Opinion: A Health Insurance Detective Story

I’VE had a long career as a business journalist, beginning at Forbes and including eight years as the editor of Money, a personal finance magazine. But I’ve never faced a more confounding reporting challenge than the one I’m engaged in now: What will I pay next year for the pill that controls my blood cancer?

After making more than 70 phone calls to 16 organizations over the past few weeks, I’m still not totally sure what I will owe for my Revlimid, a derivative of thalidomide that is keeping my multiple myeloma in check. The drug is extremely expensive — about $11,000 retail for a four-week supply, $132,000 a year, $524 a pill. Time Warner, my former employer, has covered me for years under its Supplementary Medicare Program, a plan for retirees that included a special Writers Guild benefit capping my out-of-pocket prescription costs at $1,000 a year. That out-of-pocket limit is scheduled to expire on Jan. 1. So what will my Revlimid cost me next year?

The answers I got ranged from $20 a month to $17,000 a year. One of the first people I phoned said that no matter what I heard, I wouldn’t know the cost until I filed a claim in January. Seventy phone calls later, that may still be the most reliable thing anyone has told me.

Like around 47 million other Medicare beneficiaries, I have until this Friday, Dec. 7, when open enrollment ends, to choose my 2013 Medicare coverage, either through traditional Medicare or a private insurer, as well as my drug coverage — or I will risk all sorts of complications and potential late penalties.

But if a seasoned personal-finance journalist can’t get a straight answer to a simple question, what chance do most people have of picking the right health insurance option?

A study published in the journal Health Affairs in October estimated that a mere 5.2 percent of Medicare Part D beneficiaries chose the cheapest coverage that met their needs. All in all, consumers appear to be wasting roughly $11 billion a year on their Part D coverage, partly, I think, because they don’t get reliable answers to straightforward questions.

Here’s a snapshot of my surreal experience:

NOV. 7 A packet from Time Warner informs me that the company’s new 2013 Retiree Health Care Plan has “no out-of-pocket limit on your expenses.” But Erin, the person who answers at the company’s Benefits Service Center, tells me that the new plan will have “no practical effect” on me. What about the $1,000-a-year cap on drug costs? Is that really being eliminated? “Yes,” she says, “there’s no limit on out-of-pocket expenses in 2013.” I tell her I think that could have a major effect on me.

Next I talk to David at CVS/Caremark, Time Warner’s new drug insurance provider. He thinks my out-of-pocket cost for Revlimid next year will be $6,900. He says, “I know I’m scaring you.”

I call back Erin at Time Warner. She mentions something about $10,000 and says she’ll get an estimate for me in two business days.

NOV. 8 I phone Medicare. Jay says that if I switch to Medicare’s Part D prescription coverage, with a new provider, Revlimid’s cost will drive me into Medicare’s “catastrophic coverage.” I’d pay $2,819 the first month, and 5 percent of the cost of the drug thereafter — $563 a month or maybe $561. Anyway, roughly $9,000 for the year. Jay says AARP’s Part D plan may be a good option.

NOV. 9 Erin at Time Warner tells me that the company’s policy bundles United Healthcare medical coverage with CVS/Caremark’s drug coverage. I can’t accept the medical plan and cherry-pick prescription coverage elsewhere. It’s take it or leave it. Then she puts CVS’s Michele on the line to get me a Revlimid quote. Michele says Time Warner hasn’t transferred my insurance information. She can’t give me a quote without it. Erin says she will not call me with an update. I’ll have to call her.

My oncologist’s assistant steers me to Celgene, Revlimid’s manufacturer. Jennifer in “patient support” says premium assistance grants can cut the cost of Revlimid to $20 or $30 a month. She says, “You’re going to be O.K.” If my income is low enough to qualify for assistance.

NOV. 12 I try CVS again. Christine says my insurance records still have not been transferred, but she thinks my Revlimid might cost $17,000 a year.

Adriana at Medicare warns me that AARP and other Part D providers will require “prior authorization” to cover my Revlimid, so it’s probably best to stick with Time Warner no matter what the cost.

But Brooke at AARP insists that I don’t need prior authorization for my Revlimid, and so does her supervisor Brian — until he spots a footnote. Then he assures me that it will be easy to get prior authorization. All I need is a doctor’s note. My out-of-pocket cost for 2013: roughly $7,000.

NOV. 13 Linda at CVS says her company still doesn’t have my file, but from what she can see about Time Warner’s insurance plans my cost will be $60 a month — $720 for the year.

CVS assigns my case to Rebecca. She says she’s “sure all will be fine.” Well, “pretty sure.” She’s excited. She’s been with the company only a few months. This will be her first quote.

NOV. 14 Giddens at Time Warner puts in an “emergency update request” to get my files transferred to CVS.

Frank Lalli is an editorial consultant on retirement issues and a former senior executive editor at Time Warner’s Time Inc.

Read More..

Opinion: A Health Insurance Detective Story

I’VE had a long career as a business journalist, beginning at Forbes and including eight years as the editor of Money, a personal finance magazine. But I’ve never faced a more confounding reporting challenge than the one I’m engaged in now: What will I pay next year for the pill that controls my blood cancer?

After making more than 70 phone calls to 16 organizations over the past few weeks, I’m still not totally sure what I will owe for my Revlimid, a derivative of thalidomide that is keeping my multiple myeloma in check. The drug is extremely expensive — about $11,000 retail for a four-week supply, $132,000 a year, $524 a pill. Time Warner, my former employer, has covered me for years under its Supplementary Medicare Program, a plan for retirees that included a special Writers Guild benefit capping my out-of-pocket prescription costs at $1,000 a year. That out-of-pocket limit is scheduled to expire on Jan. 1. So what will my Revlimid cost me next year?

The answers I got ranged from $20 a month to $17,000 a year. One of the first people I phoned said that no matter what I heard, I wouldn’t know the cost until I filed a claim in January. Seventy phone calls later, that may still be the most reliable thing anyone has told me.

Like around 47 million other Medicare beneficiaries, I have until this Friday, Dec. 7, when open enrollment ends, to choose my 2013 Medicare coverage, either through traditional Medicare or a private insurer, as well as my drug coverage — or I will risk all sorts of complications and potential late penalties.

But if a seasoned personal-finance journalist can’t get a straight answer to a simple question, what chance do most people have of picking the right health insurance option?

A study published in the journal Health Affairs in October estimated that a mere 5.2 percent of Medicare Part D beneficiaries chose the cheapest coverage that met their needs. All in all, consumers appear to be wasting roughly $11 billion a year on their Part D coverage, partly, I think, because they don’t get reliable answers to straightforward questions.

Here’s a snapshot of my surreal experience:

NOV. 7 A packet from Time Warner informs me that the company’s new 2013 Retiree Health Care Plan has “no out-of-pocket limit on your expenses.” But Erin, the person who answers at the company’s Benefits Service Center, tells me that the new plan will have “no practical effect” on me. What about the $1,000-a-year cap on drug costs? Is that really being eliminated? “Yes,” she says, “there’s no limit on out-of-pocket expenses in 2013.” I tell her I think that could have a major effect on me.

Next I talk to David at CVS/Caremark, Time Warner’s new drug insurance provider. He thinks my out-of-pocket cost for Revlimid next year will be $6,900. He says, “I know I’m scaring you.”

I call back Erin at Time Warner. She mentions something about $10,000 and says she’ll get an estimate for me in two business days.

NOV. 8 I phone Medicare. Jay says that if I switch to Medicare’s Part D prescription coverage, with a new provider, Revlimid’s cost will drive me into Medicare’s “catastrophic coverage.” I’d pay $2,819 the first month, and 5 percent of the cost of the drug thereafter — $563 a month or maybe $561. Anyway, roughly $9,000 for the year. Jay says AARP’s Part D plan may be a good option.

NOV. 9 Erin at Time Warner tells me that the company’s policy bundles United Healthcare medical coverage with CVS/Caremark’s drug coverage. I can’t accept the medical plan and cherry-pick prescription coverage elsewhere. It’s take it or leave it. Then she puts CVS’s Michele on the line to get me a Revlimid quote. Michele says Time Warner hasn’t transferred my insurance information. She can’t give me a quote without it. Erin says she will not call me with an update. I’ll have to call her.

My oncologist’s assistant steers me to Celgene, Revlimid’s manufacturer. Jennifer in “patient support” says premium assistance grants can cut the cost of Revlimid to $20 or $30 a month. She says, “You’re going to be O.K.” If my income is low enough to qualify for assistance.

NOV. 12 I try CVS again. Christine says my insurance records still have not been transferred, but she thinks my Revlimid might cost $17,000 a year.

Adriana at Medicare warns me that AARP and other Part D providers will require “prior authorization” to cover my Revlimid, so it’s probably best to stick with Time Warner no matter what the cost.

But Brooke at AARP insists that I don’t need prior authorization for my Revlimid, and so does her supervisor Brian — until he spots a footnote. Then he assures me that it will be easy to get prior authorization. All I need is a doctor’s note. My out-of-pocket cost for 2013: roughly $7,000.

NOV. 13 Linda at CVS says her company still doesn’t have my file, but from what she can see about Time Warner’s insurance plans my cost will be $60 a month — $720 for the year.

CVS assigns my case to Rebecca. She says she’s “sure all will be fine.” Well, “pretty sure.” She’s excited. She’s been with the company only a few months. This will be her first quote.

NOV. 14 Giddens at Time Warner puts in an “emergency update request” to get my files transferred to CVS.

Frank Lalli is an editorial consultant on retirement issues and a former senior executive editor at Time Warner’s Time Inc.

Read More..

After Death of Sattar Beheshti, Iranian Blogger, Head of Tehran’s Cybercrimes Unit Is Fired

TEHRAN — Iranian’s national police chief fired the commander of Tehran’s cybercrimes police unit on Saturday for negligence in the death of a blogger in prison.

The dismissal of the commander, Gen. Saeed Shokrian, follows investigations by Parliament and Iran’s judiciary into the unexplained death of the blogger, Sattar Beheshti, 35, who died in early November just a few days after being arrested by the cybercrimes police unit, known here as FATA.

“Tehran’s FATA should be held responsible for the death of Sattar Beheshti,” said Iran’s national police chief, Ismael Ahmadi-Moqaddam, according to the Iranian Labor News Agency.

It is unclear whether General Shokrian will also face judicial charges over the blogger’s death.

The public nature of his dismissal suggests that he will bear most of the responsibility for the death. In similar cases in the past, officials have been punished, but it is rare for them to be named and publicly dismissed on the same day.

Mr. Beheshti’s Web site, My Life for My Iran, criticized Iran’s financial contributions to the Hezbollah movement in Lebanon. Mr. Beheshti posted pictures of Lebanese youths having parties alongside images of Iranians living in poverty.

The exact cause of Mr. Beheshti’s death remains murky. Mr. Ahmadi-Moqaddam said Tuesday that investigations had ruled out torture as a cause of death, saying it was possible that Mr. Beheshti, who in pictures looks big and strong, died of “psychological shock.”

Iranian activists and bloggers say Mr. Beheshti died of injuries following beatings. Iran’s judiciary spokesman, Gholam Hussein Mohseni-Ejei, recently admitted that Mr. Beheshti — while in prison — had lodged a written complaint against an interrogator, in which he accused the man of having beaten him during his detention in Tehran’s Evin prison.

“I, Sattar Beheshti, was arrested by FATA and beaten and tortured with multiple blows to my head and body,” read the document, published by the opposition Kalame Web site. He added, “If anything happens to me, the police are responsible.”

Mr. Ahmadi-Moqaddam said that Mr. Beheshti was given tranquilizers while in the prison’s clinic, but that when handed over to the cybercrimes unit its officers denied him the same tranquilizers. “This might be regarded as neglect,” he said. “However, there were no signs of beatings on his body.”

Official statements on the cause of death have been contradictory. An influential member of Parliament who earlier denied that Mr. Beheshti had been tortured in any way told the Tabnak Web site that the blogger had been beaten, but died of shock and fear.

“Definitely he was beaten inside the FATA detention center,” the lawmaker, Alaeddin Borujerdi, told the Web site, “but he didn’t die as a result of these beatings.” He also stressed that the cybercrimes unit must change the way it deals with prisoners.

Iranian activists who have been in contact with Mr. Beheshti’s family say his relatives were not allowed to see his body before a hurried funeral on Nov. 6 in his hometown, Robat Karim, 30 miles southwest of the capital, Tehran.

In Mr. Beheshti’s final post, on Oct. 29, a day before his arrest, he said he was being threatened by security officials. “They told me that if I didn’t close my big mouth my mother should prepare to wear black clothes,” for mourning.

The Iranian Parliament’s special investigator into the case, Mehdi Davatgari, said he welcomed the commander’s removal. “This move shows the civil rights of our citizens are our top priority,” he said.

Read More..

Effort to Secure Border Crimps Commerce Along It

Samantha Sais for The New York Times

Agua Prieta, Mexico, has a main street directly south of the border fence that is active with people and businesses.

DOUGLAS, Ariz. — When the copper smelters closed, the jobs dried up and the people who used to sustain the small shops along this border city’s commercial strips left to find work elsewhere, the Ortega family looked toward the neighbor to the south, Agua Prieta, Mexico, for a new clientele.

For decades, catering to Mexicans had been a reliable business plan for the Ortegas and many other store owners here, a multigenerational band of believers who have been around too long to give up. But the tight border enforcement prompted by the Sept. 11 attacks — and amplified by the harsh realities and language of drug violence and illegal immigration — gradually made it harder to get across the border legally, then too much of a bother, and finally a discomfiting waste of time.

Like the copper smelter workers, the Mexicans, little by little, also began to disappear.

An unforgiving blow came about two years ago, when the American government stopped issuing visas in Agua Prieta, forcing whoever wanted them to travel 115 miles to Nogales, a costly undertaking for Mexicans relying on lean monthly salaries to survive.

“I understand the need for securing our border,” said Bill Thomas, 64, who runs Thomas Home Furnishings, a store his father founded 59 years ago, 11 blocks from a port of entry now so fortified and congested that the city had to build a road to steer the lines of idling cars waiting to get across away from local streets. “But what we’ve done is, we’ve shut out the honest guy.”

The feeling is the same along much of the Mexican border in Arizona, where an imposing wall of corrugated steel disconnects main streets, shared histories and binational family ties. It has also begun to seep deeper, among business owners and elected officials inside a state known for its iron-fisted approach to illegal immigration.

The Metropolitan Tucson Convention and Visitors Bureau has been running a media campaign in the Mexican border state of Sonora and its neighbor to the south, Sinaloa, to dispel any notions that Arizona is unwelcoming.

(After Arizona passed its strict immigration law in 2010, the Mexican government issued a warning to its citizens, telling them to assume that they could be “harassed and questioned” in Arizona “at any time.”)

On Nov. 16, Tucson’s mayor, Jonathan Rothschild, made his first official trip to Nogales, Mexico, to visit a port of entry that is under expansion and for which he has lobbied for an increase in staffing. At a meeting in October, mayors in the economic development committee at the Maricopa Association of Governments, a regional planning group based in Phoenix, embraced a unifying slogan: “We’re all border communities.”

“Mexicans spend about $2 billion a year in Arizona,” said the committee’s chairman, Thomas L. Schoaf, the mayor of Litchfield Park, a suburb of Phoenix. “They go to the Biltmore” Fashion Park, an upscale mall in Phoenix, and “they go to Flagstaff.”

About 21 million Mexicans cross legally into Arizona every year, Mr. Schoaf said; in Santa Cruz County, which runs along the border, their spending accounts for 40 percent of the sales tax revenue. “A significant part of our economic vitality is related to people who cross the border,” Mr. Schoaf said, “so we need to make the crossing more efficient.”

Erik Lee, the associate director of the North American Center for Transborder Studies at Arizona State University, said old infrastructure and inadequate staffing were largely to blame for the costly and unpredictably long waits at border crossings. While the number of Border Patrol agents has virtually doubled since 2004, to 23,306 from 11,684, the number of customs inspectors, who operate the ports of entry, increased by only 12 percent, to 21,893 from 19,525, according to federal statistics.

On average, it took 66 minutes to cross the border from Nogales, Mexico, to Nogales, Ariz., in 2008, costing the regional economy about $200 million, according to estimates compiled by Mr. Lee and Christopher E. Wilson of the Mexico Institute at the Woodrow Wilson International Center for Scholars.

Projections by the Commerce Department say the average time to get through ports of entry into the United States will rise to 99 minutes by 2017, a delay the department estimates could cost a total of $12 billion for the economies on the two sides.

Looking at his electronic ledger, Josué Lopez, who runs Casa Enrique Uniforms here, a store that his father, who was born in Agua Prieta, bought 39 years ago, said, “There’s a lot of money being lost in the name of security.”

Brenna Rae Goth contributed reporting.

Read More..

Syria Rebels Find Skype Useful, but Dangers Lurk

In a demonstration of their growing sophistication and organization, Syrian rebels responded to a nationwide shutdown of the Internet by turning to satellite technology to coordinate within the country and to communicate with outside activists.

When Syria’s Internet service disappeared Thursday, government officials first blamed rebel attacks. Activist groups blamed the government and viewed the blackout as a sign that troops would violently clamp down on rebels.

But having dealt with periodic outages for more than a year, the opposition had anticipated a full shutdown of Syria’s Internet service providers. To prepare, they have spent months smuggling communications equipment like mobile handsets and portable satellite phones into the country.

“We’re very well equipped here,” said Albaraa Abdul Rahman, 27, an activist in Saqba, a poor suburb 20 minutes outside Damascus. He said he was in touch with an expert in Homs who helped connect his office and 10 others like it in and around Damascus.

Using the connection, the activists in Saqba talked to rebel fighters on Skype and relayed to overseas activists details about clashes with government forces. A video showed the rebels’ bare-bones room, four battery backups that could power a laptop for eight hours and a generator set up on a balcony.

For months, rebels fighting to overthrow President Bashar al-Assad have used Skype, a peer-to-peer Internet communication system, to organize and talk to outside news organizations and activists. A few days ago, Jad al-Yamani, an activist in Homs, sent a message to rebel fighters that tanks were moving toward a government checkpoint.

He notified the other fighters so that they could go observe the checkpoint. “Through Skype you know how the army moves or can stop it,” Mr. Yamani said.

On Friday, Dawoud Sleiman, 39, a member of the antigovernment Ahrar al-Shamal Battalion, part of the Free Syrian Army, reached out to other members of the rebel group. They were set up at the government’s Wadi Aldaif military base in Idlib, a province near the Turkish border that has seen heavy fighting, and connected to Skype via satellite Internet service.

Mr. Sleiman, who is based in Turkey, said the Free Syrian Army stopped using cellphone networks and land lines months ago and instead relies almost entirely on Skype. “Brigade members communicate through the hand-held devices,” he said.

This week rebels posted an announcement via Skype that called for the arrest of the head of intelligence in Idlib, who is accused of killing five rebels. “A big financial prize will be offered to anyone who brings the head of this guy,” the message read. “One of our brothers abroad has donated the cash.”

If the uprisings in Tunisia and Egypt were Twitter Revolutions, then Syria is becoming the Skype Rebellion. To get around a near-nationwide Internet shutdown, rebels have armed themselves with mobile satellite phones and dial-up modems.

In many cases, relatives and supporters living outside Syria bought the equipment and had it smuggled in, mostly through Lebanon and Turkey.

That equipment has allowed the rebels to continue to communicate almost entirely via Skype with little interruption, despite the blackout. “How the government used its weapons against the revolution, that is how activists use Skype,” Mr. Abdul Rahman said.

“We haven’t seen any interruption in the way Skype is being used,” said David Clinch, an editorial director of Storyful, a group that verifies social media posts for news organizations, including The New York Times (Mr. Clinch has served as a consultant for Skype).

Mr. Assad, who once fashioned himself as a reformer and the father of Syria’s Internet, has largely left the country’s access intact during the 20-month struggle with rebels. The government appeared to abandon that strategy on Thursday, when most citizens lost access. Some Syrians could still get online using service from Turkey. On Friday, Syrian officials blamed technical problems for the cutoff.

The shutdown is only the latest tactic in the escalating technology war waged in Arab Spring countries.

But several technology experts warned that the use of the Internet by rebels in Syria, even those relying on Skype, could leave them vulnerable to government surveillance.

Liam Stack contributed reporting from New York; Hala Droubi from Dubai, United Arab Emirates; and Hwaida Saad from Beirut, Lebanon.

Read More..

Doctors Who Work for Hospitals Face a New Bottom Line

For decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.

But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.

Today, Boise is a medical battleground.

A little over half of the 1,400 doctors in southwestern Idaho are employed by St. Luke’s or its smaller competitor, St. Alphonsus Regional Medical Center.

Many of the independent doctors complain that both hospitals, but especially St. Luke’s, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit.

In interviews, they said their referrals from doctors now employed by St. Luke’s had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.

Boise’s experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe growing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.

In Boise, just a few weeks ago, even the hospitals were at war. St. Alphonsus went to court seeking an injunction to stop St. Luke’s from buying another physician practice group, arguing that the hospital’s dominance in the market was enabling it to drive up prices and to demand exclusive or preferential agreements with insurers. The price of a colonoscopy has quadrupled in some instances, and in other cases St. Luke’s charges nearly three times as much for laboratory work as nearby facilities, according to the St. Alphonsus complaint.

Federal and state officials have also joined the fray. In one of a handful of similar cases, the Federal Trade Commission and the Idaho attorney general are investigating whether St. Luke’s has become too powerful in Boise, using its newfound leverage to stifle competition.

Dr. David C. Pate, chief executive of St. Luke’s, denied the assertions by St. Alphonsus that the hospital’s acquisitions had limited patient choice or always resulted in higher prices. In some cases, Dr. Pate said, services that had been underpriced were raised to reflect market value. St. Luke’s, he argued, is simply embracing the new model of health care, which he predicted would lead over the long term to lower overall costs as fewer unnecessary tests and procedures were performed.

Regulators expressed some skepticism about the results, for patients, of rapid consolidation, although the trend is still too new to know for sure. “We’re seeing a lot more consolidation than we did 10 years ago,” said Jeffrey Perry, an assistant director in the F.T.C.’s Bureau of Competition. “Historically, what we’ve seen with the consolidation in the health care industry is that prices go up, but quality does not improve.”

A Drive to Consolidate

An array of new economic realities, from reduced Medicare reimbursements to higher technology costs, is driving consolidation in health care and transforming the practice of medicine in Boise and other communities large and small. In one manifestation of the trend, hospitals, private equity firms and even health insurance companies are acquiring physician practices at a rapid rate.

Today, about 39 percent of doctors nationwide are independent, down from 57 percent in 2000, according to estimates by Accenture, a consulting firm.

Many policy experts praise the shift away from independent practices as a way of making health care less fragmented and expensive. Systems that employ doctors, modeled after well-known organizations like Kaiser Permanente, are better able to coordinate patient care and to find ways to deliver improved services at lower costs, these advocates say. Indeed, consolidation is encouraged by some aspects of the Obama administration’s health care law.

“If you’re going to be paid for value, for performance, you’ve got to perform together,” said Dr. Ricardo Martinez, chief medical officer for North Highland, an Atlanta-based consultant that works with hospitals.

The recent trend is reminiscent of the consolidation that swept the industry in the 1990s in response to the creation of health maintenance organizations, or H.M.O.’s — but there is one major difference. Then, hospitals had difficulty managing the practices, contending that doctors did not work as hard when they were employees as they had as private operators. Now, hospitals are writing contracts more in their own favor.

Read More..

Doctors Who Work for Hospitals Face a New Bottom Line

For decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.

But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.

Today, Boise is a medical battleground.

A little over half of the 1,400 doctors in southwestern Idaho are employed by St. Luke’s or its smaller competitor, St. Alphonsus Regional Medical Center.

Many of the independent doctors complain that both hospitals, but especially St. Luke’s, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit.

In interviews, they said their referrals from doctors now employed by St. Luke’s had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.

Boise’s experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe growing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.

In Boise, just a few weeks ago, even the hospitals were at war. St. Alphonsus went to court seeking an injunction to stop St. Luke’s from buying another physician practice group, arguing that the hospital’s dominance in the market was enabling it to drive up prices and to demand exclusive or preferential agreements with insurers. The price of a colonoscopy has quadrupled in some instances, and in other cases St. Luke’s charges nearly three times as much for laboratory work as nearby facilities, according to the St. Alphonsus complaint.

Federal and state officials have also joined the fray. In one of a handful of similar cases, the Federal Trade Commission and the Idaho attorney general are investigating whether St. Luke’s has become too powerful in Boise, using its newfound leverage to stifle competition.

Dr. David C. Pate, chief executive of St. Luke’s, denied the assertions by St. Alphonsus that the hospital’s acquisitions had limited patient choice or always resulted in higher prices. In some cases, Dr. Pate said, services that had been underpriced were raised to reflect market value. St. Luke’s, he argued, is simply embracing the new model of health care, which he predicted would lead over the long term to lower overall costs as fewer unnecessary tests and procedures were performed.

Regulators expressed some skepticism about the results, for patients, of rapid consolidation, although the trend is still too new to know for sure. “We’re seeing a lot more consolidation than we did 10 years ago,” said Jeffrey Perry, an assistant director in the F.T.C.’s Bureau of Competition. “Historically, what we’ve seen with the consolidation in the health care industry is that prices go up, but quality does not improve.”

A Drive to Consolidate

An array of new economic realities, from reduced Medicare reimbursements to higher technology costs, is driving consolidation in health care and transforming the practice of medicine in Boise and other communities large and small. In one manifestation of the trend, hospitals, private equity firms and even health insurance companies are acquiring physician practices at a rapid rate.

Today, about 39 percent of doctors nationwide are independent, down from 57 percent in 2000, according to estimates by Accenture, a consulting firm.

Many policy experts praise the shift away from independent practices as a way of making health care less fragmented and expensive. Systems that employ doctors, modeled after well-known organizations like Kaiser Permanente, are better able to coordinate patient care and to find ways to deliver improved services at lower costs, these advocates say. Indeed, consolidation is encouraged by some aspects of the Obama administration’s health care law.

“If you’re going to be paid for value, for performance, you’ve got to perform together,” said Dr. Ricardo Martinez, chief medical officer for North Highland, an Atlanta-based consultant that works with hospitals.

The recent trend is reminiscent of the consolidation that swept the industry in the 1990s in response to the creation of health maintenance organizations, or H.M.O.’s — but there is one major difference. Then, hospitals had difficulty managing the practices, contending that doctors did not work as hard when they were employees as they had as private operators. Now, hospitals are writing contracts more in their own favor.

Read More..

Most Americans Face Lower Tax Burden Than in the 80s

What Is Fair?:
Taxes are still a hot topic after the presidential election. But as a country that spends more than it collects in taxes, are we asking the right taxpayers to pay the right amounts?

BELLEVILLE, Ill. — Alan Hicks divides long days between the insurance business he started in the late 1970s and the barbecue restaurant he opened with his sons three years ago. He earned more than $250,000 last year and said taxes took more than 40 percent. What’s worse, in his view, is that others — the wealthy, hiding in loopholes; the poor, living on government benefits — are not paying their fair share.

Kirsten Luce for The New York Times

"I don't have the answer of where to pull back. I want the state parks to stay open. I want, I want, I want. I want Big Bird, I think it's beautiful. What don't I want? I don't know," said Anita Thole, a safety supervisor for a utility contractor.

“It feels like the harder we work, the more they take from us,” said Mr. Hicks, 55, as he waited for a meat truck one recent afternoon. “And it seems like there’s an awful lot of people in the United States who don’t pay any taxes.”

These are common sentiments in the eastern suburbs of St. Louis, a region of fading factory towns fringed by new subdivisions. Here, as across the country, people like Mr. Hicks are pained by the conviction that they are paying ever more to finance the expansion of government.

But in fact, most Americans in 2010 paid far less in total taxes — federal, state and local — than they would have paid 30 years ago. According to an analysis by The New York Times, the combination of all income taxes, sales taxes and property taxes took a smaller share of their income than it took from households with the same inflation-adjusted income in 1980.

Households earning more than $200,000 benefited from the largest percentage declines in total taxation as a share of income. Middle-income households benefited, too. More than 85 percent of households with earnings above $25,000 paid less in total taxes than comparable households in 1980.

Lower-income households, however, saved little or nothing. Many pay no federal income taxes, but they do pay a range of other levies, like federal payroll taxes, state sales taxes and local property taxes. Only about half of taxpaying households with incomes below $25,000 paid less in 2010.

The uneven decline is a result of two trends. Congress cut federal taxation at every income level over the last 30 years. State and local taxes, meanwhile, increased for most Americans. Those taxes generally take a larger share of income from those who make less, so the increases offset more and more of the federal savings at lower levels of income.

In a half-dozen states, including Connecticut, Florida and New Jersey, the increases were large enough to offset the federal savings for most households, not just the poorer ones.

Now an era of tax cuts may be reaching its end. The federal government depends increasingly on borrowed money to pay its bills, and many state and local governments are similarly confronting the reality that they are spending more money than they collect. In Washington, debates about tax cuts have yielded to debates about who should pay more.

President Obama campaigned for re-election on a promise to take a larger share of taxable income above roughly $250,000 a year. The White House is now negotiating with Congressional Republicans, who instead want to raise some money by reducing tax deductions. Federal spending cuts also are at issue.

If a deal is not struck by year’s end, a wide range of federal tax cuts passed since 2000 will expire and taxes will rise for roughly 90 percent of Americans, according to the independent Tax Policy Center. For lower-income households, taxation would spike well above 1980 levels. Upper-income households would lose some but not all of the benefits of tax cuts over the last three decades.

Public debate over taxes has typically focused on the federal income tax, but that now accounts for less than a third of the total tax revenues collected by federal, state and local governments. To analyze the total burden, The Times created a model, in consultation with experts, which estimated total tax bills for each taxpayer in each year from 1980, when the election of President Ronald Reagan opened an era of tax cutting, up to 2010, the most recent year for which relevant data is available.

The analysis shows that the overall burden of taxation declined as a share of income in the 1980s, rose to a new peak in the 1990s and fell again in the 2000s. Tax rates at most income levels were lower in 2010 than at any point during the 1980s.

Governments still collected the same share of total income in 2010 as in 1980 — 31 cents from every dollar — because people with higher incomes pay taxes at higher rates, and household incomes rose over the last three decades, particularly at the top.

Read More..

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

Andrew Scrivani for The New York Times

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

For the Tofu:

1/4 cup soy sauce

2 tablespoons mirin (sweet Japanese rice wine)

1 tablespoon rice vinegar

1 tablespoon minced or grated fresh ginger

1/2 teaspoon sugar

1 tablespoon Asian sesame oil

1 pound firm tofu

For the salad:

1 romaine heart, chopped

5 cups mixed chopped or diced vegetables such as:

Green or red cabbage

Celery (from the inner heart)

Red pepper

Radishes, sliced or chopped

1/4 cup dry roasted peanuts, coarsely chopped

1/4 cup chopped cilantro (more to taste)

1 serrano pepper, seeded and minced (optional)

For the dressing:

2 tablespoons fresh lime juice

1/4 cup tofu marinade, above

2 tablespoons canola or peanut oil

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

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

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

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

Yield: Serves 4

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

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

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

Read More..

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

Andrew Scrivani for The New York Times

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

For the Tofu:

1/4 cup soy sauce

2 tablespoons mirin (sweet Japanese rice wine)

1 tablespoon rice vinegar

1 tablespoon minced or grated fresh ginger

1/2 teaspoon sugar

1 tablespoon Asian sesame oil

1 pound firm tofu

For the salad:

1 romaine heart, chopped

5 cups mixed chopped or diced vegetables such as:

Green or red cabbage

Celery (from the inner heart)

Red pepper

Radishes, sliced or chopped

1/4 cup dry roasted peanuts, coarsely chopped

1/4 cup chopped cilantro (more to taste)

1 serrano pepper, seeded and minced (optional)

For the dressing:

2 tablespoons fresh lime juice

1/4 cup tofu marinade, above

2 tablespoons canola or peanut oil

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

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

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

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

Yield: Serves 4

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

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

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

Read More..