Call for a New Children's Hospital

ABC News

The Southern Health network has revealed its plans for a new children's hospital in Melbourne, but it is waiting for State Government approval.

The network wants a 200 bed hospital with paedatric theatres, a cancer center and a bigger outpatient service to be built at the Monash Medical Centre site in Clayton.

It says the project would cost $220 million.

The State Government says the plans will be considered but no decision has been made.

The director of Monash Children's, Professor Nick Freezer says a new hospital is needed to keep up with demand in Melbourne's south-east.

"As the population grows in the south-east the demand for pediatric services increases," he said.

"We're increasing at about 10 percent per annum and at the moment we just can't continue to provide the services with the infrastructure we have in place."

The Health Minister Daniel Andrews says the Government provided planning money for it four years ago.

"Monash does need bigger buildings, they need new buildings and we're currently considering these matters as part of the budget," he said.

"No decision has been made, and again, I strongly support new and bigger buildings for Monash given the number of children they already treat."

The President of AMA Victoria, Dr Harry Hemley says a new hospital for children would help take the pressure off the Royal Children's Hospital.

"We're in the middle of a baby boom at the moment, so we really do need more paediatric and neonatal facilities, especially in the south-east where we've got a big population growth occurring down there now," he said.

"This is a very interesting proposal and should really be considered seriously by the Government."

The Opposition's Health Spokesman, Davis Davis says there is an undeniable need for extra health services in Melbourne's south-east.

"The Coalition supports a Monash Children's in principal," he said.

"There's no doubt that this Government should have been building and should have been focusing on the needs and services for children in the south-east."

Nursing Covering More Health Care

USA Today

FRANKFORT, Ky. — Each year, Wendy Fletcher says, she and two partners see more than 5,000 patients at their practice in Morehead, Ky.

They are not doctors, but rather registered nurse practitioners who say they are able to increase access to health care and make it more affordable.

"None of us are trying to play doctor," she said.

"If we'd wanted to be doctors, we would have gone to medical school," added nurse practitioner Melinda Staten of Louisville.

The Kentucky Medical Association claims otherwise and is fighting proposed legislation that would lift some limits on the ability of about 3,700 nurse practitioners in Kentucky to prescribe medication and perform other, mostly routine tasks such as signing a child's immunization certificate or certifying the need for employee sick leave.

Greg Cooper, a former Kentucky Medical Association president and family physician from Cynthiana, Ky., who testified against the Kentucky bill, said he objects to what he said "is this constant push by nurse practitioners to be physicians."

"It's a little bit frustrating, the way this has evolved," he said. "The family physician is the foundation of health care."

That argument has been echoed nationally by the American Medical Association, which issued a report last fall critical of the training that nurse practitioners receive.

Dealing with doctor shortage

As the debate over health care legislation continues in Washington, advocates for nurse practitioners say it is these primary care nurses who will make up for the shortage of primary care physicians and at the same time keep costs down.

According to the American Nurses Association, as of November, the median expected salary for a typical nurse practitioner in the United States was $83,293, while the median expected salary for a typical family practice physician was $160,586.

Rebecca Patton, president of the American Nurses Association, said that each year, state legislatures are seeing measures proposed that seek to increase the capabilities of nurse practitioners and in many cases eliminate a level of supervision from physicians.

Among recent examples she cited:

• In January, Ohio's Democratic Gov. Ted Strickland signed a bill that did away with the need for nurse practitioners moving to Ohio to repeat training with an Ohio physician as long as they have had prescribing privileges in another state at least one of the prior three years.

• In July 2009, Hawaii enacted a bill that gave nurse practitioners broader prescription authority that includes controlled substances.

In addition, the association cited several additional states that have bills pending that would either broaden or restrict prescription writing ability for nurse practitioners, including bills in Alabama, Colorado, Washington and West Virginia. And Alabama, Connecticut, Mississippi, Nebraska and New York have bills pending related to removing requirements for physician supervision or collaboration agreements.

'Don't see a big difference'

Nurse practitioners are "gaining traction because people are seeing how cost-effective they are," Patton said. "The primary care physician shortage is going to drive it."

Judi James, 56, who lives in Morehead, Ky., said she gets her basic medical care from a nurse practitioner and has no qualms about going to see a nurse rather than a doctor.

"I really just don't see a big difference," James said. "The nurses are the ones who take care of you anyway, not always the doctor. If I need a specialist, she'll send me there."

Each state sets up regulations for nurse practitioners. In Kentucky, for example, nurse practitioners are able to practice independently without being supervised by a physician. But in order to prescribe medicine they must obtain a signed agreement from a physician, even though that physician may not work directly with or consult with the nurse.

The Kentucky bill would allow nurses to forgo the agreement when it comes to certain medications, such as antibiotics and blood-pressure medication. Prescribing controlled drugs, such as narcotic painkillers and sedatives, would still require the physician agreement.

The Kentucky bill passed out of committee and could come to the full house for consideration as soon as Monday, said its sponsor, Rep. Mary Lou Marzian, a Louisville Democrat. Marzian said she's not sure the bill can make it through the Senate.

Twelve states, including Alaska, New Mexico, Montana, Wisconsin and Wyoming, and the District of Columbia allow nurse practitioners with a nursing degree to prescribe independently, including controlled substances, according to the American Nurses Association. In 29 states, laws require physician collaboration for prescribing controlled substances.

Some states have limits on which controlled substances can be prescribed by nurse practitioners. Laws in Florida and Alabama prohibit nurse practitioners from prescribing any controlled substances.

Health Care Ad Cyclorama to Clog Media Arteries

USA Today

WASHINGTON — It's not quite election season, but President Obama is on the stump, pushing his health care bill. Now, millions of dollars in political ads aimed at swaying Congress are hitting the airwaves.

Hundreds of business groups today launch a multimillion-dollar ad campaign in an effort to stop health care legislation and fire back at White House efforts to win support for a plan Obama says would expand insurance coverage to 31 million people.

The bill Obama is pushing Congress to pass by Easter "will cost jobs and stifle any creation of jobs," says Jade West of the National Association of Wholesaler-Distributors.

At the same time, the health insurance industry as soon as today will begin airing ads of its own on cable TV networks. Those ads, by America's Health Insurance Plans, aim to blunt White House criticism of insurance companies for raising rates.

"Doctors, hospitals, medicines and tests" drive up health care costs, not insurance companies, the ads say.

The group will not say how much it's spending on the ads beyond that it is at least $1 million.

The business ads by the U.S. Chamber of Commerce and nearly 250 other organizations will air on national cable networks.

In a few days, the ads will directly target members of Congress, airing in 17 states where House members either opposed health care legislation when a version passed the chamber in November or supported it but have suggested they are wavering now, according to Chamber Vice President of Government Affairs Bruce Josten.

The ads warn: "Billions in new taxes. More mandates on businesses. Health care costs will go even higher, making a tough economy worse. Washington's not getting the message. Tell Congress. Stop this health care bill we can't afford to pay."

The Chamber would not list the 17 states in the ad buy. Josten would not say specifically what the business groups are spending on the ads, only that it's between $4 million and $10 million.

"This is the endgame when it comes to the legislation," says Evan Tracey of the non-partisan Campaign Media Analysis Group, which tracks political advertising. The ads in the states are "a call to action to make the phone ring" in congressional offices.

The ads come as Obama has ramped up his own efforts to push health care through Congress in the next few weeks.

Today, he heads to the St. Louis suburbs for a reprise of his speech Monday outside of Philadelphia, where he urged Congress to pass his 10-year, $950 billion bill that also would tighten regulations on insurance companies.

In Pennsylvania, Obama appeared campaign-style in shirt sleeves as he blasted insurers for rate hikes that have left people without coverage or care and driven up the price of California health insurance quotes.

Robert Zirkelbach, spokesman for the health insurance industry group, says Obama's characterization is unfair and that insurers want to set the record straight that health care costs, not insurance rates, are what hurts the system most.

Speaking at an industry conference at The Ritz-Carlton hotel in Washington, while hundreds of union workers and other protesters who support the legislation chanted outside, Zirkelbach called Obama's depiction of the industry "politics as usual."

He said the industry supports health care changes — but not with the bill now before Congress. He says Obama's bill doesn't do enough to drive down health care costs. "It's a missed opportunity," he says.

Alzheimer's 'Epidemic' Hitting Minorities Hardest

U.S. News & World Report

Blacks, Hispanics at much higher risk for the illness, which carries huge price tag, report finds

Over 5 million Americans are living with Alzheimer's disease, and blacks and Hispanics are at highest risk of developing the disease, a new report finds.

The report, 2010 Alzheimer's Disease Facts and Figures, from the Alzheimer's Association, finds that black Americans are about two times more likely to develop Alzheimer's disease than whites, and Hispanics face about 1.5 times the risk.

"Alzheimer's is continuing to be on the rise," said Maria Carrillo, the association's senior director of medical and scientific relations. "So many people are affected by it across the country, but we are rallying to highlight the disparities that exist in populations," she said.

Much of the increase in Alzheimer's is because of increasing high blood pressure and diabetes, which increase the odds of developing Alzheimer's in all populations.

"African-Americans and Hispanics are particularly vulnerable, because the proportion of these two risk factors is higher even still," Carrillo said. "We can actually do something about this increased risk with better management of the conditions."

This year, 500,000 new cases of Alzheimer's will be diagnosed, with a greater number of new cases expected in the years to come, the report found. By 2050, the report estimates that almost a million new cases of Alzheimer's will be diagnosed annually.

In 2006, Alzheimer's was the seventh leading cause of death in the United States and the fifth leading cause of death among those 65 and older.

From 2000 to 2006, death rates declined for most major diseases, including heart disease, breast cancer, prostate cancer, stroke and HIV/AIDS. However, deaths from Alzheimer's rose more than 46 percent during that time period, according to the report.

Not only are there more cases of Alzheimer's, but more families are shouldering the burden of the disease, Carrillo said. This is particularly true for minority families who may have less access to outside care.

"There are 5.3 million Americans with Alzheimer's," noted Robert J. Egge, vice president of public policy and advocacy. "And for each of those people there are many others whose lives are consumed with caring for those Alzheimer's patients," he said.

That totals some 11 million Americans, Egge said.

In 2009, these unpaid caregivers provided 12.5 billion hours of care "valued at $144 billion, more than the federal government spends on Medicare and Medicaid combined for people with Alzheimer's and other dementias," according to the report.

Part of the problem is that Alzheimer's isn't recognized until it is in a late stage, Egge said. "So there isn't adequate care planning and other kind of support structures, especially in communities with socioeconomic disadvantages," he said.

Another reason behind Alzheimer's grim rise is that people are living longer -- escaping illnesses such as heart disease and cancer that might have killed them before Alzheimer's arose.

"We are managing many diseases that do allow us to live longer," Carrillo said. "With age being the greatest risk factor, we are just skewing our population towards the Alzheimer's arena."

Another expert agreed.

"We have some pretty effective solutions for a lifetime of cardiovascular disease risk, but your bypass and stent may just give you time to dement," said Greg M. Cole, a neuroscientist at the Greater Los Angeles VA Healthcare System and associate director of the Alzheimer's Disease Research Center at UCLA David Geffen School of Medicine.

Often, it all adds up to many years of needed care. And since it often takes a long time to die from Alzheimer's, "you may have lost touch with your loved ones for 10 years, sometimes even 20," Carrillo said.

Research dollars remain key to turning the numbers around, she said. "We really need to focus on Alzheimer's," she said. "We need more of an investment in Alzheimer's disease."

The report found that payments for health and long-term care services for people with Alzheimer's will total $172 billion this year.

In addition, Medicare costs for Alzheimer's patients are almost three times higher than for other older people, and Medicaid costs are almost nine times higher, the report found.

Many people with Alzheimer's also have one or more other medical conditions, such as diabetes or coronary heart disease, making their care even more expensive.

Yet far less is spent on Alzheimer's research than on other diseases.

In fact, "for every $25,000 the government spends on care for people with Alzheimer's and dementia, it spends only $100 for Alzheimer research," the report said.

According to Cole, "this new report details how the long predicted 'epidemic' rise in Alzheimer's disease and other dementia is already upon us."

The report also sounds the alarm that the situation may get worse before it gets better.

"We hope to have better treatments, but cures are unlikely," Cole said. "The only cost-effective answer we can realistically try to achieve is an effective prevention program in the field of michigan geriatrics," he said.

Survey Sheds Light on U.S. Bedtime Routines

CNN

Your racial and ethnic background can shape many aspects of your life: the type of food you eat, where you live, and your political views.

Now a new survey suggests that how you sleep and what you do before you hit the hay -- whether it's watch TV, pray, or have sex -- varies by ethnic group as well.

In the survey, the first of its kind, a representative sample of more than 1,000 whites, African Americans, Asians, and Hispanics ages 25 to 60 were asked about their sleep and bedtime routines. While their answers revealed plenty of differences between groups, they also showed that we have something in common: Most of us aren't sleeping well.

In each group, roughly six out of 10 people reported that they don't get a good night's sleep every night or almost every night, according to the survey, which was conducted by the National Sleep Foundation, a nonprofit organization based in Washington, D.C.

"A significant proportion of all ethnic groups are experiencing sleepiness that impacts their day to day living," says Thomas J.Balkin, Ph.D., chairman of the National Sleep Foundation. "Sleepiness impacts every aspect of our lives, so for those people who are not getting a good night's sleep, getting better sleep will make you sharper in the boardroom, give you a better quality of life, and [make] the sun seem a whole lot brighter."

Across the board, a lack of sleep appears to be affecting people's lives and relationships.

Roughly one in four people in each ethnic group said that they missed work or a family function because they were too sleepy, and a similar proportion said they were too exhausted to have sex on a regular basis.

The survey results offered a peek inside the bedrooms of Americans, and how we spend our time before drifting off.

For instance, 75 percent of African Americans reported watching television routinely in the hour before going to bed, compared with 64 percent of whites.

Only 52 percent of Asians said they watched TV before bed almost every night, but they were far more likely to use a computer or surf the Web before bed; more than half said they did so almost every night, compared with about 20 percent in the other groups.



Sexual activity also varied among the groups. Ten percent of African Americans and Hispanics reported having sex almost every night, compared with 4 percent of whites and 1 percent of Asians.

African Americans, meanwhile, were far more likely than other groups to pray before bedtime almost every night of the week.

Who -- or what -- Americans sleep with also appears to vary by ethnicity. Nine out of 10 whites who are married or "partnered" sleep with their significant others, a slightly higher rate than that among African Americans.

But three-quarters and two-thirds of Hispanics and Asians, respectively, said that they don't sleep with their partner. Those groups, however, were more likely to share a bedroom with their children.

"Asians tend to sleep with children in their beds and that could have an impact on sleep quality because anything that disrupts sleep like a dog or kid in the bed can negatively impact sleep and the restorative value of that sleep," Balkin says. Whites were more likely to sleep with their pets than other ethnic groups, the poll showed.

Although each group reported getting between six and seven hours of sleep on the average weekday (or other workday), the amount of sleep did vary significantly. African Americans got the least (about 6.25 hours), and whites got the most (just under seven hours).

With numbers like these, it's not surprising that relatively few of the survey respondents reported consistently getting a good night's sleep. "Most people require seven to nine hours of sleep to feel rested," says Balkin. "The first step is to become aware of the problem, and then make more time for sleep and engage in practices that promote good, healthy sleep."

According to Balkin, good sleep hygiene includes going to bed and waking up at the same time each day (ideally without an alarm clock); using the bedroom only for sleep and sex; abstaining from nicotine, caffeine, or alcohol after 2 p.m.; and avoiding stressful tasks right before bed.

"If you try all these tips and are still not getting enough sleep or are still sleepy, you may have a problem that requires a greater level of intervention, such as medication or light therapy, which can help re-train or reset your body's internal clock," he adds.

The rate of diagnosed sleep disorders differs among the groups, the survey found. Whites were more likely to have been diagnosed with insomnia, while African Americans were more likely to have sleep apnea, a breathing problem that causes people to wake up frequently.

What else is keeping us awake at night? Roughly 20 percent of whites, African Americans, and Hispanics said that financial problems were causing them to lose sleep at night, compared to just 9 percent of Asians. More so than other groups, Hispanics also worried about health-related concerns.

Priyanka Yadav, D.O., a sleep medicine specialist at Somerset Medical Center in Somerville, New Jersey, says that the survey's findings suggest that she and other experts in the field need to tailor their treatment to different ethnicities.

While Asians reported the fewest sleep problems and were among the least likely to use sleeping aids (such as medication), for instance, they were also least likely to bring up sleep problems with their doctors.

"Now that I know this, if I had an Asian patient, I would ask them about their sleep to get the dialogue started," says Yadav.

"It is really important to realize how ethnicities view sleep, so we can better target our treatment recommendations," she adds.

In the end, the racial and ethnic differences in the survey may be less important than the fact that so many people struggle to get a good night's, suggests Mark W. Mahowald, M.D., the director of the Minnesota Regional Sleep Disorders Center.

"There are ethnic and cultural differences and socioeconomic factors that play a role in how much sleep everyone gets, but a significant percent of the adult population is sleep deprived," he says. "The main consequence of this is impaired performance in the workplace, in the classroom, and behind the wheel, followed by irritability."

People with busy schedules often cut back on sleep to make time for other things, Mahowald adds. But, he says, "Sleep is non-negotiable and is as important as diet and exercise to our overall well-being."

Bristol-Myers Squibb to Add Five New Drugs by 2012

Bloomberg

Bristol-Myers Squibb Co. said it plans to introduce five new drugs, including treatments for cancer, diabetes and heart disease, by 2012, as its top-selling medicine, the blood-thinner Plavix, loses patent protection.

The company also said today in a statement that earnings, excluding some costs, will drop to as low as $1.95 a share in 2013 from projected 2010 profit, topping the average estimate of analyst by 7 cents.

The five new drugs may generate more than $4 billion by 2016, according Seamus Fernandez, an analyst with Leerink Swann & Co. Bristol-Myers is meeting with investors today in New York to detail its plan to overcome the loss of as much as $11 billion in annual sales to generic competition over the next six years. Lamberto Andreotti, 59, named March 2 to replace Chief Executive Officer James Cornelius in May, said he will make acquisitions and has as much as $10 billion to spend.

“Like other drug companies, Bristol-Myers may also acquire its way to its stated financial targets if needed,” Tim Anderson, an analyst with Sanford C. Bernstein & Co. in New York, said today in a note to investors. “Although it has been steadfast in saying it would only pursue smaller deals as part of its ‘string of pearls’ approach, we continue to wonder whether a larger transaction might ultimately occur.”

New treatments expected to reach the market are apixaban for blood clots, belatacept for kidney transplants, brivanib for cancer, dapagliflozin for diabetes and ipilimumab for skin cancer, the New York-based drugmaker said today in statement.

Skin Cancer Drug

Bristol-Myers said it plans to seek regulatory approval this year for the experimental melanoma treatment ipilimumab. The company may also ask regulators to clear an added use of its cancer drug Sprycel and an injectable form of Orencia for rheumatoid arthritis.

Copies of the company’s top-selling Plavix and the blood- pressure medicine Avapro are set to flood the market in 2012, erasing $7.4 billion in sales, or about 40 percent of 2009 revenue. Plavix generated $6.1 billion of those sales. The company will lose an additional $3 billion in annual revenue from its antipsychotic Abilify by 2016 from generic competition.

Sales of the HIV treatment Sustiva are also expected to fall by $800 million from 2014 to 2015, according to Steve Scala, an analyst with Cowen & Co.

In 2013, analysts were expecting Bristol-Myers to report earnings of $1.88 a share, on average, according to a survey by Bloomberg. Bristol-Myers said it plans to have “sustained growth” starting in 2014. The company projects 2010 adjusted earnings of $2.15 a share to $2.25 a share.

The earnings estimate for 2013 excludes the potential impact of legislation overhauling the health-care system and acquisitions or licensing deals, the company said in the today’s statement. It also assumes additional cost cutting, strong sales of its current products, and U.S. approval of medicines now in late-stage testing.

Hospital Study Places Price Tag on California's Dirty Air

Sacramento Bee

California's dirty air led to nearly $200 million in hospital spending over a three-year period – including $9 million in Sacramento County – because of asthma, pneumonia and other pollution-triggered ailments, according to a study released today.

With its research, Rand Corp. attempts to put a price tag on the state's bad air. The study analyzed records from hospitals and air quality agencies from 2005 to 2007. As many as 30,000 people statewide sought relief in emergency rooms because of air pollution during that period, the report states.

Sacramento County registered the fifth-highest health costs related to pollution, according to the study, trailing Los Angeles, Orange, San Bernardino and Riverside counties.

Researchers also undertook case studies at five hospitals, including UC Davis Medical Center, to determine how their finances are affected by poor air quality. From 2005 to 2007, $1.9 million was spent at UC Davis Medical Center by Medicare, Medi-Cal and other insurers to cover the cost of pollution-related care.

"California's failure to meet air pollution standards causes a large amount of expensive hospital care," said John Romley, the study's lead author.

While there is little debate that bad air often leads to bad health, particularly among those predisposed to respiratory problems, Rand researchers say their study for the first time breaks down who paid the bills.

"Very little is known about who pays for the care. It's not trivial," Romley said. "It's not just about what's being spent, but who's paying."

Medicare and Medi-Cal paid two-thirds of the costs associated with poor air quality, according to the study. Commercial insurers and other private sources footed the rest of the bill.

Among private insurers, Kaiser Foundation Health Plans accounted for $30 million of the $193 million spent during the three-year study period. The expenses borne by insurers do not include emergency room visits, researchers said.

Not surprisingly, more than two-fifths of the expenses were concentrated in traffic-choked Los Angeles County, with the rest mostly concentrated along the state's inner valleys, from Kern to Sacramento counties, where illness-causing particulates are more likely to linger.

Researchers say hospital costs are just a fraction of the hundreds of millions of dollars spent each year on pollution-related medical care. It is small wonder we are seeing a rise in California health insurance quotes.

The study focused on pollution from ozone, most commonly derived from automobile tailpipe emissions, and fine particulate matter, such as soot from fireplaces and wood-burning stoves.

"This study shows yet another side of the air pollution story by citing the health costs, both physical and financial, that Californians must pay because of smog and soot," state Air Resources Board Chairwoman Mary D. Nichols said in an e-mail sent by her office. "In particular, data like this shows why cleaning up the state's legacy fleet of diesel engines makes economic as well as environmental sense."

An agency spokesman said the Air Resources Board is moving ahead with new regulations to reduce diesel emissions by 85 percent by 2020.

Cilostazol Proves Superior to Aspirin in Preventing Second Strokes

Doctor's Guide

Treatment with the phosphodiesterase inhibitor cilostazol proved superior to aspirin therapy in preventing stroke recurrence among patients with noncardioembolic cerebral infarction, researchers said here at the 2010 International Stroke Conference (ISC).

The study was designed to prove that cilostazol was noninferior to aspirin, but, in fact, the researchers said that treatment cilostazol was statistically superior to aspirin.

"We therefore recommend cilostazol as an option for the prevention of stroke reoccurrence in noncardioembolic stroke patients who can tolerate long-term administration of this drug," said Yukito Shinohara, MD, Department of Neurology, Tachikawa Hospital, Tokyo, Japan, during his poster presentation on February 26.

For the study, researchers from 279 institutes enrolled 2,757 individuals between December 2003 and October 2006. Eventually, 2,716 of these patients received the study medication and 2,681 were included in the safety and efficacy analysis.

Patients had suffered cerebral infarction within 26 weeks prior to enrolment and symptoms had remained stable. They were randomised in a double-blinded design to receive either cilostazol 100 mg BID or aspirin 81 mg once daily.

The primary endpoint was occurrence of stroke (a cerebral infarction, cerebral haemorrhage, or subarachnoid haemorrhage).

Stroke occurred in 82 of the 1,337 patients in the cilostazol group during 2,965.9 person-years. Two of those strokes were fatal. Stroke occurred in 119 of the 1,335 patients in the aspirin group during 3,203.6 person-years. Three of those events were fatal.

Dr. Shinohara said the treatment with cilostazol reduced the risk of suffering a stroke by about 26%. "These results establish noninferiority of cilostazol to aspirin for secondary prevention of stroke," he said. "In addition, time from start of administration to occurrence of stroke was significantly longer [P = .0357] in the cilostazol group."

In safety assessment, intracerebral haemorrhage and other brain bleeds occurred more often with cilostazol. Dr. Shinohara said 23 of the 1,337 patients randomised to cilostazol experienced these adverse events compared with 57 of the 1,335 patients randomised to aspirin (P = .0004).

He also said that headache, diarrhoea, palpitations, dizziness, tachycardia, hypertension, and constipation all appeared to occur more frequently in the patients taking cilostazol.

Funding for this study was provided by Otsuka Pharma Ltd.

In Face of Primary Care Shortage, Doctors Cut Work Hours

USA Today

Doctors have steadily cut their work hours over the past decade, a new study finds, something that experts say may only worsen the health care situation.

It's not that doctors are terrible slackers. Average hours dropped from about 55 to 51 hours per week from 1996 to 2008, according to the analysis, appearing in Wednesday's Journal of the American Medical Association.

That's the equivalent of losing 36,000 doctors in a decade, according to the researchers. And it raises policy questions amid a looming primary care doctor shortage and Congress considering an expansion of health insurance coverage that would mean more patients.

The decline in hours "occurred among all groups of physicians — young, old, men, women, residents and nonresidents — and it didn't occur in other occupations," said lead author Douglas Staiger, an economics professor at Dartmouth College.

"Something has been discouraging physicians from working the long hours they used to work," he said.

Work-hour limits for residents, or doctors in training, were introduced in 2003 and brought down the average. But when researchers removed the resident doctors from the analysis, they still found a nearly 6% decline in work hours.

Growing numbers of women in the profession contributed to the decline in hours, but they weren't a big driver of the trend, Staiger said.

Payment issues may have played more of a role. The overall decrease in hours coincided with a 25% decline in pay for doctors' services, adjusted for inflation. And when the researchers looked closely at U.S. cities with the lowest and highest doctor fees, they found doctors working shorter hours in the low-fee cities and longer hours in the high-fee cities.

Greater competition and more managed care in the low-fee cities may provide a clue to why doctors are working fewer hours.

"It's not so much the fees as the hassle factor," said Dr. Robert Perlmuter, a Chicago internist, who works 60 hours a week. He told about a recent problem with a pharmacy benefit manager. A series of faxes and phone calls got conflicting answers about which of three types of insulin the patient's plan would cover. By the time it was sorted out, "the patient missed insulin for a day."

"There's so much oversight for what we do, so many people we have to answer to and so little of it improves care, it's just driving us all crazy," Perlmuter said.

Four years ago, Dr. David Ellington, a family doctor in Lexington, Va., cut back from 65 to 50 hours a week, improving his life "by a factor of about a zillion."

"It added five or six years onto my practice life — and I love what I do," Ellington said. "I couldn't have continued to do what I was doing. I couldn't do it physically, emotionally and financially. It had become overwhelming."

The researchers based their analysis on data from U.S. Census Bureau household surveys. The data included self-reported hours from about 27,000 doctors. The study was supported by a grant from the National Institute on Aging.

"This really presents a problem for us as a country as we strive to maintain a sufficient primary care work force," said Dr. Ann O'Malley of the nonpartisan Center for Studying Health System Change, which has found declines over the past decade of about two hours per week in doctor work time.

The center's surveys add a piece to the puzzle. They've found overall work hours for primary care physicians and medical specialists declining, but hours worked by surgeons remaining stable, said O'Malley who wasn't involved in the new study.

On top of that, fewer medical students are choosing primary care and more are pursuing higher paying specialties. Paying primary care doctors for the time they spend coordinating care, such as talking to other doctors and avoiding duplicative tests, could help, she said.

Primary care doctors handle 2,300 patients on average, far too many for them to be able to realistically follow guidelines for managing their patients' chronic illnesses, let alone their acute care needs, said Dr. Thomas Bodenheimer of University of California, San Francisco. He wasn't involved in the new analysis but studies work force issues in primary care.

"It's just too many patients to take care of," Bodenheimer said. "And you don't make that much money for each visit. It's really exhausting. It's extremely hard work."

Doctors Threaten Medicare Backlash

CNN Money

The American Medical Association said doctors are either seeing fewer 

Medicare patients or not accepting new Medicare patients.

NEW YORK (CNNMoney.com) -- With a 21% cut to Medicare reimbursement rates set to take effect Monday, the nation's largest physician organization has informed its members about their options -- which include shutting off practices to new Medicare patients.

"To our physicians, we are providing information on their Medicare participation options, including how to remove themselves from the Medicare program," said James Rohack, president of the American Medical Association, whose more than 250,000 members include doctors, medical students and faculty members.

Some 43 million Americans receive Medicare coverage. For doctors who accept Medicare, federal law requires that reimbursement rates be adjusted annually based on formula tied to the health of the economy.

That law says rates should be cut every year to keep Medicare financially sound. But Congress has blocked those cuts from happening in seven of the last eight years and could still do so this year.

Those temporary fixes aren't good enough anymore, warned Rohack.

He said the AMA wants the current law to be repealed and a new formula used "that more accurately reflects the cost of providing care" in determining Medicare reimbursement rates.

In the meantime, physicians are asking the AMA to prepare handouts they can give patients to prepare them for the worst-case scenario: getting dropped completely. And a new report on the AMA's Web site tells doctors how they can help their patients find other doctors if they decide to no longer accept Medicare.

"All this is a result of physicians becoming very frustrated with the situation," said Rohack. "It's regrettable, but it reflects the current political environment. Congress need a crisis before it acts."
Dropping patients

Dr. Edward Kornel, a neurosurgeon based in White Plains, N.Y., stopped seeing Medicare patients two years ago. Two colleagues in his group practice have joined him in dropping Medicare patients over the past six months.

Kornel, who's been in practice for 27 years, said he had always accepted Medicare patients in the past.

"But when I looked at my income from reimbursements, I was losing money every time I took care of a Medicare patient," said Kornel. "It wasn't covering my costs."

While Medicare patients accounted for about 20% of his total patient load, they were generating less than 5% of his income.

"I would have had to do 300 operations in one year just to break even," he said.

Still, he said he doesn't want to turn away anyone who wants him as their doctor. "If they really can't pay the fees then I will do it pro bono," said Kornel.

The American Association of Neurological Surgeons, to which Kornel belongs, has warned that Medicare patients would likely get less access to doctors if Medicare payment cuts continue.

In a survey, the association found that 65% of its 3,400 members said they are referring their Medicare patients to other doctors. About 60% said they were reducing the number of Medicare patients in their practice.

"These results paint a bleak path we are going down," said Dr. Troy Tippett, president of the association.

However, the federal government's Center for Medicare and Medicaid Services said that its own data, and other industry reports, show that only a small percentage of beneficiaries unable to get physician access.

The agency maintains that 96.5% of all practicing physicians, nearly 600,000 doctors, currently participate in Medicare.

Dr. Priscilla Arnold, an ophthalmologist based in Bettendorf, Iowa, and past president of the American Society of Cataract and Refractive Surgery, isn't buying those numbers.

"You have to assume that CMS' data reflects physicians that are accepting Medicare patients but [do] not account separately for those who are reducing the number of Medicare patients," said Arnold, who added that a majority of her patients are on Medicare.

She said she has to "realistically evaluate" every year if she can continue to see all her patients.

If this latest cut goes into effect, Arnold said many doctors in her specialty won't be able to sustain their practices. "This year, the situation is more crucial than ever," she said.

Kornel said consumers should prepare for some difficult days ahead.

"If doctors drop Medicare patients, these people will be forced to go to clinics where it's hard to get appointments, the waits are long and you get far less attention than you would otherwise get," said Kornel. "I think this situation is headed for disaster."