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Build the Wall

Build the Wall

We live in exciting times. There are forest fires everywhere. The socioeconomic and political blazes are too big to extinguish by conventional diplomatic means. Opinions about our country and its direction are as divergent as they were during the periods of time before the revolutionary and civil wars. The significant difference from previous times is that the country’s population is extraordinarily heterogeneous on specific subjects and remarkably homogeneous on others. On the points that we differ, we could start a war. Is it time to build the wall?

KP is a forty-year-old female who developed all the signs and symptoms of growth hormone deficiency after she slipped and fell on an ice patch, hitting her head on a concrete sidewalk. I have the honor of caring for her over the past ten years, giving me insight into her hormone changes because of the fall.

Blood testing revealed that she had a very low IGF-1 level. The liver converts human growth hormone(HGH) to IGF-1. Published research has proven that low IGF-1 levels are correlated with low human growth hormone. Some authorities believe that if the IGF-1 level is below a specific measure, no additional testing is needed to affirm low human growth hormone. In KP’s case, our office performed a provocation test to confirm or refute that her pituitary gland was deficient in growth hormone secretion. As expected she failed the provocation test, signifying that her growth hormone level was indeed low. Daily supplementation was indicated to reverse the signs and symptoms of growth hormone deficiency. I prescribed HGH replacement therapy. The story gets bizarre from this point forward.

KP’s medical insurance plan uses Express Scripts as their pharmacy benefit management plan (PBM). Express scripts required that KP get a second affirmative diagnosis from an endocrinologist. I sent a letter of introduction to an endocrinologist who accepted KP’s insurance. The endocrinologist evaluated KP and divulged that he had never diagnosed adult-onset growth hormone deficiency in any of his patients. However, he was confident that KP did not have it. KP was insistent that he test her for it. The endocrinologist had to educate himself on the testing for adult-onset growth hormone deficiency, after which he came up with a scheme.

KP underwent another provocation test. The endocrinologist reviewed the results and determined that she needed a second test. The one he performed showed that KP was deficient in human growth hormone. The endocrinologist did not believe the results of her first test so he repeated it. The second result was positive for growth hormone deficiency also. He could not escape the scientific facts, reluctantly agreeing with my diagnosis, he professed that he had never prescribed growth hormone to an adult. He asked KP for the dose I specified so he had some reference. He prescribed the hormone dose identical to my prescription. Subsequently, KP came to the Stone Institute to have her IGF-1 levels regulated. She did well.

Fast forward two years, KP had discontinued her human growth hormone (HGH) for several reasons but desired to get back on the hormone. Her IGF-1 measurement was in the basement. I prescribed HGH, but Express Scripts demanded she have another assessment by another endocrinologist. KP had already seen an endocrinologist who specializes in closed head injuries at the Ohio State University. That endocrinologist confirmed the diagnosis of HGH deficiency, but her determination was not good enough for the Express Scripts’ pharmacist in a review of KP’s case. KP chose another endocrinologist in Memphis to review her case since her first experience was exhausting.

I sent a thorough four-page, introduction letter with all of KP’s testing results to KP’s new endocrinologist, who stated to KP she had never diagnosed adult HGH deficiency in any of her patients. She also believed that growth hormone deficiency did not exist for the most part. KP insisted on being given a prescription for HGH. The new endocrinologist decided to perform a different provocation test than the ones we performed in our office and the ones KP’s previous endocrinologist completed. This new endocrinologist admitted that she had never ordered a provocation test for HGH on any patient in her medical career. She ordered the provocation medication, but the pharmacist would not dispense it because the prescription was for too much medicine. It was double the amount typically used for the standardized provocation test for HGH. KP’s new endocrinologist refused to alter her testing plan. The pharmacist refused to dispense the testing medication. Now we have a Memphian Standoff.

KP has now decided to return to her previous endocrinologist, in hopes that he will again prescribe HGH, even though he told her he would not because she followed-up with me instead of him. He stated he was hesitant to prescribe it because he thought HGH treatment could initiate cancer of some kind down the road.

Express Scripts is happy. The PBM does not have to provide an expensive medication to their member because the endocrinologists in Memphis are ignorant about HGH deficiency, especially in adults who acquire it because of a closed head injury. Furthermore, these endocrinologists are confused on how to proceed. Memphis area endocrinologists typically enjoy caring for thyroid disease and diabetes mellitus type 1 and type 2. If someone is suffering from another hormone-related illness, they will be hard-pressed to find an endocrinologist in Memphis to treat them. KP went to Columbus, Ohio to see an endocrinologist who confirmed her growth hormone deficiency. Express Scripts, as well as the two Memphis area endocrinologists, did not accept the diagnosis from the Columbus, Ohio expert. The FDA does not mandate that HGH be prescribed only by an endocrinologist, but Express Scripts has instituted the condition for reimbursement of the expense of HGH to its members. What about Express Scripts?

Express Scripts has been named the worst company to work for in the United States, 24/7 Wall St. compiled the rankings using data from career website Glassdoor, which gathers ratings on more than 400,000 companies globally. The list identified the 12 US companies with the lowest employee ratings, ranging from 2.3 to 2.7 out of a possible 5 points. The average company rating on Glassdoor is 3.2. With the worst average rating at 2.3, Express Scripts had 1100 employee reviews on Glassdoor, and the CEO approval rating was 28% among them, according to 24/7 Wall St. To make matters worse, Cigna is purchasing Express Scripts for sixty-seven billion dollars. After the merger, no one will get their medications unless physicians and patients are willing to climb over enormous obstacles for prior approval. It is all about cost savings by denial of care. Deny, Deny, Deny.

I wonder what would happen if Mr. Tim Wentworth, the CEO of Express Scripts needed HGH therapy. Would the worst company in the United States make an exception for their boss?  Would he be forced to see multiple physicians with varying degrees of expertise, take numerous provocation tests with similar results and be told that he just can’t seem to make the criteria to be eligible for reimbursement of the cost of HGH therapy? I seriously doubt it. He probably would stockpile HGH at each member’s expense, just in case the zombie apocalypse occurred while he was running the company.

Or maybe he would buy it from a Mexican pharmacy on the sly.  That is before we build the wall.

Doc

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