Google’s Lawyers Work Behind the Scenes to Carry the Day

SAN FRANCISCO — For 19 months, Google pressed its case with antitrust regulators investigating the company. Working relentlessly behind the scenes, executives made frequent flights to Washington, laying out their legal arguments and shrewdly applying lessons learned from Microsoft’s bruising antitrust battle in the 1990s.

After regulators had pored over nine million documents, listened to complaints from disgruntled competitors and took sworn testimony from Google executives, the government concluded that the law was on Google’s side. At the end of the day, they said, consumers had been largely unharmed.

That is why one of the biggest antitrust investigations of an American company in years ended with a slap on the wrist Thursday, when the Federal Trade Commission closed its investigation of Google’s search practices without bringing a complaint. Google voluntarily made two minor concessions.

“The way they managed to escape it is through a barrage of not only political officials but also academics aligned against doing very much in this particular case,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has worked as a paid adviser to Google in the past. “The first sign of a bad antitrust case is lack of consumer harm, and there just was not any consumer harm emerging in this very long investigation.”

The F.T.C. had put serious effort into its investigation of Google. Jon Leibowitz, the agency’s chairman, has long advocated for the commission to flex its muscle as an enforcer of antitrust laws, and the commission had hired high-powered consultants, including Beth A. Wilkinson, an experienced litigator, and Richard J. Gilbert, a well-known economist.

Still, Mr. Leibowitz said during a news conference announcing the result of the inquiry, the evidence showed that Google “doesn’t violate American antitrust laws.”

“The conclusion is clear: Google’s services are good for users and good for competition,” David Drummond, Google’s chief legal officer, wrote in a company blog post.

The main thrust of the investigation was into how Google’s search results had changed since it expanded into new search verticals, like local business listings and comparison shopping. A search for pizza or jeans, for instance, now shows results with photos and maps from Google’s own local business service and its shopping product more prominently than links to other Web sites, which has enraged competing sites.

But while the F.T.C. said that Google’s actions might have hurt individual competitors, over all it found that the search engine helped consumers, as evidenced by Google users’ clicking on the products that Google highlighted and competing search engines’ adopting similar approaches.

Google outlined these kinds of arguments to regulators in many meetings over the last two years, as it has intensified its courtship of Washington, with Google executives at the highest levels, as well as lawyers, lobbyists and engineers appearing in the capital.

One of the arguments they made, according to people briefed on the discussions, was that technology is such a fast-moving industry that regulatory burdens would hinder its evolution. Google makes about 500 changes to its search algorithm each year, so results look different now than they did even six months ago.

The definition of competition in the tech industry is also different and constantly changing, Google argued.

For instance, just recently Amazon and Apple, which used to be in different businesses than Google, have become its competitors. Google’s share of the search market has stayed at about two-thirds even though competing search engines are “just a click away,” as the company repeatedly argued. That would become the company’s mantra to demonstrate that it was not abusing its market power.

Claire Cain Miller reported from San Francisco, and Nick Wingfield from Seattle.

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Scant Proof Is Found to Back Up Claims by Energy Drinks

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.

Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.

“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.

Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.

“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”

A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.

In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.

Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.

Consider the case of taurine, an additive used in most energy products.

On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.

But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.

Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.

Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.

Read More..

Scant Proof Is Found to Back Up Claims by Energy Drinks

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.

Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.

“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.

Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.

“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”

A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.

In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.

Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.

Consider the case of taurine, an additive used in most energy products.

On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.

But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.

Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.

Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.

Read More..

Google’s Lawyers Work Behind the Scenes to Carry the Day

SAN FRANCISCO — For 19 months, Google pressed its case with antitrust regulators investigating the company. Working relentlessly behind the scenes, executives made frequent flights to Washington, laying out their legal arguments and shrewdly applying lessons learned from Microsoft’s bruising antitrust battle in the 1990s.

After regulators had pored over nine million documents, listened to complaints from disgruntled competitors and took sworn testimony from Google executives, the government concluded that the law was on Google’s side. At the end of the day, they said, consumers had been largely unharmed.

That is why one of the biggest antitrust investigations of an American company in years ended with a slap on the wrist Thursday, when the Federal Trade Commission closed its investigation of Google’s search practices without bringing a complaint. Google voluntarily made two minor concessions.

“The way they managed to escape it is through a barrage of not only political officials but also academics aligned against doing very much in this particular case,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has worked as a paid adviser to Google in the past. “The first sign of a bad antitrust case is lack of consumer harm, and there just was not any consumer harm emerging in this very long investigation.”

The F.T.C. had put serious effort into its investigation of Google. Jon Leibowitz, the agency’s chairman, has long advocated for the commission to flex its muscle as an enforcer of antitrust laws, and the commission had hired high-powered consultants, including Beth A. Wilkinson, an experienced litigator, and Richard J. Gilbert, a well-known economist.

Still, Mr. Leibowitz said during a news conference announcing the result of the inquiry, the evidence showed that Google “doesn’t violate American antitrust laws.”

“The conclusion is clear: Google’s services are good for users and good for competition,” David Drummond, Google’s chief legal officer, wrote in a company blog post.

The main thrust of the investigation was into how Google’s search results had changed since it expanded into new search verticals, like local business listings and comparison shopping. A search for pizza or jeans, for instance, now shows results with photos and maps from Google’s own local business service and its shopping product more prominently than links to other Web sites, which has enraged competing sites.

But while the F.T.C. said that Google’s actions might have hurt individual competitors, over all it found that the search engine helped consumers, as evidenced by Google users’ clicking on the products that Google highlighted and competing search engines’ adopting similar approaches.

Google outlined these kinds of arguments to regulators in many meetings over the last two years, as it has intensified its courtship of Washington, with Google executives at the highest levels, as well as lawyers, lobbyists and engineers appearing in the capital.

One of the arguments they made, according to people briefed on the discussions, was that technology is such a fast-moving industry that regulatory burdens would hinder its evolution. Google makes about 500 changes to its search algorithm each year, so results look different now than they did even six months ago.

The definition of competition in the tech industry is also different and constantly changing, Google argued.

For instance, just recently Amazon and Apple, which used to be in different businesses than Google, have become its competitors. Google’s share of the search market has stayed at about two-thirds even though competing search engines are “just a click away,” as the company repeatedly argued. That would become the company’s mantra to demonstrate that it was not abusing its market power.

Claire Cain Miller reported from San Francisco, and Nick Wingfield from Seattle.

Read More..

Pakistani Girl Shot by Taliban Leaves British Hospital

Dylan Martinez/Reuters

Malala Yousafzai, 15, was discharged from Queen Elizabeth Hospital in Birmingham on Thursday but is due to be readmitted in late January or early February for reconstructive surgery to her skull, doctors said.

LONDON (Reuters) — A Pakistani girl shot in the head by the Taliban for advocating girls’ education has been discharged from a British hospital after doctors said she was well enough to spend time recovering with her family.

Fifteen-year-old Malala Yousafzai, who was shot by the Taliban in October and brought to Britain for treatment, was discharged on Thursday but is due to be re-admitted in late January or early February for reconstructive surgery to her skull, doctors said.

The shooting of Yousafzai, in the head at point blank range as she left school in the Swat valley, drew widespread international condemnation.

She has become a an internationally recognized symbol of resistance to the Taliban’s efforts to deny women education and other rights, and more than 250,000 people have signed online petitions calling for her to be nominated for a Nobel Peace Prize for her activism.

Doctors at the Queen Elizabeth Hospital in Birmingham where Yousafzai was treated said that although the bullet hit her left brow, it did not penetrate her skull but instead travelled underneath the skin along the side of her head and into her neck.

She was treated by doctors specializing in neurosurgery, trauma and other disciplines in a department of the hospital which has treated hundreds of soldiers wounded in conflicts in Afghanistan and Iraq.

“Malala is a strong young woman and has worked hard with the people caring for her to make excellent progress in her recovery,” said Dave Rosser, the hospital’s medical director.

“Following discussions with Malala and her medical team, we decided that she would benefit from being at home.”

Yousafzai has already been leaving the hospital on a regular basis on “home leave” in recent weeks to spend time with her parents and younger brothers, who have a temporary home in central England, Rosser said.

“During those visits assessments have been carried out by her medical team to ensure she can continue to make good progress outside the hospital,” Rosser said.

Yousafzai’s father said in October he was sure she would “rise again” to pursue her dreams after medical treatment.

(Editing by Robin Pomeroy)

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Your Money: Piecing Together a Tax Plan’s Effects

It is tempting for people who earn less than $400,000 to think that they got off easy this week under the tax deal to end the fiscal impasse, given that only those with incomes above that level will be in a higher income tax bracket in 2013.

But the legislation that both houses of Congress have now approved could increase taxes on people with incomes that are not quite that high as well. That’s because the bill includes language that begins to do what both President Obama and Mitt Romney proposed at various points in the past: Limit certain tax breaks available to people who are affluent.

The new rules target two tax breaks: personal exemptions and many popular deductions like those for state and local taxes, mortgage interest and charitable contributions. For both breaks, single people with at least $250,000 in adjusted gross income and married people filing jointly with at least $300,000 in income are vulnerable. A hypothetical Texas couple could end up paying about $2,500 more in taxes, for instance.

The mechanics of how the new limits will work are now clear, though it takes a fair bit of explaining to lay them out in plain English. What we don’t know yet is how many people will end up paying more in 2013 than they did in 2012.

The uncertainty is tied to the fact that many of the targets of the legislation often end up ensnared by the alternative minimum tax. The A.M.T., and its high tax bill, may continue to catch most of them.

But let’s start with the basics. Most of the discussion here begins with that adjusted gross income figure. That’s the number you get when you subtract items from your salary or take-home pay that are often referred to as above-the-line deductions.

For the income range we’re talking about, these deductions tend to include things like health savings account contributions and alimony. People who work for themselves also get deductions for health insurance premiums, certain retirement contributions and self-employment taxes that an employer would otherwise pay.

Mark Luscombe, principal analyst with CCH, a tax information provider, points out just how confusing the use of adjustable gross income is, given that the new tax limits, the new tax bracket and the new Medicare tax are all based on different definitions of income.

Under normal circumstances, a personal exemption, for a specific dollar amount, is available for each member of your household. You then add all of the exemptions and subtract the total from your adjusted gross income, which has the effect of lowering your taxable income. CCH predicts that the personal exemption amount for 2013 will be $3,900 per person.

The new law requires taxpayers in the targeted income range to reduce the amount of their exemptions by 2 percent for every $2,500 by which their income exceeds the $250,000 or $300,000 limit. So a married, childless couple with $400,000 in adjusted gross income and $7,800 in potential exemptions could lose $6,240 of that $7,800.

The math for the limit on deductions is different. There, the rules call for you to add up the applicable deductions. Let’s say that equals $50,000. Then, you subtract from that 3 percent of the amount by which your adjusted gross income exceeds those $250,000 or $300,000 thresholds.

So if you’re a married couple with $400,000 in income, you’re $100,000 over the threshold. Three percent of that is $3,000. So you’d subtract that from $50,000. The rule, which existed for years but had been phased out more recently, is known as the Pease limitation, for Representative Donald J. Pease, the Ohio newspaper editor-turned-legislator who got it passed. As before, you can’t lose more than 80 percent of your deductions, no matter how high your income gets.

If you’re trying to figure out whether and how this may affect you, well, join the club. So much depends on your income, your state and your various deductions. All of that will affect whether the A.M.T. hits you as well.

For people who are already in the A.M.T. but will not end up with the $400,000 (for individuals) or $450,000 (for married couples filing jointly) in income necessary to be in the new 39.6 percent tax bracket in 2013, the new exemption and deduction rules may not hurt you. “I don’t think there’s enough there that you would no longer be in the A.M.T.,” said Jude Coard, a tax partner at Berdon L.L.P., of people with income in the $300,000 to $400,000 range.

Much will depend on your own situation. CCH ran two hypothetical cases for me, which you can see in the accompanying graphic. The first examined a family of four in New York with $400,000 in adjusted gross income and $79,000 in total itemized deductions. The household pays the A.M.T. in both 2012 and under the new tax rules in 2013. They pay just $790 more in 2013, but that includes $1,350 in new Medicare taxes. (The total does not include the Social Security payroll tax that has been restored to its prerecession level.)

A family in Texas, however, might have the same income but lower property taxes and no income tax and thus lower deductions for its federal tax return. Their deductions are just $43,700, but they end up being hurt more by the new rules. They would have no A.M.T. liability in 2013 and would end up paying $3,852 more, or about $2,500 if you don’t count the $1,350 from the new Medicare tax.

This is a lot to digest, so much so that even the experts at the Tax Policy Center have not yet finished updating their online calculator. Once they do, if you have the stomach to gather (or try to predict) all of the data, you can take your shot at projecting what these new rules may cost you.

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The New Old Age Blog: On the Way to Hospice, Surprising Hurdles

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.

Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Read More..

The New Old Age Blog: On the Way to Hospice, Surprising Hurdles

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.

Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”

---

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Read More..

Gadgetwise Blog: Protect Your iPhone With a Vision From Australia

Cygnett, an Australian maker of gadget accessories and cases, is strengthening its brand in the United States with a new line of slim-fit cases for the iPhone 5.

Cygnett joined with some visionary artists for the line, called the Icon Art Series, to create some striking looks, including bright graffiti designs by Tats Cru, the Bronx-based muralists, and hypnotic birds by the Australian illustrator Nathan Jurevicius. I was partial to the bold designs by the Australian indigenous artist Ronnie Tjampitjinpa, which gave the cases an out-on-the-edge feel.

The minimalist cases of the Icon line, which cost $30 apiece, snap on an iPhone 5 easily. The hard shell is durable with a soft finish that makes it easy to hold, but it’s slim enough to slide in and out of pockets. The cases do not have much padding, but they offer enough protection to safeguard a phone when it’s dropped, as I did twice with mine.

As with most cases from Cygnett, the Icon cases come with a screen shield kit, which includes a clear screen protector, a microfiber cloth and an installation card. But after several attempts to apply the adhesive screen protector and smooth out the air bubbles with the card, I gave up. Fortunately, the cases also have a slight bezel that protects the screen.

The cases have a small opening for the volume buttons, so small in fact that I had trouble reaching the button with my thumb (a thumbnail works better). The top and bottom are open for easy access to the power button, charging port and speaker.

Cygnett makes other cases that offer better protection, including the WorkMate series, which has a similar heavy-duty polycarbonate shell but adds a shock-absorbing, rubberized silicone lining. The WorkMate cases are indeed rugged, but the Icon cases are more eye-catching.

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India Ink: Charges Filed in Delhi Against Accused in Gang Rape Case

Update 5:45 p.m. Indian Standard Time

The five men accused of the gang rape of a woman in Delhi on Dec. 16, which resulted in her death, were formally charged Thursday with murder, robbery and rape in a south Delhi court.

Charges had been expected to be heard in room 207 of the court, where crowds of lawyers and journalists had gathered during the day, but they were actually read in a separate room on the same floor, causing chaos. Lawyers and media ran from one room to the other, banging on the door where the charges were read to be let into the second room.

Five men were named in the case, while a sixth suspect who has been arrested may be tried as a juvenile. Additional charges included attempted murder and destruction of evidence.

Surya Malik Grover, a magistrate who handles charges filed after 5 p.m., said an electronic version of the charge sheet would be available on Saturday.

Update, 5 p.m. Indian Standard Time
A large number of lawyers and journalists are still waiting in the Saket District Court complex for a charge sheet to be filed against the six accused in the New Delhi rape case.

The magistrate, who was expected to receive the charge sheet, left the court room two hours ago and has not been seen since. There has been no official communication about whether the accused will be brought to the court, or even if the charge sheet will be filed, as court officials expected Thursday morning.

The situation is being monitored closely by activists and others in the room who have been agitating for better protection of women and stronger punishment for rapists after a woman was raped in Delhi on Dec. 16 by several men. Several female lawyers wore red ribbon armbands as a form of protest.

“We are here to see if the government is serious about the promises they have made about a speedy trial,” said Poonam Kaushik, a lawyer and the general secretary of the Pragatisheel Mahila Sangathan, a women’s rights organization. “Where is the charge sheet?” she asked. “We are waiting. The nation is waiting.”

Noon, Indian Standard Time, Thursday, Jan. 3

A scrum of television reporters and a handful of protesters gathered outside the District Court complex in Saket, Delhi, Thursday morning, awaiting a glimpse of the six men accused in a gang rape that ended in the death of a 23-year-old woman last month.

Delhi police are expected to file charges against the accused today, including a charge of murder, which could carry the death penalty if the men are convicted. The police charges, in the form of a document expected to be hundreds of pages long, will be reviewed by Delhi High Court before they are submitted to a magistrate in the Saket court, the neighborhood where the woman was picked up by a private bus and raped.

Court officers said they expected the charge sheet to reach the Saket court by about 2 p.m. In ordinary court procedures in India, the accused would be present when charges are filed in court.

Despite widespread national and international interest in the case, there is no press conference planned on the issue Thursday, a Delhi Police spokesman said. The charge sheet itself is not likely to be made public because of confidential details the sheet contains about the case, he said.

Outside the courthouse, television cameramen scrambled to find a vantage point over a locked courthouse gate for a shot of anyone coming in and out of the building. A lack of official information about what was happening meant that rumors flew fast. The men would not actually be brought to court today, several television reporters said with certainty. Others said they would surely be produced.

So far, no defense attorney has been named for the six men, lawyers and court officers in Saket said.

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