Recommendations and Reports

December 08, 2000 / 49(RR14);1-13

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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)
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

MEMBERS

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

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

EX OFFICIO MEMBERS

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

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

Stuart Swayze, M.S.W.

Health Resources and Services Administration

Rockville, Maryland

Jerry Zelinger, M.D.

Health Care Financing Administration

Baltimore, Maryland

LIAISON REPRESENTATIVES

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

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

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

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
>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., >70 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 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
medical 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
environmental, medical, developmental, nutritional, and educational interventions for
children with elevated BLLs. ACCLPP regularly advises CDC regarding new scientific
knowledge and technological developments and their practical implications for childhood
lead poisoning prevention efforts.

INTRODUCTION

Change in the Epidemiology of Lead Poisoning

Despite the decline in average BLLs among the U.S. population, childhood lead
exposure 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 (>10 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 benefits
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
(>10 µg/dL) (5). An estimated 535,000 children enrolled in Medicaid had elevated BLLs (Table 1), with a
prevalence 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
>10 µg/dL and 83% of young children with
levels >20 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 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
American 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
service 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.

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
recommendations for health-care providers and states, as well as other agencies that
administer Medicaid programs (e.g., those serving Medicaid-eligible Native Americans).
According 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
(>10 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
>2 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., 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
interventions 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
required 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
programs 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 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.

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
communication, 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>.

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.

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 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
Medicaid program had elevated BLLs (>10 µg/dL). Of children aged 1--5 years with BLLs
>20 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.

* 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.

References

National Research Council. Measuring lead exposure in infants, children, and
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CDC. Screening young children for lead poisoning: guidance for state and local
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Health Service, CDC, 1997.

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.

CDC. Update: blood lead levels---United States, 1991--1994 [published erratum
appears in MMWR 1997;46:607]. MMWR 1997;46:141--6.

US General Accounting Office. Medicaid: elevated blood lead levels in
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GAO/HEHS-98-78.

US General Accounting Office. Lead poisoning: federal health care programs are
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US General Accounting Office. Children's health: elevated blood lead levels in
Medicaid and hispanic children. Washington, DC: US General Accounting Office, 1998;
GAO publication no. GAO/HEHS-98-169R.

California State Auditor. Department of Health Services: has made little progress
in protecting California's children from lead poisoning. Sacramento, CA: Bureau of
State Audits, 1999. Publication no. 98117.

American Academy of Pediatrics. Lead test a must for Medicaid enrollees. AAP
News, December 1999;15:6.

Title 42: The public health and welfare, Chapter 7: Social Security Act, Title XIX: Grants
to states for medical assistance programs. 42 USCS §1396d (1999).

US Health Care Financing Administration. Part 5---early and periodic screening,
diagnosis, and treatment (EPSDT). In: State Medicaid manual. Baltimore, MD: US Health Care
Financing Administration; September 1998. HCFA publication no. 45-5. Section §5123.2.
Transmittal no. 12.

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developmental consequences of low to moderate prenatal and postnatal lead exposure:
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American Academy of Pediatrics. Treatment guidelines for lead exposure in
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Wehr E, Rosenbaum S. Medicaid managed care contracting for childhood lead
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Center, Center for Health Services Research and Policy, 1998. Available on the Internet
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Center for Health Services Research and Policy. Sample purchasing
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Washington University School of Public Health and Health Services, Center for Health Services
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<www.gwu.edu/~chsrp/sps/lead/nov98/index.html>. Accessed June 30, 2000.

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using what and what difference does it make? Pediatr Ann 1998;27:234--40.

Campbell JR, Schaffer SJ, Szilagyi PG, O'Connor KG, Briss P, Weitzman M. Blood
lead screening practices among US pediatricians. Pediatrics 1996;98:372--7.

Rothenberg R, Koplan JP, Cutler C, Hillman AL. Changing pediatric practice in a
changing medical environment: factors that influence what physicians do. Pediatr Ann
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IL: American Academy of Pediatrics, Committee on Environmental Health, 1999.

Alliance To End Childhood Lead Poisoning, National Center for Lead-Safe Housing.
Another link in the chain: state policies and practices for case management and
environmental investigation for lead-poisoned children. Washington, DC: Alliance To End
Childhood Lead Poisoning and the National Center for Lead-Safe Housing, 1999.

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.

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and Information Set. Available on the Internet at <www.ncqa.org>. Accessed June 30, 2000.

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19--35 months---United States, 1997. MMWR 1998;47:956--9.

US Health Care Financing Administration. Clinical Laboratory Improvement
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BOX. Summary of recommendations on lead screening and follow-up care
for children enrolled in Medicaid

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

Administer a screening blood lead test to all children enrolled in Medicaid at
ages 1 and 2 years.

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

Implement federal requirements for lead screening and follow-up care in
state Medicaid policies and managed-care contracts.

Support health-care providers and health plans in delivering screening
and follow-up services by providing information, feedback, and
adequate reimbursement.

Ensure that children who have elevated BLLs receive environmental follow-up
services in addition to medical and case management.

Monitor screening performance and BLLs among young children enrolled
in Medicaid.

Implement innovative screening strategies to augment conventional delivery
of lead screening services.

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Table 1

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Table 2

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