INTRODUCTIONS AND OPENING REMARKS

Chairman Rawson called the meeting to order at 9:50 a.m. and directed the secretary to call the roll. All committee members attended the meeting. Chairman Rawson explained that the Legislative Committee on Health Care is a standing committee that works through the legislative session and during the interim. He introduced the members of the committee and Legislative Counsel Bureau (LCB) staff assigned to the committee.

The committee oversees a broad spectrum of issues related to quality, access, and cost of health care for all Nevadans, having addressed such issues as autism, diabetes, Nevada Medicaid, and enhancement of children’s health collection efforts.

Besides many other issues related to health care within the scope of the committee’s charge, Chairman Rawson stated the committee has been directed to address the following during the 2001-2002 interim:

· Diversion of patients in need of emergency services and care, known as “divert” (a procedure used by hospital emergency rooms to redirect ambulances and emergency medical services respondents to alternate facilities equipped with staff and resources to handle emergencies);

· Indigent care and disproportionate share payments to hospitals;

· Long-term care; and

· Patient safety and medical errors.

Senator Rawson drew attention to the other interim study committees that he would like the Legislative Committee on Health Care to coordinate with as much as possible: (1) services to persons with disabilities; (2) suicide prevention; and (3) the Task Force for the Fund for a Healthy Nevada (Nevada Revised Statutes [NRS] 439.625).

Before proceeding with the meeting, Senator Rawson offered the committee members an opportunity to make general comments.

Assemblywoman Berman thanked Chairman Rawson for allowing the bioterrorism overview to be placed on the agenda.

Assemblywoman Parnell reported she had the pleasure of attending the Cooperative Action Conference of the Health Division, Nevada’s Department of Human Resources (DHR). She explained it was important, as a member of this committee, to spend three days listening to the people who work in the health care field in Nevada. She shared that most of the people at the conference agreed the shortage of health care workers is the most serious issue facing the state. Combine this concern with the state’s population increase, particularly the senior population, Ms. Parnell pointed out, and many health care professionals are concerned that the state is not prepared to deal with its future health care issues.

Ms. Parnell said she was troubled to hear that conference attendees have a general frustration and distrust with obtaining a commitment to help from elected leaders, both at the state legislative level and with community policymakers.

Continuing, Ms. Parnell said attendees discussed ways that health care professionals could better communicate with elected officials about their concerns. She shared that conference attendees have a sense that communicating with the legislators during session is prohibited. Many professionals who work directly with the programs and clients disagree with health care administrators regarding issues to be presented to the Legislature. Another concern expressed by attendees is Nevada’s inability to often provide matching funds, which would allow health care agencies to operate federally funded programs.

Ms. Parnell said a report would be distributed to attendees of the conference. She asked staff to contact the Health Division to ensure that this committee’s members and staff receive a copy of the final report.

Senator Rawson asked Ms. Parnell to share future communications from this association so this committee may peruse any issues overlooked.

Senator Mathews indicated that before the meeting, she attended a preparedness summit in Reno, Nevada, with other governmental entities involved in preparedness issues. She said she came to the conclusion there is a lot of preparedness yet to be coordinated among the various agencies represented.

PUBLIC TESTIMONY

Chairman Rawson announced that Peggy Jo Myers and her physician, Dr. James Hogan, would present testimony at the beginning of the meeting rather than during the portion provided for public comment to accommodate Ms. Myers’ need to leave early for medical reasons.

Peggy Jo Myers

Peggy Jo Myers, concerned citizen, Las Vegas, stated she has been a diabetic for 30 years and a dialysis patient for about a year and a half. Ms. Myers’ concerns dealt with her insurance company requiring her to change from her specialist of ten years, Dr. James M. Hogan, who knows her serious medical background, to a primary care physician who is not familiar with her health history. The primary care physician will recommend a new specialist. Ms. Myers’ question to the committee was: “Does the insurance company not have to honor its contract?” Please refer to Exhibit A for a written statement of her remarks.

Chairman Rawson told Ms. Myers the insurance company does need to follow its contract. He informed her there is an ombudsman in the state who handles these types of complaints. Senator Rawson then asked staff to provide the telephone number for the Governor’s Office for Consumer Health Assistance to Ms. Myers and to follow through with her on this issue.

James M. Hogan, M.D., M.P.H.

James M. Hogan, M.D., M.P.H., Hogan Medical Center, Las Vegas, stated he was testifying on behalf of his patient, Peggy Jo Myers. Dr. Hogan reported that he has practiced medicine in the Las Vegas community for 16 years and in his view, physicians and patients are “pawns” in the current health care economic game. He said the medical community is in a crisis because of the economic downturn, and patients and physicians are suffering as a result. Dr. Hogan averred that Ms. Myers is a perfect example of someone suffering from the destruction of the doctor-patient relationship by the current system and suggested legislative redress to change this situation.

Chairman Rawson noted that future legislative hearings would cover many of the concerns raised by Dr. Hogan.

OVERVIEW OF STATE BIOTERRORISM DEFENSE PLAN

Randall Todd, Dr.P.H.

Randall Todd, Dr.P.H., State Epidemiologist, Health Division, DHR, Carson City, briefed the committee on bioterrorism defense in Nevada referencing his outline (Exhibit B). Since the events of the September 11, 2001, attack on the World Trade Center, Dr. Todd pointed out the nation’s attention has shifted from conventional kinds of terrorist attacks to biological acts of terrorism.

Dr. Todd discussed the differences between a conventional disaster or terrorist attack and that of a biological scenario. Some of our notions of disaster preparedness, he explained, are based on conventional problems that responders have had experience with and know how to respond to. When a natural disaster such as a flood or earthquake strikes, certain characteristics would pertain. It would be known rather immediately that one of these events had occurred and the scope of damages. Casualties occurring at the time of the event or shortly thereafter would, for the most part, be identified by traditional first responders—police, fire, and emergency medical personnel.

In the event of a terrorist attack, although unconventional means of delivering the attack may be used, historically some type of an explosion resulted. Dr. Todd again pointed out that this type of an event would soon be known enabling traditional first responders to identify and respond to the scope of damages fairly immediately. Even in the event of a terrorist chemical attack, whether the chemical exposure is through inhalation or skin absorption, the effects are going to be fairly immediate as with a natural disaster or explosion.

Dr. Todd emphasized everything he described would be fundamentally different in a biological attack. He offered the following example to illustrate his point: Imagine a picture of the skyline of Las Vegas under biological attack; the photo would not appear any different than it does today. A caption could be added to the photo saying “Under biological attack.” Dr. Todd stressed that the photo would appear normal because biological agents, unlike conventional or chemical weapons, can be disseminated in a covert fashion. Hence, there would be no immediate knowledge that an event had occurred. The casualties would not be immediately apparent; the incubation period for the agent that was used could take days or weeks before casualties would become known.

Dr. Todd also noted that police, fire, or even traditional emergency medical responders would not identify the casualties. Instead, health care providers in doctors’ offices, clinics, and emergency rooms would detect them. However, the health care providers might not recognize these casualties as casualties per se; the persons affected might appear to be a large number of people with nonspecific health complaints.

Continuing, Dr. Todd offered the following hypothetical scenario. The variola virus, which causes smallpox, is covertly released. Within one to two weeks, individuals infected with the virus begin seeking medical attention from their physicians or at health clinics. Their physical complaints include fever, back pain, headache, nausea, and other symptoms that many physicians attribute to a common viral infection. As the disease progresses, the infected individual develops a papular rash that is characteristic of early-stage smallpox. Since most practicing physicians have never seen a case of smallpox, it is probable that the disease would not be immediately recognized. By the time the rash progresses to the point that it is completely characteristic of smallpox and patients are beginning to die, the disease has been disseminated throughout the population by person-to-person contact. The time frame between identification of the first smallpox cases and the second wave of individuals who have contracted the disease is short. As person-to-person contacts continue, successive waves of the disease are spread to other localities around the state, throughout the nation, and around the world.

Dr. Todd pointed out that smallpox is not the only potential biological agent that could lead to this type of scenario, but it is probably the worst. He emphasized, however, that the recent anthrax threats would be somewhat different because anthrax is not passed from person to person.

Dr. Todd explained that the public health community has three key roles in dealing with bioterrorism: (1) determine that an attack has occurred; (2) identify the organism; and (3) mount some prevention strategies immediately.

However, to determine that an attack has occurred, public health agencies in the state need to be capable of detecting unusual patterns of disease, including those that are caused by unusual or even unknown threat agents. In order to accomplish this, education and training needs to occur, since health care providers are not used to reporting clusters of symptoms—referred to as syndromic reporting.

In addition to training and educating the health care community about this new way of looking at illness patterns in the community, Dr. Todd said, there needs to be staffing and training at the state and local health departments in order to appropriately respond to such reports.

According to Dr. Todd, high-profile events such as Comdex in southern Nevada and Hot August Nights in northern Nevada need additional surveillance and epidemiological capacities in place at the time of these events.

Dr. Todd stressed the public health agencies must be able to differentiate between natural disease occurrence and intentional transmission of disease, which is an important distinction when using law enforcement partners in helping deal with such situations. Identifying the organism is critical in order to react appropriately, and having enhanced public health laboratory capacity is key to identifying the agent.

Avoiding more casualties through the prevention strategy is another key role that the public health community will have to play. In order to do that, the state will need access to vaccines, antibiotics, and other medical supplies. Fortunately, Dr. Todd reported, the national pharmaceuticals stockpile is working toward having packages that can be on the ground in Nevada within about 12 hours from the time the Governor would make such a request. However, Dr. Todd stressed, a distribution infrastructure needs to be developed to ensure supplies reach the health care community and the patients who need them.

The state’s legal authority will need to address issues such as isolation and quarantine. According to Dr. Todd, many of the laws that allow public health to make such decisions are old and have not been implemented within the context of current views about civil liberties.

In addressing biological agents of concern such as anthrax and smallpox, the Centers for Disease Control and Prevention (CDC) considers something to be a high priority if the agent possesses some or all of the following characteristics: (1) it can be easily disseminated; (2) it may be transmitted from person to person, such as smallpox; (3) it causes high mortality or morbidity, such as anthrax; (4) it might cause public panic or social disruption; and/or (5) it requires special actions for public health preparedness, such as stockpiling of antibiotics and vaccines.

Dr. Todd listed seven high-priority biological agents that are on the CDC’s “A” list (page 3, item B, Exhibit B). He stated there are many lower-priority biological agents more difficult to disseminate or that cause less severe illness, but they still represent a need for enhanced public health surveillance and epidemiology.

In addressing preparedness needs, Dr. Todd covered the following:

· The need to be well aware of weapons of mass destruction such as a terrorist chemical or explosive attack versus a biological attack, which is not immediately obvious;

· Compiling a national pharmaceutical stockpile with placement in strategic locations around the country;

· Public health infrastructure enhancements at the state and local levels for epidemiology and surveillance capabilities, laboratory capacity, communications and training, and role clarification for emergency and health care entities; and

· Surge capacity to handle large numbers of ill people from an unnatural event.

Other points Dr. Todd addressed relating to Nevada’s preparedness needs were:

· Informed citizens should hold their elected officials responsible for taking the right steps and to fund necessary preparedness needs;

· Perform live drills and tabletop exercises dealing with these new kinds of biological terrorist scenarios for emergency and health care entities;

· The need for adequate public information and ensuring the media does not disseminate alarmist material that adds to the various state and local entities’ problems with members of the public and the “worried well” flooding scarce health care resources.

Dr. Todd reported that in 1999, the CDC began providing funds to state health departments so they could prepare for biological terrorism. Funding was provided for the following areas: (1) epidemiology and surveillance; (2) Health Alert Network (HAN) to develop communication and training infrastructures; and (3) laboratory capacity.

Dr. Todd further mentioned that Governor Guinn has demonstrated leadership in this area with the formation of the Weapons of Mass Destruction Steering Committee, currently known as the Homeland Security Committee. He said the right people—public health personnel, law enforcement, fire departments, and traditional first responders—are planning live drills and tabletop exercises.

Dr. Todd called attention to three lessons learned from the Microsoft anthrax letter scare in Reno during October 2001: (1) a threat does not have to be confirmed to cause public panic; (2) there is limited surge capacity in the health care system; and (3) live drills are needed to improve coordination among the various agencies.

He added that three specific issues surfaced during the Microsoft anthrax scare that underscore the need to conduct live drills:

1. There was no protocol of standards to uniformly accession letters or packages into the laboratory.

2. Once the tests were completed, there was no procedure in place regarding dissemination of the results.

3. Threat letters were picked up by hazardous materials teams and delivered directly to the state laboratory in biohazard containers. The containers were too large to be opened safely under a biological safety hood in the laboratory. It took a significant amount of time to move the containers to a place where they could be safely opened.

In his closing remarks, Dr. Todd said Nevada has accomplished much toward terrorism readiness but still has a great deal to achieve for Nevada citizens to have a sense of safety and to view the state as being prepared to deal effectively with a biological attack.

Assemblywoman Berman thanked Dr. Todd for his informative presentation and then asked him for clarification regarding the need to update the public health laws in Nevada. She also asked Dr. Todd if he could work with the committee in helping to identify which laws may need updating.

Dr. Todd clarified that he is suggesting that the current laws need to be reviewed to ensure they will serve Nevada in the event of a bioterrorism incident. Regarding the second part of Ms. Berman’s question, Dr. Todd said he, Dr. Guinan, and local health officials in Clark and Washoe Counties should review the current laws and provide recommendations to this committee and/or the Legislature as to what, if anything, should be changed.

Ms. Berman raised another question regarding the need for increased staffing and training of the state’s public health officials in dealing with such high-profile events as the upcoming Las Vegas COMDEX convention, especially in the area of possible terrorist acts at the hotels.

Dr. Todd reassured Ms. Berman that Nevada has many well-trained and well-qualified individuals working in state and local public health departments. However, he clarified, when there is a high-profile event in the state, additional surveillance can be put in place temporarily. Also, hospitals can be placed on alert, and active surveillance for specific symptom clusters that could be problematic can be instituted for monitoring on a 24-hour basis during the actual event. Dr. Todd added that the CDC has been working with some state and local health departments to develop this kind of capacity, referred to as “drop-in surveillance.”

Continuing, Dr. Todd said there are different algorithms for interpreting the data that would be obtained from such surveillance. Those are still in the test phases at CDC, he explained, but Nevada needs trained personnel who are able to identify which of these events might present high-risk situations and to then work with local health care workers, as well as the hospitality industry. Concluding, Dr. Todd reiterated that adequate preparedness for potential bioterrorism attacks will require a well-trained staff and probably additional resources.

Mary E. Guinan, M.D., Ph.D.

Mary E. Guinan, M.D., Ph.D., State Health Officer, Health Division, DHR, Carson City, briefed the committee on Nevada’s bioterrorism defense plan. Please refer to Exhibit C for a written statement of her remarks.

Additionally, Dr. Guinan referred to a summary report (Exhibit D) of all the activities of the Health Alert Network titled “Health Authorities (Nevada State Health Division, Clark County Health District, Washoe District Health Department) Response to the Events of September 11, 2001.” She noted that this information is also available on the Health Division’s Web site (http://health2k.state.nv.us).

Dr. Guinan drew attention to a draft letter sent to the President of the United States (Exhibit E) that requests further emergency assistance for state health departments. Highlighted in this letter are the following six critical areas needing urgent attention: (1) epidemiology; (2) information/communication systems; (3) media relations and public communication; (4) policy and knowledge dissemination; (5) public health laboratories; and (6) operation centers that operate 24 hours a day, seven days a week.

Continuing, Dr. Guinan said the health care system and emergency centers have been inundated with concerned persons, especially asking for anthrax and smallpox vaccinations. Dr. Guinan gave a brief history of the smallpox vaccine. Production was curtailed in 1983, and she noted that the duration of immunity of the smallpox vaccination is unknown. She said smallpox vaccinations in the United States were stopped in 1972, except for those in the military and those working in smallpox or similar poxvirus laboratories.

Dr. Guinan reported that the United States (U.S.) Department of Health and Human Services Secretary Tommy G. Thompson has ordered the production of 300 million doses of vaccinia (smallpox vaccine) that potentially will be ready in 2003.

Chairman Rawson said the bioterrorism issue is directly related to state police powers concerning the health and safety of Nevada residents. State emergency and public health systems have been seriously tested, both with false alarms and some actual alarms showing the success and the weaknesses in our program. The chairman stated the bioterrorism issue was included on the committee’s agenda to assess if federal agencies, Nevada, and other states have protocols and plans in place, not just in theory, to deal with this critical issue.

Senator Rawson stressed, working with staff, the committee will follow this issue to stay informed and to try to positively influence preparedness. Chairman Rawson directed that he, Assemblywoman Berman, and Vice Chairman Koivisto follow the bioterrorism situation and keep the Legislative Committee on Health Care informed of developments.

As a point of information, Assemblywoman Parnell shared that during the 1999-2000 interim, the Commission on School Safety and Juvenile Violence put into place school and community safety plans for all Nevada counties.

Chairman Rawson drew attention to the following ways citizens can help in being personally prepared:

· Be aware of surroundings, and ensure that personal living and working areas are clean and orderly;

· Be careful about drinking water;

· Ensure that food is cooked properly; and

· Select a healthy lifestyle.

Dr. Guinan informed the committee that the CDC has developed a course on public health law and bioterrorism in which the agency is trying to identify what state laws are needed in the event of bioterrorism and to then develop model laws. From this benchmark, the CDC can review each of the state’s laws to see if necessary provisions are in place. Dr. Guinan shared that she will be attending this course in November, which is offered through the Association of State and Territorial Health Officials (ASTHO).

Chairman Rawson said he would like to have a member of the legislative staff or a legislator attend this course to further strengthen the state’s disaster preparedness measures. He directed staff to look into the disaster mitigation fund to see if it could be used to pay for this course.

Presentation Concerning the Activities and Responsibilities

of the Legislative Committee on Health Care

Marsheilah D. Lyons

Marsheilah D. Lyons, Senior Research Analyst, Research Division, LCB, Carson City, gave a brief presentation on the four measures from the 71^st Session of the Nevada Legislature requiring action on the part of the Legislative Committee on Health Care.

The first measure, Senate Bill 484 (Chapter 292, Statutes of Nevada 2001), “requires Legislative Committee on Health Care to study diversion of patients in need of emergency services and care from hospitals that lack sufficient resources to provide needed services and care.” The committee must also address the effect of those diversions on health care delivery and health care costs.

Some additional key issues that may be considered concerning the causes of emergency diversion are: (1) a lack of sufficient intensive patient beds; and (2) staffing shortages, particularly nursing staff.

Issues having a profound impact upon public and private hospitals include: (1) billing charges to patients that are treated (as a result of diversion) by noncontracted hospitals; and (2) hospital cost reimbursement rates for services to patients that are diverted from contracted hospitals.

The next issue to be addressed by the committee, Ms. Lyons explained, deals with Senate Bill 402 (Chapter 465, Statutes of Nevada 2001), which “expands authority of Legislative Committee on Health Care to review certain issues relating to long-term care.” The measure expands the authority of the Legislative Committee on Health Care to include the identification and evaluation of, with the assistance of an advisory group, the alternatives to institutionalization for providing long-term care. Further, the bill authorizes the committee to evaluate the feasibility of obtaining certain waivers from the federal government pertaining to long-term care, which may address two subject areas: (1) elimination of the requirement that elderly persons in Nevada impoverish themselves as a condition for receiving assistance for long-term care through Medicaid; and (2) integration and coordination of acute care services through Medicare and Medicaid.

Ms. Lyons also informed the committee that DHR was provided with $800,000 and given the statutory responsibility, through Assembly Bill 513 (Chapter 541, Statutes of Nevada 2001), which “makes appropriation to Department of Human Resources for development of long-term strategic plan concerning health care needs of citizens of Nevada,” with the appropriation divided into four parts for:

1. A plan to develop and implement a methodology for the establishment and periodic adjustment of rates paid by the State of Nevada for contracted health and human services;

2. Developing a plan to ensure availability and accessibility of services that meet the basic needs of senior citizens and that support their ability to lead independent and active lives;

3. Creating a plan to ensure a continuum of health care services in rural areas of Nevada; and

4. Developing a plan to further the provision of, and ensure the availability of, services to persons with disabilities.

For the sake of comparing the Legislative Committee on Health Care’s responsibilities for long-term care to those of DHR for seniors and persons with disabilities, Ms. Lyons directed the committee’s attention to the table contained in Exhibit F.

A third issue to be addressed by the committee is outlined in Assembly Concurrent Resolution No. 7 (File No. 77, Statutes of Nevada 2001), which “directs the Legislative Committee on Health Care, through a subcommittee, to conduct an interim study concerning development of system for reporting medical errors.” Criterion that must be included in the study are found in Exhibit G.

The final measure to be addressed by the Legislative Committee on Health Care is S.B. 377 (Chapter 598, Statutes of Nevada 2001), which “revises provisions governing payment of hospitals for treating disproportionate share of Medicaid patients, indigent patients, or other low-income patients.” This measure requires the Legislative Committee on Health Care to conduct a study during the 2001-2003 biennium to review: (1) alternate methods of funding medical care for such patients; (2) the methodology and distribution of state disproportionate share intergovernmental transfer program payments; (3) the needs of rural hospitals; and (4) the sources of funding to provide medical care to Medicaid patients, indigent patients, and other low-income patients.

Ms. Lyons informed the committee that Christopher Thompson, Senior Policy Analyst, Center for Health Information Analysis, University of Nevada, Las Vegas, would discuss this measure in further detail later in the meeting.

Chairman Rawson stated that the issue of emergency room diversion would be dealt with at the next meeting of the Legislative Committee on Health Care and at other meetings if necessary. Along with a technical working group that will be dealing with some of these issues, Chairman Rawson said staff would be asked to monitor the subcommittee’s meetings to ensure that all of the issues the Legislative Committee on Health Care is required to cover are addressed.

Leslie K. Hamner

Leslie K. Hamner, Principal Deputy Legislative Counsel, Legal Division, LCB, Carson City, provided introductory comments on the statutory requirements of the Legislative Committee on Health Care, which is to review certain regulations concerning health care that are proposed or adopted by various state agencies. Ms. Hamner drew attention to a complete list of the boards subject to review by this committee and the statutory requirements of such reviews in Exhibit H titled “Information Concerning Review of Certain Administrative Regulations Related to Health Care.”

Senator Rawson asked Ms. Hamner if the State Board of Pharmacy would forward regulations it may develop to the Legislative Committee on Health Care or to the Legislative Commission.

Ms. Hamner responded that the regulations would be submitted to the Legislative Committee on Health Care.

Presentation of Background Information Regarding

Medical Care Provided to Medicaid, Indigent, and Other

Low-Income Patients in Nevada, Including Discussion of

the Methodology Used by the Department of Human Resources

in Making Certain Payments to Public and Private Hospitals

for Treating Such Patients

Chairman Rawson explained that he asked Christopher Thompson, in his capacity as a consultant, to assist the committee with the indigent care matter. Continuing, Senator Rawson said Mr. Thompson would provide an overview of the issue and also suggest approaches the committee may consider and principles the committee may follow to work through this complicated area.

Christopher Thompson

Christopher Thompson, Senior Policy Analyst, Center for Health Information Analysis, University of Nevada, Las Vegas, presented a chronology of indigent care in Nevada as outlined in Exhibit I. Historically, the primary responsibility for indigent care fell on local governments, and generally on the hospitals, whether public or private.

Moving on with his presentation on indigent care, Mr. Thompson said the study would consider several different programs and their effect on indigent care. It will also identify all sources of funding now available to hospitals to provide that care. The programs that would be covered include: (1) county indigent care programs; (2) direct hospital public funding (from tax revenues or direct county payments); (3) Health Division programs that provide direct medical care for indigents; (4) indigent accident fund and supplemental fund; (5) Nevada Check-Up; and (6) Nevada Medicaid.

In conducting the study, Mr. Thompson continued, the true cost to hospitals providing the indigent care must be reviewed, including alternative care available to individuals who are unable to pay their hospital bills and are not eligible for any of these programs.

Mr. Thompson identified some of the issues pertinent to the question of spreading costs versus revenues equally for health care to indigents, including:

· Ensuring access to quality and affordable health care for all Nevadans;

· Increasing Medicaid payments through an upper payment limit or other cost-based methodology (allowed under federal laws and regulations) to generate additional federal revenues and help offset the overall costs of Medicaid care in the state;

· Private hospitals in rural areas receiving funds;

· Providing care in the most efficient manner; and

· The appropriateness of private hospitals receiving funds.

Chairman Rawson interjected that he understood the Governor is working on increasing the Medicaid payments. If through Executive Order the Governor were to change Medicaid payments, the committee probably would not pursue an increase. Responding, Mr. Thompson indicated that regardless of any determination the Governor may make, this issue would still be involved in the study in terms of the payments and the balancing of overall costs and revenues. Chairman Rawson clarified that the committee would not want to change any action the Governor may make, but if an adjustment were made, its effect on the disproportionate share issue would need to be assessed.

Mr. Thompson reminded the committee of the indigent care requirement pursuant to NRS that requires hospitals with more than 100 beds to provide 0.6 percent indigent care. Since 1987, new hospitals have been built in Las Vegas, such as MountainView Hospital and Summerlin Hospital Medical Center, that are less likely to provide indigent care because the individuals in need are not as likely to live in those geographical areas. Mr. Thompson averred that these hospitals should not be absolved of the requirement to provide this type of care. He recommended that other means of meeting the statutory requirement for providing indigent care be examined and offered the following possible alternatives:

1. Establish a busing program to provide indigent patient transportation to outlying hospitals; and

2. Allow individual hospitals owned by the same corporation to aggregate uncompensated care.

Another issue Mr. Thompson stressed needs examining is the equity between Washoe County hospitals in northern Nevada providing indigent care, particularly Washoe Medical Center versus Saint Mary’s Hospital. In the past, Washoe Medical Center had the largest proportion of indigent care patients. That distinction has narrowed and, based on the 1995 program, Washoe Medical Center is the only hospital in Washoe County receiving disproportionate share funds. If it is appropriate to make payments to Saint Mary’s as well, Mr. Thompson pointed out, then a different system needs to be developed while maintaining compliance with federal laws regarding intergovernmental transfers and provider taxes.

Assemblywoman Berman asked Mr. Thompson where he obtained his information that MountainView Hospital and Summerlin Hospital Medical Center in Las Vegas, two hospitals in her Assembly district, were not spreading the risk pool for indigent care because of no or few indigents seeking medical care from those two hospitals. Mr. Thompson replied he had been aware of this situation for two years. He noted that one of the hospitals was not able to meet its indigent care requirement and was required to make payments under NRS 439B.300, “Legislative findings and declarations; applicability,” in lieu of providing indigent care. However, he said he had not examined any specific demographic models but would do so as part of the study. Ms. Berman asked Mr. Thompson to go over his numbers with her at some point because she would like to know what is happening in her district.

Addressing another question to Mr. Thompson, Ms. Berman wanted to know if the state has anyone assigned to review grants and federal funds available to Nevada related to indigent care. Mr. Thompson responded that the number of different kinds of federal programs dealing with indigent care is beyond this study and not something he would be able to address directly. Generally speaking, he explained, the Medicaid and Check-Up programs are open-ended, and the state can access as much funding as it would be willing to spend.

Assemblywoman Koivisto requested that all the facilities submitting reports of their indigent care costs and revenues submit them on a standardized form so the committee can examine the information from the same perspective. Mr. Thompson agreed, adding that the reports will be reviewed with those hospitals, both individually and collectively, to ensure that the information is comparable and understandable.

Chairman Rawson asked that instead of having a subcommittee handle indigent care, he would prefer that Mr. Thompson work with technical staff and report back to the Legislative Committee on Health Care so there is a better assurance of interpretation and understanding as to the status of this issue.

Adoption of Principles to Guide the

Legislative Committee on Health Care in its Study of

Programs and Funding for the Treatment of

Medicaid, Indigent, and Other Low-Income Patients Pursuant to Senate Bill 377 (Chapter 598, Statutes of Nevada 2001)

Christopher Thompson

Christopher Thompson, previously identified on page 14 of these minutes, drew attention to the last page of his handout (Exhibit I), which lists seven proposed principles to guide the Legislative Committee on Health Care in its study on indigent care pursuant to S.B. 377. Mr. Thompson offered introductory comments on each principle, specifically noting the fifth principle as a key issue regarding indigent care.

Chairman Rawson explained that these principles address issues of fairness and are meant to guide the committee through decisions and build consensus during the course this study. At this point, Senator Rawson asked for feedback on the seven proposed principles.

To keep the task at hand more manageable, Assemblywoman Berman suggested reducing the seven principles to a priority list of three.

Assemblywoman Parnell noted in her review of S.B. 377 that basic access to medical care needs to be addressed, not just hospital funding. Mr. Thompson responded that access to hospital care versus the broader issue of access to primary care is more important in one sense. However, because the funds are specific to hospitals, the concerns surrounding disproportionate share control the issue of access. He mentioned the one area where this could be addressed is by directing some of the funds specifically into Medicaid to increase physician rates. Mr. Thompson added that even though it is perhaps a more important global issue, access to primary care is probably outside the scope of this study.

Charles Duarte

Charles Duarte, Medicaid Administrator, Division of Health Care Financing and Policy, DHR, Carson City, responded to Ms. Parnell’s concern. With respect to access and broader issues of access, he agreed with Mr. Thompson that the issue has to move toward access to primary care. Mr. Duarte added that through A.B. 513, the Division of Health Care Financing and Policy is reviewing access to physician and dental services, while also assessing rates paid to the various provider categories as part of its review in the strategic health plan.

Regarding the sixth principle, Senator Washington asked Mr. Thompson if a competitive imbalance would be created by the changing demographics within Clark and Washoe Counties. Mr. Thompson responded that spreading the cost of indigent care equally among all hospitals would best serve the population by maintaining a competitive balance for all other care. However, in practice and in developing policies, changing demographics complicates the solutions. If there is a greater concentration of individuals within one area, it may not be possible to achieve a competitive balance.

After explaining how several of the principles are interrelated and could be grouped together, Chairman Rawson suggested combining the seven principles in Exhibit I as follows:

1. Access—Combines proposed principles 1, 3, and 7.

2. Maximizing Federal Funds—Maintains proposed principle 2.

3. Use of Money—Combines proposed principles 4, 5, and 6.

Chairman Rawson informed the committee that he had asked Mr. Thompson, in preparation for the work ahead, to provide data from the UB-92 database from all Nevada counties. This data, together with other information gathered by Mr. Thompson and technical staff, will be brought to the committee for review.

At this time, Chairman Rawson said he would accept a motion to approve this agenda item.

ASSEMBLYWOMAN BERMAN MOVED TO APPROVE THE THREE BASIC PRINCIPLES IN THE LEGISLATIVE COMMITTEE ON HEALTH CARE’S STUDY OF PROGRAMS AND FUNDING FOR THE TREATMENT OF MEDICAID, INDIGENT, AND OTHER LOW‑INCOME PATIENTS PURSUANT TO SENATE BILL 377 (CHAPTER 598, STATUTES OF NEVADA 2001). THE MOTION WAS SECONDED BY VICE CHAIRWOMAN KOIVISTO AND CARRIED UNANIMOUSLY.

Discussion of Subcommittees, Advisory Groups, or

Technical Working Groups, Including Possible Appointments, Compensation, and Reimbursement

Subcommittee Concerning the Development of a System for Reporting Medical Errors Pursuant to Assembly Concurrent Resolution No. 7 (File No. 77, Statutes of Nevada 2001)

Referring to Exhibit J, titled “Proposal for Conducting the Study of Medical Errors Pursuant to Assembly Concurrent Resolution No. 7 (File No. 77),” Chairman Rawson stated he would like to address the medical errors issue first. He shared that he will be giving a report to a group in Atlanta, Georgia, and has been reviewing the March/April 2000 issue of Health Affairs dealing with prescription errors and its related difficulties. Chairman Rawson noted there were 2.9 billion prescriptions issued last year filled by pharmacists; an error rate of 1 percent of that total represent millions of people.

Senator Rawson stated his preference is to address this issue through a subcommittee; even though the issue is highly charged, it is important that all interested parties be heard. He identified the following areas for this subcommittee to address: (1) medical errors; (2) peer review; (3) prescription errors (because of a documented death rate from prescription errors); and (4) staffing ratios.

Chairman Rawson indicated it is vital that the medical errors issue be reviewed by disinterested third parties. He stated the committee will be small, and he would like to see adequate hearing time so all interested parties have an opportunity to express their concerns. There will be three subcommittee meetings, and the subcommittee will report back to the Legislative Committee on Health Care so that any areas not adequately addressed during the subcommittee meetings may be given further consideration.

Chairman Rawson proposed that John Yacenda, Ph.D., M.P.H., an impartial third-party health advocate and Chief Executive Officer of Health Care Strategies, Inc., serve as the chairman for this subcommittee. Senator Rawson noted that Exhibit J mentions travel pay and an honorarium for the chairman of the committee. He explained that it is not appropriate to pay an honorarium to a nonlegislative chairman; therefore, this issue will not be considered. The chairman requested that the committee authorize the payment of consulting fees to individuals assisting the subcommittee.

For legislative representatives on the subcommittee, Chairman Rawson proposed Assemblywoman Parnell and Senator Mathews. Further, he asked that Nancy Whitman of HealthInsight serve on the subcommittee. Senator Rawson explained that HealthInsight, a nonprofit organization dedicated to improving the health care systems of Utah and Nevada, is involved in studies of Medicaid and other health care issues related to medical errors and has been successful in its efforts to mitigate or change the behavior of health care professionals. Chairman Rawson suggested that a member of the State Board of Health serve on the committee. He indicated that he initially intended to recommend Bernard Feldman, M.D., to serve on the subcommittee; however, it was his understanding that Dr. Feldman was no longer a member of the Board.

At this time, Chairman Rawson said he would accept a motion to establish the medical errors subcommittee as he outlined and asked that any motion also include authorization to pay consulting fees in an amount not to exceed $10,000.

VICE CHAIRWOMAN KOIVISTO MOVED TO APPROVE THE FORMATION OF THE SUBCOMMITTEE CONCERNING THE DEVELOPMENT OF A SYSTEM FOR REPORTING MEDICAL ERRORS PURSUANT TO ASSEMBLY CONCURRENT RESOLUTION NO. 7 (FILE NO. 77, STATUTES OF NEVADA 2001), AS OUTLINED BY CHAIRMAN RAWSON, AND TO AUTHORIZE PAYMENT OF CONSULTING FEES NOT TO EXCEED $10,000. THE MOTION WAS SECONDED BY SENATOR WASHINGTON.

Announcing the motion and the second, Chairman Rawson invited committee discussion.

Assemblywoman Berman asked that the person serving on the subcommittee from the State Board of Health be a physician. Chairman Rawson noted he did not know whether that would be the case, but he would be pleased to have Dr. Feldman, if he were interested, serve on the subcommittee in his new capacity with the University of Nevada School of Medicine.

Bernard Feldman, M.D., M.P.H.

Bernard Feldman M.D., M.P.H., Professor and Chairman, Department of Pediatrics, University of Nevada School of Medicine, Las Vegas, indicated his replacement on the State Board of Health is a physician. However, the chairman is an elected position of the Board and would not necessarily be a physician. Dr. Feldman stated he would be happy to serve on the subcommittee, and alleged he could represent his employer, the University of Nevada School of Medicine.

Chairman Rawson asked the committee if they were comfortable with Dr. Feldman’s offer to serve on the subcommittee. Obtaining a consensus, Chairman Rawson noted that Vice Chairman Koivisto and Senator Washington, who moved and seconded the motion respectively, were in agreement with Dr. Feldman serving on the subcommittee as a representative of the University of Nevada School of Medicine.

Chairman Rawson called for the vote on the motion and the second, noting the change of Dr. Feldman serving on the subcommittee instead of a representative from the State Board of Health.

THE MOTION CARRIED UNANIMOUSLY.

Additional Subcommittee, Advisory Group, or Technical Working Group Appointments

Senate Bill 402, which deals with long-term care, is an additional topic the committee must address, Chairman Rawson explained. He indicated that his preference is to handle this issue through a technical advisory group rather than through a legislative subcommittee inasmuch as the Executive Branch currently is conducting a study of this issue. Chairman Rawson said the committee would work with staff in following the Executive Branch study, and if any issues are not adequately addressed, they will be brought to the Legislative Committee on Health Care for review.

Chairman Rawson concluded this section of the agenda by letting the committee know that if other issues arise, the Legislative Committee on Health Care is not prohibited from forming additional subcommittees.

Scheduling of Future Meetings and Discussion of Future Topics

Chairman Rawson noted that the following meeting dates have been scheduled for the Legislative Committee on Health Care for the remainder of the 2001-2002 interim: November 27, 2001; January 8, 2002; February 12, 2002; March 19, 2002; April 23, 2002; and June 4, 2002. This schedule may be changed as necessary.

Public Testimony

Lawrence P. Matheis

Lawrence P. Matheis, Executive Director, Nevada State Medical Association (NSMA), asked the Legislative Committee on Health Care, as it reviews the bioterrorism issue, to also consider how the private sector is dealing with the matter. He shared that the NSMA is working with individual physicians and physician practices to coordinate education and availability in the context of preparedness, as Dr. Guinan and Dr. Todd identified during their presentations at the beginning of the meeting.

Mr. Matheis stated the Nevada State Medical Association has a commission on public health that is cochaired by Donald S. Kwalick, M.D., M.P.H., Chief Health Officer, Clark County Health District, and Trudy Larson, M.D., Professor of Pediatrics, University of Nevada School of Medicine, and the Public Health Advisor to the Washoe County District Health Department. For more than a year, this commission has been studying what physicians need to know in the event of bioterrorism acts in Nevada and last spring sent some recommendations regarding bioterrorism to the State Board of Health.

Continuing, Mr. Mathies reported that another function the NSMA performs is to keep Nevada physicians informed by alerting them to important communications, such as the CDC’s latest anthrax advisories. Mr. Mathies also shared that information from the CDC about such advisories is available through its Web site (www.bt.cdc.gov).

Concluding his comments, Mr. Mathies alerted the Legislative Committee on Health Care to the growing problem of medical liability insurance availability in Nevada for physicians, especially for obstetricians, gynecologists, family physicians who do obstetrics, emergency physicians, and general surgeons.

John Yacenda, Ph.D., M.P.H., P.A.H.M.

John Yacenda, Ph.D., M.P.H., P.A.H.M., President and Chief Executive Officer, Health Care Strategies, Inc., Carson City, said he has begun working with LCB Senior Research Analyst Marjorie Paslov-Thomas, who is assigned to the Subcommittee to Study the Development of a System for Reporting Medical Errors. Dr. Yacenda said this subcommittee will hold two meetings in Las Vegas and one in Carson City; after its final meeting, a report will be presented to the Legislative Committee on Health Care at its June 2002 meeting.

Ann Lynch

Ann Lynch, concerned citizen, Las Vegas, reported that a CDC informative telecast will take place at 2 p.m. on Thursday, October 25, 2001, in the auditorium of the Las Vegas Sunrise Hospital & Medical Center.

ADJOURNMENT

Chairman Rawson asked that a further report on bioterrorism be included on the next agenda of the Legislative Committee on Health Care and that Assemblywoman Berman keep the committee informed of new developments pertaining to this issue.

The committee’s next meeting will be held on November 27, 2001, in Carson City.

There being no further business, the meeting was adjourned at 12:25 p.m.

Exhibit K is the “Attendance Record” for this meeting.

Respectfully submitted,

_______________________________________

Gayle Nadeau

Senior Research Secretary

_______________________________________

Marsheilah D. Lyons

Senior Research Analyst

APPROVED BY:

___________________________________

Senator Raymond D. Rawson, Chairman

Date:_______________________________

LIST OF EXHIBITS

Exhibit A is the written testimony of Peggy Jo Myers, a concerned citizen from Las Vegas, Nevada, titled “My body is dying,” provided by Ms. Myers.

Exhibit B consists of an outline titled, “Biodefense Briefing,” provided by Randall Todd, Dr.P.H., State Epidemiologist, Health Division, Department of Human Resources, Carson City, Nevada.

Exhibit C is the written testimony of Mary E. Guinan, M.D., Ph.D., State Health Officer, Health Division, Department of Human Resources, Carson City, Nevada, provided by Dr. Guinan.

Exhibit D is a document titled “Health Authorities (Nevada State Health Division, Clark County Health District, Washoe District Health Department) Response to the Events of September 11, 2001,” provided by Mary E. Guinan, M.D., Ph.D., State Health Officer, Health Division, Department of Human Resources, Carson City, Nevada.

Exhibit E is a letter dated October 19, 2001, to the President of the United States from George C. Benjamin, M.S., President, and George E. Hardy, Jr., M.D., M.P.H., Executive Director, Association of State and Territorial Health Officials (ASTHO), Washington, D.C., seeking additional federal funding to combat bioterriorism for state and local public health agencies. This document was provided by Mary E. Guinan, M.D., Ph.D., State Health Officer, Health Division, Department of Human Resources, Carson City, Nevada.

Exhibit F is a handout titled “Responsibilities of the Legislative Committee on Health Care Concerning Long-Term Care, Including Discussion of the Responsibilities of the Department of Human Resources for Long-Term Strategic Planning,” provided by Marsheilah D. Lyons, Senior Research Analyst, Research Division, Legislative Counsel Bureau, Carson City, Nevada.

Exhibit G is a handout titled “Responsibilities of the Legislative Committee on Health Care Concerning the Development of a System for Reporting Medical Errors,” provided by Marsheilah D. Lyons, Senior Research Analyst, Research Division, Legislative Counsel Bureau, Carson City, Nevada.

Exhibit H is a handout titled “Information Concerning Review of Certain Administrative Regulations Related to Health Care,” which contains copies and summaries of the health care regulations that the Health Care Committee is required to review pursuant to NRS 233B.063 and 439B.225 together with cover memorandum from Leslie K. Hamner, Principal Deputy Legislative Counsel, Legal Division, Legislative Counsel Bureau, Carson City, provided by Ms. Hamner.

Exhibit I consists of a document titled “Legislative Committee on Health Care, Indigent Care Study, Pursuant to Section 6 of Senate Bill 377 [Chapter 598, Statutes of Nevada 2001], History” together with two attached documents titled “Legislative Committee on Health Care, Indigent Care Study, Pursuant to Section 6 of S.B. 377, Outline” and “Legislative Committee on Health Care, Senate Bill 377, Indigent Care Study, Principles (Proposed).” Exhibit I was provided by Christopher Thompson, Senior Policy Analyst, Center for Health Information Analysis, University of Nevada, Las Vegas.

Exhibit J is a handout titled “Proposal for Conducting the Study of Medical Errors Pursuant to Assembly Concurrent Resolution No. 7 (File No. 77),” provided by Marsheilah D. Lyons, Senior Research Analyst, Research Division, Legislative Counsel Bureau, Carson City, Nevada.

Exhibit K is the “Attendance Record” for this meeting.

Copies of the materials distributed in the meeting are on file in the Research Library of the Legislative Counsel Bureau, Carson City, Nevada. You may contact the library at (775) 684‑6827.

I.	Introductions and Opening Remarks Senator Raymond D. Rawson, Chairman
*II.	Overview of State Bioterrorism Defense Plan Mary E. Guinan, M.D., Ph.D., State Health Officer Health Division
*III.	Presentation Concerning the Activities and Responsibilities of the Legislative Committee on Health Care A. Marsheilah D. Lyons, Senior Research Analyst Research Division, Legislative Counsel Bureau (LCB) B. Leslie K. Hamner, Principal Deputy Legislative Counsel Legal Division, LCB
*IV.	Presentation of Background Information Regarding Medical Care Provided to Medicaid, Indigent, and Other Low-Income Patients in Nevada, Including Discussion of the Methodology Used by the Department of Human Resources in Making Certain Payments to Public and Private Hospitals for Treating Such Patients Christopher Thompson, Senior Policy Analyst Center for Health Information Analysis, University of Nevada, Las Vegas
*V.	Adoption of Principles to Guide the Legislative Committee on Health Care in its Study of Programs and Funding for the Treatment of Medicaid, Indigent, and Other Low-Income Patients Pursuant to Senate Bill 377 (Chapter 598, Statutes of Nevada 2001)
*VI.	Discussion of Subcommittees, Advisory Groups, or Technical Working Groups, Including Possible Appointments, Compensation, and Reimbursement A. Subcommittee Concerning the Development of a System for Reporting Medical Errors Pursuant to Assembly Concurrent Resolution No. 7 (File No. 77, Statutes of Nevada 2001) B. Additional Subcommittee, Advisory Group, or Technical Working Group Appointments
*VII.	Scheduling of Future Meetings and Discussion of Future Topics
VIII.	Public Testimony
IX.	Adjournment

MINUTES OF THE MEETING

LEGISLATIVE COMMITTEE ON HEALTH CARE

Las Vegas, Nevada

A G E N D A