THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: May 18, 2009 00:17 AM Monday;
Draft appeal Kaiser provide treatment Millie recover 8th relapse cancer.
...28...Logistical Analysis Stage V Long-term Survival.
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Default Null Subject Account for Blank Record
0403 - ..
0404 - Summary/Objective
040501 - Follow up ref SDS 49 0000. ref SDS 48 0000.
040507 - ..
0408 - Background
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...
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
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
041118 - ...as head of Member Services to whom you can submit an appeal.
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.
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...
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.
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].
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.
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
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.
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,