Pushing Back: Balancing Cost Against the Price of Missing Child Physical Abuse

Health care costs have risen faster than the average citizen’s annual income, representing nearly one-fifth of the nation’s gross domestic product and positioning health care as 1 of the nation’s largest, most profitable industries.¹  In this climate tense with exorbitant costs and inefficiency, prioritizing value-based care (VBC) (higher-quality care focused on preventive services that positively improve long-term patient outcomes) has become paramount. Fundamentally shifting the perspective of traditional, decadent health care economics, more intense scrutiny of patient-centered outcomes per dollar spent has highlighted difficulties facing many health care providers, primarily around how to quantify oft-unmeasurable value and quality.² 

Against this backdrop, many health care providers tasked with institutional, VBC cost saving have taken inventory of existing processes and turned to clinical decision support, guidelines, and pathways to eliminate expensive, haphazard “shotgun” approaches and correct nonstandardized or cost-ineffective practice gaps. Reservations regarding practices that theoretically raise cost, particularly laboratory and diagnostic test performance, have been at the forefront of clinical algorithm development, forcing providers to mine existing evidence bases to weigh risks and benefits and establish tolerable levels of clinical “unknowns.” Questions like “Will this test result really change my clinical management?” and “What is the cost of missing the condition in question?” abound. However, this framework of near-indoctrination around minimal testing sometimes threatens sound, rationale medical decision-making, truncating critically important, much-needed analysis of long-term patient-related repercussions (ie, value).

Consider child physical abuse. It is inevitable health care providers will encounter abuse victims. The National Survey of Children’s Exposure to Violence estimates 1 in 4 children experience some form of abuse or neglect in their lifetime across the United States.³  In 2017, ∼675 000 victims of abuse or neglect were reported to child protective services; an estimated 1700 children died, a rate of 9.2 per 100 000 children in the national population.⁴  Many abuse victims present to emergency departments and inpatient units for care; however, abuse detection rates are notoriously low.⁵  Nearly one-third of children diagnosed with abusive head trauma were misdiagnosed on initial presentation,⁶  and 33% of children with healing abusive fractures previously presented with injuries in which abuse was missed.⁷  Accurate and early detection of abuse is paramount; recurrent, undetected abuse frequently results in fatality.^8,9 

Although missing abuse clearly has profound, life-threatening implications, the challenge remains to accurately, appropriately identify these children while being good stewards of ever-decreasing resources in the current cost-conscious health care environment.⁹  Despite critical importance, abuse evaluations have notoriously lacked standardization across health care institutions nationally.¹⁰  American Academy of Pediatrics clinical practice guidelines endorse routine occult injury screening among suspected abuse victims and their household contacts, given the potential safety risks inherent in the household environment.¹¹  Nonetheless, skeletal survey (SS) performance in particular has varied widely across settings.¹⁰  In response, robust strategies have been developed by using flow charts, checklists, and algorithms to guide screening and evaluation of children with suspicious injuries, and local protocol implementation of routine screening performance has resulted in increased abuse identification and attenuated racial and ethnic biases in abuse evaluations.^9,12,13  Standardized screening has also prioritized evaluation of medically minor injuries, most commonly bruises, which are frequently warning signs for escalating violence. Harper et al¹⁴  identified infants <6 months old presenting with bruising who underwent occult injury screening; SS results were positive in 23%, neuroimaging resulted positive for new injuries in 27%, and abdominal injuries were revealed in 3%, an overall rate of additional injury in 50% of infants. Occult injury screening clearly offers value.

Institutions considering changes to child abuse recognition and management may face concerns from a variety of angles (health care providers, administration, billing, and use review) regarding unnecessary admissions, overuse of imaging studies, and undue burden on human resources,⁹  that is, the perceived increased costs (financial, time, resource) theoretically associated with performing American Academy of Pediatrics–recommended occult injury screening. Increased performance of SSs, MRIs and computed tomography scans, and laboratory tests are expensive, time and resource intensive, and low pretest probability frequently translates to negative results. The crux of the argument therefore is this: institutions and health care providers may be uncomfortable with standardizing diagnostics for occult abusive injuries because the perception is “it’s economically not worth it,” and the value is not there. Is there possibly a double standard for abuse, not applied to other conditions? Would we be having a similar discussion about chest radiograph worth to diagnose pneumonia? Possibly, but notions about abuse evaluations (that they are unnecessary, costly, even lower priority than evaluations for other clinical conditions) deserve to be vigorously challenged.

At our institution, we recently tackled the cost and value controversy for child abuse evaluations during implementation of a hospital-based, standardized physical abuse clinical pathway. Are associated costs worth it? Who pays for MRIs? Do siblings really need this? Are abuse hospitalizations reimbursed? These are sentiments repeatedly echoed by health care providers, hospital billing, administration, and even leadership. As the child abuse pediatrics subspecialty team routinely engaged in this population’s care, we pushed back, figuratively, perhaps controversially, and challenged our colleagues to focus long-term. What is the cost attached to a child’s life, potentially impaired by devastating disability? Our response was perhaps a little strong, maybe dramatic, but our point was costs must be balanced against the price of missing abuse. That is, what is the impact on a child’s life if a critical misstep in diagnostic evaluation allows abuse to evade detection?

Our pushback premised on issues of practicality. First, logically, 1 inevitable consequence of standardizing evaluation may in fact be increased in-the-moment costs. How consequential this is, especially when potentially predictive of future, high-quality outcomes, depends on how one defines cost and value and whether one uses short- versus long-term perspectives. In reality, worries about in-the-moment cost increases may be unfounded. Structured, standardized occult injury screening evaluations for suspected child abuse victims may actually cost save, and in 1 recent study, it was demonstrated that a structured abuse evaluation protocol in fact reduced the percentage of patients requiring hospitalization and did not confer added burden on hospital resources.⁹ 

Secondly, financial “cost” in health care is relative, highly influenced by local norms, subjective to institutions performing care, and based on negotiated reimbursement rates for specific tests. Fee schedules vary. Some institutions (like our own) even have foundational funds earmarked specifically for care-related services. There is no single cost of abuse screening to criticize and oppose. Rather, we must view cost as dependent largely on specific institutional and patient factors.

Thirdly, suspected child abuse and neglect is a billable medical diagnosis for which insurance will reimburse both for the index patient and siblings. Payers do not differentiate “household contact” from “index victim” when calculating reimbursement, and we have responsibility (in concordance with national clinical practice guidelines) to appropriately medically evaluate all children deemed potentially unsafe. Screening SSs resulted positive in ∼12% of asymptomatic household contacts younger than age 2 in 1 study.¹⁴  Furthermore, standardized protocols could potentially reduce costs. Insurance companies will undoubtedly reimburse initial stages of abuse workups; delays in workup and disposition (such as waiting for a weekday to perform an indicated MRI for a victim of abusive head trauma admitted Friday night) may realistically result in “lost” coverage days. Prioritizing VBC and child physical abuse evaluations is not incongruous but requires diligence by all involved to recognize the “unmeasured value” conferred. To cost save and achieve high-value outcomes, it is essential to garner physical resources and have mobilized personnel with preemptive adherence to recommended guidelines to ensure timely performance, thereby reducing length of stays and cost inflation. Doing the right thing, the right way, and time efficiently is paramount and has proven to be achievable.⁹ 

Realistically, some short-term costs may be unavoidably higher, but higher short-term costs are worth it in the long run if child safety is the value outcome. Consider R.S., an infant with missed, catastrophic abusive head trauma; her hospitalization at diagnosis was tremendously costly both short-term (from prolonged, intensivist level of care) and long-term (costs of foster care placement, medical day care, and now skilled institutional care). High costs are also lifelong; she is now an incredibly high-volume health care user across her life span related to irreversible neurologic devastation, an outcome potentially mitigated had more-robust, routine performance of occult injury screening been used to detect her abuse just weeks earlier.

Health care dollars spent to address abuse concerns in infants today can tangibly result in decades of future saved financial costs through adulthood. Estimated lifetime, nonfatal child abuse per-victim cost (childhood and adult health care costs, productivity losses, child welfare, criminal justice, and special education costs) is exorbitant; in a 2015 article, authors report individual lifetime cost of $830 928, amounting to $428 billion annually.¹⁵  But cost is more than this because the aforementioned all reflect only a single dimension of abuse-related cost.

Abuse has immeasurable societal impact. Societal child abuse costs are resource related, impacting law enforcement, social service agencies, and most importantly, the child’s quality of life. Abused children become adults who endure lasting effects of adverse childhood experiences impacting mood, cognition, and behavior, resulting in negative mental and physical health outcomes (eg, substance abuse, suicidality, cardiovascular disease, and infection).¹⁶  Emotional, social, psychological, and financial costs are vast. Difficult to quantify, abuse costs can never truly be recouped or reimbursed.

Good stewardship of health care costs is critically important; however, good stewardship of children’s health and safety should be vital at any cost.