V. Best Practices: Highlights From Successful Programs
SCHF researched the testing programs in several states to identify the reasons for their success. The best practices are described below.
Universal Testing Requirements: Strategic Education to Encourage Compliance
As shown in Table 1.A, most of the universal testing states have high screening rates. None of the universal testing states mentioned actively enforcing the laws that required testing. Staff in at least a few states indicated that parents bear responsibility for getting their child tested by bringing them to appointments.
Instead, these state lead programs encourage compliance, mostly through education to providers and parents. Louisiana has a social marketing campaign. New Jersey partners with regional coalitions to help publicize the testing requirement.
Massachusetts is very hands on in engaging with doctors and reminding them of the testing regulation. Staff frequently call doctors and visit them, they encourage providers to do venous rather than capillary testing to get a more reliable BLL more quickly, and they investigate reasons for low screening rates in specific communities. Lead program staff also remind doctors who aren’t testing of their obligation through formal letters.
Connecticut developed media campaigns on residential lead sources directed toward parents of children in the populations that are historically most likely to have EBLLs. The state also ensures that doctors know of the testing requirement, and doctors were part of an advisory committee providing input on the content of the initial 2009 screening law and subsequent guidance.
Data Matching & Provider Reports
A very successful “best practice” is when lead program staff are able to combine the blood lead test records of children with other state-wide registries, such as an immunization registry or Medicaid registry, to identify children who have not received a blood lead test, and use it to show providers their testing rate or who specifically needs to be tested.
Rhode Island utilizes KIDSNET, a child health registry that captures not just immunization data and lead screening data, but WIC data and home visiting data. Providers can run reports for their practice to identify children who have not been screened at all and which ones need a second test in accordance with state law. Department of Health staff can identify providers who are not running reports. On a quarterly basis, they check the system and send reports to those offices. This probably contributes to the state’s high testing rate: out of children who turned 36 months in 2015, 55% had been tested twice at least 12 months apart and 78% of those children received at least one test by 18 months.
Wisconsin’s experience highlights the importance of putting a list of who needs to be screened directly in front of providers, rather than simply offering them the option to access a database with that information. As indicated above, for six years, the state lead program collaborated with the state Medicaid agency to successfully create and distribute Medicaid Provider Testing Reports, and saw testing rates rise. They lost funding and had to discontinue the program after 2011. Testing rates have decreased each year since, in spite of the state’s continued maintenance of its Blood Lead Registry, which allows providers to see a child’s entire blood lead test history.
North Carolina’s lead program staff had also created Medicaid Provider Report Cards, although the loss of grant funding stopped the program. They plan to resume the practice, since it was very effective.
Covering the Cost of Lead Testing
Two state’s websites estimate blood lead test analysis by state laboratories to cost $11 or $25. One county health department charges up to $43 for the test.
The Affordable Care Act (ACA) requires health insurance plans subject to it (all non-grandfathered plans) to fully cover “lead screening for children at risk of exposure.” The ACA regulations define lead screening by the recommendation in the Bright Futures/American Academy of Pediatrics’ periodicity schedule. At 12 and 24 months of age, the schedule recommends “risk assessments or screenings as appropriate, based on universal screening requirements for patients with Medicaid or in high prevalence areas.” At other ages, testing is recommended only after a positive response to a risk assessment.
CDC has interpreted the Bright Futures/American Academy of Pediatrics’ recommendations at ages 12 and 24 months to include testing for children “living in high-risk areas as defined by the state or local health departments.” Louisiana and Maryland, for example, became universal testing states when they designated all areas of their state as “at high risk” or “at risk.” However, two other universal testing states, Delaware and Massachusetts, likely did not make that designation, since they label only certain areas of their states as “high risk,” and require testing for children living in those places at additional ages beyond the universal testing age(s).
In some universal testing states and others, as noted in Tables 1.A and 1.B, state law unambiguously requires insurance plans to cover testing, regardless of ACA coverage. These state laws also apply to grandfathered plans that are exempted from the ACA’s requirements. In 2016, 23% “of covered workers are enrolled in a grandfathered health plan.”
Lead program staff in some states, such as Minnesota and North Dakota, who did not know of a state requirement for private insurance to cover blood lead tests stated that they haven’t heard of coverage being denied. Vermont staff stated that insurance companies pay for the entire test or most of it.
Free or low-cost testing is offered in several states, sometimes at a local health department, to children who are uninsured or underinsured. For example, New Jersey’s local health departments are required to provide free screening to this population, accounting for an estimated 2% of the annual lead tests in the state.
State Medicaid programs generally cover blood lead tests at the CMS-required ages.
Increasing the Accessibility of Testing with “Point-of-Care” Machines
Children are more likely to be tested for BLLs when doctors can perform the blood lead testing in their offices, instead of writing an order to be filled at a distant laboratory. “Point-of-care” blood lead testing machines, such as LeadCare® II analyzers, have become popular. They allow doctors to analyze a blood lead test right in their offices and provide immediate feedback to patients on whether they need any confirmatory testing.
Point-of-care machines are widely used throughout the U.S. The Vermont Department of Health works with the state chapter of the American Academy of Pediatrics to provide LeadCare II analyzers free of charge to selected practices; Idaho provides them free to doctors testing patients enrolled in Medicaid. New Jersey provides them to local health departments to conduct screening.
Wisconsin reported that it is challenging to get doctors to report all of the results from analyses with LeadCare II machines. Pennsylvania, for example, does not require doctors to report the results of all in-office testing and analysis.
Requiring Proof of Lead Testing for Enrollment: a Double-Check on Compliance
Several states require a statement that a child has been tested for lead as a condition of enrollment in schools or child care facilities: the District of Columbia, Delaware, Iowa, Illinois, Maryland, Massachusetts, Missouri, New York, and Rhode Island. According to state staff, two local health departments in Connecticut also require this proof. The requirement can serve as a double check on whether the required screening actually took place.
However, only two states indicated that children are prevented from enrolling or remaining in school without having a test per their requirements – Connecticut (the two local health departments) and Delaware. New York stated that child care providers “must try to obtain proof,” but the child can’t be excluded from child care without documentation of a test and is just referred to get the testing.
With the exception of Iowa Department of Public Health and the Delaware Department of Education, none of the state agencies we spoke with seemed likely to monitor compliance with these rules. Personnel in the District of Columbia’s Office of State Superintendent of Education, for example, only make sure the centers or schools are checking for the blood lead test and don’t check the tests themselves.
The Iowa Department of Public Health sorts through records to determine which children are not in compliance and the Department asks the school to tell the parent to get their child tested. Although they can’t follow up on every case and they depend on education, the compliance rate is high. The Meriden Local Health Department in Connecticut reports that its requirement is also working well. Delaware Department of Education staff monitors kindergartners’ electronic medical records to check on compliance.
In addition to asking whether this requirement would help increase screening rates, selecting the appropriate ages for testing is a key factor. Although Iowa, for example, is able to ensure a high number of children are screened because more children go to kindergarten than preschool or childcare facilities, this means the test isn’t required until around 5 or 6 years old. This is after the critical testing ages of 1 and 2 years, so elevated levels could already have been missed. Most of the other states (except Massachusetts and Meriden in Connecticut) impose the requirement starting earlier than kindergarten.
Delaware staff believes this requirement boosts testing rates, as they see an increase in the number of lead tests reported around late summer and early fall, when the school year begins.
Requiring All Test Results To Be Reported
As indicated in Tables 1.A – 1.D, 40 states and the District of Columbia require all laboratories and at least all health care providers conducting in-office BLL analysis (such as with LeadCare II analyzers) to report all BLL test results for children under 72 months to the state.
Funding the Programs
Most states rely heavily on CDC funding for their lead programs. By contrast, California has established a “Childhood Lead Poisoning Prevention Fee” to pay for “health care referrals, environmental assessments, and educational activities” related to lead exposure. This annual fee is generally assessed on manufacturers “responsible for identifiable sources of lead” that currently or historically were significant contributors to environmental lead contamination. This includes businesses in the petroleum and paint industries and facilities that release lead into the air.