MINUTES OF THE
SENATE COMMITTEE ON HUMAN RESOURCES AND FACILITIES
Sixty-seventh Session
May 3, 1993
The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 1:30 p.m., on Monday, May 3, 1993, in Room 226 of the Legislative Building, Carson City, Nevada. Exhibit A is the Meeting Agenda. Exhibit B is the Attendance Roster.
COMMITTEE MEMBERS PRESENT:
Senator Raymond D. Rawson, Chairman
Senator William R. O'Donnell, Vice Chairman
Senator Randolph J. Townsend
Senator Joseph M. Neal, Jr.
Senator Bob Coffin
Senator Diana M. Glomb
Senator Lori L. Brown
GUEST LEGISLATORS PRESENT:
Assemblyman John W. Marvel, District 34
STAFF MEMBERS PRESENT:
Judy Alexander, Committee Secretary
Pepper Sturm, Research Analyst
OTHERS PRESENT:
Dr. Robert Daugherty, Dean, School of Medicine, University of Nevada, Reno
Ron Lange, Deputy Administrator, State Health Division
Lawrence P. Matheis, Executive Director, Nevada State Medical Association
Helen A. Foley, Lobbyist, Nevada Nurses Association
L. Timothy Terry, Senior Deputy Attorney General, Director, Medicaid Fraud Control Unit, State of Nevada
Mary Ellen McCarthy, Lobbyist, Senior Attorney, Nevada Legal Services
James L. Wadhams, Lobbyist
Dennis Nolan, Risk Manager, Loss Prevention Coordinator, Mercy Ambulances, Las Vegas
Mary F. Santina, Lobbyist, Retail Association of Nevada, Chain Drug Counsel and Grocery Industry Counsel
Chairman Rawson opened the hearing on Assembly Bill (A.B.) 3.
ASSEMBLY BILL 3: Expands authority of physicians' assistants, physicians and registered nurses to provide care in ambulance or air ambulance. (BDR 40-204)
Assemblyman John W. Marvel, District 34, testified A.B. 3 was a product of a problem that occurred in Humboldt County. Last summer, he was notified by a physicians' assistant, who had been told that he could not be an attendant on an ambulance, because he was not an Emergency Medical Technician (EMT). He stated, a physicians' assistant (PA) was a thoroughly trained practitioner. Dr. Robert Daugherty, Dean of the School of Medicine, University of Nevada, Reno, explained he saw there was more merit in A.B. 3 than just to address his problem, where it could be applied more on a statewide basis.
Dr. Daugherty explained, the bill had some restrictions when it originally came out, regarding size of county, to allow physicians' assistants to perform emergency care in an ambulance. He suggested that this could lead to someone having to get out of an ambulance as it arrived at a county line and stated that after this area was amended in the assembly, the bill seemed to fit the statewide needs. He explained, the School of Medicine was involved in a physicians' assistant training program for people interested in becoming PAs from rural Nevada. This particular kind of legislation would be helpful in attracting people into this field. Physician's assistants work with physicians under the Board of Medical Examiners and are licensed with physicians in rural Nevada, as well as in urban areas. He stated the School of Medicine was in support of A.B. 3.
Chairman Rawson explained, that Mr. Nolan of Mercy Ambulance, Las Vegas, was especially concerned about untrained physicians. Because of superior rank, a physician would be able to direct activities at an accident scene. If the physician had not been properly trained, problems affecting patient care might arise. In his opinion, a physician riding in an ambulance should, as a minimum, be certified for advance cardiac life support, prehospital trauma life support or advanced trauma life support. He stated, this training was widely available and designed with physicians in mind.
Dr. Daugherty reminded the committee, A.B. 3 was for physicians' assistants, not physicians. Chairman Rawson explained, that if a physician should become involved in an emergency situation, the physician may not be as well trained in emergency procedures, on an ambulance. A physician would have more foundation through their schooling, but physicians that do not work in the emergency setting, do not have those protocols in mind. He explained, it was a issue of someone working under protocol, who may have less credentials, but may be better trained for that protocol.
Assemblyman Marvel stated, the basic reason for this bill was primarily for the attendants to be on an ambulance until it could get the injured person to more qualified people in a hospital setting. He stated, there were very long distances in rural Nevada between clinics and hospitals. The clinic in McDermitt was very far from the hospital in Winnemucca and even though there were EMTs in the area, sometimes the only person on call is a PA. The big reason for the genesis of this bill was to make sure that those people had that primary of transferring them to the hospital.
Dr. Daugherty pointed out on lines 12 and 13, on page 2, where it was stated, to comply with all applicable regulations adopted, pursuant to this chapter regarding the provision of emergency medical service, and went on later in the bill to define what was required of people who deliver emergency medical service, so that the physician's assistant, in this case, would be expected to have had that kind of training. He stated, this bill was directed at PA's, not physicians. The PA would have to have the same basic training as anyone who performs this kind of service on an ambulance.
Senator Glomb referred to page 2, section 6, line 4, and asked, was there a requirement to be certified in providing emergency medical treatment. Dr. Daugherty responded, the opening sentence of that paragraph, said that people who gave emergency medical service could serve without being licensed, under the provisions of this section, but the regulations of the board must be fulfilled. Senator Glomb asked, was it difficult to become certified. Dr. Daugherty answered, no.
Assemblyman Marvel stated, the way the statute was written now, an EMT can preform this, but not a physicians' assistant, and the PA's training was more extensive than an EMT's. This was the case in McDermitt, where a PA was told he could not ride in an ambulance due to a strict interpretation of the statute.
Ron Lange, Deputy Administrator, State Health Division, stated his division licensed EMTs who were lay persons, particularly volunteers in rural areas or paid for service EMTs who have to be certified, according to state standards or district Board of Health Standards.
This would allow people who have had professional training at a higher level, such as physicians, nurses and now physicians' assistants to also ride on an ambulance, with the idea that their basic training was at a higher level than most of the EMTs to begin with. This would allow people, based upon their basic professional training, which was deemed to be at a higher level, than an EMT, to also serve on an ambulance. He stated, the State Health Division supported this bill as written and it would solve problems that may occur in the rural areas.
Chairman Rawson stated he did not want to create a arguable situation, where the state would have new legal liability. Mr. Lange advised, he did not see this as a problem area. Chairman Rawson asked, would it be a problem, if the bill was written, that these people at least had training in advanced cardiac life support. Mr. Lange responded, no.
Dr. Daugherty stated, it is not difficult to put that into a curriculum and to expect someone to have advanced cardiac life support training.
Chairman Rawson asked, could advanced cardiac life support and trauma support be added to a curriculum. Dr. Daugherty responded, he thought so.
Assemblyman Marvel asked would this also make the training for the EMT that much more precise, over and above the present training.
Chairman Rawson responded, in his opinion, an EMT was trained to the equivalent of advanced cardiac life support, but noted that all physicians do not have that.
Chairman Rawson stated, this would help the whole trauma network, and stated the committee would try to work this out so that it could be accomplished.
Senator Brown asked, what would it take to be certified to be a physicians' assistant. Dr. Daugherty answered, most of the PA programs were 2 years, many of them requiring 2 years of college. The program at the University of Nevada, Reno, School of Medicine required 2 years of college with 1 year spent in the classroom in classes such as physiology and anatomy. The second year of the program would be spent in rural areas with doctors and at the medical school in the veterans' hospital in Reno. The Board of Medical Examiners certifies the physicians' assistant, in conjunction with one supervising physician.
Lawrence P. Matheis, Executive Director, Nevada State Medical Association, testified in support of the bill, which would add extra manpower support in the rural parts of the state. He stated, in spite of all of the hypothetical, the impact of the bill zeroed in on the urban areas.
Helen A. Foley, Lobbyist, Nevada Nurses Association (NNA), explained the nurses in the association have a minimum of a baccalaureate degree. Many were advanced practitioners in many different fields of nursing. She stated, NNA was concerned in the original bill, that physician's assistants would be on the same footing as licensed physicians, and would not have to comply with rules and regulations of the State Board of Medical Examiners, as nurses did, with the Board of Nursing. She explained, the way the bill was currently written was good legislation.
Senator Neal asked was this bill within the population requirements of the small counties. Ms. Foley stated, this bill now was for all counties in Nevada. It removes the 35,000 delineation, but, on line 11, page 2, each registered nurse and certified physicians' assistant who performs such care, shall comply with all applicable regulations adopted. She noted, if communities had more stringent rules, it allowed those rules to be followed.
Chairman Rawson closed the hearing on A.B. 3.
Chairman Rawson opened the hearing on A.B. 167.
ASSEMBLY BILL 167: Enlarges criminal provisions against false claims for health care.
L. Timothy Terry, Senior Deputy Attorney General, Director, Medicaid Fraud Control Unit, State of Nevada, stated this proposal, from his office, was to serve as a prosecutorial aid, in the field of provider fraud. This would allow them, in the instance of a Medicaid fraud investigation prosecution, to point out that the provider was not only defrauding the Medicaid program, but also possibley defrauding Medicare or private pay programs. It would take away those basic defenses that pop up all the time. It had been their experience, that if a provider was defrauding the Medicaid program, he was also involved in any of the other programs that he was servicing. He explained, it had been a rather lengthy hearing on the assembly side, and in his opinion, it had the concurrence of the Nevada State Medical Association on its format. He urged the committee to pass the bill as it was now.
Chairman Rawson asked, was this for the provider, not the receiver of care. Mr. Terry responded, that was correct. Chairman Rawson asked, was there any potential for abuse with the receiver and would the legislature need to deal with that issue. Mr. Terry noted, there was the potential for recipient fraud in any insurance program. Within the Medicaid program itself, the Welfare Division had its own recipient fraud department that was headed up internally, and in his opinion, the law was adequate there. Also, with respect to recipient insurance fraud, the Attorney General's Office had an insurance fraud division that looked into that area regularly, so in his opinion, that area was covered.
Mr. Terry responded to a question by Senator Neal, in reference to line 6, section 3, and explained, that included acts of physical intimidation, but would try to encompass all the various modes in which claims are made these days. Whether it was electronically, a hard copy or a physical document, the fraud control unit wanted to make sure there was not anything left out. That was the reason for the language of any attempt.
Lawrence P. Matheis, Executive Director, Nevada State Medical Association, stated his office had worked closely with the Attorney General's Office, in refining the language of the bill, so that it got at what was intended. He stressed, if there was criminal fraud going on by a physician or another health professional, there must be ways of getting at that criminal act, stopping it and making that effort clear enough, that any other potential criminal actions would be discouraged. At the same time, there was a need to recognize that an overly-broad view of fraud and abuse, which was now in popular political rhetoric, could cause problems in the other direction.
Contract issues have been viewed as issues where there were disputes between two private individuals that contract, whether or not it was appropriate for government to determine that the party which was the third party payer, could never commit a fraudulent act. Whereas a provider was presumed always doing a fraudulent act, when it came to a question of a claim for payment, where one party would benefit from not paying and the other party would benefit from being paid. There was a concern of an overly broad approach. In his opinion, A.B. 167 contained that concern and was okay.
Mr. Matheis stated, there was one continuing area, where the Nevada State Medical Association had a disagreement. Specifically, the bill has a range of punishments, including a number of civil penalties, in section 11, subsection 2 B, line 20, which said that there would be a fine not less than $2,000 for each act of deception. The concern of the Nevada State Medical Association was that in any law, there was always a potential for constitutional challenge, if the punishments were viewed as disproportionate to the potential violation. For an example, there could be a number of the same coding violations found. If this was rigidly imposed in the wrong situation, it could lead to a disproportionate fine. What the Nevada State Medical Association recommended, was the language which was also in the federal Medicare fraud and abuse language and was not more than $2,000 fine for each act of deception. The approach here was not less than $2,000. He said, "That is our only statement of objection." Chairman Rawson asked, for a fraudulent claim of $300, should there be a $2,000 fine on that. Mr. Matheis explained, if the same act had occurred a number of times, for each act, it would be not less than $2,000 for that act, regardless of the amount. He clarified the Nevada State Medical Association was not actually proposing that amendment, but raising the issue that it could be raised at some point down the road.
Senator Neal stated that Mr. Matheis wanted to put the limit on the top, rather than the bottom. Mr. Matheis responded, he would like to and explained an example where a insurance company might come under this particular proposed legislation. He said, anytime an insurance company suspected it had been defrauded in a bill from a provider, if it was suspect that the provider was claiming to have done service that was not done, or making a claim at a coding level or billing level, different than what would be appropriate, that was the sort of issue that was contemplated by this.
Senator Neal stated, the bill did not go to the payer of health services, in terms of its penalties, but would go towards the provider. Mr. Matheis answered, that was right, this bill focused entirely on one party in the potential of a fraud situation.
Senator O'Donnell questioned, was this for Medicaid and Medicare, or for all payers. Mr. Matheis responded, it was for all payers. He explained, it was a civil matter and was focused only on where the abuse was criminal in nature and that was why the language was so focused.
Chairman Rawson stated this just allowed the Attorney General's fraud unit to go in and hit hard at people that had high volume or large numbers of fraudulent acts.
Mr. Matheis stressed, for people whose behavior was so clearly criminal in its intention, there should not only be the civil liability which was there, but an added liability that would go on to it. It was his opinion that A.B. 167 would catch that particular pattern of behavior, when it existed. He added that the Medicaid program had found rare instances of it, but it was important to send the signal. He noted, it might be wise to also look at behavior of payers.
Senator Neal asked, would this disallow the vertical integration of a doctor being associated with an insurance company, in terms of ownership. Mr. Matheis answered no, he did not think this addressed that issue.
Mr. Terry stated, this particular bill would not address that issue at all. Senator Neal asked, could a doctor be part of an insurance company, where he would submit his or her payments, to that insurance company. Mr. Matheis responded, that health maintenance organizations could have participating partners in other circumstances, but he was not sure how that would work with an insurance company.
Senator Neal referred to section 4, and asked for Mr. Terry to give an example how the intent would be proven there. Mr. Terry stated Senator Neal raised a good point, because in the original proposal, the language did not include that specific intent. It read, the facts which deceive a payor of health care, with respect to a claim, and was amended to, included an intentional act. He explained, the assembly committee and several individuals who testified, felt if there was not the specific intent element that the legislation would read too broadly and would potentially catch too many providers, who may have accidentally submitted a claim that turned out to be false.
Senator Neal asked, would a person be able to use statistical evidence to say that the intent, to make the intent standard apply here. Mr. Terry responded, that part of the prosecution case would undoubtly include all of the claims that may be involved. He referred to a case involving 1300 claims, which would be broken down chronologically, by types of services provided and would present all of that information to the trier of fact, so that the scope of the fraudulent activity could be seen and determination could be made whether or not there had been an intent to deceive the program, or whether there was a possible accident in a case of that magnitude. Senator Neal asked, even though this intent standard appeared to be limiting, as it applied in a case such as this, did it cause the Attorney General's Office enforcement problems?
Mr. Terry explained, that Medicaid fraud statutes did not impose this specific type of intent in its cases. It was a general intent, in their statutes, therefore, there was a little variation here, but the fraud control unit felt the concession could be made without jeopardizing their work.
Senator Brown asked, would the Attorney General's Office automatically go for the civil remedies, if the criminal charge was proved. Mr. Terry responded, if the Attorney General's Office prosecuted someone criminally first and convicted them, yes, the civil penalities would be automatic. Senator Brown noted, there was only triple reimbursement if the state pursued the civil remedy. Mr. Terry responded, yes that would be correct.
Senator Neal asked Mr. Terry, what would be offered, if the intent standard would be changed. Mr. Terry responded, the language in the initial bill draft, which was amended out to include the specific intent. Mr. Matheis stated, if that occurred, the Nevada State Medical Association would oppose it as setting an inappropriate standard for a criminal case. It would intervene and say it was now a criminal standard, that unintentional acts with which a payer disagreed was now a crime. Not only a crime in statement, but a crime in fact that could cost a professional license, as well as significant other penalties. He stated, the issue here was how to get at criminal intent and behavior.
Mr. Terry declared in Mr. Matheis defense, in his opinion, this particular language came about with respect to the situation that he alleged earlier. The insurance company decided to bring charges against the doctor in a contractual civil dispute. The insurance company turned over a complaint to the Attorney General's Office to look at and jeopardized the doctor's well being and his licensing status. The Attorney General's Office did not want to see that happen out of a purely civil disagreement over a claim of compensation.
Mr. Matheis explained, this was happening all the time, because payers were now in the process of redefining what would be paid. Claims were systematically down-coded. If that behavior was done by the physician, that a claim was sent and systematically up-coded, that could become the challenge of a criminal behavior. At the present time, if the payor systematically down-coded every code, no one found any fault with that behavior.
Chairman Rawson noted, that regardless of what was finally decided, the time that it took to sort it out worked in the payers benefit, by holding on to the money. He asked, this was not a bad compromise between the Attorney General's Office and the Nevada State Medical Association. Mr. Terry responded, no, but not less than $2,000 in the specific intent, were the trade offs.
Senator Coffin asked Mr. Terry, was it possible there may be fewer providers available, if this bill goes through. Mr. Terry referred the question to Mr. Matheis, and said that in his opinion, if there was a provider segment that was engaged in intentional deceitful fraudulent activity that was enriching them at the public expense, there had to be a way to get to that activity and to appropriately punish it. In his opinion, he did not think the vast majority of providers, who were honest, decent and hardworking, would be scared off. Senator Coffin expressed concern that this could be taken by an aggressive attorney general, looking for a head count or a body count. Mr. Terry stated, the hurdle here, that prevented that kind of over zealous activity was the specific intent requirement. It was a very high standard and took quite a bit of evidence to prove to the trier of fact, and it would not be an easy case to prove.
Mr. Terry responded to a question from Chairman Rawson and stated, the accidental claim or a mistake that had happened once or a couple times a year, certainly would not serve as the basis for a prosecution or this law. It would be the systematic, day-by-day, month-by-month activity that was being repeated and was knowingly false.
Senator Coffin asked, when a mistake was created by a computer erroneously, would someone have a defense by saying, they did not know this was happening. Mr. Terry noted the defense would exist, if there had been a mistake in the programming or if an improper element was being imputed into the computer.
Mr. Matheis stated, the Nevada State Medical Association was concerned to work out language, to get at real criminal behavior, but not to send a signal that every physician who agreed to a Medicaid patient was presumed to be doing it, for bad motivation. He added, in fact, doctors were taking Medicaid patients for the best of motivations.
Senator Coffin expressed his concern that people would get fearful of the long arm of the government. Mr. Terry explained that in his opinion, there was perhaps a matter of education that may be involved there. He stated that Mr. Matheis offered to have the Attorney General's Office come to a gathering of the Nevada State Medical Association to explain and define what was their philosophy and how the law would operate.
Mary Ellen McCarthy, Lobbyist, Senior Attorney, Nevada Legal Services, stated she was pleased to see that some efforts were being made to increase remedies for dealing with false claims. She raised a concern that everyone was protected but the patient. The main problem that she saw, with respect to improper behavior, consisted of providers who owed money to patients, but the patient was never reimbursed. She explained this happened, when a patient over payed a medical provider. She suggested adding some civil penalties similar to the language on page 2, line 16 through 26. This would give a remedy to the recipients of medical care, where the providers were withholding money. She gave an example of a nursing home that owed a Medicaid client over $7,000. The nursing home agreed in October of 1992, that the money was owed the client, but did not pay the reimbursement for 6 months. She stated, there were no current remedies under state law for this type of situation.
Chairman Rawson stated NRS 439B was a cost containment area of the law, and asked, would this refer to everyone. Ms. McCarthy answered, right, it would refer to a doctor who got paid by both the insurance company and the patient. Chairman Rawson asked, was the person who received the payment addressed in the bill. Ms. McCarthy answered no, because the patient was not included in the definition of payor for health care.
Senator O'Donnell stated that NRS 439B did not preclude anybody or proscribe anybody from filing a civil action. Chairman Rawson noted, the authority was included in that section.
Senator O'Donnell stated that NRS 99.040 was the interest rate that was calculated as 1 percent per month and this statute would solve that problem. He declared, 1 percent per month on any transaction that was adjudicated and not paid in time, would be paid.
Senator Brown called attention to the section that Senator O'Donnell was referring to on civil penalties, including triple damage, which was more than 1 percent per month. She stated, it only referred to people who were entitled under sections 2 to 12, of this act. She said, Ms McCarthy raised a good point, that they were looking at the payer for health care, not including an individual who paid for his own health care.
Ms. McCarthy explained, the problem she encountered was there were no teeth in the law to get those people who were holding the money and for that money to be paid within a reasonable period of time.
Senator Brown asked Mr. Terry why, under section 5, an individual paying for health care was not included as someone who could be defrauded and that it only included insurance companies or the self- insured. Chairman Rawson explained, this bill came from the Attorney General's Office specifically for the fraud division. Mr. Terry responded, that was correct. He explained, the focus was primarily on institutional payers and the situation described today, was not something that the Attorney General's Office would normally look at. He did not know if the terms of this bill would solve that. Chairman Rawson noted, the point Ms McCarthy brought up was well taken, but in his opinion, did not fit this bill.
Mary F. Santina, Lobbyist, Retail Association of Nevada, Chain Drug Counsel and Grocery Industry Counsel clarified that when Mr. Matheis was talking about some of the negations that had gone in this bill, specifically section 4, the intent to deceive, that was also addressed for pharmacy issues also, and not just doctors and medical providers. She stated, with their consideration on average wholesale price, the intent to deceive was something signed on to, and supported Mr. Matheis.
James L. Wadhams, Lobbyist, testified this bill, according to its proponents, is designed to deal with Medicare and Medicaid fraud and perhaps it should be limited to that. He explained, there are sections that apply to general claims against health insurance companies. There is a provision on claims relating to insurance companies. The fraudulent claims against insurance companies were designated by the legislature to be a felony several years ago. There are some existing statutes already in place, and in his opinion, this bill may cross over and create conflicts, where none were intended.
Mr. Terry stated, he was not aware of any conflict with existing statute, but said he would be happy to take a review of any statute that may already be in place, to make sure there was no conflict. He asked, what section did this fall under. Mr. Wadhams answered NRS 686A.281 et. seq.
Chairman Rawson asked, was it reasonable to limit this to Medicaid and Medicare, in light of the fact that there was a statute that already addressed the issue of other insurance companies. Mr. Terry said he would review this and report back to the committee. Chairman Rawson stated, there is no reason to put another reference in the law to sections that are already covered and to look at it from that standpoint. Chairman Rawson commented, in his opinion, there was no opposition to Medicaid and Medicare, and if the other references were not adequate, the committee would deal with those.
Chairman Rawson closed the hearing on A.B. 167 and put it in a work committee to be held for any committee members to work on.
Chairman Rawson reopened the hearing on A.B. 3.
Dennis Nolan, Risk Manager, Loss Prevention Coordinator, Mercy Ambulance, Las Vegas, Nevada, stated A.B. 3 did not affect their operation in Las Vegas. He stated their concern was in quality patient care that was addressed in the revised bill and agreed with the idea, in concept. However, the way the bill was written now, may have the exact opposite effect. Physicians, physicians' assistants and registered nurses are not required in their formal training to take the same type of training as the EMTs, at all three levels that paramedics and EMT intermediates were required to have, in order to perform pre-hospital skills. Chairman Rawson asked, would there be an issue in the large counties, of ambulance companies, hiring physicians' assistants or nurse practitioners cheaper than an EMT. Mr. Nolan answered, no, what would be offered to them in the way of pay, was even comparable. A physicians' assistant would probably make three times the salary of a paramedic. Chairman Rawson asked, so there would not be a natural tendency to have people end up working in the ambulance routinely? Mr. Nolan answered, probably not.
Chairman Rawson stated A.B. 3 required all of the applicable rules and regulations of any of the counties be followed. He asked, wouldn't that deal with that issue. After reviewing the bill, he stated, all of that refers back to subsection 6, of section 1, page 2. Mr. Nolan stated this had been analyzed, that physicians would answer to the Board of Medical Examiners and any regulations that pertained to them and registered nurses to the Board of Nursing. However, he was not aware of any regulations, policies, procedures or protocol that either of those organizations had to deal with the training or licensing of pre-hospital care providers. Chairman Rawson asked, were there regulations that described the training that people must have regarding intubation or resuscitation. Mr. Nolan responded, there were regulations regarding that. He added, their concern was that those people have the level of training, in addition to their formal certifications, to provide that kind of care. Chairman Rawson stated, he had talked with all parties present, and asked if there would be any objection to language that would spell out emergency personnel needed to have an advanced cardiac life support course. Mr. Nolan responded, absolutely, there are three certifications that are readily available throughout the state, which are advanced cardiac life support, pediatric advanced life support and prehospital trauma life support. He stated there are certifications that not only every advanced level provider must have to comply with, but emergency room physicians and those other people who deal with emergencies as well, are required to take those.
Chairman Rawson stated, if the bill was written so that those courses or equivalents must be taken, in their physician's assistant training, and built into the curriculum and asked, would that be sufficient. Mr. Nolan answered, yes.
Chairman Rawson said, the concern was about classes for certification and that recertification must be done periodically. He noted that this bill specifically stated, without being licensed. He asked Mr. Nolan, did he have any comments on whether or not he would want those people to have to be recertified. Mr. Nolan responded, that it would probably be prudent to have the people recertify, to assure that training was received and those level of skills could successfully be executed. He noted, that would help keep the skills of the emergency personnel at a high level.
Chairman Rawson advised the committee, it would be his inclination to go with the bill the way that it was, with the addition of those courses or their equivalent in the regular curriculum.
Senator Coffin stated, he agreed that was a good idea, to have everyone recertified. Chairman Rawson asked Mr. Matheis, would there be any problem with that. Mr. Matheis answered, no, and reminded the committee the issue was not about the training for the high tech emergency care. He restated, that in McDermitt and other places in rural areas of Nevada, an EMT may not always be available for an emergency. He stressed, all this was about was that in McDermitt, an ambulance could not roll, because a PA was not authorized to get in the back and ride in it. An air ambulance had to come out, which was not a wise use of resources. He stated, it was a overreaction to a potential that was probably not realistic, but that Nevada State Medical Association did not oppose the bill.
Mr. Nolan responded to Mr. Matheis, and explained, emergency medical services in the rural areas had evolved to a point that there are people who are trained to be EMTs to operate ambulances. The state regulations required those people to have a certain level of proficency, and the situation that was going to require a PA to get on an ambulance was the exception. Chairman Rawson reminded the committee that this came out of a specific case where an ambulance was not able to roll, because the volunteer EMT was not able to get there. The PA had to watch the patient go down hill, because of restrictions not allowing PAs to ride on a ambulance.
Mr. Nolan declared, the statement that all that was needed, was a second person to ride in the back of the ambulance, was flirting with danger, due to the fact this person may not be familar with the equipment or know what to do with the patient in a life threatening emergency.
Senator O'Donnell stated, in his opinion, there was a misconception of the duties of a PA and their dealings in a rural area. He explained, the PAs were analogous to the performing or acting physician, and perform duties on a day by day basis, not exempting the doctor, but in place of the doctor, when one was not available.
Mr. Matheis pointed out to Senator O'Donnell, that all this bill intended to do was to make PAs as available as RNs, as physicians, as EMTs, in those isolated communities.
Chairman Rawson noted, that a small county amendment should not be written here, because it would create the problem of having to stop at the county border. Mr. Matheis stated, that was the hypotethical used on the other side. He remarked, Clark County would never stop an ambulance at the border, because there was a nurse in the back, instead of their licensed EMT.
Mr. Nolan responded to a question from Chairman Rawson and explained, he had a concern that anyone allowed to ride in the back of an ambulance be required to be trained to the level of proficency that the rest of the country accepts as a national standard for an ambulance attendant.
Senator Brown asked, did the health department offer free classes to meet those requirements for volunteers. Senator Brown asked, would someone who volunteered, have to pay for the course. Mr. Nolan stated, in the urban areas, the volunteers had been paying for the courses, but in some cases, there were volunteer courses available, which the EMT office in Nevada could arrange.
Chairman Rawson advised that the Dean, of the School of Medicine, University of Nevada, Reno indicated they were willing to put the courses in their curriculum.
Chairman Rawson closed the hearing on A.B. 3. He advised he would like to accept a motion that would add those requirements, unless the current regulations of the Board of Medical examinors would already address that and advised, he would have staff look that up.
SENATOR TOWNSEND MADE A MOTION TO ADD THOSE THREE LEVELS OF TRAINING UNLESS OTHERWISE COVERED BY REGULATION TO A.B. 3.
SENATOR BROWN SECONDED THE MOTION.
Senator O'Donnell asked for a clarification. Chairman Rawson explained that the committee would go ahead with the bill, amend it to add those levels of training, because it was good training to have, unless the regulations of the State Board of Medical Examinors already dealt with that. Mr. Pepper Sturm, Research Analyst was asked to check the regulations.
THE MOTION CARRIED. (SENATOR GLOMB WAS ABSENT FOR THE VOTE.)
* * * * *
Chairman Rawson stated, the committee would hold A.B. 167 until the resolution was received on that.
Chairman Rawson brought to the attention of the committee, Senate Bill (S.B.) 391.
SENATE BILL 391: Makes various changes concerning surety bonds required of private postsecondary educational institutions.
Chairman Rawson advised that Senator Raymond C. Shaffer had a bill draft request (BDR) that was acceptable to everyone and when he had been contacted, he said in the interest of moving this, he would like this to be substituted into S.B. 391, rather than waiting for his bill draft.
SENATOR TOWNSEND MOVED TO AMEND AND DO PASS S.B. 391 WITH LANGUAGE THAT WOULD ALLOW A RESERVE ACCOUNT THAT COULD BE USED FOR RESTITUTION OF TUITION PAYMENTS FOR STUDENTS, IF A INSTITUTION WOULD GO UNDER.
SENATOR O'DONNELL SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR GLOMB WAS ABSENT FOR THE VOTE.)
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Chairman Rawson brought to the attention of the committee S.B. 197.
SENATE BILL 197: Requires health authority to allow child under 12 years of age to use public spa under certain circumstances.
Chairman Rawson advised the committee that the assembly sent back an amendment that limited this. The health authority shall not prohibit the use of a public spa by a person at least 7 years of age, but less than 12 years of age, who was under direct adult supervision. Originally another subsection was in the bill, that allowed children from 3 to 7, supervised by a parent or guardian and who does not remain in the spa for longer than 10 minutes. He explained, Otto Ravenholt, Chief Health Officer, Clark County Health District sent a letter (Exhibit C) indicating there was no reason to restrict children, if the child was out of diapers, and 3 years of age was picked as a reasonable age. He stated, he did not want to fight this bill much longer. He asked the committee did they want to concur with this or put this in conference committee and see if a lower age than 7 could be agreed upon.
SENATOR COFFIN MOVED TO NOT CONCUR WITH THE AMENDMENT.
SENATOR TOWNSEND SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR GLOMB WAS ABSENT FOR THE VOTE.)
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Chairman Rawson asked Senator Townsend and Senator Coffin to hold a conference committee on S.B. 197 and advised them to try to hold out for 3 years and that the committee would abide by what was decided.
Chairman Rawson stated, that the privies bill was being held on the secretary's desk, to see if this would affect the cattle camps. He asked Mr. Sturm to check with the legal division to see if the final version had been drafted and if this would put the cattle camps out of business.
There being no further business, Chairman Rawson adjourned the meeting at 3:20 p.m.
RESPECTFULLY SUBMITTED:
Judy Alexander,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE:
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Senate Committee on Human Resources and Facilities
May 3, 1993
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