AN OPEN LETTER TO THE DEPARTMENT OF HUMAN SERVICES
January 10, 2000
Margaret Murray, Director
Department of Human Services
Div. of Med. Asst. & Health Services
PO Box 712
Trenton, NJ 08625-0712
Dear Ms. Murray:
The purpose of this letter is twofold. First, to get Department of Human Services's (DHS) response to a recent federal clarification of State Medicaid obligations to children with elevated blood lead levels (EBLLs), and secondly, to acquaint you with the provenance and mission of CLPER, a not for profit organization I founded about a year and half ago.
I read with great interest the October 22, 1999 letter which the Director of the Center for Medicaid and State Operations, Mr. Timothy Westmoreland, has sent to all State Medicaid Directors. I seek information regarding New Jersey's compliance with its Medicaid blood lead screening obligations and your interpretation of the letter's language on certain other points.
The letter clarifies federal Medicaid policies that must be implemented by all State Medicaid Systems. It makes clear that lead inspections to determine the source of lead poisoning are definitively, not optionally, reimbursable. Fortunately, in New Jersey lead inspections are reimbursed under our Medicaid system. Assuming that the January GAO report on Medicaid coverage of EBL chiIdren is at least roughly descriptive of conditions in New Jersey, then 60% of EBL children should be covered under Medicaid and 80% should be Medicaid eligible. I have the following questions concerning NJ Medicaid coverage of lead inspections.
1. How much Medicaid money has been expended on lead inspections?
2. What is Medicaid's definition of reimbursable lead inspection activity. Does it cover risk assessment dust wipes, analysis of drinking water, soil, and comprehensive investigations to definitively determine the source of the child's lead poisoning. In brief, do our State Medicaid inspections follow the protocol established in Chapter 16 of the HUD Guidelines? This is a particularly important point because according to NJ Department of Health & Senior Services (NJDHSS) data, local health departments find lead-based paint as the source of the EBLL in only 58% of their investigations. Something is wrong here. Our inspection protocol may be allowing us to miss important vectors of lead transmission.
The letter also makes clear that follow-up services deemed "medically necessary" should also be reimbursable: "In addition, states should cover any follow-up services within the scope of the federal Medicaid statute, including diagnostic or treatment services determined to be medically necessary." (This letter is available at http://www.clper.org. Since specifically cited, it would seem that Case Management should be reimbursable. Unfortunately, Case Management is not currently being reimbursed in New Jersey.
3. Will DHS reimburse Case Management expenses?
4. Will Case Management be instituted upon the determination by a physician that it is a "medically necessary expense?"
5. Will Case Management be defined according to the CDC 1997 Screening Young Children For Lead Poisoning? This is an important question because CDC Guidance defines an Elevated Blood Level to commence at 10 mcg/dL and calls for blood lead testing at three month intervals when the child's blood level is between 10-19 mcg/dL. Our NJ lead screening regulations NJSA 26:2-137.2 to 137 define an elevated blood lead level to commence at 20 mcg/dL at which point CDC Guidelines would have to be followed.
My last questions relate specifically to CLPER's mission which, in addition to Case Management, is to get lead hazard control, i.e., interim controls, defined as Medicaid reimbursable medical interventions as is chelation therapy. Mr. Westmoreland's clarification comports exactly with CLPER's stated interpretation of Medicaid law, MEDICAID LAW AND LEAD HAZARD INTERIM CONTROLS (see attached file or go to http://www.clper.org ).
CLPER's vision is that a child's pediatrician based upon the EBLL and the environmental investigation will be able to make the determination that interim controls be applied to the child's residence as a medically necessary treatment under Medicaid's EPSDT. Interim Controls should be applied by highly trained, skilled professionals and should include such measures as lead dust removal, precision cleaning with specialized detergents, friction surface treatments and paint stabilization. The efficacy of interim controls requires scientific verification through both environmental and blood lead monitoring and consequently must be closely tied to Case Management protocols.
6. Does DHS agree that the application of interim controls should be Medicaid reimbursable, if deemed "medically necessary" by the child's examining physician?
The institution of Case Management and Interim Controls can rapidly bring significant relief to our lead poisoned children, whose plight is of longstanding tragic proportions, especially in the city of Newark. Looking at NJ DHSS data in its most benign light, 36% of residences of children with BLLs equal to or greater than 20 mcg/dL, the trigger for legally mandated investigation and lead based paint abatement, were actually abated during the year July 1, 1997 through June 30, 1999. The NJDHSS does not provide data on the length of time it takes from diagnosis to abatement. Local health officials and examining physicians agree that in many cases the court sanctioned due process in the context of the high cost of abatement effectively delay remediation for months and sometimes years.
The real condition of our lead poisoned children is actually far worse than the 36% figure would indicate:
"There were 2,030 I&A forms [Lead Poisoning Environmental Investigation and Abatement report] issued in FY 1998 There were 408 cases (20% closed without an investigation being performed. These cases were closed because:
The reported elevated result was on a capillary blood sample, and a subsequent venous confirmatory test found that the child's blood lead was not elevated
An abatement had recently been completed on the child's residence, as a result of either a previous elevated blood lead test on the same child, or an elevated blood lead test on a sibling or other child living at the same address; or
The child had never lived at the address given on the laboratory report, and the local health department was not able to locate the family.
Of the 1622 cases for which an inspection was required, inspections were completed on 1,204 (74%). Where investigations were completed, local health departments found lead paint hazards in 701 properties (58%). Lead hazard abatement had been completed on 251 of these properties (36%) as of June 30, 1998."
The most salient point to note about this data as it pertains to the 36% rate of abatements is that 418 (1622-1204) residences that required environmental investigations had not been inspected as of the time DOH compiled its data. If we assume that the percentage of inspected units found to pose a lead based paint hazard by local health department inspection (58% representing 701 properties) has validity for the 418 un-inspected units, we must add 243 properties to the 701 inspected properties for a total of 944 properties. Thus the percentage of abated properties would decline to 27%.
A second important point to note is that the issuance of 2030 I&A forms represents a substantial decline from previous years. This decline is the more startling since NJSA 26:2137.2 to 137.7, commonly known as the Universal Lead Screening regulations, were adopted on December 1, 1997. The total number of lead poisoned children in New Jersey has been projected at 6000 based upon national averages. Consequently, as acknowledged by DOH the 2030 I&A forms do not reflect the magnitude of the problem in our state.
I realize that I have raised some complex questions which require considered response. Please call on me should you think I may prove helpful in your deliberations.
Updated January 11, 2000. Note: Footnotes have been omitted; for a copy containing all footnotes, please contact CLPER.