Medicare Is Faulted in Electronic Medical Records Conversion

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

Mike Spencer/Wilmington Star-News, via Associated Press

Celeste Stephens, a nurse, leads a session on electronic records at New Hanover Regional Medical Center in Wilmington, N.C.

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

This article has been revised to reflect the following correction:

Correction: November 30, 2012

An article on Thursday about a federal report critical of Medicare’s performance in assuring accuracy as doctors and hospitals switch to electronic medical records misstated, in some copies, the timing of a statement from a Medicare spokesman in response to the report. The statement was released late Wednesday, not late Thursday.

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New Georgia Government Starts Punishing Members of Old

Justyna Mielnikiewicz for The New York Times

Georgians in the office of Archil Kbilashvili, the nation’s new prosecutor, to file complaints.

TBILISI, Georgia — These days, when the Georgian prosecutor’s office opens, people are lined up, clutching plastic bags full of documents. One after another, they are presenting their case that President Mikheil Saakashvili’s government stripped them of something: a state job, a piece of land, an apartment. Most of them want to see someone punished.

The promise that officials would be punished helped propel the billionaire Bidzina Ivanishvili to victory in October parliamentary elections, dislodging the group of politicians who had controlled Georgia for nine years. Mr. Saakashvili conceded the loss and agreed to enter the opposition, and for the first time in Georgia’s post-Soviet history, power changed hands legally.

About two months later, the Georgian experiment — to many in the West, a last hope for building democracy in inhospitable post-Soviet terrain — hangs in the balance.

Mr. Ivanishvili has embarked on the project of prosecuting former officials more swiftly than anyone expected, saying he cannot ignore the public’s demand for justice. But numerous cases are targeting political rivals, since Mr. Saakashvili remains president until next October. The authorities have already charged 23 officials from Mr. Saakashvili’s government with crimes like corruption and torture, and they may prosecute his former interior minister, who is also the leader of the Parliament’s main opposition party.

Alexander Rondeli, a political analyst, said Mr. Ivanishvili was following in the winner-take-all tradition of Georgian politics.

“In Georgia, the political enemy is an enemy. I don’t think it gives a very good image to this country, but it is our culture,” said Mr. Rondeli, president of the Georgian Foundation for Strategic and International Studies. “It’s clear now that the new political force wants to annihilate the previous one. So that is completely clear. It does not look very much like democracy, but they say that the rule of law is higher.”

It was apparent there would be some kind of legal reckoning if Mr. Saakashvili lost power. Though his government was embraced in the United States and Europe for its pro-Western orientation, complaints mounted at home, especially about police brutality and the lack of due process in the justice system.

This fall, video was released showing prison inmates being beaten and sodomized by guards, releasing a huge wave of public anger. Rights activists have long complained that officials acted with impunity in grave cases, like the death of Sandro Girgvliani, a bank executive who was abducted by law enforcement officers in 2006 after an altercation.

As a candidate, Mr. Ivanishvili promised to deliver justice swiftly, sometimes claiming he could create an independent court system in as little as a year. Asked how, he told Forbes, “You have to jail one minister — two, max — to show everyone that there will be no forgiveness. Show that there’s political will up there, and it will all line up quickly.”

Georgia’s new prosecutor, Archil Kbilashvili, said that more than 3,000 criminal complaints had been filed against former officials over the last month, and he planned to triple the number of investigators in the division handling misuse of authority. If there is a criticism he hears most often from Georgians, he said, it is that he is acting too slowly.

As an example, he offered the case of Bacho Akhalaia, a much-feared former defense and interior minister who fled the country after the elections, evidently expecting to be arrested. When news got out that Mr. Akhalaia had returned, Mr. Kbilashvili said, he had been in his job for just five days when he was inundated with “many, many phone calls” asking why he had not ordered Mr. Akhalaia’s arrest.

“I said I have no evidence against him, he is a free citizen of this country,” Mr. Kbilashvili said. Still, the next day, Mr. Akhalaia was arrested based on the relatively mild charges of striking a sergeant with a knife handle and publicly beating servicemen. After that, new allegations began to flow in from citizens who were “somehow encouraged” to testify against Mr. Akhalaia, Mr. Kbilashvili said.

Two prominent legal rights groups have already warned that Mr. Ivanishvili’s team is approaching questions of justice too hastily. Tamar Chugoshvili, of the Georgian Young Lawyers’ Association, said her group withdrew from a parliamentary effort to compile a list of political prisoners for release, because a two-week deadline made it “impossible to really study the cases in detail.”

Olesya Vartanyan contributed reporting.

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Falcons pick off Brees 5 times, beat Saints 23-13

ATLANTA (AP) — The Atlanta Falcons raced to a 17-0 lead and the defense made it stand up, picking off five of Drew Brees' passes and ending his NFL-record touchdown streak with a 23-13 victory Thursday night.

The Falcons moved to the brink of clinching the NFC South and dealt a big blow to the Saints (5-7) and their fading playoff hopes. William Moore had two of the five interceptions, which were the most of Brees' career and came four days after he had two passes picked off and returned for touchdowns in a loss to San Francisco.

Brees had thrown a touchdown pass in 54 consecutive games. He had an apparent scoring pass to Darren Sproles late in the first half, but it was nullified by a penalty.

Michael Turner scored on Atlanta's opening possession, Tony Gonzalez hauled in a touchdown pass from Matt Ryan, and Matt Bryant booted three field goals, including a 55-yarder.

The Falcons defense did the rest.

Thomas DeCoud, Sean Weatherspoon and Jonathan Babineaux also had interceptions for Atlanta, which will clinch the NFC South with a month to go in the regular season if Tampa Bay loses to Denver on Sunday.

Brees had a couple of games with four picks, but nothing like this. He finished 28 of 50 for 341 yards.

The defending NFC South champion Saints lost their second in a row and will likely have to win out to have even a faint hope of making the postseason during a tumultuous year that was marred by a bounty scandal and a season-long suspension for coach Sean Payton.

After winning so many close games, the Falcons started this one as if they were intent on a rout.

Ryan completed a pass on the first play from scrimmage, then turned it over to a running game that has struggled most of the season. Turner burst around right end for a 35-yard gain. Jacquizz Rodgers broke off two straight 14-yard gains. Finally, it was Turner going in standing from 3 yards out, giving Atlanta a quick 7-0 lead.

That was Turner's 58th touchdown in five seasons with the Falcons, breaking the team record he had shared with Terance Mathis.

Atlanta struck again in the opening minute of the second period. Julio Jones hauled in an 18-yard throw from Ryan, setting up a 17-yard touchdown pass to Gonzalez in the back of the end zone. He beat former teammate Curtis Lofton, then just flipped the ball over the goalposts instead of his customary basketball dunk.

Brees' second interception, this one a sloppy pass behind running Chris Ivory that deflected into the arms of Sean Weatherspoon, set up Bryant's 45-yard field goal for a 17-0 lead.

Then, suddenly, the game completely changed.

For the rest of the second quarter and most of the third, the Saints totally dominated. Mark Ingram scored on a 1-yard run, capping an 11-play, 80-yard drive, and New Orleans should have tacked on more points at the end of the half. But Brees made a rookie-like mistake with 12 seconds remaining, dumping a pass over the middle to Sproles with no timeouts. He was wrapped up at the Atlanta 3 and the clock ran out before the Saints could spike the ball.

But New Orleans got the ball to start the second half, and Brees went back to work. This time, he made a couple of nifty moves to avoid sacks, completing six passes on an 83-yard drive consuming 15 plays and more than 6 1-2 minutes. But the Falcons defense held again, forcing Garrett Hartley to boot a 21-yard field goal that cut it to 17-10.

Hartley connected again from much farther out on the Saints' next possession, a 52-yarder that brought New Orleans even closer.

The Falcons, meanwhile, couldn't do anything offensively. They failed to pick up a first down on five straight possessions, a stretch in which the Saints had a 289-30 lead in total yards and a staggering 18 first downs.

Finally, it was the Atlanta defense that turned things around late in the third.

Brees rolled to his right and threw over the middle, but Moore picked off the pass and returned it to the New Orleans 16. Ryan connected on first-down throws to Gonzalez and Roddy White to set up Bryant's field goal.

___

Follow Paul Newberry on Twitter at www.twitter.com/pnewberry1963

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Phys Ed: Keeping Your Eye on the Ball

Recently, researchers in England set out to determine whether weekend golfers could improve their game through one of two approaches. Some were coached on individual swing technique, while others were instructed to gaze fixedly at the ball before putting. The researchers hoped to learn not only whether looking at the ball affects performance, but also whether where we look changes how we think and feel while in action.

Phys Ed

Gretchen Reynolds on the science of fitness.

Back in elementary school gym class, virtually all of us were taught to keep our eyes on the ball during sports. But a growing body of research suggests that, as adults, most of us have forgotten how to do this. When scientists in recent years have attached sophisticated, miniature gaze-tracking devices to the heads of golfers, soccer players, basketball free throw shooters, tennis players and even competitive sharpshooters, they have found that a majority are not actually looking where they believe they are looking or for as long as they think.

It has been less clear, though, whether a slightly wandering gaze really matters that much to those of us who are decidedly recreational athletes.

Which is in part why the British researchers had half of their group of 40 duffers practice putting technique, while the other half received instruction in a gaze-focusing technique known as “Quiet Eye” training.

Quiet Eye training, as the name suggests, is an attempt to get people to stop flicking their focus around so much. But “Quiet Eye training is not just about looking at the ball,” says Mark Wilson, who led the study, published in Psychophysiology, and is a senior lecturer in human movement science at the University of Exeter in England. “It is about looking at the ball for long enough to process aiming information.” It involves reminding players to first briefly sight toward the exact spot where they wish to send the ball, and then settle their eyes onto the ball and hold them there.

This tight focus on the ball, Dr. Wilson says, blunts distracting mental chatter and allows the brain “to process the aiming information you just gathered” and direct the body in the proper motions to get the ball where you wish it to go.

A quiet, focused eye, in other words, seems to encourage a quiet, focused mind, which then makes for more accurate putting.

And in fact, after Dr. Wilson had his golfing volunteers practice for hours on either specific aspects of stroke technique or on focusing their gaze and not worrying about technique, those who had worked on their gaze were more accurate than those who had fine-tuned their technique. Those trained to focus also had lower heart rates and less muscle twitchiness, indicating less performance anxiety.

Similar results have been reported among soccer penalty kickers, who, like golfers, need to precisely place a ball but have the added distraction of a peripatetic, obstructive goalie. Many players tend to glance at the goalie as they prepare to shoot. Their eyes are not quiet, and their aim is affected.

But in a study published last year in the journal Cognitive Processing, collegiate players who were instructed to look briefly toward one of the upper, far corners of the goal and then immediately back to the ball, ignoring the goalie, significantly improved their shooting accuracy and reduced by 50 percent the number of times the goalie blocked their try, compared to teammates who didn’t quiet their gaze.

It did not seem to matter, says Greg Wood, also of the University of Exeter, who led the study, that kickers were glancing briefly toward where they planned to shoot, potentially telegraphing their intentions to the goalie. “An accurate shot kicked with typical speed will reach the goal in approximately 400 milliseconds, leaving the goalie with insufficient processing and response time,” he says. Players needn’t disguise intent if their aim is true.

Of course, merely keeping your eye on the ball won’t induce it to roll or rise to the desired location if you employ miserable technique. No amount of laser-eyed focus will get one of my putts to land. But what is interesting about Quiet Eye-style training, Dr. Wilson says, is that it can allow recreational and novice athletes with rudimentary skills to progress rapidly.

Specifically, Dr. Wilson says, after having extensively studied just how the best golfers look, he now teaches novice golfers at his lab to “keep their gaze on the back of the ball, which is the contact point for the putter, for a brief period before starting the putting action” — long enough to, for instance, “say ‘back of the cup’ to themselves,” he says. The golfers are told to hold that position throughout the putting stroke and, he says, “importantly, after contact for a split second. I often ask golfers to rate the quality of their contact on the ball from 1 to 10, before they look up to see where the ball went.”

Inexperienced putters who followed these instructions improved much more rapidly, he says, than those who merely practiced putts repeatedly.

“It seems so obvious,” Dr. Wilson says. “It is almost too simple. People assume that they are doing all of this already. ‘You mean I should look at the ball?’ Duh!”

But, he concludes, “the fact is that many people do not look at the right place at the right time.”

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U.S. Is Weighing Stronger Action in Syrian Conflict

Francisco Leong/Agence France-Presse — Getty Images

Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.

WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.

While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.

The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”

But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.

Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.

Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”

The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.

In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.

“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.

France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.

American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.

“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”

Jessica Brandt contributed reporting from Cambridge, Mass.

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Bonds, Clemens, Sosa on Hall ballot for first time

NEW YORK (AP) — The most polarizing Hall of Fame debate since Pete Rose will now be decided by the baseball shrine's voters: Do Barry Bonds, Roger Clemens and Sammy Sosa belong in Cooperstown despite drug allegations that tainted their huge numbers?

In a monthlong election sure to become a referendum on the Steroids Era, the Hall ballot was released Wednesday, and Bonds, Clemens and Sosa are on it for the first time.

Bonds is the all-time home run champion with 762 and won a record seven MVP awards. Clemens took home a record seven Cy Young trophies and is ninth with 354 victories. Sosa ranks eighth on the homer chart with 609.

Yet for all their HRs, RBIs and Ws, the shadow of PEDs looms large.

"You could see for years that this particular ballot was going to be controversial and divisive to an unprecedented extent," Larry Stone of The Seattle Times wrote in an email. "My hope is that some clarity begins to emerge over the Hall of Fame status of those linked to performance-enhancing drugs. But I doubt it."

More than 600 longtime members of the Baseball Writers' Association of America will vote on the 37-player ballot. Candidates require 75 percent for induction, and the results will be announced Jan. 9.

Craig Biggio, Mike Piazza and Curt Schilling also are among the 24 first-time eligibles. Jack Morris, Jeff Bagwell and Tim Raines are the top holdover candidates.

If recent history is any indication, the odds are solidly stacked against Bonds, Clemens and Sosa. Mark McGwire and Rafael Palmeiro both posted Cooperstown-caliber stats, too, but drug clouds doomed them in Hall voting.

Some who favor Bonds and Clemens claim the bulk of their accomplishments came before baseball got wrapped up in drug scandals. They add that PED use was so prevalent in the 1980s, 1990s and early 2000s that it's unfair to exclude anyone because so many who-did-and-who-didn't questions remain.

Many fans on the other side say drug cheats — suspected or otherwise — should never be afforded the game's highest individual honor.

Either way, this election is baseball's newest hot button, generating the most fervent Hall arguments since Rose. The discussion about Rose was moot, however — the game's career hits leader agreed to a lifetime ban in 1989 after an investigation concluded he bet on games while managing the Cincinnati Reds, and that barred him from the BBWAA ballot.

The BBWAA election rules allow voters to pick up to 10 candidates. As for criteria, this is the only instruction: "Voting shall be based upon the player's record, playing ability, integrity, sportsmanship, character, and contributions to the team(s) on which the player played."

That leaves a lot of room for interpretation.

Bonds, Clemens and Sosa won't get a vote from Mike Klis of The Denver Post.

"Nay on all three. I think in all three cases, their performances were artificially enhanced. Especially in the cases of Bonds and Clemens, their production went up abnormally late in their careers," he wrote in an email.

They'll do better with Bob Dutton of The Kansas City Star.

"I plan to vote for all three. I understand the steroid/PED questions surrounding each one, and I've wrestled with the implications," he wrote in an email.

"My view is these guys played and posted Hall of Fame-type numbers against the competition of their time. That will be my sole yardstick. If Major League Baseball took no action against a player during his career for alleged or suspected steroid/PED use, I'm not going to do so in assessing their career for the Hall of Fame," he said.

San Jose Mercury News columnist Mark Purdy will reserve judgment.

"At the beginning of all this, I made up my mind I had to adopt a consistent policy on the steroid social club. So, my policy has been, with the brilliance in the way they set up the Hall of Fame vote where these guys have a 15-year window, I'm not going to vote for any of those guys until I get the best picture possible of what was happening then," he wrote in an email.

"We learn a little bit more each year. We learned a lot during the Bonds trial. We learned a lot during the Clemens trial. I don't want to say I'm never going to vote for any of them. I want to wait until the end of their eligibility window and have my best idea of what was really going on," he said.

Clemens was acquitted this summer in federal court on six counts that he lied and obstructed Congress when he denied using performance-enhancing drugs.

Bonds was found guilty in 2011 by a federal court jury on one count of obstruction of justice, ruling he gave an evasive answer in 2003 to a grand jury looking into the distribution of illegal steroids. Bonds is appealing the verdict.

McGwire is 10th on the career home run list with 583, but has never received even 24 percent in his six Hall tries. Big Mac has admitted to using steroids and human growth hormone.

Palmeiro is among only four players with 500 homers and 3,000 hits, yet has gotten a high of just 12.6 percent in his two years on the ballot. He drew a 10-day suspension in 2005 after a positive test for PEDs, and said the result was due to a vitamin vial given to him by teammate Miguel Tejada.

Biggio topped the 3,000-hit mark — which always has been considered an automatic credential for Cooperstown — and spent his entire career with the Houston Astros.

"Hopefully, the writers feel strongly that they liked what they saw, and we'll see what happens," Biggio said last week.

Schilling was 216-146 and won three World Series championships, including his "bloody sock" performance for the Boston Red Sox in 2004.

___

AP Baseball Writer Janie McCauley and AP Sports Writers Arnie Stapleton and Dave Skretta contributed to this report.

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The Next War: In Federal Budget Cutting, F-35 Fighter Jet Is at Risk

Luke Sharrett for The New York Times

Vice Adm. David Venlet was named to lead the Joint Strike Fighter program in 2010 after problems had left it behind schedule and over budget.

LEXINGTON PARK, Md. — The Marine version of the F-35 Joint Strike Fighter, already more than a decade in the making, was facing a crucial question: Could the jet, which can soar well past the speed of sound, land at sea like a helicopter?

Luke Sharrett for The New York Times

An F-35B, the Marine Corps version of the Joint Strike Fighter.

On an October day last year, with Lt. Col. Fred Schenk at the controls, the plane glided toward a ship off the Atlantic coast and then, its engine rotating straight down, descended gently to the deck at seven feet a second.

There were cheers from the ship’s crew members, who “were all shaking my hands and smiling,” Colonel Schenk recalled.

The smooth landing helped save that model and breathed new life into the huge F-35 program, the most expensive weapons system in military history. But while Pentagon officials now say that the program is making progress, it begins its 12th year in development years behind schedule, troubled with technological flaws and facing concerns about its relatively short flight range as possible threats grow from Asia.

With a record price tag — potentially in the hundreds of billions of dollars — the jet is likely to become a target for budget cutters. Reining in military spending is on the table as President Obama and Republican leaders in Congress look for ways to avert a fiscal crisis. But no matter what kind of deal is reached in the next few weeks, military analysts expect the Pentagon budget to decline in the next decade as the war in Afghanistan ends and the military is required to do its part to reduce the federal debt.

Behind the scenes, the Pentagon and the F-35’s main contractor, Lockheed Martin, are engaged in a conflict of their own over the costs. The relationship “is the worst I’ve ever seen, and I’ve been in some bad ones,” Maj. Gen. Christopher Bogdan of the Air Force, a top program official, said in September. “I guarantee you: we will not succeed on this if we do not get past that.”

In a battle that is being fought on other military programs as well, the Pentagon has been pushing Lockheed to cut costs much faster while the company is fighting to hold onto a profit. “Lockheed has seemed to be focused on short-term business goals,” Frank Kendall, the Pentagon’s top weapons buyer, said this month. “And we’d like to see them focus more on execution of the program and successful delivery of the product.”

The F-35 was conceived as the Pentagon’s silver bullet in the sky — a state-of-the art aircraft that could be adapted to three branches of the military, with advances that would easily overcome the defenses of most foes. The radar-evading jets would not only dodge sophisticated antiaircraft missiles, but they would also give pilots a better picture of enemy threats while enabling allies, who want the planes, too, to fight more closely with American forces.

But the ambitious aircraft instead illustrates how the Pentagon can let huge and complex programs veer out of control and then have a hard time reining them in. The program nearly doubled in cost as Lockheed and the military’s own bureaucracy failed to deliver on the most basic promise of a three-in-one jet that would save taxpayers money and be served up speedily.

Lockheed has delivered 41 planes so far for testing and initial training, and Pentagon leaders are slowing purchases of the F-35 to fix the latest technical problems and reduce the immediate costs. A helmet for pilots that projects targeting data onto its visor is too jittery to count on. The tail-hook on the Navy jet has had trouble catching the arresting cable, meaning that version cannot yet land on carriers. And writing and testing the millions of lines of software needed by the jets is so daunting that General Bogdan said, “It scares the heck out of me.”

With all the delays — full production is not expected until 2019 — the military has spent billions to extend the lives of older fighters and buy more of them to fill the gap. At the same time, the cost to build each F-35 has risen to an average of $137 million from $69 million in 2001.

The jets would cost taxpayers $396 billion, including research and development, if the Pentagon sticks to its plan to build 2,443 by the late 2030s. That would be nearly four times as much as any other weapons system and two-thirds of the $589 billion the United States has spent on the war in Afghanistan. The military is also desperately trying to figure out how to reduce the long-term costs of operating the planes, now projected at $1.1 trillion.

“The plane is unaffordable,” said Winslow T. Wheeler, an analyst at the Project on Government Oversight, a nonprofit group in Washington.

Todd Harrison, an analyst at the Center for Strategic and Budgetary Assessments, a research group in Washington, said Pentagon officials had little choice but to push ahead, especially after already spending $65 billion on the fighter. “It is simultaneously too big to fail and too big to succeed,” he said. “The bottom line here is that they’ve crammed too much into the program. They were asking one fighter to do three different jobs, and they basically ended up with three different fighters.”

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Personal Health: Aiding the Doctor Who Feels Cancer's Toll

The woman was terminally ill with advanced cancer, and the oncologist who had been treating her for three years thought the next step might be to deliver chemotherapy directly to her brain. It was a risky treatment that he knew would not, could not, help her.

When Dr. Diane E. Meier asked what he thought the futile therapy would accomplish, the oncologist replied, “I don’t want Judy to think I’m abandoning her.”

In a recent interview, Dr. Meier said, “Most physicians have no other strategies, no other arrows in their quiver beyond administering tests and treatments.”

“To avoid feeling that they’ve abandoned their patients, doctors throw procedures at them,” she said.

Dr. Meier, a renowned expert on palliative care at Mount Sinai Medical Center in New York, was the keynote speaker this month at the Buddhist Contemplative Care Symposium, organized by the New York Zen Center for Contemplative Care and the Garrison Institute. She described contemplative care as “the discipline of being present, of listening before acting.”

“Counter to how the American medical system is structured, which pays for what gets done,” she said, “its approach is, ‘Don’t just do something, stand there.’ ”

But the idea is not to do just that. Rather, she said, the goal is to “restore the patient to the center of the enterprise.”

Under the Affordable Care Act, she said, unnecessary procedures may decline as more doctors are reimbursed for doing what is best for their patients over time, not just for administering tests and treatments. But more could be done if physicians were able to step away from the misperception that everything that can be done should be done.

Dr. Meier’s question prompted Judy’s oncologist to realize that what his patient needed most at the end of her life was not more chemotherapy, but for him to sit down with her, to promise to do his best to keep her comfortable and to be there for the rest of her days.

Occupational Distress

Patients and families may not realize it, but doctors who care for people with incurable illness, and especially the terminally ill, often suffer with their patients. Unable to cope with their own feelings of frustration, failure and helplessness, doctors may react with anger, abruptness and avoidance.

Visits may be reduced to a quick review of the medical chart, and phone calls may not be returned. Even though their doctors are still there, incurably ill patients may feel neglected and depressed, which can exacerbate illness and pain and even hasten death. Dr. Michael K. Kearney, a palliative care physician at Santa Barbara Cottage Hospital, told the Contemplative Care conference that doctors, especially those who care for terminally ill patients, are subject to two serious forms of occupational stress: burnout and compassion fatigue.

He described burnout as “the end stage of stresses between the individual and the work environment” that can result in emotional and physical exhaustion, a sense of detachment and a feeling of never being able to achieve one’s professional goals.

He likened compassion fatigue to “secondary post-traumatic stress disorder, or vicarious traumatization — trauma suffered when someone close to you is suffering.”

A doctor with compassion fatigue may avoid thoughts and feelings associated with a patient’s misery, become irritable and easily angered, and face physical and emotional distress when reminded of work with the dying. Compassion fatigue can lead to burnout.

In one study of 18 oncologists, published in 2008 in The Journal of Palliative Medicine, those who saw their role as both biomedical and psychosocial found end-of-life care very satisfying. But those “who described a primarily biomedical role reported a more distant relationship with the patient, a sense of failure at not being able to alter the course of the disease and an absence of collegial support,” the authors noted.

Healing the Healer

For doctors at risk of becoming overwhelmed by the stresses of their jobs, Dr. Kearney recommends adopting the time-honored Buddhist practice of “mindfulness meditation,” which involves cultivating mental techniques for stress reduction that are native to all of us but practiced by too few. He likened meditation to “learning to breathe underwater, or finding sources of renewal within work itself.”

To achieve it, a person sits quietly, paying attention to one’s breathing and whenever a distracting thought intrudes, turning one’s attention back to the sensation of breathing. This can help calm the mind and prepare it for a clearer perspective.

Dr. Kearney said this practice could help doctors “really pay attention and be tuned into their patients and what the patients are experiencing.”

“Patients, in turn,” he said, “experience a doctor who’s not just focused on a medical agenda but who really listens to them.”

He said mindfulness meditation helps doctors become more self-aware, empathetic and patient-focused, and to make fewer medical errors. It enables doctors to notice what is going on within themselves and to consider rational options instead of just reacting.

“It’s like pressing an internal pause button,” Dr. Kearney said. “The doctor is able to recognize he’s being stressed, and it prevents him from invoking the survival defense mechanisms of fight (‘Let’s do another course of chemotherapy’), flight (‘There’s nothing more I can do for you — I’ll go get the chaplain’) and freeze (the doctor goes blank and does nothing).” Such reactions can be highly distressing to a dying patient.

When a patient asks for the impossible, like “Promise me I’m not going to die,” the mindful doctor is more likely to step back and say, “I can promise you I’ll do everything I can to help you. I’m going to continue to care for you and support you as best as I can. I’ll be back to see you later today and again tomorrow,” Dr. Kearney said.

Although Dr. Kearney does mindfulness meditation for 30 minutes every morning, he said as little as 8 to 10 minutes a day has been shown helpful to practicing physicians.

In addition, doctors can factor moments of meditation into the course of the workday — say, while washing their hands, having a snack or coffee or pausing before entering the next patient room to focus on breathing.

To deal with the emotional flood that can come after a traumatic event, he suggested taking a brief timeout or calling on a friend or colleague to go for a walk.

This is the second of two columns about communication and cancer. Read the first: “When Treating Cancer Is Not an Option”

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News Analysis: Sunni Leaders Gaining Clout in Mideast

Mohammed Saber/European Pressphoto Agency

A Palestinian woman in Gaza City on Tuesday walked amid the rubble left from eight days of fighting that ended in a cease-fire.

RAMALLAH, West Bank — For years, the United States and its Middle East allies were challenged by the rising might of the so-called Shiite crescent, a political and ideological alliance backed by Iran that linked regional actors deeply hostile to Israel and the West.

But uprising, wars and economics have altered the landscape of the region, paving the way for a new axis to emerge, one led by a Sunni Muslim alliance of Egypt, Qatar and Turkey. That triumvirate played a leading role in helping end the eight-day conflict between Israel and Gaza, in large part by embracing Hamas and luring it further away from the Iran-Syria-Hezbollah fold, offering diplomatic clout and promises of hefty aid.

For the United States and Israel, the shifting dynamics offer a chance to isolate a resurgent Iran, limit its access to the Arab world and make it harder for Tehran to arm its agents on Israel’s border. But the gains are also tempered, because while these Sunni leaders are willing to work with Washington, unlike the mullahs in Tehran, they also promote a radical religious-based ideology that has fueled anti-Western sentiment around the region.

Hamas — which received missiles from Iran that reached Israel’s northern cities — broke with the Iranian axis last winter, openly backing the rebellion against the Syrian president, Bashar al-Assad. But its affinity with the Egypt-Qatar-Turkey axis came to fruition this fall.

“That camp has more assets that it can share than Iran — politically, diplomatically, materially,” said Robert Malley, the Middle East program director for the International Crisis Group. “The Muslim Brotherhood is their world much more so than Iran.”

The Gaza conflict helps illustrate how Middle Eastern alliances have evolved since the Islamist wave that toppled one government after another beginning in January 2011. Iran had no interest in a cease-fire, while Egypt, Qatar and Turkey did.

But it is the fight for Syria that is the defining struggle in this revived Sunni-Shiite duel. The winner gains a prized strategic crossroads.

For now, it appears that that tide is shifting against Iran, there too, and that it might well lose its main Arab partner, Syria. The Sunni-led opposition appears in recent days to have made significant inroads against the government, threatening the Assad family’s dynastic rule of 40 years and its long alliance with Iran. If Mr. Assad falls, that would render Iran and Hezbollah, which is based in Lebanon, isolated as a Shiite Muslim alliance in an ever more sectarian Middle East, no longer enjoying a special street credibility as what Damascus always tried to sell as “the beating heart of Arab resistance.”

If the shifts seem to leave the United States somewhat dazed, it is because what will emerge from all the ferment remains obscure.

Clearly the old leaders Washington relied on to enforce its will, like President Hosni Mubarak of Egypt, are gone or at least eclipsed. But otherwise confusion reigns in terms of knowing how to deal with this new paradigm, one that could well create societies infused with religious ideology that Americans find difficult to accept. The new reality could be a weaker Iran, but a far more religiously conservative Middle East that is less beholden to the United States.

Already, Islamists have been empowered in Egypt, Libya and Tunisia, while Syria’s opposition is being led by Sunni insurgents, including a growing number identified as jihadists, some identified as sympathizing with Al Qaeda. Qatar, which hosts a major United States military base, also helps finance Islamists all around the region.

In Egypt, President Mohamed Morsi resigned as a member of the Muslim Brotherhood only when he became head of state, but he still remains closely linked with the movement. Turkey, the model for many of them, has kept strong relations with Washington while diminishing the authority of generals who were longstanding American allies.

“The United States is part of a landscape that has shifted so dramatically,” said Mr. Malley of the International Crisis Group. “It is caught between the displacement of the old moderate-radical divide by one that is defined by confessional and sectarian loyalty.”

The emerging Sunni axis has put not only Shiites at a disadvantage, but also the old school leaders who once allied themselves with Washington.

The old guard members in the Palestinian Authority are struggling to remain relevant at a time when their failed 20-year quest to end the Israeli occupation of Palestinian lands makes them seem both anachronistic and obsolete.

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Play Your Wii U Anywhere — Even on a Train

Wii U on a Train

No need for a TV set. If you plug the Wii U in, you can interact entirely with the GamePad. This is on a Japanese Shinkansen, a high-speed train.

Click here to view this gallery.

[More from Mashable: Nintendo Unveils Wii Mini for the Canucks]

Nintendo’s new Wii U console may have one real advantage over the competition: portability. Since you don’t need a television to play a good portion of the Wii U titles, gaming on the road is as easy as locating a power outlet.

Rocket News 24 tested the console’s mobility by taking a Wii U on a Japanese bullet train, which has power outlets at every seat. Thanks to that — and a little iPhone tethering magic — their staff was able to play New Super Mario Brothers U and Call of Duty Black Ops 2 while riding comfortably.

[More from Mashable: Wii U Sells 400,000 Units in First Week]

Check out Rocket News 24 to see more pictures and a full recount of their experience.

This story originally published on Mashable here.

Gaming News Headlines – Yahoo! News

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