COMMITTEE ON LEGISLATIVE RESEARCH
OVERSIGHT DIVISION
FISCAL NOTE
L.R. No.: 1621-03
Bill No.: SB 572
Subject: Establishes a Childhood Lead Testing Program in the Department of Health.
Type: Original
Date: March 30, 2001
FISCAL SUMMARY
| FUND AFFECTED | FY 2002 | FY 2003 | FY 2004 |
| General Revenue | ($2,506,377) | ($2,918,509) | ($2,995,720) |
| Childhood Lead Fund | Unknown | Unknown | Unknown |
| Insurance Dedicated Fund | $10,000 | $0 | $0 |
| Total Estimated
Net Effect on All State Funds |
($2,496,377) to Unknown | ($2,918,509) to Unknown | ($2,995,720) to Unknown |
| FUND AFFECTED | FY 2002 | FY 2003 | FY 2004 |
| Total Estimated
Net Effect on All Federal Funds * |
$0 | $0 | $0 |
* Income and expenditures exceed $170,000 per year and net to $0.
| FUND AFFECTED | FY 2002 | FY 2003 | FY 2004 |
| Local Government | (Unknown) | (Unknown) | (Unknown) |
Numbers within parentheses: ( ) indicate costs or losses.
This fiscal note contains 13 pages.
ASSUMPTION
Officials from the Department of Elementary and Secondary Education (DES) stated DES would require 0.5 FTE Research Analyst to develop and provide questionnaires for every child to be assessed within three months of birth and at least once a year thereafter until the child is six years of age to determine whether such child is at high risk for lead poisoning. The DES anticipates total costs of $31,644 for FY 02; $38,940 for FY 03; and $39,926 for FY 04.
The DES officials also stated that every child care facility affiliated with a school system would be required to obtain evidence of lead poisoning testing. If there is no evidence of testing, the facility shall provide the parent with information about lead poisoning and locations where the child can be tested. When a parent cannot obtain such testing, the facility may arrange for the child to be tested. It is unlikely that many facilities will pay for such testing since there is no penalty associated with this provision.
Oversight assumes development of the questionnaires would occur during the first year and DES's responsibilities in subsequent years would be limited to providing the questionnaires to parents/guardians of children in the age ranges stated in the proposed legislation. As a result, Oversight assumes existing staff could develop the questionnaires in year one and provide the information during subsequent years.
Officials from the Missouri Consolidated Health Care Plan (HCP) stated this bill requires medical plans to offer coverage for testing pregnant women for lead poisoning and for all testing for lead poisoning authorized in Chapter 710. Testing for lead is done through testing blood specimens. This type of test is not costly. Therefore, this bill should have a minimal, if any, impact on the HCP.
Officials from the Department of Health (DOH) provided the following assumptions.
A. Number of additional childhood lead tests that would be done annually based on the testing guidelines in the proposed legislation. The DOH also stated there is no determination whether tests being run are capillary or venous.
# Tests per child at normal risk: # Tests per child at high risk: High Risk Children living in
9-12 mos = 1 9-12 mos = 1 home being renovated during
13-24 mos = 1 13-24 mos = 2 1 year increases by 2 tests:
25-36 mos = 1 25-36 mos = 2 Assume 5% of high risk kids
37-48 mos = 1 37-48 mos = 1 i.e. total of # of high risk
49-60 mos = 0.5 49-60 mos = 1 children x 2
61-72 mos = 0.5 61-72 mos = 1
ASSUMPTION (continued)
· Calculated by 5 groups: St. Louis City, St. Louis County, Jackson County (includes Kansas City), Greene County (includes Springfield) and Outstate (all other health jurisdictions). Unable to separate statistics for Kansas City from Jackson County or Springfield from Greene County.
· Total figures for children six years of age or less are based on 1990 census data, adjusted for 1999. Total figures were divided in 6 equal 1-year age layers.
· The 5 groups were designated a "high risk factor" based on population density, old
housing, poverty, and current EBL levels: St. Louis City = 4, Kansas City/Jackson County 2, St. Louis County, Springfield/Greene County and Outstate = 1. The high risk
factor was given a percentage rate: 5 =100%, 4 = 80%, 3 = 60%, 2 = 40% and 1 = 20% and that percentage of total children in the group were determined as high risk or average risk.
· Using the number of tests per child for each age layer above the number of tests per population group was determined and added together. A total of 424,191 tests annually would be expected to be performed.
· Currently approximately 80,000 tests are logged annually. This would increase the number of tests by 344,191 tests over what is performed currently.
B. Determine number of additional data entry FTEs both for state and in Local Public Health Agencies:
· Currently DOH enters the data for approximately 1/3 of the 80,000 annual tests, i.e. 26,666 by approximately 1.2 FTEs. This translates into 22,222 per 1FTE.
· The test increased test numbers and data entry need by regional groups:
Area Data Entry NewTest # FTE needed Assume has Need Additional
St. Louis City self 50966 2.3 1 1.3
St. Louis Co. self 80721 3.6 1 2.6
Springfield/Greene self 15,466 0.7 0.5 0.2
KC/Jackson Co. self KC only 63,492 2.9 1 1.9
Outstate DOH 213,547 9.6 1.2 8.4
Total 424,191 19.1 4.7 14.4
· Therefore 364,132 additional tests per year would require approximately 14.4 additional FTEs 8 at DOH and 6 in the LPHAs. 8 DOH Clerk Is will perform this increased data entry and follow-up of lead test information.
· 1 Health Program Representative II will be responsible for grant writing. This would be full time to apply for every federal and state lead grant that becomes available. Many grant applications require development of programs with local public health agencies or other public or private agencies.
ASSUMPTION (continued)
· There are currently 13,400 medical providers licensed to practice in the state of Missouri. Preparation and mailing of the mailing would cost approximately $10,000 based on the costs of the mailing of the testing guidelines in FY 2000.
· It is difficult to determine what the costs of conducting audits of provider records would be. An estimate is that we could contract with an agency to conduct a random sample audit for $20,000.
Assumptions: for FN 1621N SB572 State Public Health Laboratory (SPHL)
A. Number of additional laboratory tests that would be done annually at the SPHL
. Routine screening would produce an increase of 344,191 tests statewide. Follow up testing
of those children found to have initial elevated lead level would add an additional 6,138 tests.
Total increased testing is estimated to be 350,329.
. It must be noted that the following assumption is based upon the SPHL not performing lead tests for private physicians. The total number of lead laboratory tests required with this legislation is much too large to be performed by a single laboratory. Thus, private laboratories would need to be utilized. Our projections are based on serving the non-Medicaid and uninsured population. (Medicaid population can go to a contract lab).
If sufficiently more tests were sent to the State Public Health Laboratory rather than private labs, a major capacity problem would be created in the lab, resulting in significantly higher costs to the Department of Health to implement this legislation.
. The SPHL would perform lead testing for those children who receive lead testing services from
local health departments throughout the State. To determine this estimate, the immunization model for childhood immunizations was used. Approximately, 33% of childhood immunizations are performed in local health departments (city or county). Using this model, the SPHL can be expected to receive a total of 115,608 additional specimens for lead testing.
B. Number and expense of adding additional laboratory staffing to perform 115,608 lead tests.
. The SPHL presently performs approximately 14,000 lead tests annually. Based upon current staffing the following additional staff will be required. Due to laboratory space limitations, staffing needs are based upon routinely operating a 12 hour work day five days per week.
ASSUMPTION (continued)
Laboratory Manager Total Annual
(Public Health Manager B1) 1 @ $44,448 $44,448
. Provide overall scientific management and supervision
Sr. Public Health Lab. Scientist 3 @ $43,308 $129,924
. Provide scientific oversight, quality assurance verification
Public Health Lab Scientist 9 @ $37,488 $337,392
. Perform laboratory analysis of blood samples for lead
Medical Laboratory Technician II 6 @ $23,184 $139,104
. Prepare samples for analysis
Computer Info Technology Specialist 1@ $51,252 $52,252
. Integrate testing data into data system for reporting and
case management
Clerk II 2 @ $19,764 $39,528
. Prepare testing kits for mailing to providers
Clerk Typist II 4 @ $20,472 $81,888
. Perform data entry of client information and
test results plus client billing
C. Assumptions and cost of E&E required to perform additional SPHL testing.
. Laboratory equipment leasing - lead testing requires specialized laboratory testing equipment. Based upon existing workload, five additional testing setups will be required. Each testing system can be leased for approximately $25,000 per year.
Total - 5 testing systems @ $25,000 ---- $125,000
. Laboratory reagents - the chemicals and other material to perform a lead test cost approximately $3.00 per sample testing.
Total 115,608 samples @ $3.00 ----$346,824
. Blood collection kits - samples must be collected in special lead-free test tubes and packaged in
unbreakable shipping containers. These collection kits cost $2 per kit.
Total 115,608 @ $2 ---$231,216
ASSUMPTION (continued)
. Transportation costs - The SPHL employs a statewide courier to pickup and deliver laboratory samples. This is much less expensive than using mail services because of Federal laboratory specimen mailing regulations. The increased cost to extend the statewide courier contract to all local health departments, will average $3 per sample collected.
Total 115,608 samples @ $3 ---$346,824
D. Assumptions regarding fees.
Authority currently exists for the DOH to charge fees now for lead testing, but the department does not do so. It has been a struggle to get children tested for lead. Charging a fee will put up yet another barrier which will prevent children from being tested. The language is permissive regarding fees, not mandatory.
Oversight assumes that DOH would implement a fee to help cover the cost of the lead tests. The estimated revenue to the Childhood Lead Fund is unknown.
Officials from the Department of Insurance (INS) stated health insurers and HMOs will be required to amend policy forms in order to comply with legislation. It is anticipated that current appropriations and staff will be able to absorb the work for implementation of this single proposal. However, if additional proposals are approved during the legislative session, the department will need to request additional staff to handle the increase in workload. The INS estimates 171 health insurers and 29 HMOs will be required to file amendments to their policy form to comply with legislation resulting in revenue of $10,000. If multiple proposals pass during the legislative session which require policy form amendments to be filed, the insurers will probably file one amendment for all required mandates. This would result in increased revenue of $10,000 for all.
Officials from the Missouri Department of Conservation and Office of State Treasurer stated the proposed legislation would not appear to have fiscal impact on their agencies.
Officials from the Office of Secretary of State (SOS) stated this bill establishes a Childhood Lead Testing Program and Fund in the Department of Health. The DOH will promulgate rules to implement this bill. Based on experience with other divisions, the rules, regulations and forms issued by the DOH could require as many as 14 pages in the Code of State Regulations. For any given rule, roughly half again as many pages are published in the Missouri Register as in the Code because cost statements, fiscal notes and the like are not repeated in the Code. These costs are estimated. The estimated cost of a page in the Missouri Register is $23.00. The estimated cost of a page in the Code of State Regulations is $27.00. The actual cost could be more or less than the numbers given. The impact of this legislation in future years is unknown and depends ASSUMPTION (continued)
upon the frequency and length of rules filed, amended, rescinded or withdrawn. The SOS estimates the cost of the proposed legislation to be $861 [(14 pgs. x $27) + ( 21 pgs. x $23)] in FY 02.
Oversight assumes the SOS could absorb the costs of printing and distributing regulations related to this proposal. If multiple bills pass which require the printing and distribution of regulations at substantial costs, the SOS could request funding through the appropriation process. Any decisions to raise fees to defray costs would likely be made in subsequent fiscal years.
Officials from the Department of Social Services (DOS) - Division of Medical Services (DMS) stated the proposed legislation will have a fiscal impact to the DMS. Currently, the DMS provides lead testing at 12 months and 24 months of age. The legislation will require two additional tests for children under the age of six years old. The DMS estimates that there will be an average of 56,785 3-4 year old children needing testing. The current reimbursement for lead testing costs is $5.00. The estimated fiscal impact is $283,925 (56,785 eligibles x $5.00).
Officials from the Department of Public Safety - Missouri Highway Patrol (MHP) stated the Department of Highway and Transportation would respond for the MHP on this proposal.
Officials from the Department of Highway and Transportation (DHT) - Division of Resource Management stated this legislation requires health carriers to provide coverage for lead poisoning testing for pregnant women and children less than six years of age. This benefit must be covered at the same level of coverage as other covered benefits. The Department of Health in coordination with the Department of Social Services and Department of Elementary & Secondary Education is responsible for developing and providing questionnaires for every child to be assessed within three months of birth and annually until the child is six years of age to determine whether a child is at high risk for lead poisoning.
If the questionnaire indicates that a child is at high risk for lead poisoning the child shall be tested at least once every six months between the ages of six months and three years of age and then annually between the ages of three years and six years. In addition, any child to be considered at high risk and resides in housing currently undergoing renovations shall be tested at least once every three months during the renovation and once after the completion of the renovation. Children that are not at high risk for lead poisoning shall be tested once between the ages of nine and twelve months, once at two years of age and annually thereafter until the child is four years of age. The tests for lead poisoning shall consist of a blood sample that shall be sent to a state-licensed laboratory for analysis.
ASSUMPTION (continued)
To determine the fiscal impact of providing the coverage for pregnant women, the DHT found that over the past three years the Medical Plan has had an average of 1,520 pregnancies per year and Westport Benefits, DHT's third party administrator, provided the usual and customary rate (UCR) for the lead poisoning screening and specimen collection. The CPT codes the DHT used are 83645 for the screening and 36415 for the specimen collection. The average UCR, using the
rates for Jefferson City and St. Louis, are $32 for the screening and $14 for the specimen collection. The DHT assumes that this test would be part of a woman's prenatal care and no office visit charge would be necessary. The DHT also assumes that the women have met their deductibles and maximum out of pocket benefits. Therefore, the total fiscal impact to the Medical Plan for the lead poisoning testing of pregnant women would be approximately $69,920 per year [1,520 pregnancies x ($32/screening + $14/specimen collection)].
To determine the fiscal impact of providing the coverage for children, we had to determine how many of the children in DHT's plan would be at high risk for lead poisoning. The DOH provided information that they used in preparing their fiscal impact to this legislation. The DOH calculated this by five groups within the state. Those groups are St. Louis City, St. Louis County, Jackson County/Kansas City, Greene County/Springfield and Outstate (all other health jurisdictions). The DOH then designated a high risk factor based on population density, old housing, poverty and current elevated blood lead (EBL) to each of these groups. The risk factors for each group are: St. Louis City = 4, Jackson County/Kansas City = 2 and St. Louis County, Greene County/Springfield and Outstate = 1. The risk factors were then assigned a percentage rate where the percentage of total children in the group were determined as high risk. The risk factors are 5 = 100%, 4 = 80%, 3 = 60%, 2 = 40% and 1 = 20%. The DOH also used 1990 census data, adjusted for 1999, to determine the number of children in each group.
The census data from DOH showed 38,034 children in St. Louis, 84,088 in St. Louis County, 58,427 in Jackson County/Kansas City, 16,111 in Greene County/Springfield and 251,233 in Outstate. Therefore, the total population of children under the age of six was 447,893.
For purposes of this fiscal note, the DHT is going to use the percentage of children in each group to the total number of children statewide provide by the DOH to determine the demographics of the Medical Plan's children. Following are those percentages:
St. Louis City = 8.5% (38,304/447,893), St. Louis County = 18.8% (84,088/447,893), Jackson County/Kansas City = 13% (58,427/447,893), Greene County/Springfield = 3.6% (16,111/447,893), and Outstate = 56.1% (251,233/447,893). Westport Benefits provided the current number of children in the Medical Plan. Currently the medical plan has 255 children under the age of 1; 259 under the age of 2; 276 under the age of 3; 268 under the age of 4; 258 under the age of 5; and, 260 under the age of 6. Based on this information, the following was determined:
ASSUMPTION (continued)
# in # in # in Jack # in Greene/
Ages STL City STL Co. Co./K.C. Spgfld. # in OS Total
<1 22 48 33 9 143 255
<2 22 49 34 9 145 259
<3 23 52 36 10 155 276
<4 23 50 35 10 150 268
<5 22 49 34 8 145 258
<6 22 49 34 9 146 260
Total 134 297 206 55 884 1576
The number of children at high risk in each group is as follows:
# in # in # in Jack # in Greene/ Total #
Ages STL City STL Co. Co./KC Spgfld # in OS Total # of Tests of Tests
<1 17 10 13 2 29 71 1 71
<2 18 10 13 2 29 72 2 144
<3 19 10 14 2 31 76 2 152
<4 18 10 14 2 30 74 1 74
<5 18 10 13 2 29 72 1 72
<6 18 10 14 2 29 72 1 73
Total 108 60 81 12 177 438 586
The number of children not at high risk is as follows:
# in # in # in Jack # in Greene/ Total #
Ages STL.City STL Co. Co./KC Spgfld # in OS Total # of Tests of Tests
<1 5 38 20 7 114 184 1 184
<2 4 39 21 7 116 187 1 187
<3 4 42 22 8 124 200 1 200
<4 5 40 21 8 120 194 1 194
<5 4 39 21 6 116 186 0 0
<6 4 39 20 7 117 187 0 0
Total 26 237 125 43 707 1138 765
The Department of Health also determined that 5% of children at high risk will be living in a home being renovated. The DHT assumed the renovation period would be one year. The legislation would require these children to be tested every three months during the renovation period. Depending on the age of the child at the time of the renovation they could have an addition two or three tests per child. Taking the average, the DHT assumes this will result in 2.5 additional tests. The number of children at high risk and living in a home being renovated is approximately 22 (438 x .05), resulting in an additional 55 (22 x 2.5) tests. The total number of tests that the Medical Plan would be responsible for covering each year is approximately 1,406 (55+586+765) tests. ASSUMPTION (continued)
Westport Benefits, our third party administrator, provided the DHT the UCR for the lead poisoning screening and specimen collection. The CPT codes DHT used are 83645 for the screening and 36415 for the specimen collection. The average UCR, using the rates for Jefferson City and St. Louis, are $32 for the screening and $14 for the specimen collection. The DHT also assumed that there would be an office visit charge. The average office visit charge is $62.50 per visit and the Medical Plan has a $15 co-pay on PPO office visits. Assuming that the children have met their deductible, maximum out of pocket benefit, and are using a PPO physician, the total fiscal impact to the Medical Plan for the lead poisoning testing of children under the age of six years would be approximately $131,461 per year [1,406 tests x ($32/screening + $14/specimen collection + $62.50/office visit - $15 co-pay)].
The total fiscal impact to the Highway & Patrol Medical Plan is approximately $201,381. The DHT is responsible for 75% of the Medical Plan's participants and the Patrol is responsible for 25% of the participants. Based on this information, the DHT assumes that $151,036 of the cost is due to the DHT participants and $50,345 of the cost is due to Patrol participants.
Historically, the DHT and the plan members have shared in any premium increases necessary because of increases in benefits. The costs may be shared in the long run (meaning shared between three categories: absorbed by the plan, state appropriated funds, and/or costs to individuals covered under the plan). However, the DHT Commission must make a decision on what portion they will provide. Until the Commission makes a decision, the DHT can only provide the cost to the medical plan.
| FISCAL IMPACT - State Government | FY 2002
(10 Mo.) |
FY 2003 | FY 2004 |
| INSURANCE DEDICATED FUND | |||
| Income - Department of Insurance | |||
| Filing Fees | $10,000 | $0 | $0 |
| NET ESTIMATED EFFECT ON | |||
| INSURANCE DEDICATION FUND | $10,000 | $0 | $0 |
| CHILDHOOD LEAD FUND | |||
| Income - Department of Health | |||
| Fees to Defray Testing Costs | Unknown | Unknown | Unknown |
| NET ESTIMATED EFFECT ON | |||
| CHILDHOOD LEAD FUND | Unknown | Unknown | Unknown |
| GENERAL REVENUE | |||
| Costs - Department of Health | |||
| Personal Services (35 FTE) | ($856,931) | ($1,054,025) | ($1,080,375) |
| Fringe Benefits | ($285,615) | ($351,307) | ($360,089) |
| Equipment and Expenses | ($1,253,271) | ($1,402,617) | ($1,444,696) |
| Total Costs - Department of Health | ($2,395,817) | ($2,807,949) | ($2,885,160) |
| Costs - Department of Social Services - | |||
| Division of Medical Services | |||
| Medical Assistance Payments | ($110,560) | ($110,560) | ($110,560) |
| NET ESTIMATED EFFECT ON | |||
| GENERAL REVENUE FUND | ($2,506,377) | ($2,918,509) | ($2,995,720) |
| FEDERAL FUNDS | |||
| Income - Department of Social Services - | |||
| Division of Medical Services | |||
| Medical Assistance Payments | $173,365 | $173,365 | $173,365 |
| Costs - Department of Social Services - | |||
| Division of Medical Services | |||
| Medical Assistance Payments | ($173,365) | ($173,365) | ($173,365) |
| NET ESTIMATED EFFECT ON | |||
| FEDERAL FUNDS * | $0 | $0 | $0 |
* Income and expenditures exceed $170,000 per year and net to $0.
| FISCAL IMPACT - Local Government | FY 2002
(10 Mo.) |
FY 2003 | FY 2004 |
| LOCAL SCHOOL DISTRICTS | |||
| Costs of providing information to | |||
| affiliated child care facilities | (Unknown) | (Unknown) | (Unknown) |
FISCAL IMPACT - Small Business
No direct fiscal impact to small businesses would be expected as a result of this proposal.
DESCRIPTION
This act requires insurance companies to offer coverage for testing pregnant women and for children under the age of 6 for lead poisoning. This act requires the Director of the Department of Health to inform local boards of health when a case of lead poisoning is reported to the director. Health care professionals and health care organizations are required to report positive lead poisoning cases.
Beginning January 1, 2002, the Department of Health must implement a childhood lead testing program to test children under the age of 6 for lead poisoning. The test shall consist of a blood sample which must be sent to a state-licensed laboratory for analysis. The Department of Health, in coordination with the Department of Social Services and the Department of Elementary and Secondary Education, shall develop questionnaires to determine whether certain children are at high risk for lead poisoning. Children determined to be at high-risk for lead poisoning shall be tested at least once every six months between the ages of six months and three years and annually between the ages of three and six years. Children who are at high risk and are residing in housing undergoing renovation shall be tested at least once every three months during the renovation and once after the renovation is completed.
The Department of Health is to promulgate rules to identify pregnant women who may be at high risk for exposure to lead poisoning. The Department of Health is required to develop an educational mailing list to be sent to physicians informing them of the childhood lead testing program.
The Department of Health is required to convene a task force to investigate the imposition of a fee on manufacturers of products containing lead. Fees collected from such manufacturers shall be deposited in the Childhood Lead Testing Fund.
Beginning January 1, 2003, and every year thereafter, the Department of Health is required to submit a report evaluating physician compliance with the act to the General Assembly.
DESCRIPTION (continued)
The act requires child care facilities to require a child's parent to provide evidence of lead poisoning testing. If the parent fails to submit evidence of lead poisoning testing, the facility is required to inform the parent of the issue and where the parent can obtain testing for the child.
This act creates the Childhood Lead Fund. The fund is to be used to fund the administration of the childhood lead programs.
This legislation is not federally mandated and would not duplicate any other program.
SOURCES OF INFORMATION
Department of Highway and Transportation
Department of Health
Department of Social Services
Missouri Consolidated Health Care Plan
Department of Insurance
Department of Public Safety - Missouri Highway Patrol
Office of the Secretary of State
Office of the State Treasurer
Department of Conservation
Jeanne Jarrett, CPA
Director
March 30, 2001