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A sleepless night can leave you feeling bleary-eyed and tired, but most people quickly recover from a bout of insomnia. However, millions of people suffer from sleep disorders so persistent that their quality of life is compromised and various other medical disorders begin emerging. People who don’t get enough sleep can experience a multitude of physical and mental illnesses. In this article, we’ll talk about sleep disorders and how they can impact your life.

There are over one hundred different types of sleep problems that can be classified into four categories. Insomnia include difficulty falling and staying asleep. Narcolepsy and sleep apnea are examples of sleep disorders that prevent people from staying awake. People suffering from jet lag or those who have trouble sleeping because of shift work are having a disturbance in their sleep/wake cycle. People who experience sleepwalking or enuresis are experiencing sleep interruptions associated with behavioral problems. Any condition in which your sleep doesn’t follow the typical sleep phase cycle or doesn’t stay in each cycle for a sufficient period of time is a disruptive sleep disorder.

Those who have disrupted sleep tend to not experience “restorative sleep.” Sleep deprivation can make you irritable, tired, have less focus, a lower frustration level, and can lead to exhibiting behavior that’s more emotional and impulsive. One dangerous fact about sleeping disorders is that they weaken the immune system and make us more susceptible to other diseases like diabetes, cancer and even the common cold. It is not uncommon for people who suffer from sleep deprivation due to sleep disorders such as sleep apnea, narcolepsy and insomnia to also suffer from other problems including diabetes, asthma or a second sleep disorder.

When gaining insight about sleep disorders, you will find that no one is immune. Many elderly people suffer from insomnia and often have to be put on medication for the condition. Some of the common sleep disorders that affect children include night terrors, nightmares and bedwetting. Nearly seventy percent of women report that they suffer from some type of sleep disorder. Similarly, over forty percent of women admit that daytime sleepiness disrupts their daily activities. Although menopausal and pregnant women are far more likely to suffer from a sleep disorder, women are two times more likely than men to experience a malady of this kind.

Almost everyone suffers from a sleep disorder at some time, but ignoring a persistent problem could result in serious health problems. Recovery may include a lifestyle change or altering your sleep habits. Talk to your doctor about sleep disorders and find out more about the variety of treatments available. A good night of sleep can improve both your health and your quality of life.

Washington -- Primary care doctors would receive higher Medicare payment rates under a proposal that a panel of congressional advisers will send to Capitol Hill in June, but at least one lawmaker is considering such a plan before the proposal even arrives.

Medicare Payment Advisory Commission members are worried about a growing primary care physician shortage and fear that fewer new doctors are going into primary care because of the relatively low rates that Medicare pays for their services. MedPAC found that nearly 30% of beneficiaries who are looking for a new primary care physician report difficulty in doing so.

Boosting rates to those types of physicians could help address the problem by acting as a financial incentive, MedPAC decided at its April meeting in Washington, D.C. "Primary care services have become undervalued over time, and thus they risk becoming under-provided," MedPAC senior analyst Cristina Boccuti told the panel.

As a result of a review of how much it pays for each Medicare treatment, the Centers for Medicare & Medicaid Services in 2006 decided to boost the relative values it assigns to some of the types of services that primary care physicians often provide. The MedPAC proposal would go one step further by designating individual doctors as primary care or non-primary care physicians and allowing members of the first group to use a special modifier on their claims. The modifier would garner higher rates for evaluation and management services.

MedPAC likely will advise giving the administration much of the say over which doctors can use the modifier. Under one scenario, the Dept. of Health and Human Services would start with physicians who designate themselves as generalists and then target the subset who provide primary care the majority of the time.

Another option would have HHS base the rate add-on solely on how often doctors provide primary care services. This would allow specialists who offer a lot of primary care to get the extra pay.

MedPAC also voted to recommend that Medicare give additional monthly payments to physicians who provide a "medical home" for chronically ill beneficiaries. The program is already involved in a limited medical home pilot project, and MedPAC will urge that Medicare take it nationwide.

Physicians divided

Senate Finance Committee Chair Max Baucus (D, Mont.) is not waiting for the official MedPAC report to arrive on his desk before putting some of its recommendations on the table.

During an April 11 meeting with several medical specialty organizations, Baucus floated a Medicare physician payment package that he hopes to bring to the Senate floor in May. In addition to stopping upcoming across-the-board cuts for 18 months, Baucus hopes to include a primary care rate boost and a medical home project expansion. But because of Medicare budget neutrality rules, putting more money into primary care would necessitate payment cuts for other doctors. This was the case when CMS approved the relative value changes in 2006.

Nearly 30% of Medicare beneficiaries report trouble finding a primary care doctor.

The American Medical Association convened the group that recommended those relative value changes. It supports further improvements to primary care physician pay, said AMA Board of Trustees Chair Edward L. Langston, MD. But Congress should commit additional funds to Medicare so that cuts to other doctors are not needed, he said.

"Unfortunately, Medicare required the [relative value] increases to be budget neutral, which led to across-the-board reductions for all physicians, including primary care," Dr. Langston said. "Rather than another budget-neutral change that robs Peter to pay Paul, Congress should fund investments in the primary care infrastructure with additional funds."

Several physician organizations attending the Baucus meeting applauded his plan, despite its tradeoff. In an April 17 letter to Baucus, the leaders of the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Assn. wrote that Medicare pay increases focused on primary care doctors would help address the shortage.

"We look forward to working with you on the initial steps that can be taken now to provide such targeted primary care payment increases, recognizing that such increases may fall within current Medicare fee schedule budget-neutrality rules," the letter states. "Over the longer term, we believe that new ways are needed to fund primary care that take into account the evidence that primary care is associated with better outcomes and lower utilization of services covered under other parts of Medicare."

Physicians who would be on the other side of this equation reject the approach and warn that the goal of bolstering primary care could have unintended negative consequences if not done properly.

Virtually no radiologist would qualify for a primary care add-on or an evaluation and management rate boost under the MedPAC or Baucus plans, said Arl Van Moore, MD, chair of the American College of Radiology's board of chancellors. Thus, the more physicians are able to capture the extra dollars, the more Medicare would need to slash imaging payments. Medicare services, such as mammography, could become more difficult to access if the rate reductions take too big a bite, he said.

In recent years, radiologists received two blows to their payment rates through the CMS relative value adjustments and an imaging cut package approved by Congress. They fear that this proposal would be strike three, Dr. Moore said. ACR is seeking a solution that is more equitable to more specialties. "This pits one specialty against another," he said. "These proposals tend to divide medicine."

Surgeons also are worried about the consequences of shifting money to primary care based on a gut reaction to reports of a physician shortage, said Karen R. Borman, MD, professor of surgery at University of Mississippi Medical Center and a MedPAC member. The most recent CMS relative value update, for instance, shifted more money into primary care services than Medicare pays for all services in five surgical specialties combined.

Another such boost could cause increases in the volume of services in areas where spending is already on the rise and punish those who are keeping their spending in check, she said.

Washington -- Uninsured people die prematurely at a rate that equals several additional deaths per day in highly populated states, such as Texas, Florida and California, according to recent analyses by the consumer group Families USA.

The reports, released in March and April, are based on earlier studies by the Institute of Medicine and the Urban Institute, a policy research organization. Overall, uninsured people between the ages of 25 and 64 were 25% more likely to die than their same-aged insured counterparts, concluded the 2002 Institute of Medicine report from 2000 data. This increased mortality equaled an additional 18,000 deaths in 2000. The Urban Institute found that lack of insurance caused 22,000 adults' deaths in 2006.

The Families USA analysis, "Dying for Coverage," used the two organizations' methodologies to develop state-specific mortality rates for the uninsured. For example, the estimated number of uninsured adults between 25 and 64 years old in Texas who died prematurely between 2000 and 2006 was nearly 17,700, or more than seven each day, the report said.

"Health insurance really matters in how people make their health care decisions," said Ron Pollack, executive director of Families USA. "We know that people without insurance often forgo checkups, screenings and other preventive care."

But one can't conclude that being uninsured alone killed people, said Kim Bailey, Families USA senior health policy analyst. Instead, not having health insurance is associated with mortality-increasing behavior. "We can't actually attribute any individual deaths," Bailey said.

Still, lack of insurance can hasten death, said AMA President-elect Nancy H. Nielsen, MD, PhD. The death of one uninsured woman in her 50s sticks in her mind. A few years ago, a former student of Dr. Nielsen invited her to speak at a Cleveland hospital. As part of the invitation, Dr. Nielsen was given an old case to diagnose in front of an audience: A woman in her 50s without health insurance who was experiencing abdominal pain.

Uninsured people ages 25 to 64 are 25% more likely to die than their insured counterparts.

After hearing several minutes of background on the patient, Dr. Nielsen eventually asked when the woman's last Pap smear was. The answer: 10 years ago. The woman had developed uterine cancer, a curable disease if caught early. She died a few months after the initial diagnosis.

"You can dance around it all you want, but people who do not have health insurance delay the kinds of preventive care that everybody acknowledges are critical," Dr. Nielsen said. "That woman had a preventable, curable disease, and as a society we failed her because we have not made affordable health care available to all Americans."

The AMA's proposal to expand access to health insurance calls for providing tax credits or vouchers to individuals and families, based on income, to help them buy health insurance. The plan also includes expansion of health plan choices, more unified regulation of health insurance, guaranteed policy renewals, an individual insurance mandate for those earning more than 500% of the federal poverty level, and subsidies for high-risk enrollees.

But even people with health insurance die prematurely, noted Timothy Gorski, MD, an ob-gyn in Arlington, Texas. He said the premise that being uninsured leads to premature deaths is "plausible." But "there's lots and lots and lots of reasons why people don't get preventive care that could save their lives."

For example, depression leads people to delay or forgo care, as does fear of colonoscopies and other uncomfortable preventive procedures. Also, sometimes people would rather spend money on things other than health care, Dr. Gorski said.

Washington -- The Centers for Medicare & Medicaid Services did not follow federal law when it issued a directive limiting enrollment in a children's health program to kids in lower-income families, according to a new Government Accountability Office opinion.

State officials are concerned that they could not meet a provision in the CMS State Children's Health Insurance Program directive taking effect on Aug. 17. Among its restrictions, the order requires states to cover 95% of SCHIP-eligible children in families earning 200% or less of the federal poverty level before receiving federal funding to cover children in families earning 250% of poverty or more. Existing SCHIP enrollees would not be affected, the agency said.

The April 17 GAO opinion -- requested by Sen. John Rockefeller (D, W.Va.) -- found that the Aug. 17 CMS directive is a regulation that should have been submitted to the GAO and Congress for review and is not in effect until CMS does so. The Congressional Review Act requires this step to keep both the GAO and lawmakers informed of agency activities. But the law doesn't have an enforcement mechanism, said Dayna Shah, GAO managing associate general counsel.

CMS spokesman Jeff Nelligan said the opinion did not change the agency's view that the directive will go into effect on Aug. 17.

The GAO opinion arrived about a week after CMS announced that more than half of the 17 states subject to the directive's 95% standard already may have met it.

Some kids must wait

The SCHIP rules, issued on Aug. 17, 2007, are designed to make sure the program covers children from the lowest-income families first. "SCHIP was never designed or funded to serve all 78 million children in the United States at all income levels," testified Dennis Smith, then-director of the CMS Center for Medicaid and State Operations, at an April 9 Senate Finance subcommittee hearing on the directive. Smith voluntarily left his position on April 11.

States have fared better than they initially expected with the 95% standard, Smith said. At least nine of the 17 states that cover children above 250% of poverty already might meet the standard.

"We believe that it's aggressive but achievable," he said. Smith did not release the names of the nine states because CMS had not verified state-submitted data supporting their claims.

The AMA has asked the Bush administration to rescind the SCHIP directive. States have railed against the CMS policy. Five have filed lawsuits to block it. For example, states have questioned how they are supposed to calculate when they have covered 95% of eligible children. While no state would meet the standard under the Census Bureau's Current Population Survey, that count is known to underestimate Medicaid and SCHIP enrollment by several million people, testified Chris L. Peterson, a specialist in health care financing with the Congressional Research Service.

Smith said that data adjusted for the Census undercount show states faring much better than they initially expected.

The news didn't change the views of most members of a Senate Finance subcommittee, especially its chair, Rockefeller, who questioned Smith intensely during the April 9 hearing. "The [SCHIP] directive is a bold-faced attempt to subvert the law and prevent states from implementing their plans to provide health insurance coverage to millions of uninsured children nationwide," Rockefeller said.

The Aug. 17 order "is a solution to a problem that doesn't exist," he said. Of the 7 million children covered by SCHIP in 2007, only 5% were in families earning more than 250% of poverty, testified Peter Orszag, PhD, director of the Congressional Budget Office.

Rockefeller, like many other lawmakers and state officials, wants to block the SCHIP directive. He's the sponsor of the Economic Recovery in Health Care Act of 2008, which would delay until April 1, 2009, not only the SCHIP order but also seven controversial Medicaid rules CMS has issued in the last year. The bipartisan measure would provide additional federal funding to states for Medicaid and other programs. The bill, unveiled on April 3, has not yet faced a committee vote.

Sen. Chuck Grassley (R, Iowa), the highest-ranking Republican on the Senate Finance Committee, said he has no problem with the directive's goal of covering children from the lowest-income families first. "While I do have some questions about how the policy would work, I think the intent is laudable," he said.

Smith said the directive was issued to close loopholes left open by the legislation that created SCHIP in 1997. Specifically, the program limits income eligibility to 200% of poverty or 50 percentage points above a state's Medicaid eligibility. But the law does not include a definition of family income. This has allowed states to disregard certain income and, in effect, increase eligibility for SCHIP, Smith said. New Jersey, for example, covers children up to 350% of poverty by not counting any income over 200% of poverty, he said.

The directive also is designed to prevent families from dropping private insurance for children in favor of SCHIP, an effect known as crowd-out. Dr. Orszag testified that for every 100 new SCHIP enrollees, 25 to 50 had private health coverage, although it isn't clear how many of these children's parents lost coverage versus how many dropped it voluntarily.

To prevent crowd-out, the SCHIP rules also require children to be uninsured for one year before signing up for the program. "That is not meant to be punitive. It is meant to be preventive," Smith said.

Rockefeller wondered why the administration didn't apply the same 95% standard to Medicare Part D, even though Dr. Orszag testified that Part D produces the same crowd-out effect as SCHIP.

Rockefeller and some other Democrats in Congress interpreted the directive as the administration's attempt to force its SCHIP priorities on Congress and the states. Democrats and some Republicans have spent the last 18 months trying to advance legislation expanding the program to cover millions more uninsured children. President Bush has vetoed such SCHIP bills repeatedly.

Washington -- Proposed rules for patient safety organizations are a good effort toward creating a process that would keep reports on medical errors confidential, the American Medical Association said in a comment letter submitted to the Agency for Healthcare Research and Quality. But the regulations could use a few modifications to make the safeguards even stronger, the Association said.

PSOs will collect information from physicians, other health professionals, hospitals and other institutions on medical errors so the information can be analyzed and trends reported to the medical community. Congress authorized the creation of these organizations when it passed the Patient Safety and Quality Improvement Act of 2005. On Feb. 12, AHRQ published the proposed regulation that would implement the law.

"The proposed rule strikes the appropriate balance between federal oversight and the creation of a voluntary reporting system," said AMA Trustee J. James Rohack, MD. The Association was a leading advocate for passage of the patient safety legislation and applauds AHRQ "for capturing the legislation's intent in the proposed rule."

To ensure PSOs' success, the AMA will educate physicians on the reporting system, encourage their active participation and provide input on the system's creation, Dr. Rohack said.

Maintaining confidentiality is critical to making PSOs work, because physicians must trust that the information they report will not be used against them, the AMA said in its April 11 comment letter. It urged an even broader definition of patient safety work product, which is any data reported to or developed by a PSO that could improve health care outcomes. Work product also includes the deliberations and analysis of the data.

The regulation should clarify that PSOs can study data from sources that are not part of the PSO and that confidentiality extends to deliberations and analysis of these data, wrote AMA Executive Vice President and CEO Michael D. Maves, MD, MBA. The definition should be as broad as other definitions of work product in federal law, encompassing impressions, personal recollections, theories and strategies, he said. Verbal discussions among doctors also should be included.

"Physicians have a duty to share their knowledge and skills," Dr. Maves wrote. Doctors and other health care professionals shouldn't feel prohibited in any instance from discussing with each other information that may be reported to a PSO and that is critical to safe patient care and preventing harm, he added.

Keeping reported information confidential is "absolutely critical" to making PSOs work, agreed Edward J. Dunn, MD, MPH, director of policy and clinical affairs for the VA's National Center for Patient Safety in Ann Arbor, Mich.

Protecting doctors from the threat of a lawsuit is the only way to encourage reporting, he said. "If you won't protect information, you won't get reports. If there are no reports, it's hard to improve on the system."

PSO concept shown to work

Confidentiality has been a factor behind the VA's success with its medical error reporting system, Dr. Dunn said. The agency receives between 10,000 and 12,000 reports a year and has conducted almost 15,000 root cause analyses, he stated. The VA credits its PSO system for the redesign of a pacemaker that automatically turned itself off in error. A faulty program switched the device into demonstration mode, he said.

Medical culture should try to find out why someone made a mistake instead of blaming that person, Dr. Dunn added. He made a comparison to the airline community's approach to investigating crashes. "Do you leave the event learning something, or blaming the pilot?" Dr. Dunn asked. "We are always drilling down why it happened."

The AMA also expressed concerns to AHRQ about keeping PSO data from health care regulatory bodies. To encourage reporting, the rule proposes banning public and private entities that oversee physicians from becoming PSOs. This would help assure physicians that reported information is used to improve safety, not to punish or penalize, the rule explained. But a component organization could be a PSO if separated from the parent by a "firewall" between its activities and the regulatory body.

To prevent an entity from circumventing the firewall, the regulations should require additional steps, the AMA said. "Even the perception that such activity by a regulatory entity is possible could be enough to completely undermine the intent of the law," Dr. Maves wrote. The rules should force component PSOs explicitly to identify their parent organization as a regulator and specify the scope of the parent organization's regulatory authority.

The rules should be finalized by the end of 2008, according to an AHRQ source speaking on background. The agency does not discuss comment letters and declined an interview request by AMNews.