Unboxed: Stand-Up Desks Gaining Favor in the Workplace

THE health studies that conclude that people should sit less, and get up and move around more, have always struck me as fitting into the "well, duh" category.

But a closer look at the accumulating research on sitting reveals something more intriguing, and disturbing: the health hazards of sitting for long stretches are significant even for people who are quite active when they're not sitting down. That point was reiterated recently in two studies, published in The British Journal of Sports Medicine and in Diabetologia, a journal of the European Association for the Study of Diabetes.

Suppose you stick to a five-times-a-week gym regimen, as I do, and have put in a lifetime of hard cardio exercise, and have a resting heart rate that's a significant fraction below the norm. That doesn't inoculate you, apparently, from the perils of sitting.

The research comes more from observing the health results of people's behavior than from discovering the biological and genetic triggers that may be associated with extended sitting. Still, scientists have determined that after an hour or more of sitting, the production of enzymes that burn fat in the body declines by as much as 90 percent. Extended sitting, they add, slows the body's metabolism of glucose and lowers the levels of good (HDL) cholesterol in the blood. Those are risk factors toward developing heart disease and Type 2 diabetes.

"The science is still evolving, but we believe that sitting is harmful in itself," says Dr. Toni Yancey, a professor of health services at the University of California, Los Angeles.

Yet many of us still spend long hours each day sitting in front of a computer.

The good news is that when creative capitalism is working as it should, problems open the door to opportunity. New knowledge spreads, attitudes shift, consumer demand emerges and companies and entrepreneurs develop new products. That process is under way, addressing what might be called the sitting crisis. The results have been workstations that allow modern information workers to stand, even walk, while toiling at a keyboard.

Dr. Yancey goes further. She has a treadmill desk in the office and works on her recumbent bike at home.

If there is a movement toward ergonomic diversity and upright work in the information age, it will also be a return to the past. Today, the diligent worker tends to be defined as a person who puts in long hours crouched in front of a screen. But in the 19th and early 20th centuries, office workers, like clerks, accountants and managers, mostly stood. Sitting was slacking. And if you stand at work today, you join a distinguished lineage — Leonardo da Vinci, Ben Franklin, Winston Churchill, Vladimir Nabokov and, according to a recent profile in The New York Times, Philip Roth.

DR. JAMES A. LEVINE of the Mayo Clinic is a leading researcher in the field of inactivity studies. When he began his research 15 years ago, he says, it was seen as a novelty.

"But it's totally mainstream now," he says. "There's been an explosion of research in this area, because the health care cost implications are so enormous."

Steelcase, the big maker of office furniture, has seen a similar trend in the emerging marketplace for adjustable workstations, which allow workers to sit or stand during the day, and for workstations with a treadmill underneath for walking. (Its treadmill model was inspired by Dr. Levine, who built his own and shared his research with Steelcase.)

The company offered its first models of height-adjustable desks in 2004. In the last five years, sales of its lines of adjustable desks and the treadmill desk have surged fivefold, to more than $40 million. Its models for stand-up work range from about $1,600 to more than $4,000 for a desk that includes an actual treadmill. Corporate customers include Chevron, Intel, Allstate, Boeing, Apple and Google.

"It started out very small, but it's not a niche market anymore," says Allan Smith, vice president for product marketing at Steelcase.

The Steelcase offerings are the Mercedes-Benzes and Cadillacs of upright workstations, but there are plenty of Chevys as well, especially from small, entrepreneurial companies.

In 2009, Daniel Sharkey was laid off as a plant manager of a tool-and-die factory, after nearly 30 years with the company. A garage tinkerer, Mr. Sharkey had designed his own adjustable desk for standing. On a whim, he called it the kangaroo desk, because "it holds things, and goes up and down." He says that when he lost his job, his wife, Kathy, told him, "People think that kangaroo thing is pretty neat."

Today, Mr. Sharkey's company, Ergo Desktop, employs 16 people at its 8,000-square-foot assembly factory in Celina, Ohio. Sales of its several models, priced from $260 to $600, have quadrupled in the last year, and it now ships tens of thousands of workstations a year.

Steve Bordley of Scottsdale, Ariz., also designed a solution for himself that became a full-time business. After a leg injury left him unable to run, he gained weight. So he fixed up a desktop that could be mounted on a treadmill he already owned. He walked slowly on the treadmill while making phone calls and working on a computer. In six weeks, Mr. Bordley says, he lost 25 pounds and his nagging back pain vanished.

He quit the commercial real estate business and founded TrekDesk in 2007. He began shipping his desk the next year. (The treadmill must be supplied by the user.) Sales have grown tenfold from 2008, with several thousand of the desks, priced at $479, now sold annually.

"It's gone from being treated as a laughingstock to a product that many people find genuinely interesting," Mr. Bordley says.

There is also a growing collection of do-it-yourself solutions for stand-up work. Many are posted on Web sites like howtogeek.com, and freely shared like recipes. For example, Colin Nederkoorn, chief executive of an e-mail marketing start-up, Customer.io, has posted one such design on his blog. Such setups can cost as little as $30 or even less, if cobbled together with available materials.

UPRIGHT workstations were hailed recently by no less a trend spotter of modern work habits and gadgetry than Wired magazine. In its October issue, it chose "Get a Standing Desk" as one of its "18 Data-Driven Ways to Be Happier, Healthier and Even a Little Smarter."

The magazine has kept tabs on the evolving standing-desk research and marketplace, and several staff members have become converts themselves in the last few months.

"And we're all universally happy about it," Thomas Goetz, Wired's executive editor, wrote in an e-mail — sent from his new standing desk.

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The Texas Tribune: Texas Democrats Expect Deal on Medicaid Despite Perry

Despite Gov. Rick Perry's firm opposition to a central tenet of federal health reform — expanding the state's Medicaid program for those with low incomes — Texas Democrats remain optimistic that the 2013 legislative session can yield a deal that brings in billions of additional federal dollars.

Expanded coverage of Texas is produced by The Texas Tribune, a nonprofit news organization. To join the conversation about this article, go to texastribune.org.

It will be a tough sell: no Republican lawmaker has gone on record supporting the Medicaid expansion, which would add an estimated 1.8 million Texans to the joint state-federal health plan by 2022.

But State Senator Rodney Ellis, Democrat of Houston, said fiscal conservatives have an incentive to reach an agreement "because the alternative is going to cost us much more economically and dig a much deeper hole in our budget." Some Democratic lawmakers have already proposed legislation that would help them circumvent Mr. Perry or else produce a bipartisan compromise that might gain the Obama administration's support.

Under the Affordable Care Act, President Obama's health care overhaul, the federal government would cover 100 percent of the costs of expanding state Medicaid programs for three years, a share that would taper to 90 percent in later years. The Kaiser Family Foundation, a nonpartisan research group, estimated the expansion would cost Texas $5.7 billion from 2013 to 2022, which the organization called a modest price compared with the $65.6 billion that would be covered by the federal government.

The United States Supreme Court's ruling this summer allowing states to refuse to expand Medicaid gave Republican governors leverage to negotiate changes to the health care overhaul. And Mr. Perry holds the power to veto any legislation that would expand Medicaid in Texas.

"What the federal government needs to focus on is giving states more flexibility in delivering care," said Catherine Frazier, the governor's spokeswoman.

Mr. Ellis has filed a bill to put the option of Medicaid expansion on a statewide ballot as a provisional amendment to the Texas Constitution. Giving the deciding power to voters would relieve political pressure on Republican legislators and alleviate fear of a veto, he said.

Representative Garnet F. Coleman, Democrat of Houston, is also trying to provide a path toward Medicaid expansion. He plans to file an omnibus Medicaid bill that could be altered during the legislative session to incorporate Republicans' conditions for Medicaid expansion. One idea is co-insurance, Mr. Coleman said, which some Republicans have endorsed to get new Medicaid enrollees to pay a portion of their monthly health care premium.

Both political parties agree that Medicaid needs to be changed. In their 2011 budget negotiations, state legislators underfinanced Medicaid by $4.7 billion. And as the program's enrollment and costs grow, fewer providers are accepting Medicaid clients because of the state's low reimbursement rates.

Republicans say expanding Medicaid before it is overhauled will bankrupt the state or force lawmakers to redirect money from other areas of the budget, like education.

"To make the system work, we need permission from the federal government to do things like charge co-pays, promote access to private health insurance and encourage personal responsibility," Senator Jane Nelson, Republican of Flower Mound and chairwoman of the Senate Health and Human Services Committee, wrote in an editorial on her official Web site.

In an e-mail, Ms. Nelson said she could not support Medicaid expansion "as directed by the Affordable Care Act."

A representative of the federal Department of Health and Human Services said the agency "is currently evaluating areas where there may be flexibility."

If the state and the federal government cannot reach a deal to expand Medicaid in Texas, it is unclear whether any federal public assistance would be available to those people who would have qualified under the expansion.

baaronson@texastribune.org

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Opinion: A Health Insurance Detective Story

I'VE had a long career as a business journalist, beginning at Forbes and including eight years as the editor of Money, a personal finance magazine. But I've never faced a more confounding reporting challenge than the one I'm engaged in now: What will I pay next year for the pill that controls my blood cancer?

After making more than 70 phone calls to 16 organizations over the past few weeks, I'm still not totally sure what I will owe for my Revlimid, a derivative of thalidomide that is keeping my multiple myeloma in check. The drug is extremely expensive — about $11,000 retail for a four-week supply, $132,000 a year, $524 a pill. Time Warner, my former employer, has covered me for years under its Supplementary Medicare Program, a plan for retirees that included a special Writers Guild benefit capping my out-of-pocket prescription costs at $1,000 a year. That out-of-pocket limit is scheduled to expire on Jan. 1. So what will my Revlimid cost me next year?

The answers I got ranged from $20 a month to $17,000 a year. One of the first people I phoned said that no matter what I heard, I wouldn't know the cost until I filed a claim in January. Seventy phone calls later, that may still be the most reliable thing anyone has told me.

Like around 47 million other Medicare beneficiaries, I have until this Friday, Dec. 7, when open enrollment ends, to choose my 2013 Medicare coverage, either through traditional Medicare or a private insurer, as well as my drug coverage — or I will risk all sorts of complications and potential late penalties.

But if a seasoned personal-finance journalist can't get a straight answer to a simple question, what chance do most people have of picking the right health insurance option?

A study published in the journal Health Affairs in October estimated that a mere 5.2 percent of Medicare Part D beneficiaries chose the cheapest coverage that met their needs. All in all, consumers appear to be wasting roughly $11 billion a year on their Part D coverage, partly, I think, because they don't get reliable answers to straightforward questions.

Here's a snapshot of my surreal experience:

NOV. 7 A packet from Time Warner informs me that the company's new 2013 Retiree Health Care Plan has "no out-of-pocket limit on your expenses." But Erin, the person who answers at the company's Benefits Service Center, tells me that the new plan will have "no practical effect" on me. What about the $1,000-a-year cap on drug costs? Is that really being eliminated? "Yes," she says, "there's no limit on out-of-pocket expenses in 2013." I tell her I think that could have a major effect on me.

Next I talk to David at CVS/Caremark, Time Warner's new drug insurance provider. He thinks my out-of-pocket cost for Revlimid next year will be $6,900. He says, "I know I'm scaring you."

I call back Erin at Time Warner. She mentions something about $10,000 and says she'll get an estimate for me in two business days.

NOV. 8 I phone Medicare. Jay says that if I switch to Medicare's Part D prescription coverage, with a new provider, Revlimid's cost will drive me into Medicare's "catastrophic coverage." I'd pay $2,819 the first month, and 5 percent of the cost of the drug thereafter — $563 a month or maybe $561. Anyway, roughly $9,000 for the year. Jay says AARP's Part D plan may be a good option.

NOV. 9 Erin at Time Warner tells me that the company's policy bundles United Healthcare medical coverage with CVS/Caremark's drug coverage. I can't accept the medical plan and cherry-pick prescription coverage elsewhere. It's take it or leave it. Then she puts CVS's Michele on the line to get me a Revlimid quote. Michele says Time Warner hasn't transferred my insurance information. She can't give me a quote without it. Erin says she will not call me with an update. I'll have to call her.

My oncologist's assistant steers me to Celgene, Revlimid's manufacturer. Jennifer in "patient support" says premium assistance grants can cut the cost of Revlimid to $20 or $30 a month. She says, "You're going to be O.K." If my income is low enough to qualify for assistance.

NOV. 12 I try CVS again. Christine says my insurance records still have not been transferred, but she thinks my Revlimid might cost $17,000 a year.

Adriana at Medicare warns me that AARP and other Part D providers will require "prior authorization" to cover my Revlimid, so it's probably best to stick with Time Warner no matter what the cost.

But Brooke at AARP insists that I don't need prior authorization for my Revlimid, and so does her supervisor Brian — until he spots a footnote. Then he assures me that it will be easy to get prior authorization. All I need is a doctor's note. My out-of-pocket cost for 2013: roughly $7,000.

NOV. 13 Linda at CVS says her company still doesn't have my file, but from what she can see about Time Warner's insurance plans my cost will be $60 a month — $720 for the year.

CVS assigns my case to Rebecca. She says she's "sure all will be fine." Well, "pretty sure." She's excited. She's been with the company only a few months. This will be her first quote.

NOV. 14 Giddens at Time Warner puts in an "emergency update request" to get my files transferred to CVS.

Frank Lalli is an editorial consultant on retirement issues and a former senior executive editor at Time Warner's Time Inc.

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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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Health Insurers Will Be Charged to Use New Exchanges

WASHINGTON — The Obama administration said Friday that it would charge insurance companies for the privilege of selling health insurance to millions of Americans in new online markets run by the federal government.

The cost of these "user fees" can be passed on to consumers. The proposed fees could add 3.5 percent to premiums for private health plans sold in insurance exchanges operated by the federal government.

In a separate action, federal officials said that consumers would soon have access to nationwide health plans similar to those available to members of Congress and other federal employees. These plans will be offered by private insurance companies under contract with the United States Office of Personnel Management. The agency already provides insurance to eight million federal employees, retirees and dependents.

"This new initiative will promote competition in the insurance marketplace and ensure individuals and small businesses have more high-quality, affordable insurance choices," said John Berry, director of the personnel agency.

The steps announced on Friday show the White House rushing to carry out the health care law signed by President Obama in March 2010. They also illustrate the rapidly growing role of the federal government in the nation's health care system.

Consumer advocates, insurers and some state officials had expressed concern about delays in publication of the rules proposed on Friday.

Starting in October, consumers are supposed to be able to enroll in new health plans, for coverage beginning on Jan. 1, 2014, when most Americans will be required to have insurance. At least two nationwide health plans chosen by the federal government will compete with private health plans in the insurance exchanges being established in every state.

The exchanges are supposed to be financially self-sustaining after 2014. States, like the federal government, can charge fees to insurers. Or they can try to raise money in other ways — for example, by charging consumers or employers for using the exchange.

In proposing the new rule, Kathleen Sebelius, the secretary of health and human services, said that fees charged by the federal government would be "sufficient to cover the majority of costs related to the operation of federally facilitated exchanges." She did not say how the remainder of the money would be raised.

Ms. Sebelius said she could not estimate the total amount of federal user fees because she did not know exactly how many states would have federal exchanges. She said the federal fees should generally be "commensurate with fees" charged by state-run exchanges.

The federal government will run the exchange in any state that is unable or unwilling to do so. Indeed, it now appears that federal officials could be running the exchanges — alone or in partnership with local officials — in more than half the states.

Fees charged for use of the federal exchange come on top of a separate annual fee to be imposed on health insurance companies to help offset the cost of expanding coverage under the new law. The annual fees, to be apportioned among insurers according to their shares of the nation's health insurance market, are expected to total $6 billion in 2014 and more than $100 billion over 10 years.

"Any new fees to pay for the administration of exchanges will add to the cost of coverage," said Robert E. Zirkelbach, a spokesman for America's Health Insurance Plans, a trade group.

Erin Shields Britt, a spokeswoman for Ms. Sebelius, predicted that insurers would not raise prices. "Exchanges will provide already profitable insurance companies with access to 30 million new customers while cutting down insurers' marketing and advertising expenses," Ms. Shields Britt said. "Exchanges force insurance companies to compete and drive down costs for consumers. The Congressional Budget Office has estimated consumers will save up to 20 percent on their premiums."

The Office of Personnel Management said its nationwide plans would follow state insurance laws and standards, except in unusual circumstances.

The administration said it "retains authority to make the final decision" on rates if it finds that a state acted in an arbitrary or capricious way in denying a rate increase sought by a nationwide health plan.

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Hockey Coaches Defy Doctors on Concussions, Study Finds

Despite several years of intensive research, coverage and discussion about the dangers of concussions, the idea of playing through head injuries is so deeply rooted in hockey culture that two university teams kept concussed players on the ice even though they were taking part in a major concussion study.

The study, which was published Friday in a series of articles in the journal Neurosurgical Focus, was conducted during the 2011-12 hockey season by researchers from the University of Western Ontario, the University of Montreal, Harvard and other institutions.

"This culture is entrenched at all levels of hockey, from peewee to university," said Dr. Paul S. Echlin, a concussion specialist and researcher in Burlington, Ontario, and the lead author of the study. "Concussion is a significant public health issue that requires a generational shift. As with smoking or seat belts, it doesn't just happen overnight — it takes a massive effort and collective movement."

The study is believed to be among the most comprehensive analyses of concussions in hockey, which has a rate of head trauma approaching that of football. Researchers followed two Canadian university teams — a men's team and a women's team — and scanned every player's brain before and after the season. Players who sustained head injuries also received scans at three intervals after the injuries, with researchers using advanced magnetic resonance imaging techniques.

The teams were not named in the study, in which an independent specialist physician was present at each game and was empowered to pull any player off the ice for examination if a potential concussion was observed.

The men's team, with 25 players and an average age of 22, played a 28-game regular season and a 3-game postseason. The women's team, with 20 players and an average age of 20, played 24 regular-season games and no playoff games. Over the course of the season, there were five observed or self-reported concussions on the men's team and six on the women's team.

Researchers noted several instances of coaches, trainers and players avoiding examinations, ignoring medical advice or otherwise obstructing the study, even though the players had signed consent forms to participate and university ethics officials had given institutional consent.

"Unless something is broken, I want them out playing," one coach said, according to the study.

In one incident, a neurologist observing the men's team pulled a defenseman during the first period of a game after the player took two hits and was skating slowly. During the intermission the player reported dizziness and was advised to sit out, but the coach suggested he play the second period and "skate it off." The defenseman stumbled through the rest of the game.

"At the end of the third period, I spoke with the player and the trainer and said that he should not play until he was formally evaluated and underwent the formal return-to-play protocol," the neurologist said, as reported in the study. "I was dismayed to see that he played the next evening."

After the team returned from its trip, the neurologist questioned the trainer about overruling his advice and placing the defenseman at risk.

"The trainer responded that he and the player did not understand the decision and that most of the team did not trust the neurologist," according to the study. "He requested that the physician no longer be used to cover any more games."

In another episode, a physician observer assessed a minor concussion in a female player and recommended that she miss the next night's game. Even though the coach's own playing career had ended because of concussions, she overrode the medical advice and inserted the player the next evening.

According to the report, the coach refused to speak to another physician observer on the second evening. The trainer was reluctant to press the issue with the coach because, the trainer said, the coach did not want the study to interfere with the team.

"Interesting gap between theory and practice," one of the study's physicians said in the report. "The athlete's and coach's decision to return to play the next day despite incurring a minor concussion reflects what occurs thousands of times every day."

After this second instance of a coach overriding medical advice following a concussion diagnosis, the researchers talked to the coaches about the serious long-term threat their actions posed to their players' health. By the end of the study, the teams' cooperation improved markedly.

A similar study by Echlin's research team followed two Canadian junior hockey teams, with male players ages 16 to 20, for the 2009-10 season. In that study, independent specialists examined players immediately after on-ice collisions and were able to recommend they be held out of games. Coaches and trainers resisted that study as well, and one of the two junior teams dropped out during the season.

That study found concussion rates seven times higher than previously reported. In the study to be published Friday, the male players sustained concussions at three times the rate reported in most previous studies, and the female players at five times the rate reported in most studies. The women also sustained concussions almost twice as frequently as the men, despite rules in women's hockey designed to curb body checking. The brain scans taken after the season also showed substantive metabolic changes among the majority of players, including those who were not diagnosed with concussions. Researchers said the changes in the brains might be evidence of trauma caused by subconcussive blows.

"You may not need to have a diagnosed concussion to actually have changes in your white matter," said Dr. Inga K. Koerte, a researcher in the study. "It may be that subconcussive blows to your head accumulate over time, so that you develop changes that are similar to when you have one clinical concussion."

Koerte, of Brigham and Women's Hospital in Boston, Harvard and the University of Munich, stressed that the finding in this area was preliminary and required further research.

Echlin said that dismissive attitudes toward head trauma persisted in hockey at all levels, despite the widespread attention on Sidney Crosby's drawn-out recovery from concussion symptoms in 2011 and 2012.

"This is our national game which we all love," Echlin wrote, "and it is time to consider a cultural shift to address the prevention and treatment of this serious brain injury that is occurring at epidemic proportions."

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Small Employers Weigh Impact of Providing Health Insurance

Erich Schlegel for The New York Times

Robert Mayfield, who owns Dairy Queen franchises in Texas, says he is "scared to death" of the new health care law.

Like many franchisees, Robert U. Mayfield, who owns five Dairy Queens in and around Austin, Tex., is always eager to expand and — no surprise — has had his eyes on opening a sixth DQ. But he said concerns about the new federal health care law had persuaded him to hold off.

Laura Pedrick for The New York Times

Bob Bellagamba, who runs Concorde Limousine in Freehold, N.J., says there is too much uncertainty about the new law.

"I'm scared to death of it," he said. "I'm one of the ones sitting on the sidelines to see what's really going to happen."

Mr. Mayfield, who has 99 employees, said he was worried he would face penalties of $40,000 or more because he did not offer health insurance to many of his full-time workers — generally defined as those working an average of 30 hours a week or more. Ever since the law was enacted in 2010, opponents have argued that employers who were forced to offer health insurance would lay off workers or shift more people to part-time status to compensate for the additional cost. Those claims have drawn considerable attention — and considerable anger in response — in recent weeks.

John H. Schnatter, the chief executive of Papa John's, the pizza chain, said some franchisees were likely to reduce their employees' hours to avoid having to provide coverage. And an unhappy Denny's franchise owner in Florida warned that he would raise prices 5 percent as a "surcharge," adding that disgruntled customers could offset that by reducing their tips.

Some health care experts said comments like those came from outliers and sometimes resulted from confusion about a highly complicated new law, the Patient Protection and Affordable Care Act. Many of the provisions do not go into effect until 2014. Federal officials are still tweaking the fine print, like defining exactly what constitutes a 30-hour workweek. Even so, restaurants and hotels are among the industries likely to be squeezed the hardest by the law because they are low-wage industries that do not offer coverage to most of their workers.

Most employers, even small businesses, already offer health insurance, and the federal law is not expected to have a significant impact on what they do over the next year or so. But businesses that rely heavily on low-income workers, many of whom do not make enough to afford their share of the cost of the insurance premiums, are being forced to rethink their business models.

Almost half of retail and hospitality employers do not offer coverage to all their full-time employees, according to a recent survey by Mercer, a benefits consultant.

"They're all developing their strategies," said Debra Gold, a senior partner with Mercer who advises several major retailers.

Many who oppose the requirement say the cost of providing health insurance could mean hiring fewer workers. "Any dollar that gets diverted, whether it's through Obamacare or increased tax rates, puts franchisees one dollar further away from being able to expand their businesses," said Don Fox, chief executive of Firehouse Subs, a fast-growing chain of 559 restaurants based in Jacksonville, Fla. At the 30 stores the corporation owns, only full-time managers are offered coverage. Mr. Fox is wrestling with whether to absorb the considerable cost of covering 100 more employees or pay the penalties — which would probably cost him less — but risk losing valued employees to competitors who choose to offer coverage.

Employee health coverage now averages nearly $6,000 for an individual plan. That is considerable for businesses like restaurants in which the majority of workers make $24,000 a year or less, according to research by the Kaiser Family Foundation. The foundation found that only 28 percent of companies that employ large numbers of low-income workers offer health benefits. "This is where the biggest set of hurdles is," said Gary Claxton, an executive with Kaiser.

By 2014, businesses with 50 or more full-time employees will be expected to offer as yet undefined affordable coverage, based on an employee's income. For employers that fail to offer such coverage, the law typically calls for a penalty of $2,000 a worker, excluding the first 30 employees. As evidence of how sensitive the issue is, Mr. Schnatter of Papa John's took some heat for his initial statements about the possibility that franchisees would cut employees' hours to avoid penalties or having to provide coverage. His comments, made during a public appearance, were reported by a local newspaper in Florida, The Naples News. After facing a storm of criticism, he wrote an opinion piece for The Huffington Post, in which he said he had only been speculating about the law's potential impact on franchisees.

"Papa John's, like most businesses, is still researching what the Affordable Care Act means to our operations," he wrote. "Regardless of the conclusion of our analysis, we will honor this law, as we do all laws, and continue to offer 100 percent of Papa John's corporate employees and workers in company-owned stores health insurance as we have since the company was founded in 1984." Through a spokesman, Mr. Schnatter declined to comment further.

This article has been revised to reflect the following correction:

Correction: November 30, 2012

An earlier version of this article misspelled the first name of an executive with the Kaiser Family Foundation. He is Gary Claxton, not Glary.

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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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Consumer Safety Agency Studies Adult Bedrail Deaths

WASHINGTON — The Consumer Product Safety Commission on Thursday released a review of bedrail deaths and injuries of adults as it considered how to address potential hazards associated with the products.

Using data from death certificates and hospital emergency room visits, the report cited 155 deaths involving bedrails from January 2003 to this past September. About 126 of those who died were 60 or older.

Sixty-one percent of the bedrail deaths occurred at home. About a quarter occurred at a nursing home or an assisted living facility, the report said.

It also found that nearly half of those who died in bedrail accidents had medical problems — dementia, heart disease and Parkinson's disease among them. Most of the 155 deaths occurred when a person became stuck in the bedrails, mainly with his or her head or neck getting caught.

Almost 37,000 people were injured in bedrail accidents and treated at hospital emergency rooms from 2003 through 2011, the agency said. Data for 2012 was not yet available.

Consumer safety advocates, who have long campaigned for federal regulators to study bedrail deaths and injuries, called the report an important first step. But they said that it failed to address several issues, including jurisdictional matters concerning which agency has responsibility for some types of bedrails: the Consumer Product Safety Commission or the Food and Drug Administration.

The advocates said that the question of oversight remained one of the biggest problems with bedrails, because there are unanswered technical questions about which rails are medical devices and which are consumer products.

The report did not review bedrail designs for potential problems. The consumer agency has pointed out that the makers of bedrails are usually not identified on death certificates or doctors' notes.

The safety agency said it would use the findings to study what steps it should take next, including how it can educate caregivers and the public about potential hazards.

It said it had forwarded its findings to the Food and Drug Administration. The F.D.A. did not respond to requests for comment.

In response to a lack of coordination between federal regulators, Representative Edward J. Markey, Democrat of Massachusetts, called for the consumer and drug agencies, as well as the Federal Trade Commission, to form a task force to address the regulation of bedrails and bed systems, specifically rails that blur the line between being medical devices and consumer products.

"We need a national task force dedicated to addressing any regulatory gaps and protecting these vulnerable patients from preventable bedrail injuries," Mr. Markey said in a statement.

Giselle Barry, a spokeswoman for Mr. Markey, said the congressman would send a formal letter to the agencies on Friday calling for the task force.

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In Study, Fears That Life Insurers Are Courting Reserve Risk

WASHINGTON — After more than a year studying a surge of intricate financial deals in the life insurance industry, regulators said Thursday that they had found transactions that could "give the industry a black eye," but could not agree on what to do about them.

"There are some transactions out there that we're not comfortable with, and we're not sure you'd be comfortable with," Douglas Slape, chairman of the research panel, told a ballroom full of industry representatives at a conference in suburban Washington. "We can't go into the details because it's confidential."

Differences among the panelists soon became apparent as the group laid out its findings. Some expressed concern that insurers were "betting the policyholders' money," while others argued that the transactions were carefully vetted and safe.

The National Association of Insurance Commissioners convened the research project, in part, in response to an article in The New York Times on the growing practice among life insurers of offloading huge numbers of policies into opaque, off-balance-sheet subsidiaries. The transactions, often valued in the hundreds of millions or even billions of dollars, can improve the appearance of the insurers' balance sheets and free up money for other projects, or to pay shareholder dividends.

The Times article questioned whether the use of the special-purpose vehicles meant a shadow insurance industry was being created, outside the usual reach of state insurance regulators.

Diverging views among Thursday's panel of state regulators pose a problem because the transactions often involve an insurer in one state, a subsidiary in another, and policies sold to customers in any number of other states. States, rather than the federal government, are the primary regulators of the nation's insurance companies.

"Our entire financial solvency system falls apart if there is not uniformity" among state regulators, said Joseph Torti, a panelist from Rhode Island. "We need to be able to understand what our sister states are doing."

Separately, New York State is conducting its own investigation of the off-balance-sheet insurance deals. This year it called on the insurers under its jurisdiction to provide detailed information about their special-purpose subsidiaries, why they had created them, and whether the subsidiaries were counting assets that the insurer itself would not be allowed to include on its balance sheet.

In recent years, some states passed laws allowing insurance companies to set up the subsidiaries, because they were perceived as creating good jobs.

Conventional state insurance regulation protects policyholders by requiring companies to set aside enough of the premium money they take in to build reserves to pay all future claims. Companies are also required to maintain a healthy surplus, and regulators can make them stop selling new policies if they fall too far short.

When the life insurers secure their policies through special-purpose vehicles, however, they can do so without building up a body of liquid, cashlike reserves, as prescribed by regulators.

Instead, they offer some form of collateral, like a letter of credit, to stand behind the policies. Some regulators said there were cases in which the collateral was inadequate and would not have been admitted under the usual regulatory standards.

Data compiled by SNL Financial, a data and news company, shows that the practice of securing life policies through a wholly owned subsidiary has grown sharply in the last five years. In 2006, the companies SNL surveyed used such subsidiaries for 31 percent of the policies they reinsured; by 2011, it was up to 45 percent.

SNL also found that while the practice was very popular at some companies, others did not use it at all. The American International Group used subsidiaries for nearly 80 percent of the life policies that it reinsured in 2011, for instance, while Northwestern Mutual used only unaffiliated reinsurers, where the terms would be set in an arms' length transaction. Still others, like State Farm, were not reinsuring their life policies as of 2011.

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