The New Old Age Blog: Therapy Plateau No Longer Ends Coverage

Ellen Gorman, 72, a New York psychotherapist, can’t walk very far and gets around the city mainly by taxi, “which is really expensive,” she said. Twice since 2008 her physical therapy was discontinued because she wasn’t progressing. But after a knee replacement last year, she is getting physical therapy again, exercising with her therapist and building up her endurance by walking in the hallway of her Manhattan apartment building.

“Before this, I was getting weaker and weaker, and I just kept caving in,” she said.

Because of an action by Congress and a recent court settlement, Medicare probably won’t cut off Ms. Gorman’s physical therapy again should her progress level off — as long as her doctor says it is medically necessary.

Congress continued for another year a little-known process that allows exceptions to what Medicare pays for physical, occupational and speech therapy. The Medicare limits before the exceptions are $1,900 for physical and speech therapy this year, and $1,900 for occupational therapy.

In addition, the settlement of a class-action lawsuit last month now means that Medicare is prohibited from denying patients coverage for skilled nursing care, home health services or outpatient therapy because they had reached a “plateau,” and their conditions were not improving. That will allow people with Medicare who have chronic health problems and disabilities to get the therapy and other skilled care that they need for as long as they need it, if they meet other coverage criteria.

The settlement is expected to affect thousands, and possibly millions, of Medicare beneficiaries with chronic health problems like Parkinson’s or Alzheimer’s disease, stroke, multiple sclerosis and spinal cord injuries. It could also help families, as well as the overburdened Medicare budget, delay costly nursing home care by enabling seniors to live longer in their own homes.

“Under this settlement, Medicare policy will be clarified to ensure that claims from providers are reimbursed consistently and appropriately and not denied solely based on a rule-of-thumb determination that a beneficiary’s condition is not improving,” said Fabien Levy, a spokesman for the U. S. Department of Health and Human Services, which includes the Medicare program.

The lawsuit was filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four Medicare patients and five national organizations, including the National Multiple Sclerosis Society, Parkinson’s Action Network and the Alzheimer’s Association. A tentative settlement had been reached in October and on Jan. 24 a federal judge in Vermont approved the deal.

For seniors getting skilled services at home under a doctor’s order, the settlement means Medicare’s home health coverage has no time limit, Margaret Murphy told lawyers attending the annual meeting of the National Academy of Elder Law Attorneys in Washington, D. C., shortly after the then-tentative settlement was announced.

The coverage “can go on for years and years, if your doctor orders it,” said Ms. Murphy, the center’s associate director, who added that patients must be homebound (though not bedbound) and need intermittent care — every couple of days or weeks – that can only be provided by a physical therapist, nurse or other trained health care professional. When physical therapy is provided as part of Medicare’s home health benefit, the therapy dollar limits may not apply.

The settlement ensures that nursing home residents will also get coverage for skilled care regardless of improvement, but does not change the duration, which is still limited to up to 100 days per “benefit period.” That begins when a patient is admitted as an inpatient to a hospital or a nursing home for skilled care and ends after 60 days without skilled care. The agreement preserves the requirement that they must also have spent at least three days as inpatients in a hospital.

Federal officials say the settlement is not a change in Medicare coverage rules, but that statement may surprise many beneficiaries and providers.

“If someone isn’t making progress, I say, ‘Listen, I’m sorry but Medicare’s not going to cover this so you can come in for a few more sessions but then I have to let you go,’ ” said Greg Babiec, a physical therapist and one of the owners of Evolve, a private therapy practice with offices in Manhattan and Brooklyn. He had not heard about the settlement.

Beneficiaries also often lose Medicare coverage for outpatient therapy because they hit the payment limit. But under the exceptions process Congress continued for another year, the health care provider can put an additional code on the claim that indicates further treatment above the $1,900 limit is medically necessary. When treatment costs reach $3,700, the provider can submit medical documentation to support a request for another exception to cover 20 more sessions. (A Medicare fact sheet provides some additional details, but has not been updated for 2013.)

In 2011, nearly five million seniors received therapy services at a cost of $5.7 billion, and about one out of every four received an exception to the then-$1,870 limit, according to the Medicare Payment Advisory Commission, an independent government agency that advises Congress.

Just a few hours before the settlement was approved, Rachel DeGolia learned that her 87-year-old father in Chicago was going to have to stop therapy because he stopped showing improvement — again.

“Every time he stops going to physical therapy, he starts to backslide in terms of his balance, his strength and his mobility,” said Ms. DeGolia, executive director of the Universal Health Care Action Network, a national advocacy group in Cleveland. His physical therapist did not know Medicare will cover therapy to prevent her father’s condition from getting worse.

Under the settlement, Medicare officials have until next January to straighten things out by notifying health care providers. Beneficiaries are not among those to be contacted, and so far the federal officials have not issued a formal statement on the settlement.

But patients don’t have to wait for their provider to get the official word, said Judith Stein, the lead attorney for the plaintiffs and executive director of the Center for Medicare Advocacy. “This isn’t a clandestine settlement,” she said.

The center’s Web site offers free “self-help” packets explaining how to challenge a denial of coverage that is based on the lack of improvement. Ms. Stein also advises beneficiaries to show a copy of the settlement — also available from the Web site — to your health care provider at your next physical therapy appointment if you are concerned about losing Medicare coverage. (If you follow this advice, let us know what happens.)

The Web site also explains how beneficiaries can request a review of their case if they received skilled nursing or therapy services in a skilled nursing facility, at home or as outpatients and were denied Medicare coverage because of a lack of progress after Jan. 18, 2011, when the lawsuit was filed.

Dean Lerner relied on the settlement last month to ensure that his brother-in-law would continue to receive Medicare physical therapy coverage.

“My brother-in-law in St. Louis suffers from Parkinson’s disease, and has for many years, and my sister is having a devil of a time helping him as his disease progresses,” said Mr. Lerner, a retired lawyer and state health official in Des Moines, who is also a Medicaid consultant.

A physical therapist teaches his brother-in-law to stand, turn and use a walker and maintain what little strength he still has. But because his condition hasn’t improved, the therapist said Medicare would not pay for additional sessions.

“But for my being an attorney, the outcome may well have been very different, and that shouldn’t be,” he said. “Why should you have to fight?”

Read More..

The New Old Age Blog: Therapy Plateau No Longer Ends Coverage

Ellen Gorman, 72, a New York psychotherapist, can’t walk very far and gets around the city mainly by taxi, “which is really expensive,” she said. Twice since 2008 her physical therapy was discontinued because she wasn’t progressing. But after a knee replacement last year, she is getting physical therapy again, exercising with her therapist and building up her endurance by walking in the hallway of her Manhattan apartment building.

“Before this, I was getting weaker and weaker, and I just kept caving in,” she said.

Because of an action by Congress and a recent court settlement, Medicare probably won’t cut off Ms. Gorman’s physical therapy again should her progress level off — as long as her doctor says it is medically necessary.

Congress continued for another year a little-known process that allows exceptions to what Medicare pays for physical, occupational and speech therapy. The Medicare limits before the exceptions are $1,900 for physical and speech therapy this year, and $1,900 for occupational therapy.

In addition, the settlement of a class-action lawsuit last month now means that Medicare is prohibited from denying patients coverage for skilled nursing care, home health services or outpatient therapy because they had reached a “plateau,” and their conditions were not improving. That will allow people with Medicare who have chronic health problems and disabilities to get the therapy and other skilled care that they need for as long as they need it, if they meet other coverage criteria.

The settlement is expected to affect thousands, and possibly millions, of Medicare beneficiaries with chronic health problems like Parkinson’s or Alzheimer’s disease, stroke, multiple sclerosis and spinal cord injuries. It could also help families, as well as the overburdened Medicare budget, delay costly nursing home care by enabling seniors to live longer in their own homes.

“Under this settlement, Medicare policy will be clarified to ensure that claims from providers are reimbursed consistently and appropriately and not denied solely based on a rule-of-thumb determination that a beneficiary’s condition is not improving,” said Fabien Levy, a spokesman for the U. S. Department of Health and Human Services, which includes the Medicare program.

The lawsuit was filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four Medicare patients and five national organizations, including the National Multiple Sclerosis Society, Parkinson’s Action Network and the Alzheimer’s Association. A tentative settlement had been reached in October and on Jan. 24 a federal judge in Vermont approved the deal.

For seniors getting skilled services at home under a doctor’s order, the settlement means Medicare’s home health coverage has no time limit, Margaret Murphy told lawyers attending the annual meeting of the National Academy of Elder Law Attorneys in Washington, D. C., shortly after the then-tentative settlement was announced.

The coverage “can go on for years and years, if your doctor orders it,” said Ms. Murphy, the center’s associate director, who added that patients must be homebound (though not bedbound) and need intermittent care — every couple of days or weeks – that can only be provided by a physical therapist, nurse or other trained health care professional. When physical therapy is provided as part of Medicare’s home health benefit, the therapy dollar limits may not apply.

The settlement ensures that nursing home residents will also get coverage for skilled care regardless of improvement, but does not change the duration, which is still limited to up to 100 days per “benefit period.” That begins when a patient is admitted as an inpatient to a hospital or a nursing home for skilled care and ends after 60 days without skilled care. The agreement preserves the requirement that they must also have spent at least three days as inpatients in a hospital.

Federal officials say the settlement is not a change in Medicare coverage rules, but that statement may surprise many beneficiaries and providers.

“If someone isn’t making progress, I say, ‘Listen, I’m sorry but Medicare’s not going to cover this so you can come in for a few more sessions but then I have to let you go,’ ” said Greg Babiec, a physical therapist and one of the owners of Evolve, a private therapy practice with offices in Manhattan and Brooklyn. He had not heard about the settlement.

Beneficiaries also often lose Medicare coverage for outpatient therapy because they hit the payment limit. But under the exceptions process Congress continued for another year, the health care provider can put an additional code on the claim that indicates further treatment above the $1,900 limit is medically necessary. When treatment costs reach $3,700, the provider can submit medical documentation to support a request for another exception to cover 20 more sessions. (A Medicare fact sheet provides some additional details, but has not been updated for 2013.)

In 2011, nearly five million seniors received therapy services at a cost of $5.7 billion, and about one out of every four received an exception to the then-$1,870 limit, according to the Medicare Payment Advisory Commission, an independent government agency that advises Congress.

Just a few hours before the settlement was approved, Rachel DeGolia learned that her 87-year-old father in Chicago was going to have to stop therapy because he stopped showing improvement — again.

“Every time he stops going to physical therapy, he starts to backslide in terms of his balance, his strength and his mobility,” said Ms. DeGolia, executive director of the Universal Health Care Action Network, a national advocacy group in Cleveland. His physical therapist did not know Medicare will cover therapy to prevent her father’s condition from getting worse.

Under the settlement, Medicare officials have until next January to straighten things out by notifying health care providers. Beneficiaries are not among those to be contacted, and so far the federal officials have not issued a formal statement on the settlement.

But patients don’t have to wait for their provider to get the official word, said Judith Stein, the lead attorney for the plaintiffs and executive director of the Center for Medicare Advocacy. “This isn’t a clandestine settlement,” she said.

The center’s Web site offers free “self-help” packets explaining how to challenge a denial of coverage that is based on the lack of improvement. Ms. Stein also advises beneficiaries to show a copy of the settlement — also available from the Web site — to your health care provider at your next physical therapy appointment if you are concerned about losing Medicare coverage. (If you follow this advice, let us know what happens.)

The Web site also explains how beneficiaries can request a review of their case if they received skilled nursing or therapy services in a skilled nursing facility, at home or as outpatients and were denied Medicare coverage because of a lack of progress after Jan. 18, 2011, when the lawsuit was filed.

Dean Lerner relied on the settlement last month to ensure that his brother-in-law would continue to receive Medicare physical therapy coverage.

“My brother-in-law in St. Louis suffers from Parkinson’s disease, and has for many years, and my sister is having a devil of a time helping him as his disease progresses,” said Mr. Lerner, a retired lawyer and state health official in Des Moines, who is also a Medicaid consultant.

A physical therapist teaches his brother-in-law to stand, turn and use a walker and maintain what little strength he still has. But because his condition hasn’t improved, the therapist said Medicare would not pay for additional sessions.

“But for my being an attorney, the outcome may well have been very different, and that shouldn’t be,” he said. “Why should you have to fight?”

Read More..

Gadgetwise Blog: Q.& A.: Recording Video on an SD Card

How many minutes of video can I fit on the 16-gigabyte Secure Digital memory card in my camera?

The amount of video you can fit on your camera’s memory card can depend on the camera, the image quality and any special-effects modes you may be using while filming. The video section of your camera’s manual should have some specific answers on recording times for the different settings. If you chucked your manual right after you got the camera or cannot find it, check the support area of your manufacturer’s Web site or try an online manual repository like Retrevo.

For example, on the PowerShot S95 camera, Canon’s manual says you should be able to fit approximately one hour, 42 minutes and 57 seconds of video on a 16-gigabyte card when recording video at the high-definition setting of 1,280 by 720 pixels (at 24 frames per second). Switching to the standard-quality setting of 640 by 480 pixels (at 30 frames per second) lets you fit two hours, 59 minutes and three seconds of video on a 16-gigabyte SD card.

If you drop the quality level even lower to the 320 by 240 pixels (at 30 frames per second) setting, you can store more than eight hours of video on the card. Video clips may have a maximum size of four gigabytes or around 30 minutes in length at the high-definition setting, but you can resume recording new clips until the card is full.

While your camera’s manual should have more precise information, the SD Association, (an industry group devoted to creating technical standards for the Secure Digital format), has some basic information on how many minutes of video can fit on SD cards of different capacities on its site. The page also provides estimates on how many photos or approximate minutes of music fit on various SD cards.

Read More..

IHT Rendezvous: IHT Quick Read: Feb. 4

NEWS A secret legal review on the use of the United States’ growing arsenal of cyberweapons has concluded that President Barack Obama has the broad power to order a pre-emptive strike if the United States detects credible evidence of a major digital attack looming from abroad, according to officials involved in the review. David E. Sanger and Thom Shanker report from Washington.

As a Russian loan runs out and Cyprus seeks aid, Germany finds itself in a fierce debate over whether to help bail out the island nation. Liz Alderman reports from Paris.

Accounts from captives held in the siege of a Saharan gas plant in Algeria last month reveal that militants sought to orchestrate a spectacular, deadly explosion. Adam Nossiter reports from Tiguentourine, Algeria, and Nicholas Kulish from Berlin.

A sometimes frustrated figure who prized her role as a team player, Secretary of State Hillary Rodham Clinton’s instincts were often more activist than those of a White House that has kept a tight grip on foreign policy. Michael R. Gordon and Mark Landler report from Washington.

Prime Minister Mariano Rajoy of Spain is pledging to make public this week his tax returns and financial assets to refute what he described over the weekend as ‘‘apocryphal’’ documents showing that he and other senior conservative politicians had received payouts from a secret account maintained by their party. Raphael Minder reports from Madrid.

In the aftermath of the financial crash, Britain’s politicians acknowledged that they had put too much faith in a bloated financial sector that plunged the country into crisis. But rebalancing the skills of the British labor force may require a shift that is as much social and cultural as it is economic. Stephen Castle reports from North Shields, England.

In France, companies have their wings clipped by onerous social charges paid to the government and severance packages that make companies think twice before hiring and firing– but some entrepreneurs are still figuring out ways to succeed. Kimiko de Freytas-Tamura reports from Paris.

ARTS With wit and ingenuity, the British graphic designer David Pearson is rekindling interest in paperbacks. Alice Rawsthorn reviews from London.

SPORTS The Baltimore Ravens won Super Bowl XLVII. For the latest, visit http://www.nytimes.com/pages/sports/football/index.html.

The Six Nations rugby tournament kicked off with Ireland getting a hard-earned victory over the reigning champion Wales, while England scored a home victory over Scotland and Italy beat France. Huw Richards reports.

Read More..

Iceland, Prosecutor of Bankers, Sees Meager Returns

Ilvy Njiokiktjien for The New York Times

"Greed is not a crime. But the question is: where does greed lead?" said Olafur Hauksson, a special prosecutor in Reykjavik.

REYKJAVIK, Iceland — As chief of police in a tiny fishing town for 11 years, Olafur Hauksson developed what he thought was a basic understanding of the criminal mind. The typical lawbreaker, he said, recalling his many encounters with small-time criminals, “clearly knows that he crossed the line” and generally sees “the difference between right and wrong.”

Today, the burly, 48-year-old former policeman is struggling with a very different sort of suspect. Reassigned to Reykjavik, the Icelandic capital, to lead what has become one of the world’s most sweeping investigation into the bankers whose actions contributed to the global financial crisis in 2008, Mr. Hauksson now faces suspects who “are not aware of when they crossed the line” and “defend their actions every step of the way.”

With the global economy still struggling to recover from the financial maelstrom five years ago, governments around the world have been criticized for largely failing to punish the bankers who were responsible for the calamity. But even here in Iceland, a country of just 320,000 that has gone after financiers with far more vigor than the United States and other countries hit by the crisis, obtaining criminal convictions has proved devilishly difficult.

Public hostility toward bankers is so strong in Iceland that “it is easier to say you are dealing drugs than to say you’re a banker,” said Thorvaldur Sigurjonsson, the former head of trading for Kaupthing, a once high-flying bank that crumbled. He has been called in for questioning by Mr. Hauksson’s office but has not been charged with any wrongdoing.

Yet, in the four years since the Icelandic Parliament passed a law ordering the appointment of an unnamed special prosecutor to investigate those blamed for the country’s spectacular meltdown in 2008, only a handful of bankers have been convicted.

Ministers in a left-leaning coalition government elected after the crash agree that the wheels of justice have ground slowly, but they call for patience, explaining that the process must follow the law, not vengeful passions.

“We are not going after people just to satisfy public anger,” said Steingrimur J. Sigfusson, Iceland’s minister of industry, a former finance minister and leader of the Left-Green Movement that is part of the governing coalition.

Hordur Torfa, a popular singer-songwriter who helped organize protests that forced the previous conservative government to resign, acknowledged that “people are getting impatient” but said they needed to accept that “this is not the French Revolution. I don’t believe in taking bankers out and hanging them or shooting them.”

Others are less patient. “The whole process is far too slow,” said Thorarinn Einarsson, a left-wing activist. “It only shows that ‘banksters’ can get away with doing whatever they want.”

Mr. Hauksson, the special prosecutor, said he was frustrated by the slow pace but thought it vital that his office scrupulously follow legal procedure. “Revenge is not something we want as our main driver in this process. Our work must be proper today and be seen as proper in the future,” he said.

Part of the difficulty in prosecuting bankers, he said, is that the law is often unclear on what constitutes a criminal offense in high finance. “Greed is not a crime,” he noted. “But the question is: where does greed lead?”

Mr. Hauksson said it was often easy to show that bankers violated their own internal rules for lending and other activities, but “as in all cases involving theft or fraud, the most difficult thing is proving intent.”

And there are the bankers themselves. Those who have been brought in for questioning often bristle at being asked to account for their actions. “They are not used to being questioned. These people are not used to finding themselves in this situation,” Mr. Hauksson said. They also hire expensive lawyers.

The special prosecutor’s office initially had only five staff members but now has more than 100 investigators, lawyers and financial experts, and it has relocated to a big new office. It has opened about 100 cases, with more than 120 people now under investigation for possible crimes relating to an Icelandic financial sector that grew so big it dwarfed the rest of the economy.

To help ease Mr. Hauksson’s task, legislators amended the law to allow investigators easy access to confidential bank information, something that previously required a court order.

Parliament also voted to put the country’s prime minister at the time of the banking debacle on trial for negligence before a special tribunal. (A proposal to try his cabinet failed.) Mr. Hauksson was not involved in the case against the former leader, Geir H. Haarde, who last year was found guilty of failing to keep ministers properly informed about the 2008 crisis but was acquitted on more serious charges that could have resulted in a prison sentence.

Read More..

Concerns About A.D.H.D. Practices and Amphetamine Addiction

Before his addiction, Richard Fee was a popular college class president and aspiring medical student. "You keep giving Adderall to my son, you're going to kill him," said Rick Fee, Richard's father, to one of his son's doctors.

VIRGINIA BEACH — Every morning on her way to work, Kathy Fee holds her breath as she drives past the squat brick building that houses Dominion Psychiatric Associates.

Andrea Mohin/The New York Times

MENTAL HEALTH CLINIC Dominion Psychiatric Associates in Virginia Beach, where Richard Fee was treated by Dr. Waldo M. Ellison. After observing Richard and hearing his complaints about concentration, Dr. Ellison diagnosed attention deficit hyperactivity disorder and prescribed the stimulant Adderall.

It was there that her son, Richard, visited a doctor and received prescriptions for Adderall, an amphetamine-based medication for attention deficit hyperactivity disorder. It was in the parking lot that she insisted to Richard that he did not have A.D.H.D., not as a child and not now as a 24-year-old college graduate, and that he was getting dangerously addicted to the medication. It was inside the building that her husband, Rick, implored Richard’s doctor to stop prescribing him Adderall, warning, “You’re going to kill him.”

It was where, after becoming violently delusional and spending a week in a psychiatric hospital in 2011, Richard met with his doctor and received prescriptions for 90 more days of Adderall. He hanged himself in his bedroom closet two weeks after they expired.

The story of Richard Fee, an athletic, personable college class president and aspiring medical student, highlights widespread failings in the system through which five million Americans take medication for A.D.H.D., doctors and other experts said.

Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.

Richard Fee’s experience included it all. Conversations with friends and family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.

Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard’s own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that A.D.H.D. practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered,” said Dr. Parker, a psychiatrist in Virginia Beach. “I think it’s an abnegation of trust. The public needs to say this is totally unacceptable and walk out.”

Young adults are by far the fastest-growing segment of people taking A.D.H.D medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health. While this rise is generally attributed to the maturing of adolescents who have A.D.H.D. into young adults — combined with a greater recognition of adult A.D.H.D. in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors.

“Any step along the way, someone could have helped him — they were just handing out drugs,” said Richard’s father. Emphasizing that he had no intention of bringing legal action against any of the doctors involved, Mr. Fee said: “People have to know that kids are out there getting these drugs and getting addicted to them. And doctors are helping them do it.”

“...when he was in elementary school he fidgeted, daydreamed and got A’s. he has been an A-B student until mid college when he became scattered and he wandered while reading He never had to study. Presently without medication, his mind thinks most of the time, he procrastinated, he multitasks not finishing in a timely manner.”

Dr. Waldo M. Ellison

Richard Fee initial evaluation

Feb. 5, 2010

Richard began acting strangely soon after moving back home in late 2009, his parents said. He stayed up for days at a time, went from gregarious to grumpy and back, and scrawled compulsively in notebooks. His father, while trying to add Richard to his health insurance policy, learned that he was taking Vyvanse for A.D.H.D.

Richard explained to him that he had been having trouble concentrating while studying for medical school entrance exams the previous year and that he had seen a doctor and received a diagnosis. His father reacted with surprise. Richard had never shown any A.D.H.D. symptoms his entire life, from nursery school through high school, when he was awarded a full academic scholarship to Greensboro College in North Carolina. Mr. Fee also expressed concerns about the safety of his son’s taking daily amphetamines for a condition he might not have.

“The doctor wouldn’t give me anything that’s bad for me,” Mr. Fee recalled his son saying that day. “I’m not buying it on the street corner.”

Read More..

Concerns About A.D.H.D. Practices and Amphetamine Addiction

Before his addiction, Richard Fee was a popular college class president and aspiring medical student. "You keep giving Adderall to my son, you're going to kill him," said Rick Fee, Richard's father, to one of his son's doctors.

VIRGINIA BEACH — Every morning on her way to work, Kathy Fee holds her breath as she drives past the squat brick building that houses Dominion Psychiatric Associates.

Andrea Mohin/The New York Times

MENTAL HEALTH CLINIC Dominion Psychiatric Associates in Virginia Beach, where Richard Fee was treated by Dr. Waldo M. Ellison. After observing Richard and hearing his complaints about concentration, Dr. Ellison diagnosed attention deficit hyperactivity disorder and prescribed the stimulant Adderall.

It was there that her son, Richard, visited a doctor and received prescriptions for Adderall, an amphetamine-based medication for attention deficit hyperactivity disorder. It was in the parking lot that she insisted to Richard that he did not have A.D.H.D., not as a child and not now as a 24-year-old college graduate, and that he was getting dangerously addicted to the medication. It was inside the building that her husband, Rick, implored Richard’s doctor to stop prescribing him Adderall, warning, “You’re going to kill him.”

It was where, after becoming violently delusional and spending a week in a psychiatric hospital in 2011, Richard met with his doctor and received prescriptions for 90 more days of Adderall. He hanged himself in his bedroom closet two weeks after they expired.

The story of Richard Fee, an athletic, personable college class president and aspiring medical student, highlights widespread failings in the system through which five million Americans take medication for A.D.H.D., doctors and other experts said.

Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.

Richard Fee’s experience included it all. Conversations with friends and family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.

Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard’s own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that A.D.H.D. practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered,” said Dr. Parker, a psychiatrist in Virginia Beach. “I think it’s an abnegation of trust. The public needs to say this is totally unacceptable and walk out.”

Young adults are by far the fastest-growing segment of people taking A.D.H.D medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health. While this rise is generally attributed to the maturing of adolescents who have A.D.H.D. into young adults — combined with a greater recognition of adult A.D.H.D. in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors.

“Any step along the way, someone could have helped him — they were just handing out drugs,” said Richard’s father. Emphasizing that he had no intention of bringing legal action against any of the doctors involved, Mr. Fee said: “People have to know that kids are out there getting these drugs and getting addicted to them. And doctors are helping them do it.”

“...when he was in elementary school he fidgeted, daydreamed and got A’s. he has been an A-B student until mid college when he became scattered and he wandered while reading He never had to study. Presently without medication, his mind thinks most of the time, he procrastinated, he multitasks not finishing in a timely manner.”

Dr. Waldo M. Ellison

Richard Fee initial evaluation

Feb. 5, 2010

Richard began acting strangely soon after moving back home in late 2009, his parents said. He stayed up for days at a time, went from gregarious to grumpy and back, and scrawled compulsively in notebooks. His father, while trying to add Richard to his health insurance policy, learned that he was taking Vyvanse for A.D.H.D.

Richard explained to him that he had been having trouble concentrating while studying for medical school entrance exams the previous year and that he had seen a doctor and received a diagnosis. His father reacted with surprise. Richard had never shown any A.D.H.D. symptoms his entire life, from nursery school through high school, when he was awarded a full academic scholarship to Greensboro College in North Carolina. Mr. Fee also expressed concerns about the safety of his son’s taking daily amphetamines for a condition he might not have.

“The doctor wouldn’t give me anything that’s bad for me,” Mr. Fee recalled his son saying that day. “I’m not buying it on the street corner.”

Read More..

Slipstream: Consumer Data Protection Laws, an Ocean Apart

OVER the years, the United States and Europe have taken different approaches toward protecting people’s personal information. Now the two sides are struggling to bridge that divide.

On this side of the Atlantic, Congress has enacted a patchwork quilt of privacy laws that separately limit the use of Americans’ medical records, credit reports, video rental records and so on. On the other side, the European Union has instituted more of a blanket regulatory system; it has a common directive that gives its citizens certain fundamental rights — like the right to obtain copies of records held about them by companies and institutions — that Americans now lack.

Even so, United States officials maintain that the divergent approaches are equal. “The sum of the parts of U.S. privacy protection is equal to or greater than the single whole of Europe,” says Cameron F. Kerry, general counsel of the Commerce Department. He is overseeing an agency effort to help develop voluntary, enforceable codes of conduct for industry groups, like app developers, whose collection and use of consumer data are now unregulated.

Europe begs to differ.

“Yes, we share the basic idea of privacy,” says Peter Hustinx, Europe’s data protection supervisor. “But there is a huge deficit on the U.S. side.”

Alas, the data-control divide appears to be widening.

A year ago, the European Commission proposed comprehensive reforms to strengthen online privacy rights — changes that could have big repercussions for American technology companies and marketers that operate in the European Union. American officials, trade groups and tech executives have responded by taking frequent treks to Brussels and other cities, where they have urged regulators and legislators to reconsider the one-regulation-fits-all-data approach. What’s at stake, American industry representatives say, is nothing less than a free and commerce-friendly Internet.

“The ecosystem of the Internet is very delicate,” says Kevin Richards, senior vice president of federal government affairs at TechAmerica, a trade group that represents companies like Google and Microsoft. “It’s not wise to have an overly broad, prescriptive, one-size-fits-all approach that would hinder or undermine the ability of companies to innovate in a global economy.”

European Union members already have data protection laws in place, based on a directive from 1995 that laid out principles for the collection of personal information. The proposed new rules would strengthen some existing provisions. They would standardize data protections across the 27 member states. They would also provide some new rights, such as “data portability” — the right of consumers to easily transfer their text files, photographs and videos from one social network, or e-mail or cloud storage service, to another. And they would subject companies that violate the rules to penalties of up to 2 percent of their annual global revenue.

Asked for comment, Viviane Reding, the vice president of the European Commission and the architect of the proposed regulation, said in a statement: “The main problem is that our rules predate the digital age and it became increasingly clear in recent years that they needed an update.” She continued: “That is why I have proposed a root-and-branch reform of the E.U.’s data protection rules — currently under discussion in the European Parliament and the Council of the E.U. — that will both protect citizens’ rights and facilitate business in the digital age.”

BUT some provisions seem too rigid to United States officials and trade groups. They argue that the American approach — sector-specific privacy laws, in addition to industry self-regulation and enforcement by the Federal Trade Commission — is more nimble.

“We hope that Europe will move in the direction of those multistakeholder standards, and not standards which are not flexible and don’t move at Internet speed,” says Mr. Kerry, who has taken at least four trips to European cities in the last year to discuss these issues.

From the perspective of some European legislators, however, United States representatives seem more interested in protecting commerce than consumers. The full-court American effort may have backfired, they say, pushing some European officials toward even broader measures. Last month, Jan Philipp Albrecht, a representative of the European Parliament who reviewed the draft regulation, proposed additional rights for citizens — like the right not to be subject to consumer profiling.

“My impression is that the U.S. Chamber of Commerce and the Commerce Department are mostly just following the interests of Silicon Valley,” he says. “This leads to heavy pressure on the European regulator, I can say.”

But Mr. Kerry says the United States must make its views known if the systems are to work in concert.

“I know that some people have raised eyebrows at our involvement; I make no apologies,” Mr. Kerry says. “We in the United States and countries and businesses around the world are stakeholders in this process. This has an important impact on the global economy.”

The solution to this trans-Atlantic clash may simply be American ingenuity.

Last year, President Barack Obama proposed a “Consumer Privacy Bill of Rights” that would give Americans many of the same baseline protections that the draft European rule proposes to reinforce. These include the right of access to records that companies hold about them, the right to correct those records and the right to have limits on the personal data that companies collect and keep. Administration officials said they would work with Congress on legislation based on those rights and to extend oversight to industries not currently covered by federal privacy laws.

A coalition of more than a dozen American advocacy groups said it would send a letter on Monday to senior Obama administration officials, seeking a meeting to ensure that American policy makers’ efforts in Europe “are not averse to the views expressed by the president.” The coalition includes the Electronic Privacy Information Center and the Center for Digital Democracy.

“Does the Obama administration really want to be on the opposite side of the European effort to upgrade and modernize its privacy law which is at its core about the protection of a fundamental freedom?” asks Marc Rotenberg, executive director of the Electronic Privacy Information Center.

European officials hold out hope that Congress will enact baseline consumer privacy protections for Americans.

“This development — which is much welcomed in Europe — shows that we have much in common,” Ms. Reding of the European Commission said in her statement, speaking of the privacy bill of rights. “Convergence is springing up and synergies are possible.”

E-mail: slipstream@nytimes.com.

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IHT Rendezvous: In Villages, Praying for the Souls of Tibetan Self-Immolators

BEIJING — Since November, when winter began in the high Tibetan Plateau, thousands of Tibetan villagers have been gathering daily to pray for the souls of the nearly 100 Tibetans who have burned themselves to death in protest over Chinese rule, in a show of widespread support for the self-immolators among ordinary people, according to witness testimony from a person recently returned from the region.

In traditional winter prayer meetings in villages, they gather to chant “Om mani padme hum,” Tibetan Buddhism’s most important mantra, which speeds a soul toward a good reincarnation, said the person, who witnessed a meeting in the Tibetan region of Qinghai Province in China.

The meetings are a sign of support for the self-immolators and point to widespread dislike among ordinary Tibetans for repressive policies in the region that have turned it into an “open-air prison,” said one ethnic Tibetan police officer in Lhasa, quoted by the witness.

The witness cannot be identified because of the high risk of persecution by the Chinese authorities. But the reliable account of ongoing, severe repression and resentment among Tibetans confirms other reports from the Tibet Autonomous Region or from Tibetan regions in Chinese provinces, where the authorities have been cracking down as they try to stop the spread of the self-immolations.

Chinese courts last week sentenced eight Tibetans for helping self-immolators, The Associated Press reported. One man was sentenced to death with a two-year reprieve, and others were sentenced to between 3 years and 12 years in jail, according to Xinhua, the state news agency.

The detail and content of the grass-roots prayer meetings is new.

“The meetings are a traditional thing to do during the winter and are held daily in different villages, and last three days,” the witness said. They are known in Chinese as “fahui,” or dharma meetings, which are also Buddhist law meetings.

“People drive on motorbikes for long distances, 50 or 60 kilometers, to whichever village is holding a prayer meeting. It’s mostly adults, and they are anywhere between 16 and over 80 years old. As soon as they can drive a motorbike, they’ll go,” the person said.

“Around 1,000 people may attend, often going from one meeting to another without returning home.”

“Their aim is for each meeting to have chanted ‘Om mani padme hum’ 100 million times. There’s no question that they regard the self-immolators as very great, and believe that with the help of their prayers, they will come back as powerful and blessed people,” said the person, who confessed to having reservations about the self-immolations.

Yet, “It’s extremely moving. Because if the self-immolations really were a mistake, how could they get so much support and sympathy from ordinary people?”

As my colleague Jim Yardley reports from India, where many Tibetans live in exile, some there are questioning the self-immolations.

The witness confirmed that, saying: “There is a feeling among some Tibetans,” especially monks or those in the religious hierarchy, “that the Dalai Lama needs to say something to stop it.”

Yet Tibetans who are deeply unhappy with Chinese rule are constrained in how they can protest.

“The problem is that Tibetans are Buddhists. The way things are there now, in other places, people might rise up and set off bombs. But they can’t do that because Buddhists believe you shouldn’t destroy other people’s happiness. So the only way they can protest is by killing themselves,” the person said.

And so the grass-roots support goes on.

The testimony from this person also confirmed reports of a very harsh crackdown under way in Lhasa, seat of the Jokhang, Tibet’s holiest temple, and the Potala Palace, the former home of the Dalai Lama, whom Tibetans revere and who has lived in exile since fleeing the Chinese in 1959.

The crackdown, in response to the self-immolations that began not long after an uprising in Lhasa was crushed in 2008, has turned Tibet into “an open-air prison,” said an ethnic Tibetan police officer. Like some other ethnic Tibetan police officers, he was considering resigning his post, he said.

“Lhasa used to be a sacred place for Buddhism. Now it’s a sacred place for Marxism-Leninism,” he said. “Every day there are meetings where leaders both big and small tell you that maintaining stability,” or “weiwen,” in Chinese, “is the most important thing, what the main tasks in Lhasa are. Lhasa is no longer a Buddhist sacred place,” he added.

“Lhasa is stuffed with police, every 10 paces there are several. I am growing to hate my own work. It’s really not possible to keep doing it. Some have already resigned,” he told the witness.

The crackdown includes forbidding ethnic Tibetans from the outlying regions, like Qinghai or Sichuan Provinces, which lie outside Tibet proper, from traveling to Tibet, and it is strictly enforced at airports and other transport nodes. Ethnic Han Chinese, however, can pass, effectively making Tibet out of bounds for many Tibetans.

Any Tibetan from outside the region wishing to travel to Lhasa must have a “sponsor” in the city working for the government, the witness said. They must surrender their identity cards and be photographed. Uniformed and plainclothes police officers and military patrol heavily in the city, trying to stop self-immolations.

Barring ethnic Tibetans from outside Tibet, many of whom have traditionally made pilgrimages to Lhasa, means that hotels and other businesses in the city have suffered since last May, when they were ordered off bounds to such travelers. A petition is now circulating from hotel owners asking the government to compensate them financially, “or we will take our request higher.” For reasons of political sensitivity, the petition, which has been seen by this newspaper, cannot be discussed in detail.

It is also extremely difficult for ordinary ethnic Tibetans to get a passport, meaning they cannot travel overseas, the witness said. The person believes the government’s motive is to minimize accounts, like this one, of the harsh repression in the region.

“They don’t want Tibetans leaving the country and telling the world what’s happening there. Hundreds of people leaving and telling the world is very different from one or two,” the person said.

With the Lunar New Year approaching, the prayer meetings will soon be scaled back, as farm work and animal husbandry resume. For now, though, the villagers are praying hard for the souls of the dead, with millions of mantras circulating in the thin air of the plateau.

“They say, we want their lives to come back. We want world peace. They pray for Tibet to have peaceful and happy days, and the world, too,” the person said.

Said the police officer: “Living in this tightly controlled atmosphere is unbearable. There’s no feeling of happiness. But maybe it’s good this way, it may speed up the day when the situation has to change. But I don’t have the courage to self-immolate. Maybe after I retire I’ll go to Beijing and petition.”

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Media Decoder Blog: In Wake of Restructuring, NBC News President Quits

8:30 p.m. | Updated

The longest-serving president of any of the three network news divisions, Steve Capus of NBC News, stepped down from his position on Friday, six months after Comcast restructured its news units in a way that diminished his authority.

Pat Fili-Krushel, chairwoman of the NBCUniversal News Group, said in a brief telephone interview on Friday that she would “cast a wide net” while searching for a successor to Mr. Capus. In the interim, the leaders of the news division will report directly to her.

Ms. Fili-Krushel became Mr. Capus’s boss last July when Steve Burke, the chief executive of NBCUniversal, consolidated all of NBC’s news units — NBC News, the cable news channels MSNBC and CNBC, and its stake in the Weather Channel — under a new umbrella, the NBCUniversal News Group. Mr. Burke asked Ms. Fili-Krushel, one of his most trusted lieutenants, to run it, while keeping Mr. Capus and the heads of the other units in place.

Ms. Fili-Krushel worked early in her career at HBO and Lifetime. A veteran of the Walt Disney Company, where she helped program ABC, and  Time Warner, where she was an administrator, she is by her own admission not a journalist.  But now she is, by default, the highest-ranking woman in the American television news industry — not just at the moment, but in the history of the medium. The heads of the news divisions at ABC and CBS are men, as are the heads of the Fox News Channel, CNN, and Bloomberg.

Ms. Fili-Krushel has kept a low public profile, but has been a forceful presence behind the scenes, recently moving from her office on the 51st floor of 30 Rockefeller Center, near Mr. Burke’s, to a new one on the third floor, where NBC News is based. On Friday, she said she had spent her first six months “learning, listening and getting to know the players here.” She called the News Group an “unbelievably strong organization.”

Though Mr. Capus’s exit saddened many at NBC News on Friday, it came as little surprise. He had previously reported directly to Mr. Burke, but after the restructuring he reported to Ms. Fili-Krushel, and he made no secret of his unhappiness with the change. His contract had a clause that allowed him to leave in the event that he no longer reported to Mr. Burke, according to two people with direct knowledge of the arrangement at NBC, and he decided to exercise that right after months of contemplation. The people insisted on anonymity because they were not authorized by the network to speak publicly.

Mr. Capus told Ms. Fili-Krushel of his intent to leave last Friday. It is likely that he would have left sooner, but a series of major news stories kept him busy late last year — including Hurricane Sandy, the presidential election and the school shooting in Newtown, Conn. Mr. Capus also oversaw the network’s response to the kidnapping of Richard Engel and an NBC News crew in Syria last month.

“It has been a privilege to have spent two decades here, but it is now time to head in a new direction,” he wrote in an e-mail to staff members on Friday afternoon.

Mr. Capus guided NBC through a revolutionary time in news-gathering and distribution. He maintained the news division’s profitability, managed tensions between NBC News and its increasingly liberal cable channel MSNBC, and fostered new business ventures like an in-house production company and an annual education summit. Last year, he unwound an old deal with Microsoft to give the news division complete control over its Web site, now named NBCNews.com, for the first time.

Ms. Fili-Krushel wrote in a separate e-mail to staff members that “NBC News is America’s leading source of television news and Steve has been a big part of that success.”

NBC News is the producer of the most popular evening newscast in the country. But its single biggest source of profits, the morning show “Today,” fell to second place last year, behind ABC’s “Good Morning America,” for the first time since the 1990s. The decline caused widespread anxiety inside the news division and speculation that Mr. Capus would be relieved of his duties.

Inside NBC, both Mr. Capus and the executive producer of “Today,” Jim Bell, received much of the blame for the botched removal of Ann Curry from “Today” last June, which worsened the show’s already tenuous position in the ratings. Ms. Fili-Krushel was put in charge just a few weeks later.

Mr. Bell was replaced at “Today” last fall and is now the executive producer for NBC Olympics. Savannah Guthrie is now the co-host of “Today,” and Ms. Curry is a national and international correspondent for the network, but is rarely seen. Mr. Capus’s exit was seen by some at the network as the last shoe that had to drop.

In his e-mail to staff members, Mr. Capus called it an “extremely difficult decision to walk away,” noting that he started at NBC as a producer 20 years ago this month. He did not make any mention of what he would do next. “Journalism is, indeed, a noble calling, and I have much I hope to accomplish in the next phase of my career,” he wrote.

“Today” continues to lose to ABC’s “Good Morning America” among total viewers, but lately it has won a few weeks in the 25- to 54-year-old demographic that advertisers covet.

“NBC Nightly News” has more successfully fended off ABC’s “World News,” despite an aggressive push by ABC. Mr. Capus said, “NBC News has grown in all key metrics — from ratings and reputation to profitability.”

A version of this article appeared in print on 02/02/2013, on page B2 of the NewYork edition with the headline: In Wake of Restructuring, NBC News President Quits.

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