Digging into high prices for rabies protection Date: 06/28/18
By Brenda Goodman and Andy Miller
This story started the way most good stories do, with a tip. Andy heard about a woman in Georgia named Tamara Davis, who was facing thousands of dollars in medical bills because of a freak occurrence – she found a bat clinging to a dishtowel in her kitchen sink.
After interviewing her, he was struck by the details. Even though she didn’t think she’d been bitten, Davis owed more than $10,000 for shots. “Think about that,” Andy told me on the phone. “These were injections, and this is her bill.”
There was an interesting twist to her story, too. Davis had to be in Florida once when she was due for one of her series of shots. In Florida, she learned that shots to prevent rabies were offered through a local health department and were free. But back in Georgia, she had to go to hospital ER where the shots were costing her thousands of dollars.
Rabies is one of the deadliest viruses known to medicine. By the time a person starts showing symptoms, it’s nearly always fatal. Bats and other wild animals, such as skunks and foxes, are the main carriers of the infection in the United States.
The good news is that rabies is preventable with a series of shots that are given before a person shows symptoms. The regimen consists of immunoglobulin – rabies antibodies are harvested from the blood of people who have been immunized – and a series of injections of rabies vaccine. These are given on a carefully timed schedule, and they’re not cheap.
Some quick Internet research revealed that Tamara Davis wasn’t the only patient struggling to pay off medical bills for rabies shots. On social media sites, people had posted photos of jaw-dropping hospital bills – all for rabies shots.
Neither of us could remember rabies shots being so pricey. We decided to answer a few basic questions: Are rabies shots more expensive than they used to be and if so, why? If a Florida health department provided these for free, what’s the situation in other states? Could part of the price increase be due to states dropping rabies prophylaxis as a public service?
The first part – obtaining prices for the rabies prophylaxis – turned out to be tricky. When we were reporting, only two companies offered both the immunoglobulin and the vaccine in the U.S. market: Grifols and Sanofi Pasteur.
I decided to tackle the drug prices question. My go-to for drug prices, IQVIA (formerly IMS Health), told me they didn’t track prices for rabies products. I reached out to the American Society of Health-System Pharmacists (ASHP) for help and they queried their members for me. One pharmacist, who would only help on background, suggested I try a company called First DataBank for prices. First Databank helps reporters with drug prices on a case-by-case basis.
They agreed to help. We first looked with five years of data, which showed a modest rise in prices, but nothing too alarming. When we went back 10 years, however, prices really had jumped – nearly 400 percent.
I told Andy what I’d found via text. “That was well worth waiting for,” he responded. And the prices of the two drugs was virtually the same.
But this wasn’t Pharma Bro territory, right? This wasn’t a sudden hike of 5,000 percent.
We needed some context on the increases we were seeing, which were more gradual. We reached out to the Drug Pricing Lab at Memorial Sloan Kettering. Their expert, Anna Kaltenboeck, explained that most drug makers had promised to limit their annual increases on drugs, but that each price increase worked like compound interest. Over time, drug makers still saw hefty returns on relatively modest yearly markups.
In the case of rabies immunoglobulin, those price increases have nothing to do with innovation. The treatment is made almost the same way it was in the late 1800s when it was first used by Louis Pasteur.
At the same time I was trying to get pricing info, I decided to tackle the second set of questions – how many health departments offer this service? Is it cheaper for health departments than hospitals? Are fewer health departments offering this now than they have in years’ past?
My first call was to Georges Benjamin, M.D., executive director of the American Public Health Association. I was hoping that the APHA had surveyed its members at some point about rabies and might have some ready-made research they could share.
Benjamin agreed that it was an interesting question, but he didn’t know.
That meant that I had to query individual health departments to get the answers I needed. I made a spreadsheet. I went state by state, collecting the name and contact information of the public information officer at each state health department. I sent them a form email with three questions:
If a person is exposed to a bat and needs rabies PEP, for example, can they get it from a local public health department (do you keep it in stock?)
If your health departments don’t stock it, it would be very helpful to know if they once did, and if so, when they stopped offering it (a rough estimate is fine) and why. (We know this is an expensive treatment. We think it’s recently become even more expensive than it once was. We’re trying to figure out if big price hikes are preventing public health departments from keeping this in stock.)
If they do stock it, can you tell us how much it costs a patient to get the series of shots?
Most health departments got back to me right away, and I tracked their answers in the same spreadsheet. It took a few weeks, but by doing this, I was able to find out that most people who need rabies shots are sent to a hospital ER, perhaps the most expensive place to get them. While the practice of providing rabies shots through health departments was never widespread, it once was more common that it is today. Alaska, for example, ended its program recently after it could no longer afford to stock the injections, which have a short shelf life. I also learned that larger states like Texas, Florida and New York do offer the shots at reduced or no cost.
Finally, we rounded out our investigation with other patient stories. By searching social media sites, I found and interviewed a woman in North Carolina who was struggling with a big bill after being bitten by a fox, and a man in Maryland who, despite having insurance was shocked to learn how much they still owed after his wife was attacked by an angry groundhog in her garden.
We tried to find people in a variety of financial circumstances to give the story balance. We only used anecdotes we could verify with hospital bills and contacted each hospital involved for comment.
Brenda Goodman is an investigative reporter for WebMD. Andy Miller is Editor and CEO of Georgia Health News. They are the 2017 and 2018 winners of the Atlanta Press Club’s Awards of Excellence for investigative reporting.