MINUTES OF THE ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES Sixty-eighth Session April 10, 1995 The Committee on Health and Human Services was called to order at 2:00 p.m., on Monday, April 10, 1995, Chairman Vivian Freeman presiding in Room 330 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. COMMITTEE MEMBERS PRESENT: Mrs. Vivian L. Freeman, Chairman Mrs. Jan Monaghan, Chairman Mrs. Jan Evans, Vice Chairman Dr. William Z. (Bill) Harrington, Vice Chairman Mrs. Deanna Braunlin Ms. Barbara E. Buckley Mr. David Goldwater Ms. Saundra (Sandi) Krenzer Mr. Dennis Nolan Ms. Dianne Steel Ms. Patricia A. Tripple Mr. Wendell P. Williams GUEST LEGISLATORS PRESENT: Mr. Roy Neighbors STAFF MEMBERS PRESENT: Jean White, Senior Research Analyst OTHERS PRESENT: Robert Whittemore, Ph.D., Nevada State Psychological Association Martin Gutride, Ph.D., Nevada State Psychological Association Charles Faltz, Ph.D., Nevada State Psychological Association Jeffrey Corpuel, Ph.D., Nevada State Psychological Association Yvonne Wood, Ph.D., Nevada State Psychological Association Kathryn McFadden, Ph.D., Nevada State Psychological Association David Antonuccio, Ph.D., Nevada State Psychological Association Betsy Neighbors, Ph.D., Nevada State Psychological Association Charles Dickson, Ph.D., Nevada State Psychological Association Kevin Welch, R.N., Washoe Medical Center Philip Rich, M.D., Nevada Association of Psychiatric Physicians Reta Baumann, M.D., Washoe Medical Center Michael J. Lewandowski, Ph.D. Thomas F. Sheehan, Ph.D. William Danton, Ph.D., Veterans Administration Medical Cntr. Stephanie Dillon, Ph.D. Terry Rhoades, Ph.D. William J. Mayville, Ph.D. Richard Perkins, Ph.D. Marsha Berkbigler, Nevada State Medical Association Cameron McRae, Chairman, Nye County Commissioners Dick Carver, Vice Chairman, Nye County Commissioners Rachel Nicholson, Deputy District Attorney, Nye County Bill M. Welch, Nevada Rural Hospital Project Patricia Justice, Legislative Representative, Clark County Chairman Freeman apologized for the late start of the Committee meeting due to the appearance of United States Senator Harry Reid at the Assembly Floor Session. She noted a new copy of the Committee rules to address the addition of two members to the Committee plus a change in the way attendance will be recorded had been distributed to all members, (Exhibit C.) Mrs. Freeman added no discussion would be held because of the time constraints on today's meeting, however any concerns could be addressed at Wednesday's meeting. Senior Research Analyst Jean White, substituting for Pepper Sturm, was introduced. ASSEMBLY BILL 157 - Authorizes hospital to admit licensed psychologists to its staff. Mrs. Freeman reminded the Committee A.B. 157 had been heard on February 22 but no action had been taken. The proponents of the bill asked for an additional hearing, which was granted. Mrs. Freeman requested testimony be limited to one half hour each for the opponents and proponents of the bill. At the end of the hour, depending upon how the Committee feels, Mrs. Freeman stated she might put the bill in a subcommittee. She added this would be the final hearing with the full Committee on A.B. 157. Dr. Robert Whittemore, legislative chair for the Nevada State Psychological Association, coordinated the psychologists' testimony and opened the presentation with an evidence packet, (Exhibit D,) containing additional information supporting passage of A.B. 157. He mentioned three proposed amendments to A.B. 157 which would alleviate concerns expressed at the previous hearing by Dr. Harrington, Mrs. Monaghan and Ms. Steel. The amendments are as follows: 1. "Any patient admitted by a psychologist shall promptly be medically evaluated by a physician member of the medical staff of the hospital, and for each patient so admitted, a physician member of the medical staff shall be identified as responsible for all medical treatment and interventions. 2. "No hospital shall be required by law to adopt such rules, nor liable by reason of failure to adopt rules granting psychologists admitting privileges as allowed under this act. 3. "Nothing in this act shall be construed to grant prescription privileges to any professional, except as such privileges may be included within the defined scope of practice within the act under which he/she is licensed." Dr. Martin Gutride, a Nevada licensed psychologist, spoke in support of A.B. 157 from a prepared text, (Exhibit E.) Dr. Charles Faltz, Chair of the Committee on Hospital Practice for the California Psychological Association, presented his testimony a summary of which is attached, (Exhibit F.) He stated California's law concerning full status on medical staffs of hospitals is similar to the one being proposed for Nevada and added California's experience with the law had been a very positive one. There is no basis for claims that psychologists practicing independently in hospitals present any quality of care concerns nor any particular legal exposure for hospitals. Based on actual state records for nearly twenty years, there have been no problems with psychologists practicing in hospitals. The State Department of Health Services, which regulates hospital licensure and the operations of hospitals, has no reports of actions or restrictions as a result of psychologist quality of care issues. There is a report required of hospitals called an "805" report when any physician, psychologist, oral surgeon or podiatrist on the staff has a quality of care problem. There are no reports of psychologists having that kind of problem in California. The major malpractice carrier for psychologists reports there has been no increase in liability associated with psychologists practicing in hospitals. Dr. Jeffrey Corpuel, President of the Nevada State Psychological Association, spoke in favor of A.B. 157 from a prepared text, (Exhibit G,) and mentioned nine other cases illustrating transfer of care problems which are also included with his testimony. Dr. Yvonne Wood, a Nevada licensed clinical psychologist, presented one case of her own and one case from another psychologist, that illustrate problems with the transfer of patient care when a psychologist's patient is hospitalized, (Exhibit H.) Dr. Kathryn McFadden, a nurse and psychologist in private practice in Reno, also related a case that highlighted some of the problems that can occur when a patient's care is transferred, (Exhibit I.) Dr. David Antonuccio, a clinical psychologist and associate professor in the Department of Psychiatry at the University of Nevada School of Medicine, spoke in favor of A.B. 157 from a prepared text and presented several letters of support from physicians around Nevada, (Exhibit J.) Betsy Neighbors, a licensed clinical psychologist and secretary of the Nevada Psychological Association, presented testimony on behalf of the Association. She stated passage of A.B. 157 could enhance the delivery of mental health services in the public sector and presented a letter of support from Dr. Thomas Grundle of the Milwaukee County Mental Health Complex, (Exhibit K.) Dr. Chuck Dickson is in private clinical psychology practice in Reno and presented testimony in favor of A.B. 157. His point of view concerns how the ability of psychologists to admit patients could have hurt or helped Nevada State programs during the six years he was Administrator of the Division of Mental Health and Mental Retardation, (Exhibit L.) Mrs. Freeman, before requesting testimony from opponents of A.B. 157, stated her intention to place it in a subcommittee. Marsha Berkbigler, representing the Nevada State Medical Association (NSMA), spoke first in opposition to A.B. 157. She commented the position of NSMA is that, contrary to what the psychologists said A.B. 157 is an increase in their scope of practice. As a result, NSMA is very concerned about the fact the psychologists do not want to put this law within their own scope of practice statutes. Most providers in Nevada have laws that outline exactly what they can do; this legislation is no different. NSMA also sees no evidence of establishment of need because psychologists currently have the ability to treat patients within a hospital. All the family practitioners Ms. Berkbigler spoke with said if a patient is in need of hospitalization and has a psychologist, they use that same psychologist because they also favor continuity of care. In addition, Ms. Berkbigler testified there are no other states that actually allow admitting privileges. Kevin Welch, a registered nurse working at Washoe Medical Center for fifteen years in psychiatric nursing, stated he is not taking sides in the issue but is concerned that the nurses were not informed of the proposed legislation. He testified in the nurses' scope of practice, the only person he can take an order from is a licensed physician. He added only a physician can really direct and dictate quality patient care in a hospital. Social workers, psychologists and registered nurses currently collaborate on care and Mr. Welch does not see why a change is necessary. Referring again to the Nurse Practice Act, Mr. Welch reiterated registered nurses may only work under the direction of a physician but none of the nurses knew about A.B. 157, and one of them asked Mr. Welch, "Why admit if you can't treat." In addition, Mr. Welch testified passage of A.B. 157 which would allow psychologists or allied health professionals to increase their scope of practice would put an unclear and unfair burden on the system. Mr. Welch has had personal experience with psychologists who were on call for psychiatric physicians and stated it was a nightmare. He wound up calling people back and forth, possibly jeopardizing his scope of practice. Occasionally it was simply not clear whether a suggestion was an order or vice versa. The bottom line is patient safety and patient care. Patients in a hospital setting are entitled to have a physician at the helm who can fully dictate and completely treat their needs. Mr. Welch added A.B. 157 as presented states hospital administration would make the decision to allow psychologists to be on the staff and he requested hospital administrators and nurses really examine the nurses' preservation of scope of practice as well as patient care concerns. Without looking into those needs, staff splitting could occur and programs not function well and who suffers, the patient. Dr. Rita Baumann, a psychiatrist and clinical professor of psychiatry at the University of Nevada School of Medicine, spoke about the amendments proposed by the psychologists. She stated the first amendment read all patients would be required to have a physician as the admitting physician directing their patient care which is currently the system in Nevada. Dr. Baumann could see a problem developing if a psychologist gave admitting orders, then requested consultation from a medical physician who had not yet accepted responsibility for that case. She noted it could be several days before that medical physician showed up to do the consultation. When Dr. Baumann has requested consultation, even from an internist or family physician, they are not always able to come immediately and she occasionally has had to manage that case for a number of days before the primary care physician arrived in the hospital to see that patient. Dr. Baumann commented psychologists had raised the issue of repetition of services when a patient is admitted from an outpatient to an inpatient status. The psychologist changes to a consultant from being the primary care provider and the physician is now the primary care provider. Some of the repetition of services the system currently has is important. As an example, Dr. Baumann mentioned last week a new provider took another look at a patient's symptoms and discovered an operable brain tumor, probably saving that patient's life. A third issue raised by the psychologists is continuity of care. Dr. Baumann believed A.B. 157, if enacted, would not necessarily solve all the problems with continuity of care. As an example, she noted when people change insurance carriers, care may be interrupted because the patient can only use one hospital or a limited number of providers. Dr. Philip Rich spoke in opposition of A.B. 157 and particularly addressed admitting privileges stating no health care provider, including physician psychiatrists, has an automatic admitting privilege to any hospital. Admitting privileges are conferred according to the bylaws of each hospital. Relatively few states require or permit hospitals to consider an application for staff privileges by psychologists. Several of the states which do require hospitals to consider applications for staff privileges by psychologists, specifically deny psychologists who are accepted the right to admit patients, or permit them to do so only when the order is countersigned by a psychiatrist or other physician. Dr. Rich also noted when the psychologists discussed admitting patients to the hospital they stated they would ask a physician to do a physical. However, he noted no physicians had signed up to testify saying they would do those physicals. In addition, no hospitals have testified they want to grant these privileges and no nurses have testified they will take orders from the psychologists. As pointed out at the last hearing, Dr. Rich believes there would be an increased cost of patient care. Instead of one person admitting the patient, it would require two--a licensed medical doctor to do the physical plus the psychologist. Dr. Rich mentioned if he had a patient with a myocardial infarction, he would need a cardiologist to admit his patient. Just because he is a physician does not mean he is allowed to treat any patient in the hospital for any type of problem. Credentialing and privileging is a very serious thing in hospitals; it cannot be taken likely. Referring to Kevin Welch's testimony, Dr. Rich reiterated one person must be in charge of a patient's care. If Kevin, as a nurse, was called regarding an emergency, who would he call? The psychologist, the psychiatrist, the physician or would the Medical Director of the Psychiatric Unit take responsibility? It would cause confusion to have two people in charge. Dr. Rich pointed out the mind and the body working together is a basic concept. One must be trained to treat the body if one is to treat the mind. Just because a psychologist can perform psychotherapy on an outpatient basis does not mean he can treat medical problems in a hospital. Addressing rural mental health, Dr. Rich noted psychiatrists go to those areas on a weekly basis. They have contact with all the family practitioners in all the rural areas. Many of the family practitioners are very qualified to admit their patients to hospitals in the rural areas and psychologists can work with those patients. Assemblyman Harrington mentioned the amendments proposed by the psychologists have improved A.B. 157 but asked who would prevail were there to be a disagreement between the admitting psychologist and the physician who was involved in the medical care. Dr. Martin Gutride responded saying psychologists do not practice medicine and therefore the issue of medical treatment would always be in the hands of the medical physician. He added if there was a disagreement between the physician and the psychologist as to whether or not medication was indicated, he felt the two professionals would be capable of working the disagreement out. Dr. Harrington replied that does not always occur. Dr. Gutride disagreed, saying that kind of collegiality is possible. Dr. Harrington, noting among the patients who would need hospitalization included people with depressive illness, people in a crisis, people who are homicidal and suicidal and asked if there were any other diagnoses or symptom complexes that he envisioned that would require hospitalization but not medication. Dr. Corpuel replied the issue of whether to medicate or not is the physician's decision which would certainly be done in collaboration with the psychologist who admitted the patient. In terms of what kinds of diagnoses might not be medicated, from experience he has found adjustment disorders, situational anxieties, certain forms of depression and even certain forms of anxiety disorder might not involve medication, but that would be a physician decision. Dr. Corpuel added there appears to be some confusion that patients are admitted to a hospital because they need medication but that is a fallacy. Many of Dr. Corpuel's patients in psychotherapy are on medication but do not need hospitalization. A patient goes into a hospital because they need a safe environment. It is not a medical decision as to whether a patient needs a safe environment; it is a mental health decision. He believes psychologists are at least as well trained as psychiatrists to make that decision. Dr. Harrington commented he would still like some diagnoses of illnesses that a psychologist might be admitting for. Dr. Gutride responded the psychologists' scope of practice reads they can diagnose and treat mental disorders. It does not say which mental disorders they can treat. Dr. Harrington asked which of those disorders would require hospitalization but not medication. Dr. Gutride reiterated that would be a physician decision. Dr. Harrington referred to Section 8, number 1(b) which states, in part, if the board of hospital trustees admits licensed psychologists to the staff, every licensed psychologist in the county who requests that privilege should also be admitted. Dr. Harrington stated no field of medicine allows that privilege. Dr. Gutride answered when the bill was written, they simply extracted from current statutes and did not make any change in the current statutes so the same law would prevail for psychologists as currently prevails for physicians. Dr. Whittemore believed Dr. Harrington was misinterpreting the bill and quoted from A.B. 157. Mrs. Freeman thanked all parties who testified on A.B. 157, but was forced to suspend further testimony due to time contraints. She appointed a subcommittee to further examine A.B. 157 which included Assemblyman Goldwater as chairman, and Assemblywomen Monaghan, Krenzer and Braunlin. She requested all questions by Committee members be held until the subcommittee meeting. ASSEMBLY BILL 436 - Authorizes board of county commissioners in certain counties to serve as board of hospital trustees. Assemblyman Roy Neighbors from District 36 introduced A.B. 436 which was requested by Nye County. He testified for many years, Nye Regional Hospital has experienced severe, critical financial problems and there have been numerous bailouts. In 1992 the State granted payment to Nye County from the Supplemental City-County Relief Tax (SCCRT) an emergency fund in the amount of $400,000. In 1993 Nye County loaned the hospital $125,000 for a computer hoping that would help with their billing and other financial problems. As late as 1994 another $400,000 was granted to the hospital to help with accounts payable. The County Commissioners' efforts have always been directed toward keeping that very critical hospital open. When Mr. Neighbors was Nye County Manager the hospital was having financial problems and hospital vendors were calling the county for payment. Mr. Neighbors asked the County Commissioners to request an Attorney General's opinion about who was responsible for the actions of the hospital. The Attorney General's opinion was the Nye County Commissioners are responsible for the bills and the actions of the hospital. Even though the hospital district does not include the entire county, the whole county must bail Nye Regional Hospital out. Currently, the hospital is operating at a loss of $60,000-$70,000 per month. While County Manager a year and a half ago the situation was so dire, Mr. Neighbors was forced, by law, to report the hospital to the Nevada Department of Taxation. The County Commissioners take the position that if they are going to be responsible for the bills and actions of the hospital, they should be the hospital trustees. Currently the trustees from the District are elected by the people. However, there is a critical need for hospital trustees who can make hard decisions. In addition, the deep pockets of the county are being abused whenever the hospital gets in financial difficulty. Mrs. Freeman asked what removal of the SCCRT tax meant. Mr. Neighbors replied there had been a ten million dollar emergency fund when the sales tax was set up. During the 1991 Legislative Session it was decided, because of the new distribution formula for the SCCRT to all the counties, that the emergency fund was unnecessary. There was a small amount left in that fund so to do away with it, various grants were requested. Mr. Neighbors requested $400,000 at that time to enable the hospital to pay the Public Employees Retirement System (PERS) which they were in arrears on. At that time the hospital also owed $125,000 to Workmen's Compensation as well as numerous other bills. The County Commissioners want a say in the hospital's operation if they are going to be responsible for the hospital's debts. Mrs. Freeman asked whether any of the Hospital Board of Trustees were also County Commissioners. Mr. Neighbors said he did not believe so and mentioned Cameron McRae could answer that question better than he. Mrs. Freeman asked about an amendment from Clark County to A.B. 436. Mr. Neighbors explained the amendment was a housekeeping measure and he had no problem with it. He mentioned Mr. Bill Welch, representing the Rural Hospital Project, had also proposed some amendments, (Exhibit M,) that he felt he could agree to. Dr. Harrington asked whether Nye Regional Hospital was owned completely by the county or if there was any private money invested in it. Cameron McRae, current Chairman of the Nye County Commissioners, in answer to a previous question, replied no members of the County Commissioners are seated on the Hospital Board. He presented the Nye County Commissioners' request, (Exhibit N,) to amend Nevada Revised Statute (NRS) 450 to allow the Board of County Commissioners in the less populated counties (under 400,000 population) to have the same rights to serve as Board of Trustees for any county hospital or county hospital districts located within their counties. Mr. McRae also supports modifications of NRS 450.620, which will allow Nye County Board of Commissioners to serve as the Board of Trustees for the Nye County Hospital District in Tonopah. The unanimous decision of the Board to request the change to the State law came after nearly four years of intense effort to work with the Nye County Hospital District Board of Trustees to effect needed policy and management reform. Mr. McRae also provided a history of County and State funds provided to the Nye County Hospital District, (Exhibit O.) Mrs. Freeman commented on the similarity between testimony just presented by Mr. McRae and testimony in the Government Affairs Committee about the school district in White Pine County. She asked whether a recent audit of the hospital had been requested. Mr. McRae replied an independent auditor had been hired last year. Mr. Bill Offutt, County Administrator, interjected the independent audit firm that does the County's books had been hired. The firm came back with a whole series of recommendations to the Board of Trustees, the most important of which was a recommendation to reduce expenses in a whole variety of ways and saving about $600,000. Mr. Offutt testified to this date, the Board of Trustees had refused to make one cut or change. The auditor was an expert and worked in liaison with health professionals who evaluate hospitals and clinics for a living so his recommendation should have been taken seriously. Dr. Harrington asked again whether the Nye Regional Hospital had any private investors. Mr. McRae stated there are no private investors; it is a public hospital supported strictly by the ad valorem tax rate and their share of the SCCRT from the tax rolls as well as patient reimbursements. Dr. Harrington questioned whether this was a Tonopah vs Pahrump kind of problem and Mr. McRae responded it is absolutely not. He represents Pahrump and verifys the problem is not a political one. Mrs. Freeman, noting another committee was scheduled to meet in the room immediately was forced to end testimony. She noted there was no opposition to the bill, but several amendments, and agreed to meet with Nye County representatives later that day and report back to the full committee next week, if possible. Mr. McRae added the Nye County Commissioners had been approached by two parties with amendments and the Commissioners were in concurrence regarding inclusion of those amendments in A.B. 436. Mrs. Freeman adjourned the meeting at 3:30 p.m. RESPECTFULLY SUBMITTED: Terry Horgan, Committee Secretary APPROVED BY: Assemblywoman Vivian L. Freeman, Chairman Assemblywoman Jan Monaghan, Chairman Assembly Committee on Health and Human Services April 10, 1995 Page