
Ms. Sheldon:
The Fallon Tribal Health Clinic is participating. They are seeing the non-Indian children in Fallon. There is a WICHE dentist there 2 days a month, and a hygienist there 1 day a week providing dental hygiene services. The Silver Springs hospital district board is building a four-chair dental facility for their patients in Silver Springs. They have been proactive in providing services, and they are one of our partners. They received $25,000 through the grant.
We are in the process of finalizing plans in Yerington. A generous businessman is remodeling the facility and is going to lease it to us for 40 cents a square foot. It will have four chairs and will serve Yerington, Smith Valley, and probably Hawthorne. Health Access Washoe County added three more chairs to their facility, for a total of ten chairs. They are also in the process of purchasing another practice on Neil Road, which will have six chairs.
Mr. Ackerman:
We have talked about the service delivery; now, I would like to discuss the training aspects. We are putting a lot of money into the dental school and into dental residencies. One of the issues is how we make an impact statewide with our training programs. In 1989, I think we had one School of Medicine graduate practicing in the Elko community. Today, we have five who have graduated from the School of Medicine or the residency program. Many of them are there because of their rotation or training experience in the community. A few of them are there because of marriage. We have also had three or four physician assistants rotate through Elko, then practice there. The question is how do we also get our dental professionals out in the State. Training students in rural areas does make an impact, because they see opportunities and they find areas they like.
In medicine, we have residents rotate with community physicians; they go in and see patients. I understand it is difficult to do in dental practices because of chair limitations and the procedures that are done. The Great Basin College facility would allow us to bring in dental residents, give them experience in rural Nevada, and make an impact. It also allows us to show them parts of Nevada that have wonderful opportunities for opening practices. In the future, dental students and hygienists could also be rotated.
Senator Rawson:
Since the bill was drafted, I have gone back and asked them to pare down the projected financials. We have a budget (Exhibit F) that needs $204,000 the first year to start the clinic and do the remodeling of the existing building, which has been donated to the college. We have worked with the Gallaghers and brought the dental community in to see that this is not disruptive. They are appreciative and supportive of this program. The hospital has come forward in support of the program because we cannot get anyone to cover dental emergencies. The revenue from the Medicaid capitated fee for kids in the surrounding counties will bring in a revenue source that will make this possible. The $204,000 is a one‑time request to get this off the ground. Our business plan does not show a lot of profitability, but it does operate in the black.
Senator Raggio:
If it were approved, are you saying the total cost would be $204,000?
Senator Rawson:
Yes.
Mr. Bennett:
I would like to make a couple of points. First, I know Dr. Ferrillo plans a very active role for his students in regard to providing service in the rural areas. I have seen the data relating to the Nevada Check Up program, and the numbers relating to the need for dental services in the rural areas are startling. The other point is UNLV is operating a couple of dental practices primarily serving Medicaid patients. There was a learning curve related to providing service in a profitable way, but we are doing that now. It can be done.
Senator Raggio:
We will now open the hearing on S.B. 178. This has a proposed appropriation of $160,000.
SENATE BILL 178: Makes appropriation to University and Community College System of Nevada to create embalming facilities and plasticization laboratory to ensure that medical and dental schools can use anatomical specimens more efficiently for educational purposes. (BDR S-1064)
Senator Rawson:
Professional students learn anatomy by working on human bodies, which are donated by people wanting to support medicine and science. We have a willed body program in Nevada, and UNR has an intake center, which enables them to process bodies there for use by their medical students. Over 200 residents in southern Nevada also need training opportunities. To learn procedures, they have to work on the human body, but they do not have facilities in southern Nevada. Dental students also have anatomy classes. This facility will receive human bodies from the willed body program, perform the proper embalming, then do plasticization.
Plasticization is a technique which has recently been developed. Instead of using formaldehyde, all of the water is taken out of the body with acetone and silicone is substituted. It is cleaner and does not raise Occupational Safety and Health Administration (OSHA) concerns. It is plastic, but it retains the feel of human flesh. The body is permanently preserved. This means we will have to process fewer bodies, so it will be far less expensive over the long run. Formaldehyde is a carcinogen according to OSHA, so students can no longer work with bodies containing formaldehyde. The Reno facility has a grant to update their lab space to meet OSHA guidelines, but we need someone handling this in southern Nevada. They would work in conjunction with the dental school.
Recently, I went to the University of Michigan to see their facilities and the actual plasticization process. It will be a great boon to our university system to be able to do this. The alternative is we forget about using human bodies, and everything becomes virtual. I can tell you if our surgeons learn anatomy strictly from a computer, we will have increased error rates. This is an important issue to us.
Senator Raggio:
How would the $160,000 be utilized?
Senator Rawson:
It would be strictly for the long-term items, such as the building and equipment. The diagram (Exhibit G) shows the steps and equipment involved.
Senator Raggio:
Do we have a breakdown of the $160,000?
Senator Rawson:
I did not bring it with me, but I will provide it (Exhibit H). I believe all the items could be capital improvement projects because they are all longer lasting. The system has the personnel to operate this facility, so we do not need money for personnel or operating expenses.
Senator Mathews:
Did you say formaldehyde is now considered toxic?
Senator Rawson:
Yes. OSHA has a new guideline that if you are going to use specimens with formaldehyde, you have to have specific air systems and students have to wear respirators and full-body suits.
Mr. Bennett:
The dean of the dental school has provided a letter of support (Exhibit I) and recognizes the benefit of this type of facility for training medical and dental students.
Senator Coffin:
Is the term “plasticization” or “plastination”? I see both used.
Senator Rawson:
Both words are used for the process. The real term is plasticization.
Senator Coffin:
Can you then use a cadaver more often? Does it increase the use?
Senator Rawson:
It does. Sections done now last for maybe a semester, then they are discarded. A section from a plastinated body can be used for 10 years.
Senator Raggio:
We will continue the hearing on S.B. 190 from our previous meeting.
SENATE BILL 190: Makes appropriation for creation of certificate program and provision of stipends to certain teachers. (BDR S-894)
Craig Kadlub, Lobbyist, Clark County School District:
We are supportive of S.B. 190. We believe it supports one of the components of iNVest, which is the proposal endorsed by superintendents and school boards statewide. In the interest of being consistent with the iNVest proposal, Clark County School District would support amending the language in this bill so the distribution of the appropriation goes to all the regional professional development centers, rather than just the one in southern Nevada.
Senator Cegavske:
I was on an airplane with Bill Hanlon, and he explained the theory and development of this. I was impressed and enlightened as to what they are teaching the teachers and how they teach the kids. I am impressed with the program and think it is worthy of our support. I understand Mr. Hanlon actually went into classrooms and evaluated teachers on their math teaching skills. I was impressed that they went in and identified what was not happening; this knowledge was essential. They were also able to do something similar for the reading program. I am very supportive of this whole concept.
Terry Hickman, Lobbyist, Nevada State Education Association:
There has been much discussion about the need for math, science, special education, and ESL (English as a second language) teachers. That discussion has included talk about providing stipends or bonuses as an incentive to bring teachers into those fields. The Nevada State Education Association has gone on record opposing the bonuses as proposed because we believe the disparity in salaries this could create could have a long-term detrimental effect on the teaching profession. We are much more supportive of the concept represented in S.B. 190 as a way to encourage teachers to become math, science, special education, or ESL teachers. This bill provides a financial incentive for teachers to move into these fields and seeks to ensure those teachers are highly qualified. Their performance is also monitored and supported through the regional professional development program. Teachers who volunteer for this program would subject themselves to a high degree of scrutiny, and they would be compensated for participating in the program. This bill would ensure teachers possess appropriate subject knowledge, instructional skills needed to impart that knowledge, and classroom management skills necessary to create the optimum learning environment for the students. Rather than simply rewarding teachers for what they teach, this bill would reward them for improving how they teach.
The Nevada State Education Association supports stipends for teachers who receive their national board certification, because it has been shown that the rigorous process which these teachers must go through ensures their teaching performance is of the highest caliber. S.B. 190 would similarly improve the quality of teaching. We hope you will give serious consideration to S.B. 190 as a pilot program for enhancing the quality of teaching and, if successful, expanding that program from Clark County to the rest of the State through the professional development centers.
Senator Raggio:
Since there is no further business, this meeting is adjourned at 9:32 a.m.
RESPECTFULLY SUBMITTED:
Denise Davis,
Committee Secretary
APPROVED BY:
Senator William J. Raggio, Chairman
DATE: