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- Appendix A—Scope and Methodology
- 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
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.
|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.||
|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.
|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.
|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.
|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.||
|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.||
|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.||
|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.||
|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.
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.
Six Years of Age
|Children in Medi-Cal Ages One and Two|
|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|
|Los Angeles County|
|San Bernardino County|
|San Diego County|
|Santa Barbara County|
|Santa Cruz County|
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.