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A
Thank
you
at
this
time.
I
will
call
to
order
the
assembly
committee
on
health
and
human
services
today
for
those
of
us
joining
on
joining
us
online.
Please
make
sure
that
if
you
are
on
the
zoom
that
you
mute
your
microphone
unless,
when
you
are
not
speaking
to
minimize
any
background
noise
and
I'd,
also
ask
you
to
turn
on
your
cameras.
If
you
are
on
the
zoom,
because
if
you
don't,
unfortunately,
we
have
no
way
of
knowing
you're
on
the
zoom.
So
thank
you,
madam
secretary.
If
we
can,
please
call
the
roll.
C
A
A
A
Here-
and
I
will
also
note
that
assemblywoman
summers,
armstrong
is
also
present
and
if
we
can
mark
assemblywoman
benitez
thompson
present
when
she
arrives
at
this
time.
I
welcome
again
our
audience
joining
us
for
this
virtual
meeting
and
in-person
meeting
of
assembly,
health
and
human
services.
Today
we
have
two
bill
hearings.
A
I
will
tell
you,
I
think
we
are
taking
them
in
the
order
as
listed
on
the
agenda,
and
at
this
time
I
will
open
the
bill
hearing
on
senate
bill
251.
Oh,
I
am
taking
them
out
of
order.
I'm
sorry
senate
bill,
251,
welcome,
senator
gansert,
and
please
begin
when
you
are
ready.
D
Thank
you,
madam
chair
and
members
of
the
committee.
Again,
I'm
heidi
senator
heidi
sievers
cantor
answered
I'm
a
senator
from
district
15,
which
is
in
northern
nevada.
Today,
I'm
joined
by
dr
nathan
slotnick
and
my
friend
abby
whitaker.
I
want
to
give
you
a
little
background
on
on
dr
slotnick
first
and
he
he
is
an
expert
in
genetics,
so
he
will
be
talking
at
length
about
the
hereditary
mutations
for
the
broncho
one
and
two
genes.
So
dr
nathan,
slotnik
is
a
medical
geneticist
and
a
high
risk
obstetrician
and
he's
board
certified
in
both
disciplines.
D
D
That
group
has
actually
grown
dramatically
with
a
total
of
more
than
4
000
cancer
patients.
Seen
he's
also
been
a
university
nevada,
reno
school
of
medicine
faculty
member
and
has
been
widely
published
on
a
number
of
cancer.
Genetic
and
high
risk
obstetric
topics.
In
november
of
2020
he
was
named
medical
director
of
the
reproductive
genetic
medicine
at
invictae
corporation.
D
A
large
international
genetic
testing
and
services
organization-
I
also
have
with
me,
or
on
zoom
there
abby
whittaker,
who
is
a
long
time
friend
of
mine,
she's,
a
well-respected
and
award-winning
communications,
specialist
and
entrepreneur
who
founded
her
own
business.
The
abbey
agency
with
her
husband,
tai,
the
abbey
agency's
tagline,
is
where
chutzvah
meets
acumen,
which
perfectly
describes
my
friend.
D
So
since
abby's
with
us
today,
I'm
going
to
have
her
share
her
own
story,
but
I
will
say
is
that
when
abby
first
called
me
about
sponsoring
a
bill
around
braca,
I
said
I
absolutely
would
do
it.
Of
course,
I
realized
that
she
was
one
of
about
a
half
dozen
friends
who
I
personally
know
who've
been
affected
by
the
bronco
one
and
two
genetic
mutations.
D
Each
of
my
friends
had
cancers
at
an
early
age
or
had
a
family
history
and
possible
genetic
link,
but
it
had
not
been
connected.
They
were
not
told,
and
so
their
diagnosis
and
sometimes
were
quite
late.
The
screening,
referral
and
testing
that's
contemplating
this
bill
is
very
important
for
each
woman
and
it's
also
critical
for
the
families
of
women.
Who've
been
tested,
positive,
who
have
tested
positive
for
brock
mutations.
D
C
I
will
share
my
screen
in
just
a
moment,
but
I'd
like
to
take
a
moment
just
to
introduce
myself.
I
have
had
many
many
very
pleasant
years
working
in
nevada.
I've
been
licensed
to
practice
in
nevada
since
1990
and
it's
a
long
long
time
ago
and
as
our
as
senator
ganzer
had
has
mentioned,
I've
had
a
long-standing
and
dividing
interest
in
cancer,
hereditary
predisposition,
testing,
molecular
genetics
and
ways
of
offering
these
opportunities
to
both
clinicians
and
patients
in
the
state
of
nevada.
C
C
Oh
very
good.
Thank
you.
Thank
you
very
much.
It's
always
hard
to
talk
to
a
non-existent
audience.
So
thank
you
very
much
so
today
we're
going
to
address
the
issues
of
genetics
and
genomics
in
cancer,
but
I'm
going
to
put
a
plug-in
at
the
end
of
my
presentation
about
how
the
technology
that
allows
us
to
have
this
discussion
today
is
applicable
to
virtually
every
other
clinical
entity
in
medicine
and
how
we
should
really
consider
it
when
we
think
about
future
directions
that
medicine
and
medical
practice
will
take.
C
Let's
start
first
talking
about
the
genetics
of
cancer
and
talk
about
what
the
etiology
or
cause
of
cancer
really
is.
Now.
Cancer
is
due
to
an
alteration
in
the
dna
of
specific
genes
within
specific
cells
of
the
body.
C
If
the
alteration
occurs
within
one
of
the
many
cellular
control
genes,
normal
cellular
control
can
be
lost,
that
damaged
cell
reproduces,
into
more
control,
less
cells
and
a
tumor
can
develop
further
loss
of
control
results
in
spread
away
from
the
original
cell's
location.
That's
called
metastatic
disease.
C
Therefore,
and
this
is
an
important
distinction,
all
cancers
are
genetic
in
meaning
that
they
have
a
dna.
Etiology,
but
not
all
cancers
are
hereditary
in
every
sense,
then
cancer
is
a
genetic
disease.
Now,
let's
talk
about
what
that
really
means.
Now,
every
geneticist
that
I've
known
from
all
these
years
that
I've
been
in
practice
has
the
habit,
I
guess
of
whenever
we
come
across
something
unusual.
C
We
have
a
file
cabinet,
we
put
it
into
a
file
cabinet
and
when
we
get
a
chance
to
look
back
at
it
or
when
technology
advances,
we're
able
to
make
some
statements
in
that
regard,
starting
in
the
1950s
genetics,
doctors
have
put
into
their
file
cabinets
very
interesting
family
trees
having
to
do
with
cancer
and
what
they
found
for,
in
particular,
something
called
hereditary.
Breast
and
ovarian
cancer
syndrome
or
hboc
is
that
each
of
the
family
trees
have
specific
predictions
that
they
they
manifest
hereditary.
C
Hboc
family
trees
generally
show
breast
cancer
before
the
age
of
50
ovarian
cancer,
frequently
at
any
age.
Male
breast
cancer,
which
is
really
really
rare,
otherwise,
frequently
multifocal
or
bilateral
breast
cancer,
and
frequently
associated
with
certain
ethnic
backgrounds
as
well.
These
can
be
contrasted
with
non-hereditary
types
of
cancers
which
don't
have
these
particular
characteristics.
C
Hvoc
has
evolved
as
we've
learned
more
about
it
into
a
direct
association
with
breast
brca
or
breast
and
ovarian
cancer
syndrome
brca
one
and
two
genes.
Now,
let's
take
a
look
at
what
this
really
means
in
a
clinical
context
by
age
40,
one
in
200,
women
in
the
population
will
have
developed
breast
cancer,
but
if
you
have
a
mutation
in
bracha
one
or
bracha
2,
it's
more
like
the
10
to
20
percent
risk
of
breast
cancer
will
occur
by
age
50.
Two
percent
of
the
population
of
women
will
have
breast
cancer.
C
C
Now
these
ranges
occur
because
different
studies
make
different
predictions,
but
one
way
or
another.
This
is
a
huge
increase
in
risk
of
developing
breast
cancer.
It
also
affects
the
development
of
ovarian
cancer.
Approximately
one
percent
of
the
female
population
in
this
country
will
develop
ovarian
cancer
during
her
lifetime,
but
with
breast
brca
one
or
two
gene
mutations.
C
However,
it's
become
obvious
that
there
are
many
other
genes
involved
in
this
hereditary
predisposition
as
well
and
I'll
be
getting
back
to
that
in
a
few
minutes,
but
it's
more
than
just
the
development
of
cancer.
It's
it
includes
considerations
of
the
development
of
a
second
independent
cancer.
C
Five
percent
of
all
women
who
will
develop
breast
cancer
within
five
years
of
the
original
diagnosis
will
develop
a
second
breast
cancer.
But
if
you
have
a
mutation
in
either
brca1
or
brca2,
that
number
goes
to
12
to
20
percent
over
a
woman's
lifetime.
If
she
develops
breast
cancer.
The
risk
of
a
second
primary
breast
cancer
is
about
11,
but
with
a
mutation
in
either
brca
one
or
two,
it
goes
up
to
40
to
60
percent.
C
So
knowing
a
patient's
brachis
status
is
crucial
in
knowing
how
to
treat
her
well,
how
you
treat
her
medically,
but
it's
more
than
just
recurrent
disease
as
well
a
patient.
Now
male
breast
cancer
is
remarkably
rare,
but
if
you
have
a
mutation
in
brca
brca102,
especially
drca2
that
risk
goes
up
to,
seven
percent
of
the
male
population
will
develop.
Breast
cancer.
C
C
At
risk
and
surveil
them
differently,
but
it's
more
than
that
too.
We
know
that
if
you
have
a
mutation,
brca
one
or
two,
something
as
simply
as
administering
tamoxifen,
which
is
a
medication,
will
reduce
that
patient's
risk
of
breast
cancer
by
50
percent
ovarian
cancer
risk
can
be
modified
as
well.
Something
as
simple
as
the
patient
taking
birth
control
pills
can
reduce
the
risk
of
that
patient
developing
ovarian
cancer.
Even
if
she
has
a
brca102
mutation
by
up
to
60,
you
can
do
more.
C
We
know
that
we
are
currently
recommending
patients
with
drca
one
or
two
mutations,
we're
recommending
that
they
consider
bilateral
mastectomy
as
a
risk-reducing
prophylactic
measure.
Usually
this
discussion
is
recommended
with
a
breast
specialist
and
can
be
done
within
the
40
to
60
year
old
age
range
and
that
can
reduce
risk
dramatically
as
well.
C
We
know
that
we
can
further
reduce
a
woman's
risk
of
breast
cancer
by
removing
her
ovaries
and
her
tubes
usually
recommended
at
age
35
to
40.,
and
we
know
that
we
can
reduce
the
risk
of
an
ovarian
cancer
development
by
removing
a
patient's
ovaries
and
fallopian
tubes,
reducing
the
risk
rather
dramatically
as
well,
and
usually
this
is
discussed
at
in
the
35
to
40
year
old
time
range.
C
C
Those
30
trillion
cells
are
the
results
of
many
many
many,
many
cell
divisions
from
a
single
fertilized
day.
Every
time
a
cell
divides,
and
there
are
two
products
we
kind
of
assume
that
those
two
products
should
be
genetically
identical,
but
they're,
not
every
time
a
cell
divides
the
three
billion
base.
Pairs
of
dna
that
are
in
the
mother
cell
need
to
be
reproduced,
and
we
know
that
mistakes
happen.
C
C
All
of
the
genes
that
are
listed
here
in
pink
and
blue
and
gray
are
called
to
attention
and
they
work
together
to
attempt
to
repair
the
mistake
that
happens
during
cell
replication,
that
dna
double-stranded
break
and
if
everything
works
well,
the
repairs
works
fine
and
we're
back
to
a
normal
state,
but
any
time
there
is
a
mutation
in
any
one
of
the
genes
that
you'll
see
here.
C
Now
again,
what
is
the?
What
is
the
process
here?
Well,
we
use
a
sequencing
tool.
Remember
of
the
three
billion
base
pairs
of
dna.
When
we
look
at
the
dna
and
judge
whether
there
are
mutations,
we
sequence
that
dna,
the
cost
of
sequencing
the
whole
human
genome
20
years
ago,
was
100
million
dollars
up
to
300
million
dollars
and
those
numbers
come
out
of
the
human
genome
project.
C
A
whole
human
genome
clinically
use
that
information
for
less
than
500,
and
it's
going
to
create
some
rather
dramatic
changes
in
our
ability
to
identify
patients
at
risk
not
just
for
cancer
but
for
cardiovascular
disease,
developmental
delay
in
children,
birth
defects,
many
many
other
conditions
as
well,
and
it's
all
because
these
sequencing
tools
have
become
much
more
powerful
and
much
much
much
less
effect
expensive.
C
Now
that
that
ends
my
my
presentation
here,
but
I'm
more
than
happy
to
answer
questions.
D
D
If
you
test
positive
for
bronco
one
or
two
during
your
lifetime
as
a
woman,
the
odds
of
your
getting
breast
cancer
are
as
high
as
87
percent.
If
you're
positive
for
bronco
one
or
two,
your
odds
are
as
high
as
87
that
you'll
develop
breast
cancer
and
44
for
ovarian
cancer,
and
now,
if
my
friend
abby
whitaker
can
talk
a
little
bit
about
her
story.
Thank
you.
E
Hi,
thank
you
guys
so
much
hi.
My
name
is
abby
whitaker.
I,
as
heidi
mentioned,
I
am
a
cancer
survivor.
I
had
cancer
10
years
ago.
It
wasn't
breast
cancer.
Actually
it
was
an
hpv
related
cancer,
but
it
kind
of
leads
into
this
story,
so
I've
been
getting
mammograms
for
five
years
and
then
this
year
I
switched
to
a
merino
diagnostic
center
for
my
mammograms
and
they
for
the
first
time,
gave
me
a
screening
which
asked
me
some
questions
about
my
family
history
and
flagged
me
for
genetic
testing.
E
So
my
first
question
was:
is
it
free?
I
don't
want
to
pay
for
that
and
it
was
free.
So
they
gave
me
the
genetic
test
and
it
came
back
positive
for
bracha
one
and
bra
for
bracka
too
sorry,
so
I'd
already
been
through
chemo
and
radiation
with
another
cancer
and
for
those
of
you
that
maybe
have
been
through
that
experience.
E
E
I
had
a
double
mastectomy
last
thursday,
so
I
am
eight
days
out
I'm
off
the
pain
pills,
which
is
why
it
was
safe
for
me
to
come
and
testify
today.
I'm
definitely
not
myself,
but
I
am
really
really
glad
that,
especially
after
hearing
dr
slotnick's
presentation
again
that
I
had
the
chance
to
do
that
and
I
would
have
never
known
even
being
a
cancer
survivor
if
reno
diagnostic
center
hadn't
asked
me
those
questions
and
flagged
me
for
genetic
testing.
I
would
have
never
known
that.
E
I
was
bracket
too
and
I
would
have
never
been
able
to
make
that
decision
to
have
a
double
vasectomy
and
take
my
healthcare
into
my
own
hands.
So
I
you
know,
sb251
is
going
to
give
every
woman
that
chance
through
different
types
of
screening,
and
I
just
think
that
as
moms
as
sisters
as
grandmas
as
legislators,
right
we
have
so
much
on
our
plates
and-
and
we
don't
always
know,
what's
wrong
with
us,
and
this
spill
gives
women
a
chance
to
know
that
and
to
make
a
decision
like
like.
E
I
did
to
have
a
double
mastectomy
or,
as
dr
slatnick
said,
some
of
the
other
options.
So
I
thank
you
guys
for
listening.
I
thank
heidi
senator
receivers
cancer.
I
thank
you
for
all
the
work
you
put
into
this
and
all
the
co-sponsors
I
saw
from
all
sides
of
the
aisle,
and
I
think
women
in
nevada
are
going
to
be
healthier
and
better
off
because
of
this,
and
thank
you
guys
very
much.
D
D
So
these
types
of
services
are
already
covered
under
federal
law,
we're
putting
this
in
nevada
statute
to
make
sure
that
they
continue
to
be
covered.
And
again
I
want
to
thank
abby
for
her
story
and
I'm
going
to
tell
you
a
brief
one.
I
had
a
friend
that
I've
known
for
about
25
years.
I
never
knew
her
without
cancer
and
her
second
daughter's
the
same
age
as
my
oldest
daughter.
So
I
met
her
when
our
daughters
were
in
first
grade
and
she
died
last
year,
breast
cancer
and
more
recently
she
was
tested.
D
So
this
connecting
the
dots
that
you
could
be
brocco,
one
or
two
is
not
always
being
connected
to
make
sure
they
get
the
testing.
Well,
she
tested
within,
like
say
the
last
five
years
and
tested
positive
for
bracha,
and
while
she
ended
up
dying,
what
was
so
significant
about
her
testing
and
getting
getting
the
test
is
that
her
daughters
needed
to
be
tested
and
by
the
way
when
she
was
having
cancer
breast
cancer
fighting
for
her
breast
cancer?
One
time
her
sister
was
fighting
breast
cancer.
D
So
in
the
end
there
are
six
cousins
between
the
two
mothers
and
all
of
them
are
positive
for
broncha,
and
I
know
one
of
them.
Who's
32
now
has
already
had
a
bilateral
mastectomy,
because
that's
the
toast
that
she
made
when
she
conferred
with
her
physician,
but
women
need
to
get
tested,
so
they
know
their
risk
and
then
their
daughters
and
potentially
their
sons
need
to
get
tested
and
the
the
male
breast
cancer
is
much
lower.
D
It
goes
up
to
about
seven
percent,
but
the
female,
so
you
know
so
that's
significant
as
well,
but
but
women
who
test
positive
for
this
gene
and
connecting
those
dots
again
is
so
important
because
the
test
is
really
easy
and
it's
inexpensive
and
sometimes
it's
free.
So
thank
you
for
your
attention
today,
I'm
open
for
any
questions.
You
have.
A
Thank
you
senator
and
thank
you
abby
for
sharing
your
story
and
being
here
such
a
short
period
of
time
after
having
a
surgery.
I
think
sometimes
I
realize
how
accessible
we
are
this
session
under
these
protocol
to
allow
someone
to
come
here
share
their
story,
make
a
real
impact
under
the
circumstances
that
you're
in
so
I
do
appreciate
that
we
do
have
a
couple
questions,
so
I'm
going
to
start
with
assemblyman
or
liquor.
B
Thank
you
chair.
Thank
you,
senator
cancer
for
bringing
the
spill
I'd
like
very
much
like
it,
and
I
just
a
couple
things.
I
could
ask
start
on
one
of
the
reasons
why
you're
recommending
this
is
because
it's
proposing
this
because
it's
a
recommended
screening
by
the
united
states,
preventive
task
force.
B
D
Thank
you
for
the
record,
senator
heidi
sievers
cancer,
and
so
we
are
focused
right
now
on
bronco
one
and
two,
because
there
are
probably
other
ones
that
are
out
there.
What
is
helpful
for
these
is,
is
that
they're
covered
by
insurance,
and
so
we
want
to
make
sure
we
at
least
stress,
address
these
two
mutations
because
of
the
research
that's
been
done
and
the
obvious
numbers-
and
I
know
dr
schlotnick
when
we
first
talked
he
wanted.
He
was
interested
in
a
lot
of
different
mutations
that
could
potentially
be
evaluated.
B
B
D
So,
thank
you
for
the
record
senator.
How
do
you
see
first
cancer,
so
chapter
457
is
the
nevada
chapter
on
cancer
and
in
that
cancer?
D
If
you
don't
follow
everything
in
there
and
there's
a
variety
of
things,
including
like
child
support
payments,
you
could
have
a
misdemeanor
or
a
felony,
so
what
I
was
trying
to
do
is
make
sure
that
physicians
or
primary
care
providers
were
providing
these
assessments,
but
not
penalizing
them
with
a
misdemeanor
or
a
felony,
because
this
is
something
that
they're
already
doing
some
family
history,
but
this
is
a
little
bit
more
because
you
have
to
ask
about
grandparents
and
grandmothers
and
aunts
and
uncles
and
so
forth.
So
it
did
not
contemplate
anything
about
malpractice
insurance.
A
F
I
thank
you
so
much
for
the
ability
to
ask
question.
Madam
chair.
I
appreciate
the
conversation
on
this
and
it's
so
interesting
because
in
the
the
past
decade,
just
watching
how
our
legislation
has
responded
to
advances
in
medical
care,
so
just
starting
off
with
even
requiring
mammograms
and
law,
and
then
talking
a
couple
years
later
about
the
issues
around
dense
breast
tissue
and
having
really
hearty
debates
in
this
committee
about
how
we
respond
to
the
new
sciences
coming
out
and
then
being
here
with
the
braca
testing.
F
So
just
an
observation
that
the
evolution
of
our
statutes
to
respond
in
medicine.
Sometimes
we
can't
quite
keep
up
with
all
the
good
things
that
are
out
there.
The
question
I
did
have
is
on
the
just
just
for
the
record,
so
we
could
flush
out
the
continuing
education
piece
for
these.
F
So
I
know
typically-
and
I
imagine
what
you
would
want
is
that
once
enacted,
the
licensing
boards
would
set
the
hours
attachments
to
whatever
that
continuing
education
was
that's,
typically
how
it
works
where,
if
you
were
to-
and
these
are
the
medical
education
units
like
if
you,
if
the
class
you
attend,
is
three
hours
long.
It's
worth
three
hours
worth
of
credits
as
the
typical
model.
F
So
I
don't
see
any
hours
prescribed
in
here,
and
so
I'm
just
assuming
that
the
intent
is
for
the
board
to
the
licensing
board
to
promulgate
rags,
as
they
ordinarily
would
in
regards
to
the
amount
of
credits
for
the
hours
spent
in
that
educational
activity.
D
Thank
you
for
the
record,
senator
heidi
sivers
gansured,
and
so
what
I
want
to
make
sure
is
that
if
you
take
courses
on
genetics
that
they
qualify
and
are
acceptable
to,
whichever
organization
is
your
licensing
agency,
so
I
wasn't
requiring
a
certain
number
of
hours
in
genetics.
I
was
what
we
wanted
to
do
is
make
sure
if
you
took
classes
in
genetics
that
had
been
qualified,
usually
they're
national
organizations
that
they
would
be
acceptable
so
towards
the
us,
the
cmes
and
responding
to
your
first
comment.
D
You
and
I
know
what
a
heavy
lift
some
of
those
were
to
making
sure
mammograms
were
covered
and
prostate
screens
and
so
forth.
So
I'm
I'm
really
happy
to
bring
this
forward,
especially
because
it's
already
covered
at
a
federal
level,
but
it
used
to
be
very
difficult
to
have
some
of
these
things
that
really
save
money
in
the
long
term,
but
but
the
preventative
health
services
are
truly
important.
So
thank
you.
A
Okay,
seeing
none
thank
you
senator
gancert.
At
this
time
we
will
begin
testimony
and
support
opposition
in
neutral.
I
am
looking
around
the
room
and
there's
obviously
no
one
else
in
here.
So
there's
no
one
in
person
to
for
testimony
and
support
broadcast
services.
If
we
can
go
to
the
lines
for
callers
in
support
of
senate
bill,
251
I'd
remind
callers
to
please
clearly
state
and
spell
your
name
and
limit
your
testimony
to
two
minutes.
If
we
can.
G
G
H
G
A
G
I
Thank
you
chair
and
members
of
the
committee.
My
name
is
tess
opferman,
that's
o-p-s-e-r-m-a-n.
Speaking
on
behalf
of
the
nevada
women's
lobby,
we
want
to
thank
senator
sivers-ganther
for
her
hard
work
on
this
bill.
Some
numbers
to
do
with
the
brca
gene
mutation
about
13
of
women
in
the
general
population
will
develop
breast
cancer
sometime
during
their
life.
By
contrast,
55
to
72
percent
of
women
who
inherit
the
harmful
brca1
variant
and
45
to
69
of
women
who
inherit
a
harmful
brca2
variant,
will
develop
breast
cancer
for
ovarian
cancer.
I
It's
also
significantly
higher
for
those
who
who
have
the
brca1
and
brca2
gene
mutation.
These
numbers
are
significant,
ensuring
that
women
are
screened
and
those
that
are
at
risk
have
the
ability
to
get
genetic
testing
is
critical
to
preventative
care.
This
bill
will
quite
literally
save
lives.
We
urge
your
support
and
thank
you
for
your
time
today.
G
J
Hello,
my
name
is
wes
falconer,
spelling
w-e-s-l-e-y
last
name:
falconer
f-a-l-c-o-n-e-r,
I'm
calling
on
behalf
of
cancer
care
specialist
in
reno
and
real
brief.
We
would
like
to
express
the
utmost
support
for
this
bill
and
we
believe
that
the
preventative
screening
is
the
way
to
go
and
all
cancer
treatments
going
forward.
A
I
will
go
next
to
the
zoom.
Is
there
anyone
on
the
zoom
that
would
like
to
testify
in
neutral
of
senate
bill
251?
G
I
So
the
division
is
testifying
in
neutral
for
sb
251
and
within
nevada
medicaid.
We
already
cover
brocco
1
and
screening
testing
and
genetic
counseling
for
women
who
meet
the
criteria
of
the
bill
and
the
united
states
preventive
services
task
force,
and
so
therefore,
we
have
a
zero
dollar
fiscal
note
on
this
bill.
Thank
you.
G
H
All
right
hi,
my
name-
is
sergeniya
reganti,
f,
o
w
j,
a
n
y,
a
rasmus,
reganti
r
e
g,
a
n
t.
I
am
a
medical
oncologist
at
cancer
care
specialist.
I
would
like
to
totally
support
this
bill
and
thank
you
to
dr
ganza
to
bring
it
up,
because
it's
very
important
for
prevention
and
also
with
the
family
history
and
all
that,
so
I
totally
support
this
bill
again.
This
is
dr
reganti
from
cancer
care,
specialist
medical
oncologist.
A
D
Thank
you,
madam
chair
members
of
the
committee,
and
I
want
to
thank
dr
regante.
She
was
seeing
patients
and
so
was
text
to
make
sure
she
get
on
the
line,
and
I
also
want
to
thank
miss
lynch
who
testified
that
there
was
a
zero
fiscal
note
again.
This
will
increase
awareness
and
help
connect
the
dots,
so
women
who
have
the
indications
that
they
need
to
get
some
counseling
and
testing
will
get
it
and
the
the
numbers
are
astronomical,
as
far
as
your
odds
of
getting
breasts
and
ovarian
cancer,
ovarian
cancer
and
other
cancers.
D
A
Thank
you
senator
at
this
time
I
will
close
the
hearing
on
senate
bill
251
and
I
will
open
the
hearing
on
senate
bill
156
senate
bill.
156
revises
provisions
related
to
crisis
stabilization
senators,
welcome
to
assembly
health
and
human
services.
Senator
ratty,
please
begin
when
you
are
ready.
Thank.
K
A
K
K
K
K
L
It's
been
a
bad
day:
you've
been
in
a
bad
car
accident
or
experiencing
chest
pain.
Fortunately,
there
is
an
emergency
medical
system
built
to
respond
immediately
to
your
crisis.
Now
rewind,
it's
been
a
bad
day,
but
this
time
it's
due
to
a
mental
health
crisis
like
thoughts
of
suicide.
The
same
emergency
medical
system
that
responds
to
chest
pain
also
responds
to
this
type
of
crisis
and
is
less
than
ideal
to
handle
it.
Yet
it
is
this
system
that
responds
to
thousands
of
people
in
a
mental
health
crisis.
L
L
One
a
crisis
call
center
staffed
by
specialists
that
coordinate
all
levels
of
crisis
care.
They
evaluate
the
current
crisis
and
can
support
and
stabilize
up
to
90
of
the
cases
they
get.
Those
that
need
more
get
more
with
these
hubs,
dispatching
appropriate
resources
and
then
supporting
those
resources
and
finding
the
best
solutions.
L
Component,
2,
24,
7
mobile
crisis
teams
that
work
in
the
streets
meeting,
people
where
they
are
and
for
the
majority,
resolving
their
crisis.
Right
then
dispatched
by
the
call
center
hub.
They
lessen
the
burden
on
local
police
and
reduce
the
stigma
that
some
feel
when
a
uniformed
officer
knocks
on
their
door
component.
Three
crisis
stabilization
locations,
which
constitute
the
retreat
model,
can
offer
short-term
care
for
people
who
need
support
and
observation,
regardless
of
their
level
of
crisis.
L
These
programs
operate
24
7
and
are
the
right
door
to
everyone
in
a
mental
health
crisis,
including
those
that
may
require
involuntary
treatment.
These
high-tech
high-touch
facilities
divert
away
from
the
emergency
departments
and
jails
while
providing
immediate
specialized
treatment.
Police
no
longer
need
to
decide
between
eds
or
jail.
The
no
wrong
door
approach
reduces
the
time
needed
to
handle
these
cases
from
hours
to
minutes
and
allows
police
to
go
back
to
supporting
public
safety,
a
role
they're
uniquely
trained
to
do.
Let's
review
the
impact
of
the
crisis
now
model
in
maricopa,
county
arizona.
K
Okay,
so
I
was
fortunate
enough
to
be
on
a
sorry
julia
ready
for
the
record.
I
was
fortunate
enough
to
be
part
of
a
group
that
has
been
working
through
the
legislative,
inter
the
interim
so
through
the
legislative
committee
on
health
care
that
participated
with
a
group
of
folks
from
washoe
county
who
made
a
field
trip
to
maricopa
county
to
check
out
the
work,
that's
being
done
in
arizona
to
change
the
system.
K
K
I
will
be
bringing
a
couple
of
other
bills
forward
to
you
that
will
deal
with
the
crisis,
call
point
of
of
care,
which
is
really
the
the
triage
that
will
begin
making
sure
that
the
right
resources
are
getting
out
and
another
bill
that
we'll
be
talking
about
the
licensing
of
the
peer
professionals,
so
those
people
with
lived
experience
who
would
be
part
of
that
response
instead
of
law
enforcement
in
many
cases.
So
this
is
just
one
so
with
that,
I'm
going
to
focus
just
a
little
bit
more
on
the
system
of
care.
K
So
you
understand
where
this
fits
in
and
then
we'll
talk
about
the
specifics
of
this
bill
so
again,
based
on
the
crisis
now
model.
The
first
step
is
that
high-tech
crisis
call
center
in
nevada.
We
have
crisis
support
services
of
nevada,
which
is
a
statewide
national
suicide
hotline
and
that's
a
huge
asset
for
us
as
a
starting
point,
the
next
in
in
most
cases
in
the
model,
well,
okay.
K
So
if
we
go
to
the
high-tech
crisis,
call
centers
these
crisis
call
centers,
have
specialists
who
are
behavioral
health
specialists,
who
can
do
both
the
de-escalation
of
a
crisis
on
a
phone
line
as
well
as
some
follow-up
case
management
and
care
right,
so
we've
helped
the
person
to
de-escalate
and
then
we're
making
sure
that
they're
connected
to
whatever
follow-up
resources
that
they
may
need.
That's
the
first
important
step
in
the
research
from
where
this
model
is
operational
in
other
communities.
K
What's
an
important
part
of
this
model
is
that
it
that
the
crisis
call
center
is
high
tech,
and
so
because
of
that
they
have
a
system
in
the
background
where
they're
communicating
with
all
of
the
care
facilities,
and
they
know
where
there's
outpatient
appointments
where
there's
medication
that
can
be
accessed
and
where
there
are
beds
that
can
be
accessed.
So
if
that
person
does
need
care,
they
can
be
immediately
placed
into
that
system
of
care.
K
The
next
part
is
these
oops
jumped
ahead.
The
next
part
are
these
24
7
mobile
crisis
teams.
We've
done
some
work
in
the
state
to
set
up
mobile
crisis
teams.
In
the
governor's
budget
last
session
we
created
ccbhcs,
which
are
behavioral
health,
community-based
community,
behavioral
health,
centers
and
one
of
the
requirements
in
those
is
to
have
a
mobile
crisis
team.
So
we've
taken
some
steps
forward.
There's
additional
work
happening
now
on.
K
How
do
we
make
sure
that
there's
a
good
medicaid
model
to
reimburse
for
these
crisis
teams
and
there's
some
work
at
the
national
level
coming
from
catherine
cortez
masto
on
more
support
for
mobile
crisis
teams?
But
the
concept
is
here:
okay
for
the
90.
We
got
them
taken
care
of,
but
now
there's
the
10
percent
that
can't
be
stabilized
over
the
phone
and
so
that
high-tech
high-touch
call
center
can
dispatch
a
mobile
crisis
team
and
that
mobile
crisis
team
is
a
behavioral
health
professional.
K
So
it
could
be
a
licensed
social
worker,
a
psychologist,
a
psychiatrist,
an
aprn
with
a
psychic
psychiatrist
endorsement
and
a
peer
with
lived
lived
experience.
So
somebody
who
has
is
in
recovery
from
a
behavioral
health
disorder
or
substance
use
disorder
and
can
relate
to
that
person
in
a
very
different
way,
sometimes
than
a
behavioral
health
professional,
a
different
differently
situated
behavioral
health
professional.
Can.
So
that's
the
idea-
and
in
this
case
this
is
where
you
start
to
see
the
alleviation
of
rolling
law
enforcement
at
all
right
or
rolling
an
ambulance
at
all.
K
If
there
isn't
a
medical
emergency
and
there
isn't
a
safety
issue,
but
you
have
an
individual
in
crisis.
This
is
the
appropriate
team
to
deal
with
that
crisis,
and
then
that
brings
us
to
the
point
of
this
bill,
which
are
these
crisis
stabilization
centers.
So
then,
there's
a
small
portion
about
one
to
two
percent
who
can't
be
stabilized
by
either
the
phone
or
the
behavioral,
the
crisis
team,
and
they
need
to
go
to
a
facility
and
in
our
current
model,
as
the
video
indicated,
they
end
up
in
one
of
two
places.
K
They
typically
end
up
in
some
sort
of
isolation,
where
there's
a
great
period
of
time
that
they're
getting
no
contact
from
anybody,
with
the
exception
of
just
the
checking
and
on
vitals
and
making
sure
that
they
stay
alive
in
this
model,
they
go
to
something
that's
known
more
as
a
living
room
model.
So
these
are
short-term
sub-acute,
which
are
important
sort
of
medicaid
terms.
K
So
if
somebody
needs
more
than
24
23
hours
and
59
minutes
of
care,
then
they
be,
then
they
can
be
leveled
up
to
an
actual
inpatient
bed.
At
that
point,
it's
appropriate
for
them
to
go
into
an
inpatient
bed,
but
if
they
can
be
stabilized
and
leveled
down,
they
can
be
discharged
with
again
an
appropriate
case
management
plan,
so
they're
connecting
to
ongoing
outpatient
services,
medication,
whatever
it
needs,
whatever
their
needs,
are
for
them
to
stay
stable.
K
K
Part
of
the
reason
that
that
is
the
case
is
they've,
experienced
some
sort
of
trauma
in
the
past
that
it
has
this
significant
use
of
peer
staff.
Again,
I've
said
this
many
times,
but
I
think
it's
a
critically
important
piece
people
with
lived
experience,
who
look
like
talk
like
and
have
something
in
common
with
the
folks
that
they're
helping
a
commitment
to
zero
suicide
and
safer
suicide,
safer
care
principles,
which
is
something
that
the
hhs
communities
have
talked
about.
K
A
lot
missy
young
and
her
work
out
of
the
office
of
suicide
has
done
a
lot
of
work
on
that
strong
commitments
to
safety,
of
course,
and
collaboration
with
law
enforcement.
So
when
that
call
comes
in
it
might
come
into
9-1-1,
it
might
come
into
a
new
phone
number
that
we're
developing
988,
which
is
the
other
bill.
K
But
if
those
two
systems
aren't
talking
with
each
other
and
law
enforcement
on
the
street,
isn't
aware
of
and
collaborating
closely
with
this
parallel
system,
then
it
doesn't
work,
and
we
are
very
fortunate
in
the
state
of
nevada
that
we've
created
something
called
most
teams,
which
is
a
social
worker
writing
along
with
law
enforcement,
and
they
will
be
the
critical
connection
between
these
two
systems.
Along
with
the
triage
that
has
to
happen
at
the
phone.
The
phone
call
level
to
make
sure
that
folks
get
into
the
right
place.
K
That's
the
system.
So
again,
this
bill
senate
bill
156
focuses
on
the
third
aspect
of
the
system,
which
is
the
crisis
stabilization
centers,
making
sure
that
we
get
the
licensing
correct
and
the
reason
that
it's
important
that
we
get
the
licensing
correct
is.
If
we
get
the
licensing
correct,
then
these
facilities
will
be
more
eligible
for
medicaid
billing
and
medicaid
dollars
will
be
able
to
flow
through
to
create
the
business
model
that
allows
for
these
to
be
successful.
K
The
bill
itself,
as
these
were,
as
these
crisis
stabilizations
were
originally
set
up.
We
imagined
them
to
be
psychiatric
hospitals,
but
that
was
a
very
narrow
group
of
facilities
that
could
actually
step
up
and
serve
the
role.
So
the
whole
purpose
of
this
bill
is
to
broaden
the
number
of
facilities
that,
as
long
as
they
meet
the
licensing
criteria,
could
step
up
and
fill
the
role
of
crisis
stabilization
centers.
K
I
very
much
appreciate
the
intelligence
of
the
committee
to
take
you
through
the
entire
crisis
care
model,
because
I
will
be
coming
back
and
I'm
hoping
I'll
be
coming
back
before
you
with
the
other
pieces
of
it.
But
today
it's
a
relatively
simple
bill
on
the
licensing
of
the
stabilization
centers.
With
that
I
will
close
my
remarks
and
I
stand
ready
for
questions.
A
Thank
you
for
your
presentation
and
yes,
I
think
that
was
a
very
good
overview
for
what
potential
bills
are
coming.
Also
over
later
on
in
the
next
couple
of
weeks.
Do
we
have
any
questions
from
members
I
didn't
receive
any?
Oh,
I
got
one
right.
There,
assemblywoman
summer's
armstrong
go
ahead
when
you're
ready
thank.
M
You,
madam
chair,
and
thank
you
senator
ratty
for
a
very
insightful
and
presentation
on
a
very
sensitive
issue:
I'm
chandra
summers,
armstrong
assembly,
district,
six
in
southern
nevada
in
clark
county,
and
this
issue
is
of
utmost
concern.
M
My
question
is:
do
you
see
these
mobile
response
units
replacing
the
most
teams,
because
most
teams
almost
always
include
a
a
police
officer
too,
and,
and
I'm
not-
I
don't
know
a
lot
about.
I
haven't
asked
for
any
data,
but
I'm
not
sure
how
that's
being
received
and
their
success
rates.
If
you
have
any
information
about
that
I'd
love
to
know.
Thank
you.
K
Thank
you
so
appreciate
the
question
through
you
chair
when
two
assembly
woman's.
K
Thank
you
chair.
I
appreciate
the
indulgence
again
senator
rowdy
representing
senate
district
13..
I
don't
so.
The
most
teams
were
funded
by
the
state
but
then
pushed
out
to
the
local
level.
So
to
get
the
data
in
terms
of
the
effectiveness
or
the
impact
of
the
most
teams,
we
would
need
to
have
the
folks
from
clark,
county
and
washoe
county
come
and
talk
about
that,
and
so
that
would
be,
I
think,
a
question
to
the
chair.
K
If
that's
something
that
we
can
find
time
to
do
in
the
remaining,
I
think
39
days
that
we
have
left
in
the
session.
That
said,
I
in
washoe
county
and
my
role
work
with
and
I'm
familiar
with
the
most
team
there.
So
I
will
couch
my
comments
to
say
I'm
more
familiar
with
the
washoe
county.
Most
teams
than
I
am
with
the
clark
county
most
teams,
and
the
answer
is
no.
I
actually
don't
see
the
mobile
outreach
teams
replacing
the
most
teams
and
here's.
Why?
K
For
some
people
who
are
experiencing
a
behavioral
health
crisis,
there
is
a
true
public
safety
issue
and
it
would
be
inappropriate
to
roll
appear
in
a
behavioral
health
professional
into
that
situation.
You
can
imagine
issues
around
domestic
violence
that
could
be
that
situation.
You
can
imagine
issues
where
somebody
is
further
along
the
suicide
ideation
process
and
is
getting
close
to
actually
using
a
weapon
to
fulfill
their
own
suicide.
K
Where-
and
you
know,
I'm
sure
if
I
had
a
most
team
social
worker
here,
they
could
talk
to
you
about
the
wide
variety
of
reasons
why
there
are
certain
calls
they
would
not
want
to
roll
on
without
law
enforcement.
So
that's
the
first
reason.
So
the
way
it
would
need
to
work
is
at
that
first
level,
when
the
calls
are
coming
in
that
triage
is
critically
important,
that
the
right
questions
get
answered
and
911
systems
are
already
pretty
brilliant
at
this.
They
have
very
detailed
sort
of.
K
If
this,
then,
what
processes
and
systems
to
kind
of
figure
out?
What
is
the
right
resource
to
roll
and
to
give
the
folks
who
are
rolling
the
most
information
possible
so
as
they're
going
through
that
triage
system?
If
this
appears
to
be
a
behavioral
health
case
that
doesn't
have
a
public
safety
issue,
then
it
should
go
over
to
the
988
system
and
the
suicide
hotline
system.
But
if
it
still
has
a
public
safety
issue,
we
should
still
be
rolling
a
law
enforcement
and
then
the
best
case
scenario.
K
In
terms
of
how
law
enforcement
is
starting
to
approach
behavioral
health
crisis
when
they
are
paired
with
a
social
worker
and
what
they
are
learning
from
that
so
for
the
public
health
reason
and
for
the
training,
because
law
enforcement
is
going
to
be
the
response
for
some
of
these
calls,
I
think
that
we
would
want
to
have
most.
We
would
not
have
triage
and
know
when
we
have
to
roll
most
and
when
we
have
to
roll
behavioral
health
crisis
teams.
I
hope
that
answers
your
question.
A
Do
we
have
any
other
questions
from
committee
members
seeing
none?
We
will
begin
testimony.
Oh
no,
okay,
sorry
thought.
I
heard
something
over
there.
It's
just
assemblyman
hayfin
being
loud
if
we
could
move
to
testimony
in
support
opposition
neutral
of
senate
bill
156
broadcast
services,
if
we
can
go
to
the
line
for
testimony
and
support-
and
I
remind
callers
to
please
clear
the
state
and
by
your
name
and
limit
your
testimony
to
two
minutes.
G
H
Representing
nevada
royal
hospital
partners
here
today,
very
supportive
of
sc
156
and
very
appreciative
of
senator
ratty
for
working
on
language
to
allow
rural
hospital
involvement
in
this
important
process.
These
crisis
stabilization
centers,
are
important
in
the
crisis
now
system
of
care.
I
was
very
fortunate
to
have
actually
seen
them
in
practice
in
colorado
and
the
positive
impact
on
patients
in
crisis
law
enforcement
and
ems
was
phenomenal.
I'm.
H
Over
the
last
several
years,
hospital
representatives
from
clark
and
washoe
counties
have
talked
to
carson
powell's
behavior
health
department
regarding
whether
their
own
hospitals
could
open
a
similar
crisis
center.
However,
when
it
became
known
that
medicaid
only
paid
observation
or
office
visit
rates
for
these
crisis
services,
the
other
hospitals
lost
interest,
we
believe
sb
156
will
incentivize
other
hospitals
to
open
their
own
crisis.
Stabilization
centers,
it's
a
critical
piece
to
access
of
care
that
is
missing
and
to
take
today's
health
care
marketplace.
H
G
J
Nami
believes
that
public
policies
and
practices
should
promote
access
to
care
for
people
with
mental
health
conditions.
Nami
supports
the
development
and
expansion
of
mental
health
crisis
response
systems
in
every
community.
As
noted
by
senator
ratty
sb
156
addresses
the
third
core
element
of
national
guidelines
for
crisis
care
crisis.
Stabilization
programs
should
provide
a
no
wrong
door.
Access
to
mental
health
and
substance
use
care,
including
accepting
all
walk-ins
ambulance,
fire
and
police.
A
G
H
Hello,
this
is
dan
musgrove,
that's
d-a-n
capital
m-u-s-g-r-o-v-e
as
the
chair
of
the
clark
county,
children's
mental
health
consortium,
as
well
as
a
member
of
the
clark
county,
regional
behavioral
health
policy
board
and
representing
a
number
of
clients,
including
the
valley,
health
system
of
hospitals
and
west
care.
This
the.
I
H
That
the
legislature
has
been
working
on
for
the
last
two
sessions.
The
crisis
now
model
is
so
very
important
to
the
system
of
care
that
we
have
in
nevada,
especially
in
clark
county,
where
hospital
emergency
rooms
are
always
those
that
need
care
in
a
much
better
location
than
those
hospital
eds
can
provide,
and
I
just
want
to
compliment
senator
ratty
for
her
leadership
on
this
subject
as
well
as
the
legislature,
and
we
are
absolutely
in
support
of
moving
in
this
direction.
Thank
you.
A
J
Sure
glenn,
no
just
thank
you
and
to
the
senator
we're
just
here
to
answer
questions,
but
of
course
this
is
good
policy
and
there's
no
fiscal
note.
This
will
help
a
lot
of
providers.
K
Thank
you
terwyn
again,
julia
ready
for
the
record.
First
of
all,
I
need
to
correct
myself
because
I
got
a
text
during
my
presentation,
so
I
I
have
been
I'm
using
the
term
social
worker
too,
loosely
my
apologies
to
assemblywoman
benitez
thompson.
K
Some
of
them
could
be
licensed
clinical
social
workers,
but
they
are
licensed
clinicians,
not
necessarily
all
social
workers,
so
my
apologies
to
the
most
team
members
for
not
using
that
term
correctly
and
then
just
wanted
to
say
thank
you
to
the
committee
I,
while
there
is
no
fiscal
note,
a
critical
piece
of
this
is
that
the
billing
of
medicaid
is
and
you're
just
shifting
it
from
putting
it
in
a
more
expensive
part
of
medicaid
to
a
more
expensive
service
to
a
lesser,
expensive
service,
and
so
over
time.
K
I
do
believe
that
there
will
be
savings,
but
we're
still
standing
up
the
model
and
all
its
components
and
phoenix
from
the
time
they
started
working
on
it
until
the
time
they
had
it
fully
in
place
was
about
a
13-year
time
frame,
we're
about
three
years
into
the
process
here
in
nevada.
I
think
we
can
accelerate
that
significantly
by
being
focused
in
our
work
and
because
so
many
folks
have
gone
before
us.
A
Thank
you
senator
ready,
and
I
know
that
we
will
be
seeing
you
quite
a
bit
in
the
next
coming
weeks.
So
thank
you
that,
with
that
I
will
close
the
hearing
on
senate
bill
156
at
this
time.
We
will
go
to
the
lines
if
there
are
any
callers
in
public
comment
as
a
reminders
to
callers
in
public
comment.
Please
state
your
name
for
the
record
and
limit
your
testimony
to
two
minutes.
A
Thank
you,
members
of
the
committee
at
this
time.
That
concludes
our
meeting.
For
today.
Our
next
meeting
is
going
to
be
monday
april.
26Th,
I'm
presenting
a
couple
bills
in
the
senate,
so
our
vice
chair,
peters,
will
be
chairing.
That
meeting
for
probably
most
of
it
and
meeting
is
adjourned.
Have
a
good.