Hurricane Sandy and the Disaster-Preparedness Economy

Jeffrey Phelps for The New York Times

An assembly line at a Generac Power Systems plant. Generac makes residential generators, coveted items in the wake of Hurricane Sandy.

FOLKS here don’t wish disaster on their fellow Americans. They didn’t pray for Hurricane Sandy to come grinding up the East Coast, tearing lives apart and plunging millions into darkness.

But the fact is, disasters are good business in Waukesha. And, lately, there have been a lot of disasters.

This Milwaukee suburb, once known for its curative spring waters and, more recently, for being a Republican stronghold in a state that President Obama won on Election Day, happens to be the home of one of the largest makers of residential generators in the country. So when the lights go out in New York — or on the storm-savaged Jersey Shore or in tornado-hit Missouri or wherever — the orders come pouring in like a tidal surge.

It’s all part of what you might call the Mad Max Economy, a multibillion-dollar-a-year collection of industries that thrive when things get really, really bad. Weather radios, kerosene heaters, D batteries, candles, industrial fans for drying soggy homes — all are scarce and coveted in the gloomy aftermath of Hurricane Sandy and her ilk.

It didn’t start with the last few hurricanes, either. Modern Mad Max capitalism has been around a while, decades even, growing out of something like old-fashioned self-reliance, political beliefs and post-Apocalyptic visions. The cold war may have been the start, when schoolchildren dove under desks and ordinary citizens dug bomb shelters out back. But economic fears, as well as worries about climate change and an unreliable electronic grid have all fed it.

 Driven of late by freakish storms, this industry is growing fast, well beyond the fringe groups that first embraced it. And by some measures, it’s bigger than ever.

Businesses like Generac Power Systems, one of three companies in Wisconsin turning out generators, are just the start.

The market for gasoline cans, for example, was flat for years. No longer. “Demand for gas cans is phenomenal, to the point where we can’t keep up with demand,” says Phil Monckton, vice president for sales and marketing at Scepter, a manufacturer based in Scarborough, Ontario. “There was inventory built up, but it is long gone.”

Even now, nearly two weeks after the superstorm made landfall in New Jersey, batteries are a hot commodity in the New York area. Win Sakdinan, a spokesman for Duracell, says that when the company gave away D batteries in the Rockaways, a particularly hard-hit area, people “held them in their hands like they were gold.”

Sales of Eton emergency radios and flashlights rose 15 percent in the week before Hurricane Sandy — and 220 percent the week of the storm, says Kiersten Moffatt, a company spokeswoman. “It’s important to note that we not only see lifts in the specific regions affected, we see a lift nationwide,” she wrote in an e-mail. “We’ve seen that mindfulness motivates consumers all over the country to be prepared in the case of a similar event.”

Garo Arabian, director of operations at B-Air, a manufacturer based in Azusa, Calif., says he has sold thousands of industrial fans since the storm. “Our marketing and graphic designer is from Syria, and he says: ‘I don’t understand. In Syria, we open the windows.’ ”

But Mr. Arabian says contractors and many insurers know that mold spores won’t grow if carpeting or drywall can be dried out within 72 hours. “The industry has grown,” he says, “because there is more awareness about this kind of thing.”

Retailers that managed to stay open benefited, too. Steve Rinker, who oversees 11 Lowe’s home improvement stores in New York and New Jersey, says his stores were sometimes among the few open in a sea of retail businesses.

Predictably, emergency supplies like flashlights, lanterns, batteries and sump pumps sold out quickly, even when they were replenished. The one sought-after item that surprised him the most? Holiday candles. “If anyone is looking for holiday candles, they are sold out,” he says. “People bought every holiday candle we have during the storm.”

If the hurricane was a windfall for Lowe’s, its customers didn’t seem to mind. Rather, most appeared exceedingly grateful when Mr. Rinker, working at a store in Paterson, N.J., pointed them toward a space heater, or a gasoline can, that could lessen the misery of another day without power.

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Citing Affair, Petraeus Resigns as C.I.A. Director

The sudden development came just days after President Obama won re-election to a second term. Mr. Petraeus, a highly decorated general who had led the wars in Iraq and Afghanistan, had been expected to remain in the president’s administration.

Instead, Mr. Petraeus said in the statement that the president accepted his resignation on Friday after he had informed him of his indiscretion a day earlier.

“After being married for over 37 years, I showed extremely poor judgment by engaging in an extramarital affair,” Mr. Petraeus wrote. “Such behavior is unacceptable, both as a husband and as the leader of an organization such as ours. This afternoon, the president graciously accepted my resignation.”

Mr. Obama released a statement praising Mr. Petraeus for his “extraordinary service” to the country and saying that Michael J. Morell, the deputy director of the C.I.A., would take over once again as acting director. He served in that position briefly after Leon E. Panetta left the agency last year.

“By any measure, through his lifetime of service, David Petraeus has made our country safer and stronger,” the president said. Without directly addressing the affair, Mr. Obama added: “Going forward, my thoughts and prayers are with Dave and Holly Petraeus, who has done so much to help military families through her own work. I wish them the very best at this difficult time.” Ms. Petraeus is the assistant director of the Office of Servicemember Affairs at the Consumer Financial Protection Bureau.

The development came as a shock to the national security establishment. In a statement, James R. Clapper, the director of national intelligence, called the decision “a loss” to the country.

“Dave’s decision to step down represents the loss of one of our nation’s most respected public servants.” Mr. Clapper wrote. “From his long, illustrious Army career to his leadership at the helm of C.I.A., Dave has redefined what it means to serve and sacrifice for one’s country.”

By acknowleding an extramarital affair, Mr. Petraeus, 60, was confronting a sensitive issue for a spy chief. Intelligence agencies are often concerned about the possibility that agents who engage in such behavior could be blackmailed for information.

In his statement, Mr. Petraeus did not provide any details about his behavior, saying that he asked the president to be allowed “for personal reasons” to resign.

Mr. Petraeus praised his colleagues at the C.I.A.’s headquarters in Langley, Va., calling them “truly exceptional in every regard” and thanking them for their service to the country. He made it clear that his departure was not how he had envisioned ending a storied career in the military and in intelligence.

“Teddy Roosevelt once observed that life’s greatest gift is the opportunity to work hard at work worth doing,” he said. “I will always treasure my opportunity to have done that with you, and I will always regret the circumstances that brought that work with you to an end.”

Over the last several years, Mr. Petraeus had become one of the most recognizable military officials, serving as the public face of the war effort in Congress and on television.

Under President George W. Bush, Mr. Petraeus was credited for helping to develop and put in place the “surge” in troops in Iraq that helped wind down the war in that country. Mr. Petraeus was moved to Afghanistan in 2010 after Mr. Obama fired General Stanley H. McChrystal over comments he made to a magazine reporter.

In Afghanistan, Mr. Petraeus led the push for a similar increase in troops ordered by Mr. Obama, but he was unable to replicate the success he had in the Iraq conflict.

Last year, Mr. Obama persuaded Mr. Petraeus to leave the Army after 37 years to lead the C.I.A., succeeding Mr. Panetta, who moved to the Defense Department.

This article has been revised to reflect the following correction:

Correction: November 9, 2012

An earlier version of this article incorrectly stated that David H. Petraeus was expected to remain in President Obama’s cabinet. The C.I.A. director is not a cabinet member in the Obama administration.

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Lakers fire coach Mike Brown after 1-4 start

LOS ANGELES (AP) — The Los Angeles Lakers fired coach Mike Brown on Friday after a 1-4 start to his second season in charge.

Lakers general manager Mitch Kupchak announced the surprising move several hours before they hosted Golden State. Assistant coach Bernie Bickerstaff will coach the Lakers against the Warriors while the club's top brass searches for Brown's replacement after just 18 months in charge.

"The bottom line is that the team is not winning at the pace we expected this team to win, and we didn't see improvement," Kupchak said at the Lakers' training complex in El Segundo.

Los Angeles began the season with championship expectations after trading for center Dwight Howard and point guard Steve Nash, adding two superstars alongside Kobe Bryant and Pau Gasol. But the Lakers went 0-8 during the preseason last month for the first time in franchise history before stumbling into the regular season with an 0-3 start, losing to Dallas, Portland and the Clippers.

After finally beating Detroit last Sunday for their first win, the Lakers looked listless again in a loss at Utah on Wednesday, dropping to last place in the Western Conference. Los Angeles' defense has been largely poor, and the players still haven't figured out the new offense installed by Brown during training camp.

Combined with their aging core of talent and a massive payroll, Kupchak and owners Jim and Jerry Buss decided they couldn't wait another game to start winning. Brown was dismissed in a morning meeting.

"We're not looking five or 10 years down the road," Kupchak said. "This team was built to contend this year. There's no guarantee that this team can win a championship, but we feel that it can be deeply in the hunt. We're also aware that our players ... are getting older, so our feeling is that we can contend at this level for another couple of years."

Brown was hired in May 2011 to replace 11-time NBA champion Phil Jackson, signing a four-year deal worth roughly $18 million in May 2011. Kupchak said the eight-figure payout they'll have to make on Brown's contract wasn't a factor in their decision.

"It's a pretty direct message to all of us," Gasol said while leaving the Lakers' shootaround Friday morning in El Segundo. "There's no messing around. It's time for all of us to step it up."

In a brief news conference, Kupchak did nothing to squelch speculation that Jackson could return for a third tenure with the Lakers. The 67-year-old Jackson walked away from the club in 2011 with few apparent hard feelings, and his health has markedly improved during his time away from the NBA.

Kupchak said he hasn't reached out to any candidates for the job, but thinks it's likely the Lakers will hire an experienced coach who isn't currently working. Kupchak said he hasn't talked to Jackson, but Jim Buss' sister, Lakers executive Jeanie Buss, is Jackson's longtime girlfriend.

"When there's a coach like Phil Jackson, one of the all-time greats, and he's not coaching, I think you would be negligent not to know that he's out there," Kupchak said.

While Lakers fans had reacted with their usual panic whenever the 16-time NBA champions lose a few games in a row, Kupchak and Buss publicly appeared to stand firmly behind Brown, the longtime Cleveland Cavaliers coach. Brown had pleaded for patience with his integration of several new players into his lineup while everybody learned the new offense.

"I have great respect for the Buss family and the Lakers' storied tradition, and I thank them for the opportunity they afforded me," Brown said in a statement issued by the Lakers. "I have a deep appreciation for the coaches and players that I worked with this past year, and I wish the organization nothing but success as they move forward."

Brown's players all were fully behind him in public, with Bryant vocally suggesting critics of the Lakers' new offense should give them time to get it working. Bryant missed a significant portion of training camp while dealing with minor injuries, and Nash has a small fracture in his leg that has kept him out of the lineup since the Lakers' second game. Nash could be sidelined into December.

Yet the Lakers had given no indication they might pull one of the earliest coaching changes in NBA history until Kupchak gathered the players Friday morning to inform them of the decision.

"He told us the decision was made," Gasol said. "We didn't have a good start, and this is a team that was built to win. That's what we're all here to do."

Along with the usual urgency accompanying any Lakers season, Howard is under contract for just one more season before the six-time All-Star center can become a free agent. The Lakers' core players around Howard are all over 30, and the 38-year-old Nash barely made his debut before getting sidelined.

Los Angeles went 41-25 and reached the second round of the playoffs last season in Brown's debut, losing to Oklahoma City. Brown received criticism even for that largely successful season, with Magic Johnson predicting Brown would be fired if the Lakers lost to Denver in the first round.

Brown implemented a new offensive scheme this fall that didn't appear to suit his players' talents, yet the Lakers also played spotty defense, Brown's specialty. The Princeton-based offense received ridicule, but Bryant and his teammates largely defended the motion scheme, saying they needed time to implement it.

"I don't think we lost faith at any moment," Gasol said. "I think we all believed in what we were trying to do. We also understood it was going to take a little bit of time to do things the way they should have been done. As far as our game, it wasn't happening as fast as we all wanted it to."

Brown is a protégé of San Antonio coach Gregg Popovich. He led Cleveland to the 2007 NBA finals and went 272-138 with the Cavaliers, becoming the most successful coach in franchise history while compiling the league's best regular-season record in each of his last two seasons.

The 68-year-old Bickerstaff joined Brown's coaching staff in September. He was a head coach in Charlotte, Seattle, Denver and Washington, going 415-517.

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Advertising: Help Remedies Tries to Cure Ailments in Small Doses

DISAPPOINTED voters, runners with blisters and headache sufferers alike are getting some unexpected relief from a pop-up pharmacy that opened this week in the nation’s capital.

The “help shop,” which offers low-dose drugs for everyday woes, is the idea of Help Remedies, a start-up company that sells minimalist white packets directed at single medical issues like nausea, headache or insomnia.

The company, the collaboration of two marketers, is creating quirky scenes including a high-heel wearing model walking on a treadmill to market its “Help, I have a blister” packet of bandages, or a performer sleeping in a store window to drum up interest for its “Help, I can’t sleep” caplets.

This week, shoppers and passers-by attracted by the napper, for example, could go inside the temporary pharmacy to investigate its 10 over-the-counter remedies for conditions like body aches and allergies.

The store’s team fanned out to polling stations on Tuesday to hand out its headache packets, and then on Wednesday to the nearby Republican National Committee to share nausea relief. Their marketing may be seen as fun and zany, but the company founders, Richard Fine and Nathan Frank, say they have a serious message.

“We want people to see that there are simple solutions,” said Mr. Fine, who said his straightforward approach was influenced by his parents, who are medical professors specializing in epidemiology.

“Most people shop by brand or product, and it’s difficult to know what you should be buying and taking,” he said. “It is a confusing space for people who are not experts.”

Mr. Fine and Mr. Frank, who met while working in branding and advertising, decided to try to streamline what they see as an antiquated and cluttered pharmaceutical market.

“We wanted to take what’s basic and works, and make it human,” Mr. Fine said. Their strategy of providing single ingredients in low dosages is aimed at basic medical conditions that do not require hospitalization.

After starting the company in 2008, they consulted pharmaceutical sources to zero in on the drugs and dosages to use. Their “Help, I have a headache” formulation, for example, contains 325 milligrams of acetaminophen per caplet.

“That is less than the amount in an extra strength caplet,” said Mr. Fine. “If you need more, you can take more. But this is what pharmacists recommend.”

By that summer, Help Remedies was distributing its packets in some high-end hotel chains and business conferences. In 2009, the two men quit their jobs and started the company Web site, helpineedhelp.com, which includes a link to drug facts for each product.

To carve a niche in the crowded pharmaceutical market, Mr. Frank, who handles the company’s creative efforts, said he focused on offbeat marketing, including tactile packaging and performance windows, and viral videos that mixed up the serious, the absurd and even the goofy.

For the packaging, Mr. Frank settled on a flat, white, textured box that opens like a tin. Taking a page from product designers like Apple, he settled on a simple font called century schoolbook, in various colors.

The graphic work was originally done by ChappsMalina and Little Fury, design firms in New York, and was since updated by another firm, Pearlfisher.

Help Remedies, a privately held company, did not disclose its advertising spending, which was $400 in 2010 and $12,500 last year, according to figures from Kantar Media, a WPP unit.

With a small budget, the company has focused on spinning out lighthearted solutions to situations — like countering boredom by focusing on a bouncing ball or hangovers by staring at a rag — on its Web site, videos, bus shelters and other advertising and in the store windows of Ricky’s, a New York beauty supply company.

Help Remedies set up “living windows” like “Help, I’ve never been kissed,” with models on hand to give hugs and kisses in Ricky’s storefronts. There were also serious problems like “Help, I want to save a life,” that provided registration kits from the bone marrow donor center DKMS.

To expand, the company is adapting the living window approach to its first pop-up pharmacy, in Washington, which was delayed by Hurricane Sandy and got under way as the election results were unfolding.

In addition to giving “Help, I have a headache” packets to anyone who asked, the store manager, Melinda Welch, and her staff distributed 2,000 packets — for blisters and for body aches — to participants in the annual High Heel Race.

The company’s products are found in major pharmacy outlets like Duane Reade and CVS, as well as Target and Walgreens. Last year, the company reached $4 million in sales and is set to expand after Washington to San Francisco; Seattle; Portland, Ore.; Austin, Tex.; Chicago; and Miami.

As part of its expansion, the Washington store plans to hold a “Help, I am Insecure” event on Saturday with a life coach to provide support and advice, and a manicurist for those insecure about their nails, Ms. Welch said.

Other events at later dates include “Help, I am Lonely,” with an online dating site consultation, and “Help, I’m in an Argument with my Spouse,” with a relationship judge to settle differences.

William G. Daddi, the president of Daddi Brand Communications, said Help Remedies’s distinct packaging was well suited to compete in the crowded health and beauty market.

But he warned that tying so many products to whimsical marketing carried risks because “there will be consumer confusion and the remedies will be seen as novelty products.”

“To build a true brand, the consumer needs to see that the product is effective,” Mr. Daddi said. “There needs to be a link to tangible outcomes so people see that the product works.”

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Your Money: After the Storm: Managing Your Homeowner’s Claim

Tom Mihalek/Reuters

Mark Baronowski shoveled sand from the living room of a beach front property in Bay Head, N.J., last week. Many victims of Hurricane Sandy are novices when it comes to catastrophic insurance claims.

There is a sort of honeymoon period that occurs after a big storm like Hurricane Sandy, when insurance executives appear on the local news offering reassuring words. Their brightly painted vans pull into residential neighborhoods amid the standing water and debris. Everyone is hopeful. Handshakes and back-patting all around.

That period is about to end. Prices for roofers and construction materials will rise, disadvantageous parsing of policy language will commence and gangs of class-action lawyers will round up aggrieved clients who still have months of homelessness ahead of them. Many claims will take years to settle.

It happens every time, and so it will with this storm. That’s not to say that a majority of people with insurance claims won’t be satisfied with the check they receive or won’t get one quickly.

But when this many people have extensive damage to their most significant asset, billions of dollars are at stake for the companies that have the power to make them whole. So there is no reason for policyholders to be anything but wary until their own big check clears.

Many victims of Hurricane Sandy are novices when it comes to catastrophic insurance claims. So to see what sort of resistance they should expect shortly, I turned to the lawyers and adjusters-for-hire who do nothing but negotiate with insurance companies all day long. Some of them used to work for the companies, in fact.

Here are the things they warn people to watch out for:

THAT INDEPENDENT ADJUSTER Many people with damaged homes have started to meet with representatives who assessed their damaged homes to estimate repair costs. They may have introduced themselves as “independent adjusters,” but this is a misnomer. They represent the insurance company and are not neutral.

In storms like this, large numbers of these freelance claims adjusters parachute in from out of town. In the industry, they are known as storm troopers. They work 18-hour days for a while since no insurance company has enough of its own full-time staff to deploy after a storm like this one. Often, they make enough money not to work for months afterward.

“These guys have a lot of work to do, and it’s a thankless job,” said Matthew Tennenbaum, who used to be an independent adjuster but switched sides and now works for policyholders as a “public” adjuster in Cherry Hill, N.J.

Mr. Tennenbaum worries about the storm troopers’ thoroughness. “They’re going to see 10 properties a day and they’re quickly writing estimates,” he said. “If they spend an extra three or four hours properly writing one estimate, they could have written three more and made more money.”

Though many of them are former builders or contractors, they may not, if time is of the essence, always pull up every floor, explore every inch of the attic or look behind every wall. And they may not know much about your insurance company’s policy.

“The insurance companies hand them a manual, and they may not really understand the manual,” said J. Robert Hunter, the director of insurance for the Consumer Federation of America, who has worked for insurance companies and once ran the federal flood insurance program.  “It’s a crash course at that point.”

  The good news here is that these are not the people who make the final call on your claim. But many policyholders assume that their word is the final word.

WIND VERSUS FLOOD Back at headquarters, other adjusters have their eye on an exclusion that will be crucial for this storm, with its horrific storm surges but relatively mild winds: homeowner’s insurance generally does not cover floods.

Unfortunately, many people do not know this and many more have not purchased or renewed policies with the federal flood insurance program that covers up to $250,000 of flood damage. Researchers from the Wharton Risk Management and Decision Processes Center, working with colleagues at Florida State, the University of Miami and Columbia University, surveyed people in the storm’s path by telephone three days before it hit.

Among people within a block of a body of water, 46 percent had no flood insurance. In areas that had been evacuated in past storms or where the authorities advised people to leave, 58 percent did not have it. Moreover, 39 percent of all the people who thought they did have flood coverage mistakenly believed that their homeowner’s insurance covered it.

People without coverage but lots of damage from the storm surge might do one of a couple of things. A few stubborn ones will sue, arguing that if the wind drove the surge then it’s not really a flood. Judges haven’t taken kindly to this line of reasoning over the years, but that probably won’t keep people from trying again. The Federal Emergency Management Agency may also offer some assistance.

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A Transfer of Power Begins in China

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Exclusive: Google Ventures beefs up fund size to $300 million a year

SAN FRANCISCO (Reuters) - Google will increase the cash it allocates to its venture-capital arm to up to $300 million a year from $200 million, catapulting Google Ventures into the top echelon of corporate venture-capital funds.

Access to that sizeable checkbook means Google Ventures will be able to invest in more later-stage financing rounds, which tend to be in the tens of millions of dollars or more per investor.

It puts the firm on the same footing as more established corporate venture funds such as Intel's Intel Capital, which typically invests $300-$500 million a year.

"It puts a lot more wood behind the arrow if we need it," said Bill Maris, managing partner of Google Ventures.

Part of the rationale behind the increase is that Google Ventures is a relatively young firm, founded in 2009. Some of the companies it backed two or three years ago are now at later stages, potentially requiring larger cash infusions to grow further.

Google Ventures has taken an eclectic approach, investing in a broad spectrum of companies ranging from medicine to clean power to coupon companies.

Every year, it typically funds 40-50 "seed-stage" deals where it invests $250,000 or less in a company, and perhaps around 15 deals where it invests up to $10 million, Maris said. It aims to complete one or two deals annually in the $20-$50 million range, Maris said.

LACKING SUPERSTARS

Some of its investments include Nest, a smart-thermostat company; Foundation Medicine, which applies genomic analysis to cancer care; Relay Rides, a carsharing service; and smart-grid company Silver Spring Networks. Last year, its portfolio company HomeAway raised $216 million in an initial public offering.

Still, Google Ventures lacks superstar companies such as microblogging service Twitter or online bulletin-board company Pinterest. The firm's recent hiring of high-profile entrepreneur Kevin Rose as a partner could help attract higher-profile deals.

Soon it could have even more cash to play around with. "Larry has repeatedly asked me: 'What do you think you could do with a billion a year?'" said Maris, referring to Google chief executive Larry Page.

(Editing by Muralikumar Anantharaman)

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College hoops season starts with a military flair

The college basketball season gets under way Friday with a game at a Europe military base, two more aboard Navy ships and another featuring a reshaped national champion playing in a brand new building.

No. 14 Michigan State plays Connecticut, in its first game since the retirement of coach Jim Calhoun, at Ramstein Air Base in Kaiserslautern, Germany. It's the first game between Division I teams held in Europe.

Then it's on to the decks for No. 4 Ohio State against Marquette on the USS Yorktown in Charleston, S.C., and Georgetown facing No. 10 Florida on the USS Battan in Jacksonville, Fla.

No. 3 Kentucky, the defending national champion with a heralded freshman class, plays Maryland in the first college doubleheader at the new Barclays Center in Brooklyn, N.Y.

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Doctor and Patient: Comparative Effectiveness Studies Lack Impact

“Comparative effectiveness” studies, which compare one treatment for a particular illness against another to determine which works better, have received a lot of attention and billions of dollars in federal support in the last few years. But when I mentioned comparative effectiveness research recently to a colleague who I know is particularly interested in treatments and the clinical trials behind them, he let out a loud snort and guffaw before I even finished saying the words.

“It’s a great idea, but it’s not real life,” he said, regaining his composure. “Or at least not the real life of a lot of doctors and patients.”

To explain, he described a newly published study on treating children who are thought to have swallowed a small foreign object, like a coin or a toy. He reeled off a long list of laboratory tests, scans, scopes and X-rays that the researchers recommended for such cases, adding, “Those experts assume that everyone lives near big medical centers like theirs, but not all of my patients do. And what are we going to do if the insurance company doesn’t approve of all the tests we order?”

It took only a cursory review of comparative effectiveness research over the last decade for me to realize that my colleague was right. Despite many useful and even potentially cost-saving findings, many of them failed to change doctors’ practice and patient care.

Now a group of researchers has offered a cogent analysis in the journal Health Affairs to explain this failure. And they have done so using methods about as different from comparative effectiveness as research can be.

The researchers talked to more than 50 doctors, patient advocates and other health care experts, each of whom had created, conducted or evaluated comparative effectiveness research or helped introduce the findings into clinical practice. During the interviews, they referred to trials of blood pressure medications, spine surgery, antipsychotic drugs, a heart rhythm device, heart catheterizations and bone marrow transplantation, and then asked why some of these studies seemed to inspire enduring changes while others did not.

A handful of factors came up again and again. Those interviewed frequently referred to the fact that many of these studies did not address the actual needs of practicing clinicians and patients. For instance, one study of medications for treating psychosis focused on the differences in efficacy among the drugs, but mental health care providers really wanted to know about differences in safety.

Sometimes, too, a study’s conclusions required such a significant shift in thinking that doctors and patients had difficulty adjusting to the change, like the recent recommendations against using measures of the prostate-specific antigen, or PSA, as a screening test for cancer. Other times, the findings were so nuanced or ambiguous, with such complicated restrictions on what worked best when, that they simply were not incorporated into professional guidelines or recommendations.

But perhaps the most common reason for these studies’ failures came down to dollars. In the current health care system, clinicians are rewarded for doing and ordering more. Pharmaceutical and medical device firms reap fortunes from physicians’ orders, and a single change could cost them billions. Studies that endorse anything less than another expensive procedure or a newer and more expensive medication or the latest device are often destined for failure or a protracted struggle against drug and device companies that are willing to put up a costly fight.

“The incentives are all out of whack,” said Justin W. Timbie, the lead author and a health policy researcher at the RAND Corporation in Arlington, Va. “The current system favors treatments that are well paid, not necessarily those that are most effective.”

For example, one study found that generic diuretic pills that cost pennies a day worked better for patients with high blood pressure than newer drugs that could be as much as 20 times as expensive. Because hypertension affects tens of millions of Americans, this finding had the potential to save the health care system billions of dollars.

But the finding never really took hold; the percentage of patients taking the cheaper diuretics barely increased. Physicians had a difficult time changing their prescribing habits; limited funding prevented researchers from widely disseminating the results; and pharmaceutical companies waged an aggressive marketing campaign that included paying health care experts to speak about the study in a way that made their expensive drugs seem better.

Based on their findings from these interviews, Dr. Timbie and his fellow investigators offer several suggestions that may improve the impact of these studies. These include realigning financial incentives to support recommended changes in practice; incorporating a broad range of perspectives, like those of practicing doctors and patients, in the design, goals and interpretation of such studies; and, above all, proceeding with a clear strategy for all future comparative effectiveness research.

Despite the challenges, the researchers remain optimistic about the future. And for good reason. Their study was initiated by policy makers and financed by the federal office responsible for health care policy coordination and planning. And representatives from the new national organization, the Patient-Centered Outcomes Research Institute, whose mission is to develop and oversee such studies, have reviewed and discussed the suggestions with Dr. Timbie and the other authors of the study.

“The track record to now has not been great, but for the first time, comparative effectiveness research is a priority for the country,” Dr. Timbie said. “The whole process of generating new evidence has a degree of governance that has never existed before.”

“It’s all about impact now,” he added.

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News Analysis: For Obama, Housing Policy Presents Second-Term Headaches

A second-term president may be just the person to tackle America’s housing problems.

When President Obama first came into office, home prices were crashing, foreclosures were soaring and the previous Bush administration had just initiated the bailout of Fannie Mae and Freddie Mac, the government-backed entities that agree to repay mortgages if the original borrower defaults.

With the market in shambles in 2009, the Obama administration pursued a tentative housing policy, for the most part avoiding big moves that might have further weakened the housing market or banks. Eventually, there were some bolder initiatives, like the national mortgage settlement with big banks as well as the Treasury Department’s aid programs for homeowners.

But as President Obama’s first administration comes to an end, the government is still deeply embedded in the mortgage market. In the third quarter, various government entities backstopped 92 percent of all new residential mortgages, according to Inside Mortgage Finance, a publication that focuses on the home loan industry.

Mr. Obama’s economic team has consistently said it wants the housing market to work without significant government support. But it has taken few actual steps to advance that idea.

“I think Obama is absolutely committed to reducing the government’s role,” said Thomas Lawler, a former chief economist at Fannie Mae and founder of Lawler Economic and Housing Consulting, an industry analysis firm. “But no one’s yet found a format to do that.”

Housing policy is hard to tackle because so many people have benefited from the status quo. The entire real estate system — the banks, the agents, the home buyers — all depend on a market that provides fixed-rate, 30-year mortgages that can be easily refinanced when interest rates drop. That sort of loan is rare outside of the United States. And any effort to overhaul housing and the mortgage market could eventually reduce the amount of such mortgages in the country, angering many and creating a political firestorm.

In other words, the best person to fundamentally change how housing works may be a president who won’t be running for office again.

Most immediately, the housing market has to be strong enough to deal with a government pullback. Some analysts think it’s ready. “I think the housing recovery is far enough along that they can start winding down Fannie and Freddie,” said Phillip L. Swagel at the University of Maryland’s School of Public Policy, who served as assistant secretary for economic policy under Treasury Secretary Henry M. Paulson Jr.

The administration can take smaller steps first. Mr. Lawler, the housing economist, thinks the government could start to reduce the maximum amount that it will guarantee for Fannie and Freddie loans. In some areas, like parts of the Northeast and California, it is as high as $625,000. Before the financial crisis, it was essentially capped at $417,000.

The big question is whether the private sector — banks and investors that buy bonds backed with mortgages — will pick up the slack when the government eases out of the market. If they don’t, the supply of mortgages could fall and house prices could weaken.

Banks say their appetite depends on how new rules for mortgages turn out. In setting such regulations, some tough choices have to be made.

The new rules will effectively map the riskiness of various types of mortgages. In determining that, regulators will look at the features of the loans and the borrowers’ income. Banks say they are unlikely to hold loans deemed risky, and their lobbyists are pressing for legal protection on the safer ones, called qualified mortgages.

The temptation will be to make the definition of what constitutes a qualified mortgage as broad as possible, to ensure that the banks lend to a wide range of borrowers. But regulators concerned with the health of the banks won’t want a system that incentivizes institutions to make potentially risky loans.

One set of qualified mortgage regulations, being written by the Consumer Financial Protection Bureau, could be completed as early as January. Other regulators, like the Federal Reserve, are expected to take longer in finishing their mortgage rules.

Resolving the conflict between mortgage availability and bank strength may depend on the person who replaces Timothy F. Geithner as Treasury secretary. Mr. Geithner is stepping down at the end of Mr. Obama’s first term.

The Obama administration faces other daunting decisions.

One is how to deal with the considerable number of troubled mortgages still in the financial system. Banks might be reluctant to make new loans until they have a better idea of the losses on the old loans. “If you don’t ever deal with these problems, you may never get to where you want to go,” said Mr. Lawler, the housing economist.

To help tackle that issue, the new administration might decide to make its mortgage relief programs more aggressive. It might even aim for more loan modifications, writing down the value of the mortgages to make them easier to pay. The Federal Housing Finance Agency, the regulator that oversees Fannie Mae and Freddie Mac, has effectively blocked such write-downs on the vast amount of loans those entities have guaranteed.

A new Obama administration may move to change the agency’s stance on write-downs, perhaps by replacing its acting director, Edward DeMarco. If that happened, it would be a sign that the White House had a taste for more radical housing actions. The agency declined to comment.

Then there’s what to do with the Federal Housing Administration, another government entity that has backstopped a huge amount of mortgages since the financial crisis. The housing administration was set up to focus on lower-income borrowers, and it backs loans that have very low down payments. Its share of the market has grown since the crisis. The F.H.A. accounted for 13 percent of the market in the third quarter, according to Inside Mortgage Finance.

The new administration has to decide whether it wants the F.H.A. to continue doing as much business. The risk is that a big pullback by the F.H.A. could reduce the availability of mortgages to lower-income borrowers. Banks almost certainly won’t want to write loans with minuscule down payments since they are considered riskier.

Ultimately, housing policy comes down to one question: Which borrowers should get the most subsidies?

Right now, the government largess encompasses a wide swath of borrowers. But most analysts believe government support should be focused on lower-income borrowers.

“We will know that the Obama administration is serious about housing finance reform when it comes up with a proposal for affordable housing,” said Mr. Swagel, the University of Maryland professor.

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