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New drugs helping millions live longer but also bankrupt them

If you pay for good health insurance, shouldn’t you be able to afford the medicine you need? For Kristin Agar, a 63-year-old social worker in Little Rock, Arkansas, this has not been the case. In 2008, Agar began experiencing strange symptoms. Her feet swelled, her joints ached, a rash appeared on her face, and every night she would get a fever that would disappear in the morning. Her doctor diagnosed her with lupus, a disease in which the body’s immune system mistakenly attacks healthy tissue, including the skin, joints, brain or kidneys. Agar’s doctor prescribed Benlysta, the only treatment on the market specifically for lupus. But Agar says that, although she works hard and makes decent money, she isn’t able to afford Benlysta. Agar’s insurance policy pays for 80 percent of the drug’s price, or about $2,500 per dose. But Benlysta is so expensive that Agar would still have to pay $450 once or twice a month for the medicine — on top of a $770 monthly insurance premium, and her other medical costs. “I make too much money to qualify for assistance, but I don’t make enough to pay the bills,” she says. Around the U.S., people with serious diseases like Agar’s are falling through the cracks, unable to afford the medication they need even if they have good jobs and good insurance. Patients with HIV, cancer, lupus, leukemia, hepatitis C, multiple sclerosis and other serious conditions are paying huge out-of-pocket sums for necessary medication. These costs are putting heavy mental and financial stress on some of America’s most vulnerable people. And the trend is getting worse. According to Truveris, a drug pricing research firm, the combined prices for brand, generic and specialty drugs rose 10.9 percent in 2014 compared with the previous year. These rising prices are forcing some patients to take on huge amounts of debt. Others, like Kristin Agar, are forgoing medications altogether — increasing the risk that they will have more serious health complications down the road. The reasons for these trends are complex: Drug companies blame insurers, insurers blame drug companies, and researchers blame both, as well as government regulations. But the implications are clear. Patients who can’t get medications will get sicker, and when they do, families, insurance companies and the government will bear the cost. The Supreme Court ruled on Jun. 25 that the federal subsidies that help people purchase Affordable Care Act health plans are legal, ensuring that the system will survive for now, and that patients with pre-existing conditions can continue to get insurance. However, patient advocates say that much work still needs to be done to make certain that patients can afford the treatment they need. Americans of all parties now see the cost of drugs as a top concern, even more important than political aspects of the Affordable Care Act. In a poll by the Kaiser Family Foundation earlier this year, 76 percent of the public said the top priority for the president and Congress was making sure that those who need high-cost drugs for chronic conditions, such as HIV, hepatitis, mental illness and cancer, can afford them. There is no quick fix to these problems. Meanwhile, the American population is aging, and many more expensive drugs are coming on the market. The problem is likely to get much worse before it gets better. “It’s ironic: We’ve had fairly stable health care costs for a number of years, which is a truly historic achievement. We’ve saved billions and billions of dollars,” says John Rother, the president and CEO of the National Coalition on Health Care, which advocates for sustainable drug prices. “And now it looks like this one sector, pharma, is going to drive healthcare costs much more aggressively upward in the future.” - - - The number of Americans taking expensive prescription drugs is rising quickly. In 2014, 576,000 Americans took at least $50,000 worth of prescription drugs, up from only 352,000 the year before, according to a recent report by Express Scripts, which manages pharmacy benefits for government agencies, labor unions, and other big employers. Insurance companies paid the bulk of this cost, of course — more than 97 percent. Most insurance plans cap the amount that patients can pay out of pocket for drugs. After a patient reaches this maximum level — up to $6,600 for plans purchased on the federal exchange — the insurance company will pay 100 percent of drug costs. But for many patients, the problem is in getting to that spending cap. Many Americans with chronic illnesses don’t have $6,000 or more to spend on prescriptions, especially after paying a monthly insurance premium, doctor visit co-pays, and other medical costs. For many with serious illnesses, hitting that maximum annual out-of-pocket level has become inevitable. Many patients, Agar included, hit the cap within the first few months of the year. “I don’t have that money lying around to be able to do it,” she says. “I’m not a stranger to hard work, I’ll work hard six days a week and people who know me will say that,” says Agar. “But there’s a limit to what anybody can do.” For much of her career, Agar worked with cancer patients, and she saw them go through the struggle of trying to afford their medications first hand. But she never thought she would end up in the same situation. Without the drug, Agar is vulnerable to a lupus flare that could damage her organs. “I feel like a sitting duck,” she says. People living with HIV and AIDS describe similar challenges. For lower-income patients who get access to the system, federal funds will cover the cost of medical care and support services. Jaysen Foreman, a case manager who works with HIV positive youth in Charlotte, North Carolina, says patients making up to $34,000 in Charlotte can receive free HIV medication and care through the government’s Ryan White program. But those who make more than that amount often struggle to afford their medications, too. “That’s the portion that it’s really squeezing, individuals who are in the gap between what Ryan White will cover, and where people have the income to pay for the medication whatever the co-pays are,” says Jonathan Hammond, a clerk at an immigration law firm in Cincinnati who is HIV positive. Considerations about insurance and HIV-related debt have changed the course of Hammond’s life. Hammond was forced to take on a heavy debt load as a result of HIV. When he discovered that he was HIV positive in 2002, he was enrolled in a graduate school program that didn’t offer health insurance. Hammond dropped out of school and spent a decade as a manager at Starbucks, which provides health insurance to part-time employees. Hammond started studying to become a lawyer in 2013 as a way to finally escape from what he calls “the debt of HIV.” He has around $50,000 in medical-related debt alone, including charges from multiple visits to the emergency room over a decade ago, when he was very sick but didn’t yet realize that the cause was HIV. Despite Hammond’s efforts to pay that debt down, in most years his total debt grows rather than falls. Last year, Hammond paid close to $9,000 for medical care. This year, his law firm adopted a new insurance policy with a maximum out-of-pocket payment of $6,350. He met that maximum on March 7. “Beyond the stress of living with HIV and having that, [there’s] knowing that every single year that goes on, your debt is just going to get larger,” he says. - - - Nine out of 10 of the more than half a million Americans who consumed at least $50,000 in prescription drugs last year were taking what the medical industry calls “specialty medications.” These are drugs that treat complex and chronic conditions such as cancer, HIV and AIDS, rheumatoid arthritis, hepatitis, multiple sclerosis, kidney failure, and hypertension. The growth is partly due to pharmaceutical innovation that is helping those with serious illnesses live longer and healthier lives. Drug companies are rolling out life-changing treatments for chronic conditions, including cancer and hepatitis C. And patients who are taking these drugs are living longer, meaning the number of people on high-cost drugs is increasing. But the trend also has a lot to do with how pharmaceutical and insurance companies price their products, and how the government regulates them. In the debate over who is responsible for high patient drug costs, insurers and pharmaceutical companies are almost totally at odds. The pharmaceutical industry says insurers bear most of the responsibility for passing on too much of the cost of prescription drugs to consumers. “What we’re seeing in the marketplace is that insurers are requiring patients to pay an ever-growing share of their medicine costs,” says Robert Zirkelbach, a senior VP of communications at PhRMA, a trade group that represents the pharmaceutical industry. “In fact, patients are being asked to pay a far greater percentage of the price of medicine than they’re required to pay for physicians or other medical services that may cost significantly more.” Some independent researchers agree. Allison Rice, a professor at Duke Law School who teaches a training program for law students who are working with HIV patients, cites a longer-term trend in past decades toward insurers, employers and government-sponsored programs like Medicaid shifting more costs onto patients in order to encourage them to make smarter decisions about health care and reduce health care expenses overall. But while this approach might work with everyday health care, Rice says it doesn’t apply to chronic diseases. “The notion is that you can reduce health care costs by ‘putting skin in the game,‘ which I always find to be kind of hilarious when you’re dealing with people with cancer, multiple sclerosis or HIV. It’s not like they have a whole lot of choice in their meds,” Rice says. For HIV, for example, there are a limited number of drugs on the market, and each may provoke a different response in different patients. Some researchers have also found evidence that insurers offering health plans through the new federal marketplace are purposefully passing on higher costs to those with chronic illnesses, in order to discourage the sickest, and therefore most expensive, people from joining their plans. A study published in the New England Journal of Medicine in January by two researchers at Harvard argued that some insurers are discriminating against people with HIV by putting all medicines to treat the condition in the highest cost-sharing tier. Normally, insurance companies place medicines in different cost tiers in order to guide patients toward lower-cost versions of the drug. That might be a generic, or it could be a drug for which the insurer has been able to negotiate a lower price. But the Harvard study showed that some plans put all HIV medications in the highest cost tier — a practice they call “adverse tiering.” While Affordable Care Act bars insurers from discriminating against patients with pre-existing conditions, researchers say adverse tiering is designed to discourage HIV patients from joining certain insurance plans. Doug Jacobs, the lead author of the study, says they were surprised to find that adverse tiering was a widespread practice, going on in 12 of the 48 plans they looked at across the country. “The implications for people with HIV were tremendous. We estimated that if someone with HIV was in an adverse tiering plan, they would be spending more than $3,000 [a year] than if they weren’t.” Those working with HIV positive people say they have seen this phenomenon in action. Rice of Duke University says that it has been one of the barriers to people with HIV enrolling in the federal exchange plans in North Carolina. “People who realized up front that they were going to face 25-50 percent coinsurance for HIV drugs didn’t even bother to sign up,” she says. Another study by Avalere Health, a healthcare system advisory company, showed evidence of insurance companies engaging in similar practices for the high-cost medicines that treat cancer, diabetes, rheumatoid arthritis, multiple sclerosis, asthma, schizophrenia and bipolar disorder. “After the Affordable Care Act, people kind of assumed that discrimination on the basis of pre-existing conditions was completely gone,” says Jacobs. “I think it has the potential to be gone in the future, but doing so would require some vigilant oversight.” Another issue for many patients is pricing transparency. For the most expensive specialty drugs, many insurers have switched to charging patients coinsurance (a certain percentage of the drug’s total price, for example 20 percent) rather than a copay (a flat dollar fee, like $20). A study by Milliman Inc showed 41 percent of silver level plans on the federal exchange charged coinsurance greater than 30 percent for specialty medications in 2015, up from 27 percent of plans the year before. This practice not only passes along more of the cost to patients, it also prevents them from knowing how much their medications will cost before they enroll in a plan. Insurance companies don’t disclose the total price of drugs to people who are shopping on Healthcare.gov. So patients may know that they have to pay 30 percent of the price of a drug, but they won’t know what that price is until they get to the pharmacy. - - - Insurance companies claim that they are not using adverse tiering to discriminate against the sickest patients. Clare Krusing, the communications director for America’s Health Insurance Plans, an advocacy group that represents insurers, says that insurance companies are doing everything they can to provide affordable coverage. The real issue is exorbitant prices of prescription drugs, which drive up insurance premiums and increase cost sharing, says Krusing. Insurers are on the hook for much more of the rising cost of prescription drugs than patients are, Krusing points out. For example, the report from Express Scripts shows that insured patients who used more than $100,000 worth of prescription medications in 2014 paid 1.7 percent of the total cost out of pocket, on average. Insurance companies picked up the rest, including 100 percent of the cost of drugs after patients hit their out-of-pocket maximums. No matter how insurers try to ease the burden, some of those hefty drug costs have to be passed on to consumers through premiums and co-pays, says Krusing. “What patients are paying out of pocket is a direct reflection of that increase in cost.” The pharmaceutical industry claims these high costs are necessary to recoup their investments, including in the many drugs that never make it out of the laboratory, and fund the high cost of getting prescription drugs approved by the FDA. But critics say high prices are more likely a product of lengthy patents and market consolidation that gives pharmaceutical companies monopolies over certain drugs. Introducing more competition into the pharmaceutical market, both for brand name products and generic drugs, is the easiest way to slow the growth in drug prices. According to Truveris, while prices for brand-name drugs rose 14.8 percent and specialty drugs increased 9.7 percent last year, generics rose only 4.9 percent. As an example of blatant profiteering by the pharmaceutical industry, many in the health care industry point to the case of Sovaldi, the breakthrough drug that, for the first time ever, cures rather than treats hepatitis C. Gilead acquired the drug by buying its maker, Pharmasset, for $11 billion in 2012. Gilead then rolled out the miracle drug at $84,000 for the full 12 weeks of therapy — more than twice as much as Pharmasset had forecast that the treatment would cost in a 2011 filing to the SEC. Gilead took advantage of its position as the only provider of the drug at the time to charge extremely high prices, critics say -- and the market and its shareholders have richly rewarded the company for doing so. Gilead recouped the cost it paid to buy Pharmasset in just the first year of Sovaldi sales, and its stock price has doubled in the last two years. Patents are necessary to encourage companies to innovate, but they also slow the progress of cheaper generic versions of drugs to market, and allow drug companies to charge much more in the interim than they could if they had more competition. Drug makers are also accused of “evergreening” patents, making slight tweaks to an old formula to win a new patent on a drug without substantively improving the product. Rother of NCHC and others say the public needs more transparency into the opaque system of how drug companies price their products — whether prices are based on clinical studies, the value of the drug, or merely what drug makers think the market can bear. Another major issue is that private insurance companies don’t have the clout to negotiate down these high drug prices, and the government has refused to play that role, says Rother. Rother says Medicare is large enough to force drug makers to lower their prices, but the government once again decided not to negotiate for lower drug prices while crafting The Affordable Care Act — a decision Rother calls “the price of pharma’s acquiescence in the Affordable Care Act politically.” The U.S. is the only wealthy country that does not negotiate with the pharmaceutical industry over drug prices. Rother says the lack of negotiation has left the insurance industry with only very crude tools to try to counter aggressive drug pricing. One is what he calls “step therapy,” or insurers’ requirements that patients try less expensive drugs first before they move on to more expensive drugs. The other is high out-of-pocket costs. “These are not happy tradeoffs,” he says. “These are not something that anyone designing an ideal system wants to see.” In turn, the pharmaceutical industry has countered insurers’ high out-of-pocket costs with their own initiatives, called co-pay assistance. These programs help patients pay the co-insurance or co-pay costs on their prescriptions that their insurance plans require. Foreman, the case manager who works with HIV patients in North Carolina, calls co-pay assistance “a saving grace” for patients with HIV. “The pharma companies have stepped up and noticed there is a huger gap between these plans than someone can afford.” He says that, as out-of-pocket costs have increased for patients, he’s also seen co-pay assistance soar in the last few years, from roughly $3,500 to $6,500 per patient. Glen Stettin, M.D. and the senior vice president of clinical research and new solutions at Express Scripts, says that these co-pay programs perversely allow for higher health care costs. These programs help to shield many patients from the higher cost of drugs, meaning that only the insurance companies have to pay the full cost of the prescriptions. And that in turn forces insurers to raise premiums and coinsurance for people in their plans. Allie Gutshall, a 24-year-old grad student who lives in Houston, gets the medicine she needs through one of these assistance programs. Gutshall has lupus and takes Benlysta, the same expensive drug that Kristin Agar has been prescribed but can’t afford. Gutshall says Benlysta has been a miracle drug for her, allowing her to work and live a normal life. A few years ago, her joints were so swollen she couldn’t even walk to the bathroom with help. Allie says her family initially struggled to pay for Benlysta. After Allie resigned from her teaching job due to health complications, she was put on her mother’s insurance, which chose not to cover the drug. Allie’s dad had to put the $2,500 charge for a single dose of the drug on his credit card. Now, after extensive appeals to the drug maker, Allie is on their assistance program. “I’m very lucky it’s worked out this way. If my insurance company had said they would cover it, I would be paying a 20 percent co-pay of $7,500,” she says. “Even if I had got covered, it would be very difficult to come by that money every month.” But while she’s grateful for the assistance, Gutshall also recognizes the deep unfairness of these assistance programs. “My mom nearly had to take on a second-time job of being my advocate. . . Unfortunately, not everybody has a strong support system like that. They don’t have parents who are able to help out -- they might be parents themselves. It shouldn’t be that difficult to get the medications you need to be healthy and live a normal life.” - - - Some new regulations and legislation are in the works to help slow the growth of drug prices. Even as the Supreme Court decided to uphold subsidies for The Affordable Care Act, its regulations continue to evolve. The Department of Health and Human Services is expected to issue new regulations in the next few months on discrimination in the Affordable Care Act. Those new rules could force insurance companies to stop adverse tiering, or potentially allow private parties to sue insurers for discrimination against those with preexisting conditions. The bipartisan 21st Century Cures initiative will seek to address the supply side, speeding up the FDA’s approval process for new drugs. The FDA also recently approved the sale of the first-ever biosimilars, “generic” versions of biological medicines that have been marketed in other countries for years. Another bipartisan bill introduced in the house, Patients’ Access to Treatments Act, is seeking to limit cost-sharing for medications in specialty drug tiers. And many new regulations are being put in place at the state level, with Maine, Vermont, Delaware, Maryland, Louisiana and others setting limits on out-of-pocket spending. Consumer pressure is also a powerful force for change: In the past year, campaigns by patients and advocacy groups have pushed insurance companies to reexamine their plans and eliminate adverse tiering for HIV patients. A similar outcry by patients and advocates has pushed drug companies to expand co-pay assistance programs. Yet for both insurers and drug makers, the profit motive encourages them to raise prices and limit access to expensive drugs. Overall, the problem of unaffordable prescription drug costs for people with illnesses seems likely to get worse before it gets better. As Baby Boomers age, America’s population of people living with various chronic illnesses, including cancer, diabetes, high blood pressure and high cholesterol, will grow. Many more expensive prescription drugs are slated to hit the market in the next few years, and some are approved to treat conditions with larger patient populations, such as high blood pressure. According to Express Scripts, 27 of the 51 new medications the FDA approved in 2014 were specialty drugs. “Ultimately there are going to be more medications that come out that are incredibly innovative,” says Krusing of AHIP. “But if people can’t afford them, what good will they do?”

reddit

Parts of Reddit blacked out as users protest axing of host

Trying to catch up on Reddit this holiday weekend? Good luck. The “Ask Me Anything” subreddit and several other major portions of the site are inaccessible to the public, and it’s all because of the sudden apparent removal of Reddit’s popular director of communications, Victoria Taylor. Taylor, known on the community by the username “chooter,” has been a key administrator for the site’s open Q-and-A subreddit “Ask Me Anything” — a prominent section of Reddit that has hosted conversations called “AMAs” with everyone from an unnamed McDonald’s employee to President Barack Obama. Several Reddit users have posted that Taylor was let go without warning — a story that has spread through the site like wildfire and caused widespread outcry on the site. Several moderators began locking down their sections of Reddit in solidarity starting Thursday night. Users have started calling it the “AMAgeddon.” Tensions have already been running high between the company and its longtime users. Interim chief executive Ellen Pao has made several rule changes, most notably to the site’s anti-harassment policies. That’s been part of an effort to clean up the site’s reputation, a change that could make Reddit more palatable to its current users, new users and advertisers. But Pao’s changes have drawn ire from those who want the company to remain the freewheeling forum for discussion — even highly offensive discussion — that it has always been. Many Reddit users are blaming Pao for Taylor’s departure, piling on to widespread anti-Pao sentiment on the site. Reddit declined to comment on the situation because it was a personnel matter. But Alexis Ohanian, Reddit co-founder and executive chairman, has posted comments to users on the site attempting to smooth things over. Taylor has not commented publicly on the matter apart from saying on Reddit that she was “dazed” by the situation; she also thanked people for their support via Twitter: “Thank you to everyone for their good wishes and support. Love you guys.”

Food Expo 5 Things

Wine ice cream, maple water: 5 foods of the future?

NEW YORK — Chips made out of broccoli, chickpeas and kale. Wine-spiked ice cream. Popcorn that didn’t quite fulfill its destiny. Those were some of the alternate-universe products at this week’s 61st annual Fancy Food Show. Many have limited distribution and aren’t easy to find, but could signal coming trends. Buyers for places like supermarkets milled about the trade show at the sprawling Jacob Javits Center in New York City, tasting the treats on display and stuffing bags with free samples. “It’s like a secret wonderland of food,” said Louise Kramer, a spokeswoman for the Specialty Food Association, the trade group that puts on the show. The expo, which featured more than 100,000 products, is not open to the public. Here are five potential foods of the future exhibitors were showing off: WINE ICE CREAM Instead of a glass, this wine can be served in a cone. Mercer’s, a dairy in upstate New York, was offering tastes of its “wine ice cream,” which has up to 5 percent alcohol. The ice creams come in eight flavors including “Strawberry Sparkling” and “Chocolate Cabernet.” Roxaina Hurlburt, a co-owner of Mercer’s, said the dairy has been making traditional ice cream for 60 years and started packaging the wine ice cream in 2008. She said it’s sold online and in a couple of hundred locations around the country, including places like casinos and wineries. MAPLE WATER Is maple water the next coconut water? Drink Maple, based in Concord, Massachusetts, sells bottles of maple water it says is tapped from maple trees. It’s the same stuff that’s boiled down into maple syrup, but don’t expect a thick and sticky drink. The clear liquid has the consistency of water and a lightly sweetened taste, with a 12-ounce bottle labeled as having 30 calories and 7 grams of sugar. The product also seems to hit on all the prevailing dietary trends: the company’s website notes maple water is “low calorie, gluten-free, dairy-free and non-GMO.” It also says “no trees are harmed” in the collection process. The company says it’s sold in about 800 stores throughout the Northeast, including at select Whole Foods and small health food stores. “SEXY” SNACKS Holding a bag of chips with the word “Sexy” in big letters can cure shyness. At least that’s what Sexy snacks founder Robert Ehrlich told visitors to his booth. “When you hold a bag, you are sort of empowering yourself,” he says. The most notable aspects of the snacks may be the name and Ehrlich, whose claim to fame is his founding of Pirate’s Booty. Ehrlich says the snacks are a way for people to brand themselves, as they might with sneakers or handbags. The company, based in Sea Cliff, N.Y., says its products are sold in about 1,500 locations. The popcorn comes in flavors like “Bangin’ Cheddar” and “Brazilian Coconut,” and the chips in flavors including “Spinach & Matcha Tea.” HALF-POPPED KERNELS Do you think those half-popped kernels at the bottom of the popcorn bag are the best part? Now two companies are selling bags of just those bits. HalfPops and Pop’d Kerns offer the snacks in different flavors, with a one-ounce serving containing between 130 and 160 calories, depending on the flavor. HalfPops, based in Bellevue, Washington, says it uses a proprietary process to cook the kernels. Six-ounce bags of HalfPops are available online and at about 2,000 locations, including some Whole Foods and Wegman’s, said Mike Watts, the company’s vice president of marketing. BROCCOLI BITES A prevalent theme at the expo was snacks made from unusual ingredients; think bags of roasted chickpeas, cheese puffs made out of beans, and chips made out of seaweed. Another example that fell into that category was Broccoli Bites from Rhythm Foods, which also makes kale chips. Before they’re dehydrated, the broccoli is tossed in a dressing made with seeds, herbs and spices to add flavor and prevent crumbling. Each 1.5-ounce bag has 150 calories. Even though kale has surged in popularity in recent years, Rhythm Foods CEO Scott Jensen said he expects the broccoli snacks to be a lot easier to explain and sell to buyers. And he’s already working the next vegetable snack: cauliflower.

Parenting-Teen Social Media-1

How to protect your phone and gadgets from the heat

We're in the grip of a heatwave with temperatures close to or exceeding 100 degrees now for about a week. That's about 10 degrees higher than average and more than enough to give your phone and other electronic devices their own kind of heat stroke. Just a few minutes in the sun can cause your phone to overheat, but there are steps you can take to protect your sensitive equipment and avoid interruptions and worse, permanent damage. Most smartphones, including iPhones, are not designed to operate normally over 95 degrees. And if your phone starts to run hot, it will try to regulate its temperature. Signs that your phone's internal sensors have registered too much heat include a display that dims or goes black and shuts off altogether, the phone stops charging, the camera flash is disabled and, when using navigation, you'll see an alert that says your phone needs to cool down. If you notice any of these warning signs, turn your phone off and allow it to cool down. But it's much better for your phone to keep it from overheating. First, keep your phone out of the sun as much as possible — if you're outside put it in the shade or in a loose bag. You may want to remove your phone's case too, which tends to insulate the device. And don't leave it in a car, where temperatures quickly soar. Along with these simple physical measures, you can also limit your usage in very specific and perhaps surprising ways. Electronics generate heat and the harder they work, the more heat they will expel. This holds true for a full-size laptop as well as for your pint-size phone. Use just one app at a time, closing each as you finish. If you're like many users, you may not be in the habit of closing your apps, which is a fast way to run down your battery. To check, double-press your phone's start button and you will see a series of "screenshots", one for each open app. Simply swipe up to close. Some processes produce a lot more heat than others. GPS turn-by-turn navigation and graphic-laden games are the biggest culprits, so avoid these activities when it's hot. You should also turn off background app refresh, location services and Wi-Fi. An easy way to do this is by putting your phone in airplane mode. (Worried about missing a call? You can easily toggle this mode on and off to briefly check your messages.) Turn your screen brightness down as low as possible. Don't charge your phone if it's hot. Battery charging creates a lot of heat and is best left until you are back in cool conditions. And remember, drastic changes in temperature can damage sensitive electronics. When you're transitioning between hot and cool locations, turn your phone off and let it adjust to the new temperature before powering back up. Many of these principles will work for your laptop, but you can do a bit more. Clean the air vents where dust and debris can block cooling airflow. Use a can of compressed air, just make sure you're blowing the dust out of the unit and not inside the case. Make sure you're not blocking any of your laptop's vents when you're using it. Don't place your laptop directly on your lap — that's a sure way to build heat. Even a solid surface may trap heat, so consider an alternative. You can buy specialized "heat sink" mats that absorb heat from your device or stands that raise your laptop an inch or so above the work surface, which will allow air to flow. But if you're looking for an inexpensive (and likely free) way to achieve the same effect, try a slatted camping table or even a wire baking rack. Leslie Meredith has been writing about and reviewing personal technology for the past six years. She has designed and manages several international websites. As a mom of four, value, usefulness and online safety take priority. Have a question? Email Leslie at asklesliemeredith@gmail.com.

National Business

doctors

Doctors got $6.5 billion from drug, device makers

U.S. doctors and teaching hospitals got $6.49 billion from drug and medical-device makers in 2014, according to new government data on the financial links between the companies and the people who prescribe their products. The data released Tuesday range from the royalties paid to hospitals to help develop products to fees provided to medical experts to speak at a dinner with colleagues. The payments are listed in two broad categories: money to fund research and payments to entertain doctors or compensate them for consulting or other non-research purposes. By disclosing information on the payments, the U.S. government is seeking to bring transparency to the financial relationships between drugmakers and health care providers. Those ties can influence how physicians practice, even if they aren’t aware of it, said Jason Dana, a professor at Yale School of Management who studies decision-making. “If we have a financial incentive to believe something or conclude something, we kind of trick ourselves into thinking it’s true,” he said. “And we’re not always aware we’re doing it.” The government created a website, called Open Payments, to let people search for data on their medical providers. The disclosures cover payments to about 607,000 doctors and 1,121 teaching hospitals. Overall, companies made $3.23 billion in payments for research and $2.56 billion for other purposes, according to a summary posted on the website. The data also include ownership interests of $703 million. The Obama administration has been working to increase transparency in health care since the 2010 passage of the Patient Protection and Affordable Care Act. In addition to the payments posted Tuesday, the law has also led to the disclosure of how much doctors across the U.S. are paid by Medicare. “We have to know where the money is going to really understand the problem, to develop policy,” Dana said. “No pharma companies spend this kind of money in a disinterested way.” Some companies began voluntarily disclosing the payments in 2010 after the Affordable Care Act was signed. A similar disclosure requirement begins next year in Europe, while U.K. firms began posting the information in 2013. The Advanced Medical Technology Association said Tuesday that feedback from doctors helps device makers improve their products. The group, which represents device and diagnostics firms, said it supports the disclosures. Drug industry group Pharmaceutical Research and Manufacturers of America said collaboration between doctors and drugmakers helps lead to medical breakthroughs and can improve patient care.

Airline Antitrust Investigation

Airline probe would need proof beyond business as usual

WASHINGTON — As the Justice Department launches an investigation into possible collusion in the airline industry, experts say the government faces the burden of proving that carriers were deliberately signaling business decisions to each other. Airlines routinely increase flights based on demand. A particularly cold winter in the Northeast, for instance, might merit more flights to the Caribbean. And sometimes, routes are cut because there isn’t enough demand. Nothing is illegal about that. Any company can limit the supply of its own products, whether airline tickets, sneakers or smartphones. But it would be illegal for airlines to work together to limit flights in order to drive up fares. The government’s investigation is just in its initial phases. Letters went out this week to American Airlines, Delta Air Lines, Southwest Airlines and United Airlines. Together, those four carriers control more than 80 percent of the domestic seats on planes. Airlines are quick to say they can’t talk about pricing decisions. But in recent years, airline executives and Wall Street analysts have been much more open in discussing how the airlines have kept their passenger capacity — the number of seats they put into given markets — in check. With that capacity kept from growing too fast, airplanes have been fuller and carriers have been able to command higher ticket prices. That’s led to record profits. But were airlines simply responding to Wall Street’s questions about capacity, or were they illegally agreeing not to compete too hard as part of an effort to make more money? “Matching supply to demand is not a novel idea and running a company for profit is not a crime,” Raymond James analyst Savanthi Syth told investors in a note Thursday. Antitrust law draws a line between the entirely lawful practice of companies’ following each other’s behavior and companies illegally conspiring. The Justice Department appears to be hunting for communications and other signals that cross that boundary, said Andrew Gavil, who teaches antitrust law at Howard University. “The distinction involves whether or not there was really express or intentional coordination by two firms,” he said. It’s too early to know where the investigation is going. But if the government does find evidence of improper collusion, it could attempt to negotiate a consent decree with the airlines to stop them from certain behavior, such as issuing public statements about their intentions about capacity. Ever since the government stopped regulating routes and prices in 1978, airlines have struggled to avoid nasty and unprofitable fare wars. Historically, when the price of jet fuel fell, one airline would launch a new route or add extra flights on existing ones. Fares would be slashed to attract fliers and other airlines would be forced to match the new, lower fare. Airlines didn’t like it, but legally they couldn’t coordinate routes or fares. In 1982, Robert Crandall, then a senior executive who would become CEO of American Airlines, expressed his anger about these fare wars in a phone call with Howard Putnam, CEO of Braniff Airways. Putnam, who was recording the call, asked Crandall if he had a suggestion to deal with the problem. Crandall told him to raise his fares and he’d follow suit. Specifically, Crandall replied: “Yes. I have a suggestion for you. Raise your goddamn fares 20 percent. I’ll raise mine the next morning.” He said: “You’ll make more money and I will too.” The Justice Department sued and the case was settled for little more than an agreement by Crandall to keep a written record of all of his contact with other airline executives for two years. It’s unclear if there is a similar smoking-gun comment today. Airline executives have been talking publicly about how they’ve learned not to add capacity too fast. But no statement appears to be as blatant as Crandall’s. After a brief industry increase in seats in the spring, American Airlines CEO Doug Parker spoke about the need for capacity discipline to a Reuters reporter at the International Air Transport Association’s annual conference in Miami. “The real question is,” Parker said, “is this a one-time catch-up for fuel prices being lower, or is this airlines behaving like airlines used to and just increasing capacity because times are good? I don’t know if we know the answer to that yet.” A few weeks earlier, the United Airlines chief financial officer, John D. Rainey, spoke at a conference for Wall Street analysts and investors. “We are a big believer in the right balance between supply and demand, and we’ve demonstrated that with our capacity discipline,” Rainey said. “We’ve grown our (available seat miles) at less than GDP for eight consecutive years, and so we’ll continue to believe in that.” A government investigation could take years. Jonathan Baker, an antitrust law professor at American University, said investigations like this one generally need more than just circumstantial evidence. A case with explicit discussion between executives would be easy to prove. The harder challenge is one where collusion would need to be inferred from statements by executives to analysts, and other signaling.

Aetna Humana

Aetna to buy Humana as health insurer landscape shifts

Aetna aims to spend about $35 billion to buy rival Humana and become the latest health insurer bulking up on government business as the industry adjusts to the federal health care overhaul. The proposed cash-and-stock deal, announced early Friday, would make Aetna a sizeable player in the rapidly growing Medicare Advantage business, which offers privately run versions of the federally funded health care program for the elderly and some people with disabilities. The combination also would bolster Aetna’s presence in the state- and federally funded Medicaid program and Tricare coverage for military personnel and their families. Health insurers are eager to do more business with government payers due in part to a Medicaid expansion fostered by the health care overhaul and Medicare Advantage’s surging enrollment. The overhaul is expanding Medicaid coverage in several states as it seeks to provide health coverage for millions of uninsured people. Meanwhile, total enrollment in Medicare Advantage plans has tripled over the past decade to about 16.8 million people and is expected to keep growing as more baby boomers become eligible for the plans. Aetna’s acquisition of Humana would make it the largest provider of Medicare Advantage coverage, with 4.4 million members, a figure that could change depending on regulatory review. “Government markets are the most rapidly growing aspect of the system,” said Dan Mendelson, CEO of the market research firm Avalere Health. Hartford, Conn.-based Aetna announced its deal a day after the Medicaid coverage provider Centene Corp. said it would spend $6.3 billion to buy fellow insurer Health Net. That deal would help Centene expand in the nation’s biggest Medicaid market, California, and give it a Medicare presence in several western states. In addition to these deals, the Blue Cross-Blue Shield carrier Anthem went public late last month with an offer of more than $47 billion for another insurer, Cigna. Health insurers see more advantages to these big combinations than a chance to build their government portfolios. Major acquisitions can offer an infusion of new business at time when growth has slowed in the biggest part of their business, employer-sponsored health coverage. Plus more employers are opting to pay their own insurance claims and hire insurers to administer the coverage. That’s a less lucrative line of work for managed care companies. Big deals also allow companies to quickly diversify their products and cover more territory. They also can yield savings when the companies combine back-office functions and cut overlapping jobs. Both Aetna and Anthem also have cited the potential to improve their technology as a major reason behind their deals. Insurers are working to develop more apps and other tools that customers can use to shop for health care, since plans are exposing those customers to bigger medical bills through high deductibles and other insurance expenses. They also are using technology more to help monitor and improve patient care. The overhaul is accelerating a push in the industry to reimburse doctors and hospitals more based on the quality of care they provide instead of just shelling out a certain amount for each procedure performed. “Any time an industry is changing ... it requires investments to sort of successfully make that change,” said Shawn Guertin, Aetna’s chief financial officer. The impact these big acquisitions have on consumers can be murky and likely won’t be felt for at least a year, because insurers have already finalized most of their plans for coverage that starts in January. A combination may lead to fewer choices and some price changes for consumers, depending on where they live and who already is in their market. Aetna’s purchase price for Humana includes a combination of $125 in cash and $105.11 in Aetna shares for each Humana share. The total of about $230 per share, which is based on the closing price of Aetna’s stock Thursday, represents a premium of 29 percent to Humana’s trading price in late May, before The Wall Street Journal reported that it was an acquisition target. The deal’s total value amounts to about $37 billion counting debt. The combined company would be based in Hartford, Conn., led by Aetna Chairman and CEO Mark Bertolini and cover more than 33 million people. Only UnitedHealth Group Inc. and the Blue Cross-Blue Shield carrier Anthem Inc. cover more. A combined Aetna-Humana would be the second-largest insurer by revenue. The deal is expected to close in the second half of next year. Shares of Aetna and Humana closed at $125.51 and $187.50, respectively on Thursday. Markets were closed Friday for the July 4th holiday. The shares of both companies, like several other insurers, have soared to all-time-high prices this year.

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Charting every minute of an average American day

This is your life, America: hour by hour, minute by minute. The latest American Time Use Survey from the Bureau of Labor Statistics tracks where the sands in your hourglass go. This writer plotted the average American weekday and weekend day according to these numbers. “Average” is the crucial word here. Nobody actually works 4.5 hours every weekday and 1.3 hours every weekend day, for instance. But when you ask 11,000 citizens age 15 and up what they did in a given day, as the BLS did, and average their responses, this is what you end up with. Let’s start with sleep. You may be shocked to find that the average American gets 8 hours and 32 minutes of sleep on a typical workday. Wait, what? If you’re like a lot of people, the eight-hour sleep schedule sounds like a far-off dreamy ideal. Bear in mind that these numbers include responses from seniors and teens, people who typically get a lot more sleep than the rest of us. And as a BLS economist explained to me last year, these figures also include naps, as well as a number of “non-sleep activities” — reading, tossing and turning, and some, ahem, other things — that typically happen in bed. And on weekends, we sleep nearly an hour longer on average. We spend a little more than three hours on household chores and activities on weekdays and weekends. These numbers include making food, cleaning up, caring for others and performing basic personal grooming. The biggest difference between weekdays and weekends shows up in work time — 4 hours and 32 minutes of it during the week, 1 hour and 23 minutes on the weekend. Keep in mind: The numbers include people who are employed part-time, as well as retirees and those not working. Among just the people who do work on weekdays, 8.6 hours was the norm once commuting time was factored in. We watch a lot more TV on the weekends — 3 hours and 21 minutes on average, compared with 2 hours and 36 minutes during the week. Not surprisingly we also spend more time socializing and doing other leisure activities, like playing sports and games, on the weekends. And we also spend a little bit more time buying things — at the grocery store, for instance. Overall, this year’s Time Use Survey shows that, paradoxically, both hours worked and time spent watching TV have increased in the past year. As the Wall Street Journal notes, the rise in work hours is partly explained by the recovering economy — if more people are working, that average number is going to increase. With that extra work, perhaps, comes a greater need to relax and veg out at the end of the day. bc-workday (TPN)