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Description
Convene Upon Adjournment of Assembly Floor Session
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A
C
C
A
A
I
don't
know
if
her
microphone
wasn't
working
or
if
she
just
didn't
hear
her
name
called
that
I
do
see
her
present
and
I
would
ask
that
assemblyman
orrin
licker
when
he
arrives.
If
we
can
mark
him
present,
I
know
he's
currently
presenting
in
another
place
and
the
same
with
assemblywoman,
benitez
thompson
and
assemblywoman
summers,
armstrong.
A
I
will
try
to
catch
them
and
hopefully
our
my
vice
chair
will
also
be
able
to
do
that.
I
know
that
a
lot
of
you
are
just
receiving
your
lunch.
So
I
understand
if
you
need
to
eat
it,
we
need
some
energy
for
today
or
if
you
want
to
turn
off
your
camera,
because
you
don't
want
everyone
seeing
you
eat.
I
just
ask
you
when
you're
done,
if
you
could
turn
it
back
on,
that
would
be
great
and
with
that
we
do
have
a
quorum.
So
I
am
going
to
get
started.
A
I
am
going
to
take
a
couple
of
things
out
of
its
order
from
the
agenda
just
because
of
the
nature
of
people
being
in
different
places
and
presenting
in
different
committees
right
now,
but
I
will
start
with
one
of
our
bill
hearings
and
so
the
first
bill
hearing
that
we
are
going
to
start
with
is
assembly
bill
430.
So
at
this
time
I
am
going
to
open
the
hearing
on
assembly
bill
430.
A
This
bill
revises
provisions
relating
to
disabilities.
I
know
that
she
has
an
extreme
interest
in
all
things:
health
and
human
services
and
as
a
last-minute
appointee.
I
know
that
she
does
spend
a
lot
of
time
watching
our
committee
so
welcome
assemblywoman
brownmay
to
health
and
human
services,
and
I
would
ask
you
to
begin
when
you
are
ready.
D
D
We
are
very
pleased
to
be
here
today
to
present
assembly
bill
430
for
the
record.
I
am
tracy
brown
may
representing
assembly.
District
42
in
clark
county
with
me
today
is
jessica
adams
and
deputy
administrator
of
the
asian
and
disability
services,
division
of
the
department
of
health
and
human
services
and
ace
patrick
chair
of
the
nevada,
statewide
independent
living
council.
D
D
The
words
and
the
labels
that
we
use
in
statute
can
have
a
profound
effect
on
people.
Now.
This
bill
was
first
discussed
during
the
interim,
the
statewide
independent
living
council
members
identified
the
use
of
the
r
word
that
continued
to
exist
in
nevada,
revised
statutes
and,
while
the
references
to
an
association
that
association
does
not
exist
in
nevada
today
and
we
are
working
to
eliminate
that
outdated
language.
D
There
are
also
a
number
of
references
in
nrs435
that
are
inaccurate
and
offensive
to
people
with
diverse
abilities
and,
at
this
time,
I'd
like
to
turn
the
presentation
over
to
jessica
adams,
our
deputy
administrator
of
aging
and
disability
services,
and
she
will
walk
us
through
the
bill
when
jessica
is
completed.
Then
we're
going
to
turn
this
over
to
ace
and
ace
can
give
us
a
little
bit
of
perspective
of
what
it's
like
at
being.
A
member
of
the
disability
community.
A
Thank
you,
assemblywoman
brown
may
and
I'll
just
remind
presenters
to
please
clearly
state
their
name
before
they
speak.
So
we
can
have
a
clear
record.
D
D
So
I'm
going
to
walk
through
the
bill.
Ab430
does
revise
obsolete
terms
and
phrases
within
nrs
435
regarding
the
care
and
services
provided
to
persons
with
intellectual
and
developmental
disabilities.
The
proposed
changes
will
align
the
language
used
at
nrs
435
with
the
language
and
phrases
already
used
within
developmental
services
and
the
community.
D
So
section
1
revises
nrs
435.060
to
describe
the
transition
of
persons
residing
in
a
residential
facility
for
groups
to
a
non-facility
based
setting
from
being
able
to
live
in
a
more
normal
situation
to
being
able
to
reside
in
an
appropriate
community-based
setting.
That
is
not
a
facility
section
two
revises
nrs
435.115
to
remove
a
reference
to
the
state
association
of
citizens
and
the
board,
as
this
organization
no
longer
exists
in
nevada
and
as
assemblywoman
brown
may
mention,
that
is
a
offensive
term
now,
so
the
the
it
will
just
be
changed
to
that.
D
The
fee
schedules
will
be
established
by
the
administrator
of
aging
and
disability
services.
Subject
to
the
approval
of
the
director
of
the
department
of
the
health
of
health
and
human
services,
section
3
revises
nrs
435.130
to
update
the
declaration
of
legislative
intent
for
jobs
and
day
training
services.
B
B
B
Now
it
is
the
current
accepted
terminology
of
the
american
psychological
association,
the
apa
that
further
translates
into
most
government
acts
such
as
the
ada
americans
with
disabilities
act
and
the
idea
the
individuals
with
disabilities
education
act.
It
only
makes
sense
that
nevada
ensures
our
language
and
statute
follow
suit.
B
B
The
most
important
thing
to
remember
when
considering
person
first
language
is
that
it
replaces
some
very
antiquated
and
offensive
terminology
that
has
no
business
in
nevada
language
words
do
matter.
In
my
experience,
I
can
testify
to
the
fact
that
for
years
I
felt
like
a
farm
animal
being
hurted
by
doctors,
psychiatrists
and
institutions,
while
they
use
my
diagnosis
as
labels
to
push
me
through
to
the
next
provider.
B
My
life
changed
dramatically
when
professionals
began
to
address
me
about
my
diagnosis
and
not
talk
to
each
other,
about
my
diagnosis
as
if
I
didn't
even
exist,
it
may
not
seem
like
it
matters
to
people
who
have
never
had
to
remind
others
that
they
are
in
the
room,
but
I
can
tell
you
that
it
has
made
an
enormous
impact
on
the
quality
of
my
life.
I
am
a
person
with
disabilities
and
I
support
these
important
changes
proposed
in
assembly
bill
430.
D
Thank
you
chairwin.
That
is
the
the
crux
of
our
position
and
our
presentation
today,
as
you
can
see
the
words
we're
working
to
eliminate
are
words
that
isolate
us
from
each
other,
and
so
we're
really
just
trying
to
eliminate
the
misunderstanding
that
exists.
The
three
words
we
focused
on
are
normal.
According
to
everything,
I've
been
taught
normal
is
nothing
more
than
a
setting
on
my
dryer
and
should
not
be
used
when
describing
people.
D
The
word,
which
is
a
diagnostic
term
and
should
not
be
used
to
describe
people
and
then
to
insinuate
that
we
are
helping
people
to
become
more
useful,
is
just
insulting,
and
so
those
are
the
three
terms
we're
focusing
on
eliminating
in
this
bill.
We
thank
you
and
we
urge
your
support
for
for
this
bill.
Thanks
very.
A
Much
I'm
looking
around
here
do
we
have
any
other
questions
and
I
will
note
that
assemblywoman
anita's
content
had
popped
on,
but
I
see
that
she
has
popped
off,
but
she
was
present
here
for
a
while.
Do
we
have
any
other
questions
from
committee
members
or
comments?
C
Oh
thank
you,
madam
chair,
and
it's
similar
to
brown
man.
I
just
want
to
say
thank
you
for
bringing
this
forward.
I
know
we've
had
other
bills
and
resolutions
to
clean
up
obsolete
language
that
in
today's
day
and
age
we
just
no
longer
use
because
it's
not
appropriate.
So
I
thank
you
for
that.
C
Did
have
a
question
in
regards
to
the
the
nash
I
know
there's
a
national
arc.
D
Association,
thank
you
for
that
question.
Assemblywoman
brown
made
for
the
record
assemblyman
assemblement
haven
through
you,
a
chairwin.
The
national
ark
association
is,
is
just,
as
you
stated,
a
national
affiliate
organization
and
at
one
time
there
was
a
national
affiliate
here
in
nevada
that
currently
does
not
exist.
D
Changes
in
this
bill
would
not
preclude
that
from
happening,
and
if
there
was
an
advocacy
organization
that
was
so
intended
could
nationally
affiliate
with
the
arc
of
the
us,
and
I
know
that
the
division
of
aging
and
disability
services
and
our
leaders
there
would
be
very
happy
to
work
with
the
national
arc.
Currently,
the
ark
is
not
involved
in
the
fee
setting
schedule
in
nevada,
so
it
would
not
really
have
any
impact
here
at
all.
C
I
do
not
thank
you,
assemblyman
woman
brown
may
and
thank
you
chairway.
A
Seeing
then
at
this
time
I
will
go
to
do
you
have
any
I'm
sorry,
assemblywoman
brown?
May
I
should
ask
this:
do
you
have
any
callers
on
the
zoom
in
support
of
the
bill
today.
D
B
B
C
Yeah,
my
name
is
troy,
frieden
t-r-o-y-f-r-I-d-e-n.
Thank
you
for
taking
the
time
to
listen
to
my
public
comment.
I'm
the
chief
operations
officer
for
chrysalis
chrysalis
provides
services
for
over
220
people
with
intellectual
disabilities
in
nevada,
in
support
of
the
living
arrangements
and
or
jobs
and
day
training
settings.
C
C
B
F
C
B
D
Thank
you
chair.
We
just
would
like
to
thank
you
for
your
time
and
your
consideration
of
assemblyville
430.
We
appreciate
the
time
you've
taken
today
to
hear
it
and
and
know
that
our
stakeholders
are
very
grateful.
I
want
to
thank
the
administration,
jessica,
adams
and,
and
everyone
who's
worked
really
hard
on
this
bill,
the
center
for
independent
living.
So
thank
you
for
your
time
and
your
energy
today.
A
Thank
you,
and
with
that
I
will
close
the
testimony
on
assembly
bill
430.
I
know
that
we
will
probably
I
know
the
people
have
asked
if
we
could
pass
this
today,
just
for
ease
of
moving
stuff
along.
I
will
put
this
on
for
a
work
session
on
monday,
so
we
will
be
seeing
this
very
shortly.
So
thank
everyone
on
the
committee
for
your
support
of
assembly
bill
430.
I'm
sure
that
assemblywoman
brown
may
appreciate
that
and
I'm
glad
that
we
were
able
to
bring
this
bill.
A
I
know
that
it
was
inspired
in
part
by
the
conversations
that
we
had
with
minority
leader,
titus's
ajr,
that
we
heard
earlier
in
the
session.
So
with
that,
I
will
close
that.
I
know
that
we
are
waiting
for
people
that
are
going
back
and
forth
back
and
forth
and
we
do
have
a
pretty
lengthy
presentation
on
assembly
build
347.
So
I
want
to
make
sure
that
we
have
opportunities.
A
I
know
that
assemblyman
orenlicker
believed
just
speed
went
through
another
bill
hearing
in
another
department
and
so
our
another
committee,
but
if
we
can
take
just
a
three
minute
two
minutes,
I'm
gonna
say
two
minute
recess,
just
to
make
sure
that
we
can
give
time
for
transition.
A
I'm
gonna
make
sure
we
can
get
all
of
our
members
back
on
here
to
do
this
quick
work
session
for
these
two
bills
that
are
on,
and
we
will
come
back
so
again,
a
two
minute
recess
just
for
a
minute
to
see
if
we
can
get
people.
A
A
Thank
you
all.
I
will
note
for
the
record
that
assemblywoman
summers
armstrong
is
now
present
with
us.
We
do
have
11
members
present,
so
we
do
have
a
quorum
at
this
time.
I
am
going
to
move
into
our
work
session
document.
It's
a
pretty
quick
work
session
document.
First
up
we
have
assembly
bill
358
and
if
I
can
turn
this
over
to
mr
ashton,
to
summarize
the
bill.
C
C
29Th
this
bill
requires
the
suspension,
rather
than
termination
of
eligibility
for
medicaid
of
a
person
who
is
incarcerated
and
that
and
an
act
certain
other
provisions
as
summarized
in
this
work
session
document.
I
also
wanted
to
mention
that
director,
richard
woodley
of
dhhs,
provided
a
memorandum
today.
This
followed
up
on
questions
that
were
raised
during
the
bill
hearing.
The
memorandum
was
sent
to
members
by
email
and
is
also
available
on
ellis.
Madam
chair.
A
Thank
you,
and
at
this
time
I
will
let's
see
if
there
are
any
members.
The
committee
has
any
questions
I'm
looking
on
here.
I
need
big
hands
if
you
need
one
seeing
none
at
this
time,
I
would
entertain
a
motion
on
assembly
bill
358
and
again
we
are
taking
those
out
of
order.
So
I
just
want
to
melt
that
to
our
committee.
It
is
assembly
bill
358..
A
Thank
you.
I
see
a
motion
from
vice
chair,
peters,
a
second
from
assemblyman
haythan.
Madam
oh,
do
I
have
any
comments
on
the
motion.
F
H
A
Yeah
and
without
the
motion
carries,
and
I
will
actually
assign
that
floor
statement
to
myself
next,
we
can
go
to
our
next
bill
on
work
session
that
is
assembly
bill
273,
mr
ashton,
if
you
could
summarize
this
bill
and
any
amendment.
C
C
The
bill
prescribes
the
membership
and
duties
of
the
statewide
mental
health
consortium
and
allows
the
statewide
mental
health
consortium
and
each
virtual
ma
regional
mental
health
consortium
to
request
a
drafting
of
one
legislative
measure
within
the
scope,
the
statewide
or
regional
consortium.
As
applicable.
C
We
have
here
an
amendment
than
musgrove
on
behalf
of
the
clark
county.
Children's
mental
health
consortium
proposes
to
amend
subsection
4
of
nrs
433
b,
point
333
to
first
remove
the
requirement
that
the
administrator
of
the
division
of
child
and
family
services
or
the
the
deputy
administrator
of
the
division
serve
as
a
mem
serve
as
member
of
the
consortium
and
second,
instead
require
the
administrator
or
his
or
her
destiny
to
serve
on
the
consortium.
A
Thank
you
and
do
we
have
any
questions
from
committee
members?
They
know
that
there
were
some
amendments
that
were
posted
on
nellis.
I
know
that
the
bill
sponsors
reached
out
to
this
committee,
but
are
there
any
questions
at
this
time?
I
see
assemblywoman
titus
go
ahead.
I
Thank
you.
It's
not
actually
a
question,
it's
just
an
acknowledgement.
I
I
had
concerns
with
this
bill
and
the
membership
of
the
committee
concerned
that
that
members
may
be
able
to
sit
on
different
committees
on
recognizing
that
the
volunteer
world
is
somewhat
limited
and
people
with
interest
is
somewhat
limiting
and
their
capacity
to
be
able
to
fill
this
board.
I
It's
been
my
understanding
that
that's
been
clarified,
and
since
this
is
not
a
governor
appointed
board
that
members
it
doesn't
interfere
with
some
of
the
other
roles
that
that
potential
members
may
have.
So
I
just
wanted
to
make
sure
that
that
was
clear
on
the
record
and
that
answered
my
concerns.
So
thank
you,
madam
chair.
A
Thank
you.
I
appreciate
that
that
you
reached
out
to
the
bill
for
and
legal
to
get
that
answer.
Do
we
have
any
other
comments.
A
Seeing
none,
I
would
take
an
entertain,
a
motion
at
this
time
to
amend
and
do
pass.
A
G
I
E
A
Chairwin
yes,
motion
passes
and
I
will
assign
that
floor
statement
to
assemblywoman
gorlo
and
with
that.
That
concludes
our
work
session
and
at
this
time
I'm
going
to
go
ahead
and
open
the
hearing
on
assembly
bill
347.
This
bill
revises
provisions
related
to
health
care.
Due
to
the
complexity
of
this
bill,
this
presentation
will
take
a
little
bit
longer
than
usual.
Additionally,
I've
given
zoom
access
via
the
video
conference
to
certain
stakeholders
to
testify
on
this
bill,
both
in
support
opposition
and
neutral,
and
we
will
kind
of
set
this
up
a
couple
of
different
ways.
A
A
We
will
take
testimony
in
support
opposition
as
well
as
neutral.
I
have
allowed
for
certain
key
stakeholders
to
have
an
extended
opportunity
to
testify
in
opposition,
and
then
I
will
actually
open
this
back
up
for
questions
again
so
questions
after
the
main
presentations
testimony
and
then
we
will
open
it
back
up
for
test
questions
again
from
members
with
some
of
those
people
key
stakeholders
to
be
able
to
answer
any
additional
questions,
and
also
for
assemblymen
or
liquor
and
his
presenters
to
also
respond.
A
I
think
it
will
lead
for
a
more
fruitful
conversation
and
debate
about
this
policy.
I'm
going
forward-
and
I
appreciate
everyone's-
you
know
ability
to
read
this.
I
know
it
is
very
complex.
I
know
we
tried
to
have
some
stakeholder
informational
meetings
at
the
beginning
of
session
that
hopefully,
this
kind
of
triggered
some
of
those
for
those
people
that
are
not
familiar
with
the
healthcare
world
and
if
not,
this
will
probably
give
you
a
bigger
knowledge
base
to
be
able
to
process
this
particular
policy.
A
E
E
Okay,
so
thank
you
share,
win
and
members.
E
That's
okay,
so
thank
you,
chairwin
and
members
of
the
committee
for
the
record.
I
am
david
arndt
representing
assembly
district
20
on
the
east
side
of
las
vegas
from
paradise
to
henderson.
E
I'm
here
today
to
present
assembly
bill
347,
which
includes
two
proposals
to
make
our
health
care
system
much
fairer
for
patients
and
also
for
doctors,
hospitals
and
other
providers
of
health
care
assembly.
Bill
347
will
make
health
care
fair
for
them
and
it
will
make
it
more
accessible
for
patients,
especially
minority
and
poor
nevadans,
who
struggle
now
to
get
the
care
they
need.
E
I'm
joined
today
by
co-presenters
joseph
white,
jolette,
goins,
casey,
kristen
and
asia
duncan,
and
this
bill
is
for
the
medicaid
recipient,
who
can't
find
a
primary
care
physician,
because
we
don't
pay
doctors
enough
under
our
medicaid
program.
With
this
bill,
medicaid
patients
will
be
able
to
get
care
sooner
in
a
doctor's
office
rather
than
later
in
an
emergency
department
when
they
are
much
sicker.
E
This
bill
is
for
doctors,
hospitals
and
other
health
care
providers
who
do
treat
medicaid
recipients
and
lose
money
doing
so
because
our
medicaid
program,
underpays
providers
of
health
care.
This
bill
is
for
individuals
who
can't
afford
to
purchase
health
care
insurance,
because
premiums
are
too
high.
E
This
bill
is
also
for
people
who
have
health
care
insurance,
but
can't
afford
the
deductibles
or
co-payments
when
they
seek
care.
This
bill
is
for
workers
who
don't
get
wage
increases,
because
their
employers
have
to
spend
more
and
more
money,
funding,
employee
health
care
benefits
and
less
on
salary.
E
E
The
proposal
is
based
on
careful
study
and
consultation
with
health
economists
and
policy
experts
across
the
country,
including
many
of
the
stakeholders
who
participated
in
our
working
group.
Special
thanks
to
joseph
white
from
case
western
who
you'll
be
hearing
from
who
developed
the
idea,
that
is,
that
we're
presenting
in
ab
347
in
the
second
part
of
the
bill
and
natalie
johns
who's
been
working
with
me
for
three
months
on
this
and
doing
terrific
work
to
get
us
to
this
stage.
E
So,
as
I
said,
we've
had
a
working
group
for
a
long
time
now.
We've
included
stakeholders
from
across
the
spectrum:
hospitals,
other
providers,
insurers,
employers,
unions,
patient
advocates,
we've
had
formal
meetings
for
the
past
two
months
and
individual
meetings
since
december,
actually
and
we're
continuing
with
meeting
with
smaller
groups
to
get
their
perspectives.
And
as
you
see,
we
have
several
things
in
our
conceptual
amendment
that
reflects
the
input
from
our
stakeholders
and
we
were
careful
to
make
sure
that
they
had
the
framework
for
the
bill
two
months
ago.
E
So
the
motivations
first
medicaid
reimbursement
rates
in
nevada
have
been
too
low
for
too
long.
It's
unfair
to
medicaid
patients
because
it
impedes
access
if
we
don't
pay
providers
enough
they're
reluctant
to
take
care
of
medicaid
patients.
So
it's
unfair
to
patients
because
of
the
inability
to
find
providers,
it's
unfair
to
providers
as
well.
We
undercompensate
hospitals,
physicians
and
other
caregivers,
and
they
it's
just
not
fair.
E
It
also
results
in
cost
shifting.
If
we
underpay
on
the
medicaid
side
and
the
doctors
in
hospital
are
losing
money,
they
have
to
raise
their
reimbursement
rates
for
private
in
the
insured
patients
to
make
up
the
difference,
and
that
raises
health
insurance
premiums.
So
it's
unfair
to
everybody
when
we
underpay
medicaid,
our
payment
system
is
too
complicated.
E
We
don't
know
exactly
what
their
negotiated
rates
are
and
it's
a
mystery
trying
to
figure
out
how
much
you're
going
to
pay
if
you've
ever
looked
at
a
hospital
bill
and
tried
to
figure
that
out
too
much
distortion
of
market
forces
we
have
in
some
markets,
insurers
have
too
much
leverage
in
other
markets,
hospitals
and
we
it'd
be
nice
to
have
a
free
market
in
health
care,
but
we
don't
because
the
market
just
doesn't
work
in
health
care.
The
way
it's
supposed
to
so
some
providers
are
underpaid.
E
E
E
Canada
is
under
50
of
what
we
spend
japan.
45
of
what
we
spend
and
new
zealand
37-
and
it's
not
because
you
don't
get
good,
you
get
very
good
care
in
switzerland,
germany,
canada,
japan
and
new
zealand,
so
we're
overspending
on
health
care.
Why
are
we
spending
so
much?
Why
are
health
care
costs
higher?
Well,
it's
not
because
we
go
to
the
doctor
more
often
or
spend
more
time
in
the
hospital
we
actually
go
to
the
hospital.
Less
often
we
spend
less
time
in
the
hospital.
E
It's
not
because
we're
sicker
we're
actually
on
average,
there's
less
overall
sickness
in
the
united
states
than
a
lot
of
than
western
european
countries
on
average,
and
that's
because
we're
younger,
we
have
a
younger
population.
We
don't
smoke
as
much
as
in
europe.
So
it's
not
because
we're
sicker
it's
not
because
we're
more
litigious
we
may
be
more
litigious,
but
that
makes
the
cost
of
the
tort
system
account
for
less
than
one
percent
of
our
health
care
costs.
That's
not
the
reason.
The
reason
why
our
costs
are
higher
because
our
prices
are
higher.
E
You
get
an
mri
in
japan
for
a
hundred.
Fifty
dollars
here
is
fifteen
hundred
dollars.
The
reason
why
our
prices
are
higher
is
because
we
rely
on
insurance
companies
rather
than
the
government
to
negotiate
every
other
country.
Well,
maybe
there's
switzerland
doesn't
do
quite
the
extent,
but
france,
germany,
canada,
japan,
new
zealand,
all
these
other
countries
that
have
lower
health
care
costs
than
we
do.
The
reason
why
they
do
is
because
the
government
negotiates
the
prices
and
the
government
is
just
a
much
better
negotiator
than
insurance
companies.
E
So
here's
an
illustration:
the
difference
between
getting
an
appendectomy
in
nevada
and
getting
one
in
taiwan.
So
if
you
look
at
the
blue
line
at
the
bottom,
the
horizontal
flat
line,
this
is
the
cost
of
getting
an
appendectomy
in
taiwan
and
you
notice
it
doesn't
matter
where
in
taiwan
you
are
it's
the
same
price
and
it's
about
2500,
you
get
an
appendectomy,
have
your
appendix
out
in
nevada.
E
Well,
the
best
price
3
500
is
42
percent
higher
than
in
taiwan,
and
it
goes
up
from
there.
So
whether
you're
in
the
north
or
the
south,
makes
a
big
difference
and
the
highest
price-
and
this
is
from
the
public
employee
health
benefit
plan.
This
is
what
their
negotiated
rates
in
nevada
for
state
employees.
E
The
highest
is
almost
48
000,
1800
percent
higher
than
in
taiwan.
This
makes
no
economic
sense.
It's
not
because
this
forty
seven
thousand
dollar
appendectomy
is
a
better
appendectomy.
It
may
be
worse,
there's
a
very
poor
correlation
between
quality
and
costs
in
the
united
states,
and
we
should
be
where
taiwan
is
and
no
hospital.
E
E
Fair
compensation
is
what
this
bill
is
about:
no
under
compensation
and
also
no
over
compensation.
So
we
want
to
protect
against
excessive
charges
to
patients,
because
that's
a
real
problem
in
our
country
and
in
our
state.
We
want
to
simplify
the
health
care
payment
system
because
it's
hopelessly
complex,
as
I
said,
nobody
really
knows
what
the
costs
are.
Hospital
executives,
don't
even
know
what
their
hospital
pricing
is,
and
we
also
want
to
preserve
vital
market
private
market
virtues.
I
major
in
economics
in
college,
I
believe
in
markets.
E
I
want
to
have
a
market,
but
sometimes
we
have
market
failure.
When
the
market
fails,
government
has
to
step
in
correct
and
then
decrease.
The
administrative
burdens
you'll
probably
have
heard
many
times
that
all
the
paperwork
that
providers
have
to
deal
with
and
that's
a
big
reason
because
they
deal
with
different
insurers
with
different
rates.
We
can
simplify
this
in
very
important
ways.
E
That's
a
very
important
obligation
that
they
cover
their
costs
and
earn
a
fair
and
reasonable
profit.
We
just
don't
want
them
to
earn
excessive
profits,
no
gouging
of
patience
and
simplicity
with
the
state
setting
fees
instead
of
insurers.
We
no
longer
would
have
the
complicated
and
inefficient
system
of
rate
regular
negotiations
between
health,
insurers
and
health
care
providers.
We
just
have
one
set
of
rates,
just
like
medicare
does
for
people
over
65.
E
E
It's
very
carefully
thought
through
it's
not
perfect,
but
asking
the
commission
to
start
from
scratch
would
make
no
sense.
It's
like.
If
you,
if
you
want
to
buy
a
house,
you
could
hire
an
architect
and
a
contractor
and
start
from
scratch
on
an
empty
lot.
But
it's
a
lot
easier
to
buy
a
house.
That's
already
out
there.
That
may
be
90
of
what
you
want,
because
medicare
gets
to
about
90
of
a
fair
rate
and
then
for
that
final
10.
Maybe
you
need
to
repaint
the
house
or
redo
a
bathroom.
E
That's
a
lot
more
sensible
than
starting
from
scratch,
and
that's
what
we
want
this
rate
setting
commission
to
do
so.
First,
there
are
two
parts
to
the
bill,
and
now
I'll
start
going
through
the
provisions
of
the
bill.
Part
one
is
the
provider
tax,
so
the
idea
is.
We
want
to
raise
medicaid
payments
to
medicare
levels
and
the
the
low-hanging
fruit
here,
because
I
know
we
have
a
very
tight
budget.
Where
are
we
going
to
find
money
to
raise
medicare
reimbursement
rates?
E
Well,
what
we
do
with
skilled
nursing
facilities
and
other
states
do
with
other
health
care
providers?
Is
you
say
to
providers?
If
you,
let
us
impose
a
tax
on
you
for
every
dollar
you
give
us,
we
will
get
two
dollars
back
from
actually
more
than
two
dollars.
We
will
more
than
triple
what
you
give
us.
So
that's
a
think
about
that
return
on
on
investment,
triple
what
you
get
and
that's
guaranteed.
It's
not
speculative
so
and
we
we
will
follow
the
model
from
set
of
bill.
20
509
from
2017
we're
not
gonna.
E
The
bill
does
not
mandate.
The
tax
it
says
to
providers,
if
you
like
this
idea
of
giving
us
a
dollar
and
getting
three
dollars
back.
If
you
like
it,
you
can
vote
on
it.
If
two-thirds
of
you
and
each
pro
two-thirds
of
hospitals,
you
get
a
hospital
tax.
Well,
that's
through
senate
bill
509!
If
two-thirds
of
doctors
vote,
you
get
a
doctor
tax
and
you
triple
your
money.
E
So
that's
how
that
works.
The
benefits
this
will
have
fair
treatment
of
patients
and
providers,
because,
with
the
increased
dollars,
we
can
raise
medicaid
reimbursement
rates
to
fair
levels.
Basically
what
medicare
pays
and
it
reduces
the
need
for
cost
shifting
to
private
insurance,
and
we
have
some
guard
rails
in
section
7
of
the
bill.
E
So
one
thing
is
that
the
dollars
from
the
tax
have
to
be
used
to
supplement
rather
than
replace
medicaid
dollars
from
general
funds
won't
be
possible.
Now
that
we
have
this
new
source
of
funding
for
us
to
say
as
a
legislature.
Well,
we'll
just
reduce
our
general
fund
contributions
to
medicaid
can't
do
this.
We
have
to
maintain
our
existing
funding
of
medicaid.
E
This
is
to
add
on
to
what
we're
currently
funding,
and
so,
if
funds
remain
at
the
end
of
the
fiscal
year,
if
we
overestimate
the
tax
or
underestimate
how
much
has
to
be
paid
out,
then
funds
will
carry
over
to
the
next
fiscal
year
and
not
return
to
general
fund
spending.
Money
can
only
be
used
to
increase
reimbursement
rates
for
phys
providers
and,
in
the
conceptual
amendment,
there's
a
we've
added
provision
to
say
that
if
the
legislature
does
change,
the
allocation
of
funds
does
try
to
divert
funds.
E
Then
the
providers
get
to
re-vote
on
whether
they
want
to
continue
with
the
provider
tax.
Okay,
so
that's
the
first
part
getting
medicaid
reimbursement
to
medicare.
The
second
part
is
the
rate
setting.
They
say
we
have
to
increase
medicaid
rates.
To
be
fair,
we
have
to
lower
in
some
situations
private
fees.
E
So
the
principle
here
is
to
cover
reasonable
costs,
plus
fair
and
reasonable
profit.
Every
provider
will
get
fair
compensation
under
this
bill,
and
that's
that,
ultimately,
is
the
right
thing
to
do
to
make
sure
everybody
gets
fairly
paid.
So
that
means
primary
care.
Doctors
who
have
may
be
squeezed
by
insurers
and
aren't
paid
enough
even
on
the
private
side,
will
be
able
to
maintain
their
practice
not
have
to
sell
out
to
a
hospital
or
a
private
equity
firm.
E
The
rate
setting
commission
is
required
to
meet
the
standard
of
fair
and
covering
costs
and
fair
and
reasonable
profit.
It's
not
an
option,
as
I
indicated,
avoid
duplication
of
effort,
we'll
start
with
medicare
and
adjust
from
there
just
to
make
sure
we
don't
reinvent
the
wheel
in
nevada
when
somebody
else
has
put
a
lot
of
time
and
a
lot
of
hard
work
into
figuring
out
how
to
get
close
to
fair
compensation
and
for
providers
who
think
the
medicare
rates
are
unfair.
E
As
I
said,
on
average
medicare
comes
to
about
90
percent
of
hospitals,
they
can
come
in
and
say:
here's
where
medicare
is
under
estimating
our
what
we
need
to
cover
cost
and
reasonable
profit
just
show
us
the
books
and
we'll
we'll
adjust.
Accordingly,
an
independent,
independent
commission
will
set
the
rates
under
our
proposal.
Originally,
we
were
going
to
have
it
done
by
health
and
human
services,
but
feedback
from
stakeholders
persuaded
us
that
it
makes
more
sense
to
do
it
as
an
independent
commission.
E
So
that's
in
the
conceptual
amendment
and
we'll
have
a
broad
range
of
stakeholders
participating
as
well
as
representation
from
health
and
human
services
and
examples.
The
factors
the
commission
will
use
in
setting
rates
will
be
the
payer
mix
right,
because
some
providers
will
see
more
medicaid
patients.
Some
will
see
more
private
patients
so
to
overall
cover
costs
and
get
a
fair,
reasonable
profit.
E
Some
providers
will
need
a
higher
reimbursement
rate
disparities
between
primary
care
and
specialty
services.
For
a
long
time,
we
have
underpaid
primary
care
physicians.
That
makes
it
difficult
to
have
good
access
to
a
primary
care
physician.
So
we
want
to
address
that
make
sure
that
they're,
fairly
compensated
and
and
also
across
specialties,
some
specialties
are
underpaid
with
respect
to
others.
We
want
to
fix
that.
We
want
to
reward
quality
of
care
and
efficiency
of
services,
so
that
would
be
taken
into
account.
E
We
want
hospitals
and
providers
to
have
a
population
health
focus,
and
so,
under
our
current
system,
often
you
lose
money
trying
to
prevent
disease
and
maintain
the
health
of
your
population.
So
we
want
to
reward
that,
so
people
will
invest
more
in
population
health
to
the
extent
there
would
be
fun
financial
hardship
from
reducing
rates,
because
even
if
people
have
been
overpaid,
that's
they've
built
their
system
on
that
basis.
So
we
don't
want
to.
E
We
want
to
phase
any
things.
Changes
in
that
would
cause
financial
hardship
and
we
want
to
protect
the
workforce
and
quality
jobs.
One
of
the
things
we
want
to
make
sure
is
hospitals.
They
have
to
reduce
costs
to
reach
to
meet.
You
know
a
fair
reimbursement
that
they
don't
take
it
out
on
their
work,
as
I
say,
covering
reasonable
cost,
plus
fair
and
reasonable
profit.
Are
we
there
we're
not
there?
Yet
that's
why
this
bill
is
so
important
because
there
are
providers
who
earn
more
than
a
reasonable
profit.
E
So
we
have
data
on
our
short
term,
acute
general
care
hospitals,
the
ones
you're
familiar
with
as
major
you
know,
hospitals
you
go
to
the
emergency
department
when
you're
sick
or
that,
if
you
have
any
heart
surgery,
if
you
look
at
those
these
are,
these
are
data
from
most
of
the
hospitals
in
our
state,
the
major
general
care
hospitals,
as
you
can
see,
the
profit
margin
ranges
from
a
low
of
one
percent.
So
that's
too
low
that
should
come
up,
but
it
goes
up
to
a
high
of
23.
E
E
E
Okay,
what
will
be
the
impact
on
the
private
insurance
market
when
we,
when
we
adopt
rate
regulation,
we'll
get
lower
premiums
because
we're
going
to
have
fair
costs
and
not
excessive
costs?
Fair
pricing
will
lower
premiums
and
also
we'll
have
greater
competition
in
the
insurance
market,
because
it
will
be
easier
for
new
health
insurance
companies
to
come
in
and
offer
plans
because
they
right
now.
E
Insurers
have
to
create
networks
to
based
on
price,
discounting
they
say
to
doctors.
If
you
want
us
to
send
our
patients
to
you
have
to
give
us
discounts,
but
with
the
state
setting
rates
there
won't
be
any
need
for
price
discount.
In
fact,
price
discounting
will
be
prohibited
because
we
have
to
protect
doctors
from
insurers
that
try
to
drive
below
the
fair
rate.
So,
while
greater
competition
in
the
in
the
insurance
market
that
will
help
lower
premiums,
it
will
be
similar
to
the
medicare
advantage
program.
Medicare
advantage
is
the
private
insurance
side
of
medicare.
E
You
can
go
into
traditional
medicare
when
you
sign
up
and
just
go
to
any
doctor,
and
you
know
traditional
the
doctor
bills
medicare
or
you
can
have
medicare
pay
your
premium
for
a
private
insurance
plan
and
that's
a
very
robust
market.
When
I
put
in
my
zip
code
for
medicare
advantage,
there
were
like
10
or
11
insurance
companies
with
over
40
planned.
E
It's
a
very
robust
market
and,
what's
important
about
it,
is
medicare
advantage
plans
all
use
a
common
reimbursement
structure
they're
not
required
to,
but
they
in
fact
do
they
all
follow
the
medicare
fee
schedule.
So,
even
though
they
don't
compete
on,
they
don't
negotiate
rates
with
doctors.
They
still
are
able
to
compete
with
each
other
and
have
a
very
active,
thriving
market.
So
the
private
insurance
market
will
do
very
well
under
this
plan,
as
it
does
in
the
state
of
maryland,
where
they
have
pretty
significant
rate
regulation.
E
I've
covered
some
of
the
conceptual
amendments.
We've
got
some
others
remove
hospitals
from
the
provider
tax
provisions
because
they're
already
in
senate
bill
509
from
2017.
They
don't
need
to
be
here.
E
This
is
a
tweak
here.
Just
to
medicaid
rates
will
be
raised
to
the
upper
payment
limit.
That's
we
say
medicare
rates,
but
more
properly,
we
should
say
upper
payment
limit
just
to
conform
to
medicare
medicaid
rules
and
if
there's
not
a
medicare
rate,
then
average
commercial
reimbursement,
that's
a
small
tweak.
E
The
rate
setting
commission
will
publicly
disclose
all
rates.
We
need
transparency,
we're
transparency
where
we
have
opacity
right
now,
more
time
for
the
rate
setting
process,
we
had
a
short
time
frame
in
the
bill,
but
especially
for
the
first
year.
They'll
need
the
rate.
The
new
rate
sighting
commission
will
need
time
to
get
up
to
speed,
so
we'll
have
a
longer
time
frame
in
year,
one.
E
Okay.
So
just
to
sum
up-
and
thank
you
for
your
allowing
me
the
extra
time
ab4347
will
improve
access
to
health
care
for
medicaid
recipients.
It
encourages
more
nevada
physicians
to
see
medicaid
patients
more
care
in
physicians
offices,
less
than
emergency
departments.
It
provides
simplification
for
providers
and
insurers
reduces
complicated,
difficult
negotiations
between
providers
and
payers.
It's
a
hassle
and
a
headache
for
everyone.
Providers
will
not
have
to
manage
different
rates
for
different
payers
and
it
will
increase
provider
supply
in
nevada
by
raising
medicaid
reimbursement
to
medicare
levels.
E
That
will
become
a
much
more
attractive
state
in
which
to
practice,
not
to
mention
the
freezing
of
the
medical
malpractice
non-economic
damages.
Okay,
it
will
reduce
health
care
premiums
with
increases
in
medicaid
reimbursement,
less
of
a
need
for
providers
to
shift
costs
to
private
rate
pay,
insurance
and
rate
setting
will
protect
against
excessive
charges.
E
That
means
it
will
lower
cost
to
the
state
budget,
because
a
big
cost
to
our
state
budget
is
the
health
insurance
cost
for
state
employees,
and
this
will
reduce
that
and
bring
substantial
savings
in
the
state
budget,
far
more
than
the
cost
of
setting
up
this
independent
commission
and
it
will
target
regulation
and
market
failure.
Right,
as
I
said,
I
major
in
economics,
I
believe
in
markets,
but
sometimes
the
market
doesn't
work
properly.
We've
been
waiting
over
40
years
for
the
market
to
fix
itself
in
health
care.
It
hasn't
it
won't.
E
E
J
Okay,
my
name
is
joseph
white.
I
am
the
luxembourg
family,
professor
of
public
policy,
at
case
western
reserve
university,
I'm
not
one
of
your
constituents,
but
I
should
say
that
I've
been
coming
to
nevada
since
1972
when
my
sister
moved
there
in
1971,
and
she
is
a
constituent
of
representative
anderson,
assemblyman,
assemblywoman,
anderson
and
she's,
also
sad
to
say,
because
she's
utterly
not
that
healthy,
a
dual
eligible
person.
So
I
care
about
her
medicaid.
J
Thank
you
for
the
opportunity
to
testify
on
behalf
of
this
legislation,
which
would
directly
address
the
problem
of
costs
of
medical
care
in
a
way
that
no
other
state
has
attempted,
but
it
is
also
normal
in
other
rich
democracies.
I
want
to
emphasize.
I
did
not
develop
this
idea.
I
have
written
more
about
it
than
most
u.s
policies
called
health
policy
scholars
have,
but
I've
written
entirely
from
observation
of
what
other
countries
do.
J
J
We
basically
have
costs
that
as
a
size
share
of
our
economy
about
50
percent
higher
than
any
place
else
in
the
world
in
the
range
of
18
of
the
economy
compared
to
12
in
switzerland,
and
so
in
this
way
the
costs
are
actually
a
more
impressive
problem.
If
you
compared
other
countries-
and
it
also
means
that
healthcare
is
less
affordable
even
for
middle-class
persons
who,
by
american
standards
are
well
insured.
J
So
if
you're
thinking
in
terms
of
you
know
what
is
the
big
problem
for
your
voters,
the
bigger
problem
for
your
voters
is
the
cost
of
insurance
for
the
cost
of
health
care
for
people
who
have
insurance,
not
the
cost
of
health
care
for
people
who
who
don't.
That
is
a
really
big
problem
for
those
people.
But
the
the
unaffordability
of
health
care
for
people
who
have
insurance
is
a
major
major
crisis
in
the
united
states
and
it's
getting
worse
all
the
time.
J
Second,
in
negotiating
all
the
different
prices
and
all
the
different
contracts,
and
just
as
an
example,
I
was
once
giving
a
talk
in
paris
about
the
american
health
care
system,
and
I
said
that
the
cleveland
clinic
has
sixteen
hundred
doctors
and
everybody
went
ooh,
and
then
I
said
it
had
two
thousand
billing
clerks
and
people
looked
at
me
and
just
bewilderment.
J
Why
would
you
need
two
thousand
billion
clicks
and
that's
the
kind
of
variation
type
of
thing
going
on?
There
are
various
estimates
of
the
excess
costs
associated
with
our
billing
system
and
our
payment
system.
J
They
have
to
be
at
least
five
percent
of
total
spending
and
probably
much
more-
and
I
should
say
that
in
my
written
testimony,
I
provide
links
to
various
sources
on
all
this,
and
the
variation
in
prices
is
also
a
severe
problem.
J
Surprise
bills
will
disappear.
Moreover,
so
would
the
incentives
to
create
narrow
networks.
The
main
reason
for
narrow
networks
is
as
a
bargaining
technique
for
insurers.
They
seek
lower
prices
from
providers
by
threatening
to
exclude
physicians
or
hospitals
from
the
covered
lives.
That's
the
that's
the
term
that
insurers
offer
them
or
provide
for
them.
The
much
higher
prices
in
the
united
states
show
that
this.
J
I
think
it'd
be
hard
to
overstate
the
the
irritation
and
the
and
the
castles
associated
with
the
narrow
networks
and
with
the
uncertainty
about
what's
covered
and
what's
not
and
who
who
whose
care
is
covered
and
what's
not
ab347
would
create,
is
a
version
of
what
in
the
literature,
is
called
an
all-payer
system
in
an
all-payer
system,
there
are
multiple
insurers,
but
all
or
almost
all
pay
each
provider
by
the
same
rules,
and
this
massively
simplifies
billing
and
payment.
J
It
accomplishes
most
of
the
savings
that
could
be
associated
with
a
single
payer
system
or
so-called
medicare.
For
all.
There
were
versions
of
all
payer
systems.
In
many
countries,
such
as
germany,
france,
the
netherlands,
belgium
and
switzerland.
It
also
again,
as
as
doctor
like
showed,
is
how
medicare
advantage
works.
Private
medicare
advantage,
insurers,
pay
hospitals,
medicare
prices,
and
this
wasn't
wasn't,
wasn't
something
the
law
tried.
J
J
In
case
they
had
to
go
out
of
network,
but
because
the
out-of-network
plans
have
to
accept
medicare
fees,
there's
no
reason
for
an
insurer
to
contract
with
an
in-network
plan
and
pay
more
than
medicare
fees,
so
they
basically
pay
the
medicare
fees
and,
as
assemblyman
liquor
showed,
there's
actually
a
lot
of
market
competition
in
in
medicare
advantage
between
between
the
insurers
and
we're
talking.
J
You
know
here
about
basically
8347
combines
that
proposes
that
medicare
that
nevada
combined
price
setting
with
independent
insurers
in
a
way
that
already
applies
to
over
60
million
medicare
beneficiaries,
24
million
of
whom
are
medicare
advantage
plans,
and
it
takes
the
simplest
approach
to
setting
rates
start
with
medicare's
rules
and
then
deviate.
J
If
the
physician
group
or
hospital
can
make
a
reasonable
case,
for
example,
as
in
medicare
itself,
with
its
indirect
medical
ex
indirect
medical
education
expenses
and
its
disproportionate
share
hospital
payments,
there
may
be
arguments
that
a
hospital
is
extra
costs
from
teaching
or
from
a
disproportionate
share
of
uninsured
patients.
And
if
the
medicare
extra
payment
is
not
enough,
that
may
justify
higher
fees.
J
Now
providers
will
argue
that
medicare
payments
are
inherently
inadequate
and
that's
partly
because
they've
worked
with
is
they
basically
make
their
costs,
fit
whatever
money
they
can
create
and
they
have
a
great
deal
they
can
get,
and
they
have
a
great
deal
of
market
power
to
get
money
for
all
sorts
of
things,
some
of
which
many
of
us
would
not
think
are
useful.
Like
some
of
the
salaries
of
administrators,
one
should
be
skeptical
about
the
claims
about
medicare
payments
being
inadequate.
For
a
few
reasons.
J
Now
nobody
should
imagine
any
reform
will
work
perfectly,
but
the
approach
used
for
ab347
is
straightforward
and
relatively
simple.
We
should
remember
that
versions
of
all
payout
rate
setting
have
been
implemented
successfully
around
the
world
and
that
most
other
proposals
for
controlling
healthcare
costs
involved
far
far
less
positive
experience
and
evidence.
J
I
could
direct
you
to
a
huge
amount
of
stuff
that
was
actually
in
the
affordable
care
act
and
that
the
healthcare
policy
walks
have
been
proposing
over
the
years
and
in
fact
none
of
them
have
a
comparable
track
record
to
the
record
of
administrative
simplification
and
and
and
rate
setting
some
both
rate
setting
and
rate
settings
rate
simplification
that
we
see
in
other
countries
with
our
payroll
rate
setting.
A
Thank
you,
mr
white,
if
assemblyman
or
liquor,
I
believe
you
have
a
couple
other
people.
Are
they
on
to
be
a
part
of
your
presentation
or
are
they
on
for
supportive
testimony.
C
Okay,
there
we
are,
we
go
good
morning.
My
name
is
jolet
goings
and
I
wanted
to
speak
about
or
more
or
less.
I
guess
tell
a
testimony
personally
how
the
strain
that
the
health
pairs
our
health
care
policies
are
for
have
been
personally,
and
my
interest
in
the
bill
is
because
of
you
know,
hope
that
maybe
some
of
these
things
can
be
eradicated.
C
Okay,
I'm
a
senior
I
live
in.
I
have
a
my.
I
live
under
a
modest
income.
I
work
three
days
a
week
and
I
get
social
security,
but
I
do
have
health
care.
I
have
health
care
from
my
job
I
pay
which,
but
I
think
it's
a
crazy
amount
for
it,
but
we
have
to
have
health
care
and
also
when
you're
65
after
65
you're
required
to
have
medicare.
So
I
have
I'm
covered
by.
C
I
have
two
insurances.
I
have
coverage
by
two
inches
which
I'm
thinking,
okay,
good
I'll,
be
able
to.
You
know,
take
care
of
myself
be
healthy
whatever,
but
I
go
to
the
doctor
and
get
a
diagnosis.
They
give
me
a
plan
for
recovery
and
I
can't
even
afford
to
do
the
care,
because
the
deductibles
are
so
outrageous
and
when
you're
choosing
insurance,
you
don't
necessarily
understand
that
they're
telling
you
these,
they
don't
necessarily
list
all
the
deductibles.
C
You
know
you
know
you're
going
to
pay
for
office
visits.
You
know
you're
going
to
pay
sometimes
for
specific
diagnostic
testing
and
things
and
that's
okay,
but
when
you're
going
to
get
a
diagnosis-
and
they
tell
you,
this
is
what
it's
going
to
take
to
get
us
on
a
better
in
a
better
place.
C
And
then
this
is
you
know,
then
you
find
out
that
you
have
to
pay
this
deductible
before
you
can
get
the
work
done
so
for
me
is-
and
this
has
happened
to
me
more
than
once
so
it's
very
frustrating.
You
know
when
you
feel
like
you've,
taken
the
right
steps.
You've
done
the
right
precautions,
but
at
the
end
of
the
day
you
still
are
cannot
do
the
things
necessary
and
needed
to
have
the
ultimate
for
yourself.
A
D
Hi
greetings:
everyone
greetings
sharing
committee.
My
name
is
asia
duncan
I'm
a
small
business
owner,
and
today
I
come
before
you
because
simply
it's
difficult
to
pay
for
health
insurance,
not
just
for
myself
as
an
individual,
but
even
as
even
small
group
health
care
plan
options
for
my
team
are
expensive
and
unsustainable
for
my
business
at
this
time,
healthcare,
accessibility
and
affordable
healthcare
coverage,
in
my
opinion,
is
essential
to
individuals
and
families
overall
health
and
wellness.
I
care
about
the
individuals
who
work
for
me.
D
D
The
average
annual
premiums
for
for
small
group
health
plans
were
roughly
3
500
to
5
000,
on
top
of
several
other
necessary
amanda,
mandatory
insurance
coverages
that
I
have
to
have
it
just
wasn't
feasible
option
for
us
to
also
add
health
care.
In
addition
individually,
my
premium
is
around
four
thousand
and
one
dollars
a
year,
and
I
went
to
you,
know
the
marketplace
and
shopped
around
and
did
you
know
and
tried
to
find
the
best
policy
and
coverage
for
me
and
my
family,
but
I
still
I'm
still
paying
four
thousand
dollars
a
year.
D
Health
insurance
for
me
is
just
one
of
those
you
know
in
in
the
event
of
an
emergency
situation,
because
I
feel,
like
I
practice
healthy
lifestyle
healthy
living,
but
I
do
know
some
people
that
work.
For
me
they
have
pre-existing
conditions
and
other
life-altering
illnesses,
and
when
I
talk
to
them
about
health
care
they
they
often
tell
me
that
what
I
pay
them,
if
I
pay
them
too
much
and
they
won't
qualify
for
their
medicaid.
So
I
don't
really
understand
all
the
time.
You
know
how
medicaid
relates
to
pay
raises.
D
I
always
thought
it
was
a
good
thing
to
get
pay
raise,
but
you
know
some
of
them
don't
want
pay
raises
just
because
they
need
to
maintain
their.
You
know
their
medicaid.
So
I
hope
my
testimony
today
will
allow
legislators
to
considering
lower
the
cost
of
health
care.
Overall
for
small
groups
and
small
health
care
plans,
and
also
for
individuals
and
people
like
myself,
so
thank
you.
A
E
Casey
kristen,
I'm
not
sure
if
he
was
able
to
make
it,
but
that's
casey.
I'm
here
I'm
here
can.
B
I
am
kc
christon
c-h-r-I-s-t-o-n,
one
of
the
things
that
I
would
like
to
first
of
all
good
afternoon,
everyone
and
appreciate
the
invitation,
but
one
of
the
things
I
don't
necessarily
want
to
talk
about
myself.
B
B
B
A
lot
of
folks
just
are
having
a
challenging
time,
understanding
what
it
means
and
to
interpret
what
it
means
and
also
what
happens
if
they
do
this,
what
happens
if
they
do
not
do
this?
They
come
to
me
I'm
their
first
stop
like,
like
I
said
I
work
with
their
their
children
at
the
school.
So
I
get
a
lot
of
questions
and
I
find
myself
doing
a
lot
of
research
just
to
answer
basic
questions
for
the
parents.
B
I
can
understand
their
frustration
because
there
was
some
time
that
I
didn't
have
health
insurance
myself
so
being
able
to
navigate
the
medic
medicaid
medicare
system
in
in
nevada
is
challenging,
and
so
I
can
only
imagine
what
these
parents
are
going
through
on
a
daily
weekly
monthly
basis
with
multiple
children,
some
who
have
moderate
health
problems,
some
who
have
severe
health
problems.
A
Thank
you
for
being
a
part
of
this
presentation,
and
I
will
turn
this
back
over
to
assemblyman
orrin
liquor
for
any
remarks
prior
to
opening
up
for
questions.
E
Thank
you
chair.
I
don't
we
can
go
to
questions
now,
thanks.
A
Sounds
good:
we
have
quite
a
few
people
in
the
queue
and
I'm
sure
it
will
spark
a
conversation
where
other
people
will
light
up.
So
if
you
members
of
the
health
and
human
services
committee,
if
you
can
go
ahead
and
send
your
questions
to
me,
I
will
direct
the
questions
to
assemblyman
or
liquor
first.
So
we're
not
doing
this
round
robin
kind
of
where
everyone
has
an
answer
for
the
question
and
maybe
he
can
direct.
Who
would
be
the
more
appropriate
person
to
answer
that
question.
C
Thank
you,
madam
chair,
and
thank
you
assemblyman
orrin
liquor,
not
just
for
presenting
today,
but
for
the
the
number
of
stakeholder
meetings
that
you
had.
I
I
participated
in
the
working
group
with
you
and
I
know
it's
been
difficult.
C
Virtual
world
with
such
a
complex
bill,
but
I
do
think
that
your
your
passion
to
try
to
bring
health
care
to
all
parts
of
our
state
is
a
is
something
that
we
all
agree
upon.
And
so
I
just
wanted
to.
C
There
been
any
consideration
of
what
is
going
to
happen
with
the
doctor
shortage
that
we
currently
have
in
relation
to
how
this
bill
would
be
implemented.
Would
we
see
an
increase,
or
would
we
see
a
decrease,
and
would
this
be
seen
to
be
an
attractive
measure
for
to
bring
additional
medical
professionals
to
the
state?
Thank.
E
You
thank
you,
david
arnett
licker,
for
the
record
assembly
district,
20.
yeah.
I
think
this
will
do
a
lot
to
make
nevada
more
attractive.
The
low
payment
on
the
medicaid
side
is
a
perennial
and
serious
irritant
to
physicians
and
other
providers
that
we
don't
pay
them
adequately.
E
C
C
Thank
you,
chairwin.
Thank
you,
assemblyman
orrin
liquor.
I
want
to
echo
what
what
simon
hafen
said
about
your
efforts
and
and
working
this
bill,
and
I
know
you
reached
out
to
me
individually.
I
appreciated
the
opportunity
to
to
get
together
with
you
and
talk
about
it.
C
Obviously,
you
covered
a
lot
of
ground
there
and
I
know
you
may
have
touched
on
some
of
this
peripherally
at
least,
but
I'm
hoping
we
can
kind
of
zero
in
a
bit
more
talk
a
lot
about,
obviously,
the
issue
of
of
rates
and
the
rate
setting,
and
I'm
wondering
if
you
could
speak
to
under
this
bill,
who
exactly
would
set
these
rates
and
and
how
do
we
ensure
that
a
commission
will
be
educated
and
informed
enough
to
intelligently,
evaluate
and
consider
all
the
relevant
market
variables
here
and
and
not
be.
E
Thank
you
assemblyman
and
david
orentlichter
for
the
record.
That's
a
good
question
and
the
way
we're
conceiving
of
the
commission
now
is
that
it
would
have
a
board
with
a
wide
range
of
stakeholders
to
make
sure
all
voices
are
represented
and
that
insurers
providers,
employers,
workers
patients
all
are
there
to
make
sure
the
commission
takes
into
the
all
their
views
are
taken
into
account,
but
it
also
will
have
a
body,
a
staff
of
expert
analysts
who
can
look
at
the
data
and
figure
out
as
medicare
does
now.
E
We
do
it
in
that
with
our
in
the
public
utilities
a
similar
model,
so
we
do
have
to
properly
staff
it
and
properly
both
the
people
who
do
the
data
crunching
and
the
people
who
are
on
the
board,
but
there
are
good
models
out
there
and
I'm
certainly
willing
to
make
you
know
I'm
very
interested
in
feedback
on
how
we
can
design
it
as
well
as
possible,
and
perhaps
professor
white
might,
if
you're
anything
you
want
to
add.
Please
do.
J
Yeah
one
one
thing
is:
is
this
an
issue
of
how
you
think
about
you
know
what
outside
influences
are
because
the
really
important
outside
influences
are
the
people
who
are
asking
for
more
money
right
and
they're,
going
to
try
very
hard
to
influence
to
get
more
money?
I'm
not
sure
there
are
other
outside
influences
that
are
going
to
be
playing
on
these
kinds
of
things.
J
If
you're
thinking
you
know-
and
I
I
think
that
as
a
general
approach,
it
makes
sense
to
say
here's
a
standard
that,
by
the
way,
I
think
the
medicare
rates
will
be
the
medicare
rates
once
once,
costs
go
down
for
providers
due
to
low
administrative
costs
will
be
even
even
closer
or
more
certainly
adequate.
J
But
I
think
that
you
know
you
do
need
to
have
some
sort
of
process
of
of
appeals
and
just
you're
making
a
claim
that
we're
different
for
some
reason
and
that
would
probably
work
the
same
way.
Any
other
appeals
process
in
in
in
a
body
works.
You
know,
I
think
that
it's,
we
can't
be
sure
it'll
be
perfect,
but
I
think
it
should
be
pretty
good.
J
I
also
think
we
can
be
absolutely
sure
that
the
providers
who
have
the
market
power
to
depending
on
your
words
achieve
or
extort
higher
prices
will
say
it's
unfair.
I
mean
we
know
that
will
happen
for
certain.
C
Thank
you
follow
up,
madam
chair.
C
Thank
you,
someone
thank
you
for
the
response,
professor
white,
you
as
well
reference
experts,
you
know
an
expert
in
one
field
and
obviously
isn't
necessarily
an
expert
in
another.
So
I'm
wondering
you
know
what
you
have
in
mind:
we
talking
health
care
professionals,
providers,
economists,
academics,
you
know
combination
of
those
and
what
happens?
What
would
happen
if
you
know,
experts
won't
always
necessarily
agree,
you
know
and
they
may
end
up
having
based
on
their
areas
of
expertise.
Sometimes
those
things
can
come
into
conflict.
C
So
I'm
wondering
how
you
might
see
that
that
playing
out
and
what
field
or
fields
these
experts
may
be
drawn
from.
Thank
you.
J
Well,
personally,
I
would
like
accountants,
I
think,
there's
there's
going
to
be
a
claim
made
that
that
our
costs
are
higher
for
some
reason,
and
I
would
I
would
like
to
see
people
who
can
assess
assess
the
the
data
used
to
make
those
claims.
J
I
think
that
there's
an
argument
for
having
a
variety
of
skills
on
these
on
these
panels,
and
I
think
assemblyman
only
has
thought
more
about
that
than
I
have,
but
I
think
what
you
want
is
a
variety
of
skills,
a
variety
of
perspectives,
but
I
do
think
that
you
know
one
substantial
part
of
it
is
just
accounting
somebody's
somebody
is
making
a
claim
about
costs
and
you
know:
are
they?
Are
they
telling
you
the
truth?
Are
they
actually
not
understanding
their
own
costs
and
their
costs
are
actually
higher
than
they're
saying?
C
Thank
you,
madam
chair,
could
I
ask
one
more
question.
C
Thank
you
again,
it's
sort
of
a
multiple
part
question
assemblyman,
wouldn't
a
cost-based
rate
system
or
incentivize
increase
costs
of
the
structure.
That
way,
and
also
how
exactly
are
we
defining
costs
and
who
who
would
be
defining
what
those
costs
are
under
this
bill?
Thank
you.
E
Yeah
there's
that
is
one
of
the
risks
that
people
will
try
to
inflate
costs.
So
that's
one
of
the
advantages
starting
with
medicare,
because
medicare
does
a
lot
of
vetting
already
in
terms
of
what
are
reasonable
costs
and
what
are
not
reasonable
costs
and
that's
and
then
we
will
have
our
the
staff,
the
expert
staff,
the
accountants
and
the
economists
and
the
people,
the
health
policy
people
who
can
then
you
know
the
the
burden
will
be
on
the
providers
to
show
that
this
cost
is
a
reasonable
cause.
E
We
know
some
hospitals
are
more
efficient
than
others
and
the
rate
setting
commission
will
take
that
into
account
because
they'll
see
what
other
you
know,
they're
not
going
to
look
at
just
one
I'll,
be
looking
at
the
full
range
of
providers,
so
they'll
have
a
good
sense
of
who
are
the
efficient
ones
and
who
are
the
inefficient
ones
and
that's
something
they'll
take
into
account.
So
the
important
thing
is
medicare
is
already
doing
this
and
it's
been
doing
it
for
a
long
time,
and
so
we
know
it
can
be
done
in
a
pretty
effective
way.
C
All
right,
thank
you
assemblyman.
I
thank
you,
professor
white,
and
thank
you,
madam
chair.
A
I
I
have
a
question
for
you:
assemblyman
orrin
licker.
I
saw
it
in
the
amendment
you
have
a
cap
on
non-economic
med
mal
damages.
If
the
provider
group
participates
in
the
provider
tax,
can
you
kind
of
give
me
some
reasoning
behind
that?
I
know
in
your
presentation,
like
in
chief,
you
had
indicated
that
those
medical
malpractice
claims,
like
account
for
less
than
one
percent
of
like
the
cost,
was
that
a
as
a
part
of
conversations
with
stakeholders?
How
did
that
come
about
that
amendment?.
E
A
good
question:
thank
you
shared
something
in
davidorn
liquor
for
the
record
you
know,
change
is,
can
be
scary
to
people,
even
if
it's
the
right
thing
to
do
when
you're
proposing
a
significant
change
people
get
nervous
and
so
to
provide
reassurance
that
we
are
trying
to
do
the
right
thing
and
to
make
this
a
more
appealing
opportunity
for
providers
they're
trying
to
decide
whether
to
vote
for
this
provider
tax
that
making
adding
in
the
protection
on
the
medical
malpractice,
which
is
something
that
provides
a
causes.
E
A
lot
of
anxiety
for
them
is
where
anything
we
can
do
to
assure
them
that
this
is
the
right
thing
to
do,
for
them
that
they
will
be
better
off
that
their
patients
will
be
better
off.
If
we
can
anything,
we
can
do
to
provide
reassurance,
I
think
will
be
helpful.
A
E
That's
pretty
widely
accepted
national
data.
I
can
see
provide
a
particular
source
if
you'd
like,
but
that's
you
know
the
standard
view
of
what
the
total
cost
of
the
tort
system
are.
If
you
now
that
people
will
say
well
what
about
defensive
medicine
and
that
doesn't
include
defensive
medicine
and
that's
harder
to
pin
down
you
can
measure
how
much
is
spent
on
liability,
insurance
and
court
cases,
so
that
one
percent
is
a
pretty
good
number,
the
defensive
medicine.
E
You
know
that's
in
the
minds
of
doctors
so
but
estimates
there
may
go,
as
you
know,
maybe
three
or
four
percent
some
might
go
to
five
percent,
but
a
lot
of
it
is,
as
I
say,
to
provide
you
know,
even
if
it
doesn't
cost
you
dollars
to
go
to
court,
there's
a
lot
of
psychological
costs
to
having
to
defend
yourself
in
a
lawsuit,
and
so
that
that
doesn't
show
up
in
the
in
the
one
percent
of
economic
costs.
A
F
Thank
you
chair
and
thank
you
for
bringing
the
bill
additionally
would
like
to
reflect
the
sentiment
of
my
colleagues
that
the
work
you've
put
into
this
has
been
really
impressive.
I
know
I've
been
invited
to
a
number
of
meetings
had
conflicts
for
most
of
them,
but
sat
in
on
a
little
bit
of
it.
I
wanted
to
ask
a
little
bit
about
the
data
collection
that
was
referenced,
which
would
be
used
to
determine
like
the
payment
amounts
right.
Can
you
talk
a
little
bit
about
what
is
currently
being
collected?
E
Yeah
sure,
thank
you
for
that
question.
E
Vice
chair,
peters,
david
orentlichter,
for
the
record
one
of
the
advantages
of
structuring
it
the
way
the
bill
does
to
say
start
with
medicare,
so
hospitals
are
already
filing,
for
example,
medicare
cost
reports,
so
they've
already
accumulated
a
lot
of
data
to
start
with,
and
then
the
second
part
is:
if
providers
think
that
medicare
is
not
adequate,
then
they
have
the
opportunity
to
come
before
the
commission
and
say
we
need
to
raise
the
rate
by
five
percent
ten
percent,
whatever
they
think
is
right,
they
might
say
forty
percent,
and
then
they
have
the
obligation
to
provide
evidence
the
data
to
support
their
claim.
F
So
so,
I'm
totally
a
data
nerd
and
love
technology,
databases
to
data
management,
and
I
would
like
having
this
this
fantasy
of
a
process
in
which
there
we
would.
We
could
use
like
an
artificial
intelligence
to
run
an
algorithm
on
data
input
by
these
entities
and
really
leave
like
the
experts
and
people
out
of
it
after
we've,
just
like
an
oriented
a
process
that
was
amicable,
anyways
a
little
sci-fi
like
for
us
in
committee
here.
F
My
other
question
has
to
do
with
like
again
some
of
the
data
you
you
presented
related
to
the
difference
in
cost
between
medical
procedures
in
the
united
states
versus
other
countries,
and
I
wanted
to
ask
about
whether
those
accounted
for
like
the
difference
in
cost
of
living
expenses
in
the
united
states,
as
we
know,
particularly
compared
to
taiwan,
that
living
here
costs
a
little
different
than
living
in
taiwan.
So
can
you
just
explain
a
little
bit
about
how
that
is?
Normalized.
E
Yeah,
thank
you
vice
chair
peters,
david
orenlicker,
for
the
record
and
after
I
finish
professor
white,
please,
if
you
have
more,
I
don't
know
about
the
cost
of
living
in
taiwan,
so
I
was
planning
to
use
japan.
I
just
was
having
trouble
getting
the
numbers
from
japan.
Japan
has
a
much
higher
cost
of
living
and
their
prices
would
would
not
look
that
different
from
taiwan.
E
So
so
the
cost
of
moving
doesn't
explain
the
difference,
but
the
major
difference,
differences
governments
negotiate
when
you
have
a
single
buy.
You
know
negotiator
on
the
payer
side
on
the
buyer's
side,
the
purchaser
side,
the
government,
that's
just
how
government
negotiation
is
just
a
lot
more
leverage
than
we
think
of
insurers
as
be
big
and
bad
and
powerful,
but
compared
to
a
government.
They
just
don't
have
the
same
kind
of
negotiating
leverage
in
a
lot
of
communities.
E
J
This
is,
this
is
joseph
white
for
the
record,
so
a
couple
of
things
about
this
one
is
that
there
are
even
situations
where
it's
not
the
government
that
sets
the
crisis
in
germany.
J
The
insurers
get
together
and
they
the
system
sets
it
up
so
that
they
get
together
and
negotiate
as
a
side
with
the
providers
as
they
side,
but
that
has
the
same
effect.
What
you
are
doing
is
you're
concentrating
the
market
power
among
the
insurers.
So
that's
that's
in
a
way
that
doesn't
exist
in
the
united
states
american
insurers,
in
spite
of
the
fact
that
people
complain
about
them
all
the
time.
The
really
striking
thing
about
american
insurers
is,
they
are
wimps.
J
They
are
very
bad
at
negotiating
prices
and
that's
partly
because
they
have
a
choice:
they're,
actually,
a
middleman
and
on
one
side
they
are
negotiating
with
individual
employers,
who
are
very
small
compared
to
them
normally
and,
on
the
other
hand,
they're
negotiating
largely
with
concentrated
hospital
networks,
and
with
you
know,
in
in
many
communities,
it's
like
three
cardiac
care
groups
really,
and
so
they
have
to
make
a
choice.
Do
they
negotiate
harder
with
the
people
with
whom
they
have
less
market
power,
in
other
words,
with
the
providers
or
with
their
customers?
J
J
Now,
on
the
on
the
question
of
comparing
costs?
Yes,
you
cannot
simply
use
exchange
rates,
you
know
and
and
say
well
we'll
turn
the
japanese
yen
into
dollars
at
the
current
exchange
rate
and
make
the
comparison
that's
somewhat
indicative.
J
But
the
fact
is
that
it
there's
only
so
much
it
gets
you
to,
and
so
there
are
most
of
the.
So
there
are
a
lot
of
analyses
that
have
that
have
gone
into
greater
depth
and
done
things.
You
know,
one
of
the
things
is
simply
just
to
show
the
big
difference
in
percentage
of
gdp,
because
you
know
gross
domestic
product
includes,
you
know
basically
includes
you,
know
everything
in
the
economy.
So
if
we're
at
18
and
somebody
else
is
at
12
or
11,
then
we
really
must
be
spending
be
doing
something
more
expensive.
J
And
if
you
look
at
what
we're
doing
it's
prices-
okay,
not
volume,
and
some
of
that
by
the
way-
is
for
drugs,
and
this
doesn't
really
address
drugs.
Okay,
which
is
a
a
different
issue.
Okay,
different
problem,
but
but
a
major
one,
but
the
other
side
of
it
is
there
have
been
people
who
have
tried
to
control,
for
you
know
local
costs
of
living
and
so
on,
in
particular,
back
in
2007
and
2008
mckinsey.
J
You
know
that
good
left-wing
organization,
mckinsey
did
a
really
detailed
study
and
with
their
adaptation,
and
their
estimates
were
based
on
controlling
and
controlling,
for
underlying
cost
of
living
differences
totally
some
extent,
and
they
still
found
the
same
basic
story,
which
is
that
the
difference
in
cost
between
the
united
states
and
other
countries
is
due
to
prices
and
administrative
costs.
J
Having
said
that,
it's
important
to
understand
what
spending
less
would
mean,
on
the
one
hand,
probably
on
average,
not
in
every
country,
for
instance,
not
necessarily
for
non-hospital
doctors
in
japan,
american
provide
american
doctors
are
paid
more,
and
the
question
is:
if
you
care
about
doctors,
whether
the
fact
that
they
will
have,
you
know
significantly
lower
costs
because
they
won't
be
paying
all
these
administrative
staff
means
that
you
can,
you
know,
pay
them
lower
fees,
but
still
they'll
end
up
ahead
or
at
least
equal.
J
The
second
thing
you
have
to
remember
is
that,
if
we're
saying
there's
a
lot
of
unnecessary
billing
work,
then
I
have
to
admit
we
are
saying
there
are
some
jobs
that
will
have
to
go
away,
because
if
you
have
those
2000
billing
clerks
at
the
cleveland
clinic
and
you
simplify,
then
there
are
job
losses
and
then,
when
you're
doing
your
calculation
of
what
of
whether
a
hospital
needs
more
money,
you
know
if
the
ceo
is
making
three
million
dollars,
then
maybe
you
don't
want
to
accommodate
that
in
the
cla
in
the
claim
for
for
more
money.
J
So
there
are,
you
know
there
are
potential
losers.
On
the
other
hand,
the
winners
is
everybody
yeah,
potentially
our
everybody
else
again.
What
we're
talking
about
is
a
situation
in
which
even
people
with
good
insurance
are
losing
it.
J
The
big
beneficiaries
of
the
non-medicaid
part
of
this
plan
right
medicaid,
is
improved
by
paying
higher
rates,
so
people
with
medicaid
can
get
can
get
better
better
services,
but
the
big
beneficiaries
are
the
people
who
have
insurance
through
their
employer,
which
will
be
much
insurance
as
costs
go
down,
will
be
much
more
affordable
for
the
employers.
The
employers
will
have
less
need
to
cut
benefits.
Cut
benefits,
cut,
benefits
the
way
they
have
been
doing
that
doing.
J
What
is
going
on
right
now
is
the
increase
in
costs
in
the
system
has
its
biggest
effects
on
people
who
are
getting
insurance
through
their
employer.
Most
of
the
people
are
getting
it
through
medicare,
while
medicare's
prices
are
regulated,
the
people
who
are
getting
it
through
medicaid
different
problem,
the
people
who
are
getting
it
through
the
marketplaces,
their
premiums,
if
you're
under
400
of
the
federal
poverty
level,
are
limited
anyway,
limited
already.
J
F
Thank
you
for
breaking
that
down
a
little
more.
I
think
I
mean
in
response
calling
someone
a
loser
for
like
reducing
their
annual
pay
from
two
million
dollars
to
something
less
does
not
seem
like
that
big
of
a
loss
to
me
compared
to
someone
not
having
to
be
buried
for
the
rest
of
their
life
for
a
hospital
bill,
because
their
child
fell
off
their
bike.
So
you
know
the
costume
and
and
benefits
balance
has
to
have
some
perspective.
I
think,
but
thank
you
for
for
those
responses.
A
Thank
you,
sherwin
and
thank
you.
Assemblyman
orient
liquor
for
your
very
interesting
presentation.
So
my
question
is:
let's
say
somebody
breaks
their
arm
and
they
need
to
go
to
an
orthopedic.
E
So
david
or
liquor
assembly
district
20
for
the
record
will
we
have
different
rates
for
different
providers?
Potentially
it
would
if
the
bill
does
include
a
provision
to
say,
quality
of
care
should
be
taken
into
account
that
I
think
it's
a
good
idea
that
said,
quality
based
payments
do
not
have
a
very
good
track
record.
It's
a
very
good
concept
in
theory,
but
in
practice
we've
found
that
it's
been
very
difficult
to.
E
You
know:
adjust
reimbursement
based
on
quality
of
care.
It's
been
tried
for
a
long
time
and,
as
I
say
that
the
evidence
is
is
not
very
good
for
its
effectiveness,
and
but
that
said,
as
I
say,
the
bill
does
include
it
and
it
would
be
if
a
provider
could
demonstrate
that
they're
providing
higher
quality
of
care,
that
that
should
be
rewarded.
E
Okay-
and
I
just
want
to
add
professor
wright-
did
say
we
may
lose
some
right-
some
billing
clerks,
but
other
employers
who
have
lower
health
care
costs
will
be
able
to
hire
more
workers.
So
I
think
overall,
we're
more
likely
to
get
more
people
working
when
you
lower
health
care
costs.
If
you
lower
the
cost
of
operating
a
business,
you
know
you're
going
to
expand
your
business
more
quickly
and
hire
more
workers.
A
E
Assembly
and
david
aren't
looking
for
the
record.
Yes,
they
would
so
initially
they
would
come
in
and
say
we
think
we
should
have
a
higher
rate.
They
would
get
a
response
from
the
commission
and
there
would
be
an
appeals
process
within
the
commission
as
there
is
within
medicare
to
challenge
and
say
we
want
you
to
reconsider
this.
A
Do
you
have
any
other
questions,
assemblywoman
kresner?
No,
I'm
also
I'm
next
going
to
go
to
assemblywoman
titus,
who
I'm
sure
has
one
question
or
a
couple
go
ahead.
Please
ask
your
question.
I
Thank
you,
madam
chair.
I
I
do
appreciate
the
opportunity
to
ask
some
questions.
First,
I
want
to
thank
assemblyman
art
liquor
for
the
presentation
for
the
time
and
effort
that
he's
put
into
this
bill
and
that
this
discussion
is
really
a
nationwide.
Discussion
has
been
going
on
for
decades
and
to
solve
the
nationwide
problem
in
a
couple
hour.
Testimony
is
a
heavy
lift
for
anybody,
but
but
I
do
believe
that
these
are
conversations
well
worth
having.
I
So
I
do
appreciate
it
and
all
the
time
you
put
into
it
I'd
actually
like
to
go
to
the
bill
itself
and
ask
some
questions
pertaining
to
the
actual
bill,
as
opposed
to
conceptually
healthcare
and
its
issues
in
our
nation
and
and
worldwide.
Actually,
and
so
with
that,
the
the
amendment
that
you
added
and
it
plays
along
with
some
of
what
chair
nguyen
asked
regarding
on
section
seven
or
section
six.
I
Sorry
in
your
conceptual
amendment
about
the
provider
if
they
are,
if
they
choose
to
join
this,
then
they're
going
to
be
capped
on
the
economic
damages,
and
I'm
curious
about
opening
up
that
particular
chapter
and
nrs.
And
what
will
happen
to
those
providers
who
don't
sign
on
they're
going
to
have
now
unlimited
exposure?
E
Yeah
so
the
way
just
to
be
clear
all
the
way
the
assembly
woman
david,
aren't
looking
for
the
record,
the
way
that
the
provider
text
has
to
work
under
medicaid
rules.
E
If
you
come
in,
if
you
apply
it
to
a
class
of
providers,
hospitals
or
a
class
physicians
or
a
class
dentist
or
a
class,
so
you
are
allowed
to
further.
You
could
subdivide
physicians
and
say
we
only
want
pediatricians
to
come
in
or
emergency
doctors
to
come
in.
There
are
paths
to
do
that,
but
it's
very
difficult
to
do
it
that
way.
So,
let's
assume
all
doctors
come
in
as
a
class
that
that
happens.
Only
if
two-thirds
of
doctors
in
the
state
vote
to
you
know
assume
the
tax
then
medicaid
requires
that
everybody's
in.
I
It
was
about
this
economic
damage
on
a
near
amendment
and
it's
in
blue
and
it's
number
five
and
talks
about
the
non-econ
economic
damages
shall
not
be
raised
and
apply
to
provider.
I
E
I
Thank
thank
you.
I'm
not
still
we'll
move
on,
because
I
have
so
many,
and
I
want
to
get
hung
up
on
that
at
this
point
in
time.
How,
under
that
same
section,
your
amendment
under
section
six
number
one
you're,
providing
that
the
future
legislators
declare
that
we
will
not
raise
the
maximum
amount
of
non-academic
damage.
How
can
you
commit
a
future
legislative
body
to
that?
How
can
you
put
that
in
a
statement
because
we
can't
commit
commit?
You
know
we
cannot.
I
We
don't
know
what
the
next
group
up
group
makeup
will
be
of
this
body.
We
can't
commit
the
future
legislative
body
to
what
our
decisions
are
today
we
can
pass
nrs,
but
they
can
be
free
to
change
it.
So
I'm
worried
that
that
kind
of
commits
us
a
few
to
prevent
future
legislation.
Could
you
clarify
that.
E
E
We
passed
this
bill
that
had
many
parts.
It
is
a
integrated
whole
if
you
start
picking
out
one
part
it
it's
like
unraveling,
a
sweater
when
you
start
pulling
on
the
thread
and-
and
so
that
would
be
an
inappropriate
thing
to
do,
and
just
to
make
sure
that
you
think
twice
about
trying
to
do
something
like
that.
E
A
I
Thank
you.
So
at
this
point
in
time
you
know
I
having
lived
in
the
real
world
of
an
office
practice
also
in
private
practice
and
then
again
working
for
the
hospital
district.
I
know
that
medicare
does
not
reimburse
that
cost.
Now
they
don't
and
and
it's
difficult
getting
doctors
to
see,
medicare
patients.
Obviously
your
your
concerns
about
it's
even
worse:
getting
doctors
to
see
medicaid
patients
because
they
pay
at
a
lower
rate.
Right
now,
in
nevada,
medicaid
pays
95
percent
of
the
medicare
rate,
that's
pretty
much
general
what
their
reimbursement
is.
I
I
How
I
I
would
see
whoever
walked
through
my
door.
The
issue
wasn't
me
seeing
them.
The
issue
was
me:
getting
them
referred
then
to
a
provider
who
would
have
a
forbid
see
a
medicaid
patient,
but
I
could
not
get
them
to
see
a
medicare
patient.
So
I
am
concerned
that
then
setting
these
rates
and
we're
talking
about
you
know
where
the
private
insurers
are
going
to
go.
I
You're,
obligating
private
insurance
companies
to
not
just
medicaid
medicare,
but
we're
talking
about
a
global
price
control
here
that
you're
going
to
obligate
private
insurancers
to
and
then
you
know
how
will
that
encourage
anybody
to
practice
health
care
in
nevada?
So
I
have
huge
concerns
that
this
is
going
to
all
be.
Your
intention
is
to
have
them
see
more
patients.
I
think
you're
going
to
do
absolutely
the
complete
opposite
based
on
what
this
bill
presents
today.
I
So
I'm
anxious
to
hear
some
more
discussion
on
it,
but
I
have
I'm
really
concerned
about
price
setting
and
and
how
how
that
will
actually
impact
me
as
a
provider
getting
that
person
who
I
couldn't
get
seen
for
medicare
now,
let
alone
get
him
received
medicare
in
the
future.
So
I
guess
that
was
more
of
a
box.
You
know
standing
on
a
soapbox
more
than
a
question,
but
again
I'm
just
not
seeing
how
I
guess.
I
I
could
ask
this
question:
how
how
will
this
this
may
affect
medicare
rates
and
medic
people
who
see
medicaid
and
medicare,
but
those
who
don't
see
these
patients,
those
who
don't
see
medicaid
and
medicare?
Is
this
going
to
force
them
to
accept
these
same
rates
down
and
if
so,
is
the
federal
government
will
they
meet
need
to
be
changes
on
a
federal
government
regulation
standpoint.
E
David
licker
assembly
district
20
for
the
record,
I'm
confident
that
if
doctors
are
promised
that
they
will
be
paid
fair
reimbursement
for
all
of
their
patients
and
perhaps
with
medicaid,
not
quite
all
the
way
but
pretty
close,
and
that
for
all
their
pe
that
overall,
they
will
receive
fair,
fair
reimbursement
and
they
won't
have
the
hassle
of
dealing
with
negotiations
with
insurance.
Companies
and
they'll
have
extra
protection
against
liability
for
malpractice.
E
I
think
that's
a
pretty
good
deal
and
I
think
they're
I'm
not
worried
that
about
the
appeal
that
to
doctors
around
the
country,
they're
for
the
doctors
who
want
to
earn
excessive
reimbursement
and
more
than
a
fair
income.
So
I
think
we'll
lose
some
people
like
that.
E
I
think
from
what
I
know
about
doctors
that
that
and
from
what
I
know
from
myself
as
a
doctor,
that
they're
going
to
be
more
doctors,
who
will
be
attracted
to
nevada
than
will
want
to
you
know,
earn
excessive
reimbursement,
and
maybe
that's
not
good
for
patients
having
doctors
like
that,
who
care
that
much
about
how
much
they
earn
that
a
fair,
a
fair
profit
is
not
adequate,
because
if
they're
not
happy
and
excessive
profits,
that
makes
me
worry
about
how
they
how
they
deal
with
their
patients.
I
Final
question,
madam
chair:
I
promise
so
with
this
commission
determine
an
arbitrary
of
what
they
will
decide
is
a
fair
reimbursement.
Now
this
commission
does
not
the
provider
based
on
cost
etc.
This
commission
does,
will
the
commission
take
into
consideration
research
development,
advancing
or
being
able
to
grow
a
practice
or
will?
Because
does
that
add?
I
Well,
do
you
know
if
that
commission
is
it
anywhere
in
this
bill,
because
I
couldn't
see
it
if
that
commission
is
going
to
allow
for
a
reasonable
profit
margin,
so
that
then
you
can
reimburse,
and
some
other
just
you
know,
building
a
bigger
practice,
getting
new
equipment
getting
monetization
those
cost
of
doing
business
that
every
other
business
has
to
look
at
will.
Will
that
be
a
factor
considered
because
I
don't
see
it
in
the
bill.
E
David
liquor,
assembly
district
20
for
the
record,
so
that
sounds
like
something
that
would
be
part
of
the
concept
of
a
reasonable
profit.
That's
one
of
the
reasons
to
have
a
profit
is
so
that
you
can
invest
in
expansion
for
the
future,
but
it's
certainly
something
we
could
put
in
to
make
sure
it's
clear.
I
Thank
you,
madam
chair,
for
your
patience.
Thank
you,
assemblyman
linker
for
answering
the
questions.
A
Thank
you,
and
at
this
time
I'm
actually
going
to
go
to
the
phone
lines
to
start
testimony
in
support
of
assembly
bill,
I've
lost
the
number
again
one
second
assembly
bill,
347.
Thank
you
so
assembly
bill
347
broadcast
services.
I
would
remind
callers
to
please
clearly
state
and
spell
your
name
for
the
record,
and
please
limit
your
testimony
to
two
minutes
and
with
that
we'll
go
ahead
and
begin.
B
B
C
C
I
did
my
research
I
found
what
was
available
for
me,
what
was
covered
by
my
doctors
and
even
then
I
still
struggle
to
pay
my
premiums,
my
co-pays,
and
I
think
it's
a
struggle
that
a
lot
of
my
friends
who
also
share
barriers,
elements
experience
in
nevada,
there's
not
enough
folks
who
want
to
accept
medicaid,
because
the
reimbursement
rate
is
too
low
and
there's
not.
They
can't
always
see
a
doctor
because
they
can't
afford
to
even
with
insurance.
C
I
think
what
the
bill
proposes
brought
forth
by
assemblyman.
Orton
lecker
is
a
good
step
in
the
right
direction
to
further
provide
affordable.
B
B
C
As
a
second
year,
medical
student,
I've
had
the
privilege
to
volunteer
both
in
southern
nevada
and
up
here
in
northern
nevada
in
clinics
aimed
to
help
underserved
populations
a
lot
of
times.
These
patients
are
not
seen
due
to
lack
of
providers
who
accept
medicaid
as
a
result,
a
lot
of
them
slip
through
the
cracks
in
our
health
care
system.
C
It
is
my
belief
that
this
bill
will
improve
access
to
health
care
for
medicaid
patients
and
subsequently
reduce
the
incidence
of
many
preventable
diseases
that
nevadans
are
faced
with
we'll
just
kind
of
end.
On
commenting
on
the
fact
that
I
do
believe
that
this
bill
will
help
address
the
physician
shortage
here
in
nevada
by
providing
fair
compensation
to
physicians.
Thank
you.
F
Hello,
my
name
is
holla
ahmed
h-a-w-h-a-h-m-a-d
and
I'm
here
representing
the
clark
county
education
association.
So
today
we
want
to
thank
the
assemblyman
for
bringing
this
bill
forward
and
we're
in
support
of
it,
because
it's
a
very
much
needed
conversation
that
we
have
to
have
given
that
we're
in
the
midst
of
a
pandemic.
We
know
that
we
are
about
to
foresee
some
more
social
emotional
look
like
and
learning
issues
that
we're
going
to
have
to
address
in
addition
to
our
health
issues.
F
If
we
don't
start
this
conversation
now,
then
we're
going
to
be
hurting
down
the
road.
We
look
forward
to
seeing
the
still
progress
and
to
really
figuring
out
how
we
can
come
together
in
a
bipartisan
fashion
to
address
the
healthcare
needs
of
every
nevadan.
Thank
you
so
much
and
have
a
wonderful.
F
B
C
C
Health
care
workers
have
always
been
on
the
front
lines
of
caring
for
our
communities,
but
under
the
microscope
of
the
pandemic.
The
industry
and
rest
of
society
are
clearly
witnessed
to
their
dedication.
Bravery
and
stress
we
are
in
a
time
of
crisis
and
health
care.
Workers
are
stepping
up
across
the
country
and
in
nevada
to
save
lives,
sacrifice
their
own
health
and
work
to
save
the
health
of
our
communities.
C
A
A
Like
I
had
said
at
the
beginning
of
this
meeting,
I
do
plan
on
giving
them
a
little
bit
of
additional
time
just
because
they
know
that
there
is
pretty
complex
nature
of
this
bill,
and
I
know
that
the
stakeholders
kind
of
represent
some
key
industry
players
that
are
part
of
this
conversation.
A
So
I
guess
I
will
start.
I
don't
know
if
they
have
a
particular
order.
I
would
remind
them
to
again
state
their
name
and
limit
their
testimony
to
the
four
to
five
minutes
that
we
have
talked
about
before
again.
I
would
ask
them
to
stay
on
the
line,
so
they
can
be
a
part
of
any
further
questions
that
we
might
have
after
opposition
testimony.
So
with
that
I
will
start
probably.
It
looks
like
the
first
person
that
unmuted
and
turned
on
his
camera
was
jared
hildebrand.
L
Thank
you,
madam
chair,
and
I
appreciate
the
opportunity
to
be
on
the
zoom
and
give
us
give
some
provided
remarks
with
our
respect
to
our
opposition
and
and
firstly,
I'd
like
to
thank
us,
emily
and
oren
lichter
for
meeting
with
us
and
going
over
our
you
know
his
proposed
amendment
and
bill
and
and
unfortunately,
we
just
can't
get
there.
So
my
name
is
jaren
hildebrand
and
I'm
here
on
behalf
of
the
nevada
state,
medical
association
in
opposition
for
many
reasons,
but
specifically
I'd
like
to
start
with
the
provider
tax
piece.
L
L
It's
fundamentally
unfair
for
to
select
providers,
skilled,
nursing,
hospitals
and
physicians
to
be
focused
on
the
tax
to
to
bear
to
bear
the
burden,
while
other
medicaid
providers,
home
health
agencies,
personal
care,
et
cetera,
et
cetera,
hospice,
behavioral
health
are
all
folks
that
receive
or
participate
within
the
medical
medicaid
system
that
are
exempt
right.
Now,
there's
only
one
state
in
the
entire
nation
that
has
physician-specific
provider
taxes,
that
state
is
minnesota
and
they
are
currently
being
phased
out
at
the
moment.
L
L
L
Every
time
we
see
one
of
some
of
those
folks,
just
just
based
on
the
lack
of
reimbursement,
so,
like
I
said,
see,
there's
cms
requirements
that
need
need
to
be
implemented.
The
nationally
approved
provider
tax
implemented
on
on
skilled
nursing
would
make
sense
because
it
benefits
their
business
model.
They
have
a
set
population
group
that
they
serve
and
it
makes
sense
for
a
skilled
nursing
facility
to
implement
provider
taxes
get
a
higher
reimbursement
on
medic
on
medicaid.
L
L
Taxes
must
be
uniform
imposed
both
on
medicaid
and
non-medicaid
providers.
States
must
not
hold
providers
harmless
for
the
burden
of
of
the
taxes.
However,
there
is
a
safe
harbor
clause.
Providers
cannot
exceed
six
percent
of
their
revenues,
either
they
putting
into
the
tax
or
receiving
the
tax
right
now,
with
with
respect
to
the
entire
the
holistic
piece
of
the
bill,
the
peterson
milbank
and
the
ppc
have
con
picnic
as
one
of
the
five
states
to
study
this.
This
exact
bill
study.
L
This
is
sustainable
health
care
costs,
so
one
we
would
prefer
to
see
this
more.
Let's
see
how
the
ppc,
how
we
look
at
it
in
the
ppc
and
get
some
hard
data
on
this,
and
then
I
also
would
like
to
touch
on
that.
You
know
with
within
the
the
I
guess
rate
fixing
piece
we
feel.
Yes,
we
can
appreciate
the
fact
that
the
assemblyman
would
like
to
increase
the
medicaid
reimbursement
rates,
because
that's
it's
a
major
need
for
nevada.
However,
we
we
don't
think
that
the
provider
tax
is
the
right
mechanism
mechanism.
L
Just
due
to
the
fact
that
I
don't
think
within
our
physician
community
and
like
I
said
how,
how
the
various
specialties
that
we
could
get
to
a
60,
I
guess
threshold
to
trigger
those
provider,
taxes
for
those
reimbursement
rates
and,
on
the
same
token,
with
with
the
med
mal
the
chapter
40
piece
and
hitting
that
I
I
just
don't
know
if
that's
the
right
mechanism
there
for
for
a
med
malcap
or
for
discussion
on
that
piece.
I
also
would
like
to
discuss.
L
There
was
a
document
that
came
out
regarding
in
2018
with
respect
to
provider,
taxes
and
the
division
of,
or
in
the
division
of
dhc
efp
the
it's.
It
states
that
the
estimated
mining
medicaid
raised,
but
the
current
2018
would
require
an
additional
general
fund
appropriation
of
almost
86
million
dollars,
that
was
fiscal
y
or
fiscal
year
2018
and
then
an
additional
88
million
for
fiscal
year
2019.,
so
that
was
over
100,
close
to
175
million
just
for
those
two
years
now
this
is
a
new
biennium
that
perhaps
could
be.
L
The
cost
could
be
even
further
burdened
to
the
state,
and
then
I
also
wanted
to
bring
up
that.
This
is
specific
to
fee
for
service.
175
million
is
specific
to
the
fee
for
service
rates.
We
still
have
72
percent
of
all
of
our
medicaid
beneficiaries
that
run
through
mcos
and
those
are
all
con
contractual
based
with
physicians
in
in
our
health
care
system.
It's
it's
completely
separate
from
the
fee
for
service,
so
I
have
a.
L
I
have
no
idea
how
you
would
provide
a
provider
tax
on
on
a
provider
when
they're
running
everything
through
a
ce,
an
mco
and
and
they
have
a
contract
with
those
particular
mcos.
So
those
are
some
questions
I
do
have,
and
I
do
believe
with
with
the
rate
piece
I
I
think
it
would.
It
would
do
the
opposite.
In
fact,
that
physicians
would
not.
L
L
We
would
need
an
additional
288
providers
in
internal
medicine
alone,
just
like
I
said
just
to
get
to
the
national
average
in
this
state.
We
would
need
an
additional
211
physicians,
pediatric
physicians,
an
additional
244
physicians,
general
surgery,
123,
additional
surgeons,
ob
and
gynecology,
an
additional
111
positions
that
we
would
need
to
bring
to
the
state
and
if
they
don't
have
those
commercial
rates
as
higher
reimbursements.
And
I
do
again.
L
I
appreciate
the
assemblament
for
trying
to
increase
the
the
the
medicaid
rates
to
a
medicare
rate
level,
but
we
still
feel
that
that
is
unsustainable
for
our
small
businesses
and
our
small
practices
in
our
state
to
sustain,
and
we
worry
that
that
would
just
be
the
end
essentially
of
private
practice
and
folks
would
just
become
employed
physicians.
And
that's
that's
one
of
some
of
our
biggest
concerns
with
this
bill.
A
G
Thank
you,
madam
chair
members
of
the
committee.
My
name
is
tom
clark.
I
represent
the
nevada
association
of
health
plans.
We
are
the
private
insurance
carriers
here
in
the
state
we
make
up
only
19
of
the
marketplace
and
as
far
as
the
health
insurance
marketplace
is
concerned,
and
our
opposition
really
comes
into
the
relationship
that
the
health
insurance
providers
have
with
providers
and
the
impacts
of
the
rate
setting
commission
and
setting
up
those
rates
is
going
to
set
a
ripple
effect.
Much
like
mr
hildebrand
said
throughout
the
entire
market.
G
G
Now,
when
we
look
at
attracting
these
doctors,
we
recognize
as
private
insurers
that
there's
a
difference
between
a
provider
in
elko
or
genoa,
carson
city,
reno,
las
vegas,
will
the
rate
setting
commission
and
will
the
rates
be
set
at
a
rate
that
you
know
is
taking
in
all
of
those
variables,
and
I
know
mr
owen
licker
has
kind
of
addressed
that
that
the
commission
may,
but
nothing
in
the
bill
specifically
states
that
that
they'll
take
those
geographic
and
demographic.
G
You
know
concerns
into
account.
For
example,
you
know
we
need
more
african-american,
more
hispanic,
more
lgbtq
providers
in
nevada.
We
fear
that
setting
one
raid
could
send
that
ripple
effect
throughout
the
marketplace
and
not
only
keep
those
doctors
from
wanting
to
practice
here,
but
also
retain
the
doctors
that
we
do
have.
G
G
They
produced
legislation
that
would
create
the
all-payer
claims
database
and
while
we
were
opposed
to
it
back
in
2019
because
of
the
time
that
was
taken
to
really
take
a
look
at
what
the
apcd
could
do
and
the
infrastructure
for
doing
it,
we
now
support
the
legislation
as
it's
amended
and
going
forward
now.
It's
also
important
to
recognize
that
that's
just
the
collection
of
the
data
and
that
data
is
going
to
be
used
down
the
road
to
set
policies
like
ab347
contemplates.
G
So
we
you
know
if
senate
bill
40
is
to
pass
and
carlton
also
has
a
bill
that
addresses
the
apcd
if
they
pass.
We
think
that
that's
that's
fantastic,
because
if
those
bills
pass
in
a
way
that
create
the
infrastructure
for
us
to
collect
that
data,
we
can
really
have
a
stronger
policy
conversation
about
the
health
system
here
in
the
state.
G
G
So
with
with
those
issues
laid
out.
The
the
other
thing
that
I
will
mention
that
is
if,
if
this
particular
piece
of
legislation
does
pass
we're
very
concerned
about
the
effective
debt,
because
there
is
absolutely
no
way
that
we
can
stand
up
this
type
of
system
this
year.
Just
for
example,
in
the
conversations
that
we've
had
on
the
all-payer
claims
database
just
to
collect
the
data
that
infrastructure
could
take
up
to
two
years
to
set
that
system
in
motion.
G
So
with
that,
madam
chair,
I
will
remain
online
for
any
questions
that
may
come,
but
you
know
I
I
want
to
thank
mr
orton
liquor
for
having
the
stakeholder
meetings
and
the
numerous
one-on-one
meetings
that
we
had,
and
it
is
important
for
me
to
note
that
we
did
have
this
conversation
with
him
and
addressed
our
concerns
on
one-on-one
before
we
just
jumped
into
committee.
So
thank
you,
madam
chair.
A
K
Madam
chair,
if
it's
possible
to
defer
to
jim
williams,
let
him
go
before
me,
is
that
okay,
would
you.
K
H
Thank
you,
madam
chair,
and
I
appreciate
that,
for
the
record,
my
name
is
jim
wadhams.
I
am
here
today,
speaking
of
behalf
and
about
a
hospital
association.
I
want
to
thank
george
for
for
deferring
just
a
couple
of
points,
and
I
I
want
to
start
out,
even
though
we're
appearing
in
opposition.
H
I
want
to
start
out
on
a
very
positive
note
dr
ortlicher
has
has
has
put
in
time
and
thought
and
frankly
has
identified
a
major
major
problem
in
the
state,
and
that
is
our
constituents.
Access
to
medicaid
providers,
the
medicaid
reimbursement
for
hospitals
averages
about
57
of
cost,
which
is
substantially
lower
than
even
medicare
the
attractive.
The
attractive
opportunity
to
eliminate
that
deficit
certainly
would
levelize
a
lot
of
the
costs
that
have
to
be
shared.
H
Otherwise,
the
problem,
I
think,
is
that
raising
that
money
for
medicaid
is
is,
is
truly
a
problem
and
without
without
that
you
can't
achieve
even
even
what
has
been
perceived
and
represented
as
having
been
done
in
the
state
of
maryland,
where
they
have
both
medicare
medicaid
and
all
of
the
providers
under
a
common
system.
H
So
the
real
question
I
think
is
as
to
the
rate
setting
commission
itself
is
it
it
seems
to
be
roughly
patterned
after
a
public
utilities,
commission
regulatory
system-
and
it
it's
easy
to
think
about
it
in
terms
of
what
we
see
with
nevada
power
with
sierra
pacific,
with
nv
energy
or
other
utilities
that
are
regulated
that
are
truly
monopolies
and
they're
monopolies,
because
they're,
given
a
service
territory
and
a
franchise
of
service
and
the
the
the
question
I
guess
is:
is
this
really
a
competitive
market?
H
We
don't
have
a
single
seller,
we
don't
have
an
nv
energy
in
healthcare.
There
is
a
restricted
entry,
certainly
not
in
fact
the
problem
is
the
reverse.
There
is
no
restriction
on
entry
and
we
can't
develop
that
workforce
that
jared
hildebrand
from
the
state
medical
society
identified.
We
are
so
short
of
on
the
hospital
side
we've
had
elite
medical
center
was,
was
a
hospital
developed
in
southern
nevada
just
in
the
last
couple
of
years,
so
there
is
no
bar
to
to
to
entry
at
all.
H
Is
there
a
lack
of
innovation
in
the
marketplace,
which
would
be
an
indicator
of
a
monopoly?
And
that
clearly
is
not
the
case
we
have.
We
have
nicu's,
we
have
burn
units,
we
have
trauma
centers,
we
have
stroke
centers,
we
have
a
wide
array
of
services
and,
and
the
technology
is
is
here.
H
The
personnel
that
actually
staff
those
hospitals
from
the
physicians
to
the
nurses,
to
frankly
everybody
that
that
keeps
those
hospitals
operating,
has
been
a
credit
to
their
effort
and
to
the
ingenuity
and
innovation
of
those
hospitals
to
allow
that
expansion
and
contraction
to
occur.
When
we
just
last
fall
at
a
tremendous
peak
that
was
at
least
three
times
what
we
thought
was
our
peak,
maybe
eight
or
nine
months
ago,
and
I
only
mentioned
peaks,
because
the
statistics
show
that
our
cases
seem
to
be
on
the
rise
again.
H
H
H
We
have
major
major
providers
in
direct
competition,
including
I
mentioned
that
first,
the
university
medical
center
as
a
public
hospital,
major
major
anchor
hospital,
the
hca
facilities,
the
valley
health
system,
dignity
in
the
north.
We
have
renown,
we
have
prime,
and
we
have
lots
of
of
of
non-major
players
that
can
be
used
competitively,
so
it
is
a
highly
competitive
market.
H
I
I
think
what
this
raises
is
that,
while
the
the
problems
that
have
been
identified
are
are
fairly
representative
and
I
think
clearly,
a
problem
that
we
have,
because
it
impairs
access
to
health
care,
a
rate-setting
commission
doesn't
really
address
those
problems,
and
I
I
think
that's
why
we
are
in
opposition
to
this
bill.
H
There
may
be
other
ways
to
approach
this,
and
I
concur
with
mr
clark
when
he
referenced
both
the
the
study
being
done
by
the
patient
protection
commission
and
the
all
payer
claims
database.
That
will
begin
to
give
the
kind
of
data
that's
going
to
be
necessary
to
evaluate
how
you
make
these
changes.
H
Professor
white
caught
my
ear
as
well
from
from
case
western,
and
I
think
I
think
the
points
that
some
of
them
and
orient
liquor
and
and
dr
white
made
so
cogently,
is
that
we
can't
compare
nevada
to
other
countries.
We
have
to
compare
our
country
to
other
countries
which
suggests
that
the
approach
may
need
to
be
dealt
with
on
the
national
national
level.
H
We've
had
a
change
in
administration.
I
think
president
biden
is
clearly
getting
his
feet
on
the
ground
and
I
think
the
opportunity
for
the
changes
that
we
saw
with
even
in
health
care,
particularly
in
the
consolidated
budget
act
that
was
passed
that
generated.
H
I
can't
remember
how
many
trillions
of
dollars
and
other
actions
that
are
taking
place
at
the
national
level
could
very
well
provide
some
of
the
relief
that
that
that
will
alleviate
the
problems
that
we're
facing
with
a
with
a
highly
stressed
workforce,
a
capacity
crunch
which
we're
not
quite
in
at
this
point
and
hope
we
don't
regain
that.
So
I
I
think
the
problems
that
we
are
dealing
with
are
really
more
on
the
national
level
than
the
local
contracting
is
always
difficult.
I
respect
that
comment
as
well.
H
We
we
hear
complaints
about
how
difficult
these
negotiations
are,
so
that
doesn't
suggest
that
these
are
being
done
by
one-sided
transactions.
One
person
wins
and
the
other
person
loses
these
negotiations.
They
wouldn't
be
tough
if
they
weren't
being
aggressively
negotiated
by
both
parties,
and
there
are
multiple
parties
to
negotiate
with.
So
I
I
think
this
rate
setting
commission
is
is
is
an
interesting
idea
and
certainly
raises
a
lot
of
points
to
be
discussed,
but
probably
is
not
the
solution
at
this
point
in
time
in
the
marketplace.
H
Madam
chair
I'd
be
happy
to
stay
on
the
line
for
any
questions,
but
that
I
think,
concludes
my
comments
at
this
moment.
A
Thank
you,
and
with
that
we
will
go
left
to
mr
george
ross
go
ahead.
K
Thank
you
very
much,
madam
chair.
My
name
is
george
ross
g-e-r-g-e-r-o-s-s
and
I'm
speaking
on
behalf
of
hca
health
care.
First
of
all,
I'd
really
like
to
compliment
sunday
morning.
Linker
he's
pro
tremendous,
more
thought
into
this,
and
we
really
thank
him
for
the
amount
of
time
he
spent
with
the
hospital
industry
going
over
his
bill,
and
I
would
have
to
say
that
a
super
compliment
because
of
the
way
he
made
the
case
for
medicaid
rates.
K
If
there's
one
thing
it
would
not
totally
solve,
but
the
most
important
improvement
you
all
could
make
to
health
care
in
the
state
of
nevada
is
to
raise
medicaid
rates
to
those
of
medicare.
I've
never
seen
a
more
persuasive
case
for
it.
I
just
hope
it
was
more
persuasive
than
we've
been
have
been
over
the
last
two
decades
other
than
with
last
year's
increase,
for
which
we
were
very
grateful.
K
First
of
all,
I
was
actually
echo
jim
that
we
aren't
nevada
is
not
maryland,
it's
not
massachusetts,
it
doesn't
have
great
great
teaching
hospitals,
it
doesn't
have
a
panoply
of
wonderful
high-level
doctors.
It
doesn't
have
acts
massive
access
and
quality.
K
Instead,
we're
45th
or
50th
and
everything
we
in
every
single
criteria,
as
mr
hillenbrand
said,
we're
a
growing
state.
What
we
have
to
be
concerned
with,
as
we
continue
to
grow,
is
building
more
rooms,
more
beds,
bringing
in
more
doctors
providing
more
investment
we
have.
That
has
to
be
in
reality
until
we
meet
those
needs.
The
number
one
criteria
we
shouldn't
be
looking
at
bills
that
are
going
to
be
and
make
that
less
likely.
K
What
we
need
to
be
doing
is
encouraging,
not
discouraging
investment.
Now
what's
important
here
is
this
question
of
what
costs
are
taken
into
account?
Medicare
only
does
cover
89
of
the
costs.
K
We
can
argue-
and
I
I
heard
several
times
with
dr
white
in
particular-
but
implications
from
the
sponsor
that
those
are
pretty
reasonable
costs
in
reality,
there's
quite
a
few
costs
that
aren't
there
and
if
a
lot
of
costs
that
a
hospital
incurs
are
not
recognized
by
that
commission
and
the
return
is
based
upon
and
then
some
of
the
costs,
but
not
all
the
costs,
then
the
actual
return
that
the
hospital
seized
will
be
significantly
less
than
a
fair
and
reasonable
return,
and
hospitals
and
investors
make
their
decisions
based
upon
their
own
costs.
K
The
way
they
read
the
cost
and
the
return
they
see
not
on
the
costs
that
a
commission
may
see,
I
think,
that's
pretty
critical.
The
we
heard
the
sponsor
over
and
over
talk
about
as
as
well
as
his
expert
about
how
this
would
have
been,
such
so
good
for
consumers
and
customers
of
insurance
companies.
But
there
is
not
one
thing
in
this
bill
that
requires
the
insurance
company
to
pass
on
any
of
those
savings
to
the
employers
or
the
members
of
all
the
pay
or
the
patients.
K
There
is
nothing
in
there
to
require
them
to
reduce
deductibles,
to
reduce
co-pays,
to
reduce
coinsurance.
There
is
nothing
in
there
even
to
make
them
pay
the
rates
that
the
commission
would
set.
We
have
to.
We
can't
charge
anything,
but
that
we
can't
ask
for
anything
about
that.
They
don't
have
to
pay
it,
and
I
would
remind
you
all
that
a
large
portion
of
the
payers
in
this
state
are
in
reality,
erisa
plans
who,
over
whom
we
have
no
control.
K
So
I
think
those
are
pretty
critical
points
that
I
think
is
important.
I
would
also
like
to
point
out
just
a
little
big
fig
bit
here.
That
was
told
that
we
were
told
that
this
would
an
eliminate,
surprise
bill,
and
we
already
did
that
last
year.
So
that's
already
done
additionally,
we're
concerned
about
the
composition
of
that
commission.
K
That
has
to
be
a
very
fair
commission
has
to
be
a
very
balanced
commission,
and
if
there
are
those
on
that,
we
have
to
have
a
way
in
this
bill
to
appeal,
not
just
the
commission
decisions,
because
that's
not
in
there
either
or
the
timing
of
their
decisions
or
the
timing
of
when
we'll
get
their
answer
to
their
appeal.
Time
is
money
the
longer
we
have
to
wait
for
the
poor
return,
the
more
there's
something
else.
K
K
And
then,
finally,
I
usually
keep
myself
out
of
this
as
a
person,
but
I
will
say
that
I
had
personal
experience
at
the
early
part
of
my
career
in
managing
a
group
which
is
this,
which
kept
a
oil
companies,
refining
and
marketing
from
breaking
the
rules.
We
had
a
massive
amount
of
rules
of
price
controls.
K
You
you
end
up
spending
most
of
your
time,
figuring
out
how
to
how
to
man
how
to
be
on
on
board
with
the
controls,
how
to
make
money
out
of
the
controls
less
time
on
figuring
out
good
investments
and
finally,
in
terms
of
cost
savings,
you
know
we
were
told
that
we
would
be
able
to
get
rid
of
tons
of
administrative
clerks.
Well,
I
remember
going
through
all
these
cost
cuttings
and
if
you
have
100
bills
and
everyone
is
different
and
you
have
100
bills,
200
different
entities
that
are
exactly
the
same
amount.
K
Nevertheless,
you
still
have
100
bills
and
you
have
100
entities
to
whom
you
pay,
that
you
all
have
to
keep
track
of
so
you're,
not
really
going
to
save
all
that
many
people,
but
I
would
emphasize
again
that
you
know
we
have
it's
our.
We
look
at
our
own
costs
and
finally,
I
just
remind
you
that
the
role
that
sunrise
hospital
in
particular
plays
in
the
community
we're
the
largest
medicaid
provider
in
the
state.
42
of
our
patients
are
medicaid
another
six
percent.
K
Sometimes
eight
percent
are
uninsured,
which
basically
means
they
don't
act,
and
then
we
actually
have
given
the
large
medicare
customer
base.
We
only
have
16
commercial
that
we
have
to
get
the
money
from
those
commercial
client
customers
to
pay
that
gap.
Now
I
know
dr
orron
lecker
thinks
that
this
rate
will
solve
that
problem,
and
he
also
says
I
want
to
reward
efficiency,
which
we
think
we're
extremely
efficient
and
he
wants
to
reward
the
severity
of
our
caseload.
K
It's
our
experience
that,
despite
what
you
mean
that
insurance
companies
value
what
they
have
to
pay
in
a
very
high
level
compared
to
other
factors
and
all
of
a
sudden
we'll
be
stuck
with
having
to
you
know,
if
we
can't
go,
we
can't
go
bargain
today,
you
can
sit
down
and
you
can
make
a
bargain
with
various
companies
and
various
payers
and
various
plans
and
balance
all
the
contents
of
that
in
such
a
way
that
they're
happy
enough
to
come
to
the
hospital
as
a
customer
and
we're
able
to
yet
get
enough
money
to
pay
and
fill
that
hole
under
this
system.
K
I
have
absolutely
no
confidence
week.
That
would
be
that
would
be
possible.
So
again,
madam
chair,
I
want
to
call
on
you
and
thank
you
very
much
for
holding
this
hearing.
It's
been
a
very
balanced
year
and
a
fair
hearing
everybody's
getting
a
fair
chance
to
get
to
say
that
piece,
what
what
could
be
one
of
the
most
important
bills
that,
frankly,
that
I
think
I've
worked
on
my
almost
20
years
of
lobbying
into
that
actually
30
years
of
lobbying
in
nevada.
Thank
you.
A
Thank
you,
and
I
I
wanted
to
give
you
the
opportunity
to
correct
yourself,
I'm
assuming
that
you
didn't
mean
to
say
that
our
teaching
hospitals
here
at
unlv
and
unr,
were
not
not
not
excellent
and
not
growing
and
not
moving
up
in
those
standings,
but
that
we
just
didn't.
Have
the
number
that,
like
a
state
like
massachusetts,
might
have.
A
Okay
with
that,
I'm
going
to
go
to
the
phone
lines,
and
I
will
be
limiting
some
of
that
testimony.
I
know
that
we
have
other
members
that
need
to
get
moving,
and
I
know
we
may
have
some
other
follow-up
questions
based
on
that
testimony.
So
at
this
time,
if
we
can
go
to
the
phone
lines
in
testimony
in
opposition
for
the
people
on
the
phone
lines,
I
would
ask
you
to
limit
your
testimony
to
two
minutes.
A
B
B
Thank
you,
madam
chair,
for
the
record
susan
fisher
with
mcdonald
carano,
calling
on
behalf
of
nevada
state
society
of
anesthesiologists
and
also
speaking
for
the
nevada
society
of
orthopedic
surgeons.
We
are
testifying
in
opposition
284
347.
We
appreciate
the
time
that
assemblyman
orange
cooker
spent
with
us,
but
we
just
can't
get
there.
No
state
has
shown
this
provider
tax
to
work,
not
one
where
it's
been
implemented.
It's
either
been
repealed
or
simply
no
opt-ins.
B
After
several
medicaid
cuts
over
the
last
12
years,
including
a
massive
43
percent
cut
for
anesthesiologists
during
the
great
recession,
this
tax
provides
little
assurance
that
more
cuts
won't
happen.
The
economy
goes,
south,
medical
providers
get
cut
and
the
rates
don't
come
back
up
accordingly,
when
the
economy
rebounds
at
a
time
when
we're
facing
provider
shortages,
and
certainly
after
the
past
year
with
provider
burnout,
this
is
not
the
time
to
introduce
an
experiment
that
has
failed
elsewhere
into
nevada's,
already
overstressed
healthcare
environment.
B
C
Begin
hello:
this
is
dan
musgrove
on
behalf
of
the
valley,
health
system
of
hospitals.
That's
d-a-n-capital
m-u-s-g-r-o-v-e!
I
certainly
won't
be
redundant.
Madam
chair,
I
appreciate
the
last
comment
you
made
before
turning
it
over
to
more
opposition
and
that
nevada
and
this
legislature,
and
especially
hospitals,
have
worked
very
very
hard
on
expanding
our
graduate
medical
education
program.
C
I
think
you
heard
from
mr
hildebrand
that
nevada
could
become
a
place
that
physicians
see
as
unfriendly,
so
we
work
on
that
effort
to
train
those
doctors
and
then
they
end
up
leaving
and
heading
elsewhere
to
pastures
that
are
much
greener
and
we
certainly
don't
want
to
get
back
to
mccarran
airport
being
our
healthcare
facility
of
choice.
I
want
to
thank
the
chair
for
allowing
us
to
testify
giving
us
so
much
opportunity
and
absolutely
the
sponsor
for
all
the
time
that
he's
put
with
all
of
us
to
try
to
listen
to
our
concerns.
C
C
I'd
at
first
like
to
acknowledge
and
thank
simon,
ortlicker
and
miss
johns
for
all
their
work
on
this
issue
over
the
past
couple
of
months,
which
included
a
meeting
with
with
the
henderson
chamber.
Unfortunately,
the
feedback
that
the
henderson
chambers
received
on
ab347
is
that
it
exacerbates
existing
problems
in
our
healthcare
system
just
quickly.
One
one
issue
in
particular
to
highlight
is
that
the
theoretical
foundation
of
ab347
is
built
on
medicare.
Pardon
me
medicaid
rates
being
raised
to
medicare
rates,
but
but
the
bill
does
not
ensure
that
this
will
occur.
C
I'll
again,
conclude
by
thanking
us
other
mentored
liquor
for
his
tireless
work,
but
we
are
opposed
to
ab347.
Thank
you.
B
C
C
I'm
calling
in
in
opposition
today
to
ab347
I'll,
be
quick
and
simply
say
ditto
to
most
of
to
my
colleagues
and
only
add
a
few
points
in
opposition
of
assembly
bill.
347..
C
Two
key
points
to
reiterate:
medicare
rates
do
not
cover
our
costs
and
there
is
no
guarantee
in
this
bill
that
the
state
nor
rate
commission
would
pay
providers
higher
than
medicare
rates,
which
is
significantly
concerning,
and
also
the
bill
not
providing
a
way
to
appeal
or
also
address
conflict
of
interest
on
the
rate
commission
are
massively
concerning.
In
addition
to
previous
testimony,
there's
many
unknowns
related
to
this
bill
and
it's
extremely
difficult
for
my
team
to
determine
the
kind
of
impact
it
would
have
on
the
saint
rose
system.
C
But
one
issue
alone.
I
can
speak
to
if
commercial
insurance
rates
were
set
at
medicare
level
levels.
That
issue
alone
would
equate
to
a
183
million
bottom
line
reduction
to
our
market
that
serves
the
greater
las
vegas
area.
This
could
very
possibly
lead
to
elimination
of
needed
service
lines
that
we
provide
to
the
community
and
job
elimination,
possibly
for
the
very
employees
that
save
lives
in
this
state.
C
During
the
during
the
covet
19
pandemic
in
2020
alone,
which
was
an
extremely
difficult
year
with
covet
19
pandemic,
saint
rose
contributed
over
154
million
in
community
benefits,
because
saint
rose
is
a
not-for-profit
system.
Any
earnings
that
we
have
are
reinvested
back
into
the
community
to
bolster
nevada's,
limited
public
health
structure
and
pay
for
charity
care.
St
rose
has
been
doing
the
right
thing
in
this
community
since
1947,
and
this
bill
would
jeopardize
our
ability
to
adequately
treat
patients
in
our
community.
The
rate
setting
commission
is
wrong
for
nevada.
C
B
C
Joseph
heck
h-e-c-k
red
rock
government
relations
on
behalf
of
the
nevada,
osteopathic
medical
association.
We
call
in
in
opposition
to
the
bill
for
all
of
the
reasons
previously
stated
by
the
other
opponents.
The
only
other
thing
I
would
add
is
that
the
use
of
non-economic
mid-mouth
damages
as
a
potential
benefit
really
would
have
no
additional
benefit,
as
mid-mal
non-economic
damages
are
already
capped
at
350
thousand
dollars
in
nevada
laws
instituted
by
voter
initiative
in
2004.
C
again,
we
appreciate
the
assemblyman's
long-range
vision
to
try
to
increase
access
and
lower
cost,
but
we
feel
that
this
bill
is
not
the
right
way
to
go
about
it.
Thank
you.
B
C
C
And
thank
assemblyman
laker
for
his.
H
B
F
Thank
you
chair
and
members
of
the
committee
for
the
record.
My
name
is
jessica.
Carrado
j-e-s-s-I-c-a
f-e-r-r-a-t-o
here
today,
on
behalf
of
the
nevada
chapter
of
the
of
the
american
college
of
emergency
physicians
in
opposition
of
ab347,
I'd
like
to
thank
assemblyman
orenlicker
for
the
consistent
outreach
and
collaboration
with
stakeholders,
and
I'd
like
to
echo
the
comments
of
my
colleagues.
I'd
like
to
highlight
a
few
items
specific
to
emergency
departments
and
physicians
in
the
state.
F
F
Er
physicians
specifically,
are
the
most
impacted
by
the
low
medicaid
rates
throughout
the
state,
because
we
take
majority
of
those
patients
or
all
of
those
patients.
Even
though
er
physicians
are
positioned
to
benefit
the
most
from
a
provider
tax
because
we
see
more
medicaid
patients
than
any
others,
we
still
have
some
concerns
on
how
it
will
work
in
this
bill.
F
F
In
terms
of
the
rate
setting
commission,
we
have
concerns
as
well
setting
rates
at
medicare
during
the
pandemic
or
otherwise
is
problematic.
There
aren't
any
emergency
doctors
that
can
operate
solely
off.
Medicare
rate
does
not
cover
costs.
In
addition,
the
wording
in
the
bill
around
how
this
commission
would
would
raise
rates
appears
subjective.
F
Medicaid
rates
are
a
significant
barrier
for
recruiting
in
nevada,
which
impacts
patient
care.
This
comes
in
the
form
of
provider
shortages,
long
wait
times
to
see
a
provider
and
even
wait
times
and
availability
for
procedures.
We're
concerned
about
the
impacts
of
the
future
health
care
system
and
look
forward
to
continue
to
work
with
assemblyman
or
liquor
on
this
policy
moving
forward.
Thank
you.
A
You
can
go
to
our
I'm
going
to
take
a
couple
more
callers,
so
if
you
can
be
brief,
then
you
will
allow
for
other
people
to
do
it.
If
we
can
go
to
our
next
caller
in
opposition.
B
F
A
That's
testimony
yet
if
we
can
go
to
our
next
caller
in
opposition.
F
F
We
appreciate
the
open
door
and
multiple
meetings
that
assemblyman
orrin
lichter
has
had
on
this
bill,
getting
input
from
the
industry
and
appreciate
the
shared
goal
of
getting
medicaid
reimbursement
rates
increased
in
nevada.
However,
we
do
not
believe
the
provisions
of
this
bill
will
achieve
that
goal
and
will
ultimately
end
up
increasing
the
cost
of
health
care
to
the
citizens
of
nevada.
F
F
North
vista
is
not
a
large
hospital,
but
we
are
the
only
hospital
located
in
north
las
vegas
and,
unlike
other
hospital
systems
with
multiple
locations
in
las
vegas,
we
just
have
one
campus.
This
means
we
don't
have
as
much
ability
to
make
up
in
volume
what
is
lost
from
one
service
to
the
next,
the
ability
to
negotiate
with
our
fellow
providers
and
the
payers
is
important
for
a
small
player.
Thank
you
very
much
for
your
time
and
we
respectfully
requested
the
committee
not
process
this
bill.
Thank
you.
A
I'm
going
to
take
our
last
caller
in
opposition
again,
I
would
encourage
all
of
those
people
that
are
potentially
still
waiting
on
the
line
to
submit
their
written
comments
in
opposition
and
even
those
that
were
on
the
line.
They
can
do
the
same
as
well
within
24
hours
of
today's
hearing.
So
if
we
can
go
broadcast
services
to
the
last
caller
and
up.
B
C
Good
afternoon
my
name
is
chris:
bassey
v
is
in
boy,
oh
s's,
and
sam
s
is
in
sam.
He
is
an
egg
for
the
record
representing
renowned
health
good
afternoon
chairwin
and
committee
members.
First,
I
appreciate
the
assemblyman's
openness
to
share
ideas
and
hear
concerns
about
this
bill.
However,
we
are
still
opposed
to
ab347
rate
setting
for
healthcare
providers,
and
hospitals
is
not
the
right
solution
for
nevada.
C
So
at
this
point
I
think
the
majority
of
my
points
have
been
made.
So
me
too.
I
just
think
at
the
end
of
the
day,
given
this
bill
doesn't
really
provide
a
mechanism
to
achieve
the
goals
that
were
originally
stated
to
reduce
costs
at
the
consumer
level
because
it
doesn't
ever
get
to
impact
the
payers.
C
The
bill
only
puts
access
to
care
in
nevada
at
risk.
Renown
is
a
private
nonprofit,
locally
owned
and
operated
integrated
delivery
system,
primarily
located
in
washoe
county,
and
we
strive
to
continue
to
meet
the
needs
of
our
the
communities
that
we
serve
rate.
Setting
in
the
short
term
will
impact
our
ability
to
expand
capacity
and
services
to
meet
the
growing
needs
and
in
the
midterm,
will
likely
impact
our
ability
to
care
for
patients.
Thank
you
for
the
opportunity
to
participate
today.
A
Thank
you,
and
with
that
I'm
going
to
close
testimony
in
opposition.
I
am
going
to
open
it
up
briefly
for
testimony
in
neutral.
I
think
we
have
a
couple
of
people
on
the
line.
I
will
remind
people
that
neutral
testimony
is
not
taking
a
position
on
the
bill
either
for
or
against.
It
is
truly
neutral.
Testimony
broadcast
services.
Can
we
go
to
neutral
testimony.
B
A
Do
we
have
any
people
on
the
zoom
in
neutral?
If
you
are
I'd,
ask
you
to
unmute
and
turn
on
your
camera,
but
I
don't
see
any
so
at
this
time
it
will
close
testimony
in
neutral
of
assembly,
bill
347,
and
at
this
time
I,
like
I
said
before
I
will
open
this
up.
I
have
only
received
a
couple
of
messages
from
people
with
some
follow-up
questions
based
on
that
or
they
may
have
questions
for
our
bill
sponsor
or
potentially
any
of
the
witnesses.
A
No
okay
with
that,
I
will
turn
this
back
over
to
assemblyman
orrin
liquor
and
his
cobra
centers
for
any
closing
remarks.
E
J
Is
joseph
white,
a
witness,
so
I'd
like
to
say
a
couple
of
things?
One
is
that
there
is
very,
very
strong
evidence
that
there
are
substantial
extra
costs
in
the
american
health
care
system,
including
nevada
associated
with
billing.
It
is
not
the
case
that
sending
out
the
same
number
of
bills
when
the
bills
are
all
by
the
same
rules
is
just
as
expensive
as
setting
up
that
number
of
bills
with
extremely
complicated
different
rules
about
what
the
bills
involve.
If
it
were
the.
J
If
it
were
the
case,
then
the
then
the
amount
of
billing
effort
in
the
united
states
and
canada
or
the
united
states
and
many
other
countries,
but
not
the
amount
of
billing
expense,
would
not
be
so
different.
So
I
do
think
that
there
are
savings
to
be
had
and
those
savings
related
to
the
administrative
cost
and
and
the
complexity
of
the
billing
are
in
the
range
of
five
to
ten
percent
of
cost.
J
By
most
of
the
studies
that
have
been
done,
there
have
been
studies
that
show,
for
example,
that
the
average
american
physician
practice
per
doctor
is
spending
about
eighty
thousand
dollars
a
year
on
billing
compared
to
and
when
it's
just
much
lower
in
other
countries.
So
there
is
a
savings,
there
are
inefficiencies
there.
J
J
Now
I
cannot
speak
to
the
questions
of
the
shortages
of
physicians
in
nevada,
and
that
is
for
you
guys
to
to
to
think
about
and
what
the
reasons
are
for
that
right
now.
I
think
it
is
true
that
cost
per
capita
in
nevada
are
lower
than
in
a
lot
of
other
states.
J
Cost
per
capita
for
physician
services,
however,
are
not.
Are
they
about
the
same?
The
average
of
in
other
states
they're
lower
because
of
things
like
for
some
reason,
hospital
payments
and,
for
some
reason,
some
of
the
other
services
like
like,
like
home
health.
J
I
don't
know
why
that
is,
and
I
think
it's
and
I
do
think
that
there's
an
important
point
made
here
about
thinking
about
the
different
providers
that
are
involved,
whether
we're
talking
sniffs
home
health
and
so
on,
on
the
medicare
medicaid
side
and
thinking
about
the
different
providers
that
are
involved
with
you
know
other
aspects
of
healthcare.
J
I
do
think
it's
important
to
remember
that
a
whole
lot
of
employer-based
healthcare
is
erisa
plans
and,
logically,
if
costs
are
lower
for
employers,
maybe
they
won't
pass
it
off
pass
it
on,
but
it's
not
a
matter
of
their
negotiations
with
insurers
because
they
are
simply
experiencing
the
cost
directly
and
the
insurers
are
simply
processing
for
them.
So
I
think
that
that
you
need
to
think
about
how
the
elisa
plans
really
work
out
on
on
this
process.
J
So
there's
a
lot
to
think
about.
I
think
there
are
questions
to
legitimately
ask
about
supply
and
also
about
you
know
what
is
going
on
with
nevada
costs
on
the
whole
nevada
does
have
a
very
low
number
of
doctors
per
capita.
J
It
also
has
a
relatively
younger
population
than
most
states,
but
not
in
line
with
the
number
of
doctors.
I
think
there
are
significant
questions
about
what
attracts
doctors.
I
think
it's
possible
that
having
a
a
system
which
is
much
less
of
a
hassle
for
doctors
in
terms
of
dealing
with
the
billing
and
dealing
with
the
extra,
the
the
cost
structure
of
in
practices,
would
logically
mean
a
that.
J
It
would
be
easier
for
doctors
to
be
in
smaller
or
solo
practice
compared
to
what's
happening
now,
when
they
need
these,
when
they're
they're
selling
out
to
larger
practices
in
part
to
handle
the
billing
and
all
that-
and
I
think
it's
important
to
remember
that-
there's
savings
out
there
relative
to
any
other
system.
E
There
were
some
things
that
are
just
not
accurate
representations
of
the
valve,
but
the
couple
things
I
want
to
talk
about
specifically
gerund
hillebrand
from
the
state
medical
association
was
concerned
about
whether
the
provider
tax
would
be
equitable
and
and
his
concern
was
that
not
all
doctors
see
medicaid
patients,
so
they
pay
the
tax,
and
it
is
true
that
the
only
way
you
receive
money
back
and
remember
it's
a
three
to
one
return:
that's
guaranteed!
That's
not
speculative!
E
It
provides
an
incentive
to
see
medicaid
patients
and
for
those
doctors
who
are
in
a
specialty
or
a
location
where
there
just
isn't
an
opportunity
to
see
medicaid
patients,
then
one
way
to
meet
their
responsibility
to
share
in
the
care
of
medicaid
patients
is
to
pay
toward
their
care
if
they
can't
provide
the
care
themselves.
So
I
think,
in
terms
of
equity
it
work.
This
is
designed
very
well.
E
Jim
waddems,
for
the
hospital
association
suggested
that
the
health
care
market
is
a
competitive
market.
That's
at
odds
with
the
understanding
of
every
health
economist
that
I'm
aware
of
the
reason
why
we
need
this
rate.
Setting
commission
is
because
the
health
care
market
does
not
operate
like
a
competitive
market.
E
We
have
excessive
prices.
We
have
these
highly
varying
prices.
Nobody
thinks
in
the
health
economics
world
that
this
is
working
properly
and
that's
why
we
need
government
intervention
to
correct
the
market.
Failure
so
I'll
say
that
in
terms
of
what
we're
offering
providers
and
patients,
what
we're
saying
is
we
want
to
fair.
We
want
to
ensure
that
all
providers
are
fairly
compensated,
they
cover
their
costs,
they
earn
a
reasonable
profit,
and
that
means
that
there
will
be
providers
available
for
patients
we're
saying
to
providers.
E
E
We
will
provide
you
stronger
protection
against
the
threat
of
professional
liability,
all
those
things,
things
that
are
important,
that
I've
heard
over
the
years
from
health
care
providers.
We
want
to
be
fairly
paid.
We
don't
like
to
deal
with
the
administrative
paperwork
and
bureaucratic
hassle
and
we
want
to
be
ins
protected
against
unfair
malpractice
litigation.
E
All
those
things
are
in
the
bill
and
the
only
thing
that
they
don't
get
is
the
ability
to
charge
excessive
profits,
we're
not
letting
we
don't
want
them
to
gouge
patients,
and
that's
the
only
thing
they
don't
get
out
of
this
bill.
So
again,
thank
you
very
much
for
your
consideration
and
I
look
forward
to
working
with
everybody
to
move
this
forward.
A
Thank
you,
assemblyman
liquor
and
thank
you,
and
I
know
you
probably
goes
without
saying.
Thank
you
to
the
committee.
I
know
that
this
was
a
extra
long
hearing,
but
I
think
it
is
a
very
important
policy
topic
that
we
need
to
have
these
kind
of
conversations,
and
I
appreciate
everyone's
patience
with
me
trying
to
have
like
an
actual
policy
conversation
in
this
virtual
setting.
So
you
know,
obviously
you
know
the
81st
session.
A
Flexibility
and
accommodations
have
been
key,
so
I
appreciate
that
and
with
that
I
will
close
the
hearing
on
assembly
bill
347
and
at
this
time
I
will
take
comment.
I
will
go
to
public
comment.
I
don't
know
if
we
have
anyone
in
the
public
comment
line
but
broadcast
services
can
we
go
to
public
comment.
A
I
will
remind
everyone
to
please
clearly
state
your
name
for
the
record
as
well
as
limit
your
testimony
to
two
minutes,
and
I
remind
everyone
that
I
know
that
there
were
some
people
that
did
not
get
the
opportunity
to
testify
during
the
opposition
time
period.
I
would
note
that
this
is
not
the
time
to
rediscuss
the
bill
and
if
you
do
have
written
comments,
I
would
very
much
encourage
you
to
submit
those
written
comments,
and
so,
with
that
broadcast
services,
can
we
go
to
the
line
in
public
comment.
A
Oh
wonderful,
thank
you
so
much.
I
appreciate
you
saying
that
for
the
record
I
was
concerned.
I
was
good
timing
then,
but
public
comment
do
we
have
anyone
online
for
public
comment.
A
Okay,
with
that,
I
will
close
public
comment.
We
have
a
meeting
on
monday,
it'll
be
another
crazy
week.
I
don't
anticipate
us
having
to
have
any
night
or
additional
meetings
in
hhs
fingers
crossed.
Hopefully
I
didn't
just
change
my
things
myself,
but
I
want
everyone
to
keep
in
mind.
There
are
potential
a
lot
of
work
session
documents,
so
please
try
to
do
your
best
to
respond
to
committee.
Mentors
emails
about
any
concerns
that
you
have
about
their
bills
and
we
will
move
forward
with
that.
Have
a
wonderful
weekend
and
meeting
is.