MINUTES OF THE
SENATE Committee on Human Resources and Facilities
Seventy-second Session
March 31, 2003
The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 1:55 p.m., on Monday, March 31, 2003, in Room 2135 of the Legislative Building, Carson City, Nevada. The meeting was videoconferenced to the Grant Sawyer State Office Building, Room 4412, 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 K. Cegavske, Vice Chairman
Senator Maurice E. Washington
Senator Dennis Nolan
Senator Joseph Neal
Senator Bernice Mathews
Senator Valerie Wiener
STAFF MEMBERS PRESENT:
H. Pepper Sturm, Committee Policy Analyst
Patricia Vardakis, Committee Secretary
OTHERS PRESENT:
Ruth Mills, President, Nevada Health Care Reform Project
Pilar M. Weiss, Lobbyist, Culinary Workers Union Local 226, HEREIU
Jon L. Sasser, Lobbyist, Washoe Legal Services
Marie H. Soldo, Lobbyist, Sierra Health Services, Incorporated.
Robert A. Ostrovsky, Lobbyist, Nevadans for Affordable Health Care
Michael J. Willden, Director, Department of Human Resources
Chairman Rawson:
We will open the hearing on Senate Bill (S.B.) 327.
SENATE BILL 327: Provides for reuse of certain prescription drugs. (BDR 39-66)
Senator Valerie Wiener, Clark County Senatorial District No. 3:
Senate Bill 327 provides for the reissuance of certain prescription drugs. It is important to establish a Statewide policy that ensures our best use of prescription medications. Prescription costs are skyrocketing, yet we still experience substantial waste. Senate Bill 327 will facilitate substantial accountability for discarded prescriptions.
Senate Bill 327 addresses how we can efficiently and cost-effectively utilize prescriptions in four areas: 1) public and private mental health facilities; 2) skilled nursing and intermediate care facilities; 3) nonprofit care facilities; and 4) State corrections facilities and institutions.
Section 1 allows, not mandates, public or private mental health facilities to return a dispensed prescription drug not used by the patient. The patient might be allergic to the medication, it may not be effective, or the patient may die before their entire prescription drug is used. Currently, law requires the disposal of medication.
This bill will allow unused medication to be returned to the dispensing pharmacy, and to be reissued to fill other patients’ prescriptions in the same facility. This will apply if the drug is not a schedule II drug; it is dispensed or unit dosage in individually sealed doses, or it is in a bottle, sealed by the manufacturer. Other conditions may be the drug is returned unopened and sealed in the original manufacturer’s packaging or bottle the usefulness of the drug has not expired, and the packaging or bottle contains the expiration date of the usefulness of the drug. The name of the original patient, prescription number, and any other identifying information has been obliterated from the packaging or bottle before the return of the drug.
The dispensing pharmacist may reissue the drug to fill other prescriptions for other patients at the same facility if the drug is suitable, and it is according to standards established by the State Board of Pharmacy (SBP). No returned drug can be used to fill other prescriptions more than one time.
Mental health facilities that want to take advantage of this opportunity must adopt written procedures for returning drugs to the dispensing pharmacist. There must be appropriate safeguards in place to ensure the drugs are not compromised, or illegally diverted during their return. The procedures must require the maintenance and retention of records relating to the return of such drugs. The SBP must approve all procedures.
The SBP shall adopt regulations to help facilitate this program. The regulations must include the requirements for returning and reissuing drugs and for maintaining records relating requirements for return and use of drugs to fill other prescriptions.
Section 2 addresses the needs of patients in skilled nursing and intermediate care facilities, and also the needs of the medically indigent. This section parallels the practices, policies, procedures, and requirements established for returning and reissuing a prescription drug in mental health facilities. The dispensing pharmacist in this section can transfer the drug to a nonprofit pharmacy, designated by the SBP, to reissue the drug to other patients free of charge. A pharmacy reissuing to the medically indigent will be immune from civil liability for damages sustained as a result of any act or omission related to carrying out this practice if, the person, pharmacy, or facility complied with the procedures and regulations required by this program, and the act or omission does not amount to gross negligence or willful misconduct.
This section requires the SBP to adopt additional regulations related to the transfer of such drugs from a dispensing pharmacy to a nonprofit pharmacy. The SBP will need to establish regulations for record keeping to track the return of the drugs, the transfer of the drugs, and use of the transferred drugs.
Section 5 allows for return and reissuance of drugs within State correctional facilities. The bill allows a dispensing pharmacist in a correctional facility to reissue a drug within the same correctional facility. Other provisions, policies, procedures, and requirements parallel other sections of this bill.
Section 4 requires the SBP to prepare an annual report tracking the details of this program. The report will include the number of drugs returned to dispensing pharmacies, transferred to nonprofit pharmacies, and reissued to fill other prescriptions. The report will also include an estimate of the amount of money saved by reissuing drugs to fill other prescriptions and other information that the board deems necessary. The report will be posted for public inspection on the board’s Website or other link. We researched similar programs and found there was no formal tracking. Senate Bill 327 will establish a policy that will make a difference to our State institutions and the people who need medications but who cannot acquire or afford them.
Senator Cegavske:
Section one states, “… individually sealed doses or in a bottle that is sealed by the manufacturer of the drug … unopened and sealed in the original …” I was concerned about the unused portion of a prescription.
Senator Wiener:
The critical component is the word “uncontaminated.” One of the references is a “blister pack.” It would be medication not completely used. If there were loose pills in a bottle that were dispensed from the pharmacist, it would not apply to this program.
Senator Cegavske:
Who would be liable if there was a problem with redistributed medications?
Senator Wiener:
If there is something wrong with the batch, it is part of the regulations in tracking medications. One concern proposed at our meeting was in the event of a recall of a drug. The SBP was not as concerned because the batch number from the original packaging would be available. The record keeping and tracking would be a valuable tool under those circumstances.
Senator Cegavske:
What was the genesis for S.B. 327?
Senator Wiener:
This subject had been addressed during several health leadership conferences I attended. Legislators were discussing how important it would be to their states. Many of the legislators acknowledged there are people hired just to dispose of medications.
Senator Washington:
Are you sure the reissuing of the drugs will not be dispensed for illegal purposes?
Senator Wiener:
The bill requires the SBP to establish the regulation that each entity participating in this program be required to design safeguards, provide their procedures and practices to the board to show an assurance there are protections established. This was one of the concerns in the development of the bill. Law enforcement was concerned about potential contamination. The potential for damage would not be safeguarded at the highest level. The bill designates the medications can only be used in that particular correctional facility. The institutions and facilities will establish a plan, procedures, and safeguards required in S.B. 327.
Senator Washington:
Who would approve these plans?
Senator Wiener:
The SBP would approve the plans. They would establish regulations needed in the safeguards, plans, and record keeping. Each entity wishing to participate would submit the plans to the board.
Chairman Rawson:
The medications are dangerous drugs, but not schedule II drugs. We will close the hearing on S.B. 327 and open the hearing on S.B. 337.
SENATE BILL 337: Revises certain provisions relating to dispensing or distributing drugs via the Internet. (BDR 40-590)
Senator Wiener:
Last session I introduced an Internet pharmacy bill which took time to implement. Software was developed which permitted tracking the origin of many Internet pharmacies. Two years ago, it was estimated there were 6000 to 8000 Internet pharmacies, and the number was growing daily. Once the software was in place there were hundreds of Websites for pharmacy sales and distributions with thousands of links. The pharmacy board utilized this Nevada law, in conjunction with the efforts of the Drug Enforcement Administration, to close a multi-million dollar Internet pharmacy violator in Las Vegas.
The SBP concerns about the Internet pharmacies were the filling and refilling of prescription drugs using questionable quality medications. I asked our legal counsel to review S.B. 337 to see if there were unintended consequences. I have provided the committee with the opinion (Exhibit C), which reinforced our objectives in addressing the sale of unlawful medication on the Internet.
Senator Washington:
Section 1, subsection 1, paragraph (a) of the bill indicates, “any who has a reasonable cause to believe.” This language tends to leave an opening. Is that the area you are questioning?
Senator Wiener:
The first scenario was about Internet pharmacies using foreign drugs. In our country the private sector and the government provides third‑world nations with prescription drugs that are close to the expiration dates, or overages in manufacturing. There are people who go into these countries, purchase drugs of questionable quality for an inexpensive price, and sell them on the Internet. The other scenario was about a person needing to go to a doctor every time a prescription drug or refill was needed, and incur the cost of the doctor’s visit. An assurance was placed in the bill to fill and refill a prescription to the extent the law will allow with one doctor’s visit. This holds it to the same standard as if a person was filling the prescription at the pharmacy.
Senate Bill 337 refines the legislation to address consumer protection issues in using the Internet pharmacies, addressing concerns voiced by the SBP Board, and the public.
Senator Washington:
Has the discretion of the court been removed in section 1, subsection 6?
Senator Wiener:
No one has approached me with that concern.
Senator Washington:
Is it current practice?
Senator Wiener:
I will review the current law.
Senator Washington:
Could committee staff investigate this concern?
Chairman Rawson:
What is the section?
Senator Washington:
It can be found in section 1, subsection 6 of S.B. 337.
Chairman Rawson:
I will close the hearing on S.B. 337 and open the hearing on S.B. 289.
SENATE BILL 289: Establishes State Health Authority to plan for single payer health care system and for expansion of Medicaid program. (BDR 40-720)
Senator Neal:
Senate Bill 289 establishes a skeleton form of a State Health Authority (SHA) to plan for a single-payer, health care system in the State, and the expansion of the Medicaid program. Since this issue requires development, it was decided to form a committee within the Department of Human Resources to look into this matter. It would be called the SHA. It would consist of nine members appointed by the Governor, two members representing the health care industry, the director of the Department of Human Resources or designee, one person from the Department of Business and Industry or designee, and the commissioner of insurance. Their responsibility would be planning for the health care services of all the residents in the State.
There is mandatory language designating their responsibilities. The State Health Authority would determine the future needs of this State for providers of health care, medical facilities, medical equipment, and other health care services. They would develop a plan for providing health care insurance for people whose income is less than 300 percent of the federal designated level of poverty. The SHA would develop a plan for Medicaid to provide all optional services that is not authorized to provide pursuant to federal law. It will have the responsibility to develop plans for the State to purchase all of its health care services for its residents. This will include a method of funding the plan based on the study of the feasibility of reimbursing each provider of health care in 30 days after the provision of service by the provider, and at a rate determined by the SHA.
The State Health Authority would collect monthly employment health care insurance assessments from each employee who earns a wage or salary in this State. The money provided by the federal government for Medicaid appropriation from the State General Fund and the fee paid by the insurance carrier. The SHA will be empowered to obtain input from the public in developing the required plan pursuant to this section. The SHA would submit the plan it develops pursuant to subsection 1 of section 4 to the director of the Department Human Resources on or before October 1, 2004. The SHA would submit the plan pursuant to subsection 1 and any suggestions necessary for legislation to carry out the plan to the Legislature on or before January 1, 2005.
Senator Neal:
The reason for this proposal is clear. Health care costs are overrunning the State. It is time to look at something new rather than continue with the separate systems we now have in this State. We need to look at the operation of a single-payer system. There might be a way to reduce the health costs in this State. It has been reported if the State of Massachusetts had developed a plan similar to one operating in Canada, the state would have saved between $170 million to $1 billion a year on its health care plan.
I believe Nevada could do the same. We need to look at single-payer plans and determine whether they could operate in this State. They would be empowered to look at Massachusetts and Hawaii to determine if the State can reduce health costs. Many of our problems are associated with low wages. A part of the insurance problem involves children who are suffering because this State is not looking at different entities. The lack of insurance coverage affects the well being of all of our citizens.
The SHA would look at a type of universal coverage for all the insured, and uninsured people in Nevada. The coverage would be comprehensive, with no co‑pay and have a minimal overhead. There would be no investor-owned health care maintenance hospitals involved. The SHA would be able to review, study, and report on proposed changes to the next Legislative Session. This will better serve our citizens insurance needs and help improve health planning in the State. We need to look into preventive medicine for our citizens.
Chairman Rawson:
Do you know the amount of the fiscal note?
Senator Neal:
I do not know the amount of the fiscal note. We included the Department of Human Resources and other State employees working in the health care area. It should not be difficult to request information from Massachusetts and Hawaii, and then review and determine whether or not the plans were applicable to Nevada. There are two individuals from the health care industry appointed by the Governor who could serve on the SHA without an increase in pay. The SHA operation should not be costly.
Ruth Mills, Board President, Nevada Health Care Reform Project:
I am reading from prepared testimony (Exhibit D). Our mission is to assure all Nevadans quality, affordable health care. Access to health insurance is a priority issue for our coalition, and a growing need of those who live in Nevada. Page 3 (Exhibit D) there is a letter from a local doctor depicting one scenario of the uninsured. Our coalition would welcome the opportunity to work with State government to find solutions to this growing problem. We urge the passage of S.B. 289.
Pilar M. Weiss, Lobbyist, Culinary Workers Union Local 226, HEREIU:
I am reading my written testimony (Exhibit E) in support of the concept of S.B. 289. Within the context of the State’s fiscal environment, the situation of the uninsured in Nevada has reached crisis proportions. Interim measures would provide tax incentives for businesses that provide comprehensive health insurance, and disincentives for those who are overusing the public health system.
Chairman Rawson:
In your written testimony (Exhibit E), were you quoting from the Robert Wood Johnson report?
Ms. Weiss:
Yes.
Jon L. Sasser, Lobbyist, Washoe Legal Services:
I served on the State Board of Directors of the Nevada Health Care Reform Project. We are in favor of studying the feasibility of a single-payer health care system in Nevada. Senate Bill 289 focuses on one solution. During the next Legislative Session a review of the recommended changes could be conducted. This approach will be more successful than spreading the study so broadly nothing would be accomplished. I urge the committee to go forward with the study.
Chairman Rawson:
Do you have a preference as to who would conduct the study?
Mr. Sasser:
It will depend on the resources available. Mr. Willden and his staff coordinated the study concerning persons with disabilities during the last interim, which was a successful project. There was extra funding available and they worked with outside consultants.
Senator Nolan:
Do you feel the proposal on page 2, lines 18 through 31 will hinder the development of other strategies?
Ms. Weiss:
Senate Bill 289 is focusing on a single-payer system. The success of employer‑sponsored health insurance is lacking in Nevada. As a first step in understanding, if a single-payer system could be created, we need to understand what is wrong with the employer-sponsored health insurance in this State.
Senator Cegavske:
Are other states utilizing a single-payer system?
Senator Neal:
The state of Hawaii has a single-payer system. The state of Massachusetts is looking into developing a single-payer system.
Senator Cegavske:
How long has the system been in place?
Senator Neal:
They have had a plan since the 1970s.
Senator Cegavske:
Is the system doing well?
Senator Neal:
It is less expensive than our system.
Senator Cegavske:
Is it taking care of the people?
Senator Neal:
I am told the people in Hawaii want to keep the system.
Marie H. Soldo, Lobbyist, Sierra health Services, Incorporated:
Senate Bill 289 is the only bill addressing the problem of the uninsured. Sierra Health Services has been supportive of effective ways to handle this issue. We welcome an interim evaluation. One goal in S.B. 289 is to evaluate and plan for the future health care needs in the State. There is a large senior population in the State. The bill is narrowly constructed and could be broadened to look at other options, and prioritize the needs of the uninsured.
The system makes the state of Hawaii exempt from the Employment Retirement Income Security Act of 1974, and also mandates employers to provide insurance. It is not quite a single-payer system in the generic form. Hawaii has a 5 percent population of uninsured people. There are new ideas on the federal level concerning offering health insurance on a national system. We support a study evaluating our needs, and a plan to take care of the uninsured population.
Robert A. Ostrovsky, Lobbyist, Nevadans for Affordable Health Care:
We are a business coalition of 300 businesses and 110,000 employees. The members of the coalition are concerned about the rising cost of health care and the uninsured. Either we see the relationship between the cost and the uninsured through taxpayer-funded programs such as Medicaid, hospitals, or doctors must charge more to self-paying patients to balance the fund. In some hospitals 40 percent of patients do not pay anything for treatment.
I have served on three committees on this issue where little or no progress was made. Nine bill draft requests were proposed, but none were passed out of the Legislative Counsel Bureau. It is a difficult problem to address. Senate Bill 289 may not have the perfect solution, but it is a starting point in tackling the issue of the uninsured.
Chairman Rawson:
Would you be content holding the pharmacy bills until a work session?
Michael J. Willden, Director, Department of Human Resources:
Yes. We have worked through about 80 to 90 percent of the issues. We should get through the remaining issues tomorrow, and have a product that will not require much debate.
Chairman Rawson:
What is the pleasure of the committee on S.B. 327?
SENATOR WIENER MOVED TO DO PASS S.B. 327.
SENATOR NEAL SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
*****
SENATOR NEAL MOVED TO DO PASS S.B. 337.
SENATOR NOLAN SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
*****
Chairman Rawson:
On Wednesday, we will have a work session on S.B. 321 and S.B. 374. We will also schedule S.B. 289 for a work session. You may want to turn S.B. 289 into a legislative study.
SENATE BILL 321: Makes various changes concerning coverage of prescription drugs by Medicaid fee-for-service program. (BDR 38-763)
SENATE BILL 374: Makes various changes concerning coverage of prescription drugs by Medicaid fee-for-service program. (BDR 38-764)
Senator Neal:
It could go either way.
Chairman Rawson:
There is a legislative budget set aside for studies.
Senator Neal:
We will consider the alternative.
Chairman Rawson:
There being no further business at this time, I will adjourn this meeting at 3:00 p.m.
RESPECTFULLY SUBMITTED:
Patricia Vardakis,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE: