This spring, a few days after his 2nd birthday, Brigland Pfeffer was playing with his siblings in their San Diego backyard.
His mother, Lindsay Pfeffer, was a few feet away when Brigland made a noise and came running from the stone firepit, holding his right hand. She had just noticed a pinprick of blood between his thumb and forefinger when her older son called out, “Snake!”
“I saw a small rattlesnake coiled up by the firepit,” she said.
Lindsay called 911, and an ambulance took Brigland to Palomar Medical Center Escondido.
When they arrived, he was in bad shape. His hand was swollen and purple.
This spring, Brigland Pfeffer was bitten by a rattlesnake while playing in his San Diego backyard. After problems administering a starting dose of antivenom, emergency room staffers found a way that worked and stabilized the 2-year-old. He received 30 total vials of the antivenom Anavip. (Ariana Drehsler for KFF Health News)
Antivenom, an antibody therapy that disables certain toxins, is administered via an intravenous line, directly into the bloodstream. But emergency room staffers struggled to insert the IV.
“They had so many people in that room trying his head, his neck, his feet, his arms — like, everything to find a vein,” his mother said.
Still unable to start the antivenom, a doctor asked for her permission to try drastic measures. “Just get something going,” she recalled pleading.
It worked. Using a procedure that delivers medicine into the bone marrow, the medical team gave Brigland a starting dose of the antivenom Anavip. Later that day, he was transferred to the pediatric intensive care unit at Rady Children’s Hospital in San Diego, where he received more Anavip. The swelling that had spread to his armpit slowly decreased. A couple of days later, he left the hospital with his grateful parents.
Then the bills came. The Final Bill: $297,461, which included two ambulance rides, an emergency room visit, and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278 of the total bill.
The High Cost of Antivenom
The Centers for Disease Control and Prevention estimates venomous snakes bite 7,000 to 8,000 people in the United States every year. About five people die. That number would be higher, the agency says, if not for medical treatment.
Many snakebites happen far from medical care, and not all emergency rooms keep costly antivenom in stock, which can add big ambulance bills to already expensive care.
It often takes more than a dozen vials, typically costing thousands per vial, to treat a snakebite. The median number per patient is 18 vials, said Michelle Ruha, an emergency room doctor in Arizona and former president of the American College of Medical Toxicology.
Manufacturing costs alone do not explain the high price. The process remains fundamentally the same as when antivenom was developed more than a century ago. Venomous creatures are milked, then a small, non-harmful amount of toxin is injected into animals like horses or sheep. Antibodies are extracted from their blood and processed to make antivenom.
Brigland Pfeffer during his hospital stay, after he was bitten by a rattlesnake in his San Diego backyard. He received 30 vials of antivenom and spent a couple of days in pediatric intensive care. (Lindsay Pfeffer)
Why the high price? One explanation is that hospitals can — and do — mark up products to balance overhead costs and generate revenue.Brigland received Anavip at two hospitals that charged different prices.Palomar, where emergency staffers treated Brigland, charged $9,574 per vial, for a total of $95,746 for the starting dose of 10 vials of Anavip.Rady, the largest children’s hospital on the West Coast, charged $5,876 for each vial. For the 20 vials Brigland received there, the total was $117,532.
Neither hospital responded to requests for comment.
Those charges are “eye-popping,” said Stacie Dusetzina, who is a professor of health policy at Vanderbilt University Medical Center and reviewed the bills at the request of KFF Health News. “When you see the word ‘charges,’ that’s a made-up number. That isn’t connected at all, usually, to what the actual drug cost.”
For instance, Medicare — the government program for those who are at least 65 or disabled — pays about $2,000 for a vial of Anavip. On average, Dusetzina said, that is the price hospitals pay for it.
Leslie V. Boyer, a doctor and toxicology researcher, helped found a group that was instrumental in developing Anavip, as well as the other available snake antivenom, CroFab, which dominated the market for decades. In 2015, she published an editorial in the American Journal of Medicine breaking down the “true” cost of antivenom. (Boyer declined to comment.)
Using cost data collected from factory supervisors, animal managers, hospital pharmacists and other sources, Boyer developed a model for a hypothetical antivenom, at a final cost of $14,624 per vial. She found the cost of venom, included in that total, was just 2 cents. Manufacturing accounted for $9 of the $14,624 total. More than 70 percent of the price tag — $10,250 — is attributable to hospital markups, her research showed.
Another explanation for antivenom’s high cost is a lack of meaningful competition. Anavip entered the market in 2018 as the only competitor to CroFab. But its makers settled a patent infringement lawsuit with CroFab’s maker, requiring the makers of Anavip to pay royalties until 2028.
Anavip debuted at a retail price of $1,220 per vial. Boyer noted that the price later rose to cover the manufacturers’ millions of dollars in legal costs.
Because doctors know each vial could cost the patient thousands of dollars, they deploy additional doses cautiously, Ruha said. “When people need more after we’ve gotten that initial 10 vials in, we often cut that next dose down,” she said.
The Resolution
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The insurer covering Brigland — Sharp Health Plan, which did not respond to requests for comment — negotiated down the antivenom charges by tens of thousands of dollars. The cost was mostly covered by insurance. Brigland’s family paid $7,200, their plan’s out-of-pocket maximum.
Insurance did not pay all the claims, including one ambulance bill. And Lindsay said the family received a letter this summer suggesting 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 bills for ground ambulances.
Brigand’s hand healed, though nerve damage and scar tissue have left his right thumb less dexterous. He is now left-handed.“He’s very, very lucky,” Lindsay said. “He wasn’t a mama’s boy, but now he definitely is one.”
The family has since installed snake fencing around the yard.
Lindsay Pfeffer was in the backyard with her children when her son Brigland was bitten by a rattlesnake. He received 30 vials of antivenom and spent a couple of days in pediatric intensive care while she stayed close. “He’s very, very lucky,” she says. “He wasn’t a mama’s boy, but now he definitely is one.” (Ariana Drehsler for KFF Health News)
The Takeaway
There’s a saying in toxicology: Time is tissue. If bitten by a snake, “get to medical care,” Ruha said.
Not all emergency rooms have antivenom, and there are no online resources identifying which ones do. Ruha recommends going to a large hospital, which is more likely to have antivenom in stock than free-standing urgent care centers or emergency rooms.
When the bill comes, be ready to negotiate, Dusetzina said. Providers know their charges are high and may be willing to take less.Though the available tools may be difficult to use, you can compare the charges against those of other health care providers using their online public charge lists, or against average prices using cost estimation tools like Fair Health Consumer or Healthcare Bluebook.
Jackie Fortiér is a reporter with KFF Health News.