A recent study by Stanford University succeeded in examining eight years of data, to 2014, and found that initial hospitalizations involving firearm injuries cost $734.6 million a year nationally.
The Bill for Treating a Gunshot Wound: $21,000 for the First 35 Minutes
Jennifer Smith Richards, Annie Sweeney and Jason Meisner, Chicago Tribune
(TNS) - The charges started racking up the moment Annette Johnson arrived at Mount Sinai Hospital with a gunshot wound to her left forearm.
Doctors sliced open Johnson's arm and installed a $500 metal plate to shore up her shattered ulna, securing it with numerous bone screws that cost $246 apiece. There were morphine drips to quell pain, tetanus shots to prevent infection, blood screens and anesthesia.
Two years earlier in a different part of the city, Leo Leyva arrived at a North Side hospital with a gunshot wound to his back. His last memory before going under anesthesia was a nurse telling him they were going to take good care of him and to count up to 10.
As the 18-year-old drifted off, the emergency room team at Advocate Illinois Masonic Medical Center went to work to save his life, starting IV lines and X-raying his chest and abdomen before performing an emergency surgery to remove the bullet and repair the damage.
For both Johnson and Leyva, just two of the thousands of gunshot victims in Chicago every year, the first hours and days of their hospital treatment were only the start of what would be costly recoveries that continue to this day.
Still, the bills for their initial treatment were staggering. In his first 35 minutes at the hospital, Leyva had racked up $21,521 in charges, and by the time he was released three weeks later the bill totaled more than $157,000. For Johnson, who spent barely 24 hours at Mount Sinai, the hospital charges approached $27,000.
An unprecedented analysis of state data by the Tribune reveals that the initial medical costs for treating Chicago gunshot victims like Johnson and Leyva add up to tens of millions of dollars each year. And those costs are rising.
The data — obtained by the Tribune after months of negotiation with public officials — show that Chicago-area hospitals billed more than $447 million to treat some 12,000 documented victims of gun violence in the city between 2009 and mid-2016.
And even that figure represents just a fraction of the total billed. While the hospitals charge for room and board as well as equipment and drugs, the surgeons, anesthesiologists and other medical professionals who treat gunshot victims in emergency rooms across the city typically bill separately.
The data show that the victims who bear the physical and emotional scars of being shot live mostly in economically depressed and racially segregated neighborhoods. But the financial burden of caring for survivors of gunshot wounds extends well beyond neighborhood boundaries, according to the Tribune analysis.
In fact, patients who live in poverty and are insured through the publicly funded Medicaid and Medicare programs account for nearly half of the costs analyzed by the Tribune.
Dr. Amir Vafa, chief of trauma surgery and critical care at Mount Sinai, said the violence has ripple effects that touch on every aspect of the city in some way regardless of where it happens.
"It is not a 'me' or a 'you.' It's an 'us,'" Vafa said in an interview at the hospital, which serves largely black and Hispanic neighborhoods on the city's West Side. "We are all in this together. The reality is the entire fabric of society is connected, right? Nobody lives in an absolute bubble."
The numbers obtained by the Tribune do not reflect what ongoing treatment might cost patients and taxpayers once a patient is discharged, whether it's follow-up care, physical therapy or mental health treatment to address the trauma of being shot.
To highlight the financial and emotional hurdles that many shooting survivors face, Johnson and Leyva each agreed to provide their detailed medical and billing records to the Tribune.
Eight years after he was wounded, Leyva remains partially paralyzed, using a wheelchair or braces to get around, but his recovery has been remarkable in many ways.
Johnson, though, continues to struggle both physically and mentally. She's faced not only a painful recovery after surgery but also the tragic loss of her 15-year-old son, Antonio, an honor student and budding football star who was fatally shot in the same gang-related attack that left her wounded.
"This shooting, it has parted my whole family," Johnson said in an interview. "It shattered my life, physically, emotionally. It shattered my son's life. ... All he wanted to do was go to school and play football."
Putting an accurate price tag on what it costs to treat all victims of gun violence in Chicago is nearly impossible. Hospitals aren't required to note whether they've treated victims of firearm assaults, and the powerful gun lobby has successfully stifled research on gun violence at the federal level. Privacy laws also limit the types of data that the government is willing to release.
The data released to the Tribune represent more than 11,800 patient visits involving gunshot victims in Chicago, only an estimated two-thirds of the known shooting victims during the 7 1/2-year time frame studied.
The figures also don't reflect the amount ultimately paid by patients or taxpayers — a fraction of what the hospitals billed. Private insurance companies negotiate payments based on treatment, and patients who pay out-of-pocket or have no insurance also can negotiate. Medicaid and Medicare pay using a set fee schedule for procedures and hospital stays.
The data indicate that charges from area hospitals rose significantly over the 7 1/2-year span.
Hospital charges in 2009 for patients admitted in Chicago totaled $41.6 million. In 2015, the last complete year of data, hospital charges added up to a combined $62 million. Many categories of charges contributed to that increase, including charges for operating rooms and anesthesiology, both of which more than doubled.
Back in 2009, gunshot inpatients in Chicago averaged about $57,963 in charges for their hospital stay. Through the first half of last year, inpatients racked up $93,647 on average in hospital charges.
Illinois' hospital charging data also indicate that inpatient stays grew longer, most likely a factor in the escalating charges.
For each year since 2009, the average length of stay in a Chicago hospital for victims of a firearm assault hovered at about a week. For similar inpatients treated in the first half of 2016, the length of stay grew to more than nine days on average.
The breakdown in the types of insurance used by hospital inpatients makes clear that the financial burden of the medical costs associated with gun violence often falls on taxpayers, not the victims.
Nearly half of the amount for treating inpatients after a firearm assault was billed to taxpayer-funded Medicaid and, less often, Medicare. Less than one-quarter of inpatients were insured through commercial insurance or HMOs, and others either were self-pay or insured in some other way.
The data are further confirmation of how skewed gun violence is along racial and socio-economic lines. Nearly two-thirds of the hospital inpatients treated for injuries suffered as a result of firearm assault were black males ages 15 to 44, the data showed.
The costs to treat gunshot wounds are driven by the unique and critical nature of the injuries. The data paint a picture — in unadorned medical terms — of the bodily destruction: patients with injuries to the head and neck, abdomen, hips and thighs; bullets that caused open complex fractures of bones, left small intestines exposed and lacerated livers.
Doctors can't afford to take a wait-and-see approach.
"With a penetrating injury, especially a gunshot wound, the patient is so sick they immediately need to operate," said Dr. Vafa of Mount Sinai.
When alerted that a gunshot victim is en route, Mount Sinai goes into high-alert. Some 15 medical personnel are mobilized. Various tests and procedures, among them X-rays and CT scans, are ordered to determine the seriousness of the wound. Blood is readied in case a patient's blood pressure suddenly drops. Stapling devices need to be delivered to the operating room.
"The hospital needs to be in a constant state of being ready," Vafa said. "That includes people giving X-rays, people drawing blood, laboratory work, operating rooms ready to go, doctors ready to go."
How charges add up
The first shot fired at Annette Johnson should have killed her.
It was a warm September afternoon six years ago. The then-37-year-old mother of three was standing on her front stoop in Chicago's Garfield Park neighborhood unloading groceries with her youngest son, Antonio. They were talking about a new pair of pants he wanted for the upcoming homecoming dance when a car pulled up and she saw the barrel of a gun pointed out the window.
Johnson froze. She remembered wondering if that gun was really pointed in their direction. She heard the gunman yell something at her older son, Anthony Jr., who had come out of the house to help with the groceries. Then came the crack-crack-crack of the shots. The left-handed Johnson instinctively threw her left arm in front of her face.
The bullet struck Johnson just below the elbow and traveled diagonally through her forearm, fracturing her left ulna — the thinner and longer of the two forearm bones — and lodging inside her wrist. As Johnson dove to the side of the porch steps, Antonio, with his solid 6-foot, 195-pound frame, fell on top of her. Bullets whizzed into the house, one missing Johnson's teen daughter by inches and lodging in the back of her bedroom closet.
After the car sped off, Johnson pulled herself from under Antonio and asked if he was hurt. A trickle of blood ran down his neck, and he had a glazed look in his eyes. When Johnson told her son not to move because he'd been shot, he answered in a whisper, "OK." It was his last word to her.
"His head just fell forward and blood started running from his mouth," Johnson, now 43, recalled. "I ran into the house screaming. I was hysterical."
Johnson rode to Mount Sinai in an ambulance behind Antonio's. She had no feeling in her fingers. Later, X-rays showed the bullet shattered a section of her ulna before cauterizing the veins in her wrist. There was a gaping oval wound about an inch and a half in diameter where the bullet had entered and a large clot of blood underneath the skin in her wrist where it had come to a stop.
While Johnson was awaiting test results, Chicago police detectives came to her room with a photo array of suspects, handed her a pen and asked her to circle the picture of the gunman and write her initials by it. Johnson looked at the detectives and held up her useless left hand. "I said, 'How am I supposed to sign with this?'"
She looked over the photos, saw Keith Talbert's face, and instantly a chill came over her. Johnson grabbed the pen with her right hand and awkwardly circled Talbert's photo, identifying him as her son's killer.
About 11 p.m., shortly before Johnson was wheeled into the operating room for emergency surgery, a woman from the Gift of Hope organ donation network approached and asked her to sign paperwork allowing Antonio's organs to be harvested.
"It was like my whole world just crumbled right then and there," Johnson said.
Minutes later, Johnson was under anesthesia on the operating table. Doctors cut open her forearm the length of the ulna and exposed the shattered bone. Her medical records show the bone was "significantly comminuted" — reduced to small particles. The two good ends of the bone needed to be fused together using what's known as a compression plate fixed with seven 3.5-mm titanium screws.
Once the plate was in place, doctors cut around and cleaned the bullet wound and sutured the skin back together. The bullet was left in her arm after it was determined that removing it carried too much of a risk, a common practice in the treatment of gunshot victims. After she was sewn up, Johnson was moved to a recovery room.
She was released from Mount Sinai the day after the shooting with her arm in a sling, a prescription for pain pills and instructions on how to care for her wound. The bill for her surgery and overnight stay totaled $26,982.54.
The itemized, four-page bill shows how the charges added up. The first 15 minutes of anesthesia cost $437, and each additional 15 minutes was billed separately, for a total of $3,933. The metal plate was $593, each cortical bone screw was $246. The total charge for the operating room facilities came in at just under $10,000. And once her surgery was over, Johnson was moved to a "step down room" to recover from the anesthesia — at a charge of $2,713.
Medicaid took care of the bill. But there was another cost she had to worry about — her son's burial. Days after her release from the hospital, Johnson was at a funeral home picking out a casket.
Antonio was buried at Forest Home Cemetery in Forest Park. A week later the bill came: $5,535.08.
In September 2009, Leyva was 18 and living with his mom and dad and three siblings in the Logan Square neighborhood on the Northwest Side.
Life was good. Although he'd recently dropped out of high school, Leyva was stocking and bagging at a grocery store to help support his family. He played on championship baseball and basketball Park District teams and was a popular kid.
Leyva acknowledged that back then he occasionally hung out with gang members — friends from the neighborhood — but said he was never affiliated.
"I was just hanging out with the wrong people at the wrong time," he said of the day he was shot.
Leyva and some friends were driving around, waving a flag out of the car window in celebration of Mexican Independence Day. But then someone in the 2800 block of North Lawndale Avenue snatched the flag from the car. He and his friends got out to confront the group. Leyva, though, quickly decided to turn and walk away with two of his friends.
That's when he heard someone yell, "Shoot him!"
"As soon as I hit the curb, I just dropped," Leyva said. "All I can remember is just thinking about my mom. What is my mom gonna say?"
Leyva couldn't get up but managed to flip his body over. He could see the group badly beating one of his friends.
He kept trying to move his legs.
"I was trying to put a lot of effort into getting back up," he said. "I just felt so weird."
Leyva was taken by Chicago Fire Department ambulance to Illinois Masonic. When he arrived at 11:25 p.m., he was pale, cool to the touch and strapped to a board in a neck brace. He had a gunshot wound in his back and no sensation or movement below his waist.
The procedures Leyva would endure over the next three weeks are spelled out in 13 pages of billing records: blood draws, X-rays of his chest and abdomen, CT scans, painkillers and the slicing open of his abdomen to treat the damage from the bullet.
The hospital had to go into high alert given the critical nature of Leyva's wound. There was a $7,919 charge labeled "trauma active" for mobilizing doctors, residents, nurses, technicians — all the medical personnel who might have to treat him as he arrived at the hospital.
The bullet had put Leyva's major organs at risk of failure or long-term damage. One of the first services ordered was a "critical care evaluation and management." It cost $3,020.
Doctors also made an emergency intubation, ordered a blood count, tapped into his veins and gave him morphine. Each carried a charge.
Just after midnight, a CT scan captured images of bullet fragments, according to hospital notes. That was billed at $1,608.
Doctors then cut open Leyva's abdominal cavity and found the bullet had pierced his stomach, according to a discharge summary report. The surgeon removed the bullet from the abdominal wall and repaired his stomach before closing the wound.
About two weeks later, Leyva needed a second surgery to remove bullet fragments from his back, according to the report. The discharge notes pointed to improvement in Leyva's pain, but he still felt no movement or sensation below his waist.
Much of his time at the hospital remains a blur to Leyva. He does recall the morphine drips every four hours, if only because they weren't helping the burning, tingling sensation shooting from his hips to toes.
Leyva, now 26, recently described the treatment in a quiet, even voice as he sat in his wheelchair. He lifted his American Eagle T-shirt, exposing a pale white scar from surgery that runs upward from his belly button. His fingers slowly traced the crude line as he glanced downward.
Leyva then slid his finger across his belly to a small quarter-sized splotch on his left side, where a tube had been inserted, he said.
"My stomach felt so tight," he said. "I just couldn't breathe, I couldn't laugh."
After three weeks at Illinois Masonic, Leyva was discharged to the Rehabilitation Institute of Chicago.
No one had told him yet whether he would regain any movement or sensation in his legs. The second surgery had improved the pain but nothing else.
The combined price tag of Johnson and Leyva's acute medical care — $184,000 — is an important yet underreported piece of the unrelenting story of gun violence, experts say.
The financial costs are a common denominator that links all neighborhoods, said Garen Wintemute, a professor of emergency medicine at University of California at Davis who studies gun violence.
"We all have a financial stake," he said. "We are all paying for it."
Part of the reason the financial story is not often told is the difficulty in getting the data. Since there's no requirement across all states for hospitals to note whether patients are being treated as the result of a firearm assault, researchers who hope to study gun violence are usually left to use samples of data rather than complete sets.
A recent study by Stanford University succeeded in examining eight years of data, to 2014, and found that initial hospitalizations involving firearm injuries cost $734.6 million a year nationally.
The Chicago Tribune's analysis relied on data from the Illinois Department of Public Health, which collects patient information from hospitals, data that is however exempted from the Freedom of Information Act by state law.
After months of negotiation, the health department agreed to provide some data to the Tribune but restricted other information, such as naming individual hospitals. Also, the agency withheld any information regarding Caucasian children or senior citizens, arguing that since so few in those demographics are the victims of gun violence, reporters might be able to use the data to identify individual patients.
It's much the same story nationally with research on gun violence, including its financial costs, chilled by cuts in funding to the Centers for Disease Control and Prevention. The federal agency lost funding in 1996 in the wake of legislation pushed by the gun lobby that prohibited spending federal dollars on efforts to "advocate or promote gun control."
Lars Dalseide, a spokesman for the National Rifle Association, told the Tribune the NRA supported the legislation back then because of public statements by CDC officials that the research would be used to limit gun use by law-abiding Americans. Dalseide emphasized the need to look at how the justice system punishes gun offenders, saying laws already on the books should be enforced to deter violence.
Mark Rosenberg, who headed the CDC's National Center for Injury Prevention and Control when the controversial legislation passed, said the law has made it harder to answer key questions like who is shot and under what circumstances or to examine the types of weapons that are used and how they make it into the illegal market. Research on all of this would contribute to solutions on how to stem the street gun violence and reduce the costs to treat it, Rosenberg said.
"(These are) system failures that we can fix," he said. "It's crazy that we let this go on. If we did more research, there are ways to both protect the rights of law-abiding gun owners and reduce gun violence."
Long, costly recoveries
The long recoveries for Leyva and Johnson show the high price individuals pay — and the resilience it take to overcome the devastating injuries.
For Leyva, the road started at the rehab institute with slow, painful therapy to restore strength and mobility to his weakened lower body. When he started, simply balancing himself on metal bars to try to walk on braces required all his strength, leaving him sweating and dizzy. Eventually Leyva was taking "baby steps" with a walker.
The slow pace frustrated him. His resolve and spirits sagged. He wanted to stay home alone and away from others.
"I didn't feel very comfortable with myself," he said, recalling the first year after the injury. "I was depressed, stressed."
Staff members at the rehab center continued working with Leyva, constantly inviting him to play on one of the numerous sports teams they sponsor. They encouraged him to accept his life. Over time, their support helped him cope, and in many ways, grow.
Nearly eight years after the shooting, Leyva has a sense of purpose. His hands are swollen, nicked with small white blisters from his constant pushing on the rubber wheels of his chair and crashing into walls and gym floors from playing wheelchair basketball and softball in competitive leagues.
Married with a stepson, he says he has part-time jobs selling medical equipment and counseling those with disabilities on how to navigate the health care system. He is close to earning a GED and hopes to study to be a pharmacist.
"When people tell me, 'How do you live with it?' I just tell them, 'Just live,'" Leyva said. "Whether you're in a chair or not."
By March 2017, the charges for Leyva's rehab totaled $253,163.05, a tab that is being picked up almost entirely by Medicaid and is still climbing.
Meanwhile, Johnson found that losing function of her dominant hand was more life-altering than she could have imagined, even after enduring months of physical therapy. Combing her hair, putting on makeup or performing other routine tasks proved difficult. She can't grip a can opener, so she buys bags of frozen vegetables instead.
"I've had my aunt come over to peel potatoes for me," she said.
Johnson continues to struggle with limitations that go well beyond the physical, including emotional scars from seeing her youngest son killed.
Before the shooting, Johnson was running a state-funded day care out of her home, making about $2,500 a month, she said. She shut it down after her son's death and started collecting disability and unemployment. Recently, with the subsidies ending, she went to work a minimum-wage job as a liquor store cashier.
Over the past several years, Johnson's weekly grief counseling sessions at a Maywood nonprofit have cost about $5,500 in total, with the charges covered by the Proviso Township Mental Health Commission, according to data provided by the nonprofit.
She takes medication for anxiety and depression. Even though she moved to a western suburb after the shooting and the gunman, Talbert, was convicted and sentenced to 100 years in prison, she's afraid of running into gang members from the old neighborhood.
"My psychiatrist recommends that I do puzzles as a form of therapy," she said. "My mind wanders. The slightest thing will remind me of Antonio and that is all I can focus on. The other day, I saw a kid on the street who looked just like Antonio, and I just broke down crying."
Her once-strong family has fallen apart. Her eldest son, Anthony, the one who gang members had targeted, was arrested for residential burglary in April and is being held in Cook County Jail on a $100,000 bond while awaiting trial. Her daughter, Ashley, was so distraught after the shooting that she moved to Florida. Ashley, who later earned a graduate degree in science and obtained a private investigator's license, has urged her mother to make a change, too.
"She said, 'Ma, you need to leave Chicago. You live your life like a monk,'" Johnson said. "I told her I'm doing OK. I still consider this my home."
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