1
2
3 NEVADA STATE BOARD OF MEDICAL
EXAMINERS
4 BOARD MEETING
5
6
7
8
9
10
11
12
13 FRIDAY, MAY 30, 2003
14 RENO, NEVADA
15
16
17
18
19
20
21
22
23 Reported by:
MILLIE TERRY HOENSHELL, CCR No. 303
24
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 1
1 A P P E A R A N C E S
2
3 THE BOARD: CHERYL A. HUG-ENGLISH, M.D.
President
4
JACULINE
C. JONES, Ed.D.
5 Vice President
6 PAUL A. STEWART, M.D.
Secretary/Treasurer
7
DONALD H.
BAEPLER, Ph.D., DSc
8
STEPHEN K.
MONTOYA, M.D.
9
SOHAIL U.
ANJUM, M.D.
10
JOEL N.
LUBRITZ, M.D.
11
ROBIN L.
TITUS, M.D.
12
MARLENE J.
KIRCH
13
CHARLOTTE
M. BIBLE, J.D.
14 Assistant Chief Deputy
Attorney
General
15
RICHARD J.
LEGARZA, J.D.
16 General Counsel
17 LARRY D. LESSLY, J.D.
Executive
Director/Special Counsel
18
MAUREEN E.
LYONS
19 Executive Executive
Director
20 CASEY MILLER
Administrative Assistant
21 to the Executive
Director
22 ROBERT A. FRANTZ
Financial
Manager
23
24
PEGGY HOOGS & ASSOCIATES
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1 RENO, NEVADA, FRIDAY, MAY 30, 2003,
11:30 A.M.
2 --o0o--
3
4 (Whereupon the meeting was
already in
5 session.)
6 DR. HUG-ENGLISH: Okay.
We are in open
7 session.
We've had some discussions in closed sessions
8 about salaries and evaluations for various
staff members.
9 I guess we need to wait a second
because we
10 have -- Here they are.
11 At this time I would entertain a
motion on
12 staff compensations.
13 DR. BAEPLER: I will so move that the
14 compensation be an average of six percent,
some to be in
15 the
form of bonuses, as well as some of them to be built
16 into base salaries.
17 DR. HUG-ENGLISH: Okay.
And then I do think
18 we had a couple of people that we had equity
changes on
19 that are a little bit different. That would be on Doug
20 Cooper, who is our chief investigator, as
well as Lynette
21 Mason, who will be changing per position
title a bit as
22 well.
So that with the exception of those two, the rest
23 of the salaries with staff would be at six
percent, if
24 I'm understanding Dr. Baepler, and then for
the
PEGGY HOOGS & ASSOCIATES
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1 administrative staff, which would include
Larry Lessly,
2 Richard Legarza, and Maureen Lyons, those
would be done
3 in the form of a bonus; is that correct?
4 DR. BAEPLER: Correct.
5 DR. LUBRITZ: Second.
6 DR. HUG-ENGLISH: That is your motion, and
7 that was seconded. Any further discussion? All in
8 favor?
9 THE BOARD MEMBERS: Aye.
10 DR. HUG-ENGLISH: Opposed?
11 The Chair votes in favor of the
motion and the
12 motion carries.
13 MR. LESSLY: Madam President, to clarify that,
14 Mr. Frantz is also administrative staff.
15 DR. HUG-ENGLISH: I'm sorry.
That would be
16 also, in addition, a bonus.
17 MR. LESSLY: Okay.
18 DR. HUG-ENGLISH: Okay.
Moving on to
19 considering -- I guess, Larry, this is your
agenda item,
20 considering board payment for insurance
premiums.
21 MR. LESSLY: Let me explain this. As you
22 know, we are not really the State agency,
but we
23 participate in the State benefit package,
including PERS
24 and insurance. The health insurance situation with state
PEGGY HOOGS & ASSOCIATES
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1 employees gets progressively worse. Apparently now,
2 effective July 1, it appears that employees
who wish to
3 keep a $500 deductible as opposed to going
to a $1000 or
4 $2500 deductible will be required to pay --
I believe
5 it's $14.36 each per month in order to
maintain that
6 deductible at a $500 level. The deductible itself is
7 going from 250 to 500. So to even keep the 500, you have
8 to pay $14.36. My calculation is that if the Board paid
9 that on behalf of its employees, it would
cost $3,000 a
10 year.
I'd like to ask you to do that.
11 DR. BAEPLER: Question.
Are they only
12 self-undersigned or are any of them HMOs
that are
13 private?
14 MR. LESSLY: It doesn't make any difference.
15 DR. BAEPLER:
HMOs, I know you made a $500
16 deductible on HMOs, do you have to also pay
that monthly
17 fee?
18 MR. LESSLY: My understanding, this is going
19 to be -- And this is only the tentative
figure, 14.36.
20 It may vary a few cents one way or the
other.
21 DR. BAEPLER: Yeah, I was expecting 25. I
22 would move that we pick that up for
them. We have
23 options to go into several HMOs that are
private or
24 choose your own doctor under the --
PEGGY HOOGS & ASSOCIATES
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1 MR. LESSLY: I think that got limited this
2 time too.
3 DR. HUG-ENGLISH: Yes.
In the North it is.
4 In the South --
5 DR. BAEPLER: I think we have two options in
6 the South.
7 DR. HUG-ENGLISH: Right.
And that's been
8 changed in the North. So I think this $14 would be
9 fairly consistent for everybody up
here.
10 DR. BAEPLER: Yes.
11 DR. HUG-ENGLISH: So was there a second to
12 that motion?
13 MS. KIRCH: I'll second it.
14 DR. HUG-ENGLISH: Okay.
It has been motioned
15 and seconded to have the Board pick up that
insurance
16 premium that we think will be around $14 a
month per
17 employee.
Any further discussion? All in
favor?
18 THE BOARD MEMBERS: Aye.
19 DR. HUG-ENGLISH: The chair votes in favor of
20 the motion and the motion carries.
21 MR. LESSLY: The next two items under open
22 session on personnel we can probably discuss
together.
23 We have a lot of people who are going to be
leaving this
24 year.
Mr. Frantz, our financial manager, is going to be
PEGGY HOOGS & ASSOCIATES
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1 retiring.
He will be on board with us through August the
2 15th.
That will get us through the audit that he handles
3 with our CPA auditing firm and will also get
us through
4 the financial things involved in handling
the year as far
5 as biennial registration is concerned. He's then going
6 to take annual leave that he has accumulated
until
7 September the 30th.
8 Previously, we have talked about
how to handle
9 his departure, and you authorized me to put
an
10 administrative assistant in that
position. We've put
11 Ms. Peeples in that position. She has been training
12 under him.
She will end up doing most of the clerical
13 aspects of the financial management. The other aspect of
14 Mr. Frantz's job is investment
decisions. That's done by
15 three people. It's done by him, it's done by me, and of
16 course the final decision is made by the
Board's
17 treasurer.
18 My proposal is that when he
actually leaves
19 that the job description for the executive
director be
20 changed to have the executive director make
that
21 recommendation only to the
secretary/treasurer, who would
22 make the final determination. So what it boils down to
23 is that job would be divided between an
administrative
24 assistant to do the actual clerical type
work that's
PEGGY HOOGS & ASSOCIATES
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1 involved in the payroll, the writing of
checks, and that
2 sort of thing, and the financial management,
more of that
3 duty would fall to the executive director
and ultimately
4 to the secretary/treasurer. We have already done that.
5
I'm simply telling you that the training situation is
6 fine and that will happen on August 15th
when he departs.
7 In addition, Elizabeth
Larragueda, who is our
8 chief licensing specialist, has moved to Las
Vegas.
9 You'll recall she took time out to have a
child. She is
10 on maternity leave. She has been able to come back
11 periodically for a few days at a time to
help with
12
training and to help with some special projects that are
13 occurring down in licensing. She will be formally off of
14 our payroll on July 15th. It is my intention on Monday
15 to promote Lynette Mason, who is a licensing
specialist
16 in that division, to the position chief
licensing
17 specialist.
So that will cover Ms. Larragueda's
18 departure.
19 Now, the person to my left and my
deputy is
20 probably departing in about six months or
so. As you all
21 know, Maureen is going to California,
hopefully, assuming
22 her husband passes the bar. She'll either be moving to
23 California or attending his funeral if he
doesn't pass
24 the bar.
However, she is going to be departing, which
PEGGY HOOGS & ASSOCIATES
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1 leaves me short a deputy.
2 You had asked me a year ago to
begin to look
3 for replacements for both my position and
Mr. Legarza's
4 position.
We told you a year ago that this would be our
5 last year.
I would be happy to spend a little more time
6 in Bend, Oregon, and I want to do that next
summer. So I
7 think we need to come up with some deputy
positions for
8 both of these.
9 Mr. Legarza's got a problem as far as
actually
10 getting legal work done now as a result of
some things
11 that happened with respect to AB-1 and the
case load.
12 We also have a situation where I'm not sure
that the
13 medical reviewer is going to be able to
handle the work
14 load that has arisen as a result of a lot of
changes, so
15 I'm going to ask you to do this: To authorize the
16 creation of a position of deputy general
counsel, deputy
17 executive director/special counsel, and an
additional .40
18 FTE medical reviewer. I would at that point attempt to
19 fill those positions.
20 DR. HUG-ENGLISH: Okay.
Well, I'd like to
21 make a couple of comments about the need for
these
22 positions.
I think that we really are at a critical
23 stage with this Board that we need to have
some
24 additional staff to handle the additional
work load that
PEGGY HOOGS & ASSOCIATES
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1 this Board has seen in the past six months
or so, and I
2
think that it's very clear that these positions are
3 needed, and I would certainly support
that.
4 And, Larry, in your job
description, you
5 definitely have the authority to hire additional
staff
6 that's needed, and I appreciate your letting
the Board
7 know what you feel the requirements are at
this point.
8 MR. LESSLY: It would be my intention, just so
9 you know, to hire someone at not more than
100,000 in the
10 deputy general counsel's position, not more
than 120,000
11 in the deputy executive director/special
counsel
12 position, and I think we already have the money
budgeted
13 to cover Mr. Legarza and I having overlapped
until we
14 depart this year. And I believe that Dr. Stewart, when
15 he talks about the budget in a few moments,
has $50,000,
16 and it may take a little more to cover an
additional .40
17 FTE, medical reviewer. Those would be the salary ranges
18 that it would be my intention to hire them.
19 DR. BAEPLER: I would move that we authorize
20 those salary ranges. We don't have to authorize the
21 hiring, because he already has that.
22 DR. TITUS: Second.
23 DR. HUG-ENGLISH: Okay.
There is a motion to
24 authorize those salaries, which again would
be 100,000
PEGGY HOOGS & ASSOCIATES
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1 for a deputy counsel and 120,000 for a
deputy executive
2 director.
Is there any further discussion?
I'm sorry,
3 and $50,000 for us to appoint .40 additional
reviewers.
4 Any further discussion? All in favor?
5 THE BOARD MEMBERS: Aye.
6 DR. HUG-ENGLISH: Opposed?
7 The chair votes for the motion
and the motion
8 carries.
9 I would encourage, Larry, you, as
current
10 executive director, to proceed with that as
quickly as
11 possible, because I think with the need is
here now.
12 This Board really needs some additional
help. I think
13 with the requirement since AB-1 and the
special session
14
that have been imposed on this Board, we need some
15 additional staff to help us out. So I would go forward
16 as quickly as possible.
17 MR. LESSLY: I will assure you that's my
18
intention.
19 DR. MONTOYA: Ms. President, I'd like to point
20 out that it's very nice that they don't
leave us high and
21 dry by just taking off and leaving us, that
there is
22 going to be some overlap to get us used to
working with
23 the new counsel, and I just want to express
appreciation
24 for that consideration.
PEGGY HOOGS & ASSOCIATES
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1 DR. HUG-ENGLISH: I think that's well said.
2 Steve and I would second that, that it's
really critical
3 that we have some training to get people in
here for a
4 significant length of time as an overlap to
learn these
5 positions before there are changes in those
as well.
6 Okay. I guess -- Is there anything else,
7 Larry, that you want to bring up under
personnel session?
8 MR. LESSLY: I don't believe so.
9 DR. LUBRITZ: Dr. English?
10 DR. HUG-ENGLISH: Yes.
11 DR. LUBRITZ: Given that we have the increased
12 load, is now the time to consider additional
13 investigators?
14 MR. LESSLY: We have the authority already to
15 hire an additional investigator and
administrative
16 assistant.
We haven't been able to do that because the
17 legislature is in session and we have no
clue what kind
18 of money we would have left. I think there is enough
19 money, when Dr. Stewart talks about the
budget, to even
20 add an additional investigator.
21 But it would be our intention
when the
22 legislature adjourns, if we've got money, we
are going to
23 immediately hire another investigator and
another
24 administrative assistant. Back in the investigative
PEGGY HOOGS & ASSOCIATES
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1 division, you authorized that, oh, maybe six
months ago,
2 and Mr. Legarza has been holding off on that
because of
3 the legislative session.
4 MS. KIRCH: And I presume you are going to
5 replace Lynette?
6 MR. LESSLY:
No. Let's back up. I need to
7 explain that to you. Sometime ago when Elizabeth
8 announced that she was taking maternity
leave and that
9 she and her husband were moving to Las
Vegas, you
10 authorized us to double-slot. We have four positions
11 down there, and you authorized us to carry a
fifth
12 position until her departure, so there is a
promotion to
13 her position, but we'll drop from five to
four.
14 MS. KIRCH: Okay.
15 DR. HUG-ENGLISH: Okay.
Any further questions
16 about staff changes or changes in position
or additional
17 staff recruitment?
18 Okay. It's now five after noon. I know we
19 have been going for a long time. I think lunch is here,
20 and I think that we will at this point take
a recess for
21 lunch, and we'll be back at about 1:00
o'clock.
22 (Luncheon recess).
23 DR. HUG-ENGLISH: We're going to get started
24 again, and we're going to take the agenda a
little out of
PEGGY HOOGS & ASSOCIATES (775) 327-4460 13
1 order.
We are going to go to Agenda Item Number 8 and
2 have Dr. Stewart do the --
3 Doug, can you hear us down
there?
4 MR. COOPER: Yes, it's fine.
5 DR. HUG-ENGLISH: Okay.
Thank you. You're
6 looking a little lonesome down there.
7 MR. COOPER: Yeah, but the air conditioner is
8
on.
9 DR. HUG-ENGLISH: Okay.
Good.
10 We are going to move to the secretary-
11 treasurer report. Dr. Stewart is going to tell us about
12 that.
13
DR. STEWART: Okay. In front of you, the
14 first thing we are going to go through, and
we are going
15 to be somewhat pedestrian about this, is the
balance
16 sheet as of June 30th, 2003. Unfortunately, in the past,
17 that confused the legislature, because
you'll see on the
18 side is accrual basis as of 5/29. So this is how we are
19 as of today.
20 If I misspeak, Mr. Frantz, you be
sure to send
21 up a smoke signal.
22 We have $4,500,000 in CDs, and we
have a total
23 amount of cash of $4.984 million, which
sounds like we
24 are very flush. But in reality, by the time we get done
PEGGY HOOGS & ASSOCIATES
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1 with this, I will show you that we're
not. So the total
2 assets are 4.987.
3 What we have been doing is taking money
and
4 putting it into CD investments or into
government paper
5 and scheduling the maturity of these so that
somewhere
6 between 150- and $200,000 a month matures
and is rolled
7 over into the checking account to pay the
monthly
8 expenses of the Board. When we have made money on the
9 biennial registration, that money has been
put into CDs
10 and investments to mature sometime rateably
over the next
11 24 months.
So that's how we manage our money.
12 Unfortunately, the interest rates
vary between
13 1.9 and 2.3 percent. Some of what we do is government
14 paper, and it's callable. We have been called two or
15 three times on some of our larger
investments in
16 government paper, and then we try and
reinvest those.
17 As you'll see here, on the liabilities side,
we run an
18 accrual basis, not a cash basis, because
that's the way
19 governments do things.
20 There is 45,000 in vacation. There is 105,000
21 in deferred revenue for the month of
June. The
22 $1,132,200 is registration fees so far taken
in, and that
23 money will start to be spent on July
1st. The other
24 numbers are a little small.
PEGGY HOOGS & ASSOCIATES (775) 327-4460 15
1 Capital, retained earnings, or
amount of money
2 that really is in the bank that is
unallocated is the
3 $3,358,000.
So that's actually the amount of money that
4 we have.
The other money is money that will be spent in
5 the new biennium.
6 If we go to where we are on the
29th of May in
7 regard to our budget, you'll see that we
expected to
8 collect a million-four in M.D.
registrations, 35,000 in
9 PA registrations, and 79,000 in respiratory
care. And
10 what we actually have done is done a little
better in
11 M.D. fees, 1.476; PA is a little
better. We got all of
12 the respiratory care practitioners' money
earlier on, so
13 we really haven't increased that
number.
14 The total income so far for 11
months is
15 1,954,000.
The budget was 1,991,000. We are
$37,000
16 short.
17 On the expense side, we pay about
$100,000 a
18 month in running the employee side of the business,
19 including taxes and retirement and insurance
that the
20 Board pays for these employees. So when we are done at
21 12 months, the budget will be 1,263,000, and
we will
22 probably be at 1,180,000, so we are slightly
under budget
23 for the salaries that we paid.
24 Travel out of state, we're 10,000
below.
PEGGY HOOGS & ASSOCIATES
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1 Travel in state, which does not include this
meeting,
2 we're about 10,000 below. So we have done well there.
3 If you go through what we have budgeted
versus what we
4 have spent, most of the numbers are really,
really, very,
5 very close to what was budgeted. By the end of June, the
6 527- that we are currently at, we'll
probably add another
7 48,000 to get us to 565- and the budget was
583-. So we
8 are less than a percentage off there.
9 We have been trying to fix the
computers and
10 upgrade them and get everything done so that
we could be
11 web appropriate. There is another $17,000 to pay before
12 the end of this year to do that, so our
budget for
13 computers was 75-, but we ended up paying
130-. So the
14 net effect is, with where we are in income
and where we
15 are in expense, we are going to book about
$20,000 of
16 income to add to that 3,358,000 that we have
as capital.
17 So it still looks like we're doing pretty
good.
18 Now, we need to go to the budget
for next
19 year.
And where we are on the budget for next year is we
20 believe that we are going to have $2,000,000
in M.D.
21 registration fees. Currently, we only have 1.132. But
22
the last month is always real busy, and we believe we'll
23 be able to put 1,026,000 of M.D.
registration fees for
24 2003-'4 and have another 1,026,000 for 2004
and '5. So
PEGGY HOOGS & ASSOCIATES
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1 our total income will be about a million and
a half.
2 You'll remember that our cost of
doing
3 business employee-wise, because we are going
to have to
4 increase the staff on the investigative
side, is going to
5 go up.
So our cost of doing business strictly on
6 personnel is going to be a
million-seven. We are
7 estimating the travel remains about the
same.
8 Because of the increase in the
number of staff
9 and the increase in the amount of
investigations that are
10 going to have to occur, even if we don't
have anymore
11
filings against physicians -- we'll talk about that in a
12 few minutes -- we are suggesting that the
office cost is
13 going to go up and office printing is going
to go up.
14 530 is audit. And previously the audits for the
15 financial side of this has been $15,000 a
year, more or
16 less.
This year we're putting $100,000 in.
17 There was a legislative mandate
that we
18 thought was very important to appropriate
funds for to
19 make sure that we had the money if the
legislature wanted
20 either an audit of licensing procedures,
financial
21 procedures, or disciplinary procedures. And Larry felt
22 that a hundred would be approximately
correct for that.
23 The investigative number has gone up, and we
will explain
24 why we have gone from 35 to 60. Legal has gone up some.
PEGGY HOOGS & ASSOCIATES (775) 327-4460 18
1 All of those three will be taken care of,
and I'll
2 explain what those are. All four of those, the hearing
3 ones.
4 We have increased the size of the
office so
5 the rent is a firm number. We have increased the size of
6 advertising and public relations, and we
have to talk
7 about that issue, especially in view of the
question of
8 whether we should be advertising to the
public. You'll
9 remember last time we increased the amount
of money to
10 diversion.
The hospital association was giving them less
11
money. They needed more money to
do their mission in
12 diversion.
We went from 75,000 to 110,000.
13 And then there is the final
thing, 548,
14 competency.
We put $100,000 there. I have no
idea if
15 that's a good number or a bad number, I have
no idea if
16 it's high or low. I have no idea. But we have put that
17 number in there because sooner or later we
are going to
18 have to do something with competency, and
that is a good
19 guess about what we need.
20 Below the line, 35,000 for
equipment and
21 continuing the $75,000 a year keeping the
computer system
22 running suggests that at least for this
time, because of
23 all of the things that have come together in
a perfect
24 storm in regard to the Board, the cost of
doing business
PEGGY HOOGS & ASSOCIATES
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1 next year is $3,000,000. That will mean that we will dip
2 into reserves $1,488,000, which will mean at
the end of
3 next June, the current 3.358 will be dropped
by 1.488,
4 which basically leaves us with
$2,070,000. No, I did
5 that wrong.
1.870.
6 In the second biennium there
should be some
7 savings.
Hopefully, our case load will come under
8 control.
Hopefully, we will not have to finish upgrading
9 the computer, and as we learned today, there
will be
10 different mixes of employees, and some of
the employee
11 costs will go down. Even so, if the total expense
12 continues at what it is, and we lose another
million-two
13 or million-three in regard to the cost of
doing business,
14 we will end up with $500,000 in reserves at
the end of
15 the biennium.
16 It was generally thought that the
correct
17 number of reserves for the Board was one
year of expense.
18 This will give us two months of expense at
the end of
19 2005.
So this is very, very, very close.
The reserves
20 just go away. If the Board continues to have to
21 function, the 2,500 renewal fees, which I
won't have to
22 set, the rest of you will, will have to go
up to be able
23 to support the Board.
24 Some people may say that a budget
is just
PEGGY HOOGS & ASSOCIATES
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1 that, a budget, you can always save money
here, you can
2 always save money there. I will remind you that the
3 biennial budget as prepared is only off by
$22,000 for
4 the prior two years. So the budget is really what it
5 costs to run-run the organization.
6 There are contingencies that are
out there
7 that are not included in the budget, because
they're
8 contingencies, and I didn't know, Mr. Lessly
didn't know
9 how to budget for them, not knowing if we
are going to
10 have to do them.
11 There is in Senate Bill 97 a
requirement, if
12 it passes, that we in some way have to start
funding the
13 medical-legal screening panel. In Senate Bill 250, there
14 is the requirement to video-conference, as
we are doing
15 today, and the estimate of setting that up
and making it
16 work is $50,000 for the office on Terminal
Way.
17 In Senate Bill 250 there is the
request that
18 an office be started in Las Vegas, and it
blows
19 everybody's mind when you suggest that an
office in Las
20 Vegas would cost $100,000, but if you're
paying somebody
21 $3,000 a month, that's $36,000. If you're buying a
22 $1.50-a-square-foot office space at 2,000
square feet,
23 that's $3,000 a month. That is another $36,000, and
24 you're already at $72,000, and you haven't
opened the
PEGGY HOOGS & ASSOCIATES
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1 office.
You have just rented it and hired somebody to
2 work there.
You then have to put equipment in it and
3 made it functioning. So you could easily spend $100,000
4 more to maintain, run, and have an office in
Las Vegas
5 that's open during the work week.
6 Senate Bill 250 also asks for a
study dealing
7 with medical malpractice, and anybody's
guess of what
8 that would cost is anybody's guess. The numbers have
9 ranged from 1-, 3- or $400,000 since it will
be a
10 legislative request to really figure out
what's going on
11 in regard to malpractice rates, malpractice
prices. So
12
those are unfunded contingencies out there that we have
13 to wait until the legislature is done and
the governor
14 signs laws to know how much, if any, of this
is needed to
15 be done.
16 So that's the budget. I believe the budget is
17 really very close to reality as we sit here
today,
18 without the unfunded liabilities that may be
requested by
19 the legislature. And now I'll ask are there any
20 questions about the budget, budget where we
have been and
21 where we think we are going.
22 DR. BAEPLER: The reduction in the reserves
23 was anticipated when we lowered the fees.
24 DR. STEWART: Absolutely true.
PEGGY HOOGS & ASSOCIATES
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1 DR. BAEPLER: A little more than we had
2 possibly expected, but that could be offset
if we get an
3 increase in the number of PAs, doctors; new
people coming
4 into the state could offset this a little.
5 DR. STEWART: We have budgeted fees and new
6 application fees at the same rate that has
been present
7 over the last five years, which is a
variation between
8 325 and 375 doctors per year. If we believe that the
9 malpractice issues will get better, maybe
more physicians
10 will come.
If we believe that it's still a disaster,
11 maybe we will have less physicians
coming. But the
12 numbers here are budgeted for that general
number of 325
13 to 375 new physicians coming to the state,
becoming
14 active doctors and paying active fees.
15 When we had gone from $600 to
$400, without
16 the other things that we didn't think were
there because
17 they weren't there when we did that, we had
hoped to end
18 the biennium, 2005, with a million dollars
in the bank,
19 with the belief that the cost of running the
Board was
20
going to be about $200,000 a month, and we'd have about
21 five months in reserves. Now, with the extra costs, it
22 looks like we have about two months in
reserves.
23 DR. HUG-ENGLISH: Other comments about the
24 budget?
I think that was a very detailed and very good
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 23
1 explanation of the budget. And I think you can see by
2 Dr. Stewart's going through, that really the
budget is
3 very close, and it's hard to predict,
because there are a
4 lot of things that we can't -- you know,
that we don't
5 know about or that we haven't counted on
that do come up.
6 But if you look over the last couple of
years and see how
7 close the budget is to the actual expenses
of the Board,
8 I think you can project for this next year
that it would
9 likely be the same.
10 And I think it's clear from Dr.
Stewart's
11 report that within the next biennium our
reserves have
12 substantially decreased. Actually, decreased quite a bit
13 below what the recommendation is to have a
year of
14 reserves for the Board's operation. But that's what it
15 looks like at the present time.
16 Any other concerns, comments
about the
17 proposed budget? If not, I do need a motion to approve a
18 tentative budget for the next fiscal year.
19 DR. MONTOYA: So move.
20 MS. KIRCH: Second.
21 DR. HUG-ENGLISH: There is a motion and a
22 second to approve the budget for fiscal year
2003 through
23 June of 2004. All in favor?
24 THE BOARD MEMBERS: Aye.
PEGGY HOOGS & ASSOCIATES
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1 DR. HUG-ENGLISH: Opposed?
2 The chair votes in favor and the
motion is
3 carried.
4 Thank you for that report,
Paul. I think
5 since we have got you in the mode, do you
want to do your
6 investigative report as well?
7 DR. STEWART: Okay.
I will pass 68 names to
8
my right. These are cases that we
have closed. We
9 interviewed six or seven physicians and that
was what we
10 did at the investigative committee and have
asked those
11 physicians to do certain things for us. So those are the
12 cases that are closed.
13 You'll note that generally in the
past we have
14 been closing in the 121, 30, sometimes as
high as 60
15 cases.
This number is generally half of that.
The
16 investigative committee is current with
everything that
17 has been presented to us, and this is -- the
next comment
18 is not a slap at either Dick or the
investigators. It's
19 just the reality of the situation. Because of the
20 difficult times, because of the malpractice
prices,
21 because of the special work that was
required by
22 everybody in the investigative arena in an
attempt to get
23 a handle on numbers, and doctors moving out
of state, and
24 legislative requests and executive requests,
the staff
PEGGY HOOGS & ASSOCIATES
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1 has been somewhat distracted from their
primary job of
2 doing investigations and presenting the
investigations to
3 the investigative committee.
4 We had a discussion earlier that
the three
5 investigators each have somewhere between 80
and 90 and
6 100 cases that they are currently working
on, so
7 somewhere between 240 and 300 cases are
currently being
8 worked upon to present to -- a percentage of
those will
9 go to the September investigative
committee.
10 The status of the investigative
case load is
11 going to change. You'll remember that we get about 800
12 citizen complaints a year. Out of that 800, about 450 to
13 500 come under what the State Board of
Medical Examiners
14 can do and can investigate, and out of that
number we
15 find about 20 instances a year where filings
are made.
16 The medical-legal screening panel no longer
exists. All
17 that material has either than transferred to
courts or is
18 still moving through the medical-legal
screening panel,
19 plus there has been new cases filed since
October 1st.
20 Dr. Havens greatly helped us by
giving us a
21 list of where to start, at least the first
three or four
22
months of the October, November, December, January kind
23 of time frame, and letters that were sent
out suggesting
24 that if you think you might have been sued,
maybe you
PEGGY HOOGS & ASSOCIATES
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1 could check and really report it to the
Board. Those
2 letters have gone out and everybody has
appropriately
3 answered those letters. We estimate that there are 400
4 cases out there that we need to review.
5 In the past we didn't see any of
those until
6 the medical-legal screening panel made their
7 determination. Without the medical-legal screening
8 panel, the legislative mandate is that the
Board
9 investigate those, look for trends, look for
sanctionable
10 offenses, make sure that people are not
hiding in the
11 medical-legal screening panel with multiple
episodes of
12 suits against them.
13 There is a difference between a
legal suit
14 investigation and a citizen complaint
investigation, not
15 in how they are handled, but in the time
frame that it
16 takes to get an answer. The investigative committee,
17 when looking at a citizen complaint, can
look at it and
18 say it doesn't come under our jurisdiction
or this is a
19 problem of demeanor or a problem with fees
which we don't
20 have ability to do anything with, and we're
able to
21 gather the information fairly expeditiously
and can make
22 a decision usually by the next investigative
committee
23 meeting if there was a harm, if there was a
foul, if
24 something needs to be done. And I wouldn't suggest that
PEGGY HOOGS & ASSOCIATES (775)
327-4460 27
1 those are easy cases, but that's what we
know how to do,
2 and we have done them fairly well in the
past.
3 We did seven legal cases at this
IC, and they
4
are entirely different. You have
a plaintiff's attorney
5 telling you what he thinks his side of the
story is, you
6 have a defendant's attorney telling you what
he thinks
7 his side of the story is, you have a doctor
giving an
8 affidavit, you have a doctor supporting the
defendant
9 doctor in his affidavit, and sometimes you
have to go out
10 to peer review. So the time preparing the case, getting
11 it ready to discuss it with the
investigative committee
12 is longer than it is with a citizen
complaint. And the
13 medical records have to be found and you
really have to
14 figure out if the doctor really did anything
or if the
15 plaintiff's lawyer is just presenting his
case in the
16 best light to the plaintiff. And that takes a lot of
17 time.
18 And that's my worry for the
future forward and
19 the future I see. If we're really 500 of those, quote,
20 "behind," and the legislature
thinks we should be getting
21 current on those, and we already have the
300 citizen
22
complaints in the system, this system really can get
23 bogged down.
24 So I think that it's really very
appropriate,
PEGGY HOOGS & ASSOCIATES
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1 once we figure out what our liabilities are
because of
2 the legislature in regard to monetary
things, to hire one
3 new investigator and an administrative
assistant and see
4 how the case load works, and then later on
consider
5 hiring another assistant and another
investigator in an
6 attempt to get this backlog, which really
isn't a
7 backlog, it's just all those cases that we
know are there
8 that we still don't even have pieces of
paper on because
9 the lawyers are doing their lawyering in the
courts and
10 we don't have anything to review yet.
11 So I think the work of the IC,
come September
12 and come December, is greatly going to be
higher than it
13 has been before. We laugh about the amount of materials
14 you carry on the plane coming back here, and
Dr. Montoya
15 managed to bring an entire suitcase with
him. He had his
16 clothes in another bag, but he had an entire
suitcase of
17 paperwork that he was bringing back up
here.
18 I think the way that we do
business needs to
19 change.
The amount of work that the IC is going to do I
20 think is going to more than double. And I think that one
21 investigative committee cannot handle the
work load in
22 any way, shape, or form. And I am suggesting that there
23 be a change in the secretary/treasurer job
description to
24 suggest that the secretary/treasurer will be
in charge of
PEGGY HOOGS & ASSOCIATES
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1 one investigative committee, and I would
recommend that
2 the Board constitute a second investigative
committee,
3 each having at least two doctors and one
public member,
4 so that the work load at least over the next
calendar
5 year can be handled twice as fast as it
normally would be
6 handled.
I don't think the Board can medically nor
7 politically stand the possibility of being,
quote, "800
8 cases in the box," not being moved
along quickly.
9 DR. BAEPLER: Was that a motion?
10 DR. STEWART: Yes, that's a motion.
11 DR. BAEPLER: I'll second it.
12 DR. STEWART: I really believe that the IC as
13 previously constituted was busy. I think one IC just
14 can't do it, and two might not be able to do
it without
15 streamlining of the process. We talked earlier about
16 hiring more staff to do this, we talked
earlier about
17 getting an assistant to Larry to certainly
help with
18 this, as Maureen was leaving. We talked about looking
19 for a deputy to Dick.
20 Steve made the comment that it's
very nice
21 that they are not leaving and they are
training people to
22 do their job. I'm going to agree with that and make the
23 observation that the work load has more than
doubled and
24 we can sop up the extra help very quickly in
this.
PEGGY HOOGS & ASSOCIATES (775)
327-4460 30
1 So I think that's where we are
headed. It has
2 been a bad six months in regard to the
aggravation of the
3 doctors in the State in regard to unsurety
of what
4 legislation would appear. The money situation will now
5 be tight.
The work load will now be more.
We have a lot
6 of work to do in the next year. And that's my report.
7 DR. HUG-ENGLISH: Thank you, Dr. Stewart. I
8 think that's an excellent summary of where
we are and the
9 concerns that really we have been talking
about all
10 morning, not only from the staff perspective
of the
11 Board, but also the work load of the Board
members doing
12 investigative committee work. And I think the suggestion
13 of having a second investigative committee
is a good one,
14 and I know there has been a motion and a
second. I
15 wonder if there is any further discussion
from other
16 Board members.
17 DR. TITUS: Well, are you looking at having a
18 three-member board, two investigative
committees, and
19 then maybe a three-member IC, internal
affairs committee,
20 or are you looking at --
21 DR. HUG-ENGLISH: I think what the motion is
22 is to have two separate ICs. One would be chaired by the
23 secretary/treasurer, and a second IC would
be chaired by
24 another Board member that would be
appointed.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 31
1 DR. TITUS: Right now it says I think that the
2 chairman of the IC has to be a
secretary/treasurer,
3 according to our --
4 DR. BAEPLER: He suggested we change that.
5 DR. TITUS: Right, but are we ready to -- I
6 mean, it's just more than a motion. We have to do some
7 changes in our job descriptions and
everything.
8 MR. LESSLY: If you are going to have two ICs,
9 you need a motion to change the language and
the
10 secretary/treasurer's job description from
"chairs the
11 IC" to "chairs and IC."
12 DR. BAEPLER:
Paul used that exact wording. I
13 assume that was incorporated into the
motion.
14 DR. STEWART: So the way I would see this
15 happening is three people are on an IC and
there are six
16 adjudicators for that IC, three more people
are in an IC,
17 there are six adjudicators for that IC. I really wanted
18 to start out and say there would be three
investigative
19 committees, but I don't know how you could
do that
20 because the president theoretically can't
sit on an
21 investigative committee.
22 DR. BAEPLER: Two should handle it, because
23 you know it takes a while to work these
things through
24 the pipeline.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 32
1 DR. HUG-ENGLISH: I think we better start with
2 two.
We may really confuse ourselves if we go to three.
3 But I do think that two makes a lot of
sense, from the
4 perspective of sharing the work load and
getting cases
5 brought before this Board in a more
expedient manner.
6 So in further answer to your
question, Robin,
7 I think it would mean that the
secretary/treasurer chairs
8 one and then there is a second IC with a
second chairman
9
appointed by the president. And
so those two bodies
10 would function independent of each other as
ICs, and
11 there would be different adjudicators for
cases from each
12 of those committees.
13 DR. TITUS: Is it the state regs that requires
14 that the secretary/treasurer be an M.D.?
15 MR. LESSLY: There is no requirement that the
16 secretary/treasurer be an M.D. The only legal
17 requirement for an investigative committee
is that it
18 have at least one public member on it.
19 DR. BAEPLER: It could have two.
20 MR. LESSLY: It could have three.
21 MR. BAEPLER: Yes.
22 DR. MONTOYA: What if they just had one large
23 IC rather than two ICs.
24 DR. HUG-ENGLISH: Well, if we had one large
PEGGY HOOGS & ASSOCIATES (775) 327-4460 33
1 IC, then we wouldn't have enough
adjudicators.
2 MR. LESSLY: That one committee would probably
3 meet about five days a month.
4 MR. LEGARZA: The problem would be, it's clear
5 statutorily that anyone who serves on an IC
cannot serve
6 as an adjudicator. And if you're going to have to have
7 more people serve on ICs, I think you have
to have two
8 separate ICs so that you can identify --
because in every
9 complaint that I file, I identify in that
complaint who
10 the members of that IC are. If we had six on that IC,
11 we're going to get ourselves in a position
where we may
12 be criticized about some people on the IC
looking at a
13 case even maybe that they shouldn't have
looked at. So
14 if you're going to have two ICs, I think
there have to be
15 two separate and distinct ICs.
16 I think that's going to be a
little difficult
17 from the administrative standpoint, but
Doug's pretty
18 much got it set up. Larry, Doug and I have talked about
19 how we can allocate the cases, for instance,
simply on an
20 ABC, but kind of break them down evenly
before they are
21 allocated about so many that are peer review
cases, so
22 many that are recommended for closure, so
many for
23 discussion, but I think the two ICs need to
meet separate
24 and apart from each other, and that is going
to be
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 34
1 something that we're going to have to worry
how we are
2 going to coordinate, because now you've got
your IC
3 members saying Larry stole my IC time, now
he stole all
4 Friday from me, so my IC people had to come
up here
5 yesterday.
So now he's got three members of the IC who
6 they're devoting three days now to a
meeting.
7 DR. BAEPLER: We also held an interim meeting
8 about a month ago.
9 MR. LEGARZA: We had a telephone conference
10 call meeting, plus we've always had interim
meetings, so
11 our IC is now meeting eight times rather
than six times.
12 So, you know, you're asking a lot of your
Board members
13 to serve on an IC and -- anybody that's ever
served on an
14 IC knows what it's going to be, and if not,
you're going
15 to find out soon. But I think you have to have two,
16 Doctor.
17 DR. HUG-ENGLISH: How does everybody else feel
18 about that?
Marlene?
19 MS. KIRCH: Uh-huh.
It sounds like it would
20 work.
It would solve a lot of the problems that we're
21 seeing.
And at the point in time that you no longer need
22 the second committee, then you just would
not have to
23 appoint that committee. If we get to the point that our
24 case load is manageable by one, then you'd
have the one.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 35
1 DR. BAEPLER: And at the present time, not
2 only is there a huge number, but we get to
the point at
3 every meeting where we rush. You just can't avoid it.
4 It
would really be a pleasure to see a reduced case load
5 with two committees so we would have a
little bit more
6 time for deliberations.
7 MS. KIRCH: And felt that you were looking at
8
all the issues that you needed to look at.
9 MR. LEGARZA: And what Dr. Stewart didn't tell
10 you, and that you all know too, is that in
addition to
11 that 740 approximate cases -- what did we
bring in,
12 500 -- it's probably even in excess of 500
now, we get
13 about 15 a week also that come in, so
there's another,
14 what, 60 a month adding onto that. So that figure in a
15 month's time is going to be 800, and then
it's going to
16 be 860.
So we are opening -- Angie told us yesterday she
17 is opening 10 to 15 new cases currently
every week. So
18 that number of 740 is just a jumping-off
spot.
19 DR. HUG-ENGLISH: And we need to keep in mind
20 that this is one of the most important
functions of this
21 Board, is to do a thorough job of
investigating
22 complaints that come before us. So I think we do need to
23 take steps to make sure that we have
adequate staff and
24 adequate Board members involved in the
process so that we
PEGGY HOOGS & ASSOCIATES (775)
327-4460 36
1 can keep up with it. And what it will mean if we go to
2 this, I mean you all need to be aware of
that, is that
3 six Board members will be actively involved
in the
4
investigating committee process.
5 I think that that has some real
positive
6 merits to it in that I think when you're on
an
7 investigative committee it really is the
central part of
8 the workings of the Board, and you really
find out what
9 it takes to investigate a complaint, the
time involved,
10 the detail involved in reviewing that
material. And so
11 it really does I think help as far as your
understanding
12 of the whole process to be on an
investigative committee.
13 But it's a lot of work, too.
14 So I think there is a motion and
a second. Is
15 there
any further discussion on that? If not,
all in
16 favor?
17 THE BOARD MEMBERS: Aye.
18 DR. HUG-ENGLISH: Opposed?
19 Chair votes in favor of the
motion and the
20 motion carries. So we will talk a little later either
21 today or tomorrow about committee
appointments to both of
22 those.
23 MR. COOPER: Madam President, this is Doug in
24 Las Vegas.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 37
1 DR. HUG-ENGLISH: Hi, Doug.
2 MR. COOPER: Can I ask the members sitting on
3
the side to use their microphones.
They are not coming
4 through.
5 DR. HUG-ENGLISH: Thank you for the reminder.
6 We are still on the learning curve of this
process.
7 Appreciate it.
8 MR. COOPER: Thank you.
9 DR. STEWART: There are going to be some
10 complaints filed. We don't see how we can not file these
11 complaints.
You'll remember the medical society knows of
12 many doctors that have left, are leaving the
State, and
13 unfortunately they didn't notify us of these
things. The
14 mailings in January were an attempt to get
everybody to
15 tell us where they were. The Board unfortunately cannot
16 do its job if they don't know where the
doctor is
17 actively practicing.
18 There is a moving box full of
returned mail in
19 regard to letters that we have sent doctors
for their
20 biennium registration packets which
continually come back
21 to us because we do not have the right
address and we
22 have trouble finding the doctor, to either
send him the
23 material he needs to answer or the material
he needs to
24 be relicensed by July 1st. Remember we only have about
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 38
1 30 days left in the registration
period.
2 The box is big. The number of returned pieces
3 of mail is really bad, and this is even
after we tried to
4 find everybody in January with mailings of
the newsletter
5 and the mailings regarding the hearings on
continuing
6 competency and the letters to everybody
reminding them of
7 their reporting responsibilities under
AB-1.
8 So Dick is going to have a number
of
9 complaints for violation of telling us where
you are
10 actively practicing and where the medical
records are
11 actively kept.
12 In addition, we need to see a lot
more
13 renewals or requests to become inactive
before June 30th
14 or there will be a tremendous number of July
1st cease
15 and desist orders of the practice of
medicine,
16 remembering that there is no grace period,
and if you are
17 not licensed by July 1st, you are not
allowed to
18 practice.
And Dick will have to prepare a great number
19 of "you are not allowed to
practice" comments to be
20 delivered to the doctors on the 1st and 2nd
of July.
21 So the investigative committee
agreed that we
22 didn't see any other way of doing this. We tried in
23 January, we tried in March to figure out
where everybody
24 is, and we still don't know where everybody
is.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 39
1 MR. LEGARZA: And every newsletter we send out
2 talks about it, our web site talks about it,
3 Mr. Mathias's web site reminds all of his
members,
4 everybody that looks at it, and Angie's box
has probably
5 150.
We're always talking about the extra work the
6 investigative staff has to do, but that
woman has located
7 them all on the telephone. And how many telephone calls
8 she has made and they still keep coming
in.
9 So the investigative committee
decided that it
10 was about time, that maybe the only way
we're going to
11 make the point is at random select several
physicians and
12 file formal complaints against them. That will get the
13 word out.
14 DR. MONTOYA: File against them all.
15 MR. LEGARZA: Yes, sir.
16 MR. LESSLY:
I think he can do that. He's
17 going to have a deputy.
18 DR. HUG-ENGLISH: Okay.
I just wanted to make
19 a clarification too on that last motion that
we've just
20 approved, that it also included changing the
job
21 description of secretary/treasurer to the
chair of one
22 investigative committee. So I just wanted to state that
23 for the record, that that is incorporated into
that
24 motion.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 40
1 Thank you, Paul, and thank you,
Investigative
2 Committee.
I know this past year has been a tremendous
3 amount of work, and we all know what it
takes to prepare
4 for these meetings, but if you can double
that at least,
5 time-wise, it's what they have been putting
in. So thank
6 you for being willing to do that.
7 Okay. We are going to skip back now to Agenda
8 Item Number 7, that's our legal report, and
I'll turn it
9 over to Mr. Legarza.
10 MR. LEGARZA:
The only thing I have is
11 everyone is current with their terms and
conditions of
12 probationary status. The basis I've been reporting on
13 for several years now is still under
concealment in the
14 Second Judicial District, and there have
been two recent
15 petitions for judicial review that have been
filed. One
16 has been filed on behalf of Dr.
Schmerler. The
17 allegation in that is that revocation of his
license by
18 the Nevada State Board of Medical Examiners
was
19 Draconian.
20 And one has been filed on behalf
of Dr. -- I
21 think it's pronounced Abiantunge. So there are two new
22 petitions for judicial review that have been
filed, and
23 we have already filed the record in the
Second Judicial
24 District Court, and we'll be filing the
record in the
PEGGY HOOGS &
ASSOCIATES (775) 327-4460 41
1 Eighth Judicial District Court on Abiantunge
next week.
2 Dr. Schmerler was -- the
allegation against
3 Dr. Schmerler was that he was convicted of a
felony and
4 that the felony involved moral
turpitude. The felony
5 that Dr. Schmerler was convicted of
committing was income
6 tax evasion, and the Board found him guilty
of that
7 felony, and also since it was a crime of
moral turpitude,
8 revoked his license.
9 Dr. Abiantunge's was a
malpractice case. He
10 was found guilty of that. The Board issued him a public
11 reprimand, assessed him costs, and I think
ordered him to
12 take some additional CME, I believe.
13 DR. STEWART: Could I just say one thing?
14 There are, unfortunately, three doctors that
are
15 currently incarcerated. The investigative committee has
16 not forgotten those three doctors. They still do hold
17 licenses, but they are incapable of
practicing on the
18
citizens of the State of Nevada.
They have to be served
19 and go through everything just as everybody
else is.
20 One is incarcerated in Clark
County with a
21 grand jury indictment against him, but he
has not had a
22 trial.
So we really can't do anything with him.
But I
23 wouldn't want anybody to think that we have
forgotten
24 about them.
The legal wheels just take a while to do
PEGGY HOOGS &
ASSOCIATES (775) 327-4460 42
1 their thing.
2 MR. LEGARZA: The other one just got
3 convicted, and the third one is on -- at
this time.
4 DR. HUG-ENGLISH: Charlotte.
5 MS. BIBLE: I guess I don't have anything to
6 report today.
7 MR. LEGARZA: You might get the Vegas one yet.
8 Be careful.
I'm thinking about it.
9 DR. HUG-ENGLISH: All right.
Well, thank you
10 both.
11 We'll move on then to -- back to
Agenda Item
12 Number 8, and the legislative update I'm
going to
13 postpone until tomorrow, with the hopes that
perhaps
14 Mr. Lee will be able to join us. As you said earlier, he
15 is very involved today with continuing
legislative
16 issues, so hopefully we'll be able to give a
report on
17 that.
18 Do we have Carol Bowers here for
the
19 diversion, or is she going to come tomorrow?
20 MR. LESSLY: No, but her written report is in
21 your agenda book, or it's a hand-out. I'm not certain.
22 DR. HUG-ENGLISH: I don't remember seeing it.
23 MS. LYONS: No, we just got it, and it's a
24 hand-out.
PEGGY HOOGS & ASSOCIATES
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1 DR. HUG-ENGLISH: Is there a reason that Carol
2 isn't here this meeting? She usually comes.
3 MR. LESSLY: She had some conflict this
4 meeting.
5 DR. HUG-ENGLISH: Okay.
I'll give everybody a
6 moment to just review this.
7 The report is basically -- it
looks like
8 things are running smoothly with
diversion. I don't see
9 any real problems called to our
attention. Looks like as
10 of May they have 23 participants in Northern
Nevada, 41
11 in the South, and there are five currently
under
12 investigation, which brings the total of
participants to
13 64.
14 As Dr. Stewart may have
mentioned, at our last
15 Board meeting we did up the amount that this
Board
16 contribute to the diversion program to
$110,000, that
17 will help them in a financial
situation. I think the
18 Board has felt and continues to feel that
this program
19 certainly merits our support and that they
are doing a
20 good job.
21 Any comments about the report
from Carol? No
22 comments.
Do I have a motion to approve the report then?
23 DR. TITUS: So move.
24 DR. HUG-ENGLISH: There is a motion and a
PEGGY HOOGS & ASSOCIATES
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1 second to approve the diversion report. All in favor?
2 THE BOARD MEMBERS: Aye.
3 DR. HUG-ENGLISH: Opposed?
4 The chair votes in favor and the
motion
5 carries.
6 And then we don't have our
physician assistant
7 committee member here today either, but we
do -- I think
8 there is a page going around -- does
everybody have
9 that -- for their committee report.
10 This is actually interesting
talking about the
11 continued competency for PAs. Looks like according to
12 their letter here that every six years they
need to
13 retake that exam, which is called the PANCE
exam,
14 Physician Assistant National Certified Exam,
as well as
15 continued educational activities. So that's interesting.
16 DR. TITUS: I like the last statement there.
17 DR. HUG-ENGLISH: Yeah.
18 Any other comments or concerns
about PA
19 committee?
Do we need to approve those?
20 MS. KIRCH: So moved.
21 DR. HUG-ENGLISH: And from our Respiratory
22 Care Advisory Committee, I don't think we
have anybody
23 either.
And I don't think we have any additional written
24 material from them either, do we ?
PEGGY HOOGS & ASSOCIATES (775) 327-4460 45
1 MR. LESSLY: No.
2 DR. HUG-ENGLISH: Okay.
That brings us down
3 to the last item under Agenda Item Number 8,
and that is
4 the federation annual meeting, and for those
of you who
5 were able to attend, I would like maybe
someone to give
6 us some feedback on that meeting. Some of us weren't
7 able to attend because we were dealing with
some
8 legislative issues. So if Jackie or Paul or someone
9 would like to give us some feedback.
10 MS. JONES: It was very interesting going as a
11 delegate.
It's amazing how popular you become.
I made
12 it a point to talk to every person who was
running for
13 office, and I had some questions prepared
for them, which
14 threw some of them. But it was very interesting, and I
15 enjoyed that part of it, actually.
16 I think it was a mandate from the
San Diego
17 meeting that we have a more interactive
meeting, and they
18 certainly did that this time. We were able to
19 participate in the groups that we were -- we
were all set
20 up to go to different groups, small groups,
and Don led
21 one of those, and did an excellent job. In his, we had
22 real cases, of course, names were not
mentioned, and then
23 the people at our table would decide whether
we would go
24 on with recommending a further action or
not. It was
PEGGY HOOGS & ASSOCIATES
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1 very interesting.
2 Another one that I thought was
really good,
3 they had a panel that had several different
members of
4 different -- that have different functions
throughout the
5 medical community responding to a situation,
and then
6 they would each tell their perspective, and
it was very
7 interesting to hear how -- depending on what
job they
8 had, what their perspective was on this
incident. I
9 found that very interesting.
10 I thought it was a good
meeting. Much better
11 than the San Diego one.
12 DR. BAEPLER: I thought, too, that the topics
13 were extremely varied. The group session that I had, for
14 example, was medical ethics in
research. I chose four
15 research episodes around the country where
the M.D.
16 participants really were unethical. Federal funds called
17 off, and in one instance they were the
medical faculty
18 fired, and it was so bad that they fired the
department
19 chairman and the dean as well.
20 Medical boards have never looked
at this, and
21 it's just kind of a new dimension as to
whether or not
22 you want to ever get involved in ethics in
medical
23 research.
It's an exciting area and, of course, it mixes
24 up PhD's with M.D.'s and groups we have no
jurisdiction
PEGGY HOOGS & ASSOCIATES
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1
over at all. But, as usual, I
think one of the big
2 assets in going to a meeting like this is
having informal
3 conversations with board members from other
states. You
4 can ask them, you know, what are you doing
about this or
5 that, and how does this work and that work,
and I find
6 that to be about as educational as the
formal session.
7 DR. TITUS: One of the very hot topics back in
8 Chicago was this whole maintenance of
competency and
9 many, many -- all the states are questioning
and all the
10 states are looking at it, and we'll talk
about it later
11 when we talk about our issue, but it was a
concern that
12 has been led to the committee that I've been
appointed to
13 on a national-wide basis looking into how
can we help the
14 State struggle with the struggles that we
have right now
15 on this whole concept of maintenance of
competency and
16 documents of competency. And so we are hopefully going
17 to come out with some ideas for all the
states.
18 Everybody wants some suggestions. As our PA so
19 eloquently just stated, it's now ethical and
professional
20 and it's going to be mandated. So that was a big issue.
21 The other issue that I thought we
needed to
22 address before we go back wherever the next
one is, I
23 think in Washington, D.C. in the spring,
each state was
24 offered a chance to present its state, have
a little
PEGGY HOOGS & ASSOCIATES
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1 brochure, documentation, little power point
presentation,
2 and in the hallway there some of the states
took
3 advantage of that, about what's going on in
your state.
4 Oklahoma had one, and Texas had one, and
several of the
5 states had a little power point, and they
did a little
6 session on that.
7 The networking is so good that --
it really
8 does help the share of getting this monthly
or quarterly
9 program that we get from the federal -- from
the
10 federation.
We don't always look at that, and I thought
11 the way they presented the states -- they
had a little
12 break-out session on that for a half hour
where you could
13 go interact with all the other states, and
they actually
14 had some brochures and stuff. And I was thinking that it
15 would be a good thing, depending on where we
go with
16 ours, to think about maybe looking at doing
that next
17 year for the State of Nevada. I think we have a lot
18 going on that we should be proud of, and
lots of people
19 from different states were coming up to us
asking us
20 about our -- where we're at, because they
know of many of
21 our struggles, and we're setting some
precedents, and
22 they wanted to see where we were. So I think it would be
23 good to have Nevada represented.
24 DR. HUG-ENGLISH: It sounds like it was a
PEGGY HOOGS & ASSOCIATES
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1 really good meeting and that we were
represented well by
2 our Board members there. I think that we need to
3 remember that the feedback that we've had
from the
4
federation, and I think the comments that have been made
5 is that we are a leader Board in many ways,
and that
6 people do look to this Board at the
federation level as
7 well.
So I think that it's great to see such good
8 representation from this Board at that
level.
9 Okay. Let's move on to Agenda Item Number 9,
10 which is our executive staff reports. And Larry, I'll
11 turn it over to you.
12 MR. LESSLY: I have one request for staff
13 attendance in the educational meeting, and
that is from
14 Lynette Crockie, who Monday will become the
chief license
15
specialist, to attend the National Board for Respiratory
16 Care annual meeting in Kansas City on
September the 19th
17 and 20th and they pay her travel
expenses. So if I could
18 have a motion for her to be authorized to
attend.
19 MS. KIRCH: So move.
20 DR. MONTOYA: Second.
21 DR. HUG-ENGLISH: All in favor?
22 THE BOARD MEMBERS: Aye.
23 DR. HUG-ENGLISH: Opposed?
24 The chair votes in favor and the
motion
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 50
1 carries.
2 MR. LESSLY: Let me ask Maureen to do the
3 second one, but I'll just go ahead and
finish up the
4 others real quickly, if you don't mind.
5 The contract with Nevada
Broadcasters
6 Association, material on the number of runs
we've been
7 having on radio and TV is in your
material. I would
8 recommend that you approve that again for
three months,
9 July the 1st through September 30th. Once the
10 legislature has adjourned, the Broadcasters
Association
11 is going to start working on some additional
ads,
12 hopefully the kind that are no cost to us,
because we
13 don't have any developmental costs thrown
into the budget
14 for additional ads. We did increase the budget for
15 attempting to get more runs for the ads we
have.
16 So I would request that you
approve that for
17
another three months at the rate of $5,000 a month, with
18 the understanding that I'll be back to you
at the next
19 meeting with some indication about
additional spots.
20 DR. MONTOYA: Do we actually need to advertise
21 anymore?
22 MR. LESSLY: Well, we get an awful lot of
23 calls saying, "I'm calling because of
the ad, and I need
24 this information on a doctor," yeah.
PEGGY HOOGS & ASSOCIATES
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1 MS. JONES: I think it's important that we
2 continue to do it. I get feedback. That's about the
3 only thing that anybody ever mentions to me
about the
4 Board, something that they've heard either
through the TV
5 or the radio and actually called because
they've heard it
6 either on the TV or the radio. I think it's a good
7 thing.
8 DR. MONTOYA: If we're going to advertise,
9 maybe we don't need the web site.
10 DR. HUG-ENGLISH: I think that we need to
11 have different ways -- people access in
different ways,
12 and I think the web site is -- a lot of
people really
13 like to access information that way. I think other
14 people hear information via TV and radio and
so forth, so
15 I think both have a value.
16 DR. STEWART: Some of the senators thought it
17 was a waste of money. Would you just allow us to discuss
18 that for a moment?
19 MR. LESSLY: I think that's an appropriate
20 thing to discuss.
21 DR. BAEPLER: What, the web site or the
22 advertising?
23 DR. STEWART: The advertising.
24 DR. LUBRITZ: When we first started
PEGGY HOOGS & ASSOCIATES
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1 advertising, it was my impression that we
were going to
2 try it, and it did not have to be in
perpetuity, but that
3 we would see what response we got. But to my knowledge,
4 I think once we began that, I don't think
that we have
5 ever discontinued it.
6 So my question is, as Steve's, do we
need it
7 anymore?
We have certainly gotten lots of publicity,
8 albeit not what we would like to see, but I
think
9 everybody knows that we are here, certainly
all the
10 legislators know that we are here.
11 MR. LESSLY: That's not true. Some of the
12 legislators say they have never seen one of
our ads and
13 say they don't see any point in us running
ads and
14 spending that.
15 DR. LUBRITZ: I don't mean on the television,
16 I mean in the legislature. So I think it might be of
17 value to withhold it for a while and see what
happens.
18 Certainly, with Dr. Stewart's comments on
what's
19 happening to our budget, this may be one of
the places,
20 since all of our costs are increasing, it
may be one of
21 the places where we don't have it for a
quarter or two or
22 three or four quarters and see how we do,
and if it's
23 necessary, reinstitute it.
24 MR. LESSLY: I'm not certain that you have
PEGGY HOOGS & ASSOCIATES (775) 327-4460 53
1 that opportunity. Once you terminate your contract with
2 Nevada Broadcasters Association, there is no
obligation
3 to take you back. And then the last thing you want to do
4 is decide you want to do advertising again
and then be
5 forced to go on the commercial market in
order to do
6 this, because you are going to spend an
awful lot more
7 than $5,000 a month. So I guess my caution to you is be
8 real sure that's what you want to do.
9 MS. JONES: You know, I'm not so sure that
10 everybody is well versed on what the Board
does,
11 including the legislature, and I think that
this is
12 really the only time that we speak to the
general public
13 about what we do. Otherwise, I don't think they have a
14 clue what we do. And at least this gives them some
15 avenue, somebody who is just sitting down
watching
16 television, which we all do sometime or
other, gives the
17 general public a place to go if they have a
-- you know,
18 if they want to know something about their
doctor.
19 MS. KIRCH: The other thing is, if they don't
20 know -- a lot of people new to the state,
whatever,
21 everybody doesn't have internet access, and
some of
22 people that may want to know how to report
incidents, if
23 they see it, maybe they will understand
there is a way
24 for them to do it.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 54
1 MR. LESSLY: I guess one of the ways I would
2 tell you I know it's effective is probably
because of the
3 efforts of Dr. Montoya in doing the Spanish
BSA. Our
4 receptionist speaks Spanish, but I've heard
her at least
5 several times a day not having to do that
with people who
6 have heard an ad. So I guess, Dr. Montoya, you would be
7 sort
of shooting yourself in the foot if you stop doing
8 this.
9 DR. STEWART: I know we hear from the doctors
10 that also watch television that it's an
affront to the
11 profession and that we are asking the
citizens, the
12 public, the patients to file complaints
about the
13 doctors.
But I've read the scripts of every one, and
14 I've looked at these at 2:00 o'clock in the
morning when
15 I'm up checking to make sure that everybody
is still
16 breathing in my house, and I don't think we
have ever
17 said in any of these, "Call us up and
tell us that your
18 doctor did X, Y and Z wrong." But that is still the
19 interpretation of the medical profession.
20 DR. HUG-ENGLISH: Joel.
21 DR. LUBRITZ: There are various types of
22 advertising, TV being one. What I'm suggesting is that
23 if we are going to continue to advertise,
then perhaps we
24 could explore other types of
advertising. For instance,
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 55
1 lots of people read newspapers. So would it be less
2 expensive reaching a large number of people
once every
3 week or two weeks to have an article in the
newspaper,
4 the Sunday paper?
5 MR. LESSLY: I can tell you the answer to
6 that.
No, it would not be less offensive.
7 DR. LUBRITZ: Well, we don't have to spend the
8 money.
We could get someone to interview -- like they
9 have in this section, that section --
10 DR. BAEPLER: I think you would have to buy ad
11 space, probably.
12 MR. LESSLY: My suggestion would be don't stop
13 it until you know whether or not you can
start it again
14 if you want it. Do it for three more months. Let's have
15 Mr. Fisher from the Nevada Broadcasters
Association here
16
at the next meeting and talk about it with him.
17 DR. LUBRITZ: Or just decrease the amount.
18 MR. LESSLY: Sure.
19 DR. BAEPLER: Don't some states have a law, a
20 regulation that this has to be posted in
every doctor's
21 office?
22 MR. LESSLY: Yes.
23 DR. BAEPLER: Texas, I think --
24 MR. LESSLY: Several states.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 56
1 DR. BAEPLER: Several states. The medical
2 board, the phone number and so on?
3 MR. LESSLY: In some states you're required to
4 post in your office, in your waiting room,
in a
5 conspicuous location, the fact that you're
licensed by
6 that state's board of medical examiners, and
if the
7
patients who read that notice have a complaint about you,
8 here is the number they need to call.
9 DR. BAEPLER: Yeah, that certainly hits the
10 target.
11 DR. HUG-ENGLISH: I think we need to keep in
12 mind too that, you know, one of the concerns
that we've
13 heard certainly in the last two months is
that the public
14 needs more access to this Board. And I think that
15 certainly this is one way to do that. Perhaps we need to
16 look at eventually changing the ads or
updating the ads
17 or doing a different ad, because I think
they do lose
18 their effect after they have been the same
one over and
19 over again for several years. But I think the purpose in
20 notifying them of what this Board does and
what we're
21 about and how to access it, that it's
important to get
22 out.
23 And maybe there are some other
ways we can
24 look at doing that. But I think for right now, I think
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 57
1 the feedback that we've gotten from the
Board office and
2 from people that have seen it is that it's
working, and
3 that people are finding out about us and
finding out what
4 what we do and how they can contact us if
they need to.
5 So personally, I don't think we need to make
any major
6 change right now.
7 MR. LESSLY: And Joel, I'm certainly not
8 advocating at all that any more money be
spent on
9 developmental costs. And you and I were both on that
10 committee that did that last ad, and you
know what that
11 cost.
I mean this stuff is not cheap.
This is tens of
12 thousands of dollars to come up with a
commercially
13 acceptable professional ad. And I'm not willing to
14 suggest that we even do that, that the
increase in the
15 budget for the advertising was intended to
attempt to
16 increase the amount of times these ads would
be run and
17 to develop some ads at the cost of Nevada
Broadcasters
18 Association, not this Board, as they did
with
19
Dr. Montoya's ad, which in effect cost us nothing. So
20 what I'm saying is if you want to make some
changes, you
21 ought to bring Mr. Fisher from the Nevada
Broadcasters
22 Association in here and talk about what it
is you want to
23 do.
So I'd suggest you let it go for three more months.
24 We can only do it on a quarterly basis
anyway, and then
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 58
1 bring him in here and let's put him on the
next agenda
2 and hash it out.
3 DR. LUBRITZ: I'd like to make that in the
4 form of a motion.
5 DR. HUG-ENGLISH: Okay.
6 MS. JONES: I second it.
7 DR. HUG-ENGLISH: So there is a motion to
8 accept the current contract as stated for
advertising,
9 and then at our next Board meeting in
September, bring
10 him forward to discuss any changes that we
want to make.
11 And that was seconded. All in favor?
12 THE BOARD MEMBERS: Aye.
13 DR. HUG-ENGLISH: Opposed?
Chair votes in
14 favor; motion carries.
15 DR. MONTOYA: Can I ask for union scale next
16 time?
17 DR. STEWART: The money is in the residuals.
18 MR. LESSLY: As Dr. Skully used to say, we're
19 just doing the Lord's work.
20 On the status of additional
office space,
21 consideration of additional office
loication, we have
22 completed the move of all the files to the
new location
23 on the first floor of the building. The lease is
24 extended to 2009, the investigative space
has been
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 59
1 revamped so that there is now room for new
investigators
2 as well as an additional space for our
existing
3 investigative staff. That has been completed.
4 On the consideration of
additional office
5 locations, you have talked about the
necessity for an
6 office in Las Vegas, I'd like to have you
refer that to
7 staff and we will come up with something for
you.
8 MS. KIRCH: In your consideration of a
9 location in Las Vegas, have you considered
your executive
10 suite office type area?
11 MR. LESSLY: That's what we had before. I
12 haven't considered anything, and I think
that would be a
13 wonderful project for my new deputy, whoever
he may be.
14 MS. KIRCH: Or she.
15 MR. LESSLY: Or she.
16 DR. BAEPLER: I would really like to suggest
17 that if we do go ahead with that, that we
get an office
18 that either has a conference room associated
with it or
19 has one accessible in the building.
20 MR. LESSLY: That's what we had before.
21 DR. MONTOYA: I like this.
22 MR. LESSLY: I guess I'll need to motion to
23 refer that to staff if that's what you now
want to do.
24 MS. KIRCH: I so move.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 60
1 DR. MONTOYA: I'll second.
2 DR. HUG-ENGLISH: All right.
There is a
3 motion and a second to refer to staff the
consideration
4 for additional office location. All in favor?
5 THE BOARD MEMBERS: Aye.
6 DR. LUBRITZ: Can I ask a question?
7 DR. HUG-ENGLISH: Joel.
8 MR. LUBRITZ: Are there any spaces available
9 at the state building?
10 MR. LESSLY: I don't know.
11 DR. BAEPLER: I've heard they are pretty
12 cramped, but I don't know. It would be nice. They have
13 a lot of parking space there.
14 MR. LESSLY: That is obviously something we
15 would look into.
16 DR. HUG-ENGLISH: Any further comments? All
17 in favor?
18 THE BOARD MEMBERS: Aye.
19 DR. HUG-ENGLISH: Opposed?
The chair votes
20 for the motion and the motion carries.
21 MR. LESSLY: As far as the status of biennial
22 registration, as of 5:00 o'clock yesterday
we have
23 licensed 2,507 active licenses and 647
inactive. We are
24 over half way, with a month to go. Probably the smartest
PEGGY HOOGS & ASSOCIATES
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1 thing we did was start the registration
early this year.
2 It has taken a tremendous load off of the
staff.
3 We will have a panic, obviously,
again in the
4 month of June, as we always expect to, but I
don't think
5 the panic will be nearly what it has been in
the past.
6 So we're more than half way there. We would anticipate
7 about 5,000 active licensees, including
those practicing
8 in Nevada and those holding active licenses
and not
9 practicing in Nevada. The inactive, I'm not sure. I
10 would think that we would get 800 to 1,000
inactive
11 licensees.
So that's where we are at this point.
12 DR. TITUS: I just want to thank all the
13 personnel for the new cards. They are a lot more
14 efficient.
They're real professional.
15 DR. MONTOYA: I feel like a real doctor now
16 instead of just one on TV.
17 MR. LESSLY: The last thing under executive
18 staff reports is approval of the 2002 annual
report. As
19 you know, that is Maureen Lyon's responsibility. The
20 annual report has been completed, it's in
the book for
21 approval, and if you have any questions
about that one,
22 ask her about it.
23 DR. HUG-ENGLISH: I'm sorry.
I was
24 distracted.
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 62
1 MR. LESSLY: We need to approve the annual
2 report, and I just indicated that this is Ms.
Lyons'
3 responsibility. If you have questions about the annual
4 report content, she can certainly answer
them. Let me
5 just simply say we don't do a, and never
have done, a
6 glossy, extensive report. We do a straightforward
7 statistical report, and that's what we have
done this
8 time.
9 DR. BAEPLER: I think it's a good report that
10 really contains the essence of what we did,
and I move
11 that we accept it.
12 DR. TITUS: Second.
13 DR. HUG-ENGLISH: There's a motion and a
14 second to approve the annual 2002
report. All in favor?
15 THE BOARD MEMBERS: Aye.
16 DR. HUG-ENGLISH: Opposed?
The chair votes in
17 favor and the motion carries.
18 MR. LESSLY: Madam President, you are down to
19 what you can do between now and 4:30 is
Agenda Item
20 Number 17 on ratification, and the election
of officers
21 and appointment of committee members.
22 MR. LEGARZA: Also, we can do the second half
23 of Number 10, can't we?
24 MR. LESSLY: I don't think so. It says 4:30;
PEGGY HOOGS & ASSOCIATES
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1 soon thereafter, it may be heard.
2 DR. HUG-ENGLISH: But it's still under an
3 option.
Still listed as an option.
4 MR. LESSLY: There might be someone who has
5 interpreted that as something they want to
come speak on.
6 On that issue, I'd rather wait until 4:30
and do it all
7 that way.
8 DR. HUG-ENGLISH: We've been so efficient that
9 I think we are going to move right along to
Number 17,
10 and that is ratification of the licenses
issued and
11 reinstatement of licensure. You have that in your agenda
12 book.
And I do need a motion to approve that, unless
13
people have questions or comments.
14 DR. LUBRITZ: So move.
15 DR. MONTOYA: Second it.
16 DR. HUG-ENGLISH: There's a motion and a
17 second to approve the ratification of
licenses. All in
18 favor?
19 THE BOARD MEMBERS: Aye.
20 DR. HUG-ENGLISH: Opposed?
The chair votes in
21 favor and the motion carries.
22 MS. LYONS: I believe Dr. Lubritz wanted to
23 revisit Agenda Item Number 2.
24 DR. LUBRITZ: Yes.
Before closing our March
PEGGY HOOGS & ASSOCIATES
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1 meeting, I had asked Dr. Smith, Lee Smith,
who was
2 visiting from the federation, to just give
us his
3 thoughts on how the Nevada State Board of
Medical
4 Examiners was doing nationally in various
areas of
5 licensing and whatever the Board as in its
function does,
6 and I did not see that in the minutes, and
with your
7 permission, perhaps we could get that added.
8 DR. HUG-ENGLISH: I don't see a problem with
9 that.
That would just take reopening Number 2 and
10 getting out an amendment to the minutes from
the March
11 meeting.
12 MS. LYONS: Dr. Smith's response?
13 DR. LUBRITZ: Correct.
14 MS. LYONS: Which was?
15 DR. LUBRITZ: Well, he rated, and I don't
16 remember per se, but he rated us in
licensing, in
17 sanctions, in all the functions that the
Board does. And
18 I do remember that overall he felt that we
were probably
19 within, conservatively, the top 25 percent
of the boards
20 in the United States as to how we functioned
as a board.
21 He did mention some specific
areas, and I
22 honestly don't remember those, but perhaps
they could be
23 gleened from anyone's notes.
24 MR. LESSLY: We have notes. Perhaps we'll
PEGGY HOOGS & ASSOCIATES
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1 just bring those minutes back to you for the
next agenda
2 approval as amended.
3 DR. LUBRITZ: Thank you.
4 DR. HUG-ENGLISH: All in favor of amending
5 those?
6 THE BOARD MEMBERS: Aye.
7 DR. HUG-ENGLISH: Opposed?
8 The chair votes in favor and the
motion
9 carries.
10 I think the last thing that we
can do today,
11 and I've actually been requested to do
today, is to have
12 the election of officers for next year,
because we have a
13 few Board members that won't be on the
adjudications for
14 tomorrow, so they could leave early if we
take care of
15 that today.
16 So at this time I would open it
for
17 nominations for the new officers, and I
guess we would
18 start with president. Are there nominations for
19 president?
20 DR. STEWART: Yes, ma'am.
I would renominate
21 Cheryl Hug-English for another term as
president of the
22 Board.
23 DR. LUBRITZ: Second.
24 DR. HUG-ENGLISH: Are there other nominations?
PEGGY HOOGS & ASSOCIATES
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1 All in favor?
2 THE BOARD MEMBERS: Aye.
3 DR. HUG-ENGLISH: Opposed?
4 I must say to the Board thank you
for the vote
5 of confidence, and I certainly have enjoyed
serving this
6 Board.
As I've stated publicly at the legislature on
7 more than one occasion, I really consider
this an honor
8 and a privilege to serve and to serve with
each of you,
9 because I think that it's rare to find a
group that is
10 this committed to this kind of process and
dedicated to
11 the time commitment that this Board
involves. So thank
12 you.
13 At this time I'll open up for
nominations for
14 vice president.
15 DR. BAEPLER: I'd like to nominate Jackie
16 Jones for vice president.
17 DR. LUBRITZ: Second.
18 DR. HUG-ENGLISH: There is a motion and a
19 second.
Any other nominations? If not, all
in favor?
20 THE BOARD MEMBERS: Aye.
21 DR. HUG-ENGLISH: Opposed?
The chair votes in
22 favor of the nomination, and
congratulations, Jackie.
23 Or condolences.
24 And now I'll open it for
nominations for
PEGGY HOOGS & ASSOCIATES
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1 secretary/treasurer.
2 DR. MONTOYA: I'd like to nominate Don Baepler
3 for secretary/treasurer.
4 DR. JONES: Second.
5 DR. HUG-ENGLISH: Motion and second to
6 nominate Dr. Baepler for
secretary/treasurer. Any other
7
nominations? If not, all in
favor?
8 THE BOARD MEMBERS: Aye.
9 DR. HUG-ENGLISH: Opposed?
The chair votes in
10 favor and the motion carries. Congratulations, Don.
11 DR. BAEPLER: Thank you.
12 DR. HUG-ENGLISH: At this time I guess we also
13 need to, in light of what we did earlier
today, consider
14 the appointment of our new IC committee. And I would
15 like to recommend at this point that Dr.
Lubritz serve as
16 chair of that second committee, if you are
so willing.
17 DR. LUBRITZ: I would be so willing if you
18 will allow me to try.
19 DR. HUG-ENGLISH: I think that's fair.
20 I'd like to recommend that on Dr.
Baepler's IC
21 committee that Dr. Titus and Dr. Montoya
serve with Don.
22 Are
you both willing to do that?
23 DR. TITUS: Sure.
24 DR. HUG-ENGLISH: Steve?
PEGGY HOOGS & ASSOCIATES
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1 DR. MONTOYA: Sure.
2 DR. HUG-ENGLISH: Okay.
And Dr. Anjum and
3 Marlene serve with Joel on the second IC
committee. Are
4 you both willing to do that?
5 DR. ANJUM: Yes.
6 MS. KIRCH: Yes.
7 DR. HUG-ENGLISH: Great.
I'd also like to
8 appoint Jackie Jones as chair, as is in the
job
9 description for vice president of the Internal
Affairs
10 Committee, and to suggest that we really at
this point
11 don't need to have committee members unless
there are
12 some issues that come up that require us to
appoint
13 further committee members. I think that that has worked
14 in the past.
15 I guess -- can I get a motion and
a second to
16 approve those committee appointments, or can
I just
17 appoint them?
18 MR. LESSLY: You can just appoint them.
19 DR. HUG-ENGLISH: Okay.
Then you are all
20 appointed.
21 MS. KIRCH: Cheryl, I'm just looking at the
22 annual report. I thought Dr. Anjum, Dr. Montoya, and I
23 all came on the Board at about the same
time, and you've
24 got Dr. Anjum in 2002 and Dr. Montoya in
September of
PEGGY HOOGS & ASSOCIATES
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1 2002.
We were all on it in 2001.
2 MR. LESSLY: Were you?
3 MS. KIRCH: Uh-huh.
I think we all came on at
4 the same time.
5 DR. MONTOYA: Yeah, we did.
You are
6 absolutely correct.
7 MR. LESSLY: So basically it's the difference
8 of a year.
9 MS. KIRCH: We were all at the same Board
10 training association.
11 DR. MONTOYA: In 2001.
12 DR. HUG-ENGLISH: We'll get that corrected.
13 Thank you for noticing that.
14 MS. JONES: Cheryl, if I might, on my behalf
15 and perhaps on behalf of some of the other
Board members,
16 I would like to thank you for all that you
went through
17 this last year. I sat next to you at one of the
18 legislative sessions, and you were most
professional in a
19 situation that was very difficult at best,
and I just
20 really appreciate all the time that you put
in and
21 appreciate you being in attendance at all
the meetings
22 also.
23 DR. STEWART: We all appreciate that.
24 DR. HUG-ENGLISH: Thank you very much. I
PEGGY HOOGS & ASSOCIATES
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1 really do appreciate it. It has been a interesting
2 process, to say the least. But I think that what has
3 become really clear through this process and
through this
4
legislative session since we have gone and talked and
5 actually explained the process of this
Board, I think
6 that there is a far greater understanding
from the
7 legislative body of what we're about, what
we do, and the
8 commitment that goes into being a part of
this Board.
9 And I think from that standpoint alone I
think it has
10 served a very positive purpose for this
Board, although
11 there have been some interesting
moments.
12 But I do think that it has been
an educational
13 process for those from the other end of the
legislature
14 to learn a little bit more about us as well. But thank
15 you very much for those comments. I appreciate that as
16 well.
17 Before we recess for the day, I
think Dick has
18 something.
Dick.
19 MR. LEGARZA: Recess until 4:30.
20 DR. HUG-ENGLISH: I'm sorry.
21 MR. LEGARZA: On your 4:30 hearing, I'm going
22 to leave and go back to the office, and I'm
going to give
23 this
proposed consideration of the additional regulations
24 to Larry, so that if anyone shows up there
at the office
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1 to be heard on these regulations, because
that's where
2 they were noticed. We have had some telephone calls
3 telling people to come here; Angie is over
at the office
4 telling people to come here if they want to
be heard.
5 But I want to state for the
record I have sent
6 each one of you a complete set of both
workshops, the
7 workshop conducted in Reno and the workshop
conducted in
8 Las Vegas, and I have sent you also two
binders of the
9 comments we have received from individuals,
from
10 physicians and from organizations, if you
will, the
11 national pathology board and people like
that, broken
12
them down like that.
13 And in addition to that, I would
like to hand
14 out to you now additional physician comments
that I have
15 received and additional citizen comments
that the citizen
16 comments fit into that same category under
that one
17 doctor that solicited knowledge of his
patients, and you
18 now have in your possession everything that
has come in
19 on these regulations, from all written input
as well as
20 everything that was taken at the workshops
through this
21 morning.
Angie and I compiled these packets this
22 morning, so I would like to give each of you
each one of
23 these so you have an entire package, and
I'll be calling
24 you at about 4:25 to get on this speaker
phone, and Helen
PEGGY HOOGS & ASSOCIATES
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1 will take care of answering that so that if
there's any
2 communication between the two locations,
people that are
3 there will be able to participate, if
there's going to be
4 any participation.
5 I'll just hand these out to you
now.
6 DR. HUG-ENGLISH: Thank you, Dick. I think
7 you thought we didn't have enough to read;
is that right?
8 MR. LEGARZA: You only got about 27 booklets
9 this time I think.
10 DR. HUG-ENGLISH: Okay.
We'll take a recess
11 then until 4:30.
12 (Recess)
13 DR. HUG-ENGLISH: We're going to reconvene.
14 We have one agenda item left, Number
10. That's
15 consideration of amendments to NAC Chapter
630. We'll go
16 to the second part of that first, and Larry
Lessly is
17 going to address that.
18 MR. LESSLY: This is actually Mr. Legarza's
19 item, but he's back over at the office. The agenda item
20 is for us to discuss potential amendments to
NAC Chapter
21
630. The two amendments we have
proposed for you are
22 elimination of NAC 630.080, Paragraph
4. Paragraph 4 is
23 the requirement that you complete one year
post-graduate
24 training before taking Step 3 of the
USMLE.
PEGGY HOOGS & ASSOCIATES
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1 For your background knowledge,
that was a
2 policy statement in the Board manual that
was rolled over
3 to a regulation. That had to do with the Board's policy
4 on whether we would allow candidates from
Nevada to take
5 the examination without one year of
post-graduate
6 training.
Really never intended to have any bearing on
7 whether you could get a license in the State
of Nevada
8 unless you did it that way.
9 So we would suggest eliminating
that
10 paragraph.
That's Sub-Paragraph A of Paragraph 4.
And
11 eliminate Paragraph B, which is the
regulation that you
12 must pass Steps 1, 2 and 3 of USMLE within
seven years,
13 and then eliminate the paragraph requiring
10 years for
14 an MD/PhD combination, and that constitutes
our
15 recommendation.
16 Now, let me speak to the
seven-year rule on
17 the examination. I know why the federation recommends
18
that. At one time we had no
requirement and went to the
19 seven-year requirement. Part of the difficulty is the
20 contract that all boards sign with the
federation with
21 respect to conducting the USMLE for the
states. There
22 are still a couple of states I believe that
give the exam
23 themselves.
Almost everyone is contracted with the
24 federation.
PEGGY HOOGS & ASSOCIATES
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1 You pick up some liability when
you do that on
2 accommodations. We had to sign what I would call an
3 adhesion contract with respect to that,
saying that we
4 make the call on whether accommodations are
granted to
5 candidates from Nevada. We then went to the seven-year
6 rule and it cut down a lot of controversy
about that.
7 From the standpoint of does it
really make any
8 difference, the examination is what is
required to get a
9 license.
Does it really make any difference in what time
10 framework you took it in? I would say our recommendation
11 is to eliminate those three. So it would be eliminating
12 NAC 630.080, Paragraph 4 and Paragraph
5.
13 And all you need to act on here,
Dick had
14 prepared a notice for hearing on this after
you conduct
15 workshops on Tuesday, June 17th in Reno, and
on
16 Wednesday, June 18th, in Las Vegas, and then
after it the
17 Board holds a telephone conference call at
4:30 p.m. on
18 July the 8th, that's a Tuesday, to take
final action
19 after the workshop.
20 So the motion I need, if you want
to do this,
21 is to send this matter out for hearing at
workshop.
22 MS. KIRCH: I so move.
23 DR. HUG-ENGLISH: There is a motion; is there
24 a second?
PEGGY HOOGS & ASSOCIATES
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1 DR. STEWART: Yes.
May I ask one quick
2 question?
3 DR. HUG-ENGLISH: Yes.
4 DR. STEWART: This is for initial licensure
5 and not for continuing licensure or
continuing
6 competency?
7 MR. LESSLY: This has nothing to do with the
8 other agenda.
9 DR. HUG-ENGLISH: Okay.
There is a motion and
10 a second to send this out to hearing, which
will be
11 conducted in June. Is there any further discussion? If
12 not, all in favor?
13 THE BOARD MEMBERS: Aye.
14 DR. HUG-ENGLISH: Opposed?
The chair votes in
15 favor of the motion and the motion
carries. We will send
16 this out for hearing in June, and we will
talk by phone
17 in July.
18 MR. LESSLY: And just for the Board's
19 information, we will accept applications,
even though
20 you haven't taken final action until the
conference call.
21 We will go ahead and process any
applications, but we
22 won't take final action on it until you pass
the
23 regulation.
24 MS. JONES: Did you say July 8th is the
PEGGY HOOGS & ASSOCIATES
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1 conference call?
2 MR. LESSLY: He had proposed Tuesday, July
3 8th, 2003, 4:30.
4 DR. LUBRITZ: Will you send us out another
5 notice?
6 MR. LESSLY: Yes, sir.
7 DR. HUG-ENGLISH: Okay.
Then we have the
8 first part of this agenda item, which is
adoption of a
9 new regulation. Dr. Baepler is going to start us off on
10 this.
11
DR. BAEPLER: Let me, first of
all, state that
12 I am going to make a motion to table this
particular
13 measure, but I would like, on behalf of the
committee and
14 hopefully the Board, to explain why we wish
to table it
15 at this time.
16 We got a tremendous amount of
input from the
17 two hearings that we held, and from many,
many letters,
18 and several things are evident when you
analyze that
19 input, and it's all been transcribed
now. We're really
20 getting into it in terms of being able to
sit down and
21 read it more leisurely-like.
22 First of all, it's clear that
there are a lot
23 of good ideas out there. It's also clear that there are
24 special groups out there that we need to
accommodate due
PEGGY HOOGS & ASSOCIATES
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1 to the special nature of their needs. And it's also
2 clear that there's quite a bit of
misunderstanding.
3 It's remarkable how many people
address the
4 issue as having to take a test every two
years. It's
5 clear that this is something that happens
every ten
6 years, not every two years. It's also clear that the
7 vast majority of physicians in the State of Nevada
8 already meet the requirements without doing
anything
9 additional whatever, and it's also clear, if
you read the
10 regs, nobody has to take a test. There are alternatives
11 to the test that I think many people would
prefer. But
12 even the alternatives to Items 1, 2 and 3,
which
13 accommodates most of the physicians in this
state, are
14 designed to inconvenience the
physician. So somewhere we
15 need to clarify this for people.
16 We started this three years ago,
and we chose
17 the word "competency," and I wish
we could find another
18 word because we are not really looking at
competency in
19 the classic sense of what competency
consists of. And
20 the unfortunate part of using competency is
it's always
21 coupled with "testing." Someone says you can't say
22 "competency" without saying
"competency testing." You
23 know, when you talk about features or
anything like that
24 it's testing, because that measures
knowledge, but not
PEGGY HOOGS & ASSOCIATES
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1 competency.
So it's kind of an oxymoron to use the two
2 together.
3 We're interested in whether the
physician is
4 current and knowledgeable about their
discipline, and we
5 are trying to see if there is any external
evaluation
6 that happens to be physicians. I'm sure the special
7 groups that we want to accommodate, and
there may be
8
others, would be, for example, the pathologists and the
9 radiologists. They have different kinds of practices.
10 Again, those are the Board certified and
recertified or
11 zone-free certified but have hospital
privileges, they're
12 home free.
13 But in hearing the pathologists
and the
14 radiologists talk, they go through some
remarkable
15 external reviews, quality assurance, checks
and balances.
16 They meet fully the intent of what this
Board has in
17 mind, and I want to meet with groups and any
of my
18 colleagues here as well, I want to meet with
Desert
19 Radiologists and Steinberg and find some
comparable
20 groups up North, and let them help craft the
language
21 that would satisfy them and us.
22 I'm also convinced in reading the
letters and
23
hearing the testimony that there are certain doctors out
24 there that find themselves in truly a unique
and unusual
PEGGY HOOGS & ASSOCIATES
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1 experience, and we would propose that we set
up in the
2 regs the right for a doctor to petition
every ten years,
3 if it's appropriate, for an exception to
this particular
4 regulation.
I don't expect that there will be very many,
5 but there could well be some.
6 You have to remember too that
states all over
7 the country are looking at this. As earlier in the
8 meeting Dr. Titus pointed out, at the
federation national
9 meeting in Chicago, it's a topic of
conversation from
10 state after state after state. They're all where we were
11 three years ago.
12 We spent the first year trying to
find the
13 right test.
And the states are still mostly in that
14 phase.
They all want to test all of the doctors. I
15 would hope they would evolve to the point
where we are
16 three years later, to make it more
accommodating than the
17 simplistic approach of simply testing.
18 I think that we may be one of the
few states,
19 perhaps the only state, where quite possibly
there won't
20 be any test at all. You know, that is conceivable. Or
21 it may be that three or four percent of the
medical
22 community will find it more convenient to
take a test
23 rather than to sit down with two or three
colleagues in a
24 peer review type of process that is another
type of
PEGGY HOOGS & ASSOCIATES
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1 option.
2 We've come a long ways. There is no need for
3 haste.
And I really think we need to continue to find
4 input, find something that is
non-threatening, yet
5 accomplishes the goal of yes, the doctors in
the State of
6 Nevada do go through some kind of a review
process during
7 each ten-year cycle. And maybe find a better word than
8 "competency."
9 So with that as background, I
would like to
10 move that this matter be tabled.
11 DR. STEWART: Second.
12 DR. HUG-ENGLISH: Okay.
There is a motion and
13 a second to table this matter. Any further discussion
14 from Board members? Joel.
15 DR. LUBRITZ: But that being understood, with
16 continuing work being done as we may
determine
17 appropriate, and then it will be presented
at some point
18 in time.
19 DR. HUG-ENGLISH: Correct.
20 DR. BAEPLER: It's going to be understood that
21 the committee will keep working. We will invite the rest
22 of the Board to participate in this type of
23 deliberations. I am going to spend a lot of time and
24 invite anybody on the Board to talk to
doctors. But I
PEGGY HOOGS & ASSOCIATES
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1 want to make appointments with these groups,
go out and
2 visit with them and get their input, because
there are a
3 lot of good ideas out there. And I would like
4 Dr. Stewart to remain on the committee. I don't want to
5 sacrifice all of the background of this
committee by a
6 member going off of it. We need that experience.
7 Robin, I invite you to really get
involved
8 since you are on that national committee now
looking at
9 that, and we can sure pick your brain on
that. But I
10 don't even want to set a target, but
sometime during this
11 next fiscal year, perhaps December, perhaps
in the
12 spring, we need to bring forth a revised set
of
13 regulations.
14 DR. HUG-ENGLISH: Okay.
Any further comments
15 by Board members? All in favor of tabling it?
16 THE BOARD MEMBERS: Aye.
17 DR. HUG-ENGLISH: Opposed?
The chair votes in
18 favor of the motion, the motion
carries.
19 Now, this agenda item has been
tabled;
20 however, I notice we have several members of
the audience
21 both here in Reno and in Vegas. And you are certainly
22 welcome to make comments about this, with
the
23 understanding that particularly the building
in Vegas I
24 believe is going to close at 5:00
o'clock. I know
PEGGY HOOGS & ASSOCIATES
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1 they're wanting us out soon after that up
here as well.
2 We have received two books of the
hearings
3 that were both held in Reno and Las Vegas
that each Board
4 member has received and read, of comments
from physicians
5 as well as letters that have -- individual
letters that
6 have been submitted to the Board. But if you feel that
7 you have an additional comment you would
like to make at
8
this time, please come forward, identify yourself, and we
9 will be happy to listen to you.
10 Maybe we'll go to Las Vegas
first. Is there
11 anyone that wants to make a comment?
12 DR. HAVENS: This is Don Havens. I just have
13 a question of Dr. Baepler. Will these subcommittee
14 meetings be agendized so that you can have a
physician
15 input from other than just the radiologists
and
16 pathologists?
17 DR. BAEPLER: Oh, I didn't mean to infer that
18 we would restrict it. We want broad-based participation.
19 DR. HAVENS: If we would somehow know when
20 those meetings are, we could let people
know, and then
21 they could meet on a perhaps semi-formal
basis, but with
22 members of the committee to have discussions
or provide
23 input?
24 DR. BAEPLER: We can consider a mechanism for
PEGGY HOOGS & ASSOCIATES
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1 more involvement. I don't want to get it to the point
2
that it's so cumbersome that we make no progress.
3 Obviously, we welcome input. It may well be that we will
4 have to hold hearings again, too, both North
and South.
5 It could come to that.
6 Let us consider that and let me
even discuss
7 that with you. Yeah.
We definitely want input, but I
8 also want the committee and the Board to be
able to
9 function efficiently, which is sometimes
hard to do if
10 you have like 30 people in the room, all
giving you
11 suggestions and so on and you're trying to
make progress
12 on the committee. But let's consider that.
13 DR. HAVENS: Okay.
Thank you.
14 DR. HUG-ENGLISH: Any other comments from Las
15 Vegas?
16 DR. HAVENS: We have another one.
17 DR. HUG-ENGLISH: Go ahead, please.
18 DR. ARNOLD: Dr. Arnold, a dermatologist in
19 Las Vegas.
Can you give me an idea what you're talking
20 about with peer review, what it would
involve, kind of a
21 ballpark?
22 DR. BAEPLER: Yes, I can give you a ballpark.
23 It's not definitive, but we felt that to
take three
24 doctors in a similar discipline and field of
expertise,
PEGGY HOOGS & ASSOCIATES
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1 sometimes it's not able to match them
exactly. We would
2 try to find like three doctors in the North
to sit down
3 with the doctors in the South and vice
versa.
4 I think the person that asks for
the peer
5 review should have the right to refuse the
participation
6 of one or more of the peer reviewers if
there is a
7 history of some difficulty between the two
or some
8 conflict of interest. Obviously, we are not going to
9 pick two competing groups to peer review
each other. To
10 look at a person's charts and to simply sit
down and have
11 a discussion with the people about the
particular
12 practice of medicine the person is engaged
in, to get a
13 concept as to whether they are current in
the discipline
14 and how they're handling the patients,
perhaps to look at
15 a few recent charts to see how the records
are kept. I
16 really see it as that type of an informal
process.
17 I'm a scientist, and if I sit
down in a
18 conversation with a person for about an hour
in my
19 generic discipline, I can pretty well tell
whether that
20 person is current and the type of work he is
doing or she
21 is doing.
I'm not thinking of the kind of more rigorous
22 peer review that many of the specialties are
beginning to
23 now put in for recertification. But nevertheless, you
24 can tell a lot in a brief meeting of people
in similar
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 85
1 fields.
2 DR. ARNOLD: You are not talking about Board
3 type questions being asked in this type of review? For
4 example, in the letter I wrote you -- I
specialize in
5 skin surgery, and each time I do a case, I
become better.
6 I'm able to remember what the chemical is in
an oleander
7 that causes contact dermatitis.
8 DR. BAEPLER: I remember your letter very
9 well, and I think that in a peer review you
could make
10 that point, and your colleagues being in the
same or
11
similar discipline would understand that. I would hope
12 they would.
13 DR. ARNOLD: Okay.
Another physician also
14 made the suggestion that people from the
South be audited
15 by people from the North and vice versa.
16 DR. BAEPLER: This would be our hope. The
17 only difficulty I can see with that is the
-- if a great
18 many people choose this, the disparity in
numbers between
19 the North and the South is going to put a
greater burden
20 on the people in the North than it would in
the South.
21 But we also want to keep the cost down. We do not
22 envision this as a costly process
whatever.
23 If you look at the total set of
regs, we would
24 hope it wouldn't cost the majority of
doctors anything at
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 86
1 all.
You know, if you're in Category 1, Board certified,
2 knee certified, you simply send us your
credentials to
3 document that and you're home free. If you have hospital
4
affiliations, you simply send us the papers showing the
5 hospital affiliations and you're home
free. There should
6 be no cost to that type of thing.
7 DR. ARNOLD: That brings up one other point,
8 and that's people in specialties like mine
are basically
9 somewhat discriminated against. The fact that we don't
10 admit patients, that we are office-based
rather than
11 hospital-based, that kind of puts more of a
burden on
12 certain groups than others.
13 DR. BAEPLER: I would say that is becoming
14 somewhat more common. It applies to a great many people.
15 And what I would like to invite you to do,
give it a
16 little thought and write another letter
giving us an idea
17 what type of thing would work for people
like you.
18 That's really what we're looking for.
19 DR. ARNOLD: Okay.
Thanks.
20 DR. HUG-ENGLISH: Thank you.
21 Any other comments from Las
Vegas? If not,
22 I'll open it up to comments from anyone in
the audience
23 in Reno.
Anybody have anything?
24 All right, if not, I'd like to
open it up for
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 87
1 public comment on any other agenda item
that's been
2 discussed here today. If there are comments from anyone
3 in Las Vegas or Reno, we are certainly open
to hearing
4 those at this time.
5 DR. HAVENS: This is Don Havens. I want to
6 thank you for having this
teleconference. This is very
7 convenient, and I hope you're able to work
that out in
8 the future for all your meetings.
9 And Clark County Medical Society
would like to
10 congratulate and thank Dr. Stewart for his
eight years of
11 service on the Board. Thank you.
12 DR. HUG-ENGLISH: Thank you.
That's very
13 nice.
14 Hearing no other comments, we
will recess
15 until tomorrow at 8:30. And tomorrow's meeting will be
16 called at the Board office, not in this
room. So we will
17 be there and not here tomorrow. 8:30 tomorrow.
18 We're in recess.
19 (Recess at 5:05 p.m.)
20
21
22
23
24
PEGGY HOOGS & ASSOCIATES
(775) 327-4460 88
1 STATE OF NEVADA )
) ss.
2 COUNTY OF WASHOE )
3
4 I, MILDRED J. TERRY, Certified
Court
5 Reporter in and for the State of Nevada, do
hereby
6 certify:
7 That the foregoing proceedings
were taken by
8 me at 9670 Gateway Drive, Suite 100, Reno,
Nevada;
9 That the proceedings were
recorded
10 stenographically by me and thereafter
transcribed via
11 computer, under my supervision;
12 That the foregoing is a full, true,
and
13 correct transcript of the proceedings to the
best of my
14 knowledge, skill and ability.
15 I further certify that I am not
a relative
16 nor
an employee of any attorney or any of the parties,
17 nor am I financially interested in these
matters.
18 I declare under penalty of
perjury under the
19 laws of the State of Nevada that the
foregoing statements
20 are true and correct.
21 Dated this 19th day of June,
2003.
22
23
____________________________________
MILDRED
TERRY HOENSHELL, CCR No. 303
24
PEGGY HOOGS & ASSOCIATES (775) 327-4460 89