MINUTES OF THE ASSEMBLY COMMITTEE ON COMMERCE Sixty-eighth Session June 16, 1995 The Committee on Commerce was called to order at 3:45 p.m., on Friday, June 16, 1995, Chairman Larry Spitler presiding in Room 332 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. COMMITTEE MEMBERS PRESENT: Mr. Larry L. Spitler, Chairman Ms. Sandra Tiffany, Chairman Mrs. Maureen E. Brower, Vice Chairman Mr. Richard Perkins, Vice Chairman Mr. Dennis L. Allard Mr. Morse Arberry, Jr. Ms. Barbara E. Buckley Mr. Thomas A. Fettic Ms. Chris Giunchigliani Mr. David E. Humke Mr. Michael A. (Mike) Schneider STAFF MEMBERS PRESENT: Paul Mouritsen, Senior Research Analyst OTHERS PRESENT: Dr. R. G. Whittemore, Nevada State Psychology Association Mr. Ben Dasher, Nevada Life and Health Insurance Guaranty Association Ms. Peggy Manes Mr. Edward Hanley, Reno Hypnosis Center Mr. Flip Priszner, Habit Control Institute Ms. Vikki Corrigan, Hypnotherapist Ms. Paula Berkley, Psychology Board Dr. David Antonuccio, Psychology Board Ms. Marianne Miller, Hypnotherapist Ms. Bonnie Dahl, Nevada Dietetic Association Ms. Nina J. Davis, Nevada Dietetic Association Ms. Elaine Frankovich, Nevada Dietetics Ms. Kay Oring, Nevada Dietetic Association Mr. Jim Muson, Nevada Dietetic Association Ms. Elizabeth C. Richitt, Board of Psychological Examiners Mr. Dennis Ortwein, Psychology Board Mr. Daryl Capurro, NFADA Mr. Tom Harrison, Nevada Counseling Association Ms. Betty Wallace, NASAAAP Ms. Dorothy North, Drug Commission Mr. Scott Walshaw, Financial Insurance Division Ms. Mary Santina Lau Ms. Liz Breshears, Bureau of Alcohol and Drug Abuse Ms. Rhonda Moore, Deputy Attorney General Chairman Spitler announced the hearing would function as a subcommittee as the quorum fluctuated and was opened on S.B. 493. SENATE BILL 493 - Revises provisions governing assessments paid by member insurers to Nevada Life and Health Insurance Guaranty Association. Mr. Ben Dasher, Chairman of the Nevada Life and Health Guaranty Association (NLHGA), explained the mission of the Association was to pay the claims of insolvent companies who had policy holders in the state of Nevada. As of this date they had paid approximately $20 million worth of claims over the years. In order to have sufficient funds to pay the claims they assessed the approximately 900 companies that did business in the state of Nevada in an amount sufficient to pay Nevada policy holders. In addition to that particular assessment they also had an administrative assessment of $150 per year, per company. Last year, through that particular assessment, they garnered approximately $133,000 and their budget for that year was approximately $185,000 (Exhibit C). Obviously there was a shortage and periodically, every three to five years, they had to return to the Legislature and request an increase. The purpose of S.B. 493 was to request an increase to $300. Chairman Spitler indicated the language of the bill said " . . must not exceed $300 . .", and asked if they would go to the full $300? Mr. Dasher replied they would not. Mr. Spitler inquired as to the dollar amount to which they would go? Mr. Dasher anticipated it would be about $210. Ms. Tiffany queried when was the last time they had an increase? Mr. Dasher thought it was four years ago. She asked why they needed an increase? Had there been an addition to their staff, an inefficiency with automation, less dues paid, what was the reason? He said the reason was the number of insolvencies and their complexity had increased. All the insolvencies they were confronted with were multi-state insolvencies which required much additional actuarial and legal work on which they had to contract. Ms. Tiffany asked if that was usually paid out of the administrative fees? Mr. Dasher said in some degree. She asked if he was talking about increasing the administration fees out of which they paid other third parties, such as actuaries. He replied they did. She asked if they paid attorneys out of the administration fees? He replied they had a domestic Nevada attorney who was used in some cases. Ms. Tiffany confessed ignorance of insurance terminology and asked if the assessment fee was for medical, life, property and casualty insurance, and/or everybody? Mr. Dasher responded there were three forms of assessments and they depended upon the type of insolvency. If the insolvency was a life company and was for life insurance, then all life companies were assessed on the basis of the premium volume written in the state of Nevada. It was a percentage assessment based upon the amount of insurance. If it had to do with accident or health, they moved into that sector of the premium. The third sector was annuities and if the insolvency had to do with annuities it was then based upon annuity premium. Ms. Tiffany asked how many of the insurance companies were not domiciled in Nevada? Mr. Dasher replied they were all in other states but they wrote business in the state of Nevada and the challenge of the NLHGA was to pay the claims for Nevada policy holders from that fund. Ms. Tiffany inquired if they usually received a finding from a court stating the company had gone insolvent and through the court decision those were the percentage of claims they must pay? Mr. Dasher stated the company was declared insolvent by the Commissioner of its domestic state and, in turn, was declared insolvent by the Nevada Insurance Department. At that time the HLHGA was "triggered", meaning they now began to pay claims because of the fact the claims were not being paid. Ms. Tiffany asked if each state had a different "trigger" point for their domicile insurance companies? Could they end up paying out more for claims domiciled in New Jersey, for instance, than in Florida, or was there a standard? Mr. Dasher explained the Commissioner of the state of the insolvency was the responsible party for declaring the insolvency and 45 states had what was called a "states only law", which meant when the insolvency occurred they were responsible for that particular state's policy holders. Mr. Jim Smith, a Deputy Attorney General representing the Commissioner, indicated the Commissioner supported the bill. The Guaranty Association was one of the Guaranty Associations that existed in each state and was a member of the National Organization of Life and Health Insurance Guaranty Associations (NOLHGA). They performed an important and valuable service to the state. There being no more testimony or questions, the hearing was closed on S.B. 493 and opened on S.B. 517. Chairman Spitler announced there was a quorum present. SENATE BILL 517 - Revises provisions governing retail installment sales. Mr. Daryl Capurro, Nevada Franchised Auto Dealers Association (NFADA), indicated the original request for the bill had come from the Retail Association of Nevada (RAN). It was part of a two bill package to separate the issues of credit card companies, i.e., Visa, Mastercard and the like, from retail installment sales contracts and in-house credit card situations. The other bill was S.B. 516 which was being amended in the Senate at the present time and would come before the Assembly shortly. Their part in the situation was contained in S.B. 517 and he referred to a letter received from RAN (Exhibit D) outlining their concerns. Mr. John Sande, with the Nevada Banker's Association, indicated S.B. 516 and S.B. 517 separated retail installment contracts from retail charge agreements. It was desirable because there was confusion regarding different methods of doing business, one used credit cards and the other used revolving retail charge agreements. Therefore, the retailers had S.B. 517 and the banks and credit card companies had S.B. 516. Both bills had to pass together if they were going to be passed because one without the other would cause great confusion and chaos. He indicated Ms. Santina Lau had proposed amendments to the bill, one of which was extremely necessary for the car dealers represented by Mr. Daryl Capurro. Mr. Sande recommended either holding a hearing at the present time and seek an amendment on it, or if the Committee's pleasure was to hear both bills together, perhaps they could commence the drafting of the amendments so they could be heard when S.B. 516 came over from the Senate. Chairman Spitler said it seemed they should be heard together and asked when they anticipated S.B. 516 to be transmitted to the Assembly. Mr. Sande felt it should arrive early the following week. Chairman Spitler indicated if Mr. Sande wished S.B. 517 to be held until S.B. 516 was transmitted from the Senate so the two bills could be heard together the Committee would accommodate it. Mr. Sande requested they be allowed to ask bill drafting to begin working on the amendments in order to be prepared when the bills were to be processed. Mr. Spitler said it took about two weeks to get amendments done. Mr. Sande indicated that was fine. Ms. Mary Santina Lau, Executive Director of RAN, said S.B. 516 had come out of the Senate with a Do Pass recommendation without any amendments whatsoever. Mr. Walshaw, Director of the Financial Institutions Division, was unable to attend the hearing but had submitted suggested language which was in the last two pages of (Exhibit D). They were technical amendments on that section to accommodate the Franchised Auto Dealers who preprinted their contracts in bulk. RAN recommended those changes be made. Also on the original draft there was a portion which was supposed to have been amended out but had not come through properly. It was on page 5, section 15, (3), (e), lines 18 and 19, which was current but old law that reflected what was to be printed on the monthly statements but were not currently printed on monthly statements. The major corporations preprinted their monthly statements. It led to the effect that the buyer may pay his total unpaid balance. It was in contracts they had the right to prepay but the statements had the total amount due, the minimum payment required, the amount of remaining balance, and a place where the person wrote in what they were paying. They had requested deletion of those things but it had not been done in the original bill. They were very concerned if the bills did not pass together they could "mess up" either one or the other's statute because they were writing new law on S.B. 516 which would be coming from the Senate later. The entire purpose was to separate the two. She did not know if there was a way to address it legally as opposed to amending it, to help Mr. Capurro. Mr. Scott Walshaw, Commissioner of Financial Institutions, indicated the question that had come up in the bill originally was concern of the Attorney General's office that the definitions contained in the bill did not comply with the requirements of federal regulations "Z". They were concerned because they did not wish to change the vehicle contracts required to be used by the Nevada Automobile Dealers Association members. It was a major expense every time they had to change contracts and they did not want to require them to change it for a technical amendment to the definitions. Therefore, if at all possible they wanted to have the bill amended so it eliminated that possibility. He said Mr. Doug Walther, the Attorney General representing his office, had provided the language. Ms. Santina Lau said during the 1993 legislative session there was a concern by the banks when definitions were amended. They ran up against "finance charge" and "time price deferential". The attorneys from the major corporations and banks worked on consensus pieces of language that would qualify for retail installment sales contracts. It basically addressed the in- house credit cards and would cover their type of installment credit. The banks had their own bill which covered Visa, Mastercard and those types of credit operations. In section 2 of the bill they had defined "finance charge". In section 3 they defined who was the payee. Basically they were attempting to make their act comply and be able to marry across to the credit card act. When all of that was taken out of their bill draft language had to be written to bring it in. The retail sellers deemed to pay with respect to any payment made on the account. Once payment was posted through the negotiable instrument, credit was extended which changed the definition that credit was extended where liability was determined. Mr. Sande indicated the problem experienced in the last session was the definition of "finance charge" and "interest". Credit card companies and most of the statutes defined "interest" and it was most important as to what the term interest meant. Basically, in Nevada they had tried to create a haven for corporations to come in, such as City Bank and Household Finance, and set up credit card centers in Clark County. It was important for them to have clear laws defining "interest" so if there was ever a question as to which state's law applied, Nevada's law would apply that "interest" was well defined. Unfortunately they were formerly "stuck" with NRS Chapter 97 and in the retail area they were accustomed to such terms as "finance charges" or "time price differential". There had been confusion last session when they wanted to have everything defined as interest and the retailers were accustomed to the terms "time price differential" or "finance charge". They decided to separate the two completely but they had to pass together because they were taking some provisions and putting them in the credit card area, and at the same time they had similar provisions in the retail area so they would dovetail together. Ms. Santina Lau indicated section 4 changed the words and terms defined in NRS 97.025 which referred back to the act. Section 7 clearly defined the retail charge agreement and conformed it to the correct statute which stated the buyer may pay in installments to a retail seller. They were defining the retail charge agreement. Section 9 defined it as a person other than a financial institution, to clearly delineate them from banks, and entering agreements describing the terms for extension of credit to which the pursuant may, and it defined what they were going to be able to do as the retail seller, or seller, defining what they were. Section 10 changed "time balance" to "finance charge". Mr. Capurro said one of the recommended amendments from Mr. Walshaw's office changed the time balance to total of payments, and the initial balance to amount financed, plus the finance charge. Ms. Santina Lau continued -- it remained the same until section 15, page 5, lines 20 through 30 was what had to be written down if a change was made in terms of a retail charge agreement. It was exact language out of regulation "Z", the federal truth in lending, which brought it into compliance with regulation "Z". Section 17 stated limitation imposed upon provision of the chapter giving retail installment transactions. It defined retail installment transactions, a conflict between that provision and other statutes which clearly delineated them from banks. Chairman Spitler referred to section 7 where they had repealed items and asked if they had been folded into banking? Ms. Santina Lau answered yes. Ms. Giunchigliani clarified S.B. 516 would be coming over from the Senate and was a basic banking and credit card definition and format. S.B. 517 would deal with retail if the amendments were worked out correctly. The intent was the banks would continue to use the word "interest" and retail would define it as "financial charge" and the term "time price differential" would go away. Mr. Sande summarized it would be clearer for people trying to comply with the requirements of the statutes in the credit card or retail area. Ms. Giunchigliani asked if there were places they would parallel? Mr. Sande said there were places where the language would be almost identical, but since the two bills were separated they would be found in two separate NRS chapters. Mr. Capurro indicated three legislative sessions past, because there were a myriad of different sized, shaped and worded contracts in the automobile industry area, it confused not only the customer but the companies that had to deal with them. For instance, he had dealerships with franchises with all three domestic manufacturers. All three contracts were different in length, size, and wording. The idea, which was revolutionary at the time, was to come forth with a uniform contract. It was good from the consumer standpoint because no matter where they purchased an automobile there was a uniform contract, credit application form, and the like. Therefore, it was important there not be a requirement to reprint those items every time legislation changed. He requested the Committee consider submitting the proposed amendments for drafting. Chairman Spitler noted the Committee had been awaiting 14 amendments for over two weeks. Mr. Walshaw clarified his involvement with the bill. When the contract idea was first "floated", the Department of Motor Vehicles (DMV) was the agency responsible for drafting the original documents. Somewhere along the line it was decided his office would be given that task. Essentially what they were charged for was to form the basis for the contracts because they were familiar with the various laws, statutes, and regulations that would go into the construction. Over a couple of sessions they finally got the "kinks" worked out and at the present time all he did was review and monitor the contracts and, by regulation, made changes to them which were actually a part of the Nevada administrative code as they occurred in federal and/or state statute. What they were trying to do was avoid having to re-do those contracts each time there was a technical change or problem. There being no more testimony or questions, the hearing was closed on S.B. 517 and opened on S.B. 448. SENATE BILL 448 - Revises provisions governing licensing and regulation of psychologists. Ms. Paula Berkley, representing the State Psychological Board, indicated she would walk the Committee through the bill (Exhibit E) section-by-section and explain the three amendments. She introduced the bill and stated the Board was attempting to review the complaints and hearings experienced over the last couple of years. They had addressed the "themes" of the psychologists in the state and sharpened the statute so psychologists understood more clearly what they should not be doing and gave the public a better understanding of what psychologists should be doing. This would provide some preventative measures to cut down on hearings and complaints. They had a 58 percent increase in complaints over the last few years which was a concern to the Board. Not only did it cost time and money but there were misunderstandings needing to be cleared up. She explained the bill (Exhibit E) and then deferred to Dr. David Antonuccio, Treasurer of the State Psychological Board, who would explain the fee information. Dr. David Antonuccio, a psychologist at the Veteran's Administration and the University of Nevada School of Medicine, asked the Committee to turn to the section of (Exhibit E) entitled "Proposed Fees/Justification" (blue page) and he explained the fee increases. He referred to page 5, section 14 of the bill, where the various fees proposed were listed. The first one was for the written examination which would allow them to charge $100 over the cost of the examination itself. The written examination cost $250, was put out by "EPPP", was a national exam, it cost $100 to administer it, and $100 for qualification review. They were not looking to make money, just to break even and avoid running out of money and drawing on the general fund. The next fee was for the oral examination and was $100 over the actual cost. He indicated there was a detailed cost analysis for each item in the same section of (Exhibit E) on the green page. Issuance of the initial license was $25 which was the actual cost. They were proposing a cap of $400 for the biennial renewal. They were not proposing an increase of $500 but wished to have the flexibility to do so and not be required to return to the legislature to increase it in the future. That was $400 every two years, therefore, only $200 per year. California was $500 every two years, Oklahoma was $400. They had included some of the fees for other licenses within the state for comparison purposes. He felt their fees were relatively inexpensive. For restoration of a suspended license it was $100 which they considered a motivator for psychologists to keep their licenses active. For registration of a firm it was $300. It had been on the books for years that corporations were supposed to register with the Board, but they rarely did so, and this was a way to generate incentive and motivate them to register. Finally, registration of a non-resident to practice as a consultant was estimated to be $82, and they were asked for a cap of $100 and would try to recoup the costs. Dr. Antonuccio continued in the section on "Budget Information" in (Exhibit E) he referred to the red/green graph which indicated their expenditures were going to exceed their revenue and reserves by next year without any kind of fee increase. It was his responsibility as Treasurer to the Board to request fee increases so they did not end up in a situation where they had to draw upon the general fund. Ms. Berkley completed her explanation of the bill (Exhibit E) and went on to the amendments. The first amendment which was a clarification on page 2, line 18, the sentence beginning "includes", would be changed to ". . and the term may include: . .", and the words "without limitation" would be omitted. The reason for that change was because hypnotists felt it could be construed that unless one was a psychologist they would not be allowed to do hypnosis. That was incorrect. What they wanted to say was a psychologist may be trained and capable of doing hypnosis, but they were not trying to put anyone out of work. Therefore, as long as a person did not call himself a psychologist, one could be a hypnosis counselor. The second amendment/clarification had been requested by the Bureau of Alcohol and Drug Abuse (BADA) and occurred on line 29, page 2, where the words "alcohol and substance abuse" would be deleted. The reason was because of confusion in the past between the Board and BADA regarding who needed to be certified and under what circumstances. Rather than do a "quicky fix", what they preferred was to sit down with BADA after the legislative session and clean it up in order to help them in their relations with psychologists and all others who "dabbled" in alcoholism, including doctors, alcohol and drug abuse people, and marriage/family therapists. One was a title act, one was a practice act, and it had become quite confusing. The Board felt if it made everyone happy to remove those words it would be done, and afterward they would sit down together and do a thorough job. They had agreed upon that move. The third and final amendment (Exhibit F) was lengthy, came from the Governor's office and basically responded to the issues concerning a bill heard earlier in the Commerce Committee, A.B. 329. It explicitly stated when a person applied to the State Board of Psychologists for a license and had gone to "XYZ College" and obtained their degree, the Board should respond within a certain fixed time in a very specific manner regarding the sufficiency or insufficiency of his/her qualifications. This would give the applicant some direction and put it into statute. They felt if it had been in statute years ago perhaps A.B. 329 would not have been needed. The Board of Psychology supported it. Chairman Spitler asked why there had been such a dramatic increase in complaints in the field? Dr. Antonuccio explained it was consistent with what was happening nationally. The very last page of (Exhibit E) showed data from the American Psychological Association on accumulated complaints. He thought there were a couple of reasons for it. Consumers were more educated and boards were taking complaints seriously and doing a better job of pursuing them. Chairman Spitler referred to page 5, line 20, for the registration of a non-resident to practice as a consultant, and asked for some examples. Dr. Antonuccio related a police department wished to bring in a consultant to do some type of trauma work with some of the officers. An expert in another state would be brought in. For that person to practice psychology in the state of Nevada they had to be invited in by another psychologist and sign on as a consultant under the supervision of a Nevada licensed psychologist. Chairman Spitler asked if they had to do that at the present time? Dr. Antonuccio answered yes. Chairman Spitler asked if a company brought in a psychologist to discuss issues in general, did the person have to be registered in Nevada at the present time? Dr. Antonuccio said if they were practicing psychology for up to 30 days they could if invited by another licensed psychologist. Chairman Spitler queried what if a business in the private sector wished to address how to better motivate people in the work place and provide incentive to become more productive? How would that apply to the situation? Dr. Antonuccio replied if that individual was not a psychologist or claiming to be practicing psychology, the board would not be concerned about it. Chairman Spitler asked if he considered the practice of psychology giving presentations as a consultant to those trying to better understand how to improve things? Dr. Antonuccio answered, not necessarily. Chairman Spitler indicated it was a confusing issue and was not clear to him. He referred to line 17, "For the registration of a firm, partnership or corporation which engages in or offers to engage in the practice of psychology", and asked, did all the psychologists who worked for that firm have to be licensed? Dr. Antonuccio responded, yes, that was correct. Chairman Spitler asked how many firms there were in Nevada? Dr. Antonuccio was not certain, there was only one who had ever registered. It was in the statutes they were supposed to register. Chairman Spitler clarified they were not charged to register. Dr. Antonuccio agreed. Chairman Spitler asked how much money he thought they would raise from the $300? Dr. Antonuccio said it was difficult to predict. Chairman Spitler asked him how they would fund doubling the board meetings and increasing investigations if they were unsure how much money would be raised? Dr. Antonuccio said most of their revenue came from licensees themselves on the biennial fee every two years, therefore, they were not counting on the registration fees. Ms. Giunchigliani referred to page 1, section 5, where it said they would conduct service over radio and television, and asked Dr. Antonuccio to explain it. He read section 5: "Any service of a psychologist may be provided to a person or a group of persons in person or by telephone, radio, television or any other medium of communication". He maintained in the age of multimedia people were delivering services in more unusual ways. This was a way of indicating it was still the practice of psychology no matter what the medium. Ms. Giunchigliani asked if they were imparting psychology on the radio would they have to be licensed by the board? Dr. Antonuccio answered yes. She asked how they would regulate radio or television, and/or if it was out-of-state? Dr. Antonuccio pointed out that was one of the issues the bill was designed to address. For example, in Nevada telephone books there were "800" numbers for people in other states who were providing services for treatment of depression or anxiety. It was felt there was something needed to say that type of thing was, in fact, the practice of psychology in the state of Nevada. Ms. Giunchigliani was unsure how it would be handled if they were not contained within the state. Dr. Antonuccio agreed if they were not contained within the state it would be more difficult. However, if someone was doing therapy over the telephone and not in the state that was more clearly a form of psychology that should be regulated. She asked how would it be enforced? He thought it would be up to the Attorney General's office but assumed there would be a letter sent asking them to cease-and-desist unless they were properly trained. He said he had called one of the "800" numbers to find out exactly what kind of training the individuals had. They were not forthcoming and it was not clear they had adequate training to be treating suicidal patients and that sort of thing over the telephone and in another state. It was something that concerned him, personally, but he did not know how the Attorney General's office would handle it. Ms. Giunchigliani suggested they defer to their attorney on the Board for further investigation. Chairman Spitler asked if the "800" numbers were the types that put disclaimers the person should be 18 years old before they called and was entertainment. Dr. Antonuccio indicated the Reno and Las Vegas telephone books indicated they were treatment for depression and anxiety. They were not the typical "900" numbers. Ms. Giunchigliani referred to page 2, line 29, regarding the amendments on alcohol and substance abuse disorders. In subsection 1, "psychological testing evaluation", they would be able to do this for the issue of counseling, psychoanalysis, psychotherapy, hypnosis and biofeedback. She asked if all psychologists were trained in those areas and could do all testing and diagnosis. Dr. Antonuccio said it was amended to say they may include those things. They were ethically and legally bound to practice only in their areas of expertise. Ms. Giunchigliani asked how she would know if she was hiring somebody with specialty in biofeedback? Dr. Antonuccio indicated it was up to the consumer to make sure they asked for the credentials and training information. It was included in the practice of psychology but the individual should be trained for those specialties. Mr. Giunchigliani declared they did not delineate, they just gave a blanket psychologist's license versus psychologist with emphasis in "x", "y" or "z". Dr. Antonuccio agreed saying it was a "generic" license. She asked why they did not deal with that so the average consumer would know whether or not the person was properly licensed to dispense counseling, psychoanalysis, psychotherapy and hypnosis. He thought some states had tried to delineate specialty licenses but it became so complicated and cumbersome. Even the American Psychological Association had been promoting specialty boarding and it was a difficult thing to legislate. Ms. Giunchigliani asked how many hours they looked for in a transcript for those six to seven areas. Dr. Antonuccio deferred to Dr. Richitt. Elizabeth Richitt, Ph.D., stated those particular areas were not what they looked for in the transcripts. What they looked for was practicum experience in which they would include those subjects, but not necessarily particular course work. The requirement of 90 quarter hours or 60 semester hours included things like that, but they did not specify which of them had to be included. Ms. Giunchigliani pointed out the term included "without limitation" as a definition of the practice of psychology in those areas. Simply having a practicum would not necessarily guarantee they had the background. Dr. Richitt said since there were so many different areas what they had relied on was the ethical injunction upon their licensees that they were not to practice outside their area of expertise. Ms. Giunchigliani said if they were given a license just saying psychologist and all those specialties were allowed, they would not be outside their area of expertise. Dr. Richitt said if they had not been trained it would be outside their area of expertise. Ms. Giunchigliani stressed no one would know if the transcript and/or Board did not delineate as such because they gave a blanket license. Dr. Antonuccio interjected that NRS 641.112 said: "The Board shall ensure by adopting regulations enforcing the provisions of the chapter that licensees limit their practice of psychology to their areas of competence as documented by training and experience." Therefore, a consumer could make a complaint that they were treated by someone who was not trained to do what they did and the Board would be bound to investigate it. Not meaning to belabor the point, Ms. Giunchigliani asserted if they were initially going to issue a psychologist's license and hang up a shingle, if a person called on the telephone assuming the psychologist dealt with hypnosis, if there was no background specialization in hypnosis they were not violating the rules. She would not know to file a complaint and felt this was misleading to the consumer and protective of the psychologist. She asked if the language, over all, impacted psychiatry in any way? How did they define their practice? Were there other scopes of practice in different areas? Dr. Antonuccio said his understanding was psychiatry had read the bill and was comfortable with it. Ms. Berkley indicated she had passed the bill by Marsha Berkbigler who was, in her opinion, the "queen of scope-of-practice" and asked if she viewed it as an expansion of psychology's scope of practice and she had said it was not. Ms. Giunchigliani asked if there was no problem with the terminology of "emotional", "mental" or "affective". They all answered no. She asked, how about some of the other areas? Dr. Antonuccio said to his knowledge the Marriage and Family Board had no problem with it either. Ms. Giunchigliani wanted to make sure no other licensing Boards would be negatively impacted. She asked how they defined "substantially equivalent" mentioned on page 2? Dr. Richitt stated it was not substantially equivalent in both subject matter and extensive training. She explained they had taken from the model act for psychologists the listing of course work that was expected psychologists would complete, and those particular courses were looked for in transcripts from other applicants. There were eight or nine different areas where three credit hours were required in those particular areas and the additional credit hours had to be in areas pertaining to psychology to make up the 60 semester hours or 90 quarter hours required. Ms. Giunchigliani asked who within the Board did the transcript analysis? Dr. Richitt said she did the transcript analysis for licensees and Dr. Mordelero did it for psychological assistants. Ms. Giunchigliani asked if they were trained as transcript analyzers? Dr. Richitt said the legislature put in equivalent in the licensing law in 1985. Since that time the Board had tried to devise some measure where they could feel comfortable that they were setting criteria that would be equivalent and would protect the public. Ms. Giunchigliani asked if regulations were available determined by the Board defining what "substantially equivalent" or what "equivalency" was? Dr. Richitt indicated in the administrative code they had all the courses spelled out, how many credit hours were needed, and so forth. Ms. Giunchigliani asked if they ever relied on other institutions to have them review transcripts since neither of them were trained as transcript analyzers? Dr. Richitt said the only time they had relied on other institutions was when they had a foreign graduate whose credit hours did not translate well, therefore, there was an organization that reviewed foreign transcripts. Ms. Giunchigliani said many times transcripts came in with a title that did not necessarily reflect what the course work was, and if a person did not have a background in transcript analysis it could be misleading and people could be ruled out or ruled in. She asked for the code where "equivalency" was defined. Dr. Richitt indicated NRS 641.061. Ms. Giunchigliani's final question (thank the Lord!) was how many psychologists were currently licensed in the state of Nevada? Dr. Antonuccio believed it was 225 at the present time. She clarified that was exclusive of those hired as psychologists in the state, but not licensed, such as those working in prisons and child and family services. Dr. Antonuccio said that was correct. Mr. Humke was not sure he understood the amendments that were stated orally, specifically the one dealing with alcoholism and substance abuse. Ms. Berkley indicated page 2, line 29, and deleted the words "alcoholism and substance abuse". BADA wanted them to write in the bill that it should be a certified BADA counselor and should be added to their scope of practice. She had gone to the Legislative Counsel Bureau (LCB) with Kim Morgan and found that BADA was a title act as long as a person did not portray himself by the title of Alcohol and Drug Abuse Counselor. Alcohol and substance abuse was one of the mental disorders in which psychologists were trained. Therefore, because of their Ph.D. they were qualified to work in the field of alcohol diagnosis, but it did not mean as a psychologist they were able to handle that field. If they wanted to call themselves alcohol and substance abuse counselor they needed to be BADA certified. One was a title act, the other a practice act. There was much confusion on it. She asked the Board to remove it because BADA and the psychologists had the discussion before and thought it was clear, but it was not. Therefore, it behooved them to be certain to get it written correctly. It probably would be most accurately described in regulation. If they needed it in statute they would put it back. Taking it out did not preclude the psychologists who already had the ability because it was in their practice act to deal in the field and diagnose alcohol and drug abuse. It was basically a "wash" and put it back to where it was before the bill was begun and seemed to be the best approach to resolving an issue, rather than the legislature deciding it. Mr. Humke replied, despite his friends from BADA, he did not agree that the Board should take out the terms "alcoholism and substance abuse". He believed there was a mechanism, as described earlier, pursuant to Ms. Giunchigliani's questioning regarding such topics as biofeedback and hypnosis which were relatively esoteric topics and not every psychologist was trained in them. Those professionals could be regulated by regulation and they trusted them to do it. He felt they could do the same thing with alcoholism and substance abuse. Those topics were in the DSM-4 and many psychologists were conversant with treatment issues and techniques and if they met approval by regulation they would be fully licensable. He disagreed with taking it out based upon Ms. Berkley's other description. Ms. Berkley basically agreed with him but said they were trying to be "good guys"! Mr. Humke indicated Ms. Giunchigliani raised some very good questions regarding section 5. He felt the explanation regarding the use of a telephone for practicing psychology was fine. However, when they got into radio and television he felt they were not doing so well. He asked if it was their intent to call a person forward for examination to determine if they had a license if they practiced over the telephone, television or radio? Dr. Antonuccio answered, yes, if they were practicing psychology they would be accountable to the Board for their actions. In other words, therapy did not have to take place in a room with another person. He could envision a time when it would be done by video. There were computer programs at the present time mimicking therapists. It was the age of multimedia and they felt it was possible for psychology to be practiced that way and it should be in statute. Mr. Humke felt they would have problems with it, especially the medium of television. He asked if the Board had the ability to monitor all the myriad channels and all the talk shows. He wondered if they had the ability to send out notices to wherever the programs emanated from to inform them it was received in and they were practicing in the state of Nevada and please submit evidence of your licensure. Ms. Berkley agreed and remarked the intent of the Board was to monitor programs where individuals portrayed themselves as psychologists and gave advice to perhaps emotionally or mentally disturbed people. If there was a complaint from the television "patient" it gave the Board the ability to investigate to ascertain if the practicing psychologist was licensed or not. If they were not licensed they would be made to cease and desist. If the Committee did not think it was valid the Board could be flexible regarding the point. Their intention was to "set the scene" because this was the type of therapy that was beginning to happen and would continue to do so in the future. There was closed-circuit group therapy at the present time. Therapy in rural areas where there were no licensed psychologists was a perfect example. Teaching was another example where the media could be utilized appropriately. Mr. Humke said he did not like to pass unenforceable statutes. He did not know how they could enforce a licensure provision in other states when an individual presented himself/herself as a psychologist and the message was received in Nevada. The question might be asked, was it individual or group therapy or was it training? Was it personnel training in a corporate setting? That might be a way to enable them to withdraw from the situation. Dr. Antonuccio asked Mr. Humke if the service would be regulatable if it was specified to be individual or group psychotherapy delivered in that particular fashion? Mr. Humke said it would be a way, but they might find a situation where the law was unenforceable when the service emanated from a person with no other contact to Nevada except through the air waves. He suggested perhaps the Attorneys General had cooperative provisions. Ms. Rhonda Moore, Deputy Attorney General, said the provision was an attempt to explain psychologists could perform services in ways other than face-to-face. The intent was not to cross state lines. It was only an attempt to explain psychology could be practiced through various media and had nothing to do with enforcement. Ms. Berkley asked if the Committee wished to have that portion of the bill deleted? Chairman Spitler suggested it be discussed at a work session. If it was decided to change it in some way based upon the questions asked at the hearing, the Chair would be glad to distribute information for the work session. Dr. Robert Whittemore, speaking on behalf of the State Psychological Association, said they were in favor of the bill. Ms. Peggy Manes, an attorney in Reno, Nevada, wished to make clear she was representing no one but herself and, perhaps, the average consumer of health care services. She felt the definition of the practice of psychology, as reflected in the bill, was so broad it raised concerns in her mind. As the stepmother of a child with a learning disability, she had sought alternative health care and was amazed at the positive effect it provided. As an attorney concerned with laws that might have more bad consequences than good effects, she indicated she was present on less than 24 hours notice to comment on the bill. She pointed out the definition on line 18, page 2, began a new sentence that said, ". . the definition included without limitation the following . .", and listed the number of tools that all psychologists may use. Other professions used them as well and some people used them specifically as their only livelihood and profession; for instance, hypnotherapists and biofeedback professionals. There were individuals who used biofeedback in the treatment of attention deficit disorder which would fall within the discussion on the definition in item 10. Ms. Berkley, Ms. Moore, as counsel to the Board, and she had discussed it prior to the meeting. She was somewhat more comfortable with the definition, if they made the change to line 18 so it would read, ". . and mental health and may also include . .". It seemed like a distinction without a difference but, in fact, what it said then was, yes, "psychology is what it is", the practice of a larger profession which may also include the following things. However, Ms. Manes hoped the legislative history of the bill would reflect it was not the intention of the Board of Psychological Examiners, nor their counsel, to set up a statute whereby a person engaging in hypnotherapy as their sole practice and who, for instance, conducted smoking cessation clinics; or her stepson's reading tutor who addressed the fact he had attention deficit disorder and possibly dyslexia; or the chiropractor who said, "Your back problem might be stress-based, can we talk about what is going on in your life?", would not be "hauled up" before the Board as an object of a complaint or have their livelihood taken away on that basis. She understood professions needed regulation but had to have a little "give" in them to make them work. There was a large grey area surrounding the definition. She hoped the Board would pass regulation to clarify the law would not be used as a tool for a "witch hunt" for any particular alternative practice. She hoped the Committee would adopt the proposed amendments, otherwise leave well enough alone. There were organizations, on a national level, that set standards for licensed hypnotherapists. The American Council of Hypnotist Examiners and the Biofeedback Certification Council of America were two examples already in existence. Setting up special fees for psychologists and specifically licensing them in one of those areas was complex. It was complex for a reason -- the areas themselves were quite complex. She could understand including them as tools to which a psychologist had access. If a person went to a psychologist and was hooked up to an EEG for biofeedback and perceived it as "feathers and whistles", he/she should have the right to complain to the Board of Psychological Examiners the psychologist was "off his nut". However, the bill should clarify it was a perfectly reasonable tool for a psychologist to use. The flip side was, those who used any of the tools as adjuncts or as the sole focus of their practice in alternative health care should not be penalized by the bill. Chairman Spitler asked Ms. Manes if she had testified in the Senate when the bill was heard there. She pointed out she had been unaware of the bill at that time. Mr. Edward Hanley, a certified hypnotherapist from the Sierra Hypnosis Center, was present due to his concern about the definition of the practice of psychology, specifically including hypnosis which was his sole means of support. He did not hold himself out as a psychologist and offered his services to the public as a certified hypnotherapist. He expressed comfort with the suggested amendment in line 18. He asked for an exclusion in section 8 for certified hypnotherapists to clarify the intention was not to exclude them from practicing their livelihood and offering an option to people in the state who might want to come strictly for the services offered by them. Ms. Marianne Miller, a certified hypnotherapist in Reno practicing for seven years under the title of hypnotherapist, was pleased to hear there were some possibilities of amending the bill, particularly line 18. However, she was still alarmed! She had only become aware of the bill that morning and had to rearrange her schedule in order to be present. She pointed out to the Committee that she worked closely with one of the top psychologists in Reno. The psychologist referred clients to Ms. Miller and Ms. Miller referred back to her. The psychologist did it because that particular part of psychological analysis was not her expertise. She realized when she referred clients to Ms. Miller they were being taken care of in the utmost professional way using hypnosis. Clients received an all around way of healing in working with both the psychologist and the hypnotherapist. She also worked with other psychologists and marriage and family counselors. Hypnotherapy was her sole income and she felt concern that she could be out-of-business if the bill passed as written. She had called several other licensed psychologists who were unaware of the bill. If the intent of the bill was to protect the public she expressed surprise they had not been made aware of it. It was perplexing to realize psychologists had been chosen to be the group to scrutinize and have power to control other professions, such as hypnosis and biofeedback. She viewed it as an elitist bill. Another aspect that caused her concern was another expense added to the community by adding another "licensing arm" on the Board of Psychologists. It was creating another level of government. She asked how many lawsuits there were against hypnotherapists compared to licensed psychologists. She asked the Committee to look closely at the motivation of the bill insofar as people like herself who had been practicing for many years in the sole area of hypnotherapy. Chairman Spitler indicated Ms. Miller had brought up a good point in regard to noticing and said all bills were publicly noticed meetings with five day lead times. It was difficult to inform all those impacted by legislation and he was glad she had the opportunity to testify. Ms. Manes indicated the bill said "an act relating to psychologists", and, in fact, it related far more to other professions in an indirect way. People may not have been aware of it. Mr. Flip Priszner, from the Habit Control Institute in Reno, Nevada, had practiced for 17 years and expressed the same concerns as the others in opposition to the bill. He concurred with the line 18 and line 29 proposed amendments. In lines 7 and 8, for example, hypnotherapy dealt with motivation and people's desire to make changes in their lives. The bill conceived to limit motivation or the utilization of training for motivational purposes. He respectfully submitted the word "motivation" be excluded in lines 8 and 9. Chairman Spitler indicated it was in existing law and asked him if it had put him out of business? Mr. Priszner answered, no it had not. In that event he concurred with the esteemed counsel. Ms. Vikki Corrigan, indicated she was a certified hypnotist with the American Council of Hypnosis Examiners, certified with the Institute of Medical Hypnosis, the Immune System Hypnotherapy and the Forensic Investigative Hypnosis, and also belonged to the Alcoholic Rehabilitation Association (ARA) for two years. She had been practicing since 1954, in Reno for over 35 years, was 63 years old -- and it "scared the devil out of her" when she found out she might be out of business. Mr. Dennis Ortwein, the oldest member of the Board of Psychological Examiners and the only non-psychologist, urged they take care of the housekeeping and the complexities and get it on with it. During the years he had been on the Board there had been tremendous growth and they had worked diligently to protect the public as was their function. Ms. Betty Wallace, Executive Director of an alcohol and drug treatment program in Reno, Nevada, indicated they were the only program in the state that took women and children over the age of one year. She stated opposition to S.B. 448 specifically page 2, lines 28-30, which allowed psychologists, without limitation, to diagnose and treat alcoholism, substance abuse and disorders, habit or conduct. Their issue was with the scope of practice. For the past two decades Nevada had developed a comprehensive certification system assuring a level of quality and accountability in the services provided. It included a written and oral examination. There were interns working in the field who were required to take specific class work toward drug and alcohol addiction in order to sit for the test. The applicant was required to have a minimum level of the documented experience in substance abuse. For instance, a psychologist must have had 2,000 hours of experience in substance abuse in order to sit for the test to be certified as a substance abuse counselor. The test itself ensured that each person who became certified possessed a certain level of knowledge, expertise and understanding in the treatment of drug and alcohol addiction. The system acted as a quality assurance tool protecting the public from clinicians unskilled in substance abuse issues. Once certified, the clinician was still under strict regulations that continued assurance the consumer was able to obtain the best substance abuse clinical services available. Ms. Wallace stated passage of S.B. 448 opened the door to a dangerous precedent allowing a discipline that was not, by definition, skilled in substance abuse issues, to practice. In the current system, a psychologist could go through the certification process and become a certified substance abuse counselor. Under S.B. 448 that would not be required. Alcohol and drug abuse, as in all fields, was changing continually and they felt there needed to be update of information, continuation of classroom work and leverage on what material was required to be a substance abuse counselor. Substance abuse diagnosis and treatment was a very specialized discipline. It required a base of knowledge and expertise. The boundaries must be protected and the discipline not allowed to have a "blank check" with which to practice. They urged the Committee to adopt the amendments but otherwise reject the bill. Chairman Spitler asked if their position was that a physician or psychiatrist should not treat alcoholism? Ms. Wallace felt it needed to be an individual well qualified in the field of substance abuse. Ms. Liz Breshears, Chief of the Bureau of Alcohol and Drug Abuse, said physicians by law were certified to deal with substance abuse issues, particularly in terms of any medications that required a medical license to prescribe. She pointed out she was present to testify in favor of the amendment proposed by Ms. Berkley to remove alcoholism and substance abuse from section 7 of the bill. When their office called Dr. Krista Petersons to discuss the bill, their Deputy Attorney General believed there was a conflict in the wording of the section of the statutes which dealt with substance abuse counselors, which was NRS 458.360. The particular statute stated no person could hold himself out to the public as an alcohol and drug abuse counselor and it ended saying, or in any way imply that he is a certified alcohol and drug abuse counselor without being certified as a counselor by the Bureau. Currently there were 33 Ph.D. psychologists who were certified substance abuse counselors, of which 27 were clinical psychologists, several were counseling psychologists/development psychologists, and so forth. They recognized additional expertise in the field of substance abuse was needed, therefore, they went through the certification process. Only 14 of those were licensed by the Board of Psychological Examiners. Indeed, there was a gap, in essence, how individuals not certified in their field would be regulated in terms of their practice. Ms. Brower asked if taking out lines 28-30 would stop a psychologist from treating drug and alcohol abuse, they just could not treat under the name of certified? Ms. Breshears clarified if they implied they were a certified substance abuse counselor in any way. Ms. Breshears continued, because there was so much concern regarding the amount of education other counseling fields were being provided, the University of Nevada had set up a specialized minor specifically in the substance abuse counseling area. The person who oversaw it, Dr. Gary Fisher, was unfortunately unable to be present to testify. As Ms. Wallace had pointed out, it was a specialized field with specific educational needs. Individuals trained in traditional counseling had learned, to some extent, the opposite of what they had been taught academically upon entering the field. Indeed, possessing a Masters in Education Psychology and clinical social work, she had been taught if a client did not want counseling they could not be helped. Whereas, after a number of years in the substance abuse field she had learned the court mandated client was the one they wanted because denial was an important part of the disease. The client objected to mandated counseling but it was how they broke through denial. Chairman Spitler asked if she had testified in the Senate? Ms. Breshears said they were unaware and had not been contacted about the particular bill specifically addressing their area. They found out about it on second reading. Ms. Giunchigliani had perused the counseling language in the bill and asked what was wrong with the original definition? Ms. Berkley said it was not so much what was wrong with it, but they had received questions regarding the scope of practice of psychologists. The counseling bill was a good example of the public being concerned because there were five licenses at the present time, potentially six, having to do with health issues. There were alcohol and drug abuse, marriage and family therapists and psychologists. People queried, what does a psychologist do? What were they qualified to do? The public felt better with a more specific answer. Ms. Giunchigliani did not feel comfortable deleting without limitation. She felt perhaps retaining the language through lines 19 or 20, but then define and segregate those additional areas defining the hours for program and study. Or a reverse would be to define, under the exemptions, any of the statutes that listed a certification of BADA, hypnotists, and whatever, and list those statutory references. She saw it as a potential expansion of scope if they were not careful. Ms. Manes thought there a lot of assumptions being made about certifications that did not exist. There were national certifications for those areas but none in the state of Nevada. That was why they proposed the current amendment which would effectively say they could be utilized as part of psychology rather than exempting them. If they could have done it neatly they would have done so. Ms. Giunchigliani said their amendment did not accomplish what they wanted. Ms. Manes said it was the best they could have done in ten minutes. Ms. Berkley added it was not the Board's intention to cause such concern. They felt a person could be a counselor, a hypnotist or a "whatever" as long as they did not call themselves a psychologist. They were very clear about it and all other Boards had the same stipulation. She informally committed to a newsletter, published by the Board, that would summarize and explain the bills and be sent to every licensed psychologist. They were serious about improving their ability to serve and protect the public, but also not to hurt anyone. Ms. Giunchigliani appreciated the delineation they did not want them holding themselves out as psychologists, on the other hand, she did not want psychologists holding themselves out as hypnotists if that was not their area of specialization. Chairman Spitler appreciated their willingness to impart legislative intent but he said once those things were codified and in the law they fell into the hands of attorneys who, in fact, were sometimes quite skillful at reweaving legislative intent. Therefore, he could understand their fears. There being no more testimony or questions, the hearing was closed on S.B. 448 and opened on A.B. 686. ASSEMBLY BILL 686 - Requires state and local governments to select registered professional engineers, professional land surveyors and registered architects for certain public works on basis of competitive bidding. Chairman Spitler indicated A.B. 686 had filled everyone's mailbox and was an issue ripe for exploration. He did not think there was time to do much with it this legislative session. He had talked with the head of the architectural board and several other areas and indicated he would be working with them on the interim. Co-Chair Tiffany and he had agreed if there was a motion to indefinitely postpone, the Committee would entertain such. ASSEMBLYMAN PERKINS MADE A MOTION TO INDEFINITELY POSTPONE A.B. 686. ASSEMBLYMAN ALLARD SECONDED THE MOTION. THE MOTION CARRIED. SENATE BILL 389 - Authorizes physicians' assistants to prescribe controlled substances. Ms. Tiffany expressed concern about physician's assistants (PA) prescribing narcotics. Although the Board of Examiners was a regulatory Board, there were controls in the bill stating PA's could not prescribe any levels of controlled substances because they were under the auspices of a physician and the physician designated what levels of drugs they could and could not prescribe. It had satisfied her concern regarding controlled substance. She wished to add a subsection to section 2 regarding PA's having their own DEA number, which was the number tracked from the pharmacy to ascertain subscription abuse. Mr. Mouritsen and Ms. Tiffany had created the proposed amendment (Exhibit G) and indicated they had to have it perused by bill drafting. The intent was to regulate PA's would not have their own DEA number and it was still under the supervising physician. Ms. Giunchigliani appreciated the amendment because she also wished to specify they put it under the physician's DEA number. ASSEMBLYWOMAN GIUNCHIGLIANI MADE A MOTION TO AMEND AND DO PASS S.B. 389. ASSEMBLYMAN ALLARD SECONDED THE MOTION. THE MOTION CARRIED. Ms. Tiffany volunteered to take the floor statement for S.B. 389 to the floor. There being no further business, the Committee adjourned at 5:45 p.m. RESPECTFULLY SUBMITTED: Barbara Moss, Committee Secretary Assembly Committee on Commerce June 16, 1995 Page