Compassion for a hungry stray kitten led to a nip on the finger — and also took a bite out of Jeannette Parker's wallet.
In a rural area just outside Florida's Everglades National Park, Parker spotted the cat wandering along the road. It looked skinny and sick, and when Parker, a wildlife biologist, offered up some tuna she had in her car, the cat bit her finger.
"It broke my skin with his teeth," she recalls.
After cleaning off the wound, she did some research and began worrying about rabies since Miami-Dade County had warnings about that potentially fatal disease in effect at the time.
She then drove back to her home in the Florida Keys and called the health department, but it was closed.
So she headed to the emergency room at Mariners Hospital, not far from her house. She spent about two hours in the emergency room, got two types of injections and an antibiotic and says she never talked with a doctor.
"I went home happy as a clam," she said.
Then the bills came.
Patient: Jeannette Parker, a 44-year-old state fish-and-wildlife biologist. Insured through the American Postal Workers Union because her husband works for the federal government at Everglades National Park.
Total bill: $48,512, with $46,422 of that total for one preventive medication
Service provider: Mariners Hospital, part of Baptist Health South Florida, a faith-based nonprofit chain with eight hospitals and a variety of other facilities
Medical service: Parker's wound was examined, and she received the first in a series of rabies shots, as well as an injection of 12 milliliters of rabies immune globulin, an antibody that kick-starts the immune system to provide protection from the virus until the vaccine kicks in.
What gives: When you are potentially exposed to a fatal disease, you need treatment. In the moment, it's hard to shop around or say no to high prices.
The Centers for Disease Control and Prevention estimates that post-exposure preventive treatment for rabies, which includes the immune globulin and four doses of vaccine given over a two-week period, usually costs more than $3,000 on average. An estimated 40,000 to 50,000 people annually get such treatments following exposure to potentially rabid animals, the CDC says. Each hospital can set its own prices for treatment.
In Parker's case, the majority of the cost was for the rabies immune globulin. For that injection alone, the hospital billed her and her insurer $46,422. That's well above what's considered typical.
"I have never heard anything that high for immune globulin," said independent biomedical consultant Charles Rupprecht, a World Health Organization technical adviser on rabies who ran the rabies program at the CDC for 20 years. "How is that possible?"
Parker thought that seemed high after she requested and received an itemized bill from her insurer, so she Googled it.
"I saw that immune globulin was expensive, but it wasn't that expensive," she said. "I sat on it for a while because I was upset. Finally, I went by the hospital to confirm, and they said, 'Yes, that is right.' "
The rabies immune globulin is a complex product, made from blood plasma donated by volunteers who have been immunized against rabies. Three manufacturers make the product, and there are no shortages right now, the Food and Drug Administration says. Currently, the average wholesale acquisition price — the amount paid by wholesalers that then mark it up when they sell it to distributors or hospitals — is $361.26 per milliliter, according to Richard Evans, a drug industry analyst at SSR Health, part of the boutique investment firm SSR LLC.
Using that average, the cost for the 12-milliliter dose Parker received would have been $4,335.
Perhaps the hospital erred when billing, adding an extra zero?
No, said Baptist Health spokeswoman Dori Robau Alvarez in an emailed statement.
The $46,422 charge reflected list prices the hospital had in place on Sept. 22, 2018, when Parker was treated. Alvarez wouldn't disclose that rate, but simple math shows the hospital was billing $7,737 per 2-milliliter dose, which is how the immune globulin is often packaged.
Alvarez also noted that the month after Parker was treated, Mariners revamped its full price list, known as a "chargemaster." The hospital lowered its charge for rabies immune globulin to $1,650 per 2 milliliters, which would have made Parker's bill about $9,900 — still high, but not sky-high.
Hospitals revisit their chargemasters periodically. But it should be noted that this particular 79 percent cut came shortly before January, when new rules required all hospitals for the first time to post those previously hidden charge lists publicly on websites, part of the Trump administration's interpretation of the Affordable Care Act.
"Statements for patients who received treatment prior to the change would reflect the previous charge," Alvarez said.
She didn't respond to follow-up questions about the reasons for the price drop or the above-average price before the change.
Chargemaster prices are generally not what people with insurance pay. One benefit of having health coverage is that insurers negotiate discounts for in-network care. Parker went to an in-network hospital.
But not every service has a negotiated discount, said two experts on billing at America's Health Insurance Plans, the industry's trade lobby. And a discount from a very high charge remains a very large amount of money.
In Parker's case, her husband's union health plan paid $34,618 toward her total ER bill, including $33,423 for the immune globulin alone.
The health plan said it had requested an audit of the bill to check it for accuracy. In an emailed statement, the plan said not much else can be done. "Other than negotiated discounts, there is little the plan can do to challenge the hospital's charges. The charges do not rise to the level of being fraudulent," the statement concluded.
Resolution: After accounting for the insurer's payments, Parker had to pay $4,191 for the final $344 of her deductible for the year plus her 10 percent share of the charges accepted by her insurer.
"My funeral would have been cheaper," she said.
Parker learned after calling her insurer that the cat bite should have been considered an accidental injury and thus eligible for 100 percent coverage under her insurance plan, minus her remaining deductible. She is seeking to have the hospital resubmit the bill to the health plan to see if it will pick up the rest of her 10 percent share of the cost. The hospital hasn't offered to lower the price of the immune globulin to its current charge.
The takeaway: If you suspect you may have been exposed to rabies, get treated. "It's prudent that she sought immediate and appropriate medical care," said Rupprecht.
Many services that fall under the umbrella of public health can be obtained at no or low cost from local health departments. These range from vaccinations to post-exposure treatments for diseases like rabies. If possible, check with your health department to see if it offers treatment.
But with a serious disease like rabies, if those services aren't immediately available, don't wait. Head to a hospital, and make sure it's in your insurer's network, if you have a choice.
If you get a bill for what seems like an astounding amount, get the itemized bill from the hospital rather than just the summary. Moreover, now that hospital chargemasters are publicly available on hospital websites, use them.
They are long and complicated. For the moment at least, they are not written in plain English. But many are alphabetical, and it's not hard, for example, to find an entry for "Rabies IG" (rabies immune globulin).
Check how the price you've been billed compares with others in your area. (You may also be able to check for average prices on sites like HealthcareBluebook.com.) Share that information with your employer's human resources department, or use it to negotiate with your hospital and insurer.
NPR produced and edited the interview with Kaiser Health News' Elisabeth Rosenthal for broadcast. Nancy Klingener, the Florida Keys reporter for member station WLRN, 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.
DAVID GREENE, HOST:
Here's one reality in our health care system - prices that can be unpredictable and really, really high. Now, patients are told to be consumers, to shop around and find the best prices. But in some situations, you really can't do that. You are stuck at a hospital, which can charge you really whatever they want to. This is at the heart of our latest Bill of the Month segment Dr. Elisabeth Rosenthal from our partner Kaiser Health News is here to help us try and understand and dissect a huge bill that was sent to us from a listener in the Florida Keys. Dr. Rosenthal, welcome back.
ELISABETH ROSENTHAL: Thanks for having me again.
GREENE: Well, who are we talking about today?
ROSENTHAL: We're talking about a bill from Jeannette Parker. She's 44, a biologist. And she was exposed to rabies or was afraid she might've been. So, as you can imagine, she was rather alarmed.
GREENE: Yeah. I mean, that can be fatal if you don't take care of it, right?
ROSENTHAL: Absolutely. Luckily, there are really effective treatments. But it involves getting some immune globulins and then, basically, a rabies vaccine, which is exactly what Jeannette did.
GREENE: OK. Well, let's hear her story. And then I want to come back to you and ask you some questions. But her story comes to us from reporter Nancy Klingener from our member station WLRN in South Florida. She went to visit Jeannette.
NANCY KLINGENER, BYLINE: Jeannette Parker is an animal lover. That's obvious from the menagerie at her home in the Florida Keys.
JEANNETTE PARKER: Two dogs, three cats, sulcata tortoise - he's 80 pounds - poultry, fish tanks, bearded dragon (laughter).
KLINGENER: That last one's a lizard. Her cats are normally pretty shy around company, but one of them comes out to greet us while another streaks under the couch.
(SOUNDBITE OF CAT MEOWING)
PARKER: That is Breakneck Sally because she'll walk between your feet and trip you. So...
KLINGENER: Parker's love for animals has become part of her career. She's a wildlife biologist for the state of Florida, so she monitors the populations of endangered species like the Key deer and the lower Keys marsh rabbit. But her love for animals got her in trouble last September. She was on the mainland near Everglades National Park, and she saw a kitten by the side of the road.
PARKER: It's pretty common for people to dump animals in that area right outside the park.
KLINGENER: The kitten was skinny and looked like it was sick. Parker had a packet of tuna in the car and pulled over to give it some food.
PARKER: And in the process, he just grabbed onto my finger while he was eating. So he broke the skin on my finger.
KLINGENER: Parker says the kitten wasn't trying to bite her.
PARKER: And it was just a tiny, little scratch. And I was embarrassed to go to the emergency room over my tiny scratch. But he did break the skin, and I was bleeding. And there had been a rabies alert in the county that month. A couple of cats and quite a few raccoons tested positive and one otter also.
KLINGENER: So Parker went to the emergency room at Mariners Hospital just up the Overseas Highway from her house. She got the immunoglobulin injection that protects against rabies until the rabies vaccination takes effect.
PARKER: Yeah, I went home - just no big deal. I was in and out of there really fast.
KLINGENER: And then the bill came. The total cost was $48,000.
PARKER: And I thought it was a joke. I just couldn't believe it. It had to be a mistake. That was what I was thinking. I sort of laughed, and I was upset at the same time. Yeah, I couldn't believe it. For a shot, it was $48,000.
KLINGENER: Parker says she eventually stopped by the hospital to get an itemized bill, but they didn't drop the price. She had to pay $344 to cover her deductible, then 10 percent of the bill. Parker says no one at the ER said anything about cost when she was there. If she had realized how much it would be, she would've waited until Monday and gone to the county health department. The experience has given her a new perspective on money.
PARKER: I like to gauge everything now by how much my rabies shot cost. So my boss got a new roof on his house, and it cost $20,000. And I was joking that you couldn't even get half a rabies vaccination for that.
KLINGENER: One thing has not changed because of this experience. She's still an animal lover.
Would you hesitate now before pulling over if you saw a sick animal on the side of the road?
PARKER: (Laughter) Probably not.
KLINGENER: And now with the protection of her rabies vaccine, she says she might be even more inclined to stop the next time.
GREENE: That story comes to us from Nancy Klingener from member station WLRN. She was reporting from Plantation Key in Florida. I'm still with Dr. Elisabeth Rosenthal from Kaiser Health News. Dr. Rosenthal, $48,000 for a shot. And I'm just trying to do the math here. Jeannette had to pay 10 percent. I mean, she was responsible for more than $4,000.
ROSENTHAL: That's right. And, you know, rabies immunoglobulin is expensive, but many hospitals would charge about $3,000 for that. So the pricing here is pretty out of line.
GREENE: Well, why is the hospital able to charge, I mean, like, more than 10 times what it should be or what other hospitals charge?
ROSENTHAL: Well, you know, hospital prices are pretty arbitrary. There's little rhyme or reason for how they set their prices. And, hey, look, this is a medical service you can't refuse. You might've been exposed to rabies. So you're kind of a sitting duck, and they can basically charge whatever they want. The funny thing is when we looked into this, we discovered that the price of the rabies medicine Jeannette got dropped from about $7,000 a unit to about $1,650 a unit just a month or two later. So that shows you how crazy it is.
GREENE: Oh, so this hospital started charging dramatically less for this shot shortly after Jeanette was treated.
ROSENTHAL: Yes. And when we asked the hospital, they said, oh, well, we periodically adjust our prices. But I'd like to note that on January 1 this year, hospitals had to suddenly reveal their prices according to a new federal regulation. So they knew that that maybe-too-high $7,000 price would be out in the public as of January 1. So maybe they were trying to make adjustments before a new year came.
GREENE: Oh, wow. So the hospitals were trying not to look outrageous when they were actually required...
GREENE: ...To start telling people what they were charging.
ROSENTHAL: Well, that's one theory. You know, so the price dropped about 60 percent. And can you imagine if, like, you went to buy a Prius one month and it was $30,000, and the next month, on the first of the month, it was suddenly $10,000? I mean, that would be outrageous. But that's what happens in medical care all the time.
GREENE: I certainly couldn't imagine if I paid the $30,000 (laughter), and then saw it drop, like, the next day. What can you do, I mean, if you're bitten by an animal, and you go to the hospital, and you're desperate, and you don't know that they're charging this much?
ROSENTHAL: Since, for the moment, there's no kind of price-drop guarantee in health care, I think what you need to do, first of all, is protect your health. So you do need to go to the hospital. You need a rabies immunoglobulin. You should know that many public health departments will hand it out. So if it's during the week, you can check there first. And then, you know, try and go to an in-network hospital so at least you have better negotiating power.
GREENE: Is anything going to change for Jeanette? Can she get some money back?
ROSENTHAL: The problem with - in health care is that once you've spent, it's very hard to get money back. But her insurer is negotiating this. And I do hope that, you know, they look at this price drop and say, hey, what gives; we - she shouldn't be responsible for that big of a bill.
GREENE: Well, we'll hope for the best for her. Dr. Elisabeth Rosenthal, thanks as always.
ROSENTHAL: Thank you.
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