MINUTES OF THE
SENATE Committee on Human Resources and Facilities
Seventy-second Session
April 2, 2003
The Senate Committee on Human Resources and Facilities was called to order by Chairman Raymond D. Rawson, at 1:44 p.m., on Wednesday, April 2, 2003, in Room 2135 of the Legislative Building, Carson City, 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 Raymond D. Rawson, Chairman
Senator Barbara K. Cegavske, Vice Chairman
Senator Maurice E. Washington
Senator Dennis Nolan
Senator Joseph Neal
Senator Bernice Mathews
Senator Valerie Wiener
GUEST LEGISLATORS PRESENT:
Senator Mark E. Amodei, Capital Senatorial District
Senator Michael (Mike) A. Schneider, Clark County Senatorial District No. 11
STAFF MEMBERS PRESENT:
H. Pepper Sturm, Committee Policy Analyst
Cynthia Cook, Committee Secretary
OTHERS PRESENT:
Gregory Hayes, M.D., M.P.H, Associate Professor, Department of Health Ecology, University of Nevada, Reno
Alexander Haartz, M.P.H., Deputy Administrator, Health Division, Department of Human Resources
Lawrence P. Matheis, Lobbyist, Nevada State Medical Association
Scott M. Craigie, Lobbyist, Nevada State Medical Association
Weldon Havins, M.D., Clark County Medical Society
Keith L. Lee, Lobbyist, State Board of Medical Examiners
Fred L. Hillerby, Lobbyist, Nevada State Board of Pharmacy
Doyle G. Sutton, State Fire Marshal, State Fire Marshal Division, Department of Public Safety
Lee Leighton, Fire Chief, City of Sparks
Dave Drew, Chairman, State Board of Fire Services, State Fire Marshal Division, Department of Public Safety
Raymond C. McCallister, Lobbyist, Professional Firefighters of Nevada
James F. Madden, Fire Marshal, City of Henderson
Michael Heidemann, Pershing County Fire Department
Larry Farr, Fire Marshal, City of Reno
Ex-Senator Lawrence E. Jacobsen, Lobbyist, Carson City, Douglas County, and Lyon County
Vice Chairman Cegavske:
We will open the hearing on Senate Bill (S.B.) 332.
SENATE BILL 332: Revises qualifications of State Health Officer, provides for licensure of administrative physicians and clarifies restrictions on use of “M.D.” title. (BDR 40-1036)
Senator Mark E. Amodei, Capital Senatorial District:
I am the sponsor of S.B. 332 at the request of Dr. Gregory Hayes. The first part of the bill grew from circumstance when the State hired an individual for the position of State health officer. The existing licensing law requires all physicians new to Nevada to be residency trained and licensed by the Board of Medical Examiners. After the individual was hired and moved to Nevada, it was discovered he could not be licensed under our existing statutes. This is addressed in the first part of the bill. The second part of the bill deals with more technical matters in terms of specialties and the use of the M.D. designation.
Gregory Hayes, M.D., M.P.H., Associate Professor, Department of Health Ecology, University of Nevada, Reno:
Sometimes rules can be a bit too rigid, and one size does not fit all. The changes do not weaken the licensing requirements of the State. I have summarized the rationale for suggested changes (Exhibit C).
Chairman Rawson:
Is the bill satisfactory to you as it is written?
Dr. Hayes:
I believe it is satisfactory. It adds one more tool for the State to use when hiring the most qualified person.
Senator Wiener:
Is the statutory language for administrative physician defined elsewhere in the law?
Dr. Hayes:
I do not know if it is defined elsewhere.
Senator Neal:
Why does the language on page 2, line 8, except the requirements of 36 months postgraduate training as defined in Nevada Revised Statutes (NRS) 630.160, subsection 2, paragraph (d)?
Dr. Hayes:
If you have two impressive administrator applicants, you will choose the one with the residency training. There are many who are quality administrators and public health leaders who do not qualify. This language is just an option; the license does not have to be granted unless it is believed to be in the best interest of the public.
Senator Neal:
Is Nevada unable to find applicants who meet the current requirements? What are we missing by having the present law in existence?
Dr. Hayes:
In terms of the statute, there are individuals out there. Some of the most experienced public health leaders do not meet the requirements. It is not the norm, although it is becoming more so. Residency training in general is becoming more the standard. Rules can be too rigid. This is just creating a possibility, not mandating it. We are missing some excellent public health administrators.
Chairman Rawson:
We have been without a chief health officer for most of the year.
Alexander Haartz, M.P.H., Deputy Administrator, Health Division, Department of Human Resources:
The division believes S.B. 332 is beneficial to expand the pool of otherwise qualified individuals to serve as State health officer. We think the position of State health officer needs to be licensed to practice medicine.
Senator Neal:
What is the professional makeup of the division?
Mr. Haartz:
There are licensed medical doctors working in special children’s clinics. There is a range of professionals in public health, such as medical technologists, and individuals at the doctoral level working as epidemiologists. There is a State public health laboratory located in the school of medicine on the campus of the University of Nevada, Reno. The laboratory works closely with Washoe County Board of Health, the Clark County Health District, and the Health Division.
Senator Neal:
What is the health officer’s authority in relationship to the laboratory?
Mr. Haartz:
There is a director for the laboratory, with whom the State health officer would work in conjunction. It is not a supervisory relationship; it is more of a collegial relationship. The laboratory performs a narrow function in terms of analysis and detection, whereas the role of the State health officer is broader.
Senator Neal:
Is it necessary for the State health officer to be a practicing physician to administer the Health Division?
Mr. haartz:
Currently there is a professional administrator position to work in conjunction with the State health officer. We believe the State health officer needs to be a medical position. He or she provides medical guidance and support to the community health nurses, the public health nursing services programs in the 15 rural counties, and the emergency medical service program. The officer is able to effectively represent and make decisions based on medical knowledge regarding protocols, standards of care, and communicable diseases.
Senator Neal:
Over a year ago there was an anthrax scare in Nevada. Where would that type of problem be referred?
Mr. Haartz:
The samples were sent to the laboratory at the University of Nevada, Reno. They were then forwarded to the Centers for Disease Control and Prevention.
Chairman Rawson:
There has been a federal grant to allow the building of a State laboratory in southern Nevada.
Lawrence P. Matheis, Lobbyist, Nevada State Medical Association:
We support S.B. 332. The second part of the bill clarifies certain restrictions on the use of the title, “M.D.” In Nevada we have outlawed the use of the M.D. designation unless the individual is licensed by the State to practice medicine. This creates problems for physicians who go to dental school to become licensed as dentists. They are not allowed to use the M.D. designation if they do not become licensed as a physician in the State. If dentists who come to the State, and have graduated from joint M.D.‑D.D.S. programs, sequence it wrong by not completing the M.D. first, they cannot be licensed. The bill addresses that specific issue. Dr. Hayes is proposing an option be developed to permit a physician who has been certified by a specialty board of the American Board of Medical Specialties as one option to consider in lieu of some other conditions. Trying to find some flexibility for the Board of Medical Examiners while protecting the public allows greater flexibility in recruiting medical personnel to Nevada.
Scott M. Craigie, Lobbyist, Nevada State Medical Association:
We have a proposed amendment (Exhibit D).
Weldon Havins, M.D., Clark County Medical Society:
I will review a letter received from Keith R. Brill, M.D. (Exhibit E), which describes the difficulty he is facing becoming licensed in Nevada.
Chairman Rawson:
Is the effective date of July 1, 2003 acceptable, or since we are amending shall we say, “upon passage”?
Mr. Craigie:
Currently there are two situations similar to Dr. Brill’s. We would like the earliest effective date possible.
Keith L. Lee, Lobbyist, State Board of Medical Examiners:
With respect to the proposals made, the position of the board is whatever the Health Division and you believe is appropriate. Creating an administrative position puts the Board of Medical Examiners in a position to make a determination. Our concern is to make sure the administrative physician is not practicing medicine, and I think the language in the bill solves it. Does this create a whole new category of licensed physicians in administrative positions who may be brought in to manage a practice for physicians? It is up to you to make a policy decision of whether this is a legitimate category in the private sector as well. We want to make sure safeguards are in place so the public is not mislead, and the administrative physician is not seeing patients or reviewing medical records. The preference of the board would be the definition of administrative physician is further limited to apply to one in the public sector.
Chairman Rawson:
Do you wish to propose some language so we do not shoot the messenger?
Senator Wiener:
Under current law is a licensed physician required to administer a hospital?
Mr. Lee:
There is a requirement for a chief of staff at a hospital to be a licensed physician, there is not such a requirement for an administrator.
Chairman Rawson:
Under this bill you could have an administrative physician as a chief executive officer, as long as they are not practicing medicine. If they are practicing medicine, you have a definition. We can have it be a part of the record to clarify the legislative intent. I can visualize the equivalent position in the private sector of an administrative physician. One of the complaints is physicians are not good administrators, so we end up with an administrative position. I do not know if it can be more clearly defined. I will ask others if there is language they wish to add. The way it is now, the board would have to come to a decision on those things, and who is going to argue. It certainly could be thrown into the courts. It is clear, but if you wish to suggest additional language, we will listen.
Mr. Lee:
I will work on language and bring it to you. Nevada has the strictest medical licensing standards in the nation. We are going forward with regulations to make us the first State in the union to require post-licensure competency. The public policy of this State is clear. In 2001 the law was changed to require progressive postgraduate education, with all 3 years in the same discipline. I suggest the bill before us lessens our licensing standards, as does the proposal by Dr. Havins. That may be the policy you want to adopt, but I do not think it is good public policy. A real or perceived shortage of doctors is not a good reason to lower the standards. Do we then become a dumping ground for physicians who cannot get licensed elsewhere? On one hand we are worried about the quality of physicians, and on the other hand we are told we are being too tough. We at the board are proud of our licensing standards. As part of the executive branch, we administer the laws and policies you adopt. What you change, we will administer. We want you to be aware of what we believe are some concerns. When I received a copy of the letter from Dr. Brill (Exhibit E), which is dated March 18, 2003, I called Larry D. Lessly, Executive Director of the Board of Medical Examiners. I was told the information Dr. Brill received was accurate. We have a regulation that adopts the standards of when examinations must be taken. However, Mr. Leslie told Dr. Brill assuming he met all other requirements, he would not be held to the 1-year standard. To my knowledge, Dr. Brill has not responded.
Senator Wiener:
Have other doctors who were held to the standard been kept out of the licensing process prior to Dr. Brill?
Mr. Lee:
I cannot answer that since we do not track those kinds of occurrences.
Chairman Rawson:
We will close the hearing on S.B. 332 and open the hearing on S.B. 375.
SENATE BILL 375: Revises provisions governing authority of certain physicians to possess, prescribe, administer and dispense controlled substances, dangerous drugs and other drugs. (BDR 40-1055)
Senator Michael (Mike) A. Schneider, Clark County Senatorial District No. 11:
This bill concerns the ability of doctors to prescribe drugs they deem necessary for their patients. Medications could be prescribed to patients who could not obtain them in any other city or state. This would prevent the patient from going to Mexico or Europe for treatment. This bill would also be a benefit to Las Vegas in developing a research hospital.
Fred L. Hillerby, Lobbyist, Nevada State Board of Pharmacy:
The board is concerned about this bill. We are seeing more abuse of controlled substances, and some of the pain medications are very addictive. We find clinics where the doctor did not see the patient, merely prescribed enormous amounts of pain medication. Many of these drugs have street value, so people try to obtain huge quantities of them. The language in section 3, subsection 2, basically restricts the ability of our board and the licensing boards to discipline. I am afraid what is being offered is so broad it will undermine the work done to prevent the abuse of controlled substances. We have a national model to track these controlled substances for what we call professional patients. They learn how to describe symptoms and go from doctor to doctor to get drugs. When we catch these patients, we offer opportunities for rehabilitation programs, or we contact authorities. Language on page 4, lines 20 and 21, states a homeopathic physician can prescribe controlled substances. Line 25 lists those who shall not prescribe for themselves, their spouse, or children. The list does not include homeopathic physicians.
Mr. Lee:
I would like to echo the concerns stated by Mr. Hillerby. The Board of Medical Examiners, as a part of our function with doctors, is concerned about the overuse of prescriptions. Provisions on page 6, sections 8 and 9, prohibit or restrict our ability to regulate. It is abuse we worry about, and we certainly want to be able to adopt regulations to address abuse should you go forward with this bill. We can adopt appropriate regulations subject to the discretion of the board, but the deletion of certain language on page 6, lines 32 through 40, states a physician is not subject to disciplinary action for possessing, prescribing, administering, or dispensing any controlled substance. The Board of Medical Examiners has spent time to define intractable pain. They did so in 1996 for the situation when a dying individual is in such great pain, it must be dealt with from a drug standpoint. To repeal the definition would set us back, and cause great concern.
Senator Nolan:
What triggers an investigation for overuse of a prescribed drug?
Mr. Lee:
When the State Board of Pharmacy notifies us, we start an investigation.
Mr. Hillerby:
Our controlled substance tracking program will alert us of drugs being over prescribed.
Chairman Rawson:
We will close the hearing on S.B. 375, and open the hearing on S.B. 458.
SENATE BILL 458: Makes various changes to provisions governing State Fire Marshal and fire prevention. (BDR 42-515)
Doyle G. Sutton, State Fire Marshal, State Fire Marshal Division, Department of Public Safety:
This bill is related to fire prevention and the revision of provisions governing the interlocal agreements. I would like to explain how we got to the bill. It is a cleanup of language from previous legislation. Upon my appointment in 2001, the Governor put together a board to review the fire marshal’s office. The board consisted of a licensed architect, a chief of a volunteer fire department, a chief of a full-time paid fire department, a professional engineer, the State forester firewarden, a training officer of a volunteer fire department, a training officer of a partially or fully paid fire department, and a specialist in hazardous materials. The board put together a report, which was signed by the board members.
Chairman Rawson:
Are the people who signed off on the report in favor of S.B. 458? Did anyone from southern Nevada sign the report?
Mr. Doyle:
We have representatives here from southern Nevada, and I know they were involved in the process. I believe they are in favor of it.
Senator Wiener;
Would you explain what a library catalog is?
Mr. Sutton:
We maintain a catalog on the Internet, and it is also published and distributed to the fire departments. It includes upcoming classes and reference materials.
Senator Wiener:
Are firefighters able to go out of the State to receive certified training?
Mr. Sutton:
We have a board of standards and training to review the curriculum for the State, and recommend to the marshal’s office. We incorporate that as a State standard. An applicant from another state would submit his or her training experience to the fire marshal’s office, and, with my recommendation, the board makes a ruling. We would then issue a reciprocal certificate.
Chairman Rawson:
I have a note from the Legal Division there is a misprint. The reference to private schools on page 11, line 43, should read “public schools.”
Lee Leighton, Fire Chief, City of Sparks:
The changes in this bill came from throughout the State. It deletes many duplicate regulations. We received input from the rural and metropolitan areas.
Senator Neal:
How would a retrofit program be handled under this bill?
Mr. Sutton:
The responsibility for the retrofit program will remain with the office of the fire marshal.
Dave Drew, Chairman, State Board of Fire Services, Division of Emergency Management, Department of Public Safety:
I would like to add the Legislative Commission’s Subcommittee on Industrial Explosions reviewed and approved the study which led to many of the changes represented in S.B. 458.
Senator Washington:
Does the office of the State Fire Marshal Division assume control of coordinating terrorist activities?
Mr. Layton:
Under Nevada Emergency Response Plan, the fire marshal has an important role by helping to assist local fire departments.
Raymond C. McCallister, Lobbyist, Professional Firefighters of Nevada:
We are in support of this bill. We have followed the progress of the plan and agree with the area which clarifies responsibilities about inspections, certificates of occupancy, and other matters.
Senator Nolan:
Would the provisions of the bill apply to Boulder City and the City of Henderson if they were to consolidate their departments?
Mr. McCallister:
I do not believe they would automatically apply. The way I read the bill, it says they can enter an interlocal agreement with the fire marshal. It is not mandated.
James F. Madden, Fire Marshal, City of Henderson:
The City of Henderson is in support of this bill. It will allow the State fire marshal to concentrate resources in rural areas, and provide for the reduction of duplicated plan reviews. The City of Henderson combined most fire-prevention duties and merged with the building department. We now have what is called a building and fire safety department. Throughout the document there is reference made to local fire departments. We would like the reference be changed to local authorities.
Chairman Rawson:
You would like the language on page 6, line 35, used throughout the bill.
Mr. Madden:
Yes, all of the references to local fire departments. We are now a building and fire safety department, and responsible for enforcing the fire safety codes.
Michael Heidemann, Pershing County Fire Department:
The Pershing County Fire Department is in support of S.B. 458. For the rural areas, this is an excellent system of checks and balances. We often use the services of the fire marshal’s office for training.
Larry Farr, Fire Marshal, City of Reno:
The Reno City Council has not had an opportunity to review this bill or take a position. I am here to speak in opposition to portions of the bill. I participated in two of the meetings of the task force, and I voiced concerns with respect to inspections. Many of the concerns raised by Clark and Washoe Counties were about duplicate inspections. Currently, the laws of the State fire marshal apply throughout the State, but the marshal had no authority to enforce those laws in counties with a population of 100,000 or more. This legislative intent goes back to the mid 1970s. The office is fee based, and in order to generate money they charge for plan review and hazardous materials inspections. They have gone through other agencies such as the State Public Works Board or the State Board of Health to conduct plan reviews on their behalf, and collect those fees. Local agencies already conduct plan reviews. To build a hospital, health care facility, or school in Clark or Washoe County, you are subject to paying fees to the local municipality and the State fire marshal. Once the fees are paid and the plan review is complete, only the local municipality is authorized to come on-site to make an inspection.
The Reno city attorney says current language exists for interlocal agreements, and the marshal is adding additional layers of government by writing this bill. On page 8 there is new language allowing the marshal to have the authority to inspect and conduct plan reviews on hazardous materials installations. Currently the permits allow the marshal to inspect in counties with a population under 100,000, and the larger counties conduct their own inspections. The primary purpose of the permit was to raise money for a central repository of hazardous materials information which could be accessed by computer. The other portion of the fee for the marshal was to establish Statewide hazardous materials training. Under this section, the marshal will have the authority to come into all counties to inspect hazardous materials facilities and conduct plan reviews. They currently do not have such authority. The bill also says any surcharge collected by a local fire department shall be remitted quarterly to the State for the hazardous materials contingency account. Washoe County is building a high school and the State Public Works Board has the authority to sign off on the plans for all schools. They utilize the fire marshal’s office for the life safety plan check. Why do they use them instead of the local authority? Recently we received a letter from an architect for the new junior high school asking us to meet with the State fire marshal, State Public Works Board, and our local building department, in order to avoid the conflicts we had with the three new high schools in our area. The State fire marshal has become a revenue office when their primary focus should be life safety issues. I recommend this bill not be passed, and legislation worked on to specifically identify the duties of the State fire marshal with respect to the larger counties.
Senator Nolan:
We considered life safety codes and the electrical fire codes are objectively set, but it sounds from your example there are some discrepancies. Why would you not want to enter into an interlocal agency agreement with the other fire departments in the area?
Mr. Farr:
We originally tried to enter an agreement with the State fire marshal. They had some questions about indemnification and liability.
Senator Mathews:
Is there a fiscal note with this bill?
Chairman Rawson:
Not at this time.
Mr. Farr:
There may be a fiscal affect. The State fire marshal’s office has written this with the assumption we are all going to enter the agreement. If we do not, they are going to need to hire additional staff to conduct the hazardous materials inspections and plan reviews. Also, when we talk of hazardous materials, people tend to get nervous. The permits issued by the State fire marshal are for quantities of materials over certain limits. If we do not enter into an agreement, the builder of something as small as a gas station will have the City of Reno Fire Department, the City of Reno Building Department, and the State fire marshal inspecting the plans and telling him what to do.
Senator Washington:
If we wait on this bill for 2 years, would everything operate under current regulations?
Mr. Farr:
If the bill fails, there would be no risk to the public. Nothing would change with respect to life safety applications within the State. I believe all the differences can be resolved. Two years would give the State fire marshal time to work in the areas of life safety. The fire marshal would still have jurisdiction in all counties with a population under 100,000.
Senator Washington:
On page 8, line 30, there is a $60 surcharge for each hazardous materials permit. This fee is remitted to the State controller for credit to the contingency account for hazardous materials. Does the local fire department get any use of these fees?
Mr. Farr:
No. We have an annual city fee of $100. The builder of a gas station could be charged twice.
Chairman Rawson:
Did you testify on S.B. 118?
SENATE BILL 118: Revises provisions governing ability of State Fire Marshal to regulate construction, maintenance, and safety of buildings and structures in certain counties. (BDR 42-850)
Mr. Farr:
Yes, I testified in support of the bill.
Ex-Senator Lawrence E. Jacobsen, Lobbyist, Carson City, Douglas County, and Lyon County:
I am in favor of anything we can do to preserve the volunteer fire departments and better the fire service.
Mr. Sutton:
I would like to address some issues brought up by Mr. Farr. In counties with a population of over 100,00, the State fire marshal currently has some authority. It includes State-occupied buildings, hazardous materials certification, the inspection and certification of health and foster care facilities, and public schools. We have had many meetings and worked hard to improve our relationship throughout the State. We are currently working on an interlocal agreement with the City of Reno to bring forth a memorandum of understanding and cooperation. I have made efforts for all parties to share concerns, address issues, and not duplicate services. We are working to delegate the ability of local authorities to eliminate duplication. Fees are negotiable, with an interlocal agreement, for any work the locals do. The $60 is important because it is used for training throughout the State.
Mr. Drew:
This effort began in 1998. Resources are needed to go to the areas that cannot provide the services for themselves. If we wait 2 more years, the problems in the rural areas are going to continue.
Chairman Rawson:
We will close the hearing on S.B. 458. We have suggested amendments to S.B. 332.
SENATOR CEGAVSKE MOVED TO AMEND AND DO PASS AS AMENDED S.B. 332.
SENATOR WIENER SECONDED THE MOTION.
Senator Mathews:
Are we going to address any of the concerns raised by Mr. Lee?
Chairman Rawson:
There were no written proposed amendments. Mr. Lee raises concerns, but I do not believe this bill degrades the process or the responsibility. We will report this to the floor, and if he has something he wants the committee to look at I will be glad to, but we do have a deadline.
THE MOTION CARRIED. (SENATOR WASHINGTON WAS ABSENT FOR THE VOTE.
*****
Chairman Rawson:
We have a work session scheduled for S.B. 289.
SENATE BILL 289: Establishes State Health Authority to plan for single payer health care system and for expansion of Medicaid program. (BDR 40-720)
My suggestion is, because of the fiscal note for this bill, we change this to make it a legislative study to include the participants listed in the bill, and we should add some legislators. We can amend and do pass.
SENATOR CEGAVSKE MOVED TO AMEND AND DO PASS AS AMENDED S.B. 289.
SENATOR WIENER SECONDED THE MOTION.
THE MOTION CARRIED. (SENATOR WASHINGTON WAS ABSENT FOR THE VOTE.
*****
Chairman Rawson:
I am going to ask for a work session to be scheduled for S.B. 458. This meeting is adjourned at 4:05 p.m.
RESPECTFULLY SUBMITTED:
Cynthia Cook,
Committee Secretary
APPROVED BY:
Senator Raymond D. Rawson, Chairman
DATE: