A child needed antivenom for a snakebite. It cost more than $200,000.
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 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.
Pfeffer called 911 that day in April and an ambulance rushed Brigland to Palomar Medical Center Escondido.
The medical procedure
When they arrived, Brigland’s hand was swollen and purple.
Antivenom, an antibody therapy that disables certain toxins, is usually administered from an intravenous line directly into the bloodstream. But emergency room staffers struggled to insert the IV.
After many tries, they finally used a procedure that delivers medicine into the bone marrow, giving Brigland a starting dose of the antivenom 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 his armpit slowly decreased. A couple of days later, he left the hospital with his grateful parents.
Then the bills came.
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The final bill
It was $297,461, which included two ambulance rides, an emergency room visit and a couple of days in pediatric intensive care. Antivenom alone accounts for $213,278.80 of the total bill.
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The billing problem
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, which hasn’t fundamentally changed since antivenom was developed more than a century ago, does not explain the high price. 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.
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Why the high price?
One explanation is that hospitals 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 $9,574.60 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 $5,876.64 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 “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.
Another explanation for antivenom’s high cost is a lack of meaningful competition. Anavip entered the market in 2018 as the only competitor to the antivenom CroFab. But its makers settled a patent infringement lawsuit with CroFab’s maker, requiring the makers of Anavip to pay royalties until 2028.
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The resolution
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. Pfeffer said she 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 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,” Pfeffer said.
The family has since installed snake fencing around the yard.
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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 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.
You can compare the charges against average prices using cost estimation tools like Fair Health Consumer or Healthcare Bluebook.
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Bill of the Month is a crowdsourced investigation by KFF Health News that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it’s been cited in statehouses, at the U.S. Capitol, and at the White House.
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