CONTACTS 

SUBJECTS
Cellulitis Lymphedema Recovered Millie Released from Hospital Emerge

3003 -
3003 -    ..
3004 - Summary/Objective
3005 -
300501 - Follow up ref SDS 13 0000. ref SDS 12 0000.
300502 -
300503 -
300504 -
300505 -
300506 -
300507 -
300509 -  ..
3006 -
3007 -
3008 - Progress
3009 -
300901 - Millie is having breakfast.  She hasn't talked to anyone yet about the
300902 - time for release.
300904 -  ..
300905 - She thinks she will be ready to go OA 1000.
300907 -  ..
300908 - Pam called this morning.
300910 -  ..
300911 - Primary care physician examined Millie this morning.  Cellulitis
300912 - inflammation and swelled left arm appear completely cleared.
300913 -
300914 -
300916 -  ..
300917 - Neupogen Prescribed for 1 Treatment Precaution Maintain Blood Counts
300918 -
300919 - Follow up ref SDS 13 9U65.
300920 -
300921 - The doctor advised that Millie's blood counts are rising after
300922 - starting treatment with Neupogen yesterday. ref SDS 13 9U65  He wants
300923 - Millie to take Neupogen one more day at home as a precaution for blood
300924 - counts to fully recover by 061110 for her starting her next cycle of
300925 - chemotherapy.
300926 -
300927 -     [...below, Kaiser Pharmacy quotes cost for 1 shot of Neupogen,
300928 -     plus cost of syrenge is over $400; and the patient must carefully
300929 -     figure out how to get the medication into a syrenge. ref SDS 0
300930 -     JS4U
300932 -  ..
300933 - Doctor Kim also examined Millie.  He feels her left arm has fully
300934 - recovered from cellulitus, but has prescribed antibiotics to continue
300935 - with pills for the next 10 days at home.
300936 -
300937 -     [On 061110 cellulitus treatments end; examination indicates
300938 -     patient recovered. ref SDS 14 MW8J
300940 -      ..
300941 -     [On 061112 cellulitus relapse, call Kaiser to get prescription
300942 -     ordered to continue treatments. ref SDS 15 FP5O
300944 -      ..
300945 -     [On 061113 primary care physician notified of cellulitus relapse,
300946 -     and medication prescription renewed, and symptoms seem under
300947 -     control, ref SDS 16 5K5G; doctor responds that further examination
300948 -     not required unless condition worsens. ref SDS 16 MN8P
300950 -      ..
300951 -     [On 061203 patient relapses, ref SDS 18 MF9H, very slight
300952 -     temperature; notify primary care physician. ref SDS 18 5X3N
300953 -
300954 -
300955 -
300956 -
300958 -  ..
3010 -
3011 -
3012 - 1013
3013 -
301301 - Arrived at the hospital.  Millie was dressed.  Amy was presenting
301302 - hospital documentation, including medication instructions.
301304 -  ..
301305 - Amy explained that the hospital pharmacy wants Millie to skip Coumadin
301306 - treatment tonight, because her INR has jumped to 3.4.
301308 -  ..
301309 - Millie will corrdinate with Gloria at the Kaiser Coagulation Treatment
301310 - Clinic in Martinez for Coumadin treatments going forward.
301312 -  ..
301313 - Another attendant came with payment instruments.  The bill is about
301314 - $1,500 for 5 days in the hospital, at $300 per day.  Millie paid by
301315 - credit card.
301317 -  ..
301318 - Left the 3rd floor.
301320 -  ..
301321 - Went to the Discharge pharmacy at the entrance to the hospital.
301323 -  ..
301324 - Millie requested the drugs orgered by the primary care physician and
301325 - Doctor Kim....
301327 -  ..
301328 - The pharmacist said that 10 days of antibiotics prescribed by Doctor
301329 - Kim cost $10.
301330 -
301332 -  ..
301333 - Neupogen Cost $450 for 1 Treatment Patient Draws Medication from Vial
301334 -
301335 - The pharmacist advised that the 1-shot of Neupogen prescribed by the
301336 - primary care physician today, per above, ref SDS 0 OU5J, will cost
301337 - Millie over $400 with the Membership discount.
301339 -  ..
301340 - The pharmacist further advised that Millie will need a needle to draw
301341 - the Neupogen from the vial.  This will cost an additional $40 or so to
301342 - buy the equipment.
301344 -  ..
301345 - Millie asked about cost containment and efficient care.  Yesterday, on
301346 - 061031 the doctor prescribed Neupogen.  This work was accomplished at
301347 - no extra cost, and the work was performed by a trained professional,
301348 - so that Millie did not require training and experience for
301349 - self-injection. ref SDS 13 9U65  Today, the doctor again prescribed
301350 - the same Neupogen regimen and the cost is over $400 and requires the
301351 - patient to perform professional work without training, all for a
301352 - single treatment.  What is the justification for dramatic change in
301353 - delivery of care?  What alternatives were considered to meet
301354 - requirements for cost containment?   When was excessive charges
301355 - disclosed to the patient for determination of cost effective care?
301356 - Why not get the same treatment given yesterday in the hospital to the
301357 - patient again today while still in the hospital?
301359 -  ..
301360 - The Pharmacist said he can only go by what is in the computer.
301361 -
301362 -        [...below, pharmacy eventually got permission to charge $40 for
301363 -        pre-configured Neupogen treatment. ref SDS 0 JS81
301365 -  ..
301366 - Millie asked about orientation and training to draw the fluid from the
301367 - vial for a treatment in the correct amount.  She explained that past
301368 - treatments have come pre-configured with the correct amount already
301369 - loaded in a throw-away syrenge.
301371 -  ..
301372 - Millie said that $450+ is expensive for about an ounce medication
301373 - required for 1 shot.
301378 -
301379 -     [On 070131 similar experience avoiding $60 charge to send CT test
301380 -     files to UCSF for treatment. ref SDS 19 KM80
301382 -  ..
301383 - Millie asked why 10-day treatment costs $10, per above, ref SDS 0
301384 - LL38, and 1 day treatment costs $450?
301386 -  ..
301387 - The pharmacist said again there is nothing he can do, because they
301388 - have to go by what is in the computer.  He feels the doctor must have
301389 - entered the order differently in the computer.  At this point a
301390 - supervisor joined the discussion, and confirmed that the amount
301391 - charged for medications is out of their hands.
301393 -  ..
301394 - Millie related past practice with self-administered Neupogen.  The
301395 - treatment was provided in a syrenge ready for injection.  For example,
301396 - on 020520 the doctor prescribed a 5-day treatment, and everything was
301397 - pre-configured.  The patient did not have to do anything except make
301398 - the injection. ref SDS 3 SQ4H  A few years later, on 050415 a 3-day
301399 - treatment was also pre-configured.  Millie recalled the cost was less
301400 - than $50, and she has never had to worry about drawing the correct
301401 - amount of medication from a vial. ref SDS 1 RF4M
301403 -  ..
301404 - Millie asked if prices have changed Neupogen?
301406 -  ..
301407 - The pharmacist said that prices have not changed, but the Discharge
301408 - Pharmacy does not have Neupogen in that form.
301410 -  ..
301411 - Millie asked the pharmacist to verify the prescription.  She told the
301412 - pharmacist that, if $450 plus the worry of figuring out how much to
301413 - draw from a vial for one treatment, is Kaiser's best price and best
301414 - practice for quality control, then she will skip the treatment as not
301415 - cost effective.  Since the prescription is only precautionary, per
301416 - meeting with the doctor, shown above, ref SDS 0 JR9N, and the purpose
301417 - of the treatment to lift WBC for chemotherapy treatment next week, and
301418 - since WBC normally rises during the week off medication with
301419 - capecitabine (Xeloda), which is next week, she is willing to take that
301420 - chance based on past experience, and balanced against Kaiser's
301421 - quotation of $450 or so.
301423 -  ..
301424 - The pharmacist called the primary care physician to clarify the
301425 - prescription.  This took about 20 minutes.
301427 -  ..
301428 - Walked back to the parking garage, and drove the care to the front of
301429 - the hospital for picking up patients.  This is the same are where
301430 - emergency ambulances bring patients to the Emergency Room.
301432 -  ..
301433 - The attendant said to park in a red zone.
301435 -  ..
301436 - Parked and went in to the Discharge Pharmacy.
301437 -
301439 -  ..
301440 - Neupogen 1 Treatment Price Changed to $40 Medication Pre-configured
301441 -
301442 - About 10 minutes later, the supervisor came into the lobby and said
301443 - that the pharmacy had found one Neupogen treatment syrenge which is
301444 - pre-configured with medication, according to past practice.  The cost
301445 - is $40, and the medication was approved by the primary care physician.
301447 -  ..
301448 - As a result, Millie was charged $40 instead of the initial quotation
301449 - of $450, per above. ref SDS 0 JS4U
301456 -  ..
301457 - Millie paid $40, instead of the initial quotation of $450.
301458 -
301459 -     [On 070131 similar experience avoiding $60 charge to send CT test
301460 -     files to UCSF for treatment. ref SDS 19 KM80
301461 -
301462 -
301464 -  ..
3015 -
3016 -
3017 - 1143
3018 -
301801 - Arrived home.
301802 -
301803 - Millie called Gloria and left a message with Doctor Kim's prescription
301804 - to skip Coumadin today.  Millie asked Gloria to call with instructions
301805 - taking Coumadin going forward.
301806 -
301808 -  ..
3019 -
3020 -
3021 - 1649
3022 -
302201 - Gloria called while we were at dinner.
302202 -
302203 - She gave Millie the Coumadin protocol for the next week.
302205 -  ..
302206 - Millie proposed the next blood test on 061109, which is the day before
302207 - starting the next cycle of chemotherapy treatment.  She gets a blood
302208 - draw to test for getting treatment the next day on 061110, and can
302209 - include a PT test for Coumadin treatments.
302211 -  ..
302212 - Gloria agreed.
302214 -  ..
302215 - Millie requested confirmation via email.
302216 -
302217 -
302218 -
3023 -

SUBJECTS
Coumadin Protocol Pulmonary Emboli Treatement Warfarin Instructions

3203 -
3204 - 2107
320501 -  ..
320502 - Instructions Coumadin Pulmonary Emboli Treatment Gloria
320503 - Coumadin Protocol Pulmonary Embolism Coagulation Treatment Clinic
320504 -
320505 - Millie received ref DRT 1 0001 from Gloria saying...
320506 -
320507 -    1.  Your INR Result: INR 3.3 11/01/2006
320508 -
320509 -            [On 061116 submitted letter to Kaiser asking for results of
320510 -            blood test and any new instructions. ref SDS 17 J39N
320512 -         ..
320513 -    2.  Your Target range: INR Low Range: 2  - INR High Range: 3
320515 -         ..
320516 -    3.  Thank you for taking your protime blood test.  This is the best
320517 -        way to know that your Warfarin (generic for Coumadin) dose is
320518 -        safe and working well for you.
320519 -
320520 -    4.  ** CONTINUE SAME DOSE  and get regular protime blood tests **
320522 -         ..
320523 -    5.  Warfarin Dosing Instructions: Using Warfarin 4MG Tablet (BLUE
320524 -        in color):  Take 2MG (1/2 tab) on Sundays; take 4MG (1 tab)
320525 -        Monday thru Saturday.  ONE TIME DOSE:  Take 0MG on Wednesday
320526 -        11/1/06 ONLY.
320528 -         ..
320529 -    6.  Please have your next protime blood test on: Follow up date:
320530 -        11/9/06
320532 -         ..
320533 -    7.  No appointment is needed. We will contact you by phone or by
320534 -        mail with your results soon after your blood test.  If you do
320535 -        not hear from us in 3 or 4 days after your lab work, please
320536 -        contact us at 925/372-1628.  If at all possible, please do not
320537 -        have your INR labs done on Fridays or weekends unless
320538 -        specifically instructed to do so by the Anticoagulation Clinic.
320539 -        Friday labs usually will not be evaluated until Monday mornings
320540 -        and these labs often have to be repeated.  Should you have any
320541 -        questions or concerns, please call us.
320543 -         ..
320544 -    8.  PLEASE call me if your dose differs from this OR if you missed
320545 -        any doses.  Also, call to report any changes or factors which
320546 -        may effect your warfarin levels, including changes in
320547 -        medications, activity, recent illness, alcohol consumption or
320548 -        major increases or decreases in the overall amount of green
320549 -        vegetables that you normally eat. You may need to come in for
320550 -        an INR sooner.
320551 -
320552 -
320553 -
320554 -
320555 -
320556 -
320557 -
320558 -
320559 -
320560 -
320561 -
320562 -
320563 -
320564 -
3206 -