Rabies Post-bite Treatment

firebus's picture

Rationalization

It seems like everyone in Buenos Aires who owns a dog and lives in an apartment has a dog walker to take their dogs out every day. You constantly see dog walkers in the street with 10 or 20 dogs, all on separate leashes, walking around perfectly happily. Many more dogs that would be considered safe or responsibile for dog walkers in the US.

There are also a number of amazing dog parks in BsAs. You'll see tens and tens of dogs in one area of a park - some of them roaming free, some staked out on leashes. It always seems like a couple of people are watching over 100 dogs.

Putting 2 and 2 together, it's easy to theorize that the dog walkers work in pairs, ferrying dogs to the park in the morning, and home in the evening. In the middle of the day, the two partners hang out in the park with their pack.

On our first day in BsAs we were walking through a park and I approached one of the walkers to try and confirm my theory. One of the staked-out dogs wasn't comfortable with a weird gringo hollering at his friend and gave me a warning bite in my lower leg. In the language of the CDC rabies exposure guidelines this was a provoked attack (Which is a good thing! A rabid dog will attack unprovoked, going out of their way to mess with you).

Since it seemed like a kind of sketchy situation (even though the guy seemed perfectly happy to talk to me, and later regretful that I was such a moron), I decided to walk away from it. Later I realized that the bite had (barely) broken the skin, making two shallow holes in my shin and calf. There was no apparent damage to my heavy jeans, so it's most likely that there was no contact between the dog's saliva and my blood.

Later I did some research and discovered that BsAs has a very responsible rabies vaccine program for dogs, and that there are no recent cases of dog to human transmission of rabies. Since I didn't want to learn about the Argentine medical system on my vacation, and since rabies takes at least 10 days to incubate (and tends to take longer the farther away the bite is from the brain), I rationalized that I could call my doctor when I got home and treat it then if I had to.

By the time I got home a week later, rabies exposure seemed like such a negligible possibility that I decided not to investigate - knowing that if I did I would almost certainly be advised to get treatment since the result of a wrong answer is almost-certain death. But later that week, I started getting headaches (one of the symptoms of rabies), and I became anxious enough that I was polling myself for new symptoms a few times a day.

Since rabies can take years to present, and I didn't want to spend years worrying about my possible sudden and stupid demise, and because I watched the videos in that PLoS Medicine article, I decided to 'fess up and call my PA. My PA advised me to call the state health department. The state health department advised me to call the local health department. The local health department, as expected, advised post-bite treatment, and I decided to do it.

Economics

Post-rabies treatment consists of 4 sets of shots. The first is a rabies vaccine and some amount of rabies immune globulin (based on weight - I needed about 2000 units). The next 3 are rabies boosters. Rabies treatment is generally given in the E.R., although I had the option to go to the health department's vaccine clinic as well. I called my insurance company to see how much I would have to pay.

I have a $1,000 deductible per calendar year, and I have about $940 remaining this year. After the deductible is exhausted, in-network E.R. visits are covered in full after a $150 co-pay. Out-of-network expenses are generally covered at 80%.

Hospital

My insurance was willing to cover vists 2-4 in full (I'm not exactly sure why - it has something to do with the fact that the extra visits are required by the treatment, and are not the result of my irresponsible choices), and they advised me that I should be able to get the co-payments refunded by the hospital after the claims were handled.

According to the billing department at the hospital, each rabies shot costs $488. I couldn't get an estimate for the immune globulin, but let's assume it's twice the amount of a single shot (you'll see why in the next section).

Full list-price of the treatment is around $3,000, although presumably the insurance company doesn't pay list price. My best-case scenario out of pocket expense would be $940. The Murphy's Law scenario, if I couldn't get the co-payments refunded, would be $1,380.

Clinic

The published prices for the clinic are $49 per visit, $225 per rabies shot, and $455 for the immune globulin (at $65 per 300 unit vial), for a full list price of $1,553. I would have to pay up-front and then submit claims myself to the insurance company.

My best-case scenario - getting an 80% refund for costs after the deductible - would be $1,062.52. The Murphy's Law scenario - if I couldn't get the insurance to pay the claims at all - would be the full $1,553.

Since both best-case and Murphy's Law scenarios were better at the E.R., I chose that option.

Conclusion

If I was unable to have all the treatments done this year (the treatments take place over a 15-day period), my deductible would reset making the clinic the much better option. I think that even assuming the insurance company is getting a discount off list price from the hospital, the clinic is probably the cheaper option for them, but my interests are not aligned with theirs in this case.

The E.R. also involves more (and less predictable) waits for me, although I can work in the waiting room so it's not a total loss. Finally I'm not sure if the estimate I got from the hospital includes labor - I know the last time I went to the E.R. there were separate charges from the pharmacy, from the doctor on duty, etc. etc. This shouldn't effect my out-of-pocket, but might might effect the equation for the insurance company.

As I biked over to the E.R. for my first treatment, I realized that my headaches were due to caffeine withdrawal (every now and then I take a couple of weeks off). Facepalm. Having done the research, and knowing that I was likely to scare myself again the next time I had any illness, it seemed like a good idea to go through with it anyway.


Powered by Drupal - Design by Artinet - Amazon Affiliate