Performance Improvement 1996. The Effect of Mandated Managed Care for Medicaid Populations on the Practice of Public Health: The Example of Childhood Lead Poisoning Prevention



This study examined the likely effects of managed care reforms on the delivery of childhood lead poisoning prevention (CLPP) programs. Three major service-related components of CLPP programs--screening, laboratory analysis, and case management--were evaluated at selected State and local public health departments (S/L PHDs). Results suggest that, as managed care continues to increase its share of the health care market, there is a possibility that appropriate childhood lead screening will decrease, that the participation of public laboratories in performing blood lead analysis will decline, and that followup services for children with elevated lead levels will be delivered outside the traditional health department setting. Assurance that these activities continue to be performed adequately will require public health monitoring of screening and followup and carefully written Medicaid managed care contracts. This report focuses on CLPP programs, but the underlying question it asks--how can we ensure that important public health services to children (and others in need) will continue as managed care takes over health care systems, including Medicaid--has broad implications for many other programs.


This study was undertaken to (1) gain a thorough perspective on how various State reform efforts using different types of managed care arrangements have influenced, either positively or negatively, the three major service components of CLPP programs; (2) gather detailed information about how selected programs are handling the challenges presented by managed care and, where possible, identify patterns and themes; and (3) identify strategies that might help lead poison prevention grantees and other providers respond creatively to the challenges of a new health care environment.


State health care reforms are diverse, but current trends suggest that privatization of direct services previously delivered by the public sector is on the rise. Marked increases in the cost of health care are driving this trend. By 1993, Medicaid was the single largest and fastest growing component of most State budgets, accounting for 18.4 percent of the States' total expenditures.

In an effort to stem rising health care costs, many States have turned to managed care models to deliver personal health care services to low-income persons and to other vulnerable populations, including those eligible for Medicaid. At this time, all but eight States offer some type of managed care to Medicaid enrollees; approximately 25 percent of all Medicaid enrollees are part of a managed care arrangement, and most of these individuals are in full-risk capitation programs, which generally are responsible for all care rendered. The shift from the traditional indemnity insurance system to a managed care system is expected to alter markedly the delivery of direct and nondirect services. The type of managed care organization (MCO) models that predominate within a State will likely further affect the role of public health agencies.

At both the State and local levels, CLPP programs serve primarily the most vulnerable of populations--children of low-income families. Several mechanisms provide ongoing support for these programs. For example, the Centers for Disease Control and Prevention (CDC), which launched its CLPP initiative in 1989, funds 37 S/L PHDs in an effort to develop comprehensive programs to screen, identify, and provide adequate medical and environmental followup to children with elevated blood lead levels (EBLLs). The future of this and other programs is uncertain, however, because of changes in our health care delivery system. In October 1993, the Lead Poisoning Prevention Branch (LPPB) of CDC commissioned a study to examine the effects of managed care reforms on CLPP programs, with a focus on CDC-funded activities. The results of the CDC-initiated study are presented in this report.


The five sites chosen include three states (Indiana, Rhode Island, and Tennessee), one county (Pinellas County, Florida), and one city (Minneapolis, Minnesota). They serve as models for how S/L PHDs can adapt to a managed care environment, and were selected on the basis of their involvement in a range of managed care environments and their varied responses to managed care. Teams of two contractor staff members and at least one CDC/LPPB staff member conducted the site visits. Initial site visits took place between July and September 1994; followup interviews with key personnel from all sites were conducted by phone in February 1995. Team members interviewed CLPP program staff responsible for each of the major service components of the program. They also interviewed maternal and child health staff, Medicaid staff, and key administrators. A mix of State and local respondents was sought. Where possible, the contractor/CDC team interviewed MCO staff. The report's authors acknowledge that the study's findings are based on data from a limited number of case study sites.


This report recognizes the extent to which managed care has been incorporated into our health care system. For the three components studied (screening, lab analysis, case management), data indicate that services, and therefore the individuals who receive these services, will be adversely affected in the absence of legislated mandates or highly specific contracts written between the State Medicaid agency and the MCOs operating within the State.

Data on the first component--screening--indicated that the number of lead screenings in the surveyed States decreased between 1993 and 1994. In Tennessee, for example, approximately 40 percent fewer screens were reported in 1994 than were projected for that year, but decreases in lead screenings occurred studywide. Possible explanations for the decrease include inadequate reporting and communication between private and State laboratories; poor provider compliance (e.g., with Early and Periodic Screening, Diagnosis, and Treatment program [EPSDT]); and difficulty in obtaining approval for screening.

The report recommends the following strategies to help States ensure that lead screenings are conducted: increase provider-based education and advocacy; legislate a screening mandate; expand reporting requirements; add lead screening to the State's quality assurance indicators; enforce EPSDT; retain some public sector service delivery role, including joining MCO networks as primary care providers; and try to obtain blanket authorization for lead screening within the private sector.

Data on the second component studied--lab analysis--indicated that data collection in general is likely to be severely affected by managed care, particularly in States without a strong and comprehensive reporting law. Historically, CLPP programs have received the data on blood lead tests primarily from public laboratories, whether or not a State had a reporting mandate. Surveyed sites reported success using the following strategies: establish a reporting law; mandate the use of public laboratories for selected tests; establish price (and other) incentives; and focus on the importance that surveillance serves in maintaining and improving public health.

Case management services, including necessary followup treatment and retesting of children with EBLLs, are currently performed by CLPP staff either directly or through links with other public agencies. Data from site visits revealed that private providers and MCOs had a number of concerns about CLPP case management services and admitted to a lack of knowledge of comprehensive care and followup, a lack of ability, and a lack of incentive. The report suggests the following strategies to ensure appropriate and adequate case management: establish reporting laws; identify and separately fund core public health functions; require data collection at the individual person level; require that case management responsibilities be detailed in the MCO contract; and encourage mandated or contractual relationships between MCOs and S/L PHDs.

Finally, the report recommends that S/L PHDs seek to maintain public sector service delivery, build a legal infrastructure to influence the behavior of private providers, and fund core public health functions with monies derived from non-Medicaid sources.

Use of Results

In the evaluation of the activities of the lead programs funded by CDC, MACRO International, Inc., studied the effect on lead programs of the shift to managed care of formerly public-sector patients and assessed three lead poisoning prevention program functions: screening, lab analysis, and case management.

As a result, LPPB was able to improve its guidance to State and local childhood lead poisoning prevention offices about the appropriate language for State Medicaid managed care contracts requiring lead poisoning prevention services. LPPB was also able to provide guidance on improving data systems to monitor managed care performance. Thus, some programs have quickened the pace of their efforts to complete monitoring systems, and others have formed ties with Medicaid agencies.

In addition, investigators studied the community perspective on the childhood lead poisoning prevention efforts of public health agencies. Representatives of two types of community groups were consulted: umbrella organizations, which generally have national or State-level structure and support, and community-based organizations, which are generally local in origin and support. Representatives participated in focus groups to discuss several topics, including their relations with public health agencies and their visions of how to improve these relationships. As a result, some programs have been able to change their tactics for collaborating with community-based organizations, and some have broadened the focus of their collaborative efforts.

Agency sponsor:

National Center for Environmental Health

Federal contact:

Nancy Tips
PIC ID: 4743.1
NTIS Accession Number: PB 96-144670

Performer organization:

MACRO International, Inc., Silver Spring, MD