Medicare Is Faulted in Electronic Medical Records Conversion

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

Mike Spencer/Wilmington Star-News, via Associated Press

Celeste Stephens, a nurse, leads a session on electronic records at New Hanover Regional Medical Center in Wilmington, N.C.

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

This article has been revised to reflect the following correction:

Correction: November 30, 2012

An article on Thursday about a federal report critical of Medicare’s performance in assuring accuracy as doctors and hospitals switch to electronic medical records misstated, in some copies, the timing of a statement from a Medicare spokesman in response to the report. The statement was released late Wednesday, not late Thursday.

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Recipes for Health: Asian Chopped Salad With Seasoned Tofu ‘Fingers’ — Recipes for Health

Andrew Scrivani for The New York Times

I like to serve the baked seasoned tofu “fingers” warm on top of the salad. They are delicious cold, too; it is worth making up a separate batch for the refrigerator. If you have an assortment of vegetables leftover from Thanksgiving dinner, throw them in!

For the Tofu:

1/4 cup soy sauce

2 tablespoons mirin (sweet Japanese rice wine)

1 tablespoon rice vinegar

1 tablespoon minced or grated fresh ginger

1/2 teaspoon sugar

1 tablespoon Asian sesame oil

1 pound firm tofu

For the salad:

1 romaine heart, chopped

5 cups mixed chopped or diced vegetables such as:

Green or red cabbage

Celery (from the inner heart)

Red pepper

Radishes, sliced or chopped

1/4 cup dry roasted peanuts, coarsely chopped

1/4 cup chopped cilantro (more to taste)

1 serrano pepper, seeded and minced (optional)

For the dressing:

2 tablespoons fresh lime juice

1/4 cup tofu marinade, above

2 tablespoons canola or peanut oil

1/3 cup low-fat buttermilk or plain nonfat yogurt

1. Marinate the tofu: combine the soy sauce, mirin, rice vinegar, ginger and sugar in a 2-quart bowl. Whisk in the sesame oil and combine well. Drain the tofu and pat dry with paper towels. Slice into 1/3-inch thick slabs and cut the slabs in half lengthwise to get “fingers” approximately 1/3 inch thick by 3/4 inch wide. Blot each finger with paper towels. Add to the bowl with the marinade and gently toss to coat. Cover and refrigerate for 15 minutes to an hour, or for up to a day.

2. Meanwhile, heat the oven to 375 degrees and line a baking sheet with parchment. Lift the tofu out of the marinade and arrange the pieces on the parchment-covered baking sheet. Bake for 7 to 10 minutes, until the edges are just beginning to color and the marinade sets on the surface of the tofu. Remove from the heat.

3. In a large bowl, combine all of the salad ingredients. Whisk together the dressing ingredients and toss with the salad. If desired, transfer to a platter. Garnish with the tofu strips and serve.

Yield: Serves 4

Advance preparation: The chopped vegetables can be prepared up to a day ahead and refrigerated in a well covered container. The tofu marinade will keep for two days in the refrigerator. The baked seasoned tofu will keep for several days in the refrigerator.

Nutritional information per serving: 317 calories; 20 grams fat; 2 grams saturated fat; 8 grams polyunsaturated fat; 9 grams monounsaturated fat; 1 milligram cholesterol; 19 grams carbohydrates; 5 grams dietary fiber; 470 milligrams sodium (does not include salt to taste); 16 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Recipes for Health: Asian Chopped Salad With Seasoned Tofu ‘Fingers’ — Recipes for Health

Andrew Scrivani for The New York Times

I like to serve the baked seasoned tofu “fingers” warm on top of the salad. They are delicious cold, too; it is worth making up a separate batch for the refrigerator. If you have an assortment of vegetables leftover from Thanksgiving dinner, throw them in!

For the Tofu:

1/4 cup soy sauce

2 tablespoons mirin (sweet Japanese rice wine)

1 tablespoon rice vinegar

1 tablespoon minced or grated fresh ginger

1/2 teaspoon sugar

1 tablespoon Asian sesame oil

1 pound firm tofu

For the salad:

1 romaine heart, chopped

5 cups mixed chopped or diced vegetables such as:

Green or red cabbage

Celery (from the inner heart)

Red pepper

Radishes, sliced or chopped

1/4 cup dry roasted peanuts, coarsely chopped

1/4 cup chopped cilantro (more to taste)

1 serrano pepper, seeded and minced (optional)

For the dressing:

2 tablespoons fresh lime juice

1/4 cup tofu marinade, above

2 tablespoons canola or peanut oil

1/3 cup low-fat buttermilk or plain nonfat yogurt

1. Marinate the tofu: combine the soy sauce, mirin, rice vinegar, ginger and sugar in a 2-quart bowl. Whisk in the sesame oil and combine well. Drain the tofu and pat dry with paper towels. Slice into 1/3-inch thick slabs and cut the slabs in half lengthwise to get “fingers” approximately 1/3 inch thick by 3/4 inch wide. Blot each finger with paper towels. Add to the bowl with the marinade and gently toss to coat. Cover and refrigerate for 15 minutes to an hour, or for up to a day.

2. Meanwhile, heat the oven to 375 degrees and line a baking sheet with parchment. Lift the tofu out of the marinade and arrange the pieces on the parchment-covered baking sheet. Bake for 7 to 10 minutes, until the edges are just beginning to color and the marinade sets on the surface of the tofu. Remove from the heat.

3. In a large bowl, combine all of the salad ingredients. Whisk together the dressing ingredients and toss with the salad. If desired, transfer to a platter. Garnish with the tofu strips and serve.

Yield: Serves 4

Advance preparation: The chopped vegetables can be prepared up to a day ahead and refrigerated in a well covered container. The tofu marinade will keep for two days in the refrigerator. The baked seasoned tofu will keep for several days in the refrigerator.

Nutritional information per serving: 317 calories; 20 grams fat; 2 grams saturated fat; 8 grams polyunsaturated fat; 9 grams monounsaturated fat; 1 milligram cholesterol; 19 grams carbohydrates; 5 grams dietary fiber; 470 milligrams sodium (does not include salt to taste); 16 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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U.S. Is Weighing Stronger Action in Syrian Conflict

Francisco Leong/Agence France-Presse — Getty Images

Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.

WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.

While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.

The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”

But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.

Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.

Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”

The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.

In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.

“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.

France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.

American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.

“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”

Jessica Brandt contributed reporting from Cambridge, Mass.

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Tool Kit: Video Gaming on the Pro Tour, for Glory but Little Gold

When Sean Plott was 15, he and his older brother, Nick, begged their mother to fly them from Kansas to Los Angeles for a video game tournament.

For Cara LaForge, their single mother, who was struggling to start a new business, the expense was steep. Her sons passionately insisted they could win, so she conceded. But there was a catch: “If you don’t win, you’re going to pay me back,” she recalled.

They didn’t win.

Ms. LaForge didn’t make her sons pay her back, but in a way, they have. Eleven years later, she is the business manager at Sean Plott’s company Day[9]TV, which broadcasts daily videos online geared toward gamers. The two brothers are celebrity personalities in the world of StarCraft II, a popular strategic game. Sean Plott was featured on Forbes’s 30 under 30 list in 2011.

Video games have evolved from an eight-bit hobby to a $24 billion industry in 2011, according to the NPD Group, a research firm. As more people play games, more of them compete in structured competitive tournaments, complete with fans, sponsors and lucrative contracts. It’s a long and tough slog, as Ms. LaForge’s story suggests.

But just how crazy is it to encourage your gamers to get off the couch and hit the road to play for money? Maybe a little crazier than encouraging a child to become a professional bowler or chess master. Professional gamers follow a track similar to professional golfers, entering several tournaments a year and collecting prize money, said Brian Balsbaugh, founder of the eSports Management Group, an agency that serves pro gamers. (Yes, professional gaming has already advanced to the point where the top players have agents.) Major League Gaming — the scene’s largest tournament organizer in North America — hosts four major competitions a year. In November, it held the Fall Championship in Dallas.

Although some players are paid handsomely — the top prize in Starcraft II is $25,000, and corporate sponsorships can pull in much more cash — for most, the prospect of making good money as a pro is still doubtful. Professional gaming’s financial structure is top-heavy, so only the best players earn significant incomes of $100,000 to $200,000. “We’re at a point where only about 40 people in the U.S. can make a living playing video games,” said Sundance DiGiovanni, chief executive of Major League Gaming. “I’d like to get it to a hundred. I think we’re a year or two away from that.”

For a beginner, expenses like travel, hotels and registration fees can be costly, especially for a parent picking up the bill for a teenager with little income. Tom Taylor, who goes by Tsquared and is a champion at the shooter game Halo, recalled selling things like PlayStation games or Pokémon cards on eBay to pay his way.

To cover those costs, talented players can sign contracts to play for sponsored teams, like Mr. Taylor’s squad, Str8 Rippin. The average salary for competitive gamers ranges from about $12,000 to $30,000, said Marcus Graham, a former pro and gaming personality who is also known as djWHEAT.

These players make the biggest commitments, playing about eight hours a day. Some sponsors have the players live together to build chemistry with teammates. Mr. Taylor, who ran team houses in Chicago and Orlando, Fla, said the practice time jumps to 10 to 14 hours a day as a tournament approaches.

A well-known team franchise like Evil Geniuses — considered the Yankees of pro gaming — can dole out lucrative contracts, over six figures for superstar players, said Alexander Garfield, the team’s chief executive.

The most marketable stars — those with a mix of talent and charisma like Mr. Taylor and Kelly Kelley, a k a MrsViolence — can attract individual sponsorships independent of a team. SteelSeries, a maker of gaming accessories, signs deals for up to $80,000 that cover major expenses for the most prominent gamers, said Kim Rom, the company’s chief marketing officer. SteelSeries also makes smaller deals with relative unknowns it thinks have potential. The company sponsors up to 200 gamers in the United States, though only about 20 pros get those top-notch deals, Mr. Rom said.

But while professional gaming is increasingly popular, in recent years the gaming world has had to rework its marketing approach. Organizers have sought to rebuild the scene since 2008, when a few leagues, like the Championship Gaming Series, folded. Before 2009, mainstream broadcasters like ESPN2 featured tournaments on television. Since then, the league has turned to the Web, rather than TV, for its lifeblood. This year, Major League Gaming began broadcasting on GameSpot.com, a division of CBS Interactive. That change in direction is an example of altered expectations — at least in the short term — for the kinds of careers professionals will have. It is also a warning that the odds of making it big are slim. Ken Yamauchi, the father of Coby Yamauchi, a 16-year-old professional and one of the scene’s rising stars, said he always reminded young gamers, “Use this as a steppingstone. You expect to support a family, buy a house through gaming? It’s not going to happen.”

The smartest personalities build their brands enough to make the bulk of their money on peripheral jobs. The Plott brothers are popular eSports broadcasters, providing live commentary during matches. Many gamers also have sponsored YouTube channels and sign contracts with services like Twitch.tv, a Web site that streams tournament video. Morgan Romine, a former captain of the all-female team Frag Dolls, now works full time as an eSports liaison for Red 5 Studios, a video game maker based in California.

If the tournaments aren’t a way to make money for college, one’s experiences on the competitive circuit can look good on college applications.

“Colleges want to see kids who are passionate in one area,” said Bev Taylor, founder of the Ivy Coach, a college admissions consultancy. But she suggests framing it in a way that emphasizes the community aspect of gaming. “They won’t accept anyone they think will just sit in their dorm room all day,” she said.

Once a player is accepted into college, gaming can still have its perks. Mona Zhang founded the Collegiate StarLeague while she was a freshman at Princeton, organizing intercollegiate tournaments for StarCraft II players. The league now has over 600 teams from schools like Yale and the Massachusetts Institute of Technology. The league also gives out two “Excellence in eSports” scholarships, said Ms. Zhang, who has since graduated.

Competitive gaming even has its fingerprints on the corporate world. In 2011, Sean Plott helped start the After Hours Gaming League, a gaming tournament that pits teams from technology companies like Google, Twitter and Facebook against each other.

Mr. Plott describes it as “a modern twist to the corporate softball league.” It’s not going to make anyone rich, but it’s fun. As video games were designed to be.

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Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by from companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

Read More..

Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by from companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

Read More..

App Smart: Apps for Home Repairs for the Handy and the Less So

With the holiday season approaching, the last thing you need is to worry about home repairs. And as rain and cold try to penetrate your house, it’s inevitable that something will go awry — a pipe will burst or that warped window frame will let in too much of the cold. That’s my problem right now — a window frame in my bathroom just won’t seal against the breeze (a minor problem, certainly, considering the damage from Hurricane Sandy, but a problem that is crying to be fixed). I could try to repair it myself, but I’m not too confident in working with aluminum windows, so I may end up calling a professional.

Multi Measures HD for iPad can become a spirit level, a surface level, a ruler, a protractor, a plumb bob and more.

The Finding Home & Hardware app locates suppliers.

Tips for fixing frozen pipes on wikiHow.

For issues like this, or even just to while away hours doing some D.I.Y. research, there are many apps to help.

If you find yourself struggling to repair something and really need a handyman, a simple way to find a suitable one nearby is Yelp’s app, free on iOS and Android. Yelp, often a go-to for restaurant advice, works for home repair experts, too. Type “handyman” or “plumber” into the app’s “Filter” boxes, along with location, and it will show a list of people and businesses. The advantage of Yelp is the ability to see how previous clients rated the quality of work. Read several reviews, as people’s experiences and expectations can vary.

For a more controlled experience, try RedBeacon (free on iOS and Android), a popular app with many positive reviews. RedBeacon covers only certain metropolitan areas across the United States, however, and may not help everyone. Unlike Yelp’s more open platform, RedBeacon has a list of approved businesses and tries to match the task at hand with the right worker. The app operates through a “request” system: users enter job details, and can provide photos and video. The system also has reviews, and can help schedule a time for the work.

More confident do-it-yourselfers may tackle a problem on their own. If it’s urgent, like a broken water heater or even water damage after a leak, the WikiHow How To and DIY Survival guide (free on Android and iOS) might be useful. Type in a few key words about the problem into the app’s Search page and the guide will return some advice. Its information pages are clear and well laid-out. They begin with an introductory description, then offer a list of steps to follow. The app displays the necessary tools and items, and includes tips and warnings (like shutting off the electricity before trying to fix a water heater). When you’re done with the home repair tasks, this app can teach self-defense tricks or help you fix your car. But it’s not an exhaustive reference on home upkeep or emergency repairs.

Some apps can turn a smartphone into an actual work tool. One app for iOS devices is Multi Measures ($1, or $2 for an “HD” iPad version). The app’s interfaces are attractive and easy to read, and it offers a long list of measurement options that use the device’s sensors. It can become a spirit level, a surface level, a ruler, a protractor, a plumb bob and more. It even has a decibel meter to measure volume, and a teslameter, which measures magnetic fields. This last option turns the device into a metal detector, which could be useful if you’re trying to find buried treasure, or just nailheads that show where the studs are in your walls.

The Smart Tools app is roughly equivalent to Multi Measures, on Android, for $2.50. And some free apps for iOS and Android promise similar features (sometimes separately — for example, Smart Protractor for angles, free on Android, or Dual Level, free on iOS). The apps’ quality can vary significantly, but they cost nothing to download and test-drive.

Finally, when it comes to buying supplies, an app like Finding HOME & Hardware ($1 on iOS and Android) is invaluable. It shows nearby hardware stores that meet your needs.

Happy D.I.Y.-ing. (Or, at least, I hope your apps find you an efficient and cheap plumber!)

Quick Calls

For smartphone or tablet users who dislike the map services from Apple and Google, Nokia’s Here app is a new, free alternative. It is available on iOS now and will be on Android devices later. You may prefer its clean, elegant design to the alternatives. ... In time for holiday shopping, Amazon now has an Android tablet-optimized version of its free Amazon Mobile shopping app ready, with one-click purchase options.

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News Analysis: Sunni Leaders Gaining Clout in Mideast

Mohammed Saber/European Pressphoto Agency

A Palestinian woman in Gaza City on Tuesday walked amid the rubble left from eight days of fighting that ended in a cease-fire.

RAMALLAH, West Bank — For years, the United States and its Middle East allies were challenged by the rising might of the so-called Shiite crescent, a political and ideological alliance backed by Iran that linked regional actors deeply hostile to Israel and the West.

But uprising, wars and economics have altered the landscape of the region, paving the way for a new axis to emerge, one led by a Sunni Muslim alliance of Egypt, Qatar and Turkey. That triumvirate played a leading role in helping end the eight-day conflict between Israel and Gaza, in large part by embracing Hamas and luring it further away from the Iran-Syria-Hezbollah fold, offering diplomatic clout and promises of hefty aid.

For the United States and Israel, the shifting dynamics offer a chance to isolate a resurgent Iran, limit its access to the Arab world and make it harder for Tehran to arm its agents on Israel’s border. But the gains are also tempered, because while these Sunni leaders are willing to work with Washington, unlike the mullahs in Tehran, they also promote a radical religious-based ideology that has fueled anti-Western sentiment around the region.

Hamas — which received missiles from Iran that reached Israel’s northern cities — broke with the Iranian axis last winter, openly backing the rebellion against the Syrian president, Bashar al-Assad. But its affinity with the Egypt-Qatar-Turkey axis came to fruition this fall.

“That camp has more assets that it can share than Iran — politically, diplomatically, materially,” said Robert Malley, the Middle East program director for the International Crisis Group. “The Muslim Brotherhood is their world much more so than Iran.”

The Gaza conflict helps illustrate how Middle Eastern alliances have evolved since the Islamist wave that toppled one government after another beginning in January 2011. Iran had no interest in a cease-fire, while Egypt, Qatar and Turkey did.

But it is the fight for Syria that is the defining struggle in this revived Sunni-Shiite duel. The winner gains a prized strategic crossroads.

For now, it appears that that tide is shifting against Iran, there too, and that it might well lose its main Arab partner, Syria. The Sunni-led opposition appears in recent days to have made significant inroads against the government, threatening the Assad family’s dynastic rule of 40 years and its long alliance with Iran. If Mr. Assad falls, that would render Iran and Hezbollah, which is based in Lebanon, isolated as a Shiite Muslim alliance in an ever more sectarian Middle East, no longer enjoying a special street credibility as what Damascus always tried to sell as “the beating heart of Arab resistance.”

If the shifts seem to leave the United States somewhat dazed, it is because what will emerge from all the ferment remains obscure.

Clearly the old leaders Washington relied on to enforce its will, like President Hosni Mubarak of Egypt, are gone or at least eclipsed. But otherwise confusion reigns in terms of knowing how to deal with this new paradigm, one that could well create societies infused with religious ideology that Americans find difficult to accept. The new reality could be a weaker Iran, but a far more religiously conservative Middle East that is less beholden to the United States.

Already, Islamists have been empowered in Egypt, Libya and Tunisia, while Syria’s opposition is being led by Sunni insurgents, including a growing number identified as jihadists, some identified as sympathizing with Al Qaeda. Qatar, which hosts a major United States military base, also helps finance Islamists all around the region.

In Egypt, President Mohamed Morsi resigned as a member of the Muslim Brotherhood only when he became head of state, but he still remains closely linked with the movement. Turkey, the model for many of them, has kept strong relations with Washington while diminishing the authority of generals who were longstanding American allies.

“The United States is part of a landscape that has shifted so dramatically,” said Mr. Malley of the International Crisis Group. “It is caught between the displacement of the old moderate-radical divide by one that is defined by confessional and sectarian loyalty.”

The emerging Sunni axis has put not only Shiites at a disadvantage, but also the old school leaders who once allied themselves with Washington.

The old guard members in the Palestinian Authority are struggling to remain relevant at a time when their failed 20-year quest to end the Israeli occupation of Palestinian lands makes them seem both anachronistic and obsolete.

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General Allen Investigation Narrows Focus

WASHINGTON — Two and a half weeks after Defense Secretary Leon E. Panetta announced an inquiry into e-mail exchanges between Gen. John R. Allen of the Marines and a socialite in Tampa, Fla., some 15 investigators working seven days a week in the Pentagon inspector general’s office have narrowed their focus to 60 to 70 e-mails that “bear a fair amount of scrutiny,” a defense official said.

Alex Wong/Getty Images

Gen. John R. Allen testifying before the House Armed Services Committee in March. He is being investigated over e-mails he sent to Jill Kelley, who was also an acquaintance of David H. Petraeus.

Tampa Bay Magazine, via Associated Press

Jill Kelley with her husband, Scott.

The official did not disclose the content of the e-mails, but senior Pentagon officials have described the voluminous correspondence between General Allen, the top NATO commander in Afghanistan, and the socialite, Jill Kelley, as potentially “inappropriate communication.” Law enforcement officials say the e-mails number in the hundreds and cover a period of two and a half years starting in 2010, when General Allen was the deputy commander of Central Command, based in Tampa.

The investigation, which is delaying and could derail General Allen’s appointment to be the NATO supreme allied commander in Europe, is on a fast track but is unlikely to be completed before the end of the year. Investigations of senior officers in the inspector general’s office usually take about seven months on average, although normally there are only two or three investigators assigned to a case.

The defense official, who asked not to be named because of the nature of the inquiry, said investigators were trying to determine whether the e-mails violated Defense Department policy, government regulations or military law. They were discovered in the course of an F.B.I. investigation into anonymous e-mails to Ms. Kelley warning her to stay away from David H. Petraeus, then the C.I.A. director. The F.B.I. found that the e-mails had been sent by Paula Broadwell, Mr. Petraeus’s biographer; he admitted to having had an affair with Ms. Broadwell and resigned on Nov. 9.

Like General Allen, Mr. Petraeus, a retired four-star general, was a social acquaintance of Ms. Kelley when he was stationed at MacDill Air Force Base in Tampa, headquarters of the Central Command.

The e-mails between General Allen and Ms. Kelley were sent to the Pentagon by the F.B.I. on Nov. 11. “They just forwarded the evidence,” the official said, referring to the F.B.I. “People have to go through and decide if they fit one of three potential violations.” Those violations include misconduct, which could range from inappropriate language on a government computer to adultery, prohibited under military law; more than an incidental use of government property for personal matters; and security breaches.

The defense official said there was no evidence so far that there had been security violations. General Allen, who is in Kabul planning the drawdown of American forces from Afghanistan, is cooperating with the investigation and has said through associates that he did not commit adultery. The inquiry does not appear to have progressed to interviews with General Allen, 58, who is married and the father of two, or Ms. Kelley, 37, the wife of a cancer surgeon and the mother of three.

Gen. Joseph F. Dunford Jr., who has been nominated to succeed General Allen as part of a regular military rotation, is expected to be confirmed by the Senate before the end of the year and to be in Kabul by February. General Allen is expected to return to the United States at that time, but it is unclear what he will do.

There have been conflicting accounts of the nature of the e-mails between him and Ms. Kelley. A law enforcement official has described some of them as sexually explicit. Pentagon officials briefed on the matter say they have been told that half a dozen are embarrassing. But General Allen’s associates say they are innocuous and contain little beyond language like “you’re a sweetheart.”

Although Ms. Kelley’s e-mail correspondence with General Allen has not been made public, dozens of her e-mails to Mayor Bob Buckhorn of Tampa have been released under Florida’s public record laws and refer to her friendship with both General Allen and Mr. Petraeus.

A year ago, after inviting the mayor to a birthday party for one of her children, she added a casual P.S.: “I’ll be in DC this weekend with Petraeus, but let’s set up a double date when I return!” Last January, she wrote to a mayoral aide, “I’m up in DC having dinner tonight with Gen. Petraeus and Gen. John Allen.”

Thom Shanker and Eric Schmitt contributed reporting.

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