Michigan Office of Administrative Hearings and Rules  
Administrative Rules Division (ARD)  
MOAHR-Rules@michigan.gov  
REGULATORY IMPACT STATEMENT  
and COST-BENEFIT ANALYSIS (RIS)  
AGENCY INFORMATION:  
Department name:  
Health and Human Services  
Bureau name:  
Public Health Administration  
Name of person filling out RIS:  
Talisa Gauthier  
Phone number of person filling out RIS:  
517-284-4853  
Email of person filling out RIS:  
GauthierT1@michigan.gov  
RULE SET INFORMATION:  
ARD assigned rule set number:  
2023-74 HS  
Title of proposed rule set:  
Universal Blood Lead Testing  
COMPARISON OF RULE(S) TO FEDERAL/STATE/ASSOCIATION STANDARDS  
1. Compare the proposed rules to parallel federal rules or standards set by a state or national licensing agency  
or accreditation association, if any exist.  
There are no parallel federal rules or standards set by a state or national licensing agency or accreditation  
association.  
A. Are these rules required by state law or federal mandate?  
Yes, MCL 333.5474d, 333.9206(1), and 333.9227.  
B. If these rules exceed a federal standard, please identify the federal standard or citation, describe why it  
is necessary that the proposed rules exceed the federal standard or law, and specify the costs and  
benefits arising out of the deviation.  
There are no federal standards or citation for these rules.  
2. Compare the proposed rules to standards in similarly situated states, based on geographic location,  
topography, natural resources, commonalities, or economic similarities.  
These proposed rules, which describe requirements for blood lead testing of minors at specified ages, are to comply  
with legislation enacted in 2023 (2023-PA146 and 2023-PA- 145), which updates the Public Health Code, adding MCL  
333.5474d and amending MCL 333.9206(1). They expand on the federal Medicaid requirement that children enrolled  
in Medicaid are to be tested at 12 and 24 months, or if not tested previously, by 72 months, to include all children at  
these ages. There are total of 14 other states with legal requirements for blood lead testing of all children (“universal  
testing”) at certain ages, not just children enrolled in Medicaid. [See 2018 50-State-Survey-Lead-Screening-for-  
Children-Not-Enrolled-in-Medicaid.pdf (networkforphl.org). Indiana enacted universal testing in 2022.] Nearby states  
with universal testing requirements include Indiana and Iowa. Indiana MEA 1313 requires that healthcare providers  
confirm that all children under age 7 have been tested for lead, and if not, to offer this testing. The law directs the  
Indiana Department of Health to “establish guidance and standards for health care providers”; the health department  
guidance states that all children should have a blood lead test at around 1 and again 2 years of age, or if no record of  
a prior test, a test between 28 and 72 months. Iowa Code 135.105D and administrative rules require every child to  
MCL 24.245(3)  
RIS-Page 2  
have had a blood lead test at school entry and recommends the test by age 2. In addition, Massachusetts has  
regulations (105 CMR 460) for mandatory childhood blood lead testing that are very similar to Michigan law, including  
testing at 12 and again at 24 months and, in addition, testing of children at age four if they live in a city or town  
determined by the state health department to be at high risk for childhood lead poisoning.  
A. If the rules exceed standards in those states, please explain why and specify the costs and benefits  
arising out of the deviation.  
The rules are similar to most other universal testing states’ requirements in that they mandate testing for all  
young children rather than just the testing children as Medicaid requires for Medicaid-enrolled children. Other  
testing requirements for high risk children in the rules, which are mandated by 2023-PA-146, are similar to  
some of the other universal testing states, including Massachusetts.  
3. Identify any laws, rules, and other legal requirements that may duplicate, overlap, or conflict with the  
proposed rules.  
There are no laws, rules, and other legal requirements that may duplicate, overlap, or conflict with the proposed rules.  
Medicaid also requires testing of children enrolled in Medicaid at ages one and two or, if not previously tested, by age  
six, but these are the same intervals as in these proposed rules, and which are required in the law (MCL 333.5474d).  
A. Explain how the rules have been coordinated, to the extent practicable, with other federal, state, and  
local laws applicable to the same activity or subject matter. This section should include a discussion of  
the efforts undertaken by the agency to avoid or minimize duplication.  
These rules do not conflict with or duplicate any federal, state, or local laws.  
PURPOSE AND OBJECTIVES OF THE RULE(S)  
4. Identify the behavior and frequency of behavior that the proposed rules are designed to alter.  
As required by MCL 333.5474d, these rules delineate the ages at which all minors should be tested for lead exposure  
by both mandating the offering of testing at prescribed ages by physicians and by ensuring that families can make  
informed choices based on knowledge of their child’s testing history. The purpose of these rules, and the law under  
which they are being promulgated, is to prevent adverse health effects from exposure to lead by identifying children  
with exposure, so that actions can then be taken to eliminate lead from the children’s environments. The requirements  
of the laws as enacted in these rules will help simplify physician behavior because physicians will order the test for  
every child at age 12 and 24 months rather than having to triage every child at those ages to determine if they are at  
risk or enrolled in Medicaid. These requirements also engage families in testing and preventive health decisions by  
having blood lead testing information available in their child’s certificate of immunization.  
A. Estimate the change in the frequency of the targeted behavior expected from the proposed rules.  
Physicians will order blood lead testing of all minors at selected ages and with prescribed risk factors rather  
than just some minors after determining if they are at risk of lead exposure or are enrolled in Medicaid.  
B. Describe the difference between current behavior/practice and desired behavior/practice.  
Currently, only children enrolled in Medicaid are required to be tested at prescribed ages. Furthermore,  
physicians are advised to evaluate whether other children should be tested based on a complicated risk  
questionnaire, but risk screening questionnaires have been found in some research to be little better than  
chance in actually identifying children with significant lead exposure. Behaviors to be changed by these rules  
include physician office practice and informed decision-making by families.  
C. What is the desired outcome?  
Lead is harmful in any amount to children’s growth and development. The desired outcome is to eliminate lead  
poisoning by identifying all children with lead exposure. Note that, although not part of these rules, current  
public health practice is to follow up with identified children to take actions to eliminate exposure in their  
environments, and these activities will continue into the future. The primary source of exposure to lead is from  
deteriorating paint in older homes. Children are most likely to have lead in their blood at ages 1 and 2 because  
of their increased mobility and hand-to-mouth behavior. Early detection of exposure is important as their bodies  
absorb lead more readily at younger ages.  
5. Identify the harm resulting from the behavior that the proposed rules are designed to alter and the likelihood  
that the harm will occur in the absence of the rule.  
MCL 24.245(3)  
RIS-Page 3  
Under the current blood lead testing approach in Michigan, which leaves out many young children, it is likely that  
children with lead poisoning have gone undetected and thus they will continue to be exposed and suffer long term  
adverse health effects from that exposure.  
A. What is the rationale for changing the rules instead of leaving them as currently written?  
These are new rules as mandated by MCL 333.5474d.  
6. Describe how the proposed rules protect the health, safety, and welfare of Michigan citizens while promoting  
a regulatory environment in Michigan that is the least burdensome alternative for those required to comply.  
MCL 333.5474d requires MDHHS to promulgate rules that implement the requirements of the law for blood lead  
testing of minors, the purpose of which is to protect all children from the adverse health effects of lead. These rules  
meet the requirements of the law, while specifying the least burdensome way physicians can comply with the  
components of the requirements of MCL 333.5474d and its companion in MCL 333.9206(1). Currently about 110,000  
children under age 6 are tested for lead poisoning, of which 3.5% (3,850) have elevated blood lead levels triggering  
interventions by local health departments. Under these rules the numbers of children tested and with those with  
elevated levels are expected to double, ensuring identification of many more children who will then receive  
interventions to protect them from the harmful effects of lead.  
7. Describe any rules in the affected rule set that are obsolete or unnecessary and can be rescinded.  
This is a new rule set.  
FISCAL IMPACT ON THE AGENCY  
Fiscal impact is an increase or decrease in expenditures from the current level of expenditures, i.e., hiring  
additional staff, higher contract costs, programming costs, changes in reimbursements rates, etc. over and  
above what is currently expended for that function. It does not include more intangible costs for benefits, such  
as opportunity costs, the value of time saved or lost, etc., unless those issues result in a measurable impact on  
expenditures.  
8. Please provide the fiscal impact on the agency (an estimate of the cost of rule imposition or potential savings  
for the agency promulgating the rule).  
The fiscal impact on MDHHS as a result of the proposed rules will be related to the increased number of children  
tested annually. Specifically: (1) processing the expected increased numbers of blood lead specimens submitted to  
the MDHHS laboratory for testing, (2) managing the data from increased numbers of laboratory reports of blood lead  
tests (all laboratories must report test results under R. 325.9081-9086), (3) providing technical support to local health  
departments who provide services to children with confirmed elevated blood lead levels (estimated at approximately  
3.5% of all blood lead tests), and (4) managing the expected increase in numbers of requests for MDHHS to support  
lead inspection and abatement services in homes of children with elevated blood lead test results. The estimated  
fiscal impact can range from $1 million to $5 million depending upon compliance with new testing requirements, to  
cover increased staffing, laboratory equipment, and information technology support. There are no potential savings for  
MDHHS with rule promulgation.  
9. Describe whether or not an agency appropriation has been made or a funding source provided for any  
expenditures associated with the proposed rules.  
No appropriations were included in the laws. See MCL 333.5474d and MCL 333.9206(1).  
10. Describe how the proposed rules are necessary and suitable to accomplish their purpose, in relationship to  
the burden(s) the rules place on individuals. Burdens may include fiscal or administrative burdens, or  
duplicative acts.  
The rules are necessary because they are mandated by MCL 333.5474d and 333.9206(1). They are suitable to  
accomplish the goal of the laws, which is to protect children from the adverse health effects of exposure to lead  
through blood lead testing, because they explicate the requirements of the law on physician office practice and on  
MDHHS to ensure that parents are aware of their child’s blood lead testing history via the child’s certificate of  
immunization. The fiscal or administrative burdens on physicians should be minimal given that physician practices  
with pediatric patients already have administrative systems to test or order blood lead tests. Furthermore,  
requirements for including blood lead test results in the Certificate of Immunization are already in place through a data  
linkage process at MDHHS.  
MCL 24.245(3)  
RIS-Page 4  
A. Despite the identified burden(s), identify how the requirements in the rules are still needed and  
reasonable compared to the burdens.  
As mandated by the legislature, the rules are required. The rules are reasonable because without this increased  
testing there will be children with long term impacts of lead poisoning.  
IMPACT ON OTHER STATE OR LOCAL GOVERNMENTAL UNITS  
11. Estimate any increase or decrease in revenues to other state or local governmental units (i.e., cities,  
counties, school districts) as a result of the rule. Estimate the cost increases or reductions for other state or  
local governmental units (i.e., cities, counties, school districts) as a result of the rule. Include the cost of  
equipment, supplies, labor, and increased administrative costs in both the initial imposition of the rule and  
any ongoing monitoring.  
The law and its implementing rules will have no increased or decreased revenues to other state or local governmental  
units. It will impact costs to local health departments because they are required under the Public Health Code to  
monitor blood lead test results reported to the state, provide services to children with lead exposure, and ensure  
public awareness of the hazards of lead and importance of blood lead testing. Based on other states’ experiences  
with implementation of universal blood lead testing requirements, a gradual increase in the number of children tested  
is expected over several years thus there will be fewer costs in early years than in the future. A legislatively mandated  
report prepared by a workgroup in 2020 estimated that with universal blood lead testing of one- and two-year-olds,  
local health departments would need at least $43 million to provide comprehensive lead elimination and response  
services. At a minimum, in the first few years, annual increased costs are estimated at $6.75 million for 1 Full Time  
Equivalent professional staff multiplied by 45 Local Health Departments, to be allocated by pediatric population size.  
12. Discuss any program, service, duty, or responsibility imposed upon any city, county, town, village, or school  
district by the rules.  
No new programs or services will be added to the responsibilities of local health departments to ensure compliance  
with the rules’ requirements. However, these requirements will increase the workload on already limited local public  
health capacity to provide services such as delivery of public and physician education, community outreach, and in-  
home nursing case management to children with elevated blood lead levels identified by the additional testing  
required by the rules.  
A. Describe any actions that governmental units must take to be in compliance with the rules. This section  
should include items such as record keeping and reporting requirements or changing operational  
practices.  
The rules require MDHHS (1) to maintain already existing data systems so that blood lead test results of  
children are automatically included in children’s certificates of immunization, (2) to maintain a list of high-risk  
jurisdictions where children should be tested at age 4, and (3) to maintain a system of education for physicians  
about lead poisoning and blood lead testing. No other governmental units are impacted by the specific  
requirements in the rules.  
13. Describe whether or not an appropriation to state or local governmental units has been made or a funding  
source provided for any additional expenditures associated with the proposed rules.  
No appropriation has been made. Currently, local health departments bill Medicaid for activities to follow up on  
children with elevated blood lead levels, and Federal Block Grant dollars are provided to support community  
education. There are no long-term General Fund appropriations to MDHHS or local health departments to support this  
work.  
RURAL IMPACT  
14. In general, what impact will the rules have on rural areas?  
All physicians are required to comply with the testing requirements, regardless of location, thus there will be no  
differential impact on physicians practicing in rural areas.  
A. Describe the types of public or private interests in rural areas that will be affected by the rules.  
There are no differential impacts on public or private interests in rural areas from these blood lead testing  
mandates.  
MCL 24.245(3)  
RIS-Page 5  
ENVIRONMENTAL IMPACT  
15. Do the proposed rules have any impact on the environment? If yes, please explain.  
Increased blood lead testing of children will result in the identification of more sources of lead which will result in  
removing more lead from the environment and mitigating lead sources in the home.  
SMALL BUSINESS IMPACT STATEMENT  
16. Describe whether and how the agency considered exempting small businesses from the proposed rules.  
This is a legislative mandate that applies to all businesses, including doctors’ offices, regardless of size.  
17. If small businesses are not exempt, describe (a) the manner in which the agency reduced the economic  
impact of the proposed rules on small businesses, including a detailed recitation of the efforts of the agency  
to comply with the mandate to reduce the disproportionate impact of the rules upon small businesses as  
described below (in accordance with MCL 24.240(1)(a-d)), or (b) the reasons such a reduction was not lawful  
or feasible.  
Because the rules apply to all businesses as required by statutory mandate, MDHHS did not consider the economic  
impact on small businesses nor made efforts to reduce the impact. The legislation required that all businesses comply  
with the mandate. The rules do not have a disproportionate impact on small businesses.  
A. Identify and estimate the number of small businesses affected by the proposed rules and the probable  
effect on small businesses.  
The American Medical Association indicates that about 54% of all practicing physicians work in small practices  
of 10 or fewer physicians. In Michigan, there are approximately 1,000 practicing pediatricians and 2,500 family  
practice physicians (estimated number of family practice physicians who have pediatric patients), which would  
suggest that at about 1,900 physicians (54% of 3,500) would meet the definition of small businesses. There is  
no anticipated effect on small businesses with these proposed rules. Both large and small businesses are  
required to comply with the mandate.  
B. Describe how the agency established differing compliance or reporting requirements or timetables for  
small businesses under the rules after projecting the required reporting, record-keeping, and other  
administrative costs.  
By legislative mandate, all businesses are affected equally.  
C. Describe how the agency consolidated or simplified the compliance and reporting requirements for  
small businesses and identify the skills necessary to comply with the reporting requirements.  
The rules do not specify differential compliance requirements for small businesses (i.e., small physicians’  
practices) because the law applies equally to all physicians. The reporting requirement for all tests positive to be  
sent to MDHHS in the absence of the laboratory sending in those results are the same for all small physician  
practices.  
D. Describe how the agency established performance standards to replace design or operation standards  
required by the proposed rules.  
This section is not applicable as this is a new rule set and the agency did not establish performance standards  
to replace any design or operation standards.  
18. Identify any disproportionate impact the proposed rules may have on small businesses because of their size  
or geographic location.  
By legislative mandate, all physician practices must comply with the requirements equally, whether small physician  
offices or larger practices. There is no disproportionate impact on small businesses because of their size or  
geographic location.  
19. Identify the nature of any report and the estimated cost of its preparation by small businesses required to  
comply with the proposed rules.  
Smaller physician offices, as with larger offices, are required to notify the health department via a report of a child’s  
blood lead test result only if there is evidence that the laboratory reporting requirement had not been met by that  
laboratory per R 325.9081 to 325.9086. Anticipated costs would be minimal because over 99% of test results are  
reported by laboratories; the cost of mailing or transmitting a report to MDHHS is approximately $1.  
20. Analyze the costs of compliance for all small businesses affected by the proposed rules, including costs of  
equipment, supplies, labor, and increased administrative costs.  
MCL 24.245(3)  
RIS-Page 6  
Minimal staff costs in physicians’ offices of all sizes will likely be incurred to ensure that all children in each physician’s  
office are testing according to the requirements of the rules. This may involve phone calls and charting reminders and  
providing lead results to MDHHS for the very small number of test results where a laboratory failed to report the  
results. Approximate costs of an office assistant salary of an average of $20 an hour (based on Bureau of Labor  
Statistics 2023 mean hourly rate for an office assistant) to take a phone call, chart reminders, and provide results to  
MDHHS, if needed, for approximately 2 hours per month per physician, would be $480 per year per physician.  
21. Identify the nature and estimated cost of any legal, consulting, or accounting services that small businesses  
would incur in complying with the proposed rules.  
There should be no costs imposed by these rules for legal, consulting or accounting services for small businesses to  
comply with the rules.  
22. Estimate the ability of small businesses to absorb the costs without suffering economic harm and without  
adversely affecting competition in the marketplace.  
As per answer in 20, the costs would be minimal for each physician’s office at approximately $480, per year. This  
suggests there wouldn’t be economic harm that adversely affects competition in the marketplace.  
23. Estimate the cost, if any, to the agency of administering or enforcing a rule that exempts or sets lesser  
standards for compliance by small businesses.  
There are no exemptions or lesser standards for compliance by small businesses; therefore, the agency’s  
enforcement efforts would remain the same with each business, regardless of size. It would likely cost the agency  
more to devote staff time to determining which physicians work for small businesses and then enforce different  
requirements for those individuals than keeping the same standards for all businesses.  
24. Identify the impact on the public interest of exempting or setting lesser standards of compliance for small  
businesses.  
Setting lesser standards would be contrary to the public interest because it would result in unequal treatment of  
children depending on their physician practice size.  
25. Describe whether and how the agency has involved small businesses in the development of the proposed  
rules.  
The law was enacted following legislative public hearings where physician organizations had opportunities to discuss  
their concerns. A draft of the rules was shared with these organizations, and they were asked to share the draft  
proposed rules with their membership and provide comments, questions and concerns back to MDHHS. MDHHS  
considered and responded to all comments, questions, and concerns from physicians when finalizing the proposed  
rules.  
A. If small businesses were involved in the development of the rules, please identify the business(es).  
Members of the Michigan chapter of the American Academy of Pediatrics and the Michigan Academy of Family  
Practice, which include physicians in small practices, were asked to comment on a draft rule set before  
finalizing the proposed rules, as noted above.  
COST-BENEFIT ANALYSIS OF RULES (INDEPENDENT OF STATUTORY IMPACT)  
26. Estimate the actual statewide compliance costs of the rule amendments on businesses or groups.  
Assuming 2 hours per month of administrative staff time per practicing physician at $20 an hour, compliance costs per  
physician/businesses should be approximately $480 per year. This would total $480 per year on 3500 physicians in  
answer 19A; 480 multiplied by 3500 or $1.68 million statewide.  
A. Identify the businesses or groups who will be directly affected by, bear the cost of, or directly benefit  
from the proposed rules.  
The affected groups include businesses (physicians’ office practices) and governmental agencies (local health  
departments and MDHHS) whom will be directly affected by these rules, as well as children residing in the State  
of Michigan. The local health departments, which receive minimal funding now for their lead poisoning  
prevention activities, will see cost increases as physicians comply with the testing requirements in the rules.  
Physicians may see a cost increase regarding staffing to comply with the new rules. Those who directly benefit  
are children and families in the State of Michigan who will experience better health because of early detection of  
lead exposure and thus removal of lead in the environment and mitigation of lead sources in homes.  
MCL 24.245(3)  
RIS-Page 7  
B. What additional costs will be imposed on businesses and other groups as a result of these proposed  
rules (i.e., new equipment, supplies, labor, accounting, or recordkeeping)? Please identify the types and  
number of businesses and groups. Be sure to quantify how each entity will be affected.  
Staff in physician’s offices will need to set up office procedures and conduct follow-up to ensure that children  
are tested at the specified ages and in accordance with risk factors. Local health departments will need  
additional staffing to monitor and conduct interventions related to increased numbers of tested children.  
27. Estimate the actual statewide compliance costs of the proposed rules on individuals (regulated individuals or  
the public). Include the costs of education, training, application fees, examination fees, license fees, new  
equipment, supplies, labor, accounting, or recordkeeping.  
There are minimal compliance costs to physicians associated with the proposed rules. Their office practices will need  
to establish procedures to ensure that all children meeting the age and risk factor requirements are offered the blood  
lead test, but these should have only minor impact on office staff time and medical records management. Further, the  
impact of these rules will vary depending on the number of pediatric patients in the practice. Assuming 2 hours per  
month of administrative staff time per practicing physician at $20 an hour, compliance costs per physician should be  
approximately $480 per year. MDHHS will provide educational materials at no cost so that physicians understand the  
requirements within the rules. In addition, MDHHS will offer trainings where physicians will be able to receive  
continuing medical education (CMEs) credits at no cost, which they can use to maintain their medical licenses. The  
proposed rules only require physicians to test for blood lead or offer the test, they do not have requirements for any  
other individuals or the public.  
A. How many and what category of individuals will be affected by the rules?  
There are approximately 1,000 practicing pediatricians and 2,500 practicing family practice physicians who  
have pediatric patients who will be affected by the rules.  
B. What qualitative and quantitative impact do the proposed changes in rules have on these individuals?  
Qualitatively, by ensuring that all children receive a blood lead test at prescribed ages/having certain risk  
factors, physicians can be assured that all their pediatric patients are protected from exposure to lead and those  
who need lead mitigation services will not miss out on them. Quantitatively, 3500 physicians per answer in 28  
will be affected with administrative costs totaling $1.68 million statewide.  
28. Quantify any cost reductions to businesses, individuals, groups of individuals, or governmental units as a  
result of the proposed rules.  
There are no cost reductions for regulated businesses or governmental agencies.  
29. Estimate the primary and direct benefits and any secondary or indirect benefits of the proposed rules. Please  
provide both quantitative and qualitative information, as well as any assumptions.  
Numerous studies have documented the long-term adverse health effects of lead on children and the benefits of early  
interventions to reduce their exposure, as summarized in a report from the President’s Task Force on Environmental  
Health Risks and Safety Risks to Children. One study concluded that “…the negative outcomes previously associated  
with early-life exposure [to lead] can largely be reversed by intervention.” There are estimated cost reductions to  
society at large because more children with lead poisoning will be identified by implementation of the testing  
requirements in the rules, and this will trigger actions to reduce adverse health impacts on them and, by removing or  
mitigating lead sources in the environment, ensure that other children are not exposed to lead. A report published in  
2016 estimated annual costs associated with lead poisoned children (including increased health care, increased  
crime, increased special education, and decline in lifetime earnings) in Michigan at approximately $270 million.  
However, with early detection provided by blood lead testing and interventions that mitigate lead-based paint from  
homes, there would be a greater than $100 million return on investment annually.  
30. Explain how the proposed rules will impact business growth and job creation (or elimination) in Michigan.  
Indirectly, because of the increased numbers of children tested whose homes are contaminated with lead, more  
opportunities for employment in lead abatement construction may exist. Additionally, there will be a need for greater  
capacity regarding in-home environmental investigations, which are sometimes provided by private environmental  
firms.  
31. Identify any individuals or businesses who will be disproportionately affected by the rules as a result of their  
industrial sector, segment of the public, business size, or geographic location.  
No one will be disproportionately affected; the law applies to everyone.  
32. Identify the sources the agency relied upon in compiling the regulatory impact statement, including the  
methodology utilized in determining the existence and extent of the impact of the proposed rules and a cost-  
benefit analysis of the proposed rules.  
MCL 24.245(3)  
RIS-Page 8  
As reflected in 32(A), the agency relied upon statistical evidence from various governmental and national  
organizations, as well as using research studies and reports. Information regarding a cost benefit analysis was  
determined by the hourly rate of an office assistant in Michigan, which was provided by the US Bureau of Labor  
Statistics 2023 mean wage estimates for Michigan, and was the source of the costs to physicians statewide in  
implementing the rule or $1.68 million.  
A. How were estimates made, and what assumptions were made? Include internal and external sources,  
published reports, information provided by associations or organizations, etc., that demonstrate a need  
for the proposed rules.  
Estimates of the number of impacted physicians [Pediatricians (N=1,000) and Family Practice physicians  
(N=3,500)] were provided by email from the Executive Director of the Michigan American Academy of Pediatrics  
who noted that he used published statistics from the US Bureau of Labor Statistics.  
The estimate of the number of Family Practice physicians who have pediatric patients was based on a study  
titled: “A cross-sectional study of factors associated with pediatric scope of care in family medicine.”  
Estimates of the percent of physicians with pediatric patients who are in small practices (i.e., business) were  
obtained from a survey conducted by the American Medical Association, available at AMA analysis shows most  
physicians work outside of private practice | American Medical Association (ama-assn.org), and this percentage  
was applied to the estimated number of physicians with pediatric patients.  
Estimates of the impact of the rules on local health departments were based on personal communications  
between local health department staff and MDHHS and material in a report titled “Lead Elimination and  
Response Costs Workgroup” available at Lead Elimination and Response Costs Workgroup - Final, Per Section  
1238 of PA 67 of 2019 (michigan.gov)  
Estimates of the benefits to society of compliance with blood lead testing and environmental lead mitigation  
interventions were from a report by the Ecology Center and the Michigan Network for Children’s Environmental  
Health titled “Costs of Lead Exposure and Remediation in Michigan: Update”, available at Microsoft Word -  
Lead.Report.Designed.Final.docx (ecocenter.org)  
The estimated mean hourly wage for an office assistant was obtained from the Bureau of Labor Statistics May  
2023 state occupational employment and wage estimates, Michigan, available at Michigan - May 2023 OEWS  
State Occupational Employment and Wage Estimates (bls.gov)  
The estimate of the number of Family Practice physicians who have pediatric patients was based on a study  
titled: “A cross-sectional study of factors associated with pediatric scope of care in family medicine.”  
Estimates of the percent of physicians with pediatric patients who are in small practices (i.e., business) were  
obtained from a survey conducted by the American Medical Association, available at AMA analysis shows most  
physicians work outside of private practice | American Medical Association (ama-assn.org), and this percentage  
was applied to the estimated number of physicians with pediatric patients.  
Estimates of the impact of the rules on local health departments were based on personal communications  
between local health department staff and MDHHS and material in a report titled “Lead Elimination and  
Response Costs Workgroup” available at Lead Elimination and Response Costs Workgroup - Final, Per Section  
1238 of PA 67 of 2019 (michigan.gov).  
Estimates of the benefits to society of compliance with blood lead testing and environmental lead mitigation  
interventions were from a report by the Ecology Center and the Michigan Network for Children’s Environmental  
Health titled “Costs of Lead Exposure and Remediation in Michigan: Update”, available at Microsoft Word -  
Lead.Report.Designed.Final.docx (ecocenter.org).  
ALTERNATIVE TO REGULATION  
33. Identify any reasonable alternatives to the proposed rules that would achieve the same or similar goals.  
This was a legislative mandate. There were no other alternatives identified.  
A. Please include any statutory amendments that may be necessary to achieve such alternatives.  
There are no statutory amendments needed.  
MCL 24.245(3)  
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34. Discuss the feasibility of establishing a regulatory program similar to that proposed in the rules that would  
operate through private market-based mechanisms. Please include a discussion of private market-based  
systems utilized by other states.  
This does not apply to this legislatively mandated set of requirements for testing of children for lead. The legislation  
specifically mandated that MDHHS develop the rules, which include oversight and training of the regulated individuals  
(i.e., physicians).  
35. Discuss all significant alternatives the agency considered during rule development and why they were not  
incorporated into the rules. This section should include ideas considered both during internal discussions  
and discussions with stakeholders, affected parties, or advisory groups.  
The age-based blood lead testing requirements in the rules are mandated by statute. MDHHS considered  
alternatives in designating high risk communities for testing at age 4 and arrived at the list in the rules based on  
statistically defined and widely accepted criteria that identify geographic areas at high risk for lead exposure.  
ADDITIONAL INFORMATION  
36. As required by MCL 24.245b(1)(c), please describe any instructions regarding the method of complying with  
the rules, if applicable.  
MDHHS will provide education, training, outreach, written materials, video webinars and other tools to educate  
physicians on the requirements of the rules.  
MCL 24.245(3)  
;