Hospital-Based Intervention Can Save Lives. A Growing Movement Is Betting on Medicaid to Fund It.
Hospital-Based Intervention Can Save Lives. A Growing Movement Is Betting on Medicaid to Fund It.
By Chip Brownlee, The Trace, August 19, 2021
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The violence intervention team at Hartford Communities That Care is available 24 hours a day, seven days a week, 365 days a year. Within 20 minutes of getting a call from Saint Francis Hospital in Hartford, Connecticut, the staffers spring into action to help a shooting victim recover — from more than just their physical wounds. In many cases, the patient is still unconscious, their name unknown.
Hospital-based violence intervention programs — often called HVIPs — like Hartford’s have shown they can successfully prevent violence and save money. At least 19 states have some form of these programs. But in a healthcare system governed by insurance plans and their strict, complex reimbursement rules, it can be difficult to get coverage for services focused on preventing violence, rather than treating its outcomes.
However, financial support for this type of intervention is about to get a lot more reliable in at least two states, beginning next year. In June, Connecticut Governor Ned Lamont, a Democrat, signed a bipartisan bill that will direct the state’s Medicaid agency to cover the costs of hospital-based violence intervention programs for beneficiaries. Just a few days later, Illinois Governor JB Pritzker, also a Democrat, signed a broad bill aimed at “reimagining public safety” that included similar language supporting Medicaid funding for intervention services.
Illinois and Connecticut are unlikely to be the last states to commit Medicaid funding to violence prevention. Earlier this year, the Biden administration told states that the public insurance program for people with low incomes can — and should — cover this type of work. In Connecticut, not one lawmaker voted against the bill. “We were very careful also not to frame it in the sense that this was a gun bill,” said Andrew Woods, the director of Hartford Communities That Care, the first nonprofit to establish an HVIP in Connecticut. “It’s really about helping people.”
Of course, there are also long-term financial incentives to support such programs: Without intervention, gunshot victims are likely to be hurt again or remain involved in gun violence, research has shown. Gunshot injuries are some of the most expensive to treat, costing the healthcare system more than $1 billion a year, according to one recent report, while another places the total cost at more than $2.8 billion. The vast majority of these victims are uninsured or covered by Medicaid, which leaves the public footing the bill for their care.
“We know that so much of gun violence is retaliatory, and this is a strategy that can prevent that,” said Connecticut state Representative Jillian Gilchrest, a Democrat who championed the bill. “I hope other states will see that we made this move.”
At hospitals, violence intervention workers act as security personnel, vetting visitors who say they’re family members or friends of patients. And they work with patients’ loved ones, too, offering a sense of calm and support and trying to discourage retaliation against those who they believe fired the gun. “We reduce the anxiety,” Woods said.
Once the victim has stabilized, intervention workers talk them through the idea of post-traumatic stress and what signs might indicate they’re experiencing it. They make sure patients understand the resources and support available to them — including victims compensation and Medicaid — and set up longer-term support like healthcare that they can access at home, job training or schooling, counseling and therapy, and transportation. The bedside intervention is, more than anything, a way to reach at-risk people at a time when their need is most pronounced.
“The sooner we can get there, the better our potential is for a better outcome for these individuals and their families,” Woods said.
Woods also directs the Connecticut Hospital Violence Prevention Collaborative, which played a major role in advocating for the new law. Hospital-based intervention programs don’t charge their clients, relying instead on outside funding — until next year, when Medicaid starts covering the costs. But grants, philanthropic support, and Victims of Crime Act funding don’t necessarily offer stability in the long run. No one expects Medicaid to cover all costs, but it could create a level of baseline funding to keep the doors open.
“Imagine a hospital is running a cardiac-cath lab, but it doesn’t have a guarantee for more than two years. You’re constantly wondering if you’re going to be able to take care of heart attacks or not,” said Kyle Fischer, an emergency medicine physician in Maryland and policy director at the Health Alliance for Violence Intervention, an association of HVIP programs. “It’s no way to run a service.”
The new coverage will also help other hospitals looking to set up violence prevention programs, said Jonathan Gates, a trauma and vascular surgeon at Hartford Health. Gates, who has worked with gunshot victims for decades, said physicians aren’t always equipped to help patients recover from wounds that aren’t physical. “I see them. I take care of them, and we love to be partners in getting them better, of course, but there are things that we don’t understand,” he said.
The Health Alliance has 40 participating members nationwide and works with about as many emerging programs. The number is growing, but it still represents a proportionally small presence among the 536 trauma centers verified by the American College of Surgeons, the hospitals most likely to treat gunshot victims.
In an April webinar, Biden administration officials at the Centers for Medicare and Medicaid Services advised state leaders that federal Medicaid dollars could cover evidence-based violence prevention programs.
“This is a really huge moment,” Fatimah Loren Dreier, the executive director of the Health Alliance, told The Trace, about the webinar. “Medicaid and public health dollars being deployed in this way is remarkable in helping us move towards this larger paradigm shift of violence as a public health issue.”
Advocates like Woods hope encouragement from the federal government will inspire other states to start supporting violence prevention based in hospitals. Though states administer Medicaid and determine eligibility and coverage, they rely on federal matching funds to cover most of the costs. At least one state, California, considered covering HVIPs with Medicaid in 2019, but concerns that the Trump administration wouldn’t provide matching funds led legislators to drop the effort.
The advice from Biden’s Centers for Medicare and Medicaid Services has been much clearer. It listed not one but nine ways states could support these prevention programs. Fischer said he has fielded calls from advocates and officials in five different states over the course of a single week asking about using Medicaid funding for violence prevention.
“There’s no ‘one size fits all,’” Fischer said. “Will this spur more activity? I think the answer will certainly be ‘yes.’”
