Health care utilization and costs associated with physical and nonphysical-only intimate partner violence.

Physical and nonphysical types of intimate partner violence (IPV) are common in women, with lifetime prevalence ranging from 17 to 34 percent for physical IPV, and 12 to 35 percent for nonphysical abuse (e.g., verbal threats; chronic controlling behavior; Coker et al. 2002; Thompson et al. 2006). In addition, each of these types of abuse (physical and nonphysical) has been shown to be independently associated with adverse health outcomes in women, including depression, poor self-reported health, low energy, and diminished social functioning (Coker et al. 2002; Bonomi et al. 2006; Bonomi et al. 2007; Breiding, Black, and Ryan 2008; Ellsberg et al. 2008). A growing literature has documented elevated health care utilization for women with a history of IPV compared with women without comparable abuse histories (Bergman, Brismar, and Nordin 1992; Plichta 1992; Ulrich et al. 2003; Coker et al. 2004; Fanslow and Robinson 2004; Max et al. 2004; Amar and Gennaro 2005; Arias and Corso 2005; Snow Jones et al. 2006; Rivara et al. 2007). Costs associated with this increased health care utilization are significant, with a recent study, for example, showing that abuse-related health care utilization amounted to US$19.3 million in excess annual costs for every 100,000 women enrolled in a large health plan (Rivara et al. 2007). Despite a growing literature on the costs of IPV, we found only one health plan-focused study that examined costs associated with the specific type(s) of IPV women experienced (Snow Jones et al. 2006). This study estimated the relationship between physical and nonphysical types of IPV and health services utilization and costs in 383 women enrolled in a health maintenance organization. Average annual health care costs (in 2005 dollars) were highest for women who experienced both physical and emotional abuse (US$5,648 versus US$2,101 for never-abused women). When costs were aggregated over a 3-year period, women with physical, sexual, and emotional abuse had the highest costs compared with never-abused women (US$9,673 versus US$4,826), followed by women with physical and emotional abuse (US$9,210) and women with emotional abuse only (US$6,931). In addition, women who were abused in the past year had costs that were 122 percent higher than for never-abused women and 60 percent higher than women who experienced abuse before the past year. In spite of important new information from the study, the sample was small, cost estimates were unstable, and the cost differences between abused and nonabused women were not statistically significant in two-sided tests. Additionally, the authors did not consider the costs associated with various types of abuse according to the timing of women's abuse. Max and colleagues (2004) estimated costs of IPV at the U.S. population level using data from the Medical Expenditure Panel Survey and the National Violence Against Women Survey. The study found that medical costs (i.e., costs associated with emergency visits, outpatient visits, hospital stays, etc.) amounted to US$2.6 billion per year (1995 dollars)—US$2.4 billion attributable to physical assault and US$1.6 million to rape by an intimate partner. Mental health service costs amounted to US$1.4 billion per year, with more than 80 percent of these costs attributable to physical assault. The study provided valuable information on health care utilization and costs primarily in victims of physical types of violence. However, it did not consider nonphysical types of abuse, other than stalking, and like the study by Snow Jones et al. (2006), it did not examine health care costs associated with types of abuse according to the timing of women's abuse. Additional studies are needed to examine the relationship between health care utilization and costs associated with the type of IPV according to the timing of the abuse, as different patterns of utilization may be present depending on both the type and timing of women's abuse exposure. For example, women with ongoing physical abuse may be high utilizers of emergency health services, whereas women with ongoing physical or nonphysical abuse only may be high utilizers of mental health services for their experiences. The present investigation estimated annual health care utilization and costs associated with physical versus nonphysical types of abuse according to the timing of the abuse exposure (ongoing, recent, or remote), in a cohort of 3,333 women randomly sampled from the membership files of a large health care delivery system. Information from the present study is useful for researchers, clinicians, and policy makers at the health plan level interested in knowing how women present for health care services and how costs are incurred depending on the types and timing of abuse experienced.