Advertising: With Change Coming, Aetna Targets Employers

AS the country marches toward a new health insurance system, insurance companies have spent millions on consumer advertising to position themselves as health care companies.

But because a majority of Americans are insured through their employers, the insurance companies have to reach several audiences. Speaking to human resources professionals, health care providers and policy makers is still an important part of many insurance companies' marketing plans.

Aetna, one of the largest of the companies, will introduce a new campaign on Tuesday aimed at those groups. It will highlight the company's goal of cutting billions of dollars of expenditures through so-called Big Data, electronic health records and other technologies as well as encouraging better coordination among health care providers. The campaign, called "Our Healthy," will run online, in print and on mobile devices through the end of 2013.

"We believe that the health care system is desperately in need of improvement," said Robert Mead, the senior vice president of marketing, product and communications at Aetna. Mr. Mead cited a report by the Institute of Medicine that tallied more than $760 billion in health care "waste" created annually as a result of consumer fraud, unnecessary procedures and excessive administrative costs.

The campaign was created by OgilvyOne in New York and is an extension of a consumer campaign called "What's Your Healthy?" that Aetna began earlier this year. Both "What's Your Healthy?" and "Our Healthy" are part of a $50 million advertising and marketing strategy for the company.

"If you're a consumer, you don't know what things cost," Mr. Mead said. "You don't know what things are worth. You don't always know how to get the most value out of the health system. We have to bring everybody to the table."

Mr. Mead said the campaign also stressed the need for health care providers to shift to a model known as "accountable care," which shifts their reimbursement models for health care professionals from being paid for the volume of services they perform to being paid based on the outcomes of patient care. Accountable care systems are usually linked to technologies that help health care providers measure performance and manage patient data. Aetna has 27 accountable health care agreements with hospitals and other health care providers around the country.

A video for the "Our Healthy" campaign features Mark T. Bertolini, the chief executive of Aetna, explaining the company's goals. "Unless you fix that health care system, you cannot fix the economy," Mr. Bertolini said in the video. "If we fix just 20 percent of it, we could pay for the Affordable Care Act. We could insure everyone without increasing taxes."

Like other insurance companies, Aetna has over the last few years been ramping up its technical products and services. It created Healthagen, a division of the company that sells health technology services to consumers and providers, like a mobile application that helps patients assess their symptoms and find doctors.

"The fee-for-service model is broken," Mr. Mead said. "The Affordable Care Act encourages the system to move to accountable care," he added. "The challenge with that is that doctors and hospitals need technology and support to make that work."

But more technology and more data may not solve the problem of waste in health care, said Robert S. Huckman, a professor of business administration at Harvard Business School and the faculty co-chairman of the Harvard Business School Healthcare Initiative. "When you're talking about having to manage waste in the system, most would agree that a lack of coordination rests at the heart of a lot of it," he said. "Data without an educated way of querying that data is not helpful. It is a start."

While insurance companies like Aetna have access to vast amounts of patient data that could be used to manage costs, according to Mr. Huckman, the economic impact of even widely adopted technologies like electronic health records is still unclear. "Within providers and within a hospital, the electronic records have made greater inroads. But the question of moving toward greater coordination and greater interoperability is an issue we are still grappling with."

The cost of health care, however, is something everyone can agree is too high, Mr. Huckman said: "I think the cost issue is most salient right now for most Americans. It hits you front and center when you look at some of the prices." He noted how costs could vary widely depending on where a person lived and who their insurer was. "It shouldn't vary that much," Mr. Huckman said. "The cost of a product on Amazon is the same no matter where I buy it from. It does defy a little bit of explanation."

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Nyad 1st to Swim to Florida From Cuba Without Cage

KEY WEST, Fla. — Looking dazed and sunburned, U.S. endurance swimmer Diana Nyad waded ashore Monday and became the first person to swim from Cuba to Florida without the help of a shark cage.

The 64-year-old Nyad swam up to the beach just before 2 p.m. EDT, about 53 hours after starting her journey from Havana on Saturday. As she approached, spectators waded into waist-high water and surrounded her, taking pictures and cheering her on.

"I have three messages. One is, we should never, ever give up. Two is, you're never too old to chase your dream. Three is, it looks like a solitary sport, but it is a team," she said on the beach.

"I have to say, I'm a little bit out of it right now," Nyad said. She gestured toward her swollen lips, and simply said "seawater."

Her team said she had been slurring her words while out in the water. She was placed on a stretcher on the beach and received an IV before she was taken by ambulance to a hospital. But her doctor later declared her essentially healthy and expected her to recover quickly from dehydration, swelling and sunburn.

"I just wanted to get out of the sun," she said after coming ashore on a scorching, sunny day amid calm seas.

It was Nyad's fifth attempt and what she had said would be her last try to complete the approximately 110-mile swim. She tried three times in 2011 and 2012. Her first attempt was in 1978.

"It's historic, marvelous," said Jose Miguel Diaz Escrich, the Hemingway Marina commodore who helped organize the Cuba side of Nyad's multiple attempts.

"I always thought she could do it given her internal energy, her mental and physical strength, her will of iron," said Diaz Escrich, whom Nyad has called a longtime friend.

"More than the athletic feat, she wants to send a message of peace, love, friendship and happiness ... between the people of the United States and Cuba," he added.

President Barack Obama was among a flurry of public officials and celebrities who tweeted congratulations. The president's tweet read: "Never give up on your dreams." Others who tweeted included Ryan Seacrest, who wrote "We should never ever give up ... you never are too old to chase your dreams."

Nyad later told broadcast outlet CNN her swim wasn't easy but she was determined with each stroke forward to "push Cuba back, and push Florida towards" her.

"With all that experience I have, especially in this ocean, I never knew I would suffer the way I did," she told CNN. "For 49 hours the wind just blew like heck, and it was rough."

Nyad's previous try was cut short amid boat trouble, storms, unfavorable currents and jellyfish stings that left her face puffy and swollen.

This time, she wore a full bodysuit, gloves, booties and a mask at night, when jellyfish rise to the surface. The new silicone mask caused bruises inside her mouth, making it difficult for her to speak, she told her team as she neared land.

Doctors traveling with Nyad had been worried about her slurred speech and her breathing, but didn't intervene, according to Nyad's website.

"She was incredible to watch the whole way through," said one of her doctors, Derek Covington, speaking with The Associated Press afterward.

Covington said Nyad was given IV fluids on her arrival to combat dehydration and was resting and being checked out at a medical center as a precaution.

Although she had some swelling of the lips, tongue and the airway near the mouth, Nyad wouldn't need a long recovery, the doctor said, calling her stable and "very healthy."

Meanwhile, her website declared her team was in a mood to celebrate, with the words "Party Time."

Nyad jumped from the seawall of the Hemingway Marina into the warm waters off Havana Saturday morning to begin swimming. She paused occasionally for nourishment, but never left the water.

The support team accompanying her had equipment that generated a faint electrical field around her, designed to keep sharks at bay. A boat also dragged a line in the water to help keep her on course.

Sumaya Haddin, of Miami, had been tracking Nyad's swim before her family's weekend trip to Key West. She was surprised to see Nyad's flotilla from a parasail off Smather's Beach on Monday morning, thinking she wouldn't arrive for another day.

"You couldn't see her, you could just see the boats. It was very exciting," she said.

Haddin said Nyad still had her fighting spirit when she arrived: "Getting into the ambulance, she had her peace sign up, her fist up. She was still fired up."

Australian Susie Maroney successfully swam the Strait in 1997 with a shark cage, which besides protection from the predators, has a drafting effect that pulls a swimmer along.

In 2012, Australian Penny Palfrey swam 79 miles toward Florida without a cage before strong currents forced her to stop. This June, her countrywoman Chloe McCardel made it 11 hours and 14 miles before jellyfish stings ended her bid.

In 1978, Walter Poenisch, an Ohio baker, claimed to have made the swim using flippers and a snorkel. Critics say there was insufficient independent documentation to verify his claim.

Nyad frist garnered national attention in 1975 when she swam the 28 miles around the island of Manhattan in just under eight hours. In 1979 she swam the 102 miles from North Bimini, Bahamas, to Juno Beach, Fla., in 27.5 hours.

Nyad is also an author of three books, a motivational speaker and has been a reporter and commentator for NPR.

___

Associated Press writer Anne-Marie Garcia in Havana contributed to this report.

Online:

www.diananyad.com

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The New Old Age Blog: In California, Intense Debate Over Home Care

An important struggle over home health care is playing out in California, the nation's most populous state, including nearly five million residents age 65 and older.

Unions and organizations representing the elderly have joined together to push for legislation that would license agencies, certify workers and create a publicly accessible caregiver registry. Home care agencies are pushing back, saying they favor regulation but oppose the measures under consideration. The legislation, Assembly Bill 1217, has already passed the State Assembly and was passed out of the State Senate's appropriations committee on Friday. It will be up for a vote on the Senate floor next week.

An estimated 1,400 home care agencies and 120,000 paid caregivers would be affected by the proposed legislation, which is essentially an effort to bring consumer protections to an industry that has been likened to the Wild West. "It's just not right that I can check the license status of an air-conditioning repairman but I can't do so for someone coming into my home to care for a loved one," said Assemblywoman Bonnie Lowenthal, a Democrat and the bill's sponsor.

Currently, a business license is all that is required in California for organizations that offer home care, defined as nonmedical services for the elderly who need help using the bathroom, dressing, bathing and performing other basic tasks.

That leaves older adults and their families without the means to check whether agencies are adequately overseeing their caregiving staff. And elderly people who hire caregivers online or through referral agencies — which maintain lists of caregivers but do not employ them directly — have no easy, reliable way of checking these individuals' qualifications.

Although agency officials in California insist they follow reputable practices, a study published last year by researchers at Northwestern University found that few agencies perform comprehensive background checks on caregivers or provide reliable training or supervision.

Nationwide, 27 states require home care agencies to be licensed or certified, according to a 2011 report from the Private Duty Homecare Association. A lack of regulatory oversight puts consumers at risk of inadequate care, abuse or neglect, experts warn. Those risks were highlighted in an April 2011 study from the California Senate Office of Oversight and Outcomes highlighting the lack of screening for caregivers.

In one case described in the report, a home care agency placed Daisy Lee Joubert, a convicted felon, in the home of Ileen and Norman Jonas, where she stole an estimated $100,000 in retirement checks and jewelry. Apprehended, Ms. Joubert pleaded guilty to eight counts of embezzlement.

Under the proposed Home Care Services Consumer Protection Act of 2013, California home care agencies would have to obtain a state license by July 1, 2014, or face a fine of up to $900 a day. Agencies would be required to conduct background checks on caregivers, assess their performance annually and supervise their activities in a client's home every 90 days.

For their part, caregivers would be required to obtain certification after undergoing background checks, a test for tuberculosis and five hours of basic training. Their names and locations would appear on a Web site maintained by the state.

Home care agencies say they have no quibble with licensing and certification requirements. But the agencies think that ensuring the competency of workers should be voluntary and their responsibility, not the state's, said Dean Chalios, president of the California Association for Health Services at Home, an industry organization.

And home care agencies strongly oppose the creation of a caregiver registry, which would disclose the names of their workers to competitors and union organizers.

"What this is really all about is trying to unionize home care workers in California," said Kathy Janz, a nurse and executive director of Matched CareGivers, an agency that operates in San Mateo and Santa Clara Counties.

Imposing extra costs on agencies could backfire, making their services unaffordable for families and driving them to gray markets like Craigslist, where no consumer protections exist, warned Assemblywoman Mariko Yamada, a Democrat who earlier this year introduced an alternative bill.

And requiring home care workers to obtain certification could reduce the pool of workers and make it more difficult for the elderly to get services, Kevin Smith, director of operations for the Home Care Association of America, said in a written statement.

Laphonza Butler, president of United Long Term Care Workers, a branch of the Service Employees International Union in California, is a strong supporter of A.B. 1217 and skeptical of the home care industry's arguments. "If they accept responsibility for training workers and maintaining standards, I wonder why they haven't done it," she said.

Gary Passmore, vice president of the Congress of California Seniors, which also supports the legislation, said that "we need to make home care more of a profession," whether caregivers provide services through agencies or not. With agency costs in California averaging $30 to $35 an hour — versus $15 to $17 an hour for referral agencies and $8 to $12 for individual contractors — middle-class families should have the ability to hire workers who have been vetted by the state directly, he said.

The Direct Care Alliance and PHI (Paraprofessional Healthcare Institute) represent home care workers nationally. Officials at both organizations said in interviews that they supported certification programs and enhanced training for caregivers. The Direct Care Alliance offers a voluntary certification program, but only 807 caregivers have applied. PHI is working with several states to put in place a 77-hour model curriculum for personal care aides, said Steven Edelstein, the organization's national policy director.

Last year, Gov. Jerry Brown of California vetoed home care legislation similar to A.B. 1217, citing the potential impact on small businesses. But now the state is in better fiscal shape, and it is not clear whether he would veto the bill again if it makes its way through the Assembly.

"Certainly, a goal we'll continue working toward is to make sure all agencies meet basic standards for providing home care," Ms. Yamada said.

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Sharks Absent, Swimmer, 64, Strokes From Cuba to Florida

MIAMI — This time, nature tipped its hat, and Diana Nyad finally conquered the 110-mile passage from Cuba to Florida that had bedeviled her for 35 years.

Sharks steered clear, currents were friendly, and storms took most of the Labor Day weekend off.

The 64-year-old endurance swimmer emerged dazed and sunburned from the surf on Smathers Beach in Key West, Fla., just before 2 p.m. on Monday after nearly 53 hours in the ocean, a two-day, two-night swim from her starting point in Havana. She had survived the treacherous Florida Straits, a notorious stretch of water brimming with sharks, jellyfish, squalls and an unpredictable Gulf Stream. And she became the first person to do so unaided by the protection of a shark cage.

It was her fifth attempt, coming after four years of grueling training, precision planning and single-minded determination. Her face scorched and puffy from so many hours in the salt water, she leaned on one of her friends and said from the beach:

"I have three messages. One is we should never, ever give up. Two is you never are too old to chase your dreams. Three is it looks like a solitary sport, but it takes a team."

Coming at an age when few people try to set endurance records, Ms. Nyad's swim lit up Twitter and Facebook with postings about perseverance and grit, including a tweet from President Obama: "Congratulations to Diana Nyad. Never give up on your dreams."

Ms. Nyad's success was built on her failures — the first in 1978, when she was 28, and the most recent last year at age 62. After each attempt, she improvised, learning what to adjust, whom to consult and which new protective protocol to consider.

"Diana did her homework," said Bonnie Stoll, Ms. Nyad's friend and chief handler, shortly after Ms. Nyad completed her swim.

Two summers ago, she was felled midswim by a long asthma attack, her first ever. This year, she added a pulmonologist to her 35-member support team, Ms. Stoll said.

Box jellyfish, which are especially venomous, have been a constant source of danger; Ms. Nyad was stung so badly on previous swims she had to stop. To break that cycle, she found an expert on box jellyfish this year to help her contain the threat.

In the evenings, Ms. Nyad donned a special suit with long sleeves and pant legs to protect her. She slathered "sting stopper" gel to form a barrier to keep out the venom. On Saturday night, she also wore a special mask that covered her face. But the mask proved uncomfortable, cutting her mouth and tongue so badly, and impeding her breathing, that she discarded it after the first night.

The course was mostly clear of box jellyfish this time. When she finally encountered a cluster, it was on her approach to Key West. The shark divers swam ahead of Ms. Nyad to disperse the swarm.

In 2011, Ms. Nyad decided to use a team of shark divers who carried special zappers to ward off the predators. Trial and error also presented new options. She learned which wet suits were more forgiving on her skin in saltwater and which special drinks and nutrition gels best fueled her. (She ingested them, sometimes through a tube, while treading water.)

But there were two things Ms. Nyad could not control: the weather and the current. This time, both cooperated.

"I think that Mother Nature said, 'You know what? Let her go,' " Ms. Stoll said.

Unlike past swims derailed by squalls that pushed her off course, only one storm hit this weekend. It came on Sunday night and lasted a little under 90 minutes, Ms. Stoll said. Ms. Nyad followed her protocol and swam through it, accompanied by shark divers.

Sharks, always a menace, were nowhere to be seen this time.

The favorable currents carried her along so swiftly that Ms. Nyad finished her swim a day earlier than expected, Ms. Stoll said. On average, Ms. Nyad swims about 1.6 miles an hour. With the current propelling her, she cruised at 5 m.p.h. during one stretch, Ms. Stoll said, adding, "Everything was in our favor."

To help her focus, Ms. Nyad relied, as she always has, on her favorite songs. Over and over, she hums them in her head, her strokes falling in time with the music's cadence: "Ticket to Ride" by the Beatles echoed on one stretch, "Paperback Writer" on another.

"Swimming is the ultimate form of sensory deprivation," Ms. Nyad said in the month before her 2011 swim. "You are left alone with your thoughts in a much more severe way."

Through the years, others have tried to swim from Cuba to Key West and failed. In June, an Australian, Chloe McCardel, swam 11 hours and 14 miles before jellyfish stings forced her to stop.

In 2012, another Australian, Penny Palfrey, swam 79 miles until strong currents waylaid her. In 1978, Walter Poenisch, an Ohio man, said he made the swim using flippers and a snorkel, but he lacked independent documentation to verify it.

Susie Maroney did complete the swim in 1997, but she did so inside a shark cage that was being pulled by a boat, providing a draft that made swimming much easier. The first time Ms. Nyad attempted the swim, in 1978, she also used a shark cage. She did not use a shark cage this time.

Whenever Ms. Nyad scrambled, heartbroken and exhausted, onto a boat after a failed attempt, she vowed it would be her last. "It was a fairy tale," she said after her second attempt, in August 2011, "but the fairy tale didn't come true."

After last summer, Ms. Stoll said she was convinced that the Florida Straits were unswimmable. "I thought it wasn't humanly possible or she would have done it," Ms. Stoll said. "I was glad to be wrong."

This article has been revised to reflect the following correction:

Correction: September 2, 2013

An earlier version of this story incorrectly stated the time of Diana Nyad's arrival from Cuba on a beach in Key West, Fla. The swimmer arrived just before 2 p.m. on Monday, not at 1:20 p.m.

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Well: Dress Up Your Salad With Grains

You can turn a simple salad into a hearty, texture-rich dish just by adding a few grains, writes Martha Rose Shulman in this week's Recipes for Health.

When a grain is not the main ingredient in a salad you appreciate it for its texture and for the nutty flavor it contributes to the dish. Authentic Middle Eastern tabouli, for example, is a parsley salad to which a small amount of fine bulgur adds a bit of substance. I made a tabouli of sorts this week with lots of parsley and a little bit of barley, and I made a kale salad with a little bit of quinoa added. Both of these I served as side dishes or starters.

I had a bit more bulgur, couscous and brown rice on hand so I used them for more substantial salads, one that combined bulgur and greens, another that mixed an assortment of different grades of brown rice and a little bit of farro with roasted red peppers, herbs and feta. I used the remains of a box of whole wheat couscous and a little bit of sorghum (you can also use Israeli couscous) to show off my tomato crop. They were all perfect dishes for hot summer days. Those that don't call for seasonal summer vegetables will also be great at any time of year.

Here are five ways to dress up your salad with grains.

Kale and Quinoa Salad With Plums and Herbs: The kale is the main ingredient here, with quinoa adding texture and bulk.

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Brown Rice and Farro Salad With Roasted Pepper, Basil, Arugula and Feta: Roasted pepper and a vinaigrette dressing infuse a chewy, savory mix of rice and farro.

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Parsley Salad With Barley, Dill and Hazelnuts: This lemony salad is enriched with a small amount of barley and toasted hazelnuts.

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Raw and Cooked Tomato and Herb Salad With Couscous and Sorghum: In this salad, two types of couscous show off summer's tomato bounty.

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Bulgur Salad With Greens, Barberries and Yogurt: Barberries are a tart dried fruit that add an interesting flavor to this salad.

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The New Old Age Blog: In California, Renewed Debate Over Home Care

An important struggle over home health care is playing out in California, the nation's most populous state, including nearly five million residents age 65 and older.

Unions and organizations representing the elderly have joined together to push for legislation that would license agencies, certify workers and create a publicly accessible caregiver registry. Home care agencies are pushing back, saying they favor regulation but oppose the measures under consideration. The legislation, Assembly Bill 1217, has already passed the State Assembly and was passed out of the State Senate's appropriations committee on Friday. It will be up for a vote on the Senate floor next week.

An estimated 1,400 home care agencies and 120,000 paid caregivers would be affected by the proposed legislation, which is essentially an effort to bring consumer protections to an industry that has been likened to the Wild West. "It's just not right that I can check the license status of an air-conditioning repairman but I can't do so for someone coming into my home to care for a loved one," said Assemblywoman Bonnie Lowenthal, a Democrat and the bill's sponsor.

Currently, a business license is all that is required in California for organizations that offer home care, defined as nonmedical services for the elderly who need help using the bathroom, dressing, bathing and performing other basic tasks.

That leaves older adults and their families without the means to check whether agencies are adequately overseeing their caregiving staff. And elderly people who hire caregivers online or through referral agencies — which maintain lists of caregivers but do not employ them directly — have no easy, reliable way of checking these individuals' qualifications.

Although agency officials in California insist they follow reputable practices, a study published last year by researchers at Northwestern University found that few agencies perform comprehensive background checks on caregivers or provide reliable training or supervision.

Nationwide, 27 states require home care agencies to be licensed or certified, according to a 2011 report from the Private Duty Homecare Association. A lack of regulatory oversight puts consumers at risk of inadequate care, abuse or neglect, experts warn. Those risks were highlighted in an April 2011 study from the California Senate Office of Oversight and Outcomes highlighting the lack of screening for caregivers.

In one case described in the report, a home care agency placed Daisy Lee Joubert, a convicted felon, in the home of Ileen and Norman Jonas, where she stole an estimated $100,000 in retirement checks and jewelry. Apprehended, Ms. Joubert pleaded guilty to eight counts of embezzlement.

Under the proposed Home Care Services Consumer Protection Act of 2013, California home care agencies would have to obtain a state license by July 1, 2014, or face a fine of up to $900 a day. Agencies would be required to conduct background checks on caregivers, assess their performance annually and supervise their activities in a client's home every 90 days.

For their part, caregivers would be required to obtain certification after undergoing background checks, a test for tuberculosis and five hours of basic training. Their names and locations would appear on a Web site maintained by the state.

Home care agencies say they have no quibble with licensing and certification requirements. But the agencies think that ensuring the competency of workers should be voluntary and their responsibility, not the state's, said Dean Chalios, president of the California Association for Health Services at Home, an industry organization.

And home care agencies strongly oppose the creation of a caregiver registry, which would disclose the names of their workers to competitors and union organizers.

"What this is really all about is trying to unionize home care workers in California," said Kathy Janz, a nurse and executive director of Matched CareGivers, an agency that operates in San Mateo and Santa Clara Counties.

Imposing extra costs on agencies could backfire, making their services unaffordable for families and driving them to gray markets like Craigslist, where no consumer protections exist, warned Assemblywoman Mariko Yamada, a Democrat who earlier this year introduced an alternative bill.

And requiring home care workers to obtain certification could reduce the pool of workers and make it more difficult for the elderly to get services, Kevin Smith, director of operations for the Home Care Association of America, said in a written statement.

Laphonza Butler, president of United Long Term Care Workers, a branch of the Service Employees International Union in California, is a strong supporter of A.B. 1217 and skeptical of the home care industry's arguments. "If they accept responsibility for training workers and maintaining standards, I wonder why they haven't done it," she said.

Gary Passmore, vice president of the Congress of California Seniors, which also supports the legislation, said that "we need to make home care more of a profession," whether caregivers provide services through agencies or not. With agency costs in California averaging $30 to $35 an hour — versus $15 to $17 an hour for referral agencies and $8 to $12 for individual contractors — middle-class families should have the ability to hire workers who have been vetted by the state directly, he said.

The Direct Care Alliance and PHI (Paraprofessional Healthcare Institute) represent home care workers nationally. Officials at both organizations said in interviews that they supported certification programs and enhanced training for caregivers. The Direct Care Alliance offers a voluntary certification program, but only 807 caregivers have applied. PHI is working with several states to put in place a 77-hour model curriculum for personal care aides, said Steven Edelstein, the organization's national policy director.

Last year, Gov. Jerry Brown of California vetoed home care legislation similar to A.B. 1217, citing the potential impact on small businesses. But now the state is in better fiscal shape, and it is not clear whether he would veto the bill again if it makes its way through the Assembly.

"Certainly, a goal we'll continue working toward is to make sure all agencies meet basic standards for providing home care," Ms. Yamada said.

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Chinese Chicken Processors Are Cleared to Ship to U.S.

The Department of Agriculture on Friday approved four Chinese poultry processors to begin shipping a limited amount of meat to the United States, a move that is likely to add to the debate over food imports.

Initially, the companies will be allowed to export only cooked poultry products from birds raised in the United States and Canada. But critics predicted that the government would eventually expand the rules, so that chickens and turkeys bred in China could end up in the American market.

"This is the first step towards allowing China to export its own domestic chickens to the U.S.," said Tony Corbo, the senior lobbyist for Food and Water Watch, an advocacy group that works to promote food safety.

The U.S.D.A.'s decision follows years of wrangling over the issue, and comes as Americans are increasingly focused on the origin of their food.

In recent years, imports have been the source of contamination, prompting broader worries about food safety. The Food and Drug Administration just released an analysis of imported spices, showing high levels of salmonella in coriander, oregano, sesame seeds and curry powder.

China does not have the best track record for food safety, and its chicken products in particular have raised questions. The country has had frequent outbreaks of deadly avian influenza, which it sometimes has been slow to report.

Recently, an F.D.A. investigation tied the deaths of more than 500 dogs and a handful of cats to chicken jerky treats that came from China. The treats, which were eventually recalled, additionally were blamed for sickening more than 2,500 animals.

The proposed sale of Smithfield Foods to Shuanghui International, a major Chinese food processor, has added to the industry scrutiny. In July, senators from both parties questioned Larry Pope, the chief executive of Smithfield, about the implications of his company's deal for food safety and United States employment.

Mr. Pope responded that the deal was intended to address the rising demand for meat in China and that American workers would be employed in that effort. "This means increased capacity for U.S. producers, more jobs in processing and more exports for the U.S. economy," Mr. Pope said. "At the same time, we will continue to supply our same high-quality, renowned products to U.S. consumers."

The poultry trade between the United States and China has been contentious for years. Under the Bush administration, the U.S.D.A. moved to allow imports of chicken from China, which has banned imports of American beef since 2003 over worries about mad cow disease.

In response, Congress blocked Chinese chicken exports. China retaliated by slapping huge tariffs on American chicken. The fight ended up at the World Trade Organization, which ruled that the tariffs were too high.

After that, the U.S.D.A. then audited Chinese processing plants, giving its approval for them to process raw birds from the United States and Canada.

Under the new rules, the Chinese facilities will verify that cooked products exported to the United States came from American or Canadian birds. So no U.S.D.A. inspector will be present in the plants.

And because the poultry will be processed, it will not require country-of-origin labeling. Nor will consumers eating chicken noodle soup from a can or chicken nuggets in a fast-food restaurant know if the chicken came from Chinese processing plants.

"We certainly don't look forward to any more imports, but we also realize free trade is a two-way street," said Tom Super, spokesman for the National Chicken Council, which represents big chicken processors in the United States. "We're hoping the Chinese will look a little more favorably on our chicken products and on other U.S. agricultural imports."

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Taylor Farms, Big Food Supplier, Grapples With Frequent Recalls

Nicole Bengiveno/The New York Times

A Taylor Farms vegetable processing plant in Yuma, Ariz., where shredded cabbage and carrots are mixed with lettuce.

Taylor Farms, the large vegetable producer whose salad mix is being investigated in connection with an outbreak of illness involving hundreds of people in 22 states, has had an unusual number of voluntary recalls for potentially tainted products in the last three years.

The recent investigation of greens used at Olive Garden, Red Lobster and possibly other restaurant chains follows three recalls by Taylor Farm this year. The company initiated three others in 2012 and three in 2011, according to the Food and Drug Administration.

Bruce Taylor, chief executive of Taylor Farms, attributed the number of recalls to the sheer size of his company — it sells as much salad as its next three largest competitors combined. "Just if you do the sheer math, our recalls relative to our size are fewer than anybody else," Mr. Taylor said.

Only the most recent was prompted by an outbreak of illnesses, he added. Since June of this year, more than 600 cases of cyclosporiasis, an intestinal disease caused by Cyclospora cayetanensis, a parasite that is transmitted through feces, have been reported. Although not all reported cases were tied to Taylor Farms produce, this is the largest outbreak of cyclosporiasis since 1997.

Food safety experts said the number was somewhat higher than they would expect, even given Taylor's size. "While produce companies have by far the most recalls among food companies in general, I'd say one every 12 to 18 months is more the standard," said Gene Grabowski, a consultant who assists companies in dealing with the public and the media over food recalls.

Taylor competitors Dole and Fresh Express, a unit of Chiquita Brands, each had four recalls in 2012 and one in 2011. Neither company has conducted a recall so far this year, according to F.D.A. records.

Bill Marler, a lawyer who specializes in food safety litigation, also said that even for a company of its size, the rate of recalls by Taylor seemed a bit high. "That's quite a number of recalls over that time period," Mr. Marler said.

But several of those recalls could have been prompted by random inspections by state health agencies under a federal program that is now defunct, he said.

Taylor and other large produce companies had successfully lobbied to get rid of it, arguing that by the time the program identified a pathogen, the tainted product had already long since been consumed, making it hard to recall.

Shelly Burgess, a spokeswoman for the F.D.A., which is responsible for the safety of fruits and vegetables, among other foods, said there was no specific number of recalls that would require greater scrutiny by the agency.

"In assessing whether a firm should be subject to increased F.D.A. scrutiny, the agency takes many risk factors into account beyond the number of recalls the firm has initiated," Ms. Burgess wrote in an e-mail.

Mr. Taylor said many of the recalls were prompted by the company's own food safety regimen. For example, preliminary company tests drove the decision to issue a 39-state recall of organic baby spinach that was potentially contaminated with E. coli, he said.

"We have a protocol where we do an initial test and get an initial positive or negative and then follow that with a confirmation test that gives a positive or negative," he said. "I violated that protocol, though, out of an abundance of caution, acting to recall the product before we got the final result."

Mr. Taylor said the final testing found no contamination, turning the company's recall into a withdrawal of any remaining products from the market. "It was a fire drill we didn't need to do," he said.

And two of Taylor's recalls this year — almost 700 cases of its BBQ Flavored Ranch Salad with Chicken and a Black Forest ham and Swiss cheese sandwich sold under the Wawa stores' name — involved undeclared allergens like peanuts, not pathogens. "We make 700 items with over 2,000 components," Mr. Taylor said. "If an employee picks up the wrong item, we have a recall."

This week, Taylor Farms resumed operations at its Mexican processing facilities, which were the source of the greens tainted with Cyclospora, after an inspection by the Food and Drug Administration found conditions met known safety protocols.

The Centers for Disease Control, which is working with the F.D.A. on the matter, said this week that while investigations in Nebraska and Iowa had linked the outbreaks there to products from Taylor Farms of Mexico, preliminary analysis of more recent cases in Texas suggested the greens involved did not come from there.

"Although the investigation of cases in 2013 is ongoing, available evidence suggests that not all of the cases of cyclosporiasis in the various states are directly related to each other," the C.D.C. said.

Mr. Marler said he had not yet filed a lawsuit in the case for that reason. "Something else is going on, and I think it's probably environmental," he said.

Mr. Taylor wondered whether flooding earlier this summer in the areas where the problem surfaced provided the conditions for bacterial infections. He said notices posted in Nebraska, Iowa and Texas had warned residents in flooded regions to boil their water. "It's pure speculation on my part," he said, "Iowa and Nebraska represent somewhere around 4 percent of the salad sold from our plant in Mexico in any given week."

This article has been revised to reflect the following correction:

Correction: August 31, 2013

An article on Friday about recalls involving products from Taylor Farms, a big national food supplier, misstated the recent action involving the company's salad mix. The company's produce is being investigated in connection with an outbreak of cyclosporiasis; the mix was not recalled, as any that might have been a source of the illness had most likely already been consumed or was no longer in the food system. The article also misstated the nature of Cyclospora cayetanensis. It is a parasite, not a strain of bacteria.

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Chinese Chicken Processors Are Cleared to Ship to U.S.

The Department of Agriculture on Friday approved four Chinese poultry processors to begin shipping a limited amount of meat to the United States, a move that is likely to add to the debate over food imports.

Initially, the companies will be allowed to export only cooked poultry products from birds raised in the United States and Canada. But critics predicted that the government would eventually expand the rules, so that chickens and turkeys bred in China could end up in the American market.

"This is the first step towards allowing China to export its own domestic chickens to the U.S.," said Tony Corbo, the senior lobbyist for Food and Water Watch, an advocacy group that works to promote food safety.

The U.S.D.A.'s decision follows years of wrangling over the issue, and comes as Americans are increasingly focused on the origin of their food.

In recent years, imports have been the source of contamination, prompting broader worries about food safety. The Food and Drug Administration just released an analysis of imported spices, showing high levels of salmonella in coriander, oregano, sesame seeds and curry powder.

China does not have the best track record for food safety, and its chicken products in particular have raised questions. The country has had frequent outbreaks of deadly avian influenza, which it sometimes has been slow to report.

Recently, an F.D.A. investigation tied the deaths of more than 500 dogs and a handful of cats to chicken jerky treats that came from China. The treats, which were eventually recalled, additionally were blamed for sickening more than 2,500 animals.

The proposed sale of Smithfield Foods to Shuanghui International, a major Chinese food processor, has added to the industry scrutiny. In July, senators from both parties questioned Larry Pope, the chief executive of Smithfield, about the implications of his company's deal for food safety and United States employment.

Mr. Pope responded that the deal was intended to address the rising demand for meat in China and that American workers would be employed in that effort. "This means increased capacity for U.S. producers, more jobs in processing and more exports for the U.S. economy," Mr. Pope said. "At the same time, we will continue to supply our same high-quality, renowned products to U.S. consumers."

The poultry trade between the United States and China has been contentious for years. Under the Bush administration, the U.S.D.A. moved to allow imports of chicken from China, which has banned imports of American beef since 2003 over worries about mad cow disease.

In response, Congress blocked Chinese chicken exports. China retaliated by slapping huge tariffs on American chicken. The fight ended up at the World Trade Organization, which ruled that the tariffs were too high.

After that, the U.S.D.A. then audited Chinese processing plants, giving its approval for them to process raw birds from the United States and Canada.

Under the new rules, the Chinese facilities will verify that cooked products exported to the United States came from American or Canadian birds. So no U.S.D.A. inspector will be present in the plants.

And because the poultry will be processed, it will not require country-of-origin labeling. Nor will consumers eating chicken noodle soup from a can or chicken nuggets in a fast-food restaurant know if the chicken came from Chinese processing plants.

"We certainly don't look forward to any more imports, but we also realize free trade is a two-way street," said Tom Super, spokesman for the National Chicken Council, which represents big chicken processors in the United States. "We're hoping the Chinese will look a little more favorably on our chicken products and on other U.S. agricultural imports."

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Well: Dress Up Your Salad With Grains

You can turn a simple salad into a hearty, texture-rich dish just by adding a few grains, writes Martha Rose Shulman in this week's Recipes for Health.

When a grain is not the main ingredient in a salad you appreciate it for its texture and for the nutty flavor it contributes to the dish. Authentic Middle Eastern tabouli, for example, is a parsley salad to which a small amount of fine bulgur adds a bit of substance. I made a tabouli of sorts this week with lots of parsley and a little bit of barley, and I made a kale salad with a little bit of quinoa added. Both of these I served as side dishes or starters.

I had a bit more bulgur, couscous and brown rice on hand so I used them for more substantial salads, one that combined bulgur and greens, another that mixed an assortment of different grades of brown rice and a little bit of farro with roasted red peppers, herbs and feta. I used the remains of a box of whole wheat couscous and a little bit of sorghum (you can also use Israeli couscous) to show off my tomato crop. They were all perfect dishes for hot summer days. Those that don't call for seasonal summer vegetables will also be great at any time of year.

Here are five ways to dress up your salad with grains.

Kale and Quinoa Salad With Plums and Herbs: The kale is the main ingredient here, with quinoa adding texture and bulk.

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Brown Rice and Farro Salad With Roasted Pepper, Basil, Arugula and Feta: Roasted pepper and a vinaigrette dressing infuse a chewy, savory mix of rice and farro.

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Parsley Salad With Barley, Dill and Hazelnuts: This lemony salad is enriched with a small amount of barley and toasted hazelnuts.

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Raw and Cooked Tomato and Herb Salad With Couscous and Sorghum: In this salad, two types of couscous show off summer's tomato bounty.

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Bulgur Salad With Greens, Barberries and Yogurt: Barberries are a tart dried fruit that add an interesting flavor to this salad.

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