THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: May 18, 2009 00:17 AM Monday; Rod Welch

Draft appeal Kaiser provide treatment Millie recover 8th relapse cancer.

1...Summary/Objective
...28...Logistical Analysis Stage V Long-term Survival.


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CONTACTS 
020304 -
0204 -
0205 -

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 49 0000. ref SDS 48 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 090423 Millie met with Tara in the Breast Care Clinic at UCSF for
040902 - examination, which showed recovery from side effects of radiation and
040903 - hyperthermia treatments during February and March 2009. ref SDS 31 QR3M
040904 - This was confirmed in Millie's letter to the medical team later that
040905 - day on 090423. ref SDS 32 ZL6T  Tara also found expanding IBC on the
040906 - lower left arm, ref SDS 31 DW6F, also confirmed in the letter to the
040907 - medical team. ref SDS 32 ZL7P
040909 -  ..
040910 - At that time, on 090423 Tara planned to discuss with Doctor Hsu in the
040911 - UCSF Radition Oncology Department concerns about slow healing of
040912 - radiation side effects in Millie's breastbone area. ref SDS 31 R15K
040913 - Collaboration plans were further confirmed in Millie's letter to the
040914 - medical team on 090423. ref SDS 32 ZL7V
040916 -  ..
040917 - In the afternoon on 090423 1315 Millie met with Doctor Hsu to check on
040918 - recovery from radiation side effects. ref SDS 31 4H5G  Doctor Hsu gave
040919 - Millie a "thumbs up" that she was well enough to take time from
040920 - treatment to go on a 2-week vacation, ref SDS 31 FJ6K, and despite
040921 - confirming diagnosis of IBC relapse on the lower left arm, ref SDS 31
040922 - 5G4G, and despite growing doubts about vertical line of sking infected
040923 - either by IBC or radiation side effects. ref SDS 31 EX4I  The doctor
040924 - recommended against taking a biopsy because the skin was thought to be
040925 - radiated, and surrounding tissue was radiated, and so this would delay
040926 - and prevent normal recovery from a biopsy wound. ref SDS 31 456H
040928 -  ..
040929 - On 090423 2337 Millie's letter to medical team reports Doctor Hsu's
040930 - favorable report that IBC cannot recur in treated areas, because
040931 - nothing can grow in treated areas. ref SDS 32 ZL9V  The letter further
040932 - confirms UCSF plans to treat IBC recurrence on the lower left arm as a
040933 - chronic disease with systemic agents prescribed by Doctor Rugo in the
040934 - Breast Care Clinic, ref SDS 32 ZL4X, and notes the meeting scheduled
040935 - with Doctor Rugo on 090514. ref SDS 32 ZL5Q
040937 -  ..
040938 - Yesterday on 090510 1553, Millie submitted an agenda for the meeting
040939 - on 090514 to start treatment of the 8th relapse. ref SDS 33 QH9J  The
040940 - letter was hurried to fit commitments for attending Mother's Day
040941 - family event.  In the afternoon on 090510 1953, after retrurning home,
040942 - Millie sent a second letter to further explain the agenda for meeting
040943 - on Thursday 090514 at UCSF with Doctor Rugo. ref SDS 34 FJ3G
040945 -  ..
040946 - This morning, called and talked to Amanda about coordinating to
040947 - facilitate the agenda for meeting with Doctor Rugo on Thursday,
040948 - 090514, particularly on requirements for blood tests at Kaiser, as
040949 - discussed in Millie's letter on 090510 1953. ref SDS 34 LJ7X
040951 -  ..
040952 - Amanda requested a copy of Millie's letter to the medical team that
040953 - explains details about getting a lab.  Millie sent the letter to
040954 - Amanda and requested clarification on requirements for a lab.
040955 - ref SDS 35 YN33  After sending the letter to Amanda this afternoon,
040956 - Kaiser notified Millie on 090511 1427 that Doctor Johnson has a
040957 - standing order at Kaiser for Millie to get a monthly blood test,
040958 - ref SDS 36 FJ5L; so, Millie then sent a letter notifying the medical
040959 - team that the blood draw will be done on 090512, so that people can be
040960 - prepared for a productive meeting at UCSF on 090514. ref SDS 36 FJ6G
040962 -  ..
040963 - On 090511 2013, Doctor Rugo sent a letter saying that scope for labs
040964 - at Kaiser performed to support examinations at UCSF should be
040965 - determined by Kaiser rather than by UCSF. ref SDS 37 RF4J
040967 -  ..
040968 - On 090511 2313, Millie notified Doctor Rugo that case study on 090325,
040969 - ref SDS 23 KZ6N, shows UCSF has been setting the scope on labs at
040970 - Kaiser for the past 3 years that are used to guide the work for
040971 - Millie's care at UCSF on referral from Kaiser, ref SDS 38 YN4L
040973 -  ..
040974 - On 090512 Millie went to Kaiser for the lab.  ref SDS 39 6Z4F
040976 -  ..
040977 - On 090513 1654 Millie submitted results of Kaiser's lab to UCSF,
040978 - ref SDS 40 N54I, and notifies Doctor Mason at Kaiser's Outside
040979 - Referrals Department about more mistakes at Kaiser that causes poor
040980 - coordination of Millie's care at UCSF on referral from Kaiser.
040981 - ref SDS 40 ZH6W, and follows up Doctor Mason's plan on 090420 for
040982 - Kaiser to work harder with greater diligence to avoid mistakes in
040983 - order to continue doing labs at Kaiser rather than include labs for
040984 - referral at UCSF for Millie's treatments at UCSF. ref SDS 30 8G3N
040986 -  ..
040987 - Millie received a letter from Pam who works for Doctor Mason in
040988 - Kaiser's Outside Referrals Department, and asking why the Outside
040989 - Referrals Department was notified about mistakes at Kaiser performing
040990 - labs required for Millie's care at UCSF on referral from Kaiser.
040991 - ref SDS 41 2T5L
040993 -  ..
040994 - Millie replied to Pam's letter explaining patient history assists
040995 - Doctor Mason evaluate requirements for effective coordination because
040996 - chronic mistakes at Kaiser can be avoided by performing labs at UCSF
040997 - for Millie's care at UCSF. ref SDS 42 PQ5N
040999 -  ..
041000 - On 090514 0830 Millie met with Doctor Rugo, ref SDS 43 TP9L, and the
041001 - doctor prescribed treatment in the MPA clinical trial to help Millie
041002 - recover from the 8th relapse of cancer. ref SDS 43 A13N  The doctor
041003 - was encouraged about powerful new treatments becoming available to
041004 - treat Millie, ref SDS 43 3F7M, but was very discouraged saying Kaiser
041005 - would never get on board to treat Millie's cancer as a chronic
041006 - disease. ref SDS 43 3F82  As a first step to order treatment, Doctor
041007 - Rugo sent a letter to Kaiser recommending treatment for Millie with
041008 - the MPA protocol that is targeted to Millie's patient profile.
041009 - ref SDS 43 DI63
041011 -  ..
041012 - On 090514 2346, Millie sent a letter notifying the medical team,
041013 - ref SDS 44 LF3H, about the new MPA treatment prescribed by UCSF, and
041014 - cited the letter Doctor Rugo sent to Kaiser explaining prospects for
041015 - recover, ref SDS 44 WF9V; and Millie's letter further submitted the
041016 - agenda for meeting tomorrow with Doctor Johnson at Kaiser to perform
041017 - oversight review. ref SDS 44 WF9Y
041019 -  ..
041020 - On 090515 0952, Doctor Rugo sent a reply this morning to Millie and
041021 - the medical team saying that Kaiser notified UCSF that Kaiser refused
041022 - to treat Millie for recovering from the 8th relapse of cancer.
041023 - ref SDS 45 GR4O
041025 -  ..
041026 - On 090515 1017, Millie notified the medical team that Kaiser is
041027 - responsible for her care, must prescribe treatment based on the best
041028 - evidence, and that Millie will meet with the primary care physician
041029 - today at 090515 1140 and support review for ordering treatment
041030 - recommended by Doctor Rugo, and in time to effective. ref SDS 46 EY5L
041032 -  ..
041033 - On 090515 1140 Millie met with Doctor Johnson, primary care physician
041034 - at Kaiser to prescribe treatment for Millie's 8th relapse of cancer.
041035 - ref SDS 47 J47M  The doctor asked Millie to assist him preparing an
041036 - appleal to Memeber Services for clarification of incorrect guidance he
041037 - received from Doctor Mason. ref SDS 47 655R
041039 -  ..
041040 - On 090515 1518 Millie received a letter from Doctor Rugo wishing
041041 - Millie good luck requesting Kaiser reverse failure to perform
041042 - agreement to prescribe standard of care treatment for Millie's 8th
041043 - relapse of cancer. ref SDS 48 PW7H
041045 -  ..
041046 - On 090516 0858, Millie notified Doctor Rugo that Doctor Johnson going
041047 - to bat for Millie at Kaiser to prescribe treatment by filing appeas
041048 - with Memeber Services. ref SDS 49 SY4O
041050 -  ..
041051 - Today, 090518 0017 prepared a draft appeal for Doctor Johnson to file
041052 - with Member Services on requirements for prescribing Millie's
041053 - treament to recover from the 8th relapse of cancer...
041054 -
041055 -    1.  Subject: Draft Appeal to Member Services Authorize Clinical Trial at UCSF
041056 -        Date: Mon, 18 May 2009 02:37:01 -0700
041061 -         ..
041062 -    2.  Dear Doctor Johnson,
041064 -         ..
041065 -    3.  Per your request in the meeting at Kaiser on 090515 1140, here
041066 -        is some language that may guide filing an appeal to Member
041067 -        Services. ref SDS 47 655Y
041068 -
041069 -            [On 090519 1536 Doctor Johnson changed his mind; he sent
041070 -            the draft appeal to Doctor Mason, and tells Millie to file
041071 -            an appeal with Member Services, which is incorrect since at
041072 -            this time Millie has not been denied medical services; and
041073 -            the doctor further says he is suddenly relieved of
041074 -            responsibility performed continuously the past 8 years to
041075 -            prescribe treatment for Millie to recover from cancer,
041076 -            because Kaiser's Outside Referrals Department has a better
041077 -            understanding of Medicare. ref SDS 50 5K7H
041079 -             ..
041080 -            [On 090519 1613 Millie responds thanking Doctor Johnson for
041081 -            timely response, ref SDS 51 8V8H, and asks Kaiser to
041082 -            prescribe treatment for Millie to recover from 8th relapse
041083 -            of cancer. ref SDS 51 TY3X
041085 -             ..
041086 -            [On 090616 1245 Doctor Rugo advised that "everybody is now
041087 -            on board" for Millie's treatment going forward, ref SDS 54
041088 -            D647, referring to Millie's proposal on 090518 treating
041089 -            "Stage V" patients for long term survival. ref SDS 0 W93Q
041091 -         ..
041092 -    4.  For Doctor Rugo, please don't read all of this - just letting
041093 -        you know work is in progress to get authorization for your
041094 -        proposal to Doctor Johnson last week - thanks.
041096 -         ..
041097 -    5.  If we don't get approval for clinical trials, can Doctor Rugo
041098 -        and Doctor Hsu come up with treatment using radiation and
041099 -        hyperthermia in areas not previously treated?  Since the
041100 -        original referral was for hyperthermia and doxil, this seems to
041101 -        invite treating my new condition with multi-modal solution.
041102 -        Just wondering...
041104 -         ..
041105 -    6.  For Doctor Johnson...
041107 -         ..
041108 -    7.  As you further requested, after our meeting in your office on
041109 -        Friday, ref SDS 47 TY5K, I visited with S Chinston (not sure
041110 -        about spelling from her hand writing), and she gave me the
041111 -        name...
041113 -         ..
041114 -        Isabel Martinez
041115 -        Operations Director
041116 -        Kaiser Walnut Creek
041117 -
041118 -        ...as head of Member Services to whom you can submit an appeal.
041119 -
041120 -            [On 090519 1536 Doctor Johnson changed his mind; he sent
041121 -            the draft appeal to Doctor Mason, and tells Millie to file
041122 -            an appeal with Member Services, which is incorrect since at
041123 -            this time Millie has not been denied medical services; and
041124 -            the doctor further says he is suddenly relieved of
041125 -            responsibility performed continuously the past 8 years to
041126 -            prescribe treatment for Millie to recover from cancer,
041127 -            because Kaiser's Outside Referrals Department has a better
041128 -            understanding of Medicare. ref SDS 50 5K7H
041130 -             ..
041131 -            [On 090616 1245 Doctor Rugo advised that "everybody is now
041132 -            on board" for Millie's treatment going forward, ref SDS 54
041133 -            D647, referring to Millie's proposal on 090518 treating
041134 -            "Stage V" patients for long term survival. ref SDS 0 W93Q
041136 -         ..
041137 -    8.  Suggest sending information copies to Doctor Mason and to Paula
041138 -        McPhail, who handled the first claim in 2007.  Paula's email
041139 -        address is:  ***************
041141 -         ..
041142 -    9.  Incidentally, S Chinston asked for your name, and said somebody
041143 -        would call you; had ominous implications of being sent for
041144 -        "reeducation."
041146 -         ..
041147 -   10.  The foundation of appeal is "deference to doctor discretion for
041148 -        medical necessity."
041150 -         ..
041151 -   11.  This appeal seeks approval first for Doctor Rugo's proposal to
041152 -        treat me in a specific clinical trial, as presented in her
041153 -        letter to you on 090514;, ref SDS 43 DI63; and, second,
041154 -        approval for an expansive and innovative referral for Doctor
041155 -        Rugo to treat my cancer as a chronic disease, which you have
041156 -        discussed at length the past 6 months, if time permits see case
041157 -        study on 090325. ref SDS 23 L15M
041159 -         ..
041160 -   12.  Doctor Rugo noted in the meeting at UCSF that getting the
041161 -        pieces in place for a broad solution will be difficult.
041162 -        ref SDS 43 3F82  So is living with IBC for 8 years; we can't
041163 -        get there if we don't try.  It would certainly require
041164 -        collaboration between Kaiser and UCSF to develop a model for
041165 -        solving the health care cost problem that is exploding
041166 -        nationally, and in Europe.
041167 -
041168 -            [On 090519 1536 Doctor Johnson changed his mind; he sent
041169 -            the draft appeal to Doctor Mason, and tells Millie to file
041170 -            an appeal with Member Services, which is incorrect since at
041171 -            this time Millie has not been denied medical services; and
041172 -            the doctor further says he is suddenly relieved of
041173 -            responsibility performed continuously the past 8 years to
041174 -            prescribe treatment for Millie to recover from cancer,
041175 -            because Kaiser's Outside Referrals Department has a better
041176 -            understanding of Medicare. ref SDS 50 5K7H
041178 -             ..
041179 -            [On 090616 1245 Doctor Rugo advised that "everybody is now
041180 -            on board" for Millie's treatment going forward, ref SDS 54
041181 -            D647, referring to Millie's proposal on 090518 treating
041182 -            "Stage V" patients for long term survival. ref SDS 0 W93Q
041184 -         ..
041185 -   13.  The appeal initially presents the patient's position on
041186 -        Evidence of Coverage (EOC), which you can do as a factual
041187 -        matter without an opinion on the merits.  Then the appeal gives
041188 -        reasons for your interest in the case to support standard of
041189 -        care for oncology, with implications for other patients
041191 -         ..
041192 -   14.  This is comprehensive so you can pick and choose analysis that
041193 -        seems most appropriate.  Notice there is construction of
041194 -        conversation you related with Doctor Mason.  This may require
041195 -        editing, since what you mentioned on Friday was limited.
041197 -         ..
041198 -   15.  Here goes...
041199 -
041200 - *************************
041202 -         ..
041203 -    1.  Isabel Martinez
041204 -        Operations Director
041205 -        Kaiser Walnut Creek
041207 -         ..
041208 -    2.  Subject:  Authorization Clinical Trial Medicare Patient
041209 -                  Deference to Doctor Discretion for Medical Necessity
041211 -                  Inflammatory Breast Cancer (IBC)
041213 -         ..
041214 -    3.  Dear Ms. Martinez:
041216 -         ..
041217 -    4.  Millie **** has been my patient for the past 8 years beginning
041218 -        on March 21, 2002. ref SDS 2 0001  She has been a model
041219 -        patient treated for breast cancer in the Oncology Department at
041220 -        Kaiser Walnut Creek.  She has a complex medical history and
041221 -        patient profile [shown in the record meeting with Millie at
041222 -        Kaiser on 090213, ref SDS 20 ES7I, that leads me to seek
041223 -        support from Member Services under deference to doctor
041224 -        discretion for medical necessity to continue her care at UCSF
041225 -        on referral for the following clinical trial...
041227 -         ..
041228 -    5.  UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
041230 -         ..
041231 -        Study Title: MPA Revisited: A Phase II Study of
041232 -        Anti-Metastatic, Anti-Angiogenic Therapy in Postmenopausal
041233 -        Patients with Hormone Receptor Negative Breast Cancer
041234 -        (see protocol listed in 090514 0830 from meeting at UCSF with
041235 -        Doctor Rugo, ref SDS 43 CT9K)
041237 -         ..
041238 -    6.  I recently spoke with Doctor Mason, Director of Outside
041239 -        Referrals.  He recommended I personally file this request in
041240 -        light of urgency for Millie to get timely treatment, since
041241 -        Kaiser has no treatments for Millie's patient profile [see case
041242 -        study on 090325 0830, ref SDS 23 L15M], and she was diagnosed
041243 -        with recurrent cancer for the 8th time on May 14th by Doctor
041244 -        Rugo at UCSF [the doctor's letter to Kaiser, ref SDS 43 DI63].
041245 -        Each time cancer recurs, there is a narrowing margin for error
041246 -        providing treatment in time to be effective [cited in case
041247 -        study on 090213, ref SDS 20 PL5K].  As a result, time is of the
041248 -        essence to provide treatment.
041249 -
041250 -            [On 090519 1536 Doctor Johnson changed his mind; he sent
041251 -            the draft appeal to Doctor Mason, and tells Millie to file
041252 -            an appeal with Member Services, which is incorrect since at
041253 -            this time Millie has not been denied medical services; and
041254 -            the doctor further says he is suddenly relieved of
041255 -            responsibility performed continuously the past 8 years to
041256 -            prescribe treatment for Millie to recover from cancer,
041257 -            because Kaiser's Outside Referrals Department has a better
041258 -            understanding of Medicare. ref SDS 50 5K7H
041260 -             ..
041261 -            [On 090616 1245 Doctor Rugo advised that "everybody is now
041262 -            on board" for Millie's treatment going forward, ref SDS 54
041263 -            D647, referring to Millie's proposal on 090518 treating
041264 -            "Stage V" patients for long term survival. ref SDS 0 W93Q
041266 -         ..
041267 -    7.  Millie is aware that at sometime between 2002 and the present
041268 -        date, Kaiser changed practice and stopped referring Medicare
041269 -        patients for clinical trials on the grounds that Medicare
041270 -        provides a benefit for patients to self-refer in order to
041271 -        advance scientific discovery (see EOC section 7) [reviewed on
041272 -        070927, ref SDS 11 OU84].  In the event a patient disagrees with
041273 -        Kaiser's care, Medicare provides flexibility to go anywhere for
041274 -        treatment.
041276 -         ..
041277 -    8.  Millie rejects benefits of self-referral and requests benefits
041278 -        of her coverage for Kaiser to prescribe and provide care.  She
041279 -        wants continued benefit of Kaiser integrated team care,
041280 -        comprehensive coordination of case management, and protections
041281 -        of cost containment, including referral where required by
041282 -        medical necessity (see EOC section 2).  Since she has been with
041283 -        Kaiser for 30 years, she wants continuity of care.  She feels
041284 -        self-referral for treatment would interrupt benefits of her
041285 -        coverage with Kaiser, and relieve Kaiser of responsibility for
041286 -        her care.  As a stage IV cancer patient suffering an 8th
041287 -        relapse, Millie has neither the expertise, time, nor energy to
041288 -        assume responsibilities of self-referral.
041290 -         ..
041291 -    9.  Oncology is an integrated practice that requires careful
041292 -        attention to patient history for diagnosis and treatment
041293 -        decisions.  Millie's patient profile listed in her record on
041294 -        February 13th, is very complex. ref SDS 20 ES7I
041296 -         ..
041297 -   10.  Item #15 treatment history [citing the record on 090121,
041298 -        ref SDS 14 H16M, shows Millie has already received all of the
041299 -        drugs available at Kaiser for her diagnosis of secondary IBC
041300 -        stage IV.
041302 -         ..
041303 -   11.  This actually occurred at the end of 2006, when Millie was
041304 -        referred for treatment in a clinical trial at UCSF beginning in
041305 -        2007 [reported on 070105 meeting at Kaiser, ref SDS 7 PK68]
041306 -        Kaiser deferred to doctor discretion for medical necessity.  At
041307 -        that time, I began a collaboration with Doctor Rugo managing
041308 -        Millie's tests and coordinating her care at Kaiser, and
041309 -        approving her treatments at UCSF recommended by Doctor Rugo.
041310 -        Collaboration with Doctor Rugo at UCSF has been effective the
041311 -        past 3 years meeting Kaiser's standard of care for oncology.  I
041312 -        reviewed with Millie on March 25th the normal trajectory for
041313 -        her IBC disease, and showed she has survived 7 relapses, nearly
041314 -        300% longer than most patients treated for IBC. ref SDS 23 P39M
041316 -         ..
041317 -   12.  With these results, Millie asked me on Friday to prescribe her
041318 -        next treatment for her 8th relapse.
041320 -         ..
041321 -   13.  Millie is currently being treated by Doctor Rugo and Doctor Hsu
041322 -        at UCSF on a referral for hyperthermia and chemotherapy
041323 -        (Doxil), which was proposed by Doctor Rugo to me in a letter on
041324 -        January 29, 2009 [reported the next day on 090130, ref SDS 16
041325 -        TZ6H].  At that time her disease was cascading out of control.
041326 -        Doctor Rugo requested the referral to UCSF Radiation Oncology
041327 -        to achieve local control of Millie's IBC.  This was achieved
041328 -        after 4 weeks of treatment.  Millie made a significant recovery
041329 -        under Kaiser's authorization # A023141470 dated February 2,
041330 -        2009 [received in the record on 090205. ref SDS 18 278T].
041332 -         ..
041333 -   14.  On March [31st], Doctor Hsu diagnosed recurrent disease in an
041334 -        area that was not treated during the initial phase of radiation
041335 -        and hyperthermia [received in the record on 090401, ref SDS 24
041336 -        R24X].  Weeks later on April 23rd, Doctor Hsu examined Millie
041337 -        again and confirmed initial feeling that Millie has suffered an
041338 -        8th relapse of cancer, and 7th relapse of IBC. ref SDS 31 5G4G
041340 -         ..
041341 -   15.  As Millie's primary care physician I can prescribe under EOC
041342 -        section 2 continued treatment with radiation and hyperthermia.
041343 -        Kaiser has currently authorized payment for this care.  Doctor
041344 -        Hsu points out that treatment with additional hyperthermia
041345 -        regimen at this time conflicts with standard of care for
041346 -        oncology.  He explains correctly that this regimen has limited
041347 -        use, because patients can only tolerate 2 applications, what he
041348 -        calls "2-bullets." ref SDS 31 UG6L  The proper treatment under
041349 -        Kaiser protocol is to prescribe systemic treatment to hold
041350 -        powerful tools with limited use in reserve until Millie again
041351 -        faces a loss of control situation, as occurred this past
041352 -        January.  As a result, on April 23rd, Doctor Hsu referred
041353 -        Millie back to the UCSF Breast Care Clinic for Doctor Rugo to
041354 -        prescribe a systemic treatment that will "maintain" Millie's
041355 -        recovery. ref SDS 31 UG6I
041357 -         ..
041358 -   16.  In my recent discussion with Doctor Mason in Kaiser's Outside
041359 -        Referrals Department, he asked if I have any drugs to prescribe
041360 -        in order to give Millie the benefit of her insurance coverage
041361 -        that does not involve a clinical trial?
041363 -         ..
041364 -   17.  In March 2004, I prescribed a clinical trial for Millie [shown
041365 -        on 040318, ref SDS 3 PU6M].  She strongly objected, saying she
041366 -        preferred treatment with a proven track record [reported on
041367 -        040318, ref SDS 3 DG4J].  Like Doctor Hsu recently on April
041368 -        23rd, I explained to Millie at that time on March 18, 2004
041369 -        Kaiser's standard of care for oncology is to hold powerful
041370 -        cancer drugs in reserve until they are really needed, and to
041371 -        experiment with clinical trials that have shown evidence of
041372 -        effectiveness in earlier phase I trials, to find a treatment
041373 -        that is effective.  Kaiser and Millie deferred to doctor
041374 -        discretion, and so 5 years ago, Gemzar and Navelbine were held
041375 -        in reserve for Millie. ref SDS 3 DG4X
041377 -         ..
041378 -   18.  Today, Kaiser protocol prevents me from prescribing these drugs
041379 -        previously held in reserve because of tolerance issues for
041380 -        Millie's patient profile [reported to Millie during the meeting
041381 -        at Kaiser on 090515 0830, ref SDS 47 658J].
041382 -
041383 -            [On 090605 Millie received documentation from Kaiser that
041384 -            says Gemzar requires "extreme caution" given after a
041385 -            patient has been treated with radiation, which Millie
041386 -            received for 4 weeks in February and March, and contiues to
041387 -            suffer side effects; Kaiser further says treatment with
041388 -            Gemzar requires avoiding blood thinners, and Millie is
041389 -            required to take blood thinners every day for PE.
041390 -            ref SDS 52 V34K
041392 -             ..
041393 -            [On 090616 1245 Doctor Rugo advised that "everybody is now
041394 -            on board" for Millie's treatment going forward, ref SDS 54
041395 -            D647, referring to Millie's proposal on 090518 treating
041396 -            "Stage V" patients for long term survival. ref SDS 0 W93Q
041398 -         ..
041399 -   19.  This paints Millie into an untenable box.  Kaiser's former
041400 -        standard of care to use clinical trials for holding proven
041401 -        drugs in reserve, results in denying her needed treatment at a
041402 -        crucial time in her care.  If the current procedure of denying
041403 -        support for clinical trials were applied in 2004, I could have
041404 -        prescribed truly effective drugs with the possibility of a cure
041405 -        or at least significant recovery.  Having denied the patient
041406 -        opportunity for recovery, Kaiser can support Doctor Rugo in the
041407 -        current effort to provide equivalent recovery, as recommended
041408 -        by Doctor Hsu, rather than force me to prescribe treatment
041409 -        currently authorized with hyperthermia at UCSF, and which
041410 -        violates standard of care for oncology.
041412 -         ..
041413 -   20.  Treatment in the clinical trial will likely run 50% to 30% of
041414 -        the cost for another phase of radiation and hyperthermia at
041415 -        this time, because the clinical trial drug is paid for by the
041416 -        study sponsor, blood work is paid by Medicare, and this
041417 -        treatment will be given orally, so infusion costs are avoided
041418 -        as well.  Cost containment with prospects of maintenance
041419 -        "systemic" treatment helps avoid the cost of labor and
041420 -        equipment intensive radiation and hyperthermia.
041422 -         ..
041423 -   21.  Millie objects to self-referral because of very practical
041424 -        reasons.  At Kaiser she is a "patient."  All of her time and
041425 -        that of Kaiser's providers is focused on recovery and well
041426 -        being. These same conditions lie when Millie gets treatment at
041427 -        UCSF on referral from Kaiser.
041429 -         ..
041430 -   22.  Self-referral totally reverses this focus.  Unlike Kaiser, who
041431 -        has vast marketing standing at UCSF, as a source of revenue, a
041432 -        single self-referral patient is primarily a "debtor."
041434 -         ..
041435 -   23.  Whereas, Kaiser can demand support and justification for
041436 -        referral charges, and can negotiate equitable billings,
041437 -        including comprise on questionable issues, a single patient is
041438 -        simply a debtor, who is usually weak and enfeebled wracked by
041439 -        cancer, side effects, and often emotionally staring death in
041440 -        the face, and so is easily forced into payment of incorrect
041441 -        billings by a barrage of unending harassment.  No bill
041442 -        collector calls the Kaiser CEO with scare tactics and
041443 -        name-calling to secure payment of improper billings.
041445 -         ..
041446 -   24.  Millie purchased insurance for the right to be a patient,
041447 -        rather than a debtor, and this right should enable reasonable
041448 -        access to standard of care for oncology, which includes
041449 -        clinical trials, regardless of age.
041451 -         ..
041452 -   25.  As former director of oncology for the Mt Diablo region, the
041453 -        change from using clinical trials as standard of care, to
041454 -        disparate treatment for Medicare patients introduces criteria
041455 -        that seems like age discrimination.  Every patient is not a
041456 -        good candidate for clinical trials.  Medical judgments involve
041457 -        a great many factors.  Age is a big factor that requires doctor
041458 -        discretion identifying patients who can benefit from treatment
041459 -        and withstand side effects.  However, age per se is not the
041460 -        criteria.
041462 -         ..
041463 -   26.  Doctors are trained to evaluate medical health through
041464 -        examination and testing.  Kaiser routinely gives deference to
041465 -        doctor discretion to prescribe care for medical necessity.  I
041466 -        and my colleagues in the Oncology Department must ask about the
041467 -        efficacy of basing medical care strictly on age, i.e., treating
041468 -        those on Medicare differently from the general population.  If
041469 -        I cannot prescribe care equally for patients, then I am forced
041470 -        into disparate treatment, having to keep track of who is and is
041471 -        not on Medicare.  Rather than spending time on prescribing
041472 -        standard of care, I wind up shading the prescription in endless
041473 -        discussions of what patients can afford.  This seems
041474 -        conflicting with HMO objectives and practice.
041476 -         ..
041477 -   27.  Since Millie has done well with treatment at UCSF, and has been
041478 -        well served with clinical trials continuously since 2004 under
041479 -        Kaiser's standard of care, and since treatments she could have
041480 -        had to recover from cancer were denied under Kaiser's former
041481 -        standard of care for oncology to rely on clinical trials, since
041482 -        Kaiser has no other treatments available, and since treatment
041483 -        proposed for clinical trial conforms with Kaiser standards to
041484 -        support non-Phase I studies, and since the patient is unable to
041485 -        perform self-referral case management, request deference to
041486 -        doctor discretion for medical necessity to prescribe continued
041487 -        treatment in clinical trials at UCSF, and which will save 30% -
041488 -        50% on the cost of alternative care.
041489 -
041490 -            [On 090519 1536 Doctor Johnson changed his mind; he sent
041491 -            the draft appeal to Doctor Mason, and tells Millie to file
041492 -            an appeal with Member Services, which is incorrect since at
041493 -            this time Millie has not been denied medical services; and
041494 -            the doctor further says he is suddenly relieved of
041495 -            responsibility performed continuously the past 8 years to
041496 -            prescribe treatment for Millie to recover from cancer,
041497 -            because Kaiser's Outside Referrals Department has a better
041498 -            understanding of Medicare. ref SDS 50 5K7H
041499 -
041501 -         ..
041502 -   28.  Logistical Analysis Stage V Long-term Survival.
041504 -         ..
041505 -   29.  In discussions with Doctor Mason on this case, the doctor cited
041506 -        advantages of consolidating case management for oversight and
041507 -        auditing control.
041509 -         ..
041510 -   30.  Since Millie already has Kaiser authorization # A023141470, and
041511 -        since her care requires experimenting to discover "maintenance"
041512 -        systemic treatment with multi-modal methods, Kaiser and UCSF
041513 -        can achieve cost containment through consolidating referral
041514 -        work under a single account.
041515 -
041516 -            [On 090519 1536 Doctor Johnson changed his mind; he sent
041517 -            the draft appeal to Doctor Mason, and tells Millie to file
041518 -            an appeal with Member Services, which is incorrect since at
041519 -            this time Millie has not been denied medical services; and
041520 -            the doctor further says he is suddenly relieved of
041521 -            responsibility performed continuously the past 8 years to
041522 -            prescribe treatment for Millie to recover from cancer,
041523 -            because Kaiser's Outside Referrals Department has a better
041524 -            understanding of Medicare. ref SDS 50 5K7H
041526 -             ..
041527 -            [On 090616 1245 Doctor Rugo advised that "everybody is now
041528 -            on board" for Millie's treatment going forward, ref SDS 54
041529 -            D647, referring to Millie's proposal on 090518 treating
041530 -            "Stage V" patients for long term survival. ref SDS 0 W93Q
041532 -         ..
041533 -   31.  Issuing multiple authorizations presents a mammoth logistical
041534 -        challenge separating charges between clinical trial work and
041535 -        treatment with currently authorized hyperthermia and
041536 -        chemotherapy.  How would Doctor Hsu and Doctor Rugo, and
041537 -        colleagues at UCSF distinguish charges for discussing clinical
041538 -        trial aspects of recovery from other multi-modal care involving
041539 -        hyperthermia, now approved for payment by Kaiser.
041541 -         ..
041542 -   32.  Millie is the tip of the spear signaling what will become an
041543 -        avalanche of patients in the next 10 years with long-term
041544 -        survival that essentially comprise a "stage V" level to care
041545 -        for cancer as a chronic disease [proposed by Doctor Johnson
041546 -        shown by case study on 090325. ref SDS 23 L15M
041548 -         ..
041549 -   33.  Supporting Millie's treatment at UCSF on clinical trial
041550 -        provides  research to assess requirements and design modalities
041551 -        in time to meet the challenge of looming age demographics.
041553 -         ..
041554 -   34.  Sincerely,
041555 -
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