This spring, a few days after his second birthday, Brigland Pfeffer was playing with his siblings in his San Diego backyard.
Her mother, Lindsay Pfeffer, was a few feet away when Brigland made a noise and ran from the stone fire pit, holding her right hand. She noticed a sting of blood between her thumb and forefinger when her eldest son screamed, “Snake!”
“I saw a little rattlesnake coiled up by the bonfire,” he said.
Pfeffer called 911 and an ambulance transported Brigland to Palomar Escondido Medical Center.
The medical procedure
When they arrived, Brigland’s hand was swollen and purple.
Antivenin, an antibody therapy that deactivates certain toxins, is usually administered intravenously, directly into the bloodstream. But emergency room staff had difficulty inserting the IV.
“There were so many people in that room testing his head, his neck, his feet, his arms, everything to find a vein,” Pfeffer said.
Still unable to administer the antidote, a doctor asked for permission to try drastic measures. “Just get something going,” he recalled pleading.
It worked. Using a procedure that delivers medication to the bone marrow, the medical team gave Brigland an initial dose of the antidote Anavip.
He was transferred to the pediatric intensive care unit at Rady Children’s Hospital, where he received more Anavip.
The swelling that had spread to the armpit slowly subsided. A couple of days later, he left the hospital with his grateful parents.
Then the bills arrived.
The final bill
$297,461, which included two ambulance rides, a visit to the emergency room and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278.80 of the total bill.
The billing problem: the high cost of antivenin
The Centers for Disease Control and Prevention estimates that venomous snakes bite between 7,000 and 8,000 people in the United States each year. About five people die. That number would be higher, the agency says, if it weren’t for the medical treatment.
Many snake bites occur far from medical care, and not all emergency rooms keep expensive antivenoms in stock, which can add large ambulance bills to already expensive care.
More than a dozen vials, typically costing thousands of dollars each, are often needed to treat a snake bite. The average amount per patient is 18 vials, said Michelle Ruha, an emergency physician in Arizona and former president of the American College of Medical Toxicology.
Manufacturing, which has not fundamentally changed since the antivenom was developed more than a century ago, does not explain the high price. Poisonous creatures are milked and then a small, harmless amount of toxin is injected into animals such as horses or sheep. Antibodies are removed from your blood and processed to produce an antidote.
Why the high price? One explanation is that hospitals increase product prices to balance overall costs and generate revenue.
Brigland received Anavip at two hospitals that charged different prices.
Palomar, where emergency personnel treated Brigland, charged $9,574.60 per vial, for a total of $95,746 for the initial dose of 10 Anavip vials.
Rady, the largest children’s hospital on the West Coast, charged $5,876.64 for each vial. For the 20 vials Brigland received there, the total was $117,532.80.
Neither hospital responded to requests for comment.
Those charges are “surprising,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center who reviewed the bills at the request of KFF Health News. “When you see the word ‘charges,’ it’s a made-up number. That’s usually not related at all to the actual cost of the drug.”
For example, Medicare, the government program for people at least 65 years old or disabled, pays about $2,000 for a vial of Anavip. On average, Dusetzina said, that’s the price hospitals pay for it.
Leslie Boyer, a physician and toxicology researcher, helped found a group that was instrumental in the development of Anavip, as well as the other available snake antivenin, CroFab, which dominated the market for decades. In 2015, he published an editorial in the American Journal of Medicine breaking down the “real” cost of the antidote. (Boyer declined to comment for this article.)
Using cost data collected from factory supervisors, animal handlers, hospital pharmacists and other sources, Boyer developed a model for a hypothetical antidote, with a final cost of $14,624 per vial. He discovered that the cost of the poison, included in that total, was only 2 cents. Manufacturing accounted for $9 of the total of $14,624.
More than 70% of the price ($10,250) is attributable to hospital margins, their research showed.
Another explanation for the high cost of the antidote is the lack of significant competition. Anavip entered the market in 2018 as the only competitor to CroFab. But its creators settled a patent infringement lawsuit with CroFab’s maker, requiring Anavip’s makers to pay royalties through 2028.
Anavip debuted at a retail price of $1,220 per vial. Boyer noted that the price was later raised to cover the manufacturers’ millions of dollars in legal costs.
The resolution
The insurer that covers Brigland, Sharp Health Plan, which did not respond to requests for comment, negotiated a reduction in antivenom charges by tens of thousands of dollars.
The cost was mostly covered by insurance. Brigland’s family paid $7,200, the maximum out-of-pocket amount for their plan.
Insurance did not pay all claims, including an ambulance bill. Pfeffer said he received a letter this summer indicating they owe an additional $11,300 for Brigland’s care. While the landmark No Surprises Act protects patients from many out-of-network bills in emergencies, the law controversially exempted ground ambulance bills.
Brigland’s hand healed, although nerve damage and scar tissue made his right thumb less dexterous. Now he is left-handed.
“He’s very, very lucky,” Pfeffer said.
The family has since installed snake fencing around the garden.
The takeaway
There is a saying in toxicology: time is tissue. If you are bitten by a snake, “seek medical attention,” Ruha said.
Not all emergency rooms have antivenin and there are no online resources to identify which ones do. Ruha recommends going to a large hospital, which is more likely to have antivenom available than free-standing emergency rooms.
When the bill arrives, be prepared to negotiate, Dusetzina said. Providers know their charges are high and may be willing to accept less.
You can compare charges to average prices using cost estimating tools like Fair Health Consumer or Healthcare Bluebook.
Bill of the Month is a collaborative investigation by KFF Health News and The Washington Post’s Well+Being that analyzes and explains medical bills. Since 2018, this series has helped many patients and readers reduce their medical bills and has been cited in statehouses, the U.S. Capitol, and the White House. Do you have a confusing or scandalous medical bill you want to share? Tell us!
