Summer Bummer: A Young Camper's $142,938 Snakebite

Apr 30, 2019
Originally published on May 1, 2019 6:16 pm

Editor's note: In the audio version of this story, we reported that a tourniquet was applied to the ankle of a 9-year-old after she was bitten by a venomous snake. The Centers for Disease Control and Prevention explicitly says applying a tourniquet is not recommended. Instead, seek immediate medical attention and keep the person who was bitten calm and still.

It was dusk as Oakley Yoder and the other summer camp kids hiked back to their tents at Illinois' Jackson Falls last July. As the group approached a mound of boulders blocking the path, Oakley, then 9, didn't see the lurking snake — until it bit a toe on her right foot.

"I was really scared," Oakley said. "I thought that I could either get paralyzed or could actually die."

Her camp counselors suspected it was a copperhead and knew they needed to get her medical attention as soon as they could. They had to keep her as calm and motionless as possible — the venom could circulate more quickly if her heart raced from activity or fear.

One counselor gave her a piggyback ride to a van. Others distracted her with Taylor Swift songs and candy as the van sped from their location in a beautiful but remote part of the Shawnee National Forest toward help.

First responders met them and recommended Oakley be taken by air ambulance to a hospital.

The helicopter flight transported Oakley 80 miles from a school parking lot just outside the forest to St. Vincent Evansville hospital in Indiana, where she received four vials of antivenin. She was then transferred to Riley Hospital for Children in Indianapolis for observation.

Her 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. Once she made it, doctors closely observed her condition, her toe still oozing and bruised. By lunchtime, Perry said, physicians reassured the parents that Oakley would be OK.

"It was a major comfort for me to realize, OK, we're getting the best care possible," said Perry, who is a health care ethics professor at the business school at Indiana University, Bloomington. Less than 24 hours after the bite, Oakley left the hospital with her grateful parents.

Then the bills came.

Patient: Oakley Yoder, now 10, of Bloomington, Ind. Insured through Indiana University, Bloomington, where her father and mother work as faculty.

Total bill: $142,938, including $67,957 for four vials of antivenin ($55,577.64 was charged for air ambulance transport). The balance included a ground ambulance charge and additional hospital and physician charges, according to the family's insurer, IU Health Plans.

Service providers: St. Vincent Evansville hospital, part of Ascension, a nonprofit, Catholic health system. Riley Hospital for Children, part of Indiana University Health, a nonprofit health system. Air Evac Lifeteam, an air ambulance provider.

Medical service: The essential part of Oakley's treatment involved giving her four vials of snake antivenin called CroFab.

What gives: When bitten by a venomous snake, there is no time to waste. If left untreated, a venomous bite can cause tissue damage, hemorrhaging and respiratory arrest. Children tend to experience more severe effects because of their small size.

CroFab has dominated the U.S. market for snake antivenin since its approval in 2000. When Oakley was bitten, it was the only drug available to treat venomous bites from pit vipers. (Oakley probably was bitten by a copperhead snake, a type of pit viper, the camp directors told her parents.)

But with only one antivenin available in the U.S. at the time, the drugmaker, London-based BTG Plc, essentially had a monopoly.

The average list price for CroFab is $3,198 per vial, according to the health care information tech company Connecture. Manufacturing costs, product improvements and research all factor into the drug's price, said Chris Sampson, spokesman for BTG.

A Mexican version of snake antivenin can cost roughly $200. But it couldn't be sold in the U.S. (More about that 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 price in the U.S. can be attributed to 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 at times working with colleagues over the border in Mexico, her group was instrumental in developing CroFab.

Antivenins were first developed more than a century ago. Although CroFab is safer and purer than antivenins of the past, the process — while labor-intensive — remains fundamentally the same. Snakes, spiders and other creatures are milked for their venom, then a small amount of the toxin is injected into animals like horses or sheep. The animals then make antibodies without falling ill, and the protective molecules are extracted from their blood and processed to make antivenin.

What patients pay for CroFab can widely vary. Treatment may require a few vials or dozens of them — it depends on factors like the size of the patient, the potency of venom in the bite and how quickly the patient is treated. The more antivenin needed, the higher the cost.

Oakley shows the toe on her right foot that a snakebite deformed when she was hiking at an Illinois summer camp in July 2018. These were the same shoes she wore when she was bitten.
Chris Bergin for KHN

But hospitals also jack up the price, even though some of these facilities purchase the drug at a discount, said Dr. Merrit Quarum, chief executive officer of WellRithms, a health care cost containment company.

In Oakley's case, St. Vincent Evansville hospital charged $16,989.25 for each unit of CroFab, according to the facility's bill. That's more than five times higher than the average list price.

WellRithms analyzed Oakley's bill from St. Vincent Evansville at Kaiser Health News' request and found providers generally accept $16,159.70 for all four vials of the drug.

In a statement, St. Vincent Evansville noted that the family was not responsible for that full tab and instead was expected to pay less than $3,500. But the facility appears to have since lowered its price for CroFab. According to its price list — posted online to satisfy a recent federal requirement — the drug now costs $5,096.76 per vial.

And the snake antivenin market in the U.S. now has another drug competing for patients: Anavip. The Mexican product — launched in October — has a list price of $1,220 a vial in the U.S., according to Rare Disease Therapeutics, which distributes the drug in the U.S.

Anavip's arrival was stalled by a lawsuit filed by BTG in 2013, claiming the drug infringed on its patent.

The drug's true effect on the market remains unclear. CroFab and Anavip are not entirely interchangeable. (The FDA hasn't approved Anavip for copperhead bites, for instance.) And, as part of the legal settlement, Anavip-makers must pay royalties to BTG until the CroFab patent expires in 2028.

Resolution: The insurer IU Health Plans negotiated down the antivenin and air ambulance charges and ended up paying $44,092.87 and $55,543.20, respectively. After adjustments to additional bills, IU Health Plans paid a total of $107,863.33. Oakley's family didn't pay a dime out of pocket for her emergency care, but such high outlays contribute to rising premiums.

Secondary insurance offered through the summer camp covered $7,286.34 in additional costs that otherwise would have come out of Perry and Yoder's pockets for their deductible and coinsurance. The policy covers up to $25,000 in damages.

Oakley's foot is healed, but her 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, and yet he said 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 health care. "I know that in this country, in this system," he said, "that is a miracle."

Takeaway: Hospitals and insurers can negotiate; snakes don't. If you've been bitten by a snake "take care of your injury," said Boyer. Don't wait while you worry about the cost.

When you get a bill, compare what the facility charged with other health care providers' prices using their public charge lists online. Cost estimation tools like Fair Health Consumer or Healthcare Bluebook allow you to see how your bill compares with the average.

There is momentum growing for potential government action on drug prices. In states and in Congress, different proposals have been floated, which include allowing Medicare to negotiate drug prices, tying the U.S. 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 generic drug approvals or allowing for imports from other countries.

Consumers should keep an eye on these proposals as they move through the legislative and political process.

NPR produced and edited the interview with Kaiser Health News' Elisabeth Rosenthal for broadcast. WFYI's Jake Harper provided audio reporting.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that isn't affiliated with Kaiser Permanente.

Copyright 2019 Kaiser Health News. To see more, visit Kaiser Health News.

AUDIE CORNISH, HOST:

From Capitol Hill to the campaign trail, politicians of all stripes say they want to lower prescription drug prices. And it's an issue we see reflected in the medical bills you send us for our Bill of the Month segment. We're joined now by Dr. Elisabeth Rosenthal. She's editor-in-chief of Kaiser Health News. Welcome to the studio, Elisabeth.

ELISABETH ROSENTHAL: Thanks for having me.

CORNISH: So introduce us to the family that sent in April's Bill of the Month.

ROSENTHAL: Well, this month, we're meeting the Yoder-Perry family. They live in the college town of Bloomington, Ind., where both parents work for Indiana University. And they encountered a super-high drug price for a drug that literally saved the life of their 10-year-old daughter.

CORNISH: Now, Jake Harper with member station WFYI in Indianapolis actually visited them. He's going to pick up the story from here.

JAKE HARPER, BYLINE: Something's making noise on the trail near Oakley Yoder's house.

OAKLEY YODER: Probably either a snake or a frog. Hope it's a frog. Hopefully it's not a snake.

HARPER: Oakley loves being outside, but snakes are not her favorite animal. She was away last summer on a climbing trip in southern Illinois. And at dusk, her group headed back to camp.

OAKLEY: I felt something, like, grab onto my foot. So I think it went into this side of the toe. That's where the dent right here is. And I thought it was just thorns or glass or something like that.

HARPER: But the pain started to move up her leg. It was a snake bite, probably a copperhead. She told the counselors, and to keep the venom from spreading, they put a tourniquet around her ankle. One of them gave her a piggyback ride out of the woods.

OAKLEY: And I felt his sweat. I could feel how worried he was. I thought I was going to get paralyzed or die or get my foot cut off. I had so many things that - in my mind that could have happened.

HARPER: While they waited for help, the counselors got Oakley to relax with Gushers candy and Taylor Swift.

Do you remember what song?

OAKLEY: "You Belong With Me."

HARPER: How's it go?

OAKLEY: You wear high heels, I wear sneakers. You're cheer captain, and I'm on the bleachers.

(SOUNDBITE OF SONG, "YOU BELONG WITH ME")

TAYLOR SWIFT: (Singing) Dreaming about the day when you wake up and find...

HARPER: Did it calm you down?

OAKLEY: Yeah. Like, we listened to it, like, at least 20 times.

HARPER: Oakley eventually got in a helicopter and was taken to St. Vincent Hospital in southern Indiana. She got four vials of antivenom before they sent her north to a children's hospital in Indianapolis.

JOSH PERRY: It was around 5 or 5:30 in the morning when the ambulance from St. Vincent arrived.

HARPER: Oakley's parents, Josh Perry and Shelli Yoder, met her at the second hospital. Shelli says Oakley's leg was swollen and dark.

SHELLI YODER: It was pretty far up her leg, let alone her toe. I mean, I was pretty worried about where this was going.

HARPER: But the specialists said the antivenom was working. Oakley was out of the hospital in a day. She couldn't play outside for a while, which was frustrating. And she says her foot is still kind of numb from the bite. But she could walk and run in about a month. And she even got some presents out of the whole thing. That period was a little more stressful for her parents. They both teach at Indiana University. And Perry actually researches health care ethics. They knew enough to worry about the bills.

PERRY: I was holding my breath walking to the mailbox to see, what's the next step in this saga?

HARPER: St. Vincent gave Oakley four vials of antivenom called CroFab. The list price - $3,200 per vial. And the hospital charged way more, more than five times that amount. After all the bills came, Perry added them up. The charges for treating Oakley's snakebite totaled $143,000.

PERRY: It just seems unconscionable that you would inflate prices by such an extraordinary amount. It took my breath away.

CORNISH: That's Josh Perry telling his daughter's story to reporter Jake Harper in Bloomington, Ind. Elisabeth Rosenthal is here to talk more. And how did this bill grow to over $140,000?

ROSENTHAL: Well, a big chunk of that - about $55,000 - was the air ambulance, which this little girl clearly needed. I mean, this is a big emergency. And we've talked about high air ambulance prices before on Bill of the Month. But the other big chunk, which we want to talk about today, is for those four tiny vials of antivenom that she got. That was more than $60,000.

CORNISH: Why? Why are those four vials so expensive?

ROSENTHAL: Well, when your kid gets a poisonous snake bite, they'll die without rapid treatment. So you're vulnerable to financial extortion. Look. Even with the antivenom, she ended up with signs of early gangrene in her leg.

CORNISH: But $60,000?

ROSENTHAL: There's two reasons why it gets so high. The first is the drug maker in this case had a monopoly on the product. Only one company had the license to sell this antivenom when Oakley got bitten. And the U.S. doesn't regulate drug prices. It's not a particularly high-tech drug, but in our country, the wholesale price was $3,200 per vial at the time. The same or similar drug in Mexico is $100 or $200. The second thing is there's a big hospital market. Like booths at a restaurant, the hospital has a captive audience here and can markup with abandon. And in this case, they did five times the wholesale costs.

CORNISH: That ended up being $143,000 that the Oakley family was charged. How much of that did they pay in the end?

ROSENTHAL: They're extremely lucky. They didn't pay anything. You could call it a miracle. They had zero dollars out of pocket. The camp came in to pay what their insurance didn't. But I would add the bigger problem is when your insurer and your company jumps in to save you from these extortionate bills, well, the next year, the prices for premiums in your company are likely to go up.

CORNISH: Is there any movement to bring down prices for this particular antivenom, especially for people who don't have insurance miracles?

ROSENTHAL: Yeah, these guys were lucky. There is a second company that now makes antivenom in the U.S. The problem is only two drugs doesn't make competition. In studies, we've seen that you need really four or five competitors in a market to really bring down prices.

CORNISH: Is there any way that politicians could level the playing field, anything the Trump administration could do or lawmakers?

ROSENTHAL: Well, this kind of case is exactly why other countries do regulate drug prices. We don't seem to be going in that direction. So I'm looking for the next year to see what Nancy Pelosi and Donald Trump can come up with.

CORNISH: Elisabeth Rosenthal's editor-in-chief of Kaiser Health News. And if you have a medical bill you want us to investigate, head on over to NPR's Shots blog. Transcript provided by NPR, Copyright NPR.