MINUTES OF THE ASSEMBLY COMMITTEE ON HEALTH AND HUMAN SERVICES Sixty-eighth Session June 7, 1995 The Committee on Health and Human Services was called to order at 1:45 p.m., on Wednesday, June 7, 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 Mr. Wendell P. Williams COMMITTEE MEMBERS EXCUSED: Ms. Patricia A. Tripple STAFF MEMBERS PRESENT: H. Pepper Sturm, Chief Principal Research Analyst OTHERS PRESENT: Jeffrey Artz, Dept. Of Motor Vehicles and Public Safety Criminal History Repository Frank Adams, Nevada Division of Investigation Sharon Ezell, State Health Bureau of Licensing John Sarb, Division of Child and Family Services Stephen Shaw, Bureau of Alcohol and Drug Abuse Keith W. Macdonald, Nevada State Board of Pharmacy Mike Hillerby, Nevada State Board of Pharmacy Stephanie Tyler, Nevada Board of Dental Examiners Dr. Thomas Sculley, Secretary, Board of Medical Examiners Bobbie Gang, Nevada Pharmacists Association ASSEMBLY BILL 580 - Requires certification of laboratories to analyze water. Chairman Freeman reminded committee members that A.B. 580 had been amended by this committee and re-referred to the Assembly Committee on Ways and Means because it had a fiscal note. She explained the bill's sponsor had concerns about it going to Ways and Means, so yesterday she re-referred it back to this committee. However, even though A.B. 580 would be funded by fees collected from the laboratories, the Chairman of the Ways and Means Committee agreed it must go through that committee. As a result, Mrs. Freeman requested a new motion to amend, do pass and re-refer to Ways and Means. She stated she believed Assemblywoman Evans had made the original motion. Mrs. Evans mentioned she understood there were some concerns about the original motion. Mrs. Freeman reminded the committee there had been a suggestion that testing for "waste" be included in the amendments, however it had not been part of the motion. The amendment the committee had voted to pass only involved line 3, page 1 where the word "jointly" was amended to the word "each". ASSEMBLYWOMAN JAN EVANS MOVED TO AMEND, DO PASS AND RE-REFER A.B. 580 TO THE ASSEMBLY COMMITTEE ON WAYS AND MEANS. ASSEMBLYWOMAN JAN MONAGHAN SECONDED THE MOTION. THE MOTION CARRIED. ********* ASSEMBLY BILL 491 - Provides for imposition of additional administrative sanctions against child care facility for certain violations and expands restriction upon smoking of tobacco in child care facility. Mrs. Freeman, sponsor of A.B. 491, explained she was eliminating the provisions regarding smoking in a public building and as a result would be submitting two amendments on the Assembly floor the next day. Mrs. Freeman stated the committee would take no action on A.B. 491 today, however she had wanted to inform committee members of her intentions. ********* ASSEMBLY BILL 605 - Provides that certain persons arrested must be tested for sexually transmitted disease. Assemblyman Harrington presented the subcommittee report of its meeting on June 6, 1995 and proposed amendments to A.B. 605, (Exhibit C). The subcommittee voted to recommend that the full committee entertain a motion to "Amend and Do Pass" A.B. 605. Assemblywoman Buckley mentioned the HIV/AIDS Coalition from Las Vegas had expressed a number of concerns at the initial hearing on A.B. 605, (Exhibit D). The amendments proposed by the subcommittee were to have been drafted to meet those concerns, however the coalition was never consulted. As a result, Ms. Buckley requested the bill be held until the coalition's concerns had been fully alleviated. Mrs. Freeman agreed to hold action on A.B. 605 until the committee heard from the coalition. Mrs. Evans, as a member of the subcommittee, concurred with Ms. Buckley. Assemblywoman Steel inquired what liability the health authority might incur if they made a mistake on their testing or their decision to test or not to test. No one answered her question. Mrs. Freeman suggested members of the subcommittee meet informally and discuss their concerns before the next full committee meeting. ********* ASSEMBLY BILL 681 - Revises provisions governing submission of fingerprints used during investigation of person who provides child care. John Sarb, Administrator of the Division of Child and Family Services (DCFS), explained A.B. 681 was requested by his division to correct a legislative audit finding by bringing the statute into compliance with current practice. At present the division has many applicants for child care employment who go directly to their local law enforcement agencies to be fingerprinted. The fingerprints are then sent on to the Federal Bureau of Investigation (FBI) for a background check. That procedure was worked out with law enforcement agencies after enactment of the law mandating fingerprint checks. However if the language of the law were to be literally observed, Division of Child and Family Services staff would be required to take those fingerprints, send them to local law enforcement agencies who would then forward them on to the FBI. Only local law enforcement agencies can send fingerprints to the FBI so as a result there would be delays in hiring for child care facilities all over the state, or the alternative would be a significant increase in DCFS staff to be available to take those fingerprints. Mr. Sarb testified passage of A.B. 681 would allow DCFS to designate local law enforcement agencies as the recipient of those fingerprints, as is current practice, then they could be sent on to the FBI. He noted this solution had been presented to the audit subcommittee of the Legislative Commission and met with their approval. Jeffrey Artz, Nevada Highway Patrol Records/Identification Supervisor for the Criminal History Repository, requested a language change to A.B. 681 because, as he noted, "the FBI has gotten real picky" about which applicant fingerprint cards they would accept for background check purposes. He stated all applicant fingerprint cards go to the Criminal History Repository for submission to the FBI. Mr. Artz requested addition of language to line 7 that would cause the sentence to read ". . . to forward the fingerprints to the criminal history records repository for the transmittal to the Federal Bureau of Investigation . . . ." If that language was included in A.B. 681, Mr. Artz maintained there would be no question of the FBI accepting the fingerprint cards for background check purposes. Mr. Sarb agreed since the repository was the only agency that could send fingerprints to the FBI, they would have to be the designee, so he did not see a need for the amendment. He admitted the suggested language did make what would happen with fingerprints more clear. He also indicated a concern that there would be no time to get the amendment. Mrs. Freeman inquired if Mr. Artz were comfortable with A.B. 681 passing with its current language. He replied he was not because the FBI continues to request specific language be in the state statute or they may begin rejecting fingerprint cards. Mrs. Freeman commented the amendment was not a complicated one and there should be no problem getting it from the bill drafters. ASSEMBLYWOMAN BARBARA BUCKLEY MOVED TO AMEND AND DO PASS A.B. 681. ASSEMBLYWOMAN SAUNDRA KRENZER SECONDED THE MOTION. THE MOTION CARRIED. ********* SENATE BILL 363 - Exempts certain facilities for care of adults from payment of fees related to licensure. Sharon Ezell, Bureau Chief for Licensure and Certification for the Health Division, explained the purpose of S.B. 363 was to exempt adult day care facilities from paying licensure fees. She indicated exemption of those facilities would impact their budget, however she still would like to remove adult day care facilities from any licensure requirements. She stated this type of provider was very limited within Nevada with only 259 beds in eight licensed facilities. Ms. Ezell noted residents were in the facility only part of a 24 hour day, so assuring quality of care would not be totally dependent upon a licensure process. Most of the people who utilize adult day care do so in order to work or to provide respite and Ms. Ezell mentioned her division rarely receives a complaint about adult day care. Mrs. Evans inquired about the impact on the division's budget. Ms. Ezell agreed fees from licensing adult day care were a part of the division's budget and if those facilities were exempted from paying fees, there would be no income from that source. As a result licensure and certification services would be provided free and fees to other entities might have to be increased to compensate. Mrs. Evans asked if an estimate of lost revenue had been made. Ms. Ezell replied the division had estimated the loss at approximately $20,000. Ms. Krenzer noted the fiscal note for S.B. 363 was $6,300. Ms. Ezell apologized, saying she had thought the figure was closer to $20,000. Ms. Krenzer stated her disagreement with Ms. Ezell's requested amendment. She believed if someone wanted to question the license of a facility it should still be under the division's purview to monitor and issue licenses. Mrs. Freeman, commenting that Senator Titus, S.B. 363's sponsor, had requested the bill not be heard today because she would be unable to be present, suggested S.B. 363 be scheduled for another hearing and that Ms. Ezell use the intervening time to resolve the questions brought up today. Assemblywoman Braunlin requested information on the operators of the state's day care facilities, where they are located, what current federal oversight there was and what oversight was being done by Nevada for its licensing. Ms. Steel mentioned there is a growing senior population in Nevada and that doing away with the application and licensing fees, might, in the future, be eliminating more than the current estimate of $6,300. ********* SENATE BILL 36 - Requires development of program to track prescriptions for certain controlled substances filled by pharmacies. Mike Hillerby, representing the Nevada State Board of Pharmacy, stated S.B. 36 would allow pharmacists to set up a computerized system to track certain controlled substance prescriptions. He indicated the board and the Division of Investigation had cooperatively developed a computerized program to track prescriptions filled by a pharmacy in schedules II, III or IV. Mr. Hillerby explained the inappropriate use of drugs, sometimes called "doctor shopping" involved a person going to ten, fifteen or twenty different providers to get controlled substance prescriptions, which are usually painkillers. The person then goes to fifteen, twenty or more different pharmacies to get those prescriptions filled. Concern by oncologists and pain management specialists had prompted the Senate to add an amendment to S.B. 36 which stated the bill could specifically not infringe on the legal and legitimate use of controlled substances to control pain. Keith Macdonald, Executive Secretary of the State Board of Pharmacy, explained the board was charged with licensing pharmacists, pharmacies, drug wholesalers, drug distributors and a variety of people involved in handling pharmaceutical drugs in the state. He mentioned controlled substances are those drugs that have psychological and physiological abuse potential and include about ten percent of all prescribed drugs. Mr. Macdonald explained the purpose of the program would be to divert people from the criminal justice system. He also stated administration of the program by the Bureau of Alcohol and Drug Abuse, and the other divisions listed in section 1, subsection 1(b) would be of an oversight nature only. They would not be required to raise fees or be in the active operation of the program. Mrs. Monaghan, mentioning NRS 453.155, pointed out the board currently has the authority to determine patterns of misuse or abuse of controlled substances and questioned why S.B. 36 was necessary. Mr. Macdonald agreed the board has that power, however he stated it was being done in a very manual, labor intensive way. Mrs. Monaghan inquired if using computers to monitor drug use could be accomplished under current statutes. Mr. Macdonald agreed and mentioned Deputy Attorney General Louis Ling had indicated as much. However, because of concerns about patient confidentiality, the Board of Pharmacy had wanted to introduce the program as a bill so people would have an opportunity to testify and would be aware of what the board was doing. Mrs. Evans inquired whether the board must design its own computer software to implement the program. Mr. Macdonald replied several states are currently monitoring controlled substances using one commercial program however it is very expensive so the board may have one written. Mrs. Evans asked how many prescriptions for controlled substances were written per day. Mr. Macdonald said it depended upon whether they included monitoring the mail order prescription industry of Nevada. He stated about 40,000 prescriptions were filled daily in Nevada and if ten percent of those were for controlled substances, that would still be a considerable number of prescriptions to track. Mr. Macdonald explained 97 percent of Nevada pharmacies already have computer systems and prescriptions for controlled drugs are already set aside. Basically, all a pharmacy would pay for would be software in their computers to allow them to send the information to a central repository by modem, disk or tape. The program for sorting and accumulating the information is already available. Mrs. Evans wondered how easy it would be to track the mail order industry. Mr. Macdonald replied the mail order industry had already indicated willingness to provide tapes of this information for Nevada residents only. Noting a provision in S.B. 36 would allow fee increases, Mrs. Evans asked what the start-up costs and ongoing expenses might be and who would pay those costs. Mr. Macdonald stated estimated start-up costs were between $200,000 and $250,000. In addition, they estimate two people could run the program so, in addition to rent and other expenses, ongoing costs might be around $60,000 to $80,000 per year. Mrs. Braunlin mentioned if the computerized program had simply been implemented without S.B. 36, it would have been brought to the public's attention because the board would have had to go through the rule making process. Mr. Macdonald agreed. Mrs. Braunlin stated she believed the reason to implement the computer program using S.B. 36 would allow the board to come back to the Legislature or interim finance and request they be allowed to charge a fee. Mr. Hillerby agreed absolutely with Mrs. Braunlin's statement. He testified it was the intent of the amendment, and the board's intent during testimony before the Senate, that they would not be raising any fees without specific approval by the Legislature. There had been concern, he explained, both from the pharmacy industry and from some individual senators, that the board not use a "back door" to pay for the program. Mr. Hillerby noted S.B. 36 was not making a change in policy, only in how policy was implemented. Resources would be shifted, he said, from a manual system to an automated one. Mrs. Braunlin, referring to line 20 on page 2 of the bill, expressed concern that those pharmacies dispensing large numbers of controlled substances, for instance a pharmacy in a medical office building where there was a lot of pain management, might end up being penalized. Mr. Macdonald testified fees were not established on volume. All pharmacies pay a $150 fee to dispense controlled drugs. He added the administrators of the program would be taking into account physicians who, in the course of their routine practices, must dispense a lot of pain medications. For the record Mr. Macdonald stated, "The Board of Pharmacy acknowledges that there is not any limit to necessary analgesia for pain." Dr. Harrington commented S.B. 36 was an excellent bill and would truly expedite things and make it a lot easier for those physicians who deal with requests for pain medications on a regular basis and who wonder if some of the people are abusing the system. Stephen Shaw, Administrator of the Rehabilitation Division of the Bureau of Alcohol and Drug Abuse (BADA), testified BADA was one bureau within the division. He mentioned he wished to set the record straight as far as clarification of the language on page 1, line 10 which states "Be administered by the board, the division, the bureau of alcohol and drug abuse of the rehabilitation division of the department of employment, training and rehabilitation . . . ." Mr. Shaw emphasized previous testimony indicated bill sponsors had no intention for BADA to have any fiscal or actual programmatic responsibility. He stated BADA's input, in an advisory capacity only, had been requested when establishing the program. Mr. Shaw indicated the bureau had no objection to helping in an advisory capacity only and wanted to go on record indicating that. He also asked if that was the committee's understanding as well. Mrs. Freeman suggested Mr. Shaw send a letter to the committee that could be entered into the record, (Exhibit E,) and she also suggested the committee ask for a legislative letter of intent that would make it very clear. Mr. Shaw agreed with those suggestions and emphasized a letter of intent would certainly meet his needs. Dr. Tom Sculley, Secretary of the Board of Medical Examiners, agreed with Dr. Harrington in expressing full support for S.B. 36. He believed passage of the bill would allow much quicker identification of physicians who might be abusing their prescription writing privileges. Frank Adams, Deputy Chief with the Division of Investigation, the second responsible party mentioned in S.B. 36, expressed full support for the bill. He testified the division had worked very closely with the Board of Pharmacy to develop S.B. 36. They are concerned about organized gangs or groups of people who do abuse the physicians and the medical system. Those are the people his division wants to concentrate on, not the individuals who are abusing and who should be diverted out of the criminal justice system. Ms. Steel, mentioning fee increases, inquired how large the increase would be and who would be paying it. Mr. Macdonald replied the function of the Board of Pharmacy and its fee process was to have a fee for every practitioner who prescribes controlled substances so the approximately 4,300 Nevada practitioners are each charged $50 every two years. The board also collects many other fees and as a result, has the funds available to do the job and anticipates no fee increases in the near future. Bobbie Gang, representing the Nevada Pharmacists Association, testified the association does support S.B. 36. ASSEMBLYWOMAN JAN MONAGHAN MOVED DO PASS ON S.B. 36 WITH A LEGISLATIVE LETTER OF INTENT. ASSEMBLYMAN WILLIAM HARRINGTON SECONDED THE MOTION. THE MOTION CARRIED. There being no further business, the meeting was adjourned at 3:00 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 June 7, 1995 Page