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Mar 2018

Epidemic of Gun Violence Creates Double Jeopardy for Providers

The rampant epidemic of gun violence in the United States shows no sign of abating.  It has reached such proportions that more than 100,000 people are shot each year in the U.S. and gun-related deaths are now the third leading cause of injury-related deaths in the United States.  To put this in some perspective, in the U.S., for every 100,000 people, 25.3 will visit an ER with a gunshot wound each year, a much higher number than in other developed counties such as Germany, Japan or the U.K.

What is often underreported and underappreciated is the impact gun violence has on healthcare providers who are charged with addressing the health consequences of this violence.  As the unsung heroes of the story, they are the ones who can least afford to suffer the negative impact it has on finances, operations and human resources.

From a financial standpoint, an analysis  from Stanford University School of Medicine estimated the initial hospitalization cost of firearm injuries to be more than $700 million a year.  Another study from Johns Hopkins School of Medicine puts the total yearly charges associated with treating gunshot patients at nearly $3 billion.

These staggering costs are generally borne by the healthcare providers themselves, private payors and taxpayers through various government payment programs.  It’s worth noting that the same Johns Hopkins study showed that a significant amount of those hospitalized for gunshot injuries had no healthcare coverage or were categorized as self-pay, which, of course, increases the financial risk for providers.

And most of this cost can be attributed to maintaining and operating Trauma Centers, which are where the majority of gunshot wounds need to be – and are – treated.  As the frequency and number of these injuries continues to increase, so will the demand for Trauma Center care, which is one of the most expensive types of care a hospital can provide.

In fact, according to recent studies and analyses reported by National Institutes of Health, (NIH), the total readiness cost for all Level I Trauma Centers in the U.S. is well in excess of $35 million a year with an estimated average cost of over $6 million per year per Trauma Center.  This represents an enormous challenge to the financial viability of many of the nation’s hospitals since nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20 percent of inpatient costs for trauma care.

As if this were not enough to contend with, workplace violence in the healthcare industry tends to be higher than in other industries.  In fact, one study showed that about 75 percent of workplace violence tends to take place in health care settings, including long-term and post-acute care facilities.  While most of the reported incidents were not linked to gun violence, there has been an increase in the number of intentional gun violence homicides at healthcare facilities.  The majority of these incidents took place inside hospitals with the ER being the most common site of gun violence followed by parking lots. Almost a third of perpetrators committed hospital shootings because of some dissatisfaction with the healthcare provider and/or its staff.

Gun Violence and Mental Illness

While no one denies that mental illness has a role in the gun violence epidemic, given the politicized environment involved, it is not surprising that there are conflicting data as to what percentage of gun violence can be attributable to mental illness.  One study found that more than half of public mass shootings were committed by people who had been diagnosed as mentally ill or showed signs of having a serious mental disorder.  Many, almost 40 percent, displayed some sort of red flag before engaging in the violence.

On the other end of the research spectrum, some studies show a much smaller link between mental illness and gun violence. One by the National Institutes of Health showed that anywhere between 4 and 20 percent of gun violence incidents are caused by people with a serious mental illness. And another from Duke University reported that 4 percent of gun and other violence is traceable to schizophrenia, bipolar disorder and depression – the three mental health conditions most often involved in violent incidents.

But no matter which statistic is being cited, it clear that certain individuals are more prone than others to fall victim to the types of mental illness that could trigger violence.  Moreover, the vast majority do show some warning signs that healthcare providers, social workers and other competent authorities can be on the lookout for.  Knowing the risk factors can enhance current screening efforts to prevent the violence before it happens or at the very least make it harder for the affected individual to secure a weapon.

For example, one study suggested that traumatic childhood experiences or smoking pot when a teenager or young adult are factors that increase the risk of mental disorders.  It also suggested that young males, ethnic minorities and people living in socioeconomically disadvantaged areas are more likely to experience the types of mental illness that could make them more prone to violence.

Some of the red flags that indicate the potential for gun violence are festering anger, a feeling of alienation and bitterness over real or perceived wrongs.  While these may not meet the criteria for a diagnosable mental illness, they can readily lead to violence.  Another element often found in gun violence is substance abuse, which is a factor in some 40 percent of shootings.

What Can Healthcare Providers Do?

Providers may want to play a more active role in reducing gun violence in their communities and facilities while taking steps to protect their balance sheets from the impact of meeting a growing need for Trauma Center care.

  • Support Mental Health Education in the Community: All research indicates that mental health plays a role in gun violence, that risk factors for mental health issues can be detected, and that individuals tend to exhibit warning signs or “red flags” before engaging in gun violence.  Healthcare providers may offer ongoing community outreach programs on mental health issues including education on the role that nutrition and lifestyle choices play in reducing risk factors.  For example, many instances of depression, a key factor and predictor of violent behavior, can be avoided or better treated by making certain lifestyle changes.  Providers may also want to support and offer addiction recovery services given the association of substance abuse with gun violence.
  • Review Financial and Operational Models: There is a limit to cost-shifting trauma center costs to the government, charities and insured patients. It is therefore very important that providers review their various reimbursement models to ensure they are pricing their services and products to account for the high costs of maintaining 24/7 trauma center readiness. They may also need to thoroughly review their existing private and government payor procedures to ensure all prerequisites for payments can be timely met.  This will go a long way to reducing the denial of payment for medically necessary services.

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