MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-Second Session
April 30, 2003
The Committee on Health and Human Serviceswas called to order at 1:39 p.m., on Wednesday, April 30, 2003. Chairwoman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
Note: These minutes are compiled in the modified verbatim style. Bracketed material indicates language used to clarify and further describe testimony. Actions of the Committee are presented in the traditional legislative style.
COMMITTEE MEMBERS PRESENT:
Mrs. Ellen Koivisto, Chairwoman
Ms. Kathy McClain, Vice Chairwoman
Mrs. Sharron Angle
Mr. Joe Hardy
Mr. William Horne
Ms. Sheila Leslie
Mr. Garn Mabey
Ms. Peggy Pierce
Ms. Valerie Weber
COMMITTEE MEMBERS ABSENT:
Mr. Wendell P. Williams
GUEST LEGISLATORS PRESENT:
Assemblyman Lynn Hettrick, District No. 39
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Terry Horgan, Committee Secretary
OTHERS PRESENT:
Greg Hayes, M.D., M.P.H., Associate Professor, University of Nevada, Reno
Larry Matheis, Legislative Advocate, Nevada State Medical Association
Alex Haartz, Deputy Administrator, State Health Division, Nevada Department of Human Resources
Keith Lee, Legislative Advocate, Nevada Board of Medical Examiners
Louis Ling, General Counsel, Nevada State Board of Pharmacy
Chairwoman Koivisto:
The Committee on Health and Human Services will come to order, please. [Roll was taken.] We have two bills on our agenda today. We’ll begin with S.B. 332.
Senate Bill 332 (1st Reprint): Revises qualifications of State Health Officer, clarifies restrictions on use of “M.D.” title and makes various changes relating to licensure of physicians. (BDR 40-1036)
Greg Hayes, M.D., M.P.H., Associate Professor, University of Nevada, Reno:
[Identified himself.] Senator Amodei asked me to present the bill because my wife, an attorney, and I had originally written it. I teach medical ethics at the University of Nevada, Reno (UNR), and it’s from that context that I got involved in this subject.
The state of Nevada hired Dr. Hugh Stallworth to be its new State Health Officer and then quickly fired him because he didn’t have the required 36 months of progressive, postgraduate training, more generally called residency, in preventive medicine. We lost a really good public health administrator and I became concerned.
[Another example concerns an emergency room doctor] I knew of who had practiced, with distinction, in Nevada. [He] had even received an award as the first ER (emergency room) doctor in Carson City who was board-certified. [He] went to Vermont to teach emergency medicine and was thinking of coming back to Nevada, but was told he couldn’t because he didn’t have a full residency in that specialty.
This bill was written not to weaken the medical licensing requirements but to add some much needed flexibility in some key areas. The people in Nevada [shouldn’t have to] lose out in terms of being able to utilize the services of some quality doctors who are turned away unnecessarily, in my mind.
[Dr. Hayes presented Committee members with a copy of his “Rationale for S.B. 332” (Exhibit C). He continued.] The State Health Officer area of the bill adds a restrictive “administrative physician” license category. This complements S.B. 411, which will be heard next. If a search committee feels that the best candidate is someone with excellent leadership skills and experience in public health administration, but [who] has no residency training, we could hire that person under this “administrative only” category. This is just a tool for a search committee to use if it is appropriate.
The next area of the bill says that you can apply for licensure if you’re board-certified or have 36 months of what they call progressive, postgraduate training, residency in other words, focused in one area. Right now, you have to have at least 36 months [of residency] to be board-certified. However, because 2 of the 24 medical specialties, family practice and emergency medicine, are new enough, there are still practicing doctors who never had the opportunity to take those residencies because they did not exist.
Board certification is the best measure of competence and quality we have in American medicine. All the [first] teachers of [family practice and emergency medicine programs] lacked residencies because they didn’t exist when those [physicians] went to school. They, among others, were allowed to sit [for those] boards [when they were developed] to try to pass those exams. They’ve kept up their certification so these are quality docs who are being penalized because Nevada law says one must have a residency. It’s age discrimination in a sense because they didn’t have the opportunity to take board exams. All the teachers of emergency medicine lacked residencies, particularly in the beginning [years of that specialty]. In a few more years this will be a moot point because folks who were allowed to sit for the board exams based on experience only will have retired or passed away and everybody will have residency training in all those specialties.
The third part of the bill is about a very specialized but important area concerning folks in a combined program who receive both an M.D. and a dental degree. There are very few of these programs in the country, but they vary in terms of how they sequence the years. Those that start with medicine then do dental have no trouble under the current laws. Those that start with dental and then do medical come up a little short in terms of having at least 36 months of residency training after the M.D. degree is granted. Oregon Health Sciences University in Portland is an example. They have 48 months of residency-type training, but only 24 months come after the M.D. [degree] is granted, so they can’t obtain a medical license here. This [part of the bill] would add a little flexibility and say only 24 months of at least 36 months, as the law currently requires, has to happen after the technical point in this combined program when the medical degree is granted. These are all accredited programs, all quality programs, but they sequence the years [differently]. All the students [become] quality docs at the end.
[Dr. Hayes, continued] The fourth part of the bill came up after I wrote my article for the newspaper last June (Exhibit D). That is the issue of using the “M.D.” title. I learned that if you’re a professor at the University hired in a non-clinical capacity and have an M.D. [degree] but are not licensed, you’re not supposed to have that on your business card or letterhead [stationery], et cetera. [Under the current law], you can only use the “M.D.” in any printed way if you are licensed to practice medicine. That’s truly unfair because someone who earns an M.D. can use it for other reasons, not to deceive anyone, not to practice medicine without a license, but to do other things such as run a health-related program or [fill] a non-clinical [position] at UNR or UNLV (University of Nevada, Las Vegas). This [change] would eliminate that aspect of the [existing] law but would leave plenty of teeth in the law. If you practice medicine without a license, it’s a felony. If you say you have an M.D. [degree] and you don’t, it’s a felony.
The fifth part was added as an amendment during the Senate hearings. It has to do with honoring the board certification element as the gold standard in American medicine. The example used in that case was a [board-certified] OB/GYN [obstetrician/gynecologist who] wanted to practice in Clark County but couldn’t because of a technicality. One part of one medical testing procedure was done too early, I believe in the first year after medical school, [when that examination should be taken after the second year]. The individual passed the test the first time he [took it] but couldn’t be licensed in Nevada. Someone asked how many people had been affected by this [particular set of circumstances], but no one knew. The amendment would basically say that board certification, which requires all the standard testing through medical school, et cetera, and its own specialty testing, is sufficient for that step in the application process.
Those are basically the five areas in S.B. 332, [which was] introduced to inject a measure of fairness into the laws so that the people in Nevada can be served by some very quality people who are left outside our borders right now.
Chairwoman Koivisto:
Questions from the Committee?
Assemblyman Mabey:
Has the term “administrative physician” ever existed in another state, or are you just making up that term for somebody who’s a physician and [who would] come to Nevada but not practice medicine?
Dr. Greg Hayes:
I went to my wife, who’s a practicing lawyer, and I said, “How can we deal with this? This job is an administrative job, a leadership job. What can we do if that person doesn’t have residency training? I don’t want him to practice medicine; I want him to do this [other] task.” I honestly don’t know if [the term] exists in another state. It’s just targeting the issue and saying we want an administrator.
Assemblyman Mabey:
They would still be physicians; they went to medical school. [Dr. Hayes concurred.]
On the second part, let’s say you are an older physician and were grand- fathered in for your board certification but had not completed a residency program. Would that apply to those people?
Dr. Greg Hayes:
Right. But just remember, “grandfathered in” in the sense that they were allowed to sit for the boards and attempt to pass these rigorous, long, tough, board [exams]. Plenty of folks chose not to even try, but they had the opportunity.
Assemblyman Mabey:
Right, so as long as they took the test and passed it…
Dr. Greg Hayes:
And that was only in the early days of the board exams. And only the quality [physicians] got through the hoops, and then kept [their board certification] over the years.
Assemblyman Mabey:
The last part [of S.B. 332] – aren’t they addressing the deal about the degree in another Senate bill? [Dr. Hayes responded that it had appeared in a number of places.]
It was in Commerce and Labor, I think. [Dr. Hayes agreed.] Is the wording going to be the same?
Dr. Greg Hayes:
In our case we’re deleting the aspect of it that says you can’t use a degree you earned, as long as you use it in a non-deceptive way. There are other [provisions] in the law that would hammer you if used it in a deceptive way.
Chairwoman Koivisto:
In S.B. 332, in paragraph (b) of subsection 1, you’re deleting subsection (b), but yet that is being retained in S.B. 411. What is the disconnect?
Dr. Greg Hayes:
I cannot address S.B. 411; I wasn’t part of creating it. S.B. 332 goes further than S.B. 411 in creating this more restricted kind of category if the best candidate can only be had through that avenue.
Could you redirect me to [the part of the bill in question]?
Chairwoman Koivisto:
Page 1, Section 1, paragraph (b) of subsection 1.
Dr. Greg Hayes:
“Be certified, or eligible for certification, by the American Board of Preventive Medicine”?
Chairwoman Koivisto:
Right. [That language is deleted in S.B. 332] but it’s left in S.B. 411 and I’m not sure…
Dr. Greg Hayes:
This goes further. This is to address some of those very quality, experienced public health leaders and administrators that do not have this residency, or possibly any residency. The few I know, for example, have many, many years, maybe a decade, in the U. S. Public Health Service after their internship. They never did a residency but went on to other tasks and are in very high positions now of great authority. They never did a residency but have excellent skills administratively. If that kind of person applied here and [the search committee decided] that was the best person, this gives them a way to hire [that individual] but just in that area, not to practice medicine.
Chairwoman Koivisto:
If we want to leave that out, as it is in S.B. 332, then we also have to take it out of S.B. 411.
Dr. Greg Hayes:
I understood S.B. 411 allowed for other types of residencies. Is that true, Larry? [Larry Matheis agreed.] A preventive medicine residency wasn’t required.
Larry Matheis, Legislative Advocate, Nevada State Medical Association:
[Introduced himself.] These are two different approaches to getting around the problem created by having certification by the American Board of Preventive Medicine as a necessity for being considered for State Health Officer. That is one route that many physicians who are going into public health careers take, but there are others. I think that the pool [of qualified applicants] is very small when trying to recruit. In S.B. 332 the approach is to take that [requirement] out, but then by the changing of the overall licensure of physicians in Section 7, any of the appropriate board certifications would be able to be considered, including that one but not limited to that one.
In S.B. 411 the approach is they can either have that particular board or they can have gone on to get a master’s in public health (M.P.H.) and have experience on a different track. It’s simply a different way of trying to expand the pool of who could qualify as State Health Officer. These are two different approaches, but they are each an approach to try to increase the pool, as I understand it.
Assemblyman Mabey:
I have the same confusion. They are both in the same section [of NRS] but the wording is going to be different in each bill. I don’t know if Legal could help us with that [confusion].
Assemblyman Horne:
I’m noticing the exact same thing. We’re talking about NRS 439.090. If we were to pass both bills as [currently drafted], they would conflict because one statute has deleted “to be certified by the American Board of Preventive Medicine,” but in the [other bill], the State Health Officer [must be certified by the American Board of Preventive Medicine]. If we pass S.B. 332 we have to make the language in S.B. 411 match, because it [speaks] to the definition of the requirements of the State Health Officer.
Dr. Greg Hayes:
I’m more familiar with S.B. 332, which goes further. For example, you could hire someone as an administrative-only physician and you’ve deleted this other preventive medicine requirement. As a search committee, you can then make other rules in terms of how you rank your applicants. You’d probably want someone with preventive medicine [experience if the applicant] was an excellent leader.
Assemblyman Horne:
That’s fine, but [the sections] have to say the same thing.
Larry Matheis:
I think the Senate has creatively given you options. [The bills] are not inconsistent but they would be if you passed both in their current forms. The issue is that the state Health Division, the Department of Human Resources, wants to be able to broaden the pool so it’s not limited to someone who is only [certified by] the American Board of Preventive Medicine. That’s also the case in S.B. 332. S.B. 332 then goes on to change the overall structure of the importance of board certifications and that would apply then to the State Health Officer. [S.B. 332] also would like to have, as an alternate pathway, looking at other ways people get into public health medicine. You have to “massage” the language because I think that you would want the M.P.H. and the experience in public health added as an optional criterion. [You may have to amend out] the limitation that it has to be that particular certification board. Conceptually it’s not that difficult an issue.
Dr. Greg Hayes:
Why do you need all this written in statute? I think you need to paint the extremes in statute. Having been on lots of search committees, I can set a whole lot of other criteria in the terms of how I’m going to rank my applicants, including M.P.H.s. You need to define [only] the boundaries in statute. That was my approach in S.B. 332.
Larry Matheis:
I do have some history as to why this is in statute in the first place. It’s because Nevada, for about 20 years, didn’t have a qualified State Health Officer, just a physician who was on contract to do other things because he was paid for by the federal government. In the 1980s it was decided that [not having a full-time or working state health officer who knew about public health] was not acceptable for any state. The reason it was put in statute was because, for 20 years, we avoided making a difficult decision and, therefore, we did not have the capacity to deal with the early days of the HIV (Human Immunodeficiency Virus) epidemic and other issues where we didn’t have the expertise in that key position.
Chairwoman Koivisto:
Dr. Hayes, I agree. We should set the boundaries and let the details be filled in by the search committee. That is the way it should be done.
Alex Haartz, Deputy Administrator, State Health Division:
[Introduced himself.] The Health Division is in conceptual support of S.B. 332 and the notion of being able to cast as broad a net as possible in terms of candidates who we can interview and consider. My testimony is limited to the first section [of the bill, NRS] 439.090, that you’ve just been talking about.
What we have found in terms of recruiting for a state health officer is that there is a limited pool of eligible candidates when it’s limited to actual certification by the American Board of Preventive Medicine. That led us to our own bill, S.B. 411. I would just like to comment that there is a conflict [between the two bills] and we’re supportive of the overall notion that Nevada have the best opportunity to hire the best candidate. I’d also like to clarify for the record that although it was a painful time, Dr. Stallworth was never actually hired by the state Health Division. We had an offer pending subject to his ability to be licensed by the Board. Unfortunately it turned out at the last minute, both to our surprise and his, that he was unable to be licensed. It had the same effect, though; it had the same appearance.
Chairwoman Koivisto:
We have two proposed amendments to S.B. 332. Have Senator Amodei and Dr. Hayes vetted those amendments?
Assemblyman Lynn Hettrick, District No. 39 (Douglas County, parts of Carson City and Washoe County):
I communicated with Senator Amodei a week ago and again today. He said to go ahead and bring this amendment [to the Committee] (Exhibit E). I explained to him what it was and what it was attempting to do. He had no problem with [the amendment]. I did not know that Dr. Hayes would be here presenting, so he has not seen the amendment. Mr. Lee did look at this as well as Mr. Matheis just now. We have concerns about what [my amendment] does and how it does it. Since it appears you have some questions and this bill might go to a work session, I would like to get on the record that we would like to amend this if we can.
Barton Hospital, which practices at South Lake Tahoe in California and in Douglas County, Nevada, has hired a doctor who is prepared to come to Douglas County and go to work in one of their facilities. He went to get licensed by the state of Nevada after accepting and signing the contract. He found out that his background doesn’t satisfy licensure requirements in the state of Nevada. [My] amendment addresses that concern. However, when we looked at this just now we were not certain this was appropriate and we want to do a little background [work] before suggesting to you that you should proceed. I would like to let you know that we do need to [adopt this amendment] if it’s appropriate. If you are going to take this bill to work session I will get the doctor and his background properly vetted with Keith Lee and the Board of Medical Examiners, [et cetera], to make sure it’s appropriate. If it is, I will let you know. If it is not, I will tell you that we don’t think [the amendment] is appropriate.
Chairwoman Koivisto:
We won’t work on your amendment at this point. We have Keith Lee, who has signed in against S.B. 332.
Keith Lee, Legislative Advocate, State Board of Medical Examiners:
I signed in in opposition to S.B. 332 because I am going to propose an amendment that amends Section 7. I will say that the State Board of Medical Examiners supports Sections 1, 2, 3, 4, 5, and 6. In fact, we worked with the [Human Resources and Facilities Committee and Senator Amodei] to get the language in Section 4 reworked and we’re comfortable with it.
The State Board of Medical Examiners is part of the Executive Branch and, as such, we execute whatever public policy you make. Obviously, the licensing standards in Chapter 630 [of NRS] are the public policy you have made. We also view it as our role to advise you on what we think is appropriate public policy in this area. After we give you that counsel, and you give it whatever weight you choose to and change public policy, we obviously will execute that public policy.
What I have presented to the Committee is a proposed amendment (Exhibit F) to S.B. 332. I’ve visited this amendment with Senator Amodei. I’ve also dropped it off at Senator Rawson’s office because he was the chair of the committee that heard this [bill] on the Senate side. Prior to the hearing today I shared it with Larry Matheis.
What we’re proposing to do in Section 7 is to delete Section 7 as it is in the bill and to put in Section 7 as it has been amended into S.B. 250. S.B. 250 is a bill on the Senate side that combined three separate bills that dealt with licensure and Board of Medical Examiners issues and a number of other things regarding boards in the state. The reason I’m bringing this language here is that I’m not sure what’s going to happen to S.B. 250. It has now been re-referred to Senate Finance, so it’s still in the Senate. The Board thinks there’s a couple of pieces of important legislation in S.B. 250 that we would propose be put in S.B. 332.
The first is in Section 7. What this does is addresses a part of the doctor’s concerns, although you’ll note that [the language reads], “Is currently, and has been in the previous seven years, certified by a specialty board of the American Board of Medical Specialties…” We want the physician to currently be certified, but we think the physician must have taken [whichever] certification in the [preceding] seven years. In other words, we don’t want someone who’s board-certified [but] who’s been out there for a number of years. We’re not sure that person is someone we want practicing medicine in this state. We think there ought to be some sort of time frame on when that last certification was received so there is some assurance to the general public that, while the physician is board-certified, he or she is not just currently board-certified but has been board-certified or re-certified [within] some number of years, and we’re suggesting seven.
[Mr. Lee continued.] This does not address the doctor’s concerns beginning at line 33 on page 3. We are still suggesting that it is good public policy for you to keep into effect the law that you passed last session, which is that [a physician] must have 36 months of progressive postgraduate education. What that means is that after he has received his medical degree, he must have had three years of postgraduate study in the same subspecialty or specialty. We don’t think it’s good public policy that he may spend one year in postgraduate work in one subspecialty and decide to switch and get two more [years] there. We don’t think that’s good public policy and you agreed with us last [session]. If [you don’t agree that] it’s sound public policy, then of course we will do whatever you tell us to do in terms of implementing the law.
I appreciate what the doctor’s concerns are with respect to the language proposed at line 33. Our concern there is a timeliness factor. I might suggest that perhaps we could deal with both the doctors’ issues and the Board’s issues. As I understand the doctor’s testimony, there were two subspecialties that were of some concern to him. One was emergency medicine and one was family practice. If you think that his proposal is well taken, we ought to restrict that to those two subspecialties. If we carve [the exception for those two subspecialties] out which, as the doctor says, are fairly recent subspecialties; I would suggest that [they not only] be currently board-certified, but have been certified in the past number of previous years, seven years, for instance.
With respect to the language beginning on page 3, line 44, as it continues over to the next page, we at the Board believe this carves out an exception for probably a very limited number of physicians. We’re not sure it’s warranted. Current policy has decreed that one must have three years of postgraduate study in the same specialty after graduation from medical school, after receiving a medical degree. What I believe this proposed change to the law would say is that one may take a year of postgraduate work in dentistry, for instance, then decide to go to medical school and that one year will apply. I hear someone saying, “No,” so I may be incorrect. What we’re suggesting is that the three years of postgraduate study needs to be in the same specialty and needs to occur after you’ve received your medical degree. I’m not sure if we’re talking about a limited number of physicians or if it’s good public policy to draw up legislation that really is only for a very limited number of people.
[Mr. Lee, continued] I am suggesting that you add a new section to S.B. 332 and I think this is a very important section. This has been amended into S.B. 250, but I’m suggesting we put it [into S.B. 332] because I’m not sure where S.B. 250 is going to end up at the end of the session.
By way of some background, you all know that we have an OB/GYN shortage in Clark County in Las Vegas. What we’re attempting to do in this new proposed section is address that by allowing the Governor to declare that there are critically unmet needs with regard to the number of physicians who are practicing in a medical specialty within the state or any geographic area of the state.
If the Governor so declares, then the Board of Medical Examiners may waive the progressive three-year postgraduate education requirement and admit that person. This language was taken from the concept that is presently in the law that allows a county commission to petition the Board of Medical Examiners to declare a critically unmet geographic area so that we can waive that. It occurred to us as we were talking about these [shortages] in our work sessions that [we] could take the concept that allows the Board to waive the three-year postgraduate requirement if there’s a geographic unmet need and put it into a specialty unmet need. We think this type of language would go a long way toward addressing the OB/GYN problem in Clark County. We think this is good public policy and that we ought to put it in this bill if [you also think] it makes sense to do so.
Assemblyman Horne:
I [have] a concern about the amendment’s suggestion about the Governor determining “critically unmet needs.” Doesn’t that open it up for possible abuse? Under this, as I read it, the Governor can say, “Yes, Dr. Smith. I can go ahead and allow you to practice in this state.” I actually had somebody when I was campaigning say, “My father is interested in being able to practice dentistry here without [taking] the [dental] board [exam]. Can you help him? Can you pass something for that?” I said, “No!” [People who want that type of favor] are out there looking for [those loopholes]. I don’t know what criteria the Governor would have to meet to show there’s a critical need. Is it going to be arbitrary? [Would he be able to say], “I think there’s a critical need here and I’m going to [allow] my friend who I grew up with [to practice medicine] here and not [have to] take these board [exams]?”
Keith Lee:
I understand that’s a legitimate concern. On page 3, paragraph 2, (a), (b), and (c), we are suggesting that there are criteria the Governor should consider before he determines there’s an unmet critical need. Once he makes that declaration of a critically unmet specialty need in some geographic area of the state, that simply allows the Board of Medical Examiners, when it receives an application for licensure from a physician, to waive the three-year postgraduate study requirements. That position must still meet all the other requirements. You’ll note that the Board is not required to, but may waive those. The Board still has the final authority in determining whether this physician ought to be licensed to practice medicine in the state. Hopefully, the “good-old-boy” system will not be at work and we’re not going to have the situation you suggested, Assemblyman Horne, happen. We hope we’ve crafted this language so that we avoid that situation.
[From the Board’s perspective], we don’t care whether it’s the Governor or someone else who makes the declaration, we just think it’s not appropriate for the Board to declare an unmet need and then go ahead and [license physicians]. Some authority other than the Board of Medical Examiners needs to make that determination or that declaration. That then triggers our ability to look at license applications and waive the three-year postgraduate education requirement if the physician meets all other standards of licensure.
Assemblyman Mabey:
Let’s say the Governor declares an unmet need, then a physician would have to have one year of training. Let’s say he did one year of obstetrics, but he’s been practicing in another state for five years. Then he could get a license here, is that the way it would work?
Keith Lee:
That is correct. There was no creativity on our part in drafting this. This [language] was taken directly from [NRS] 630.171, I think. It’s the statute we already have in place that allows a county commission, and this was primarily for the rural areas, to declare that there’s a geographical unmet need and that we [the Board of Medical Examiners] have the same authority. All this flowed from that particular language. This wasn’t new language that wasn’t already in the law. We simply tried to shift that into this new area of unmet critical specialty need.
Assemblyman Mabey:
I need to think about this more. An obstetrician who’s just done one year of training and then practiced for five years, that’s not the kind of obstetrician I’d want to take care of my wife, or any other specialty for that matter. I have some concerns about this.
Keith Lee:
I appreciate that, Assemblyman. This was a concept we’ve pulled together using that other language. From the Board’s standpoint we welcome your expertise. If the concept makes sense, how do we get there from here? [Assemblyman Mabey indicated he would be glad to help.]
Chairwoman Koivisto:
Before we go further with the amendment, this licensure part [of S.B. 332] should really be heard in the Assembly Commerce Committee. This is not the purview of this Committee. I’m going to recommend to Assemblyman Hettrick, for his amendment as well, that he request an emergency measure as Minority Leader to do that.
Keith Lee:
I defer to that and have no problem [presenting this amendment] wherever it’s appropriate to do so. I assume [your recommendation concerns] this new proposed section I’ve just been addressing?
Chairwoman Koivisto:
That’s correct. Other questions from the Committee?
Assemblyman Mabey:
This seems quite complicated to me, and as a physician I’d like to spend more time with this. If there was ever a desire by the Chair to have a subcommittee, I would be glad to be part of it so that we could maybe work these things out.
Chairwoman Koivisto:
I was going to suggest that to work your way through this, you’d need a law degree as well. We will bring S.B. 332 back to Committee and it will go to a work session. I’ll talk to Assemblyman Hettrick and suggest that he might want to look into [requesting] an emergency bill in order to deal with [his] issue.
We’ll bring S.B. 411 to the Committee. I think this is Mr. Haartz’s [bill].
Senate Bill 411 (1st Reprint): Revises certain provisions relating to qualifications and appointment of State Health Officer. (BDR 40-1243)
Alex Haartz, Deputy Administrator, State Health Division:
[Introduced himself.] S.B. 411 was a bill requested by the Health Division that arose out of our historical difficulty in hiring or recruiting for a new [State] Health Officer when the incumbent leaves. As the law currently states it requires licensure as a physician in Nevada as well as either certification by the Board for Preventive Medicine [or eligibility for certification by that Board].
What we have found is that the hiring pool for candidates is just too small. It’s difficult to attract interested parties to Nevada. As a result, the Health Division proposed this bill which provided added flexibility in that in lieu of either certification or eligibility for certification, an otherwise qualified physician licensed to practice medicine in Nevada could have a masters degree in public health as well as some relevant experience.
The other aspect of this bill is to clarify the physician’s status in the personnel system. Over time there have been unresolved questions from the state Department of Personnel with regard to how this position has been established in the law. The advice we received said that for purposes of hiring, the position [of State Health Officer] is an appointed or unclassified one. For purposes of dismissal, [the position] is classified. That has created some conflict in how we do personnel issues. Therefore, given the nature and the status of it and its profile we are proposing it be clearly stated that [the position of State Health Officer] is in the unclassified service.
According to information provided by the Association of State and Territorial Health Officials, of all states 22 state health officials have either masters in public health or doctorates in public health. Twenty-nine states require the state health official to be licensed to practice medicine. This would make us very consistent with other states and would make us competitive in the recruitment process.
Chairwoman Koivisto:
Questions from the Committee? [There were none.] I will bring S.B. 411 back to Committee and we will [take action] at the same work session where we work on S.B. 332.
At this point, let’s take a look at the bill to recycle used drugs, S.B. 327.
Senate Bill 327: Provides for reuse of certain prescription drugs.
(BDR 39-66)
Louis Ling, General Counsel, Nevada State Board of Pharmacy:
You asked us to be here and available to answer questions you might have regarding the way this bill would work.
Chairwoman Koivisto:
My recollection of the testimony on this bill was that it [would apply] to care facilities. Correct me if I’m wrong, but when someone is an inpatient in a facility, they’re not given a prescription for 30 days, 20 days, 10 days, or whatever. The doctor writes an order that this person be given so many milligrams of whatever at certain intervals. I’m having trouble understanding. If a drug is prescribed and the nurse is not able to administer the drug, the drug goes back to the pharmacy, is credited to the person’s bill, and it’s already being done. So what is the purpose of this [bill]?
Louis Ling:
There are three types of facilities under the bill to which this could apply: one is public or private mental health facilities; the second one, in Section 2, is going to be the skilled nursing facilities or facilities for intermediate care; the third one Senator Wiener was proposing were the correctional facilities, the jails and prisons.
The scenario you outlined is correct. If you have an inpatient pharmacy in your facility then this really isn’t going to get invoked, this bill will not [involve] you because those pills are going to go out to the patients. If the patient doesn’t take them they go back to the pharmacy. What this [bill] is intended to get at is those situations and those facilities where that may not be the case. Not every hospital or mental health facility, for example, has its own [in-house] pharmacy; some of them are being serviced from the outside. Certainly that’s going to be true for the skilled nursing facilities and the intermediate-care facilities. Sometimes those patients are getting their medications filled from the outside. My understanding was that Senator Wiener was trying to reach a very limited group of [facilities].
Assemblyman Mabey:
In those latter two cases, where would the prescription be coming from?
Louis Ling:
From a retail pharmacy or a pharmacy servicing that facility from the outside. Some of them are contracted to service the facilities because they aren’t big enough or have any reason to have a fully-staffed, in-house pharmacy.
Chairwoman Koivisto:
Again, I have to ask the same question. This is a skilled nursing facility. The drug would presumably be kept in a cabinet at a nursing station. The patient wouldn’t have a bottle of pills. [Mr. Ling replied that in most cases, Chairwoman Koivisto was correct.]
So, it seems to me that the drug is going to already be in a locked cabinet and only a dose would be taken to the patient at one time.
Louis Ling:
As I understand it, S.B. 327 was intended to [reuse] those [medicines] coming from the manufacturer in unit-dose packaging, which are what is being returned right now. We’re talking a very limited scope of things that can be returned under our present law because of that. If the [medication] were sitting in a vial from a pharmacy, or even if the vial came from the manufacturer that way, a bottle of 30 [pills] or whatever, once that seal is broken those can’t be returned. What can be returned under the present law is the unit-dose packaging. When Senator Wiener asked us to look at this bill we added a couple other things just to keep up with the state of the art. There is some unit-dose packaging that we understand is coming in tapes instead of foil-sealed pouches [so] it’s just a tape with individual doses. There are some packages now in bottles that are sealed by the manufacturer. If you haven’t had to break that seal to serve that patient then there should be no risk to taking those back. The only packages under this bill that will come back would be anything [still sealed by the] manufacturer. Any [product] that has a broken seal you don’t want to have coming back and then going out to another patient.
The scope of this bill is very narrow in its actual application and effect out there. [In] the third section [S.B. 327] we’ve left determination of how they’re going to do this in [the prison system up to them], because their situation is slightly different in the way they handle medications in the jail and we really didn’t want to get in the middle of that. The Pharmacy Board will still have oversight of that but the actual responsibility for making those policy decisions would be made in the correctional facilities themselves. It’s a very narrow bill.
Chairwoman Koivisto:
I spoke to more than one pharmacist about this and they were absolutely appalled.
Louis Ling:
If their understanding was that this bill was going to allow open vials to come back, yes, that’s obviously not the practice of pharmacy. The unit-dose packaging has been coming back in very limited amounts and under those very limited requirements in the present statute. This was just going to attempt to broaden the reach of that statute to a couple of other types of facilities.
Assemblywoman Weber:
My concern is still the reissuing of drugs even if they’re individually bubble-packed. Are there going to be labeling requirements so that those who are dispensing know this was a reissued drug? My concern is that the quality of the medication could be altered, especially since now it sounds like these pharmacies are not on site and the return of the drug will be outside of the dispensing facility. I still have angst about that.
Louis Ling:
The way the bill is structured, when the drugs come back the pharmacist has to look at the drug, make sure that the seals haven’t been breached, and then also make sure that the drug is still viable to dispense and not expired. Otherwise, the re-labeling of the drug itself is not intended to indicate to that next patient, at least the way the bill’s drafted right now, that this has been reused. You’re supposed to remove any labeling or anything that would indicate that [the drug] had been used by a prior patient. [This would retain] patient confidentiality, because you obviously don’t want to have the previous patient’s information on your prescription.
The only [drugs] that will be coming back are going to be medications where generally the prescription label is going to be on the manufacturer’s packaging on the outside of the box. The unit-dose packaging that we’re talking about primarily is the way antihistamines come over the counter. It’s in foil packages. If none of the foil has been damaged on that [medicine] and it comes back and the pharmacist simply puts a new label on the outside of that box, the patient is still getting a viable drug that could have just come off his shelf a week earlier. We’re not talking about something that’s been out in circulation for a year. It’s still going to have to be in-time; it’s still going to have to be viable or else the pharmacist can’t use it.
Assemblywoman Weber:
I’m really hung up on the package insert meaning that [to retain] quality drugs need to be kept at certain temperatures. We know in southern Nevada our temperatures exceed ambient room temperatures all the time. If there’s a chain of events that show that [the medicine] was transported at proper temperature I wouldn’t have a problem with it. I’m not seeing that we are adhering to quality standards as originally administered in the package insert from the manufacturer. Typically [the drug] moves in one direction from the pharmacy to the patient and that’s the end of the road. Now we’re sending it back the other direction and we’re losing control. Part of what I had understood the [bill’s] sponsor to say was that there would be no reissue for more than one time which, if we’re doing quality measures, why don’t we just use it all up? There apparently is some concern [about quality control because] we can’t reissue it more than one time.
Louis Ling:
Senator Wiener brought the Pharmacy Board in early on to help her work with those same concerns such as whether we’re talking about situations where the drug’s quality could be compromised by the way it would be handled. That’s one of the reasons we suggested that [the drugs] not go back and forth to only reuse [the drug] once. [The bill’s sponsor said], “Isn’t it a shame that when the doctor, for whatever reason, has to change that prescription for that patient, and he discovers this maybe two days into the course of treatment, now you’re going to have to throw away all the rest of that drug. You can’t reuse it and that patient’s not going to use it.” It was her intent to try to reach that situation.
I understand what you’re saying about Las Vegas. It’s a very real concern with us when we’re inspecting our wholesalers, for example. We make sure they’re not storing those drugs in the back next to the garage door where the [temperatures can climb] to 120 degrees. If these drugs were coming back to the pharmacy they would be coming back under the same conditions they went out, which would be some kind of delivery van or some other service related to the pharmacy. [The drugs would] potentially take two more trips. That would be the most they could take. I don’t know if that’s going to compromise the effectiveness of that drug. The bill requires that the pharmacist make sure that that drug otherwise comply with requirements for the original issuance of the drug.
Assemblywoman Weber:
I believe the intent of the bill is wonderful. I want to make sure that we don’t pass drugs on to individuals who can’t pay for them. [It’s as though] we really are saying to them that the quality [of drugs] that go to them is not important. That’s my concern.
Louis Ling:
We share that concern and we shared that with Senator Wiener. It’s one of the reasons we asked her to limit this to just one reuse.
[One of our concerns was] the [part in S.B. 327] about the nonprofit pharmacy that would be allowed to take these [drugs] back and then be allowed to provide them at no cost. [We wanted] to make sure that those people, who couldn’t afford medications but were going to qualify to receive them through a program like this, not receive second-class medicine. Right now the way the bill is set up, [the drugs] still have to be intact, in the manufacturer’s original packaging. If there’s any breach of the original manufacturer’s packaging, [the drugs] can’t be used. About the only difference between the product they would get at the end of the process used in this bill [and a newly filled prescription] would be that the product might have been out for another three or four weeks than it otherwise would have been. They’re still going to get the same product in the same manufacturer’s packaging and it has to have the same product inserts or else it can’t be dispensed again. If [the drug] is expired it can’t be sold either. Either way, the patient receiving this drug should be receiving the same quality medication.
Assemblywoman Pierce:
The more I hear about this, the more I have concerns. I appreciate what Senator Wiener’s trying to do. We all dislike seeing very expensive drugs get thrown away. The whole picture of drugs being transported and the paper trail that would have to follow them and making sure they were only sent out one other time… It seems like a lot of bureaucracy and I’m not sure that in the end it would save money, which I think is what we’re trying to do here. That’s my feeling about [the bill] at this point.
Chairwoman Koivisto:
Let me go back to Ms. Weber’s questions. How does the State Board of Pharmacy propose to follow the drugs? If we were to pass this bill, how would the State Board follow these drugs to ensure their credibility?
Louis Ling:
We talked with Senator Wiener about that at length because one of the things [the Board] must ensure is that the lot number and the expiration date of that drug is tracked. If that lot gets recalled, for example, we have to be able to find it and get it from wherever it is.
Our intent was to write regulations that would require that if a drug came back, a log would have to be kept of the expiration date, the date it came back, and the lot number. We’re not exactly sure how this would work, but probably what we would be trying to do is say that that particular product would need to be reused first. We could set it up so that it could be reused first to get it off the shelf first so it’s not going to expire. A lot of times the expiration date will be very similar to what [is already] on [the pharmacies’] shelves. It’s going to be mostly keeping track of that by a log and then the log will show that [the drug] goes out. The tricky part will be, and we don’t have an answer to this, how we would know if that [drug] came back a second time. If that same lot number goes out and then comes back a second time are we going to know it’s the same one. We’ve tried to work our way through that. We haven’t yet presented this concept to the Board. Maybe [the Board staff] have some ideas. We’ve just been working with Senator Wiener. Our intent was that it all be done on paper; a log would keep track of this.
Assemblyman Mabey:
I share the same concerns that the other people have. If they’re in a prison and they get this bubble pack given to them and they don’t use it, what happens to that medicine? Is it thrown away or is it taken back?
Louis Ling:
In the prison system right now if, for instance, 12 [unit doses] had been dispensed in a bubble pack and that patient was no longer taking that medication, [it] can’t [be] reused. They just don’t have the authorization right now. The only authorization we have presently is the statute that’s part of this bill [which] doesn’t allow that in the corrections [system].
Assemblyman Mabey:
So they don’t get just one pill a day?
Louis Ling:
In dispensing they only get the pills they’re supposed to get at the time they’re supposed to get them.
Assemblyman Mabey:
Let’s say an inmate’s on an antibiotic and he’s supposed to take one pill every six hours for a week. Does the pharmacy keep each pill and then every six hours send it to the prison inmate?
Louis Ling:
I don’t know if this is true in all cases but I do know in most cases the patient/inmate has to go to some place in the prison to get the pills dispensed to him. They don’t have pill bottles laying around in prison cells. [The patients go] to somebody [who] dispenses medications to them on an individual-dose basis.
Assemblyman Mabey:
Would this bill help a prison or not?
Louis Ling:
It would help only to the extent that if the patient was dispensed something that was in manufacturer’s unit-dose packaging, and then for whatever reason the doctor changed the patient’s medication regimen, if there were unused portions of the product that had not yet had their seals broken, they could go back and be used for another patient.
Assemblyman Mabey:
Let’s say a patient was to take 28 pills over a week’s time. Would those 28 pills leave the pharmacy and go to a different place and then be dispensed to [the patient]?
Louis Ling:
Yes. Not all of the correctional facilities have an in-house pharmacy. Many of them are being serviced from a central location in Carson City. The prescriptions come into Carson City, [are filled], and then [the medicines] are going out to the prisons and being kept there in a dispensary. Those can now come back and be reused.
Assemblyman Mabey:
I think I could support the part of the bill dealing with the prisons but I have more concern with the other parts [of the bill]. I commend Senator Wiener for this [concept] but I also heard her say that she never worked with the pharmacists when she [drafted the bill] and that’s who really ought to be in here trying to work on this bill, too. That would have helped.
Louis Ling:
She came to us and asked for our help initially because her concern was whether [the Board of Pharmacy] could even do this and if so what the practical concerns would be. For a regulatory board, the biggest single regulatory concern we still have is the one raised by the Chair: how we are going to keep track of these [drugs] going back and forth. We told her we would do the best we could if this passes to come up with some regulations that would monitor the way the drugs flow.
Chairwoman Koivisto:
The tracking was one of the concerns raised by the pharmacists I talked to as well. They’re already working long hours and, as you know, we have the same kind of shortage of pharmacists as we do of nurses. I’m not sure it’s a wise thing to do to put this kind of extra load on them. I think Dr. Mabey’s right. My feeling about this is that maybe we should do a pilot [program]. This was suggested to me by Ms. McClain when we first heard the bill: Do a pilot [program] in the prison system and get a report back, see how it works, if it really does save money, and if they’re able to track the drugs. I think that would be a safer route to try something like this on a small scale first instead of [the original concept]. It’s kind of a risky proposition, I think.
Assemblywoman McClain:
I agree. I think this is a progressive idea but I’m not too sure how well we could really get our arms around it. I suggested a pilot program in the prisons because there is more control [in that environment]. I’d be willing to support that but not out in the private [sector] yet.
Chairwoman Koivisto:
Any other comments or questions from the Committee? [There were none.] Do we want to try to pass [S.B. 327] the way it is, do we want to amend the bill to make it a pilot project to be conducted in the prisons, or do we want to just kill the bill?
Assemblyman Horne:
I think a pilot program in the prison system could be problematic. Because the oversight is different I believe there’s more opportunity for abuse in the prison system, particularly with drugs. That concerns me. Maybe [the pilot program could be in] another smaller type of facility where we could rely more on the data we receive.
Chairwoman Koivisto:
But then are we not looking at the same thing, experimenting on mental health patients as opposed to experimenting on prisoners? This is a pretty slippery slope. [Back and forth conversation among Committee members.]
Mr. Ling, maybe you can help us here. Is this practice currently prohibited in facilities, for instance the mental health facilities?
Louis Ling:
The present statute, [NRS] 639.267, addresses facilities for skilled nursing or facilities for intermediate care. Inside a mental health facility that has its own inpatient pharmacy, this is not going to be an issue because they are going to issue the drugs on a unit-of-use basis.
The way this is being used right now is there are some pharmacies that specialize in serving intermediate-care facilities and skilled nursing facilities. [Those private pharmacies] are outside the facilities. They are the ones that will get these medications back and they’re [currently] recycling the medications with all these same restrictions—[the drugs] have to be in unit-dose packaging and all those kinds of things. This is not happening very often but [when it does] it is only in those kinds of facilities.
Chairwoman Koivisto:
Why do we need this bill, then? If [recycling of drugs] is already being done in those facilities, why do we need this bill?
Louis Ling:
I’m not sure I’m the person to answer that question. Senator Wiener’s idea was if it works in that environment, could that same model [be applied] to these other environments—the mental health facilities and the correctional facilities. The correctional facilities were a good idea because state money essentially pays for everything, so if we can reuse those [drugs] that’s money we’re not throwing away. [Regarding] the other facilities, I think she just wanted to expand a system that was already being used into some other facilities. That was my understanding of her intent.
Assemblywoman McClain:
But it wouldn’t apply to prisons because [the prisoners] are not being prescribed pills that they keep [with them].
Louis Ling:
It would actually because the prison system pharmacy is here in Carson City and they are filling prescriptions for all of the other facilities statewide. They will get a prescription for an inmate that might [come from the manufacturer] in unit-dose packaging. That will be dispensed to the facility where that particular inmate is. If the doctor changes that prescription and there is [medicine] left, that, theoretically, comes back to the central pharmacy here in Carson City.
Assemblywoman McClain:
So [the medicine] does come back?
Louis Ling:
Yes, it could come back because they’re not going to keep it out at the prison if that patient doesn’t need that medication any more. When it’s returned to Carson City, Senator Wiener’s intent was that it could then be reused as long as the conditions in [S.B. 327] were met.
Assemblywoman McClain:
They can’t be reused now even though they’re individually packed?
Louis Ling:
Right, and that’s simply a matter of statutory authorization. The present statute only extends to the facilities listed in the statute. That’s an enabling kind of thing and one of the reasons she was saying, “Let’s just apply this model to some other areas.”
Assemblywoman McClain:
So maybe we need to do it in the prisons then.
Chairwoman Koivisto:
Since the current statute says “skilled nursing or facility for intermediate care,” could we just add “the prison system” to that area in the statute?
Louis Ling:
If that ends up being the intent of the Committee. We already have our regulations in place so we’d just add that into our regulations. That would certainly cover it under the present system and they would be brought into the present system. That’s a fairly clean way to do that.
Chairwoman Koivisto:
Pleasure of the Committee? Could you clarify for us, Marla?
Marla McDade Williams, Committee Policy Analyst:
Section 6 of S.B. 327 amends NRS 639.267, which is what we were just discussing, and which currently allows a pharmacist who provides a regimen of drugs in unit doses to a patient in a facility for skilled nursing or facility for intermediate care to credit the person or agency that paid for the drug for any unused doses. The pharmacist may return the drugs to the dispensing pharmacy, which may reissue the drugs to fill other prescriptions.
The language amended in the bill refers back to “in accordance with the provisions of Section 2” and Section 2 goes back to language allowing a facility for skilled nursing or a facility for intermediate care to return a prescription drug that is dispensed to a patient of the facility, but will not be used by that patient, to the dispensing pharmacy. What we were just discussing is simply amending that statute to add a pharmacist who provides a regimen of drugs in unit doses to a patient in a facility for skilled nursing or facility for intermediate care, “or a correctional institution.” Add “correctional institution” into that [language], which I think means that we would delete Section 1 of S.B. 327, delete Section 2, and then we have to decide if it is still necessary for the Board [of Pharmacy] to compile annual reports concerning this practice. I believe we would have to delete Section 5 as well and then the other changes there would follow, based on our action.
If you look at Section 1, that language is for a public or private mental health facility. As we discussed earlier, if we were concerned about having this affect all private facilities we could, like we’re doing with the Department of Corrections, add into Section 6 as well, “facilities of the Division of Mental Health and Developmental Services” because that’s a public facility.
Chairwoman Koivisto:
I think probably we’d want to leave [in the bill] the part about a report from the State Board, that was Section 4, except I think we’d have to take out subsection 1(b) “the number of drugs transferred to nonprofit pharmacies.” I think that’s where the concerns are. We want that [language] out.
Assemblywoman McClain:
If we want the Board [of Pharmacy] to give us a report, where would they get their information? What are they going to report to us? I really got the distinct feeling that the Board was not excited about having to do that.
Louis Ling:
The only way I can see that the Board would be able to make that report would be to add another piece of paperwork to the pharmacists in those facilities and they would have to be logging all of that, and then letting us know. We could gather that data, and we certainly would if that’s your will. You’re right. The last thing the pharmacies or we need right now is more paperwork, but we would do that. It was part of the intent [of S.B. 327] to show that this bill is saving money to the state prison system and you may not know that unless you track it in some way.
Marla McDade Williams:
For my own clarification, under Section 6, does that limit reissuance of a drug to only the original patient? You can’t reissue a drug to another patient in any of those facilities under this statute?
Louis Ling:
No. In practice it is being reissued to other patients. When they come back in the unit-dose packaging they’re just coming back and going into the pharmacy’s inventory and going back out.
Assemblywoman McClain:
We’re talking about the dispensing pharmacy inside one of these facilities and not a Walgreen’s Pharmacy or anything [like that]?
Louis Ling:
These are not retail pharmacies. They are either pharmacies inside the facilities themselves, or inside the system in the case of the correctional facilities. Or they are specialty pharmacies that specialize in serving the needs of these long-term care facilities.
Assemblywoman McClain:
How many dispensing pharmacies would qualify under what we’re talking about now, a handful, a dozen, fifteen?
Louis Ling:
No, the number wouldn’t be anywhere near that high. The prison facility has one pharmacy, we have a pharmacy that’s serving the mental health facilities, we would have probably three or four pharmacies serving nursing home beds or the long-term care facility-type beds in the south, and in the north we have one or two. You could probably count [the pharmacies] on two hands.
Assemblywoman McClain:
If you did have to collect that information from that many [pharmacies] I guess it wouldn’t be too overwhelming.
Louis Ling:
The burden on the Board’s staff wouldn’t be as bad as the day-to-day burden on the pharmacies themselves who are going to have to track this.
Assemblywoman McClain:
It would be good information to have down the road.
Chairwoman Koivisto:
I think the financial person for the institutions would be able to extrapolate that information by the number of patients and the cost of drugs. They must be doing spreadsheets or something [similar] now to be able to do their budgets. I think they would be able to extrapolate that information and be able to tell us if there’s a cost savings in their operations. That way we wouldn’t have to put the burden on the pharmacists.
Louis Ling:
The only burden on the pharmacist in any of these scenarios is they’re going to have to know that 12 of X [drug] came back and was re-dispensed somewhere else along the line. The actual costs and doing all of that, you’re right, that’s relatively minimal stuff and this isn’t happening a lot so we’re not talking about a lot of transactions either. If the intent of this [bill] is to save the state money, it might be worth knowing how much [money is being saved] and whether this is worth the effort.
Assemblywoman McClain:
They wouldn’t have to track the individual pill. They wouldn’t have to say, “Joe used this pill and now we’ve prescribed it for somebody else.” They’d throw it back into a bucket and that pill’s going to get re-prescribed, but in the end the numbers will come out right.
Assemblyman Hardy:
I think it gets back to that recall issue. If [the pill] came from a different lot and a problem [develops] with a particular medicine, if it’s in a bucket you don’t know who that bucket went to or what part of that bucket [might be affected].
Louis Ling:
It wouldn’t be quite as simple as [Assemblywoman McClain stated]. It would have to be logged. The pharmacist would have to log in how many [pills] came back of what lot number, what the expiration date on [the pills] was, and when they were re-dispensed. A slight amount of tracking would need to be done.
Assemblywoman Leslie:
I’m not sensing a whole lot of appetite [for the bill from] this Committee. Rather than IP [indefinitely postpone] it perhaps, as a courtesy to the Senator, we could just let it be in case she has an overwhelming argument that we’re missing. I certainly have no appetite for [the bill]. I think we’re trying too hard. If we have to try this hard, I think there’s something wrong with the concept.
Chairwoman Koivisto:
We’ll just put S.B. 327 back.
Senate Bill 277 (1st Reprint): Requires using agencies to purchase prescription drugs, pharmaceutical services, or medical supplies and related services only through Purchasing Division of Department of Administration under certain circumstances. (BDR 27-26)
We have Senate Bill 277. This is the one that requires [state] agencies to purchase prescription drugs, pharmaceutical services, or medical supplies and related services only through the Purchasing Division of the Department of Administration under certain circumstances. This was also testified on by Bill Moell, the Director of State Purchasing. [Any] comments or questions from the Committee on S.B. 277? That was the bill on bulk purchasing.
Assemblywoman Leslie:
I don’t object to the bill. I think our state agencies already go through [the state Purchasing Division]. Am I missing something? Why do we need this bill?
Assemblyman Hardy:
I think one of the issues we were talking about [at the hearing on the bill] was best value versus lowest price. That would be a constraint we would remove by [passing] this bill even if central purchasing is still [buying the goods or services]. It probably is a reasonable thing to do, I think.
Chairwoman Koivisto:
I think we have enough Committee members here that we can move this bill, or whatever we want to do with it.
ASSEMBLYWOMAN WEBER MOVED DO PASS ON S.B. 277.
ASSEMBLYWOMAN McCLAIN SECONDED THE MOTION.
Assemblyman Horne:
I wasn’t here when this bill was heard. I’m going to abstain so I can have time to read the bill. I’ll vote on the Floor.
Chairwoman Koivisto:
I don’t believe there was any opposition when this bill was testified to.
Assemblywoman Pierce:
I think I have the same question as Assemblywoman Leslie just asked. [Was] it explained that this was already happening? They’re not already required to get the best price? Aren’t all state agencies required to get the best price?
Chairwoman Koivisto:
My recollection of the testimony, and Marla can probably help me with this, was that all the agencies don’t always go through [the] state Purchasing Division. One of the other provisions in the bill was that, if an agency contracted to buy something [outside] State Purchasing and was able to get a better value than what State Purchasing was able to, they would share that information and State Purchasing would then piggyback onto that arrangement. It would be a cooperative way for the state agencies to save money.
[There were no further comments or questions from the Committee.]
THE MOTION CARRIED. (Mr. Horne abstained. Mrs. Angle and Mr. Williams were absent for the vote.)
Chairwoman Koivisto:
[Next we’ll take up] Senate Bill 337. This bill had seven co-sponsors.
Senate Bill 337: Revises certain provisions relating to dispensing or distributing drugs via the Internet. (BDR 40-590)
Marla McDade Williams:
Senate Bill 337 was heard on April 23. It revises certain provisions relating to the dispensing or distributing of drugs over the Internet. There wasn’t any testimony provided in opposition to the bill. It prohibits Internet pharmacies from filling prescriptions if the drug has not been lawfully imported into the United States or if the prescription was not delivered to the patient in accordance with applicable state and federal laws and regulations. It prohibits a person from knowingly aiding another person in any act that violates the provisions of the bill, and it specifies penalties for the violations.
Chairwoman Koivisto:
Questions or comments from the Committee?
Assemblywoman Leslie:
I like the concept of this bill. That whole Internet prescription thing bothers me. I get the same [advertising] e-mails you get. I’m kind of surprised [the Assembly] Judiciary Committee isn’t hearing this in terms of the penalty. I don’t think we heard any testimony from law enforcement about whether the Category B felony is an appropriate penalty for this. [It was mentioned that law enforcement attended the hearing and had no objection.] Okay, I think I probably support it.
Assemblyman Horne:
Again, I wasn’t here. Was there discussion [about] the enforcement?
Chairwoman Koivisto:
There was testimony that there are four or five actual Internet hubs and all the rest of these hundreds of e-mails we’re getting offering us whatever drugs we want are offshoots from those [hubs]. The Attorney General’s office has worked out a system so that they’re able to follow these [e-mails] back to where they come from. The Attorney General’s office has done a good job of tracking these folks down. This is something they’ve been working on for four or five years.
ASSEMBLYWOMAN McCLAIN MOVED DO PASS ON S.B. 337.
ASSEMBLYMAN HARDY SECONDED THE MOTION.
THE MOTION CARRIED. (Mr. Horne abstained. Mr. Williams was absent for the vote.)
Chairwoman Koivisto:
Anything else to come before the Committee? [There was no response.] Seeing nothing, we’re adjourned [at 3:29 p.m.].
Terry Horgan
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairwoman
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