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A
A
Here
it
appears
everyone
is
present
today.
So
welcome
welcome
to
our
audience
joining
us
here
in
person
we
have
a
full
room
which
is
always
exciting
and
also
welcome
to
our
audience
joining
us
either
online
by
phone
or
virtually
on
our
youtube
channel.
Today
we
will
start
with
the
work
session
and
we
do
have
three
bills.
I
realize
I
have
crammed
a
lot
into
this
agenda
here
today,
so
thank
you.
A
Everyone
in
advance
for
your
patience
before
we
begin
to
some
housekeeping
matters,
I'd
like
to
make
some
several
of
those
for
individuals
that
are
present
in
the
meeting
room.
Please
keep
your
face
coverings
on
and
maintain
social
distancing
and
members
of
the
public.
Again,
you
may
provide
testimony
in
various
ways
which
are
all
listed
on
the
agenda.
If
you
are
not
able
to,
or
you
would
like
to
add
additional
information,
you
can
always
do
that
in
written
form
and
submit
that
up
to
48
hours
after
the
meeting
adjournment.
A
Finally,
if
you
have
electronic
devices,
especially
cell
phones
and
laptops,
in
fact
I'm
looking
at
mine-
because
I
know
mine
is
on-
please
mute-
those
I
know
we
all
love
those
banging
and
dinging-
that
comes
from
our
computers
and
our
phones,
but
if
we
could
turn
those
off,
that
would
be
great
and
with
that
we
will
move
to
our
first
agenda
item,
which
is
the
work
session
document
and
just
for
the
people
that
are
on
the
zoom
or
in
the
room
senate
bill
188.
A
At
this
time
I
will
be
taking
that
off
the
work
session
document
and
we
will
go
forward
and
I
will
start
from
the
top
with
senate
bill
21,
mr
ashton,
if
you
could
go
over
the
summarize
the
bill.
E
E
Therefore,
we
will
start
with
senate
bill
21,
which
we
heard
on
april
28th,
and
this
bill
provides
that,
in
addition
to
the
current
requirements
to
conduct
background
checks
on
current
employees,
public
or
private
institutions
and
agencies,
to
which
a
junior
court
commits
a
child
and
certain
facilities
that
providers,
a
residential
mental
health
treatment
to
children,
must
conduct
background
checks
of
applicants
for
employment
to
determine
whether
a
potential
employee
has
charges
pending
against
him
or
her
or
has
been
convicted
of
several
specified
crimes.
E
A
Thank
you
with
that.
I
will
take
any
questions
from
committee
members
seeing
none.
I
would
entertain
a
motion
to
do
pass
at
this
time.
Actually
is
it
amended?
No,
it's
just
do
pass
so
moves.
Do
I
have
a
second
all,
those
in
favor
say
aye
aye,
any
opposed,
say,
nay,
and
if
I
can
get
hands,
so
I
can
make
this
for
the
record.
It
looks
like
we
have
assemblywoman
black
assembly
woman,
titus,
assemblyman,
haven,
assemblywoman
krasner.
A
I
got
you
assemblywoman
krasner
and
assemblyman
matthews
with
that
there
is
a
majority,
and
so
the
motion
does
pass
and
I
will
assign
that
floor
statement
to
assemblywoman
summers,
armstrong.
E
Thank
you,
madam
chair,
for
the
record
patrick
ashton,
lcb
senate
bill
146.
We
heard
this
bill
on
april
28th.
This
bill
revises
laws
related
to
behavioral
health
care
for
children,
with
emotional
disturbance
who
are
subject
to
the
jurisdiction
of
a
juvenile
court
for
reasons
relating
to
protection
from
abuse
and
neglect.
E
Specifically,
when
such
a
child
is
admitted
to
a
public
or
private
inpatient
psychiatric
treatment
facility,
the
bill
requires
the
administrative
officer
or
staff
of
the
facility
to
ask
the
person
or
entity
with
legal
custody
of
the
child,
whether
he
or
she
has
a
health
care
provider
who
regularly
provides
mental
or
behavioral
health
care.
If
the
child
has
such
a
provider,
staff
of
the
facility
must
make
a
reasonable
effort
to
consult
with
the
provider
concerning
the
child's
admittance
and
care
and
to
coordinate
on
a
plan
to
discharge
the
child
from
the
facility.
A
Members
of
the
committee
do
we
have
any
questions
regarding
senate
bill
146,
seeing
none
at
this
time.
I
would
entertain
a
motion
to
do
pass.
I
have
a
motion
from
assemblywoman
peters
and
the
second
from
assemblywoman
titus.
Do
we
have
any
questions
on
the
motion
seeing
none
all
those
in
favor
say:
aye
aye,
all
those
opposed,
say,
nay,
that
was
a
unanimous
and
the
motion
passes
and
I
will
assign
that
floor
statement
to
assemblywoman
titus
next.
If
we
can
move
to
senate
bill
156.
E
Additionally,
the
bill
expands
the
existing
requirement
that
dhhs
take
any
action
necessary
to
ensure
crisis
stabilization
services
provided
at
a
psychiatric
hospital
with
a
crisis.
Stabilization
center
endorsement
are
reimbursable
under
medicaid
to
include
such
services
provided
at
any
hospital.
With
this
endorsement.
E
A
D
A
Thank
you
and
I'll
remind
all
committee
members.
You
always
have
the
right
to
change
your
vote
and
I
know
ll
members
have
been
very
diligent
about
letting
me
know
if
they
do
plan
on
doing
that.
So
I
appreciate
that.
Do
we
have
any
other
comments
on
the
motion
seeing
none
all
those
in
favor
say:
aye
aye,
all
those
opposed,
say,
nay,
and
if
you
could
raise
your
hands,
I
think
I
saw
assemblywoman
black
and
assemblyman
matthews
as
nays.
The
motion
carries
next.
If
we
can
move
to
senate
bill.
A
A
E
We
heard
senate
bill
251
on
april
23rd,
and
this
bill
requires
primary
care
providers
to
attempt
to
determine
whether
adult
women
to
whom
they
provide
services,
have
a
personal
or
family
history
of
certain
cancers
or
meet
other
criteria
for
which
the
united
states
preventive
services
task
force
recommends
screening
for
a
harmful
mutation
of
the
brca
gene.
If
certain
criteria
are
met,
primary
care
providers
must
screen
for
the
mutation
provide
written
notice
of
the
need
to
discuss
genetic
counseling
and
testing
provide
genetic
counseling
and,
if
clinical
clinically
indicated,
provide
genetic
testing.
E
A
A
I
see
a
motion
from
assemblywoman
gorlo.
I
think
that's
who
it
was
yup
and
the
second
from
assemblywoman
titus.
Do
we
have
any
comments
on
the
motion?
I
think
we
do
go
ahead.
Sen,
assemblyman,
liquor.
H
Is
problematic
the
one
granting
protection
from
professional
discipline
for
physicians?
I
think
that's
a
bad
precedent
to
create
to
use.
E
E
A
A
I
have
a
motion
from
assemblywoman
peters
and
a
second
from
assemblywoman
summers.
Armstrong.
Do
we
have
any
comments
on
the
motion
around
seeing?
None
all
those
in
favor
say:
aye
hi,
all
those
opposed,
saying,
nay,
and
if
you
could
raise
your
hands
so
I
have
assembly,
woman,
black
assemblyman,
matthews,
assemblywoman,
krasner,
assemblyman
haven
and
assemblywoman
titus.
The
motion
does
carry
and
I
will
assign
that
floor
statement
to
assemblywoman
gorlo.
E
Thank
you,
madam
chair,
for
the
record
patrick
ashton,
legislative
council
borough
senate
bill
364.
We
heard
this
bill
on
april
21st.
It
requires
the
state
board
of
health
to
adopt
regulations
requiring
a
hospital
or
independent
center
for
emergency
medical
care
to
provide
certain
training
to
employees
who
provide
care
to
victims
of
sexual
assault
or
attempted
sexual
assault.
E
A
A
Thank
you,
assemblyman
matthews.
Do
we
have
any
other
members
or
any
comments
from
members
seeing
none
at
this
time,
all
those
in
favor
say
aye
aye,
all
those
opposed,
say,
nay.
I
have
one
nay
it's
assembly,
woman,
black,
but
the
motion
carries
and
I
will
assign
that
floor
statement
to.
E
A
A
Thank
you,
assemblywoman
krasner.
With
that
motion,
do
I
have
a
second,
I
have
a
second
from
assemblywomanpeters.
Do
we
have
any
comments
on
the
bill
at
this
time,
seeing
none
I'm
looking
around,
seeing
them?
Okay
at
this
time,
I
will
all
those
in
favor
say:
aye
hi,
all
those
opposed,
say,
nay,
that
passed
unanimously,
so
that
motion
carries
and
I
will
assign
that
floor
statement
to
assemblywoman
thomas
next
and
last
on
our
work
session
document.
We
have
senate
bill
398,
mr
ashton,.
E
E
It
requires
the
juvenile
justice
oversight
commission
to
submit
a
report
to
the
legislative
committee
on
child
welfare
and
juvenile
justice
by
august
2022,
containing
an
update
on
the
progress
made
by
the
division
of
child
and
family
services
of
the
department
of
health
and
human
services
in
implementing
its
current
five-year
plan,
as
well
as
any
recommendations
for
legislation
relating
to
improvements
to
the
upcoming
five-year
plan.
Any
disparities
in
the
juvenile
justice
system
related
to
race
or
ethnicity,
and
compliance
with
the
federal
juvenile
justice
and
delinquency
prevention
act.
There
were
no
amendments,
madam
chair.
A
A
A
Can
we
get
a
hand?
I
think
I
got
assemblyman
matthews
and
assemblywoman
black
as
nays
the
motion
carries
and
I
will
assign
that
floor
statement
to
family
woman
krasner
and
that
concludes
our
work
session.
Yay
good
job,
you
guys,
we
do
have
three
bill
hearings.
I
am
going
to
take
them
slightly
out
of
order
as
they
are
listed
on
the
agenda.
I
am
going
to
start
with
senate
bill
379.
A
So
at
this
time
I
will
well
let
me
make
sure
I
have
379.
Yes,
I
see
senator
hardy
there.
So
at
this
time
I
will
now
open
the
bill
hearing
on
a
senate
bill.
379
welcome
to
the
assembly
committee
on
health
and
human
services
senator
hardy.
Please
begin
when
you
are
ready.
F
So
the
the
bill
is
pretty
simple
in
its
organization,
so
we
want
to
attract
more
providers,
especially
for
the
underrepresented
groups
and
specialties.
F
There
will
be
a
survey
sent
hopefully
electronically
in
which
the
practitioner
provider
will
fill
out
the
survey
and
the
survey
is
interested
in
things
that
will
tell
us
where
you're
at
and
that's
on
page
three,
if
you'd
like
to
read
the
type
of
license
from
line
three
down
to
about
32
and
all
of
those
things
are
the
things
that
we're
interested
in
in
order
to
figure
out
how
we
can
improve
our
delivery
of
health
and
be
able
to
make
our
our
people
healthier.
F
And
then
the
working
group
that
will
be
set
up
with
under
the
direction
of
the
director
of
human
and
health
services
will
meet
and
recognize
that
they
have
to
make
a
questionnaire.
They'll
do
that
and
then
the
goal
is
on
page
4
lines:
18
through
23
attract
more
persons,
including
without
limitations,
members
of
unrepresented
groups
etc,
and
then
two
improve
health
outcomes
and
public
health
in
this
state.
F
The
survey
response
cannot
be
used
to
disqualify
someone
from
approval
of
their
license.
It
is
confidential
if
this
survey
will
include
doctors
of
every
kind,
nurses,
mental
health
providers,
chiropractors
oriental
medicine,
podiatrists,
marriage
and
family
counselors,
sociologists,
psychologists,
alcohol
and
drug
gambling,
and
as
much
as
you
are
interested
in
alacrity,
I
am
happy
to
field
any
questions
as
long
as
they're
not
very
hard.
A
D
I
thank
you,
madam
chair,
for
the
question
and
thank
you
senator
hardy
for
presenting
the
bill.
I
just
had
some
concerns
and
and
questions
regarding
some
of
the
the
questions
on
this
questionnaire
and
what
the
purpose
is
ultimately,
because
I'm
not
convinced
that
two,
one
of
which
it's
the
race
and
ethnicity,
on
number
b,
future
plans
on
what
somebody's
planning
on
doing
and
I'm
just
wondering,
how's
that
relevant
to
somebody's
qualifications
to
when
they
do
their
license.
F
Thank
you
for
the
question,
madam
chair.
If
I
may.
F
Senator
thank
you,
assemblywoman
titus.
The
this
survey
has
nothing
to
do
with
the
licensing
of
the
person
as
much
as
who
they
are
and
what
they're
doing,
and
the
confidentiality
is
really
crucial
with
this,
because
if
there
is
a
physician
or
a
practitioner,
that's
going
to
be
planning
on
going
somewhere
else.
We
do
not
want
that
person
to
be
identifiable,
and
so
the
confidentiality
will
be
of
utmost
importance.
F
F
I
will
note
that,
where
I'm
coming
from
as
pardon
the
expression,
an
old
white
male,
I
may
not
be
as
trustworthy
and
trusted
in
some
communities
as
others,
and
if
I
don't
have
people
who
look
like
other
people,
then
they
may
not
trust
those
people.
So
I
am
very
interested
in
getting
and
recruiting
people
that
are
in
for
lack
of
a
better
word
of
bipart
community,
for
instance,
and
having
that
opportunity
to
grow
the
trust
factor
in
the
medical
and
counseling
world
of
nevada.
D
No,
I
appreciate
that
that
answer
and
that's
one
of
my
concerns
is
that
it
may
be
used
to
perhaps
not
hire
somebody
or
focus
on
on
somebody
how
they
identify
and
and
what,
if
they
don't
want
to
answer
this
will.
F
F
F
D
So
if
it's
it's
optional,
which
is
a
good
thing
and
then
we're
going
to
use
it
from
a
statewide
level,
maybe
to
identify
some
priorities
and
certain
recruitments,
and
I
guess
that
dr
peckham
has
to
answer
that
where
what
this
is
going
to
how
this
will
help
us
change,
how
we
see
it
because
in
my
mind,
to
solve
some
of
these
problems
is
making
sure
we
encourage
people
from
every
background
to
go
into
the
fields
where
we
need
them,
and
healthcare,
as
you
pointed
out,
is,
is
critical
that
you
have
confidence
in
your
provider
that
it
helps
if
your
provider
understands
your
background
or
can
identify
with
you
and
you
can
identify
with
them.
D
A
Mr
packham
go
ahead,
please
remember
to
say
your
name
before
you
begin.
G
These
are
very
important
for
a
number
of
programs
that
are
critical
to
bringing
and
keeping
positions
and
other
health
professionals
in
the
state
of
nevada,
and
in
addition
to
that,
I
believe
that
the
bill
will
improve
the
collection
of
data
to
inform
a
wide
range
of
where
our
health
care
needs
are
by
profession.
So
I
think,
that's
all.
I
would
add.
F
And
I'm
sure,
if
I
may
go
ahead
joe
hardy
for
the
record,
I
have
a
little
sign
sometimes
on
these
places
that
it
says,
define
acronyms
and
so
dr
packham
would
love
to
define
hipsa
for
all
of
us,
so
we're
on
the
same
page.
F
G
Absolutely
forgive
me
on
that
again,
john
packham
for
the
record.
Nipsa
stands
for
health,
professional
shortage
area,
there's
essentially
three
types
of
shortage
areas
or
designations.
They
are
primary
care
oral
health
or
dental
and
mental
and
behavioral
health
professionals
area,
and
these
are
critical
for
basically
making
nevada
providers
and
facilities
eligible
for
loan
repayment,
enhanced
reimbursement
and
so
forth,
and
I
would
just
stress
the
urgency
when
we
talk
about
access
to
care.
G
Access
to
care
is
affected
by
those
designations,
and
it's
it's
it's
critical
for
us
to
get
it
right
and
to
take
advantage
of
those
particular
designations.
I
I'd
like
to
just
re-emphasize.
This
is
not
simply
or
purely
a
data
collection
bill.
It's
a
data
collection
bill
that
will
perform
and
improve
access
in
earth.
D
Thank
you,
sir,
and
thank
you,
madam
chair,
for
the
questions.
J
J
Thank
you,
dr
packham,
for
defining
hipsa
I'd
like
to
ask
why
your
request
does
not
include
a
exit
survey,
if
that's
at
all
possible
why
doctors
leave-
and
I
think
that
that
I'm
curious
and-
and
I
say
that,
if
I
just
may
madam
chair,
our
family
lost
our
pediatrician.
J
He
was
our
pediatrician
from
the
time
my
two
older
sons
were
like
seven
or
eight
years
old,
all
the
way
up
to
our
youngest
son,
who
just
turned
19.
he's
a
black
man.
We
actually
grew
up
in
the
same
city
in
oakland,
california.
We
didn't
go
to
the
same
school,
but
we
had
these
things
in
common
and
to
have
a
man
who
looked
like
my
sons,
take
care
of
them
all
their
their
life,
to
be
able
to
speak
to
them,
to
be
able
to
have
a
relationship
with
them
and
our
families.
J
It
made
a
huge
difference
and
how
they
responded
to
health
care
and
the
instructions
that
he
gave
them
as
they
were
going
through
each
year
and
all
of
a
sudden
he
was
gone,
and
I
never
found
that
why-
and
I
just
lost
my
ob
gyn,
who
was
I've
had
for
20
years
same
thing
right,
so
even
as
we're
collecting
data
about
why
people
re-up
their
licenses,
if
there
will
be
any
way,
you
all
can
find
out
why
people
leave,
because
that
also
might
inform
why
we
have
shortages
here.
Thank
you.
A
K
Thank
you
so
much,
and
so
I've
questions
on
the
I'll
start
with
the
kind
of
the
mechanics
of
how
we're
going
to
collect
this.
So
it's
section
5
sub
2,
so
the
director
shall
develop
and
make
available
and
the
director
being
439.
So
the
department
of
health
and
human
service
director
shall
make
available
to
each
professional
licensing
board
so
to
all
of
those
licensing
boards
a
through
double
b,
a
way
to
collect
this
data
electronically.
F
G
I'm
happy
to
answer
that
again,
john
packham
for
the
record,
there's
a
variety
of
ways
that
that
can
be
done
technologically
and
so
not
to
not
to
dodge
the
question,
but
I
think
what
the
licensing
boards
would
like
for
us
to
consider
or
think
about
on.
G
The
whole
idea
is
to
make
this
as
seamless
as
possible
so
that
again,
every
two
years
for
most
professions,
when
you
renew
your
license:
you're
spending,
maybe
five
to
eight
minutes
again,
providing
very
valuable
information
that
the
state
and
other
agencies
would
use
to
inform
policy.
There
is
a
document
that
I
hope
is
out
there
as
an
exhibit.
It's
a
background
paper
put
together
by
about
a
dozen
of
us,
who've
been
working
on
this
issue
and
it
provides
kind
of
some
great
examples
of
how
other
states
have
done
this.
G
The
beauty
of
this
proposed
piece
of
legislation
is
that
we
do
not
have
to
reinvent
the
will.
There
are
a
number
of
state
models
out
there.
We've
received
wonderful
advice
from
both
the
national
conference
of
state
legislatures,
as
well
as
the
national
governors
association,
and
they
have
some
tried
and
true
models
out
there
ready
ready
to
roll.
G
If,
when
we
proceed
on
this,
so
again,
we
don't
have
to
reinvent
the
will,
there's
a
variety
of
ways.
We
can
do
this,
but
I
I
I'm
confident
again
that
this
is
worth
the
lift.
K
Thank
you
so
much,
and
so
I
guess
that
the
next
piece
would
be
are
all
of
the
boards
in
a
place
where
they
would
be
able
to
do
that.
I
know
that,
just
with
conversations
of
different
boards
throughout
different
times,
they
are
in
different
states
of
solvency
they're
in
different
states
of
having
data
tech.
I
know
that
with
one
board
a
few
years
back,
when
we
were,
they
were
still
doing,
many
of
them
still
doing
paper.
K
Application,
renewals
and
the
cost
to
go
to
an
electronic
version
was
going
to
be
north
of
30
000
and-
and
so
I
want
to
say,
a
couple
sessions
back-
we're
trying
to
figure
out,
maybe
how
to
pool
some
of
those
tech
needs,
I'm
on
some
of
the
smaller
boards,
and
so
just
knowing
that
this
is
a
really
big
swath
of
boards.
I'm
sure
you've
asked,
but
so
for
the
legislative
record
are,
are
all
the
boards
going
to
be
in
a
in
a
place
to
kind
of
dovetail
into
the
system
that
you're
talking
about.
G
Again,
john
packham,
for
the
record,
my
honest
answer
would
be
no.
They
will
not
all
be
in
the
same
place
by
my
count.
There
are
28
boards
that
license
or
regulate
anywhere
from
70
to
75
professions,
and
they
are
all
over
the
map
in
terms
of
the
software
they
use
for
licensure
renewal,
some
still
do
pencil
and
paper
and
so
forth.
K
May
madam
chair
yeah
that
I
and
I
appreciate
that-
and
I
appreciate
the
honesty
of
that,
because
it's
I'm
looking
at
the
end
of
the
bill
and
I
see
we've
got
different
implementation
dates
for
different
sections.
So
I
guess
for
those
boards
that
are,
it
looks
like
you've
done
an
assessment
of
the
board
so
depending
on
where
the
boards
are
at
you're
addressing
different
implementation
dates.
So
is
that
why
we're
seeing
different
ones
is
that
the
ones
who
are
already
doing
renewals
and
licensing
electronically?
K
G
Yes
again,
john
packing
for
the
record,
I
think
another
thing
I
would
point
out
is
that
the
time
in
which
health
professionals
renew
their
license
varies
again
from
board
to
board
some
are
on
a
rolling
basis.
Some
are
every
other
year.
I
believe
I'm
homie
to
this
the
state
board
of
medical
examiners.
G
You
renew
your
license
every
two
years
following
I
can't
remember
what
year
it
falls
on,
but
it's
by
june
30th
every
other
year,
and
so
the
way
to
think
about
this
is
that
the
the
data
will
not
start
rolling
in
immediately.
It
will
be
phased
in
over
the
next
couple
of
years,
but
in
two
or
three
years
we
will
begin
to
have.
G
Some
solid
data
again
on
health
professions,
not
just
practice-
characteristics,
socio-demographic
characteristics.
It
is
the
pleasure
of
hhs.
We
can
address
some
of
the
concerns
raised
in
a
previous
question
about
retirement
plans
or
likelihood
of
leaving
or
exiting
the
profession
or
the
state.
I
thought
those
are
important
questions.
G
K
Thank
you
so
much
and
then
for
for
the
boards
that
are
are
still
need
to
address
the
tech
issue.
I
guess:
does
this
re
require
them
to
figure
out
how
to
get
themselves
to
an
electronic
renewal,
or
would
they
stay
paper
and
then
just
like
an
insert
notification
in
your
renewal
letter?
That
says,
by
the
way,
go
to
this
link
and
do
this
this
electronic
or
this
survey
electronically,
until
such
point,
if
and
when
they
can
afford
the
cost
to
be,
you
know,
do
everything
online
and
with
all
the
tech.
G
Yeah
again,
john
packing
for
the
record,
I
think
the
answer
to
that
is
a
qualified,
yes
and-
and
that
is
I
think
this
begs-
that
we
need
to
be
flexible
in
how
this
is
implement,
implemented
and
rolled
out.
Some
states
have
a
super
agency
overseeing
licensing,
so
you're
dealing
with
one
type
of
software
and
one
common
way
of
renewing
your
license,
we're
different
again.
Each
board
is
different
and
I
think
we
will
have
to
be
flexible
and
patient
in
how
this
is
implemented.
Given
those
very
that
variation.
K
K
Okay,
so
just
for
the
record
on
this
in
subsection
five,
the
the
number
f
the
working
hours
and
then
the
location,
so
I
guess
what
you
would
want
to
know.
I
guess
what
are
you
looking
for
in
that?
What
would
when
we
go
when
someone
a
licensee
goes
to
to
complete?
That
is
that
going
to
be?
K
G
Yeah
again,
john
for
the
record,
let
me
just
kind
of
speak
to
the
the
general
intent
of
that.
I
did
a
survey
about
10
years
ago
on
registered
nurses
in
the
state,
and
one
of
the
things
that
I
discovered
in
that
survey
is
that
about
15
or
20
percent
of
those
nurses
worked
in
a
county
that
was
different
from
where
they
had
their
license.
Licensure
renewal
mailed
back
to
them.
G
So
while
it's
good
to
know
how
many
licensed
physicians
or
nurses
work
in
a
given
county
or
part
of
the
state,
we
really
need
to
know
where
they're
practicing,
where
they're
working
the
type
of
employer,
they're
working
for
you
working
in
a
hospital
or
a
clinic
setting
or
a
public
health
agency
and
so
forth,
so
that
the
intent
of
that
type
of
question
is
to
get
a
better
sense.
For
example,
with
respect
to
health,
professional
shortage
area
designation.
Are
you
providing
care
in.
G
Underserved
area,
what
percent
of
your
patient
panel
or
population
is
on
medicaid
and
so
forth,
so
that
as
we're
trying
to
assess
that
we're
getting
better
information
on
actually
where
you
practice
medical
care
as
well,
as
are
you
providing
patient
care,
a
number
of
physicians
work
in
administrative
or
university
settings?
This
will
give
us
a
better
handle
again
on
exactly
where
care
is
being
provided.
How
much
and
the
types
of
populations
those
professionals
are
serving.
K
K
I
guess
there
wouldn't
be
just
the
assumption
that,
just
because
your
licensing
type
is
listed
in
here
that
you
are
necessarily
working
in
the
healthcare
field,
that's
something
that
you
would
kind
of
ask,
first
and
foremost
for
some
of
them
they're
more
obvious,
like
physicians,
but
you
know
some
of
the
other
ones
they
may
or
may
not
be
in
the
health
care
field.
Like
you
think
of
social
workers,
some
might
be
in
child
welfare
and
some
might
be
in
in
medical.
So
I
guess
you
would
ask
that
question.
K
G
Yeah
again,
john
packard,
for
the
record,
our
idea
would
be
to
still
ask
every
health
professional
renewing
their
license
so
that
we
could
get
our
arms
around
that
for.
G
If
we're
getting
data
on,
for
example,
physicians,
whose
primary
specialty
is
family
medicine,
it's
important
to
not
only
know
kind
of
what
the
universe
of
family
medicine
positions
are
in
the
state
or
a
given
county
and
so
forth.
But
from
that
how
many
are
actually
providing
patient
care?
How
many
have
an
active
license?
How
many
are
working
full
time
and
so
forth,
because
we
know
that
for
every
100
physicians
in
family
medicine,
maybe
80
85
are
actually
in
direct
patient
care.
That's
upset.
Some
are
working
full-time.
Some
are
working
part-time.
M
G
Coverage,
this
type
of
data
will
really
inform
that
much
better
than
anything
we
currently
have
right.
Now
I
can
tell
you
how
many
family
physicians
are
licensed
in
clark
county.
I
have
no
clue
on
what
the
fte
of
that
number
is
providing
direct
patient
care
or
serving
medicaid
patients
or
working
in
medically
underserved
areas
and
so
forth.
We
need
answers
to
those
questions.
K
And
I
appreciate
that
you
keep
using
the
the
example
of
physicians,
but
when
I
just-
and
this
is
why
I'm
asking
for
the
record-
because
that
list
I-
and
I
tell
me
if
I'm
reading
it
wrong,
because
you
know
that
happens
too,
but
I
see
the
reference
to
all
of
the
healing
arts
so
you're
not
looking
just
for
a
subset
of
the
healing
arts.
You
do
mean
the
entire
list
of
everyone,
that's
in
the
629.031
okay.
K
G
John
pacquiao's
record,
I
think
a
real
quick
way
of
trying
to
illustrate
that
is
I'm
interested
in
the
state's
primary
care
capacity,
and
that
doesn't
mean
just
family
medicine
or
internal
medicine
docs.
It
also
means
hitting
our
arms
around
advanced
practice,
nurses
and
physician
assistants,
who
we
know
are
critical
to
primary
care
capacity
in
our
state.
So
pick
your
profession,
you
have
that
kind
of
variation
in
how
many
are
practicing,
how
many
are
providing
patient
care
versus
administrative
work
and
so
forth?
I
think
the
answer
to
that
question
is
yes.
K
There's
just
a
couple:
others
like
music
therapists
in
there,
they
may
or
may
not
be
in
a
medical
setting
and
then
what
is
the
other
one?
I
think
it's
a
sports,
a
sports
one
that
may
or
may
not
be
in.
I
think
it's
a
sports
trainer
that
may
or
may
not
be
in
a
medical
setting.
K
So
there
was
just
a
couple
of
them
that
I
thought
I
wasn't
quite
sure
and
we
should
flush
out
on
the
record
kind
of
what
you're
trying
to
scoop
up
and
and
the
scope
of
it,
because
it'll
be
a
lot
of
people
through
these
licensing
boards
and
and
some
of
them
ask
them.
I
know
my
licensing
board
asks
me
about
the
county.
I
work
in
and
the
kind
of
work
I
do
and
the
institution
I
work
for
and
all
that
kind
of
stuff.
So
I
don't,
I
think,
for
some
of
the
professions.
K
A
lot
of
this
won't
be
new,
I'm
thinking
about
how
I'm
going
to
answer
a
lot
of
these
things,
which
is
why
I'm
like
okay
working
hours
in
location-
it's
like
well,
you
know
I
spend
you
might
spend
part
of
my
time
out.
Patient
might
spend
part
time
inpatient.
So
I
guess
you
would
just
want
how
many
hours,
I'm
in
the
hospital
versus
how
many
hours
I'm
at
the
office
versus
how
many
hours
I'm
spending
in
patient
homes.
K
So
I
I
would
just
kind
of
report
that
I
guess
you're
going
to
give
me
a
free
form
box
to
report
that
as
more
of
a
qualitative
response
right
and
as
opposed
to
just
a
drop
down
and
with
numbers
and
then
you'll
sort.
All
of
that
out.
G
Again
for
the
record,
I
think
the
way
to
think
about
that
some
of
the
wording
or
grading
the
capture
of
that
data
are
to
be
determined
and
so
that
the
standard
methodology
in
this
line
of
research
is
to
phrase
a
question
in
a
typical
work
week.
How
much
of
your
time
is
involved
with
direct
patient
care,
administrative
work,
paying,
etc,
and
so
forth,
like
that.
G
I'm
I'm
hoping
that
the
bill
is
not
overly
prescriptive
on
wording
of
questions
and
questionnaires
and
so
forth.
That
leads
some
of
that
down
the
line.
As
long
as
we're
again
going
back
to
an
original
point,
I
made
finding
out
how
many
providers,
regardless
of
what
field
you're
in
or
providing
direct.
G
A
Thank
you
for
those
questions
and
those
answers
as
well.
I
also
want
to
remind
committee
members.
This
is
a
bill
that
came
out
unanimously
from
a
work
session
from
the
legislative,
an
interim
committee
on
the
let's
see,
which
one
was
it:
the
legislative
committee
on
health
care,
and
so
it
was
there.
K
Well,
I'll
just
I'll
just
say
that,
because
I
think
that's
important
point,
but
I
also
think
it's
important
to
note
that
the
legislative
record
that
we
create
in
committee
is
the
legislative
record
that
we
don't
have
a
precedent
for
referring
to
interim
committees
and
the
work
that
they
do
is
legislative
records.
So
if
that's
helpful
for
us,
but
the
only
formal
actions
that
that
we
take
are
when
we're
in
session.
So
I
always
think
it's
helpful
to
mention.
A
I
don't
disagree
and
I'm
not
discouraging
questions
and
creating
a
legislative
history.
I
just
wanted
to
make
sure
the
members
knew
that
I
know
that
it
was
left
out
during
the
introduction
of
the
bill,
and
I
know
that
the
interim
committee
wanted
to
make
sure
that
that
was
also
included
on
the
record
in
place.
People
had
some
additional
information
that
they
wanted
to
look
at
at
some
of
those
other
discussions
that
were
had
during
that
interim.
A
But
again,
I
would
encourage
anyone
to
ask
questions
and
create
that
legislative
history,
because
I
do
agree
that
we
do
need
to
have
the
intent
clearly
on
the
record.
Do
we
have
any
other
questions
from
committee
members
at
this
time.
A
C
C
They
had
been
able
to
use
one
of
the
wonderful
programs
from
the
federal
government
to
do
loan
repayment
to
some
of
their
health
care
professionals
and,
unfortunately,
because
nevada
didn't
have
sufficient
data
to
be
able
to
compete
well,
when
the
next
time
came
around
to
renew
that
kind
of
a
program
that
helps
us
to
recruit
healthcare
providers
and
specifically
healthcare
providers
too,
and
to
serve
low
income
and
underserved
populations.
C
So
I
just
want
to
underscore
that
this
is
not
just
about
collecting
data,
but
is
that
absolutely
about
collecting
enough
data
to
be
able
to
compete
well
and
to
know
where
we
need
to
invest
our
resources
and
energy,
but
also
to
be
able
to
draw
down
some
federal
resources
so
that
we
can
recruit
providers
particularly
to
hard
to
serve
communities
thanks.
So
much.
A
A
A
N
L
L
N
M
Gaffney,
madam
chair
and
members
of
the
committee
for
the
record
bradley
mayer,
b-r-a-d-l-e-y
m-a-y-e-r
partner
and
argentine
partners
representing
the
southern
nevada
health
district
today,
and
just
to
echo
some
of
joelle's
comments
really
want
to
thank
dr
hardy
and
dr
packham
for
bringing
this
bill
forward.
We
think
collecting
this
data
can
have
a
meaningful
impact
on
how
we
deliver
health
care
in
southern
in
in
nevada,
and
so
we
would
urge
your
support
of
this
bill,
and
I
thank
you
for
your
time.
A
Thank
you
at
this
time.
I
will
begin
testimony
in
opposition
to
senate
bill
379.
Is
there
anyone
in
the
room
seeing
no
one?
Is
there
anyone
on
the
zoo?
I
don't
see
anyone
there
broadcast
services.
If
we
can
go
to
the
line
in
opposition
testimony.
A
O
Thank
you
hi.
My
name
is
kyra
morgan
k-y-r-a-m-o-r-g-a-n
and
I'm
the
state
biostatistician
for
the
department
of
health
and
human
services.
I
just
wanted
to
provide
a
little
bit
of
clarity
on
data
collection
and
that
piece.
The
idea
behind
data
collection
is
that
the
survey
would
be
created
and
maintained
by
dhhs.
O
In
order
to
be
able
to
follow
that
leak
and
complete
the
survey,
there
really
is
no
technical
requirement
from
the
perspective
of
the
survey
distribution
on
behalf
of
the
boards,
with
the
exception
of
just
making
that
link
available
to
their
members,
the
data
would
then
be
submitted
via
an
individual.
Following
that
link,
they
would
be
taken
to
a
page
to
complete
the
questionnaire
and
the
responses
to
those
questions
would
be
directed
back
to
dhhs.
O
The
department
of
health
and
human
services
without
actually
having
to
be
received
by
the
boards
themselves,
and
so
I
think
that
that
not
only
eliminates
a
lot
of
workload
from
the
perspective
of
a
technical
requirement
on
the
boards.
It
also,
I
think,
eliminates
concern
that
those
responses
could
be
used
in
any
kind
of
you
know
negative
way
in
regards
to
confidentiality
of
the
data.
So
I
just
wanted
to
make
those
points
of
clarification,
and
that's
all
I
had
thank
you.
K
Thank
you
so
much.
I
appreciate
that
venture,
so
I
think
I
heard
a
piece
that
was
important,
which
was
you're
just
the
the
the
responsibility
of
the
board
will
just
be
to
make
the
link
available
to
their
licensees
so
and
that's
a
good
distinction
because
I
was
trying
to
figure
out.
Is
you
know?
Okay
are
boards
going
to
have
to
stand
up
an
electronic
web
base
and
some
are
moving
there
and
some
aren't
so?
K
Would
we
inadvertently,
you
know,
be
causing
some
of
these
smaller
boards
to
have
to
really
get
their
their
tech
in
line,
which
typically
just
means
more
licensing
fee
increases
which
are
fine?
If
you
need
them,
they
need
to
go
there,
but
you
know
was
that
going
to
happen
in
the
time
frame
that
this
implementation
date
was
looking
at
so
as
long
as
they
provide
the
information
to
their
licensee,
which
could
include
a
little
piece
of
paper,
a
little
notice
and
their
renewal
notice,
then
the
board
has
met
their
obligations
on
their
part
for
this
legislation.
O
Cairo
morgan
for
the
record,
that's
correct.
The
idea
with
us.
Maintaining
the
survey
would
be
that
we
would
take
the
burden
away
from
the
licensing
boards.
We
would
cover
the
technical
aspect
of
that
and
then
anyone
with
access
to
a
smartphone
or
computer
would
be
able
to
follow
that
link
and
submit
their
data
directly
to
dhhs.
A
J
Thank
you,
madam
chair,
miss
morgan
or
ms
dodson
on
the
line.
We
know
that
all
the
I'm
learning
today
that
all
of
the
boards
do
not
have
full
capacity
web
capability,
but
will
the
link
also
be
available
somewhere
on
their
website,
even
if
they
don't
have
the
ability
to
have
online
renewal?
I
I
heard
my
co.
My
assemblywoman
benitez
thomas
speak
about
a
piece
of
paper,
but
often
people
will
just
go
to
websites
to
look
up
stuff.
O
Yeah,
cairo
morgan
for
the
record,
with
the
department
of
health
and
human
services,
similar
to
what
dr
pakkam
stated
earlier.
There
are
a
number
of
ways
that
we
can
accomplish
this
and
I
think
the
bill
keeps
it
broad
as
to
not
prescribe
exactly
how
it
will
be
done,
but
but
absolutely
yes,
once
the
the
survey
is
created
and
a
link
is
provisioned,
then
that
link
could
be
distributed
via
an
email
list
serve.
It
could
be
printed
in
hard
copy,
it
could
be
posted
on
a
website.
O
There
are
a
number
of
ways
that
that
could
be
distributed,
and
typically
from
the
technical
perspective,
how
that
works
is
as
we
update
the
survey
as
long
as
we
keep
it
at
that
link
maintenance,
as
far
as
where
that
link
is
stored,
is
extremely
minimal,
and
so
so
the
short
answer
is
yes,
but
we
don't
have
the
exact
details
worked
out.
There
are
a
number
of
mechanisms
we
could
utilize.
A
Thank
you,
miss
morgan.
Do
we
have
any
other
questions
from
committee
members
seeing
none
if
we
could
go
back
to
the
zoom
for
any
other
additional
testimony
in
neutral
of
senate
bill
379,
I
see
miss
chapel
on
there.
I
don't
know
if
you
would
like
to
provide
neutral
testimony,
but
please
go
ahead.
If
you
would
like
to.
B
O
B
A
F
F
A
Thank
you,
and
with
that
I
will
close
the
hearing
on
senate
bill
379.
Next
we
will
move
to
senate
bill
391
and
I
will
open
that
hearing.
Welcome
senator
ratty
back
to
assembly,
human
health
and
human
services.
She
is
here
to
present
senate
bill
391,
which
revises
provisions
relating
to
dentistry.
Please
begin
when
you
are
ready.
C
C
Unfortunately,
then
there
was
a
pandemic
and
coming
into
this
legislative
session,
we
knew
that
we
probably
would
not
have
very
much
success
with
anything
that
had
a
significant
fiscal
note,
and
so,
during
the
interim,
as
we
got
to
the
work
session,
we
paired
that
list
back
significantly
and
really
eliminated
most
of
the
things
that
had
a
fiscal
note,
knowing
that
this
just
wasn't
the
time
to
be
looking
at
significant
expansions
of
program,
expansions
of
program
or
services.
C
So
one
of
the
things
that
we
learned
during
the
pandemic
is
that
we
had
this
whole
field
of
professionals
that
could
lean
in,
but
that
actually,
when
it
comes
to
oral
health,
we
have
very
little
infrastructure
built
in
terms
of
an
emergency
management
structure,
very
little
training,
very
little
identification
of
who's
available
and
how
they
would
be
available
and
that
that
was
something
that
we
needed
to
rectify.
So
that
was
the
first
piece,
and
the
second
is
that
our
state
nrs
lags
when
it
comes
to
the
concept
of
teledentistry.
C
So
we've
done
a
lot
of
work
in
the
legis
in
this
legislative
body.
Over
multiple
sessions
on
telehealth
and
telehealth
was
certainly
has
seen
a
dramatic
expansion
and
acceleration
of
acceptance
during
the
pandemic,
but
we
hadn't
done
a
lot
of
work
on
tele
dentistry,
and
so
we
wanted
to
to
update
the
statutes
when
it
came
to
teledentistry
so
to
be
very
clear
and
transparent.
C
Since
the
interim,
I've
had
a
couple
of
conversations
with
richard
whitley,
the
director
of
health
and
human
services,
about
some
of
the
challenges
for
recruiting
the
state's
own
dental
health
workforce.
So
these
were
not
issued
parts
that
came
out
of
the
interim
committee,
but
things
that
got
added
on
afterwards.
C
C
We
say
that
you
know
if
you're
going
to
have
a
full-time
job
with
the
state,
you
probably
shouldn't
be
doing
any
outside
work,
with
the
exception
that
our
public
health,
dental
hygienist,
is
a
part-time
position,
because
we
haven't
had
the
resources
to
fund
it
at
a
full
full-time
level
and
so
to
recruit.
Somebody
into
that
position,
you're,
basically
saying
hey
we'd
like
to
hire
you
for
a
part-time
job
and
you're
not
allowed
to
do
any
other
work
to
be
able
to
pay
your
bills,
which
is
just
impractical
on
its
face.
C
So
I'm
going
to
take
you
through
the
parts
that
are
very
specific
to
the
oral
health
staff,
because
I
don't
think
it
would
be
appropriate
to
ask
dr
capuro
to
do
those
piece
pieces
and
she
is
one
of
those,
those
team
members
and
then
I'm
going
to
ask
dr
capuro
to
take
you
through
the
very
specific
sessions,
special
sections
about
telehealth
and
and
emergency
response
in
the
oral
health
community.
C
C
Instead,
it
allows
for
an
and
you
they
could
be
a
licensed
protection
practitioner.
So
that's
one
option,
but
it
allows
for
an
alternate
option,
which
is
that
they
would
have
a
masters
in
public
health
and
have
graduated
from
a
coda
approved
dental
health
college,
so
they
would
have
completed
their
dental
health,
education
and
a
coda
approved
educational
facility
and
would
have
a
masters
of
public
health.
C
This
would
allow
for
recruitment
from
say
somebody
who's
been
working
in
academia
for
a
while
and
is
no
longer
using
their
practitioner's
license
and
just
hasn't
updated
that
license.
It
will
allow
for
much
greater
ease
of
recruitment
from
out
of
state.
So
when
a
dental
health
officer
would
come
here,
they
would
be
able
to
get
this
license.
That
is
basically
specifically
created
for
our
dental
health
officer,
so
you're
going
to
find
that
in
section
1.,
section
1.3
is
the
section
that
removes
the
prohibition
on
the
dental
hygienist
from
having
outside
work
again.
C
So
I
will
pause
there,
because
those
are
the
sections
of
the
bill
that
specifically
relate
to
the
licensing
of
the
dental
health
professionals
and
ask
madam
chair:
do
you
want
to
do
questions
and
answers
on
that
piece?
Only
or
would
you
like
dr
capro
to
go
through
the
tele-dentistry
and
emergency
response
sections
of
the
bill,
and
then
we
can
do
questions
globally.
C
So
those
are
the
highlights
of
the
our
dental
health
workforce
for
the
state
and
I'll
turn
it
over
to
dr
capro
and
ask
her
to
walk
through
the
tele-dentistry
and
emergency
response.
Sections.
P
P
I
just
wanted
to
kind
of
start
with
a
little
bit
of
background
that
the
landscape
of
healthcare
is
changing
as
our
service
delivery
models
and
so
to
adapt
to
these
changes
and
implement
lessons
learned
from
the
dental
community's
response
to
the
pandemic.
P
Research
has
identified
that
associations
between
poor
oral
health
and
chronic
disease
conditions
such
as
diabetes,
heart
lung
disease
and
stroke.
However,
in
2019
what
we
saw
was
35.3
percent
of
nevada
and
adults
reported.
They
had
not
visited
a
dentist
or
dental
clinic
within
the
last
year,
and
23
percent
of
nevada
adults
respond
respond
that
they
experience
anxiety
due
to
the
conditions
of
their
mouth
and
teeth.
P
We
know
that
low-income
adults,
individuals
and
families,
as
well
as
racial
and
ethnic
minorities,
are
disproportionately
affected
by
oral
health
problems,
and
the
kova
19
pandemic
has
aggravated
these
health
care
inequities.
It's
led
to
dental
office
closures
to
all
but
emergency
services
from
march
16th
to
may
4th.
We
had
a
cancellation
of
school-based
preventative
touch
points
and
there's
also
been
a
change
in
the
dental
workforce,
which
we
may
not
realize
for
several
years.
P
So
many
of
the
lessons
learned
from
providing
dental
care
during
the
pandemic,
including
the
expanded
use
of
teledentistry
and
inclusion
of
dental
professionals
as
emergency
responders,
is
addressed
in
this
bill.
Section
10
to
I'll
walk
you
more
in
detail
through
these
two
components
of
teledentistry
and
dental
emergency.
Responders.
P
There
are
numerous
dental
professionals
who
are
technically
trained
to
save
lives,
but
who
don't
do
not
have
the
specific
types
of
training
that
would
be
necessary
to
step
in
during
an
emergency
or
public
health
disaster,
and
this
lack
of
training
impairs
the
state's
ability
to
respond
quickly
and
efficiently
to
emergencies
and
disasters,
and
so
this
training
is
addressed
in
this
section
and
section
17
adds
a
dental
emergency
responder
to
the
committee
on
emergency
medicine
services.
P
The
last
component
in
the
bill
is
teledentistry,
so
just
as
a
little
bit
of
background
during
the
2020
stay-at-home
orders,
there
was
an
exponential
rise
in
the
number
of
teledental
visits
june
2019.
There
were
roughly
102
teledental
visits
for
medicaid
patients.
That
number
grew
to
934
in
may
of
2020,
and
this
increase
occurred
without
a
framework
for
safe
and
efficient
utilization
of
teledentistry.
P
The
section
19
to
21
includes
a
teledental
exam
that
meets
certain
criteria
as
an
option
to
fulfill
school
entrance
requirements.
Section
22
to
27
defines
what
tele-dentistry
is
section.
28-31
requires
the
dental
practitioner
to
follow
clinical
requirements,
ethical
standards
and
confidentiality
of
the
patient's
information
during
intelligent
visit.
P
It
also
outlines
the
practitioner
patient
relationship
and
outlines
informed
consent
as
well
section
32-35
ensures
communication
complies
with
all
hipaa
laws
and
the
patient
information
is
secure
and
encrypted
section
33
outlines
when
referrals
should
be
made
to
ensure
that
there's
adequate
in-person
care
when
it's
needed
section
34
requires
the
nevada
state
board
of
dental
examiners
to
adopt
regulations
governing
teledentistry
and
section
37
and
39
outline
a
one-time,
tele-dentistry
educational
course
of
for
dental
practitioners.
C
Thank
you
very
much,
dr
capero,
again
senator
julia
ready
for
the
record.
I
believe
that
is
the
entirety
of
our
presentation
and
we
stand
ready
to
answer
questions.
A
D
Thank
you,
madam
chair,
and
thank
you
senator
rowdy
for
bringing
us
bill
forward.
As
a
city
member
of
the
I
was
a
member
of
the
interim
health
committee.
However,
we
never
see
the
bills
actually
written.
It
was
also
a
general
concept
of
what
our
priority
going
to
be
for
bill
presentation.
So
I
have.
I
have
a
couple
questions
on
the
bill
under
section
one
number
one
and
two,
where
you're
actually
removing
the
requirement
that
they
be
a
licensed
dentist
in
the
state.
D
So
at
no
time
then
can
our
our
dental
health
officer
see
patients
practice
on
anybody,
give
advice,
consult
and
so
you're
removing
them
from
their
ability
to
practice
or
you
could
do
they?
Will
you
ultimately
require
that
they
get
a
license
in
the
state,
because
I
understand
that
perhaps
you
want
to
recruit
somebody
they're
not
currently
licensed
in
nevada
and
there
may
be
a
delay.
So
I
certainly
understand
that
you
may
be
able
to
recruit
them
and
not
have
them
licensed
at
the
time.
C
Thank
you
for
the
question.
Senator
reddy
through
you
chair
when
two
assemblywoman
titus.
C
C
Then,
if
you
would
follow
me
to
page
19
and
now
we're
looking
at
section
27.5,
this
is
the
section
where
the
board
shall,
without
the
criminal
clinical
examination
required
issue
the
limited
license
to
a
person
to
practice
dentistry
or
dental
hygiene
who,
and
so,
if
you
follow
that
on
to
page
20,
it's
a
person.
Who's
entered
into
a
contract
with
the
state
dental
health
to
serve
as
the
state,
dental
health
officer
or
the
hygienist
satisfies
the
requirements
of
those
chapters
pays
the
fee.
C
And
then
it
talks
about
the
limited
license
how
you
get
that
license,
how
the
fee
and
then,
if
you
go
to
five,
which
is
line
19,
shall
not
for
the
duration
of
the
limited
license,
engage
in
the
private
practice
of
dentistry
or
dental
hygiene
in
the
state
or
accept
compensation
for
the
practice
of
dentistry
or
dental
hygiene
in
this
stage,
except
such
compensation
may
as
may
be
paid
to
the
person
by
the
division
of
public
and
behavioral
health,
etc.
C
So
I
think
you
see
it
there
only
within
the
scope
of
his
or
her
appointment
as
the
dental
health
officer
or
the
dental
hygienist,
and
then
six
is
important
not
later
than
seven
days
after
the
termination
of
the
contract.
So
now
they
are
no
longer
an
employee
of
the
state,
provide
written
notice
of
the
termination
to
the
board
and
surrender
surrender
the
limited
license.
C
So
if
they
were
interested
at
that
point
in
going
back
into
practicing
dentistry
or
maybe
practicing
dentistry
for
the
first
time
in
the
state
of
nevada,
they
would
have
to
apply
for
and
obtain
their
license
to
practice.
So
I
hope
that
that
answers
your
question.
It's
the
combination
of
section
1
and
section
27.5
that
lay
out
what
the
new
path
is
and
what
the
requirements
of
that
new
path
are.
D
Thank
you
for
that
follow-up,
madam
chair,
so,
and
thank
you
for
that
clarification.
Another
question.
On
section
1.7,
you
say
that
if
a
medicaid
recipient
presents
to
the
emergency
room,
there's
a
list
of
dental
providers
that
must
be
given
to
them
or
or
displayed
somewhere,
is
it
in
my
practice?
D
We
always
made
sure
everyone,
those
who
weren't
on
medicaid
those
who
were
uninsured,
underinsured,
insured,
etc,
had
follow-up
instructions
and
had
access
to
lists
of
providers
that
we
would
refer
them
to
whether
it
was
the
ophthalmologist
whether
it
was
the
orthopedist
and
all
of
the
above,
including
a
dentist,
and
I'm
worried
that
why?
Why
are
you
signaling
out
that
the
medicaid
recipient
has
to
have
this
list
and
it
has
to
be
posted.
C
P
Thank
you
for
the
question
assemblywoman
titus
for
the
record.
I
am
dr
anthony
capraro,
so
this
language
specifically
talks
about
medicaid
recipients,
because
that
is
the
patient
pool
that
we
have
some,
that
we
know
that
services
are
provided
for
this
for
for
this
non,
but
they
come
in
I'm
sorry!
So
sorry,
let
me
let
me
kind
of
back
up
so
when
they
come
in
for
a
non-traumatic
dental
emergency
right
now.
P
Somebody
that's
seen
at
the
hospital
there's,
no
definitive
treatment,
that's
provided
and
so
providing
intelligent
services
to
that
group
will
ensure
that
they're
able
to
access
real-time
care
and
those
services
are
provided
under
medicaid,
and
so
that's
why
this
language
has
come
about
so
that
there's
some
type
of
information
when
they're
in
the
hospital
emergency
room
and
they
don't
go
from
that
emergency
room
back
to
the
emergency
room
when
their
condition
flares
up
again.
P
Adults
in
the
state
have
dental
coverage
for
emergencies,
but
we
are
trying
to
link
them
to
a
provider,
and
so
that's
why
this
is
more
specific
to
the
medicaid
patient.
But
I
would
hope
that
if
the
hospital
was
had
some
signage
about
intelligent
providers
or
the
use
of
tele-dentistry,
that
any
patient
in
the
hospital
would
become
aware
of
that
and
would
use
those
services.
D
Thank
you
for
that.
Just
a
clarification.
I
I
just
want
to
make
sure
that
the
medicaid
patient
isn't
seen
as
getting
lesser
care,
because
they're
they're
forced
to
use
the
tele-dentistry,
whereas
another
patient
might
be
referred
right
to
the
dentist,
and
so
I'm
just
an
in-person
visit.
So
I
just
want
to
make
sure
there's
parity
there
that
it's
just
not
medicaid
well
you're
on
medicaid.
So
now
you
have
to
do
this
tele-dentistry!
D
That's!
Actually!
You
know
I'm
just
always
anxious
when
a
certain
subset
is
provided
one
avenue
and
not
everybody
else
has
provided
that
ad
avenue
or
the
reverse.
So
I
needed
some
clarity
that
indeed
somehow
rather
this
helped
care
for
all
patients
and
I'm
just
not
seeing
that
so.
Thank
you,
madam
chair.
P
Oh
for
the
record,
I'm
dr
capraro,
so
we
are
not
trying
to
change
what
is
provided
in
the
hospital,
the
patients.
All
patients
would
still
have
to
be
triaged
in
the
hospital.
This
is
simply
a
referral
mechanism
to
ensure
that
those
patients
that
have
this
medicaid
benefit
are
able
to
receive
it.
So
it's
a
type
of
care
coordination.
C
So,
having
served
on
many
health
committees
with
assemblywoman
titus,
I
know
where
she's
going
with
that
line
of
questioning
and
I
would
again
julia
ready
for
the
record.
I
would
be
happy
to
look
into
it
a
little
bit
further.
C
So
this
is
really
trying
to
get
at
that
under
utilization
of
our
our
medicaid
dental
health
benefit,
but
I'm
happy
to
take
a
look
at
it
if
we
need
to
expand
the
language
that
anybody
who
has
a
dental
emergency
should
get
this
list.
I
think
that
will
happen
naturally,
but
that's
the
genesis
of
this.
If
that's
helpful,
for
contact
yeah.
D
Thank
you
senator
much
appreciated
and
much
very
clear.
Thank
you
and
thank
you,
madam
meister,
and
I
see
the
chairs
back.
So
thank
you.
Q
Thank
you,
madam
chair,
and
thank
you
senator
reddy,
for
bringing
for
this
sbe
391.
My
question
is
basically
a
question
of
clarity
or
understanding.
Q
I
I've
started
reading
in
section
section
10
through
16,
and
when
I
got
to
section
13
and
subsection
5
and
I'm
not
understanding,
you
know
where
it
says.
Q
A
dental
responder
may
not
be
held
civilly
or
criminally
liable
for
any
act
or
admission
performed,
while
providing
or
supervising
the
provisions
of
emergency
medical
care,
immunization,
medical
care
and
a
mobile
clinic
or
humanitarian
care.
In
accordance
with
this
section
and
the
regulations
adopted
pursuant
there
to
un
unless
the
act
of
or
admission
omission,
and
then
it
just
goes
down
to
five
subsection,
a
amounts
to
willfully
misconduct
or
gross
negligence,
and
I
wanted
to
know
who
determines
what
is
willful
misconduct
or
gross
negligence,
because
I'm
not
seeing
where
the
patient
in
this.
Q
In
this
you
know
who's
who's
under
the
care
of
a
dental,
responder.
Q
The
to
tell
you
know,
authorities
that
they
feel
like
there
was
misconduct
or
negligence.
Thank
you.
C
Thank
you
great
question,
again:
julia
raddy
for
the
record.
C
So
it
is
my
belief-
and
I
don't
believe
we
have
legal
counsel
with
us
today,
but
I
feel
relatively
confident
that
this
is
the
boilerplate
language
that
is
in
place
for
all
emergency
response,
and
so
it
acknowledges
that
in
an
emergency
response,
sometimes
our
providers
are
going
to
need
to
make
an
emergency
take
emergency
action
and
we
try
to
give
them
some
protection,
a
limited
protection
from
liability
if
they
are
offering
operating
operating
within
good
faith
within
the
scope
of
their
their
license
to
provide
assistance
to
somebody
in
an
emergency.
C
So
that's
the
first
sort
of
premise
specifically
getting
down
to
the
exceptions
to
that,
and
these
are
very
important
exceptions.
So
this
is
not
a
get
out
of
civil
court
or
get
out
of
criminal
court
free
card
and
going
back
to
my
monopoly
days.
I
guess
so.
It
does
not
amount
to
that
at
all,
because
if
there's
been
willful
misconduct
or
gross
negligence
or
they
were
under
the
influence,
you
lose
that
that
liability
protection.
C
If
you
will
now,
I
will
just
say
I
try
to
stay
out
of
the
judiciary
committee
as
much
as
possible,
because
there
are
lawyers
on
our
our
members
of
all
of
our
caucuses.
Who
really
know
this
significantly
better
than
I.
But
at
the
end
of
the
day,
the
decider
will
be
the
judge
right
because
really
this
is
about
if
there
were
a
criminal
charge
filed
or
if
there
were
a
civil
complaint,
so
that
patient,
if
they
had
had
perceived
that
they
had
been
harmed,
their
remedy
would
be
to
file
a
civil
complaint.
C
And
then
the
judge
would
look
at
that
civil
complaint
and
the
the
judge's
starting
point
would
be
well.
They
have
some
limited
immunity
here
because
it
was
an
emergency,
but
if
they
were
under
the
influence
or
it
meets
the
standard
of
willful
or
misconduct
or
gross
negligence,
which
are
legally
defined
terms
that
courts
are
accustomed
to
working
with.
So
this
is
really
all
about
that
system.
The
court
system
and
the
court,
and
specifically
the
judge,
would
be
the
person
who
would
decide
and
please
chairwind
feel
free
to
bail
me
out.
A
I
was
going
to
just
indicate
that
miss
ocran
is
actually
on
the
zoom
right
now
she
has
been
available
and
I
will
turn
it
over
to
clarify
or
confirm
what
you
had
just
mentioned.
Go
ahead,
miss
so
chris.
L
Q
Time,
thank
you
so
with
this
it
doesn't,
you
know
to
me.
It
looks
like
that
a
patient
does
not
have
the
ability
to
seek
restitution
for
what
they
feel
might
be
just
the
way
it's
worded
here
to
me,
that's
just
my
opinion.
Thank
you.
Thank.
C
You
I
I
appreciate
the
clarification
and
the
perception
I
again
julia
ready
for
the
record
again,
it's
relatively
standard
language
that
we
have,
I
think
in
in
all
of
our
emergency
response,
and-
and
I
just
want
to
be
very
clear-
it's
not
my
intent
that
we
are
removing
a
patient's
right
to
seek
remedy.
They
absolutely
have
that
right
to
seek
remedy.
C
A
J
If
my
memory
serves,
we
had
a
bill
just
yesterday
in
in
the
judiciary
that
talked
about
removing
the
dental
board
and
I'm
trying
to
figure
out
consolidating,
I
think
some
of
the
boards,
and
that
was
really
surprising.
So
I
actually
texted
my
doctor,
my
dentist,
to
ask
if
he
knew
anything
about
it
and
how
would
this
affect?
C
Thank
you
for
the
questions,
assemblywoman
julia
ready
for
the
record,
so
I
am
not
in
a
position
to
answer
that
question
in
that
it
was
not
my
bill
and
I
have
not
sat
on
the
committees
who
have
heard
that
bill,
so
I
can't
claim
to
be
be
familiar
with
it
in
a
detailed
way.
I
think
legal
counsel
might
be
best
again
to
chime
in
that
what
happens
if
two
bills
pass
that
are
in
conflict
with
each
other?
C
A
L
Carly
ocran
for
the
record.
I
would
need
some
additional
time
to
research.
The
specifics
of
that
bill,
but
senator
raddy
is
absolutely
correct
in
the
event
that
a
bill
passes
and
is
enrolled
that
conflicts
with
another
bill.
Our
office
has
a
review
process
whereby
we
ensure
that
substantive
conflicts
are
not
are
not
passed
without
being
addressed
during
the
legislative
session.
I
Thank
you
chairwin,
and
thank
you
for
your
presentation,
I'm
just
looking
at
sections
19,
20
and
21
we're
talking
about
tele-dentistry
and
dental
homes
and
virtual
dental
homes.
It
talks
about
public
schools,
private
schools
and
child
care
facilities
that
require
children
to
receive
dental
examinations.
I
C
P
Thank
you
for
the
question
for
the
record,
I'm
dr
capro.
It
is
specified
in
this
bill
and
I'm
looking
for
the
section.
I
think
it's
section
28,
that
a
person
that
provides
a
tele-dentistry.
P
Would
need
to
be
licensed
in
this
state,
so
they
would
need
to
be
licensed
in
nevada
and
so
the
virtual
dental
home
model.
What
what
I've
seen
in
other
states
when
they
have
a
virtual
dental
home
model,
it's
more
a
patient
who
doesn't
have
maybe
they're
living
in
a
rural
community.
P
There
isn't
a
dentist
near
them
and
so
they're
receiving
care
via
the
teledentistry
with
that
licensed
provider
in
this
in
the
state
that
they're
living
in
and
there's
also
language
regarding
informed
consent
that
determines
that
the
patient
is
in
the
state.
Dentist
is
practicing
it.
I
hope
that
answers
the
question.
I
I
P
I
I
would
say
that
I
guess
technically,
if
the
paid,
if
the
provider
is
licensed
in
multiple
states,
but
is
also
licensed
in
nevada,
so
they're
following
nevada
statutes
and
laws,
then
that
would
technically
be
possible.
P
But
the
the
provider
would
also
need
to
provide
referrals,
so
that's
also
outlined
in
the
bill.
So
if
the
patient
needed
care
that
the
dentist
could
not
provide
to
teledentistry,
they
have
to
be
aware
of
the
surrounding
provider
network
and
loca
and
refer
the
patient
to
care.
So
the
child
would
not
be
without
a
referral
network.
If
that
was
the
case,.
O
May
I
add
something:
this
is
a
jessica
wood
interim
state.
Hygienist.
I've
worked
in
this
model
before
so.
One
thing
that
might
be
helpful
as
a
visualization
is
to
think
of
this
as
kind
of
like
a
hub
and
spoke
model
where
the
dentist
may
be
in
one
location.
But
then
other
members
of
the
dental
team,
like
a
dental,
hygienist
or
a
dental
therapist,
would
be
out
in
say
a
rural
community,
and
so
they
are
collaborating
with
that
dentist
to
give
them
kind
of
the
oftentimes.
O
The
dental,
hygienist
or
the
dental
therapist
will
be
collecting
some
sort
of
information,
whether
it's
x-rays,
intra-oral
pictures
and
sending
it
back
to
that
dentist
who's,
not
actually
in
that
community,
maybe
not
even
in
the
state.
C
The
only
piece
that
I
would
add
to
that
is
that
it
does
end
up
actually
becoming
critically
important
for
a
state
of
nevada
that
has
so
many
of
our
communities
that
are
right
on
the
border,
and
so,
if
you
think
about
some
of
our
eastern
nevada
communities,
where
a
good
chunk
of
their
care
might
come
from
salt
lake
city
or
southern
nevada
communities,
where
a
good
chunk
of
their
care
might
come
from
across
the
border
over
in
arizona
or
right
here,
where
we
have
some
good
relationships
with
our
california
providers.
A
Thank
you
I'm
looking
around.
I
know
that
there
were
several
kinds
of
questions,
but
I
believe
other
people
asked
those
questions
and
they
were
answered,
but
I'm
just
doing
one
more
round
around
here:
okay,
seeing
no
more
questions
at
this
time,
we
will
begin
testimony
in
support
of
senate
bill
391.
If
we
can
go
to
anyone
in
the
room.
I'd
ask
you
to
approach
the
table
state,
your
name
and
please
limit
your
testimony
to
two
minutes.
H
Thank
you,
members
of
assembly,
health
and
human
services
for
the
record.
My
name
is
eddie
avalisser
eddie
ab-l-e-s-e-r,
representing
the
nevada
dental
association
this
afternoon.
Thank
you
all
for
hearing
the
bill
and
the
testimony,
as
provided
by
senator
ratty.
We
want
to
extend
our
appreciation
to
senator
ratty
for
sponsoring
and
bringing
the
bill
out
of
the
interim
the
hard
work
that
was
done
in
the
interim
on
this
topic
and
thank
dr
caprero
for
her
efforts
in
bringing
these
much-needed
pieces
of
policy
before
you.
H
A
A
Okay,
if
this
time
we
can
start
opposition
testimony,
is
there
anyone
in
the
room
to
provide
opposition
testimony
seeing
none
is
there
anyone
on
the
zoom
to
testify
in
opposition,
don't
believe
we
have
anyone.
I
don't
see
anyone
and
broadcast
services
if
we
can
go
to
the
line
in
opposition.
N
M
Begin
hi,
my
name
is
dr
villa
sastry.
Sorry,
I
was
trying
to
figure
out
the
the
the
navigation
of
the
unmute
mute,
I'm
the
ceo
of
teledintry.com
and
I
actually
am
in
support
of
this
bill.
I
just
wanted
to
give
a
call
and
thank
you
to
all
the
members
on
the
call,
as
well
as
dr
center
as
senator
randy,
as
well
as
dr
anthony
capril,
for
putting
together
this
legislation
and
want
to
offer
my
full
support
for
it.
Thank
you
so
much.
A
N
N
N
M
Hello
good
afternoon,
this
is
dr
palarasio
for
the
record.
My
last
name
is
p,
a
l
e
r,
a
cio,
and
I
am
a
licensed
practicing
dentist
in
nevada
and,
at
the
same
time,
president
of
las
vegas,
dental
association.
I
am
here
to
post
sb
391,
the
state
dental
health
officer
needs
to
be
a
qualified
nevada
licensed
dentist.
M
M
The
current
state,
dental
hygienist
officer,
is
already
working
outside
of
her
position,
thus
possibly
violating
current
state
law.
Why
would
the
nevada
legislature,
who
are
responsible
for
protecting
the
citizens
of
nibara,
propose
sb
391
to
have
an
unlicensed
and
unqualified
individual,
be
the
state
of
dental
health
officer?
M
Thank
you
very
much
and
for
the
record
also,
I
am
a
long-time
medicaid
provider
and
there's
a
lot
of
problems
that
we
encountered
and
I
would
be
glad
to
testify
during
legislative
committee.
If
there's
a
need-
and
I
would
like
to
discuss
the
big
disparity
of
a
dental
care
under
medicaid
program,
I
would
love
to
receive
any
telephone
calls
from
any
of
our
legislators.
A
Thank
you,
and
at
this
time
I
will
go
to
any
neutral
testimony.
Do
we
have
anyone
testifying
in
neutral
in
the
room,
seeing
none
do
we
have
anyone
on
the
zoom
to
testify
in
neutral.
N
O
Having
that
clinical
experience
for
our
policy,
development
has
been
a
great
boon
to
us
in
trying
to
improve
our
dental
policy
and
our
dental
programming,
and
we
appreciate
the
help
thanks
very
much.
N
M
Hi
this
is
dr
villa
sastragon,
ceo
of
teledancer.com.
I
just
wanted
to
speak
in
support
of
dr
kapuru
and
everything
that
she
did
last
year
with
regards
to
how.
A
A
A
C
Thank
you,
madam
chair.
I
appreciate
the
opportunity
first
of
all,
just
want
to
let
the
committee
know
that
nobody
has
contacted
me
with
any
concerns
about
the
bill
directly
or
asked
for
any
conversation
or
any
changes
to
the
bill
so
sitting
here
in
the
hearing
today
was
my
first
knowledge
that
there
were
any
concerns.
None
of
this
came
up
on
the
senate
side
either.
C
I
would
also
like
to
note
that
the
changes
in
the
bill
with
regard
to
the
current
health
staff
are
neutral
and
not
intended
to
be
specific
to
any
one
individual.
They
came
about
because
of
a
conversation
that
I
had
with
the
director
about
the
challenges
for
these
particular
positions
and
again
the
chief
dental
officer
position.
This
aligns
it
very
similarly
to
what
we
do
with
the
chief
health
officer,
and
I
think
that
there
are
some
very
legitimate
reasons
as
to
why
we
would
want
to
do
that.
C
I
am
disappointed
that
anybody
wants
to
make
this
about
anyone,
individual
or
personal,
and
just
would
give
you
my
assurance
as
the
chair,
that
this
is
about
good
policy
and
is
about
nothing
more
than
that.
So
with
that,
I
know
that
there
were
some
questions
and
concerns.
If
there's
anybody
on
the
committee,
that
is
looking
specifically
for
an
amendment
that
they
would
like
to
this
bill.
That
would
help
you
to
support
it.
C
A
Thank
you
and
that
I
will
close
the
senate
the
hearing
on
senate
bill
391
and
I
will
open
the
hearing
on
senate
bill
329
and
I
see
senator
lang
here.
Senate
bill
329
revises
provisions
related
to
competition
in
healthcare
markets.
I
believe
she
is
presenting,
along
with
several
others
that
are
on
the
zoom
and
potentially
here
in
the
room
as
well.
So
I
will
let
you
begin
when
you
are
ready.
I
Thank
you,
madam
chair
and
members
of
the
committee
for
the
record,
I'm
roberta
lang.
I
represent
senate
district
7
in
clark
county
and
thank
you
for
the
opportunity
to
present
senate
bill
329
before
you
today.
This
bill
aims
to
enhance
transparency,
around
health
care
consolidation
and
limit
anti-competitive
contract
practices
between
hospital
systems
and
health
insurers
in
nevada.
I
I
According
to
a
new
report
from
the
national
academy
for
state
health
care,
policy
quote:
rampant
consolidation
in
nearly
every
state
has
created
dominant
health
care
systems
that
use
anti-competitive
contract
practices
to
charge
super
competitive
prices,
especially
to
commercial
insurance
plans.
End
quote:
the
kovit
19
pandemic
is
expected
to
further
accelerate
this
consolidation
and,
according
to
the
kaiser
family
foundation,
a
large
body
of
research
demonstrates
that
provider
consolidation
leads
to
higher
health
care
prices
for
private
insurance.
I
At
the
same
time,
these
increased
prices
have
little
or
no
impact
on
quality
of
care,
utilization
rates
or
efficiency.
Nick
vada
currently
does
not
have
many
tools
to
review
or
regulate
consolidation
in
the
health
care
market.
We
have
a
pretty
high
bar
before
mergers
and
acquisitions
are
referred
by
state
reviewed
by
state
agent
agencies.
I
I
Joining
me
to
provide
additional
information
regarding
the
real
world
effect
of
these
issues,
as
well
as
to
discuss
the
technical
details
of
the
bills
and
amendments
are
stacy.
Sasso,
executive,
director
of
the
health
services
coalition,
maya
holmes,
healthcare
research
manager
for
the
culinary
health
fund,
bob
bond
director
of
public
policy
for
the
culinary
health
fund
and
katie
goodingson
senior
health
policy,
researcher
for
the
source
on
health
care,
price
and
competition,
and
I
will
exchange
seats
with
chelsea
capiro
with
the
griffin
company
who
will
direct
the
questioning
to
the
appropriate
person.
A
N
Good
afternoon
for
the
record
stacey
sasso
executive
director
for
the
health
services
coalition,
we
want
to
thank
senator
lang
for
bringing
this
needed
bill
forward
and
working
with
us
and
other
stakeholders
on
the
language
and
intent.
We'd
also
like
to
thank
chairwoman
nguyen
vice
chair
peters
and
the
committee
members
for
their
consideration
of
sb
329.
N
The
health
services
coalition
represents
25
union
and
employer
sponsored
health
plans
in
southern
nevada,
including
mgm
void,
gaming,
firefighters,
metropolitan
police
department
and
numerous
unions,
including
the
culinary
electrical
workers,
plumbers
and
others.
The
coalition's
main
focus
is
to
bring
affordable
quality
health
care
to
our
estimated
300
000
covered
lives.
It's
the.
N
N
B
Good
afternoon,
thank
you
for
hearing
this
bill.
Thank
you,
madam
chair,
and
the
rest
of
the
committee
for
the
for
the
record.
My
name
is
bobette
bond.
I
am
the
culinary
health
fund
policy
director
and
the
culinary
health
fund
is
a
non-profit
health
fund
that
provides
comprehensive
benefits
for
60,
000
members
and
their
dependents,
so
about
125
000
lives.
We
cover
we're
part
of
the
coalition
that
you
just
heard
about
from
stacy,
and
our
labor
management
partnership
includes
most
of
the
hotels,
downtown
casinos,
airport
food
services
and
laundries
in
las
vegas
industrial
laundries.
B
Our
priority
is
to
ensure
access
to
high
quality
and
affordable
healthcare
in
nevada,
for
both
public
and
private
payers
and
patients.
Healthcare
dollars
are
precious
and
in
limited
supply.
I
think
you've
heard
a
lot
about
that
this
session
as
every
session
healthcare
is
a
critical
need,
though,
and
so
we
have
to
be
effective
stewards
of
those
monies,
so
we
we
spend
our
time
trying
to
find
what
is
the
cost
drivers?
B
Where
is
their
opportunity
to
improve
the
system,
to
reduce
price
control,
price
and
increase
access
and
also
educate
our
members
and
improve
quality?
It's
kind
of
like
that's
the
space
that
we
try
to
fill
in
this
community
nationally,
as
you
just
heard
from
senator
lang,
there's
been
tremendous
consolidation
in
the
health
care
industry.
B
We
know
it's
happening.
We
know
consolidation
is
happening
in
the
markets
because
we
see
it
in
our
claims
in
our
contracts.
We
see
it
when
we
see
that
a
hospital
system
has
hired
an
er
group
that
now,
instead
of
being
owned
by
er
doctors
in
nevada,
is
owned
by
a
private
equity
company.
We
have
a
couple
of
experiences
of
that
happening
in
las
vegas
with
the
er
group,
specifically.
B
But
there's
not
a
lot
of
transparency
about
it,
for
you
as
policy
makers
or
for
us
to
really
understand
the
trends
and
the
impact
on
price
and
nevada
is
just
behind
on
hospital
transparency
behind
on
healthcare,
transparency
in
general
and
trying
to
identify
our
policy
issues.
Price
is
a
primary
factor
behind
our
health
care
costs
and
compared
to
other
nations,
and
consolidation
and
lack
of
competition
is
a
major
high
price
issue.
B
So
we
go:
let's
go
to
slide
two
so
you're.
Seeing
who
the
coalition
is.
Prices
for
health
care
have
increased
much
faster
than
inflation.
You
heard
senator
lang
talk
about
it
and
this
slide
is
a
just
a
testament
to
between.
In
the
last
20
years,
the
cost
of
hospital
services
has
increased
200
percent
when
overall
inflation
in
that
time
has
create
increased
54.6
to
compare
how
that
has
hit
the
all
of
us
college
tuition
in
that
time
has
increased
170
percent.
B
Other
medical
services
have
increased.
120
percent
housing
has
increased
60
percent,
so,
while
the
average
overall
inflation
rate
has
gone
up,
54.6
hospitals
are
at
200
percent
next
slide
just
to
further
demonstrate
how
that
feels
to
us.
If
those,
if
the
same
thing
happened
in
the
supermarket
we'd,
now
be
paying
50
over
the
last
20
years,
we'd
be
paying
57
for
a
set
of
oranges,
eggs,
the
cardinal
exit
cost
of
65
and
a
gallon
of
milk
would
cost
us
160.
B
There's
two
kinds
of
there's
really
three
kinds
of
consolidation
going
on:
one
is
horizontal
mergers
which
I'm
going
to
talk
about
now.
Another
is
vertical
mergers
and
then
the
private
equity
issues,
so
basically
studies
show
that
healthcare
consolidation
results
in
higher
prices
and
without
improving
quality
and
that's
happening
when
hospitals
by
other
hospitals
or
doctor
groups
by
other
doctor
groups.
That's
what
horizontal
mergers
are
you
see
an
increase
in
prices,
you
see
an
increase
in
premiums,
you
see
reduced
wage
growth
for
the
workforce
and
you
don't
see
improvement
in
quality
in
general.
It
does.
B
It
seems
like
it's:
it's
not
an
indicator
of
increased
quality
next,
so
that's
horizontally
by
each
other
vertical
mergers.
It's
where
one
group
buys
a
lower
group
in
the
healthcare
tier
like
a
hospital
buys
a
doctor
group,
and
we
have
some
state
laws
about
that
in
this
state.
But
we
also
have
some
cases
where
doctor
groups
are
buying.
I
mean
are
being
bought
by
hospital
groups
that
results
in
higher
clinical
prices.
B
It
also
results
in
higher
hospital
prices
and
again
little
to
no
quality
improvement.
Specific
ways
that
this
happens
is
when
a
hospital
buys
a
physician
group
and
it
can
then
start
charging
a
facility
fee
for
a
physician
group,
so
you're
paying
an
additional
fee
for
no
additional
care
because
of
who
owns
the
facility
because
of
who
phones
the
facility.
Now,
when
a
hospital
group
buys
a
physician
group,
so
that's
one
really
clear
way
that
prices
are
increasing
next.
B
Are
we
all
done
so?
In
the
last
five
years,
there's
been
over
10
billion
dollars
of
private
equity
investment?
That's
gone
into
health
care
nationally
and,
as
I
said,
we're
seeing
that
in
nevada
now
and
we
are
trying
to
get
our
arms
around
it.
So
state
and
federal
authorities
exist
to
protect
this
competition.
You
can
kind
of
see
the
ag
bill
that
moved
through
session
this
time
that
you
guys
probably
heard
there's
an
ag
bill
that
tried
to
think
about
how
to
better
look
at
these
mergers.
B
But
these
mergers
fly
too
far
below
the
radar
screen
for
the
ag's
to
be
involved
in
them
and
they're
not
about
the
ag
only
gets
involved
when
a
merger
is
so
large
that
it
really
changes
the
entire
market
all
at
once,
and
what
we're
seeing
is
incremental
change
that
you
don't
see
at
all.
You
just
feel
it
and
you
pay
for
it,
so
it
can
take
years
and
tremendous
resources
to
do
this
through
the
courts.
B
And
so
what
we're
trying
to
do
is
increase
our
opportunity
to
interrupt
the
price
trends
that
are
going
on
with
eliminating
some
of
the
non
competitive
languages.
In
our
contracts,
but
also
create
enough
transparency
to
see
what's
going
on,
even
if
we
can't
interrupt
it
through
some
transparency
laws
that
we
don't
have
right
now
and
that's
our
goals,
so
I'd
like
to
pass
it
on
to
maya
holmes
from
culinary
health
fund
who's
going
to
talk
about
the
bill
itself.
Thank
you.
R
For
the
record,
I
am
maya
holmes
with
the
culinary
health
fund.
Sb
3329
will
ensure
that
nevada
has
accessible
data
on
what
is
happening
in
our
healthcare
markets.
Collecting
basic
information
on
health
care,
mergers
and
acquisitions
is
critical
for
the
state
policy
makers,
patients
payers,
employers
and
other
stakeholders
to
understand
consolidation
in
our
health
care
markets
and
guide
decisions
that
protect
competition
and
patient
choice.
Sb
329
will
also
prohibit
anti-competitive
contracting
practices
that
hospitals
and
health
care
providers
with
market
dominance
can
demand
because
payers
need
to
have
them
in
their
networks.
R
Sb
329
will
address
market
players
using
their
market
power
to
drive
up
prices
and
thwart
competition
based
on
price
and
quality.
Recent
settlements
and
two
major
anti-trust
lawsuits,
one
in
california
and
another
in
north
carolina,
ended
with
many
types
of
anti-competitive
contracting
or
ended.
I'm
sorry
ended
many
types
of
contracting
anti-competitive
contracting
practices
through
those
settlement
agreements.
However,
the
settlements
do
not
set
legal
precedent
and
only
apply
to
the
health
systems
involved
in
the
lawsuits.
R
Anti-Competitive
contracting
practices
like
all
or
nothing
in
anti-steering
and
anti-tiering
provisions
prevent
health
plans
from
directing
or
incentivizing
or
communicating
with
patients
to
move
them
towards
lower
cost
higher
quality
care.
These
provisions
also
prevent
other
hospitals
from
benefiting
if
they
offer
better
deals
or
higher
quality.
They
also
stop
patients
and
health
plans
from
shopping
for
and
getting
the
best
deal
that
is
appropriate
for
themselves.
R
Specifically,
sb
329
has
two
primary
provisions.
The
first
provision
provides
important
transparency
into
consolidation
of
our
health
care
markets.
The
bill
will
require
reporting
on
health
care
deals
in
nevada,
involving
hospitals
and
physician
groups
within
60
days
after
they
have
cur
occurred,
and
this
is
just
basic
summary
information
that
will
be
reported
and
it's
listed
out
in
the
bill,
but
we
do
not
expect
this
to
add
any
significant
administrative
burden.
This
should
all
be
easy
and
accessible
information.
R
Sb
329
also
requires
dhhs
to
post
the
information
contained
in
the
notices
on
an
internet
website
maintained
by
the
department
connecticut
already
does
this
and
has
done
so
for
several
years.
Dhhs
will
also
prepare
an
annual
report
regarding
market
transactions
and
concentration
in
health
care,
based
on
the
notices
and
post
the
report
on
an
internet
website
maintained
by
the
department,
the
bill's
other
major
provision
will
make
specific
anti-competitive
contract
provisions,
unfair
trade
practices,
prohibited
provisions
will
be
void
and
severable.
R
The
prohibit
the
prohibitions
will
also
only
apply
to
new,
not
existing
contracts,
so
it
will
not
disrupt
existing
agreements.
The
specific
contract
provisions
between
hospitals,
health
systems,
providers
and
health
plans
that
will
be
prohibited,
as
in
fair
trade
practices,
are
anti-tiering
and
anti-steering
provisions.
The
anti-trust
language.
We
want
this
bill
to
end,
prohibits
flexibility,
to
promote
programs
that
help
patients
find
the
lowest
cost
and
highest
quality
care
in
the
network
based
on
patient
choice
and
priority.
R
That
is
what
steering
does
in
plan
design,
instead
of
forcing
us
to
treat
every
hospital
the
same,
which
is
what
the
monopoly
like
language
does
we
net?
We
now
would
have
to
I'm
sorry.
We
now
have
to
contract
with
all
hospitals
the
same
way,
regardless
of
the
rates
they
are
charging
or
their
quality.
This
prevents
plans
from
educating,
directing
or
incentivizing
patients
to
utilize
lower
cost
higher
quality
care.
R
R
We
usually
want
this
too,
so
patients
are
not
confused
about
where
to
go
in
a
network,
but
when
a
hospital
system
controls
the
majority
of
beds
in
a
community
and
they
force
this
provision
into
the
contract,
we
can't
negotiate
on
an
even
playing
field.
If
we
need
our
members
to
have
access
to
hospitals
near
them,
we
have
to
take
all
the
hospitals,
the
company
controls,
even
if
one
has
quality
problems,
even
if
it
drives
up
health
care
costs
or
is
a
lower
quality
facility.
R
Sb
329's
prohibitions
on
anti-competitive
contracting
provisions
like
anti-tiering
and
anti-steering
and
all
or
nothing
will
not
limit
the
ability
of
a
hospital
providers
or
plans
to
negotiate
networks
or
what
those
networks
will
look
like.
It
will
simply
affect
language
that
restricts
the
ability
of
plans
to
communicate
with
educate,
direct
or
incentivize
their
members
to
utilize,
lower
cost,
higher
quality
care,
which
benefits
the
patients
and
the
pla
and
the
plans.
R
S
In
our
research.
We
look
at
what
other
states
are
doing
and
as
maya
described,
there
were
two
big
lawsuits
alleging
any
competitive
use
of
any
tearing
or
any
steering
clauses
and
after
those
lawsuits
were
settled
after
great
time
and
expense.
Many
states
have
sort
of
taken
up
the
mantle
and
asked
what
they
could
do
to
prevent
some
of
this
legislation
as
well
as
you
can
see
from
my
map,
massachusetts
is
the
only
state.
S
That's
actually
banned
these
provisions
already
in
statute
and
their
law
passed
more
than
two
decades
ago,
at
the
federal
level
congress
considered
banning
these
provisions
in
a
couple
of
bills.
Last
year
and
one
in
the
lower
healthcare
costs,
act
of
2019
actually
came
close
to
passing
and
the
cbo
issued
a
report
about
that
bill
and
found
that
nationwide.
If
there
was
a
ban
on
any
tiering
any
steering
clauses
nationwide,
the
country
would
save
over
a
billion
dollars
over
10
years.
S
S
Similarly,
for
all
or
nothing
clauses,
the
other
clause
that
sb
329
would
prohibit.
Massachusetts
is
the
only
state
that
has
a
restriction
and,
frankly,
it's
a
pretty
narrow
restriction.
It
only
applies
in
narrow
network
or
tiered
network
plans.
But
again
this
clause
was
considered
in
that
lower
health
care
costs
act
in
congress
and
so
far
this
year,
six
states
are
considering
banning
these
provisions.
S
So
I
helped
write
some
model
legislation
for
the
national
academy
of
state
health
policy
on
nashp,
because
they
were
getting
interest
from
states
to
ban
the
use
of
these
clauses
in
most
insurance
contracts,
and
so
just
to
summarize,
there's
growing
interest
in
the
ways
that
state
laws
can
support
any
trust
enforcement
by
banning
specific
provisions
that
have
been
used
to
drive
up
prices
by
dominant
health
firms-
and
I
am
happy
to
take.
A
Questions,
and
are
you
all
ready
for
questions
at
this
time?
Okay,
wonderful!
If
we
can
go
to,
I
will
start
well
I'll,
just
start
down
the
road
here.
If
I
can
start
with
assemblyman
hafen.
R
Thank
you,
madam
chair,
a
number
of
questions,
but
I
just
kind
of
like
to
start
with
trying
to
get
a
better
understanding
of
what
we're
doing
here.
Under
the
current
law,
a
hospital
and
the
the
doctor
groups
are
covered
under
one
plan.
It's
it's
kind
of
one
negotiation,
and
what
we're
trying
to
do
is
is
split
that
up,
I
think
the
term
used
was
monopoly.
C
B
B
B
B
What
the
second
thing
we're
trying
to
do
is
we
have
contracts
where
this
monopoly
language
is
in
the
contracts
and
it's
not
a
monopoly
between
a
hospital
and
a
doctor
right
now.
So
much
that
we're
talking
about
today,
but
there
it
is
a
hospital
system
that
has
a
monopoly
number,
a
percent
of
beds
that
has
created
a
monopoly
in
the
area.
They
have
over
half
the
beds
hospital
beds,
and
so
they
insert
language
into
the
contract.
B
That
requires
you
to
not
do
any
of
these
other
creative
things
about
working
with
a
physician
group.
That
is,
you
know,
not
their
physician
group
or
a
hospital
that
is
not
in
their
system.
That
has
a
great
like
women's
health
program,
and
they
call
that
anti-steering
that
when
we
tell
our
patients
that
there's
a
better
place
to
go,
they
call
that
steering
the
patient
and
so
our
contracts
with
one
hospital
system.
Don't
allow
that
and
it
then,
because
it
doesn't
allow
in
one
system
it's
impacting
all
the
systems,
because
we
can't
do
it
anywhere.
B
We're
not
the
only
ones
that
face
this
issue,
but
we're
the
ones
bringing
it
to
the
to
the
legislature
today.
Was
that
helpful.
A
R
And
I
I
under
fully
understand
that
the
the
way
the
insurance
and
the
hospital
systems
work
is
is
very,
very
confusing
myself.
I
struggle
with
trying
to
figure
out
where
I
can
go
and
where
I
can't
go.
R
My
concern
here,
though,
is,
is
right.
Now,
under
the
current
system,
I
have
a
fairly
comfortable
way
of
of
navigating
when
I
go
to
the
hospital
that
some
of
these
things
are
going
to
be
covered
and
it
appears
under
this
bill.
The
intent
is
to
actually
break
that
up.
So
if
I
end
up
at
a
hospital,
that's
under
my
plan,
the
radiologist
group
may
or
may
not
be
covered
under
this
plan,
and
that
just
draws
some
very
serious
concerns
to
me
and
and
and
hopefully
you
could
address-
why
that's
a
benefit.
R
B
I'm
above
it
bond
for
the
record
assembly
in
haven.
I
don't
think
that's
the
that
is
not
where
this
bill
is
intended
to
go
where
this
bill
is
intending
to
go,
is
if
you're
in
negotiations
to
the
hospital-
and
you
know
the
quality
scores
or
the
the
the
price
of
that
hospital
is
higher
in
price
and
lower
in
quality
than
other
hospitals.
B
Then
you
want
to
be
able
to
negotiate
a
rate
with
that
hospital.
That
is
takes
that
into
account
where
you
can
negotiate
a
different
rate
for
one
hospital
than
another.
That's
one
thing
that
we
would
like
to
do
in
our
contracts.
So
that's
why
we
talk
about
it
when,
in
monopoly
terms,
their
language,
that's
being
inserted
into
contracts,
does
not
let
us
do
that,
so
we're
not
trying
to
eliminate
that
hospital
from
the
contract
we're
trying
to
be
able
to
steer
people
to
it
in
different
ways.
B
So
if
it's
the
most
expensive
contract
we
have,
then
we
would
tell
our
patients
look.
You
can
go
to
these
other
three
places
for
less
money.
This
is
your
cost
share.
It's
lower
somewhere
else
or
it's
better
quality
we'd
be
able
to
work
with
one
hospital
on
their
special
like
women's
health
program.
That's
a
real
example
we're
dealing
with
right
now,
so
it's
not
about
breaking
up
the
hospital.
The
doctors
at
all.
P
O
O
O
If
you
go
to
radiologist
a
it's
going
to
cost
you
this,
if
you
go
to
b,
it
may
cost
you
this.
Some
of
our
contracts
restrict
us
from
even
giving
information
about
costs
to
different
what
different
hospitals
may
cost.
If
we
go
there
or
if
we,
if
you
know
a
member
says
how
much
will
this
knee
surgery
cost
us,
you
know
we
we
struggle
with
being
able
to
direct
them
and
say
if
you
want
to
go
to
hospital
a
versus
hospital
b,
here's
what
that
price
difference
is
going
to
be.
C
B
For
the
record
just
to
follow
up,
that's
that
is,
that
is,
I
think,
it's
important
to
say.
We
think
that
fixing
this
will
impact
the
networks
really
much
better,
because
right
now,
our
only
alternative
is
to
eliminate
this
hospital
system
from
our
network,
and
we
don't
want
to
do
that.
We
want
people
to
have
choice,
but
we
want
the
members
to
drive
that
choice.
We
want
them
to
be
informed
about
which
hospital
they
want
to
go
to.
B
So
if
you
want
to
go
to
the
great
women's
hospital,
because
it's
got
a
high
quality
care
around
deliveries,
then
we
want
to
be
able
to
save
that
information.
But
if
you
don't,
if
you
want
to
go
to
whatever
hospital
your
favorite
obstetrician
is
practicing
at
then
you
should
be
able
to
do
it,
but
this
is
going
to
be
the
price
difference.
We
can't
do
that
right
now,.
A
And
go
ahead
and
follow
up,
and
I
would
just
ask
the
presenters
if
you
could
just
have
one
person
respond
to
the
question
I
know.
Sometimes
you
may
need
additional
people,
but
I
don't
wanna.
We
have
quite
a
few
people
that
want
to
ask
questions,
so
I
want
to
make
sure
we
have
the
opportunity
to
do
so.
Go
ahead
with
your
follow-up.
R
But
thank
you,
madam
chair,
and,
and
I'm
sorry
I'm
just
I'm
not
following,
maybe
because
I'm
not
an
insurance
provider
or
a
doctor,
but
first
I
hear
that
that
we
we
want
to
split
up
the
monopolies
and,
and
now
we're
talking
about
we
want
to.
We
want
to
we.
We,
as
the
insurance
provider,
want
to
steer
patients
to
one
hospital
or
the
other,
and
so
I'm
really
confused.
Now
what
it
is
that
we're
actually
trying
to
do
here.
O
For
the
record
chelsea
caprara,
this
is
not
about
breaking
up
monopolies.
This
is
about
having
the
opportunity
and
the
ability
to
provide
our
members,
the
patients,
your
your
constituents
with
information
about
their
health
care
and
chelsea
corporal
for
the
record.
If
it's
helpful,
I
can
follow
up
with
you
offline
as
well.
As
I
know,
the
chair
said
there
might
be
some
more
questions.
I.
R
J
So
let
me
just
follow
up
with
assemblyman:
hey,
hey
ben
okay:
it's
been
a
long
day
all
right,
so
I
had
a
high
risk
pregnancy
many
years
ago
and
my
ob
gyn
really
wanted
me
to
go
to
a
particular
hospital
where
I
could
receive
good
care
for
the
delivery
of
that
child
and
that
child
was
not
in
that
hospital
was
not
in
my
group
plan.
J
I
want
to
go
to
this
other
hospital
and
I
would
be
able
to
go
there
or
would
allow
you
as
the
group
to
have
that
hospital
as
options,
because
you
look
at
your
body
of
insureds
and
see
that
you
have
older
patients
and
that
there
may
be
a
need
for
a
place
for
women
to
go
for
high
risk
pregnancies,
and
maybe
the
group
that
you
have
a
contract
with
doesn't
have
the
facility
in
there,
and
you
could
add
that
group
another
hospital
into
the
options
for
that
group.
That's
what
I'm
trying!
N
Okay,
sorry
having
a
little
issue
here,
I
don't
know,
can
I
get.
B
Okay,
madam
chair,
sorry,
we're
sorry
we're
like
too
many
speakers
assembly
woman.
I
think
it's
the
second
what
you
said
it
wouldn't
it
would
allow
the
it
would
allow
the
insurance
plan
flexibility
to
create
opportunities
for
you
to
go
to
the
hospital.
You
might
pay
a
different
amount
for
that,
though,
and
that's
called
steering.
B
Alternatively,
the
hospi.
The
insurance
plan
would
not
put
that
hospital
on
network,
and
then
you
wouldn't
have
the
opportunity
to
go
there
at
all.
So
it's
a
way.
Our
perception
of
this
is
it's
a
way
to
keep
all
the
hospitals
contracted,
but
have
options
that
are
more
or
less
expensive,
depending
on
the
cost
and
the
quality
of
that
hospital,
and
that
would
be
a
decision
that
you
could
make
with
your
doctor.
It
increases
the
decision
making
you
can
make
with
your
doctor.
O
O
B
We
follow
the
health
services
coalition,
a
series
of
scores.
Some
of
them
are
built
into
our
contracts,
for
example,
what
the
rate
of
sepsis
is
that
a
hospital
would
have
or
how
many
readmissions
the
hospital
has.
Those
are
numbers
that
we
collect,
but
it's
also
public
record.
There
are
public
databases
that
are
created
on
cms,
which
manages
medicare
and
medicaid.
They
have
a
set
of
scores
that
they
use
to
compare
every
hospital
in
the
country
to
each
other.
B
There's
a
company
called
leapfrog
that
has
a
national
set
of
scores
where
they're
comparing
quality
and
there's
other
tools
out
there
too,
that
are
used,
but
those
are
the
two
biggest
ones.
Those
are
the
two
most
commonly
used
ones,
so
they
allow
you
to
see
how
hospitals
are
doing
across
certain
factors,
and
then
you
can
bring
that
into
the
way
that
you
want
to
contract
and
the
way
that
you
want
to
educate
your
membership.
O
B
A
bit
bond
for
the
record:
that's
exactly
what
we're
trying
to
get
to.
We
would
like,
if
their
ob
department
is
really
great,
to
be
able
to
sort
of
highlight
that
in
the
way
we
structure
the
plans
and
every
plan
is
going
to
structure
the
the
way
it
works
best
for
their
members.
There's
no
like
one
structure,
but
if
everyone's
contracted
and
we
can
tear
or
steer,
we
could
design
a
plan
that
says
okay,
this.
B
This
hospital
has
the
best
ob
scores,
so
we're
going
to
have
the
lowest
rates
to
go
to
this
hospital
because
they
have
the
best
outcomes
versus
we're
not
going
to
kind
of
tell
you
that
about
the
radiology
program,
we're
going
to
tell
you!
You
know
what
we
know
about
the
radiology
program
for
those
scores
that
we
can
get.
So
it's
it's
to
help
us
develop
some
consumer
tools
and
some
patient
choice,
while
keeping
all
the
hospitals
contracted.
B
O
H
Thank
you,
chair
and,
and
thank
you
senator
and
all
the
presenters
question
on
the
economics
of
this
I
mean
regarding
section
20.9
c,
you
know
my
understanding
is
that
hospital
firms
are
able
to
provide
contractually
lower
prices
when
they
are
assured
of
higher
volumes,
and
so
assuming
that's
the
case
when
you
have
the
the
the
force
fragmentation
under
this,
which
I
think
is
what
sally
when
haven
was
getting
at.
How
would
this
lead
to
anything
but
higher
prices?
H
It
would
just
seem
to
me
that
that
section,
subsection
c
and
d
of
section
20.9,
I
believe
it
is
but
would
just
work
together
to
make
health
care
more
complex
and
more
expensive
for
patients.
Thank.
H
B
B
B
We
don't
really
see
the
quality
in
this
hospital
for
this
procedure,
we'd
like
to
talk
about
different
rates,
and
I
think
what
will
happen
is
it's
possible
as
you're,
suggesting
that
the
rate
at
one
hospital
would
go
up
for
us
not
from
not
for
members,
but
for
us
to
pay
that
rate,
but
in
others
it
would
go
down
and
being
able
to
steer
people
to
the
best
care.
For
that,
for
that
procedure,
they
need
will
help
us
manage
costs
and
outcomes.
B
So
I
think
we
do
get
value
out
of
a
rate
of
having
all
the
hospitals
contracted,
but
we
have
no
flexibility
in
this
tiering
and
steering
language.
So
if
we
remove
that
tyrion
string
language,
then
everything
else
is
handled
in
the
contract
and
if
the
hospitals
want
to
charge
us
more
because
we
now
are
able
to
steer
our
patients,
that's
a
negotiation.
We're
going
to
have
with
the
hospitals
instead
of
just
a
prohibition.
A
Next,
I
have
assemblywoman
titus.
D
Thank
you
senator
lang
for
bringing
the
bill
forward
because,
frankly,
I
think
your
concerns
about
health
care
costs
are
definitely
accurate
as
far
as
the
health
care
costs
going
up
and
what
are
we
doing
to
lower
health
care
costs
and
having
having
had
to
give
up
private
practice
after
15
years
in
private
practice
and
go
work
for
a
local
hospital,
because
I
couldn't
afford
to
be
a
private
practitioner
any
longer,
I'm
acutely
aware
of
the
problems
in
health
care
and
cost,
and
I
have
concerns
about
what
this
bill
does,
however,
and
and
perhaps
the
opposite
of
what
you're
trying
to
solve.
D
One
of
the
things
I
have
a
question
on
is
that,
as
as
a
insurance
provider
or
payer
as
you
are
the
culinary
union,
I
see
you
being
almost
guilty
of
the
very
thing
you're
trying
to
then
have
phys
say:
physicians
or
providers
are
because
do
your
culinary
union
members
have
options
of
another
insurance
plan
other
than
what
you
give.
B
D
B
D
All
right,
thank
you
for
that.
The
next
thing
is
when,
when
you
make
a
contract,
when
you
have
a
contract
as
a
provider,
I
know
many
years
ago
there
was
something
called
the
stark
laws
that
came
out
and
there
was
already
federal
legislation
that
was
put
together
to
prevent
some
things
where
a
provider
would
own
a
in
the
interest
of
lowering
cost
on
the
federal
government,
recognized
that
providers
shouldn't
own
the
x-ray
equipment
that
they
then
refer
their
patients
to,
and
there's
been
national
concerns
about
that,
indeed,
increasing
the
cost
of
health
care.
D
D
So
I
I
think
the
concept
and
the
solution
would
be
if
we
truly
did
know
and
ask
all
across
the
board,
what's
the
actual
cost
of
doing
business,
because
I
think
that
for
me
would
be
the
solution
to
the
cost
reimbursements
and
I
think,
I'm
not
sure
you're
asking
the
providers
the
right
questions
as
opposed
to
preventing
them
from
joining,
because
I
had
to
join
something
else,
because
I
couldn't
stay
in
business
and
to
go
after
the
providers
and
even
making
a
felony
if
they
on
on
20.9.
D
That
becomes
a
felony
if
we're
we're
trying
to
stay
alive.
Because,
frankly,
most
of
these
mergers
are
happening
not
because
they
want
to
make
more
money.
But
frankly
they
want
to
stay
in
business.
They
want
and
they
can't
survive
in
a
small
group
of
five
because
they
don't
get
reimbursed
enough.
So
I'd
support
efforts
along
your
line
to
let's
find
out
what
the
true
cost
of
doing
business
is
and
then
make
sure
that
you
cover
the
cost
of
doing
business.
D
And
then
you
know,
there's
not
the
winners
and
losers
that
I
see
right
now
that
you
then
are
in
the
driver's
seat
of
negotiating
these
contracts,
and
for
for
me
this
does
absolutely
the
opposite
of
the
problem.
I'm
hearing
you're
trying
to
solve,
which
is
allow
your
members
to
know
where
they
could
go
and
what
those
costs
really
are
generally
are
and
then
direct
them
that
if
you
go
to
this
hospital,
this
cost
is
this,
and
I
do
that
now
in
healthcare-
and
I
have
my
my
patients
say:
okay
call.
D
B
M
B
Felony
is
not
about
the
merger
it's
about
it's.
It
makes
it
prohibitive
to
have
these
language
in
the
contract
that
doesn't
allow
us
to
tear
and
steer
that's,
what's
being
prohibited
that
that
language
no
longer
can
be
used
in
contracts
to
prohibit
us
from
doing
the
tearing
that
we're
talking
about
or
the
steering.
That's
all
we're
trying
to
stop
and
the
reason
it's
a
felony
is
that's
the
way
the
state
law
is
written
about
what
happens
in
a
situation
where
you're
dealing
with
this
anti-trust.
D
Well,
I
have
a
lot,
but
I'm
I'm.
Thank
you,
madam
chair,
for
the
questions,
and
I
appreciate
everyone's
time.
O
Thank
you
chair
and,
if
you
would
indulge
me,
I
have
questions
on
both
section
one
of
the
bill
in
section
20.9.
If,
if
I
may,
I
will
start
with
my
clarifying
legal
questions
in
section
one,
there
were
a
couple
of
concerns
about
the
breadth
of
which
this
section
would
cover
mergers
and
acquisitions.
O
As
we
know,
not
every
hospital
or
provider
network
in
this
state
is
isolated
to
the
state
of
nevada.
So
in
this
language
would
this
pertain
to
only
mergers
and
acquisitions
in
the
state
of
nevada
and
then
my
second
question,
which
I
think
can
be
answered
by
legal
at
the
same
time
is
we
talk
about
other
affiliations
between
physician
group
practices?
We
talk
about
physician
group
practices,
hospitals
does
this
pertain
to
those
like
situations
in
which
we
have
an
insurance
company?
S
B
Bond
through
the
record
assemblyman
peter
assemblyman
peters,
are
you
directing
that
to
me?
Are
you
directing
that
to
legal?
Because
I
know
what
the
intent
of
the
bill
is.
It
would
probably
the
intent
of
the
bill.
Is
that
your
second
question?
Yes,
it
would
capture
those,
and
your
first
question:
would
this
cross
state
lines
would
be
no
because
it's
a
state
statute,
so
you
know
hca
hospital.
They
have
three
hospitals
in
las
vegas.
This
would
only
impact
them
in
las
vegas.
It
wouldn't
impact
them
in
arizona.
O
L
L
Oh
no,
no
problem
so
I'll.
Take
the
questions
one
at
a
time,
starting
with
whether
or
not
this
applies
to
providers
that
have
groups
that
are
in
other
states.
So
it
is
possible
that
this
bill
would
apply
to
providers
that
had
groups
in
other
states
if
those
groups
merged
with
groups
in
this
state,
so
the
committee,
if
it
so
chose,
could
amend
the
bill
to
make
the
bill
only
applicable
to
provider
groups
in
this
state.
L
I
think
the
committee
would
need
to
specify
exactly
how
that
would
look
and
then,
with
regards
to
the
other
question
section,
one
of
the
bill
does
not
apply
to
insurers.
So
I'm
not
sure
if
that
addresses
your
two
concerns,
but
that's
how
the
bill
works
as
it's
currently
drafted.
O
Thank
you
yeah.
My
question
is
as
related
to
groups
such
as
optum,
who
have
like
provider
umbrellas
that
they
also
have
under
their
insurance
network
and
as
they
purchase
those
providers
under
their
umbrella.
Would,
though,
would
that
scenario
be
captured
under
the
data
collection
described
in
section
one,
or
would
it
be
excluded?
Because
optum
is
an
insurance
company.
O
Thank
you
for
that
clarification
and,
if
I
may
chair,
I
have
additional
questions
related
to
section
20.9,
I'm
taking
that
as
a
yes
go
ahead.
Okay,
so
intent
of
this
language.
O
Now
I'm
not
familiar
with
contract
language
in
your
negotiated
contracts
with
healthcare
providers,
and,
as
I
read
some
of
this,
I
got
concerned
about
situations
in
which
you
would
want
to
have
those
hospitals
and
their
the
attached,
like
groups
in
the
same
coverage
right
and
if
that
was
your
only
option,
which
is
one
of
the
scenarios
we
have
in
northern
nevada.
O
We
have
two
major
hospital
groups
and
I'm
I
often
patients
prefer
to
be
using
those
those
network
groups
because
they
and
they
know
that
they're
covered
under
their
insurance
or
they're
connected
through
either
how
their
they
share
data
or
how
they,
how
they
bill
or
whatever.
O
O
Would
that
qualify
as
this
requires
the
third
party
to
place
all
providers
of
health
care
affiliated
with
the
business
entity
in
the
same
tier
or
is
there
a
separate
language
in
the
contract
that
says
upon
contracting?
We
limit
you
to
only
our
our
our
groups
and
net
under
our
network
umbrella
and
they
are
listed.
O
B
B
It's
we
would,
I
think
what
we
would
do
is
your
second
example,
but
I
want
to
make
sure
I
understand
what
you're
saying
what
we
would
do
in
the
contract
is.
Actually
I
probably
I
just
need
you
to
explain
it
again.
O
B
Thank
you
for
the
record
about
that
fund.
We
actually
have
language
in
some
of
our
contracts
that
we
have
been
unable
to
remove
through
contract
negotiations.
That
says,
you
are
not
allowed
to
tear
or
steer
in
any
way,
and
when
we
say
what
we
want
to
do
is
start
a
program
where
we
can
provide
a
special
benefit
inside
our
fund
or
inside
our
coalition
to
allow
people
to,
for
example,
go
to
a
women's
health
program.
B
That's
only
at
one
hospital,
and
we
want
to
make
a
separate
price
for
that,
and
we
want
to
have
our
maternity
patients
go
there.
That's
called
tearing,
that's
called,
steering
we're
not
allowed
right
now
to
do
it
because
of
that
one
sentence
in
our
contract
that
prohibits
tearing
and
steering-
and
that's
all
we're
trying
to
do-
is
remove
that
one
sentence
and
then
allow
the
rest
of
the
contract
to
flow
as
a
contract
would.
O
B
A
bit
fun
for
the
record.
I
think
the
language
is
just
nationally
established
language
and
was
suggested
by
our
consultant
to
make
sure
that
we
captured
the
issues
that
staring
and
tearing
are.
I
think
it
just
became
a
more
specific
explanation,
but
the
intent
is
what
you
just
said:
that's
where
you
go.
O
O
Okay,
because
I
I
I
have
I
don't
want
to
have
a
scenario-
come
up
where
an
insurance
provider
has
made
a
has
a
contract
with
a
health
provider,
that's
that
in
inadvertently
puts
them
in
a
situation
where
they
have
restricted
their
network
to
only
that
provider,
umbrella
right
and
then
put
them
in
this
category.
And
so
that's
my
concern
wanting
to
get
on
the
record
that
the
intent
is
not
to
capture
those
scenarios
that,
in
that
good
faith
negotiation,
those
situations
can
happen.
O
But
what
this
is
really
trying
to
get
at
is
that
anti-steering
anti-tiering
clause
that
prohibits
you
from
doing
those
things
within
your
map,
your
member
groups
and
then
my
third
question
and
I
apologize
sheriff.
I
can
go
on
one
more
question.
My
other
question
had
to
do
with
whether
how
this
language
that
you're
presenting
here
in
section
20.9,
compares
to
the
language
that
was
referenced
in
maryland.
S
Sorry
this
is
katie
goodickson
for
the
record.
I
think
you
meant
massachusetts.
S
The
language
is
quite
similar.
I
would,
I
think
that
any
cheering
any
steering
is
the
same.
I
would
have
to
go
back
and
read
that,
but
I
can
get
the
the
statute
citation
or
something
for
the
committee,
and
it
is
very
similar
to
massachusetts
on
the
annie
tearing
any
steering
portion
of
the
bill
that
one
clause.
O
A
K
Well
maybe
we
have
one
here,
assemblyman
or
elector,
who
might
have
sat
around
and
read
one
of
these
contracts
before
I
can
imagine
that
most
of
us,
although
if
we
work
in
health
care
or
might
see
things
kind
of
on
the
ward
level
or
the
floor
level,
if
you
will
of
things,
you
know
that
what
gets
negotiated
and
what
gets
contracted
are
rarely,
I
think,
kind
of
seen
or
or
read
by
people
right.
Some
of
these
things
are,
I
imagine,
considered
proprietary.
K
So
it's
not
something
where
we
have
a
bunch
of
these
that
we
can
lay
around
laying
around
that
we
can
read.
So
I
thought
what
might
be
helpful
is
really
clearly
on
the
a
b
c
and
d
on
these
shell
knots
and
we've
been
kind
of
focusing
on
a
on
the
steering
right,
the
incentives.
K
But
if
you
could
go,
if
you
could
do
an
example
of
what
the
shell
knot
is
and
then,
if
enacted,
what
the
will
allow
is
right
just
so
that
we
can
hold
an
example
of
each
one
of
these
things
in
our
head.
K
I've
heard
a
reference
to
a
women's
clinic,
but
I
don't
think
I
have
it
quite
contextually,
and
so
I,
if,
if
we
could
do
that,
I
think
that
might
be
how
helpful
to
kind
of
give
us
and
also
good
for
the
legislative
record
on
you
know
kind
of
concretely
where
we,
where
we
are
in
the
status
quo
on
a
through
e
and
then
where
the
the
bill
will
will
lead
us
with
a
through
e.
K
Like,
for
example,
on
a
I'm
like
incentives,
well
is,
I
don't
know,
do
we
have
incentives
defined
somewhere?
I
guess
do
when
we
think
of
incentives.
Is
it
just
like
a
bonus
in
an
hsa?
Is
it
a
lollipop?
You
know
what
I
mean
so
so
I
guess
that's.
What
I'm
looking
for
is
take
it
down
to
that
that
the
level
where
a
little
bit
more
pedestrian
and
outside
of
contract
law
an
example
for
a
through
e.
B
All
right,
I'm
gonna,
try
to
do
this
unless,
unless
somebody
else
on
the
phone
can
do
it
faster
than
me,
somebody
else
on
the
line
so
either
katie
or
either
stacy,
who
does
with
their
contracts
all
the
time
is
one
of
you
more
comfortable
just
going
through
this.
B
Individual
okay,
they
might
have
to
help
me
a
little
bit
with
this.
So
a
restricts
a
third
party
so
from
offering
incentives.
We
want
to
remove
that
so
that
we
can
offer
incentives
for
a
covered
person
to
use
a
specific
provider,
meaning
they
could
have
a
lower
copay.
That
would
be
an
incentive.
They
have
a
lower
copay
to
go
to
a
specific
provider
right
now,
that's
prohibited
that
would
be
allowed
under
number.
A
b
restricts
the
third
party
from
assigning
providers
in
healthcare
into
tears.
B
Right
now,
we
have
to
have
all
of
our
hospitals.
Have
completely
equal
communication
materials,
co-pays
deductibles
listing
in
our
director.
Everything
has
to
be
exactly
the
same
amongst
our
providers.
If
we
had
tears,
we
could
say
okay
for
knee
surgery
at
this
hospital,
it's
going
to
cost,
and
we
do
this
in
our
benefit
design
and
our.
B
B
S
So
I'll
jump
in
this
is
catherine
dixon
for
the
record,
so
this
would
be
if
a
health
system
said
you
need
to
put
all
of
all
of
our
clinics
in
the
same
tier
at
the
same
cost
sharing.
So
if
you
want
to
put
our
women's
health
at
the
lowest
cost
pay,
you
have
to
also
put
our
radiology
group
and
our
mri
machines
at
that
same
group.
So
it
just
allows
it
prohibits
a
health
system
from
saying
everybody
has
to
be
at
the
same
tier
and
gives
the
insurer
or
the
payer
the
flexibility
there.
S
I
think
I'll
just
keep
going
by
that.
The
fourth
one
is
to
restrict
require
a
third
party
to
contract
with
the
business
entity
affiliated
with
the
provider
as
a
condition
of
entering
that
contract.
So,
for
example,
if
you
wanted
to,
if
an
insurer
wanted
to
contract
with
only
the
main
hospital
and
not
all
of
their
affiliated
clinics
that
they
felt
were
of
lower
quality,
this
would
prevent
the
health
system
from
only
offering
a
contract
that
was
for
all
of
those
systems.
S
S
That
one
is
more
about
exclusive
contracting;
that
one
is
where
the
provider
prohibits
the
third
party
from
contracting
with
somebody
else.
So
if
you
want
to
contract
it
with
us,
we're
the
only
ones
that
can
provide
that
service.
K
Thank
you
so
much
that
helps
in
my
apologies,
because
pieces
of
the
the
audio
were
not
great,
and
then
I
have
not
great
ears
and
my
hearing
aid
broke
and
I
can't
continue
until
next
week.
So
I
just
want
to
clarify,
I
don't
have
them
in,
and
the
work
life
is
hard.
So
when
we
were
talking,
I
think
it
was
on
the
b
and
then
the
c
where
we
were
talking.
K
So
it's
the
price
tearing
it's
not
necessarily
a
categorical
tearing
okay
and
then
that's
that
also
the
same
then
for
c
it'd
be
the
categorical
tiering
of
or
not
categorical,
but
pricings
in
different
tiers
versus
them
versus.
I
think
we
were
talking
about
a
women's
clinic
and
an
mri
group.
All
groups
having
to
be
like
one
cost
to
the
to
the
person
to
the
insurer
to
the
insured
person.
B
Catherine
you're
going
to
have
to
help
because
I'm
I'm
I'm
sorry
for
the
record
by
that
bond.
I
want
to
make
sure
that
you're
responding
to
exactly
what
what
she's
saying
in
the
last
part
of
her
sentence,
I'm
not
sure
that's
what
that
is.
Oh.
S
Okay,
so
this
is
katherine
goodickson
for
the
record
on
part
c,
it
would
depend
on
how
the
insurer
has
structured
those
tiers.
S
So
typically
they
are
different
cost
either
co-pays
or
cost
sharing,
but
it
actually
would
be
up
to
the
insurer
to
determine
what
it
would
mean
to
be
in
tier
one
versus
tier
two,
but
but
the
the
language
there
is
just
prohibiting
the
health
system
from
requiring
everything
to
be
in
the
same
tier
with
that
same
cost
sharing
or
co-pay
or,
however,
those
tiers
have
been
structured
and
then
the
restriction
on
b
is
just
a
restriction
to
even
putting
them
in
tears.
K
Is
this
the
normal
course
of
business,
then
that
then
right
it
did
that
the
the
way
that
these
the
the
trends
of
the
contracts
and
the
way
that
the
contracts
are
folding
are
coming
out
are
doing
are
across
the
board,
no
matter
where
you
go
to
contract
you're,
going
to
run
into
kind
of
these
tier
restrictions
and
and
the
the
networking
contracting
to
contract
with
the
d
right
contracting
with
affiliates
like
if
you're
going
to
contract
with
me,
you
got
to
have
the
whole
caboodle
kind
of
thing.
K
B
Bumped
up
the
record,
I
don't
know
how
unique
it
is
and
we
don't
do
it
now.
We
don't
do
it,
because
if
it's
held
up
in
one
contract
it
would
be
held
up
it.
We
can't
do
any
tearing
or
steering
so
I
don't
know
how
common
the
tearing
is
or
the
steering
in
plans.
We
just
don't
do
it
and
the
coalition
doesn't
do
it
and
what
we'd
like
is
to
in
order
to
make
sure
we
keep
all
of
our
hospitals
contracted
the
ability
to
do
it.
K
So
it's
just,
it
sounds
like
that
sounds
like
de-aggregating
and
then
negotiating
all
of
these
pieces
out
and
then
we're
in
chapter
5,
9a
right
so
we're
in
the
chapter
on
unfair
trade
practices
and
everything
like
that-
and
I
guess,
as
as
I
read
the
the
chapter-
and
this
is
you
know,
general
law,
applicable
law-
there's
nothing
really
targeted
towards
health
care
in
here
right
now,
but
I
understand
that
the
chapter
has
been
applied
kind
of
towards
healthcare,
so
we
have
some
case
law
out
there
on
on
some
of
these
things,
I
would
imagine
like
the
the
the
non-competes,
although
I
think
that's
what
d
would
be
interpreted
as
the
contract
with
our
affiliates,
but
I
don't
actually
don't
see
anything
in
here.
K
K
But
I
guess,
am
I
correct
in
that
assumption
as
well,
that
that
that
five
598
gets
used
as
a
tool
in
health
care,
but
I
would
guess
from
the
shell
not
not
as
not
as
frequently
as
as
we
might
think,
or
it's
an
arduous
process,
or
it
feels
like
in
when
it
comes
specifically
to
conversations
about
these
contracts.
The
level
is
is
a
it
different
than
it
might
be
for
investigating
other
types
of
acquisitions
and
such.
B
But
unfor
the
record,
I
think
we
might
need
catherine
again
on
this,
but
I
what
what
I
meant,
what
I'm
understanding
from
what
you're
saying
is
the
unfair
trade
practice
language
and
that
language
was
just
referenced
in
statute
because
we
want
it
to
be
unfair.
We
don't
have
any
other
hooks
on
this.
We
don't
have
any
other
way
to
prohibit.
We
don't
have
a
fine,
we
don't
have
a
way
to
you
know
otherwise,
penalize
a
contract
that
has
this
in
it.
I
think.
What's
going
to
happen,
is
we
just
won't
have
this
language
anymore?
B
S
So
to
just
jump
in
this
is
katie
good
extent
for
the
record,
other
states,
so
california
and
north
carolina,
california,
brought
it
under
state
any
trust
law,
their
lawsuit
against
sutter
against
state,
any
trust
law.
So
at
a
certain
level,
this
does
rise
to
in
any
trust
violation
that
could
be
brought
under
state
any
trust
law,
but
this
basically
eliminates
the
need
for
proving
kind
of
the
standards
and
the
geographic
markets,
etc
that
are
needed
for
an
anti-trust
lawsuit
that
you
know
the
sutter
case
took
a
decade
to
reach
settlement.
A
H
You
know
I
had
prepared
remarks
to
give
today
and
after
listening
to
some
of
the
comments
you
know
it
brought
me
back.
H
This
gray,
hair
here
is
means
I've
just
been.
I'm
old
and
I've
been
here
a
long
time,
but
there
was
a
my
first
session.
Lobbying
was
in
1999
with
just
a
dumb
firefighter
here
trying
to
hold
our
own.
I
was
also
the
chairman
of
a
health
insurance
trust
fund
and
I
got
asked
us
to
attend
a
subcommittee
hearing
one
day
that
one
evening
and
the
discussion
was.
H
The
clinical
psychologists
were
trying
to
pass
statute
that
we
made
it
so
that
the
marriage
and
family
counselors
couldn't
see
certain
patients
they
had
to
go
to
a
doctor
first
and
not
to
the
licensed
counselors,
and
I
listened
to
the
whole
hearing.
The
chairman
of
the
committee
said:
hey
you've
been
here
all
the
time
you
want
to
come
on
up
and
say
anything.
I
said
you
know
yeah.
I
do,
and
I
said
I
know
this
is
unusual.
Can
I
ask
a
question
of
them
and
she
said
sure
so
I
said
so.
H
If
somebody
came
to
you
and
they
had
a
problem
with
a
marriage
problem
or
family
counseling
problem,
would
you
refer
them
to
them
and
they
said?
No?
Why
would
we
were
licensed
to
do
that?
We
wouldn't
do
that.
I
said
so:
you're,
basically
cutting
them
out
of
the
business.
H
H
They
won't
go
see
that
person
and
if
they
don't
get
the
mental
health
care
that
they
need
bad
things
happen,
the
more
things
change
the
more
they
stay
the
same.
That
was
in
1999
we're
battling
every
day
as
a
chairman
of
the
health
trust,
and
I
watch
these
people
that
run
these
health
programs.
Now
I
had
only
3
3
500
members
in
our
trust
fund
and,
as
dr
titus
said,
constantly
trying
to
keep
your
head
above
water.
H
H
So
the
bottom
line
is
we're
constantly
trying,
whatever
methods
techniques
we
can
to
limit
our
liability.
H
We
believe
that
you
know
senate
bill
329,
allows
patients
and
health
plans
to
shop
for
and
get
the
best
options
available
to
them,
both
in
quality
and
cost,
and
so
for
those
reasons.
Madam
chair,
we
are
in
support
of
this.
Our
150
000
members
and
their
families
need
techniques
just
like
these
to
try
and
limit
the
costs
that
are
going
out
of
their
pocket
every
day,
and
so
for
that.
Madam
chair,
we're
in
support
of
this.
Thank
you
very
much.
A
N
M
Good
afternoon,
chair
and
members
of
the
committee,
my
name
is
paul:
katha,
that's
spelled
c-a-t-h-a
and
I
represent
the
culinary
union.
The
culinary
union
supports
sb
329,
because
healthcare,
affordability,
quality
and
access
are
critical
concerns
for
culinary
union
members.
Consolidation
in
the
healthcare
industry
drives
up
prices,
but
not
the
quality
of
our
healthcare.
Sb
329
will
take
important
steps
to
understand
how
consolidation
impacts
our
healthcare
markets.
In
addition,
sb
329
will
stop
anti-competitive
contracting
practices
that
prevent
patients,
employers
and
plans
from
shopping
for
and
getting
the
best
deal.
N
L
I
am
the
secretary
treasurer
of
ufcw
local
7-eleven
on
behalf
of
the
6800
members
of
united
food
and
commercial
workers.
Local
7-eleven,
I'm
speaking
in
support
of
sb-329
sb
329,
will
allow
the
state
policy
makers,
patients
payers
and
other
stakeholders
to
understand
consolidation
in
our
health
care
markets
and
its
impact
on
prices,
affordability,
quality
and
access.
It
will
provide
vital
information
to
guide
decisions
that
protect
competition
and
patient
choice.
L
Sb
329
will
also
prohibit
anti-competitive
contracting
practices
that
hospitals
and
health
care
providers
with
market
dominance
can
demand
because
payers
have
to
have
them
in
their
networks.
This
will
prevent
dominant
market
participants
from
exercising
their
market
power
to
drive
up
prices
and
sport,
competition
based
on
price
and
quality,
anti-competitive
contracting
practices
like
all
or
nothing
anti-steering
and
anti-tearing
prevent
health
plans
from
directing
or
incentivizing
patients
towards
lower
costs,
higher
quality
care.
These
provisions
also
prevent
other
hospitals
from
benefiting
if
they
offer
better
deals
or
higher
quality.
L
They
also
stop
patients
and
health
plans
from
shopping
for
and
getting
the
best
deal.
Sc-329
will
prohibit
anti-tiering
and
anti-steering
clauses
which
require
health
plans
to
place
all
of
the
health
systems.
Hospitals
in
the
most
favorable
tier,
with
the
lowest
cost
sharing,
regardless
of
the
rate
they
are
charging
or
their
quality.
N
M
M
M
I
wish
that
my
culinary
health
fund
advocate
could
give
me
advice
on
which
place
is
best
for
me
to
go
a
place
that
is
safe,
a
medical
professional
that
has
a
good
doctor
and
a
clinic
that
is
the
lowest
co-pay
for
me,
but
right
now,
due
to
anti-steering
and
anti-tearing
language
and
hospital
contracts.
My
culinary
health
fund
is
not
able
to
give
me
complete
information
that
I
need
and
deserve
that
and
that's
not
right.
M
N
M
T-O-D-D-I-N-G-A-L-S-V-E-E
good
afternoon,
madam
chair
members
of
the
committee,
my
name
is
todd
englesby,
I'm
the
president
of
the
professional
firefighters
in
nevada.
We
are
here
in
support
of
sb
329.
Managing
our
healthcare
and
its
cost
is
a
full-time
job
for
us.
We
are
constantly
putting
our
lives
and
health
on
the
line
from
work.
Related
physical
injuries
to
heart
and
lung
disease
due
to
the
cancer
causing
carcinogens
we
are
exposed
to
daily
is
vitally
important
that
this
piece
of
legislation
pass.
M
Without
this
we
have
situations
where
we
are
unable
to
communicate
to
our
members
about
where
they
can
get
the
best
care
due
to
anti-tiering
and
anti-steering
language
that
we
are
forced
to
into
with
our
hospital
contracts.
Our
self-funded
health
trusts
need
to
be
able
to
educate
our
members,
especially
about
where
they
can
get
the
highest
quality
and
lowest
cost
care,
and
there
are
many
times
where
we
are
prohibited
from
doing
that,
especially
in
the
field
that
is
so
ripe
with
injuries,
disease
and,
unfortunately,
premature
death.
It
is.
M
It
is
wrong
that
we
are
restricted
from
giving
our
members
the
basic
information.
This
bill
brings
transparency
about
what
is
going
on.
In
the
health
care
market
in
nevada
and
allows
us
to
educate
our
members
about
the
best
options
out
there
for
them,
we
ask
your
support
for
fb
329
and
help
our
members
so
they're
able
to
take
care
of
themselves.
So
we
can
take
care
of
all
our
residents
and
guests
to
nevada.
Thank
you.
A
T
A
A
T
Okay,
first,
I
want
to
express
our
profound
appreciation
to
sponsor
the
bill
senator
lang
she
met
with
us
with
an
open
with
an
open
mind
and
gave
us
a
great
deal
of
time
to
go
over
this
bill,
and
we
really
appreciated
that.
The
most
critical
piece
of
this
bill
is
the
anti-trust
section.
20.9.1
hca
does
not
do
a
they
do
not
do
b.
They
do
not
do
e.
So
what
we're
really
going
to
focus
on
is
c
and
d.
T
This
now
the
opponent
said
seem
to
imply
that
they
thought
this
would
be
the
case,
but
there
are
lawyers
out
there
who
I've
talked
to
who
have
read
this
and
believe
that
this
may
prohibit
that
from
happening.
We
would
like
to
have
explicit
language
allowing
the
provider
to
offer
such
incentives.
T
This
would
enable
a
higher
volume
of
patience
and
less
enable
and
more
discounted
rate.
It
would
also
permit
coordination
of
care.
Hca
has
consciously
put
together
a
system
which
enables
the
the
providers
to
get
the
patient
to
the
right
place
for
the
needed
treatment
in
a
timely
manner,
thus
seamlessly
to
the
patient,
so
that
we
would
like
to
be
able
to
explicitly
know
that
that's
permitted
to
do
and
why
that's
important
is
that
at
the
end
of
this
bill,
it
says
a
violation
of
this
section
is
a
felony,
and
these
this
language
is
pretty
vague.
T
We've
already
had
discussions,
which
is
what
it
means.
It's
very
important,
that
normal
bargaining
process
not
get
you
into
a
situation
where
you
can
be
accused
by
an
aggressive
attorney
or
an
aggressive
opponent
or
committing
a
felony
with
regard
to
d.
Similarly,
the
providers
should
be
able
to
incentivize
the
payer
to
contract
with
affiliated
groups,
and
what
we're
thinking
of
here
is
those
groups
that
provide
your
radiology
treatment.
T
Your
anesthesiology
treatment,
your
hospitalists,
having
the
having
these
together,
is
essential
to
provide
the
continuity
and
con
coordination
of
care,
as
well
as
preventing
the
difficult
situation
that
can
happen
when
a
patient
thinks
she's
going
or
she's
going
to
an
inpatient
to
an
in-network
hospital
and
then
wakes
up
after
surgery
to
find
out
that
the
anesthesiologist
or
the
radiologist
or
the
next
one.
The
hospitalist
is
in
a
different
network
and
all
of
a
sudden
they're
paying
out
of
network
charges
plus
when
you're
out.
When
you
don't
have
that
connections,
you
have
much
less
coordination.
T
Much
less
cooperation,
so
we'd
love
to
see
that
section
cut
out
altogether.
But
if
not,
it
should
be
changed
to
explicitly
permit
the
provider
to
incentivize
the
payer
in
the
bargaining
process,
to
contract
with
affiliated
groups
as
a
necessary
for
proper
continuity,
coordination
and
integration
of
care.
T
Without
that,
this
puts
the
patient
in
a
very
difficult
situation,
and
I
will
I
would
point
out
that
my
understanding
is
that
the
sutter
agreement,
which
was
referred
to
actually
allows
hospitals
to
ask
for
the
contracts
with
doctors
providing
services
in
their
in
that
area
or
in
those
at
hospital.
For
the
reason
of
continuity
of
care.
T
It's
not
a
law,
it's
only
a
settlement,
but
they
even
apparently
made
that
provision.
So
essentially,
failure
to
fix
c
and
d
is
we're.
Asking
leaves
the
patients
in
a
very
difficult
situation.
They
would
be
facing
a
fragmented
disorganized,
confusing
medical
environment
in
terms
of
both
health
care
and
figuring
out
their
billing.
T
It'll
be
and
and
having
everybody,
at
least
in
the
same
network,
certainly
would
make
life
exceptionally
easier.
Finally,
anti-trust
anti-trust
violations
should
not
constitute
a
felony
antitrust
cases
are
typically
civil
cases.
The
language
of
c
d
is
ambiguous
and
open
to
very
varied
interpretations.
T
To
make
trying
to
achieve
a
situation
where
the
doctor
groups
serving
a
hospital
are
in
a
payer's
network.
A
felony
is
a
recipe
for
much
worse
and
expensive
care,
as
well
as
a
very
anxious
and
confusing
world
for
the
patient,
and
since
the
the
beginning,
statements
in
the
early
part
of
this
testimony
for
the
bill
talked
a
lot
about
health
care
costs,
and
this
is
a
way
to
bring
down
health
care
costs.
So
I
think
I
have
the.
T
I
have
the
right
there
to
say
that
the
single
most
important
thing
this
legislature
and
the
advocates
of
this
bill
could
do
to
bring
down
their
health
care
costs
is
to
join
together
with
all
of
us
and
convince
the
legislature
to
increase
medicaid
reimbursements
to
providers.
The
single
reason
why
those
costs
are
so
high
is
because
we
have
to
shift
such
a
large
amount
of
costs
onto
the
commercial
and
trust
fund
payers.
T
Very
simple
we
talked
about.
We
saw
the
chart
from
the
this
the
lady
from
hastings,
about
how
much
healthcare
costs
have
gone
up.
Well,
since
2001
hospitals
have
got
one
raise
in
medicaid
rate,
medicaid
of
two
and
one
half
percent,
which
was
taken
away
from
us
last
summer.
Again,
that's
all
we've
gotten!
If
you
wonder
why
costs
are
going
up,
that
is
a
very,
very
large
reason.
K
I
appreciate
that,
and
so
I
guess
going
back
to
the
same
question
that
I
I
had
about
the
in
the
20.9
on
the
shell
not
and
the
a
through
e
and
it
it
looks
like.
We've
got
a
b
and
e
off
the
table,
we're
focusing
on
c
and
d.
So
I
guess,
could
you
just
talk
a
little
bit
more
about
the
practices
that
are
allowed
now
that
will
become
the
shall
not
and
then
what
it
will
allow
from
from
the
from
from
your
perspective.
Well.
T
I
can't
speak
for
any
other
company
on
that
and
I'm
not
the
negotiator
on
ours,
but
I
can
tell
you
that
we
do
not
require
them
all
to
be
in
the
same
tier.
We
do
not
require
them
all
to
be
to
contract
with
all
of
our
of
our
entities,
but
we
would
like
to
be
able
to
incentivize
them
to
do
so
if
we
chose
to
and
if
they
sure,
if
we
could
give
them
an
incentive
good
enough
wait
for
them
to
do
it
would
be.
T
You
know,
we'd
love
that
and
hopefully
they
would
find
the
higher
the
lower
price
we
could
give
them
for
that
volume
to
be
attractive.
That's
part
of
the
bargaining
process.
We
just
want
to
make
sure
that
the
normal
bargaining
process,
because
of
the
way
this
bill
is
worded,
is
not
suddenly
becoming
a
crime.
K
K
So
like
on
on
the
d
with
the
contracting
with
the
affiliates,
obviously,
if
a
hospital
wants
to
say:
okay,
here's
the
hospital
network
we've
built
out,
so
not
the
insurers
network,
but
the
hospital
networks
we've
built
out,
so
we've
got
the
hospital
and
then
we've
got
the
clinics
and
we've
got
an
urgent
care.
You
know
we've
got
specialties
right,
so
you
wanna,
so
the
idea
would
be
there
just
two
e
to
incentivize
people
to
stay
in
the
hospital
network
and
that
that
would
be
contracted
and
negotiated
the
incentive
to
stay
in
versus.
K
T
Of
all
one
kid
we
don't
demand
it,
we
don't
mandate
that,
but
we
like
to
incentivize
it,
but
we
don't
mandate
it.
We
don't
that
I
know
for
sure,
but
in
terms
of
d
that
has
to
do
with
the
the
way
we
read
that
when
it's
at
affiliated
entities,
it's
not
necessarily
the
ones
we
own,
but
it's
the
ones.
We
we
believe
that
means
in
this
case
it
could
is
basically
we're
talking
about
where
we
are.
T
T
I
didn't
mention
er,
because
that
situation
was
pretty
well
taken
care
of
last
session,
so
I've
been
focusing
on
the
others,
but
it's
a
real
mess
when
you
go
and
you
all
of
a
sudden
you've
got
to
pay
an
out
of
network
suddenly
you're
sitting
in
there
with
another
network
doctor
when
you're
in
a
network
hospital,
and
if
we
can
look,
you
know
from
a
patient
point
of
view.
Those
are
the
kind
of
things
that
say
what
does
this
bill
mean?
Why
do
I
have
this?
Why
do
I
have
that?
T
And
you
know
it
drives
you
crazy,
and
this
will
make
life
a
lot
simpler,
a
lot
more
organized,
but
even
more
importantly,
it
will
help
coordinating
care,
because
when
you
can
work
with
your
hospitals
working
with
these
groups
where
they
have
contracts,
they
can
interact
and
coordinate
the
best
thing.
The
best
example
I
can
give
you
of
some
of
this
is
when
I
had
an
operation
at
mountain
view
on
my
elbow
and
had
my
stitches
out
the
next
morning.
T
I
guess
I
moved
around
too
much
in
the
bed
and
quite
a
lot
of
blood
on
my
pillow
in
my
bed,
so
I
got
knocked
the
car
and
ran
down
down
the
freeway
to
southern
hills
in
the
er.
It
took
me
about
10
to
15
seconds
to
get
in
there,
because
all
my
info
was
right.
There
same
computer
system
boom,
they
had
everything
they
needed
very
coordinated.
They.
T
They
could
see
everything
that
happened
to
me
right
there
and
if
you
start
having
all
these
discrete
groups,
I
I
I
respect
what
the
proponents
are
trying
to
do
here.
I
I
you
can
see
this
if
they
have
their
requirement,
they
they
know
objective,
but
I
think
that
we
want
to
make
sure
that
our
ability
to
provide
the
best
possible
care
that
we
can
in
a
coordinated
manner
to
the
patients
and
to
give
them
as
good
an
experience
as
possible
is
not
inadvertently
or
adverbially
eliminated.
By
the
way
this
bill
is.
K
K
And
I
guess
I
should
clarify
when
I
was
saying
like
the
hospital
and
kind
of
their
network,
and
I
was
referencing
the
buildings.
We
know
that
you
know
well,
I
guess
for
most
people
work
in
hospitals.
You
know
that
no
one's
like
very
few
people
are
like
hospital
employees.
They've
got
the
brick
and
mortar,
and
then
you
hire
the
groups
to
come
in
and
and
do
and
kind
of
the
physician
groups
to
come
in
most
likely,
the
physician
group.
K
So
you
might
the
admin
you
have
and
those
tend
to
be
like
the
payroll,
the
hr
and
maybe
some
other
ones
tend
to
be
direct
employees.
But
I
I
don't
know,
maybe
10
of
the
people
you
see
in
the
hospital
are
actually
hospital.
K
Employees
and
the
rest
are
contract
groups,
so
the
nurses
are
all
employees,
the
nurses,
yeah,
and
so,
when
you,
when
you
get
to
when
I'm
talking
about
those
those
kind
of
specialty
clinics
or
the
the
urgent
cares,
it's
the
groups
that
are
staffing,
those
so
on
e
it
talks
about,
shall
not
do
exclusive
contracting.
So
then
those
provider
groups
will
just
have
to
go
we'll
we'll
be
contracting.
With
multiple
insurance
insurance,
multiple
entities
as
well,
which
I
think
they
can
do
now
right
because
we
we.
T
J
Thank
you
so
much
sir,
for
sticking
in
there
with
us
to
answer
all
these
questions.
This
is
really
complicated
and
I
think
that
we're
all
our
intent
is
to
do
the
right
thing
for
the
our
constituents.
My
my
question
is
this
bill.
If
I'm
not
mistaken,
when
I
listen
to
the
earlier,
testimony
does
not
allow
for
there
to
be
fines
and
fees
if
people
don't
comply.
J
So
if
there's
no
vehicle
for
fines
and
fees
and
the
only
vehicle
that's
allowed
here
is-
is
a
felony
or
or
some
type
of
of
what
else
can
be
done,
because
I
think
we've
seen
enough
corporate
misbehavior
that
even
often
when
people
our
feet
are
fined,
they
continue
poor
behavior
because
they
can
afford
to
pay,
and
so
I
mean
it
may
seem
egregious,
but
maybe
if
you've
got
a
suggestion,
how
we
can
get
people
to
comply.
T
If
you
at
least
make
it
a
misdemeanor,
not
a
felony,
but
ideally
you
could
put
fines
and
you
could
put
penalties
in
that
are
meaningful,
but
we
even
then
we
would
think
if
we
can,
if,
if
you
just
put
allow
normal
bargaining
because
the
proponents
referenced
several
times-
that's
a
current.
T
That's
part
of
bargaining,
the
contract,
if
you
could
just
put
in
here
that
we're
allowed
to
incentivize
things
those
two
the
items
I
talked
about,
we
wouldn't
have
any
worries
and
we
wouldn't
be
worrying
about
getting
a
felony
because
we
wouldn't
be
breaking
the
law.
We
don't
do
a.
We
don't
do
b.
We
don't
do
e
so
and
we
just
want
to
make
sure
that
we
can
continue
to
provide
coordinative
high
quality
care.
That's
good
for
the
patient
and
puts
the
patient
in
a
good
place
without
committing
a
felony.
A
And
if
I
could
just
clarify
mr
ross
doesn't
598
already
have
those
violations
already
go
to
district
court?
Isn't
that
existing.
A
A
T
I
could
comment
that
I
had
done
a
lot
of
health
law
health
lobbying
up
here
for
about
two
decades
and
every
time
you
change
the
health
care
law.
It
shows
up
in
about
one
little
blue
line
at
about
seven
or
eight
very
long
paragraphs,
because
there
are
all
these
different
kinds.
I
see
no
reason
why
this
can't
be
I'm
not
the
lawyer,
but
somehow
to
look.
Maybe
we
could
put
a
different
section
get
rid
of
the
felony.
If
that's
what
it
requires
make
a
new
section.
A
Okay,
mr
russ,
at
this
time
I'm
going
to
go
to
there
any
other
individuals
in
the
room
to
testify
in
opposition
to
senate
bill
329.
I
So
you
know
this
is
a
complicated
bill,
but
I
just
I
do
know
that
when
people
get
sick
or
their
loved,
one
gets
sick,
they
want
the
state
of
the
art
hospital,
they
want
the
best
doctors,
but
here
in
nevada
we
have
one
of
the
lowest
medicaid
reimbursement
rates
in
the
united
states
and
and
in
the
special
session
we
reduced
it
an
additional
six
percent
to
the
medicaid
reimbursement
rate.
I
T
I
don't
think
it
will
help,
as
I
pointed
out,
if
it,
if
it
passes
as
it's
written,
I
think
will
have
a
negative
impact
on
how
people
see
health
care
and
how
people
experience
health
care
and
for
the
reasons
I
stated,
I
have
no
question
about
that.
I
think
the
best
thing
we
can
do
to
improve
health
care
in
this
state
is
to
increase
the
medic,
because
you
you
need
to
pay
doctors
enough
to
take
medicaid
patients.
T
You
know
we
have
we're
very
low
on
medical,
but
when
you
go
down
you
drive
through
henderson,
you
drive
through
parts
of
summerlin.
You
know
I've
seen
any
shortage
of
doctors.
Where
you
see
the
shortage
of
doctors
is
in
east
las
vegas
north
las
vegas
northeast
las
vegas
they
and
where
do
all?
Where
do
the
majority
of
the
folks
who
take
who
are
on
medicaid
live
those
same
places?
T
I
just
said
you
need
to
pay
the
doctors
enough
that
they
will
to
take
and
see
medicaid
patients
and
similarly,
if
you
paid
the
hospitals,
some
somewhat
fair
rate
comparable
to
other
states
when
they
said
when
our
you
know,
we
have
a.
I
know
it
was
said
earlier,
but
we
do
have
at
least
five
entities
who
own
hospitals
in
las
vegas.
T
You
know
it's
fairly
competitive
when
you
do
those
contracts,
you
know
that's
one
reason
why
somebody
apparently
tries
a
few
some
of
these
other
things
to
be
to
get
an
edge,
it's
quite
competitive,
so
it
won't
take
long
if
you
start
raising
the
medicaid
reimbursement
rates
when
the
cost
shifting
gets
less
and
the
contracts
to
the
providers
rather
to
the
payers
go
down,
and
you
know
we
don't
we
don't
like
having
to
do
that.
But
if
you
don't
push
those
rates
up,
you
know
we
are.
The
hospitalists
doesn't
survive.
T
A
No,
that's
okay.
I
just
know
that
we
have
other
people
that
want
to
testify
here
as
well,
so
I'm
gonna
start
going
to
them.
So
if
we
could
broadcast
services
that
we
could
go
to
the
line
to
receive
testimony
in
opposition
to
senate
bill
329
again,
I
would
remind
callers
to
please
state
their
name
and
limit
your
testimony
to
two
minutes.
A
N
B
M
Chair
and
members
of
the
committee
for
the
record,
my
name
is
jim
wadhams,
I'm
speaking
on
behalf
of
the
nevada
hospital
association
and,
first
of
all,
I'd
like
to
thank
senator
lang
for
the
time
that
she
spent
actually
many
many
hours
talking
openly
and
the
sponsors
of
the
bill,
including
bob
ed
bond
and
stacy
sasso.
That
has
been
a
very
open
and
robust
discussion
and
the
bill.
The
bill
with
the
amendment
447
is
actually
much
improved.
We
do
still
have
some
concerns
and
part
of
the
reason
has
been
addressed
in
these
questions.
P
M
Element
of
the
section
20.9
is
very
serious
and
it
has
to
be
precise.
Many
of
the
members
questions
have
drawn
attention
to
the
ambiguity,
for
example,
in
the
phrase
in
what
we've
just
been
talking
about
c
and
d
on
business
affiliate.
Does
that
mean
the
affiliation
of
the
in-house
basic
hospital
services
such
as
lab
and
radiology
and
anesthesiology,
or
is
that
a
reference
to
external
but
affiliated
facilities?
M
P
M
Look
at
page
21
of
the
amendment
anyway,
it's
section
20.9
subsection
one.
I
think,
there's
a
concern
that
there
may
be
an
ambiguity
in
the
way
that
language
is
written,
that
a
restriction
on
changing
the
incentives
after
the
contract
is
entered
into
may
be
barred
as
well,
and
I
don't
think,
that's
the
sponsors
and
clearly
not
the
senator's
intent,
and
I
don't
think
from
what
we've
heard
from
the
opponents.
That's
their
intent
and
I
think
the
language
needs
to
be
clarified
in
that
regard.
M
Finally,
I
think
it
is.
It
would
be
worthwhile,
at
least
to
have
committee.
L
M
L
M
M
L
M
M
The
opportunity
to
testify
thank
you,
madam
chair.
N
L
Good
afternoon
sharon
nguyen
members
of
the
committee
for
the
record.
My
name
is
katie
ryan
k-a-t-I-e-r-y-a-n
and
I'm
system,
director
of
nevada
government
relations
for
dignity,
health,
saint
rose,
dominican,
st
rose,
is
also
in
opposition
to
sc
329.
For
many
of
the
reasons
already
cited
by
my
colleagues,
anti-competitive
practices
are
not
an
issue
in
the
state
and
if
there
are
any
health
systems
doing
this,
the
ag's
office
can
deal
with
bad
actors.
L
Saint
rose
also
does
not
mandate
that
payers
contract
with
our
entire
network.
The
contracting
restrictions
piece
of
the
bill
in
section
20.9,
is
severely
problematic
and
will
make
navigating
health
care
coverage
even
more
difficult
for
patients,
while
also
creating
access
to
care
and
quality
issues.
By
interrupting
the
continuum
of
care,
this
could
also
be
harmful
to
health
equity.
There
is
nothing
in
this
bill
that
would
prevent
payers
from
making
their
members
go
to
the
cheapest
place
of
care
and
not
giving
them
a
choice.
How
is
this
confusion
and
frustration
better
for
the
patient?
L
N
M
Minutes
good
afternoon,
madam
chair
dan
musgrove,
on
behalf
of
the
valley
hill
system
of
hospitals,
that's
d-a-n
capital
m-u-s-g-r-o-v-e.
I
won't
be
repetitive,
mr
ross,
mr
wadhams
and
ms
ryan
were
excellent
in
their
comments.
The
valley
health
system
has
a
number
of
hospitals
in
southern
nevada
and
we're
beginning
to
start
a
second
hospital
in
reno.
We
have
one
currently
in
sparks
and,
as
was
discussed,
there
is
something
to
be
said
for
continuity
of
care,
and
I
think
mr
ross
captured
it
very
correctly.
M
But
you
know
there
is
an
ability
for
us
to
go
to
exactly
what
assemblywoman
krasner
said
in
that,
when
someone
shows
up
at
our
door
in
an
emergency
situation,
they
want
the
best
of
care
and
we
save
systems
money,
insurance
systems
money
by
not
replicating
sys.
N
B
L
N
L
We
appreciate
senator
lang
and
the
representatives
of
the
culinary
health
fund
for
initially
working
with
the
industry
on
the
bill
and
working
to
determine
if
there
are
were
unintended
consequences
that
could
be
corrected
in
the
bill
language.
We
do,
however,
oppose
fb
329,
as
amended
as
the
majority
of
our
concerns
have
not
yet
been
addressed.
Our
primary
concerns
include
the
following.
First,
we
believe
payers
and
providers
should
be
allowed
to
negotiate
and
mutually
agree
on
contract
terms.
L
L
A
A
A
I
Thank
you
chair.
I
won't
be
long.
I
don't
want
to
stand
in
between
everyone's
cinco
de
mayo
celebration
this
evening,
but
we've
heard
a
lot
today
and
you're
all
right.
This
is
a
very
complex
bill
and
we
wouldn't
bring
this
bill
to
you
if
there
hadn't
been
reasons
that
needed
it,
and
so
we
continue
to
work
with
the
hospitals,
who
are
the
people
that
seem
to
have
the
most
problems
with
the
bill.
I
Mr
ross
and
I
talked
about
that
earlier
in
the
week,
we
just
wanted
to
make
sure
that
we
could
get
the
bill
to
you
in
a
timely
manner,
but-
and
you
heard
today
that
from
legal
that
the
felony
is
not
something
we
wanted
to
add
in
it's
something
that's
already
in
statute
that
is
applicable
to
this
language
as
well,
and
so
that's
why
that's
there?
I
We
also
know
that
the
attorney
general
deals
with
monopolies
and
he
he
can
go
after
monopolies.
We
want
to
be
able
to
give
the
attorney
general
some
teeth
into
anti-trust
stuff,
that's
happening,
or
that
could
happen
in
our
health
care
system
in
nevada
and
that's
why
legislative
language
and
statute
is
so
important
in
this
bill.
So
we
are
open
to
any
questions
you
might
have.
I
A
Thank
you,
senator
lange,
and
I
thank
you
to
the
committee.
You
guys
have
been
very
patient.
I
know
that
when
I
said
we
weren't
going
to
be
having
committee
last
friday
to
allow
people
some
time
to
grieve
and
mourn
and
attend
the
services
that
we
would
have
a
long
week.
So
I
appreciate
everyone's
patience
here
today,
in
being
so
attentive
to
the
bills
that
were
presented
before
us,
and
with
that
I
will
close
the
hearing
on
senate
bill
329
and
we
will
move
to
public
comment
broadcast
services.