CONTACTS 

SUBJECTS
UCSF Examination Medical Team Approve Start Next Cycle Treatment Cet
Arm Right Rash Slight Similar IBC Appearance on Left Arm Not Diagnos

0404 -
0404 -    ..
0405 - Summary/Objective
0406 -
040601 - Follow up ref SDS 41 0000. ref SDS 40 0000.
040602 -
040603 -
040604 -
040605 -
040607 -  ..
0407 -
0408 -
0409 - Progress
0410 -
041001 - Millie met with the medical team.  Condition appears stable,
041002 - consistent with CT test report a few weeks ago on 070930, and reported
041003 - in the record for the meeting today, see below. ref SDS 0 4N7K
041005 -  ..
041006 - Blood test results for lab performed at Kaiser yesterday were not
041007 - reported to UCSF in time for the meeting.  Jackie is following up her
041008 - letter to Arlette, reported on 071017, ref SDS 46 Q45F, to get the
041009 - report from Kaiser.  She proposed patient coordination with Kaiser to
041010 - get test results for Labs done at Kaiser will fit UCSF referral
041011 - coordination model better than reliance on the UCSF clinical trial
041012 - coordinator.
041014 -  ..
041015 - The UCSF pharmacy delayed treatment today for an hour or so until
041016 - after Kaiser submitted the report for the blood test yesterday at
041017 - Kaiser in Martinez. ref SDS 46 UW5J  This corrects prior quality
041018 - control problems when blood counts were found to be too low for
041019 - treatment after treatment was given.
041020 -
041022 -  ..
041023 - Lab Blood Test Report
041024 -
041025 - Follow up
041026 -
041027 - While Millie was in the Infusion Clinic on the 5th floor, after
041028 - meeting with the doctor, Jackie brought a fax she received from
041029 - Arlette for the blood test at Kaiser yesterday. ref SDS 46 OS5K, and
041030 - which Jackie had coordinated with Arlette, ref SDS 46 Q45F, responding
041031 - to Millie's letter on 071015 asking about doing labs at Kaiser in
041032 - order to solve the payment dispute between UCSF and Kaiser.
041033 - ref SDS 45 KH5T
041035 -  ..
041036 - The report does not show CA 15-3, ref SDS 48 5K6K, because the cancer
041037 - marker takes a day or so to prepare the diagnostic; nor is the value
041038 - for NEUTS shown, because Kaiser uses an ANC number, and this report
041039 - was done by Kaiser.
041040 -
041041 -     [On 071019 Millie letter asks UCSF for CA 15-3 and NEUTS,
041042 -     ref SDS 49 UW5J, to support considerations about returning to
041043 -     active duty at work. ref SDS 49 JC6X
041045 -      ..
041046 -     [On 071023 Kaiser submitted CA 15-3 but not ANC, ref SDS 50 HP4L,
041047 -     and omitted part of the blood test report. ref SDS 50 JM41
041049 -  ..
041050 - Kaiser calculates an ANC composite number to assess safety for
041051 - patients to get treatment.  UCSF calls this same calculation NEUTS,
041052 - reported on 070301. ref SDS 28 P560  The blood test eventually received
041053 - from Kaiser today does not list ANC.  On 060814 Diana clarified the
041054 - formula at Kaiser for calculating ANC. ref SDS 19 P563
041056 -  ..
041057 - WBC          = 4.3............ ref SDS 0 UH37
041058 - Neutrophils  = 36%  .......... ref SDS 0 QK4L
041059 - Bands        = 0
041060 -
041061 -                    4.3 x 1000 x (.36 + 0) = 1548
041063 -  ..
041064 - Kaiser ANC 1548 correlates to UCSF NEUTS 1.54.
041066 -  ..
041067 - NEUTS 1.54 for the test on 071017 appears to have dropped slightly
041068 - from 1.69 for the test last month at UCSF on 070920.  At UCSF, 1.54 is
041069 - below the level for safe treatment shown as 1.8 - 6.8, but 1548 is
041070 - slightly above Kaiser's standard of 1500.
041071 -
041073 -  ..
041074 - CT Test 070930 Reviewed at UCSF Shows Stable NED Condition
041075 -
041076 - Follow up ref SDS 43 0001. ref SDS 40 EH5G.
041077 -
041078 - Prior CT test on 070723 was received on 070802. ref SDS 35 O85M
041080 -         ..
041081 -        Test History No Evidence Distant Metastasis
041082 -        Distant Metastasis No Evidence 5 Years Imaging Tests
041083 -
041084 -        Follow up ref SDS 35 LW6M, ref SDS 33 DA8O.
041085 -
041086 -        Type    Date           Received          Source
041087 -         CT     070930 reported on 071018........... ref SDS 0 VK8L
041088 -         CT     070723 reported on 070802........... ref SDS 35 IM6M
041089 -         CT     070520 reported on 070524........... ref SDS 33 DA6Q
041090 -         CT     070326 reported on 070329........... ref SDS 31 DA6Q
041091 -         CT     070131 reported on 070202........... ref SDS 26 1Y8G
041092 -         PET/CT 061227 reported on 070102........... ref SDS 22 1Y8G
041093 -         CT     060930 reported on 061012........... ref SDS 20 284J
041094 -         MRI    060708 reported on 060711........... ref SDS 18 PT4K
041095 -         Xray   060623 reported on 060711........... ref SDS 18 WJ6G
041096 -         CT     060505 reported on 060523........... ref SDS 17 E355
041097 -         PET    060414 reported on 060428........... ref SDS 16 WJ6G
041098 -         PET    060120 reported on 060126........... ref SDS 15 WJ6G
041099 -         PET/CT 051005 reported on 051007........... ref SDS 14 WJ6G
041100 -         CT     050530 reported on 050610........... ref SDS 13 G75L
041101 -         CT     050325 reported on 050422........... ref SDS 12 G75L
041102 -         CT     041217 reported on 041230........... ref SDS 11 G75L
041103 -         CT     041103 reported on 041104........... ref SDS 10 WV7H
041104 -         CT     040921 reported on 041005........... ref SDS 9 NL4N
041105 -         CT     040710 reported on 040811........... ref SDS 8 H85S
041106 -         CT     040410 reported on 040416........... ref SDS 7 LK5L
041107 -         CT     040307 reported on 040318........... ref SDS 6 LK5L
041108 -         CT     031031 reported on 031205........... ref SDS 5 IG9K
041109 -         CT     030626 reported on 030710........... ref SDS 4 AL6N
041110 -         CT     030428 reported on 030508........... ref SDS 3 LK5L
041111 -         PET    021218 reported on 030109........... ref SDS 2 LK5L
041112 -         PET    020529 reported on 020603........... ref SDS 1 0001
041114 -  ..
041115 - CT test on 070930 (received from Kaiser on 071002), ref SDS 43 615J...
041117 -             ..
041118 -            [On 071213 received next CT scan prerformed on 071210.
041119 -            ref SDS 51 0J7N
041121 -         ..
041122 -    1.  Procedure Note 0357370409/30/200708:08:25WCRX0101 10/2/2007
041123 -        FISCH, ALLAN EUGENE (M.D.)
041125 -         ..
041126 -    2.  CT OF THE CHEST, ABDOMEN AND PELVIS
041127 -
041128 -    3.  ** HISTORY **:
041129 -        Breast CA
041131 -         ..
041132 -    4.  ** FINDINGS **:
041133 -        Compare 7-23-07: Left mastectomy noted. There is no axillary
041134 -        adenopathy. The lungs are unchanged, free of infiltrates or
041135 -        masses. There are no pleural effusions. There are no hilar or
041136 -        mediastinal masses seen. The heart is normal in size.
041137 -
041138 -            [On 071213 CT test on 071210 reports findings in the report
041139 -            for this test on 070930 show lymph node right axillary 8 x
041140 -            7 mm; increased to 11 x 11 mm; indicating analyst either
041141 -            overlooked the 8 x 7 mm node or determined this was too
041142 -            small to report. ref SDS 51 SR5P
041144 -             ..
041145 -            [On 071213 CT test on 071210 reports "stable 1.6 x 0.7 cm
041146 -            pretracheal lymph node," ref SDS 51 SR5P; "stable" implies
041147 -            this condition was shown in the report today for the test
041148 -            on 070930, however, the report makes no such finding.
041149 -            ref SDS 0 KK6J
041151 -         ..
041152 -        The liver, spleen, pancreas and adrenal glands are unchanged.
041153 -        The kidneys are unchanged.  The aorta is normal in caliber.
041154 -        There is no adenopathy and no evidence of free fluid.  Scans
041155 -        through the pelvis are unchanged.
041157 -         ..
041158 -        There are stable degenerative skeletal changes.
041159 -
041160 -    5.  ** IMPRESSION **:
041161 -        Unchanged CT scan of the chest, abdomen and pelvis.
041162 -
041163 -        A. FISCH M.D.
041164 -
041166 -  ..
041167 - Examination by Brigid and Doctor Rugo shows no progression of IBC
041168 - disease.
041169 -
041170 -     [On 071019 Millie notifies UCSF of considerations for returning to
041171 -     work. ref SDS 49 4Q3H
041172 -
041173 -
041174 -
041175 -
041176 -
041177 -
041178 -
041179 -
0412 -

SUBJECTS
Arm Right Rash Slight Similar IBC Appearance on Left Arm Not Diagnos

0603 -
060401 -  ..
060402 - Arm Right Slight Rash Similar Appearance IBC Not Diagnosed IBC
060403 -
060404 - Millie reported new slight rash on upper, inner right arm extending
060405 - below the elbow on inner arm area, first noticed yesterday.  Rash
060406 - presents low intensity dispersed red dots, similar in texture to IBC
060407 - rash on upper left arm.
060409 -  ..
060410 - Brigid recalled slight rash on right arm occurred previously, reported
060411 - on 070301. ref SDS 27 H15M  At that time, the rash persisted for
060412 - several weeks, reported on 070315. ref SDS 29 FO6H  A week later on
060413 - 070322 the nurse in the Infusion Clinic reported no evidence of rash
060414 - on the right arm. ref SDS 30 LI4M
060416 -  ..
060417 - Brigid also recalled Cellulitis occurred as slight rash on entire left
060418 - arm observed during meeting on 070607.  At that time, Doctor Rugo made
060419 - examination and prescribed home treatment for Cellulitis. ref SDS 34
060420 - ZI35  This progressed rapidly after the meeting, ref SDS 34 TU6J,
060421 - resulting in UCSF treating Millie for Cellulitis in the Infusion
060422 - Clinic. ref SDS 34 8J37
060424 -  ..
060425 - Doctor Rugo noted today there is no evident rapid progression that
060426 - occurs with Cellulitis.  The condition is closer to what occurred on
060427 - 070301,per above. ref SDS 0 SL8M
060429 -  ..
060430 - This may be an example of inflammation side effects from cetuximab
060431 - noted in UCSF documention received on 070116, ref SDS 24 MH4Q, which
060432 - was mistaken for Cellulitis during examination at Kaiser on 070330.
060433 - ref SDS 32 F46F
060434 -
060435 -
060436 -
0605 -

SUBJECTS
Default Null Subject Account for Blank Record

0703 -
070401 -  ..
070402 - Cut Loose by Kaiser Patient Independent Contractor with UCSF
070403 -
070404 - Follow up ref SDS 38 XH5H, ref SDS 37 I49K.
070405 -
070406 - Doctor Rugo expanded today on the record of communications arranging
070407 - for Millie's treatment at UCSF last January.  She seemed to indicate
070408 - having interpreted communications with Kaiser after 070119 to mean
070409 - that Millie was "cut loose" by Kaiser to be an independent contractor
070410 - managing the transaction between UCSF and the patient, including
070411 - Medicare, and without benefit of her bargain with Kaiser for insurance
070412 - premiums to pay for account management, which Kaiser is obligated to
070413 - perform under Senior Advantage EOC Section 2, reviewed on 070927.
070414 - ref SDS 42 WS6M
070416 -  ..
070417 - This condition of being "cut loose" from Kaiser performing contract
070418 - management, including payment of expenses, was not conveyed to Millie
070419 - prior to UCSF performing work on the referral, and has never been
070420 - disclosed by Kaiser nor UCSF.
070422 -  ..
070423 - On 070130 Millie met at UCSF for the first time to start work, and
070424 - gathered from the doctor that business arrangements had been resolved
070425 - between Kaiser and UCSF, and that UCSF and Kaiser would work as a team
070426 - collaborating on Millie's care. ref SDS 25 AQ5L  There was no
070427 - discussion of costs and payments at that time on 070130, other than
070428 - that the doctor was relieved Millie would not get stuck with a big
070429 - bill, ref SDS 25 LY9H, because Kaiser had previously agreed in
070430 - correspondence with UCSF on 061230 to pay any costs not covered by the
070431 - clinical trial. ref SDS 21 3X6K  Kaiser in fact at all times performed
070432 - as retaining responsibility for managing Millie's referral at UCSF by
070433 - making regular examinations providing oversight of UCSF work, shown by
070434 - the meeting at Kaiser on 070202, ref SDS 26 0000, and continuing
070435 - regularly to the present, exactly the same as Kaiser did for prior
070436 - referrals, when Kaiser paid all costs - see case study listed on
070437 - 070830. ref SDS 36 LQ5I
070439 -  ..
070440 - The doctor apologized today about complex billings from UCSF, cited in
070441 - Millie's letter to the doctor on 071011, ref SDS 44 UW5J, saying
070442 - payment would be deferred until UCSF clarifies procedures and amounts.
070443 - ref SDS 44 K64Q  Doctor Rugo indicated that accounting is "another
070444 - world" far apart from the medical services department, and so she
070445 - cannot get involved in determining who all at UCSF bills patients for
070446 - medical services.
070448 -  ..
070449 - California Supplemental Support Clinical Trials Medicare Patients
070450 -
070451 - Doctor Rugo explained today an understanding that California law
070452 - requires HMOs to pay for referrals treating patients with clinical
070453 - trials, including 20% coninsurance called out in Medicare law,
070454 - reviewed on 070917. ref SDS 39 4Q3I
070456 -  ..
070457 - The doctor feels Kaiser is fighting this additional requirement in
070458 - California law.
070460 -  ..
070461 - Research with...
070462 -
070463 -    California law HMO referral "clinical trials" cancer Medicare
070464 -
070465 - ...yields sources that seem to say California HMO's must pay for
070466 - standard of care for referrals to treat cancer...
070468 -  ..
070469 - Another source says about half-way through the page...
070470 -
070471 -        Health Net
070472 -        HMO  Plan 52Y
070473 -        Summary of benefits and Disclosure Form
070474 -
070475 -              http://healthnet.com/static/custom/unprotected/pdfs/ccsf_hmo_benefit_summary.pdf
070477 -         ..
070478 -        Clinical trials Routine patient care costs for patients
070479 -        diagnosed with cancer who are accepted into phase I, II, III,
070480 -        or IV clinical trials are covered when medically necessary,
070481 -        recommended by the member's treating physician and authorized
070482 -        by Health Net.  The physician must determine that participation
070483 -        has a meaningful potential benefit to the member and the trial
070484 -        has the rapeutic intent.  For further information, please refer
070485 -        to the EOC.
070487 -  ..
070488 - This is actually what happened at Kaiser.  The doctor reviewed the
070489 - trial and determined it is the best treatment for the patient, and
070490 - prescribed it, reported on 070105. ref SDS 23 PK7L
070492 -  ..
070493 - Questions are whether Health Net scope of coverage for clinical trials
070494 - of patients diagnosed with cancer applies to senior folks who have
070495 - Medicare.  Kaiesr is hanging its position on Medicare benefits.
070497 -  ..
070498 - Presumably Health Net has a legal team comparable to Kaiser, and so if
070499 - they conclude the Health Net clinical trial scope is supported in the
070500 - law, then Kaiser may be reaching too far denying such coverage.
070502 -  ..
070503 - May have found a source for federal health law...
070504 -
070505 -        Health Administration Responsibility Project
070506 -        Relevant WWW Links
070507 -
070508 -              http://www.harp.org/links.htm
070509 -
070510 -
070511 -
070512 -
070513 -
0706 -