MINUTES OF THE ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES Sixty-eighth Session May 31, 1995 The Committee on Health and Human Services was called to order at 1:45 p.m., on Wednesday, May 31, 1995, Chairman Vivian Freeman presiding in Room 119 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 GUEST LEGISLATORS PRESENT: Ms. Chris Giunchigliani STAFF MEMBERS PRESENT: H. Pepper Sturm, Chief Principal Research Analyst OTHERS PRESENT: Cindy Pyzel, Attorney General's Office Carlos Brandenburg, Division of Mental Health and Mental Retardation Lonna Burress, Nevada State Board of Nursing Jim Boscacci Paul Gowins, Nevada Assistive Technology Council Donny Loux, Division of Rehabilitation Yvonne Sylva, State Health Division Guy Perkins, Division of Insurance Jan Gilbert, League of Women Voters Janice C. Pine, Saint Mary's Health Network Steve Lewis, Health Insight Paula Treat, Charter Hospital Hamilton Moore, Psychiatric Survivors' Association Richard French Patricia A. Folk Nancy Patnaude Marie Soldo, Nevada Association of Health Maintenance Organizations ASSEMBLY BILL 584 - Creates advisory subcommittee on health care planning to provide advice to legislative committee on health care. Assemblywoman Evans, representing Assembly District 30, presented background information on her bill A.B. 584, (Exhibit C,) which included proposed amendments. Chairman Freeman inquired if Mrs. Evans could have her amendments ready by next Monday's work session. Mrs. Evans replied she certainly hoped so. Assemblyman Harrington asked if there was anything currently preventing the legislative health care committee from asking the categories of people listed in A.B. 584 to participate when they hold hearings. Mrs. Evans explained the interim health committee takes up a variety of issues and often has a very full agenda so she wanted a separate group set aside to focus just on health planning. Assemblywoman Krenzer disclosed she works for Sierra Health Care Options, a wholly owned subsidiary of Sierra Health Services, and though they may be a participant in the category "organizations for managed care", she sees no conflict and will be voting on A.B. 584. Assemblywoman Monaghan asked how large the group would be. Mrs. Evans, mentioning large groups can become unwieldy, indicated smaller, task force groups could tackle the issues, once they had been defined, so the entire committee would only meet periodically. Mrs. Evans explained the task groups would take testimony from around the state in contrast to the entire committee which will probably only meet in Carson City, Las Vegas and Reno. Mrs. Freeman agreed the standing committee on health care has a really big job and also noted it is very expensive to move that many committee members and their staffs around the state. Assemblywoman Buckley inquired whether Mrs. Evans had received a copy of a letter dated May 30 from Dr. Feldman of the Governor's Maternal and Child Health (MCH) Advisory Board. Mrs. Evans nodded her head, "yes." Ms. Buckley asked if she had any comments with regard to his suggestion that the composition of her committee include someone from that board as well as families with young children, pregnant women and persons with disabilities. Mrs. Evans pointed out a number of groups had called or written to ask they be included. She stated the bill drafters had collapsed some categories, for instance item (p) on page 2, "Clients of health care services funded by public revenue." She agreed she would have no problem adding the public health board and the MCH Advisory Board, in addition to categories that may be mentioned in testimony today. Dr. Harrington inquired as to the fiscal note on A.B. 584. Mrs. Evans explained it covered the salary and per diem of two legislators plus staff expenses but other participants would be "on their own nickel." She added a fund for the interim health committee had been established and unless there were extraordinary expenses, that fund should be adequate. In addition, line 40, page 2 of A.B. 584 reads, "Accept gifts, grants and donations", which would leave the door open for other kinds of support. Dr. Harrington noted A.B. 584 contains some parallels to the plan devised by Hillary Clinton and mentioned one of the problems with that plan was they did so much in secret. He asked if this committee would be subject to open meeting laws and would be noticing their activities. Mrs. Evans agreed that was an important issue and stated the committee would make certain its meetings were completely noticed and people invited, and emphasized it would fall short of its goal if it did anything less. She reiterated her desire to hear from all sides and build a consensus. Mrs. Freeman mentioned as of April, 1995, the net amount reserved in the statutory committee on health care's fund totaled $56,807.67. The fund receives approximately $35,000 per year so she believed there would be funding available for the committee proposed by A.B. 584. Mrs. Freeman requested committee members not schedule subcommittee meetings during the time Health and Human Services is meeting. She noted it creates quite a problem because the committee is left without a quorum, its members are not present to take testimony and the committee cannot vote. She also requested the Chair be informed when committee members leave a meeting. Assemblyman Nolan apologized for not being present and explained one of his bills was being heard in another committee which was why he had been late. Marie Soldo, representing the Nevada Association of Health Maintenance Organizations, expressed support for A.B. 584 because it would provide for a dialog of stakeholders. Ms. Soldo requested the medically indigent and the uninsured be included among the issues discussed. Lonna Burress, Executive Director of the Board of Nursing, also expressed support for A.B. 584. She mentioned the partnership and collaboration in exchanging ideas with other groups offered by the bill was very appealing. Ms. Burress believes major changes are coming and all 16,000 Nevada nurses want to be a part of those changes. Mrs. Freeman inquired how Ms. Burress would see this subcommittee interfacing with the statutory committee on health care. Ms. Burress believed the subcommittee would enable a chance for dialog and discussion about other options with colleagues who have a different focus and perspective. The whole blending of the professions is what she sees as unique in the concept for this subcommittee. Jack Mayes, Executive Director of the Northern Nevada Center for Independent Living, expressed his support for A.B. 584 on behalf of the center, its consumers and its board of directors. He requested adding a category including persons with disabilities to the list because he noted the list included approximately nine representatives of providers but only three representatives of consumer groups. Donny Loux, Chief of the Office of Community Based Services of the Rehabilitation Division, presented additional testimony in support of A.B. 584 by reading from her prepared text, (Exhibit D.) She indicated she had served on three advisory task forces and in her experience, having a group with a broad base of experience was invaluable because as they deliberated, planned policy or made recommendations, they could always call on a member with expertise in the field under discussion. Jim Boscacci, representing Paul Gowins and the Nevada Assistive Technology Council, made a presentation in favor of A.B. 584 and also requested inclusion of the disabled community in the makeup of the committee, (Exhibit E.) In addition, Mr. Boscacci distributed copies of a position statement from the council's Opinion Leaders Forum on health care reform, (Exhibit F.) Dr. Harrington disclosed he is a physician but announced he would be participating in the discussion and voting on A.B. 584. Mrs. Evans stated she believed disabled individuals were included in the category "clients of health care services . . ." but agreed they should have their own specific designation in A.B. 584 and would be happy to include it. Jan Gilbert, representing the League of Women Voters of Nevada, testified the League supports A.B. 584, however she noted consumers were not represented on the advisory committee. Janice Pine, representing Saint Mary's Health Network, stated she was very definitely in support of the bill. She mentioned Saint Mary's had been trying to get a group such as this together for round table discussions that might produce some innovative ways to solve some of Nevada's health care problems. Ms. Steel inquired of the bill's sponsor how A.B. 584 would be impacted should block grants for health care be initiated. Mrs. Evans replied the Department of Human Resources was very concerned about how the new proposals for block grants would affect them across the board in all of their divisions and agencies. She stated the department had been very proactive on the subject and already gone to the money committees with a proposal to work on a transition plan to monitor what would be coming out of Washington, how Nevada might be impacted and what changes might have to be made. Mrs. Evans noted the advisory committee would keep the Department of Human Resources informed, and added the "department" was included on line 8, page 1 of A.B. 584. Ms. Steel, referring to section 3 which states, "Develop a comprehensive plan to improve the financing and delivery of health care . . .", assumed the advisory committee would be developing recommendations about how block grant funds would be spent. Mrs. Evans agreed plans would need to be developed in light of any changes in federal funding that might occur. Dr. Harrington mentioned the people who would be paying for this medical care were not included and thought someone from the Nevada Taxpayers Association should be included. Mrs. Evans stated she had no objection and if it were the committee's wish, she would be more than happy to add that category to the list of participants. Ms. Pine observed in Washoe County the Truckee Meadows Human Services Association had been meeting once a week to come up with thoughts, suggestions and plans about what might happen if block grants were approved. Ms. Pine sees the advisory subcommittee as an excellent place for various entities to come forward with information concerning their particular area of expertise. Guy Perkins, Assistant Supervisor for the Life and Health Section of the Insurance Division, testified the Insurance Commissioner as well as the Director of the Department of Business and Industry both agreed to support A.B. 584. They believed this to be a good way to get another start on health care. Steve Lewis, Director of Nevada Programs for Health Insight, explained they are the quality approvement organization for Medicare and Medicaid. He stated there was a need for dialog among stakeholders and the dialog needed to be at the front end, in the middle and throughout the policy development process. He mentioned today's current problems have become "nightmarishly more complicated" and certain stakeholders are now conflicted in their roles. For instance, a physician deals on the one hand with the imperatives of his clinical training and on the other hand with the economic realities of the expense of health care. Mr. Lewis also requested a very major effort be made to ensure that the advisory committee, and the statutory committee it would serve, had access to significantly better quality health care data. Mrs. Braunlin disclosed she is married to a Nevada licensed primary care physician and would not be voting on A.B. 584. Mr. Goldwater stated he works for a group of doctors, but sees no conflict and would be voting on A.B. 584. Mr. Nolan disclosed he would be considered an "(I)" in the categories listed on page 1 of A.B. 584 but did not see that passage of the measure would effect him any more than any other professionally trained person and so he would be voting on the bill. Mrs. Freeman requested those interested in A.B. 584 work with Mrs. Evans on any amendments and closed the hearing. ASSEMBLY BILL 634 - Revises provisions governing procedure for involuntary court-ordered admission of persons into mental health facilities. Assemblywoman Giunchigliani, representing District Nine, testified A.B. 634 was the result of a recommendation from the Commission on Mental Health and Mental Retardation Task Force on the denial of rights for private psychiatric facilities. The recommendation was to reduce the amount of time between the filing of papers for involuntary commitment and the court hearing itself. The bill is designed to limit unjustified incarceration of Nevada citizens by the Nevada psychiatric industry without a court hearing. She added she believes A.B. 634 to be reasonable and workable. Mrs. Monaghan asked if three days was adequate time to get to a court. Ms. Giunchigliani stated she believed adequate testimony would be presented that three days is enough time, however, she added the committee should take that into consideration and may want to exclude weekends and holidays. She mentioned the state agencies might favor that approach, but looking at current statute, a facility must appoint and test within 24 hours. The court appearance would be upon filing of the petition and since all the testing should have occurred within 24 hours, 72 hours would be reasonable. She emphasized she would be willing to listen to testimony because she wants A.B. 634 to be workable. Hamilton Moore, an attorney for the Psychiatric Survivors Association in Las Vegas had backup material distributed to the committee, (Exhibit G,) and then began his presentation in support of A.B. 634 by teleconference from Las Vegas. Mr. Moore represents a group of people "who have been victimized by the power invested in the psychiatric industry under the current legislation". Mr. Moore stated the Legislature has empowered any physician in the state to hold someone in a mental institution for 14 days without any kind of judicial review. He emphasized every court in the country that had considered a time period of this length prior to judicial review had found it to be unconstitutional. He added the constitutionality of Nevada's provision is the subject of litigation filed by the Office of Protection and Advocacy and was currently pending in the Ninth Circuit Court. Mr. Moore testified the problem had arisen because physicians with a financial interest in keeping people in the hospital are able to control what gets into the patient's record as well as threaten them with the fact they would be held for a minimum of 14 days unless they agree to stay in the hospital voluntarily. He stated there is no realistic possibility of any relief, for the people who are incarcerated because the law provides no direct relief only by writ of habeas corpus, which is very expensive. Mr. Moore became involved in the issue in 1989 when a young woman named Debra Schlotfeldt came to him as a client. She stated she had gone to Charter Hospital to obtain some marriage counseling, but was incarcerated there and held against her will for a period of time. The outcome of that case, plus newspaper reports about similar incidents, were included in Mr. Moore's exhibit which was distributed previously to committee members. He indicated the case took five years to try, cost $37,000 and he emphasized most people in Nevada would not be able to go through that kind of litigation to vindicate what had happened to them. Mr. Moore believed A.B. 634 would remove the power to incarcerate people from those who have a financial interest in their incarceration. Under current law, the hospital and private psychiatrist who stand to make money from placing individuals in those institutions have a 14 day carte blanche because the Legislature has provided that people incarcerated pursuant to the mental health statutes must pay for that incarceration and must do so whether they want it or not. Another problem Mr. Moore mentioned occurs regarding control of records. He explained when a person is locked in a mental health institution, they are not tape recorded or given any type of record so there is no record of how those people appear or what they said, other than what was recorded by those with a financial interest. A.B. 634 would end that entirely because a hearing would be required within three days of a person's confinement and that hearing would be recorded, the remarks of the individual could be heard and the facts determined by someone who did not have a financial interest. Mr. Moore indicated he had been contacted by over one hundred people throughout Nevada with similar problems, many of whom had responded to television advertising and gone to Charter Hospital, or one of the other psychiatric hospitals, expecting help. They were branded as suicidal and held in the institutions against their will. Frequently, he stated, those holds took the form of so-called "voluntary" holds. In reality, a psychiatrist would tell the patient he could be held in a mental institution for 14 days without the say-so of any other individual. The patient was given the choice of being an involuntary admission, or going along voluntarily and perhaps getting out earlier and as a result, many people choose voluntary admission. Mr. Moore stated the victims present would testify that had they been afforded the opportunity of a judicial hearing within three days of their incarceration they all would have taken it. They believe an unbiased, judicial officer listening to them testify would not have found them to be a clear and present danger to themselves and would not have committed them. Mr. Moore reiterated every federal or state court which had considered an incarceration period, without judicial review, as lengthy as Nevada's had found it to be unconstitutional. He also mentioned at a time of escalating health care costs, it was ironic the Legislature had enacted a system that provided an opportunity for the psychiatric industry to bill patients for treatment they do not want and the power to collect that money. Enactment of A.B. 634, Mr. Moore further explained, would bring Nevada into compliance with federal case law and constitutional requirements and would be similar to working statutes in Texas and California. Mrs. Freeman asked where complaints from the northern part of the state had come from. Mr. Moore replied in southern Nevada, most of the complaints had come from Charter and Monte Vista Hospitals; while in the north, they came from the Truckee Meadows facility. Mr. Goldwater inquired whether most of the complaints involved people who had insurance or whose expenses would be covered in some other way. Mr. Moore affirmed he had yet to receive a complaint from someone who was not insured with one exception and that was when a spouse or family member was willing to pay cash to have a family member locked up. Patricia Folk testified in 1981 she saw a physician for minor depression and wanted to get into group therapy to help with insomnia. In less than ten minutes the physician stated he would "respect her integrity and if she didn't go into the hospital, she would be held against her will". After 14 days she was drooling at the mouth, incoherent and near toxic shock. She said, "It was the scariest thing anyone can go through being put in a hospital, medicated and cared for until your insurance runs out." Ms. Folk testified three days were a long time and emphasized "the minute someone tells you you can be held in a hospital against your will, you should immediately have some rights and three days should be the maximum amount of time". Richard French, a retired Air Force Lieutenant Colonel, expressed strong support for A.B. 634. He testified he suffered agonies and indignities at the hands of an institution into which he had voluntarily signed himself. Mr. French was diagnosed as a manic depressive by Charter Hospital, which was correct, but the treatment he received was terrible. He was confined, isolated, given medications against his will and every time he objected to such treatment he was threatened with being turned over to the state mental health facility and probably never released. It became apparent to Mr. French it was the doctor's intention to hold him as long as his insurance coverage lasted and then release him, regardless of condition, as he had seen done with many other patients. Mr. French called his lawyer and, in combination with his relatives, was finally able to get released. However, the medications Charter Hospital placed him on caused hallucinations, he wound up back at Charter where he was overmedicated, which caused a stroke. Tests performed at Lake Mead Hospital proved he was simply overmedicated. Mr. French noted treatment at Lake Mead Hospital cleared up the worst effects of the overmedication, however palsy and partial memory loss remain. Mr. French reiterated it was readily apparent to him, as a patient and observer of other patients' treatment, that the driving factor behind patient treatment at Charter Hospital is to "rip off the patients and their insurance companies". Nancy Patnaude expressed strong support for A.B. 634 and testified she was held against her will for over 17 days and she emphasized the difference between 14 days and three days changed her life. In her case she lost her job, her credit, was forced to file bankruptcy and must go to counseling every month as a result of the things that happened while she was a patient at Charter Hospital. Carlos Brandenburg, Acting Administrator for the Division of Mental Hygiene and Mental Retardation, expressed concern for the effects passage of A.B. 634 might have on public institutions. The family court currently conducts a weekly hearing at the Nevada Mental Health Institute on all petitions or individuals who are evaluated as potentially dangerous to themselves or others. At one time those hearings were held at the Washoe County District Court and the clients were subjected to very humiliating and less than dignified ways of being transported to court. Mr. Brandenburg mentioned Judge Scott Jordan of the Washoe District Court informed him if A.B. 634 passed in its current form they would no longer be able to have the court meet at the institute because to comply with the proposed legislation would require three court hearings a week. Cynthia Pyzel, a deputy attorney general assigned to represent the Division of Mental Health and Retardation, mentioned in 1989 the laws involving involuntary civil commitment were substantially changed at the request of the Office of Protection and Advocacy. At that time the 14 day period and the entire statutory scheme was deemed appropriate because they wanted an additional step added. An evaluation at the end of 72 hours was to be conducted by two independent professionals and 14 days would allow time for those people to make reports back to the courts so a more meaningful evaluation of the patient's need to actually be committed could be made. In addition, it was felt since the average length of stay in a public sector mental facility was 11 days most of those people would be discharged and there would be no need to go forward with a hearing and actually impose commitment. Ms. Pyzel emphasized the current statutes are constitutional and she has so informed her client. In addition, she mentioned last session the Legislature mandated information about one's rights as a client and how to contact the advocate's office be provided on admission to every facility, public as well as private. She assumed the incidents described by Ms. Patnaude, Mr. French and Ms. Folk occurred prior to the 1993 Legislative Session. Ms. Pyzel also stressed the importance of continuing to hold court hearings on commitments at the mental health facilities themselves. She believed the results of those hearings were greatly enhanced by virtue of the courts having access to treating physicans, test results, and the independent psychologists and psychiatrists who reviewed the patients. In conclusion, she requested the committee not adopt the recommendations of A.B. 634. Paula Treat, representing Charter Hospital, echoed Ms. Pyzel`s opposition to A.B. 634. She testified she and her client had been working over the years with legislators and committees to formulate workable solutions to general problems and not just individual court cases. Dr. Harrington, mentioning court dockets, inquired what an acceptable time frame might be. Ms. Treat replied at least seven or eight days, excluding weekends and holidays. Mr. Brandenburg interjected Washoe District Court Judges Mcgee and Jordan believed anything less than seven days would be unworkable for them. Mrs. Evans mentioned judges go to the institute one day a week and Mr. Brandenburg concurred. She asked if the institute would go back to the practice of taking its patients into court if A.B. 634 passed. Again Mr. Brandenburg agreed he would have to transport patients at least three times a week and added they are usually transported in restraints so some degree of control may be maintained. Ms. Steel inquired if it would be feasible to install some kind of teleconferencing system between the court house and the mental health facility. Mr. Moore explained in Clark County the system is run by a series of appointed hearing masters appointed by the family court and hearings are held one day a week in the southern Nevada mental health facility. He emphasized if the committee did not modify the time frame by which these people must have a judicial hearing, it would be going on record as supporting a faster hearing period for Nevada's criminals than for people who had sought help from Nevada's mental health industry. Mrs. Freeman closed the hearing on A.B. 634 after requesting all interested parties discuss possible amendments with Ms. Giunchigliani. Mrs. Freeman requested committee introduction of BDR 38-857 which revises provisions governing submission of fingerprints used during investigation of person who provides child care. ASSEMBLYWOMAN JAN EVANS MOVED FOR COMMITTEE INTRODUCTION OF BDR 38- 8 5 7 . ASSEMBLYMAN DAVID GOLDWATER SECONDED THE MOTION. THE MOTION CARRIED. ********* ASSEMBLY BILL 637 - Revises provisions governing crimes related to tobacco and licensing of cigarette dealers. Pepper Sturm, Legislative Counsel Bureau researcher, explained the subcommittee on A.B. 637 met the preceding day and voted to recommend that the full committee entertain a motion to amend and do pass the bill. He presented the proposed amendments to the committee, (Exhibit H,) and gave a brief overview of each one. Mrs. Freeman indicated she would not request a vote on the amendments today. Mrs. Evans noted the bill contained an appropriation. Mrs. Freeman agreed and stated A.B. 637 would be going to Ways and Means. She also mentioned she was working with Liz Breshears of the Bureau of Alcohol and Drug Abuse who had stated the administration does support this expenditure. There being no further business, the meeting was adjourned at 3:45 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 May 31, 1995 Page