What is the cost of care in the richest county in America?
Roused by Kaiser Health News and National Public Radio’s “Bill of the Month,” this new monthly series will spotlight medical bills to shed light on health care prices in Jackson Hole and help residents better manage costs.
Wyoming hospitals write off roughly $120 million a year in care for those who can’t afford to pay, according to Wyoming Hospital Association testimony at the state Legislature’s Joint Revenue Committee in November. Wyoming also has the highest annual premium in the nation — $9,620 — for adults with an insurance plan through the Affordable Care Act Marketplace.
The adrenaline-seeking spirit of Jackson Hole makes for exciting stories, and sometimes bone-chilling medical bills. This week, the News&Guide will look at rabies, the exorbitant cost of the vaccine compared with other countries, and how two women navigated their care. Sarah Nicole’s last name was kept out of this story due to her privacy concerns over financial and medical details. — Ed.
Iquitos, Peru, is the largest city in the world that cannot be reached by car. Visiting this wildly remote section of the Amazon Rainforest requires a 16-hour boat ride, or a short flight, because there are no roads. Sarah Nicole, a 23-year-old special education teacher and yoga instructor in Jackson, happened to find herself at a monkey reserve there in November 2021.
Upon Nicole’s arrival at Isla de los Monos, visitors were directed to remove any accessories and phones from their person because the reserve’s monkeys are known to cling on to human visitors. One tourist didn’t heed the warnings and kept on a red, beaded bracelet.
The eye-catching piece of jewelry piqued one primate’s interest. In a matter of seconds, the monkey launched at the lady and ripped off her bracelet. It wasn’t a candy bracelet, unfortunately, so when the monkey tried to shove the fallen red beads in its mouth, Nicole swooped to the rescue. While the monkey was spared, Nicole was not.
The monkey took a big chomp onto Nicole’s leg, marking her with a bleeding, galaxy-colored bruise. She sat in disbelief, trying to brave away the pain, eventually washing it off. The monkey dared to make amends by cuddling on her lap after the incident, but she didn’t find the affection so cute anymore.
Back in Iquitos, Nicole visited a doctor, worried she might have been infected with rabies. While the physician shrugged off the bite, confident that monkeys at that sanctuary are clean, he did advise that she receive the rabies vaccine.
As the vaccine is a four-shot series, with specific timing, Nicole decided to wait until she was back in the United States to deal with the wound. After all, she had a bunch of backpacking trips lined up that she wasn’t ready to lose.
Around one month later, she scheduled a phone appointment with a doctor at St. John’s Health to see about the bite. The doctor was stumped. “No one has ever come to Jackson, Wyoming, having been bit by a monkey,” she remembered him saying.
After conferring with other medical experts around town, the doctor insisted she get the rabies vaccine series, as the disease can lay dormant for up to a year, according to the Centers for Disease Control and Prevention, WebMD and the World Health Organization.
Fear of water, fear of fresh air, hyperactivity, gradual paralysis and coma are typical rabies symptoms, and nearly every case is fatal. Fewer than 20 cases of human survival from clinical rabies have been documented in the United States, as of the end of 2021, according to the CDC.
The risk was a matter of life and death, but the cost of the shot series was more than $20,000.
Nicole’s gross income that year was $24,000 — about $10,000 above the federal poverty line. At the time, she was busy earning a degree in elementary education, which meant her part-time restaurant job barely could tackle the payment on thousands she owed in student loans.
The doctor insisted that he would help her gain financial assistance through St. John’s Health, but she shouldn’t wait to get the shots. So she did.
Her hospital bill after the contributions of her insurance company, United Health Care, totaled more than $3,300, which she couldn’t afford.
Nicole completed an application for financial aid through the hospital. Because her annual income was not far from the poverty line, the hospital paid for 90% of the bill. Nicole swiped her card for a mere $300.
St. John’s financial assistance applications can take up to 30 days for final approval, though the committee tries to respond within 10 days. The hospital has a budget of $3.6 million for charity care this year and approves around 80% of applications, according to Vivian Bencomo, the patient assistance coordinator.
Applicants must submit bank statements from the last 60 days, income verification, W-2 tax forms from the previous year and a hardship letter explaining their situation and why they need financial aid. If they are not approved, or if the hospital can’t help more, the financial assistance committee will sometimes grant patients discounts on their bills or offer a payment plan. There is also the Caring Access Fund through St. John’s that can help patients who are financially strapped.
Accessing St. John’s charity care isn’t always straightforward, though. The financial assistance committee cannot tell patients the exact amount of aid it will contribute before a patient receives a bill. Unplanned operating room fees, for example, can sometimes hike bills, which is why advance estimates can’t be exact.
For Maggie Nelsen, a personal trainer in Jackson, the uncertainty over how much St. John’s and her medical insurance company would cover for a rabies vaccine pushed her ultimately to turn down a potentially life-saving immunization.
In November, Nelsen vacationed on the Azuero Peninsula in Panama, rich with abundant vegetation, crystal-colored seas — and bats.
On her second night in Panama, she discovered bat droppings on the floor of the beach house where she was staying, and quickly realized a beam that ran across the ceiling enabled bats to fly into the rooms.
At first, Nelsen was “grossed out,” but she didn’t think much of the bats. When she offhandedly mentioned them to some Panamanians, they joked about how bat rabies wasn’t a real concern. After her eighth night in the bat-infested house, she returned to the States and reported her exposure to the Teton County Public Health Department, just to be safe.
Immediately, the public health officials urged her to get the rabies vaccine series. Nelsen said she was never bitten, nor scratched, by any of the bats, as far as she’s aware, but CDC guidelines recommend that “if you wake up with a bat in your room, you may have been exposed to rabies and should see your doctor or call your health department, even if you don’t feel a bite.”
Nelsen was conflicted. She was confident that the Panamanian bats never touched her skin, but the health department urged her to get vaccinated. The vaccine series can cost more than $20,000 at St. John’s without insurance, and around $10,000 at the clinics she called in Idaho Falls and Salt Lake City.
Her insurance company, Wyoming Blue Cross/Blue Shield, couldn’t guarantee whether the vaccine would qualify for coverage. The company said it would be covered but only if it was “deemed emergent,” Nelsen recalled.
When she asked what criteria constitutes emergency care, Blue Cross/Blue Shield couldn’t answer. The Emergency Medical Treatment and Labor Act prohibits hospitals from proactively quoting costs, so those who need emergency care can seek it.
Nelsen couldn’t be confident that the shot series would be covered, especially because she had no proof that a bat made physical contact with her while she was sleeping. After she asked St. John’s for a quote on the rabies vaccine, the hospital could provide only an average price estimate, which was more than $23,000 without insurance.
A representative with the hospital’s billing department, Richelle Heldwein, responded to Nelsen’s cost concerns via email, offering “payment plans” and “financial assistance for those who qualify.”
According to the St. John’s financial assistance policy, patients are eligible for aid if they:
• Demonstrate a “willingness, but inability to pay”
• Have an out-of-pocket balance that exceeds $2,600 — even after the help of insurance if they have it
• “Other sources of payment” are unavailable, like the sale of assets or financial support from friends, family and institutions
• Exhaust all available health insurance, money from legal settlements and benefits from a health care sharing ministry (a group of members who share religious or ethical beliefs and contribute dues, which are used to pay for members’ medical costs).
Because Nelsen wasn’t completely sure she would qualify, she decided to reject the shots.
While there remains no diagnostic test for detecting a rabies infection before the onset of the clinical disease, she decided to take a gamble in the name of keeping out of debt.
“Ten thousand is a lot,” Nelsen said. “It’s more than my car.”
She devoted many hours to researching bats and rabies, talking with Latin American bat experts at the Smithsonian museum and chiropterologists in Panama. It was ultimately a bat researcher in Panama who gave her satisfying guidance.
After examining photos she took of the bat and asking for the exact location in Panama where she was exposed, the chiropterologist said the bat in the photo was likely not carnivorous. Because Nelsen didn’t report any known salivary-blood contact with the bats, the expert didn’t think a rabies shot would be necessary.
In 1996, the CDC Advisory Committee on Immunization Practices launched a new advisory that those exposed to bats, even when “physical contact cannot be elicited,” should receive the rabies vaccine.
In the first five years to follow the enactment of this policy, the rate of rabies vaccinations in the State of New York rocketed over 1,000%, from 131 in 1995 to 1,755 by 2000.
The price of the vaccine soared since the creation of this advisory, from approximately $2,000 to more than $10,000 by 2013. For two of the three primary doses recommended by the CDC — made by HyperRAB and Imogam — prices have shot up more than 370% from 2007 to 2017, from around $750 to more than $3,500.
The price of the rabies vaccine in the United States is also substantially higher than in other countries. Take the National Health Service in the United Kingdom, for example, which estimates the cost of the entire rabies vaccination series at a maximum of £180, or less than $200. The drug is dosed based on a patient’s weight, which is why the price fluctuates from person to person.
Rabies immune globulin, which is the primary shot of the rabies vaccine, is pricier than an average flu shot because it’s derived from human blood, which has to be screened for disease. The drug also has a shelf life of a few years after production, so most health care providers do not stock this vaccine.
This means that most patients seeking rabies treatment in the United States must visit emergency rooms, which can increase medical billing by hundreds or thousands of dollars for copayments and facility fees.
While St. John’s charity care and the help of medical insurance effectively tackled the fees of the rabies vaccine in the case of Nicole, advance promise is not always possible. Nelsen fell into that gap, in lacking visible proof of bat contact to justify the vaccine to providers and insurers, but faced fear from CDC recommendations that her exposure could be fatal.
Have a medical bill or explanation of benefits that seems worthy of examination? Or a health care procedure that turned out to be surprisingly affordable? Email us your story with the subject line “Health Care Calculations” to mdm@jhnewsandguide.com and it may be included, with your permission, in one of our monthly features.
