JCAR PACKAGE WRITTEN
COMMENTS/DHHS RESPONSE-
UNIVERSAL BLOOD LEAD TESTING
NAME OF PERSON PROVDING
COMMENTS
ORGANIZATION
RULE NUMBER
COMMENT
DHHS RESPONSE
Kenneth Rosenman, MD
Michigan Occupation and R 330.301-Definition
As with other public health
requirements (i.e., communicable
1) The statutory duty to test or order a test is imposed on physicians; the corresponding rules cannot transfer that duty to
any other classification of health professional. This does not prevent a physician from delegating selected tasks, such
Environmental Medical
Association (MOEMA),
R 330.302
disease reporting), the law should state as performing the test, to other health professionals as allowed by law. So long as it is within the health professional’s
that a licensed health care professional scope of practice and permitted by law, any such health professional may perform the test on behalf of a supervising
rather than a physician is the
professional responsible for blood lead primary medical care to many children. MDHHS will outreach to these and other health care professionals through
testing in children. To limit the law to
professional organizations and other channels of communication to ensure their awareness of the testing requirements.
physician to satisfy the physician’s duty. MDHHS recognizes that Nurse Practioners and Physician's Assistants provide
physicians does not reflect the current 2) The rules cannot limit physicians to those with patients under age 6 because the statute applies to all physicians with
state of medical practice where nurse "minor" patients and the legal definition of "minor" is a person under the age of 18. Furthermore, because the statute
practioners and physician assistants
says "physician' without any qualifications, the rules cannot limit the definition of "physician" to physicians with
provide a large percentage of medical specified medical specialties.
care to children under the age of six,
particularly for routine checkups and
vaccinations. It is during these regular
checkups that most childhood blood
lead testing will be performed . Second,
the law should be changed to only cover
licensed health professional who have
patients under the age of six. It makes
no sense to include licensed health care
professionals such as internists and
gerontologists who never see children.
Amy Zaagman, MCMCH Exe. Director Michigan Council for
Maternal and Child Health
General
We support the rules as presented.
MCMCH has been a longtime supporter
and advocate of monitoring
No response required.
environmental toxins in children and
pregnant women and participated in the
workgroup that created the
recommendations that guided thefinal
language in PA 146 of 2023 and led to
these proposed rules.
Ashley Zuverink, on behalf of Ruth Ann Green & Healthy Homes General
GHHI wholly supports the
No response required.
Norton, President & CEO
Initiative (GHHI)
Administrative Rule Set “Universal
Blood Lead Testing,” MOAHR Rule
Division No. 2023-74 HS, rules R
330.301 - R 330.319. Childhood lead
poisoning causes unnecessary and
permanent effects on a child’s brain and
organ development. No level of lead
exposure is safe...Based on our
experience in Maryland and other
states, we will happily provide support
as Michigan moves to implement
universal lead testing.
Colin J Ford, CEO
Michigan Chapter of the 330.301 Rule 1 (h)
1) Because the statute says "physician" without any qualifications, the rules cannot limit the definition of "physician" to
physicians with specified medical specialties. 2)The statutory duty to test or order a test is imposed on physicians; the
corresponding rules cannot transfer that duty to any other classification of health professional. This does not prevent a
physician from delegating selected tasks, such as performing the test, to other health professionals as allowed by law.
So long as it is within the health professional’s scope of practice and permitted by law, any such health professional
may perform the test on behalf of a supervising physician to satisfy the physician’s duty. MDHHS recognizes that Nurse
Practioners and Physician's Assistants provide primary medical care to many children. MDHHS will outreach to these
and other health care professionals through professional organizations and other channels of communication to ensure
their awareness of the testing requirements.
330.301 Rule 1 (h) broadly defines
physician as any individual holding a
medical license. The proposed rule
incorporates all allopathic or
American Academy of
Pediatrics
330.302
osteopathic physicians which may
include physicians who are not in a
position to effectively counsel
parents or provide follow-up care to
children (for example, this could
include radiologists, pathologists,
anesthesiologists, emergency
medicine, etc.), additionally, this
wording may not capture nurses or
other licensed professionals who
would otherwise be in a position to
benefit from the information provided
by testing.
MDHHS recognizes that annual well-child visits do not always happen exactly on a child’s birth month, and we
MIAAP supports the idea of testing or believe a reasonable interpretation of the age requirement is: ”…at around [12, 24, months]…”. This allows for
the physician to exercise their judgement as to when to test a child who has missed the 12 or 24 month window.
MDHHS will include this interpretation when providing job aids and conducting outreach to physicians about
the rules.
ordering tests for children at the ages
of 12 and 24 months. However, there
are some practical limitations to this
requirement that may undercut the
desired effect. For example, a child
may miss or reschedule a
twelve-month visit and be 13 months
at the time of the visit. Additionally,
because of the narrow wording of the
age requirement, it is unclear what
obligation the physician would
have to test or order a test for the
patient if the 12 months of age
window is missed.
The statute does not require that every physician test, or order a test, for every child at specified ages or risk factors.
Rather, the statute establishes minimum mandatory blood lead testing for each child residing in Michigan; a 12-month
test and a 24-month test and a test at other intervals depending on risk factors. This means that a physician treating a
minor patient must ensure that the child is tested at the required ages either by testing or ordering the test for a child
that has not yet had the test, or by verifying that the tests have occurred. MDHHS will make this clear in educational
materials and job aids when providing education and outreach to physicians and families about the requirements in the
rules. These materials will note that the American Academy of Physicians (AAP) recommends that blood lead testing
should be a routine part of a child’s primary care, and compliance with Michigan’s schedule of testing requirements
should ensure that all children who are being exposed to lead will be identified so that appropriate interventions can
take place. It is best that blood lead testing be ordered or performed in the office of a child’s primary care physician,
according to the testing schedule identified in the implementing rules. But recognizing that not all children are able to
The language as currently written is
ambiguous with respect to a child
who has already been tested and has
had that information entered into the
child’s certificate of immunization.
As currently written, the language
appears to require any physician to
test or order a test if the child falls
within any of the age or risk
categories. Children may be tested in
settings outside of a physician office be seen by primary care physicians as recommended, the statute and rules require that any physician treating a minor
patient must ensure these crucial tests occur. Collaboration among all providers of medical care to a child, with the
child’s medical home as the hub, is critical to the maximal accuracy, efficiency and effectiveness of the care of the
child and the appropriate testing of the child for lead exposure.
such as WIC, and children may have
multiple visits with multiple
physicians over the course of a
month. For example, a
12-month old child was tested for
lead at their WIC visit and that
information was entered into MCIR.
Then later that same month this child
went to a well-child visit with their
pediatrician, was seen by a sub-
specialist such as a
gastroenterologist, then later visited
an urgent care and finally required a
trip to an emergency room. In this
circumstance, all
of the physicians listed would be
required to test or order a test for the
child.
1. Clarify that the testing requirement
applies to primary care physicians,
physicians providing routine care, or
physicians who have an ongoing care
relationship with the minor patient. As
currently written, the mandate applies to
all physicians who treat a minor
Stacey Hettiger, Senior Director,
Advocacy and Payor Relations
Michigan State Medical
Society (MSMS)
330.301 Rule 1 (h)
330.302
1) Because the statute says "physician" without any qualifications, the rules cannot limit the definition of "physician" to
physicians with specified medical specialties. 2)The statute does not require that every physician test, or order a test,
for every child at specified ages or risk factors. Rather, the statute establishes minimum mandatory blood lead testing
for each child residing in Michigan; a 12-month test and a 24-month test and a test at other intervals depending on risk
factors. This means that a physician treating a minor patient must ensure that the child is tested at the required ages
either by testing or ordering the test for a child that has not yet had the test, or by verifying that the tests have occurred.
MDHHS will make this clear in educational materials and job aids when providing education and outreach to physicians
and families about the requirements in the rules. These materials will note that the American Academy of Physicians
(AAP) recommends that blood lead testing should be a routine part of a child’s primary care, and compliance with
Michigan’s schedule of testing requirements should ensure that all children who are being exposed to lead will be
identified so that appropriate interventions can take place. It is best that blood lead testing be ordered or performed in
the office of a child’s primary care physician, according to the testing schedule identified in the implementing rules. But
recognizing that not all children are able to be seen by primary care physicians as recommended, the statute and rules
require that any physician treating a minor patient must ensure these crucial tests occur. Collaboration among all
providers of medical care to a child, with the child’s medical home as the hub, is critical to the maximal accuracy,
efficiency and effectiveness of the care of the child and the appropriate testing of the child for lead exposure.
regardless of the physician’s specialty,
whether the minor will
return for follow-up care, or whether
tests, counseling, and treatment are part
of the physician’s regular practice.
2. Clarify that a physician does not need
to conduct or order a test if either of the
following have occurred and been
confirmed by checking the minor’s
electronic immunization record in the
Michigan electronic immunization
information system:
A. The minor patient has already been
tested pursuant to the specified schedule.
B. A case of lead poisoning has already
been diagnosed by a physician.
