Clark County Medical Society

County Line

Newsletter XXVI   March 2002

Contents

Asset Protection:  Planning for Your Residence

Member Applicants

Member News

Clarification

President’s Message

Executive Director Editorial

Nevada Health Centers

Emergency Preparedness in Clark County

CME Calendar

CCMS Upcoming Events

Clark County Health District Disease Statistics

Classifieds

 

 

Asset Protection:  Planning for Your Residence

Russ Bowler, Esq., Jeffrey Burr and Associates, Attorneys at Law

            Personal injury lawsuits have become prevalent in our society.  Being "injured" by an individual or company with "deep-pockets" seems to almost have the allure of winning a lottery.  Some state legislatures, apparently having determined that astronomical money damages verdicts are such a problem, have enacted statutes to cap the amounts that can be recovered in some of these lawsuits.  Nevada has no such laws.

            The financial and emotional toll of defending a lawsuit can be immense.  A person being sued is likely to agonize over the prospect of being found liable for a large money judgment (thereby becoming a judgment debtor).  Upon becoming a judgment debtor, potentially all of the non-exempt assets of the individual become subject to the reach of the party winning the lawsuit, the judgment creditor.  This commences the collection process portion of the legal proceedings.  Often an attorney who specializes in locating and obtaining the assets of a judgment debtor will be hired to assist a judgment creditor in satisfying his claim.

            Many techniques have been developed to lessen the risks of losing one's assets in a lawsuit.  These techniques are generally referred to as "Asset Protection Planning."  In this article I will focus on some techniques used to specifically protect one asset: the residence.

            There is an old saying that "A man's home is his castle."  The Nevada Legislature appears to have adopted this belief.  There are some statutory provisions that allow individuals to protect their residences from the reach of certain creditors.  These include the homestead exemption, the provision for allodial title, and the Nevada On Shore Trust ("NOST").  In addition to discussing these protections, in this article I will discuss a federal transfer tax provision, the QPRT, that may also provide some protection for one's residence.

The Homestead Exemption. Nevada law exempts various assets from a forced sale on execution.  In other words, certain assets are beyond the reach of judgment creditors (and a bankruptcy trustee).  The residence (also including mobile homes and condominiums) of an individual is an exempt asset, subject to certain conditions. First, only up to $125,000 of the equity in a residence is protected. Second, in order to obtain the protection a declaration must be made. This declaration is made by properly completing a form and filing it with the county recorder along with the recording fee. Third, the owner must actually live in the residence.  Finally, the exemption only protects the owner from certain types of creditors.  For example, the protection does not extend to mechanics' liens on the property, taxes, or creditors whose loans are secured by the residence.  Also, this exemption does not inhibit the IRS in its collection efforts.

            Interestingly the exemption may be obtained even after the homeowner has been sued.  However, I recommend not waiting until then to file the declaration.  Also, a husband and wife are only allowed one exemption; they cannot double their homestead exemption amount.  The homestead is not generally effected by owning the property in a revocable living trust.

            Obtaining the protection offered by the homestead exemption is a rather simple procedure.  All homeowners should take advantage of it.

A Homestead/Community Property Consideration.  There is another asset protection planning technique that combines the homestead exemption with community property laws.  If one spouse is exposed to a high degree of risk through his/her profession, the couple may consider converting all of their community assets into separate property.  With certain exceptions the separate property of one spouse will be protected from the creditors of the other spouse.  After the conversion takes place, the spouses can elect to allocate the homestead exemption to the at-risk spouse.  Thus, the whole exemption protects the spouse who is most likely to be sued.

Allodial Title.  In recent years the Nevada Legislature enacted a new property tax law.  This law allows the owner of a single-family dwelling (including its appurtenances and the land) to obtain somewhat of a "Super-Homestead Exemption" by establishing allodial title to their residence.  The concept of allodial title is derived from the ancient legal concept of allodium wherein the ownership of land was outright and could not be taken by others.  This was truly a concept of outright ownership.  Although we speak of owning our real property outright, our current laws subject land to creditors' claims including property tax claims.  One will eventually lose their land if they do not pay the property taxes due thereon.

            The Nevada allodial title law essentially allows individuals who own and occupy a single-family residence to prepay the taxes on that property for the remainder of their lives. Once the taxes are prepaid, the state treasurer issues a certificate of allodial title to the owner.  Subject to certain exceptions, the owner will not have to pay any more property taxes on that property as long as the allodial title is not relinquished.

            In addition to these tax aspects, property for which a certificate of allodial title is issued cannot generally be taken by judgment creditors.  Thus, it is like a homestead without a limitation on the dollar amount that is protected.  Unlike the regular homestead exemption, the allodial title exemption generally protects the property against mechanic's lien creditors and state and local taxing authorities.  However, obtaining allodial title does not protect the property from the reach of the IRS or from certain criminal forfeiture provisions.

            Unfortunately, the following examples provided by the state treasurer's office, illustrate the high cost of this protection.  Both examples are based on the state's actuarial tables and assume a residence with a taxable value of $300,000 and therefore an assessed value of $105,000 (assessed value is thirty-five percent of the taxable value) at the time of a lump sum payment.  These examples also assume that the applicants agree to a recalculation upon making substantial improvements to the residence.  The lump sum cost of allodial title for a seventy-five year old man is $145,000.  The lump sum payment for a fifty year old man is $1,300,000. These high costs effectively make allodial title planning unavailable.

            [Ex.Dir. Note: when the property owner dies the balance in the trust account may be paid to the heirs at a 3% APR interest, or the new title holder may elect to continue to hold the property in allodial title by applying to the Nevada State Treasurer and prepaying the property taxes from the age of the new title holder to the age of the former title holder when that title holder obtained allodial title.  More information regarding allodial title may be obtained by calling Janet at the Nevada State Treasurer's office (775-684-5600) or by visiting the Nevada Treasurer's website at www.nevadatreasurer.gov.  The cost renders allodial title impractical for all but the most elderly of physicians.]

            There are other potential problems with allodial title.  Unlike the homestead exemption, it is unclear whether allodial title would protect a homeowner from a creditor if obtained after a lawsuit was filed.  Further, it is not clear how the allodial title exemption would apply under the new bankruptcy provisions.  I understand that as of the beginning of February 2002 the state treasurer's office has received about a dozen applications for allodial title since the program started in October 2001.

The NOST.  The NOST is a powerful asset protection technique.  In 1999 the Nevada legislature passed a law allowing individuals to protect their property from creditors by putting that property in trust for their own benefit.  Property is a general term, as all types of assets can be owned by a NOST.  Nevada is one of only four states that allows the use of these types of trusts.  With one exception, assets transferred into a NOST are subject to creditor claims for up to two years after the transfer.  Thus, the homestead exemption should be used in addition to the NOST.

            Under the statutes, a NOST cannot be required to make distributions to a grantor/beneficiary of the trust.  This may present an issue with a NOST owning a residence in which the grantor/beneficiary resides.  Living in the residence could be construed to be a required distribution from the trust.  If a judge found this to be the case, then it is possible that asset protection features of a NOST could be invalidated.  It is possible that in such a case all of the assets in the NOST could then be reached by creditors.  Thus, an individual should consider creating two NOSTs, one for the residence and another for their investment assets.

Qualified Personal Residence Trust (QPRT).  The QPRT is a creature of federal transfer tax law.  It is designed to lower gift and estate taxes.  It allows a person to reduce the value of their estate by retaining an interest in their home for a desired period of years while giving away the remainder interest to someone else (usually family members).  The gift of the remainder interest is subject to gift tax.  Once the designated period of years has expired the transferor no longer has an ownership interest in the residence; however, he/she may lease it from the owner (the trust) for fair market value rent.

            The value of this technique is that it allows a person to transfer an asset out of their estate at a reduced value for gift tax purposes.  Because the transferor retains an interest in the home, only the value of the remainder interest is taxable.  Appreciation in value of the residence occurring after the transfer is not taxable to the transferor if he/she outlives the designated term.  Thus, the risk of this technique is that the transferor may not live to the end of the term of years.  In such a case the full value of the home at the date of the transferor's death is included in the estate.

            An example will help illustrate this technique.  Parent (fifty years old) owns a residence with a fair market value of $1,000,000.  She/he wants to retain the home for ten years and then have the ownership transfer in trust to her/his children.  The value of the retained ten year interest will vary depending on the terms of the trust agreement and the applicable federal rate of interest.  We will assume a rate of 5.6%.  The amount transferred or remainder interest in this scenario is $591,950.  This is the amount of the gift for gift taxes purposes.  Assume that eight years after the transfer the residence is worth $1,400,000 and that after ten years it is worth $1,500,000.  If the parent dies at year eight years the full value of the residence will be included in her/his estate.  If the parent lives for more than ten years, none of the residence will be taxed her/his estate.

            The QPRT also has some asset protection features.  Assume that the parents in the above example are sued and a judgment is obtained against them.  Their term interest in their home (over the amount of the homestead exemption) will be subject to the judgment creditor's reach.  However, such an asset is not so desirable to a creditor.  The creditor would only have the home for the remainder of the term of years and such an asset would be difficult to sell.

Conclusion.  I have outlined a few ways to protect a residence from the reach of certain creditors.  This article is intended as an overview of these techniques, as I have not been able to outline all of the requirements and issues involved.  The discussion of the QPRT technique only begins to touch the surface.  The homestead exemption is the least complex of these techniques and should generally be utilized by all homeowners.  The NOST is a powerful way to protect the residence and other assets.  The NOST should not replace, but be used in addition to the homestead exemption.  The other techniques should be considered in the appropriate circumstances.

            These and other asset protection planning techniques should also be considered in the context of your overall estate and asset protection plan, which may include making annual gifts to children, the use of limited partnership and limited liability companies, the use of a Nevada On Shore Trust (NOST) and other techniques.  It is important to sit down with your advisor(s) and discuss how your objectives can best be met.  From your objectives an estate/asset protection plan can be formulated and implemented to protect your assets from the reach of creditors.

Jeffrey Burr and Associates, Attorneys at Law specializing in Estate Planning and Asset Protection

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Member Applicants

If you have any pertinent information about the following membership candidates, please contact:

Clark County Medical Society

2590 E. Russell Rd.

Las Vegas, NV 89120

Applicants To Go Before Credentialing Committee

Syed Akbarullah, MD, Internal Medicine

Marsha Matsunaga-Kirgan, MD, Ob-Gyn

Lisa A. Roberts, MD, Ob-Gyn

Jerome F. Ziarko, DO, Family Practice

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Member News

            The Father Joe's M.A.S.H. Village Medical Clinic is a free clinic that the at-risk homeless, homeless, low income and uninsured community can access free of charge.  The clinic opened its door on May 15, 2000.  The clinic has a laboratory and on site dispensary.  Services offered at the clinic include, pediatrics, podiatry, primary care and case management.  M.A.S.H. clinic is open weekdays and is staffed by a medical director, George Kaiser, MD, clinic manager, medical social worker, nurses, medical receptionists and a physician assistant.

            The clinic is now requesting your help.  We currently have physicians, nurse practioners, and physician assistant and nurses volunteering at the clinic, we encourage you to bring your talents and specialties to help others.  Last year the clinic provided 5,116 patient visits. The clinic also provides preceptorship and externship hours to students in medical specialties from, UNR, Western University, UNLV.

            If you are interested in volunteering at M.A.S.H. medical clinic or have other questions, please contact, George Kaiser, MD or Debra Gulley-Collins, clinic manager at 702 388-0088 extensions 253 or 288.

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Clarification

In the February 2002 County Line, Nevada Preferred Professionals was referred to as a stand-alone network. When NPP was purchased recently by Universal Health Network, it became a preferred provider organization.

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President’s Message

Raj Chanderraj, M.D., 2001-2002 CCMS President

            The medical community in Las Vegas never experienced the kind of turmoil which we are all going through presently. We are all experiencing a crisis - which is national in its scope but more critical locally in its effects.

            There are three reasons that come to my mind to explain the present crises:

            1) Insurance Companies: Being the only industry that is exempt from antitrust laws, they carry on their business with more power than the Maharaja of Timbuktu. Their income, derived from stock investment in a bull market, allowed them to offer predatory pricings and, when the market took a dive, the only alternative to increase their incomes was to raise the premiums. They openly flaunt their responsibility to create profit for Wall Street rather than to provide service to their consumers.

            2) Victim Culture: Trial lawyers, contrary to what is being said, are pursuing a large number of frivolous claims and are presenting a sad face of the victims who are so taken by this. Victims agonize that they are absolving themselves of their neglect of their health care and penalizing the health care provider for less than satisfactory outcomes.

            3) Physician Arrogance: Our demeanor in the courtrooms is primarily responsible for the huge jury awards for pain and suffering that are totally disproportionate to the actual damages for care. Additionally, our nonparticipation in the political process has allowed legislators to take monies from our pockets and give it to other causes.

            There is a large group of physicians who believe that AMA and the medical societies do not do anything. The actual fact is that the physicians who say this are not aware of what is going on in those societies. When they receive a bill for membership dues, they simply don’t want to pay and, to justify their nonpayment, they say, “they don’t do anything.” This is analogous to the situation when our patients complain about their bill and say, “He didn’t do anything.” We all know this is not true but we carry on with similar behavior when we receive the AMA or medical societies bills.

            A lot of caring physicians spend anywhere from 10 to 20 uncompensated hours attending meetings, gathering information, testifying at key legislature hearings and try to influence the outcome of the bills. This is being done in spite of total indifference by the majority of physicians. The effort we put in is enormous and, please, we don’t need any compliments but DO NOT SAY NOTHING IS BEING DONE.

            I would encourage all of you to become more involved in organized medicine because this is the only avenue for your survival.

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Executive Director Editorial

Weldon (Don) Havins, M.D., J.D., CCMS Executive Director/CEO and Special Counsel

Insurance Availability Update

            At the time of writing this article, the Division of Insurance has scheduled a meeting for March 4th of all insurers in Nevada who have been approved to write physician professional liability insurance.  The insurers at this meeting are to present information as to:  their market intentions; market conduct; practices in rating and adherence to filed rates and rating plans; underwriting practices, including treatment of loss experience and treatment of "incidents" versus "claims"; premium payment plans, including tail coverage; and equity in tail coverage in this state.  The hearing will commence at 10:00 AM in Carson City and will be video-conferenced to the Grant Sawyer State Office Building, 555 East Washington Street, Room 4401 in Las Vegas.  The public, including physicians, are invited to attend.

            The companies approved to write primary insurance PLI health care provider policies are:  American Physicians Assurance Corporation, Chicago Insurance Company (Interstate), Continental Casualty Company (CNA) First Professionals Insurance Company (FPIC), Medical Insurance Exchange of California (MIEC), National Union Fire Insurance Company of Pittsburgh, PA (AIG), Physicians Insurance Company of Wisconsin (PIC Wisconsin), St. Paul Medical Liability Insurance Company, The Doctor's Company, G.E.'s Medical Protective Company, TIG Insurance Company, Health Care Indemnity, Inc., Utah Medical Insurance Association, Northwest Physicians Mutual Insurance Company, and NCMIC Insurance Company.

            Of these, St. Paul's departure is known to all.  [We are informed that Chicago Insurance Company (Interstate) is writing no new policies and is leaving Nevada.]  St. Paul insures 1328 physicians in Nevada as of December 2001 (precise number courtesy of Commissioner of Insurance and Larry Matheis).  The majority of insured physicians practice in southern Nevada.  While Northwest Physicians Mutual Insurance Company has been approved to sell physician PLI policies in Nevada, we were unable to affirm that any policies have been sold.  Health Care Indemnity, Inc. and NCMIC Insurance Company are reportedly not selling new insurance in southern Nevada.  First Professionals Insurance Company (FPIC) has been approved to sell PLI insurance to Nevada physicians but to date has not decided to venture into the southern Nevada market. 

            CNA (Continental Casualty Company) received approval February, 2002 for a 52% increase in premiums.  MIEC (Medical Insurance Exchange of California) received approval for a 19.5% premium increase in October, 2001.  MIEC sales of new policies are reportedly disproportionately greater in northern Nevada although, contrary to rumor, MIEC is selling new policies in southern Nevada.  TIG Insurance Company reportedly is being extremely selective about adding new business in southern Nevada.  The Utah Medical Insurance Company apparently writes policies only for physicians in small communities bordering Utah.

            There appear to be five insurers actively available to write PLI insurance for southern Nevada physicians needing a new insurer.  These five companies are:  American Physicians Assurance Corporation (formerly MICOA), AIG (National Union Fire Insurance Company), PIC Wisconsin, The Doctor's Company, and G.E.'s Medical Protective Company. 

            American Physicians Assurance (APA) Corporation (William B. Cheeseman, CEO, 1301 N. Hagadorn Road, East Lansing, MI  48823) has been criticized by several obstetricians who state they were "dumped" because they had one indemnity paid or "dumped" because they had more than one incidence reported to the company in the last five years.  APA has offered to sell policies with $500,000/$1,500,000 limits for a 25% reduction in the insured's limits of $1 million/$3 million.  Dennis Coffin, APA's agent in southern Nevada, recently wrote in a letter to Dr. David Weaver that "each 50% reduction in limits translates to a 25% reduction in premium, approximately."  Dennis Coffin can be reached at the SCW Agency Group-Nevada, Inc. at 702-320-3001.

            AIG (National Union Insurance Company, Maurice Greenberg, President and CEO, 70 Pine Street, New York, New York 10270) is reportedly writing a "few" new policies in southern Nevada.  Physicians have reported that AIG will reduce premiums for substantial increases in deductible.

            PIC Wisconsin (William Montei, President and CEO, P.O. Box 45650, Madison, WI 53744-5650)

received a 7.5% rate increase in May, 2001 (affecting Clark County physicians only).  In December, 2001 PIC received approval for another 20% increase (also only affecting southern Nevada physicians).

            The Doctors' Company (Manuel Puebla, President, 185 Greenwood Road, Napa, CA, 94558-0090) received a 14% increase in premiums in January, 2001.  The Doctors Company recently filed for another 28% overall rate increase, apportioned 51% for Clark County and 12% for those outside of Clark County.  The Doctors' Company joins all the others in utilizing stringent underwriting standards for new business.

            General Electric's Medical Protective Company (Timothy Kenesey, President and CEO, 5814 Reed Road, Fort Wayne, IN  46835-3568) is the most recent entry into the southern Nevada active physician PLI market.  MedPro is unique in offering "Occurrence" insurance and well as "Claims-made" coverage.  Occurrence PLI insurance provides coverage for the period of the insurance and for all subsequent claims filed for the period when covered by that insurance.  Occurrence insurance requires no "tail coverage" purchase.  MedPro offers "new" physician Occurrence coverage for approximately the same price their fifth year (mature) coverage under a claims-made policy.  Claims-made coverage requires payment of a "tail" (hence, the term tail coverage) if the physician is not renewed, retires, or if the company (like St. Paul) decides to cease selling PLI insurance.  Tail coverage costs run from 1.7 to 2.8 of the last annual premium and cover events accrued (i.e., which occurred) during the period of coverage, regardless of date of the subsequently filed claim.  Physicians not purchasing tail coverage are not insured for a claim filed after the termination of coverage unless they obtain "prior acts" or "nose" coverage from a subsequent carrier.  Claims-made policy premiums progressively increase until the fifth year when the "mature" premium policy price levels.  (This, of course, assumes no increase in premiums approved by the Insurance Commissioner in the interim.)

            A new insurer entering the Nevada PLI market could be in Nevada for one year selling claims-made insurance and the next year decide to discontinue selling PLI insurance.  Claims-made policy holders would need to purchase tail coverage to be insured for a subsequent claim involving the year of coverage.  Occurrence policy holders, in this situation, would be covered for subsequent claims filed in the year of coverage without the necessity of purchasing tail coverage.

            While a physician seeking new coverage may wish to obtain quotes from more than one broker, physicians should be aware that applications submitted through competing brokers that contain conflicting information on the same physician has resulted in no insurer willing to quote in the primary insurance market.  While it may well be prudent to utilize more than one broker to obtain a wider group of insurer quotes, one should be certain that applications do not contain conflicting information.

            Hopefully, all this information will be corrected and updated on March 4th at the Commissioner of Insurance and PLI insurers meeting.

Mutual Binding Arbitration Agreement

            A recent jury verdict has increased concern about the reasonableness of jury verdicts in medical malpractice cases.  The patient, in June of 1994, at the age of 71, underwent a colorectal surgery procedure known as the Bacon Modification of the Cucait Pull Through, for treatment of his colon cancer.  Post-operatively the patient was incontinent which required the patient to wear adult diapers.  The patient refused to have a colostomy which would have ameliorated the need for diaper wear.  A four-day trial ended with the jury finding for the plaintiff and against the surgeon:  $20,000.00 for future medical costs, $1,000,000.00 for past pain and suffering, and $500,000.00 for future pain and suffering.  (In California, under the MICRA law, this verdict would automatically have been reduced to $270,000 under the provision limiting pain and suffering non-economic damages to $250,000).

            Some physicians have suggested the use of mutual binding arbitration as a means to avoid inappropriate jury verdicts.  Kelly Testolin, Esq. (partner in Hale, Lane, Peek, Denison, Howard, and Anderson) and I produced the adjacent arbitration agreement (on page 9), based on the California MICRA arbitration agreement provision, and mindful of Nevada's adoption of the Uniform Arbitration Agreement Act of 2000, found in Nevada Revised Statutes (NRS) 38.

            Contracts signed under duress and agreements coerced from the other party are not enforceable.  Patients must be given a copy of the agreement and have a 30-day period to rescind the contract in writing.  The 30-day period is utilized to minimize the chance of a claim of duress or coercion.  The agreement binds both physician and patient to submit disputes regarding the provision of medical services to arbitration rather than proceeding to litigation through the courts.

            An arbitration agreement does not circumvent the Medical Dental Screening Panel process.  An arbitration agreement simply substitutes the arbitration process for the litigation process in resolving disputes in court.  However, arbitration does avoid the jury as a decision-maker (finder of fact).  The arbitration panel (using American Arbitration Association rules) or arbitrator (if one uses the single arbitrator of the Uniform Act) decides negligence (or not) and the award.  While arbitrators can award the full panoply of remedies available to juries, many feel arbitrators provide a more reasonable resolution of disputes.  Any physician contemplating the use of arbitration agreements should first discuss their full implications with the physician's attorney.

            This Mutual Binding Arbitration Agreement example and the text of NRS 38 can be found at www.clarkcountymedical.com on the temporary CCMS web site in the Miscellaneous section.

EXAMPLE:

MUTUAL BINDING ARBITRATION AGREEMENT

 

Patient’s Name: ___________________________________

 

This mutual binding arbitration agreement constitutes an integral part of a contract for medical services by

 

and between __________________ and ________________ who agree to be bound as described hereunder:

                      (name of physician)           (name of patient)

 

1. It is under stood that any dispute as to medical malpractice, that is, as to whether any medical services rendered under this Contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided in Nevada law, and not by lawsuit or resort to court process except as Nevada law provides for judicial review of arbitration proceedings.  Both parties to this Contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

 

2. Such arbitration shall be in accordance with the current arbitration rules of the American Arbitration Association.  This Mutual Binding Arbitration Agreement shall apply to any legal claim or civil action in connection with any and all medical services rendered, whether inpatient or outpatient, against

Dr. _______________ or any of Dr. ______________’s employees or contracted staff.

 

3.  The execution of this Mutual Binding Arbitration Agreement shall not be a precondition of the furnishing of medical services by Dr. _____________________.  This Mutual Binding Arbitration Agreement may be rescinded by written notice from the Patient or Patient’s legal representative within 30 days of signature.

 

4.  The Mutual Binding Arbitration Agreement shall bind the parties hereto, including newborns, and the heirs, representatives, executors, administrators, successors, and assigns of such parties and newborns.

 

 

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.  SEE ARTICLE 1 OF THIS CONTRACT.

 

 

Date: ___________________________   Time: ____________________ A.M./P.M.

 

Signature: _______________________________________________________

                         (patient/parent/legal guardian/legal representative)

 

If signed by other than patient, indicate relationship: ________________________________

 

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Nevada Health Centers

Steven Hansen, Chief Executive Officer, Nevada Health Centers

            Nevada Health Centers, Inc. (NVHC) has a mission to provide access to quality health care services throughout Nevada.  Our vision is that through advocacy, education and community outreach, all residents and visitors in Nevada have full access to affordable health care. The company's philosophy is founded on the principle that all people, regardless of where they live or their ability to pay, have the right to quality health care services.

            Nevada Health Centers Inc. is a Federally Qualified Community Health Center (FQHC) program.  This FQHC program is a Federal grant funded under Section 330 of the Public Health Service Act to provide for primary and preventive health care services in medically underserved areas throughout the US and its territories. There are currently an estimated 850 funded Community Health Programs across the United States.  There are two in the state of Nevada.  NVHC is a private, not for profit 501(c)(3) Corporation.  For the first eighteen years of its existence, NVHC was a public entity, a consortium of counties known as Central Nevada Rural Health Consortium.  Originally incorporated in 1977, it was one of the first federally funded Community Health Centers (CHC), as authorized under the Public Health Service Act of 1976.  In 1994, the organization's name was changed to Nevada Rural Health Centers, Inc., and it became a not for profit corporation. In June 2001, the name of the organization changed to Nevada Health Centers, Inc. to better represent the mission of the company.

            NVHC is currently operating thirteen (13) clinics, staffed by physicians, physician assistants and nurse practitioners.  Our clinics provide primary health care in the following locations: Amargosa Valley, Austin, Beatty, Carlin, Crescent Valley, Eureka, Jackpot, Gerlach, Carson City, Las Vegas (North Las Vegas Family Health, Martin Luther Family Health and Las Vegas Outreach Clinic) and Wendover.  We also operate a centralized pharmacy that provides nine of our frontier clinics with dispensaries. NVHC provides health-screening services via our Mobile Mammography Van "Health in Motion", which consist of mammograms, breast exams, pap smears, and bone density tests.

            NVHC has three chief management officers, which include: the Chief Executive Officer, Steven C. Hansen; the Chief Financial Officer, Linda Costa; and, the Chief Medical Officer Dr. Carl Heard.  We operate out of two administrative offices, one located in Carson City and the other in Las Vegas.  All finance, purchasing, accounts payable, accounts receivable, and human resources are based out of the administrative offices.  Program managers for our Health Care for the Homeless, Mammovan, and Pharmacy projects are housed in these two main offices.  Each medical clinic has a clinic manager assigned to the facility to bridge the gap between administration and clinic operations.

            NVHC is governed and directed by a policymaking Board of Directors. The members consist of representatives from each community served, and include a cross section of professionals, industrial, and residential interests and activities in the region. They represent a mix of sex, age and ethnicity. Four of the fourteen available positions are designated for residents of Clark County. Due to federal mandates under the Public Health Services, the Board must also have a majority of members who are actual users of our clinics. In addition, because of the diverse population and health care needs of Las Vegas, it was necessary to form an Advisory Board to focus on the needs of Las Vegas. 

            NVHC depends on a balanced distribution of funding sources.  Currently NVHC revenue comes from four main sources: 50% patient charges, 25% federal grants, 22% local/county contributions, 3% private contributions and donations.

            NVHC Las Vegas History: in December 1999, the Bureau of Primary Health Care regarding providing primary care services in Las Vegas contacted NVHC.  The Bureau requested that NVHC become the emergency grantee in the Las Vegas area due to the financial instability of the Community Health Center that was currently operating.  In April 2000, Nevada Health Centers, Inc. opened North Las Vegas Family Health Center located at 2225 Civic Center Dr.  In July 2000, we opened our Las Vegas Outreach Clinic in the Old Catholic Charity building but as move to 403 W Wilson during the construction of the new Catholic Charity building. The Outreach Clinic focuses on providing free primary health care for the homeless population. This clinic also has an outreach team that goes onto the streets to help this same population. In November 2000 we opened Martin Luther King Family Health Center at 1700 Wheeler Peak behind the VA facility.  The staffs for all these clinics are culturally appropriate for the communities and patients we serve.

            As previously stated, NVHC has been providing primary care services to Nevadans since 1977.  Nevada Health Centers developed administrative operations in Las Vegas in January 2000, and clinic services began in April 15, 2000.  Year-to-date for 2001, there have been 13,501 patient encounters in Clark County. We are experiencing a steady patient volume increase of 3% to 5% each month.  Currently, we operate with three family practice physicians, two physician assistants and eleven support and administrative staff distributed across three clinics and an administrative office.  In our medical facilities we focus on providing medical care, and all administrative functions including billing, purchasing, finance and human resource issues are handled in our administrative offices.  As productivity increases and funding becomes available, we will add medical providers to meet the need of the populations we are serving.  In Las Vegas patient revenues distribution has been 73% uninsured, 17% insured, 2% Medicare and 3% Medicaid.  Nationally Community Health centers have a distribution of 50% unisusured and 50% insured.  This revenues distribution continues to be the greatest factor that slows our growth.  The need has proven to be there, however revenue to hire more providers is lagging behind. 

            The demographic information of our population is 38% Hispanic, 28% White, 21% African American, 2% Asian, and 11% undeclared.  In addition, approximately 76% of our patients are under 100% of the Federal Poverty Level (FPL), and 21% is between 100% and 200% of the FPL.  Sixty-two percent of our patient populations are women, and 33% of the patients are under the age of nineteen. 

In 2001, our homeless clinic and outreach teams have seen approximately 1,394 homeless patients, which equates to 2,300 encounters.  Our homeless patients receive free primary health care, including prescription drugs.  Our outreach teams have also developed networks of specialists that will see these patients.  These activities are supported through a Health Care for the Homeless grant through the Bureau of Primary Health Care.  In addition, NVHC contracts with Catholic Charities to provide health screenings of approximately thirty immigrants from various different countries each month.  

            Our scheduling system encourages patients to make appointments prior to being seen by our providers.  However, approximately 40% of all patients seen in our current Las Vegas facilities are walk-ins. We strive to accommodate our patients and will continue to do so in all of our locations.

            In June 2001, Nevada Health Centers became the permanent grantee for the Community Health Center services in Las Vegas.  Nevada Health Centers, Inc. is committed to serving the underserved populations of Clark County.  We have learned to be successful in sustaining a Community Health Center program there must be partnerships.  We look forward to continuing our development of partnerships and creative associations with the County, Local Governments, and the medical community.

[Ex. Dir. Note:  Mr. Hansen is committed to working with legislators to expand the Good Samaritan Laws in Nevada to cover physicians volunteering their time in a Federally Qualified Community Health Center.  If successful, physicians volunteering time in this or other federally qualified health center would be either immune to lawsuit for medical malpractice or held to a "gross negligence" standard to be proved with only clear and convincing evidence.  At this time, however, physicians volunteering their time in such a clinic is subject to Nevada's usual standards for medical malpractice: "breach of the duty of care" causing injury with a "preponderance of the evidence" standard of proof.]

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Emergency Preparedness in Clark County

Clark County Health District, Dr. Donald Kwalick, Chief Health Officer

            Prior to September 11, 2002 the Clark County Health District was involved in planning and preparation activities in the event of a natural or man-made disaster. Post September 11, these activities have been pushed to the forefront in terms of awareness and priorities.

            Health District activities related to emergency preparedness include the completion of a comprehensive plan that outlines agency responsibilities and response protocols by division and section. For example, an integral component of the plan is the nursing and clinics division Mass Immunization Plan. Public health nurses would use this plan to ensure individuals are effectively immunized in the event there is widespread exposure to a vaccine preventable disease.

This emergency/disaster plan as a whole will be tested in March of this year when district personnel participate in a biological tabletop scenario that examines issues the community would face while responding to a terrorist event involving a biological weapon.

            The exercise is coordinated through the Clark County All-Hazard Local Emergency Planning Committee (LEPC) to facilitate a collaborative multi-agency, multi-jurisdictional planning and training effort. The tabletop exercise is a part of the Nunn-Lugar-Domenici Domestic Preparedness Program, created under Title XIV of the National Defense Authorization Act of 1996. The program is administered by the U.S. Department of Justice, Office for State and Local Domestic Preparedness Support. The City of Las Vegas is one of the nation's 120 cities participating in this program.

            In conjunction with this exercise the Centers for Disease Control and Prevention (CDC) will provide a National Pharmaceutical Stockpile (NPS) simulation package for training purposes. The goal of the NPS is to "maintain a national repository of life-saving pharmaceuticals and medical material that will be delivered to the site of a chemical or biological terrorism event in order to reduce morbidity and mortality in civilian populations."

            In the event of a significant biological or chemical incident, the CDC would deliver a "push package" to the local community upon federal request from a state division of health or emergency management. The push package arrives via cargo aircraft and contains essential medications, IV supplies, respiratory supplies and other medical equipment to support the community's immediate needs until additional assets can be deployed. The recipient community is responsible for the subsequent off-loading, transportation, break-down and distribution of the pharmaceutical products.

            "These two events will provide an ideal tool for assessing our current plan and resources. After the exercise is completed all participants should have a better understanding of their roles and responsibilities in the event of an emergency," said Dr. Donald Kwalick, chief health officer for the health district.

            The March exercise will focus on improving the understanding of a response concept and identifying opportunities and challenges. The emphasis will be on interagency coordination, integration of capabilities, problem identification and resolution.

            While this exercise uses a scenario involving the deliberate release of a biological agent, the lessons learned will have wide-ranging value. Inter-agency coordination and response is vital to a community's response to a multitude of incidents that could include deliberate acts, large-scale accidents and natural disasters.

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CME Calendar

Cardiovascular Consultants   691-9154

Clark County Medical Society   739-9989

Southwest Medical Associates   242-7731

Some courses also approved for nursing CEUs.

3/14 - “Alternative Medicine: Treatment of Cardiovascular Disease with Nutritional Medicine,” 7:30 a.m., 1 hour

4/11 - “Genetics Update for the Primary Care Provider,” 7:30 a.m., 1 hour

Sunrise Hospital   731-8210

UMC   383-2604

Valley Hospital   388-4847

3/7 - Family Practice Department Meeting, 7 a.m.

3/12 - “Pseudomonal Infections and Their Prevention,” noon

3/26 - “Treatment of Systemic Fungal Infections,” noon

4/9 - To Be Announced

4/23 - “Reduction of Adverse Cardiac Events - The HOPE Trial,” noon

5/14 - “Hodgkins Disease: An Overview,” noon

5/28 - “Venous Thromboembolic Disorders,” noon

6/11 - “The Use of Intravenous PPI’s,” noon

6/25 - “Update on Asthma,” noon

7/9 - “Vaginal Births After Cesarean Sections(V-Bacs),” noon

7/23 - “Making the Valley Hospital Website Work For You and Your Patients,” noon

*Special Note:  CCMS members can receive free CME courses on the internet with World Medical Leaders.

To have your CME courses listed on our calendar, please contact Deborah Barton at 739-9989.

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CCMS Upcoming Events

March 30 - Distribute Nominating Ballots for 2002-2003 offices

May 1 - Distribute Election Ballots for 2002-2003 offices

May 2-5 - NSMA Annual Meeting, Coronado, California

Mid-June - Installation Dinner (date and location TBA)

 

Clark County Health District Disease Statistics *

JANUARY 2002

 

DISEASE

CASES REPORTED

YEAR TO DATE

 

Jan. 2001

Jan. 2002

2001

2002

VACCINE PREVENTABLE DISEASES

DIPTHERIA

0

0

0

0

HAEMOPHILUS INFLUENZA (invasive)

0

0

0

0

HEPATITIS A

9

3

9

3

HEPATITIS B

2

3

2

3

INFLUENZA

16

1

16

1

                                                                                MEASLES

0

0

0

0

                                                                                    MUMPS

0

0

0

0

                                                                              PERTUSSIS

0

0

0

0

POLIO

0

0

0

0

                                                                                RUBELLA

0

0

0

0

TETANUS

0

0

0

0

SEXUALLY TRANSMITTED DISEASES

                                                                                       AIDS

14

18

14

18

                                                                          CHLAMYDIA

284

396

284

396

                                                                         GONORRHEA

134

147

134

147

HIV

17

8

17

8

                                        SYPHILIS (Primary & Secondary)

0

0