Blood lead poisoning in children: An old challenge with new solutions
Gary Goldstein, MD, thinks managed care hates carveouts, and he should know. The physician and president of Johns Hopkins University’s Kenn edy Kreiger Institute (KKI) in Baltimore has been trying for years to get an MCO in Mary land’s Medicaid program to pick up his program for treating and preventing lead poisoning in children, with no success.
The distractions that have consumed Medicaid managed care org anizations since the program was made mandatory in 1997, says Mr. Goldstein, are likely part of the reason. The reasons Maryland Medicaid managed care officials give are broader, though, and suggest how specialty care can get caught by shifts in technology as well as politics.
Lead poisoning in children seems at first like an embarrassing relic that rightly belongs to a previous, less-informed generation. But while lead poisoning among children is on the decline, it is, in fact, still a serious health problem that affects an estimated 930,000 mostly inner-city children between the ages of 1 and 5. And the official estimates may not reflect the full extent of the problem.
"On the whole, the states have a dismal record of implementing federal Medicaid requirements for lead screening, and the federal government has not taken adequate steps to monitor and hold the states accountable," says a report late last year from the National Health Law Program in Washington, DC.
In response to the problem, Baltimore health care providers have — with great success — turned to the tools and techniques of disease management to cut blood lead levels in children while cutting overall expenditures.
"Unlike managing hypertension or asthma, this crosses several territories in how to best prevent it," says Mr. Goldstein. "If you’re going to have a real intervention, there has to be an environmental component to it that is not traditionally health care."
Because lead poisoning is an ailment that disproportionately affects urban and low-income children, Medicaid providers traditionally are the first to see the need for treating and preventing it. Kennedy Kreiger’s community-based orientation is the product of intense collaboration in the early 1990s between institute representatives and Maryland Medicaid officials.
The strategy has been shown to cut costs for treating lead-poisoned children and win favor among the children and families who participate. The institute’s approach reduced costs of caring for lead-poisoned children to 62% of the historical costs, according to a recent report by the Princeton, NJ-based Center for Health Care Strategies. At the same time, the program was able to replicate the reductions in blood lead levels that had been achieved under a traditional fee-for-service model.
When Medicaid officials rolled out mandatory Medicaid managed care in 1997, they discontinued the contract with Kennedy Kreiger and did not carve out the service from the MCO contracts. Officials at the Maryland Department of Health and Mental Hygiene, the state’s Medicaid agency, recently analyzed whether restarting the program would be a good idea and recommended against it.
There is "no evidence that children with lead poisoning are receiving inappropriate treatment within the MCOs," says the report to the Maryland legislature. "It would be inappropriate and counterproductive for MCOs to be responsible for all other care, including primary and specialty care, and not be responsible for lead treatment. This would make it much more difficult for the MCOs to manage and coord inate necessary health care for treatment."
The revolving door
Lead poisoning lives up to its reputation as a disease of children in urban areas and older, pre-1950 housing, as lead-based paint is the most common source of childhood lead exposure in the United States. While children still can and do get lead poisoning from eating paint chips, the image is not wholly accurate. Lead is more commonly transmitted through paint dust, and it’s also leached from old lead water pipes.
Health insurers’ conventional approach to childhood lead poisoning is to treat the immediate illness while ignoring the environmental and socioeconomic factors that created the problem. Invariably, this strategy sends treated children back to a toxic environment that exposes them again to lead poisoning and creates the need for yet another treatment. In 1993, health professionals at the institute’s Lead Poison-ing Prevention Clinic decided there had to be a better way.
Community the key
Administrators saw a shift to community-based services as the key to breaking the vicious cycle of hospitalization and re-hospitalization — and ensuring long-term success — for the poisoned children they served. To move services out of the KKI Children’s Hospital, they created in 1994 within the hospital an eight-bed outpatient lead poisoning treatment unit. The focus of the clinical care was the lead poisoning prevention clinic at the institute, which had been in existence since 1973. The clinic was and is a specialty referral center for the region and serves about 650 children each year.
KKI envisioned organizing the services for children under a single capitation contract. The institute proposed to the Maryland Depart ment of Health and Mental Hygiene managing a child with lead poisoning for a capitated amount based on the blood level the child has upon entry into the program. The contract allowed for the reimbursement of social and community-based services intended to modify the environment that poisoned the child in the first place.
The innovative twist was that chelation services, blood-cleansing procedures heretofore done on an inpatient basis, could be done in a residential setting. KKI administrators anticipated the cost savings of that approach to be 30% to 50% of previous expenditures.
Even the KKI’s lowest level did not encompass the full range of blood lead poisoning in the community; the Centers for Disease Control and Prevention (CDC) in Atlanta establishes a blood lead "action level" of 10 mcg/dL or higher. About 20.5% of Maryland’s children between ages 1 and 5 — and 30.5% of Baltimore’s children of the same age — have blood lead levels high enough to be considered lead poisoning by the CDC.
The capitation contract proposed not only to address a single episode of blood lead poisoning, but also to prevent the child from being poisoned again and needing repeat treatments. To come up with the broad array of medical and social services needed and an estimate of the related costs, KKI administrators pored over historical data in the Medicaid program. Capitation rates were calculated with adjustment for age, blood lead levels, and number of children in the household receiving treatment. Services covered were housing, medication, clinic visits, laboratory services, core staff costs, other direct services as needed, and administration and overhead.
The annual cost of caring for a child with blood poisoning ranged from $2,952 to $15,652, depending upon the child’s blood lead level. Clinically, the program was able to maintain the typical reduction found in a child’s blood lead levels that had been achieved under the more expensive, hospital-based model for treating lead poisoning.
Shift to outpatient care
Since the early 1990s, outpatient technology for treating blood lead poisoning has become simpler, and thus the institute’s relative advantage in avoiding hospitalization has diminished, says Susan Tucker, a health care financing administrator within the Maryland Department of Health and Mental Hygiene.
Tasks once accomplished within the capitated program are being handled within the state’s public health infrastructure and still with in a disease management model, but at a lower cost than the institute’s, Ms. Tucker says.
Administrators at the Center for Health Care Strategies, which published the report, are not disheartened by the program’s inability to nab a contract with one of the HMOs in Maryland’s mandatory Medicaid managed care program, which went into effect in 1997. Children still are seen at the institute but under more traditional financial and care management arrangements.
"It would have been perfect if the HMOs would have, in turn, contracted with KKI," concedes Karen Brodsky, the center’s vice president for programs. "I would imagine there were a number of distractions . . . that just prevented the managed care organizations from making this a priority."
KKI’s relationship with Maryland’s Medicaid program already had been discontinued when the institute approached the Center for Health Care Strategies about publicizing the lead poisoning prevention program. The center was so impressed with KKI’s approach that it agreed to showcase the strategy as a best practice among Medicaid HMOs.
"The other opportunity I think this does present for states in Medicaid managed care is where states have strong primary care case management programs [PCCM] or where they are trying to advance those PCCM programs to be more proactive around disease management," explains Ms. Brodsky. "This presents them with a wonderful opportunity to try a model that’s been tested and is very well documented."
A report on the Kennedy Kreiger Institute program is available from the Center for Health Care Strategies, 353 Nassau St., Princeton, NJ 08540. Telephone: (609) 279-0700. Web: www.chcs.org. Contact Mr. Goldstein at (410) 502-9483.
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