Recommendations
and
Reports
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
Atlanta, Georgia 30333
December 8, 2000 / Vol. 49 / No. RR-14
Recommendations for Blood Lead
Screening of Young Children
Enrolled in Medicaid: Targeting a Group
at High Risk
Advisory Committee on Childhood
Lead Poisoning Prevention (ACCLPP)
Centers for Disease Control and Prevention .................. Jeffrey P. Koplan, M.D., M.P.H.
Director
The material in this report was prepared for publication by
National Center for Environmental Health ................ Richard J. Jackson, M.D., M.P.H.
Director
Division of Environmental Hazards
and Health Effects ....................................... Michael A. McGeehin, Ph.D., M.S.P.H.
Director
The production of this report as an
MMWR
serial publication was coordinated in
Epidemiology Program Office ........................................... Barbara R. Holloway, M.P.H.
Acting Director
Office of Scientific and Health Communications ....................... John W. Ward, M.D.
Director
Editor,
MMWR
Series
Recommendations and Reports ...............................
Suzanne M. Hewitt, M.P.A.
Managing Editor
Amanda Crowell
Project Editor
Lynda G. Cupell
Visual Information Specialist
Michele D. Renshaw
Erica R. Shaver
Information Technology Specialists
The
MMWR
series of publications is published by the Epidemiology Program Office,
Centers for Disease Control and Prevention (CDC), U.S. Department of Health and
Human Services, Atlanta, GA 30333.
SUGGESTED CITATION
Centers for Disease Control and Prevention. Recommendations for blood lead
screening of young children enrolled in Medicaid: targeting a group at high risk.
Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP). MMWR
2000;49(No. RR-14):[inclusive page numbers].
Vol. 49 / No. RR-14 MMWR i
Contents
Background ......................................................................................................... 1
Introduction ......................................................................................................... 3
Change in the Epidemiology of Lead Poisoning .......................................... 3
Medicaid Children at High Risk for Having Elevated Blood Lead Levels .... 3
Health Care Financing Administration (HCFA) Policies
for Blood Lead Screening of Children Enrolled in Medicaid ................... 4
Recommendations to Ensure Screening and Follow-up Care
for Children Enrolled in Medicaid .................................................................. 5
ACCLPP Recommendations for Health-Care Providers ................................ 5
ACCLPP Recommendations for States and Other Agencies
That Administer Medicaid Programs......................................................... 6
Future Considerations ...................................................................................... 11
Conclusion ........................................................................................................ 11
References ......................................................................................................... 11
ii MMWR December 8, 2000
Carla C. Campbell, M.D., M.S.
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Cushing N. Dolbeare
Housing and Public Policy Consultant
Washington, D.C.
Anne M. Guthrie, M.P.H.
Alliance to End Childhood Lead Poisoning
Charlottesville, Virginia
Birt Harvey, M.D.
Pediatrician
Palo Alto, California
Richard E. Hoffman, M.D., M.P.H.
Colorado Department of Public Health
and Environment
Denver, Colorado
Advisory Committee on Childhood Lead Poisoning
Prevention (ACCLPP)
Membership List, February 2000
CHAIR
Susan K. Cummins, M.D., M.P.H.
Chief, Childhood Lead Poisoning Prevention
Branch
California Department of Health Services
Oakland, California
EXECUTIVE SECRETARY
Jerry M. Hershovitz
Chief, Lead Poisoning Prevention Branch
National Center for Environmental Health,
CDC
Atlanta, Georgia
Amy A. Murphy, M.P.H.
City of Milwaukee Health Department
Milwaukee, Wisconsin
Estelle B. Richman, M.A.
Philadelphia Department of Public Health
Philadelphia, Pennsylvania
Joel D. Schwartz, Ph.D.
Harvard School of Public Health
Boston, Massachusetts
Michael W. Shannon, M.D., M.P.H.
Children’s Hospital Boston
Boston, Massachusetts
Michael L. Weitzman, M.D.
University of Rochester
Rochester, New York
Michael Bolger, Ph.D.
U.S. Food and Drug Administration
Washington, D.C.
John Borrazzo, Ph.D.
U.S. Agency for International Development
Washington, D.C.
David Jacobs, Ph.D.
U.S. Department of Housing and Urban
Development
Washington, D.C.
Ronald L. Medford, M.S.
U.S. Consumer Product Safety Commission
Bethesda, Maryland
MEMBERS
EX OFFICIO MEMBERS
Walter Rogan, M.D.
National Institute of Environmental Health
Sciences
Research Triangle Park, North Carolina
Robert J. Roscoe, M.S.
National Institute for Occupational Safety
and Health, CDC
Cincinnati, Ohio
William H. Sanders, III, Dr.P.H.
U.S. Environmental Protection Agency
Washington, D.C.
Allan Susten, M.D.
Agency for Toxic Substances and Disease
Registry
Atlanta, Georgia
Vol. 49 / No. RR-14 MMWR iii
American Academy of Pediatrics
J. Routt Reigart, II, M.D.
Charleston, South Carolina
American Association of Health Plans
Eric K. France, M.D., M.S.P.H.
Denver, Colorado
American Industrial Hygiene Association
Steve M. Hays
Nashville, Tennessee
American Public Health Association
Rebecca Parkin, Ph.D., M.P.H.
Washington, D.C.
Association of Public Health Laboratories
Henry Bradford, Jr., Ph.D.
New Orleans, Louisiana
Advisory Committee on Childhood Lead Poisoning
Prevention (ACCLPP)
Membership List, February 2000 — Continued
LIAISON REPRESENTATIVES
Association of State and Territorial Health
Officials
Peter M. Nakamura, M.D., M.P.H.
Juneau, Alaska
Council of State and Territorial
Epidemiologists
Bela Matyas, M.D., M.P.H.
Jamaica Plain, Massachusetts
National Center for Lead Safe Housing
Pat McLaine, M.P.H.
Columbia, Maryland
Stuart Swayze, M.S.W.
Health Resources and Services
Administration
Rockville, Maryland
Jerry Zelinger, M.D.
Health Care Financing Administration
Baltimore, Maryland
iv MMWR December 8, 2000
Vol. 49 / No. RR-14 MMWR v
The following CDC staff members prepared this report:
Alan B. Bloch, M.D., M.P.H.
Lisa R. Rosenblum, M.D., M.P.H.
Division of Environmental Hazards and Health Effects
National Center for Environmental Health
in collaboration with
Anne M. Guthrie, M.P.H.
Alliance to End Childhood Lead Poisoning
vi MMWR December 8, 2000
Vol. 49 / No. RR-14 MMWR 1
Recommendations for Blood Lead Screening
of Young Children Enrolled in Medicaid:
Targeting a Group at High Risk
Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP)
Summary
Children aged 1–5 years enrolled in Medicaid are at increased risk for having
elevated blood lead levels (BLLs). According to estimates from the National
Health and Nutrition Examination Survey (NHANES) (1991–1994), Medicaid
enrollees accounted for 83% of U.S. children aged 1–5 years who had BLLs
³
20
µg/dL. Despite longstanding requirements for blood lead screening in the
Medicaid program, an estimated 81% of young children enrolled in Medicaid had
not been screened with a blood lead test. As a result, most children with elevated
BLLs are not identified and, therefore, do not receive appropriate treatment or
environmental intervention.
To ensure delivery of blood lead screening and follow-up services for young
children enrolled in Medicaid, the Advisory Committee on Childhood Lead
Poisoning Prevention (ACCLPP) recommends specific steps for health-care
providers and states. Health-care providers and health plans should provide
blood lead screening and diagnostic and treatment services for children enrolled
in Medicaid, consistent with federal law, and refer children with elevated BLLs for
environmental and public health follow-up services.
States should change policies and programs to ensure that young children
enrolled in Medicaid receive the screening and follow-up services to which they
are legally entitled. Toward this end, states should a) ensure that their own
Medicaid policies comply with federal requirements, b) support health-care
providers and health plans in delivering screening and follow-up services, and c)
ensure that children identified with elevated BLLs receive essential, yet often
overlooked, environmental follow-up care. States should also monitor screening
performance and BLLs among young children enrolled in Medicaid. Finally, states
should implement innovative blood lead screening strategies in areas where
conventional screening services have been insufficient. This report provides
recommendations for improved screening strategies and relevant background
information for health-care providers, state health officials, and other persons
interested in improving the delivery of lead-related services to young children
served by Medicaid.
BACKGROUND
High blood lead levels (i.e., ³70 µg/dL) can cause serious health effects, including
seizures, coma, and death (
1
). Blood lead levels (BLLs) as low as 10 µg/dL have been
associated with adverse effects on cognitive development, growth, and behavior among
2 MMWR December 8, 2000
children aged 1–5 years (
1
). Since the virtual elimination of lead from gasoline and other
consumer products in the United States, lead-based paint in homes remains the major
source of lead exposure among U.S. children (
1
). Most commonly, children are exposed
through chronic ingestion of lead-contaminated dust (
2
).
Because children with elevated BLLs in the 10–25 µg/dL range do not develop clinical
symptoms, screening is necessary to identify children who need environmental or medi-
cal intervention to reduce their BLLs. CDC has recommended specific interventions to
reduce elevated BLLs (
2,3
). To ensure delivery of blood lead screening and follow-up
services for young children enrolled in Medicaid, the Advisory Committee on Childhood
Lead Poisoning Prevention (ACCLPP) has recommended specific steps for health-care
providers and states (Box).
ACCLPP also is developing updated recommendations of specific guidelines for envi-
ronmental, medical, developmental, nutritional, and educational interventions for chil-
dren with elevated BLLs. ACCLPP regularly advises CDC regarding new scientific knowl-
edge and technological developments and their practical implications for childhood lead
poisoning prevention efforts.
Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP)
Recommendations on Lead Screening and Follow-up Care
for Children Enrolled in Medicaid
Recommendations for Health-Care Providers
1. Administer a screening blood lead test to all children enrolled in Medicaid at ages
1 and 2 years.
2. Refer children identified with elevated blood lead levels (BLLs) for
environmental and public health services and provide appropriate medical
management.
Recommendations for States and Other Agencies That Administer
Medicaid Programs
1. Implement federal requirements for lead screening and follow-up care in state
Medicaid policies and managed-care contracts.
2. Support health-care providers and health plans in delivering screening and
follow-up services by providing information, feedback, and adequate
reimbursement.
3. Ensure that children who have elevated BLLs receive environmental follow-up
services in addition to medical and case management.
4. Monitor screening performance and BLLs among young children enrolled in
Medicaid.
5. Implement innovative screening strategies to augment conventional delivery of
lead screening services.
BOX. Summary of recommendations on lead screening and follow-up care for
children enrolled in Medicaid
Vol. 49 / No. RR-14 MMWR 3
INTRODUCTION
Change in the Epidemiology of Lead Poisoning
Despite the decline in average BLLs among the U.S. population, childhood lead expo-
sure remains a major environmental health problem in the United States (
4
). During
1991–1994, CDC estimated that 890,000 (4.4%) children aged 1–5 years had elevated
BLLs (³10 µg/dL), based on data from Phase 2 of the National Health and Nutrition
Examination Survey (NHANES) III (
4
). The prevalence of elevated BLLs was 5.9% among
children aged 1–2 years and 3.5% among children aged 3–5 years (
4
). Children aged
1–5 years were more likely to have elevated BLLs if they were poor, of non-Hispanic
black race, or lived in older housing (
4
). The prevalence of elevated BLLs was higher
among non-Hispanic black children (21.9%) and Mexican-American children (13.0%)
living in housing built before 1946 than among non-Hispanic white children (5.6%) living
in such older housing. Risk for an elevated BLL was higher among low-income children
living in housing built before 1946 (16.4%) than among high-income children living in
older housing (0.9%) (
4
).
In response to NHANES III information regarding the distribution and prevalence of
lead poisoning among U.S. children, CDC changed its national blood lead screening
recommendations to a state-based approach. In
Screening Young Children for Lead
Poisoning: Guidance for State and Local Public Health Officials
, issued in 1997, CDC called
on state health departments to develop plans to ensure screening of all children at high
risk for having elevated BLLs (
2
). To develop such plans, CDC recommended that state
health departments assess local data on BLLs and risk factors. If no statewide plan exists,
states should screen virtually all young children, as recommended in the 1991 edition of
Preventing Lead Poisoning in Young Children
(
2,3
). Because young children living in
poverty are at high risk for elevated BLLs, CDC recommended various strategies for
increasing blood lead screening for all such children, including young children enrolled in
Medicaid (
2
). Specifically, CDC recommended that children who receive Medicaid ben-
efits should be screened unless there are reliable, representative blood lead data that
demonstrate the absence of lead exposure among this population.
Medicaid Children at High Risk for Having
Elevated Blood Lead Levels
After publication of CDC’s 1997 guidelines (
2
), CDC and the U.S. General Accounting
Office (GAO) further analyzed data from Phase 2 of NHANES III, confirming that children
enrolled in Medicaid are at high risk for having elevated BLLs (³10 µg/dL) (
5
). An esti-
mated 535,000 children enrolled in Medicaid had elevated BLLs (Table 1), with a preva-
lence among children aged 1–5 years (9%) three times greater than that among young
children not enrolled in Medicaid (3%) (
5
). Medicaid enrollees accounted for 60% of
children aged 1–5 years who had BLLs ³10 µg/dL and 83% of young children with levels
³20 µg/dL (
5,6
).
This analysis also documented low screening rates among young children enrolled in
Medicaid (
5
), with 81% of those aged 1–5 years and 79% of those aged 1–2 years not
receiving a blood lead test (
5,7
). Of an estimated 535,000 children aged 1–5 years who
were enrolled in Medicaid and had elevated BLLs, 352,000 (65%) had not been screened
4 MMWR December 8, 2000
with a blood lead test and, therefore, did not receive appropriate medical and public
health case management, follow-up care, and environmental services to reduce their
BLLs (Table 2) (
5
). Several states have also reported low screening rates for children
enrolled in Medicaid (
8
).
Health Care Financing Administration (HCFA) Policies
for Blood Lead Screening of Children Enrolled in Medicaid
Current HCFA policies require that all young children enrolled in Medicaid be screened
with a blood lead test (i.e., federal Medicaid requirements). In December 1999, the Ameri-
can Academy of Pediatrics (AAP) supported this policy, emphasizing the higher risk for
elevated BLLs among children enrolled in Medicaid (
9
).
Since 1989, federal law has required states to screen children enrolled in Medicaid
for elevated BLLs as part of prevention services provided through the Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) program. The EPSDT program provides
screening and entitles children to any federally allowable diagnostic and treatment ser-
vice necessary to correct the condition found by the screening (
10
). Details of blood lead
screening requirements are periodically revised by HCFA, which administers the Medi-
caid program at the federal level.
Federal Medicaid regulations were updated in 1998 to require that all children must
receive a blood lead screening test at ages 12 and 24 months. All children aged 36–72
months who have not previously been screened must also receive a blood lead test (
11
).
A blood lead test is the only required screening element. There is no waiver to this
Medicaid requirement for blood lead screening at this time.
TABLE 2. Estimated number of children aged 1–5 years who had undetected
elevated blood lead levels — United States, 1991–1994
Estimated number of children
with elevated blood lead levels
who had not been previously screened
Mean Lower limit Upper limit
All children 565,000 344,000 786,000
Children on Medicaid 352,000 270,000 434,000
Children not on Medicaid 213,000 131,000 295,000
Source: US General Accounting Office. Medicaid: elevated blood lead levels in children.
Washington, DC: US General Accounting Office, 1998; GAO publication no. GAO/HEHS-98-78.
TABLE 1. Estimated number of children aged 1–5 years who had elevated blood
lead levels — United States, 1991–1994
Estimated number of children
with elevated blood lead levels
Mean Lower limit Upper limit
All children 890,000 526,000 1,254,000
Children on Medicaid 535,000 290,000 780,000
Children not on Medicaid 355,000 157,000 553,000
Source: US General Accounting Office. Medicaid: elevated blood lead levels in children.
Washington, DC: US General Accounting Office, 1998; GAO publication no. GAO/HEHS-98-78.
Vol. 49 / No. RR-14 MMWR 5
RECOMMENDATIONS TO ENSURE SCREENING AND
FOLLOW-UP CARE FOR CHILDREN ENROLLED IN MEDICAID
To ensure blood lead screening and appropriate follow-up care for young children at
risk for lead poisoning and enrolled in Medicaid, ACCLPP makes the following recom-
mendations for health-care providers and states, as well as other agencies that adminis-
ter Medicaid programs (e.g., those serving Medicaid-eligible Native Americans). Accord-
ing to CDC recommendations, if there are no reliable blood lead data demonstrating the
absence of lead exposure among this population, health-care providers should a) screen
all young children enrolled in Medicaid with a blood lead test in accordance with HCFA
policy, b) provide medical management and care, and c) refer children with elevated
BLLs for environmental and public health case management.
ACCLPP Recommendations for Health-Care Providers
• All children enrolled in Medicaid should be screened with a blood lead test at
ages 12 and 24 months or at ages 36–72 months if they have not previously been
screened.
ACCLPP recommends administration of a blood lead screening test for all children
enrolled in Medicaid at ages 12 and 24 months; children who have not previously
been screened should be tested at ages 36–72 months (
11
). Administrating a risk-
assessment questionnaire instead of a blood lead test does not meet Medicaid
requirements.
If children are exposed to lead, their BLLs tend to increase during ages 0–2 years
and peak at ages 18–24 months (
12
). Therefore, screening is recommended at
both ages 1 and 2 years to identify children who need medical management and
environmental and public health case management (
2
). Identifying a child with an
elevated BLL at age 1 year might prevent additional increases during ages 1–2
years. In addition, a child with a BLL <10 µg/dL at age 1 year might have an
elevated level by age 2 years, underscoring the importance of rescreening at age
2 years. For example, among children at selected clinics in high-risk areas of
Chicago in 1997, the prevalence of elevated BLLs (³10 µg/dL) was 17% among
children approximately aged 1 year and 29% among children approximately
aged 2 years (Helen Binns, M.D., M.P.H., Children’s Memorial Hospital,
Northwestern University Medical School, personal communication, January
2000). Thirty-nine percent of children whose BLLs were <10 µg/dL at age 1 year
(during 1995–1996) were retested at age ³2 years (during 1996–1997), and 21%
had developed elevated BLLs since their initial screening. Screening is
recommended for previously untested children aged <6 years to rule out
subclinically elevated BLLs during critical stages of development.
• Children identified with elevated BLLs require evaluation and referral for
appropriate follow-up services.
Children identified with elevated BLLs should be evaluated and treated in
accordance with CDC guidelines for follow-up care, including care coordination
and public health, medical, and environmental management (
2,3,13
). Few
children will have BLLs high enough to warrant intensive medical treatment (e.g.,
6 MMWR December 8, 2000
chelation therapy) (
13
). However, many children with elevated BLLs will need
follow-up services, including more frequent blood lead testing, environmental
investigation, case management, and lead hazard control (
2,3
). In many
jurisdictions, public health or environmental agencies are available to provide or
coordinate follow-up care for children with elevated BLLs who are referred by
health-care providers. ACCLPP is developing updated recommendations for
environmental, medical, developmental, nutritional, and educational interven-
tions for children with elevated BLLs.
ACCLPP Recommendations for States and Other Agencies
That Administer Medicaid Programs
The actions recommended by ACCLPP for states (and other agencies administering
Medicaid programs) establish the framework necessary to support and, in some cases,
help health-care providers and administrators of managed-care plans provide the re-
quired blood lead screening and follow-up services to children enrolled in Medicaid. (The
considerable variation in the state-by-state design and administration of Medicaid pro-
grams precludes assignment of specific agency responsibility.) Implementing some of
the following strategies will require establishing new roles and partnerships for Medicaid
agencies and health departments.
• Ensure that state Medicaid policies and program materials on blood lead
screening are in compliance with federal Medicaid requirements.
According to an audit by GAO, 24 of 51 state Medicaid program policies were less
rigorous than HCFA requirements (
6
). States should review their EPSDT policies
and program documentation, particularly health-care provider manuals and
EPSDT screening schedules, to ensure they comply with HCFA policy.
• Ensure that state Medicaid managed-care contracts explicitly include federal
blood lead screening requirements and provide for follow-up services for
children identified with elevated BLLs.
In 1997, of 42 state contracts with Medicaid managed care organizations (MCOs)
evaluated by George Washington University, 20 (48%) discussed lead-related
services, and 15 (36%) discussed blood lead screening (
14
). Few contracts
specified a recommended frequency for screening services or addressed the
obligation to provide medical and environmental services for children with
elevated BLLs. Contracts that explicitly describe mandated health-care services
create legally enforceable duties of the contractor more effectively than contracts
that refer readers to the underlying statutory provision (
14
).
In states where young Medicaid beneficiaries are receiving care from MCOs,
state Medicaid agencies should review existing contracts to ensure explicit
inclusion of blood lead screening and follow-up services for children with elevated
BLLs. These contracts also present an opportunity to require reporting of blood
lead screening test results and to establish quality assurance measures.
Particularly important are provisions for state oversight and feedback to the
health-care provider regarding performance. To help states develop Medicaid
Vol. 49 / No. RR-14 MMWR 7
managed-care contracts that promote blood lead screening and lead poisoning
prevention, sample purchasing specifications are available for childhood lead
poisoning prevention services (
15
). In developing their managed-care contracts,
states should decide whether to permit health-care providers to refer Medicaid-
enrolled children to off-site laboratories to have their blood drawn, a practice that
imposes an additional burden on families and could cause lower screening rates.
• Provide information to health-care providers regarding Medicaid blood lead
screening policies and the data that justify them.
Health-care providers are more likely to implement clinical practice guidelines if
they perceive the guidelines are based on scientific evidence on how to improve
care (
16
). Physicians’ perceptions regarding the importance of lead poisoning
also influence implementation of screening guidelines (
6,17
). In addition, because
CDC, AAP, and HCFA policies have been revised multiple times in the recent past,
some health-care providers might be unaware of blood lead screening
recommendations. State Medicaid and public health agencies should collaborate
with medical professional associations and other stakeholders to develop health-
care provider education initiatives. Such educational programs should include
information regarding a) the content of and scientific basis for blood lead
screening recommendations, including differences between federal regulations,
policies, and requirements; b) state Medicaid policy and contracts; c) state laws;
and d) state screening plans. Educational initiatives also could promote reporting
of blood lead test results by health-care providers and build community support
for childhood lead poisoning prevention.
• Ensure that health-care providers receive adequate Medicaid EPSDT program
reimbursement and capitation rates for blood lead screening and follow-up
services.
Health-care providers need adequate reimbursement for their medical services,
as do MCOs, which monitor their expenditures closely (
18
). Medicaid blood lead
screening services are usually provided by physicians and MCOs as part of a
larger package of prevention services for children (i.e., the EPSDT program) and
are reimbursed as a package. In states where the list of required EPSDT services
has been expanded without compensatory increases in reimbursement rates,
there are substantial disincentives to providing the full range of EPSDT services
or participating in the Medicaid program. All states should review the
reimbursement rates and capitation rates for EPSDT services and blood lead
screening and treatment services to ensure that reasonable compensation is
provided to health-care providers and MCOs. In addition, other resources could be
made available to health-care providers to promote blood lead screening. For
example, health-care providers working in medically underserved areas with
children at high risk for elevated BLLs could receive hand-held lead screening
devices at no charge, and arrangements should be made for screening results to
be reported to public health authorities.
8 MMWR December 8, 2000
• Ensure that children identified with elevated BLLs receive environmental follow-
up in addition to other components of case management.
For blood lead screening to be a meaningful prevention service, identification of a
child with an elevated BLL must trigger services that will lower the child’s BLL.
Any treatment regimen that does not eliminate lead exposure is inadequate (
19
).
Services needed by a child with an elevated BLL can include environmental
investigation to identify the source of the exposure and lead hazard control to
eliminate its pathway, along with case management services to ensure that the
child receives all necessary public health, environmental, medical, and social
services (
2,3
).
Children enrolled in Medicaid are entitled by federal law to all necessary follow-up
services allowable under the Medicaid program (
10
). Current HCFA policy
requires that all state Medicaid programs cover a one-time environmental
investigation to determine the source of lead and the necessary case-
management services (Timothy M. Westmoreland, HCFA, personal communica-
tion, October 22, 1999) (
11
). Yet many states have failed to establish
reimbursement mechanisms for these covered services (
20
). As of early 1999,
only 22 state Medicaid agencies reported covering environmental investigation,
whereas 20 reported covering case management (
6,20
).
HCFA policy on coverage of a one-time environmental investigation to determine
the source of lead is limited to the health professional’s time, as well as activities
during an on-site investigation of the child’s home or primary residence. This
policy effectively allows activities such as visual assessment of the home,
interview of occupants, and on-site X-ray fluorescence (XRF) analysis of lead
paint content, when analyzers are available (Timothy M. Westmoreland, HCFA,
personal communication, October 22, 1999). HCFA policy prohibits state Medicaid
programs from covering the costs of environmental laboratory analyses (e.g.,
testing paint, dust, or water samples for lead content). These analyses are critical
components of environmental investigations for children with elevated BLLs.
ACCLPP recommended Medicaid coverage for these laboratory services in a
letter from ACCLPP Chair Susan K. Cummins, M.D., M.P.H., to the Secretary of the
U.S. Department of Health and Human Services (DHHS) (August 1999).
Finding resources to reduce children’s exposure to lead poses additional
challenges. Medicaid offers no explicit coverage for lead hazard control measures
(
11
). However, HCFA has approved, under a research and demonstration waiver
(Section 1115), a Rhode Island program featuring comprehensive follow-up care
for children with elevated BLLs that uses Medicaid funds to replace windows in
the homes of certain children (
21
). U.S. Department of Housing and Urban
Development (HUD) Lead Hazard Control Grant funds of $60 million in fiscal year
(FY) 2000 are available in approximately 200 jurisdictions. In addition, lead hazard
control is an eligible activity for block grant funds provided to state and local
governments under HUD’s Community Development Block Grant and HOME
Investment Partnerships programs, which received $4.8 billion and $1.6 billion,
respectively, in FY 2000. To receive these HUD funds, jurisdictions must develop
plans and submit applications; information is available on the Internet at
<www.hud.gov/lea>.
Vol. 49 / No. RR-14 MMWR 9
• Measure health-care provider performance on blood lead screening, give
feedback to providers, and consider incentives and other quality-control
measures to promote lead screening and ensure follow-up care.
Measuring performance and providing feedback on the delivery of health-care
services affect the patterns of both health-care provider and health plan
practices, including increasing screening rates (
16,18
). The widely used Health
Plan Employer Data and Information Set (HEDIS) is based on the premise that
measurement and reporting of plan performance will increase commitment to the
measured services (
22
). In 1997, of 42 state contracts with Medicaid MCOs
evaluated by George Washington University, 11 (26%) contracts discussed
quality-control or performance measures related specifically to lead, and 10
(24%) contained lead-specific reporting requirements (
14
). State Medicaid
agencies should measure the blood lead screening performance of participating
health plans and health-care providers, provide feedback on their performance,
and develop collaborative approaches for improving performance. State
Medicaid agencies should consider focused quality-control or incentive measures
to promote federally mandated clinical practices. Independent chart audits,
automated reminder systems, visible enforcement actions, and task-specific
financial incentives or penalties might be appropriate in some instances to
improve performance.
For example, screening rates in Iowa increased after reminders were sent to
health-care providers (Rita Gergely, Iowa Department of Public Health, personal
communication, December 1999). In addition, the Iowa Department of Public
Health is considering a plan to identify health-care providers’ claims for Medicaid
reimbursement for EPSDT screening visits for which there are no associated
claims for blood lead tests. Local programs and federal Title V Maternal and Child
Health programs would receive this information, which would be used to inform
identified health-care providers of the Medicaid policy on blood lead screening.
• Ensure that state information systems allow tracking of blood lead screening
and prevalence of elevated BLLs among young children enrolled in Medicaid.
In late 1997, GAO reported that only 12 states could readily provide information
regarding the number of children enrolled in Medicaid, as well as those who had
been screened for and identified as having elevated BLLs (
6
). HCFA policy now
requires states to report the annual number of blood lead screening tests
provided to Medicaid-enrolled children, beginning FY 1999 (revised HCFA form
416). State information systems should be developed or enhanced to a) monitor
blood lead screening rates, b) meet the HCFA policy reporting requirement,
c) assess the prevalence of elevated BLLs among children enrolled in Medicaid,
and d) ensure that blood lead tests are reported systematically to public health
agencies. Some states are shifting from information systems for fee-for-service
claims to systems for managed care; other states must work with both systems.
Some states do not have public health reporting mechanisms to monitor blood
lead screening results, and most states have not linked Medicaid enrollment
information and blood lead test results.
10 MMWR December 8, 2000
Information systems are being enhanced in some states. For example, Illinois,
Iowa, Connecticut, North Carolina, Wisconsin, and Utah are developing systems
to link Medicaid records and blood lead screening data. Iowa has developed a
method for the Title V program to import blood lead screening data from the
state’s childhood lead poisoning prevention program. Rhode Island has
developed an integrated pediatric public health tracking and information system
(i.e., KidsNet) for pediatric preventive health services (e.g., blood lead screening
and vaccination) (
23
).
• Establish partnerships between Medicaid agencies and other programs that
serve children enrolled in Medicaid to ensure these children receive appropriate
services.
Some obstacles to blood lead screening for children enrolled in Medicaid are not
unique to blood lead screening but reflect the challenge of delivering preventive
care to hard-to-reach segments of this population. To increase screening rates,
some state and local programs are developing blood lead screening initiatives
with other public programs. Some states are collaborating with the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC), Head
Start, or other programs for families receiving government assistance or with
programs delivering preventive health services to Medicaid-enrolled children.
For example, Iowa is working to establish partnerships with its Title V program
and the WIC program. The concerted efforts and copious resources dedicated by
immunization programs to increase vaccination coverage among young children
in recent years is showing impressive results, including for children living in
poverty. In 1997, vaccination coverage rates for U.S. children aged 19–35 months
living in poverty ranged from 86% for measles-containing vaccine to 93% for
three doses of diphtheria and tetanus toxoids and pertussis vaccine (including
80% for the newer hepatitis B vaccine) (
24
). Public health agencies should review
the literature in this field, as well as their own program successes, to identify
models and links with other programs that could be adapted to improve blood lead
screening performance for Medicaid-enrolled children.
• Use new blood lead screening technologies to improve blood lead screening
services.
In 1997, the U.S. Food and Drug Administration (FDA) cleared for marketing a
hand-held blood lead testing device for health-care facilities and physician
laboratories certified by the Clinical Laboratory Improvement Amendments
(CLIA)* (
25
). This device provides “real-time” blood lead screening results, and
other portable devices are in development. Use of these portable lead testing
devices can improve access to blood lead screening. These devices allow
immediate feedback to families and eliminate the delay associated with a follow-
up visit. If the test result shows an elevated BLL, the result can be confirmed by
*In 1988, CLIA established minimum quality standards for all laboratories. Based on the
complexity of the testing performed, laboratories must comply with various quality-control
regulations. CLIA categorizes the hand-held lead screening device as “moderately complex.”
This designation limits the device’s use to certified laboratories participating in proficiency
testing programs and meeting other federal criteria. Thus, most physicians’ offices cannot
use this device because most are not certified to conduct this type of testing.
Vol. 49 / No. RR-14 MMWR 11
immediate retesting, and the family can be provided lead education and help to
limit lead exposure. State Medicaid and public health agencies should collaborate
to develop innovative ways to use this and other new screening technologies to
enhance lead poisoning prevention services.
For public health facilities, CLIA requirements for use of this device can be met
through collaboration with state public health laboratories, which can oversee
quality control, coordinate proficiency testing, and provide training and
certification of personnel. When hand-held devices move blood lead analysis
from traditional laboratories to the field, information systems should be
established to ensure that blood test results are reported systematically to the
appropriate public health agencies so that valuable screening data are included in
state tracking systems. Ideally, new blood lead testing devices for field or office
use would provide automatic collection and reporting of blood lead test results.
FUTURE CONSIDERATIONS
HCFA policy requires blood lead screening for all young children enrolled in Medicaid
and does not currently permit any variation from this requirement. However, HCFA will
be working with ACCLPP to develop an approach that would permit targeted screening of
Medicaid-enrolled children in states where adequate data support such a policy. ACCLPP,
in conjunction with CDC, has agreed to assist HCFA in considering this approach by
developing scientifically based criteria for targeted screening. Targeted screening should
be considered only on the basis of reliable and representative blood lead data (e.g., from
screening and population surveys).
CONCLUSION
During 1991–1994, an estimated 535,000 U.S. children aged 1–5 years in the Medic-
aid program had elevated BLLs (³10 µg/dL). Of children aged 1–5 years with BLLs ³20 µg/
dL, 83% were enrolled in Medicaid. Because most young children enrolled in Medicaid
have not been screened with a blood lead test as required by law, an estimated 352,000
children with elevated BLLs have never been identified or treated. Failure to comply with
Medicaid blood lead screening requirements forfeits the opportunity to use this targeted
risk group to efficiently identify children with elevated BLLs who could benefit from
medical and public health follow-up services.
To improve performance in this area, health-care providers and health plans should
provide blood lead screening and diagnostic and treatment services for children enrolled
in Medicaid and refer children with elevated BLLs for environmental and public health
follow-up services. At the same time, states should ensure that young children enrolled
in Medicaid receive the appropriate blood lead screening and follow-up care to which
they are legally entitled.
References
1. National Research Council. Measuring lead exposure in infants, children, and other
sensitive populations. Washington, DC: National Academy Press, 1993.
2. CDC. Screening young children for lead poisoning: guidance for state and local public
health officials. Atlanta, GA: US Department of Health and Human Services, Public Health
Service, CDC, 1997.
12 MMWR December 8, 2000
3. CDC. Preventing lead poisoning in young children: a statement by CDC—October 1991.
Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC,
1991.
4. CDC. Update: blood lead levels—United States, 1991–1994 [published erratum appears in
MMWR 1997;46:607]. MMWR 1997;46:141–6.
5. US General Accounting Office. Medicaid: elevated blood lead levels in children.
Washington, DC: US General Accounting Office, 1998; GAO publication no. GAO/HEHS-
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6. US General Accounting Office. Lead poisoning: federal health care programs are not
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Vol. 49 / No. RR-14 MMWR 13
21. Rhode Island Department of Human Services. How did Rhode Island get HCFA approval to
use Medicaid funds for window replacement for children with lead poisoning?
[Memorandum]. Providence, RI: Rhode Island Department of Human Services, February
23, 1999.
22. National Committee for Quality Assurance. HEDIS: Health Plan Employer Data and
Information Set. Available on the Internet at <www.ncqa.org>. Accessed June 30, 2000.
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health: a public health integrated information systems approach. Am J Prev Med
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24. CDC. Vaccination coverage by race/ethnicity and poverty level among children aged 19–35
months—United States, 1997. MMWR 1998;47:956–9.
25. US Health Care Financing Administration. Clinical Laboratory Improvement Amendments:
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progdesc.htm>. Accessed June 30, 2000.
14 MMWR December 8, 2000
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