State Auditor Releases Report on Medi-Cal Childhood Lead Level Testing

On Tuesday, California State Auditor Elaine Howle released a report entitled, “Childhood Lead Levels: Millions of Children in Medi-Cal Have Not Received Required Testing for Lead Poisoning.” The audit was conducted on the Department of Health Care Services (DHCS) and the California Department of Public Health (CDPH) and found that from fiscal years 2009-10 through 2017-18, more than 1.4 million of the 2.9 million one- and two-year old children enrolled in Medi-Cal did not receive any of the required lead level tests and another 740,000 children missed one of the two tests.

State law generally requires that children enrolled in Medi-Cal receive tests for elevated lead levels at the ages of one and two years. According to DHCS’ data, the rate of eligible children receiving all required tests was less than 27 percent. Many of these children, according to the State Auditor’s office, live in areas of the state with high occurrences of elevated lead levels. The Auditor determined that DHCS has not effectively overseen Medi-Cal managed care plans to ensure that children are receiving the required lead tests.

DHCS has only recently begun developing a performance standard for measuring whether managed care plans are ensuring that children receive such tests. While DHCS is developing an incentive program to increase payments to healthcare providers for each lead test they report administering, the State Auditor is concerned by how long it may take these programs to influence lead testing rates. The State Auditor further concluded that DHCS could take more immediate action to increase the number of children receiving the tests, such as requiring health plans to identify children who have not received lead tests and reminding their healthcare providers of the need to provide the tests.

Related to CDPH, which is charged with the prevention and management of lead poisoning cases, the State Auditor determined that it has failed to focus on addressing lead hazards before children are exposed to them and has failed to meet legislative requirements concerning lead poisoning. State law requires CDPH to identify geographic areas at high risk for childhood lead exposure and publish an analysis of such areas each year beginning in March 2019; CDPH had not done so as of October 2019. It also failed to meet a statutory requirement to post on its website a list of certain census tracts in which children have tested positive for specified lead levels. The State Auditor conducted a similar analysis and found that from fiscal years 2013-14 through 2017-18, half of children with elevated lead levels were located in just 15 percent of the state’s census tracts.

Moreover, the State Auditor found that CDPH’s efforts do not appear to align with preventing future instances of lead poisoning in geographic areas in which children are at the greatest risk, given that CDPH contracts with childhood lead poisoning prevention programs at local agencies and only requires local programs to monitor abatement in homes of children who already have lead poisoning. The State Auditor also determined that CDPH could not demonstrate the effectiveness of local prevention program outreach activities in reducing lead exposure in high-risk areas. Also included in the State Auditor’s report is an examination of the CDPH Childhood Lead Poisoning Prevention Program, which was found to allocate funding to local prevention programs based on a funding formula that uses outdated information on the number of children with lead poisoning in each jurisdiction, leading to significant differences in the services that local programs have been able to provide.

The State Auditor detailed a series of recommendations for the Legislature, DHCS, and CDPH:

  • The Legislature should:
    • Amend state law to require laboratories to report contact information and unique identifiers with children’s lead test results.
  • DHCS should:
    • Prioritize its effort to adopt a performance standard for lead tests and ensure that this standard is specifically designed to monitor its success in meeting the State’s requirements for lead testing of one- and two-year old children.
    • Incorporate into its contracts with managed care plans a requirement that plans identify each month all children without records of required lead tests and remind the responsible healthcare providers of the need to test those children.
  • CDPH should:
    • Immediately complete and publicize an analysis of high-risk areas throughout the state.
    • Either require local prevention programs to demonstrate the effectiveness of their outreach or analyze the cost-effectiveness of approaches such as proactive abatement and require the local prevention programs to replace or augment their outreach to the extent resources allow.
    • Prioritize meeting legislative requirements, including updating the factors healthcare providers use to determine whether children are at risk of lead exposure.
    • Update its allocation formula to take into account the most recent data for the number of children with lead poisoning in each jurisdiction.

DHCS, in responding to the Auditor’s report, agreed with the recommendations and has prepared corrective action plans to implement them. CDPH also agreed or partially agreed with the Auditor’s findings. The State Auditor found that both DHCS and CDPH’s approaches for implementing certain recommendations do not fully address the related findings and concerns.

The full State Auditor report is available here.