Financial analysis of acetaminophen suicide in a teen girl.
At the boyfriend's apartment, the door was open so she walked in unannounced. Regrettably, she found her boyfriend having sex with another girl from her dorm! She was totally shocked and ran back to her dorm room crying. It was dark outside, her mood and intent darker ... She wanted to hurt him, make him feel sorry ... make him feel really sorry. "Why? ..." as she opened the economy-sized bottle of Extra Strength Tylenol[TM] (acetaminophen 500 mg) and swallowed the first handful ... "How could you? ..." as she ingested the second handful. She cried herself to sleep, trying to forget everything ...
Tammy is a Hazel State University student. As a full time student, she pays a health service fee that allows her to access the student health center and the counseling center. Tammy would have had the opportunity to go to the counseling center for assistance after her initial thoughts of depression. The counseling center professionals (trained counselors, and psychologists) would provide a session of psychotherapy lasting about 50 minutes. After they finished the meeting, they may have referred her to the student health center to rule out physiologic causes. Necessary labs would be drawn (thyroid studies, chemistry panel, complete blood count) and necessary psychotherapeutics would be given. Laboratory work is covered under Tammy's health service fee. Caught early, a plan for Tammy's depressed thinking would be made, she might be encouraged to speak with her parents, and a call to her dormitory resident might alert him/her to offer extra support. At this point Tammy would probably not be suicidal, and antidepressant therapy may be initiated. The cost of various antidepressants/benzodiazepine is outlined below. Follow-up therapy sessions at the Hazel State Counseling center would be provided at no additional cost. Table 1 offers fees for this level of prevention and primary care, which amount to about $144.
Tammy's Suicide Attempt
... It was daylight when Tammy T opened her eyes. She felt nauseated and her stomach hurt. She looked at the bottle of Tylenol and remembered. Her emotions surfaced again. She began to cry, picked up her cell phone and called her boyfriend. Weeping she tells him what he made her do... He calls 911. The intake person at the ambulance company compiles this information:
Subject: TT, 18 year old Caucasian female
Weight: 121 lbs (55kg)
Type: Intentional Ingestion.
Substance: Extra Strength Acetaminophen (Tylenol)
Contains: Acetaminophen 500 mg per tablet
Maximum recommended dose: 4 gm/day, not to exceed 1 gm/dose (average 1 gram q 6 hrs)
Goal of Ambulance Personnel
The ambulance crew must stabilize immediate life-threatening conditions and initiate supportive care. They must gather all information about the overdose, such as attempting to determine time of ingestion and any vomiting since. They must transport all suspected medicine/container(s) with the patient and report any other pertinent findings from the scene. Ambulance personnel find 178 tablets remaining in bottle.
Estimated Ingestion dose: "Two handfuls." Original bottle count #500 (economy-savings size).
Maximum recommended use = 8 tablets or 4 grams/day. This is the 4th week of the Fall semester. Therefore, it is possible that if Tammy used a recommended daily dose every day of the semester 224 tablets would be out of the bottle. (Formula: 7 days x 4 wks = 28 days x 8 tabs = 224 tabs.) That potentially would leave 226 tablets in the bottle prior to the toxic ingestion (500-224=226). There are 178 tablets left in the bottle when the ambulance nurses arrive. Thus, potentially Tammy has ingested 48 tablets in an 8-hour period (226 - 178 = 48 tabs x 500 mg = 24 grams estimated ingestion in an 8-hour period). This is determined to be potentially critical by the ambulance nurse.
Symptoms of an acetaminophen (APAP) overdose are nausea, vomiting, diarrhea, abdominal pain, sweating, seizures, confusion, and an irregular heartbeat. Acetaminophen is the most widely used pharmaceutical analgesic and antipyretic agent in the United States and the world; it is contained in more than 100 products. As such, acetaminophen is one of the most common pharmaceuticals associated with both intentional and accidental poisoning. The antidote to this poisoning is Acetylcysteine (Mucomyst)
In the United States, acetaminophen is one of the most common pharmaceutical agents involved in overdose, as reported to the American Association of Poison Control Centers (Farrell, 2006). APAP toxicity is the most common cause of hepatic failure requiring liver transplantation in Great Britain and the second most common cause of liver failure requiring transplantation in the United States.
Assessment: Tammy T is very emotional and a little confused; she admits to ingesting a couple of handfuls of Tylenol but can't remember the time, only that it was dark. Her airway is patent and her breathing effortless, even mixed with her weeping. Radial pulses are strong but noted to be irregular; Blood pressure is within normal range; she complains of abdominal pains "all over" and is nauseated; she denies any vomiting since ingestion. Her skin has good color but she is slightly diaphoretic. Previous medical history is insignificant. Her routine medications are oral contraceptives. She denies allergies. Her last menstrual period is unknown.
1. Basic psychiatric support; situational reassurance; inform according to cooperation level; set limits as needed for safety of patient and crew during transport to hospital. 2. Oxygen (nasal cannula) low flow.
3. Electrocardiogram (ECG) monitoring.
4. Pulse Oximetry.
5. IV Normal Saline with blood draw.
6. Blood Glucose determination via glucometry
7. Dextrose 50 W 25 grams prn low blood sugar (<60 with altered level of consciousness=ALOC)
8. Narcan 2 mg IV prn ALOC.
9. Transport to hospital emergency room, estimated at 2.0 miles.
Cost analysis of ambulance crew assessment and transport is found in Table 2. Transporting Tammy to the Emergency Room cost $1,535.
Emergency Room Care
Tammy's arrival is expected from the ambulance radio report. She is moved onto a hospital gurney in a private room; a bedside report is given by the medic; the receiving ER nurse begins care immediately. Soon after her arrival the physician begins a focused history and physical. At this point, Tammy's overdose journey begins to accelerate ...
Treatment: (summary: Toxic ingestion > 8 hours previous to admission)
1. Reception vital signs, supportive care with continuous monitoring 1:1 care (1 hr).
2. Maintain IV estimate delivering 2-3 liters normal saline while in Emergency Room.
3. Labs: Complete blood count, Comp-12, serum HCG, acetaminophen level, ASA level, PT/PTT; type & cross match/blood band; urinalysis, urine toxicology screen, serum ethanol.
4. 12 lead EKG.
* CT brain without contrast indicated prn ALOC.
* Zofran prn nausea/vomiting.
* Additional antiemetics indicated prn.
* Activated charcoal po or by nasogastric (NGT) tube
* Acetylcysteine indicated prn serum acetaminophen level/ingestion time graph.
* N-acetylcysteine is given as a loading dose of 140 mg/kg in 200 mL of 5% D/W given over 15 min, followed by 70 mg/kg IVPB over 15-20 min q4hr x 17 doses.
* Foley catheter indicated prn.
* NGT indicated prn.
* IV start indicated prn.
8. Social Services request to establish liaison between patient and parents; friends, and university inquirers.
9. Typically, assessment from mobile crisis team from County Mental Health would be requested to complete psychological evaluation after medical clearance.
Too Much Tylenol
Tammy (TT) ingested too much Tylenol too long before onset of antidotal treatment ... The estimated emergency room treatment/observation time is 2-4 hours. Tammy's serum acetaminophen level was extremely high; her serum value was plotted on the Rumack-Matthew nomogram (see Figure 1)--the toxic value guided further care. Other lab values were abnormal, including her liver enzymes. Maximum therapy was initiated to avoid acute liver failure, including activated charcoal and N-acetylcysteine (NAC) administration. Even though TT did not appear critically ill and her vital signs were all within normal limits, arrangements were made for admission to the ICU. The ER physician and hospitalist feared fulminant hepatic failure. They discussed TT's case with a local gastroenterologist, who suggested a consult with the hepatologist and transplant surgeon at the local Tertiary Medical Center (example of such a center: http://www.cpmc.org/advanced/liver/) in San Francisco. Meanwhile, TT is prepared for transport to ICU to continue her journey ... The total costs of Tammy's emergency room visit was $8,912 and can be found in Tables 3a and 3b.
[FIGURE 1 OMITTED]
ICU day #1. After Tammy's (TT) evaluation by the hospitalist in the emergency room, TT is admitted to ICU. Orders are received for serial assessment of acetaminophen levels, routine ICU observation and nursing care, oxygen at 3 L per nasal cannula, an IV infusion of D5-1/2NS at 60 mL/hr, Mucomyst 385 mg q4h x 17 doses, and a formal gastroenterology consultation. California Poison Control is also notified of the situation by phone, and is following the case.
TT continues to be awake, alert, tearful at times, with stable vitals and normal assessment findings. A social worker talks with TT, and TT admits to binge-drinking for several weeks in college before her overdose. The gastroenterologist formally consults and orders routine labs in the morning. Throughout her first 24 hours in ICU, TT continues to complain of generalized diffuse abdominal pain with anorexia and nausea, and is medicated with Zofran prn. Her serum acetaminophen levels continue to rise through the night.
ICU day #2. TT's morning lab values are worrisome, and indicate higher than normal BUN, creatinine, ammonia, and bilirubin levels, an extremely high AST level (20,000), an INR of 2.3, and her acetaminophen level has continued to rise. The hospitalist is increasingly concerned about TT upon his morning rounds, and orders a Vitamin K injection for her coagulopathy and Lactulose 30 mL for her high ammonia. Poison Control is also updated via phone.
Upon the afternoon evaluation by the gastroenterologist, TT is increasingly lethargic, complains of increasing abdominal discomfort, and is seen vomiting small amounts of frank blood. A Protonix infusion is started, labs are checked more frequently, TT is made NPO, and preliminary arrangements are made for a possible transfer to a tertiary facility. Her parents arrive and stay at the bedside.
ICU day #3. TT's neurological status deteriorates to coma after midnight, her skin is jaundiced, ascites is noted, and she is incontinent of guiac positive stool. Serial labs indicate anemia and thrombocytopenia, increasing BUN and creatinine (now indicating acute renal failure), increasing coagulopathy with an INR of 4.3, and worsening ammonia levels. A foley is inserted, 02 is changed to mask, and a central venous line is inserted for central venous pressure monitoring and blood product administration. Lactulose enemas are given, a nasogastric tube is inserted for mucomyst administration, and the Protonix drip is continued.
The gastroenterologist, upon morning rounds, advises the family that TT's condition is critical. He states that her acetaminophen overdose, along with her recent binge drinking, has caused fulminant hepatic failure; since there is no definitive therapy to regenerate her liver or reverse injury, he recommends immediate transfer to a tertiary facility for a liver transplant.
The costs for 3 days intensive care stay in the local community hospital are $25,250. Tables 3a and 3b contain a breakdown of the costs.
Tertiary Cost. TT's journey to San Francisco begins... Destination: Tertiary Medical Center liver transplant organization. Tammy leaves the hospital ICU; the flight crew assumes TT's care. Any treatment she needs in the next few hours can be done during transport until she reaches her destination. The helicopter flight to San Francisco International is uneventful. The ICU team did a good job stabilizing her before she left. An ambulance ride from the airport to Tertiary Pacific takes about half an hour. The flight crew works with the ambulance personnel to secure her safe transport. Bedside report is given and TT is now in the care of Tertiary Pacific's liver transplant team. The flight and ground ambulance costs to move TT were $41,121 and are presented in Table 4.
Liver transplant. An attempt is made to save Tammy's life though a liver transplant and anti rejection medications. The cost of a liver transplant is laced with many variables that make it complicated to quantify the cost of treatment. Variations such as type of liver disease, age, health prior to liver transplant, complications after surgery, type of medical insurance the person carries, how long it will take to acquire a liver, distance of where the liver is harvested, hospital charges, and physicians and surgeon charges vary widely.
According to a local hospital liver transplant finance web page, "occasionally, patients may prefer to pay out of pocket for all transplantation costs," but a local admissions and financial coordinator stated in her 8 years of experience no case has been conducted on a self-pay basis. The National Transplant Assistance Fund supports multiple fundraising opportunities to help families in need of a transplant.
Each situation is handled on a case-by-case basis and must undergo an extensive evaluation process with a financial counselor to review specific insurance coverage issues related to the transplant. Blue Cross policy requires prior coverage to exist before the overdose occurred and another affiliate noted regardless of coverage specifics $180,000 is the maximum amount paid in 2006 for a liver transplant and treatment. Medi-Cal insurance has a maximum allowable payment for each procedure and will only grant payment to an approved Medi-Cal facility. According to the Medi-Cal beneficiary assistant, the maximum allowable amounts Medi-Cal will pay for a liver transplant is not available for public information. If the patient had Medicare, it would be considered the primary insurance and cover 80% of charges and Medi-Cal would pay the remaining 20% of charged services. Unfortunately TT does not qualify for Medicare.
The Center for Health Statistics reports patient discharge data indicating that total charges for liver transplantations exceeded $1.2 billion during the 1999-2003 time period, with an average hospital charge of $385,434. The majority of these charges (61%) were expected to be paid by private insurance, followed by Medi-Cal (18%) and Medicare (16%). The remaining 15% of hospital charges for liver transplantations were expected to be paid by individual payers, or by other government and nongovernmental sources.
Sood and Jones (2006) report drug-related hepatotoxicity is the leading cause of acute liver failure (ALF) in the United States. The outcome of ALF is related to the etiology, the degree of encephalopathy, and related complications. Unfortunately, despite aggressive treatment, many patients die from fulminant hepatic failure (FHF). Prior to orthotopic liver transplantation (OLT) for FHF, the mortality rate was generally greater than 80%. Approximately 6% of OLTs performed in the United States are for FHF. However, with improved intensive care, the prognosis is much better now than in the past, with some series reporting approximately a survival rate of 60%.
The costs of the liver transplant surgery is $353,350 and anti rejection drugs are $6,835. These are listed on Tables 5 and 6.
Hospice & Palliative Prevention Cost. Unfortunately, Tammy's liver transplant is not taking hold. TT lies semi-conscious after her liver transplant rejection in Tertiary Medical Center. Her family remains in shock but no longer in denial. They are being comforted around the clock by staff and pastoral services. Tammy's mortality is now clearly visible. The family was told and has accepted that no other curative efforts are available. Home hospice care is suggested as an alternative to remaining in the hospital. TT's parents want their only child to be at home when she dies. TT's attending doctor writes the order for hospice services. A hospice nurse visits TT and her parents. Tammy's needs are assessed and resources determined before discharge. Necessary equipment is ordered. Appropriate arrangements are made for a hospital bed to be delivered with the other equipment before TT arrives home. The hospice nurse also orders another valuable benefit; a physical therapist will make a home visit to demonstrate/educate TT's parents in proper turning and lifting.
TT is transported home by ambulance the next day. She is somnolent and unable to care for even her basic needs. Social Service is deeply involved with her parents. A lot of other services linked to hospice assist the parents who are trying to cope with their unfolding heartbreak. Pain and hydration concerns are addressed; TT's comfort measures are met with dignity and respect. The scenario plays out with kindness, compassion, and selflessness from everyone involved. TT's eyes close 3 days after arriving home never to open again ...
[FIGURE 2 OMITTED]
Hospice cost information. Hospice care is individualized. It is a multidisciplinary approach usually orchestrated by the hospice nurse who retrieves primary physician orders as indicated. The hospice nurse is self-directed and is not limited to a minimum or maximum time allotment per visit. The closer a client approaches his/her imminent death, the more time the nurse may stay. Each patient's situation is different. The daily rate covers all nursing time. All equipment such as ambulatory aides, hospital bed, oxygen, dressing supplies, or anything else called for, is covered in the daily rate charge. Home health aides, social services, physical therapist, and dietician are also included in the price/day. There is no additional charge for massage, aroma therapy, and other forms of alternative therapy for pain control or maximizing function and coherence. Lists of local volunteers are readily available for family assistance in care, or even a needed "mental health" break. If around-the-clock care is determined and family resources have been exhausted, an outside agency could be hired at an out-of-pocket expense. This is rarely needed as most hospice agencies have large numbers of individuals who volunteer their services, day or night. The costs for hospice care were $531 and are delineated on Table 7.
This case study is based upon real similar cases of the nurse practitioner authors who live and work in the emergency room in a university town. The assessment, prevention and treatment of teen depression is essential. The purpose of this article was to show not only the human related trajectory of unidentified and untreated depression, but to delineate the fiscal implications as well. Where Tammy T's identification and treatment of situational depression would have cost $144, her untreated depression and suicide attempt would have cost as much as $407,677 (see Table 8). Figure 2 displays these differences. There are immense costs contained in our present tertiary-based healthcare system. These authors support the American Nurses Association's focus on prevention and hope to see in their lifetimes a universal coverage for all Americans.
The authors want to make known they attempted to reflect as much accuracy in the cost of services associated with Tammy T's "worst case scenario" acute toxic acetaminophen ingestion. Actual billing and coding for services rendered could vary. The authors recorded dollar amounts obtained from many phone interviews with their respective hospital billing department personnel. Billing department personnel were asked to give dollar-amount for the level of care Tammy T scenario required as she traveled through the system; then expected collection of billed services dependent on her healthcare coverage. The 2006 dollar amounts listed in the article were used to compare costs associated with a successful suicidal gesture taken by a desperate teen. They are not intended to reflect actual costs.
The local medical center where charges were obtained has a program that operates out of the Social Services department with a strong link to the billing department. A specific bill for services rendered can be written-off entirely for individuals that can prove financial hardship through scrutiny and verification of income and financial liabilities. The verification process is coordinated by the individual's case manager. After the successful completion of this step, a letter of hardship is written by the individual and is submitted with copies of income/liability statements for approval. For the fiscal year 2006, this small community hospital wrote-off $5,439,824 in charges. It is possible that some of TT's uncompensated bills would have been absorbed by the hospital.
This article discusses a sensitive issue that is complex and provocative, and will undoubtedly stimulate a variety of opinions. What do you think? Post your comments about this topic on the Pediatric Nursing Web site and read what others have to say as well. Visit our homepage at www.pediatricnursing.nel and click on "Discussions."
The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of Pediatric Nursing Journal or the publisher.
Anita J. Catlin, DNSc, FNP, FAAN
Pediatric Ethics, Issues, & Commentary focuses on exploring the interface between ethics and issues in clinical practice. If you have suggested topics or cases for consideration in the column, please contact Anita J. Catlin, DNSc, FNP, FAAN, at email@example.com
Acknowledgement: Authors would like to acknowledge Dr. Anita Catlin for assistance in manuscript preparation.
American Nurses Association. (1997). ANA position statements. Promotion and disease prevention. Retrieved 08/02/2007, from http://www.nursingworld.org/database
Farrell, S.E. (2006). Toxicity, acetaminophen. Retrieved November 1, 2006, from http://www.emedicine.com/emerg/topic819.htm
California Pacific Health Care. (2006). Sutter Health Care affiliate financial matters: Liver transplant costs. Retrieved December 5, 2006 from http://www.cpmc.org/advanced/liver/patients/topics/ finance.html#Transplantation%20Costs
California State University, Chico. (2006). Personal and phone interviews with Student Health Center N.P.; Counseling Center manager re: Mental Health Services. Retrieved December 1, 2006.
Merck Manual. (2005). Merck manual's online medical library, acetaminophen poisoning. Retrieved November 2, 2006, from http://www.merck.com/mmpe/sec21/ch326/ch326c.htmI#BGBHFGBA
National Transplant Assistance Fund. Retrieved December 2, 2006 from www.transplantfund.org
Sood, G. K., & Jones, B.A., (2006). Acute liver failure. Retrieved December 2, 2006 from http://www.emedicine.com/med/ topic990.htm
Sutocly, J., & Balasubramanian, S. (2005). End stage liver disease (ESLD): Morbidity, mortality and transplantation in California 1999-2003. Center for Health Statistics. Retrieved December 5, 2006 from http://www.dhs.ca.gov/hisp/chs/OHIR/reports/
Michael Ferris, MSN, RN, FNP, is Flight Nurse, Enloe Medical Center Chico. CA.
Matthew Haskett, BSN, RN, CCRN, is Masters in Nursing Student, Sonoma State University, Rohnert Park, CA.
Stephanie Pilkington. MSN, RN, FNP, is Nurse Practitioner, Northstate Cardiology Consultants, Chico. CA.
Marty Williams, MSN, RN, FNP, is a Family Nurse Practitioner, Enloe Medical Center, Chico, CA.
Table 1. Primary Care Health Center Fee $103.00 (Provides coverage for the entire school year) Antidepressant Therapy $37.50 Lexapro (or similar drug) Starting dose of 10mg q. day The student pharmacy sells 20 mg tablets, which are scored and can be halved. 15 tablets (1 month supply) Antianxiety Therapy $3.00 Ativan (generic lorazepam) 0.5 mg PO q. 6 hours prn anxiety 15 tabs 1 mg each Total $143.00 Table 2. Cost Analysis Of Ambulance Crew Assessment And Transport Out of Pocket Cost Blue Cross MediCal/CMSP $1,535.00 Total. $975.75 Total. $125.30 Total. $1,471 base Pays 65% services Pays 118.20 base ALS + $32/mile rendered ALS treatment and transport, $3.55/mile. Table 3a. Emergency Room Cost Cost in U.S. Dollars Emergency Room Level 5 1,819 Observation (4x) 360 Infusion Therapy 1st hour 446 Infusion Therapy add hour (3x) 462 Emergency Room IV Injection 103 ERMD Fee Compre--HI COMP 275 EKG Tracing Only (ED Only) 193 EKG Physician Interp & Report 70 Sub Total $3,728 Imaging Chest X-Ray 214 CAT Scan Brain w/o contrast 1,646 Sub Total $1,860 Social Services 0 Mobile Crisis Evaluation 0 EMERGENCY ROOM TOTAL $8,912 Cost in U.S. Labs Dollars CBC w/auto cliff 123 PT 55 PTT 169 HCG, Serum Qual 186 Comprehensive 12 Chem 209 Acetaminophen 247 Aspirin 212 Rh Typing 33 Crossmatch 94 Urine Tox Screen 240 Blood Alcohol 125 Total lab costs $1,693 Allowed ER Supplies IV Fluid NS 1000cc (3) $240 Meds Mucomyst 6gms/30ml (12) 1,356 Zofran (1) 15 Activated Charcoal (1) 20 Pharmacy total $1,391 Table 3b. ICU Charges Cost in U.S. Dollars Day #1 ICU bed / nursing care & supplies--24 hours $3,915 Hospitalist consult, day 1 $811 Gastroenterology consult $945 Acetaminophen level x 4 $102.32 Mucomyst x 5 doses $94.95 Zofran x 3 doses $92.80 Total $5,961.07 Day #2 CBC x 3 $36.66 CMP x 3 $59.88 PT x 3 $22.26 PTT x 3 $33.99 Magnesium $12.65 Ammonia $27.51 Vitamin K $23.74 Lactulose 30mL x 4 $20.01 Mucomyst x 6 $113.94 Protonix bolus and infusion $118.87 ICU bed / nursing care & supplies--24 hours $3,915 Hospitalist care, 1 day $240 Gastroenterology consult, day 2 $314 Acetaminophen level x 4 $102.32 Zofran x 3 doses $92.80 Total $7,857.09 Day #3 CBC x 2 $24.44 CMP x 2 $39.92 PT x 2 $14.84 PTT x 2 $22.66 Magnesium $12.65 Ammonia $27.51 Vitamin K $23.74 Lactulose enema $20.01 Mucomyst x 3 $113.94 Protonix infusion $65.42 ICU bed / nursing care & supplies--12 hours $1,958 Hospitalist care/critical care time $645 Gastroenterology consult, day 3 $314 Acetaminophen level x 2 $51.16 Blood products $8,098.00 Total $11,431.29 Total Secondary Care Cost Out of Pocket Cost Blue Cross Medical/CMSP $25,250 $6,945 $6,060 (Discounts 2006 contract = Pays 24% of described at end $2,315/day ICU billed services of article apply.) services rendered rendered. Table 4. Ground and Air Transportation Costs Out of Pocket Blue Cross MediCal/CMSP Ground Ambulance $6,271 $4,076 $651 from EMC to CPMC paramedic/BLS Air Ambulance to SF $34,850 nurse/ $22,653 ~$8,500 and Ground from SF paramedic to CPMC Table 5. Estimated Costs of Liver Transplant Service Service Out of Pocket Blue Cross Medical/CMSP Transplant Surgery * Pre-Eval/Testing 314,600 204,490 75,504 * Organ recovery * Recovery/In-pt * Extensive Lab tests Anesthesia 1,550 1,007 379 F/U visits x 1yr 21,900 14,235 5,256 Medications/mo 10,000 6,000 2,400 Parents Lodging/mo 2,000 n/a n/a Pt Lodging s/p DC Must be w/in 30mi x 3,000 n/a n/a 1 month Physical Therapy 300 200 50 Total $353,350 $225,932 $83,589 Table 6. Organ Transplant Medications (anti-rejection and other) Neoral or Prograf $1,500/month Cellcept $800/month Septra $7.50/month Prednisone $5.50/month Proton pump inhibitor $160/month Nystatin $172/month Valcyte $2,000/month HBIG 5 cc vial $2,190/month Total $6835 Table 7. Hospice Cost Analysis Out of Pocket Cost Blue Cross MediCal/CMS $531 $363 ($121/day) $411 ($177/day) (Contracted ($137/day) Rate 2006) Table 8. Costs Suicide Toxic Tylenol Ingestion 18-year-old Female Prevention Out of Pocket Blue Cross MediCal/CMSP Preventive 143 n/a n/a Primary 8,912 2,318 2,139 Secondary 25,250 6,945 6,060 Tertiary 330,185 229,932 86,589 Hospice 531 363 411 Transport costs Local Ambulance 1,535 Ground Ambulance 6,271 4,076 651 Air Ambulance 34,850 22,653 8,500 Totals $407,677 $265,924 $104,350
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|Title Annotation:||Pediatric Ethics, Issues & Commentary|
|Author:||Ferris, Michael; Hasket, Matthew; Pilkington, Stephanie; Williams, Marty|
|Date:||Sep 1, 2007|
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