MINUTES OF THE
SENATE Committee on Human Resources and Facilities
Seventy-second Session
March 3, 2003
The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 1:40 p.m., on Monday, March 3, 2003, in Room 2135 of the Legislative Building, Carson City, Nevada. The meeting was videoconferenced to the Grant Sawyer State Office Building, Room 4406, 555 East Washington Avenue, 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 Raymond D. Rawson, Chairman
Senator Barbara Cegavske, Vice Chairman
Senator Maurice E. Washington
Senator Dennis Nolan
Senator Joseph Neal
Senator Bernice Mathews
Senator Valerie Wiener
GUEST LEGISLATORS PRESENT:
Senator Alice Constandina (Dina) Titus, Clark County Senatorial District No. 7
STAFF MEMBERS PRESENT:
H. Pepper Sturm, Committee Policy Analyst
Cynthia Cook, Committee Secretary
OTHERS PRESENT:
Janelle Kraft, Budget Director, Las Vegas Metropolitan Police
Richard E. Steinberg, President, WestCare Community Triage Center
Kathryn Landreth, Chief of Policy and Planning, Las Vegas Metropolitan Police
Gary E. Milliken, Lobbyist, American Medical Response
Michael J. Willden, Director, Department of Human Resources
Michael R. Alastuey, Lobbyist, Clark County, University Medical Center
Vic Davis, Nevada Alliance for the Mentally Ill
Jon L. Sasser, Lobbyist, Washoe Legal Services
Robert Desruisseaux, Assistant Technology Specialist, Northern Nevada Center for Independent Living
Jan Gilbert, Lobbyist, Progressive Leadership Alliance of Nevada
Chairman Rawson:
We call the meeting to order. I ask for committee introduction for two bill draft requests (BDRs).
BILL DRAFT REQUEST 34-452: Makes various changes concerning administrative due process hearings pursuant to Individuals with Disabilities Education Act. (Later introduced as Senate Bill 234.)
BILL DRAFT REQUEST 38-746: Revises provisions governing payment of hospitals for treating disproportionate share of Medicaid patients, indigent patients or other low-income patients. (Later introduced as Senate Bill 235.)
SENATOR CEGAVSKE MOVED TO INTRODUCE BDR 34-452 and BDR 38-746.
SENATOR WIENER SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR WASHINGTON, SENATOR NOLAN, AND SENATOR NEAL WERE ABSENT FOR THE VOTE.)
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Chairman Rawson:
We will open the hearing on Senate Bill (S.B.) 94.
SENATE BILL 94: Provides for medical treatment in medical facility other than hospital under certain circumstances for certain allegedly mentally ill persons and for medical treatment for certain persons who are under influence of controlled substance. (BDR 39-745)
Janelle Kraft, Budget Director, Las Vegas Metropolitan Police:
The Chronic Public Inebriate Task Force has recommended measures to resolve hospital emergency room overcrowding. It is estimated mentally ill and chronic inebriates account for 13,000 emergency room visits annually. Individuals receive high-priced medical screening and wait for days in the emergency room. The task force determined an alternative would be to establish a crisis triage center at WestCare, a nonprofit provider of alcohol and substance use treatment, near University Medical Center and Valley Hospitals. This bill enables emergency responders to bring individuals experiencing mental illness or chronic inebriation to the crisis center rather than admitting them to hospital emergency facilities. The task force has met with the Bureau of Licensure and Certification, Division of Mental Health and Developmental Services, WestCare Community Triage Center, paramedics, and police. This bill will allow the transport of individuals to other than emergency rooms.
Chairman Rawson:
I would like to establish some history for the record. There is a serious problem with divert and backup in our hospitals. The most recent estimate is 800 hours of divert monthly, and it impacts all hospitals. An average of 53 individuals with mental health disease are backed up in hospitals. Although one‑third to one–half are identified with mental health disorders, the remaining individuals must be released without accessing needed services. The situation has resulted in the doubling of ambulance response time.
We are receiving hundreds of e‑mails urging us to cut the budget. Nevada is fifty-first in the country in many important services. When people want to cut the budget, this is one of the consequences. We have already cut to the bone, and backup in hospitals is the result. People who have the means to pay for emergency service suffer because of ambulance response time.
Ms. Kraft:
There are an estimated 60 thousand individuals in southern Nevada with serious mental illness. We have 88 beds provided by the Division of Mental Health and Developmental Services to handle that load. The cost to the taxpayer is massive. The problem is reflected in resources at hospitals, police departments, and the courts. The average citizen does not realize the costs associated with not treating the mentally ill.
Richard E. Steinberg, President, WestCare Community Triage Center:
The bill is modeled after plans implemented by various states. WestCare has volunteered to expand their facilities to meet the need. WestCare will provide medical treatment for detoxification and a mental health component. This will allow people who are not in need of emergency room care to be diverted to a triage center on the first assessment. The idea is to divert the large number of persons who are blocking the emergency rooms. The county and cities have come together with the hospitals, each paying one-third of the cost. I would like to see the word “staff” inserted on line 7, page 3, and line 42, page 42 before the word “secure.”
Can we process this bill without worrying about the fiscal note?
Mr. Steinberg:
We are only looking at this bill as a vehicle to move people to the triage center and divert them from hospitals.
Senator Wiener:
Studies have indicated savings for triage versus hospital stays. Do you know the numbers?
Mr. Steinberg:
There have been two studies by entities outside the treatment arena. The results of the first were $7 saved for every $1 invested; the second study claimed $14 saved for every $1 invested.
Senator Wiener:
You mentioned chronic public inebriates are the primary reason for congesting the system. Do you have any numbers?
Kathryn Landreth, Chief of Policy and Planning, Las Vegas Metropolitan Police:
Studies indicate mental health holds have eclipsed chronic public inebriate holds in our emergency rooms. In 2001 the cost of treating 5858 chronic public inebriates was $7 million dollars; the cost of treating 6864 mental health holds was over $9 million. Mental health holds may stay in the hospital longer than those in for detoxification.
Ms. Kraft:
The bill allows emergency responders to transport individuals to an alternative facility for appropriate treatment. We want to expand the current law which requires individuals suffering from mental illness be taken to an emergency room.
Chairman Rawson:
The current requirement exists because people suffering from a medical problem were misdiagnosed as being inebriated, while they may be in a diabetic coma. Will there be adequate safeguards to avoid this?
Ms. Kraft:
The bill states the Division of Mental Health and Developmental Services of the Department of Human Resources shall adopt regulations to define emergency services or care. We are working with division staff to develop an algorithm for emergency responders to follow. There is staff available at the triage center to do medical clearance. We have vehicles, donated by the City of Las Vegas, to transport directly to the hospital if during the clearance it is determined an individual requires medical services. Police and firemen make a quick assessment in the field before transport. There are individuals who are dual‑diagnosed and often it is hard to distinguish between an epileptic seizure, a serious mental illness crisis, or an overdose. We want the opportunity to transport to one place for determination.
Senator Nolan:
I am more comfortable with a paramedic’s ability to respond, make an assessment, and transport to triage than I am with police and peace officers making the evaluation. The officers generally do not have the training or the basic gear necessary to distinguish between a diabetic person and an acute inebriate.
Mr. Steinberg:
Current law allows law enforcement to transport an individual under the influence of alcohol or drugs to a detoxification center. WestCare became involved as a detoxification center in 1987. We have been treating close to 4000 individuals a year at the center, with law enforcement being the deliverer. If there are problems, there is an immediate transport to the hospital. The triage center involves the medical school, doctors, 24-hour nursing staff, and other medical support.
Chairman Rawson:
If a paramedic team thinks medical attention is necessary, is there anything to preclude delivery without delay to emergency?
Mr. Steinberg:
Nothing in this bill would preclude immediate transport to emergency.
Senator Nolan:
We would like assurance there is a minimum level of care available such as a nurse who can identify life-threatening situations.
Mr. Steinberg:
We now have a medical support system in place when the individual is first examined. The evaluation determines where the individual will be treated.
Senator Nolan:
Currently if a paramedic treats an individual with something invasive, they are mandated to transport to the hospital where initial contact was established.
Mr. Steinberg:
A number of active groups, including emergency room doctors, fire department personnel, and paramedics are evaluating the system on an ongoing basis. The problem is so large it has touched everyone, and the parties involved have been coming up with solutions.
Senator Wiener:
Are you addressing the concerns of the Bureau of Alcohol and Drug Abuse?
Mr. Steinberg:
The Bureau of Alcohol and Drug Abuse and the Division of Mental Health and Developmental Services are actively working together. The issue of co‑occurring substance abuse and mental disorders is a growing concern. The federal Substance Abuse and Mental Health Services Administration has block grants for co-occurring issues. We are discussing the issue on a regular basis.
Ms. Landreth:
The Southern Nevada Adult Mental Health Coalition, which was formed to find solutions for these problems, supports this legislation. We have just finished training 31 police officers in crisis intervention techniques. Having a place where the mentally ill, who are in crisis or suicidal can receive immediate assessment and treatment, will significantly help in dealing with the suicide problem in Nevada. Across the nation 16 percent of prison inmates are mentally ill. The cost impact for Nevada is estimated to be $20 million annually. This bill will reduce jail-overcrowding problems as well as deal with the emergency room crisis.
Chairman Rawson:
Legislation passed in this session will take effect on October 1, 2004. Is that date appropriate?
Ms. Kraft:
Our interlocal agreement requires us to secure funding and begin operating by June 30, 2003.
Chairman Rawson:
I will instruct staff to include “upon passage and approval” when preparing the amendments for our work session.
Gary Milliken, Lobbyist, American Medical Response:
We would like to add “private agency” on page 3, lines 14 through 16.
Senator Neal:
I find the language on page 3, lines 5 through 13, disturbing. By putting discretionary authority into the statute, a person who is unlawfully under the influence of a controlled substance and arrested can be transported to jail or to a facility. Sole discretion by an officer does not mean the individual is going to get the treatment he or she deserves. Once the determination is made there is no recourse. Why do you want that authority?
Mr. Milliken:
Speaking from a private ambulance perspective, if the police and fire departments are going to have the ability, we wish to be included. When we are called, our emergency medical personnel determine where to transport the individual.
Senator Neal:
If the condition of the individual appears to require emergency treatment, the discretion of where to transport lies with an emergency medical technician or a peace officer. An ambulance driver or emergency medical technician is required to have some medical knowledge, but there is no such requirement for a peace officer.
Chairman Rawson:
We will close the hearing on S.B. 94 and open the hearing on S.B. 138.
SENATE BILL 138: Requires Department of Human Resources to enter into agreement with Federal Government to determine eligibility for Medicaid at same time Federal Government determines eligibility for Supplemental Security Income Program. (BDR 38-703)
Senator Dina Titus, Clark County Senatorial District No. 7:
During the interim, I chaired the Legislative Commission’s Subcommittee to Study the State Program for Providing Service to Persons with Disabilities. Over the course of the interim, the subcommittee held five public meetings. Testimony was heard from State agencies, local government, members of the disabled community, advocacy groups, private organizations, and experts in the field. We also worked in cooperation with the Department of Human Resources. Throughout the proceedings two things emerged. Servicing the disabled should be a priority for Nevada as opposed to an afterthought. When the disabled can lead productive lives, we all benefit. We attempted to identify existing services and programs so they would be more assessable to the disabled. The bill before you represents a convergence of those goals. Senate Bill 138 requires the Department of Human Resources to enter into an agreement with the federal government to establish a single eligibility to ensure all eligible at risk children and adults with disabilities quickly receive the assessments and services they need.
Senator Neal:
As I understand this bill, it supposes Nevada will use the same requirements for Medicaid as those for Supplemental Security Income (SSI).
Michael J. Willden, Director, Department of Human Resources:
In general, all people who receive Supplemental Security Income are categorically eligible for Medicaid. The difference is how states link those individuals into the Medicaid program. The choices are to automatically accrete them into Medicaid, which Nevada does not, or require a separate application, which Nevada does. If an individual receives SSI, they must apply separately in Nevada for Medicaid and any other benefits for which they may be eligible.
The bill states if Nevada uses the same rules as the federal government to determine eligibility for Medicaid, the director shall do certain things. It seems if the rules are not in place, you do nothing.
Mr. Willden:
The wording may not be clear, but the attempt is to automatically accrete to Medicaid, once SSI eligibility is determined. I would suggest legislation might not be needed; this simply may be a policy decision.
Chairman Rawson:
I believe this is a clarification. If we make the change, this gives us the authority to reform the agreement with the federal government. We have not signed over our State’s rights because Medicaid may change in the future and not have as favorable a program as they have currently. I can see why we want to keep the ability to opt out. We will clarify this with the bill drafter to see why it was worded in that manner. This bill is only for determining Medicaid eligibility.
Mr. Willden:
Currently, the Welfare Division contracts with the Social Security Administration to make SSI determinations. Once the determination is made, the states have a choice to either automatically accrete recipients or to have a separate application process.
Chairman Rawson:
As a result, recipients may go as long as 2 years before their benefits show up, even though the federal government has approved them.
Mr. Willden:
Two years is the length of time the federal process takes. Once a recipient is determined to be eligible for SSI and applies for Medicaid, no more than 10 days elapse before enrollment. The advantage of automatic accretion is people are quickly enrolled. The disadvantage is the individuals will not have the opportunity to sign up for other programs such as food stamps. There are an estimated 3000 recipients of SSI in Nevada not enrolled in Medicaid. If they all enrolled, the cost could be as much as $3.5 million. However, if they had medical needs, they would probably already be enrolled.
Chairman Rawson:
Whether those needs are being paid through Medicaid or property taxes, they are being paid with taxpayer dollars.
Mr. Willden:
Finally, Nevada Operations Multi-Automated Data Systems (NOMADS) would need to be modified to automatically accrete these individuals. The impact to the General Fund would be for one-half of the expenses for the change.
Senator Washington:
For what reasons are those receiving SSI not applying for Medicaid?
Mr. Willden:
To my knowledge, the prime reason is they have not had a health care need.
Senator Washington:
If the estimated 3000 recipients of SSI in Nevada not enrolled in Medicaid were enrolled, and the cost could be as much as $3.5 million, then the State General Fund would be obligated for approximately one-half.
Mr. Willden:
If you subscribe to the thinking the 3000 recipients of SSI would access Medicaid, the State could be impacted $3.5 million. However, if you believe those with medical needs have accessed the system, the impact would be just for the expense of modifying the computers.
Chairman Rawson:
The unknowns emphasize the debate. I will close the hearing on S.B. 138 and reopen the hearing on S.B. 94.
Ms. Kraft:
The new language in section 2 of S.B. 94 is intended to mirror what is actually happening with inebriated individuals. Officers are allowed to take those individuals to a detoxification facility rather than to jail. We want to expand this to include those who are under the influence of a controlled substance. Currently, if an officer encounters an individual under the influence of a controlled substance, the requirement is to take the person to jail.
Senator Neal:
I do not like a situation where blacks and Hispanics may be taken to jail while whites are taken to a triage center.
Ms. Kraft:
I agree that is a possibility. Currently, all people under the influence of a controlled substance are taken to jail. This is an alternative.
Senator Neal:
To make the case, there is a possibility that could happen and serve as notice to police officers.
Michael R. Alastuey, Lobbyist, Clark County, University Medical Center:
Clark County did not file a fiscal impact statement because the wording appears to expand the types of facilities certain services could take place without increasing the fiscal burden on the county.
Ms. Kraft:
There is no intention to increase the cost to the county, merely to expand the options.
Mr. Alastuey:
The Division of Mental Health and Developmental Services is given regulatory rights to prescribe the medical facilities to which a person may be admitted. The county would want to retain the discretion to designate or recognize such facilities.
Vic Davis, Nevada Alliance for the Mentally Ill:
We have worked closely with Las Vegas Metropolitan Police on this issue, and look forward to the triage center helping people get back on their feet. Getting into treatment is the key, and S.B. 94 will work as a jail-diversion program.
Chairman Rawson:
We will close the hearing on S.B. 94 and reopen the hearing on S.B. 138.
Jon L. Sasser, Lobbyist, Washoe Legal Services:
Basically, every state has the choice of being a part of the Medicaid system. If a state is part of the system, SSI recipients are automatically eligible for Medicaid. It makes sense to have a one-stop shop instead of a two-stop shop. There are currently 38 states using this system. The Governor’s Task Force on Disability heard testimony concerning hardship to individuals who cannot access medical service until they receive their Medicaid card. I am of the opinion this will not cost the State extra money, because people with medical needs who are automatically eligible for these benefits are using them.
Robert Desruisseaux, Assistant Technology Specialist, Northern Nevada Center for Independent Living:
The center is in favor of S.B. 138. I was a member of the Governor’s Task Force on Disability and heard from families who testified obtaining transportation to nearest office was a barrier. The first need of those who are not yet enrolled in Medicaid will probably be a costly visit to the emergency room. Automatic enrollment can prove to be a less costly choice.
Jan Gilbert, Lobbyist, Progressive Leadership Alliance of Nevada:
The alliance supports S.B. 138. We have encouraged the Department of Human Resources to do this one-stop shop, and we believe there will be a cost savings over time.
Senator Wiener:
Can the additional costs for changing NOMADS be offset by savings in not having a separate application process?
Mr. Willden:
The department does not believe there will be a savings associated with automatic accretion. Upon enrollment there are notices and cards to be mailed.
Chairman Rawson:
We will close the hearing on S.B. 138. There being no further business, this meeting is adjourned at 3:06 p.m.
RESPECTFULLY SUBMITTED:
Cynthia Cook,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE: