Report Finds Inequities in Payments for Medicare

WASHINGTON — Medicare uses inaccurate, unreliable data to pay doctors and hospitals, the National Academy of Sciences said Wednesday.

Although Medicare is a national program, it adjusts payments to health care providers to reflect regional differences in wages, rent and other costs.

But in a new report, a panel of experts from the academy’s Institute of Medicine said the payment formulas were deeply flawed.

The system of paying doctors has “fundamental conceptual problems,” and the method of paying hospitals is so unrealistic that almost 40 percent of them have been reclassified into higher-paying areas, the report said.

White House officials agreed to commission the study in March 2010 — in the last tense days of Congressional debate over President Obama’s health care overhaul — as a way to secure the votes of lawmakers from Iowa, Minnesota, Wisconsin and other states who believed their doctors and hospitals had long been shortchanged by Medicare. As a result of such underpayments, the lawmakers said, many parts of their states have difficulty recruiting doctors, nurses and other practitioners, and consumers often have difficulty finding specialists.

However, the new study says that geographic adjustments should be used to increase the accuracy of Medicare payments, not to address shortages of providers in some places.

The report criticizes the current arrangement under which Medicare distributes tens of billions of dollars based on regional variations in wages, rents and other costs in 441 hospital labor markets and 89 payment zones for doctors. Of the physician payment zones, 34 cover entire states.

The panel said Medicare should recognize a single set of 441 payment areas for doctors and hospitals alike.

As a result of such a change, the panel said, “higher-cost areas would be separated from lower-cost areas,” and payments to doctors in metropolitan areas would generally increase, while payments to doctors in some rural areas could be expected to decrease.

Michael D. Abrams, executive vice president of the Iowa Medical Society, said he was “a little surprised” and disappointed that the panel did not acknowledge that Medicare overemphasized the importance of geographic differences in office rents.

“You could argue that it costs more to deliver health care in rural America, in sparsely populated areas, than in densely populated areas,” Mr. Abrams said.

“Office space is a lot more expensive in Brooklyn, N.Y., than in Brooklyn, Iowa,” he said, but Medicare’s payment formula gives too much weight to such differences.

Mr. Abrams said he was concerned that the panel’s recommendations could “make things worse” for many doctors and patients in his state. The panel will analyze the impact of its recommendations in a report next spring.

By the end of this year, under the new health care law, the secretary of health and human services must send Congress a plan to revise the way Medicare adjusts payments to reflect regional differences in hospital wages.

Any such plan could have major economic and political implications. Wages account for about two-thirds of hospital costs, the panel said, and regional differences are substantial, with a registered nurse paid almost twice as much per hour in San Francisco as in Springfield, Mo.

Under the new health law, geographic adjustments may not increase total costs to Medicare, so that an increase in payments to one hospital or group of hospitals must generally be offset by decreases in payments to others.

Frank A. Sloan, a professor of economics at Duke University and chairman of the study panel, said Medicare needed to find a new source of data on commercial office rents. The current measure, based on rent for a two-bedroom apartment, does not accurately reflect the prices doctors face, he said.

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Audit Finds Long Waits for Breast Exams

The audit examined waiting times at nine health care facilities in the 2009 fiscal year and found that the worst were at Elmhurst Hospital Center in Queens, where women had to wait 148 calendar days for routine screening mammograms and 50 working days for diagnostic mammograms, when cancer is suspected.

John C. Liu, the city comptroller, said in a statement accompanying the audit that the long waiting times “placed women in jeopardy” and violated the city’s policies, which recommend waits of no more than two weeks for routine screening.

He said women who had to wait long times for appointments were more likely to miss them.

Ana Marengo, a spokeswoman for the city’s Health and Hospitals Corporation, which runs the public health system, said that the comptroller’s data was outdated and that high-risk patients at its hospitals received mammograms within 24 to 72 hours.

“If there is a lump, if there is a family history, if there is a high-risk individual that had cancer before, all those are considered urgent,” and the patient would be seen within 72 hours, Ms. Marengo said. She conceded that “two years ago, the wait time was longer,” and that even now, in cases in which the risk of cancer was considered lower, the wait could still be longer.

At Elmhurst, she said, the wait as of December 2010 was 20 days for screening and 23 days for a general diagnostic test, as opposed to an urgent one.

At Queens Hospital Center, the wait for a screening test was 56 days in December, Ms. Marengo said. “It’s due to volume and higher demand,” she said. “We only have a certain amount of resources.”

The audit found that the longest waits for diagnostic tests were at Bellevue Hospital Center, with 17 working days; Gouverneur Healthcare Services, with 20; Kings County Hospital Center, with 21; Woodhull Medical Center, with 28; and Elmhurst, with 50.

For screening tests, the longest waits were 41 calendar days at Woodhull in Brooklyn, 49 days at Queens, and 148 days at Elmhurst.

Elmhurst Hospital conducted the most mammograms, 11,425, and Queens was second, with 10,544, the comptroller said.

Last year, public hospitals performed 100,000 mammograms systemwide, up from about 92,000 in 2009, Ms. Marengo said.

View the original article here

Climate Changes Hinder Crop Yields, Study Finds

Wheat yields in recent years were down by more than 10 percent in Russia and by a few percentage points each in India, France and China compared with what they probably would have been without rising temperatures, according to the study.

Corn yields were off a few percentage points in China, Brazil and France from what would have been expected, said the researchers, whose findings were published in Friday’s issue of the journal Science.

Some countries saw small gains from the temperature increases, however. And in all countries, the extra carbon dioxide that humans are pumping into the air acted as a fertilizer that encouraged plant growth, offsetting some of the losses from rising temperatures caused by that same greenhouse gas.

Consequently, the study’s authors found that when the gains in some countries were weighed against the losses in others, the overall global effect of climate change has been small so far: losses of a few percentage points for wheat and corn from what they would have been without climate change. The overall impact on production of rice and soybeans was negligible, with gains in some regions entirely offsetting losses in others.

But the authors of the study — David Lobell and Justin Costa-Roberts of Stanford University, and Wolfram Schlenker of Columbia University — pointed out that temperature increases were expected to accelerate in coming decades, making it likely that the challenges to food production will grow in an era when demand is expected to rise sharply.

Over the period covered by the study, 1980 to 2008, temperatures increased briskly in many of the world’s important agricultural regions. A notable exception was the United States: for reasons climate scientists do not fully understand, temperatures in the Midwestern corn and soybean belt during the summer crop-growing season have not increased in recent decades.

“One way to think of it is that we got a pass on the first round of global warming,” Dr. Lobell said.

However, the study found that in virtually all of Europe, large parts of Asia and some parts of Africa and South America, temperatures during the growing season have warmed by an average of several degrees since 1980, increasing the likelihood of extremely hot summer days. The study also looked at rainfall, but changes were relatively minor compared with the temperature increases.

Plants are known to be sensitive to high temperatures, especially if the hot days occur when they are flowering. “In many of these countries, a typical year now is like a very warm year back in 1980,” Dr. Lobell said.

Wheat, rice, corn and soybeans account for the majority of calories consumed by the human race, either directly or as meat from animals raised on grains. Because demand for these grains is inflexible and rising, the losses from climate change probably accounted for price increases of about 6 percent in the four major commodities, the study’s authors found.

At today’s grain prices, that calculation implies that climate change is costing consumers, food companies and livestock producers about $60 billion a year.

“We aren’t talking about the sky falling,” Dr. Lobell said. “But we are talking about billions of dollars of losses. Every little bit of production is valuable when we’re trying to feed the world.”

If the price estimate is correct, it makes climate change a small contributor to a large trend. The prices of many foodstuffs have doubled or tripled in recent years as a result of a host of factors, including rapidly rising food demand in Asia, government mandates to use crops for biofuel production and extreme weather that may or may not be linked to climate change.

The authors of the new study specifically excluded the effects of extreme weather like brief heat waves and flash floods because of limitations in the data that they used. For that and other reasons, Dr. Lobell said, the study’s estimate of the impact of climate change is probably conservative.

View the original article here

Climate Changes Hinder Crop Yields, Study Finds

Wheat yields in recent years were down by more than 10 percent in Russia and by a few percentage points each in India, France and China compared with what they probably would have been without rising temperatures, according to the study.

Corn yields were off a few percentage points in China, Brazil and France from what would have been expected, said the researchers, whose findings were published in Friday’s issue of the journal Science.

Some countries saw small gains from the temperature increases, however. And in all countries, the extra carbon dioxide that humans are pumping into the air acted as a fertilizer that encouraged plant growth, offsetting some of the losses from rising temperatures caused by that same greenhouse gas.

Consequently, the study’s authors found that when the gains in some countries were weighed against the losses in others, the overall global effect of climate change has been small so far: losses of a few percentage points for wheat and corn from what they would have been without climate change. The overall impact on production of rice and soybeans was negligible, with gains in some regions entirely offsetting losses in others.

But the authors of the study — David Lobell and Justin Costa-Roberts of Stanford University, and Wolfram Schlenker of Columbia University — pointed out that temperature increases were expected to accelerate in coming decades, making it likely that the challenges to food production will grow in an era when demand is expected to rise sharply.

Over the period covered by the study, 1980 to 2008, temperatures increased briskly in many of the world’s important agricultural regions. A notable exception was the United States: for reasons climate scientists do not fully understand, temperatures in the Midwestern corn and soybean belt during the summer crop-growing season have not increased in recent decades.

“One way to think of it is that we got a pass on the first round of global warming,” Dr. Lobell said.

However, the study found that in virtually all of Europe, large parts of Asia and some parts of Africa and South America, temperatures during the growing season have warmed by an average of several degrees since 1980, increasing the likelihood of extremely hot summer days. The study also looked at rainfall, but changes were relatively minor compared with the temperature increases.

Plants are known to be sensitive to high temperatures, especially if the hot days occur when they are flowering. “In many of these countries, a typical year now is like a very warm year back in 1980,” Dr. Lobell said.

Wheat, rice, corn and soybeans account for the majority of calories consumed by the human race, either directly or as meat from animals raised on grains. Because demand for these grains is inflexible and rising, the losses from climate change probably accounted for price increases of about 6 percent in the four major commodities, the study’s authors found.

At today’s grain prices, that calculation implies that climate change is costing consumers, food companies and livestock producers about $60 billion a year.

“We aren’t talking about the sky falling,” Dr. Lobell said. “But we are talking about billions of dollars of losses. Every little bit of production is valuable when we’re trying to feed the world.”

If the price estimate is correct, it makes climate change a small contributor to a large trend. The prices of many foodstuffs have doubled or tripled in recent years as a result of a host of factors, including rapidly rising food demand in Asia, government mandates to use crops for biofuel production and extreme weather that may or may not be linked to climate change.

The authors of the new study specifically excluded the effects of extreme weather like brief heat waves and flash floods because of limitations in the data that they used. For that and other reasons, Dr. Lobell said, the study’s estimate of the impact of climate change is probably conservative.

View the original article here

Audit Finds Long Waits for Breast Exams

The audit examined waiting times at nine health care facilities in the 2009 fiscal year and found that the worst were at Elmhurst Hospital Center in Queens, where women had to wait 148 calendar days for routine screening mammograms and 50 working days for diagnostic mammograms, when cancer is suspected.

John C. Liu, the city comptroller, said in a statement accompanying the audit that the long waiting times “placed women in jeopardy” and violated the city’s policies, which recommend waits of no more than two weeks for routine screening.

He said women who had to wait long times for appointments were more likely to miss them.

Ana Marengo, a spokeswoman for the city’s Health and Hospitals Corporation, which runs the public health system, said that the comptroller’s data was outdated and that high-risk patients at its hospitals received mammograms within 24 to 72 hours.

“If there is a lump, if there is a family history, if there is a high-risk individual that had cancer before, all those are considered urgent,” and the patient would be seen within 72 hours, Ms. Marengo said. She conceded that “two years ago, the wait time was longer,” and that even now, in cases in which the risk of cancer was considered lower, the wait could still be longer.

At Elmhurst, she said, the wait as of December 2010 was 20 days for screening and 23 days for a general diagnostic test, as opposed to an urgent one.

At Queens Hospital Center, the wait for a screening test was 56 days in December, Ms. Marengo said. “It’s due to volume and higher demand,” she said. “We only have a certain amount of resources.”

The audit found that the longest waits for diagnostic tests were at Bellevue Hospital Center, with 17 working days; Gouverneur Healthcare Services, with 20; Kings County Hospital Center, with 21; Woodhull Medical Center, with 28; and Elmhurst, with 50.

For screening tests, the longest waits were 41 calendar days at Woodhull in Brooklyn, 49 days at Queens, and 148 days at Elmhurst.

Elmhurst Hospital conducted the most mammograms, 11,425, and Queens was second, with 10,544, the comptroller said.

Last year, public hospitals performed 100,000 mammograms systemwide, up from about 92,000 in 2009, Ms. Marengo said.

 

Audit Finds Long Waits for Breast Exams

The audit examined waiting times at nine health care facilities in the 2009 fiscal year and found that the worst were at Elmhurst Hospital Center in Queens, where women had to wait 148 calendar days for routine screening mammograms and 50 working days for diagnostic mammograms, when cancer is suspected.

John C. Liu, the city comptroller, said in a statement accompanying the audit that the long waiting times “placed women in jeopardy” and violated the city’s policies, which recommend waits of no more than two weeks for routine screening.

He said women who had to wait long times for appointments were more likely to miss them.

Ana Marengo, a spokeswoman for the city’s Health and Hospitals Corporation, which runs the public health system, said that the comptroller’s data was outdated and that high-risk patients at its hospitals received mammograms within 24 to 72 hours.

“If there is a lump, if there is a family history, if there is a high-risk individual that had cancer before, all those are considered urgent,” and the patient would be seen within 72 hours, Ms. Marengo said. She conceded that “two years ago, the wait time was longer,” and that even now, in cases in which the risk of cancer was considered lower, the wait could still be longer.

At Elmhurst, she said, the wait as of December 2010 was 20 days for screening and 23 days for a general diagnostic test, as opposed to an urgent one.

At Queens Hospital Center, the wait for a screening test was 56 days in December, Ms. Marengo said. “It’s due to volume and higher demand,” she said. “We only have a certain amount of resources.”

The audit found that the longest waits for diagnostic tests were at Bellevue Hospital Center, with 17 working days; Gouverneur Healthcare Services, with 20; Kings County Hospital Center, with 21; Woodhull Medical Center, with 28; and Elmhurst, with 50.

For screening tests, the longest waits were 41 calendar days at Woodhull in Brooklyn, 49 days at Queens, and 148 days at Elmhurst.

Elmhurst Hospital conducted the most mammograms, 11,425, and Queens was second, with 10,544, the comptroller said.

Last year, public hospitals performed 100,000 mammograms systemwide, up from about 92,000 in 2009, Ms. Marengo said.

 

Low-Salt Diet Ineffective, Study Finds. Disagreement Abounds.

In fact, officials at the Centers for Disease Control and Prevention felt so strongly that the study was flawed that they criticized it in an interview, something they normally do not do.

Dr. Peter Briss, a medical director at the centers, said that the study was small; that its subjects were relatively young, with an average age of 40 at the start; and that with few cardiovascular events, it was hard to draw conclusions. And the study, Dr. Briss and others say, flies in the face of a body of evidence indicating that higher sodium consumption can increase the risk of cardiovascular disease.

“At the moment, this study might need to be taken with a grain of salt,” he said.

The study is published in the May 4 issue of The Journal of the American Medical Association. It involved only those without high blood pressure at the start, was observational, considered at best suggestive and not conclusive. It included 3,681 middle-aged Europeans who did not have high blood pressure or cardiovascular disease and followed them for an average of 7.9 years.

The researchers assessed?the participants’ sodium consumption at the study’s start?and at its conclusion by measuring the amount of sodium excreted in urine over a 24-hour period.? All the sodium that is consumed is excreted in urine within a day, so this method is the most precise way to determine sodium consumption.

The investigators found that the less salt people ate, the more likely they were to die of heart disease — 50 people in the lowest third of salt consumption (2.5 grams of sodium per day) died during the study as compared with 24 in the medium group (3.9 grams of sodium per day) and 10 in the highest salt consumption group (6.0 grams of sodium per day).? And while those eating the most salt had, on average, a slight increase in systolic blood pressure — a 1.71-millimeter increase in pressure for each 2.5-gram increase in sodium per day — they were no more likely to develop hypertension.

“If the goal is to prevent hypertension” with lower sodium consumption, said the lead author, Dr. Jan A. Staessen, a professor of medicine at the University of Leuven, in Belgium, “this study shows it does not work.”

But among the study’s other problems, Dr. Briss said, its subjects who seemed to consume the smallest amount of sodium also provided less urine than those consuming more, an indication that they might not have collected all of their urine in an 24-hour period.

Dr. Frank Sacks of the Harvard School of Public Health agreed and also said the study was flawed.

“It’s a problematic study,” Dr. Sacks said. “We shouldn’t be guiding any kind of public health decisions on it.”

Dr. Michael Alderman, a blood pressure researcher at Albert Einstein College of Medicine and editor of the American Journal of Hypertension, said medical literature on salt and health effects was inconsistent. But, Dr. Alderman said, the new study is not the only one to find adverse effects of low-sodium diets. His own study, with people who had high blood pressure, found that those who ate the least salt were most likely to die.

Dr. Alderman said that he once was an unpaid consultant for the Salt Institute but that he now did no consulting for it or for the food industry and did not receive any support or take any money from industry groups.

Lowering salt consumption, Dr. Alderman said, has consequences beyond blood pressure. It also, for example, increases insulin resistance, which can increase the risk of heart disease.

“Diet is a complicated business,” he said. “There are going to be unintended consequences.”

One problem with the salt debates, Dr. Alderman said, is that all the studies are inadequate. Either they are short-term intervention studies in which people are given huge amounts of salt and then deprived of salt to see effects on blood pressure or they are studies, like this one, that observe populations and ask if those who happen to consume less salt are healthier.

“Observational studies tell you what people will experience if they select a diet,” Dr. Alderman said. “They do not tell you what will happen if you change peoples’ sodium intake.”

What is needed, Dr. Alderman said, is a large study in which people are randomly assigned to follow a low-sodium diet or not and followed for years to see if eating less salt improves health and reduces the death rate from cardiovascular disease.

But that study, others say, will never happen.

“This is one of those really interesting situations,” said Dr. Lawrence Appel, a professor of medicine, epidemiology and international health at Johns Hopkins Medical Institutions. “You can say, ‘O.K., let’s dismiss the observational studies because they have all these problems.’?” But, he said, despite the virtues of a randomized controlled clinical trial, such a study “will never ever be done.” It would be impossible to keep people on a low-sodium diet for years with so much sodium added to prepared foods.

Dr. Briss adds that it would not be prudent to defer public health actions while researchers wait for results of a clinical trial that might not even be feasible.

?Dr. Alderman disagrees.

“The low-salt advocates suggest that all 300 million Americans be subjected to a low-salt diet. But if they can’t get people on a low-salt diet for a clinical trial, what are they talking about?”

He added: “It will cost money, but that’s why we do science. It will also cost money to change the composition of food.”

 

Low-Salt Diet Ineffective, Study Finds. Disagreement Abounds.

In fact, officials at the Centers for Disease Control and Prevention felt so strongly that the study was flawed that they criticized it in an interview, something they normally do not do.

Dr. Peter Briss, a medical director at the centers, said that the study was small; that its subjects were relatively young, with an average age of 40 at the start; and that with few cardiovascular events, it was hard to draw conclusions. And the study, Dr. Briss and others say, flies in the face of a body of evidence indicating that higher sodium consumption can increase the risk of cardiovascular disease.

“At the moment, this study might need to be taken with a grain of salt,” he said.

The study is published in the May 4 issue of The Journal of the American Medical Association. It involved only those without high blood pressure at the start, was observational, considered at best suggestive and not conclusive. It included 3,681 middle-aged Europeans who did not have high blood pressure or cardiovascular disease and followed them for an average of 7.9 years.

The researchers assessed?the participants’ sodium consumption at the study’s start?and at its conclusion by measuring the amount of sodium excreted in urine over a 24-hour period.? All the sodium that is consumed is excreted in urine within a day, so this method is the most precise way to determine sodium consumption.

The investigators found that the less salt people ate, the more likely they were to die of heart disease — 50 people in the lowest third of salt consumption (2.5 grams of sodium per day) died during the study as compared with 24 in the medium group (3.9 grams of sodium per day) and 10 in the highest salt consumption group (6.0 grams of sodium per day).? And while those eating the most salt had, on average, a slight increase in systolic blood pressure — a 1.71-millimeter increase in pressure for each 2.5-gram increase in sodium per day — they were no more likely to develop hypertension.

“If the goal is to prevent hypertension” with lower sodium consumption, said the lead author, Dr. Jan A. Staessen, a professor of medicine at the University of Leuven, in Belgium, “this study shows it does not work.”

But among the study’s other problems, Dr. Briss said, its subjects who seemed to consume the smallest amount of sodium also provided less urine than those consuming more, an indication that they might not have collected all of their urine in an 24-hour period.

Dr. Frank Sacks of the Harvard School of Public Health agreed and also said the study was flawed.

“It’s a problematic study,” Dr. Sacks said. “We shouldn’t be guiding any kind of public health decisions on it.”

Dr. Michael Alderman, a blood pressure researcher at Albert Einstein College of Medicine and editor of the American Journal of Hypertension, said medical literature on salt and health effects was inconsistent. But, Dr. Alderman said, the new study is not the only one to find adverse effects of low-sodium diets. His own study, with people who had high blood pressure, found that those who ate the least salt were most likely to die.

Dr. Alderman said that he once was an unpaid consultant for the Salt Institute but that he now did no consulting for it or for the food industry and did not receive any support or take any money from industry groups.

Lowering salt consumption, Dr. Alderman said, has consequences beyond blood pressure. It also, for example, increases insulin resistance, which can increase the risk of heart disease.

“Diet is a complicated business,” he said. “There are going to be unintended consequences.”

One problem with the salt debates, Dr. Alderman said, is that all the studies are inadequate. Either they are short-term intervention studies in which people are given huge amounts of salt and then deprived of salt to see effects on blood pressure or they are studies, like this one, that observe populations and ask if those who happen to consume less salt are healthier.

“Observational studies tell you what people will experience if they select a diet,” Dr. Alderman said. “They do not tell you what will happen if you change peoples’ sodium intake.”

What is needed, Dr. Alderman said, is a large study in which people are randomly assigned to follow a low-sodium diet or not and followed for years to see if eating less salt improves health and reduces the death rate from cardiovascular disease.

But that study, others say, will never happen.

“This is one of those really interesting situations,” said Dr. Lawrence Appel, a professor of medicine, epidemiology and international health at Johns Hopkins Medical Institutions. “You can say, ‘O.K., let’s dismiss the observational studies because they have all these problems.’?” But, he said, despite the virtues of a randomized controlled clinical trial, such a study “will never ever be done.” It would be impossible to keep people on a low-sodium diet for years with so much sodium added to prepared foods.

Dr. Briss adds that it would not be prudent to defer public health actions while researchers wait for results of a clinical trial that might not even be feasible.

?Dr. Alderman disagrees.

“The low-salt advocates suggest that all 300 million Americans be subjected to a low-salt diet. But if they can’t get people on a low-salt diet for a clinical trial, what are they talking about?”

He added: “It will cost money, but that’s why we do science. It will also cost money to change the composition of food.”

 

With Liposuction, the Belly Finds What the Thighs Lose

THE woman’s hips bulged in unsightly saddlebags. Then she had liposuction and, presto, those saddlebags disappeared.

Photo after photo on plastic surgery Web sites make liposuction look easy, its results transformative. It has become the most popular plastic surgery, with more than 450,000 operations a year, each costing a few thousand dollars.

But does the fat come back? And if it does, where does it show up?

Until now, no one knew for sure. But a new study, led by Drs. Teri L. Hernandez and Robert H. Eckel of the University of Colorado, has answered those questions. And what he found is not good news.

In the study, the researchers randomly assigned nonobese women to have liposuction on their protuberant thighs and lower abdomen or to refrain from having the procedure, serving as controls. As compensation, the women who were control subjects were told that when the study was over, after they learned the results, they could get liposuction if they still wanted it. For them, the price would also be reduced from the going rate.

The result, published in the latest issue of Obesity, was that fat came back after it was suctioned out. It took a year, but it all returned. But it did not reappear in the women’s thighs. Instead, Dr. Eckel said, “it was redistributed upstairs,” mostly in the upper abdomen, but also around the shoulders and triceps of the arms.

Dr. Felmont Eaves III, a plastic surgeon in Charlotte, N.C., and president of the American Society for Aesthetic Plastic Surgery, said the study was “very well done,” and the results were surprising. He said he would mention it to his patients in the context of other information on liposuction.

The finding raises questions about plastic surgery. Liposuction has been around since 1974 and is heavily advertised. Why did it take so long for anyone to do this study?

Maybe it’s because such a study is very difficult, said Dr. Samuel Klein, director of the Center for Human Nutrition at the Washington University School of Medicine. It takes a team of researchers, and money. Fat must be measured precisely, with scans.

And surgery, said Jonathan Moreno, an ethicist at the University of Pennsylvania who has studied the field, is not like other areas of medicine.

“A lot of it has to do with the culture of surgery, which is literally hands-on,” he said. Surgeons, he added, often feel a deep connection to their patients that makes it difficult for them to agree to clinical trials that involve randomizing patients.

Another problem, Dr. Moreno said, is that different surgeons have different skills and different techniques. Surgery is not like taking a drug, where one pill is just like every other.

So instead of doing rigorous studies, surgeons tend to innovate, inventing their own procedures and publishing anecdotes about patients, a practice that can be misleading.

But in this case, the outcome did not depend on the surgeon. It depended on the biology of fat. And obesity researchers say they are not surprised that the women’s fat came back. The body, they say “defends” its fat. If you lose weight, even by dieting, it comes back. And, the study showed, if you suck out the fat with liposuction, even if it’s only a pound, as it was for subjects in the study, it still comes back.

“It’s another chapter in the ‘You can’t fool Mother Nature’ story,’ ” said Dr. Rudolph Leibel, an obesity researcher at Columbia University.

Some researchers have their own anecdotes. Dr. George Bray, a professor of medicine at Louisiana State University, once saw a young woman who was so distraught by her protruding abdomen that she had an operation to slice off some of her abdominal fat.

“Her lower abdomen was considerably thinner,” Dr. Bray said. “But the areas above it picked up the extra fat.”

Then there are the studies with laboratory rodents that had fat surgically removed. The fat always came back. And, like the women in the new study, the rodents got their fat back in places other than the place where it was removed, Dr. Klein reported. They grow new fat cells to replace the ones that were lost.

The same thing happened to the women who had liposuction. It turns out, Dr. Leibel said, that the body controls the number of its fat cells as carefully as it controls the amount of its fat. Fat cells die and new ones are born throughout life. Scientists have found that fat cells live for only about seven years and that every time a fat cell dies, another is formed to take its place.

But why wouldn’t the women grow new fat cells in their thighs? The answer, Dr. Klein said, may be that liposuction violently destroys the fishnet structure under the skin where fat cells live.

Nonetheless, the women in the study who had liposuction were happy, Dr. Eckel said. They had hated their hips and thighs and just wanted that fat gone.

As for the women in the control group, when the study ended and they knew the results, more than half still chose to have liposuction.

 

New Census Finds China’s Population Growth Has Slowed

BEIJING — China’s population grew more urbanized, educated and older as the growth of the world’s most populous nation slowed to a pace half that of the previous decade, results of the 2010 census released on Thursday indicated.

The census also documented a vast internal migration, concluding that more than 261 million citizens — nearly one in five — were living in places other than where China’s household registration process had indicated that they did. Most of those are probably migrant laborers who have swelled big cities in search of higher-paying jobs so as to send money back to families that remain in rural areas.

The government said China’s population was 1.34 billion, an increase of 73.9 million, or 5.8 percent, from the last tally in 2000. That was below the 1.4 billion that United Nations demographers were predicting when the head count was conducted last November, and the slowest rate of growth in nearly half a century, demographers said.

The average household size shrank by 10 percent, to 3.1 people, and the urban population surged by more than 45 percent, leaving urban and rural Chinese nearly equal in number, the census indicated.

Wang Feng, head of the Center for Public Policy at Tsinghua University in Beijing, said the data show that China “has completely turned a page in its demographic history.”

“It is now a post-transitional population, with very low fertility, quite low mortality, and is being increasingly urbanized,” he said in an e-mail on Thursday. “Such a highly mobile society produces a tremendous dynamism for the Chinese economy and society, and at the same time poses great challenges for the government’s political control.”

Mr. Wang also said that documentation of a rapidly aging society raised new questions about China’s population-control policies, which since 1980 have limited many families to a single child. But President Hu Jintao struck a cautious note in a speech on Tuesday, the state news service Xinhua reported, telling a bureau of the Communist Party’s Central Committee that China should “stick to and improve its current family planning policy and maintain a low birthrate.”

For a country dead set on joining the ranks of the globe’s most advanced nations, the huge count yielded both promising and disturbing results.

The share of Chinese who were educated rose sharply. University graduates are now about 8.9 out of 100 citizens, an increase of about 2.5 times, and rates of those who have graduated from high school and vocational schools also rose, though not as much.

Yu Xie, a professor of sociology, statistics and population studies at the University of Michigan, said the increase in the number of college-educated Chinese would “place China in a better position in international competition for economic growth.”

“Future economic growth will not only come from manufacturing but from services and high technology,” he said, which will require better-educated workers. “China is already prepared for a post-industrial transition.”

But the figures also revealed less promising trends. They confirmed a yawning gender gap, with 118 male newborns for every 100 females, a disparity researchers blame partly on family planning policies that they say have encouraged abortions of female fetuses.

The population aged markedly: the share of Chinese under age 15 dropped 6.3 percent, while that of those over 60 rose by 2.93 percent. That presages a shrinking labor market, which economists predict will increase pressure for higher wages and divert a gusher of government money into pensions, medical care and other services for the elderly.

The growing proportion of older people can be explained partly by China’s low fertility rate in recent decades, with fewer births to offset the aged. Cai Yong, a demographer at the University of North Carolina, Chapel Hill, said the number of children under 15 was even lower than expected, pointing to a fertility rate of about 1.4 children per woman.

That is significantly below the government’s estimated fertility rate of 1.8, and should put pressure on China’s leaders to loosen family planning policies, he said.

Ma Jianting, the director of China’s National Bureau of Statistics, said at a news conference on Thursday that the slowed rate of population growth showed that the one-child policy had “eased the pressure on resources and the environment and laid a relatively good foundation for steady and rapid economic and social development.”

But he suggested that the population’s rapid aging was a matter of potential concern. “We also need to pay close attention to the new changes of our population structure, adhering to the family planning policy while cautiously and gradually improving the policy to promote more balanced population growth in the country,” the state-run Xinhua news agency quoted him as saying.

 

Poll Finds Egyptians Full of Hope About the Future

The poll, conducted by the Pew Research Center and based on face-to-face interviews with 1,000 Egyptians, is the first credible survey since the revolution lifted many restrictions on free expression. It is also the first to directly address Western debate over whether the revolution might drift toward Islamic radicalism.

The poll found about 30 percent of Egyptians have a favorable view of Islamic fundamentalism and about the same number sympathize with its opponents. About a quarter have mixed views.

That range was exemplified by attitudes toward the Muslim Brotherhood, the previously outlawed Islamist group.

Many in the West have assumed that as the best-organized nongovernmental organization in Egyptian society, the Muslim Brotherhood might quickly dominate Egyptian politics — a view long espoused by the Mubarak government. The poll shows the Muslim Brotherhood is indeed regarded favorably by about three in four Egyptians, receiving very favorable ratings from 37 percent of respondents and somewhat favorable ratings from an additional 38 percent.

But that put the group roughly at a par with the April 6 Movement, a new and relatively secular and progressive youth group that played a leading role in organizing the revolution. Seven in 10 viewed that group favorably, with 38 percent viewing it very favorably and 32 percent viewing it somewhat favorably. The poll’s margin of samplinfg error is plus or minus four percentage points.

Only 17 percent of respondents said they would like to see the Muslim Brotherhood lead the next government. Al Ghad, a liberal party led by Ayman Nour, a formerly jailed presidential candidate, was favored to lead the new government by roughly the same number. And one in five supported the New Wafd Party, a secular liberal party that was recognized under Mr. Mubarak.

Nearly two-thirds of Egyptians said civil law should strictly follow the Koran, but then the existing Constitution of Egypt’s largely secular state said that it is already based on the Koran.

Sobhi Saleh, a prominent member of the Muslim Brotherhood and a former parliamentary candidate, dismissed the poll’s findings as wildly overstating the support for other parties. Only the Brotherhood has a broad organization and a well-known platform, he argued, predicting success at the polls. “These findings are wrong, and it’s only a matter of two months until you see that,” he said.

Amr El Shobaki, a political analyst in the Ahram Center for Political and Strategic Studies, said the results reflected an Egyptian habit of shrugging off apparent contradictions between a traditionalist faith and modern lifestyles. “That’s why people can have a favorable impression of the April 6 Movement and like the Brotherhood at the same time,” he said. “Average people enjoy a high degree of reconciliation between Islam and modern ideas. So they are conservative but not extreme.”

The poll also found that a majority of Egyptians, 54 percent, want to annul the 1979 peace treaty with Israel that has been a cornerstone of Egyptian foreign policy and the region’s stability. The finding squares with the overwhelming anecdotal evidence that Egyptians feel Israel has not lived up to its commitments in its treatment of the Palestinians. But more than a third of respondents, 36 percent, favored keeping the treaty, and the poll did not ask the more controversial question of whether Egyptians wanted to sacrifice the three decades of peace they have enjoyed along the border.

Mr. Saleh of the Muslim Brotherhood, however, said he supported maintaining the treaty.

“There is a difference between the people’s feelings toward Israel and their political assessment,” he said “Those who want to maintain the treaty are motivated by Egypt’s interest. It is not because they accept Israel.”

The poll found the military extraordinarily popular, reflecting its decisive role in ultimately pushing Mr. Mubarak aside, and 9 in 10 approved of the work of Field Marshal Mohamed Hussein Tantawi, Mr. Mubarak’s former defense minister and the current head of the interim military council running the country.

But it was conducted in the two weeks that ended April 7, before recent controversies over the military’s use of force against demonstrators in Tahrir Square in Cairo. Still, the results may raise concern for Egyptian liberals anxious to see the military relinquish power to civilian authority. Only 27 percent of respondents called that very important.

Among presidential candidates, the poll confirmed the widespread belief that Amr Moussa, the head of the Arab League and a former Mubarak foreign minister, is the front-runner. About 9 in 10 have a favorable view of him, including 41 percent who have a very favorable view. Seven in 10 had a favorable view of Mr. Nour, another candidate known for challenging Mr. Mubarak and going to jail, with 32 percent viewing him very favorably. And 57 percent had a favorable view of Mohamed ElBaradei, a Nobel Prize winner and former head of the International Atomic Energy Agency. But many complain that he has spent most of his career outside his native Egypt, and 39 percent of Egyptians reported an unfavorable view of him.

None of the three is considered an Islamist.

Mr. Shobaki, the political analyst, argued that the core of Mr. Moussa’s support was the majority who did not participate in the revolution but voted for a constitutional referendum. “These are the people who are looking for stability, want their economic conditions to be improved and do not necessarily want to see drastic changes,” Mr. Shobaki said.

The poll found Egyptians remarkably bullish on their revolution and, in its aftermath, their future. Nearly two-thirds said they were satisfied with their country’s direction, and 6 in 10 were optimistic about the future. Although open political elections would be a novelty in Egyptian history, most had some degree of faith that they had won democracy. Forty-one percent said a free and fair choice in the next election was very likely, and 43 percent said it was somewhat likely. Only 16 percent said it was unlikely.

Fifty-four percent said a democratic government was worth the risk of political instability, while only 32 percent held the opposite view, the Mubarak government’s mantra that stability was more important.

But asked about their most important concerns for the future, the broadest majority — 82 percent — said improving economic conditions was very important; 79 percent said a fair judicial system was; 63 percent said law and order, the same portion that said freedom of speech; and only 55 percent said honest elections.

Slightly fewer, 50 percent, said it was very important for religiously based parties to be able to participate in government.

 

Obama Panel to Curb Medicare Finds Foes in Both Parties

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Mr. Obama wants to expand the power of the 15-member panel, which was created by the new health care law, to rein in Medicare costs.

But not only do Republicans and some Democrats oppose increasing the power of the board, they also want to eliminate it altogether. Opponents fear that the panel, known as the Independent Payment Advisory Board, would usurp Congressional spending power over one of the government’s most important and expensive social programs.

Under the law, spending cuts recommended by the presidentially appointed panel would take effect automatically unless Congress voted to block or change them. In general, federal courts could not review actions to carry out the board’s recommendations. The impact of the board’s decisions could be magnified because private insurers often use Medicare rates as a guide or a benchmark in paying doctors, hospitals and other providers.

Last week, in his speech on deficit reduction, Mr. Obama said he wanted to beef up the board’s cost-cutting powers in unspecified ways should the growth of Medicare spending exceed certain goals. Supporters say the board will be able to make tough decisions because it will be largely insulated from legislative politics.

Lawmakers do not agree. Representative Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee, called it “a rationing board” and said Congress should not “delegate Medicare decision-making to 15 people appointed by the president.” He said Mr. Obama’s proposal would allow the board to “impose more price controls and more limitations on providers, which will end up cutting services to seniors.”

Senator John Cornyn, a Texas Republican who introduced a bill last month to repeal the Medicare board, said the president’s proposal “punts difficult decisions on health spending to an unelected, unaccountable board of bureaucrats.”

Representative Allyson Y. Schwartz, a Pennsylvania Democrat prominent on health care issues, said: “It’s our constitutional duty, as members of Congress, to take responsibility for Medicare and not turn decisions over to a board. Abdicating this responsibility, whether to insurance companies or to an unelected commission, undermines our ability to represent our constituents, including seniors and the disabled.”

Ms. Schwartz signed up on Friday as co-sponsor of a bill to repeal the board.

The purpose of the panel, according to the health care law, is to reduce the rate of growth in Medicare spending per beneficiary. The law sets annual goals — “target growth rates” — for Medicare spending below the average of the last 15 years.

Board members will be subject to Senate confirmation — no easy feat in the current political climate. Terms are six years. Members can serve no more than two full consecutive terms. The White House has yet to submit any nominations for the board.

“Why have legislators?” asked Representative Pete Stark of California, the senior Democrat on the Ways and Means Subcommittee on Health.

In some ways, Mr. Stark said, expanding the power of the board could be as bad as giving vouchers to Medicare beneficiaries to buy private insurance. “In theory at least, you could set the vouchers at an adequate level,” he said. “But, in its effort to limit the growth of Medicare spending, the board is likely to set inadequate payment rates for health care providers, which could endanger patient care.”

Representative Shelley Berkley, Democrat of Nevada, said she wanted to repeal the Medicare board. “I have great faith that this administration can put together a strong, independent and knowledgeable board,” Ms. Berkley said, but she said she had less confidence in future administrations.

Mark Parkinson, president of the American Health Care Association, which represents nursing homes, said his members disliked the board because it would allow Congress and the president to “subcontract out difficult decisions.”

Still, the idea of a more potent Medicare board could be a live option if the White House insisted on it in budget negotiations with Congress.

Mr. Obama said last week that he would “reduce wasteful subsidies and erroneous payments,” cut spending on prescription drugs and take other steps to save $500 billion in Medicare and Medicaid by 2023. “But if we’re wrong and Medicare costs rise faster than we expect,” he said, the Medicare board would have “the authority to make additional savings by further improving Medicare.”

The president’s proposal would set stricter goals for Medicare spending and establish some type of automatic cost-cutting device as an “enforcement mechanism,” but Mr. Obama did not say exactly how it would work.

Kathleen Sebelius, the secretary of health and human services, described the board as a backstop to “ensure that health costs are reduced.” The board might not have to take action if the president’s other proposals slow the growth of Medicare spending, she said.

The board grew out of proposals by Mr. Obama and Senator John D. Rockefeller IV, Democrat of West Virginia.

“Medicare payment policy should be determined by experts, using evidence, not by the undue influence of special interests,” Mr. Rockefeller said.

AARP, the American Medical Association and the American Hospital Association voiced concern about the president’s latest proposal.

“Relying on arbitrary spending targets is not a good way to make health policy, especially when decisions may be left to the unelected and unaccountable,” said A. Barry Rand, chief executive of AARP, the lobby for older Americans.

Under the law, the board cannot make recommendations to “ration health care,” raise revenues or increase beneficiaries’ premiums, deductibles or co-payments. This increases the likelihood that the board will try to save money by trimming Medicare payments to health care providers.

 

Obama Panel to Curb Medicare Finds Foes in Both Parties

 

Mr. Obama wants to expand the power of the 15-member panel, which was created by the new health care law, to rein in Medicare costs.

But not only do Republicans and some Democrats oppose increasing the power of the board, they also want to eliminate it altogether. Opponents fear that the panel, known as the Independent Payment Advisory Board, would usurp Congressional spending power over one of the government’s most important and expensive social programs.

Under the law, spending cuts recommended by the presidentially appointed panel would take effect automatically unless Congress voted to block or change them. In general, federal courts could not review actions to carry out the board’s recommendations. The impact of the board’s decisions could be magnified because private insurers often use Medicare rates as a guide or a benchmark in paying doctors, hospitals and other providers.

Last week, in his speech on deficit reduction, Mr. Obama said he wanted to beef up the board’s cost-cutting powers in unspecified ways should the growth of Medicare spending exceed certain goals. Supporters say the board will be able to make tough decisions because it will be largely insulated from legislative politics.

Lawmakers do not agree. Representative Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee, called it “a rationing board” and said Congress should not “delegate Medicare decision-making to 15 people appointed by the president.” He said Mr. Obama’s proposal would allow the board to “impose more price controls and more limitations on providers, which will end up cutting services to seniors.”

Senator John Cornyn, a Texas Republican who introduced a bill last month to repeal the Medicare board, said the president’s proposal “punts difficult decisions on health spending to an unelected, unaccountable board of bureaucrats.”

Representative Allyson Y. Schwartz, a Pennsylvania Democrat prominent on health care issues, said: “It’s our constitutional duty, as members of Congress, to take responsibility for Medicare and not turn decisions over to a board. Abdicating this responsibility, whether to insurance companies or to an unelected commission, undermines our ability to represent our constituents, including seniors and the disabled.”

Ms. Schwartz signed up on Friday as co-sponsor of a bill to repeal the board.

The purpose of the panel, according to the health care law, is to reduce the rate of growth in Medicare spending per beneficiary. The law sets annual goals — “target growth rates” — for Medicare spending below the average of the last 15 years.

Board members will be subject to Senate confirmation — no easy feat in the current political climate. Terms are six years. Members can serve no more than two full consecutive terms. The White House has yet to submit any nominations for the board.

“Why have legislators?” asked Representative Pete Stark of California, the senior Democrat on the Ways and Means Subcommittee on Health.

In some ways, Mr. Stark said, expanding the power of the board could be as bad as giving vouchers to Medicare beneficiaries to buy private insurance. “In theory at least, you could set the vouchers at an adequate level,” he said. “But, in its effort to limit the growth of Medicare spending, the board is likely to set inadequate payment rates for health care providers, which could endanger patient care.”

Representative Shelley Berkley, Democrat of Nevada, said she wanted to repeal the Medicare board. “I have great faith that this administration can put together a strong, independent and knowledgeable board,” Ms. Berkley said, but she said she had less confidence in future administrations.

Mark Parkinson, president of the American Health Care Association, which represents nursing homes, said his members disliked the board because it would allow Congress and the president to “subcontract out difficult decisions.”

Still, the idea of a more potent Medicare board could be a live option if the White House insisted on it in budget negotiations with Congress.

Mr. Obama said last week that he would “reduce wasteful subsidies and erroneous payments,” cut spending on prescription drugs and take other steps to save $500 billion in Medicare and Medicaid by 2023. “But if we’re wrong and Medicare costs rise faster than we expect,” he said, the Medicare board would have “the authority to make additional savings by further improving Medicare.”

The president’s proposal would set stricter goals for Medicare spending and establish some type of automatic cost-cutting device as an “enforcement mechanism,” but Mr. Obama did not say exactly how it would work.

Kathleen Sebelius, the secretary of health and human services, described the board as a backstop to “ensure that health costs are reduced.” The board might not have to take action if the president’s other proposals slow the growth of Medicare spending, she said.

The board grew out of proposals by Mr. Obama and Senator John D. Rockefeller IV, Democrat of West Virginia.

“Medicare payment policy should be determined by experts, using evidence, not by the undue influence of special interests,” Mr. Rockefeller said.

AARP, the American Medical Association and the American Hospital Association voiced concern about the president’s latest proposal.

“Relying on arbitrary spending targets is not a good way to make health policy, especially when decisions may be left to the unelected and unaccountable,” said A. Barry Rand, chief executive of AARP, the lobby for older Americans.

Under the law, the board cannot make recommendations to “ration health care,” raise revenues or increase beneficiaries’ premiums, deductibles or co-payments. This increases the likelihood that the board will try to save money by trimming Medicare payments to health care providers.

 

Report Finds Sri Lanka Attacked Civilians

 

“Tens of thousands lost their lives from January to May 2009, many of whom died anonymously in the carnage of the final few days,” the report said, significantly increasing the United Nations estimate for the civilian death toll in the last days of the war.

The long-awaited report, the result of an extensive investigation by Marzuki Darusman, a former Indonesian attorney general, contradicted the government’s assertion that the war had been a humanitarian effort aimed at liberating civilians trapped with the Tamil Tigers in an ever shrinking corner of northern Sri Lanka.

“The government shelled on a large scale in three consecutive no-fire zones, where it had encouraged the civilian population to concentrate, even after indicating that it would cease the use of heavy weapons,” the report said, according to a leaked copy that was published over the weekend in The Island, a Sri Lankan newspaper. “Most civilian casualties in the final phases of the war were caused by government shelling.”

In a statement, the government rejected the report as “fundamentally flawed” and based on “patently biased material, which is presented without any verification.”

The Sri Lankan government has come under harsh scrutiny for its handling of the war against the Tamil Tigers, a separatist rebel group that for decades sought to establish a Tamil homeland in the north and east of the island nation. The Tigers fought a vicious and bloody insurgency that pioneered brutal tactics like using female suicide bombers and forcibly conscripting children as soldiers.

Mahinda Rajapaksa, Sri Lanka’s president, had pledged to end the war in his successful 2005 campaign. By May 2009, his troops had the Tigers pinned down in a remote corner of the northeast. The government refused to allow any civilian observers into the war zone, where hundreds of thousands of people were trapped between the rebels and government troops.

The government claimed it had a zero-tolerance policy for civilian casualties, but people who escaped the war zone told of indiscriminate shelling of civilians by the government. No one has been able to pinpoint the exact number killed because much of the area remains off limits to outsiders.

The Sri Lankan government has set up its own body to look into the last days of the war, the Lessons Learnt and Reconciliation Commission. The United Nations report said that the government panel was riddled with conflicts of interest and was not impartial, concluding that it “has not conducted genuine truth-seeking about what happened in the final stages of the armed conflict, not sought to investigate systematically and impartially the allegations of serious violations on both sides of the war.”

The United Nations report also said that the Tamil Tigers had committed war crimes. “Despite grave danger in the conflict zone, the L.T.T.E. refused civilians permission to leave, using them as hostages, at times even using their presence as a strategic human buffer between themselves and the advancing Sri Lanka Army,” it said, referring to the rebels’ formal name, the Liberation Tamil Tigers of Eelam.

“From February 2009 onwards, the L.T.T.E. started point-blank shooting of civilians who attempted to escape the conflict zone, significantly adding to the death toll in the final stages of the war.”

 

World Bank report finds selling virtual goods in games more profitable than 'real' economy

 A report commissioned by the World Bank's infoDev unit has cast fresh light on one of the more fascinating aspects of our brave new interconnected world: the virtual economy. The "third-party gaming services industry" -- where wealthy but impatient players have someone else grind away at online games for them in exchange for monetary reward -- is one of the focal points of the study, chiefly owing to it having generated revenues in the region of $3 billion in 2009 and now serving as the primary source of income for an estimated 100,000 young folks, primarily in countries like China and Vietnam. What's encouraging about these findings is that most of the revenue from such transactions ends up in the country where the virtual value is produced, which contrasts starkly with some of the more traditional international markets, such as that for coffee beans, where the study estimates only $5.5 billion of the $70 billion annual market value ever makes it back to the producing country. The research also takes an intriguing look at the emerging phenomenon of microwork, which consists of having unskilled workers doing the web's version of menial work -- checking images, transcribing bits of text, bumping up Facebook Likes (naughty!), etc. -- and could also lead to more employment opportunities for people in poorer nations. To get better acquainted with the details, check the links below or click past the break.