U.S. Economy Adds 155,000 Jobs; Jobless Rate Is 7.8%

American employers added 155,000 jobs in December, about apace with job growth over the last year, the Labor Department reported on Friday.

The biggest gains were in health care, food services, construction and manufacturing, and the government sector showed modest job losses, the report said. The unemployment rate was 7.8 percent, the same as in November, whose rate was revised up from 7.7 percent.

“It’s not a home-run report by any stretch, but it’s constructive,” said John Ryding, chief economist at RDQ Economics. “It’s another month of fairly stable, solid, moderate job creation.”

Over the course of 2012, the country added 1.8 million net jobs, despite continued job losses in the government sector and anxiety and uncertainty related to a looming fiscal tightening.

Economists are unsure of what the rest of the year holds for the American job market, but most are forecasting more of the same: hiring fast enough to stay just ahead of population growth, but still too slow to make a sizable dent in the 12.2-million-person backlog of unemployed workers.

A number of encouraging trends in the economy suggest that businesses have good reason to speed up hiring, including the housing recovery, looser credit for small businesses, a rebound in China and pent-up demand for new autos. Friday’s jobs report also showed slightly faster wage growth and longer working hours in December, both of which bode well for hiring.

But Congress’s last-minute deal to raise taxes earlier this week will offset some of these sources of growth, since higher taxes trim how much money consumers have available to spend each week.

“Job creation might firm a little bit, but it’s still looking nothing like the typical recovery year we’ve had in deep recessions in the past,” Mr. Ryding said. “There’s nothing in the deal to do that and nothing in this latest jobs report to suggest that. We’re a long way short of the 300,000 job growth that we need."

The fiscal compromise also renewed for a year the federal government’s emergency unemployment benefits program. That allows workers to continue receiving unemployment benefits for up to 73 weeks, depending on the unemployment rate in the state where they live, and acts as a stimulus to the American economy because unemployment benefits are spent almost immediately.

The extension has proved to be a tremendous relief to the 2 million workers who would have otherwise abruptly lost their benefits this week.

“We woke up on Wednesday morning and saw the news and just said, ‘thank God, thank God, thank God,’ and then went out and went food shopping because we knew we had money coming in,” said Gina Shadis, 56, of Newton, N.J.

Both she and her husband, Stephen, were laid off within the last 14 months from jobs they had held for more than a decade: she from a quality assurance manager position at an environmental testing lab, and he as foreman and senior master technician at an auto dealership. They are now each receiving $548 per week in federal jobless benefits, or about a quarter of their pay at their most recent jobs.

“It has just been such a traumatic time,” she said. “You know you wake up in the morning with shoulders tense and head aching because you didn’t sleep the night before from worrying.”

While Congress’s deal on New Year’s Day brought clarity to tax and unemployment benefits policies, lawmakers have still not settled their disputes about federal spending cuts and the debt ceiling. Economists worry that the lingering uncertainty over these issues could discourage businesses from investing in more workers or equipment.

“We may be seeing the calm before the storm right now,” said Ian Shepherdson, chief economist at Pantheon Macroeconomic Advisors, noting that a recent survey from the National Federation of Independent Business found that alarmingly few small companies plan to hire in the coming months. “Small businesses are wringing their hands in horror at what’s going on in Washington.”

In the meantime, more than six million workers have exhausted their unemployment benefits altogether since the recession began in December 2007, according to the National Employment Law Project, a labor advocacy group.

Millions of workers are sitting on the sidelines and so are not counted in the total tally of unemployed. Some are merely waiting for the job market to improve, and others are trying to invest in skills to appeal to employers who are already hiring.  

“I have a few prospects who say they want me to work for them when I graduate,” said Jordan Douglas, a 24-year-old single mother in Pampa, Tex., who is enrolled in a special program that allows her to receive jobless benefits while attending school full time to become a registered nurse. She gets $792 in benefits every two weeks, a little less than half of what she earned in an administrative position at the nursing home that laid her off last year.

She calculates that her federal jobless benefits will run out the very last week of nursing school.

“This had to have been a sign from God that I had to do this since it all worked out so well,” she said.

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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.

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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.

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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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News Analysis: Debt Deal Fails to Allay Fears on U.S. Global Power

WASHINGTON — Two years ago the departing chairman of the Joint Chiefs of Staff, Adm. Mike Mullen, declared that “the most significant threat to our national security is our debt.” After a decade in which the nation had chased Al Qaeda and invaded Iraq, Admiral Mullen was saying, in essence, that the biggest enemy was us.

Paula Bronstein/Getty Images

Some analysts worry that the United States will not maintain influence in places like Myanmar.

Now that Congress and President Obama have slipped past the latest budget deadline with a bill that does little to address the country’s long-term debt issues — and by some measures might worsen them — the worries of the national security establishment have been reignited. Most pointedly, military and diplomatic experts wonder whether the United States is at risk of squandering its global influence.

“There’s a sense that we’ve been playing roulette with our position, and this deal does nothing to stop that,” Richard N. Haass, the president of Council on Foreign Relations, said in an interview. His coming book, “Foreign Policy Begins at Home,” is part of a wave of recent literature arguing that America’s reduced global ambitions are linked to its status as a debtor nation.

Vali Nasr, who will soon publish “The Dispensable Nation,” argues that the debt, among other economic woes, has allowed Mr. Obama and other Democrats to justify a retreat from global engagement. “It’s made it far easier to say ‘We can’t do more,’ ” said Mr. Nasr, the dean of the School of Advanced International Studies at Johns Hopkins University. “And without addressing the debt issues, it will be easier to make that argument for years to come.”

A departing senior diplomat at the State Department who requested anonymity, ruminating on the outcome of the confrontation on the fiscal crisis, said that the failure to attack the long-term debt issues would become another reason “to turn our backs on the Middle East and trim our sails on the new focus on Asia.”

That is the theme that the Chinese — who have an interest in portraying the United States as a declining power unable to manage its economy — are already promoting. “The politicians have chosen to kick the can down the road,” the state-run Xinhua news agency said in a commentary on Wednesday. “The can will never disappear,” it continued, warning that the United States was falling “into an abyss you can never come out of.”

Most evidence suggests that the country’s debt is not an immediate crisis. The deficit is expected to shrink somewhat in coming years, and even after the United States lost its AAA bond rating, foreigners have remained willing to lend the country money at very low interest rates. That is a sign of confidence in the American economy and a recognition that Europe and Asia have problems of their own.

But the aging of the population and the growth of health costs will most likely cause the deficit to grow rapidly in coming decades, meaning that the most difficult choices about taxes and spending are still ahead. Absent decisions on those issues, the government will have fewer resources and be more dependent on foreign lenders — increasingly the Chinese.

“Partly it is about resources,” Mr. Haass said, referring to the national security implications of the deficit. “But it is also about reducing your vulnerability to the machinations of currency markets and potentially hostile central bankers” who choose whether to buy American debt.

“When we appear to be dysfunctional, as we have in recent times, it makes it hard to be the model for the democratic, capitalistic model we say we want to be in the world,” he added.

History suggests that the relationship between debt and American power is a complex one, subject to differing interpretations by both economists and historians. The federal debt exceeded 100 percent of the gross domestic product at the end of World War II, but the postwar period nonetheless marked the beginning of America’s superpower status. The debt fell fairly steadily during the cold war, and it was cut to about a third of gross domestic product by the end of the Nixon administration — even as the country retreated into a post-Vietnam War funk.

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More Americans Seek Jobless Benefits

WASHINGTON — The number of Americans filing new claims for unemployment benefits rose last week, the Labor Department said Thursday, but the data was too distorted by the holidays to offer a clear reading of labor market conditions.

Initial claims for state unemployment benefits increased 10,000 to a seasonally adjusted 372,000, the government said.

A Labor Department official said data for nine states, including California and Virginia, had been estimated last week because of the Christmas and New Year holidays. This suggested the numbers will be revised next week.

The prior week’s figure was revised to show 12,000 more applications than previously reported. Claims data reported for the week ended Dec. 22 had been artificially depressed by the holidays, which resulted in data for 19 states being estimated.

The four-week moving average for new claims, a better measure of labor market trends, rose 250 to 360,000. The claims data has no bearing on December’s national employment report, scheduled for release on Friday.

Employers are expected to have added 150,000 jobs to their payrolls last month, little changed from 146,000 in November, according to a Reuters survey of economists.

The claims report showed the number of people still receiving benefits under regular state programs after an initial week of aid increased 44,000 to 3.25 million in the week ended Dec. 22.

A separate report Thursday said that American private-sector employers added more new jobs than expected last month, helping the job market end 2012 on a high note.

The ADP National Employment Report showed the private sector added 215,000 jobs last month, comfortably above economists’ expectation of a 133,000 gain. The report is jointly developed with Moody’s Analytics.

“The underlying economy has momentum, and the employment data confirms that,” said John Brady, managing director at R.J. O’Brien & Associates in Chicago. “The hope and prayer of the market is that our political leaders don’t screw it up.”

November’s private payrolls tally was also revised upward to show a gain of 148,000 from the previously reported 118,000.

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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.”

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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.”

---

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

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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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U.S. Drone Strike Kills a Top Pakistani Militant

ISLAMABAD, Pakistan — An American drone strike killed a top Pakistani militant commander in a northwestern tribal region, security officials said on Thursday. The death of Maulvi Nazir was seen as a serious blow to Taliban fighters who attack United States and allied forces in neighboring Afghanistan.

The drone strike took place Wednesday night and targeted Mr. Nazir’s vehicle in the Angoor Adda area in South Waziristan. Five other people were also killed, including one of his key aides, officials said.

“He has been killed. It is confirmed,” said a senior Pakistani intelligence officer, who spoke on condition of anonymity. “The vehicle he was traveling in was hit.

Mr. Nazir was traveling from Birmal to Wana, the main town in South Waziristan, when his vehicle was struck by the drone.

In a separate drone strike in North Waziristan on Thursday morning, at least four people were killed when a vehicle was targeted. The identities of those killed were not immediately known.

Mr. Nazir, believed to be in his 30s, was based in the western part of the South Waziristan tribal region. He led the Ahmadzai Wazir tribe and his loyalists regularly joined attacks on American forces across the porous border with Afghanistan. Unlike other Taliban factions, Mr. Nazir’s fighters did not attack Pakistani military or government targets, instead focusing on the war inside Afghanistan. He was believed to have signed a peace pact with the Pakistani military.

Mr. Nazir was allied with Hafiz Gul Bahadur, a leading warlord in North Waziristan. The nonconfrontational posture of the two commanders toward the Pakistani military often led to them being labeled here as “good Taliban.”

Asad Munir, a former Pakistan Army brigadier and the intelligence chief in Peshawar, said the killing of Mr. Nazir could lead to a spurt in violence.

“A dangerous scenario for Pakistani military would be joining of hands of Hafiz Gul Bahadur and Maulvi Nazir supporters with Tehrik-e-Taliban Pakistan.”

Mr. Munir said the area controlled by Mr. Nazir’s forces had been “relatively peaceful” but his death increased the chances of attacks on military targets. Mr. Nazir had survived two earlier drone strikes. In November, he survived a suicide attack, which was blamed on Tehrik-e-Taliban Pakistani, or T.T.P., the Pakistani Taliban who conduct attacks inside Pakistan. Following the suicide attack, he expelled rival Mehsud tribesmen from territory controlled by his fighters.

Mr. Nazir also opposed the presence of Uzbek fighters inside Pakistan and, with the help of the Pakistani military, pushed Uzbeks out of his region several years ago.

Some analysts said that militants like Mr. Nazir could be troublesome for the Pakistani military once the withdrawal of American forces from Afghanistan begins in 2014.

“Maulvi Nazir would probably have posed a problem for the Pakistan Army if and when a political settlement is reached in Afghanistan in 2014. But in the interim, the killing of Nazir and his deputies likely hurts the Pakistan Army’s efforts against the T.T.P. in South Waziristan,” said Arif Rafiq, an adjunct scholar at the Middle East Institute, based in Washington.

"Nazir would probably have wanted to hold on to his local jihadist fiefdom, making him a long-term threat for the Pakistani state,” said Mr. Rafiq.

The suspicion that the Pakistani military gave a nod to Mr. Nazir’s killing could result in attacks on Pakistani troops in some areas in South Waziristan, analysts said.

Pakistani officials publicly denounce American drone strikes but have privately acknowledged the effectiveness of the campaign.

Ismail Khan reported from Peshawar, Pakistan.

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