Dear Chicago, Cook County and Illinois Residents,
For starters, let me begin by saying that I am not an expert on criminology, sociology, or why murder happens. In fact, I have very little understanding for why people take to violence to solve problems. I do not look down upon those who do, in fact, my guess is those acts of violence are a "means to an end" for folks living in a pretty crappy situation.
But what I can say with confidence is that I love the city of Chicago and am troubled by the rate of violence in my hometown. As of today's post, there have been 476 homicides in the city of Chicago. More than once per day, a person is being killed in our town. (And by the way, if you are curious about the data, the Chicago Redeye provides an updated spreadsheet to the public) Each one of these homicides is tragic for the individuals involved, their families, and the communities. Young lives are permanently changed (or ended) and nothing good comes out of these killings for anyone.
In addition, I can say with confidence that each of these incidents are EXTREMELY expensive for all parties involved. Beginning with healthcare, victims of violent crime often require very expensive surgeries, treatments, doctor visits, physical rehabilitation, etc, ...and sometimes even the best of modern medicine cannot save a life. Paying for these services is often the obligation of the state, as victims are frequently enrolled in Medicaid, a state-run health insurance program for low-income individuals that is intended to pay healthcare-related expenses for those without insurance.
The healthcare cost of each gunshot is estimated at approximately $50,000, and for those who know about our state's Medicaid program, we are broke. So you can start doing the math in your head, but let me cut to the chase: these incidents are contributing to our state, county and city financial crisis. If we only looked at homicides, the state has incurred approximately $23 Million in expenses...and this is only 2012, and only healthcare expenses for victims who have died. This dollar amount does not take into account the cost of the courts, the cost of the rehabilitation system (prison/jail), and other downstream costs that are incurred when someone decides to resort to violence.
And if you have picked up a newspaper in the last two years, you know our city, county, and state are BROKE. So those bills that are sent to the state are being paid, but often with long delays and at a very small percentage of what it actually costs for those patients to receive care.
On top of it, the organizations that care for victims (hospitals, instituations) are running on shoe-string budgets and swimming in operational messes. Ever visit an Emergency Department on a Saturday night in the city of Chicago? Well I have, and its not pleasant when you're there for a legitimate health concern, feeling miserable, and the nurses/doctors and others are not available. And what happens when a victim shows up an ED? Nurses, doctors and others swarm to the victim, taking services from others in need. This creates delays, chaos in our emergency departments, and awful care for patients.
So to recap:
- People are dying every day from violence in Chicago; more frequently than any other major city in the United States
- Each of these deaths are expensive to the state and the organizations who serve victims of crime
- The costs of these incidents are staggering and bills are not being paid or are being paid late.
- Considering ONLY healthcare related costs, we in Illinois have spent somewhere in the neighborhood of $23,000,000 on care for people who eventually died.
So here goes:
About a year ago, I had a chance to see The Interrupters--a fantastic Documentary that tells the story about Cure Violence's (formerly Cease Fire) work in our community to minimize the frequency of violence. The film (which I highly, highly recommend) shows the powerful story of how “interrupters” work alongside members of their community to prevent the gunshot, the stabbing, the assault, etc., before it happens. If you saw Hoop Dreams, this film was done by the same producers and is outstanding--whether you live in Chicago or elsehwere.
In addition to the work of the Interrupters themselves, the film includes their Physician Champion highlighting the data/metrics that validate the impact their work has had in some of the city’s most violent neighborhoods (their website has info about the film and data if you are curious). While controversial; Cure Violence hires former gang members, criminals, etc., to work alongside current gang members and kids to minimize violence before it happens. This idea, involving those who have "been there before" has been known to work on many public health problems--just think about the success of 12-step programs and the millions they have helped if you're looking for an example.
After watching the film I couldn’t help but think about where many of the victims end up after the incident: our hospitals and trauma centers in the Chicago area. And as I thought about the tremendous costs of these hospitalizations, the chronic overcrowding of EDs, and the missions of our local healthcare entities (to keep the public healthy), an idea came to me.
My idea is to create a “Shared Savings” program between geographic areas where Cure Violence is involved and Chicago's local hospitals/trauma centers. In a nutshell: if Cure Violence is successful in reducing the frequency of violence in specific areas, we should see fewer admissions to these facilities. With fewer admissions, there should be some type of cost savings for these facilities, given who the payer is (Medicaid) and the high cost to care for victims.
With the money the hospital saves, a portion could be returned as a “payment” from local hospitals back to the Community (or Cure Violence) based on improved performance in a designated geographic area. We’d need some good information about the true costs of each violent act, and good data on location/site of each incident, but I'd imagine we could dig this up or figure that out that amount based on some historical data.
So with my idea, let’s say Neighborhood A has 200 victims brought to a Trauma Center Z in 2012 at a cost of $10M (based on $50K/per estimate). If this number is reduced to 150 in 2013, Trauma Center Z would save $2.5M, and provide a payment back to the Neighborhood (or Cure Violence) based on what the hospital saved by having 50 fewer victims brought to their facility. Even if Trauma centers paid just 5% of the savings to the community, this would be $125,000; enough to pay a salary or two for the Cease Fire team, another social worker in the community, etc. All in all, it could be a "win win" all around: fewer kids dying, fewer victims taking up beds, money saved by the hospital, money gained by the community/group solving the problem, and an ongoing revenue stream to support those working to solve the problem.
And if you think this idea is crazy or unique, it is not. A similar type of “shared savings” initiative with the community is going on in Camden, New Jersey with the work mentioned in a fantastic New Yorker article from several months back by Atul Gawande. Although the work in Camden is focused on different conditions (Asthma, Diabetes, etc.) my concept is very similar—using geographic data to identify frequency of admissions and providing financial rewards to community-based efforts that reduce the admissions. As time has gone on, the folks in Camden have found, there is something very powerful about returning savings back to the organization, community, and people most effective in solving the problem and I believe in the people of Chicago when it comes to tackling the problem.
I could even envision posting "real time" performance metrics so that communities and the city is aware how geographic regions are performing relative to their goal...I mean, if we can post deaths due to traffic accidents on highways, the speed I'm travelling, and all sorts of nonsense on billboards, why can't we display death rates so others can track something meaningful to them and their areas?
My thinking is the money returned to the Community could be spent on anything the community (or Cure Violence) feels will prevent even more violence….whether its training or treatment programs, lighting on streets, more parks, special events, Gun “Buyback Programs”, more Cure Violence staff, etc. but I suppose that is getting ahead of ourselves and something I know very little about.
But this idea of spending the money on what the community feels is needed can be very powerful—when those involved in the problem have a vested interest in its solution, we tend to see traction/engagement (this is one of Lean’s core tenets…those closest to it are the best ones to fix it). In Camden, there are buildings in the worst neighborhoods where citizens (not trained Administrators or Physicians) are making decisions about how they want to spend the money they’ve received from hospitals that came due to avoidable ER admissions!
The way I see it, we are getting precisely the type of results (Homicides) that our Government, Healthcare, Judicial, and Law Enforcement system is set up to create. If we'd like to see a different outcome, we need to think radically different about how we tackle the problem before it becomes a problem and reward what we want to see, rather than resorting to methods that have shown to be ineffective, expensive, and far from proactive.
If what you read about here interests you, I'd welcome feedback, ideas and suggestions to build on the idea and bring it to the right folks. Before you suggest Cure Violence and a major health system...yes, I have reached out and no I have not heard anything. This probably needs to get to the Mayor, Alderman, County, State, or other entity so if you have friends in high places, feel free to pass along.
Great post and idea! Is there a name/title for this idea? That may help with spread and let those involved feel ownership too. Maybe mr. Emanuel wants to do something radical and progressive to steal some headlines from his NYC counterpart mr bloomberg...? - connor
ReplyDeleteInteresting concept, but I find a flaw in some of the logic. Just because an ED would potentially have less gunshot victims doesn't translate to them have a couple extra million dollars in their pocket at the end of the year. The hospital will still be open and still operate with staff, stocked with supplies, lights on, heat on, etc. (all the things that cost them money to run their business). In your example above, the $2.5M in savings is fake money that doesn't really exist at the hospital. It is really $2.5M less that they would have to bill various payers. Also, let's say that there was only 1 hospital for all of Chicago. If we eliminated all homicides in Chicago for the year, it would equate (roughly) to 1 less patient in the hospital per day. One could argue that the real financial impact would be that we would theoritically staff less nurses, docs, need less supplies, etc. But 1 less patient per day would not constitue any staffing changes (where healthcare spends most of it's money).
ReplyDeleteThe only way something like this would potentially work is if the payer (Medicaid, Blue Cross, etc.) were the ones paying the community the "shared savings", not the hospitals. Although if you are going to rely on reimbursement from Medicare, good luck.
-Charlie Golf