$150,000 medical bill for snakebite

By now I’m sure you’ve heard about the $150,000 medical bill that one “adventurer” incurred when he attempted to take a “selfie” with a rattlesnake. Over half the bill, almost $84,000, was for “pharmaceuticals” — i.e. the antivenin plus other drugs which would’ve included painkillers, saline fluids for hydration, antibiotics, and whatever else was administered during his visit to the emergency room.

Now a lot of people are looking purely at the numbers and not thinking beyond that. Accusations of “gouging” are abundant with regard to this case. Two hospitals were drained of antivenin treating this guy. So how is it that can result in a bill of $150,000?

Quite simply: the cost of producing the antivenin.

Now articles point out that there is only one licensed supplier of antivenin for the United States. Automatically this makes people think “monopoly” and that the producer is charging exorbitant prices simply because they can. Without competition, what’s to stop them? And it’s not like governments can stop them from importing the antivenin simply because that would mean condemning a lot of treatable cases.

While a valid concern, it hides the primary detail with regard to antivenin and why it is so expensive: the risks with its production.

The production of antivenin requires one thing: venom. There are not many people in the world qualified to actually properly handle these animals in order to obtain the venom safely. So if you think you’re qualified to handle snakes, spiders, and other venomous creatures in order to milk them of their venom, feel free to go into competition with the other venom suppliers — the few that exist — and provide the venom a at price that undercuts the other suppliers. All you need is several of each type of animal, the facilities and personnel to house and manage them, and, of course, the facilities for storing and milking the venom. And all the various licenses and certifications that go along with that.

Beyond that, there’s the venom itself. As I said, there aren’t many people in the entire world qualified to handle snakes and spiders for the purpose of milking them — such as those who collect and harvest venom from the vicious and infamous Sydney funnel-web.

And different animals produce differing amounts of venom. The Sydney funnel-web, for example, doesn’t produce much. Harvesting will only get one or two mL per spider, meaning to get a decent quantity for making antivenin, you need a lot of spiders. And in Australia there is only one supplier for that venom: the Australian Reptile Park. And they house, if I recall the video correctly, over a hundred spiders. For many venomous animals, there is only one or a few suppliers.

So this puts supply in short supply, and when it comes to the law of supply and demand, short supply but high demand means prices don’t stay low. They aren’t charging a particular price for the venom simply because they can, but because they have their own costs to cover — storing and maintaining the animals, and insuring against the risks with handling them, among others. That is the basics of economics, and when you add up all of those costs, you get a rather eye-opening number.

Given the life-saving treatments that they are helping produce, you would basically have to presume that the people making the pricing decisions are cold-hearted or heartless assholes who are just out to make a buck instead of cover their costs with a slight markup. But that is likely how a lot of people see anyone working in the medical industry in any capacity who is not giving away their services for free.

Antivenin is also quite specialized — read: costly — in its production. Popular Mechanics lays out the steps:

1. Harvesting the venom — As I already said, this is specialized work, and often there are only one or a few venom suppliers for any given species. But if you think you have the skills to do it, feel free to go into competition with the other suppliers.

2. Cold storage and labeling — it’s extremely important that the venom be properly labeled. Some antivenins, particularly those for spiders, must be specific to the venom they target. CroFab is more generalized simply because of the nature of the venoms they target.

3. Selecting a host animal — That’s right, the venom is injected into an animal (usually a horse) so that their immune systems can create antibodies against the venom material. Don’t worry, it’s only a really tiny, dilute quantity that is injected.

4. Preparing the “vaccine” — This is the most important part. Diluted venom, sometimes with an additional adjuvant, is prepared as a kind of “vaccine” to be injected into the host animal. The animal is injected multiple times in very tiny quantities (under a milliliter) in different locations on the body. Multiple venoms may also be injected into the same animal to get a variety of antibodies, allowing one antivenin to work against multiple species. An example is CroFab, the only antivenin in the United States licensed for snakebites, and known to work against all North American snake venoms except the Coral snake — i.e. “red and yell, kill a fellow”.

Coral snake antivenom was produced by Pfizer, but they ceased production due to mounting losses — i.e. not enough people are bit by coral snakes every year to justify the cost of producing the antivenin — though they announced in 2013 that they would resume production. Foreign manufacturers have produced coral snake antivenin, but the licensing requirements and costs to introduce it to the United States have stalled availability.

5. Purifying and licensing — After waiting enough time for the animal to develop antibodies against the venom, blood is drawn and the plasma is separated from the blood. The antivenin is derived from the animal’s plasma. Popular Mechanics also notes that one of the biggest hurdles, adding into the mix a significant cost as well, to bringing the antivenin to market in the US is FDA licensing, which can take as long as 10 years and cost hundreds of millions of dollars if not over a billion dollars.

6. Human use — Once licensed and cleared for human use, the antivenin is freeze dried or distilled into a powdered concentrate, and must be stored refrigerated or below-freezing as well. It usually takes between 25 and 30 of vials of antivenin for a single patient. The concentrate is diluted into saline and administered to the patient. The antibodies in the solution bind to the venom and neutralize it, and the liver and kidneys carry it out of the body.

Beyond the steps, the antivenin is only one part of the ER visit. For example while waiting for antivenin for a Timber rattlesnake bite to “kick in”, a person may need to be put on antihemophilic drugs to counteract the hemophiliac effect of the venom. Neurotoxic venom, such as the aforementioned coral snake, mean that the patient will need to be on artificial respiration or a negative pressure ventilator to keep the patient alive during respiratory paralysis.

The cost per vial of antivenin is going to vary. CroFab costs upwards of $2,000 per vial to the hospital and has a shelf life of three years. The cost reflects the costs that go into the antivenin, including the risks involved at all stages. This cost will be passed on to the patient or the taxpayers, and means that a snakebite can leave someone who is uninsured with a massive amount of financial liability.

And yet many want all of this basically given away for free.

The only thing that will bring down the cost of the antivenin is greater production and availability of it. For this we need market competition — i.e. more venom harvesters selling venom to more antivenin producers. Unfortunately the very nature of harvesting the venom is what will keep supplies low and suppliers few, as it is a very high risk profession for which there is bound to be very high insurance and payroll costs.