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At dusk, Oakley Yoder and the other children from the summer camp returned home to their tent in Jackson Falls, Illinois, last July. As the group approached a bunch of rocks blocking the path, Oakley, then aged 9, did not see the threatening snake – until he nibbled a toe of the right foot.
"I was really scared," Oakley said. "I thought I could either paralyze or die."
Counselors on his side suspected that it was a Copperhead and knew that they had to call on her as soon as possible. They had to keep her as calm and motionless as possible – the venom could move faster if her heart was pounding.
A counselor gave him a ride on a van. Others have been distracted with Taylor Swift's songs and sweets as the van was spinning from their location in a beautiful but secluded part of the Shawnee National Forest for help.
The first responders met with them and recommended that Oakley be transported by air ambulance to a hospital.
The helicopter flight transported Oakley 80 kilometers from a school parking lot just outside the forest to St. Vincent Evansville Hospital, in Indiana, where she received four vials of antivenom. She was later transferred to the Riley Children's Hospital in Indianapolis for observation.
His parents, Josh Perry and Shelli Yoder, were already in bed that night when they received a call about what had happened in Oakley. They jumped into the car and arrived at Riley about two hours before their daughter. Once she was successful, the doctors closely watched her condition, her foot still oozing and bruised. At lunchtime, Perry said, the doctors assured the parents that Oakley would be fine.
"It was very comforting for me to realize, OK, we are getting the best possible care," said Perry, professor of ethics of health care 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 arrived.
Patient: Oakley Yoder, now 10 years old, from Bloomington, Indiana, is insured by Indiana University in Bloomington, where her father and mother work as teachers.
Total invoice: $ 142,938, including $ 67,957 for four antivenom vials ($ 55,577.64 for air ambulance transportation). The balance included ground ambulance fees and additional hospitalization and doctor fees, according to the family insurer, IU Health Plans.
Service providers: St. Vincent-Evansville Hospital, owned by Ascension, a nonprofit Catholic health system. Riley Hospital for Children, owned by Indiana University Health, a nonprofit health system. Air Evac Lifeteam, a supplier of air ambulances.
Medical service: The essential part of Oakley's treatment was giving him four bottles of snake antivenin called CroFab.
Which give: When he is bitten by a venomous snake, there is no time to lose. If left untreated, venomous sting can cause tissue damage, hemorrhages, and respiratory arrest. Children tend to experience more serious effects because of their small size.
CroFab has dominated the American snake counterfeit market since it was approved in 2000. When Oakley was bitten, it was the only drug available to treat venomous bites from vipers. (Oakley was probably bitten by a copper snake, a kind of viper, the camp director explained to his parents.)
But with a single antivenom available in the United States at the time, London-based drug manufacturer BTG Plc had essentially a monopoly.
The average CroFab catalog price is $ 3,198 per bottle, according to the health information technology company Connecture. Manufacturing costs, product improvements and research all affect the price of the drug, said Chris Sampson, BTG spokesperson.
A Mexican version of the snake antivenom can cost around $ 200. But he could not be sold in the United States (more on this in a moment.)
Dr. Leslie Boyer, founding director of the VIPER Institute, a venom research center at the University of Arizona, acknowledges that some of the prices in the US can be attributed to the stringent requirements imposed by the Food and Drug Administration in testing and monitoring. But more than that, she added: "It's a profitable drug and everyone wants a piece of it."
She should know that her group, funded by government grants and sometimes working with colleagues on the other side of the Mexican border, has been instrumental in the development of CroFab.
Antivenoms were developed for the first time more than a century ago. Although CroFab is safer and purer than antivenoms, the process – while requiring a lot of work – remains fundamentally the same. Snakes, spiders and other creatures are treated for their venom, then a small amount of the toxin is injected into animals such as horses or sheep. The animals then make antibodies without getting sick and the protective molecules are extracted from their blood and turned into an antivenom.
What patients pay for CroFab can vary considerably. The treatment may require a few vials or dozens – it depends on factors such as the size of the patient, the power of the venom in the bite and the speed of the patient's treatment. The higher the serum required, the higher the cost.
But hospitals are also driving up prices, even though some of these facilities are buying the drug at a lower price, said Dr. Merrit Quarum, chief executive officer of WellRithms, a health cost-reduction company.
In the case of Oakley, St. Vincent Evansville Hospital billed $ 16,989.25 for each CroFab unit, according to the facility bill. It's more than five times higher than the average list price.
WellRithms analyzed St. Vincent Evansville's Oakley bill at the request of Kaiser Health News and found that suppliers generally accepted $ 16,159.70 for the four vials of the drug.
In a statement, St. Vincent Evansville pointed out that the family was not responsible for this tab in full and had to pay less than $ 3,500. But the installation seems to have dropped since the price of CroFab. According to its price list – published online to meet a recent requirement of the federal government – the drug now costs $ 5,096.76 US per bottle.
And the antivenom snake market in the US now has another drug competing for patients: Anavip. The Mexican product – launched in October – has a list price of US $ 1,220 per bottle in the United States, according to Rare Disease Therapeutics, which distributes it in the United States.
The arrival of Anavip was blocked by a lawsuit filed by BTG in 2013, alleging that the drug was forged on his patent.
The real effect of the drug on the market remains unclear. CroFab and Anavip are not fully interchangeable. (The FDA has not approved Anavip for the Copheadhead bites, for example.) And, as part of the legal settlement, Anavip manufacturers are required to pay royalties to BTG until the end of the year. The expiration of the CroFab patent in 2028.
Resolution: The insurer's health insurance plans IU have negotiated a reduction in air and air ambulance fees and ended up paying $ 44,092.87 and $ 55,543.20 respectively. After adjusting for the additional bills, the UI health plans paid a total of $ 107,863.33. Oakley's family did not pay a cent for their emergency care, but such high expenses contribute to the increase in premiums.
The secondary insurance offered during the summer camp covered $ 7,286.34 in additional costs that would otherwise have come out of Perry and Yoder's pockets for their deductibles and co-insurance. The policy covers up to $ 25,000 in damages.
Oakley's foot is healed, but his toe bends slightly downward and is sensitive to pressure. She intends to return to the same summer camp this year.
Perry teaches a course on the ethics of the health care industry, yet he was shocked by the cost of care provided in Oakley. But he is aware that it is rare for a patient to end up paying nothing for health care. "I know that in this country, in this system," he said, "it's a miracle."
To take away: Hospitals and insurers can negotiate; snakes do not do it. If you've been bitten by a snake, "take care of your injury," said Boyer. Do not wait while you worry about the cost.
When you receive an invoice, compare what the facility has billed to prices from other health care providers using its online public rates. Cost estimating tools such as Fair Health Consumer or Healthcare Bluebook allow you to compare your bill to the average.
Potential government action on the price of drugs is gaining momentum. In the states and in Congress, various proposals have been made, including allowing Medicare to negotiate drug prices, linking the price of expensive drugs to the average price of other developed countries, and allowing the government to introduce drug prices. competition in any market – such as speeding up generic approvals or allowing imports from other countries.
Consumers must monitor these proposals throughout the legislative and policy process.
NPR produced and edited the interview with Elisabeth Rosenthal of Kaiser Health News for broadcast. Jake Harper of WFYI provided an audio report.
Kaiser Health News is a non-profit news service covering health issues. It is an independent editorial program of the Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
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