Lead exposure remains a public health threat due to the persistence of lead in the environment. Children of lower socioeconomic status are more likely to live in homes with lead-based paint hazards.1 However, many children are never screened for blood lead levels, including those at high risk for lead exposure. Consequently, many children with elevated blood lead levels are never identified and do not receive interventions to reduce lead exposure, thereby increasing their risk for the health and neurobehavioral problems associated with early exposure to lead.2
In 1994, the Wisconsin Childhood Lead Poisoning Prevention Program (Wisconsin Childhood Lead) began systematically collecting information on all blood lead tests conducted in Wisconsin. Wisconsin Statute § 254.13 requires that laboratories report to the Department of Health Services the results and demographic information associated with all blood lead tests. Wisconsin Childhood Lead has worked with laboratories and health care providers to develop a comprehensive blood lead reporting system that includes both electronic laboratory reporting and hard copy reporting for laboratories without electronic reporting capabilities. The blood lead testing data for children younger than 16 years are maintained in the Systematic Tracking of Elevated Lead Levels and Remediation (STELLAR) database, which forms the basis for analyses and surveillance activities conducted at the state level.
In recent years, many health care providers have begun using point-of-care devices. These devices allow blood samples to be analyzed on site. Clinics using these devices may not know that they are acting as a laboratory and must report test results directly to the state. Wisconsin Childhood Lead has worked with the device manufacturer to maintain a list of more than 150 providers and laboratories that have purchased these devices to inform them of Wisconsin's reporting requirements. However, some devices are obtained after market. It is challenging to communicate with users about their reporting requirements and difficult to obtain complete and timely reporting of results from all providers.
The federal Medicaid program requires that all children enrolled in Medicaid receive a blood lead screening test at 12 and 24 months of age in association with their Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) medical visits. Targeted screening is permitted only with prior authorization from federal Medicaid.3,4 Medicaid-enrolled children older than 24 months and up to 72 months of age who were not previously tested should receive a blood lead test. In spite of this screening requirement, the US Government Accounting Office reported in 1999 that federal health care programs, such as Medicaid, were not effectively testing at-risk children.5 Specific to Wisconsin, a review of 2004 lead program data showed that only 56% of Medicaid-enrolled 1-year-olds, 43% of 2-year-olds, and 13% of previously untested 3- to 5-year-olds received lead testing. Fewer than one-third of Medicaid-enrolled children had been tested at both 1 and 2 years of age, and the majority (two-thirds) did not receive appropriate testing according to federal Medicaid requirements. Medicaid-enrolled children were more likely to be lead poisoned than children not enrolled in Medicaid. Among children tested in 2004, 5% of Medicaid-enrolled children had a blood lead level of 10 μg/dL or more, the level of concern at that time, compared with 1% of non-Medicaid children. While 60% of children tested were enrolled in Medicaid, a much higher proportion (82%) of children with a blood lead level 10 μg/dL or more were enrolled in Medicaid. These findings indicated the need to increase testing, so all lead-poisoned children are identified and receive appropriate services.
One barrier to increasing screening is the challenge of identifying children who have not received appropriate testing at the state level. Wisconsin Childhood Lead and Wisconsin Medicaid undertook efforts to encourage appropriate screening of Medicaid children and improve blood lead surveillance data quality. Both programs are located within the Department of Health Services and have a data-sharing agreement that allows for the linkage of data to evaluate and improve program effectiveness. Medicaid data were linked to the Wisconsin blood lead testing data to implement 2 projects. The first project (“Project 1”) was initiated in 2006 to increase blood lead testing of at-risk children. The second project (“Project 2”) was initiated in 2015 as a quality assurance effort to ensure that all blood lead tests for Medicaid-enrolled children were reported to Wisconsin Childhood Lead in accordance with state-reporting requirements.
Wisconsin Medicaid data were linked to the Wisconsin blood lead testing data for these projects. The linking procedure was developed in SAS, consisting of a series of algorithms derived from first name, last name, and date of birth, including exact match, name match with variations on date of birth, partial name matches in cases with multiple surnames, soundex matches, and matches where 1 name is a substring of the corresponding name (ie, Rob = Robert).
Project 1: Medicaid provider report cards
Wisconsin Childhood Lead and Wisconsin Medicaid collaboratively designed provider report cards to provide direct feedback to physicians regarding their blood lead testing practices relative to the federal testing requirements. The report cards included data on the numbers of Medicaid-enrolled children seen by the provider, the number tested, and the overall provider testing rate. Children who were tested at Women, Infants, and Children (WIC) program clinics or other nonmedical sites were included in the number tested. The report cards contained information on federal Medicaid requirements for blood lead testing at specific ages and comparison data for the top-performing provider in the state.
Provider report cards were first distributed in June of 2006 and included data from July 1, 2004, to June 30, 2005. The time between test data and when the provider received the report card packet allowed sufficient time for billing of services, data matching, and report card development. Report cards were sent to providers who had seen 50 or more Medicaid-enrolled children who were due for an age-appropriate blood lead test in the previous year. During June 2007 to 2011, the report cards were sent to providers who had seen 25 or more Medicaid-enrolled children in the previous year (Figure 1). These providers covered nearly 90% of Medicaid children who received medical services. In 2007 and subsequent years, the report card packets included the list of children in that provider's practice who had not yet received a lead test.
Provider report card information was extracted from Medicaid enrollment, claims and encounters data, and Wisconsin Childhood Lead blood lead test data. Testing information was provided for 3 age groups, according to Medicaid testing requirements, and allowed for tests done within several months of the birthday as defined by Wisconsin Medicaid for age-appropriate testing:
- 1-year olds: Children 6 months through 16 months of age on the date of the office visit and/or blood lead test.
- 2-year olds: Children 17 months through 29 months of age on the date of the office visit and/or blood lead test.
- 3- to 5-year-olds not previously tested: Children 30 months through 71 months of age on the date of the office visit and/or blood lead test who were not previously tested.
The number of Medicaid-enrolled children in each age category, seen by the provider, included children seen for limited types of office visits and procedure codes. One-third of the visits were HealthCheck/EPSDT examinations and two-thirds were interperiodic visits of low-moderate severity and low complexity (typically 15 minutes). These interperiodic visits were included to capture additional opportunities for testing if it was not done during the HealthCheck/EPSDT examination. The report card included an overall testing score for the provider based on the number of children seen in the 3 age groups combined and the number who were tested. A testing score was calculated for each individual age group.
A subset of provider types and provider specialty codes was used to identify primary care providers and included pediatricians, family medicine physicians, internal medicine physicians, general practice physicians, osteopathic physicians, pediatric nurse practitioners, physician assistants, and other HealthCheck (EPSDT) screening providers. Specialists were not included under the assumption that they do not normally do blood lead testing.
Project 2: Improve blood lead surveillance quality
Medicaid claims and encounter data were obtained from Wisconsin Medicaid for 2007-2015 to identify children for whom a blood lead test was billed using Current Procedural Terminology code 86355 (assay of lead). This code is used for billing by the laboratory that tests the blood lead sample. This is the only code that can be used for the procedure and is specific to testing for blood lead. These records were cross-referenced with Wisconsin Childhood Lead blood lead test result data.
Blood lead tests identified that had been billed to Medicaid using this Current Procedural Terminology code, but were not in the Wisconsin Childhood Lead test result data, were considered to be performed but not reported. Extensive review of unreported tests revealed that some tests were in the blood lead database under a variant of the child's name or date of birth or under the child's previous name as tracked in the Medicaid-enrollment data. The remaining unreported tests were sorted by the Medicaid provider who billed for the test. A list was created for each billing provider that included the child's name, Medicaid number, date of birth, and date of service for the blood lead test. Wisconsin Childhood Lead staff contacted each billing provider by telephone to inform them of the unreported tests and their reporting responsibility and requested the test results. The provider's list of unreported tests was securely e-mailed or faxed to them with instructions for reporting. Each billing provider was asked to add the sample type, test result and analyzing laboratory to the list, and return the completed list to Wisconsin Childhood Lead. Childhood Lead staff maintained a tracking spreadsheet to record the date of contact, primary contact name and phone number, the date the list was sent, and the date when test results were received from the billing provider. Follow-up phone calls were made until all test results were received, the reason for the unreported tests had been determined, or the test records were determined to be irretrievable. Although the provider's list of unreported tests included only tests billed to Medicaid, Childhood Lead staff asked the providers to identify and report tests performed on non-Medicaid children in order to improve completeness and quality of the overall surveillance program.
Project 1: Medicaid provider report cards
In 2007, 1 year after the first report cards were sent, the number of children younger than 6 years who were tested for lead increased by 12%, with 10 170 more children tested than in the previous year. This was the first substantial increase in testing in 4 years. The annual number of children tested continued to increase from 81 834 in 2006 to 106 003 in 2010 (Figure 2). Between 2006 and 2010, testing of Medicaid-enrolled children increased by 31%. The percentage of Medicaid-enrolled children receiving an age-appropriate test increased from 46% in 2004 to a high of 55% in 2010 (Figure 3). Annual overall provider report card scores increased from average scores of 42% in 2006 to 69% in 2010. In 2011, the number of children tested decreased to 104 708 children from the high in 2010.
Informal feedback from providers who contacted Wisconsin Childhood Lead after receiving their report card indicated that barriers to testing include the belief that children under their care were not at risk or had been tested elsewhere (eg, at WIC); lack of awareness of the Medicaid testing requirements; and logistical barriers or loss to follow-up when children were referred to an outside laboratory for the blood draw. Providers expressed the need to receive test results from other sites, such as WIC, Head Start, or other nonmedical testing sites. Providers stated that the list of untested children served as an action list and provided the information needed to contact families and schedule appointments to obtain the missing test.
The provider report cards were suspended after 2011 because of loss of funding from the Centers for Disease Control and Prevention that resulted in reduced program staffing. The number of children tested decreased each subsequent year and fell to 84 245 children in 2016.
Project 2: Improve blood lead surveillance quality
There were 549 786 blood lead tests identified in the Medicaid claims and encounters data, of which 9035 (2%) were not in the Childhood Lead blood lead testing database. There were 471 billing providers (282 outpatient clinic; 189 laboratory/hospital) who had unreported tests. Clinics that performed on-site testing of blood lead samples with a point-of-care testing device comprised 21% of sites with unreported tests and accounted for 43% of the total number of unreported tests. All sites with unreported tests were contacted and 84% of test results were retrieved (Table). Providers could not retrieve 16% of the unreported test records. Outpatient clinics accounted for 72% of the unreported tests and 74% of the irretrievable tests.
Most of the contacted billing providers were unaware that test results had not been reported to Wisconsin Childhood Lead. Common problems identified included misunderstandings on the part of clinic or the laboratory staff of how to report test results; whose responsibility it is to report; and when reports should be submitted. A common occurrence was that newly hired staff were oriented to the point-of-care devices but not educated on lead-reporting requirements.
The Department of Health Services is committed to protecting the health of Wisconsin children and eliminating childhood lead poisoning. Collection of high-quality blood lead data and lead poisoning surveillance are vital parts of that responsibility. Physicians and other health care providers play a crucial role in screening for blood lead levels and preventing childhood lead exposures. Timely identification of children with elevated blood lead levels allows prompt coordination of public health interventions to protect children from ongoing lead exposure and reduce the harmful effects of lead. However, surveillance data showed that not all health care providers tested children appropriately and not all blood lead tests were appropriately reported. Evaluations of other state programs have revealed similar findings;6–9 a review of lead screening in Ohio, for example, found that fewer than half of Medicaid-enrolled children received appropriate testing.6 Testing estimates based on the National Health and Nutrition Examination Survey indicate that this is a widespread issue.10
Childhood lead poisoning prevention programs can effectively utilize Medicaid data to increase testing and improve blood lead surveillance. Linking blood lead data with Medicaid enrollment and claims and encounters data has many benefits including
- identification of children not receiving required blood lead testing and providing notifications to the providers for follow-up;
- opportunities to provide targeted outreach and education to providers and at-risk families to perform appropriate testing; and
- evaluation of reporting practices and improved blood lead surveillance.
The Centers for Disease Control and Prevention program funding was restored in 2014 and allowed Wisconsin Childhood Lead to hire staff and restart the report card project in 2016. In fall 2016, report cards with 2015 testing data were distributed to Medicaid providers who had seen 15 or more Medicaid-enrolled children in that time period. The impact of the 2016 report cards will not be known until 2017 and 2018 blood lead test data are complete.
Based on the improved testing outcomes observed after distributing provider report cards, Wisconsin Childhood Lead plans to continue this outreach annually as resources allow. Report cards serve as an education opportunity for clinical providers. Surveys have shown that primary care providers often fail to test Medicaid-enrolled children because of lack of familiarity with screening recommendations.7,8 Reviews of Medicaid data suggest that some providers may be improperly targeting screening and potentially missing children with elevated blood lead levels.9
To allow timely access for providers to blood lead test results that were performed outside of their practice setting, the Department of Health Services makes lead results available through the Wisconsin Blood Lead Registry (Lead Registry), a secure Health Insurance Portability and Accountability Act–compliant system, via the Wisconsin Immunization Registry portal. Wisconsin Childhood Lead updates the Lead Registry each week with newly reported test results from the Childhood Lead blood lead testing database, including tests done at WIC, Head Start, or other nonmedical screening sites. Providers use the Lead Registry to identify children who have not been tested or are due for another test at an upcoming appointment and children with elevated blood lead levels that were measured at another practice and whose families need counseling.
Many Wisconsin health care providers lack awareness of blood lead test reporting requirements. This is a barrier that must be addressed and corrected on an ongoing basis to ensure compliance with reporting and to improve blood lead surveillance through complete and timely documentation of all children tested. To ensure compliance with reporting requirements, particularly by point-of-care testing sites, Wisconsin Childhood Lead recognizes the need to identify new device purchasers and educate existing users on state-reporting requirements.
Implications for Policy & Practice
- Childhood lead poisoning prevention programs can effectively utilize Medicaid data to
- encourage appropriate and timely testing of at-risk children by health care providers to improve blood lead surveillance, and
- identify missing blood lead test results and take actions to obtain the missing results in order to improve the quality and completeness of blood lead data.
- Primary health care providers should ensure that Medicaid-enrolled children in their care receive the age-appropriate tests.
- Many Wisconsin health care providers lack awareness of blood lead test reporting requirements. Outpatient clinics account for the largest proportion of unreported tests and highest priority should be given to working with these sites to improve reporting practices.
1. Centers for Disease Control and Prevention. Preventing Lead Exposure in Children: A Housing-Based Approach to Primary Prevention of Lead Poisoning. Atlanta, GA: Centers for Disease Control and Prevention; 2004. https://www.cdc.gov/nceh/lead/publications/primarypreventiondocument.pdf
. Accessed June 1, 2018.
2. US Department of Health & Human Services. National Toxicology Program Monograph: Health Effects of Low-Level Lead. Washington, DC: US Department of Health & Human Services; 2012. https://ntp.niehs.nih.gov/pubhealth/hat/noms/lead/index.html
. Accessed June 1, 2018.
3. Centers for Medicare & Medicaid Services. Early periodic screening diagnosis and treatment: lead screening. https://www.medicaid.gov/medicaid/benefits/epsdt/lead-screening/index.html
. Accessed June 1, 2018.
4. Centers for Medicare & Medicaid Services. CMCS Informational Bulletin: Coverage of Blood Lead Testing for Children Enrolled in Medicaid and the Children's Health Insurance Program. Baltimore, MD: US Department of Health & Human Services; 2016. https://www.medicaid.gov/federal-policy-guidance/downloads/cib113016.pdf
. Accessed June 1, 2018.
5. US Government Accounting Office. Lead Poisoning: Federal Health Care Programs Are Not Effectively Reaching At-Risk Children. Washington, DC: US Government Accounting Office; 1999. https://www.gao.gov/assets/160/156458.pdf
. Accessed June 1, 2018.
6. Polivka BJ, Salsberry P, Casavant MJ, Chaudry RV, Bush DB. Comparison of parental report of blood lead testing in children enrolled in Medicaid with Medicaid claims data and blood lead surveillance
reports. J Community Health. 2006;31(1):47–55.
7. Kemper AR, Clark SJ. Physician barriers to lead testing of Medicaid-enrolled children. Ambul Pediatr. 2005;5:290–293.
8. Deloye AH, Marquez ER, Gerstenberger SL. Determining childhood blood lead screening
compliance among physicians. J Community Health. 2017;42:779–784.
9. Kemper AR, Cohn LM, Fant KE, Dombkowski KJ. Blood lead testing among Medicaid-enrolled children in Michigan. Arch Pediatr Adolesc Med. 2005;159:646–650.
10. Jones RL, Homa DM, Meyer PA, et al Trends in blood lead levels and blood lead testing among US children aged 1 to 5 years, 1988-2004. Pediatrics. 2009;123:e376–e385.