Lead Poisoning:

Federal Health Care Programs Are Not Effectively Reaching At-Risk Children

HEHS-99-18: Published: Jan 15, 1999. Publicly Released: Jan 26, 1999.

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Pursuant to a congressional request, GAO examined: (1) the risk of lead poisoning faced by young children served by federal health care programs; (2) the extent to which children served by these programs have been screened for this condition; (3) key reasons why screenings may not be occurring; and (4) problems that federal health care programs face in ensuring that children who have harmful lead levels in their blood receive timely follow-up treatment and other services.

GAO noted that: (1) the children served by federal health programs remain at significant risk for elevated blood lead levels; (2) three-fourths of all the children found to have an elevated blood lead level in the Centers for Disease Control and Prevention (CDC) 1991-94 survey were enrolled in Medicaid or the Special Supplemental Food Program for Women, Infants and Children (WIC) or were within the target population for the Health Center Program; (3) this equates to nearly 700,000 children nationwide; (4) more than 8 percent of the surveyed children aged 1 through 5 who were served by federal health care programs had a harmful blood lead level, a rate almost five times the rate for children who were not in these federal programs; (4) despite federal policies, most children in federal health care programs have not been screened; (5) for nearly two-thirds of the surveyed children aged 1 through 5 identified by CDC as having elevated lead levels, the blood lead test conducted as part of the CDC survey was the first such test they had received; (6) projecting these results nationally, more than 400,000 U.S. children in federal health care programs have undetected elevated blood lead levels; (7) other data that GAO analyzed for specific federal health programs tended to corroborate the overall low screening rates reported in CDC's survey and also showed that screening rates vary greatly from state to state and locality to locality; (8) screening is often not occurring because federal screening policies are largely not monitored at the federal and state levels; (9) one underlying reason for low screening rates is the widespread belief among providers that lead exposure is no longer a problem in their communities; (10) most state officials GAO contacted lacked reliable, representative data on the prevalence of elevated blood lead levels and the extent of screening in their states; (11) another problem is that many children are not receiving adequate preventive health care services, visiting the doctor only when they are sick; (12) follow-up treatment for children identified with elevated blood lead levels is complex and potentially resource intensive; and (13) at health centers and state and local health departments visited across the country, GAO found wide variation in the extent of timely follow up.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HCFA has taken several actions to implement GAO's recommendations. On October 22, 1999, the Director of the Center for Medicaid and State Operations, HCFA, sent all Medicaid Directors a letter to lay out the requirements for lead screening for children in Medicaid and to communicate the findings of GAO's report. On April 28, 2000, the HCFA Director of the Center for Medicaid and State Operations, Director of CDC, Administrator of the Health Services and Resources Administration, and Assistant Secretary for Children and Families cosigned a letter designed to encourage lead screening of at risk populations and to promote coordination at the federal, state, and local levels to ensure Medicaid-enrolled children receive appropriate screening tests and services and to encourage data-sharing. This letter was sent to all lead programs, state health programs, state epidemiologists, and state Medicaid programs. On June 9, 2000, HCFA approved the award of a grant to the Alliance to End Childhood Lead Poisoning to (1) educate Medicaid staff and health care providers about the need for lead screening and follow-up care, (2) improve delivery of lead screening and follow-up care, and (3) promote monitoring of Medicaid lead screening and follow-up care and identify model or innovative and promising approaches to improvement. In July 2000, CDC and HCFA signed an interagency agreement which provides for a CDC lead poisoning prevention expert to be detailed to work on-site at HCFA within the Family and Children's Health Programs Group. The detailee is responsible for providing technical assistance and consultation to HCFA on lead poisoning related policies and issues and serve as a liaison between HCFA and CDC to improve communications and information exchange on childhood lead poisoning. He is assisting in improving the collection of Medicaid lead screening data through development of methods of sharing/linking of data between state Medicaid agencies and health departments and/or other local agencies, among other responsibilities.

    Recommendation: To improve the awareness of providers and the public about the prevalence of elevated blood lead levels among young children in their communities and to enhance the effectiveness of targeted screening efforts, the Health Care Financing Administration (HCFA) and CDC should work more closely with state Medicaid and CDC-supported programs to encourage information-sharing and the development of data needed to better identify at-risk children. Specifically, state Medicaid programs should be encouraged to work with state health departments to develop systems to identify the prevalence of elevated blood lead levels among children in Medicaid.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  2. Status: Closed - Implemented

    Comments: CDC has established a performance goal of increasing Medicaid screening by 20 percent by December 2003. An HHS working group with representatives from CDC, HCFA, HRSA, AHCPR, etc., was organized to implement a department Lead Prevention Initiative to address screening and treatment issues. On April 28, 2000, the HCFA Director of the Center for Medicaid and State Operations, Director of CDC, Administrator of the Health Services and Resources Administration, and Assistant Secretary for Children and Families cosigned a letter designed to encourage lead screening of at risk populations, and to promote coordination at the federal, state, and local levels to ensure Medicaid-enrolled children receive appropriate screening tests and services and to encourage data-sharing. This letter was sent to all lead programs, state health programs, state epidemiologists, and state Medicaid programs. In July 2000, CDC and HCFA signed an interagency agreement which provides for a CDC lead poisoning prevention expert to be detailed to work on-site at HCFA within the Family and Children's Health Programs Group. The detailee is responsible for providing technical assistance and consultation to HCFA on lead poisoning related policies and issues and to serve as a liaison between HCFA and CDC to improve communications and information exchange on childhood lead poisoning. He is assisting in improving the collection of Medicaid lead screening data through development of methods of sharing/linking of data between state Medicaid agencies and health departments and/or other local agencies, among other responsibilities.

    Recommendation: To improve the awareness of providers and the public about the prevalence of elevated blood lead levels among young children in their communities and to enhance the effectiveness of targeted screening efforts, the Health Care Financing Administration (HCFA) and CDC should work more closely with state Medicaid and CDC-supported programs to encourage information-sharing and the development of data needed to better identify at-risk children. Specifically, state Medicaid programs should be encouraged to work with state health departments to develop systems to identify the prevalence of elevated blood lead levels among children in Medicaid.

    Agency Affected: Department of Health and Human Services: Public Health Service: Centers for Disease Control and Prevention

  3. Status: Closed - Not Implemented

    Comments: This recommendation should be deleted as the CDC part is not applicable to HCFA.

    Recommendation: To improve the awareness of providers and the public about the prevalence of elevated blood lead levels among young children in their communities and to enhance the effectiveness of targeted screening efforts, HCFA and CDC should work more closely with state Medicaid and CDC-supported programs to encourage information-sharing and the development of data needed to better identify at-risk children. Specifically, CDC should require grant applicants to: (1) demonstrate that they have, or have systems to obtain, representative, reliable data on the prevalence of elevated blood lead levels in their states or communities or to commit to conducting periodic surveys to obtain such data; and (2) commit to developing mechanisms for distributing such information to the public and providers.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  4. Status: Closed - Implemented

    Comments: To improve data collected by CDC grant applicants, CDC awarded grants to some states for developing model surveillance systems for collecting representative data as suggested by GAO.

    Recommendation: To improve the awareness of providers and the public about the prevalence of elevated blood lead levels among young children in their communities and to enhance the effectiveness of targeted screening efforts, HCFA and CDC should work more closely with state Medicaid and CDC-supported programs to encourage information-sharing and the development of data needed to better identify at-risk children. Specifically, CDC should require grant applicants to: (1) demonstrate that they have, or have systems to obtain, representative, reliable data on the prevalence of elevated blood lead levels in their states or communities or to commit to conducting periodic surveys to obtain such data; and (2) commit to developing mechanisms for distributing such information to the public and providers.

    Agency Affected: Department of Health and Human Services: Public Health Service: Centers for Disease Control and Prevention

  5. Status: Closed - Implemented

    Comments: In response to the recommendation, HHS required states to report on the number of blood screening tests provided to young children under the EPSDT program by including a new reporting element on its annual reporting form.

    Recommendation: To improve screening rates within Federal health programs, HCFA and the Health Resources and Services Administration (HRSA) should improve the monitoring of compliance with federal lead screening policies within the Medicaid and health center programs. Specifically, HCFA should require state Medicaid agencies to report on the lead screening services that are provided to children within the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program and to document progress in meeting lead screening performance goals. HCFA should require the states that do not meet expectations to develop plans for improving their performance.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  6. Status: Closed - Not Implemented

    Comments: This recommendation is not applicable to HRSA.

    Recommendation: To improve screening rates within Federal health programs, HCFA and the Health Resources and Services Administration (HRSA) should improve the monitoring of compliance with federal lead screening policies within the Medicaid and health center programs. Specifically, HCFA should require state Medicaid agencies to report on the lead screening services that are provided to children within the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program and to document progress in meeting lead screening performance goals. HCFA should require the states that do not meet expectations to develop plans for improving their performance.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

  7. Status: Closed - Not Implemented

    Comments: Not applicable to HCFA.

    Recommendation: To improve screening rates within federal health programs, HCFA and HRSA should improve the monitoring of compliance with federal lead screening policies within the Medicaid and health center programs. Specifically, HRSA should use current monitoring mechanisms to better ensure that health centers follow all federal lead screening policies.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  8. Status: Closed - Implemented

    Comments: HRSA is updating its lead screening and treatment policy for issuance in October/November 2000. Other steps taken include revising its uniform data system to require reporting on lead testing, follow-up, and treatment (also expected to be completed by the end of calendar year 2000).

    Recommendation: To improve screening rates within federal health programs, HCFA and HRSA should improve the monitoring of compliance with federal lead screening policies within the Medicaid and health center programs. Specifically, HRSA should use current monitoring mechanisms to better ensure that health centers follow all federal lead screening policies.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

  9. Status: Closed - Not Implemented

    Comments: In 2007, CMS indicated it no longer was working on this effort because states were required to screen at risk kids.

    Recommendation: To improve screening rates within federal health programs, HCFA and HRSA should improve the monitoring of compliance with federal lead screening policies within the Medicaid and health center programs. Specifically, HCFA and HRSA should develop a process for waiving universal lead screening requirements when state programs can demonstrate that they have representative and reliable data and data systems upon which to base local policies.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  10. Status: Closed - Not Implemented

    Comments: CMS has indicated it no longer was working on this effort because states are required to screen at risk kids.

    Recommendation: To improve screening rates within federal health programs, HCFA and HRSA should improve the monitoring of compliance with federal lead screening policies within the Medicaid and health center programs. Specifically, HCFA and HRSA should develop a process for waiving universal lead screening requirements when state programs can demonstrate that they have representative and reliable data and data systems upon which to base local policies.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

  11. Status: Closed - Implemented

    Comments: HHS has established a departmental Lead Poisoning Prevention initiative with numerous planned activities, including supporting improved managed care contracts. CMS contracted with the Alliance to End Childhood Lead Poisoning to, among other things, perform lead poisoning prevention education and outreach to managed care organizations and providers.

    Recommendation: To ensure that state Medicaid agencies' managed care contracts clearly delineate appropriate lead screening and treatment responsibilities, HCFA and CDC should work together to provide guidance to state Medicaid agencies on including lead screening and treatment protocols in managed care contracts.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  12. Status: Closed - Implemented

    Comments: CDC has contracted with George Washington University (GWU) to develop model contract language and to assess the extent that state Medicaid agencies have implemented the model language. Part of the expectations for this process is that GWU will work with state Medicaid agencies to train them on how to establish appropriate contract provisions for ensuring lead screening and treatment occurs. This training is currently underway at states.

    Recommendation: To ensure that state Medicaid agencies' managed care contracts clearly delineate appropriate lead screening and treatment responsibilities, HCFA and CDC should work together to provide guidance to state Medicaid agencies on including lead screening and treatment protocols in managed care contracts.

    Agency Affected: Department of Health and Human Services: Public Health Service: Centers for Disease Control and Prevention

  13. Status: Closed - Implemented

    Comments: CMS issued a state Medicaid Director a letter presenting the findings of GAO's report and discussing the importance of compliance with federal lead screening and treatment policies. The letter and its attachments clarified that states should cover any follow-up services for children who have been screened for lead, within the scope of the Medicaid statute, including medically necessary diagnostic or treatment services. The letter clarified that case management and investigations to determine the source of lead were covered services.

    Recommendation: To ensure that state Medicaid agencies more consistently provide for reimbursement for services for lead-poisoned children, HCFA should clarify in regulation or Medicaid policy the expectation that, in line with CDC recommendations, all state Medicaid agency EPSDT programs include reimbursements for investigations to determine the source of lead exposure and case management services for children identified with elevated blood lead levels. Further, HCFA should consult with CDC to delineate and clarify its expectations for the other services it deems medically necessary to treat children who have elevated blood lead levels.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration

  14. Status: Closed - Not Implemented

    Comments: CMS indicated in 2007 it had no plans to implement this recommendation.

    Recommendation: To improve the efficiency and effectiveness of lead screening and other preventive health care efforts and to marshal federal health care resources for reaching at-risk children, the Department of Health and Human Services (HHS) should identify ways to integrate lead screening and lead poisoning prevention activities with immunization activities in other health programs under HHS. HHS should explore options for better coordinating interventions to improve lead screening and treatment with other preventive health services such as immunization. One such option HHS should consider would establish a formal agreement or requirements for coordinating HHS' lead screening and treatment activities with those of the WIC program.

    Agency Affected: Department of Health and Human Services

 

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