Chris Bergin by KHN
It was dusk while Oakley Yoder and the other children from summer camp returned to their tents in Jackson Falls, Ill., Last July. As the group approached a pile of rocks blocking the path, Oakley, then 9, did not see the snake lurking – until she bit her right toe.
"I was really scared," Oakley said. "I thought I might be paralyzed or really die."
His camp counselors suspected it was a copper head and knew they needed to get their medical attention as soon as they could. They had to keep her as still and as still as possible-the poison could circulate more quickly if her heart flashed with activity or fear.
A counselor gave him a ride on the back of a van. Others distract her with music and candy from Taylor Swift as the van rush from its location in a beautiful but remote part of the Shawnee National Forest to help.
The rescuers received them and recommended that Oakley be taken by an air ambulance to a hospital.
The helicopter flight transported Oakley, 80 miles from a school parking lot, to the St. Vincent Evansville Hospital in Indiana, where it received four vials of antivenom. She was then transferred to Riley Hospital for Children in Indianapolis for observation.
His parents, Josh Perry and Shelli Yoder, were already in bed that night when they got the call about what had happened to Oakley. They jumped in the car and arrived at Riley about two hours before their daughter. After she arrived, the doctors watched her condition closely, her toe still running and bruised. At lunchtime, Perry said, the doctors assured their parents that Oakley would be fine.
"It was great comfort for me to realize, okay, we're getting the best care possible," said Perry, who is a professor of health ethics at the Indiana University business school in Bloomington. Less than 24 hours after the bite, Oakley left the hospital with his grateful parents.
Then the bills came.
Patient: Oakley Yoder, now 10, from Bloomington, Indiana. Insured by Indiana University in Bloomington, where her father and mother work as teachers.
Total Account: $ 142,938, including $ 67,957 for four vials of antivenom ($ 55,577.64 was charged for air ambulance transportation). The scale included a ground ambulance fee and additional expenses with hospitals and doctors, according to the family insurer, IU Health Plans.
Service Providers: St. Vincent's Evansville Hospital, part of Ascension, a nonprofit Catholic health care system. Riley Hospital for Children, part of Indiana University Health, a non-profit health system. Air Evac Lifeteam, an air ambulance provider.
Medical service: The essential part of Oakley's treatment involved giving her four bottles of snake antivenom called CroFab.
What gives: When bitten by a venomous snake, there is no time to lose. If left untreated, a poison bite can cause tissue damage, bleeding, and respiratory arrest. Children tend to suffer more severe effects because of their small size.
CroFab has dominated the American snake venom market since its adoption in 2000. When Oakley was stung, it was the only drug available to treat venomous stings in snakes. (Oakley was probably bitten by a copper snake, a type of viper, the camp directors told her parents.)
But with only one antivenom available in the US at the time, the drug company, BTG Plc, based in London, had essentially a monopoly.
The average table price for CroFab is $ 3,198 per bottle, according to health information technology company Connecture. Manufacturing costs, product improvements and research all contribute to the price of the drug, said Chris Sampson, a BTG spokesman.
A Mexican version of snake antivenom can cost around $ 200. But it could not be sold in the US (more on that in a moment).
Dr. Leslie Boyer, founding director of the VIPER Institute, a poison research center at the University of Arizona, recognizes that part of the price in the US can be attributed to the strict Food and Drug Administration requirements for testing and monitoring. But more than that, she added, "It's a profitable drug and everyone wants a piece of it."
She should know: Funded by government grants and sometimes working with colleagues from the Mexican border, her group was instrumental in the development of CroFab.
Antivenins were first developed over a century ago. Although CroFab is safer and purer than the antivenins of the past, the process – though labor intensive – remains fundamentally the same. Snakes, spiders and other creatures are milked by their venom, so a small amount of the toxin is injected into animals like horses or sheep. The animals then produce antibodies without becoming diseased, and the protective molecules are extracted from the blood and processed to produce the antivenom.
What patients pay for CroFab can vary greatly. Treatment may require a few bottles or dozens of them – this depends on factors such as the size of the patient, the potency of the poison in the bite and how fast the patient is treated. The more antivenom needed, the higher the cost.
But hospitals also raise the price, though some of those facilities buy the drug at a discount, said Merrit Quarum, chief executive of WellRithms, a healthcare cost containment company.
Chris Bergin by KHN
In the case of Oakley, St. Vincent Evansville Hospital charged $ 16,989.25 for each CroFab unit, according to facility law. This is more than five times higher than the average list price.
WellRithms reviewed Oakley's St. Vincent Evansville bill at the request of Kaiser Health News and found that providers generally accept $ 16,159.70 for all four bottles of the drug.
In a statement, St. Vincent Evansville noted that the family was not responsible for this complete guide, and instead was expected to pay less than $ 3,500. But the installation seems to have lowered its price to CroFab. According to its price list – published online to meet a recent federal requirement – the drug now costs $ 5,096.76 per bottle.
And the US snake venom market now has another drug competing for patients: Anavip. The Mexican product – launched in October – has a list price of $ 1,220 per vial in the US, according to Rare Disease Therapeutics, which distributes the drug in the US.
The arrival of Anapiv was paralyzed by a lawsuit filed by BTG in 2013, claiming that the drug infringed its patent.
The true effect of the drug on the market is still unclear. CroFab and Anavip are not fully interchangeable. (The FDA did not approve Anavip for copper head bites, for example). And, as part of the legal agreement, Anavip manufacturers must pay royalties to BTG until the CroFab patent expires in 2028.
Resolution: Insurance company IU Health Plans has negotiated the costs of the antivenom and air ambulance and ended up paying $ 44,092.87 and $ 55,543.20, respectively. After adjustments to the additional accounts, IU Health Plans paid a total of $ 107,863.33. The Oakley family did not pay a penny for their emergency care, but such high expenses contribute to the increase in premiums.
Secondary insurance offered through summer camp covered $ 7,286.34 in additional costs that would otherwise have come out of Perry and Yoder's pockets for deduction and coinsurance. The policy covers up to $ 25,000 in damages.
Oakley's foot is healed, but the toe bends slightly down and is sensitive to pressure. She plans to return to the same summer camp this year.
Perry teaches a course on the ethics of the health care industry and yet he said that the cost of Oakley's care shocked him. But he is aware of how rare it is that a patient ends up paying nothing for medical care. "I know that in this country, in this system," he said, "this is a miracle."
Take away: Hospitals and insurers can negotiate; snakes do not. If you were bitten by a snake, "take care of your injury," Boyer said. Do not wait while you care about the cost.
When you receive an account, compare what the facility charges with other healthcare providers' prices by using their online public billing lists. Cost estimating tools, such as Fair Health Consumer or Healthcare Bluebook, let you see how your bill compares to the average.
There is a growing momentum for potential government action on drug prices. In the states and in Congress, different proposals have been launched that include allowing Medicare to negotiate drug prices, tying the American price of expensive drugs to the average price in other developed countries, and allowing the government to inject competition into a market when there is none – such as speeding up generic drug approvals or allowing imports from other countries.
Consumers should keep an eye on these proposals as they move forward in the legislative and policy process.
NPR produced and edited the interview with Elisabeth Rosenthal of Kaiser Health News for broadcast. Jake Harper from WFYI provided audio reports.
Kaiser Health News is a non-profit news service that covers health issues. It is an independent Kaiser Family Foundation program that is not affiliated with Kaiser Permanente.