High cost of antivenin

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tomharten
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High cost of antivenin

Post by tomharten » September 9th, 2015, 12:33 pm

There was a piece in the Washington Post today about the high cost of antivenin in the U.S. and the drivers for the exorbitant pricing. I heard a preview for a similar story on NPR, but hadn't heard their full coverage.

Here's a link to the post story:

http://www.washingtonpost.com/news/wonk ... -medicine/

Tom

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Re: High cost of antivenin

Post by Hans Breuer (twoton) » September 10th, 2015, 4:20 am

Thanks for posting this!. This is unbelievable. Seventy percent of the price is hospital markup, while the drug per se only costs pennies. ""It's a markup intended to be discounted back down," Boyer explained in an interview. But if you don't have insurance? The negotiating is all on you." The reason insurance was invented is called "SHIT HAPPENS EVEN TO THE MOST SELF-RELIANT". There's no excuse for lacking health insurance coverage. Even Americans have a choice now :-)

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tomharten
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Re: High cost of antivenin

Post by tomharten » September 10th, 2015, 5:33 am

I was pretty shocked as well. Even for those with insurance, people with the most basic plans often have a high deductible, so they're still pretty well screwed should they need these medications.

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Re: High cost of antivenin

Post by chrish » September 10th, 2015, 5:57 am

This is a problem inherent in our insurance system in the US. Because there is no regulation, insurance companies basically get to decide what they want to provide the doctor/dentist/hospital for their services rather than having to pay what the clinician/hospital bills for the service. Many times, the insurance companies actually pay less than it costs the clinician to provide the service (pay assitants, liability insurance, etc.)

In other words, if a doctor decides they think it should cost $50 for their time involved to give you a physical, they could then bill your insurance that $50. But the insurance company would then come back and say "Sorry, we are only going to pay you $20 for that hour of your time". So the doctor is forced to bill the insurance company $150 so that they will get paid the $50 it costs them to provide the service. The problem is that if you don't have insurance, you may get billed the full $150 which the doctor knows is an overcharge. That's why most clinicians will lower their charges if you pay cash, just ask.

It is similiar to the markups you see in tourist markets overseas. The seller deliberately overprices the item so there is room for haggling and still a profit margin.

Imagine if you could go into BestBuy and find a $1200 television you wanted and when you got to the checkout you decide you only want to pay $400 and the clerk has to accept it. That's what clinicians (and hospitals) are faced with everyday.

If the insurance companies would pay what the services actually cost as billed, this wouldn't happen. Obviously, the hospitals/clinicians would have to bill a fair/reasonable cost for the service for this to work, which is what got us here in the first place.

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Re: High cost of antivenin

Post by simus343 » September 10th, 2015, 7:23 am

What I got from this is, if I get bitten here in Florida, go to Mexico. Or, if it is a dusky pygmy, I'd go all in and tough it out. Not smart, no one should do it, but I've never been one to follow my own advice.

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Re: High cost of antivenin

Post by Jimi » September 10th, 2015, 9:19 am

f I get bitten here in Florida, go to Mexico. Or, if it is a dusky pygmy, I'd go all in and tough it out
Unfortunately, this is the calculation many make.

I once spent a few hours around lunchtime in a McDonald's backing up a friend who'd suffered a 1-fang, stab & retreat bite right next to his fingernail, from a medium-sized copperhead. A great hospital was immediately across the street, in case he started developing full-body symptoms. He didn't, just took some antihistamines and some ibuprofen or something, and drank lots of water. He was sweating with pain, and the hand swelling was pretty impressive, but by bedtime my friend was able to sleep. The next day was a bit better, and after a few days all was - apparently - well. Organ damage? Who knows...but besides this first-hand experience, I know of plenty of other people who have done this. One died. I also know quite a few people who've been bitten and made the far safer, but far more expensive choice of going straight to the hospital. Getting away for under $50K is basically unheard-of.

It's sad, because you can actually go to Mexico or Brazil or Costa Rica and buy GREAT antivenoms, which would be pretty efficacious against all our taxa (in some cases probably better than what Savage makes...), very cheaply (e.g., $100-120/vial). But getting them back into the country legally is a monstrous FDA hassle. And getting a doctor to use them, when they aren't FDA-approved, would also be...unlikely. Eh, maybe in Vegas, ha ha. Might have to give them a kidney though. Ha ha.

But if I lived really close to the border I'd think about developing a relationship with a bite-experienced MD just across the other side. I'd at least look into it, from a cost/risk standpoint.

I also keep quite a bit of cash in my accounts, for all manner of emergencies. As Chris noted, using cash, not insurance, can be a great way to save money on medical bills. Quite a system we've got here.

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Re: High cost of antivenin

Post by Noah M » September 11th, 2015, 8:54 am

Sadly, this doesn't surprise me. I've read/heard similar things for other medicines and treatments. Some of you may remember, probably within the past 2 years, there was some media coverage about how the cost of a procedure can very depending upon where it is done. That is, I thought the journalists found that hospitals charge more for procedures if the hospital is in a wealthy state or area. I think they used some heart procedure for comparisons, and the cost to do it in California was double or more than the cost to do it in Mississippi.

Pretty much everybody I have talked to inside the medical system and outside, blames the insurance companies. I'm sure drug manufacturers have greedy tendencies, but they have a balance to walk between making a drug to help people and making a profit. The insurance companies seem to not really pay attention to the 'care' part of healthcare.

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Re: High cost of antivenin

Post by simus343 » September 13th, 2015, 8:29 am

I think the cost in California for some procedures is double Mississippi because so is the standard of living cost.

Jimi, I've never known any humans to not use antivenin, but I have known a medium-small dog to pull through a large cottonmouth bite with nothing but antibiotics and rest. The person you knew that died? Was it from a larger rattlesnake species, or a copperhead like your friend that you waited it out with? From what I understand, pygmies and southern copperheads are not lethal to healthy people.

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Re: High cost of antivenin

Post by Kfen » September 13th, 2015, 11:20 am

simus343 wrote: From what I understand, pygmies and southern copperheads are not lethal to healthy people.
I was also (mistakenly?) under the impression that there have not been any confirmed fatalities due to copperheads that did not involve some other complication, i.e. allergic reaction, prior heart condition, etc.

Does anyone have the facts?

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Re: High cost of antivenin

Post by Jimi » September 14th, 2015, 10:54 am

The person you knew that died? Was it from a larger rattlesnake species
Well, I had met this guy earlier, but then I moved out of state well before this incident happened, so I really didn't know him any more - I just heard about it and went "damn, I used to know that guy". The snake was an adult N FL canebrake. Madness to try & tough it out - they're hot like a scute. And the yield is just ridiculous - we're talking tablespoons. Anyway, perhaps he began by thinking he'd approach the situation in one way, but by the time he realized the error he was too incapacitated to switch course (there's a strong neurotoxic component to horridus venom in that part of their range). Another fundamental hot-keeping rule he violated was, he was home alone and decided to interact with the animal. And, apparently he had no real plan for what to do in the event of an accident, which - if he'd had one - would have led him to have kept a phone in his hot room, with an emergency number already programmed into it. What can I say, it was his 3rd bite, he maintained a certain path of behavior and he paid for that path with his life. Not a surprising outcome, sadly.
I have known a medium-small dog to pull through a large cottonmouth bite with nothing but antibiotics and rest.
This is pretty routine. Dogs are tough. I was backpacking once in the Trinity Alps (NorCal) with some friends and a ~ 6-yr old female Am Staff. The dog located and engaged a large adult NorPac and was rewarded with a juicy wet bite in the face. We were about 10-12 miles from the trailhead (and then about 3 hours' drive back to town), and the dog weighed about 70 lbs, so 1) we weren't going to make the dog walk out and 2) we weren't going to carry her out! We decided to just set up camp right on the spot, mid-afternoon, and to bury her right there if she died. Old school, pioneer-days stuff. Pretty heavy, this was truly a beloved, sweet dog.

This dog was super food-motivated, but probably for the first time in her life, she opted out of dinner. (She had major balloon-face.) She was a seriously unhappy camper, had a terrible night. Nobody slept well. But by morning she was able to eat breakfast. The camping trip continued, the second afternoon we made it the last couple miles to our destination lake (either Grizzly or Papoose, if I recall), and Aries the dog lived out her full life expectancy, with no apparent long-term effects other than a little bald spot on her muzzle. I doubt she ever hassled another snake...

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tomharten
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Re: High cost of antivenin

Post by tomharten » March 8th, 2017, 6:29 am

Saw this interesting article discussing the use of nanotechnology as a cheaper and effective treatment for envenomation.

https://www.sciencedaily.com/releases/2 ... 141217.htm

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Re: High cost of antivenin

Post by Fieldherper » March 8th, 2017, 8:15 am

Antivenoms are expensive in the US and there are several factors that play into this.
Crofab, for example, which is the primary antivenom used to treat North American pit viper envenomations, can be $3-4,000 per vial.
At face value, this seems crazy, but when one looks deeper into the situation, the high cost is more easily understood.

First, Crofab research and development started in the late 1970s. Scientists were becoming better at analyzing different snake venoms and evaluating the many different toxins that can be found in individual venoms. Since venom composition differs significantly between species and even within species, making a "one size fits all" antivenom to cover all the pit vipers found in North American is challenging. The approach was to select a mix of species with the broadest possible toxin coverage. They settled on C. atrox, C. adamanteus, C. scutelatus, and A. piscivorous. To cover intra-species venom variability, they needed snakes from different populations/regions. So for instance, the mojave rattlesnakes used come from CA, different locales in AZ, and other states. The same is true for the other species.

The snakes are housed in special facilities which provide strict husbandry requirements. The snakes are cared for by a veterinarian and specially trained keepers. Every aspect of care, feeding, and venom extraction are carefully controlled and all data recorded. The venom does not come from "rattlesnake roundups" or other similar sources. Once venom is extracted from animals from across the range, it is assayed to ensure that enough of each toxin is present to generate the appropriate antibody response in the sheep that are used to make the antivenom.

The venom is then sent to Australia where the sheep are kept, also under highly-controlled conditions. Why Australia? Because they have never had prion disease in livestock, aka, "Mad Cow" disease in Australia. The possibility of transmitting disease from livestock to humans in a biological drug is unacceptable. The sheep are immunized with the venom in Australia in accordance with a strict protocol that, through trial and error, has shown to produce the best antibody response. When the sheep are producing sufficient antibodies, their serum is collected and then purified to remove non-essential proteins, yielding the raw antivenom. The antibodies are then assayed and pooled to produce a standardized initial product. Other purification steps take place in parts of Europe. The finished product is sent to the US for distribution.

So one can see that just making the antivenom is a laborious and highly technical process with high controls all along the way. The R&D started in the 1970s but the product was not FDA approved for widespread use until around 2000. This is because getting any drug FDA approved takes a lot of time and a lot of money. Clinical trials needed to be performed to demonstrate safety and efficacy.

Now you have a drug that is expensive to make in accordance with American standards. Couple that with the fact that snakebite in the US is a rare condition when compared to most other illnesses. It is not a significant public health problem in this country. There is not a huge incentive for a pharmaceutical company to make antivenom when compared to drugs for high blood pressure, diabetes, or other far more common conditions. Antivenom is an "orphan drug," that is a necessary drug used to treat a rare condition. The company needs to charge more for the product in order to generate a sufficient profit to justify the drug's production.

Any person who shows up to a US hospital who needs antivenom will get it regardless of that person's ability to pay/insurance status, etc... This is federal law (EMTALA). Many snakebite victims will not be able to pay due to lack of insurance and the hospital will eat the cost. This is one reason that the hospital marks up the product further. They need to try to recoup costs.


This is a very brief summary, but I hope this illustrates some of the reasons as to why antivenom in the US is expensive.

FH

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Re: High cost of antivenin

Post by tomharten » March 8th, 2017, 10:38 am

So, that's the gist of the article that I posted today. That the "nanogel" technology could be a completely different approach to developing new treatments for snake bite. According to the article:

"Zeroing in on protein families common to many serpents, the UCI researchers demonstrated that they could halt the worst effects of cobras and kraits in Asia and Africa, as well as pit vipers in North America. The team synthesized a polymer nanogel material that binds to several key protein toxins, keeping them from bursting cell membranes and causing widespread destruction. O'Brien knew he was onto something when the human serum in his test tubes stayed clear, rather than turning scarlet from venom's typical deadly rupture of red blood cells."

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Re: High cost of antivenin

Post by MCHerper » March 10th, 2017, 6:26 am

Fieldherper wrote:Antivenoms are expensive in the US and there are several factors that play into this.
Crofab, for example, which is the primary antivenom used to treat North American pit viper envenomations, can be $3-4,000 per vial.
At face value, this seems crazy, but when one looks deeper into the situation, the high cost is more easily understood.

First, Crofab research and development started in the late 1970s. Scientists were becoming better at analyzing different snake venoms and evaluating the many different toxins that can be found in individual venoms. Since venom composition differs significantly between species and even within species, making a "one size fits all" antivenom to cover all the pit vipers found in North American is challenging. The approach was to select a mix of species with the broadest possible toxin coverage. They settled on C. atrox, C. adamanteus, C. scutelatus, and A. piscivorous. To cover intra-species venom variability, they needed snakes from different populations/regions. So for instance, the mojave rattlesnakes used come from CA, different locales in AZ, and other states. The same is true for the other species.

The snakes are housed in special facilities which provide strict husbandry requirements. The snakes are cared for by a veterinarian and specially trained keepers. Every aspect of care, feeding, and venom extraction are carefully controlled and all data recorded. The venom does not come from "rattlesnake roundups" or other similar sources. Once venom is extracted from animals from across the range, it is assayed to ensure that enough of each toxin is present to generate the appropriate antibody response in the sheep that are used to make the antivenom.

The venom is then sent to Australia where the sheep are kept, also under highly-controlled conditions. Why Australia? Because they have never had prion disease in livestock, aka, "Mad Cow" disease in Australia. The possibility of transmitting disease from livestock to humans in a biological drug is unacceptable. The sheep are immunized with the venom in Australia in accordance with a strict protocol that, through trial and error, has shown to produce the best antibody response. When the sheep are producing sufficient antibodies, their serum is collected and then purified to remove non-essential proteins, yielding the raw antivenom. The antibodies are then assayed and pooled to produce a standardized initial product. Other purification steps take place in parts of Europe. The finished product is sent to the US for distribution.

So one can see that just making the antivenom is a laborious and highly technical process with high controls all along the way. The R&D started in the 1970s but the product was not FDA approved for widespread use until around 2000. This is because getting any drug FDA approved takes a lot of time and a lot of money. Clinical trials needed to be performed to demonstrate safety and efficacy.

Now you have a drug that is expensive to make in accordance with American standards. Couple that with the fact that snakebite in the US is a rare condition when compared to most other illnesses. It is not a significant public health problem in this country. There is not a huge incentive for a pharmaceutical company to make antivenom when compared to drugs for high blood pressure, diabetes, or other far more common conditions. Antivenom is an "orphan drug," that is a necessary drug used to treat a rare condition. The company needs to charge more for the product in order to generate a sufficient profit to justify the drug's production.

Any person who shows up to a US hospital who needs antivenom will get it regardless of that person's ability to pay/insurance status, etc... This is federal law (EMTALA). Many snakebite victims will not be able to pay due to lack of insurance and the hospital will eat the cost. This is one reason that the hospital marks up the product further. They need to try to recoup costs.


This is a very brief summary, but I hope this illustrates some of the reasons as to why antivenom in the US is expensive.

FH
Great info all around! I do have two questions however. First, you mentioned sheep, but I thought that I had read that CroFab was a horse-based serum? From your post that is not the case, but where did that come from?

Also, why is Antivypmyn not a consideration in the United States? I thought that it was at least as effective as CroFab.

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Re: High cost of antivenin

Post by lateralis » March 10th, 2017, 9:27 am

Many snakebite victims will not be able to pay due to lack of insurance and the hospital will eat the cost. This is one reason that the hospital marks up the product further. They need to try to recoup costs.
Unfortunately this is not the case if you have a SSN. You will repay the bill one way or the other, or you will have your credit destroyed by our ever so compassionate healthcare system and the collection dogs they turn loose. If you are going to play with venomous snakes make sure you have insurance, it's common sense.

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Re: High cost of antivenin

Post by WSTREPS » March 11th, 2017, 7:07 am

The problem of over the top medical expense's isn't a problem that's inherent to the insurance system in the US. Due to no regulation. That's a load of BS. There's two sides to that story.

Poison pill: Inflated antivenom bills shed light on high drug costs

http://america.aljazeera.com/articles/2 ... costs.html

I have taken a couple of bites over the years but never have had antivenom . I did do some hospital time. There was no antivenom manufactured for one of the species that bit me (the doctors wanted to improvise with something they thought was close and I told them no way) and the other time I didn't want any. My insurance covered things nearly 100%. It ended up costing me a few hundred bucks out of pocket. When it comes to venomous snake bites. I have seen a lot of them ( a lot being relative to the event), just about everything.
If you are going to play with venomous snakes make sure you have insurance, it's common sense.
That's sound advice. And Ill add to that. If you cant afford decent health insurance don't waste your time playing with snakes. Spend it getting your life together.


Ernie Eison

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Fieldherper
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Re: High cost of antivenin

Post by Fieldherper » March 12th, 2017, 8:20 am

Great info all around! I do have two questions however. First, you mentioned sheep, but I thought that I had read that CroFab was a horse-based serum? From your post that is not the case, but where did that come from?
Crofab is definitely made with sheep serum and is therefore "ovine." The older product, Wyeth Polyvalent Antivenin, was made with horse serum and was "equine." Many foreign antivenoms are still equine. I am speculating here, but I believe that sheep are easier to breed and care for than horses. The Wyeth product, which was around since the 1950's, was very effective against North American pit viper envenomations, but had a significant risk of severe and even deadly allergic reaction. This was due to the fact that it contend the entire IgG antibody molecule as well as other horse serum contaminants. The risk of immediate or delayed reaction to the serum was very high.
Crofab uses the specific part of the antibody that binds the different venom proteins, the Fab fragments. There are smaller and less antigenic than the entire antibody molecule. The product is also filtered to remove proteins that are not involved in venom-binding. This greatly reduces the risk of allergic type reactions with Crofab.


"Also, why is Antivypmyn not a consideration in the United States? I thought that it was at least as effective as CroFab."

Antivipmyn seems to be a good product. It is an Fab2 antivenom that is effective against North American pit vipers. It is made in Mexico and is not currently in wide use in the US, but may be someday. Crofab is what most US hospitals carry at the present time.

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