MINUTES OF THE
SENATE Committee on Commerce and Labor
Seventy-second Session
April 1, 2003
The Senate Committee on Commerce and Labor was called to order by Vice Chairman Warren B. Hardy II at 7:06 a.m., on Tuesday, April 1, 2003, in Room 2135 of the Legislative Building, Carson City, Nevada. The meeting was videoconferenced to the Grant Sawyer State Office Building, Room 4401, 555 East Washington Avenue, Las Vegas, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
COMMITTEE MEMBERS PRESENT:
Senator Randolph J. Townsend, Chairman
Senator Warren B. Hardy II, Vice Chairman
Senator Ann O’Connell
Senator Raymond C. Shaffer
Senator Joseph Neal
Senator Maggie Carlton
COMMITTEE MEMBERS ABSENT:
Senator Michael Schneider (Excused)
GUEST LEGISLATORS PRESENT:
Senator Raymond (Ray) D. Rawson, Clark County Senatorial District No. 6
Senator Alice Costandina (Dina) Titus, Clark County Senatorial District No. 7
Senator Stephen D. Newman, State of Virginia
STAFF MEMBERS PRESENT:
Courtney Wise, Committee Policy Analyst
Maryann Elorreaga, Committee Secretary
Makita Schichtel, Committee Secretary
OTHERS PRESENT:
Rudy Manthei, D.O., Lobbyist, Keep Our Doctors In Nevada
Trey Delap, Deputy Executive Director, the State Board of Osteopathic Medicine
Lawrence P. Matheis, Lobbyist, Nevada State Medical Association
Jake L. Parmer, Lobbyist, Barr Laboratories
Mary Lau, Lobbyist, Retail Association of Nevada
James W. Morgan, Lobbyist, Novartis Pharmaceuticals
Fred L. Hillerby, Lobbyist, Nevada State Board of Pharmacy
Lynn Fulstone, Lobbyist, Sunrise Hospital and Medical Center
Marcia L. Holmberg, Lobbyist, University Medical Center
Tim Crowley, Lobbyist, Nevada Resort Association
Sharon Atkinson, Executive Director, Board of Examiners for Alcohol and Drug Abuse Counselors
Denise F. Quirk
Maureen Brower, Lobbyist, Westcare
Rena Nora, M.D., Board Member, Commission on Mental Health and Developmental Services, Department of Human Resources
Bobbie Gang, Lobbyist, National Association of Social Workers–Nevada
Rob Hunter
Carol O’Hare
Bo Bernhard
Judy Wieberg
Vice Chairman Hardy:
As vice chairman, I will open the meeting on Senate Bill (S.B.) 281.
SENATE BILL 281: Revises provisions relating to osteopathic physicians. (BDR 54-985)
Rudy Manthei, D.O., Lobbyist, Keep our Doctors in Nevada:
I am the president of the Osteopathic Board of Medical Examiners. Mr. Delap is in Las Vegas to discuss this bill.
Trey Delap, Deputy Executive Director, State Board of Osteopathic Medicine:
I am the deputy executive director of the Board of Osteopathic Medicine. This bill has four aspects I would like to address.
Vice Chairman Hardy:
For scheduling purposes, we will table that bill and open the hearing on S.B. 283.
SENATE BILL 283: Revises requirements for issuance of limited license to practice dentistry or dental hygiene. (BDR 54-1095)
Senator Raymond (Ray) D. Rawson, Clark County Senatorial District No. 6:
This bill allows residents to practice dentistry while they are in a residency program. The existing law requires a dentist to have a license to practice from another state. The top residents graduate and do not stop to practice, but go straight into their residency program. This year, the top three residents applied, and were denied as they did not have a license to practice elsewhere. These dentists have graduated, taken the boards, and are continuing their schooling, rather than practicing before continuing their schooling. This bill also protects against dentists from practicing in a private practice outside the training situation.
I would now like to introduce S.B. 350.
SENATE BILL 350: Authorizes dentist who holds a medical degree to identify himself by that degree under certain circumstances. (BDR 54-928)
Senator Rawson:
This bill was drafted, not as an attempt to fool the public, but to allow those who have earned a medical degree but are not licensed as a physician to identify themselves as doctors of medicine and use the letters “M.D.” They would need to put on their letterhead, “Practicing Dentistry.” Dentists and oral surgeons are precluded from using their medical degrees as titles. For example, the assistant dean of the dental school, an M.D. from Pennsylvania, has an M.D. after her name, but cannot technically list it, as she has not gone through the State licensing process. She does not attempt to practice medicine. She is a dentist in an administrative position. She did earn a degree and should be able to use that title.
Senator Neal:
On S.B. 350, does M.D. stand for medical doctor in this language?
Senator Rawson:
Yes. The dentists have earned their medical doctor degree, but have not continued residency programs to license themselves, as a medical doctor or M.D., doctor of dental surgery or D.D.S., doctor of medical dentistry or D.M.D. If the word doctor is in front of a name, the public might misconstrue the meaning. However, using the initials D.D.S. does entitle a dentist to use the word doctor in front of his name.
Senator Neal:
If a person earns a college degree, he cannot put those initials behind his name in this State?
Senator Rawson:
Correct. In the past we worried that a person might try to misrepresent himself. We tried to clarify by current statute that they cannot.
Vice Chairman Hardy:
Beyond a doctor identifying his education and giving the patient a comfort level of his experience, is there a public policy reason for this bill?
Senator Rawson:
I think the issue is recognition of the 4 years of schooling obtained. We do not make the distinction to other practices they cannot use those titles. A doctor of philosophy (Ph.D.) can list doctor before his name, which implies he is a medical doctor. In the academic world, those who earn a degree have a right to disclose that degree.
Vice Chairman Hardy:
Is it a national practice to recognize these dentist residents?
Senator Rawson:
Yes. Other states do not require a preexistent license from another state to practice while in residency.
Dr. Manthei:
I agree with Senator Rawson. A trained and educated physician who earns a doctorate should be able to credential himself, whether that includes M.D., doctor of osteopathy (D.O.), or D.D.S. This level of training should be identified, regardless if a person is practicing medicine in the field at the time or not. I think any practicing or retired physician should be able to maintain the honor of achieving that level of education and should be able to be represented by that degree. It is up to the medical boards to safeguard against anyone practicing outside of licensure obtained in the State.
Senator Neal:
I think it is inappropriate that a degreed person, moving to Nevada, might find himself in an illegal situation by displaying that degree.
Lawrence P. Matheis, Lobbyist, Nevada State Medical Association:
We support S.B. 350. It makes it clear that a dentist who has earned an M.D. can display that degree. Current law has recently become a problem due to rigidity in interpretation. The public might equate having an M.D. as being licensed to practice medicine. They are two separate processes. I recommend passing this bill. I also advise looking at the Board of Medical Examiners’ advertising budget. If the public is confused by the difference in having an M.D. degree and being licensed, perhaps the committee could direct the board to use television and radio advertising money to clarify.
Vice Chairman Hardy:
We will close the hearing on S.B. 350 and S.B. 283. We will return to S.B. 281.
Mr. Delap:
A criminal background check, or a set of fingerprints, would give us information about any existing felonies, criminal records, or outstanding warrants. There are currently eight states requiring a background check. The only complaint from those states is the amount of time required to obtain results. Most of these states will grant a license provision only pending receipt of the report from the Federal Bureau of Investigation (FBI) and the National Crime Information Center (NCIC). If the report comes back negative, the license is affected. With the redistribution of resources at the federal level, there will be an increase in efficiency in obtaining results. The board found it logical to do a background check on these physicians since we currently test teachers and other professions. We want to know that our D.O.s are safe. If a licensee only has the background check pending licensure, that licensee is sometimes granted a provisional license.
Vice Chairman Hardy:
Does submitting one’s fingerprints to the repository automatically trigger a background check?
Mr. Delap:
Yes, the fingerprints are sent to the Central Repository for Nevada Records of Criminal History for submission to the FBI. The FBI requires specific State language before they will access the NCIC. The professional licensing boards are not law enforcement agencies, and will not perform these types of checks.
Vice Chairman Hardy:
Is the wording specific enough? It sounds as if the fingerprint submission to the FBI addresses a background investigation.
Mr. Delap:
The amendment I proposed to the Legislative Counsel Bureau is more specific, allowing the FBI to conduct this background check. The Legislative Counsel Bureau made the language uniform with other entities that access the criminal information. The language should be sufficient.
The next section of the bill increases the number of physician members. Currently, the board has five members, four physicians and one public member. We value the input of the public member. I think this member is underestimated.
The public members tend to refocus the board on its fundamental purpose to protect the public.
The workload of our board, in addition to the challenge of scheduling five physicians for a meeting, is difficult. We would like to increase the board to include five physician members and two public members, for a total board membership of seven. It would increase the input of the public. It would also allow the board to break into committees more easily. We anticipate our workload in the upcoming years to increase in administrative hearings, regulation workshops, and other administrative work. This increase in board members would help us gear up for the increase in workload.
Vice Chairman Hardy:
Senator Carlton, does this conflict with S.B. 310?
SENATE BILL 310: Makes various changes relating to certain occupational boards and commissions. (BDR 54-223)
Senator Carlton:
I do not believe so. It would be the first step towards my goal for S.B. 310. I will take it further saying that boards having to do with medicine have a safety net provider as a member of the public. This would be a good step forward.
I am confused in section 3, that five members must be licensed under this chapter, and then it says two members are residents. Is the total composition a board of five, with two public members?
Mr. Delap:
Correct.
Courtney wise, Committee Policy Analyst:
To clarify, is this a total of five or seven members?
Mr. Delap:
It will be a total of seven members, with five physicians and two public members.
Dr. Manthei:
The board’s desire to increase its size is related to the requirements found in S.B. 250, as well as A.B. No. 1 of the 18th Special Session, where it is almost mandatory we review any malpractice judgments. This additional workload will require a more active participation in reviewing these incidents to determine merit. For us to comply with these bills, and to work in behalf of the public’s safety, we will need a larger board.
SENATE BILL 250: Revises various provisions relating to regulated businesses and professions. (BDR 57-835)
Vice Chairman Hardy:
Let us clarify the request, which is a change from five existing members to seven members. We are increasing the members who are licensed from four to five, and residents from one to two.
Mr. Delap:
The language in section 4 is very strict regarding confidentiality when working with an investigation. Previously, the language stated any information, “except to the extent necessary” to conduct an investigation is confidential, even if the investigation is dismissed. No one ever got access to the information, even with a court order. There is a fright or flight syndrome with physicians who have had these types of complaints. They tend to go west when they encounter problems in the east. They target Nevada and the western states because of our lax laws. They may have a problem with a board in another state, and they choose to come here. Or perhaps one of our physicians is under investigation. Instead of him remaining for the investigation, he will leave the State. This provision allows us to release any investigative information to another licensing authority or law enforcement agency. It would also help during an investigation to work with other agencies, including the federal government. The way the statute was written, if strictly interpreted, would block us from sharing our investigative findings with the FBI or other investigative agencies.
Senator Neal:
Does the board have the authority to make findings in absentia?
Mr. Delap:
I believe, after a complaint becomes formal by being introduced by a board member, the information then becomes public information. This is regardless of the physician being present.
Senator Neal:
Can a board, based on facts found during the investigation, make a finding?
Mr. Delap:
This bill deals with the investigative process prior to the filing of a formal complaint.
Senator Neal:
Does the board have the authority to investigate a physician without a complaint?
Mr. Delap:
No. We must have a complaint first.
Senator Neal:
Once you have a complaint, can a board then investigate the complaint even if the physician leaves the State?
Dr. Manthei:
If a physician is not present, we can still proceed and take disciplinary action.
Mr. Matheis:
Once the board has filed public notice of a complaint that has been investigated and adjudicated, the physician may waive appearing, or not show up. Either way, the board is fully empowered to act on the information.
As far as initiating an investigation, while almost all investigations begin with complaints, both the State Board of Osteopathic Medicine and the Board of Medical Examiners can initiate an investigation. For example, an ad in a newspaper that would seem to violate the law could cause the board to begin an investigation.
Senator Neal:
I ask because we have heard another bill that addressed the notes from an investigation. Mr. Delap seems to be saying he can release the notes from an investigation, rather than the findings. I agree with findings being passed on to whatever agency requests it, but sharing notes of the investigation is questionable.
Vice Chairman Hardy:
I agree. There can be many reasons a complaint may be dismissed. If physicians are coming from other states to escape prosecution on revocation of their licenses, do those states submit information to us? I see the benefit to other states when our doctors with complaints move there, but I do not understand how it helps us with doctors having problems elsewhere moving to Nevada.
Mr. Delap:
That depends on the law of the other state. They have varying confidentiality laws. Ohio will release information resulting from an investigation as long as the state they are releasing to maintain their same level of confidentiality.
Vice Chairman Hardy:
It is not a situation, then, of reciprocity, where a state will provide information to us if we provide information to them?
Mr. Delap:
This bill is more targeted to our physicians who find themselves in an investigation and leave the State. The osteopathic board and medical board differ. If an osteopath gives up his license, or elects to not renew his license, our attorneys interpret it as giving up a property right, and we no longer have jurisdiction. If we are investigating an egregious claim, and the doctor goes to another state, we can give out information.
Vice Chairman Hardy:
How many other states provide us information relating to a complaint that has been dismissed?
Mr. Delap:
I do not have that information.
Vice Chairman Hardy:
I believe releasing information on a complaint that has been dismissed is something we have to carefully consider from a policy perspective. I agree with Senator Neal, I am more comfortable if a finding is shared.
Senator Shaffer:
I commend the idea of putting two public-sector members on the board. In 1993, Senator Townsend appointed me a subcommittee of one to straighten out a funeral board. I added the requirement of two people from the public sector sitting on the board. Today our State funeral board has five people, two from the private sector, one of which chairs the board. It is working out well. The citizen’s needs are being served with this two bird-dog system.
Mr. Delap:
The remainder of the bill has some corrective measures. In chapter 630 of Nevada Revised Statutes (NRS), it addresses licensed medical or allopathic physicians. We studied the language to fit this bill. As an osteopathic physician can execute the duties of an allopathic physician, they should have the same exclusions on certain activities. In speaking with the Legislative Counsel Bureau, they recommended we input these changes.
Vice Chairman Hardy:
Does this not broaden the scope of practice of osteopathic medicine, by expanding all sections of NRS?
Mr. Delap:
No. An osteopath is trained similarly to an allopathic physician. Some chapters include both studies of medicine.
Senator Neal:
In section 1, subsection 3, paragraph (a) of S.B. 281, referring to NRS 633, is the act as committed described in this chapter, or is disciplinary action described in this chapter?
Ms. Wise:
It is in the osteopathic medicine chapter, NRS 633.741 which indicates unlawful acts osteopathic doctors can commit, including practicing without a license, practicing beyond scope of license, presenting as his own credentials of another, and those types of acts.
Senator Neal:
Does the chapter include any acts not associated with medicine?
Ms. Wise:
No. It addresses employing an osteopathic physician’s assistant before approval, filing for a license issue, and other practices related to osteopathic medicine.
Senator Neal:
There is a bill from the Assembly that deals with felony convictions and employment. I want to ensure there is no conflict of interest with these two bills.
Vice Chairman Hardy:
As I understand provisional licensing, it is pending the report from the FBI. I believe it is common to add a stipulation on a provisional license so it cannot be renewed.
Dr. Manthei:
We thank you for this bill. Our board is in favor of helping the public sector feel more comfortable with health care issues. We will comply, as long as we have the ability to staff and to respond to your requests.
Vice Chairman Hardy:
Without further discussion, we will close the hearing on S.B. 281 and further discuss S.B. 350. There is clarification of who is entitled to use the initials M.D. in their title. Only those in dentistry cannot do so.
Ms. Wise:
In section 1, subsection 5, it states the initials M.D. cannot be used “except in the manner authorized by NRS 630A.220.” This provision deals with homeopathic medicine, and states a physician licensed under that chapter who holds a degree such as a doctor of medicine or a doctor of osteopathy may identify himself by that degree or its appropriate abbreviation, meaning D.O. or M.D. Homeopaths may use D.O. or O.D., but also have to say they practice homeopathic medicine. This bill adds dentist with medical degrees into the definition.
SENATOR O’CONNELL MOVED TO DO PASS S.B. 350.
SENATOR TOWNSEND SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR SCHNEIDER WAS ABSENT FOR THE VOTE.)
*****
SENATOR O’CONNELL MOVED TO DO PASS S.B. 283.
SENATOR TOWNSEND SECONDED THE MOTION.
Senator Carlton:
I want to clarify this refers to dental residents who have a contract with the university and community college system only. Is this correct?
Ms. Wise:
Yes. Section 1, subsection 1, paragraph (c) stipulates they have entered into a contract with the university. They would not be practicing.
THE MOTION PASSED. (SENATOR SCHNEIDER WAS ABSENT FOR THE VOTE.)
*****
Vice Chairman Hardy:
As Senator Carlton would like additional clarification on S.B. 281, we will postpone it for future discussion. We will open the hearing on S.B. 387.
SENATE BILL 387: Revises provisions relating to drugs and prescriptions. (BDR 54-656)
Jake L. Parmer, Lobbyist, Barr Laboratories:
Barr Laboratories is a founding member of America’s generic industry, and a founding member of the Generic Pharmaceutical Association. Our company develops, manufactures, and markets a number of products including cancer agents, cardiovascular drugs, and hormone replacement therapy used in the treatment of various women’s health care disorders. We are here in support of S.B. 387.
Senator Stephen D. Newman, State of Virginia:
I am here with Barr Laboratories, which has facilities in New York, New Jersey, Pennsylvania, and Ohio. I want to commend the committee for bringing to light S.B. 387. This measure will dramatically lower the prescription drug costs and will serve as a model for other states in considering a variety of legislation designed to control the escalating costs of health care in the United States. I have a handout, titled “Hearing Before the Nevada Committee on Commerce and Labor Senate Bill No. 387 – Revises Provisions Relating to Drugs and Prescriptions,” which addresses the sameness, safety, and savings of the generic drugs (Exhibit C. Original is on file in the Research Library.)
Senator O’Connell:
Is the difference in cost between generic and brand products the initial money needed to introduce a new drug to the market, or is it the cost of advertising?
Senator Newman:
The pharmaceutical industry gives us the best health care in the world at a reasonable rate. The Hatch-Waxman Act has a 17-year exclusivity clause. Often, drugs will go into a 50-year exclusivity, such as Coumadin. This was off patent for decades. Hatch-Waxman anticipates a time of exclusivity during which they will have the opportunity to recover those costs. After that time, the monopoly becomes open for competition, and reasonable rates kick in. For example, Prozac is a controversial yet vitally important drug. Once Prozac came off patent, it dropped to about 10 percent of the cost. Those 17 years in Hatch‑Waxman are cost-recovery time. Advertising is not the reason for the cost.
Senator O’Connell:
The drug companies have a protected window, and afterwards the market is open for the drug.
Senator Newman:
One last step is included in the process. When a generic drug enters the market and breaks a patent, because it is an illegal, they also get 6 months of exclusivity.
Senator Neal:
Senator Newman, in other states where this law has been enacted, how is the efficacy of the drugs ensured?
Senator Newman:
This bill does not ensure efficacy. Efficacy is ensured by the Food and Drug Administration (FDA) guidelines. If you make a batch of Coumadin, a blood thinner, in New Jersey or Virginia, the next batches made must be so similar there are no bio-equivalent differences. The batch made in New Jersey must be similar to the one produced in Virginia. We have laws for a seamless interaction between the generics and brand products. Tylenol and Advil are chemical dissimilar products, and we could discuss efficacy with dissimilar products.
Senator Alice Costandina (Dina) Titus, Clark County Senatorial District No. 7:
A generic drug must contain the same active ingredient and be identical in strength, dosage, form and route of administration as a branded drug. It must also meet the same indications, dosage, and labeling, and the same batch‑to‑batch requirements for strength, purity and quality.
Vice Chairman Hardy:
Senator O’Connell had brought up a question of absorption rate of non-active ingredients. Is there a compelling reason for a doctor to prescribe brand drugs?
Senator Newman:
According the FDA, only two things can vary with the drugs. The color and the shape may change. There is no need to differentiate between the branded product and the generic, besides color and shape. What if a physician is not comfortable prescribing a particular generic drug? This bill clearly gives him the ability to write “Dispense as Written.”
Senator O’Connell:
Are you saying there is no difference in the coating of a generic drug? I have heard of a person having abdominal side effects from a generic drug not evidenced in the brand drug.
Senator Newman:
There can be a difference in the outside coating of a pill. However, it has to have the exact same absorption rate. It cannot vary.
Mary Lau, Lobbyist, Retail Association of Nevada:
We support S.B. 387. There is another bill from the State Board of Pharmacy, which addresses language for generic drugs. They were interested in combining their language with this bill. We have an amendment with a few changes, titled “Requested Amendment for Senate Bill 387- Senator Titus” (Exhibit D). We spelled out the procedure for physicians writing “Dispense as Written” prescriptions on paper, by facsimile, or other electronic prescribing device.
Senator O’Connell:
Could we ask one of the representatives from Barr Laboratories to answer a question regarding sepsis? The drugs available for this illness, which are still experimental, are costing around $6000 per dose. The druggist does not normally stock this drug. Because the drug is so sparse, it is hard to obtain. Can you update us on this illness, which kills hundreds or thousands of people?
Senator Newman:
I cannot answer the specific-drug question. I can say generally, pharmacies get products based on the need for the product. The open market determines supply. The only way you see a reduction of prices, as you did with Prozac, is when the exclusivity has expired. Then a company can provide these drugs at a reasonable price. Once the price goes down, the inventory will pick up.
Senator Titus:
I understand sepsis is only treated in the hospital. There is not an outpatient drug for it.
Senator O’Connell:
I know that Senator Tiffany’s doctor had a difficult time locating the drug when she was ill. Did they find the drug from a hospital? The doctor specified a hard‑to-obtain drug.
James W. Morgan, Lobbyist, Novartis Pharmaceuticals:
It was an experimental drug, and therefore relatively new. It is a drug administered in an inpatient setting. This bill only affects outpatients buying drugs through a pharmacy or drug store.
Ms. Lau:
We want to make sure the doctor always has the choice to make a drug decision. We would like to make cost a consideration.
Senator Neal:
What about the repealed section of the bill? What effect would it have?
Ms. Wise:
This wording was repealed because so much of the language was placed in NRS 639.2583. The repealed section requires a pharmacist to advise a patient before he makes a substitution on the generic drug and the price difference. The patient may refuse the proposed substitution. This bill takes this information, changes it, and moves it to a more appropriate section, which is NRS 639.2583, rather than NRS 639.2585. There is no need to have the language repeated.
Mary Lau:
I believe all the language is included in sections of the new drafted language. If you like, I will make sure every part of the repealed section is included in our amendment.
Senator Titus:
I believe the repealed section is on page 2, lines 11 to 26.
Ms. Wise:
Correct. The need for language in NRS 639.2585 is no longer needed, as it is contained in the new bill, under duties and authorities of the pharmacist, rather than a separate portion pertaining to presenting a prescription.
Senator Neal:
How does the pharmaceutical board show efficacy of generic drugs? I heard testimony of diluted drugs coming into the State.
Fred L. Hillerby, Lobbyist, Nevada State Board of Pharmacy:
In the case of drug-distribution schemes, there is no guarantee. Approved generic drugs can be guaranteed, if a pedigree, or opportunity exists to know where the drug has been before delivered for use. Drugs that cannot be tracked are subject to tampering for profit.
Senator Titus:
This could be a problem with any drug, not just generic drugs.
Mr. Hillerby:
Generic drugs approved by the FDA would not be the problem.
Senator Neal:
Should we be concerned with efficacy?
Mr. Hillerby:
We must be concerned when dealing with the drug-distribution system. We do not have to be concerned with FDA-approved generic drugs.
Vice Chairman Hardy:
When we address S.B. 425, we will address some of those concerns. Senator Titus, would you touch on section 4 with regard to disclosing of gifts? I am curious if other states employ this kind of reporting system.
SENATE BILL 425: Makes various changes relating to pharmacy. (BDR 54-530)
Senator Titus:
Vermont is one state on the cutting edge of this issue. There are two aspects to cutting costs of prescription drugs. If broken down, 47 percent of drugs prescribed are generic but only cost 8 percent of the money spent. We need to make generic drugs more accessible. The second aspect is truth in detailing. Besides Vermont, there are around 13 states that have some version of reporting. A report sent to the board will tell them which drug companies are providing what kinds of benefits to doctors, to trace why a particular doctor would only prescribe a certain brand-name drug.
Vice Chairman Hardy:
I would be concerned if a doctor had anything on his mind when he prescribes a drug, besides the medical need.
Senator Titus:
The preprinted prescription pads are easy to hand out, as opposed to the doctor thinking about the drug name, writing it down, and then signing it.
chairman Townsend:
Senator Titus, are you comfortable with the amendment from Ms. Lau?
Senator Titus:
Yes.
Vice Chairman Hardy:
I understand the need to disclose a co-payment amount. Insurance companies paying for the bulk of the drugs drive up the cost of insurance.
Senator Titus:
This bill would result in savings for individuals, employers, insurers, and for the State through our Medicaid program. As we address prescriptions for our Senior RX program, we realize we need to expand the focus. This bill would be a step toward the goal.
Senator Carlton:
My health plan sends a yearly statement telling how much drugs would have cost if I did not have health care coverage. There is a ratio at the bottom showing what I paid for the year, and what I would have paid without insurance. We inform our membership on how the value of the prescription drug component of health care. People become better consumers after seeing those figures.
Vice Chairman Hardy:
Even though consumers might not be paying for the drug, when they see the cost to the insurance company, I think most people are reasonable and will make the right choices based on fact. My co-payment is the same regardless of my choice of generic or brand, but I always ask for generic.
Lynn Fulstone, Lobbyist, Sunrise Hospital and Medical Center:
We are in support of this bill. We understand this would not apply to hospital pharmacies. Is that the intent? Could we clarify this in the bill? Hospitals have formularies to keep costs down similar to health plans.
Senator Titus:
We are only addressing drugs purchased in a drugstore, not in a hospital.
Senator Neal:
Are we addressing health plans, which are controlled by an employer, or the individual who fills a prescription from his doctor?
Senator Titus:
Both.
Senator Neal:
In the bill I see the employer covered in section 3, but where does it address the general public?
Senator Titus:
Section 1 discusses the pharmacist’s responsibility. The general public is covered by saying the pharmacist will advise the customer, whether an individual or a health plan carrier.
Vice Chairman Hardy:
As I understand it, the duty is on the pharmacist. There is nothing the consumer, whether insured or not, will have to do differently.
Senator Newman:
It is those individuals paying out of pocket that will make the direct savings. The person walking off the street can pay $70 for a brand drug, or $13 for generic, unless the prescription is written, “Dispense as Written.”
Ms. Wise:
The provisions in section 8 do not apply to a prescription issued to a person if a substitution would violate the terms of a health care plan that maintains a mandatory exclusive or closed formulary.
Ms. Fulstone:
It would apply, if it would include hospitals that have formularies as well.
Ms. Wise:
I will check with our legal department for the answer.
Marcia L. Holmberg, Lobbyist, University Medical Center (UMC):
The UMC has an inpatient and an outpatient pharmacy, all clustered within the formulary. We also wanted to know if the outpatients are included. We are in support of the bill.
Mr. Morgan:
Concerning section 4, the United States Department of Health and Human Services, Office of Inspector General, is about to issues guidelines for the industry to curtail the activities giving a negative light on the industry. The Pharmaceutical Research and Manufacturers Association, or PHRMA, has just issued guidelines. This legislation will provide uniformity in compliance throughout the country, as opposed to 50 different state requirements. Many companies have reduced their promotional activities. We continue to provide information and samples for physicians. A reporting of these types of activities would be required from this bill. As an industry we are striving to police ourselves. We anticipate federal guidelines to be handed down. I ask you to consider deleting section 4.
Vice Chairman Hardy:
Why is it a hardship to disclose the value of drug samplings?
Mr. Morgan:
It is not a hardship. If we ask a physician to participate in a clinical trial and pay him a fee or subsidy to participate, would this qualify as an activity you want to monitor to prevent negative impact on prescribing habits? I do not think so.
Vice Chairman Hardy:
If you wish to create an amendment clarifying your thoughts, we can look at it.
Mr. Morgan:
You mentioned, Senator Hardy, you did not want a physician considering anything besides your health when prescribing a drug, such as a subsidy or gift, and I agree. The companies that have abused these practices have been curtailed significantly, as a result of existing guidelines from PHRMA and the inspector general, as well as our internal policies.
Vice Chairman Hardy:
They would also be curtailed significantly by section 4 of this bill.
Senator Titus:
I do hope we receive some federal guidelines, but in the meantime, we need to have State level guidelines. If the committee desires, we can make some changes. We can separate the penalty from the report, making only the report requisite. We can also exempt samples from the reporting. These would be better options than eliminating the entire section.
Senator O’Connell:
Some disciplines in medicine address certain populations, such as the geriatric patients. I know such a doctor and he receives grants plus a fee for his participation in testing groups of patients to determine causes for ailments among that age group. Would this fall under section 4?
Mr. Morgan:
As broadly written as it stands, yes it would.
Senator Titus:
For experimental medical programs that accept voluntary patients, the doctor normally receives grants. It is not our intent to penalize these types of payments. However, it would not be a bad thing to be made public, either.
Vice Chairman Hardy:
It would require a simple act of disclosure.
Senator Townsend:
My concern is we may not have considered the numerous grant-and-fee type situations such as the one Senator O’Connell brought up, which might be affected. Our goal is to give the medical board regulation to put the patient first. Their goal should be to protect the public first, and the licensee second. We can craft an amendment accommodating the manufacturer’s ability to continue to market their product as long as they disclose the information. We do not want to create many exemptions, some of which should be disclosed. Let us set a parameter for the medical board, and trust them to work within those boundaries. We also need to have some level of trust in our physicians.
Drug advertisements are now targeted at the public, and being advertised in a mass manner. It is no longer the days when only the doctor knew about the drugs.
The language is tight, but the essence is on target. We want the public to have knowledge of these reports showing any disclosure their doctor may have submitted.
Vice Chairman Hardy:
We will wait on an amendment for this bill. We will now hear S.B. 351.
SENATE BILL 351: Requires licensure or certification for persons who counsel compulsive gamblers. (BDR 54-123)
There was a bill in the judiciary committee similar to this on compulsive gambling. Their bill required a fiscal note of $250,000. We want to make sure we are on the same track as that bill.
Tim Crowley, Lobbyist, Nevada Resort Association:
The bill you are referring to is S.B. 349. It addresses certification and treatment of problem gambling. It sets up a board to certify problem gambler counselors, and provides $250,000 toward treatment costs. This amount is merely seed money to set up grants, but will not reach far into real treatment costs. We are in full support of S.B. 349.
SENATE BILL 349: Provides for certification of gambling counselors and course
of study and funding of programs for treatment and prevention of
problem gambling. (BDR 54-155)
Vice Chairman Hardy:
This bill does not have a direct appropriation, as does S.B. 349. However, it does have a fiscal note for local and State governments.
Senator O’Connell:
How much of what is covered in S.B. 349 might be duplicated in our bill?
Mr. Crowley:
The bills vary. This bill takes the existing drug and alcohol board of examiners and adds the obligation of certifying problem gambler counselors. We believe S.B. 349 is a better bill because it establishes a board created solely for problem gambling. There is co-morbidity with various compulsive behaviors. We want to ensure there are licensed certified counselors specifically trained to recognize problem gambling versus drug and alcohol counselors who are licensed and now claim they can counsel problem gamblers. They need appropriate training for this field. We could meld the bills together.
Senator O’Connell:
What segment of our population would be considered problem gamblers?
Mr. Crowley:
A State study in 2002 identified 1 to 2 percent of our population to be pathological gamblers.
Senator Neal:
Have you read the University of Nevada, Las Vegas (UNLV) report that was recently released?
Mr. Crowley:
Yes. We conducted a follow up to their study, and our findings refute their findings. Their study does not recognize co-morbidity. That factor alone inflates their numbers. Co-morbidity means a patient suffers from several compulsive behaviors such as drug and alcohol abuse, and problem gambling.
Chairman Townsend:
The proper term is not co-morbidity, but co-occurring disorder. This is the term we use on the president’s commission. We want to focus on the difference in scope of practice between our bill and S.B. 349. We have this bill because we are the board committee. I am not sure if S.B. 349 addresses certification, educational requirements, experience, and who will perform the certification.
Mr. Crowley:
It addresses the education requirement of a person to have a college degree and practice as a counselor. There is no problem gambling board currently. It creates a new board of five members to certify problem gambling. The board will define the specific definition of a problem gambler. The $250,000 fiscal note would go to the Department of Human Resources to be used as grant money to raise further funds for treatment of problem gambling. The department would house that fund. The board would be self-sustaining.
Chairman Townsend:
Have you submitted a budget on this board?
Mr. Crowley:
No.
Chairman Townsend:
If you create a board, you must have a budget, fees associated with the budget, scope of practice, and educational requirements. If this bill gets to the Senate floor, this committee will turn it down if it does not meet the standards we set for all boards.
Mr. Crowley:
I suggest we take this bill and S.B. 349 and compare them section by section.
Chairman Townsend:
I am not sure how many people will desire to get licensed to do this type of counseling. This bill created an umbrella to start a board, and then from there, once there are sufficient numbers of people, you could spin off. To start a board is a big expense.
Mr. Crowley:
We want to ensure the problem gamblers have access to trained counselors. The treatment of this illness is ongoing. The fees and assessments are provided for in S.B. 349.
Senator Carlton:
I am concerned this bill will be lost in the Senate Committee on Finance. This is a serious problem, and I would hate to lose the option to certify these counselors if the bill is lost. I work in the industry, and I have been exposed to this problem. It is a multi-issue problem. There are often drug and alcohol problems associated. I would like to explore this bill.
Sharon Atkinson, Executive Director, Board of Examiners for Alcohol and Drug Abuse Counselors:
The board speaks in support of S.B. 351, and recommends do pass with these amendments (Exhibit E). Basically, we ask you to grandfather in individuals who are nationally certified as gambling counselors and currently licensed by the board. We could also include members of the Board of Examiners for Social Workers, and the Board of Examiners for Marriage and Family Therapists if they are currently licensed and have the national gambling counseling certificate. We would like the grandfather period to end June 30, 2004.
Also, we ask you to lower the number of hours of practical experience to 2000 hours.
Chairman Townsend:
Under section 20, line 28, the bill reads, “The Board shall issue a license.” When the word shall is used, you have no option. You will issue a license or a certificate without examination “to a person who holds a license or certificate as a counselor of compulsive gambling in another state … deemed by the board to be substantially equivalent to the requirements set forth in the provisions of this chapter.” We might want to reconsider using the word shall. What if another jurisdiction has different standards? They could challenge the issue of “substantially equivalent.” You may wish to not certify a person based on his behavior, but according to this wording, you will not have a choice. You need some flexibility.
Ms. Atkinson:
Thank you, I would like to change the word “shall” to “may.”
Vice Chairman Hardy:
Is there a national certification for a gambling counselor that is recognized in our State?
Ms. Atkinson:
My research found most states have voluntary gambling counselors, or those certified under a national gambling counseling board.
Vice Chairman Hardy:
Do you not think certified as a counselor for problem gambling is broad enough?
As I read your amendment, it states a person would have to be certified as a counselor of problem gambling, or be nationally certified as a counselor for problem gamblers. Is there a distinction between these two?
Ms. Atkinson:
I could not find one state that had state certification for gambling counselors. I did not have time to research all 50 states. I am aware there is a national counseling association, which has high standards. I want to include those who are nationally certified to be grandfathered. We need a pool of people who have met the minimum standards.
Vice Chairman Hardy:
Do these individuals currently have certification similar to this bill?
Ms. Atkinson:
Correct.
Senator O’Connell:
If we are only dealing with 1 to 2 percent of the population as being considered problem gamblers, what are the statistics on drug and alcohol abusers?
Denise F. Quirk:
I am a licensed marriage and family therapist, drug and alcohol counselor, and nationally certified gambling counselor in the State. I am with Red Hawk Counseling. I would be guessing the national statistics for alcoholism is about 8 to 10 percent.
Senator O’Connell:
What are the State numbers?
Ms. Quirk:
I do not know.
Vice Chairman Hardy:
I find it interesting our Board of Examiners for Alcohol and Drug Abuse Counselors would not have numbers of how many residents are affected. Do we not track those numbers?
Ms. Atkinson:
The bureau of drug and alcohol abuse tracks those numbers as part of their treatment and prevention statistics. Our board licenses and certifies counselors.
Senator Neal:
Ms. Quirk, where did you become certified as a gambling counselor?
Ms. Quirk:
I obtained my national certified gambling counselor status via long distance training. It has taken me years to accomplish. It was a long arduous process as there is no one in northern Nevada that could supervise me. The National Counsel on Problem Gambling certified me.
Senator Neal:
If we pass this bill, you would be one of the few people who could enjoy the benefits.
Ms. Atkinson:
We would like to allow currently licensed counselors to practice who only need 1000 hours of practical experience. This is the number needed for social workers, nurses with master degrees, and marriage and family therapists.
Lastly, we ask to insert the language from S.B. 349 to read, “The Board may apply for, accept and expend grants, gifts, donations, bequests or devises for the purpose of carrying out the duties of the Board.” This would grant the board authority to accept bequests, gifts, and grants for use to provide additional services to the field.
Maureen Brower, Lobbyist, Westcare:
We are in favor of the bill. We feel it is important counselors for problem gamblers are qualified and certified. This would upgrade treatment. There are some benefits from S.B. 349 we could add to this bill.
Vice Chairman Hardy:
We are going to gather all the information needed on the two bills, and then Senator Carlton will work on a recommendation.
Rena Nora, M.D., Board Member, Commission on Mental Health and Developmental Services, Department of Human Resources:
I am the medical advisor for the Nevada Council on Problem Gambling, and a board member of the National Council on Problem Gambling. I was chairperson of the first defined board for gambling counselors, established 20 years ago in New Jersey. We support any bill establishing quality of care and professional standards for gambling counselors. However, we have three concerns not addressed in this bill. The diagnosis of problem gambling was recognized 23 years ago.
The composition of the board lacks the gambling-specific knowledge and experience. I would question the credibility of such a board. It should be required they have gambling education, specific hours in the practice, and possibly pass an examination.
If the certification board for gambling counselors falls under the alcohol and drug abuse board, there is a conflict. This is why states like New Jersey did set it up differently. Although this field has existed 23 years, and there is a lack of current counselors, it is a growing problem. These numbers would impact the already busy drug and alcohol board. We would like a specific board that could devote full time and attention to this problem.
This bill did not provide for funding of treatment. We know early diagnosis and treatment saves money. Untreated patients end up with unpaid debts, unemployment, social service needs, and criminal justice time. It sounds as if 1 to 2 percent of our population with this problem is a small number. It is a small‑volume, high-impact disorder.
In our haste to establish a certification board, we do not want to do it wrong. This would only do a disservice to problem gamblers and their families.
Bobbie Gang, Lobbyist, National Association of Social Workers–Nevada:
We are neutral on this bill. We believe it serves a necessary purpose for certifying and licensing gambling addiction counselors. It also contains an exemption for clinical social workers who have training in gambling addiction and are certified, according to the social worker’s board, to do this type of counseling. This might also apply to other mental health providers.
I was at the hearing for S.B. 349. I was concerned we did not have an opportunity to testify to the policy issues in the bill. There were no exemptions for any mental health providers. I think I understood other mental health professionals are not trained in gambling addiction. Social workers in this field have to prove competency to the board.
Senator O’Connell:
Are you saying there is more than one certification needed to work in this field?
Ms. Gang:
It is my understanding clinical social workers are able to provide gambling‑addiction counseling if they have demonstrated competency in the field to the Board of Examiners of Social Workers. Some counselors also have this national certification. I am not sure if it is required by the social worker’s board to have the national certification. I will find out.
Senator O’Connell:
Could you also identify the number of hours set, whether it is 2000 hours of practical experience, or not?
Ms. Quirk:
Correct, it is 2000 hours needed.
Ms. Gang:
My last concern is the lack of information normally found in a board bill. I did not see fees to a justified budget. The $250,000 is provided for the gambling‑addiction prevention programs, but there is no budget for the board.
Senator O’Connell:
Are social workers also certified to work in drug and alcohol abuse fields? Is the certification the same?
Ms. Gang:
The Board of Examiners for Social Workers requires a demonstration of competency.
Senator O’Connell:
Does your board also certify them?
Ms. Atkinson:
We have numerous licensed alcohol and drug abuse counselors also licensed by the social workers board. They have double licenses.
Senator O’Connell:
Are the various certifications uniform in their requirements? If you are certified by one entity, do you hang out a shingle and claim to have this certification?
Ms. Quirk:
As a marriage and family therapist, I could treat families who have drug, alcohol, or gambling issues. However, it is my opinion it would be unethical to do so if the family wanted specific drug, alcohol, or gambling counseling. This is why I am opposed to S.B. 351. Problem gambling certifications need to be separate from other certifications.
Senator Carlton:
We have counselors in learned professions practicing in multidisciplines. Regardless of the discipline, they would be regulated under their particular board. As a marriage and family therapist, Ms. Quirk is regulated under that board, but to hold herself out as an alcohol or drug counselor, she would have to license through the other board. If we include gambling counselors under this board, this would be another discipline under their jurisdiction.
Senator O’Connell:
I understand. Are we licensing for the same practice in different areas and is it not necessarily uniform what is required in each area? This is a concern.
Senator Carlton:
If they are practicing in different disciplines and receiving licensure from the same board, they would have to have the same qualifications. The exception would be if the board found an individual’s qualifications as being substantially equivalent. We need a matrix on the different boards and disciplines in order to cross reference for uniformity.
Senator O’Connell:
My concern is saying social workers are qualified to practice in gambling counseling, but Ms. Quirk, who is not a social worker nor licensed by the social worker’s board, is qualified. We need a uniform statement of criteria.
Senator Carlton:
I believe independent boards looking at applications would consider the criteria. I will find answers and put together an information packet so we may understand the intricacy of multidiscipline licensing.
Ms. Gang:
The board that deals with substance abuse allows social workers, psychologists, psychiatric nurses, clinical social workers with master degrees, or Ph.D.’s, are to be exempt from having to go through their licensure. Their training and educational experience, combined with a demonstration of competency are sufficient. I am not representing the board of social workers.
Ms. Quirk:
I have been in practice for almost 11 years, specializing in treatment for gamblers for the past 5 years. My concerns are specific. The term “compulsive” gambling is not a recognized term. The correct terminology is either “pathological” or “problem gambling.”
Senator Neal:
How do you diagnose problem gambling?
Ms. Quirk:
This is a mental health/multilayered issue. The problem may not be immediately apparent, unless the patient brings up the issue. I would assess based on questions.
Senator Neal:
Would other disciplines diagnose the problem gambler in the same manner?
Ms. Quirk:
Yes. Another concern is the lack of mention for specific training and education needs for the board members. I am concerned we, the counselors who specialize in treating problem gamblers, would not be well represented. Senate Bill 349 mandates that four out of five board members must be trained and educated specific to problem gambling.
Senator Carlton:
The social workers board did not initiate this bill. We do need a representative on the board.
Ms. Quirk:
I testified in support of S.B. 349. I feel it is more complete and more specific to the needs of problem gamblers and their families.
Senator Neal:
In comparing the two bills, they seem to be dealing with the problem after the fact. How do we keep the problem from occurring?
Ms. Quirk:
Prevention is addressed in S.B. 349.
Vice Chairman Hardy:
We will take a long look at S.B. 349 in dealing with this bill.
Ms. Wise:
Ms. Quirk referenced section 28 of S.B. 349, which adds the prevention of problem gambling. The State board is to adopt regulations establishing courses of study for prevention. This is the only reference to prevention.
Ms. Quirk:
In S.B. 349, section 33, problem gambling means reoccurring and persistent maladaptive behavior relating to gambling which causes disruptions in any major area of life, including but not limited to psychological, physical, social, or vocational. Section 34, which references the fund to support programs for the prevention of problem gambling, is created.
Rob Hunter:
I am a Ph.D. clinical licensed psychologist. l have worked in the addiction field my entire career. I opened the first professional private drug and alcohol clinic in Las Vegas in the early 1980s. For the past 17 years, I have focused on gambling problems, and have directed the largest gambling treatment center in this part of the country. There is a big difference from treating drug and alcohol problems to treating gambling problems. We need special certification. I believe S.B. 349 is a better bill.
Carol O’Hare:
I am the executive director of the Nevada Council on Problem Gambling. I am here in behalf of the council. I was neutral on the bill until I heard prior discussion. Now I am in opposition. The council is in support of S.B. 349. I support the concern problem gambling is a specialty field. It may not have been considered such 20 years ago, but it is an emerging field, which needs appropriate attention.
There has been concern on impact to existing boards. I believe there is a solution to be found by mirroring other states. We are not questioning credentials of any other provider in the State. Existing license and certification criteria in other disciplines do not require adequate amounts of training specific to problem gambling.
I question the support of the bill by the drug and alcohol board that clearly has a lack of knowledge in problem gambling. We cannot cut and paste language from the drug and alcohol certification, and do gambling any justice. We want our population to be given the highest level of care, instead of tucking this issue into an existing board which is already loaded with cases.
Senator Carlton:
The new board to be created under S.B. 349 would license about how many people, roughly?
Ms. O’Hare:
There is no benefit to a person making the initiative to become licensed in this field. There is no support or funding for treatment. If a treatment fund is created, then more people will be able to seek licensure.
Senator Carlton:
If money is available for treatment, then you are saying people will start treating for this disease? Is the current lack of funds keeping people from becoming certified to treat the disease?
Ms. O’Hare:
Yes. Some existing providers are limited when their sources of funding do not permit them to use their funds to treat problem gamblers. We must respect their need to make a living.
Senator Carlton:
How many people will be licensed by the proposed board by S.B. 349? Setting up a board is an involved process. For us to be able to evaluate how the board will function, we need to have an idea how many people will be regulated by it.
Ms. O’Hare:
I will look to other states that have followed this course of action to get comparable numbers for you.
To address the previous issue of identifying problem gambling, it is not always apparent. Very few people walk in and admit to a gambling problem. It is a hidden disorder because we do not publicly identify or recognize it. My concern is while any trained professional is capable of assessing and diagnosing a disorder; there would still be needed training in the specific field of problem gambling. Not just anyone with licensure could assess a patient for this problem. Given the proper training in this field, then marriage and family counselors, drug and alcohol counselors, psychologists, psychiatrists, and all mental health providers are capable of becoming our greatest resource in treating problem gambling.
Senator Neal:
In S.B. 349, there is a definition for problem gambling. Where did this definition come from?
Ms. O’Hare:
The Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, states the definition.
Senator Neal:
What would be included in maladaptive behavior?
Mr. Hunter:
In simplified terms, these people move money around, gamble when they should not, often on credit cards, and lose money they cannot afford to lose.
Ms. O’Hare:
The lack of this definition in S.B. 351 is one of our concerns the bill is an effort to rush a solution without proper thought involved.
Vice Chairman Hardy:
We are going to do further research to think through some of these concerns.
Bo Bernhard:
I am the director of gambling research at the University of Nevada, Las Vegas. There are several types of gambling experts in the State, with problem gambling experts being one of them. I sit on the Board of the Problem Gambling Center and the Nevada Council on Problem Gambling. Both boards have over 100 years of collective experience in dealing with, researching, and treating problem gamblers. There is evolving scientific knowledge. I would be happy to be involved in the next step of the bill.
Senator Neal:
Mr. Bernhard, did you hear the comment from Mr. Crowley’s comment about the UNLV study?
Mr. Bernhard:
I was not the author of the recent UNLV study, nor was I involved with the study commissioned by the Nevada Resort Association.
Judy Wieberg:
I am a mental health provider for over 15 years. I came here today neutral, but it sounds as if S.B. 349 would be a more appropriate bill. If S.B. 351 is pursued, I have some concerns with section 20. It states, “to a person who holds a license or certificate as a counselor of compulsive gamblers in another state.” I would like it to include licensed professional counselors. Few states have this licensure as worded. Over 46 states have a licensed professional counselor field. These people are trained and interned at the masters level, which is a much higher level than our State drug and alcohol counselors who intern at the high school level.
In section 26, subsection1, paragraph (c) of S.B. 351, it states an intern, who actually sees patients, can have a high school diploma. I would like to raise this standard to require a bachelor of arts degree or a bachelor of science degree.
Vice Chairman Hardy:
We will adjourn at 10:10 a.m.
RESPECTFULLY SUBMITTED:
Makita Schichtel,
Committee Secretary
APPROVED BY:
Senator Randolph J. Townsend, Chairman
DATE: