Toolbox for Improving Program
Processes and Health and Housing
Outcomes:
Experiences of the NYSDOH Lead
Primary Prevention Program
Panelists
Moderator:
Amy Murphy, MPH,
Consultant & TA Provider to the NCHH &
NYSDOH
Panelists:
• Cathe Bullwinkle, Oneida County Health Department
• Debra Lewis, Onondaga County Health Department
Prevalence of Childhood Lead
Poisoning
New York
State
4.8%
United
States
2.6%
NY State CLPPP
8 original pilot
locations funded
in 2007
15 grantees
operating
through 2013
Year
Funding Amount
2007-2008
$3 million
2008-2009
$5 million
2009-2010
$7.7 million
2010-2011
2012-2013
$10 million
Childhood Lead Poisoning
Prevention Program – CLPPP
FIVE GOALS
Identify high risk housing
Develop partnerships and engage the community
Promote LHC interventions
Build lead-safe work practice capacity
Identify& leverage community resources
15 Target Counties
NCHH
• Provides technical &
evaluation
assistance
• Grantees required to
conduct cost
analysis and/or
outcomes evaluation
Technical Assistance Briefs
• Cost Analysis Templates &
Guidelines
• Effectiveness of targeting
high risk blocks
• Post-remediation follow-up
• Projecting the burden of
exposure in areas with low
screening rates
Approaches to Cost Analysis
•Cost of Illness: Economic burden
of a disease
•Cost Analysis: Value of the
resources required to implement an
intervention
•Cost-Effectiveness Analysis:
Costs saved because an adverse
health condition was prevented
•Cost-Benefit Analysis: Net benefit
determined by subtracting the
monetary benefit (averted adverse
health or environmental outcomes)
from the cost of the intervention
Cost Analysis
• Health Care Expenditures
• Special Education
• Juvenile Delinquency
• Early Intervention Program
• Cost of Program Services
• Benefit of Window
Replacement
• IQ & Lifetime Earnings Loss
• Return on investment
Cost of Illness
 Magnitude of a public health
problem in monetary terms
 Medical, nonmedical, social
and educational costs
 Potential savings associated
with an implementing an
intervention
Health Care & Public Costs
• Direct health care costs of
lead poisoning:
–
–
–
–
Screening
Medical Management
Nursing Case Management
Environmental Services
• 2006 Consumer Price Index
• Conservative estimates
• Includes only direct medical
costs for children
Cost of Illness Estimates
Blood Lead Level
Number of
Children
10-15µg/dL
250
Estimated Health
care cost per
child
$74
Cost Incurred
15-20µg/dL
150
$74
$11,100
20-45µg/dL
95
$1,207
$114,665
45-70µg/dL
5
$1,335
$6,675
>70µg/dL
0
$3,444
0
$18,500
500 children
Total Costs
$150,949
Special Education Expenditures
•
Impaired neurobehavioral
function
•
20% of children with blood lead
levels >25 µg/dL will need
special education.
•
School districts have average
annual cost of special education
•
Standard Education: $8,322
Special Education: $14,317
Differential: $5,995
•
•
Three years of special
education needed on average
Juvenile Delinquency
• Estimated that 10% of
juvenile delinquency may be
attributed to lead poisoning.
• $34,000 per year to
incarcerating youth.
IQ & Lifetime Earnings Loss
Basic Formula
IQ loss within BLL group
X
Earnings loss per IQ point
X
Number of children/ category
=
Net lifetime earnings loss
Mathematical formula for the 2-10 µg/dL group
1. Average Rate of IQ Loss per µg/dL within BLL Group X Total IQ
Points Lost within BLL Group
5 x .513 = 2.565
2. Lifetime Earning Loss X Total IQ Points Lost = Loss per child
$18,948 X 2.565 = $48,627
3. Applied to the number of children within BLL Group (60)
Lifetime earning loss x Number of children
60 X $48,627 $2,917,636
IQ and Lifetime Earnings Loss
Blood lead
level
Number of
Children
(Prevalence)
Average
Blood Lead
Level
Average
Rate of IQ
Loss per
µg/dL
within BLL
Group
Total IQ
Points Lost
within BLL
Group
Lifetime
Earning Loss
within BLL
Group
($18,958, x
Total IQ
Points Lost)
Applied to
the number
of children
within BLL
Group
2-10 µg/dL
60
5
.513
2.565
$48,627
(Lifetime
earning loss
x number of
children)
$2,917,636
10-20 µg/dL
40
15
.19
6.08
$115,265
$4,610,586
>20 µg/dL
10
20
.11
7.03
$133,275
$1,332,747
110
Net lifetime earnings loss
$8,860,969
Costs of Lead Exposure in NYS
Cost of Illness - Childhood Lead Exposure
New York State -2010 (including NY City)
• Cost of illness estimates 2010
• Impact of lead exposure on
health care expenditures,
special education, and lifetime
earnings loss
• NYC: $1,555,637,637 (62%)
Impact
Total Cost
Health Care
$3,281,942
Special Education
$1,260,883
IQ and Lifetime
Earnings Loss
$2,514,923,250
Total
$2,519,466,075
Early Intervention
• Identify children served by
EIP
• Eliminate those served due
to other issues
• De-identify eligible children
• Extract & organize EIP
service data
• Link EIP services to costs
Oneida County
Costs of Child Find & Early Intervention Newly
Diagnosed Children with EBL > 15 ug/dL
• Refer all children < 3 at risk for
developmental disabilities
• Screening - Ages & Stages Questionnaire
• 186 children 2009-2010
– 5.3% of all new admissions to CF & EIP
Calculating EIP Costs
1) Identify children with lead exposure being served by EIP.
1)
Determine if children are being served by EIP because of lead exposure
2) De-identify the children by assigning a unique child ID.
3) Extract and obtain information on EIP services received and enter
into an Excel spreadsheet.
1) Date of enrollment
2) Length of enrollment
3) Service type: Speech Language Pathology (SLP), Occupational Therapy
(OT), Physical Therapy (PT), Special Instruction Teacher/Special
Education services, Other Services
4) Determine costs for EIP Services (In Oneida County, the cost per unit is
the same for all services)
4) Calculate the value of third party reimbursement for services (if
available)
5) Calculate the cost of EIP services per year and per child.
Early Intervention Program
• Evaluation to assess & monitor needs
– $59.43 per child
• Costs of Services: $134,414 (2009-10)
– $4,596 Average Total Cost of EIP/Child
– $2,143 Average Net Costs after
Reimbursement/Child
Services Provide/Cost Analysis
Services
Physical Therapy
Occupational Therapy
Speech Therapy
Cost
Breakdown
77%
16%
7%
Additional Efforts
• Cost of Illness Estimates 2009-11
• Prevalence Decreases in Target Areas
– Quantify the impact of program efforts over
time
Onondaga
Compare EIP Costs:
• Children identified with EBL > 5 ug/dL before
EIP enrollment
• Children identified with EBL > 5 ug/dL after
EIP enrollment
• Children receiving EIP services who did not
have an EBL
Methodology
• Obtain EIP intake logs for 2009
< 36 months of age
• Match with LeadWeb
Surveillance Data for children
• Extra EIP Child Service Reports
of eligible children
• Calculate Costs of EIP services
for each category
EIP Cost Comparison
Category
Number of
Children
Average Cost
Total Cost
One BLL > 5ug/dL
prior to EIP
67
$2,994
$200,580
One BLL >5 ug/dL
after EIP
enrollment
88
$4,610
$405,664
No BLL but tested
prior to EIP
142
$5,604
$795,765
No BLL and not
tested prior to EIP
73
$9,115
$664,606
Discussion of Findings
• Children without an EBL referred at an earlier
age due to more severe delays and greater
need for services?
• Would the findings have been different if used
a threshold of 15 ug/dL?
• Need to control for age? Referral source?
• Look at multi-year service data?
LEAN QI Process
Goal: To study the enforcement process
Process Elements:
• Process mapping
• Visioning
• Time studies
• Policy review
• Inclusion of staff at all levels
Issues of Concern
•
•
•
•
Gaining access/contacting tenants
Multiple field visits
Clerical task duplication
Inefficient management of electronic
documents
• Long compliance time frames
• Hearing schedule backlog
Policy & Procedure Changes
• Updated tenant screening form
• Integration of enforcement efforts –
– Combine hearing notice, order posting,
reinspections
• Notice & Information eliminated
• Policy on vacant properties
• Electronic case files and folders
Additional Efforts
• IQ & Lifetime Earnings Loss
Costs of Program Services
1. Document protocols or
procedures
5. Average time across
staff
2. Specify staff roles
6. Identify hourly rates
3. Develop time
estimating worksheets
7. Calculate intervention
costs
4. Document time for
each step over a
period of time
8. Determine indirect
costs
9. Link to program
outputs/activities
Risk Assessment Costs by Type
Includes program activities from the time a housing unit is referred
into the program thru dust wipe clearance.
Risk Assessment - No hazards identified:
Risk Assessment - Hazards identified:
Risk Assessment – Enforcement:
$235.17
$1,088.70
$1,366.22.*
Analysis:
•When enforcement is needed the costs to the program increases,
at a minimum, by $277.52.
•This cost is incurred per hearing date.
•Some cases have multiple hearing dates due to chronic noncompliance.
Monetary Benefit of Window Replacement
• Formula:
Market Value Benefit +
Health Benefit –
Lead Hazard Control Costs
= Net Benefits (CBA)
Varies by housing size, # of
windows replaced and age
of housing.
• Energy Star Window Savings:
– 15-24% reduction in energy
bills
– $20 for every dollar per year
in energy savings
• Increase in Property Values:
– $100 per window
– 95% costs of paint
stabilization
• Health benefits:
•
•
•
$6,847 Pre-1940 Housing
$2,847 1940-1959 Housing
$632 1960-1977 Housing
Data Required
 Risk assessment costs
 Window replacement costs
 Paint stabilization costs
 Cleanup and lead dust
clearance costs
 Number of windows replaced
 Annual energy bill pre-lead
hazard control
Monetary Benefit of Window Replacement
Window Replacement
800 ft2
Attached
7 Windows
$6,118
1200 ft2
Detached
10 Windows
$9,684
1800 ft2
Detached
16 Windows
$15,494
Weighted Average Interior Paint Stabilization
$146
$146
$146
Weighted Average Exterior Paint Stabilization
$291
$291
$291
Specialized Cleanup
$386
$510
$510
Lead Dust Clearance Testing
$175
$219
$219
Average Cost
$7,116
$10,850
$16,660
Annual Energy Savings (15%-25%)
$130-216 / yr
$194-324 / yr
$292-486 / yr
Windows
$5,485
$8,681
$13,890
Weighted Average Interior Paint Stabilization
$144
$144
$144
Weighted Average Exterior Paint Stabilization
$270
$270
$270
Average Market Value Benefit
$5,899
$9,095
$14,304
Weighted Average in Pre-1940 Housing
$6,847
$6,847
$6,847
Weighted Average in 1940–1959 Housing
$2,847
$2,847
$2,847
Weighted Average in 1960–1977 Housing
$632
$632
$632
Costs
Market Value Benefits
Average Lead Hazard Reduction Benefit
Formula
Costs:
Window Replacement: Actual Installed Cost
$
Paint Stabilization: Actual Cost
$
Cleanup and Lead Dust Clearance Testing: Actual
Cost
$
Total Cost = A
$ Sum of all homes
Market Value Benefits:
Windows Market Benefit = $100/window +
(20% of the previous year annual energy bill) x 20)
$
Paint Stabilization Market Benefit = 95% of Actual
Cost
$
Total Market Value Benefit = B
$ Sum of all homes
Lead Hazard Reduction Benefits
Pre-1940 units multiplied by $6,847
$
1940-1959 units multiplied by $2,847
$
1960-1977 units multiplied by times $632
$
Applicable Lead Hazard Reduction Benefit = C
Net Benefits: B + C - A
$Sum of all homes
$
Projecting Prevalence
Step 1. Are the demographics of children screened the
same as the general population of children?
Prevalence rate X Number of children < 6
Step 2. If not representative….
Determine prevalence rates by race
Multiply by the number of children of that racial/ethnic origin
Add the projections to determine the burden of lead exposure
Effectiveness of Targeting High Risk Blocks
Questions:
Is there a
neighborhood
effect?
Efficacy of
canvassing and
focusing on
exterior lead
hazard control.
• Identify comparable
geographic areas
• Document baseline
prevalence
• Determine postintervention burden of
lead exposure
Post-remediation Follow-up
• How long to housing units remain lead safe?
• What is the level of maintenance after LHC and how
important is it?
• What is the contribution of dust lead tracked in from
outside sources?
• What is the value of a lead safe housing registry?
• How realistic are community-wide remediation
targets?
Post-remediation Follow-up Analysis
• Number & extent of LBP hazards at each interval.
• What rooms or components have a higher likelihood of
reoccurring hazards?
• How long do housing units remain lead-safe?
• Where are dust lead levels the highest post remediation?
• Variance based on who conducted the work?
Considerations
• Change in inspectional/risk assessment protocols?
• Change in interventions standards?
• Change in who can conduct work?
• Systems requiring maintenance?
• Communicate results to owners.
Post-remediation Follow-up Options
• Comparison of baseline & post-remediation
paint condition.
• Examination of post-remediation paint
condition & dust levels.
• Comparison of baseline & post-remediation
paint condition & dust levels.
Return on Investment
Controlling lead hazards
For every dollar spent on LHC, $17-$221 returned in
health benefits, increased IQ, higher lifetime
earnings, tax revenue, reduced spending on special
education and reduced criminal activity
Vaccination
Returns $5.30 - $16.50 for every dollar invested in
immunizations
References
•
Gould E. 2009. Childhood Lead Poisoning: Conservative Estimates of the Social and Economic Benefits of
Lead Hazard Control. Environmental Health Perspectives. 117(7): 1162-1167. Uses IQ point loss value of
$17,815 from Schwartz, et al (1994) based on 2006 USD.
•
Korfmacher KS. 2003. Long-Term Costs of Lead Poisoning: How Much Can New York Save by Stopping
Lead? Working Paper: Environmental Health Sciences Center, University of Rochester, 9 July 2003.
Available: http://www.sehn.org/tccpdf/lead%20costs%20NY.pdf [accessed 10 October 2008].
•
Lanphear BP, Hornung R, Khoury J, Yolton K, Baghurst P, Bellinger DC, et al. 2005. Low-Level
Environmental Lead Exposure and Children’s Intellectual Function: An International Pooled Analysis. Environmental Health
Perspectives. 113:894-899.
•
Nevin R, Jacobs D, Berg M, Cohen J. 2008. Monetary Benefits of Preventing Childhood Lead Poisoning
with Lead-Safe Window Replacement. Environmental Research. 106: 410-419.
•
Oklahoma Department of Health. September 2010. Economic Impact of Childhood Lead Poisoning. The
Bulletin. pp 40-43. Uses IQ point loss value of $18,958 based on 2009 USD (adjusted for inflation).
•
Zhou F, Santoli J, Messonnier ML, Yusuf HR, Shefer A, Chu SY. 2005. Economic Evaluation of the 7Vaccine Routine Childhood Immunization Schedule in the United States, 2001. Archives of Pediatrics &
Adolescent Medicine 159:1136–1144.
Questions?