MINUTES OF THE ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES Sixty-eighth Session April 12, 1995 The Committee on Health and Human Services was called to order at 1:30 p.m., on Wednesday, April 12, 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. Patricia A. Tripple Mr. Wendell P. Williams STAFF MEMBERS PRESENT: H. Pepper Sturm, Chief Principal Research Analyst OTHERS PRESENT: Kerry Carroll Davis, Senior Research Analyst Martha W. Coon, NASAC Michael Torphy, Washoe Legal Services Kevin Quint, NV. Assoc. Of State Alcohol & Drug Abuse Programs Anne Taylor, Salvation Army Liz Breshears, Chief, Bureau of Alcohol & Drug Abuse April Townley, Medicaid Jerry Crum Chairman Freeman announced Monday's meeting would be held in Room 119 because of the large audience expected. ASSEMBLY CONCURRENT RESOLUTION 21- Directs development of proposal to amend state plan for assistance to medically indigent to include coverage for treatment of substance abuse provided to recipient of Medicaid in nonhospital setting. Kerry Carroll Davis, researcher for the standing Committee on Health Care, testified on A.C.R. 21, (Exhibit C.) She reminded the Committee that as a member of the Legislative Counsel Bureau staff she could not testify in support or opposition of the resolution but could provide background information and testimony as to the origin of A.C.R. 21. Assemblyman Nolan asked whether success rates of indigent patients out of hospital based facilities were discussed during the interim committee hearings. Ms. Davis replied there had been some testimony in that area, but she would leave the answer to an official from the Bureau of Alcohol and Drug Abuse (BADA). Assemblyman Goldwater queried why the legislation had been drafted in the form of a resolution instead of a bill. Ms. Davis responded the Welfare Division is currently working on a federal waiver for Medicaid Managed Care and some of the interim committee members felt with all the responsibilities associated with preparation of the waiver, it would be onerous to require application for this additional waiver. She added the Welfare Division is already working on this project. Martha W. Coon, a retired school teacher, testified she had considerable experience with the problem of alcoholism and the way it effects families and individuals. Since 1964 she has been a member of the Washoe County Council on Alcoholism and Drug Abuse, now known as NASAC. She stated many diseases from malnutrition to tuberculosis, from serious dental problems to heart disease are medically treated when one of the major causes is alcoholism. Ms. Coon reiterated alcoholism is often disguised by medical problems and she strongly urged passage of A.C.R. 21. Nonhospital and nonmedical therapy programs have proven to be very cost effective and both inhouse and outpatient therapy are often productive. She added NASAC has operated such a program for approximately 20 years and both medical response and recidivism rates have been very positive. Michael Torphy, an attorney with Washoe Legal Services, encouraged adoption of A.C.R. 21, however he pointed out a problem he believed could plague administration of the resolution. He said the use of non-hospital based settings had been tried in other states. In Texas the attempt to admit people on an inpatient basis to those facilities has been denied by the Health Care Financing Administration (HCFA), the room and board costs of the expansion of the coverage to include the inpatient setting was objectionable to HCFA. There is an advantage to including inpatient services for the treatment of minors. The trick is to word exactly who will be placed where, meaning children would be put into one of the four categorically eligible inpatient treatment facilities. Mr. Torphy noted those facilities are well laid out within HCFA regulation and the use of inpatient treatment with respect to minors has been proven to be more effectual than outpatient treatment services. Mr. Torphy requested the Committee consider A.C.R. 21 positively however direction should be given with respect to the administration of A.C.R. 21 to consider inpatient treatment facilities on behalf of children. Mrs. Freeman asked whether Mr. Torphy had an amendment to A.C.R. 21. He replied he had not had time to prepare language. Mrs. Freeman suggested Mr. Torphy prepare a draft amendment and at the end of the hearing the Committee could look at it. Kevin Quint, President of the Nevada Association of State Alcohol and Drug Abuse Programs, a provider organization for the community based Bureau of Alcohol and Drug Abuse subsidized programs, spoke on behalf of A.C.R. 21. He stated community based, nonhospital treatment programs represent continuum care throughout the state. The continuum includes detoxification, short and long term residential, various types of outpatient modalities as well as aftercare services. The programs represented by his association serve youth and adults, male and female. Each program is accredited by the state of Nevada and adheres to very high professional standards. Services are delivered in Clark County, Washoe County and most rural counties. Each program is a private, not-for-profit entity that is independently governed and managed. Mr. Quint commented at the present time, Medicaid only pays for hospital based substance abuse treatment which is appropriate for clients who require medical care during their treatment. Most people accessing treatment services can do without such an intensive level of care. As recognized in A.C.R. 21, nonhospital treatment is less expensive than hospital treatment so use of nonhospital programs that are accredited by BADA will result in savings. Mr. Quint testified allowing the nonhospital portion of the treatment field to treat recipients of Medicaid will not only result in savings, but is a step in the right direction in affording access to many who do not need medical intensive hospital based programs. Additionally it gives more choices to those who may feel more comfortable in a less medically oriented milieu. Also, the continuum of care is already represented in these programs. Finally, Mr. Quint testified A.C.R. 21 would enable most Medicaid recipients to access treatment in their own communities. Mr. Nolan asked what the success rate for nonhospital based treatment facilities is, meaning people who might have arrested their situation long-term. Mr. Quint replied Liz Breshears from BADA had specific numbers, but he believes, in terms of life style indicators such as criminal justice involvement, medical involvement and vocational issues, treatment works. One national study showed 70 percent of the people improved after treatment. They did not all stay sober and clean from drugs, but their life style indicators were greatly improved. Anne Taylor, Program Administrator for the Salvation Army Adult Rehabilitation Program in Reno, stated she supports A.C.R. 21. Ms. Taylor has years of experience in the field and has watched the struggle with the problem of how to deal with addiction to both alcohol and drugs. She agreed with Ms. Coon that many medical problems hide addiction and felt many of the reasons people are seen in hospital emergency rooms and hospitals are due to addiction. Sheriff Vince Swinney, recently retired Washoe County Sheriff, told a group involved in rehabilitation programs that he felt 80 percent of the people occupying his 500 bed/800 resident jail were addicted to alcohol or drugs. Many who have worked in the field for many years have known that a war on drugs would be just about as successful as the war on poverty has proven to be. The prevention and treatment route is very successful. The Salvation Army's unit is 76 beds; soon to be reduced to 60 beds because they are trying to become accredited as the inpatient continuum of care. The Bureau of Alcohol and Drug Abuse has already accredited the Salvation Army's unit for intensive outpatient care. Ms. Taylor believes Medicaid help is profoundly necessary and the Salvation Army supports A.C.R. 21. Liz Breshears, Chief of the Nevada Bureau of Alcohol and Drug Abuse, repeated Kerry Davis' testimony about a national study that determined current Medicaid expenditures have a 20 percent ratio of funding for hospital bed days that are attributable to substance abuse. In addition, that study showed treatment of a number of diseases, if coexisting with substance abuse, ended up being twice as long as if the disease existed alone. In responding to Mr. Nolan's question about successes, Ms. Breshears mentioned giving each Committee member a copy of a book entitled Invest in Treatment; It Pays. Ms. Breshears quoted a sampling from the book, which is a compilation of studies that were conducted in numerous states in their publicly funded, social model, drug treatment programs. She referred to the state of Colorado where the average rate of arrest per 100 clients 24 months prior to treatment was 58.5. The rate per 100 clients 24 months after treatment had dropped to 18.9. In a one year followup, criminal arrests in Ohio decreased by 92 percent and jail time decreased by 93 percent. In the state of Washington, four years after disposition, drivers who received deferred prosecution (rather than being sentenced to jail they were sentenced to treatment in lieu of jail) had a non-recidivism rate of 78 percent whereas those who actually were convicted of Driving Under the Influence and did their time, had only a 52 percent non-recidivism rate. A study done in Nevada by St. Mary's Hospital looked at hospital emergency room costs one year prior to treatment and then those same costs one year after treatment. St. Mary's found emergency room visits decreased by 62 percent and hospital days were reduced by 73 percent. In addition, St. Mary's looked at those individuals who were detoxified within their chemical dependency program versus those who were detoxified in a regular hospital floor setting. The difference in cost was over $5,000 in the regular hospital setting as opposed to $1,800 per person within their chemical dependency unit. BADA has preliminary results on a small outcome study conducted by the University of Nevada Center of Applied Research. The study compared employment three months prior to treatment and three months after treatment. The number of days employed doubled for the clients who were able to be contacted and the amount of moneys earned in salaries doubled for that period of time. Ms. Breshears also noted the increased availability of treatment became an effective use of funding within the Medicaid system and also improved worker productivity. She mentioned two studies, one in Texas and one in Ohio, supporting that finding. She added a bill providing funding for an outcome study of the publicly funded treatment system in Nevada had been passed by the Assembly Judiciary Committee. Mrs. Monaghan, after complimenting Ms. Breshears on her testimony, requested she comment upon juveniles being placed in hospital versus placement in a nonhospital setting and the possibility that the United States Congress might prohibit drug abuse as a disability to qualify for Supplemental Social Security Income (SSI). Ms. Breshears responded SSI may be a safety net. If the net is removed, it essentially acts as a barrier for a group of people accessing treatment. Ms. Breshears wondered what other alternatives exist for those people. In Nevada there are 1,700 people annually who try to access funded treatment programs and are denied because there is no room. Ms. Breshears believes the state picks up the costs in other systems such as criminal justice, domestic violence or child abuse. April Townley, a Welfare Division Deputy Administrator for Medicaid, discussed juvenile treatment and noted state agencies such as the Division of Child and Family Services, do not pay for room and board in treatment foster homes, but pay for the treatment. Ms. Townley testified the Welfare Division supports A.C.R. 21, but their budget does not include any money for additional optional services. As a result, they would have to be assured funding would truly be diversionary, that is people who are currently going to the hospital would go to a nonhospital base, or the structure would be such that already existing state funds would be used as the state match. Mrs. Freeman noted A.C.R. 21 requires developing a proposal and questioned whether Ms. Townley was saying even development of a proposal would require taking money from someplace else. Ms. Townley replied once her agency states it will cover certain types of residential treatment services, it cannot limit the language further by stating the state's match must be put up. The proposal must be carefully constructed so other state funds could be accessed or prove the funding is truly diversionary from a hospital, otherwise there would be no money to pay for the services. Ms. Townley added development of a proposal takes a lot of time, but could be absorbed by the staff. Mrs. Freeman asked where the Medicaid waiver is now. Ms. Townley stated it had been submitted a week and a half ago. Mrs. Freeman asked about recommendations concerning the timing of A.C.R. 21. Ms. Townley replied if all goes as planned and managed care starts next January, the services named in A.C.R. 21 would become the responsibility of the contractor for the enrolled population. Welfare would be left serving the non-enrolled who are the aged, blind and disabled. Bobbie Gang, representing the National Association of Social Workers/Nevada Chapter, stated the association has over 150,000 members worldwide and over 650 members in Nevada. Her organization supports A.C.R. 21 because currently there are no nonprofit community based programs in the state of Nevada eligible to receive Medicaid payments. Medicaid will only cover hospital based treatment programs but treatment in hospital based medical model programs is expensive and no more effective than community based social model programs. Currently the state pays 100 percent for treatment in nonprofit social model facilities. The state also pays 50 percent when Medicaid covers the more expensive hospital based programs. Ms. Gang testified more cost effective treatment with the same level of effectiveness could be provided by amending the state Medicaid plan to provide payment for treatment in social model based nonhospital settings. Significantly more treatment could be provided for the same amount of money. Mr. Torphy presented his amendment, (Exhibit D.) Ms. Townley stated she had no objections to Mr. Torphy's amendment, but noted the Welfare Division already met that intent. Under their federal guidelines that must cover services for children if those services are covered under the Medicaid provisions, whether or not they cover those services for anyone else. ASSEMBLYWOMAN JAN EVANS MOVED TO AMEND AND ADOPT A.C.R. 21. ASSEMBLYWOMAN SAUNDRA KRENZER SECONDED THE MOTION. THE MOTION CARRIED. (ASSEMBLYWOMAN DIANE STEEL WAS ABSENT AT THE TIME OF THE VOTE.) ASSEMBLY CONCURRENT RESOLUTION 22 - Encourages Department of Human Resources to require person who contracts with Medicaid to provide coordinated care to use national data base to obtain certain information. Ms. Davis also worked with the interim committee on preparation of A.C.R. 22 and presented her testimony on that measure, (Exhibit E,) stating the resolution requires the Department of Human Resources to require Medicaid managed care contractors to query the National Practitioner Data Bank when credentialing their providers. Ms. Davis provided a chart from a recent Office of Inspector General report that reviewed hospitals' compliance with the reporting requirements for the data bank, (Exhibit F). Although hospitals are only one entity that must report, the chart indicates from 1990 to 1993, Nevada had the highest rate of hospital adverse action reports per 1,000 hospital beds. Assemblywoman Braunlin disclosed that her husband is a Nevada licensed physician. She added it was unlikely A.C.R. 22 would materially affect his pecuniary interest, therefore she would be voting on the resolution. Assemblyman Harrington disclosed he is a physician and will not be voting on A.C.R. 22. Assemblywoman Krenzer disclosed she works for Sierra Health Care Services, a managed care organization. She stated because neither resolution treats Sierra Health Care Services any differently than any other managed care organization, she would be voting on the resolutions. Mr. Nolan asked whether the data bank included information on health care providers that are institutions as well as individual physicians and dentists. Ms. Davis responded the resolution requires Medicaid managed care contractors, who will be chosen through a bidding process in the coming months, to access this data bank when they credential their providers. Right now they may voluntarily access that information, but it is not required. Mr. Nolan replied he is familiar with an annual publication by all the state medical boards, which is a culmination of the actions taken against health care providers, physicians and dentists and is accessible in most libraries. Ms. Davis acknowledged familiarity with that publication, which is different from the data bank, and added licensing boards are not the only entities required to report to the data bank. Professional societies, hospitals and health plans that take any kind of adverse action against a physician would also contribute their data. Mr. Goldwater disclosed he works for Fremont Medical Center, a Medicaid managed care contractor, but did not feel there was any conflict of interest and would be voting on both resolutions. April Townley tesitfied the Welfare Division also supports passage of A.C.R. 22. They believe one of the important points about moving to a managed care or coordinated care program is to assure quality. Recently the Welfare Division released a "Request for Information" and in it were the quality standards they have developed. The Agency will monitor those reports on an ongoing basis. In addition, federal regulations require they have an outside quality assurance person do a quality assessment every year. A.C.R. 22 adds one more function that could be done to assure quality of care. She noted Welfare staff had looked to see what kind of information the data bank has and whether it was accessible. The HMO's can have access to the information, and Welfare will require compliance with A.C.R. 22 at the time they put out their Request For Proposal. Jerry Crum testified the roots of A.C.R. 22 began with testimony he gave before the Legislature's Interim Committee on Health Care on February 18, 1994. Nevada needs a fiscally sound Medicaid model that will provide quality services to its citizens who use Medicaid. Mr. Crum wanted to help the Interim Committee find solutions and felt his ideas would do that. ASSEMBLYWOMAN JAN MONAGHAN MOVED TO ADOPT A.C.R. 22. ASSEMBLYMAN DENNIS NOLAN SECONDED THE MOTION. THE MOTION CARRIED. (ASSEMBLYMAN BILL HARRINGTON ABSTAINED. ASSEMBLYWOMAN DIANNE STEEL WAS ABSENT AT THE TIME OF THE VOTE.) Mrs. Freeman noted both resolutions had concurrent introductions to the Assembly Committee on Elections and Procedures. She commented there had been some confusion as to whether that Committee should hear all resolutions. Mrs. Freeman checked with Chief Clerk Mouryne Landing, who agreed the resolutions should have only gone to Health and Human Services. Mrs. Freeman added since the resolutions had already been jointly introduced, their next stop will be to the Elections and Procedures Committee before going to the Assembly Floor. There being no further business, the meeting was adjourned at 2:30 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 12, 1995 Page