The New Old Age Blog: Forced to Choose: Nursing Home vs. Hospice

An older person, someone who will die within six months, leaves a hospital. Where does she go?

Almost a third of the time, according to a recent study from the University of California, San Francisco, records show she takes advantage of Medicare’s skilled-nursing facility benefit and enters a nursing home. But is that the best place for end-of-life care?

In terms of monitoring her vital signs and handling IVs — the round-the-clock nursing care the skilled-nursing facility benefit is designed to provide — maybe so. But for treating end-of-life symptoms like pain and shortness of breath, for providing spiritual support for her and her family, for palliative care that helps her through the ultimate transition – hospice is the acknowledged expert.

She could receive hospice care, also covered by Medicare, while in the nursing home. But since Medicare only rarely reimburses for both hospice and the skilled-nursing facility benefit at the same time, this hypothetical patient and her family face a financial bind. If she opts for the hospice benefit, which does not include room and board at the nursing home, then she will be on the hook for hundreds of dollars a day to remain in the facility.

She could use the hospice benefit at home, of course. But, “we know these patients are medically complex,” said Katherine Aragon, lead author of the study in The Archives of Internal Medicine, and now a palliative care specialist at Lawrence General Hospital in Massachusetts. “And we know that taking care of someone near the end of life can be very demanding, hard for families to manage at home.” And that assumes the patient has a family or a home.

For some patients, a nursing home, though possibly dreaded, is the only place that can provide 24/7 care.

But if she uses the skilled-nursing facility benefit to pay for room and board in a facility, she probably has to forgo hospice. (The exception: if she was hospitalized for something unrelated to her hospice diagnosis. If she has cancer, then trips and breaks a hip, she can have both nursing home coverage and hospice. If cancer itself caused the bone to fracture, no dice.)

Let’s acknowledge that these are lousy choices.

The study, using data from the National Health and Retirement Study from 1994 through 2007, looked at more than 5,000 people who initially lived in the community – that is, not in a facility. About 30 percent used the skilled-nursing facility benefit during the final six months of life; those people were likely to be over 85 and family members said, after their deaths, that they had expected them to die soon. (The benefit is commonly referred to as S.N.F., which people in the field pronounce as “sniff”).

The choice to use S.N.F. had ongoing repercussions. Almost 43 percent of those who used it died in a nursing home and almost 40 percent in a hospital. Just 11 percent died at home, though that is where most people prefer to die, studies repeatedly show.

Among those who didn’t use the S.N.F. benefit, more than 40 percent died at home.

In effect, nursing homes were providing end-of-life care, expensively and probably not so well, for almost a third of the elderly population.

The skilled-nursing facility benefit, Dr. Aragon pointed out in an interview, is meant to provide rehabilitation. “The hope is that someone will get stronger and go home,” she said.

Sometimes, of course, that is what happens.

“What we may be missing is that this patient is on an end-of-life trajectory,” she continued. “Maybe they can’t get stronger.”

Moreover, Dr. Aragon pointed out, nursing homes often have financial incentives to keep re-hospitalizing patients. After three days in a hospital, the skilled-nursing facility benefit starts anew, and it reimburses at a higher level than Medicaid, which pays for most nursing home care.

Because this unhappy choice between hospice care and nursing home reimbursement reflects federal policy, there may be little that individual families can do. If physicians are willing to honestly discuss their patients’ prognosis, to assess whether a nursing home stay will lead to rehabilitation or whether it is where a patient will likely die, sooner rather than later, families may have some personal options.

If they knew that death was likely within a few months, they might try to provide care at home with hospice help for that limited time, difficult as that is. Or they might be able to muster enough money to pay for a few months in a nursing home, so that their parent can be a resident and still receive hospice care.

But these are still lousy choices. “Palliative care should be part of nursing home care,” said Alexander K. Smith, the study’s senior author and a palliative care specialist at the University of California, San Francisco. “And that regulation that prevents concurrent use of the S.N.F. benefit and hospice isn’t in the interest of patients and families.”

Coming up in a future post: Experimenting with a concurrent-coverage option.

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

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Most Americans Face Lower Tax Burden Than in the 80s

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

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

Kirsten Luce for The New York Times

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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Gadgetwise Blog: A Tower Pleasing to the Ears and Eyes

The Zikmu Solo, a stereo speaker tower from Parrot, a mobile-products maker based in Paris, has a sleek, monolithic look that is sure to turn heads at parties.

Designed by Philippe Starck, the French product designer and architect, the tower produces balanced stereo sound through an acoustic configuration that puts a speaker on each side, a third in the front and a woofer in the base. Atop the tower, which stands about 30 inches high, is a dock for an iPod or iPhone.

The tower also has Bluetooth and Wi-Fi capability for those who prefer to stream their music and maintain the aesthetic appeal of the obelisk, which comes in five colors and costs $1,000.

But the tower’s simple design suggests an ease of use that is not necessarily the case. After several attempts to get the Bluetooth to work, I resorted to rebooting the speaker. When I finally got the tower paired with my iPhone 5, the connection was still sketchy, working with some apps but not others. I tried pairing other devices, but ran into similar problems.

Establishing a Wi-Fi connection required a bit of troubleshooting as well. In the end, I simply docked my iPod on top of the tower and hit “play.”

And then the sound emitting from the tower was amazing, filling the living room (and every other room in my apartment) with rich, luscious tones and a deep bass. It was akin to sitting in a concert hall.

Parrot created an app for iOS devices that allows users to adjust the audio settings of the Zikmu Solo. Unfortunately, the app was not ready when I tested the tower; Parrot said it would be updated soon.

The issues I had with the Zikmu were minor and would not normally be a problem. But this ultramodern speaker would be the centerpiece of any room. It looks and sounds impressive, and the last thing any owner wants when showing it off is to deal with technical problems.

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Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

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Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

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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.

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Rebel Leaders in Congo Send Mixed Signals on Leaving Goma

Jerome Delay/Associated Press

A man said to be from a Rwandan rebel group was held Tuesday. Rwanda said fighters crossed from Congo and attacked a village.

NAIROBI, Kenya — Rebel leaders in the Democratic Republic of Congo sent out mixed signals on Tuesday, with some saying they were withdrawing troops from the strategic city of Goma, which they captured last week, while others maintained that such a pullout would occur only if the Congolese government met a lengthy list of demands.

On Tuesday night, Amani Kabasha, a rebel spokesman, said: “There are no conditions. We are withdrawing our troops starting tomorrow.”

But earlier Tuesday, Jean-Marie Runiga, head of the rebels’ political wing, said the rebels would leave Goma only if the Congolese government released political prisoners, investigated the murder of opposition supporters, dissolved the national election commission and convened a conference of opposition leaders and members of the Congolese diaspora — demands that the government immediately dismissed as a “farce.”

Perhaps equally worrisome, the Rwandan government said that 150 fighters from another renegade group crossed from Congo into Rwanda on Tuesday and attacked a village at dawn, setting off a battle with Rwandan troops. It was the first such incursion on Rwandan soil in years and added to the escalating tensions between Rwanda and Congo, neighbors that essentially went to war against each other twice in the 1990s.

Many Congo analysts have been expecting the rebels, who call themselves the M23, to eventually withdraw from Goma, one of the biggest cities in eastern Congo, because the rebels have only a few thousand troops and seem to be overstretched trying to defend all the territory they have seized in recent weeks.

Still, the capture of Goma severely damaged the credibility of President Joseph Kabila of Congo, setting off protests across the country, and it is not clear what his next move will be.

“This ain’t over yet,” said Jason Stearns, a well-regarded Congo analyst who runs a blog called Congo Siasa, or Congo politics.

“It will be difficult to find a compromise — the M23 deeply mistrust Kabila,” Mr. Stearns said, “while the Congolese government is wary of reintegrating their enemies yet again into the army.”

The M23 rebels began as a different rebel force — the National Congress for the Defense of the People or C.N.D.P. in French — before being integrated into Congo’s national army as part of a March 23, 2009, peace deal. This year, they reinvented themselves again into rebels, taking their name from the date of the unfulfilled peace accord.

Few analysts ever believed that the 2009 peace deal would stick because of the rebels’ links to Rwanda, which has a history of covertly fomenting rebellions in eastern Congo as a way to carve out a sphere of influence in one of the most mineral-rich areas of the world. Most of the M23’s top officers are Tutsi, the ethnic group that dominates Rwanda’s military and government, and the suspicion was that the Tutsi officers in the Congolese Army were actually taking their orders from Kigali, Rwanda’s capital, instead of Kinshasa, Congo’s capital.

The M23 rebels have made a major effort to promote non-Tutsi to civilian leadership positions, broadening their base of support and making them an even more pernicious threat to Mr. Kabila, who was already despised by many across Congo, suspected of stealing from public coffers while so many roads, bridges, hospitals and schools sink into rot.

A lingering question though is who actually is control of the organization. Despite handing out political posts to non-Tutsi like Mr. Runiga, who is referred to as “the president,” Tutsi military officers still call the shots. On Tuesday, it was the Tutsi officers who said that they were pulling out of Goma and that they would relocate their troops to 12 miles beyond the city, as called for in an agreement reached by several African heads of state trying to quell the Goma conflict.

The trouble with the M23 started this spring when Mr. Kabila, under pressure from Western governments, indicated he was going to arrest Bosco Ntaganda, a Congolese Tutsi general and former rebel commander nicknamed the Terminator, who is wanted by the International Criminal Court on war crimes charges. The Congolese government also planned to shake up the power structure of the troops in eastern Congo, which the M23 rebels said was a violation of the original 2009 deal.

The troops then mutinied and took over town after town, culminating in Goma’s capture last Tuesday.

Several rebel fighters have said that they never planned to stay in Goma, a city of as many as one million people, because ruling it would be a headache. But even if the M23 rebels depart Goma, many of their agents are likely to remain. Goma’s police force has been heavily infiltrated, as evidenced last week by Rwandan-speaking police officers strolling around in brand-new uniforms. Veteran police officers said that they had no idea who the new commanders were and that they suddenly popped up on Goma’s streets as the rebel soldiers were marching into town.

“All of us have been disarmed,” said one police officer who was frightened to have his name published. He said that only the new Rwandan-speaking officers were allowed to carry guns.

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Ex-NASA Scientist’s Data Fears Come True

In 2007, Robert M. Nelson, an astronomer, and 27 other scientists at the Jet Propulsion Laboratory sued NASA arguing that the space agency’s background checks of employees of government contractors were unnecessarily invasive and violated their privacy rights.

Privacy advocates chimed in as well, contending that the space agency would not be able to protect the confidential details it was collecting.

The scientists took their case all the way to the Supreme Court only to lose last year.

This month, Dr. Nelson opened a letter from NASA telling him of a significant data breach that could potentially expose him to identity theft.

The very thing he and advocates worried about had occurred. A laptop used by an employee at NASA’s headquarters in Washington had been stolen from a car parked on the street on Halloween, the space agency said.

Although the laptop itself was password protected, unencrypted files on the laptop contained personal information on about 10,000 NASA employees — including details like their names, birth dates, Social Security numbers and in some cases, details related to background checks into employees’ personal lives.

Millions of Americans have received similar data breach notices from employers, government agencies, medical centers, banks and retailers. NASA in particular has been subject to “numerous cyberattacks” and computer thefts in recent years, according to a report from the Government Accountability Office, an agency that conducts research for Congress.

Even so, Dr. Nelson, who recently retired from the Jet Propulsion Laboratory, a research facility operated by the California Institute of Technology under a contract with NASA, stands out as a glaring example of security lapses involving personal data, privacy advocates say.

“To the extent that Robert Nelson looks like millions of other people working for firms employed by the federal government, this would seem to be a real problem,” said Marc Rotenberg, the executive director of the Electronic Privacy Information Center, an advocacy group which filed a friend-of-the-court brief for Dr. Nelson in the Supreme Court case.

In a 2009 report titled “NASA Needs to Remedy Vulnerabilities in Key Networks,” the Government Accountability Office noted that the agency had reported 1,120 security incidents in fiscal 2007 and 2008 alone.

It also singled out an incident in 2009 in which a NASA center reported the theft of a laptop containing about 3,000 unencrypted files about arms traffic regulations and wind tunnel tests for a supersonic jet.

“NASA had not installed full-disk encryption on its laptops at all three centers,” the report said. “As a result, sensitive data transmitted through the unclassified network or stored on laptop computers were at an increased risk of being compromised.” Other federal agencies have had similar problems. In 2006, for example, the Department of Veteran’s Affairs reported the theft of an employee laptop and hard drive that contained personal details on about 26.5 million veterans. Last year, the G.A.O. cited the Internal Revenue Service for weaknesses in data control that could “jeopardize the confidentiality, integrity, and availability of financial and sensitive taxpayer information.”

Also last year, the Securities and Exchange Commission warned its employees that their confidential financial information, like brokerage transactions, might have been compromised because an agency contractor had granted data access to a subcontractor without the S.E.C.’s authorization.

In a phone interview, Dr. Nelson, the astronomer, said he planned to hold a news conference on Wednesday morning in which he would ask members of Congress to investigate NASA’s data collection practices and the recent data breach.

Robert Jacobs, a NASA spokesman, said the agency’s data security policy already adequately protected employees and contractors because it required computers to be encrypted before employees took them off agency premises. “We are talking about a computer that should not have left the building in the first place,” Mr. Jacobs said. “The data would have been secure had the employee followed policy.”

The government argued in the case Dr. Nelson filed that a law called the Privacy Act, which governs data collection by federal agencies, provided the scientists with sufficient protection. The case reached the Supreme Court, which upheld government background checks for employees of contractors. The roots of Dr. Nelson’s case against NASA date back to 2004 when the Department of Homeland Security, under a directive signed by President George Bush, required federal agencies to adopt uniform identification credentials for all civil servants and contract employees. As part of the ID card standardization process, the department recommended agencies institute background checks.

Several years later, when NASA announced it intended to start doing background checks at the Jet Propulsion Laboratory, Dr. Nelson and other scientists there objected.

Those security checks could have included inquiries into medical treatment, counseling for drug use, or any “adverse” information about employees such as sexual activity, or participation in protests, said Dan Stormer, a lawyer representing Dr. Nelson.

But Dr. Nelson and other long-term employees of the lab challenged the legality of those checks, arguing that they violated their privacy rights. NASA, they said, had not established a legitimate need for such extensive investigations about low-risk employees like themselves who did not have security clearances or handle confidential information. Dr. Nelson, for example, specializes in solar system science — concerning, for example, Jupiter’s moon Io and Titan, a moon of Saturn — and publishes his work in scientific journals

“It was an invitation to an open-ended fishing expedition,” Dr. Nelson said of the background checks.

In friend of the court briefs for Dr. Nelson, privacy groups cited many data security problems at federal agencies, arguing that there was a risk that NASA was not equipped to protect the confidential details it was collecting about employees and contractors.

In 2008, the United States Court of Appeals for the Ninth Circuit in San Francisco temporarily halted the background checks, saying that the case had raised important questions about privacy rights. But last year, the Supreme Court upheld the background investigations of employees of government contractors.

Dr. Nelson said he retired from the Jet Propulsion Laboratory last June rather than submit to a background check. He now works as a senior scientist at the Planetary Science Institute of Tucson.

NASA has contracted with ID Experts, a data breach company, to help protect employees whose data was contained on the stolen laptop against identity theft. Mr. Jacobs, the NASA spokesman, said the agency has encrypted almost 80 percent of its laptops and plans to encrypt the rest by Dec. 21. He added that he too received a letter from NASA warning that his personal information might have been compromised by the laptop theft.

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

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

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