Medicare paid $5.1B for poor nursing home care


SAN FRANCISCO (AP) — Medicare paid billions in taxpayer dollars to nursing homes nationwide that were not meeting basic requirements to look after their residents, government investigators have found.


The report, released Thursday by the Department of Health and Human Services' inspector general, said Medicare paid about $5.1 billion for patients to stay in skilled nursing facilities that failed to meet federal quality of care rules in 2009, in some cases resulting in dangerous and neglectful conditions.


One out of every three times patients wound up in nursing homes that year, they landed in facilities that failed to follow basic care requirements laid out by the federal agency that administers Medicare, investigators estimated.


By law, nursing homes need to write up care plans specially tailored for each resident, so doctors, nurses, therapists and all other caregivers are on the same page about how to help residents reach the highest possible levels of physical, mental and psychological well-being.


Not only are residents often going without the crucial help they need, but the government could be spending taxpayer money on facilities that could endanger people's health, the report concluded. The findings come as concerns about health care quality and cost are garnering heightened attention as the Obama administration implements the nation's sweeping health care overhaul.


"These findings raise concerns about what Medicare is paying for," the report said.


Investigators estimate that in one out of five stays, patients' health problems weren't addressed in the care plans, falling far short of government directives. For example, one home made no plans to monitor a patient's use of two anti-psychotic drugs and one depression medication, even though the drugs could have serious side effects.


In other cases, residents got therapy they didn't need, which the report said was in the nursing homes' financial interest because they would be reimbursed at a higher rate by Medicare.


In one example, a patient kept getting physical and occupational therapy even though the care plan said all the health goals had been met, the report said.


The Office of Inspector General's report was based on medical records from 190 patient visits to nursing homes in 42 states that lasted at least three weeks, which investigators said gave them a statistically valid sample of Medicare beneficiaries' experiences in skilled nursing facilities.


That sample represents about 1.1 million patient visits to nursing homes nationwide in 2009, the most recent year for which data was available, according to the review.


Overall, the review raises questions about whether the system is allowing homes to get paid for poor quality services that may be harming residents, investigators said, and recommended that the Centers for Medicare & Medicaid Services tie payments to homes' abilities to meet basic care requirements. The report also recommended that the agency strengthen its regulations and ramp up its oversight. The review did not name individual homes, nor did it estimate the number of patients who had been mistreated, but instead looked at the overall number of stays in which problems arose.


In response, the agency agreed that it should consider tying Medicare reimbursements to homes' provision of good care. CMS also said in written comments that it is reviewing its own regulations to improve enforcement at the homes.


"Medicare has made significant changes to the way we pay providers thanks to the health care law, to reward better quality care," Medicare spokesman Brian Cook said in a statement to AP. "We are taking steps to make sure these facilities have the resources to improve the quality of their care, and make sure Medicare is paying for the quality of care that beneficiaries are entitled to."


CMS hires state-level agencies to survey the homes and make sure they are complying with federal law, and can require correction plans, deny payment or end a contract with a home if major deficiencies come to light. The agency also said it would follow up on potential enforcement at the homes featured in the report.


Greg Crist, a Washington-based spokeswoman for the American Health Care Association, which represents the largest share of skilled nursing facilities nationwide, said overall nursing home operators are well regulated and follow federal guidelines but added that he could not fully comment on the report's conclusions without having had the chance to read it.


"Our members begin every treatment with the individual's personal health needs at the forefront. This is a hands-on process, involving doctors and even family members in an effort to enhance the health outcome of the patient," Crist said.


Virginia Fichera, who has relatives in two nursing homes in New York, said she would welcome a greater push for accountability at skilled nursing facilities.


"Once you're in a nursing home, if things don't go right, you're really a prisoner," said Fichera, a retired professor in Sterling, NY. "As a concerned relative, you just want to know the care is good, and if there are problems, why they are happening and when they'll be fixed."


Once residents are ready to go back home or transfer to another facility, federal law also requires that the homes write special plans to make sure patients are safely discharged.


Investigators found the homes didn't always do what was needed to ensure a smooth transition.


In nearly one-third of cases, facilities also did not provide enough information when the patient moved to another setting, the report found.


___


On the Web:


The OIG report: http://1.usa.gov/VaztQm


The Medicare nursing home database: http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1&AspxAutoDetectCookieSupport=1


___


Follow Garance Burke on Twitter at —http://twitter.com/garanceburke.


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Why Should We Care? The Politics of Picking a Pope





Feb 28, 2013 9:34am


gty pope farewell jef 130228 wblog Why Should We Care? The Politics of Picking a Pope



                             (Image Credit: L’Osservatore Romano/Vatican/Getty Images)


ANALYSIS


VATICAN CITY – In a U.S presidential campaign, the New Hampshire primary is thought of as “retail politics,” where the candidates actually get to meet and have contact with real voters.


That’s Walmart, compared to a Vatican conclave. This process is more of a boutique.


READ MORE: Benedict XVI Begins Final Day as Pope


All the voters and all the viable candidates can fit into one room. In some cases, they have known each other – or known “of” each other – for years. In some cases, they have worked with (or against) each other in the daily management of the church.


It’s not just the fancy costumes, the churchly rituals or the sweep of history that makes this process so fascinating. There’s also the sheer human drama of it all.


VIDEO: Pope Benedict’s Last Sunday Prayer Service


For the 115 men planning to take part in the conclave to elect a pope, all of whom have devoted their lives to the Catholic church, this choice might well be the most important contribution they make. A lifetime of service reduced to a single election.


It’s also crucial for the world’s 1.2 billion Roman Catholics.


The new pope will set the tone of the institution on issues of life and death: abortion, birth control, genetic medicine, euthanasia and more.


He’ll frame the church’s role in the moral debate about the way we live our lives, as individuals and as families. Divorce, gay rights, adoption, education, the role of women (not least in the church) are all areas in which previous pope’s have exerted tremendous influence.


He’ll instantly be the most powerful spiritual leader in the world, a global ambassador for Christian values (however he and the rest of the church interpret that mandate).


9 Men Who Could Replace Pope Benedict XVI


Will he be able to win over a wayward flock? Many have left the church, bitterly disappointed by the betrayal of pedophile priests, the mismanagement of arrogant administrators or even what they perceive as the institution’s irrelevance in the modern era.


At its best, the church is a voice of compassion and social justice. But it has also, at times, been a voice of intolerance, as well as a bastion of the status quo.


On one level, this is local politics. Each voting cardinal – even the ones who live thousands of miles away – has a titular church, an actual church here in Rome assigned to them where they officially serve as the pastor. So the conclave represents the Roman clergy’s electing the next Bishop of Rome.


At another level, it’s global. Prelates from 50 countries do their best to discern (through the guidance of the Holy Spirit) how to make the universal church thrive in a new millennium.


Win or lose in a presidential election, we all know it’ll start all over again in four years’ time. There are checks and balances too, so, for better or worse, “change” tends to be largely a campaign slogan.


It would be sheer exaggeration to say any presidential contest were a battle for the soul of the United States.


But in a very real way that’s what this process is for the world’s largest church.



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Portugal seizes 79 tonnes of meat containing horse






LISBON: Portuguese authorities said they had launched fraud proceedings after seizing 79 tonnes of wholesale food and thousands of packaged meals that contained horsemeat despite not being labelled with it.

The 79 tonnes of "meat and meat-based products" were seized in plants that processed, packaged and distributed meat to supermarkets, the government's Economic and Food Safety Authority said in a statement.

Authorities also seized nearly 19,000 packets of food "such as lasagne, hamburgers, canneloni and meatballs" in retail and distribution outlets, said the statement published on Tuesday.

Five criminal cases of fraud were opened over the seizures, it added, without giving further derails.

A vast food scandal has erupted across Europe after horsemeat was found in supposedly beef ready-made meals and burgers in Britain and Ireland.

Among various companies implicated in the scandal, Swiss food giant Nestle last week withdrew dishes destined for restaurants in Portugal, Spain and Italy.

- AFP/xq



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India silent over US-backed resolution against Lanka at UN rights body

NEW DELHI: India is not ready to reveal its hand on the US-sponsored resolution against Sri Lanka at the UN Human Rights Council (UNHRC). And, the radio silence is all for a good reason.

Despite the loud support by DMK and AIADMK members in the Rajya Sabha for the resolution on Wednesday, there is discomfort within the Indian government regarding the document's fine print. Sources said recommendations in the resolution are "intrusive", which would be unacceptable for India.

However, India will continue to push Sri Lanka to devolve more power to the Tamil areas, as part of the promise of the 13th amendment. Colombo maintains that most of the amendment has been implemented, but they wanted to "adjust" some of what was left to work on. The government has set up a select committee, but the Tamil parties have refused to be part of it.

Although the text of the resolution has not yet been made public, it is believed that the US resolution calls for an international committee to monitor that justice, equity, accountability and reconciliation are implemented by the Lankan government. India would much rather like that issues of accountability are kept as sovereign responsibility of a nation and not imposed from outside. Like China, India is opposed to externally imposed solutions on countries.

Foreign minister Salman Khurshid remained non-committal on how India would vote at the UN body. He told the Rajya Sabha on Wednesday that while the recent photographs of Prabhakaran's son's death were "very sad, very moving, very tragic" and "that is the reason we have engaged with Sri Lanka". This accountability, he said, should come from within, rather than from outside. "When accountability comes from within, there is a greater chance of sustainability," he added.

India has more problems with the report of the UN High Commissioner for Human Rights Navi Pillay. Her report, which the US has said it will support, calls for an "independent, international inquiry" into the Lankan actions during the concluding phase of the war against the LTTE. The report also calls for investigations of "violations" of international law. In addition, India is uncomfortable with the idea of special rapporteurs being appointed to visit Sri Lanka, fearing that at some stage it could come back to bite New Delhi.

"Our initiative is to find a solution... go beyond pain and anger. We want a sustainable settlement to the issues in Sri Lanka. "There is no question of our having a blinkered vision of the ground situation," Khurshid said.

Traditionally, India did not support country-specific resolutions, though New Delhi went against its own unwritten rule to vote against Sri Lanka at the UNHRC last year. Second, there is a strong opinion in the government that the US resolution is basically going after an easy target. "There is no accountability sought in the wars in Iraq or Afghanistan, where there was significant violations of international law," said sources.

Quietly, the government is also wary of fanning the flames of ethnic nationalism among the Tamils again, given the dangers of that operating in India as well. In the past year, Tamil Nadu has seen violence against Lankan tourists and pilgrims which has got the Centre worried.

Human rights organisations like Human Rights Watch (HRW) have documented horrific tales of rape and torture of Sri Lankan Tamil detainees who have told their stories after fleeing from the country. This is in addition to the film, No Fire Zone by Callum McCrae, which showed disturbing visuals of Prabhakaran's son's last hours.

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Vt. lye victim gets new face at Boston hospital


BOSTON (AP) — A Vermont woman whose face was disfigured in a lye attack has received a face transplant.


Doctors at Boston's Brigham and Women's Hospital say 44-year-old Carmen Blandin Tarleton underwent the surgery earlier this month.


A team worked 15 hours to transplant the facial skin, including the neck, nose, lips, facial muscles, arteries and nerves.


The 44-year-old Tarleton, of Thetford, Vt., was attacked by her former husband in 2007. He doused her with industrial strength lye. She suffered chemical burns over 80 percent of her body. The mother of two wrote a book about her experience that describes her recovery.


It was the fifth face transplant at the Boston hospital.


Physicians are planning to discuss the case Wednesday at the hospital.


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Pope Thanks Crowd in Final Address












On his final full day as the leader of the Roman Catholic Church, Pope Benedict XVI thanked a huge crowd for respecting his historic decision to step down and told them that God will continue to guide the church.


"The decision I have made, after much prayer, is the fruit of a serene trust in God's will and a deep love of Christ's Church," Benedict said to cheers in his last public words as pope.


Benedict, 85, is the first pope to resign in 600 years. He told the crowd today that he was "deeply grateful for the understanding, support and prayers of so many of you, not only here in Rome, but also throughout the world."


Pope Benedict's Last Sunday Prayer Service


Under sunny skies on this late February day, hundreds of thousands of people, some waving flags, some banners, flocked to Vatican City to see Benedict make a final lap around St. Peter's Square. Throughout his eight-year papacy, Benedict has conducted a weekly audience from St. Peter's. Before delivering his last papal address today, Benedict waved to the festive group of supporters as he toured the square in his glass-encased popemobile.


The city of Rome planned for more than 200,000 people to head to the Vatican for today's event. Streets around St. Peter's were blocked off to cars as pedestrians from around the world headed to the square.








The Conclave: Secret World of Picking the Pope Watch Video











Papal Appearance: Faithful Flock to Saint Peter's Square Watch Video





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The conclave to elect Benedict's replacement will start next month at a date yet to be determined. Benedict issued a decree known as a "motu poprio" that will allow cardinals to convene the conclave sooner than the March 15 date that would have been mandated under the old rules.


Benedict today asked the faithful to pray for him and for the new pope.


"My heart is filled with thanksgiving to God who ever watches over his church," Benedict said.


The German-born Benedict, who had appeared frail at times in recent months, seemed more energized in his remarks today. He has said he will devote more time to prayer and meditation after he leaves the papacy.


Benedict will meet Thursday with his cardinals in the morning and then flies by helicopter at 5 p.m. to Castel Gandolfo, the papal residence south of Rome. Benedict will greet parishioners there from the palazzo's balcony, his final public act as pope.


Then, at 8 p.m., the exact time at which his retirement becomes official, the Swiss Guards standing outside the doors of the palazzo at Castel Gandolfo will go off duty, their service protecting the head of the Catholic Church finished.


In retirement, Benedict will continue to wear white and will be called "Pope Emeritus," or the "Supreme Roman Pontiff Emeritus" or "Your Holiness," the Vatican announced Tuesday. Benedict will ditch his trademark red shoes, opting for a pair of brown shoes given to him on a trip to Mexico. But he will still reside on Vatican grounds in a former nunnery.


Benedict's final days as pope have been marked by controversy. For nearly a week now Italian newspapers speculated that Benedict really resigned because of a dossier he was given detailing a sex and blackmail scandal in the Catholic Church. The Italian media news reports do not state any attribution.


It turns out a dossier does exist. The Vatican spokesman Monday underscored that the contents of the dossier are known only to the pope and his investigators, three elderly prelates whom the Italian papers have nicknamed "the 007 cardinals."


But the dossier itself will remain "For the Pope's Eyes Only."






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Italy faces post-vote stalemate, spooking investors


ROME (Reuters) - The Italian stock market fell and state borrowing costs rose on Tuesday as investors took fright at political deadlock after a stunning election that saw a comedian's protest party lead the poll and no group secure a clear majority in parliament.


"The winner is: Ingovernability" ran the headline in Rome newspaper Il Messaggero, reflecting the stalemate the country would have to confront in the next few weeks as sworn enemies would be forced to work together to form a government.


In a sign of where that might lead, former prime minister Silvio Berlusconi indicated his center-right might be open to a grand coalition with the center-left bloc of Pier Luigi Bersani, which will have a majority in the lower house thanks to a premium of seats given to the largest bloc in the chamber.


Results in the upper house, the Senate, where seats are awarded on a region-by-region basis, indicated the center-left would end up with about 119 seats, compared with 117 for the center-right. But 158 are needed for a majority to govern.


Any coalition administration that may be formed must have a working majority in both houses in order to pass legislation.


Comedian Beppe Grillo's anti-establishment 5-Star Movement won the most votes of any single party, taking 25 percent. He shows no immediate inclination to cooperate with other groups.


Despite talk of a new election, the main established parties seem likely to try to avoid that, fearing even more humiliation.


World financial markets reacted nervously to the prospect of a stalemate in the euro zone's third largest economy with memories still fresh of the crisis that took the 17-member currency bloc to the brink of collapse in 2011.


In a clear sign of worry at the top over what effect the elections could have on the economy, Prime Minister Mario Monti, whose austerity policies were repudiated by voters, called a meeting with the governor of the central bank, the economy minister and the European affairs minister for later on Tuesday.


Other governments in the euro zone sounded uneasy. Allies of German Chancellor Angela Merkel made no secret of disappointment at Monti's debacle and urged Rome to continue with economic reforms Berlin sees as vital to stabilizing the common currency.


France's Socialist finance minister also expressed "worry" at the prospect of legislative deadlock in Italy but said that Italians had rejected austerity and hoped Bersani's center-left could form a stable government to help foster growth in Europe.


INSTABILITY


Fabio Fois, an economist at Barclays bank, said: "Political instability is likely to prevail in the near term and slow the implementation of much needed structural reforms unless a grand coalition among center-left, center-right and center is formed."


Berlusconi, a media magnate whose campaigning all but wiped out Bersani's once commanding opinion poll lead, hinted in a telephone call to a morning television show that he would be open to a deal with the center-left - but not with Monti, the technocrat summoned to replace him in a crisis 15 months ago.


"Italy must be governed," Berlusconi said, adding that he "must reflect" on a possible deal with the center-left. "Everyone must be prepared to make sacrifices," he said of the groups which now have a share of the legislature.


The Milan bourse was down more than four percent and the premium Italy pays over Germany to borrow on 10-year widened to a yield spread of 338.7 basis points, the highest since December 10.


At an auction of six-month Treasury bills, the government's borrowing costs shot up by more than two thirds. Investors demanded a yield of 1.237 percent, the highest since October and compared to just 0.730 percent in a similar sale a month ago.


Berlusconi, who was forced from office in November 2011 as borrowing costs approached levels investors feared would become unsustainable, said he was "not worried" about market reaction to the election and played down the significance of the spread.


The poor showing by Monti's centrist bloc reflected a weariness with austerity that was exploited by both Berlusconi and Grillo; only with the help of center-left allies did Bersani beat 5-Star, by just 125,000 votes, to control the lower house.


The worries immediately went beyond Italy's borders.


"What is crucial now is that a stable functioning government can be built as swiftly as possible," said German Foreign Minister Guido Westerwelle. "This is not only in the interests of Italy but in the interests of all Europe."


The euro skidded to an almost seven-week low against the dollar in Asia on fears about the euro zone's debt crisis. It fell as far as $1.3042, its lowest since January 10.


"NON-PARTY" SURGES TO THE TOP


Commentators said all Grillo's adversaries underestimated the appeal of a grassroots movement that called itself a "non-party", particularly its allure among young Italians who find themselves without jobs and the prospect of a decent future.


The 5-star Movement's score of 25.5 percent in the lower house was just ahead of the 25.4 percent for Bersani's Democratic Party, which ran in a coalition with the leftist SEL party, and it won almost 8.7 million votes overall - more than any other single party.


"The 'non-party' has become the largest party in the country," said Massimo Giannini, commentator for Rome newspaper La Repubblica, of Grillo, who mixes fierce attacks on corruption with policies ranging from clean energy to free Internet.


Grillo's surge in the final weeks of the campaign threw the race open, with hundreds of thousands turning up at his rallies to hear him lay into targets ranging from corrupt politicians and bankers to German Chancellor Angela Merkel.


In just three years, his 5-Star Movement, heavily backed by a frustrated generation of young Italians increasingly shut out from permanent full-time jobs, has grown from a marginal group to one of the most talked about political forces in Europe.


RECESSION


"It's a classic result. Typically Italian," said Roberta Federica, a 36-year-old office worker in Rome. "It means the country is not united. It is an expression of a country that does not work. I knew this would happen."


Italy's borrowing costs have come down in recent months, helped by the promise of European Central Bank support but the election result confirmed fears of many European countries that it would not produce a government strong enough to implement effective reforms.


A long recession and growing disillusionment with mainstream parties fed a bitter public mood that saw more than half of Italian voters back parties that rejected the austerity policies pursued by Monti with the backing of Italy's European partners.


Monti suffered a major setback. His centrist grouping won only 10.6 percent and two of his key centrist allies, Pier Ferdinando Casini and lower house speaker Gianfranco Fini, both of parliamentarians for decades, were booted out.


"It's not that surprising if you consider how much people were let down by politics in its traditional forms," Monti said.


Berlusconi's campaign, mixing sweeping tax cut pledges with relentless attacks on Monti and Merkel, echoed many of the themes pushed by Grillo and underlined the increasingly angry mood of the Italian electorate.


Even if the next government turns away from the tax hikes and spending cuts brought in by Monti, it will struggle to revive an economy that has scarcely grown in two decades.


Monti was widely credited with tightening Italy's public finances and restoring its international credibility after the scandal-plagued Berlusconi, who is currently on trial for having sex with an under-age prostitute.


But Monti struggled to pass the kind of structural reforms needed to improve competitiveness and lay the foundations for a return to economic growth, and a weak center-left government may not find it any easier.


(Additional reporting by Barry Moody, Gavin Jones, Catherine Hornby, Lisa Jucca, Steven Jewkes, Steve Scherer and Naomi O'Leary; Writing by Philip Pullella; Editing by Alastair Macdonald)



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Impact of China's demand for iron ore on shipping industry






SINGAPORE : China's appetite for iron ore may be among the few bright spots for the shipping industry this year, although there are still many empty vessels plying the waterways.

Analysts have said that those unable to wait out the recovery are likely to go under.

After years of low freight rates, overcapacity and few cargoes, dry bulk shipping firms are finally seeing the light on the horizon.

Credit Suisse predicts China's appetite for iron ore will grow 11 per cent this year, fuelling a pick-up for shippers.

Credit Suisse expects this to spur global commodity demand to 5.3 per cent, from 4.8 per cent last year.

Mercator Lines (Singapore) believes 2013 may be a turning point.

During its third quarter, the dry bulk shipping company was forced to lower its debt by selling one vessel, and terminating settlement agreements with two of its chartered vessels in advance.

Shalabh Mittal, CEO of Mercator Lines (Singapore), said: "We have seen the worst in 2012. 2013 will be more of consolidation...We have already seen the current freight rates are better than 2012's average. So even though it is a very small increase from a very small base, the sentiments reflect that the growth in trade is happening."

But that does not mean a quick turnaround for the global market.

Industry watchers expect overcapacity rates to remain high.

ICAP Shipping said there is still an oversupply of about 16 per cent in the dry cargo market.

Christopher Jones, director of Sale & Purchase at ICAP Shipping, said: "This year, we do not see too much of an improvement. One of the key factors is the oversupply of tonnage in all sectors.

"Freight rates are still lolloping and we seize on any kind of upturn, but analysing ore trades into China for example, they are very slack at the moment because of the high price of iron ore."

ICAP Shipping added that unless more older vessels exit the market by 'scrapping', or the demolition of old ships, market fundamentals are not going to return to equilibrium anytime soon.

Meanwhile, others unable to hold out will either have to fold or find a more profitable business to operate in, like oil and gas.

Patrik Wheater, editor of Shipping World & Shipbuilder, said: "We are seeing a lot of diversification in the shipbuilding side. Shipyards, either building bulk carriers, tankers, that market is not as good as it once was, so they need to diversify and look at other segments and the oil and gas segment is a saving grace for some yards.

"Although last year 900 Chinese shipyards closed, more shipyards are likely to close in China this year."

So far in 2013, the Baltic Dry Index (BDI), the key benchmark for international freight rates, has risen 6.4 per cent, a minor recovery at least, from last year's near 60 per cent slump.

- CNA/ms



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Afzal Guru allegedly justified Parliament attack in letter written four years ago

SRINAGAR: Parliament attack convict Mohammad Afzal Guru had in a letter, purportedly written by him over four years ago, said that there was no need to be ashamed of the December 13 attack on Parliament, but had stopped short of owning any responsibility for it.

In the letter written to editor of a local Urdu weekly, Guru, who was hanged in Delhi's Tihar jail on February 9, asked Hizbul Mujahideen chief Syed Salahuddin not to be "ashamed of December 13" and stop terming the attack as a "conspiracy".

Editor of the Urdu weekly Shabnum Qayoom said that he had been receiving Guru's letters and articles and is sure that this letter was written by him.

"I used to receive his (Guru's) letters and articles, so this was nothing new. The handwriting is the same as the previous letters and articles. I do not care if people believe it to be authentic or not," he said.

Asked why he did not publish the letter for four years, he said he did not deem it appropriate.

"I believe he was swept by emotions. He was not involved but he thought that as there was no way for escape, why not accept and achieve martyrdom. I did not think it was appropriate to publish the letter that time as it would have been taken as an evidence against him, but now that he is no more, I went ahead with it," he said.

Guru had said in the letter, "I request Salahuddin to not call the attack of December 13 as a conspiracy. It pains my heart. The attacks are related to Kashmir issue. If the attack was a conspiracy, then the whole struggle is a conspiracy. We should not be ashamed of December 13".

He said as long as the Kashmir issue is kept unresolved, India and its rulers will have "temporary peace".

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Koop, who transformed surgeon general post, dies


With his striking beard and starched uniform, former Surgeon General Dr. C. Everett Koop became one of the most recognizable figures of the Reagan era — and one of the most unexpectedly enduring.


His nomination in 1981 met a wall of opposition from women's groups and liberal politicians, who complained President Ronald Reagan selected Koop, a pediatric surgeon and evangelical Christian from Philadelphia, only because of his conservative views, especially his staunch opposition to abortion.


Soon, though, he was a hero to AIDS activists, who chanted "Koop, Koop" at his appearances but booed other officials. And when he left his post in 1989, he left behind a landscape where AIDS was a top research and educational priority, smoking was considered a public health hazard, and access to abortion remained largely intact.


Koop, who turned his once-obscure post into a bully pulpit for seven years during the Reagan and George H.W. Bush administrations and who surprised both ends of the political spectrum by setting aside his conservative personal views on issues such as homosexuality and abortion to keep his focus sharply medical, died Monday at his home in Hanover, N.H. He was 96.


An assistant at Koop's Dartmouth College institute, Susan Wills, confirmed his death but didn't disclose its cause.


Dr. Richard Carmona, who served as surgeon general a decade ago under President George W. Bush, said Koop was a mentor to him and preached the importance of staying true to the science even if it made politicians uncomfortable.


"He set the bar high for all who followed in his footsteps," Carmona said.


Although the surgeon general has no real authority to set government policy, Koop described himself as "the health conscience of the country" and said modestly just before leaving his post that "my only influence was through moral suasion."


A former pipe smoker, Koop carried out a crusade to end smoking in the United States; his goal had been to do so by 2000. He said cigarettes were as addictive as heroin and cocaine. And he shocked his conservative supporters when he endorsed condoms and sex education to stop the spread of AIDS.


Chris Collins, a vice president of amFAR, the Foundation for AIDS Research, said many people don't realize what an important role Koop played in the beginning of the AIDS epidemic.


"At the time, he really changed the national conversation, and he showed real courage in pursuing the duties of his job," Collins said.


Even after leaving office, Koop continued to promote public health causes, from preventing childhood accidents to better training for doctors.


"I will use the written word, the spoken word and whatever I can in the electronic media to deliver health messages to this country as long as people will listen," he promised.


In 1996, he rapped Republican presidential hopeful Bob Dole for suggesting that tobacco was not invariably addictive, saying Dole's comments "either exposed his abysmal lack of knowledge of nicotine addiction or his blind support of the tobacco industry."


Although Koop eventually won wide respect with his blend of old-fashioned values, pragmatism and empathy, his nomination met staunch opposition.


Foes noted that Koop traveled the country in 1979 and 1980 giving speeches that predicted a progression "from liberalized abortion to infanticide to passive euthanasia to active euthanasia, indeed to the very beginnings of the political climate that led to Auschwitz, Dachau and Belsen."


But Koop, a devout Presbyterian, was confirmed after he told a Senate panel he would not use the surgeon general's post to promote his religious ideology. He kept his word.


In 1986, he issued a frank report on AIDS, urging the use of condoms for "safe sex" and advocating sex education as early as third grade.


He also maneuvered around uncooperative Reagan administration officials in 1988 to send an educational AIDS pamphlet to more than 100 million U.S. households, the largest public health mailing ever.


Koop personally opposed homosexuality and believed sex should be saved for marriage. But he insisted that Americans, especially young people, must not die because they were deprived of explicit information about how HIV was transmitted.


Koop further angered conservatives by refusing to issue a report requested by the Reagan White House, saying he could not find enough scientific evidence to determine whether abortion has harmful psychological effects on women.


Koop maintained his personal opposition to abortion, however. After he left office, he told medical students it violated their Hippocratic oath. In 2009, he wrote to Senate Majority Leader Harry Reid, urging that health care legislation include a provision to ensure doctors and medical students would not be forced to perform abortions. The letter briefly set off a security scare because it was hand delivered.


Koop served as chairman of the National Safe Kids Campaign and as an adviser to President Bill Clinton's health care reform plan.


At a congressional hearing in 2007, Koop spoke about political pressure on the surgeon general post. He said Reagan was pressed to fire him every day, but Reagan would not interfere.


Koop, worried that medicine had lost old-fashioned caring and personal relationships between doctors and patients, opened his institute at Dartmouth to teach medical students basic values and ethics. He also was a part-owner of a short-lived venture, drkoop.com, to provide consumer health care information via the Internet.


Koop was born in the New York City borough of Brooklyn, the only son of a Manhattan banker and the nephew of a doctor. He said by age 5 he knew he wanted to be a surgeon and at age 13 he practiced his skills on neighborhood cats.


He attended Dartmouth, where he received the nickname Chick, short for "chicken Koop." It stuck for life.


Koop received his medical degree at Cornell Medical College, choosing pediatric surgery because so few surgeons practiced it.


In 1938, he married Elizabeth Flanagan, the daughter of a Connecticut doctor. They had four children, one of whom died in a mountain climbing accident when he was 20.


Koop was appointed surgeon-in-chief at Children's Hospital in Philadelphia and served as a professor at the University of Pennsylvania School of Medicine.


He pioneered surgery on newborns and successfully separated three sets of conjoined twins. He won national acclaim by reconstructing the chest of a baby born with the heart outside the body.


Although raised as a Baptist, he was drawn to a Presbyterian church near the hospital, where he developed an abiding faith. He began praying at the bedside of his young patients — ignoring the snickers of some of his colleagues.


Koop's wife died in 2007, and he married Cora Hogue in 2010.


He was by far the best-known surgeon general and for decades afterward was still a recognized personality.


"I was walking down the street with him one time" about five years ago, recalled Dr. George Wohlreich, director of the College of Physicians of Philadelphia, a medical society with which Koop had longstanding ties. "People were yelling out, 'There goes Dr. Koop!' You'd have thought he was a rock star."


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Ring reported from Montpelier, Vt. Cass reported from Washington. AP Medical Writers Lauran Neergaard in Washington and Mike Stobbe in New York contributed to this report.


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