Considering an HVIP
Health care providers should consider a number of guidelines when advocating for introducing an HVIP within their own facilities.
Any hospital treating over 100 assaults, gunshot wounds, stab wounds, and other violence-related injuries each year, both in emergency departments and trauma activations, should establish an HVIP. The consequences of interpersonal violence extend well beyond the violently injured people, affecting the health and life of their whole community. Given the recurrent nature of violent injury, HVIPs that prevent just one violent injury can produce cascading benefits for community health.
By preventing reinjury and retaliation, HVIPs also hold great potential to save hospitals money by reducing the amount of uncompensated care provided to violently injured patients. Several studies have shown how and at what scale HVIPs save costs. An HVIP in San Francisco found that programs are cost-effective at a scale of approximately 100 young adult patients served annually. At that scale, programs generate 24 quality-adjusted life years (QALY), a measure of both quality and quantity life improvements, and produces hospital savings of $4,100. In Oakland, an HVIP quantified the financial investment required to create a single QALY and found that programs can achieve one QALY per $2,941, a figure much lower than accepted values for effective public health interventions for other diseases (by contrast, hypertension and hyperlipidemia are estimated to cost between $33,500 and $50,000 per QALY). Research demonstrates that HVIPs have the potential to save money for insurers of high-risk patient populations. A 2014 study found that if HVIP service delivery were provided to high-risk patients, it would result in a national savings of $69 million to the Medicaid program after the ACA expanded to provide coverage for low-income childless adults. Finally, a cost-benefit simulation of an HVIP used several models to examine effects across health care, criminal-justice, and lost-productivity costs. Overall, nearly all models showed savings from a health care, public sector, and societal perspective, with the most conservative showing to be roughly revenue neutral from a health care perspective and the most optimistic model predicting savings across all sectors of over $4 million.
For non-profit hospitals, establishing an HVIP helps meet Internal Revenue Service community benefit requirements. The HAVI has determined that approximately 100 violent injuries per year is the economy of scale that warrants employing a full-time equivalent violence prevention professional. Surveys of HAVI network members reveal that a full-time violence prevention professional can serve 40 to 50 patients per year who consent to long-term follow-up.
Beyond advocating for HVIPs within their facilities, health care providers can advocate that establishing an HVIP be deemed a recommended standard of practice for treating violent injuries by respected medical committees. Much as health care research has informed standards of emergency medical care, public health research on risk and protective factors for violent injury should inform standards of trauma center practice. The American College of Surgeons’ (ACS) Committee on Trauma’s Resources for Optimal Care of the Injured Patient (often called the “Orange Book”) sets standards that trauma centers must meet to receive ACS verification. ACS verification confirms that trauma centers have the resources necessary to provide patients with “optimal trauma care.” While trauma centers are officially certified by government entities at state and local levels, many governments use ACS verification standards as criteria for certification. For the ACS to recommend that trauma centers treating more than 100 violent injuries establish an HVIP would help increase awareness about the model as an evidence-supported strategy to address patients’ injury-related psychosocial needs, risk of reinjury, and necessary follow-up medical care.
Influencing Policy
Health care providers can influence policy by advocating for state regulation, state legislation, and federal legislation that supports HVIPs.
Taking the first steps in a policy advocacy project is always the hardest. It’s frequently unclear where to start, who to talk to, and what strategy is needed to accomplish it. Health care providers can begin by asking themselves what problem they are trying to solve:
Are patients’ victims of crime compensation applications being rejected for unclear reasons?
Is additional funding needed to expand HVIPs to other hospitals?
Are patients encountering barriers in interacting with local service agencies?
Once they have identified the problem, a good first step is to reach out to the agency or person with jurisdiction over the problem. For example, if there are difficulties with victims of crime compensation applications, that would mean meeting with the state’s VOCA administrator. It is important not to assume that “bad people” are causing the problem. Sometimes what appears to be a policy difficulty can be due to misunderstandings or bureaucratic procedures. If a few respectful meetings can fix the problem without involving regulators or legislators, that is ideal.
However, not all problems are fixed so easily. Frequently, policy change will require a change in either regulation or legislation. As a general rule, it is best to address problems through regulation rather than legislation. Initial discussions with a representative should help indicate whether the problem can be addressed through regulations alone or requires legislative action. Additional research and discussions with local experts will further clarify the issue. The HAVI Policy Working Group is a crucial resource and is available to assist members in all phases of the policy process from initial planning to policy proposal to implementation.
Once they have decided on the best way to address the problem, health care providers should find a champion and assemble a team. Ideally, they should choose a leader who has the time, energy, expertise, and credibility to drive the effort.
Policies are rarely passed as the result of one group’s solitary advocacy. For a greater chance of success, health care providers should survey their local landscape and build a coalition with other community members who support the same policy. It will also provide additional expertise, more people to share tasks, and more resources to invest in the project.
In practice, this coalition-building approach has led to important victories for HVIPs. In Philadelphia, it allowed the Healing Hurt People program to get Medicaid reimbursements through state agency regulation. In both Virginia and New Jersey, the state governors have announced VOCA funding due to grassroots advocacy. Meanwhile, Maryland created a violence prevention fund through the law passed under HB432.