Adderall, a Drug of Increased Focus for N.F.L. Players

The first time Anthony Becht heard about Adderall, he was in the Tampa Bay locker room in 2006. A teammate who had a prescription for the drug shook his pill bottle at Becht.

“ ‘You’ve got to get some of these,’ ” Becht recalled the player saying. “I was like, ‘What the heck is that?’ He definitely needed it. He said it just locks you in, hones you in. He said, ‘When I have to take them, my focus is just raised up to another level.’ ”

Becht said he did not give Adderall another thought until 2009, when he was playing in Arizona and his fellow tight end Ben Patrick was suspended for testing positive for amphetamines. The drug he took, Patrick said, was Adderall. Becht asked Patrick why he took it, and Patrick told Becht, and reporters, that he had needed to stay awake for a long drive.

Those two conversations gave Becht, now a free agent, an early glimpse at a problem that is confounding the N.F.L. this season. Players are taking Adderall, a medication widely prescribed to treat attention deficit hyperactivity disorder, whether they need it or not, and are failing drug tests because of it. And that is almost certainly contributing to a most-troubling result: a record-setting year for N.F.L. drug suspensions.

According to N.F.L. figures, 21 suspensions were announced this calendar year because of failed tests for performance-enhancing drugs, including amphetamines like Adderall. That is a 75 percent increase over the 12 suspensions announced in 2011 and, with a month to go in 2012, it is the most in a year since suspensions for performance-enhancing drugs began in 1989.

At least seven of the players suspended this year have been linked in news media reports to Adderall or have publicly blamed the drug, which acts as a strong stimulant in those without A.D.H.D. The most recent examples were Tampa Bay cornerback Eric Wright and New England defensive lineman Jermaine Cunningham last week.

The N.F.L. is forbidden under the terms of the drug-testing agreement with the players union from announcing what substance players have tested positive for — the urine test does not distinguish among types of amphetamines — and there is some suspicion that at least a few players may claim they took Adderall instead of admitting to steroid use, which carries a far greater stigma. But Adolpho Birch, who oversees drug testing as the N.F.L.’s senior vice president for law and labor, said last week that failed tests for amphetamines were up this year, although he did not provide any specifics. The increase in Adderall use probably accounts for a large part of the overall increase in failed tests.

“If nothing else it probably reflects an uptick in the use of amphetamine and amphetamine-related substances throughout society,” Birch said. “It’s not a secret that it’s a societal trend, and I think we’re starting to see some of the effects of that trend throughout our league.”

Amphetamines have long been used by athletes to provide a boost — think of the stories of “greenies” in baseball clubhouses decades ago. That Adderall use and abuse has made its way to the N.F.L. surprises few, because A.D.H.D. diagnoses and the use of medication to control it have sharply increased in recent years.

According to Dr. Lenard Adler, who runs the adult A.D.H.D. program at New York University Langone Medical Center, 4.4 percent of adults in the general population have the disorder, of which an estimated two-thirds are men. Birch said the number of exemptions the N.F.L. has granted for players who need treatment for A.D.H.D. is “almost certainly fewer” than 4.4 percent of those in the league.

The rates of those with the disorder fall as people get older; it is far more prevalent in children and adolescents. A report from the Centers for Disease Control and Prevention, using input from parents, found that as of 2007, about 9.5 percent or 5.4 million children from ages 4 to 17 had A.D.H.D. at some point. That was an increase of 22 percent from 2003. Boys (13.2 percent) were more likely to have the disorder than girls (5.6 percent).

Of children who currently have A.D.H.D., 66.3 percent are receiving medication, with boys 2.8 times more likely to receive medication. Those 11 to 17 years old are more likely to receive medication than younger children.

But Adderall, categorized by the Drug Enforcement Administration as a Schedule II controlled substance because it is particularly addictive, is also used by college students and even some high school students to provide extra energy and concentration for studying or as a party drug to ward off fatigue.

Dr. Leah Lagos, a New York sports psychologist who has worked with college and professional athletes, said she had seen patients who have used Adderall. She said she believed the rise in its use by professional athletes mimicked the use by college students. Just a few years ago, she said, it was estimated that 1 in 10 college students was abusing stimulants like Adderall and Ritalin. That estimate, Lagos said, has almost doubled.

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Corner Office | Sandra L. Kurtzig: Sandra Kurtzig of Kenandy, on Keeping Companies Focused

Q. Tell me about your approach to leadership.

A. I think that one of the most important things in working with anybody, whether you’re the boss or the person being managed, is that you have to have mutual respect. I’ve always been very open and down to earth. I’ve never taken myself very seriously. I show self-confidence, and I think that if you don’t show self-confidence, no one is going to buy from you and no one’s going to want to work with you.

I’m transparent, and I ask people on a regular basis what they like about their job and what they don’t like about their job. What can we be doing better? In your previous job, how did you do it? What worked better and what worked worse than what we are doing now? I’m constantly asking people for their opinions.

A key thing is surrounding myself with people that, No. 1, I respect, and No. 2, I like. Then I ask their opinions and really listen to them. Two-way conversations are an important ingredient for building a company. Nowadays, I hear that so many younger people who are starting companies are so used to working on the Internet that they tend to send only e-mails and communicate with their screens more than they communicate with people around them. You need to interact with people and not just your computers.

Q. How has your leadership style evolved over time?

A. I’m more self-confident now, and I make decisions faster. I know what information I need because I’ve been there, done that before. I’m also more willing to change the decisions and modify them so that we get to the end faster.

I don’t run after “shiny objects.” That’s a mistake that a lot of people make in running a company, especially in starting one. They tend to get a lot of opportunities from people who want to partner with them. And these are just shiny objects, because there are very few partners that end up being right for your company. So I’m much more selective. If I hear something, I’m very quick to think, ‘Hey, that’s a shiny object; let’s get back to work.’ I think that’s what’s so distracting to a lot of companies — they see a big customer or some other distraction, and they spend too much time on it and they lose their way.

Q. What else?

A. I’m willing to take risks. If you don’t have some fear of failure, then you’re not taking enough risks. I probably was much more conservative the first time around.

But I am conservative in hiring. I don’t over-hire. The reason is that you can get a lot more work done with fewer people. If you have a lot of people, you have to give them something to do, and you have to give them something to manage, and then you have to manage them. You can get a lot less done. So you want to have a core set of people while you’re really trying to discover your product, your direction, your market. And the more people you have, the more difficult it is to take risks because it affects a lot more people.

I’m also at a point in my life where I like to choose customers I want to work with, because if I don’t like working with them, we’re not going to be very good at it. And we’ve actually fired two customers. That’s something that I think is important and might be very strange and surprising to people. We had some customers when we first started and we were trying to make our way and figure out the market, and not all of them were ultimately right for us.

Q. How do you hire? What questions do you ask?

A. I would certainly ask people: “Why are you here? What do you know about our company that made you want to interview for this job?” If they haven’t done their homework and don’t even know why they’re there, then that’s a real red flag for me.

The second thing I’ll say is: “Why do you want to leave the company you’re at right now? Looks like you’re doing a pretty good job, and you’re doing well. What is it that you don’t like there?”

It’s always very eye-opening to know whether they don’t like it because of politics, because I always think that people can create their own politics to some extent. So that sort of makes me nervous. They’d better have a pretty good answer to those two things. Otherwise, we’re near the end of the interview at that point.

Q. Tell me more about your point that people can create their own politics.

A. If they say they don’t like the politics at their current job, I’ll ask them, “How’s that affecting your ability to do your job?” Then I would evaluate whether I think that they should be able to handle that and get around it, or whether it really is a serious political situation.

I interviewed somebody and he was telling me all about the politics within the company. The longer we talked, the more I thought he was the one creating the politics.

Q. What qualities are you looking for?

A. You hire people in your own style. If you hire people in your own style, they will in turn hire people in their style. So I want somebody who I feel is open and smart. I’m not saying I’m that smart, but maybe I am a little bit smart.

And I want people who are self-deprecating, who don’t take themselves too seriously.

And are they willing to work hard? If they have just too many outside interests that are going to take away from their ability to focus on the job, then I’m probably a little less likely to hire them.

Q. In those cases when someone doesn’t work out, what’s usually the problem?

A. They’re just in over their head. They painted a picture in the interview that they know certain things, but they really aren’t up for the task. And you can never demote somebody. Sometimes the people that you hire are good, but they’re just not good at the job they’re in, and a demotion doesn’t work. So you have to move on.

This interview has been edited and condensed.

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Alarm as China Issues Rules for Disputed Area

Kham/Reuters

Fishing boats off Vietnam’s coast in the South China Sea. One Chinese official said the new rules applied to disputed islands, too.

HAIKOU, China — New rules announced by a Chinese province last week to allow interceptions of ships in the South China Sea are raising concerns in the region, and in Washington, that simmering disputes with Southeast Asian countries over the waters will escalate.

The move by Hainan Province, which administers China’s South China Sea claims, is being seen by some outside analysts as another step in the country’s bid to solidify its claims to much of the sea, which includes crucial international shipping lanes through which more than a third of global trade is carried.

As foreign governments scrambled for clarification of the rules, which appeared vague and open to interpretation, a top Chinese policy maker on matters related to the South China Sea tried to calm worries inspired by the announcement.

Wu Shicun, the director general of the foreign affairs office of Hainan Province, said Saturday that Chinese ships would be allowed to search and repel foreign ships only if they were engaged in illegal activities (though these were not defined) and only if the ships were within the 12-nautical-mile zone surrounding islands that China claims.

The laws, passed by the provincial legislature, come less than a month after China named its new leader, Xi Jinping, and as the country remains embroiled in a serious dispute with Japan in the East China Sea over islands known in China as the Diaoyu and as the Senkaku in Japan.

The laws appear to have little to do with Mr. Xi directly, but they reinforce fears that China, now the owner of an aircraft carrier and a growing navy, is plowing ahead with plans to enforce its claims that it has sovereign rights over much of the sea, which includes dozens of islands that other countries say are theirs. And top Chinese officials have not yet clarified their intent, leaving room for speculation.

If China were to enforce these new rules fully beyond the 12-nautical-mile zones, naval experts say, at stake would be freedom of navigation, a principle that benefits not only the United States and other Western powers but also China, a big importer of Middle East oil.

An incomplete list of the laws passed in Hainan was announced by the state-run news agency, Xinhua, last week.

In an interview here on Saturday, Mr. Wu said the new regulations applied to all of the hundreds of islands scattered across the sea, and their surrounding waters. That includes islands claimed by several other countries, including Vietnam and the Philippines.

“It covers all the land features inside the nine-dash line and adjacent waters,” Mr. Wu said. The nine-dash line refers to a map that China drew up in the late 1940s that demarcates its territorial claims — about 80 percent of the South China Sea, whose seabed is believed to be rich in oil and natural gas.

That map forms the basis for China’s current claims. Some neighboring countries were outraged when China recently placed the nine-dash map on its new passports. Vietnam has refused to place its visa stamps in the passports as they are, insisting a separate piece of paper be added for the stamp.

Mr. Wu, who also heads a government-sponsored institute devoted to the study of the South China Sea, said the immediate intention of the new laws was to deal with what he called illegal Vietnamese fishing vessels that operate in the waters around Yongxing Island, where China recently established an expanded army garrison.

The island, which has a long airstrip, is part of a group known internationally as the Paracels that is also claimed by Vietnam. China is using Yongxing Island as a kind of forward presence in a bid for more control of the South China Sea, neighboring countries say.

The Chinese Foreign Ministry said last week that China was within its rights to allow the coast guard to board vessels in the South China Sea.

The new rules go into effect on Jan. 1. According to a report in an English-language state-run newspaper, China Daily, the police and coast guard will be allowed to board and seize control of foreign ships that “illegally enter” Chinese waters and order them to change course.

Mr. Wu acknowledged that the new rules had aroused alarm in Asia, and the United States, because they could be interpreted as a power grab by China.

“A big worry for neighboring countries and countries outside the region is that China is growing so rapidly, and they see it is possible China taking over the islands by force,” he said. “I think China needs to convince neighboring countries that this is not the case.”  Essentially, he said, countries had to trust that China would not use force in the sea.

The Philippines, an ally of the United States and one of the most vociferous critics of China’s claims in the South China Sea, reacted strongly to the new rules.

Bree Feng contributed reporting from Haikou, and Elisabeth Bumiller from Washington.

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Brazil Registers Anemic Growth in 3rd Quarter, Surprising Economists

SÃO PAULO, Brazil — Brazil’s economy registered anemic growth in the third quarter as investment levels remained disappointingly low, according to figures released on Friday. The results cast doubt on policies meant to prevent Brazil from turning into a laggard among Latin America’s economies.

Gross domestic product grew just 0.6 percent from the previous quarter, stunning economists who had forecast double that rate. Brazil’s economy is now expected to grow only about 1 percent in 2012, delivering a challenge to President Dilma Rousseff, who has tried to increase growth through an array of huge stimulus projects.

Even economists with favorable views of Ms. Rousseff’s policies of assertively directing large government banks and other state-controlled enterprises to promote growth expressed surprise. The figures reflect a sharp departure from 2010, the last year of Luiz Inácio Lula da Silva’s presidency, when Brazil’s economy grew 7.5 percent.

Antônio Delfim Netto, an influential former economic policy chief, called the G.D.P. figures “a tragedy” in comments to reporters here on Friday. Under Ms. Rousseff, who has been president since 2011, Brazil is on track to deliver its weakest two-year period of growth since the early 1990s, before a stabilization program that radically restructured the economy. Finance Minister Guido Mantega contends that Brazil is on the cusp of a recovery, forecasting 4 percent growth next year.

While growth has declined considerably from the boom years, the slowdown has been blunted by state-supported projects aimed at creating jobs, like a shipbuilding sector conceived to support the oil industry. Brazil’s unemployment rate, 5.3 percent, is still hovering near historical lows.

Authorities are also financing broadly popular antipoverty programs. Federal spending surged 9 percent in October compared with October 2011, partly a result of outlays for an moderate-income housing program called Minha Casa Minha Vida (My House My Life). As millions of poor Brazilians are shielded from the slowdown, Ms. Rousseff’s approval ratings remain high.

Still, critics are growing more vocal about the need for Brazil to become more energetic in addressing complex structural dilemmas weighing the economy down, including its byzantine bureaucracy and woeful public schools. Ms. Rousseff is moving to address these issues; she changed an oil royalties bill on Friday, shifting 100 percent of future proceeds to an education fund.

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Doctors Who Work for Hospitals Face a New Bottom Line

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

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

Today, Boise is a medical battleground.

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

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

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

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

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

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

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

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

A Drive to Consolidate

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

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

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

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

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

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Tiffany Reports 30% Drop in Third-Quarter Income

Tiffany & Company reported Thursday that its third-quarter net income fell about 30 percent, citing a higher-than-expected tax rate, economic weakness and high precious metal and diamond costs.

The jewelry company’s results missed Wall Street’s expectations, and it cut its full-year earnings forecast. Its shares dropped 6.2 percent.

For the quarter ended Oct. 31, Tiffany earned $63.2 million, or 49 cents a share, compared with $89.7 million, or 70 cents a share, a year earlier. Analysts polled by FactSet had forecast earnings of 63 cents a share.

Tiffany’s chairman and chief executive, Michael J. Kowalski, said in a statement that the company had expected its quarterly results would be affected by continuing economic softness and comparisons with the year-earlier quarter. But he added that the retailer’s gross margin rate of 54.4 percent — down from 57.9 percent in the prior-year period — was weaker than expected and its tax rate was higher than expected. Gross margin, a key performance metric, is the amount of each dollar in revenue a company actually keeps.

While cautious about worldwide economic conditions, Mr. Kowalski said the company anticipated that its results would improve during the holiday season, partly because of easier year-over-year sales comparisons but also because of new stores and new products.

The holiday season is critical for retailers, as it can make up to 40 percent of stores’ annual revenue.

Tiffany’s revenue increased 4 percent, to $852.7 million, in the third quarter, from $821.8 million a year earlier. Wall Street had expected revenue of $858.8 million in the latest period.

Tiffany now expects 2012 earnings of $3.20 to $3.40 a share. Its prior outlook was for earnings of $3.55 to $3.70 a share. Analysts are predicting earnings of $3.59 a share.

Tiffany shares dropped $3.93, or 6 percent, to close at $59.80.

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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.

This article has been revised to reflect the following correction:

Correction: November 30, 2012

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

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Medicare Is Faulted in Electronic Medical Records Conversion

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

Mike Spencer/Wilmington Star-News, via Associated Press

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

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

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

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

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

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

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

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

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

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

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

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

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

This article has been revised to reflect the following correction:

Correction: November 30, 2012

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

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Barnes & Noble Posts a Profit, but Sales of Digital Content Slows

Barnes & Noble reported a modest profit for its fiscal second quarter on Thursday, but growth in its digital content sales slowed as it faced increased competition from rivals like Amazon and Google.

The company, the largest conventional bookseller, has invested heavily in its Nook e-business as consumers increasingly shop online and read e-books. Barnes & Noble said revenue from its Nook business grew, but revenue from devices fell because of lower average selling prices. Digital content revenue grew 38 percent, but that was down from a 46 percent increase in the fiscal first quarter.

Investors were hoping for higher growth, and shares of Barnes & Noble fell $1.79, or 11 percent, to $14.26.

Barnes & Noble reported net income of $2.2 million for the three months that ended Oct. 27. That translates to a loss of 4 cents a share, however, after the impact of preferred stock dividends. That matched analysts’ expectations, according to FactSet. The results compare with a loss in the same quarter last year of $6.6 million, or 17 cents a share.

Revenue was nearly flat at $1.88 billion. Analysts expected revenue of $1.91 billion.

Revenue from the company’s Nook division rose 6 percent to $160 million. Barnes & Noble introduced two new Nook e-readers, a 7-inch Nook HD and 9-inch Nook HD Plus, during the quarter, and began shipping them just after the quarter closed.

In a call with analysts, William Lynch, the chief executive of Barnes & Noble, said the company expected digital content buying to pick up after the holiday season, when Nooks are expected to be popular gifts.

The company said Nook unit sales doubled over the busy four-day shopping weekend around Thanksgiving as the company increased markdowns at retailers like Target and Wal-Mart Stores.

But the Nook faces tough competition from other new devices this holiday season, including Apple’s iPad Mini, new Amazon Kindles and Google’s Nexus tablet.

“They’re maintaining their market share by way of promoting and discounting,” said Peter Wahlstrom, an analyst at Morningstar. “But it’s a more competitive marketplace.”

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General Assembly Grants Palestine Upgraded Status in U.N.

Damon Winter/The New York Times

The Palestinian Authority president, Mahmoud Abbas, center, was congratulated by Turkey’s foreign minister, Ahmet Davutoglu. More Photos »

UNITED NATIONS — More than 130 countries voted on Thursday to upgrade Palestine to a nonmember observer state of the United Nations, a triumph for Palestinian diplomacy and a sharp rebuke to the United States and Israel.

But the vote, at least for now, did little to bring either the Palestinians or the Israelis closer to the goal they claim to seek: two states living side by side, or increased Palestinian unity. Israel and the militant group Hamas both responded critically to the day’s events, though for different reasons.

The new status will give the Palestinians more tools to challenge Israel in international legal forums for its occupation activities in the West Bank, including settlement-building, and it helped bolster the Palestinian Authority, weakened after eight days of battle between its rival Hamas and Israel.

But even as a small but determined crowd of 2,000 celebrated in central Ramallah in the West Bank, waving flags and dancing, there was an underlying sense of concerned resignation.

“I hope this is good,” said Munir Shafie, 36, an electrical engineer who was there. “But how are we going to benefit?”

Still, the General Assembly vote — 138 countries in favor, 9 opposed and 41 abstaining — showed impressive backing for the Palestinians at a difficult time. It was taken on the 65th anniversary of the vote to divide the former British mandate of Palestine into two states, one Jewish and one Arab, a vote Israel considers the international seal of approval for its birth.

The past two years of Arab uprisings have marginalized the Palestinian cause to some extent as nations that focused their political aspirations on the Palestinian struggle have turned inward. The vote on Thursday, coming so soon after the Gaza fighting, put the Palestinians again — if briefly, perhaps — at the center of international discussion.

“The question is, where do we go from here and what does it mean?” Salam Fayyad, the Palestinian prime minister, who was in New York for the vote, said in an interview. “The sooner the tough rhetoric of this can subside and the more this is viewed as a logical consequence of many years of failure to move the process forward, the better.” He said nothing would change without deep American involvement.

President Mahmoud Abbas of the Palestinian Authority, speaking to the assembly’s member nations, said, “The General Assembly is called upon today to issue a birth certificate of the reality of the state of Palestine,” and he condemned what he called Israeli racism and colonialism. His remarks seemed aimed in part at Israel and in part at Hamas. But both quickly attacked him for the parts they found offensive.

“The world watched a defamatory and venomous speech that was full of mendacious propaganda against the Israel Defense Forces and the citizens of Israel,” Prime Minister Benjamin Netanyahu of Israel responded. “Someone who wants peace does not talk in such a manner.”

While Hamas had officially backed the United Nations bid of Mr. Abbas, it quickly criticized his speech because the group does not recognize Israel.

“There are controversial issues in the points that Abbas raised, and Hamas has the right to preserve its position over them,” said Salah al-Bardaweel, a spokesman for Hamas in Gaza, on Thursday.

“We do not recognize Israel, nor the partition of Palestine, and Israel has no right in Palestine,” he added. “Getting our membership in the U.N. bodies is our natural right, but without giving up any inch of Palestine’s soil.”

Israel’s ambassador to the United Nations, Ron Prosor, spoke after Mr. Abbas and said he was concerned that the Palestinian Authority failed to recognize Israel for what it is.

“Three months ago, Israel’s prime minister stood in this very hall and extended his hand in peace to President Abbas,” Mr. Prosor said. “He reiterated that his goal was to create a solution of two states for two peoples, where a demilitarized Palestinian state will recognize Israel as a Jewish state.

“That’s right. Two states for two peoples. In fact, President Abbas, I did not hear you use the phrase ‘two states for two peoples’ this afternoon. In fact, I have never heard you say the phrase ‘two states for two peoples’ because the Palestinian leadership has never recognized that Israel is the nation-state of the Jewish people.”

The Israelis also say that the fact that Mr. Abbas is not welcome in Gaza, the Palestinian coastal enclave run by Hamas, from which he was ejected five years ago, shows that there is no viable Palestinian leadership living up to its obligations now.

Jennifer Steinhauer contributed reporting from Washington, Isabel Kershner from Jerusalem, and Khaled Abu Aker from Ramallah, West Bank.

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