The Cost of Surviving Armed Violence: Who Pays?

On a happy day in February 2014, 13-year-old DeAndre Knox was attending a birthday party at a friend’s house in Indianapolis when a stray bullet penetrated a window and hit his head.

At the hospital, the internal bleeding was so excessive that “the left side of his skull had to be removed so his brain wouldn’t explode,” recalls his mother, Diandra Decos. “Months later, he underwent surgery to replace part of his skull and put a tube in his head to drain cranial fluid.”

DeAndre lived – but eight years later, he can’t walk or speak. His constant suffering included hospitalization, multiple surgeries, physical and mental therapy, and bouts of pneumonia resulting from the development of lung infections.

“Life never goes back to the way it was,” Dykos said recently after visiting her son at a hospital near their home, where he was being treated for a severe case of pneumonia. She says the total cost of his care is in the millions; The psychological losses are incalculable.

DeAndre is among more than 80,000 people who survive each year from gun-related injuries — more than double the 40,000 who are killed by gunshots annually, according to studies including 2020 report Led by researchers at the University of Pennsylvania’s Perelman School of Medicine (PSOM).

Most of what we hear about the gun violence epidemic in this country revolves around deaths. Zeroy Song, MD, PhD, associate professor of health care policy and medicine at Harvard Medical School who has studied the cost of firearm injuries, notes that there is relatively little interest in firearm injury survivors. “The implication is that people who did not die are generally fine. We tend to forget about it.”

Many are not well. While some are treated quickly in emergency departments (EDs), perhaps having a flesh wound sutured, others face large, expensive, and sometimes painful medical procedures that extend months, years, or a lifetime. Some have to deal forever with damaged organs, damaged or removed limbs, chronic pain or trauma.

“Injuries and long-term morbidity affect patients, their families, and the community,” said Chad Krause, MD, emergency physician, FACEP, an emergency physician and researcher at Geisinger Health System in Pennsylvania, who has studied the types of injuries and care resulting from mass shootings.

Cost Accounts

Obtaining and analyzing detailed data on gun casualties in the United States is particularly challenging. For starters, there is no nationwide government database of firearm accidents – other than databases designed to provide details about each plane accident And every killer Car accident. For nearly 25 years, spending bills in Congress did not provide any federal money dedicated to the study of gun injuries, until 2019, which resulted in Several new projects Scope limited.

In addition, it is difficult to fully track any patient’s expenses, not only within the hospital system but privately across various providers outside of hospitals, including primary care physicians, specialists, home health aides, and therapists.

“We’re working in a data-limited area,” says Thomas Weiser, MD, MPH, a trauma surgeon and assistant clinical professor of surgery at Stanford Health in California.

Current data shows that while self-harm is the leading cause of firearm deaths in the United States, most gun injuries (both fatal and non-fatal combined) are caused by Attacks and accidents. The researchers used various records, such as databases of insurance payments and emergency department visits, to dig deeper into the financial impact of those injuries. Among their findings:

Initial costs are high. Immediately after the shooting, most victims are treated only in the emergency department: about 50,000 annually, according to the US Public Accountability Office (GAO). Another 30,000 are admitted for in-hospital treatment.

The average ED care for gun-related injuries is $1,500 per patient, while the median primary care for those admitted as inpatients is $31,000, resulting in a total annual $1 billion in initial medical costs, according to the Government Accountability Office Report 2021. “This is likely to be a significantly underestimated,” the report says, because the accounts do not include some expenses that are not tracked in the patient’s discharge data.

One study that specifically looked at more than 704,000 people who arrived at the emergency department with firearm-related injuries found significantly higher costs. the study By Johns Hopkins Medicine in Maryland, covering 2006 through 2014, average ED fees per patient were found to be $5,254 per year, and inpatient fees to be $95,887, which adds up to $2.8 billion per year.

Costs continue to rise after primary care. a Survivor Care Study Published in June, conducted by Song and fellow researchers at Harvard Medical School and Massachusetts General Hospital, they found that medical spending for gunshot victims increased an average of $30,000 during the first year after injury — four times higher than concurrent medical spending in a control. A group of patients without firearm injuries. The study found that with about 85,000 survivors of firearm injuries each year, this amounts to $2.5 billion in additional spending for survivors in the first year.

Dealing with constant physical and psychological pain leads to ongoing expenses. The study found that during the year following a shooting injury, survivors (compared to a control group) experienced a 40% increase in pain diagnoses, a 51% increase in psychiatric disorders, and an 85% increase in substance use disorders…accompanied by increased pain and psychiatric medications “.

The pain extends to family members. Dycus says that she and her other son periodically received mental health care related to Deandre’s condition. “When someone in your family survives, you’re in a whirl of emotions,” she says. When his condition deteriorates “You have hope and faith that he survives, that will be stripped away.”

Readmission is another significant cost. The Government Accountability Office report says that up to 16% of survivors who initially stayed in the hospital were readmitted at least once due to injury, with average costs between $8,000 and $11,000.

The type of firearm and the intent of the shooter affect the severity of the injuries. a study Led by the University of Iowa School of Public Health, it found that the most expensive average admission costs were for “legal interventions,” primarily as police shootings ($33,462 for admission), and assault rifles ($32,237), while the lowest The cost was for unintended injuries ($16,975).

Mass shootings injuries are particularly severe and costly. Mass shootings account for a minority of gun-related injuries, but the average medical costs for those injuries are $64,976 per person, according to study It was published in May by Kraus and other researchers from the Departments of Emergency and Trauma Services across the country. The study looked at 403 patients from 13 incidents over a seven-year period. It included all injuries, such as those sustained by falls while fleeing a gunshot wound, as well as healthcare use after initial treatment.

The costs go beyond medical care. Medical expense estimates do not reveal the full costs of firearm injuries, because the expenses are also borne by other organizations involved in the issues, such as police departments, justice systems, social services, and employers. “Firearm injuries are causing waves of costs outside the health system,” says Corinne Peek-Asa, MPH, MPH, who was lead author of the Iowa Study on Firearm Types and Intent to Shoot and is now Vice President of Research at UCLA. San Diego (University of California).

study Released in July by Everytown for Gun Safety, it was estimated that gun violence produces an “economic outcome” of $557 billion annually, including long-term medical care, criminal justice system resources, lost wages, reduced worker productivity, and a reduced quality of life for victims and their families.

Implications for service providers and policy makers

The expenses for treating gunshot survivors are distributed to people and organizations, and some expenses are never paid for.

study Published in 2019 by researchers at Stanford Health (including Weiser), after looking at six years of patient data, they found that the government bears nearly half of all hospital expenses. Of the $5.47 billion in costs during the study period, Medicaid and Medicare paid $2.5 billion, while private insurance and self-pay patients $1.1 billion each.

Dycus says one expense “I’ll never forget” came in a statement from her insurance company explaining what was paid by a company that flew DeAndre from a rehab center to a hospital to treat a medical emergency: $75,000.

What happens when patients do not have insurance? In the Johns Hopkins Medicine study looking at primary ED and inpatient care, researchers noted that more than half of the 704,000 patients studied were uninsured or self-paying. This often left hospitals absorbing the expense as unpaid care.

Researchers who study the financial impact of firearm injuries hope their findings will help stimulate the development of strategies and policies to better reduce and treat injuries.

The findings provide “evidence in support of the feasibility study to reduce gun violence,” says Beck Asa of the University of California, San Francisco.

“Your taxes, my taxes, are used to pay for injuries to these patients,” Weiser says, noting that most of the costs are borne by the federal and state governments, which jointly fund Medicaid. “The state has a vested interest in understanding the financial ramifications of policies” related to firearms.

The researchers stress that their call to reduce gun injuries is not a call for a gun ban. In fact, Peek-Asa and Kraus are gun owners.

“I live in rural Pennsylvania, where gun ownership is rampant, including among doctors.” Krause says. “I’m thinking about the implications of this research in terms of harm and risk reduction.”

Reducing the risk of firearm injuries could include policies including manufacturing, marketing and stockpiling of weapons, training of gun owners, and determining who has access to the most serious and costly injury-inducing weapons, the researchers say.

For providers, researchers hope that knowing the type of physical and mental health care that firearm injury survivors and their families need can enable hospitals and doctors to better prepare for and coordinate this care.

“This can mean allocating program resources to survivors and family members of survivors to avoid the ultimate consequences of nonfatal firearm injuries,” Song says. “Like better coordination between primary care and mental health care, so that when we take care of a survivor of a firearm injury, it’s not just about physical injuries. And that could mean better coordination with other professionals.”

September issue of gamma Focuses heavily on firearm injuries, with perspective articles calling for a national data system to track injuries and deaths; for academic medical centers to step up efforts to address gun violence; for companies to become more involved in reducing gun violence for employee health and corporate financial reasons; and more.

Knowing the effects of gun violence first-hand, Dycus became an activist to help victims and educate the public. volunteer with Mothers demand workestablish and direct Purpose 4 Amya resource center for supporting families affected by gun violence, and created and led an advocacy and support program at the Indianapolis City Police Department for survivors of nonfatal shootings and violence.

Her main message to the community: “Injured souls are important. Don’t forget about them just because they lived.”

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