State of the Art: Tablets Are Hot Holiday Gifts, but Which One to Buy? - Review

From left: J. Emilio Flores for The New York Times, Jim Wilson/The New York Times, Everett Kennedy Brown/European Pressphoto Agency

From left, the Kindle PaperWhite, the iPad Mini and the  Nexus 7.

The other day, I joined NPR for a segment about high-tech holiday gifts. I was ready for the calls from listeners. I’d brushed up on cameras, phones, laptops, music players and game consoles. I was prepared to talk about limiting screen time, digital addiction, cyberbullying. I knew where to get the best deals.

But all six callers had the same question: “What tablet should I get?”

There were variations, of course. “— for my kid?” “— for my elderly father?” “— just for reading?” “— for not much money?” But in general, it was clear: the gadget most likely to be found under the tree this year is thin, battery-powered and flat.

No wonder people are confused. The marketplace has gone tablet-crazy. There’s practically a different model for every man, woman and child.

There’s the venerable iPad, of course. And now the iPad Mini. There are new tablets from Google, also in small and large. There are Samsung’s Note tablets in a variety of sizes, with styluses. There are $200 touch-screen color e-book/video players. There’s a new crop of black-and-white e-book readers. There are stunningly cheap plastic models you’ve never heard of. There are tablets for children (and I don’t mean baby aspirin).

So how are you, the confused consumer, supposed to keep tabs on all these tablets? By taking this handy tour through the jungle of tablets 2012. Keep hands and feet inside the tram at all times.

DIRT-CHEAP KNOCKOFFS You can find no-name tablets for $100 or even less. You can also find mystery-brand Chinese tablets in toy stores, marketed to children.

Don’t buy them. They don’t have the apps, the features, the polish or the pleasure of the nicer ones. The junk drawer is already calling their names.

E-BOOK READERS The smallest, lightest, least expensive, easiest to read tablets are the black-and-white e-book readers. If the goal is simply reading — and not, say, watching movies or playing games — these babies are pure joy.

Don’t bother with the lesser brands; if you’re going to get locked into one company’s proprietary, copy-protected book format, you’ll reduce your chances of library obsolescence if you stick with Amazon or Barnes & Noble.

Each company offers a whole bunch of models. But on the latest models, the page background lights up softly, so that you can read in the dark without a flashlight. (These black-and-white models also look fantastic in direct sun — now you get the best of both lighting conditions.)

The one you want is the Kindle PaperWhite ($120), whose illumination is more even and pleasant than the equivalent Nook’s.

Of course, plain, no-touch, no-light Kindles, with ads on the screen saver, start as low as $70. But the light and the touch-screen are really worth having.

COLOR E-READERS/PLAYERS Amazon and B.& N. each sell a seven-inch tablet that, functionally, lands somewhere between an e-book reader and an iPad. They have beautiful, high-definition touch screens. They play music, TV shows, movies and e-books. They can surf the Web. They even run a few handpicked Android apps like Netflix and Angry Birds.

They’re nowhere near as capable as full-blown, computerlike tablets of the iPad/Nexus ilk, mainly because there are so few apps, accessories and add-ons. But they cost $200; you’re paying only a fraction of the price.

The big two here are, once again, Amazon and B.& N. If you’re not already locked in to one of those companies’ books and videos because you owned a previous model, the Nook HD is the one to get. It’s much smaller and lighter than the Kindle Fire HD. It has a much sharper screen. And the $200 price includes a wall charger (the Fire doesn’t) and no ads (the Fire does). Or get the classy Google Nexus 7, also $200. Although its book/music/movie catalog is far smaller, its Android app catalog is far larger (but see “iPad versus Android,” below).

BIG COLOR READERS/PLAYERS This year, both Amazon and B.& N. have introduced jumbo-screen (9-inch) versions of their HD tablets. Here again, B.& N. offers a better value than its 9-inch Kindle Fire HD rival. For $270, the Nook HD+ offers a sharper screen, lighter weight, no ads, a memory-card slot and a wall charger.

E-mail: pogue@nytimes.com

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Yasser Arafat's grave dug up in poisoning probe

RAMALLAH, West Bank -- Forensic experts from Switzerland, France and Russia on Tuesday took 20 samples each from the remains of Palestinian leader Yasser Arafat after his grave in the presidential headquarters here was opened.

The experts will take the samples to their respective countries to carry out tests to determine if Arafat, who died on Nov. 11, 2004, at a military hospital in France, was killed by polonium, a poisonous radioactive material.

French hospital reports at the time said he died from a massive brain hemorrhage, but gave no details on what caused a related blood condition, giving rise to Palestinian suspicions he was killed by Israel. Arafat's wife requested at the time that no autopsy be performed, and Israeli officials have labeled as ridiculous any allegations that they played a role in his death.

The process Tuesday took only hours. The grave, buried 12 feet underground, was opened early in the morning and Palestinian forensic technicians removed samples for the international experts.

After the grave was again closed, Palestinian officials held a short ceremony in which they laid wreaths.

Members of the media were not allowed to witness the grave opening; the site was sealed from view by blue industrial sheeting.

Tawfik Tirawi, head of the Palestinian committee investigating Arafat's death, said at a news conference following the exhumation that the process went smoothly and that "everything was done legally and professionally."

He stressed that the remains of Arafat were handled only by Palestinians and that none of the international experts had touched the corpse.

Abdullah al-Bashir, a Jordanian doctor who heads a Palestinian medical committee empowered to follow up on the circumstances of Arafat’s death, said results should be available in about three months.

"If polonium was evident, we would have reached the truth," he said, "and if it was not, we would want them [the experts] to continue searching until they determine what kind of poison was used."

Bashir, who was Arafat's personal doctor, said he believes that the Palestinian leader died of poisoning and that the French hospital medical reports did not rule out that possibility.

The Palestinians said that if polonium is determined to be the cause of death, they will have hard evidence that Israel was behind it.

"Once we get the evidence, we are going to ask the International Court of Justice to follow up on this matter, and this will be our first case after we become a non-member state in the United Nations," said Tirawi, a former head of Palestinian intelligence.

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New Nuclear Engine Could Power Deep-Space Exploration

Researchers have tested a small prototype of a nuclear-reactor engine design that could one day power deep-space exploration probes.

The proposed design is based on a Stirling engine – an engine first invented in the 19^th century that uses hot pressurized gas to push a piston. It would use a 50-pound nuclear uranium battery to generate heat that is then carried to eight Stirling engines to produce about 500 watts of power.

Scientists at NASA’s Glenn Research Center and Los Alamos National Laboratory have tested a pared-down prototype of this design using a small nuclear source and a single Stirling engine that produced about 24 watts of energy. Most deep-space probes require about 600 to 700 watts of power, so it will still be a while before this early test produces something capable of powering a spacecraft. This is the first test of a nuclear reactor system to power a spacecraft conducted in the U.S. since 1965.

Nuclear engines are important because they make possible exploration of the entire solar system. Beyond Mars, sunlight is so weak that solar panels would have to be football-field-sized in order to eke out enough power to run a spacecraft and transmit data back to Earth.

For the last few decades, NASA has used plutonium-238 to power its deep-space probes, including the Voyager spacecrafts and the Cassini mission currently in orbit around Saturn. But beginning in the early 1980s, the U.S. began decommissioning its plutonium production sites and by 1992 had no way to generate new plutionium-238. NASA’s Curiosity rover, which is right now driving around Mars, carried some of the last bits of American plutonium with it to the Red Planet.

In 2011, NASA and the Department of Energy received about $10 million to restart plutonium production, and should soon be capable of generating a few pounds of the material each year. This tiny amount will be highly coveted for deep-space missions. A nuclear Stirling engine that generates electricity using more-abundant uranium would reduce the demand for plutonium-238.

If they are created, such reactors would help keep scientists busy exploring the giant outer planets and all their moons for decades to come. Stirling engines could also be used to power a robotic probe on Venus, generating enough power to keep the machine cool in the midst of the planet’s hellish surface temperatures.

Video: Los Alamos National Laboratory

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Disney Channel to debut ‘Sofia the First’ Jan. 11

NEW YORK (AP) — Disney says its animated children‘s series “Sofia the First” will premiere Jan. 11 on the Disney Channel and Disney Junior networks.

Created for kids ages 2 to 7, “Sofia the First” is about a young girl who becomes a princess and learns that honesty, loyalty and compassion are what makes a person royal.

Sofia is voiced by “Modern Family” actress Ariel Winter, and her mother is played by “Grey’s Anatomy” star Sara Ramirez.

Last week’s premiere of the “Sofia the First” animated movie drew a total audience of more than 5 million viewers. It was the year’s top-rated cable TV telecast among kids ages 2 to 5.

In the series’ debut episode, Sofia strives to become the first princess to earn a spot on her school’s flying derby team.

Entertainment News Headlines – Yahoo! News

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Amid Hurricane Sandy, a Race to Get a Liver Transplant

It was the best possible news, at the worst possible time.

The phone call from the hospital brought the message that Dolores and Vin Dreeland had long hoped for, ever since their daughter Natalia, 4, had been put on the waiting list for a liver transplant. The time had come.

They bundled her into the car for the 50-mile trip from their home in Long Valley, N.J., to NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan. But it soon seemed that this chance to save Natalia’s life might be just out of reach.

The date was Sunday, Oct. 28, and Hurricane Sandy, the worst storm to hit the East Coast in decades, was bearing down on New York. Airports and bridges would soon close, but the donated organ was in Nevada, five hours away. The time window in which a plane carrying the liver would be able to land in the region was rapidly closing.

In a hospital room, Natalia watched cartoons. Her parents watched the clock, and the weather. “Our anxiety was through the roof,” Mrs. Dreeland said. “It just made your stomach into knots.”

The Dreelands, who are in their 60s, became Natalia’s foster parents in 2008 when she was 7 months old, and adopted her just before she turned 2. They have another adopted daughter, Dorothy Jane, who is 17.

Natalia is a “smart little cookie” who loves school and dressing up Alice, her favorite doll, her mother said. At age 3, Natalia used the word “discombobulated” correctly, Mr. Dreeland said.

Natalia’s health problems date back several years. Her gallbladder was taken out in 2010, and about half her liver was removed in 2011. The underlying problem was a rare disease, Langerhans cell histiocytosis. It causes a tremendous overgrowth of a type of cell in the immune system and can damage organs. Drugs can sometimes keep it in check, but they did not work for Natalia.

In her case, the disease struck the bile ducts, which led to progressive liver damage. “She would have eventually gone into liver failure,” said Dr. Nadia Ovchinsky, a pediatric liver transplant specialist at NewYork-Presbyterian. “And she demonstrated some signs of early liver failure.”

The only hope was a transplant.

Dr. Tomoaki Kato, Natalia’s surgeon, knew that the liver in Nevada was a perfect match for Natalia in the two criteria that matter most: blood type and size. The deceased donor was 2 years old, and though Natalia is nearly 5, she is small for her age. Scar tissue from her previous operations would have made it very difficult to fit a larger organ into her abdomen.

Though Dr. Kato had considered transplanting part of an adult liver into Natalia, a complete organ from a child would be far better for her. But healthy organs from small children do not often become available, Dr. Kato said. This was a rare opportunity, and he was determined to seize it.

But as the day wore on, the odds for Natalia grew slimmer. The operation in Nevada to remove the liver was delayed several times.

At many hospitals, surgery to remove donor organs is done at the end of the day, after all regularly scheduled operations. The Nevada hospital had a busy surgical schedule that day, made worse by a trauma case that took priority.

At the hospital in New York, Tod Brown, an organ procurement coordinator, had alerted a charter air carrier that a flight from Nevada might be needed. That company in turn contacted West Coast carriers to pick up the donated liver and fly it to New York.

Initially, two carriers agreed, but then backed out. Several other charter companies also declined.

Mr. Brown told Dr. Kato that they might have to decline the organ. Dr. Kato, soft-spoken but relentless, said, “Find somebody who can fly.”

Dr. Kato used to work in Miami, where pilots found ways to bypass hurricanes to deliver organs. Even during Hurricane Katrina, his hospital performed transplants.

“I asked the transplant coordinators to just keep pushing,” he said.

Mr. Brown said, “Dr. Kato knew he was going to get that organ, one way or another.”

As the trajectory of the storm became clearer, one of the West Coast charter companies agreed to attempt the flight. The plan was to land at the airport in Teterboro, N.J. The backup was Newark airport, and the second backup was Albany, from where an ambulance would finish the trip.

The timing was critical: organs deteriorate outside the body, and ideally a liver should be transplanted within 12 hours of being removed.

Early Monday, as the storm whirled offshore, the plane landed at Teterboro. Soon a nurse rushed to tell the Dreelands that she had just seen an ambulance with lights and sirens screech up to the hospital. Someone had jumped out carrying a container.

At about 5 a.m., the couple kissed Natalia and saw her wheeled off to the operating room.

Three weeks later, she is back home, on the mend. The complicated regimen of drugs that transplant patients need is tough on a child, but she is getting through it, her father said.

Recently, Mr. Dreeland said, he found himself weeping uncontrollably during a church service for the family of the child who had died. “Their child gave my child life,” he said.

Though only time will tell, because the histiocytosis appeared limited to Natalia’s bile ducts and had not affected other organs, her doctors say there is a good chance that the transplant has cured her.

This article has been revised to reflect the following correction:

Correction: November 27, 2012

An earlier version of a picture caption with this article misspelled the surname of the family whose daughter received a liver transplant. As the article correctly noted elsewhere, it is Dreeland, not Vreeland.

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Dark Warnings About Future of Internet Access

PARIS — Every time an Internet user watches “Gangnam Style” on YouTube, packets of digital data course through the global telecommunications system, converging on an iPhone, a tablet or a laptop.

Having missed out on most of the lucrative revenue that the explosion of digital content has generated for Internet companies, telecommunications providers in Europe, Africa, the Middle East and elsewhere now want to charge them for carrying this traffic.

No way, the content providers say.

This commercial and ideological clash is set for a showdown next week, when representatives of more than 190 governments, along with telecommunications companies and Internet groups, gather in Dubai for a once-in-a-generation meeting.

The ostensible purpose of the World Conference on International Telecommunications is to update a global treaty on technical standards needed to, say, connect a telephone call from Tokyo to Timbuktu. The previous conference took place in 1988, when the Internet was in its infancy and telecommunications remained a highly regulated, mostly analog business.

Critics of the International Telecommunication Union, the United Nations’ agency that is organizing the meeting, see a darker agenda. The blogosphere has been raging over supposed plans led by Russia to snatch away control of the Internet and hand it to the U.N. agency.

That seems unlikely. Any such move would require an international consensus, and opposition is widespread. Terry Kramer, the U.S. ambassador to the conference, has vowed to veto any change in how the Internet is overseen.

Hamadoun Touré, secretary general of the telecommunications union, has repeatedly said that it has no desire to take over the Internet or to stifle its growth. On the contrary, he says, one of the main objectives of the conference is to spread Internet access to more of the four and a half billion people around the world who still do not use it.

And yet, groups as diverse as Google, the Internet Society, the International Trade Union Confederation and Greenpeace warn that the discussions could set a bad precedent, encouraging governments to step up censorship or take other actions that would threaten the integrity of the Internet.

“This is a very important moment in the history of the Internet, because this conference may introduce practices that are inimical to its continued growth and openness,” Vinton G. Cerf, vice president and chief Internet evangelist at Google, said during a conference call.

Google set up a Web site last week, “Take Action,” encouraging visitors to sign a petition for a “free and open Internet.” The campaign is modeled on the successful drive last winter to defeat legislative proposals to crack down on Internet piracy in the United States.

Analysts say the outcry over censorship and Internet governance is a red herring; the real business of the conference is business.

“The far bigger issue — largely obscured by this discussion — are proposals that are more likely to succeed that envision changing the way we pay for Internet services,” Michael Geist, an Internet law professor at the University of Ottawa, said by e-mail.

In one submission to the conference, the European Telecommunications Network Operators’ Association, a lobbying group based in Brussels that represents companies like France Télécom, Deutsche Telekom and Telecom Italia, proposed that network operators be permitted to assess charges for content providers like Internet video companies that use a lot of bandwidth.

Analysts say the proposal is an acknowledgment by telecommunications companies that they cannot compete in the provision of digital content.

“The telecoms realize that they have lost the battle,” said Paul Budde, an independent telecommunications analyst in Australia. “They are saying, ‘We can’t beat the Googles and the Facebooks, so let’s try to charge them.”’

The European lobbying group says that without the new fees, there will be no money to invest in the network upgrades needed to deal with a surge in traffic. Regulators have required European telecommunications operators to open their networks to rivals, and the market for broadband is fiercely competitive, with rock-bottom prices.

In the United States, by contrast, most telecommunications companies have been permitted to maintain local monopolies — or duopolies, with cable companies — in broadband, keeping prices higher. And U.S. regulators have ordered broadband providers to give equal priority to all Internet traffic. Such “network neutrality” is incompatible with charging content providers for carriage.

Analysts say this may explain why U.S. telecommunications companies have not joined the European call for a new business model.

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Congress returns as 'fiscal cliff' talks slow

WASHINGTON – Congress returned in a lame duck session with no signs of quick compromise to prevent a tax hike for most Americans early next year.

Talks between the White House and Republican leaders in the House continued behind closed doors. Current tax rates expire Dec. 31.

Emboldened by his re-election, President Obama took his case for raising taxes on the wealthiest Americans to the public on Monday. He warned that the threat of higher taxes on middle-class Americans could dampen the Christmas shopping season.

"The President has called on Congress to take action and stop holding the middle class and our economy hostage over a disagreement on tax cuts for households with incomes over $250,000 per year," the White House said in a statement.

Quiz: How much do you know about the fiscal cliff?

The White House got a boost from billionaire investor Warren Buffett, who said the wealthy – himself included – should pay more. Noting the nation’s growing gap in income disparity, Buffett dismissed the Republican argument that tax hikes would hamper investments.

“In recent years, my gang has been leaving the middle class in the dust,” Buffett said. “So let’s forget about the rich and ultrarich going on strike and stuffing their ample funds under their mattresses if — gasp — capital gains rates and ordinary income rates are increased.”

Key Republicans, including House Speaker John A. Boehner, have signaled they are willing to put new tax revenues on the table, creating the outlines of a possible deal. Several Republican lawmakers used the Sunday talk shows to distance themselves from their party’s anti-tax pledge, publicly breaking with conservative stalwart Grover Norquist, although they insisted any agreement must include spending cuts.

A so-called grand bargain of tax hikes and spending cuts has eluded Washington in the past, but both political parties are wary of rattling the financial markets and sparking a crisis in consumer spending. Wall Street has signaled a bold deficit-reduction plan is needed to prevent a credit downgrade.

PHOTOS: 2016 presidential possibilities

No talks between the president and congressional leaders have been scheduled. The parties had agreed to meet this week to put the framework of a two-part deal on the table.

If Republicans continue to fight higher tax rates for the wealthy, Boehner will face pressure to propose an alternative way to raise new revenue – either by closing individual loopholes or capping deductions in a way that produces new money.

“Congressional and White House staff continue to work to find common ground that is consistent with the ‘balanced approach’ the White House says it wants – with significant spending cuts, and without job-killing small business tax hikes,” said a senior House leadership aide.

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Lisa.Mascaro@latimes.com

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Twitter: @LisaMascaroinDC

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Active Auto Safety Gets in Your Face

Cars are getting smarter and beginning to react on their own, but the gray matter manning the helm is still the vehicle’s Achilles heal. So to really get inside a driver’s head, automakers are going through their faces, analyzing expressions and muscle movements to determine whether the person at the wheel is too distracted, too tired or even too angry to safely control their ride.

In conjunction with PSA Peugeot Citroën, scientists at the Transportation Center and Signal Processing 5 Laboratory of Ecole Polytechnique Fédérale de Lausanne (EPFL) in Switzerland are developing a technology that uses a camera to capture facial expressions and software to look for telltale signs of distraction as well as emotions that could indicate that the driver is not up to the task at hand. Think of it as a concerned co-pilot who can not only read your mood, but also take action before your mental condition clouds your driving decisions.

“We aim at optimally exploiting computer vision technologies to improve safety and comfort in cars through more natural human-machine interfaces,” Jean-Philippe Thiran, the director of EPFL’s Signal Processing 5 Laboratory, told Wired.

Olivier Pajot, PSA Peugeot Citroën’s EPFL representative, said in a statement that the automaker is using the research to “make the interface between the car and the driver more intuitive,” and that reading intentions from a driver’s facial expression “is a very natural interactive mode.”

While facial-recognition technology has become commonplace for everything from surveillance to social media data mining, applying it in the car presents a unique set of challenges, starting with where to place the camera so that it doesn’t obstruct the driver’s view. “One of the possible options is to place it behind the steering wheel, which would require a system that’s quick enough to recapture the face detection after the arms of the steering wheel interrupt it,” Thiran said.

Another issue is adapting to the changing lighting conditions, such as when a car goes into a tunnel or at night when active safety systems are most beneficial – and when nodding off at the wheel usually happens. EPFL also acknowledges that the technology has to perform as well when drivers are facing the camera as it does as when they turn their heads.

The next step is to test the facial-recognition technology in real-world conditions. It’s currently fitted to a prototype vehicle, and EPFL is refining the technology by increasing the number of images processed.

Other automakers and suppliers are also exploring safety research by pointing a camera at the driver’s mug while behind the wheel and capturing and analyzing the data.

Toshiba showed a facial-recognition system that searches for distraction and also allows tuning the radio with a blink of an eye. BMW’s “pupilometry” research focuses on tracking driver’s eyeballs to better understand how much visual stimuli can be absorbed before distraction ensues, while the Swedish company Tobii Technology has developed a system that watches a drivers’ eyes – even when they’re wearing sunglasses – to tell if they’re glued to their smartphone or showing signs of fatigue.

“Our goal is to build the technological base to detect and situate a driver’s face at any moment in time,” Thiran said. “Using this, it will then be possible to build and test various driver assistance applications such as eye tracking, fatigue detection, lip reading and so on,” although it’s doubtful that your car could automatically book you into an anger-management program. For now, at least.

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Beyonce documentary premiering on HBO in February

NEW YORK (AP) — Beyonce is getting personal.

HBO announced Monday that a documentary about the Grammy-winning singer will debut Feb. 16, 2013. Beyonce is directing the film, which will include footage she shot herself with her laptop.

The network said the documentary will include “video that provides raw, unprecedented access to the private entertainment icon and high-voltage performances.” It will also feature home videos of her family and of the singer as a new mother and owner of her company, Parkwood Entertainment.

Beyonce said in a statement the untitled project was “personal” to her. She is married to Jay-Z. They had their first child, daughter Blue Ivy Carter, in January.

The 31-year-old will perform at the 2013 Super Bowl halftime show on Feb. 3, 13 days before the documentary airs.

Entertainment News Headlines – Yahoo! News

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Hospitals Face Pressure From Medicare to Avert Readmissions

After years of gently prodding hospitals to make sure discharged patients do not need to return, the federal government is now using its financial muscle to discourage readmissions.

Medicare last month began levying financial penalties against 2,217 hospitals it says have had too many readmissions. Of those hospitals, 307 will receive the maximum punishment, a 1 percent reduction in Medicare’s regular payments for every patient over the next year, federal records show.

One of those is Barnes-Jewish Hospital in St. Louis, which will lose $2 million this year. Dr. John Lynch, the chief medical officer, said Barnes-Jewish could absorb that loss this year, but “over time, if the penalties accumulate, it will probably take resources away from other key patient programs.”

The crackdown on readmissions is at the vanguard of the Affordable Care Act’s effort to eliminate unnecessary care and curb Medicare’s growing spending, which reached $556 billion this year. Hospital inpatient costs make up a quarter of that spending and are projected to grow by more than 4 percent annually in coming years, according to the Congressional Budget Office.

The readmission penalties will recoup about $300 million this year. But the goal is to pressure hospitals to pay attention to what happens to their patients after they walk out the door. The penalties have captured the attention of hospitals, and many are trying to improve their supervision of discharged patients’ recoveries.

“I’ve been doing this for over two decades and talking to hospital leaders about readmissions, and I used to get polite but blank stares,” said Dr. Eric Coleman, a professor at the University of Colorado Anschutz Medical Campus who has devised widely adopted methods to reduce hospitalizations. “Now they’re paying attention.”

With nearly one in five Medicare patients returning to the hospital within a month — about two million people a year — readmissions cost the government more than $17 billion annually.

Hospitals’ traditional reluctance to tackle readmissions is rooted in Medicare’s payment system. Medicare generally pays hospitals a set fee for a patient’s stay, so the shorter the visit, the more revenue a hospital can keep. Hospitals also get paid when patients return. Until the new penalties kicked in, hospitals had no incentive to make sure patients didn’t wind up coming back. The maximum penalty is set to double next October and then reach 3 percent of reimbursements in October 2015. Medicare also is expanding the list of conditions it will assess in setting punishments.

Right now it only evaluates readmissions of heart attack, heart failure and pneumonia patients, counting every rebound, even ones not related to the original reason for hospitalization. The penalties are based on readmission rates in the past and applied to future payments for all Medicare patients.

Researchers say that while some readmissions are unavoidable, many are caused by the short shrift hospitals have given patients on their way out.

Jonathan Blum, principal deputy administrator for the Centers for Medicare and Medicaid Services, said the penalties had helped galvanize hospitals’ efforts to avoid readmissions. “We’ve seen a small but significant reduction,” he said. “That tells me we’ve focused the industry on improvement.”

Medicare’s tough love is not going over well everywhere. Academic medical centers are complaining that the penalties do not take into account the extra challenges posed by extremely sick and low-income patients. For these people, getting medicine and follow-up care can be a struggle.

At Barnes-Jewish Hospital, Dr. Lynch said physicians from all over the Midwest referred their sickest heart patients to his facility for transplants and other major interventions. But those patients can skew his hospital’s readmissions numbers, he said: “The weaker your heart, the more advanced your emphysema, the more likely you are to be readmitted to the hospital.”

Dr. Lynch said Barnes-Jewish set up follow-up appointments for patients who didn’t have their own doctors. But about half of the patients never showed up, he said, even after the hospital made reminder phone calls and arranged for free rides. Sending nurses to see patients at home did not significantly reduce readmission rates either, he said.

“Many of us have been working on this for other reasons than a penalty for many years, and we’ve found it’s very hard to move,” Dr. Lynch said. He said the penalties were unfair to hospitals with the double burden of caring for very sick and very poor patients.

“For us, it’s not a readmissions penalty,” he said. “It’s a mission penalty.”

Various studies, including one commissioned by Medicare, have found that the hospitals with the most poor and African-American patients tended to have higher readmission rates than hospitals with more affluent and Caucasian patients. But the studies also determined that some safety-net hospitals performed better than average, showing that hospitals can overcome the challenges posed by the kinds of patients they treat.

In some ways, the debate parallels the one on education — specifically, whether educators should be held accountable for lower rates of progress among children from poor families.

“Just blaming the patients or saying ‘it’s destiny’ or ‘we can’t do any better’ is a premature conclusion and is likely to be wrong,” said Dr. Harlan Krumholz, director of the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, which prepared the study for Medicare. “I’ve got to believe we can do much, much better.”

Some researchers fear the Medicare penalties are so steep, they will distract hospitals from other pressing issues, like reducing infections and surgical mistakes and ensuring patients’ needs are met promptly. “It should not be our top priority,” said Dr. Ashish Jha, a professor at the Harvard School of Public Health who has studied readmissions. “If you think of all the things in the Affordable Care Act, this is the one that has the biggest penalties, and that’s just crazy.”

With pressure to avert readmissions rising, some hospitals have been suspected of sending patients home within 24 hours, so they can bill for the services but not have the stay counted as an admission. But most hospitals are scrambling to reduce the number of repeat patients, with mixed success.

A few days after Eda Laurion was discharged from the Banner Del E. Webb Medical Center near Phoenix after treatment for her congestive heart failure in August, a nurse showed up at her house.

“She helped explained the medicines I’m taking, the side effects, what they do for you,” said Ms. Laurion, 91, of Sun City West.

Still, readmissions can’t always be prevented. The nurse, Sue Koner, sent Ms. Laurion back to the hospital after two weeks for dangerously low sodium caused by an undiagnosed kidney problem. However, Ms. Laurion avoided re-hospitalization in October when Ms. Koner deduced that her hallucinations were a reaction to an antibiotic.

Overseeing former patients is expensive and time-consuming, so many hospitals are relying on financing from community health organizations and foundations. Ms. Koner works for Sun Health, a foundation-supported nonprofit. Since Sun Health started its program in November 2011, only nine of 213 patients have been readmitted.

Dr. Krumholz said hospitals should think of readmissions as a challenge to overcome. “One day, we’ll look back,” he said, “and we’ll be incredulous that one out of every five patients ended up back in the hospital.”

This article was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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