As you are undoubtedly aware, in the recent election a majority of Nevada voters approved Ballot Question 3 (Keep Our Doctors in Nevada or "KODIN"), which provides for significant changes in Nevada's medical malpractice statutory framework. Changes will be imposed in particular on plaintiffs' attorneys' fees, non-economic damage awards, the allocation of damages among defendants, the limitations period, the collateral source rule, and future damages. We understand that you likely have many questions about the upcoming changes to the medical malpractice statutory scheme. To assist you, we provide this overview of Ballot Question 3, and the corresponding changes in the statutory framework.

Plaintiff Attorney Contingency Fee Limitations

Plaintiffs' attorneys in medical malpractice cases will be limited in what they can charge pursuant to contingency fee agreements. This area was previously unaddressed in Nevada law. The usual fee in medical malpractice actions in this community has been 40% of the total recovery. This change in the law will limit the fees an attorney can charge a person seeking damages against a negligent provider of health care in a medical malpractice action. Essentially, it will provide a progressively greater percentage of any award or settlement to the injured patient, limiting the amount that goes to the patient's attorney. The statute reads:

"An attorney shall not contract for or collect a fee contingent on the amount of recovery for representing a person seeking damages in connection with an action for injury or death against a provider of health care based upon professional negligence in excess of:

(a) Forty percent of the first $50,000 recovered;

(b) Thirty-three and one-third percent of the next $50,000 recovered;

(d) Fifteen percent of the amount of recovery that exceeds $600,000.

* * *

The limitations set forth in subsection 1 apply to all forms of recovery, including, without limitation, settlement, arbitration and judgment."

This provision purports to limit attorneys' fees on every settlement or judgment from November 24, 2004 forward.

On November 23, 2004, Justices of the Nevada Supreme Court, met with the Secretary of State to "canvass," or review, the recent election results pursuant to NRS 293.395(2). ¹ Under NRS 293.395(2) and NRS 295.125, ² the provisions of Ballot Question 3 were adopted upon certification of the election results by the Supreme Court and Secretary of State and became effective immediately, making the first effective day of the statute November 24, 2004.

The statute expressly states that the provisions regarding the cap on noneconomic damages, the abolition of joint and several liability, and the shortening of the statute of limitations apply prospectively only, meaning they apply only to actions accruing on or after the effective date of the statute. ³ "The amendatory provisions of sections 5, 6, and 8 of this act apply only to a cause of action that accrues on or after the effective date of this act." In other words, those provisions only apply to actions arising from allegedly wrongful conduct causing damage on or after November 24, 2004. The statute is silent as to whether the provisions regarding plaintiff attorney contingency fee limitations, the collateral source rule, and periodic payment of future damages are to be applied prospectively or retroactively (in other words, to causes of action arising out of allegedly wrongful conduct that occurred before the effective date of the statute.) The statute's silence as to these particular provisions (in comparison to its explicit directives regarding the other provisions) implies that the unaddressed provisions of KODIN were intended to be applied retroactively. ⁴ On the other hand, as a general rule, newly enacted statutes affecting substantive rights are presumptively prospective. It is probably safe to assume, however, from the statute's silence that the unaddressed provisions of KODIN, including the provision limiting plaintiff attorney contingency fees, are to be applied retroactively. How such retroactive application will play out remains to be seen, and will likely be challenged upon its first application.

Limitation of Non-Economic Damages to $350,000 Without Exception

In perhaps the most significant feature of Question 3, the exceptions to the caps on general damages have been eliminated. The new cap language states:

"In an action for injury or death against a provider of health care based upon professional negligence, the injured plaintiff may recover noneconomic damages, but the amount of noneconomic damages awarded in such an action must not exceed $350,000."

"Noneconomic damages" are defined as damages to compensate for pain, suffering, inconvenience, physical impairment, disfigurement, and other nonpecuniary damages. The law passed in 2002 provided that a person seeking damages in a medical malpractice action is limited to recovering $350,000 in noneconomic damages from each defendant, with 2 exceptions. The first exception allowed an injured person to receive more than $350,000 if the wrongdoer committed gross malpractice. ⁵ The second exception allowed a person to receive more than $350,000 if the court determines by clear and convincing evidence admitted at trial, after a jury verdict or finding of damages at a bench trial, that "exceptional circumstances" justify an award in excess of the cap. "Exceptional circumstances" were left undefined by the legislature. Notably, under the 2002 law, even where exceptions to the cap applied, awards of general damages could not, when combined with the economic damages awarded, exceed the defendant's liability limits.

The new law strictly limits the recovery of noneconomic damages to $350,000 per action. First, it removes the two statutory exceptions to the $350,000 cap, taking away judicial discretion to eliminate the cap regardless of the level of conduct at issue or magnitude of the harm. Additionally, the new law eliminates the "stacking" of the $350,000 in noneconomic damages from each defendant to each plaintiff in cases involving multiple parties. ⁶ In other words, a plaintiff may now recover only $350,000 total in noneconomic damages, rather than $350,000 from each defendant. These changes also eliminate the requirement that a health care provider maintain a $1 million/$3 million professional liability limit policy in order to enjoy the protection of the cap. The limitation of recovery to an amount equal to or less than the defendant's professional liability insurance policy limit was repealed as well.

This section expressly applies only to causes of action accruing on or after November 24, 2004, thereby avoiding constitutional challenge on that basis.

Elimination of Joint and Several Liability for Health Care Providers Rendering Medical Services Within the Scope of Their License

The new law abolishes joint and several liability altogether in medical malpractice cases, for all categories of damage. The new statute provides:

"In an action for injury or death against a provider of health care based upon professional negligence, each defendant is liable to the plaintiff for economic damages and noneconomic damages severally only, and not jointly, for that portion of the judgment which represents the percentage of negligence attributable to the defendant.

* * *

This section is intended to abrogate joint and several liability of a provider of health care in an action for injury or death against the provider of health care based upon professional negligence."

Previously, Nevada law treated noneconomic damages differently from economic damages. Each one of multiple defendants in medical malpractice actions was severally-not jointly-liable for noneconomic damages. Thus, a single defendant among multiple defendants in a medical malpractice action was only liable for the percentage share of noneconomic damages attributable to that defendant's wrongful conduct-he or she did not have to pay the share attributable to the wrongful conduct of other defendants. With respect to economic damages, ⁷ under former law, a defendant was jointly and severally liable for these damages, meaning a defendant could be required to pay the injured person for not only his or her percentage share of the verdict, but also for the wrongful conduct of all other defendants with respect to the plaintiffs' out-of-pocket damages.

KODIN repeals joint and several liability for economic damages, and treats liability for recovery of economic damages in medical malpractice cases the same as for noneconomic damages, such that defendants are only severally, but not jointly liable. The jury will, in a medical case, apportion liability by percentage among the multiple defendants, and, if contributory negligence is an issue, the plaintiff. Each defendant will be liable for his percentage share of the economic and noneconomic damages, but no more.

This section expressly applies only to causes of action accruing on or after November 24, 2004.

Statute of Limitations Changed From 2 Years From the Date of Discovery of the Alleged Negligent Injury to 1 Year

The electorate also shortened the statute of limitations. The new statute provides.

"Except as otherwise provided in subsection 3, an action for injury or death against a provider of health care may not be commenced more than 3 years after the date of injury or 1 year after the plaintiff discovers or through the use of reasonable diligence should have discovered the injury, whichever occurs first."

Currently, the law requires an injured person to file a medical malpractice lawsuit within 3 years of the date of the injury, or 2 years from the time the person discovers or through reasonable diligence should have discovered the injury, whichever comes first. ⁸ The new law changes the latter part of the statute of limitations, requiring an injured patient to sue within 1 year, rather than 2, of the time the patient discovered, or through the use of reasonable diligence should have discovered, the injury. The 3-year period will remain unchanged. ⁹

In other words, where malpractice is obvious (wrong limb surgery, for example), and the injury and the suspected malpractice are simultaneous, the plaintiff has only one year to bring the claim. Where the malpractice is not immediately evident, but a patient can be shown to have been placed on notice of potential malpractice (for example, where it can be established the patient sought the advice of a malpractice attorney or was advised by another provider that negligence occurred) then the claim will be lost if not brought within one year of this knowledge, but in no event later than three years after the event of malpractice.

This section expressly applies only to causes of action accruing on or after November 24, 2004.

Collateral Source Rule Changed to Permit the Defendant to Introduce Evidence of Payments Made to the Plaintiff

KODIN also changes the handling of collateral source benefits, which are insurance and other proceeds an injured claimant has recovered for the injuries which are the subject of the lawsuit. The new provision reads:

"In an action for injury or death against a provider of health care based upon professional negligence, if the defendant so elects, the defendant may introduce evidence of any amount payable as a benefit to the plaintiff as a result of the injury or death pursuant to the United States Social Security Act, any state or federal income disability or worker's compensation act, any health, sickness or income-disability insurance, accident insurance that provides health benefits or income-disability coverage, and any contract or agreement of any group, organization, partnership or corporation to provide, pay for or reimburse the cost of medical, hospital, dental or other health care services. If the defendant elects to introduce such evidence, the plaintiff may introduce evidence of any amount that the plaintiff has paid or contributed to secure his right to any insurance benefits concerning which the defendant has introduced evidence.

* * *

A source of collateral benefits introduced pursuant to subsection 1 may not:

(a) Recover any amount against the plaintiff; or

(b) Be subrogated to the rights of the plaintiff against a defendant."

Currently, damages that an injured person is allowed to recover in a medical malpractice action may be reduced by benefits the person received from a third party, such as Medicaid, private insurance, or workers' compensation. However, jurors are not permitted to know of these payments and reimbursements. Instead, under current law, the jury hears evidence of the medical expenses "incurred," makes its award, and then the court after verdict reduces the award by the amount of any "collateral source" payment, unless there is a lien right. Under the new law, the jury will be allowed to consider these benefits (as well as any premiums paid by the plaintiff to secure the coverage which generated the benefits.) The lien holder will lose its lien rights if the benefits are introduced at trial.

This provision appears to apply retroactively, so that it will govern any trial after November 24, 2004 no matter when the cause of action accrued.

Any Party Permitted to Request Periodic Payments of Future Damages Over $50,000

Finally, the Ballot Question creates a right in the defendant to pay future damages ¹⁰by periodic payments.

"In an action for injury or death against a provider of health care based upon professional negligence, a district court shall, at the request of either party, enter a judgment ordering that money damages or its equivalent for future damages of the judgment creditor be paid in whole or in part by periodic payments rather than by a lump-sum payment if the award equals or exceeds $50,000 in future damages."

The old statute permitted the court to order an award of future economic damages to be paid in periodic payments "at the request of the claimant," which rarely (if ever) occurs because the plaintiff usually wants his money "now." This creates a situation where the "lump sum" of money may be expended for purposes other than for which it was intended (future medical care), causing a plaintiff who has expended those funds to become a financial burden on others or on the taxpayers of the state for his future medical care. By requiring periodic payments of future damages, the patient receives payments of the award in future increments so that money is available to pay for medical and other expenses.

This provision will apply to pending cases.

Many questions, of course, remain open regarding the issues created by these impending changes in the laws, and we can anticipate that many aspects of the law's enforceability and constitutionality will be challenged as cases affected by these provisions are decided. In particular, we anticipate significant constitutional challenges to the strict new general damages cap, and to the limitations on attorneys' fees. We also anticipate that governmental agencies and insurers who routinely recover money on liens in these cases will challenge the elimination of their rights.

1 - NRS 293.395(2) reads as follows:

"On the fourth Tuesday of November after each general election, the justices of the Supreme Court, or a majority thereof, shall meet with the Secretary of State, and shall open and canvass the vote for the number of presidential electors to which this state may be entitled, United States Senator, Representative in Congress, members of the Legislature, state officers who are elected statewide or by district, district judges, or district officers whose districts include area in more than one county and for and against any question submitted."

2 - NRS 295.125 reads as follows:

"1. If a majority of the registered voters voting on a proposed initiative ordinance vote in its favor, it shall be considered adopted upon certification of the election results and shall be treated in all respects in the same manner as ordinances of the same kind adopted by the council. If conflicting ordinances are approved at the same election, the one receiving the greatest number of affirmative votes shall prevail to the extent of such conflict.

2. If a majority of the registered voters voting on a referred ordinance vote against it, it shall be considered repealed upon certification of the election results."

3 - The new statute reads as follows:

4 - The question of whether a statute applies prospectively or retrospectively is one of legislative intent, although there are constitutional limitations on efforts to retroactively affect existing rights with new legislation.

5 - "Gross malpractice" is defined as the failure to exercise the required degree of care, skill or knowledge that amounts to: (a) A conscious indifference to the consequences which may result from the gross malpractice; and (b) A disregard for and indifference to the safety and welfare of the patient.

6 - The old statute provided that "the non-economic damages awarded to each plaintiff from each defendant must not exceed $350,000." The new statute removes the language "to each plaintiff from each defendant."

7 - "Economic damages" include out-of-pocket damages for medical treatment, care or custody, loss of earnings and loss of earning capacity.

8 - The 3-year/2-year statute was itself a shortening of the prior statute of limitations, which prior to October 2002 was 4-year/2-year.

9 - Keep in mind that exceptions to the 1/3 statute remain in effect as follows:

3. This time limitation is tolled for any period during which the provider of health care has concealed any act, error or omission upon which the action is based and which is known or through the use of reasonable diligence should have been known to him.

4. For the purposes of this section, the parent, guardian or legal custodian of any minor child is responsible for exercising reasonable judgment in determining whether to prosecute any cause of action limited by subsection 1 or 2. If the parent, guardian or custodian fails to commence an action on behalf of that child within the prescribed period of limitations, the child may not bring an action based on the same alleged injury against any provider of health care upon the removal of his disability, except that in the case of:

(a) Brain damage or birth defect, the period of limitation is extended until the child attains 10 years of age.

(b) Sterility, the period of limitation is extended until 2 years after the child discovers the injury.

10 - "Future damages" includes damages for future medical treatment, care or custody, loss of future earnings, loss of bodily function, or future pain and suffering of the judgment creditor.

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Clark County District Court Medical Malpractice Filings Against Health Care Providers, Jan 2001 – Nov 2004

2001 2002 2003 2004

Jan 39 33 108 61

Feb 20 14 98 72

Mar 35 30 169 123

Apr 37 34 111 81

May 37 35 126 65

Jun 27 24 103 90

Jul 19 100 114 45

Aug 54 51 76 67

Sep 20 65 105 79

Oct 37 83 110 59

Nov 38 184 59 78

Dec 9 170 67

Sum 372 823 1246

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President’s Message

By Michael P Colletti, M.D., 2004-2005 CCMS President

A few months before the election, I was in a doctors' lounge eating lunch, talking to a physician I hadn't seen in about a year. He is a general internist. We talked about many things. He told me a brief story I have not forgotten. I saw him again a few days ago and asked his permission to use this story.

About twenty years ago, when he first came to Las Vegas, he developed an interest in treating pregnant women with toxemia. He became skillful at this and was consulted by several obstetricians to see in-hospital consultations. He found this very enjoyable and rewarding. When it came time to renew his malpractice insurance, his insurance carrier informed him that they would no longer provide him coverage if he continued to care for pregnant women with toxemia. He had to make the decision twenty years ago to limit his liability. He stopped seeing pregnant women with toxemia. One can only imagine how many pregnant women with toxemia were deprived of his care. Over time, his knowledge and skill would have increased. He may well have passed this interest and knowledge to other student physicians.

Many of us, as physicians, have similar stories to tell, either about ourselves or fellow physicians. Physicians bear risk and responsibility foreign to any other professional group. Overall, Americans have been ill-served by a legal system that would deprive them of the best possible medical care. Hopefully, this era of placing million-dollar targets on physicians will soon come to an end. In addition to California, Nevada may become a role model for the rest of the States of America. We need a medical system that will provide fairly for patients injured in the course of medical treatment. Physicians do not get up in the morning and go to work with the intention of causing harm to their patients. When physicians are accused of malpractice, plaintiff attorneys frequently portray them as bad or evil. To the trial attorneys, this is not personal. It's business. To us, as physicians, it's personal. To us, it is not just the cost of doing business.

All of us know physicians in other states. Many of those physicians will be looking to physicians in Nevada for information and guidance to enable their states to pass legislation similar to MICRA in California and KODIN in Nevada. We need to share this information with them. We are all physicians of the United States caring for all Americans.

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In Memoriam

The Clark County Medical Society regrets to announce the passing of pediatric pulmonologist Ruben Diaz, MD on December 2. He had been a CCMS member since 1993.

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Community Acquired Methicillin Resistant Staphylococcus Aureus (CAMRSA) – A New Paradigm

By Gary Skankey, M.D., Infectious Disease

Since the 1960's, methicillin-resistant Staphylococcus aureus (MRSA) has been a recognized nosocomial pathogen. Risk factors include hospitalization (exposure to other high risk patients) or other long-term care facility, surgery, dialysis, and IV drug use. Rates are regionally variable throughout the US but average 40-50% in hospitals.

Methicillin-resistant S. aureus has been identified in the community, most typically as a result of exposure to one of the above risk groups. However, several years ago, reports began to appear of MRSA infections in patients without any apparent risk or exposure to risk groups. These were considered "community acquired." Initially, they were not serious and only required use of other antimicrobial agents.

In 1999, MMWR reported several deaths in children due to community-acquired MRSA. The origin, genetics, and epidemiology was not well understood, and subsequently, numerous investigators began looking at this somewhat new phenomenon.

Since then, a few important distinctions have been observed. Genetically, methicillin resistance is carried on a Staphylococcal Cassette Chromosome of the mec type (SCCmec). Four variants were identified. Of note, SCCmec type I was an extremely small (and now archaic) gene. Types II and III were subsequently larger genes and are the most common in hospital-acquired MRSA (HAMRSA). The strain identified as community-acquired has been labeled type IV (CAMRSA). The importance of this is revealed in the fact that the type IV gene is very small and very mobile. So, genetically, CAMRSA can be viewed as distinctly different from HAMRSA. Studies have suggested that the majority of CAMRSA isolates are clonally related.

In addition to being genetically different, CAMRSA carries more virulence factors, most notably Panton-Valentine Leukocidin, which attributes to more severe disease in low-risk patients.

Since the SCCmec type IV is so small, it tends not to carry other resistance determinants that make the organism resistant to non-beta lactam antibiotics. Consequently, CAMRSA is often susceptible to other antimicrobials such as trimethoprim-sulfamethoxasole, minocycline, rifampin, and clindamycin (along with vancomycin, linezolid and the streptogramins) - see figure.

Several risk groups have been identified including: MSM (men who have sex with men), IV drug users, incarcerated persons, and others who play contact sports or other close proximity groups (day care centers, etc.).

Taking this all into consideration, choices of empiric treatment of skin and soft tissue infections, and osteomyelitis in high risk groups should include MRSA coverage. Oral regimens should contain trimethoprim-sulfamethoxazole, plus or minus rifampin, and more serious infections should involve the use of vancomycin. Other infections in which staphylococcus aureus is often a cause, such as pneumonia and bacteremia, might also need coverage for MRSA until culture data are finalized.

In summary, CAMRSA occurs in patients without previously identified risk factors common for HAMRSA. Patients with skin and soft tissue infections without exposure to long-term healthcare risk, but within one of the above risk groups, should have appropriate cultures and sensitivities ordered. Empiric therapy will usually consist of trimethoprim-sulfamethoxazole +- rifampin or vancomycin.

References: available on request. Send an e-mail to Ebbin@sierrahealth.com

Sponsored by Nevadans for Antibiotic Awareness (www.nevadaaware.com) and an unrestricted educational grant from Ortho-McNeil Pharmaceuticals

Figure 1.

Naimi TS, et al. Epidemiology and Clonality of Community-Acquired Methicillin-Resistant Staphylococcus aureus in Minnesota, 1996-1998. CID 2001;33:990-6

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New Members – November 2004

· Richard A Byrd, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Garland A Cowan, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Neel V Dhudshia, MD, General Surgery, 3131 LaCanada St #217, Las Vegas, NV 89109

· J Marlow Fenn, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· James S Forage, MD, Neurosurgery, 3061 S Maryland Pkwy #200, Las Vegas, NV 89109

· John T Goodsell, DO, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Mark B Heinonen, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Stuart S Kaplan, MD, Neurosurgery, 3061 S Maryland Pkwy #200, Las Vegas, NV 89109

· Aloysius N Lwin, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Gregory R McGovern, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· David A McRae, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Michael Messina, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Rosendo (Don) F Motero, MD, Anesthesiology, 129 W Lake Mead Dr #B-18, Henderson, NV 89015

· Mostafa I I Sheta, MD, Family Practice, 282 E Lake Mead Dr, Henderson, NV 89015

· Donald P Wingard, MD, Family Practice, 600 Whitney Ranch Rd #A-1, Henderson, NV 89014

Michael G Wood, MD, Cardiovascular Surgery, 1090 E Desert Inn Rd #202, Las Vegas, NV 89109

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Reinstated Member

· Mark G Henderson, MD, Ob-Gyn

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Applicants To Go Before Credentialing Committee

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

· David T C Chan, MD, Family Practice

· Ethan M Cruvant, MD, Internal Medicine

· Russell T Nevins, MD, Orthopaedic Surgery

For information on becoming a member of the Clark County Medical Society, call Marlaina Burns at 739-9989

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Alliance Message

By Marian Haas and Kathie Slaughter, 2004-2005 CCMS Alliance Co-Presidents

As we start the new year, we are looking forward to many exciting events which are different from our usual luncheon format. Our January meeting will be a Brunch at Nordstrom on January 11 from 8:00 to 10:00 a.m. We will have a wonderful brunch buffet served inside the store with presentations on fashion accessorizing and make up and then have the remainder of the morning to shop the store before it opens for all business. This promises to be a wonderful event that can hopefully allow members who have difficulty in attending luncheons to attend a morning activity. Our plan is to then offer a February dinner event. We are looking into many possible locations that would allow us to have a social event for members in which to bring spouses and friends. It is hoped that by providing nontraditional times for our meetings we can accommodate members with busy daytime schedules.

We extend our many thanks to Nighat Abdulla for opening her home to us for our December luncheon. It was an elegant affair in a spectacular home with the most gracious hostess. We would also like to thank our generous members who donated over 110 items of toys, clothing, and gift certificates which were donated to Child Haven, the emergency shelter that provides temporary care for neglected, abused, or abandoned children. We will then continue to support Child Haven on an ongoing basis for the remainder of the year, asking for donations at each luncheon.

Our thanks also go to Kim Watson, who ran our Greeting Card Project. With the help of many over 250 doctors and 10 corporate sponsors we raised approximately $13,000 which will be used for support our Nursing Scholarships, the CASA Foundation, and Child Focus.

We are looking forward to the Fashion Show Fundraiser will be held on March 15th at Neiman Marcus in the Fashion Show Mall and our April Luncheon will be in the home of April Stewart. If you wish to join us, please contact Wendy Agrawal @ 228-6360, Swati Khamamkar @242-8542, Marian Haas @838-9840, or Kathie Slaughter @ 878-4981. You may also get information from the Clark County Medical Society @ 739-9989.

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Health District advocates legislative changes

By Donald Kwalick, MD MPH Clark County Health Officer

The Clark County Health District is following and supporting a number of issues to be brought before the 2005 Nevada State Legislature, including tobacco control, solid waste management and trauma system development. While these and many other issues are of import, I would like to highlight two issues of particular concern to the health district.

Restoration of Health Aid to Counties

The Clark County District Board of Health unanimously approved a resolution in November urging Governor Guinn to re-fund Health Aid to Counties (HAC) at $1.10 per capita in order to develop a chronic disease prevention and control program. The Washoe County District Board of Health passed a similar resolution and both were submitted to the Governor's office for consideration.

In order to address budgetary shortfalls in 2002, the State asked each division to implement budget cuts. In response, the Nevada State Health Division (NSHD) eliminated HAC funding, essentially transferring the burden of the cuts to the local health districts. During the 2003 legislative session NSHD submitted its biennial budget which included an optional decision unit for funding of the HAC account. Legislative staff recommended eliminating the funding, the legislature accepted the recommendation, and the account remains un-funded.

Restoration of this funding is a top priority. For two decades prior to its elimination, services provided by Nevada's local health districts on behalf of the health division have been funded through HAC. Furthermore, a recent survey conducted by the National Association of County and City Health Officials (NACCHO) found state funding of local health departments across the country typically runs in the range of 20 to 30 percent of their total budgets, a sharp contrast to the 4 percent requested.

It is important the State support public health activities in the two largest population centers. The issue of chronic disease has long been overlooked but has become increasingly important as the costs associated with obesity, diabetes, asthma, arthritis, cancer and heart disease continue to mount.

Access to Emergency Health Care

On July 9, 2004, Clark County declared a state of emergency when more than 100 non-medical patients filled the emergency departments, threatening basic health care services. Currently, patients who are a harm to self or others are placed on legal hold in our emergency departments until they are medically cleared and a bed opens up at the State Psychiatric Hospital. On a routine basis these patients occupy 20 percent of all emergency department beds. On July 9, this number swelled to 33 percent of the 345 emergency beds. On average, the Legal Hold patient spends 4 days in a bed designed to treat patients in under 4 hours.

A remedy for this situation must be enacted in order to avert a future crisis. Southern Nevada has a State Psychiatric Bed rate of 8.1 per 100,000 population, while Northern Nevada has a rate of 24.1 and the Unites States average is 33.4 per 100,000. Funding must be secured to allow the use of empty beds at facilities such as WestCare for medically cleared patients until State hospital beds are available, medical clearances to be conducted at facilities other than emergency departments and the building of a new State Psychiatric Hospital.

The State has the responsibility for mental health services and these services must be expanded in order to meet the needs of our local population and to eliminate the impact on an already overtaxed health care system in Southern Nevada.

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Referral Tallies

Referrals to CCMS members in the fourth quarter of 2004 (through December 15)

Specialty Referrals

Addiction Medicine 0

Allergy 1

Anesthesiology 0

Cardiology 7

Cardiovascular Surgery 2

Colon & Rectal Surgery 4

Dermatology 5

Diagnostic Radiology 0

Endocrinology 3

Family Practice 13

Gastroenterology 3

General Surgery 3

Geriatrics 3

Gynecologic Oncology 0

Hematology 2

Infectious Medicine 0

Internal Medicine 15

Nephrology 1

Neurology 7

Neurosurgery 2

Ob-Gyn 9

Oncology 2

Ophthalmology 4

Oral/Maxillofacial Surg. 1

Orthopaedic Surgery 9

Otolaryngology 6

Pain Mgmt/Medicine 2

Pathology 0

Pediatrics 2

Physical Med/Rehab 0

Plastic Surgery 10

Psychiatry 10

Pulmonology 4

Radiology 0

Rheumatology 1

Thoracic Surgery 0

Urology 6

Vascular Surgery 0

Totals 137

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Classifieds

· PRIMARY CARE OFFICE SUBLEASE IN Henderson (Pecos/Wigwam) available for M.D. and/or other health professionals - ancillary staff and use of scheduling system, phones, equipment all optional. Start your business here with referrals in house. Call 595-6168.

· NEEDED: PART-TIME (RETIRED IS FINE) physicians (Dermatology, Urology, Gynecology, Pulmonology, Cardiology, Neurology and Rheumatology) with active Nevada license to work within a dedicated research clinic. Fax your CV/Resume to 257-8209.

· VIP CLINIC MINI-SUITE – in truly elegant setting. In Green Valley by Anthem/Seven Hills. Ideal for sub-specialist to expand to Green Valley. Call 938-0190.

· WANTED: WELL-ESTABLISHED, 6-YEAR-OLD medical practice seeking part time Nevada licensed Family Practice, General Practitioner (M.D. or D.O.), flexible scheduling, No HMO, competitive salary. E-mail your CV to PmsJim@msn.com or call (702) 326-3309 anytime.

· ADVERTISE IN COUNTY LINE CCMS members get up to 3 free classified ads (up to 40 words) per year. For further information on rates, call Deborah at 739-9989.

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CME CALENDAR

Cardiovascular Consultants 691-9154

Clark County Medical Society 739-9989

St. Rose Hospital 616-5832

Southwest Medical Associates 242-7735

1/13 - “HIPAA Update”

2/10 - “Cardiology Update”

3/10 - “Men’s Health: Sexual Dysfunction in the Elderly”

Summerlin Hospital 233-7572

1/8 - “Bioterrorism and Weapons of Mass Destruction Training,” 8 a.m., 5 CME hours

1/29 - “Bioterrorism and Weapons of Mass Destruction Training,” 8 a.m., 5 CME hours

2/5 - “Bioterrorism and Weapons of Mass Destruction Training,” 8 a.m., 5 CME hours

3/12 - “Bioterrorism and Weapons of Mass Destruction Training,” 8 a.m., 5 CME hours

3/26 - “Bioterrorism and Weapons of Mass Destruction Training,” 8 a.m., 5 CME hours

Sunrise Hospital 731-8210

1/12 - “Breast Cancer,” 6:30 p.m.

1/22 - “Bioterrorism (WMD),” 9 a.m., 4 CME hours

UMC 383-2604

1/8 - “Weapons of Mass Destruction & Ethical Issues,” 7:30 a.m., 7 CME hours

2/12 - “Weapons of Mass Destruction & Ethical Issues,” 7:30 a.m., 7 CME hours

3/19 - “Weapons of Mass Destruction & Ethical Issues,” 7:30 a.m., 7 CME hours

4/9 - “Weapons of Mass Destruction & Ethical Issues,” 7:30 a.m., 7 CME hours

Valley Hospital 388-4847

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

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Clark County Health District Disease Statistics* - November 2004

DISEASE CASES REPORTED YEAR TO DATE

Nov 2003 Nov 2004 2003 2004

VACCINE PREVENTABLE DISEASES

DIPTHERIA 0 0 0 0

HAEMOPHILUS INFLUENZA 0 1 8 7

(invasive)

HEPATITIS A 1 0 15 6

HEPATITIS B 4 1 59 47

INFLUENZA 1 0 48 53

MEASLES 0 0 0 0

MUMPS 0 0 2 0

PERTUSSIS 0 3 22 10

POLIOMYELITIS 0 0 0 0

RUBELLA 0 0 0 0

TETANUS 0 0 0 0

SEXUALLY TRANSMITTED DISEASES**

CHLAMYDIA 401 367 4305 4410

GONORRHEA 181 209 1849 2253

SYPHILIS (Early Latent) 0 0 19 11

SYPHILIS (Primary & Secondary)1 2 8 34

ENTERICS

AMEBIASIS 2 0 16 12

BOTULISM-INTESTINAL 0 0 1 0

(INFANT)

CAMPYLOBACTERIOSIS 9 7 93 84

CHOLERA 0 0 0 0

CRYPTOSPORIDIOSIS 0 0 5 2

E. COLI O157:H7 0 4 17 20

GIARDIA 8 6 89 65

ROTAVIRUS 8 42 392 585

SALMONELLOSIS 5 11 110 110

SHIGELLOSIS 2 7 49 51

TYPHOID FEVER 0 0 0 1

VIBRIO 0 0 1 4

YERSINIOSIS 0 1 1 3

OTHER

ANTHRAX 0 0 0 0

BOTULISM INTOXICATION 0 0 0 0

BRUCELLOSIS 0 0 0 0

COCCIDIOIDOMYCOSIS 2 5 31 52

ENCEPHALITIS 0 0 1 1

HANTAVIRUS 0 0 0 0

HEMOLYTIC UREMIC 1 0 1 0

SYNDROME(HUS)

HEPATITIS C 0 0 1 3

HEPATITIS D 0 0 0 0

LEGIONELLOSIS 4 0 8 4

LEPROSY 0 0 0 1

LEPTOSPIROSIS 0 0 0 0

LISTERIOSIS 0 0 3 5

LYME DISEASE 0 0 3 0

MALARIA 1 0 2 5

MENINGITIS, 12 5 130 79

ASEPTIC/VIRAL

MENINGITIS, BACTERIAL 1 2 20 17

MENINGOCOCCAL DISEASE 0 0 6 4

PLAGUE 0 0 0 0

PSITTACOSIS 0 0 0 0

Q FEVER 0 0 0 0

RABIES (HUMAN) 0 0 0 0

RELAPSING FEVER 0 0 0 0

RSV 52 34 1302 1082

TOXIC SHOCK SYNDROME 0 0 2 4

TUBERCULOSIS 9 6 67 67

TULAREMIA 0 0 0 0

UNUSUAL ILLNESS 0 0 0 2

WEST NILE VIRUS 0

Contents

Medical Malpractice Reform 2004

Clark County District Court Medical Malpractice Filings Against Health Care Providers, Jan 2001 – Nov 2004

President’s Message

In Memoriam

Community Acquired Methicillin Resistant Staphylococcus Aureus (CAMRSA) – A New Paradigm

New Members – November 2004

Reinstated Member

Applicants To Go Before Credentialing Committee

Alliance Message

Health District advocates legislative changes

Referral Tallies

Classifieds

CME CALENDAR

Clark County Health District Disease Statistics* - November 2004