CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 17 0000, ref SDS 14 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Vitals Elevated Inflammation Face Patient Suffering Emotional Trauma
040902 -
040903 - Follow up ref SDS 13 SS5K.
040904 -
040905 - The doctor initially asked Millie about inflammation on her face, and
040906 - noted possible correlation with elevated blood pressure today, whether
040907 - this is stress related, discussed further below, ref SDS 0 QY9V, and
040908 - cited in the Medical Chart. ref SDS 0 Y53O
040910 -  ..
040911 - Yesterday, Brigid at UCSF asked the same question during the meeting
040912 - to start the next cycle of treatment in the clinical trial.  At that
040913 - time, OA 0830 in the morning, Millie's face showed signs of uniform
040914 - redness, typical of sunburn from exposure to the sun.  The condition
040915 - was less severe, than the night before when Millie returned from
040916 - vacation.
040918 -  ..
040919 - Millie returned from vacation Wednesday, 070919, evening arriving OA
040920 - 2300.  The day before on 070918 she was in the sun for about 5 hours
040921 - walking the streets of Rome.  Normally, Millie would have worn a hat
040922 - to keep sun off of her face, but starting out the sky was overcast,
040923 - and there was a heavy rain for a short period.  However, the rain
040924 - stopped, and the sky cleared, resulting in prolonged exposure to the
040925 - sun.
040927 -  ..
040928 - Brigid noted Millie's condition for follow up.
040930 -  ..
040931 - Today, inflammation on the face has further subsided, perhaps due to
040932 - declining affects of sun exposure on Tuesday in combination with
040933 - rising affects of cetuximab treatments yesterday at UCSF.  Explanation
040934 - of side effects on cetuximab was received from UCSF on 070116, and
040935 - warns about skin inflammation in addition to rash. ref SDS 8 MH4Q
040936 -
040937 -
040939 -  ..
040940 - IBC Examination No Evident Increase Red Rash Inflammation
040941 -
040942 - Today, the doctor examined Millie's left arm, and noticed no evident
040943 - increase in IBC rash and inflammation from the prior examination
040945 -  ..
040946 - Similarly, her chest shows no progression of disease from reduced
040947 - levels seen on prior examination 2 months ago.  He feels this
040948 - indicates cetuximab has been a successful treatment for the past 9
040949 - months.
040950 -
040951 -
040953 -  ..
040954 - CT Test Planning Assess Treatment Clinical Trial UCSF
040955 -
040956 - Millie reported plans discussed yesterday for UCSF to order another CT
040957 - test. ref SDS 17 EH5G  The doctor will order the test when Kaiser
040958 - receives the request from UCSF.
040959 -
040960 -            [On 070930 CT test at Kaiser. ref SDS 20 0001
040962 -             ..
040963 -            [On 071018 report on CT test today 070930 was reviewed with
040964 -            the medical team at UCSF. ref SDS 23 4N7K
040965 -
040966 -
040967 -
0410 -

SUBJECTS
Default Null Subject Account for Blank Record

0503 -
050401 -  ..
050402 - Emotional Trauma Elevated Vitals Inflammation Cancer Signals
050403 -
050404 - The doctor asked Millie how she is coping emotionally?  Her blood
050405 - pressure seems elevated today, in addition to having noticable
050406 - increased facial inflammation, per above. ref SDS 0 QY5I
050407 -
050408 -            [On 090129 Tara diagnosed Millie was suffering from
050409 -            elevated physical pain, which correlated with recent
050410 -            separated shoulder and progression of cancer, and based on
050411 -            elevated vitals, reported in Millie's letter to the medical
050412 -            team on 090130. ref SDS 32 AY7T
050414 -  ..
050415 - An emotional roller coaster reported during examination at Kaiser on
050416 - 070105, ref SDS 7 Y642, was reviewed at UCSF on 070301. ref SDS 9
050417 - Y642  Two weeks later on 070315 UCSF nurse practitioner asked how
050418 - Millie is coping emotionally with big swings in patient assessment?
050419 - ref SDS 10 6A7J  Stress and trauma compound from complexity of case
050420 - history reported on 070525, ref SDS 12 Y642, and rising medical issues
050421 - listed at that time. ref SDS 12 LU3J  Millie's letter to Kaiser on
050422 - 070516 illustrate emotional challenges of changes in prognosis.
050423 - ref SDS 11 ZJ9N
050424 -
050425 -            [On 070926 letter from mental health reports investigating
050426 -            issues. ref SDS 19 QY5I
050428 -             ..
050429 -            [On 070926 case study shows overwhelming complexity of
050430 -            Millie's case causes emotional doubt and worry for cancer
050431 -            patient. ref SDS 19 OS4G
050433 -             ..
050434 -            [On 071001 submitted follow up letter with further
050435 -            background showing requrements for Kaiser to pay for
050436 -            Millie's care on referral to UCSF. ref SDS 21 QY5I
050438 -             ..
050439 -            [On 071001 case study showing clinical trials are
050440 -            prescribed by Kaiser as the best treatment for Millie.
050441 -            ref SDS 21 LE3G
050443 -             ..
050444 -            [On 080125 Millie fell and injured right eye and arm.
050445 -            ref SDS 27 N65K
050447 -             ..
050448 -            [On 080226 another IBC patient reports emotional roller
050449 -            coaster living with cancer. ref SDS 30 M36X
050451 -  ..
050452 - Emotional anxiety has escalated the past few months receiving 100 or
050453 - so invoices from UCSF suddenly demanding payments of $10K annually for
050454 - treatment which conflicts with arrangements in on 061230 between
050455 - Kaiser and UCSF for Kaiser to pay any costs not covered by the
050456 - clinical trial. ref SDS 6 3X6K  Delay resolving payment increases
050457 - worry about UCSF terminating treatments related to 4 issues presented
050458 - at UCSF during a meeting on 070830. ref SDS 15 T94O
050459 -
050460 -            [On 071006 new invoices from UCSF indicate annual charges
050461 -            escalate to $20K per year. ref SDS 22 PRWW
050463 -  ..
050464 - The doctor noted today Millie's rising emotional condition in the
050465 - medical chart, per below. ref SDS 0 Y53O  Millie has been taking
050466 - Atavin to relieve worry from doubt about endless invoices arriving in
050467 - the mail each day with incomprehensible charges that conflict with
050468 - understandings on entering the clinical trial at UCSF.  She asked how
050469 - many Atavin tablets are safe to take each day?
050470 -
050471 -            [On 071006 Millie unable to talk with Kaiser's
050472 -            representative calling to investigate failure to perform
050473 -            payment for treatment on referral to UCSF. ref SDS 22 KA5J
050475 -  ..
050476 - Case study on 061020 reports complexities of Millie's case,
050477 - ref SDS 5 T25H, create roller coaster of emotional trauma including 45
050478 - medical problems, ref SDS 5 M46V, compounded by Kaiser's problems
050479 - paying for referral to UCSF. ref SDS 5 M53Q
050481 -             ..
050482 -            [On 071031 Millie received notice UCSF plans to terminate
050483 -            treatments because Kaiser has not paid for referral work.
050484 -            ref SDS 24 KM4J
050486 -             ..
050487 -            [On 080125 Millie fell and injured right eye and arm.
050488 -            ref SDS 27 N65K
050490 -             ..
050491 -            [On 080226 another IBC patient reports emotional roller
050492 -            coaster living with cancer. ref SDS 30 M36X
050493 -
050494 -
050495 -
0505 -

SUBJECTS
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0603 -
060401 -  ..
060402 - Oncology Mental Health Correct Mistakes Applying Government Regulations
060403 - Atavin 4 Tablets Relieve Stress Cancellation Referral Cancer Treatment
060404 - Government Regulations Changes Cause Kaiser Failure Pay Referral Bills
060405 -
060406 - The doctor advised that a lot of patients have similar experience due
060407 - to changes in governement regulations.  He prescribed 4 tablets spaced
060408 - throughout the day are generally safe to treat anxiety from doubt, and
060409 - worry about getting treatments when Kaiser fails to perform payment
060410 - duties owed to the patient.
060412 -  ..
060413 - Previously, on 060217 Millie requested consultation on mental health
060414 - to deal with stress from mastectomy surgery on 051021, and seemingly
060415 - significant recovery from cancer.  At that time the doctor explained
060416 - cancer patients suffer trauma from emotional roller coaster with big
060417 - swings in diagnosis, response to treatment, and prognosis. ref SDS 2
060418 - Y64H  On 070217 the doctor made a referral to Behavioral Medical
060419 - Specialist (BMS). ref SDS 2 JL5G
060421 -  ..
060422 - Today, the doctor recommended that Millie meet with the oncology
060423 - mental health therapyst again to help cope with rising panic attacks
060424 - from emotional stress, per above. ref SDS 0 QY9V
060425 -
060426 -            [...below, medical chart notes patient suffering panic
060427 -            attacks due to bills for treatment, ref SDS 0 Y53O;
060428 -            treatment plan prescribes mental health consultation and
060429 -            Ativan for panic attacks. ref SDS 0 WF8P
060431 -  ..
060432 - Millie recalled poor results working with Kaiser's mental health
060433 - people on the prior referral, which was reported to the doctor in her
060434 - letter to Kaiser on 060320. ref SDS 3 RE4Y  Later on 060428 the
060435 - doctor could not recall receiving the letter, and learned that Millie
060436 - was traumatized consulting with Mental Health who seemed to indicate
060437 - Millie was too healthy for treatment. ref SDS 4 619N
060439 -  ..
060440 - The doctor feels Millie's new situation will get better support from
060441 - staff in Mental Health Department.  He made a referral for mental
060442 - health consultation, noted in the medical chart treatment plan, shown
060443 - below. ref SDS 0 WF8P  At the end of the meeting the doctor called the
060444 - Mental Health therapyst to schedule a meeting with Millie, per below.
060445 - ref SDS 0 QZ82
060447 -  ..
060448 - The doctor complemented referral to Mental Health with prescription
060449 - for Ativan to treat panic attacks until Kaiser and UCSF resolve
060450 - conflicts in payment for Millie's treatment on referral.
060451 -
060452 -            [...below, medical chart treatment plan prescribes Ativan
060453 -            for panic attacks. ref SDS 0 WF8P
060455 -             ..
060456 -            [On 070925 Kaiser mental health therapyst called to
060457 -            schedule meeting with Millie on payment issues. ref SDS 18
060458 -            QY5I
060460 -             ..
060461 -            [On 070926 letter from mental health reports investigating
060462 -            Millie's case involving complex issues. ref SDS 19 QY5I
060464 -             ..
060465 -            [On 071116 the doctor reported progress approving payment
060466 -            for Millie's treatment on referral to UCSF. ref SDS 25 BO6L
060468 -             ..
060469 -            [On 071116 Millie reported Kaiser and UCSF continue sending
060470 -            notices her treatment will be terminated. ref SDS 25 BO70
060472 -             ..
060473 -            [On 080118 doctor recommends again Millie consult with
060474 -            Mental Health therapyst. ref SDS 26 X14J
060476 -             ..
060477 -            [On 080125 Millie fell and injured right eye and arm.
060478 -            ref SDS 27 N65K
060480 -             ..
060481 -            [On 080129 Millie schedules meeting with Mental Health
060482 -            department on 080201. ref SDS 28 RB7F
060484 -             ..
060485 -            [On 080201 mental health therapyst advised that prior
060486 -            consultation reported on 060428, ref SDS 4 619N, dismissing
060487 -            Millie's need for assistance was improper. ref SDS 29 SG7K
060488 -
060489 -
060490 -
0605 -

SUBJECTS
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0703 -
070401 -  ..
070402 - Medicare Regulations Frequent Changes Overwhelm Kaiser Accounting Dep
070403 - Kaiser Received Correspondence Failure Perform Duty to Pay for Referral
070404 -
070405 - The doctor reported having received correspondence on Kaiser's dispute
070406 - with UCSF over payments for Millie's care in the clinical trial
070407 - ordered by Kaiser on 070105, and based on arrangements the doctor made
070408 - in correspondece with Doctor Rugo on 061230. ref SDS 6 3X6K
070410 -  ..
070411 - He did not disagree with any analysis presented in the record showing
070412 - Kaiser made a referral, and Millie did not self-refer for treatment at
070413 - UCSF.
070415 -  ..
070416 - The doctor indicated Kaiser is hampered reaching equitable resolution
070417 - in cases like Millie because frequently changing Medicare regulations
070418 - and requirements make long term cost sharing agreements with UCSF and
070419 - others problematic, and further because rising drug prices increase
070420 - pressure on service providers to find more revenues that offset fixed
070421 - term insurance agreements with customers.  The doctor feels volitile
070422 - regulations invite opportunists to "game the system" with excessive
070423 - charges.  The patient gets stuck in the middle between professionals
070424 - negotiating over fixed revenues who see the patient as a safety valve
070425 - for increasing cash flow they cannot collect from each other or from
070426 - the government.  He cited Sweden for maintaining average annual cost
070427 - of treating patients is $3K, while in the US the annual cost is double
070428 - at $6K.
070430 -  ..
070431 - The doctor explained that cetuximab is an example of skyrocketing drug
070432 - prices that force doctors to look for ways to cut costs and increase
070433 - revenues.  He indicated that cetuximab is very expensive for doctors
070434 - to prescribe unless there is a clinical trial that pays for drug
070435 - costs.  Referring Millie to UCSF was sound medical practice, reported
070436 - on 070105, ref SDS 7 PK7L, and today, it turns out is also good
070437 - financial strategy that saved Kaiser a lot of money exercising its
070438 - duty to provide the care Millie needs.
070440 -  ..
070441 - The doctor feels Kaiser has very good relations with UCSF.
070442 -
070443 -
070445 -  ..
070446 - Emotional Stress Doctors Suffer Applying Medicare Regulations
070447 - Medicare Regulations Cause Strong Emotional Objections by Doctors
070448 -
070449 - The doctor apologized for being emotional on this subject.  He said
070450 - the tragic dimension of rising regulatory complexity is that cancer
070451 - patients, who are least able to cope and most vulnerable to rising
070452 - costs become convenient targets of opportunity for financial
070453 - professionals looking to squeeze more revenue into balance sheets.
070454 - Emotionally stressed patients unable to fathom the system are easily
070455 - pressured into paying up in order to relieve anxiety over losing their
070456 - treatments, their life, their home, and self-respect, noted at UCSF o
070457 - 070830. ref SDS 15 9K7G
070458 -
070459 -
070461 -  ..
070462 - Referral to UCSF More Cost Effective than Treatment at Kaiser
070463 -
070464 - The doctor indicated that getting approval to treat Millie at Kaiser
070465 - with cetuximab based on success at UCSF would require several levals
070466 - of approval that take a lot the doctor's time preparing justification,
070467 - and would be resisted by management in order to avoid high drug costs,
070468 - especially for cetuximab, per above. ref SDS 0 QY58
070469 -
070470 -            [On 080627 primary care physician seems to indicate Kaiser
070471 -            can treat Millie with cetuximab and Carboplatin.
070472 -            ref SDS 31 JW9F
070474 -  ..
070475 - Similarly, getting approval from Doctor Rugo to contract part of the
070476 - clinical trial to Kaiser to avoid accounting battles between Kaiser
070477 - and UCSF over allocation of costs of Millie's treatments would also
070478 - take several levels of approval at Kaiser, which would take a lot of
070479 - the doctor's time.  He seemed to indicate these changes would not be
070480 - impossible, but would be resisted as unnecessary to treat only one
070481 - patient.
070483 -  ..
070484 - Sometimes improving treatment and reducing costs to save lives, time,
070485 - and money, requires slowing down in order to speed up.  Investing time
070486 - to configure, test, and study treatment for one patient, yields
070487 - knowledge that scales up to treat many.
070489 -  ..
070490 - The doctor feels his schedule does not have enough time to meet and
070491 - develop a referral coordination plan for Millie's care at UCSF.
070492 - Similarly, Doctor Rugo did not have time to meet with Millie
070493 - yesterday.
070494 -
070495 -            [...below, medical chart reports patient suffers emotional
070496 -            panic due to UCSF billings, ref SDS 0 Y53O; doctor
070497 -            prescribed Ativan to treat panic attacks. ref SDS 0 WF8P
070499 -             ..
070500 -            [...below, medical chart treatment plan schedules
070501 -            consultation with social therapyst, and prescribes
070502 -            medication to calm emotional attacks. ref SDS 0 WF8P
070504 -  ..
070505 - At the end of the meeting, the doctor called to schedule a meeting
070506 - with oncology mental health, per above, ref SDS 0 QY45, to review ways
070507 - and means for Kaiser to pay for costs of Millie's treatment on
070508 - referral to UCSF in order to cope with emotional trauma of doubt and
070509 - worry, per above. ref SDS 0 QY9V  The doctor got a voice mail saying
070510 - the mental therapyst is on vacation for 2 weeks.  He left a message to
070511 - call and schedule a meeting with Millie, as shown in the Medical
070512 - Chart, shown below. ref SDS 0 WF8P
070513 -
070514 -            [On 070925 Karen called to facilitate solution of Kaiser's
070515 -            payment issues for referral of Millie's treatment to UCSF.
070516 -            ref SDS 18 QY5I
070518 -             ..
070519 -            [On 070926 letter from Karen reports investigating issues.
070520 -            ref SDS 19 QY5I
070522 -             ..
070523 -            [On 070926 case study shows overwhelming complexity of
070524 -            Millie's case causes emotional doubt and worry for cancer
070525 -            patient. ref SDS 19 OS4G
070527 -  ..
070528 - These understandings are reflected by the medical chart for the
070529 - meeting today...
070530 -
070531 -    1.  This is a 71 year old woman with a history of inflammatory
070532 -        cancer of left breast who was initially diagnosed 03/04/02.
070533 -        She had recurrent disease noted initially in the cervical LN's
070534 -        03/03/04.  She has been treated on several salvage regimes.  On
070535 -        E2100 Study with Avastin, she had a PE noted on CT 11/03/2004.
070536 -        She was placed on anticoagulation therapy for one year.  Then,
070537 -        because of progression of disease, the patient was started on
070538 -        Taxotere and Xeloda 4/15/05.  She had a total of 8 cycles
070539 -        ending 9/16/05.  She had a palliative left mastectomy performed
070540 -        10/21/05.  Then her left chest lesions began expanding again.
070541 -        The patient started Taxotere and Xeloda again 07/21/06 for 7
070542 -        cycles. She was started on a Clinical Trial 02/01/07 at UCSF
070543 -        and was randomized to the Erbitux only (no Carbo) Arm.  Patient
070544 -        is her for follow up.  States rash on chest and LUE is present.
070545 -        She is less SOB.  The patient has just returned from a vacation
070546 -        and her rash worsened with sun exposure.
070548 -         ..
070549 -        She has not seen Mental Health yet.  The patient is having
070550 -        panic attacks due to bills from UCSF.
070551 -
070552 -            [On 070925 Karen called to facilitate solution of Kaiser's
070553 -            payment issues for referral of Millie's treatment to UCSF.
070554 -            ref SDS 18 QY5I
070556 -             ..
070557 -            [On 070926 case study shows overwhelming complexity of
070558 -            Millie's case causes emotional doubt and worry for cancer
070559 -            patient. ref SDS 19 OS4G
070561 -         ..
070562 -    2.  Current medications include:
070564 -         ..
070565 -        TIMOLOL MALEATE 0.5% EYE DR
070566 -        WARFARIN 4MG TABLETS
070567 -        ACYCLOVIR 800MG TABLETS
070568 -        LORAZEPAM 1 MG TABLETS
070569 -        ERBITUX
070571 -         ..
070572 -    3.  Physical Examination (PE)
070573 -
070574 -        Performance Status: 0
070575 -        Chest wall: decreased erythema on lower left chest wall
070576 -        Ext: LUE edema with patch of erythema involving upper arm; LUE measured at 31
070577 -        cm
070579 -         ..
070580 -    4.  Lab:
070581 -
070582 -        PT, Patient H 24.8 Sec
070583 -        PT INR 2.5 Ratio
070584 -        CA 15-3 H 56 U/mL
070585 -        Creatinine 0.63 mg/dL
070587 -  ..
070588 - On 070906 letter to Kaiser with copy to UCSF notified that CA 15-3 28
070589 - for blood test at UCSF. ref SDS 16 G15I
070591 -  ..
070592 - Medical chart continues...
070593 -
070594 -    5.  Imaging:
070595 -
070596 -        05/20/07 CT THORAX, ABDOMEN, PELVIS W CONTRAST - no change
070597 -        12/27/06 BASE SKULL TO MIDTHIGH PET/CT
070598 -        10/16/06 HAND, TWO VIEWS
070599 -        10/13/06 MAMMOGRAPHY UNILATERAL
070600 -        07/08/06 MRI BRAIN WO/W CONTRAST(STD)- negative
070602 -         ..
070603 -    6.  Impression:
070604 -
070605 -        1. Metastatic breast cancer (IBC)lung, lymph node and chest wall
070606 -        2. LUE lymphedema; improved
070607 -        3. Hx of PE; on Warfarin INR 2-3
070608 -        4. Rash worsened
070609 -        5. Anemia
070610 -
070612 -         ..
070613 -    7.  Treatment Plan:
070614 -
070615 -        1. Continue Warfarin
070616 -        2. Continue Clinical Trial on Erbitux [cetuximab]
070617 -        3. UCSF to add Carbo if progresses
070618 -        4. Mental Health referral
070619 -        5. Continue Ativan for panic attacks
070620 -        6. FU Oncology MSW
070621 -        7. Repeat CT's
070622 -        8. RTC 8 weeks
070623 -
070624 -            [On 070925 Karen called with Kaiser Mental Health to help
070625 -            cope with emotional trauma from doubt and worry, per above,
070626 -            ref SDS 0 QY5I, by facilitating solution of Kaiser's
070627 -            payment issues, per above, ref SDS 0 QZ82, for referral of
070628 -            Millie's treatment to UCSF. ref SDS 18 QY5I
070630 -             ..
070631 -            [On 070926 letter from Karen reports action investigating
070632 -            issues to resolve problems causing emotional trauma.
070633 -            ref SDS 19 QY5I
070635 -             ..
070636 -            [On 070926 case study shows overwhelming complexity of
070637 -            Millie's case causes emotional doubt and worry for cancer
070638 -            patient. ref SDS 19 OS4G
070639 -
070640 -
070643 -
070644 -
070645 -
070646 -
070647 -
070648 -
070649 -
070650 -
070651 -
0707 -