Well: Price for a New Hip? Good Luck Getting a Reliable Estimate

Jaime Rosenthal, a senior at Washington University in St. Louis, called more than 100 hospitals in every state last summer, seeking prices for a hip replacement for a 62-year-old grandmother who was uninsured but had the means to pay herself.

The quotes she received might surprise even hardened health care economists: only about half of the hospitals, including top-ranked orthopedic centers and community hospitals, could provide any sort of price estimate, despite repeated calls. Those that could gave quotes that varied by a factor of more than 10, from $11,100 to $125,798.

Ms. Rosenthal’s grandmother was fictitious, created for a summer research project on health care costs. But the findings, which form the basis of a paper released on Monday by JAMA Internal Medicine, are likely to fan the debate on the unsustainable growth of American health care costs and an opaque medical system in which prices are often hidden from consumers.

“Transparency is all the rage these days in government and business, but there has been little push for pricing transparency in health care, and there’s virtually no information,” said Dr. Peter Cram, an associate professor of internal medicine at the University of Iowa, who wrote the paper with Ms. Rosenthal. He added: “I can get the price for a car, for a can of oil, for a gallon of milk. But health care? That’s not so easy.”

President Obama’s Affordable Care Act focused primarily on providing insurance to Americans who did not have it. But the high price of care remains an elephant in the room. Although many experts have said that Americans must become more discerning consumers to help rein in costs, the study illustrates how hard that can be.

“We’ve been trying to help patients get good value, but it is really hard to get price commitments from hospitals — we see this all the time,” said Jeff Rice, the chief executive of Healthcare Blue Book, a company that collects data on medical procedures, doctors visits and tests. “And even if they say $20,000, it often turns out $40,000 or 60,000.”

There are many caveats to the study. Most patients — or insurers — never pay the full sticker price of surgery, because insurance companies bargain with hospitals and doctors for discounted rates. When Ms. Rosenthal balked at initial high estimates, some hospitals produced lower rates for a person without insurance.

But in other ways the telephone quotations underestimated prices, because they did not include the fees for outpatient rehabilitation, for example.

In an accompanying commentary, Andrew Steinmetz and Ezekiel J. Emanuel of the University of Pennsylvania acknowledged that there was “no justification” for the inability to provide estimates or for the wide range of prices. But they said that more rigorous data on quality — like infection rates and unexpected deaths — were required to know when high prices were worth it.

“Without quality data to accompany price data, physicians, consumers and other health care decision makers have no idea if a lower price represents shoddy quality of if it constitutes good value,” they wrote.

But, broadly, researchers emphasized that studies had found little consistent correlation between higher prices and better quality in American health care. Dr. Cram said there was no data that “Mercedes” hip implants were better than cheaper options, for example.

Jamie Court, the president of the California-based Consumer Watchdog, said: “If one hospital can put in a hip for $12,000, then every hospital should be able to do it. When there’s 100 percent variation in sticker price, then there is no real price. It’s about profit.”

Dr. Cram said the study did contain some good news: some of the country’s top-ranked hospitals came up with “bargain basement prices” in response to repeated calls. “If you’re a good consumer and shop around, you can get a good price — you don’t have to pay $120,000 for a Honda,” he said.

But that shopping can be arduous in a market not set up to respond to consumers. To get a total price, Ms. Rosenthal often had to call the hospital to get its estimate for on-site care, and a separate quote from doctors. And many were simply perplexed when she asked for a price upfront, Ms. Rosenthal said, adding, “The people who answered didn’t know what to do with the question.”

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How to Cope With Time Zone Changes and Jet Lag When Flying

Ilona De March, who lives in Amsterdam and travels frequently to Atlanta, has a strict rule when she flies across time zones: no alcohol.

A business traveler for 20 years, Ms. De March, a president at BCD Travel, knows the intricacies of long-haul flying — what works and what doesn’t.

When she arrives, she has another guideline. “I don’t lie down because then I would fall asleep,” she said. “I get busy working; I contact people in Atlanta. Then I am able to go to sleep at the right time.” What is the right time?

For her, the right time is nighttime in Atlanta. “I am trying to listen to my own body,” said Ms. De March, who oversees BCD Travel’s operations in Europe, the Middle East and Africa.

She still relishes the lifestyle. “I still haven’t lost the interest,” she said, though she added that “the travel isn’t as glamorous as it used to be, with tighter security.”

Yet, according to circadian rhythm experts, the lifestyle can take a toll on the mind and body. Just how much it affects an individual varies.

Research from June 2012 by AirPlus International, a global corporate card provider, in partnership with Business Travel Market, showed that executives who travel frequently could suffer from “decreases in mental capacity, increased stress levels and decreased productivity.”

The study, which used a tiny device called the Bodyguard to monitor heart rate variations, compared travelers with nontravelers during a 72-hour period.

The business travelers showed reduced mental capacity, diminished communication skills, decreased ability to concentrate and engage others, reduced tolerance levels and an increased risk of ill health. It corroborated earlier research by Mark Rosekind, the former director of NASA’s fatigue countermeasures program who is now a member of the National Transportation Safety Board. The average executive’s productivity and performance while traveling drops up to 20 percent, largely because of insufficient sleep, according to Dr. Rosekind’s research.

How well individuals cope with crossing time zones varies, and everyone must learn what works. “There are some people who can do it,” said Simon Shepard, a physical therapist in London for Optima-life, a British health and performance organization. He worked on the AirPlus study. “There are some people who are adaptable and can cope very well,” he said. But some people are less aware of travel’s effects, and believe they are sleeping better than they are. Mr. Shepard says he encourages frequent travelers to fly in first class or business class, avoid alcohol, move around while in flight, arrange for an early hotel check-in, have a car waiting when they arrive and stay hydrated before, during and after the flight.

David F. Dinges, a performance expert who has worked with NASA astronauts and has conducted research in the area of sleep deprivation and time zones, agreed that everyone dealt with travel across time zones differently. “Some tolerate it better than others. All get in deficit. There are large individual differences.”

Generally, he said, there are three types of people when it comes to crossing time zones. One, which he calls Type 3, who are very disrupted, “really affected”; Type 2, who are somewhat affected; and Type 1, who seem to take longer before they show the effects of frequent travel across time zones. “They cope pretty well,” said Dr. Dinges, who is chief of the division of sleep and chronobiology at the Perelman School of Medicine at University of Pennsylvania.

Dr. Dinges, who travels frequently from Philadelphia to Moscow and Philadelphia to Paris, recounted instances when he and other scientists had arrived in Moscow, Paris, Singapore or Tokyo, and, while waiting in the lobby for a limousine to take them to a meeting, boasted of how well they did with the time zone difference and lack of sleep. The next thing he heard, Dr. Dinges said, was one scientist asking: “Where’s my computer?” Then another: “Where’s my passport?” Both headed back to their hotel rooms to get the missing items.

“What people say has nothing to do with reality,” Dr. Dinges said. “You can have loss of short-term memory, which is especially likely to happen in a novel environment.”

One of the benefits of proper sleep is that it ensures that the brain works efficiently.

Sleep deprivation, Dr. Dinges said, is associated with obesity, diabetes, stroke and heart attack, which could be enough to make frequent travelers question their lifestyle, and some do, he said. Those who have the most difficulty are the ones who quit the lifestyle, if they can. “Eat fish, salad, fruit, juices for vitamins and energy,” said Chris Crowley, senior vice president for global client management for Europe, the Middle East and Africa for BCD Travel. “The big lesson is not to drink alcohol. I’ve been traveling like this for 20 years. I used to accept the first glass of Champagne offered. I would be sluggish and struggling when I arrived. You have to approach the long-haul travel like you’re at work, as a kind of mission. Be as fit as you possibly can be, as well as you possibly can be.”

Dr. Dinges, 63, who has been traveling to far-flung places for 35 to 40 years, said he had developed routines particular to his needs. He does not sleep on planes, drinks no alcohol, avoids rich foods and does not put his airplane seat back, choosing to work instead. “Know your strengths and weaknesses, what happens to you, what kind of mistakes you’re likely to make.” In addition, he said, he tries to arrive at his destination the day before his business meetings.

Over-the-counter sleep medication usually remains in the body for less time than prescription drugs, he said. “Know what drug at which dose is right for you. Don’t guess at it, and don’t mix sleep medication with alcohol.”

Those who travel across time zones recommend a nap to keep going. “Grab sleep whenever you can,” said Mr. Crowley, who travels 220 to 230 days a year. “Even if you’re not tired, you’ll sleep an hour.”

One caveat: Set two or three alarms to make sure you are awake in time for the business meeting or other work commitment.

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Ambitious makeover planned for old housing project

Denise Penegar puts a little extra effort into the teenage girls, the ones who've dropped out of high school to care for their firstborns.

Don't be afraid, the outreach worker tells them. Come down to the housing project's community center, get your GED and some job skills. Change your life.

"I was one of those girls," said Penegar, now 51 and still living in Jordan Downs, the Watts housing project where she was born.

Sometimes, she imagines how different her life might have been if someone had knocked on her door when she was 17, caring for her first baby. What would it have meant just to have "someone who is here who can help pick me up"?

Penegar is on the front lines of a bold social experiment underway at Jordan Downs, a project notorious to outsiders for its poverty, blight and violence but seen by many longtime residents, for all its problems, as a close-knit community worth preserving.

In the last year, the Housing Authority of the City of Los Angeles has begun an effort to transform Jordan that could cost more than $600 million. The plan is to turn the complex of 700 aging units into a mixed-income community of up to 1,400 apartments and condominiums, with shops and restaurants and fancy touches such as native plant gardens. The city hopes to draw in hundreds of more-affluent residents willing to pay market rate to live side by side with the city's poorest.

Spurred by changes in federal funding and policy, such "mixed use" developments have sprung up in place of infamous housing projects all over the country. But experts say Jordan is taking an approach that has not been tried on this scale.

Typically, public housing residents are moved out ahead of the bulldozers, scattered to search for new shelter. In Los Angeles, the housing authority has promised that any of the 2,300 Jordan residents "in good standing" can stay in their old units until the day they move into new ones. The project is to be built in phases, beginning with units on 21 acres of adjacent land purchased by the authority in 2008 for $31 million.

To ease the transition, the city has dispatched "community coaches" like Penegar, along with teachers, social workers, therapists — even police officers whose charge is not to make arrests but to coach youth football and triathlon teams.

In essence, officials intend to raze the buildings, not the community — and radically change its character.

It will be an enormous challenge, with success likely to be measured in tiny increments.

Only 47% of adults at Jordan reported any wages to the housing authority last year. As in many urban projects, poverty and social ills have multiplied through the generations, leaving some residents unfamiliar with opportunities and expectations beyond the neighborhood. Some rarely leave the area.

Before inviting in new neighbors with expectations of safety and comfort, the housing authority has begun flooding Jordan Downs with social services. Many of the programs are focused on women, because more than 60% of Jordan Downs' tenants live in households headed by single mothers. But men are targeted too — for job training and lessons in parenting, for instance.

By December, 10 months into the effort, more than 450 families had been surveyed by intake workers and 280 signed up for intensive services.

"Most people would say it's ambitious, but I think it's essential," said Kathryn Icenhower, executive director of Shields for Families, the South Los Angeles nonprofit that is running many of the new programs under a more than $1-million annual contract with the housing authority.

It is unknown, however, how effective the social services will be, how easy it will be to draw in wealthier residents and how many millions of dollars the federal government — a major source of funding — will provide.

Already, the housing authority has picked a development team — the for-profit Michaels Organization and the nonprofit Bridge Housing, both with respectable track records in other cities. But with financing still uncertain, it is unclear exactly how many units will be built or how much various occupants would pay.

Ultimately, a working family could pay hundreds of dollars more in rent than unemployed tenants next door for a nearly identical unit. Officials say they do not expect Watts to draw the same kind of high-income residents as the former Cabrini Green project in Chicago, which sat on prime real estate near downtown. But Jordan is in a convenient location, near the intersection of the 105 and 110 Freeways; and in a high-rent city like Los Angeles, even the steepest rates at Jordan are likely to seem a bargain.

Despite the onslaught of social services and some palpable changes — including a 53% plunge in the violent crime rate at Jordan last year — financial risks abound.

Later this spring, the authority plans to put in an application for $30 million from the federal government's Choice Neighborhoods Program as seed money. Without it, the project could be delayed.

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Wired Science Space Photo of the Day: Wings of the Seagull Nebula

This image shows the intricate structure of part of the Seagull Nebula, known more formally as IC 2177. These wisps of gas and dust are known as Sharpless 2-296 (officially Sh 2-296) and form part of the “wings” of the celestial bird. This region of the sky is a fascinating muddle of intriguing astronomical objects — a mix of dark and glowing red clouds, weaving amongst bright stars. This new view was captured by the Wide Field Imager on the MPG/ESO 2.2-metre telescope at ESO’s La Silla Observatory in Chile.

Image: ESO [high-resolution]

Caption: ESO

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All eyes on Frank Ocean as Grammy Awards kick off

LOS ANGELES (AP) — Everybody’s thinkin’ about Frank Ocean.

Ocean is a cause celebre and the man with the momentum as Sunday’s Grammy Awards kicked off with pre-telecast wins by Rihanna and Mumford & Sons. One of six top nominees with six nominations apiece, the 25-year-old R&B singer turned cultural talking point will have the music world’s attention.

It remains to be seen if it will be the “Thinkin Bout You” singer’s night, but there’s no question he’s dominated the discussion so far. Already a budding star with a gift for building buzz as well as crafting songs, Ocean was swept up by something more profound when he told fans his first love was a man last fall as he prepared to release his major-label debut, “channel ORANGE.”

It was a bold move and one that could have submarined his career before it really even got started. Instead, everyone from Beyonce to the often-homophobic R&B and rap communities showed public support. It was a remarkable moment.

“It speaks to the advancements of our culture,” renowned producer Rick Rubin said. “It feels like the culture’s moving forward and he’s a representative of the new acceptance in the world for different ideas, which just broadens (our experience), makes the world a better place.”

A recent altercation in a parking lot with Chris Brown only focused more attention on Ocean. Ocean says Brown was the aggressor; both are competing against each other in one of the Grammy categories.

Ocean is up for the major awards best new artist, album of the year and record of the year when the show airs live on CBS at 8 p.m. EST from the Staples Center, sharing top-nominee billing with fun., Dan Auerbach of The Black Keys, Mumford & Sons, Jay-Z and Kanye West.

The Grammy pre-telecast awards show got under way Sunday afternoon at the Nokia Theatre with 70 trophies up for grabs, including rock, pop, rap and country categories. Rihanna‘s “We Found Love,” featuring Calvin Harris, won the day’s first award, short form music video. Mumford & Sons took their first Grammy, winning along with Old Crow Medicine Show and Edward Sharpe and the Magnetic Zeros for their long form video documentary “Big Easy Express.”

Celebrities also began rolling down the red carpet in the early afternoon, but it remained to be seen if any would try to skirt CBS’s mandate that stars dress appropriately with butts, breasts and other sensitive areas covered adequately.

“”I think it’s just, you know, we should always stay classy and dress according to the event that’s being held,” Ashanti said on the red carpet. “So I don’t think people should be limited so much and told what you can and cannot do. But, you know, you do have to have a certain class and prestige about yourself.”

Ocean might be riding a wave toward some of the night’s biggest honors, but R&B and hip-hop performers have had a spotty history at the Grammys recently when it comes to major awards.

Only one R&B act has won album of the year this century, and it’s hard to even call him just an R&B act given his legend, artistic scope and material: Ray Charles for his “Genius & Friends,” an all-star collaboration that was honored posthumously.

Also limiting Ocean‘s chances for a clean sweep are his fellow top nominees. Fun. became just the second act to sweep nominations in all four major categories with a debut album, equaling Christopher Cross‘ 1981 feat. Like Cross’ “Sailing,” the New York-based pop-rock band has ridden along on the crest of an inescapable song: “We Are Young,” featuring Janelle Monae.

Cross won five Grammys, sweeping the major awards. Fun. likely will have a much harder time piling up that number of victories because of the buzz surrounding the group’s competitors. It’s not just Ocean who has people talking.

London-based folk-rockers Mumford & Sons had one of the top-selling albums of the year with “Babel” and already has a history with The Recording Academy’s thousands of voters, having been nominated for major awards the year prior. Also, The Black Keys have a winning track record at the Grammys.

And don’t count out West and Jay-Z, who were shut out of the major categories but remain very much in voters’ minds.

Jack White’s “Blunderbuss” competes with fun.’s “Some Nights,” Ocean‘s “channel ORANGE,” Mumford’s “Babel” and The Keys’ “El Camino” for the night’s top award, album of the year.

Gotye’s “Somebody That I Used To Know,” featuring Kimbra, Taylor Swift’s “We Are Never Ever Getting Back Together” and Kelly Clarkson’s “Stronger (What Doesn’t Kill You)” join the fun., Ocean and Black Keys entries in record of the year.

Fun. and Clarkson also are nominated for song of the year along with Ed Sheeran’s “The A Team,” Carly Rae Jepsen’s “Call Me Maybe” and Miguel’s “Adorn.”

And rounding out the major categories, fun., Ocean, Alabama Shakes, Hunter Hayes and The Lumineers are up for best new artist.

Those major nominees figure prominently on the 3 1/2-hour telecast, broadcast live on CBS.

Swift will kick things off with a show-opening performance. Fun. and Ocean will take the stage. Others scheduled to perform include Justin Timberlake, Carrie Underwood, Clarkson, White and Juanes.

There will be no shortage of mashups the Grammys have become famous for, either. Elton John, Mavis Staples, Mumford, Brittany Howard, T Bone Burnett and Zac Brown are saluting the late Levon Helm, who won the Americana Grammy last year a few months before his death. The Keys will join Dr. John and the Preservation Hall Jazz Band on stage. Sting, Rihanna and Bruno Mars will perform together. Other team-ups include Miranda Lambert and Dierks Bentley, and Alicia Keys and Maroon 5.

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AP writer Nekesa Mumbi Moody in Los Angeles contributed to this report.

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Online:

http://grammy.com

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Follow AP Music Writer Chris Talbott: http://twitter.com/Chris_Talbott.

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For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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American and US Airways Are Expected to Announce Merger This Week

After months of negotiations, American Airlines and US Airways are expected this week to announce a merger, which would create the nation’s biggest airline and concentrate even further a once-fragmented industry.

A merger would expand American’s domestic network, particularly in the Northeast and the Southwest, and create a more formidable competitor internationally. The combined airline would jump ahead of United Airlines and Delta Air Lines, both of which have grown through mergers of their own in recent years.

The combination would probably bring to an end the wave of consolidation that has swept the industry. Since 2001 there have been five large mergers, reducing the number of airlines to three main carriers, along with a handful of low-cost carriers like Southwest Airlines and JetBlue, and regional carriers.

These mergers have led to cuts in service to many smaller cities around the country. But they have also created healthier and more profitable airlines that are able to invest in new planes and products. Faced with rising fuel costs, and losing tens of billions of dollars in the last decade, airline executives argued that the only way to survive was to consolidate capacity.

American, which has been in bankruptcy protection since November 2011, is currently the nation’s third-largest airline with domestic and international flights; US Airways is the fourth.

The boards of both carriers are expected to meet on Monday to approve the combination, which then needs to be approved by a bankruptcy judge in New York. A tie-up also requires the approval of federal regulators and antitrust authorities. But analysts expect regulators to approve the deal since there is little overlap between the two networks and no hubs in the same cities.

Even if the deal clears all these hurdles, the merged airline still faces a range of challenges. Airline mergers are often rocky — involving complex technological systems, big reservation networks as well as large labor groups with different corporate cultures that all need to be combined seamlessly. United angered passengers last year after a series of merger-related computer and reservation mistakes, and late and delayed flights.

A deal would be a major victory for Doug Parker, the chairman of US Airways, who began pursuing a merger with the bigger carrier soon after American filed for bankruptcy. His argument — that American could succeed against bigger airlines only if it combined networks with US Airways — swayed American’s creditors who have a critical say in the company’s future.

The carriers have been discussing a deal for months. In recent days, both sides have moved much closer but were still trying to figure out how much the merged carrier would be worth and how management positions would be split.

Tom Horton, American’s chairman, who was opposed to a merger for much of the last year, was offered a position as nonexecutive chairman, said a person familiar with the matter but who asked not to be identified because the talks were still under way. US Airways shareholders could end up with about 28 percent of the new airline, and American’s creditors would have 72, this person said.

A merger could be structured to take effect as American exits bankruptcy. The airlines are pushing for a deal before Feb. 15, when some nondisclosure agreements with American bondholders are set to expire.

The new airline will be called American Airlines and based in Dallas. It will have a combined 94,000 employees, 950 planes, 6,500 daily flights, nine major hubs, and total sales of nearly $39 billion. It would be the market leader on the East Coast, the Southwest and South America. But it would remain a smaller player in the Pacific and Europe, where United and Delta are stronger.

Mr. Parker deftly outmaneuvered Mr. Horton by lobbying American’s employees. He gained an important edge last April when he won the public support of American’s three main labor groups. More recently, pilots from both airlines agreed on how they would work together if the merger succeeded.

The success of these labor discussions, even before the merger was formally discussed, helped persuade American’s creditors to follow Mr. Parker’s strategy.

Mr. Horton, and American’s management team, had argued that they should complete the carrier’s reorganization and emerge from bankruptcy as an independent airline before considering any mergers.

But under pressure from Mr. Parker, the management of American Airlines was eventually forced by its creditors to talk to Mr. Parker about a merger. All that was left then was to figure out who was going to lead the merged airline and how much it would be worth.

Mr. Parker, more than anyone in the business, knows the difficulty of integrating two airlines. In 2005, he orchestrated the merger of the airline he was then running, America West, with a larger carrier, US Airways. But pilots from each of these two original airline have yet to agree to a common contract and seniority rules, and, to this day, cannot fly together.

The difficulty is likely to be compounded at American. In bankruptcy, American cut thousands of jobs, reduced benefits, froze pensions, and sought higher productivity rules from its employees.

Before the US Airways-American deal, the last major combination was the acquisition of AirTran by Southwest, completed in 2011. That followed the merger of United and Continental Airlines in 2010, which created the current leader, and before that Delta with Northwest.

American has major hubs in Dallas, Miami, Chicago, Los Angeles and New York. But it has been steadily losing ground to its rivals over the last decade while racking up losses that have totaled more than $12 billion in over 10 years.

US Airways has hubs in Phoenix, Philadelphia and Charlotte, and has a big presence at Washington’s National Airport.

Its shareholders will have to vote on the proposed merger.

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A delicate new balancing act in senior healthcare

When Claire Gordon arrived at Cedars-Sinai Medical Center, nurses knew she needed extra attention.

She was 96, had heart disease and a history of falls. Now she had pneumonia and the flu. A team of Cedars specialists converged on her case to ensure that a bad situation did not turn worse and that she didn't end up with a lengthy, costly hospital stay.

Frail seniors like Gordon account for a disproportionate share of healthcare expenditures because they are frequently hospitalized and often land in intensive care units or are readmitted soon after being released. Now the federal health reform law is driving sweeping changes in how hospitals treat a rapidly growing number of elderly patients.

The U.S. population is aging quickly: People older than 65 are expected to make up nearly 20% of it by 2030. Linda P. Fried, dean of the Columbia University Mailman School of Public Health, said now is the time to train professionals and test efforts to improve care and lower healthcare costs for elderly patients.

"It's incredibly important that we prepare for being in a society where there are a lot of older people," she said. "We have to do this type of experiment right now."

At Cedars-Sinai, where more than half the patients in the medical and surgical wards are 65 or older, one such effort is dubbed the "frailty project." Within 24 hours, nurses assess elderly patients for their risk of complications such as falls, bed sores and delirium. Then a nurse, social worker, pharmacist and physician assess the most vulnerable patients and make an action plan to help them.

The Cedars project stands out nationally because medical professionals are working together to identify high-risk patients at the front end of their hospitalizations to prevent problems at the back end, said Herb Schultz, regional director of the U.S. Department of Health and Human Services.

"For seniors, it is better care, it is high-quality care and it is peace of mind," he said.

The effort and others like it also have the potential to reduce healthcare costs by cutting preventable medical errors and readmissions, Schultz said. The federal law penalizes hospitals for both.

Gordon, an articulate woman with brightly painted fingernails and a sense of humor, arrived at Cedars-Sinai by ambulance on a Monday.

Soon, nurse Jacquelyn Maxton was at her bedside asking a series of questions to check for problems with sleep, diet and confusion. The answers led to Gordon's designation as a frail patient. The next day, the project team huddled down the hall and addressed her risks one by one. Medical staff would treat the flu and pneumonia while at the same time addressing underlying health issues that could extend Gordon's stay and slow her recovery, both in the hospital and after going home.

To reduce the chance of falls, nurses placed a yellow band on her wrist that read "fall risk" and ensured that she didn't get up on her own. To prevent bed sores, they got her up and moving as often as possible. To cut down on confusion, they reminded Gordon frequently where she was and made sure she got uninterrupted sleep. Medical staff also stopped a few unnecessary medications that Gordon had been prescribed before her admission, including a heavy narcotic and a sleeping pill.

"It is really a holistic approach to the patient, not just to the disease that they are in here for," said Glenn D. Braunstein, the hospital's vice president for clinical innovation.

Previously, nurse Ivy Dimalanta said, she and her colleagues provided similar care but on a much more random basis. Under the project, the care has become standardized.

The healthcare system has not been well designed to address the needs of seniors who may have had a lifetime of health problems, said Mary Naylor, gerontology professor at the University of Pennsylvania School of Nursing. As a result, patients sometimes fall through the cracks and return to hospitals again and again.

"That is not good for them and that is not good for society to be using resources in that way," Naylor said.

Using data from related projects, Cedars began a pilot program in 2011 and expanded it last summer. The research is continuing but early results suggest that the interventions are leading to fewer seniors being admitted to the intensive care unit and to shorter hospital stays, said Jeff Borenstein, researcher and lead clinician on the frailty project. "It definitely seems to be going in the right direction," he said.

The hospital is now working with Naylor and the University of Pennsylvania to design a program to help the patients once they go home.

"People who are frail are very vulnerable when they leave the hospital," said Harriet Udin Aronow, a researcher at Cedars. "We want to promote them being safe at home and continuing to recover."

In Gordon's case, she lives alone with the help of her children and a caregiver. The hospital didn't want her experiencing complications that would lengthen the stay, but they also didn't want to discharge her before she was ready. Under the health reform law, hospitals face penalties if patients come back too soon after being released.

Patients and their families often are unaware of the additional attention. Sitting in a chair in front of a vase of pink flowers, Gordon said she knew she would have to do her part to get out of the hospital quickly. "You have to move," she said. "I know you get bed sores if you stay in bed."

Gordon said she was comfortable at the hospital but she wanted to go back to her house as quickly as she could. "There's no place like home," she said.

Two days later, that's where she was.

anna.gorman@latimes.com

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DC Comics Turns the Occupy Movement Into a Superhero Title

Eighteen months after the phrase first entered the collective public consciousness, the plight of the 99 percent is coming to mainstream superhero comics — via a new series from the second biggest publisher in the American comic industry, which just happens to be a subsidiary of a multi-national corporation that makes around $12 billion a year. Irony, anybody?

In May, DC Comics will launch two new series taking place in their mainstream superhero universe that offer different insights into the class struggle in a world filled with superheroes, alien races and inexplicable events. The Green Team, written by Tiny Titans and Superman Family Adventures creators Art Baltazar and Franco, with art by Ig Guara, revives an obscure 1975 concept about teenage rich kids who try to make the world a better place with their outrageous wealth. In an interview promoting the series, Franco promised that it would address questions like “Can money make you happy?” and “If you had unlimited wealth, could you use that to make the lives of people better?”

Obviously, this is one of the more fanciful series DC will be publishing.

But while DC is promoting The Green Team series as the adventures of the “1%,” its companion title, The Movement, is teased as a chance for us to “Meet the 99%… They were the super-powered disenfranchised — now they’re the voice of the people!”

“It’s a book about power,” explained The Movement writer Gail Simone. “Who owns it, who uses it, who suffers from its abuse. As we increasingly move to an age where information is currency, you get these situations where a single viral video can cost a previously unassailable corporation billions, or can upset the power balance of entire governments. And because the sources of that information are so dispersed and nameless, it’s nearly impossible to shut it all down.”

“The thing I find fascinating and a little bit worrisome is, what happens when a hacktivist group whose politics you find completely repulsive has this same kind of power and influence,” she elaborated in an interview at Big Shiny Robot. “What if a racist or homophobic group rises up and organizes in the same manner?”

While the concept is ambitious, the idea that a comic capable of living up to the book’s populist inspiration could come from DC Entertainment still strikes some as unlikely. Matt Pizzolo, the editor of the Occupy Comics anthology, told Wired that “though DC Comics did help launch Alan Moore and David Lloyd’s seminal anarchist epic V For Vendetta over two decades ago, it’s unlikely they would do so today. Between dismantling Vertigo and frankensteining Watchmen, the past year has demonstrated DC isn’t a safe place for bold creators who want to tell the kinds of stories that would inspire things like Occupy, rather than just cash in on them.”

Still, Simone says that the use of the iconography and language of a real-world populist movement is deliberate, promising that the book will reflect today’s decentralized political world and offer ”a slice of rarity that we’re unlikely to see in most superhero books.”

This wouldn’t the first time that DC has attempted to offer pre-packaged populist rebellion, of course; in addition to the aforementioned publication of the anti-establishment V For Vendetta, the company’s Vertigo imprint also published Grant Morrison’s The Invisibles, a series centering around an international organization struggling against forces of authority and repression that included anti-corporate themes.

Only time will tell whether The Movement will live up to the subversive examples of these earlier books, or just end up a well-intentioned piece of topical super heroics that trades on, and commodifies, a real political movement.

The Movement #1 will be available in both print and digital formats on May 1, while The Green Team #1 will be released on May 22.

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In Nigeria, Polio Vaccine Workers Are Killed by Gunmen

At least nine polio immunization workers were shot to death in northern Nigeria on Friday by gunmen who attacked two clinics, officials said.

The killings, with eerie echoes of attacks that killed nine female polio workers in Pakistan in December, represented another serious setback for the global effort to eradicate polio.

Most of the victims were women and were shot in the back of the head, local reports said.

A four-day vaccination drive had just ended in Kano State, where the killings took place, and the vaccinators were in a “mop-up” phase, looking for children who had been missed, said Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, one of the agencies running the eradication campaign.

Dr. Mohammad Ali Pate, Nigeria’s minister of state for health, said in a telephone interview that it was not entirely clear whether the gunmen were specifically targeting polio workers or just attacking the health centers where vaccinators happened to be gathering early in the morning. “Health workers are soft targets,” he said.

No one immediately took responsibility, but suspicion fell on Boko Haram, a militant Islamist group that has attacked police stations, government offices and even a religious leader’s convoy.

Polio, which once paralyzed millions of children, is now down to fewer than 1,000 known cases around the world, and is endemic in only three countries: Nigeria, Pakistan and Afghanistan.

Since September — when a new polio operations center was opened in the capital and Nigeria’s president, Goodluck Jonathan, appointed a special adviser for polio — the country had been improving, said Dr. Bruce Aylward, chief of polio eradication for the World Health Organization. There have been no new cases since Dec. 3.

While vaccinators have not previously been killed in the country, there is a long history of Nigerian Muslims shunning the vaccine.

Ten years ago, immunization was suspended for 11 months as local governors waited for local scientists to investigate rumors that it caused AIDS or was a Western plot to sterilize Muslim girls. That hiatus let cases spread across Africa. The Nigerian strain of the virus even reached Saudi Arabia when a Nigerian child living in hills outside Mecca was paralyzed.

Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who tracks vaccine issues, said the newest killings “are kind of mimicking what’s going on in Pakistan, and I feel it’s very much prompted by that.”

In a roundabout way, the C.I.A. has been blamed for the Pakistan killings. In its effort to track Osama bin Laden, the agency paid a Pakistani doctor to seek entry to Bin Laden’s compound on the pretext of vaccinating the children — presumably to get DNA samples as evidence that it was the right family. That enraged some Taliban factions in Pakistan, which outlawed vaccination in their areas and threatened vaccinators.

Nigerian police officials said the first shootings were of eight workers early in the morning at a clinic in the Tarauni neighborhood of Kano, the state capital; two or three died. A survivor said the two gunmen then set fire to a curtain, locked the doors and left.

“We summoned our courage and broke the door because we realized they wanted to burn us alive,” the survivor said from her bed at Aminu Kano Teaching Hospital.

About an hour later, six men on three-wheeled motorcycles stormed a clinic in the Haye neighborhood, a few miles away. They killed seven women waiting to collect vaccine.

Ten years ago, Dr. Larson said, she joined a door-to-door vaccination drive in northern Nigeria as a Unicef communications officer, “and even then we were trying to calm rumors that the C.I.A. was involved,” she said. The Iraq and Afghanistan wars had convinced poor Muslims in many countries that Americans hated them, and some believed the American-made vaccine was a plot by Western drug companies and intelligence agencies.

Since the vaccine ruse in Pakistan, she said, “Frankly, now, I can’t go to them and say, ‘The C.I.A. isn’t involved.’ ”

Dr. Pate said the attack would not stop the newly reinvigorated eradication drive, adding, “This isn’t going to deter us from getting everyone vaccinated to save the lives of our children.”

Aminu Abubakar contributed reported from Kano, Nigeria.

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