Appendix A

Scope and Methodology

The Joint Legislative Audit Committee (Audit Committee) directed the California State Auditor to examine the oversight of blood lead tests and associated services by DHCS and CDPH. Table A below lists the objectives that the Audit Committee approved and the methods we used to address them.

Table A
Audit Objectives and the Methods Used to Address Them
Audit Objective		Method
1	Review and evaluate the laws, rules, and regulations significant to the audit objectives.	Identified and reviewed relevant federal and state laws, rules, and regulations related to lead testing and lead poisoning prevention.
2	Determine whether DHCS, CDPH, and a selection of applicable contracted agencies complied with relevant laws and regulations governing blood lead level testing and follow‑up services for children. If any of the agencies did not meet statutory or regulatory requirements, identify the reasons.	Evaluated the policies and processes CDPH uses to establish thresholds for blood lead concentrations that indicate the need for follow‑up services. We determined that CDPH adopted federal standards. Evaluated CDPH’s process for notifying children’s parents or guardians of the results of lead tests and environmental assessments. We determined that health care providers are responsible for informing parents and guardians of lead test results, and environmental investigators provide the results of environmental assessments at their conclusion. Determined how CDPH plans to meet new requirements established by Senate Bill 1041 (Chapter 690, Statutes of 2018) to inform health care providers about lead testing requirements and the risks and effects of lead exposure. Determined whether CDPH has adequate and appropriate procedures for revising lead testing protocols and policies. We determined that CDPH’s policy is to base revisions to its policies on CDC guidance. Evaluated the adequacy of DHCS’ procedures to ensure that providers comply with the state regulation requiring the provision of lead tests for children in Medi‑Cal.
3	For at least the previous three years, determine how many children enrolled in Medi‑Cal for at least three months received blood lead tests at age 12 months and age 24 months, respectively. Additionally, determine how many children did not receive the two required blood lead tests by age 24 months and did receive them before age 72 months. To the extent possible, determine how many of these children with elevated blood lead levels received the appropriate follow‑up services as required by laws and regulations, identify which agencies provided the services, and assess whether the services provided were appropriate or duplicative. Furthermore, to the extent possible, identify how many children who should have received tests did not, and how many who should have received appropriate services did not.	Analyzed DHCS’ data to determine the number of children who were enrolled in Medi‑Cal and received blood lead tests. Our analysis included child Medi‑Cal beneficiaries with full‑scope benefits who were eligible for at least three consecutive months that spanned their first or second birthdays. We considered a child as having a test at age one or age two if the child received a blood lead test within six months of the child’s first or second birthday, respectively. For children who did not receive a test at age two, we determined whether they subsequently received a blood lead test before turning age six. Analyzed CDPH data to identify children with elevated lead levels and determined whether those children received the necessary follow‑up lead tests within CDPH’s specified timelines. As we discuss in Chapter 3, data limitations affect CDPH’s ability to assign lead test results to the correct children in its case management system. Therefore, our analysis identified unique children based on their names and birthdates. Reviewed a selection of cases of children with elevated lead levels to assess whether the children received appropriate case management services in accordance with CDPH guidelines and contracts with local agencies and whether CDPH and local prevention programs duplicated services provided by other agencies. We found that the children received appropriate case management services and that the services CDPH and local prevention programs provided to these children were not duplicative of services provided by other agencies.
4	Determine how DHCS and CDPH collect and share data and reporting related to blood lead level testing and follow‑up services for children in Medi‑Cal, and assess whether the information is shared efficiently and effectively between the two entities. Assess how the entities use the collected data and whether other opportunities exist to make use of the collected data to better serve children with elevated blood lead levels and to improve statutory or regulatory compliance.	Determined how DHCS and CDPH collect and share information on lead testing and follow‑up services. DHCS and CDPH collect data for different purposes and share the information through an interagency agreement. Assessed the efficiency and effectiveness of data collection, reporting, and sharing between DHCS and CDPH and determined whether increased sharing could better ensure that children receive tests and services in a timely manner and in accordance with applicable law. We found that CDPH’s existing agreement with DHCS provides sufficient access to obtain the data necessary to meet a new requirement to report the numbers of children enrolled in Medi‑Cal who did and did not receive lead tests. Determined how DHCS and CDPH use the data they collect to serve children with elevated blood lead levels and to comply with state law. Identified opportunities to make use of the available data to better serve children, including analyzing the potential benefits of making CDPH data available to DHCS. State law changed in June 2019 to allow CDPH to share its data with DHCS to better ensure that children enrolled in Medi‑Cal receive lead tests and related services. Determined whether additional data reporting by providers and laboratories would allow CDPH to better target its lead poisoning reduction efforts.
5	Determine whether DHCS and CDPH maintain complete data for blood lead level test results and follow‑up services for children. Assess how CDPH and DHCS ensure that they receive accurate and complete data from entities they work with to administer blood lead level tests and follow‑up services, such as contracted local agencies and managed care plans. Additionally, determine how this data is managed and utilized to ensure entities comply with laws and regulations in providing tests and services.	Evaluated the consistency and effectiveness of DHCS’ efforts to ensure accurate and complete data. Evaluated the effectiveness of CDPH’s efforts to ensure accurate and complete data, including how it manages its backlog of test results and how the backlog hinders its ability to mitigate lead risks. Evaluated CDPH’s efforts to ensure that laboratories accurately and completely report all required data with the results of lead tests in a timely manner. Reviewed a selection of lead test results and verified the accuracy of the blood lead levels using source documentation from the laboratories. Evaluated the two agencies’ management and use of data to ensure compliance with applicable law.
6	Assess the extent to which the programs to manage blood lead testing and lead exposure prevention administered by DHCS and CDPH are achieving their respective missions. If the programs are not meeting their missions, identify the major reasons why not.	Evaluated DHCS’ facility site reviews and other oversight activities to ensure that all children in Medi‑Cal receive lead tests. Analyzed a selection of lead poisoning cases to evaluate the effectiveness of CDPH’s case management process by determining whether CDPH followed its procedures and whether the procedures resulted in decreases in the children’s lead levels. We did not find any instances where the case management deviated from CDPH’s procedures, and we found that in nearly all cases, the children’s lead levels decreased. Determined the extent to which DHCS and CDPH coordinate or overlap in providing case management services to children who have been exposed to lead. The nature of the services each agency provides are different, resulting in minimal risk of overlap. Evaluated how well CDPH identifies and mitigates environmental lead risks in specific geographic areas through environmental lead testing or other processes. Reviewed how CDPH assesses the progress it has made toward eliminating lead poisoning and determined that it does so by tracking the percentage of tested children with elevated lead levels over time. We found that during the past five years, these percentages have not consistently decreased. Researched efforts to identify and mitigate lead exposure used by a sample of other states. To the extent possible, quantified the effect of these efforts. Identified questions included in lead screening questionnaires for a sample of other states and compared them to California’s screening regulation.
7	Determine the extent to which DHCS and CDPH could achieve programmatic efficiencies, cost‑savings, and more effective service provision through greater coordination of blood lead level testing and follow‑up services as required by laws and regulations.	Identified the expenditures and revenues of CDPH’s lead prevention fund. Evaluated the appropriateness of the major costs of the lead prevention program. Determined the financial sustainability of the lead prevention program and CDPH’s plan to improve its financial outlook. Determined whether CDPH followed appropriate practices in selecting a new case management system. We found that it is in the early stages of procuring the new system. Identified whether CDPH and DHCS overlap in their functions and whether reducing this overlap could result in increased efficiencies or cost savings. We found that the functions each agency serve are different, resulting in minimal overlap.
8	Determine what efforts DHCS and CDPH have taken to increase the number of children who receive blood lead level testing and follow‑up services to comply with applicable laws and regulations.	Determined the extent of DHCS’ efforts to increase the number of children who receive lead testing. Determined how CDPH targets its outreach to areas of the State where childhood lead exposure is especially prevalent. CDPH stated that it does not target specific areas of the State where childhood lead exposure is especially prevalent. To the extent possible, correlated CDPH’s and the local prevention programs’ outreach efforts with increased lead testing in individual jurisdictions. Identified policies and best practices in the 10 states with the highest lead testing rates for Medicaid‑enrolled children.
9	Identify and display the geographic distribution of and identify any possible factors that may help explain concentrations of children with elevated blood lead levels. Additionally, identify the geographic distribution of areas with children who should have been tested and have not been.	Geographically identified and mapped children with elevated lead levels and children enrolled in Medi‑Cal who should have received lead tests but did not. We were able to map more than 99 percent of required and missed Medi-Cal lead tests, as well as 92 percent of children with elevated lead levels. Identified and documented possible factors that may help explain concentrations of children with elevated blood lead levels. We did not identify factors with consistent relationships to geographic distributions of children with elevated lead levels, which may be attributable to inconsistent testing rates in different geographic areas.
10	Review and assess any other issues that are significant to the audit.	None identified.

Source: Analysis of Audit Committee’s audit request number 2019‑105, planning documents, and analysis of information and documentation identified in the table column titled Method.

Assessment of Data Reliability

The U.S. Government Accountability Office, whose standards we are statutorily required to follow, requires us to assess the sufficiency and appropriateness of the computer‑processed information that we use to support our findings, conclusions, and recommendations. In performing this audit, we relied on DHCS’ Management Information System/Decision Support System and CDPH’s Response and Surveillance System for Childhood Lead Exposures II (case management system) to identify when children received blood lead tests and the results of the tests. To evaluate these data, we reviewed existing information about the data, interviewed agency officials knowledgeable about the data, and performed electronic testing of the data. We identified various limitations with the data.

Specifically, we reviewed a 2015 report from an organization DHCS contracted with that revealed concerns with both the completeness and the accuracy of DHCS’ data from 2012. This report issued several recommendations to DHCS in an effort to improve data quality, and DHCS took steps to implement these recommendations. Further, a 2019 report from the same contractor found that DHCS’ 2016 data were more complete and accurate than its data from 2012, but it also found gaps in the quality of the more recent data. However, we are unable to quantify the effect these issues had on the data we used for this audit because we were unable to perform completeness or accuracy testing as source documentation was available only at individual medical providers throughout the State, making such testing cost‑prohibitive. With respect to the case management system, as we discuss in Chapter 3, we noted that insufficient data from laboratories, such as names, birth dates, and unique identifiers, limits CDPH’s ability to assign lead test results it receives from laboratories to the correct children in its system.

As a result of these data limitations, we found that the Management Information System/Decision Support System and case management system data were of undetermined reliability for our purposes. Although this determination may affect the precision of the numbers we present, there is sufficient evidence in total to support our findings, conclusions, and recommendations.

Appendix B

Many Children in Medi‑Cal Who Did Not Receive All Their Lead Tests Live in the 50 Census Tracts Where Elevated Lead Levels Are Most Common

As part of this audit, we identified those geographic areas where the largest numbers of children under age six with elevated lead levels reside and determined for the same areas the number of missed tests children in Medi‑Cal at ages one and two should have received. From fiscal years 2013–14 through 2017–18, the results of lead tests for the 50 California census tracts with the most children with elevated lead levels showed that in nine census tracts in Sacramento County nearly 700 children under age six had elevated lead levels, and children at ages one and two who were enrolled in Medi‑Cal in those areas missed nearly 70 percent of their required tests. Similarly, in eight census tracts in Fresno County, children at ages one and two in Medi‑Cal missed nearly half of the required tests (4,408 of 9,026), despite the fact that 488 children under age six with elevated lead levels lived in those areas. Los Angeles County also had seven census tracts among the 50 with the most children with elevated lead levels, while Humboldt County and Imperial County each had four, as Table B shows.

Table B
The 50 Census Tracts in the State With the Most Children Under Six With Elevated Lead Levels
Fiscal Years 2013–14 Through 2017–18
	All Children Less Than Six Years of Age	Children in Medi-Cal Ages One and Two
County Census Tract Number	Number of Children with Elevated Lead Levels*	Number of Lead Tests Children in Medi-Cal Should Have Received	Number of Lead Tests Children in Medi-Cal Missed	Percentage of Lead Tests Children in Medi‑Cal Missed
Sacramento County
62.01	153	1,135	743	65%
55.05	91	815	511	63
74.23	82	1,130	821	73
60.02	76	588	402	68
61.02	75	809	482	60
77.01	58	726	518	71
56.05	55	725	426	59
74.13	44	1,021	761	75
61.01	43	421	327	78
Subtotal of These Sacramento Census Tracts	677	7,370	4,991	68%

Fresno County
6	87	1,364	658	48%
26.01	79	1,197	567	47
24	67	977	490	50
25.02	61	1,047	479	46
4	52	1,172	554	47
5.02	52	630	298	47
20	46	1,254	588	47
71	44	1,385	774	56
Subtotal of These Fresno Census Tracts	488	9,026	4,408	49%

Los Angeles County
2319	57	1,067	537	50%
2293	54	942	523	56
2318	49	974	474	49
2267	48	929	514	55
2285	47	925	530	57
2316	42	984	561	57
2327	42	871	488	56
Subtotal of These Los Angeles Census Tracts	339	6,692	3,627	54%

Humboldt County
1	85	482	246	51%
2	74	645	323	50
105.01	46	583	302	52
111	41	496	214	43
Subtotal of These Humboldt Census Tracts	246	2,206	1,085	49%

Imperial County
121	62	1,393	453	33%
116	47	1,097	322	29
122	44	1,241	330	27
115	41	973	296	30
Subtotal of These Imperial Census Tracts	194	4,704	1,401	30%

San Bernardino County
49	60	1,371	818	60%
55	50	2,203	1,432	65
56	47	1,428	935	65
Subtotal of These San Bernardino Census Tracts	157	5,002	3,185	64%

Orange County
749.01	61	1,571	510	32%
746.02	51	1,360	440	32
Subtotal of These Orange Census Tracts	112	2,931	950	32%

San Diego County
157.01	69	1,187	691	58%
163.02	42	730	468	64
Subtotal of These San Diego Census Tracts	111	1,917	1,159	60%

Madera County
8	56	1,443	413	29%
9	51	1,840	503	27
Subtotal of These Madera Census Tracts	107	3,283	916	28%

Riverside County
405.02	54	726	460	63%
428	43	1,991	1,261	63
Subtotal of These Riverside Census Tracts	97	2,717	1,721	63%

Kings County
17.01	84	1,780	967	54%

Tehama County
5	52	869	365	42%

Monterey County
137	47	763	230	30%

Santa Barbara County
24.03	45	2,060	868	42%

Kern County
13	44	1,975	1,029	52%

Alameda County
4062.01	44	595	288	48%

Santa Cruz County
1103	43	1,571	783	50%

Source: CDPH’s case management system data and DHCS’ Management Information System/Decision Support System data.

Note: The table above shows the 50 census tracts that had the most children with elevated lead levels, which range from 41 to 153 children. There is one additional census tract not represented in the table that also had 41 children with elevated lead levels. We did not include this census tract because it had fewer children in Medi-Cal with missed tests than the census tract we included.

* An elevated lead level exists when blood in the body reaches or exceeds a concentration of 4.5 micrograms.