Bill of the Month: Treatment of Rabies After a Cat Bite: Shots

Compassion for a hungry stray cat resulted in a pinch of the finger – and also nibbled Jeannette Parker's wallet.

In a rural area near the Everglades National Park in Florida, Parker spotted the stray cat along the road. He looked lean and when Parker, a biologist, offered him food, the cat bit his finger.

"It broke my skin with her teeth," she recalls.

After cleaning up the wound, she did some research and began to worry about rabies since Miami-Dade County had received warnings about this potentially deadly disease that was in effect at the time.

She then returned home to the Florida Keys and called the health department, but the office was closed.

She went to the emergency room at Mariners Hospital, not far from her home. She spent about two hours in the ER, received two types of injections and an antibiotic and she never spoke to a doctor.

"I came home happy like a clam," she said.

Then the bills arrived.

Patient: Jeannette Parker, a 44-year-old biologist specializing in fish and wildlife. Insured with the American Postal Workers Union because her husband works for the federal government at Everglades National Park.

Total invoice: $ 48,512, including $ 46,422 for preventive medication

Service provider: Mariners Hospital, owned by Baptist Health South Florida, a non-profit denominational chain of eight hospitals and various other institutions.

Medical service: Parker's wound was examined and she received the first of a series of rabies vaccines, as well as an injection of 12 milliliters of rabies immune globulin, an antibody that stimulates the immune system so the protect from the virus until the vaccine is triggered.

Which give: When you are potentially exposed to a deadly disease, you need treatment. In the moment, it is difficult to go around or say no to high prices.

The Centers for Disease Control and Prevention estimate that a post-exposure rabies preventive treatment, which includes immunoglobulin and four doses of vaccine administered over a two-week period, typically costs more than $ 3,000. According to the CDC, approximately 40,000 to 50,000 people benefit from such treatments each year after being exposed to potentially rabid animals. Each hospital can set its own prices for treatment.

In the case of Parker, the bulk of the cost was for rabies immune globulin. For this one injection, the hospital charged him $ 46,422, as well as to his insurer. This is well above what is considered typical.

"I've never heard anything so high for immunoglobulin," said Charles Rupprecht, independent biomedical consultant, technical advisor for rabies at the World Health Organization, who directed the CDC's rabies control program for 20 years. "How is it possible?"

Parker thought it sounded high after asking and receiving a detailed invoice from her insurer, so she found it on Google.

"I saw that immunoglobulin was expensive, but it was not this dear, "she said," I sat on it for a while because I was upset. Eventually, I went to the hospital to confirm and they told me, "Yes, that's right." "

Rabies immunoglobulin is a complex product made from blood plasma from rabies immune volunteers. Three manufacturers manufacture the product and, according to the Food and Drug Administration, there is no shortage currently. Currently, the average wholesale purchase price – the amount paid by wholesalers who then rate it when they sell it to distributors or hospitals – is $ 361.26 per milliliter, according to Richard Evans. , analyst of the drug industry at SSR Health, which is part of the boutique investment. SSR LLC company.

Using this average, the cost of the 12 milliliter dose received by Parker would have been $ 4,335.

Maybe the hospital made a mistake in billing by adding an extra zero?

No, said Baptist Health spokeswoman Dori Robau Alvarez in a statement.

The fees of $ 46,422 reflected list prices that the hospital had put in place on September 22, 2018, when Parker had been treated. Alvarez would not disclose this rate, but a simple calculation shows that the hospital billed $ 7,737 per 2-milliliter dose, which is why the immunoglobulin is often packaged.

Alvarez also noted that the month following Parker's treatment, the sailors had reorganized his full price list, known as "charge master". The hospital reduced its anti-rabies immunoglobulin tariff to $ 1,650 per 2 milliliters, which would have pushed Parker's bill to about $ 9,900 – still high, but not exorbitant.

Hospitals periodically visit their guardmasters. However, it should be noted that this 79% reduction occurred shortly before January, when new rules required all hospitals to publicly publish these previously obscured fee lists on websites, in accordance with the rules. Interpretation of the Affordable Care Act by the Trump Administration.

"Statements from patients who received treatment before the change would reflect the previous charge," said Alvarez.

She did not answer follow-up questions about the reasons for the drop in prices or the above-average price before the change.

The prices of Chargemaster are generally not those paid by the insured. One of the benefits of health coverage is that insurers are negotiating discounts for networked care. Parker went to a network hospital.

But not all services benefit from a negotiated discount, said two billing experts at the US Health Insurance Plans, the industry's trade lobby. And a discount on a very high charge is a very large sum of money.

In Parker's case, her husband's health insurance plan provided $ 34,618, including $ 33,423 for immunoglobulin alone.

The health plan stated that he had asked for an audit of the bill to verify its accuracy. In a statement sent by email, the plan indicated that it could not be done much else. "Apart from the negotiated discounts, the plan can hardly dispute the costs of the hospital.The fees are not fraudulent," the statement said.

Resolution: After taking into account the insurer's payments, Parker had to pay $ 4,191 for the last $ 344 of his deductible for the year, plus his 10% share of the fees accepted by his insurer.

"My funeral would have been cheaper," she said.

After calling his insurer, Parker learned that the cat's bite should have been considered an accidental injury and therefore eligible for 100% coverage under his insurance plan, net of the remaining deductible. She wants the hospital to resubmit the bill to the health care plan to see if it will assume the rest of its 10% share of the costs. The hospital has not proposed to lower the price of immunoglobulin to its current load.

The delivery: If you think you have been exposed to rabies, get treatment. "It is prudent that she seek immediate and appropriate medical attention," said Rupprecht.

Many public health services can be obtained inexpensively or cheaply from local health services. These range from vaccinations to post-exposure treatments to diseases such as rabies. If possible, check with your health department to see if it offers treatment.

But with a serious illness like rabies, if these services are not immediately available, do not wait. Head to a hospital and make sure it's part of your insurer's network, if you have a choice.

If you receive an invoice for an amount that seems surprising to you, get the detailed bill from the hospital rather than the recap. In addition, now that hospital leaders are publicly available on hospital websites, use them.

They are long and complicated. For the moment at least, they are not written in fluent English. But many are alphabetic and it is not difficult, for example, to find an entry for "Rabies IG" (anti-rabies immunoglobulin).

Check the price charged compared to prices in your area. (You can also check average prices on sites such as HealthcareBluebook.com.) Share this information with your employer's Human Resources department or use it to negotiate with your hospital or insurer.

NPR produced and edited the interview with Elisabeth Rosenthal of Kaiser Health News for broadcast. Nancy Klingener, a Florida Keys reporter for the WLRN member station, 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.