Now, just as California’s law aid-in-dying law takes effect this week, Shavelson has added another specialty: A consultant to physicians and terminally ill patients who have questions about how it works.

“Can I just sit back and watch?” Shavelson asked  from his cottage office. “This is really an amazing opportunity to be part of establishing policy and initiating something in medicine. This is a major change … [that] very, very few people know anything about and how to do it.”

Shavelson is the author of the 1995 book, “,” which followed five terminally ill people over two years as they determined whether to amass drugs on their own and end their lives at a time of their choosing. He was present at the death of all of them.

He followed the issue closely for several years, but ultimately moved on to other projects — among them a book about addiction and a about people who identify as neither male nor female.

Then last fall came the  giving terminally ill adults with six months to live the right to request lethal medication to end their lives. The law takes effect Thursday.

Shavelson decided he had to act, adding that he feels “quite guilty” about having been away from the issue while others pushed it forward.

His website, went up in April, and he’s outlined the law at “grand rounds” at several Bay Area hospitals this spring. His practice will be focused on consulting not only with physicians whose patients request aid-in-dying, but also with patients themselves. As he indicates on his site, he will offer care to patients who choose him as their “attending End-of-Life physician.”

Shavelson is adamant that this is “something that has to be done right.” To him, that means starting every patient encounter with a one-word question: “Why?”

“In fact, it’s the only initial approach that I think is acceptable. If somebody calls me and says, ‘I want to take the medication, my first question is ,’Why? Let me talk to you about all the various alternatives and all the ways that we can think about this.'”

Shavelson worries that patients may seek aid-in-dying because they are in pain. So first, he would like all his patients to be enrolled in hospice care.

“This can only work when you’re sure that the patients have been given the best end-of-life care, which to me is most guaranteed by being a part of hospice or at least having a good palliative care physician. Then this is a rational decision. If you’re doing it otherwise, it’s because of lack of good care.”

California is the fifth state to legalize aid-in-dying, joining Oregon, Washington, Vermont and Montana. The option is very rarely used. For example, in ,  just 155 lethal prescriptions were written under the state’s law, and 105 people ultimately took the medicine and died.

California’s new law goes into effect on June 9. Catch up on KHN’s coverage of the issue:

Under the California law, two doctors must agree that a patient has six months or less to live. The patient must be mentally competent. At least one of the meetings between the patient and his or her doctor must be private, with no one else present, to ensure the patient is acting independently.

Patients must be able to swallow the medication themselves and must affirm in writing, within the 48 hours before taking the medication, that they will do so.

Shavelson says he has been surprised by the poor understanding of the law among some health care providers. One insisted the law was not taking effect this year; another asked how the law would benefit his patients with Alzheimer’s disease. (Patients with dementia don’t qualify under the law because they are not mentally competent.)

The law does not require that health care providers participate in ending terminally ill patients’ lives. Many physicians are “queasy” about the law, Shavelson said, and are unwilling to prescribe to patients who request the lethal medication — even when they think having such a law in place is the right thing to do.

“My response to that is as health care providers, you might have been uncomfortable the first time you drew blood. You might have been uncomfortable the first time you took out somebody’s gall bladder,” he said. “If it’s a medical procedure you believe in and you believe it’s the patient’s right, then it’s your obligation to learn how to do it — and do it correctly.”

Shavelson predicts that many physicians who are initially reluctant to provide this option to their patients may become more comfortable after the law goes into effect and they see how it works.

Burt Presberg, an East Bay psychiatrist who works with cancer patients and their families, attended a talk by Shavelson, and it led to some soul searching.

He wrestles with his own comfort level in handling patient requests. When he talks, he often pivots from his initial point to “on the other hand.”

Presberg says he is concerned that patients suffer from clinical depression at the end of life. Sometimes they feel they are a burden to family members who could “really push for the end of life to happen a little sooner than the patient themselves.”

His experience is that terminally ill patients with clinical depression can be successfully treated. He said he believes Shavelson will be aware of the need to treat depression,”but I do have concerns about other physicians.”

“On the other hand,” he added, “I think it’s really good that this is an option.”

Shavelson says he’s already received a handful of calls from patients, but mostly he’s spent his time before the law takes effect talking to other physicians. He needs a consulting physician and a pharmacist who will accept prescriptions for a lethal dose of medicine.

Then his mind returns to the patient. “It’s important … that we’re moving forward,” he said. “It’s crucial that we do that because this is part of the rights of patient care to have a certain level of autonomy in how they die.”

To him, this type of care “isn’t so tangibly different” from other kinds of questions doctors address.

“I’m just one of those docs who sees dying as a process, and [the] method of death is less important than making sure it’s a good death.”

This story is part of a partnership that includes , NPR and Kaiser Health News.

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Today, that same ward is filled with diabetes patients.

“I feel like we are with diabetes where we were in 1990 with the AIDS epidemic,” Schillinger said. “The ward is overwhelmed with diabetes — they’re getting their limbs amputated, they’re on dialysis. And these are young people. They are suffering the ravages of diabetes in the prime of their lives. We’re at the point where we need a public health response to it.”

Schillinger and other researchers at the University of California at San Francisco are setting up a project called , to spell out the health dangers of too much added sugar in our diets. The project aimed at consumers includes a user-friendly Web site and materials such as television commercials that public health officials can use for outreach. Health departments from San Francisco to New York City have agreed to participate.

There’s a reason the word “science” is part of the project’s name. The UCSF team distilled 8,000 studies and research papers and found strong evidence that the consumption of too much added sugar overloads vital organs and contributes not just to Type 2 diabetes but also to heart disease and liver disease.

Although there are no federal guidelines that recommend a limit on sugar consumption, the American Heart Association (AHA) urges cutting back dramatically. The average American consumes the equivalent of in added sugar. The men should reduce that to no more than nine teaspoons and women should consume less than six teaspoons. The similar limits.

Laura Schmidt, a professor of health policy at UCSF’s medical school, is also part of the Sugar Science team. “Right now, the reality is that our consumption of sugar is out of whack,” she says, “and until we bring things back into balance, we need to focus on helping people understand what the consequences are.”

Schmidt is quick to point to the food environment as a driver of the increase in obesity over the past generation. “The only major change in the diet that explains the obesity epidemic is this steep rise in added sugar consumption that started in the 1980s,” she says.

That sugar isn’t just making us fat, she says, “it’s making us sick.”

Schillinger concurs, saying Sugar Science has no political agenda and wants to generate “credible science, what we understand and don’t understand about sugar.”

It’s about knowing how much sugar is too much, researchers say.

But knowing how much sugar you’re eating can be challenging. Some key facts on the Sugar Science Web site are these:

— Added sugar is hiding in 74 percent of packaged foods, including some products that are considered healthful and may not be viewed as sweet, such as yogurt, pasta sauce and salad dressing. ( would include a separate line for added sugars.)

— Overloading on fructose, a common type of added sugar, can damage your liver — just like too much alcohol.

— One 12-ounce can of soda a day can increase your risk of dying of heart disease by one-third. That same soda can have as many as nine teaspoons of sugar. (Sugar is listed by grams on nutrition labels; .)

The site also includes tips for cutting down on sugar. The easiest way to do so, the researchers say, is to stop drinking sugar-sweetened beverages.

More than in the American diet comes from sugary drinks. The Sugar Science researchers also recommend reading nutrition labels. Although there are 61 names for sugar on ingredient labels, the UCSF team says that “if the chemical name has an ‘ose’ at the end — as in dextrose, fructose, lactose — it’s likely to be added sugar.”

Lisa Aliferis is editor of . This article, which was done in collaboration with , is part of a partnership that includes , and Kaiser Health News.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

Three California doctors are among the top five nationally in billing for the most complex office visits, according to data released by Medicare and analyzed by ProPublica and KQED.

Most doctors’ billing patterns to the Medicare program fall in the middle ground between simple and complex.

In California, only 5 percent of doctors’ office visits for Medicare patients were billed at the highest level in 2012. It is unusual for doctors to determine — and bill — a large proportion of their office visits as complex.

The analysis of Medicare billing data — which was made public for the first time last month — shows that in billing for the highest number of the most complex office visits. In addition, they tended to bill at the highest level significantly more frequently than peers in their specialty.

— In Orange County, , a hematologist-oncologist, billed Medicare for 6,340 of these visits in 2012, the most of any doctor in the country and significantly more frequently than similar specialists nationwide. Almost 79 percent of his office visits were billed at the highest level, whereas other hematologist-oncologists only billed 12 percent of their office visits the same way.

— In the Santa Cruz County community of Freedom nearly every one of cardiologist ‘s patients received – and was charged for – the highest complexity visit. Mace billed Medicare for these high level visits almost 10 times more often than other cardiologists in California, and the third most in the country

— Cardiologist ranks fifth in the country for the number of times he billed the most complex type of visit to his office in Los Angeles. His average patient received four of these visits in a year, compared to the one visit typical of other cardiologists in the state.

“That’s unusual for a doctor who’s not seeing patients in the hospital,” said Lamar Blount, a Medicare billing expert with the Health Law Network consultancy in Atlanta. “Usually cardiac patients in the hospital are the ones that are about to die.”

KQED conducted this analysis in conjunction with ProPublica, which published a last week. ProPublica also developed a tool, which allows consumers and journalists to look up a provider and see how often he or she bills at the highest level for office visits.

Patients Pay More, Too

These billing patterns raise questions for Medicare as a whole and for individual patients who pay a percentage copay. The higher level visits cost more. “Twenty percent of $200, for example, is obviously more than 20 percent of $100,” said Christina Melnykovych, president of Coding Continuum and an expert in insurance billing. “There’s a direct correlation between the service level billed and the paid amount, and thus the copay impacts the patient.”

All established patient office visits are coded under a category called “evaluation and management.” These visits are billed at one of five levels, with “5″ being the most complex. Established patients are people the provider has seen at least once before. First-time doctor appointments are coded differently.

The Centers for Medicare and Medicaid Services, which runs Medicare, declined to comment for this story and in a statement said they have not seen the data analysis.

“Some providers have sicker patients, thus are more likely to bill at [evaluation and management] coding levels that carry higher payments. Every day we work with providers to make patient care the priority, and at the same time ensure they use [evaluation and management] codes that reflect the level of service provided,” the agency said. “It’s our assessment that it would be highly unusual for a provider to knowingly use the highest (level) code … for all or nearly all of his or her outpatient visits.”

Only one percent of California doctors billed Medicare at the highest level for all of their office visits for their established patients.

Coding experts stress that while the numbers cited for the doctors above do not by themselves indicate wrongdoing, they do raise eyebrows.

‘I’m Not An Average Cardiologist’

We tried to reach all of the doctors named in this report, with repeated phone calls plus faxes detailing our questions. Drs. VanderMolen and Schapira did not respond to our requests.

Dr. Mace sent us a written statement in which he vigorously defended his billing patterns. “I’m not an average cardiologist,” he wrote. “I spend a great deal of time taking care of patients. I generally spend 12-16 hours per day in the practice of medicine. I do not take any lunch breaks. I am on call 24 hours a day, seven days a week and do not take vacations. By being available and devoting a great deal of resources to the patients, I hope that this comprehensive care translates to improved quality of life for my patients and hopefully, improved quantity of life (longevity).”

But billing for an individual visit is not about a physician’s dedication. Experts say it is about the patient’s complaint that day. “What was it about the patient’s clinical presentation and condition that warranted billing a level 5 service?” Melnykovych said.

In his statement, Mace said he had been “subject to several audits” over many years in regards to this level 5 billing code. He says that Medicare “has found all of the office visits reviewed to be correctly coded.”

While the established office visits are not based on time, per se, as a metric for coding, the American Medical Association assigns average time that would normally go along with different visit levels. For a level 5 visits, it’s 40 minutes, Melnykovych said.

If VanderMolen spent the average 40 minutes during all the 6,340 visits which he billed Medicare, that would mean he saw patients 16 hours a day — presuming he worked every weekday in 2012. Medicare paid VanderMolen nearly $750,000 for these level 5 visits in 2012. He was reimbursed another $1.6 million by Medicare for other services performed.

Overpayment can happen for many reasons, including simple error. “But that doesn’t preclude the federal government or any payer from coming to the (doctor) and getting their money back,” Melnykovych said.

Sometimes the excuse is legitimate. Blount said if a doctor is affiliated with a teaching hospital – Schapira is a professor at the school of medicine at UCLA – that could explain a higher volume of patients at higher level codes. In his statement, Mace said that he is “currently on staff at Stanford.”

A spokesman for Stanford Hospital and Clinics said in an email to KQED that Mace is an “independent community cardiologist who has ‘courtesy admitting’ privileges at Stanford Hospital & Clinics. Dr. Mace is not on Stanford’s faculty.”

VanderMolen’s says that he “has had several university, hospital, and other appointments.” It does not indicate any current affiliations with any academic medical centers.

Problems can also arise from the billing set up at a doctor’s office. Many doctors don’t do their own billing, Blount says. They dictate their office notes from a visit or fill out a checklist, and then a clerk in the billing department enters a code.

“Many times a physician is not even aware of what their claims are or how their claims are coded,” Blount says.

He has also seen a rising trend in unintended coding errors that mirror the rise of the implementation of electronic medical record systems. Many of these systems include an automated coding function. A physician will type in medical observations and treatment protocols, and then an algorithm will determine the code.

“Those algorithms are subject to human error,” Blount says. “Some mistakes are being made by the electronic medical record vendors in how they designed the product that they’re selling.”

Still, according to Medicare rules, the ultimate responsibility for billing always rests with the doctor.

Frequent visits

It’s not just the total number of visits that could raise red flags among auditors — repeat complex visits by individual patients could also be a cause for concern.

is listed in Medicare’s billing database as an outpatient emergency medicine doctor in Newhall, a suburb of Los Angeles. Typically, this kind of physician sees patients at an outpatient urgent care center for any range of simple, non-urgent complaints, like sore throats, to more urgent matters, like a broken wrist.

According to KQED’s analysis, Ordog’s patients received – on average — 30 of the most complex office visits in 2012. The average for other emergency medicine doctors is 1 complex visit per patient.

“That’s a little suspect,” says Patrice Morin-Spatz, a medical coding expert and trainer.

This is not the first time questions have arisen around Ordog’s medical practices. In the mid-2000s, Ordog served numerous times as an expert medical witness in court cases arguing that mold in residential units and work environments made his patients severely ill.

The California Medical Board tried to revoke Ordog’s medical license in 2006 for “repeated negligent acts, incompetence, making false statements, and inadequate record keeping,” according to legal documents. He was put on probation and permitted to continue practicing medicine but prohibited from participating in any litigation. Ordog was found to have violated the terms of his probation by preparing reports for four patients in workers’ compensation claims. He signed a settlement agreement in September that extended his probation until March 2015.

Ordog did not respond to repeated requests for comment made via phone, fax, and to his attorney.

How We Did This

KQED partnered with ProPublica to analyze provider billing patterns for regular office visits for Medicare patients. ProPublica released its national report Thursday. We used data released in April by the Centers for Medicare and Medicaid Services showing the payments made to providers in Medicare’s Part B program in 2012.

KQED focused its analysis only on California providers who billed Medicare for at least 100 office visits for established patients in 2012.

We looked at the doctors who billed Medicare at the highest level (5) for the majority of their office visits. We also looked for other unusual patterns, including providers whose patients received an unusually high number of level 5 visits, or doctors who provided level 5 visits to an unusually high percentage of their patients.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).