#am having heart attack-like symptoms and was hard to concentrate. but its probably not a heart attack and just blood circulation issue.

[magz]

Ok bye

[bts7writings]

BTS Reaction When You Have Philophobia (Fear of Love)

A/N - I looked into the phobia and since there were 7 common symptoms, I thought i’d be better to give one each to the member and see their reactions towards that. Hope you enjoy it!!!!!

JIN

feelings of intense fear or panic

You freeze up sometimes, while other times you start having a panic attack and  they only way to stop is to start counting the number of tiles on the floor. Falling in love with Jin was gentle enough that he noticed those little things.

He noticed how you try suppressing your anxiety when you walked together by clenching your jaw or when you try shaking away the fear by tapping your fingers when he gets closer to you. You try so hard to suppress it and he doesn't want to bring it up, but when you start blinking away tears when you start to smile too much he has to.

“Tell me,“ His thumb gently passes over your cheek as both of his hands cup your face, “Does it hurt?“

“You probably think I’m depressing,“ you sniffle, “always finding something wrong or bad or thinking the worst or-“

“I think it’s a little bit different - yes” He smiles and leans his face closer so that you'd look him in the eyes, “But we’re here fo each-other and you probably think I’m too happy and easy-going and goofy-” he stops when he sees you roll your eyes and smile. He leans into kiss you softly “You need to tell me your fears and I’ll tell you mine, but that doesn't mean they’ll happen. Fears don’t come to life unless they happen and I’m trying my best to not let them happen”

SUGA

avoidance

It’s been a week and you feel like an idiot for hanging up on him after he confessed just how much he loves you. You knew that the right and sane thing to do was to call him back and say the L word back and then everything goes back to normal, but every fiber of your being clenches tightly whenever you even think about calling or going to his studio.

It wasn't a coincidence when Hoseok suggest you try this new coffee place down the street. it wasn't a coincidence that he was there - headphones half on, hooded eye, bottom lip captured on his teeth. It wasn't a coincidence that you sat down next to him waiting for him to finish his current project.

“I figured I’d give you space” he said after a while of silence, refusing to look up from his computer. “Its...I know it’s not easy for you.”

You sip your drink, careful to think about what you want to happen and what you don’t want to happen and what you cant let happen.

“Do you want me here?” Your eyes snap up to his, they looked tired.

“Ye-”

“No, I mean here here.” He closed his laptop, trying to lean in a bit closer. “As in even if you're hiding from me, you don’t want me to stop trying to find you type of here.”

“Thats a pretty long explanation of here“ you try to joke you way out of it.

He doesn't smile, “Y/N.“

“I want you here - I do, but...”The hairs on the back of your neck are pulling you to try and make a run for it, “I can’t say it back, yoongi. I want you here, but i can’t say it back.”

“I didn't ask you to say it back.” He carefully reaches over his work - trying to feel if your pulse raises higher than usual, “You want me here and I want to be here.”

He’d chide you for not telling him about it sooner, “I have to right to know that the person i love is afraid of love” - he’d say. The truthfully harsh words would always get accompanied by a small caress or kiss on the top of the head. For someone who has mastered hiding themselves and their feelings - he had great ways of getting them out of you and when you needed your headspace he’d be more than happy to rent out a studio or give you his empty apartment, just as long as you where avoiding and hiding with him knowing.

RM

sweating

You try distancing yourself from Namjoon. He always insisted on you leaning against him when watching a movie - instead of moving to another - further - seat. It would be great, unless you didn't have this hypersensitivity to this specific form of affection.

Your sweat glands started to produce wherever there was covered skin.

He comes back and before you can see what he went to get in such a rush, he puts both of his hands on your cheeks.Your elbows shrugged in surprise from the coolness that was placed on your checks. He kept his hand over the ice packets on your checks, never once showing his discomfort.

“I know its kinda hot in here” liar - you roll your eyes, the windows were fully open.

“I’m not making it better, am I?” He lets go of one icepack in order to come your hair out of your face.

Once you explain in a excruciating embarrassing matter, he just takes your hand and starts drawing on any vein he can find, easing in the silence between the two of you. He wont pressure you to talk about it and wont even try to ask unless you're open to the idea of discussing it - all he wants is to see you better because if he feels amazingly happy from loving you - he wants you to feel the same.

JHOPE

rapid heartbeat

“It’s okay” He shushes you as you try and shake your head - its not okay. “Come here.”

When he finds out about your certain episodes where you fear the feeling that is consuming both of you - he uses an exposure method. Over-flooding you with the love you deserve until you can accept it without having the fear of it going away or being lessened.

His hand goes to the back of your head, pressing your ear to his own chest. “It’s okay.” His other hands goes calmly up and down your back trying to smooth out your small shiver. “It’s okay, hear my heartbeat - its normal to feel it out of your chest” He hums carefully leaning into a more comfortable position, “I love you and my heart beats out of my chest whenever you appear because I love you - I’m okay, you're okay, we’re okay.”

JIMIN

difficulty breathing

Your throat closed up again and you stare out at Jimin as you feel a distance between the two of you. He casually says the word love to the other members, to the staff, even to the sun, but when it came to you things were different.

You couldn't say it back, even if he is the literally embodiment of what love is. You take a deep breath, trying to not be faltered by the feeling of pure love coming into you as you watch him practice his choreography.

He asked you to accompany him to the studio, since the other members were busy and he needed someone to help him. The air that you take in becomes lighter and useless to your lungs as it demands more, but pushed out everything.

Your breathing becomes erratic and forced, so much so that one side of your head starts to hurt. You give one last glance to Jimin before making your way to the hall 

“Are you okay?” You hear from the outside of the door, “I lowered the temperature in the room again to make sure you don’t get too hot, maybe-”

You open the door and give a half-smile to him - you know that if you didn't come out he’ll find someway of going into the girls bathroom.

His eyes widen as he sees how flushed and out of breathe you are, “Don’t.... lower the.... temperature, you’ll get.... sick.”

“O-okay,“ His hands go to cup yours that are on your side. He pulls them over your head and leans in carefully so theres little to no room separating the two of you, “This usually helps me when I’m breathing too hard.”

When you explain to him carefully why the hyperventilating might get better or worse with time; his smile is gone because he wont fully get it, his eyebrows are pulled to crease in-between because he’s going to try and get it, and his hands remain on yours because he needs you to get that he’s not letting them go.

V

difficulty functioning

You’ve been reading the same line over the past thirty minutes. At first you think it’s your actually lack of interest for the article assigned, but now you start to notice that it has to do a lot with Taehyung’s very strong presence.

“I can’t concentrate” you admit, gathering up your books to begin packing. He quickly stares up from his phone when he sees you moving.

Taking out on an air-pod, his pouting whines go “I didn't do anything! Why are you leaving?”

The domestic bliss of all of this makes you more uncomfortable then blissful and that has nothing to do with the fact that you might be in love with this scenario and the guy thats here.

You open your mouth to answer, but theres nothing you can really say.

“You don’t like me, do you?“ He scoffs, mostly to himself, but you see how your sudden urge to always leave the room when he’s there might have translated wrongly. Your panic of him thinking you don’t like him overcomes the panic of you thinking you do like him.

“N-no“ He looks up to you, he just loves making uncomfortable eye contact. “I just cant concentrate and focus properly when you’re around, its not that i don’t like you - its that I do like you and you’re smiling right now so I’m just going to leave“

“I’ll leave you to collect yourself“ his smile widens as the tint of your cheeks change and the corner of your lips turn downwards, “So i’ll be behind the door when you’re done with your work.“

He doesn't think much of it at first, not really sure if he could even help. He’d try to even suggest not dating as a form to make you more comfortable, but he’d end up just hating himself for even suggesting that. All he wants to do is assure you that the fear is something that you both have to work on.

JUNGKOOK

nausea

“So are you’re afraid to love me or are you afraid of loving me?” He chooses his words wisely, but he knows that whatever you answer its going to take him a good minute to digest what it means. When you don’t know how to respond, he just casually nods. “Just because I confessed to you doesn't mean I expected a responds back, but I don’t know how to respond to this” he answers honestly.

“I just want you to know that loving me isn't ideal - its not easy-” you stop your sentence when he stares back at you, half angered, “I’m sorry”

His gaze softens when he realizes his must have looked angry, “No - don’t apologize. I don’t love you because it’s easy or ideal. I love you in-spite of all of that” he half-jokes, “I’m just confused, what do you mean you’re afraid of it?”

“I mean every-time you look at me, i feel amazing for one second and then the next i feel like i want to throw up from the amount of fear that goes into loving a person.“ He sits down and motions you to sit on his lap, which you do since arguing with him on it would be counterproductive, “I mean i don’t want you to be annoyed and angry because I know i can be difficult and i know some girls would be easier to love and you can have a perfect-”

His lips go on your temple and he starts to hum deeply so you’d quiet down. after a while of silence he leans out and puts his hand on your lap. “I know...I know loving someone else is easier because they wont loose their appetite from laughing too much and they wont hesitate every-time my hand reaches out - I know.” He leans in to kiss your temple again, “But they wont be you” 

requested by @yoongisbabygirl93​ 

__________________________________________________

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Rules + Regulation ♡

[imagine-loki]

Broken Trigger Warning - Depression

TITLE: Broken

CHAPTER NO./ONE SHOT: One-shot

AUTHOR: breemaggs

ORIGINAL IMAGINE: Imagine Loki helping you through a new medication regimen. At first you don’t even tell Loki that you’re taking medication, you’re embarrassed and afraid that he’ll think you’re weak. Soon you can’t hide the exhaustion, the mood swings and the insomnia that occurs while you and your doctor attempt to find the perfect dosage. (Click to read the full imagine!)

RATING: M

NOTES/WARNINGS: Trigger Warning for discussion of depression. Rated M for language.

I was a zombie. No, I was past the zombie phase. I was just straight up exhausted. And I was starting to get frustrated. And distraught. This was supposed to be helping me. Instead it was making me worse.

And logically, I knew that new medication tended to make you dip before it picked you back up, but it had already been several weeks and two dose increases and things still weren’t better. I wanted to throw in the towel. It wasn’t working. I wasn’t sure it would ever work.

Patience, my psychiatrist said. And I knew she was right. Depression didn’t work on a time table and medication wasn’t magic. It took time to get the medication and dosage right. And giving up after two increases wasn’t going to get me anywhere. If the next one didn’t help... We’ll, then she agreed that we would need to try something different. But we weren’t there yet.

I knew recovery was a long road; I’d been walking it for years. I’d been through med changes. I’d been through the ups and downs. And the truth was... I was just tired. I was tired of trying. Tired of failing. Tired of fighting. Tired of pretending. Tired of everything. This exhaustion was deeper than just the physical symptoms.

And then there was all the effort that I put into my great act. My mask. That was another level of exhaustion. Pretending everything was okay when it wasn’t... That was hard. And I had been doing it for so long. I didn’t want to be strong anymore. I wasn’t sure I was even capable of being strong anymore.

I swiped at my leaking eyes and readjusted myself on the floor for the third time since I’d sat down. I tried to focus on the fireplace in front of me. The flames used to relax me. Now I just wished they would consume me. I sighed and cast a quick glance at the clock on the wall. Three-thirty in the morning. Witching hour. Just another reminder that I should be sleeping.

My boyfriend, Loki of Asgard, was having no trouble sleeping. Which was how I preferred it; that way he couldn’t see me like this. But he wasn’t stupid so I knew I that I probably didn’t have a lot of time until he figured it out. Or at least figured out that something was amiss, since he had no idea that I even had a mental illness, let alone one that was overrunning my entire life. So far I’d managed to get away with the excuse of getting up early for beating him out of bed. And makeup went a long way towards hiding the bags under my eyes. And bright smiles hid the pain behind my eyes. And after years of pretending, I was excellent at acting like everything was sunshine and daisies when it was anything but.

But, like I said, I knew it wouldn’t last forever. I wouldn’t be able to keep the act up much longer. I wouldn’t be able to hide behind my mask. Because I was slipping. I was starting to get irritated at the smallest things and it had already earned me more than a few strange looks from him.

Fuck. My eyes watered again and I dropped my head into my hands. When had it gotten so out of control? When had it started running my life? I didn’t know. I knew that I was ashamed and embarrassed.

Why can’t you just snap out of it? Other people have it so much worse than you. You’re being irrational.

I knew all of that! People had routinely thrown those phrases at me in the past. As if I wasn’t aware. As if I was willingly going through this. As if I was just trying to get attention. I choked back a sob. How could I possibly expect Loki to still love me after he found out about this? I was so broken.

I bit my lip, trying my best to keep quiet as the emotions engulfed me. I had never met anyone who actually understood what I was going through aside from my psychiatrist and counselor. But a part of me felt like they didn’t count. Because they were trained to understand and deal with these things. I’d never met another person outside of my treatment that understood. Even my own mother, the only family I had left, had walked away from me after my diagnosis.

Selfish, she had called me.

While I knew that that wasn’t true, the word still stung. And it still hurt that she didn’t even try to understand what I was going through. It had set the precedent for everyone else I had ever told. Relationships? Forget those. They always left after I opened up to them. So I stopped telling them.

And I had held true to that, refusing to give a voice to my pain in Loki’s presence. But it was all about to come crashing down.

I took a shuddering breath and tried to calm down. Freaking out was not going to help and it would probably just spin me into a panic attack. So I did my breathing exercises and closed my eyes. I hugged my knees to my chest and laid my head down on the surface the position created.

Maybe... maybe I could catch a few minutes of sleep... I just had to calm down. I had to relax. I had to breath. I had to remember that, no matter how bleak things seemed, the sun would rise in the morning. Maybe things would look better in the morning light. I gave a soft, cynical laugh. Things tended to look worse when the sun was shining, in my opinion. It was as if the sun was mocking me and my darkness with it’s bright light.

I started humming softly to myself as I rocked back and forth. I concentrated on my made up song and just let go. I just... let... go...

xoxo xoxo

I woke up violently. I came up swinging, my heart racing, confusion consuming me. I didn’t know where I was. I didn’t know what was going on.

“Shhh,” a voiced murmured. “It’s okay. Did you sleep here all night?”

Fuck. Understanding hit me like a truck. I must have passed out in front of the fireplace last night after my mini melt down. And I hadn’t gotten up before Loki. And now... I was propped up on the floor with my back against the couch. He was crouched in front of me. My bottom lip quivered at the implications. I had known my time was running out, but I thought I’d have a little more time than this.

I fought for normalcy. “No...?” Shit. That was the opposite of normal. “No. I got up early and I must have drifted off...” Better, but still not terribly believable.

I watched a frown twist on his lips. “What time did you get up? It’s only twenty after five.”

Double fuck. “Um, I’m not sure. I didn’t look at the clock. I got up to pee and then I just sat down...”

Ohhh, this was going downhill so fast. His frown deepened. Fuck, fuck, fuck. I felt my eyes well up. This was it. This was the end. I wasn’t going to be able to lie myself out of this one. I wasn’t going to be able to hold it together long enough to try. I bit my lip hard, trying to bring myself back to the moment.

“I guess I was having trouble sleeping,” I finally admitted quietly, dropping my head so that my hair fell into my eyes.

He didn’t say anything for what seemed like a long time. I’m sure it was no longer than thirty seconds or so. But it felt like a lifetime.

“Again? You haven’t slept more than a few hours a night for months.”

My heart dropped to my stomach with his words. Stupid! I was so stupid. Did I really think I would be able to fool a Norse God into believing my white lies? Especially this God. I should have known better. My throat burned with the effort of keeping my tears at bay. I slowly drew in a breath.

I didn’t know what to say.

His hand came up and tilted my head so that our eyes met. I slid my eyes away from his and he made a frustrated noise.

“Look at me.” His words were gentle, but commanding.

I lifted my eyes. What he saw in them, I’ll never know, but his jaw clenched and my heart spasmed. I wanted to look away, but found myself held captive in his eyes. There were so many emotions swirling in their depths that I couldn’t pick them apart.

“Do you want to tell me what’s going on with you?” he asked softly.

“I...” My voice cracked. I tried again. “Not particularly...”

He sighed. “I have been very patient with you, love. But I cannot be patient when you are so distressed. Tell me how to help.”

I sobbed, but tried to swallow it. It came out garbled and I couldn’t bear to look at him any longer.

“You can’t,” I practically wailed. “It’s... Its just who I am.”

I began crying in earnest, my emotions taking me over completely. He sank down to the floor and pulled me into his lap. He whisked one hand through my hair soothingly while the other held me tight around my waist. He rocked me back and forth, singing to me quietly in another language. I fisted my hands in the material of his sleep shirt, sucking in desperate breaths as I tried to calm down for the second time this morning.

It took me much longer to come down this time around. Probably because there was more at stake. I licked my lips and tried not the think about it, lest I work myself up again. I felt Loki press a kiss to my forehead and almost lost it again.

“Please,” he entreated. “Let me help you. Tell me what’s wrong.”

I bit my lip. Did I dare? I shook my head slightly and he tightened his arms around me. Please. I just... I didn’t even know how to tell him. I didn’t even know what to tell him. There was so much...

“I can’t help if I don’t know. I want to, no, I need to help you,” he pleaded.

The raw emotion coloring his voice ended up making the decision for me. I opened my mouth and just started talking. It was word vomit that no one except my counselor had ever heard.

I apologized for lying to him. I told him that I didn’t want to lie to him, but I wanted to keep him. I told him about how I was worried he would be disgusted with me. I told him about my nightmares. I told him about the insomnia. I explained my mood swings. I told him about the new medication. I told him about my mother. I told him about counseling. I told him about everything.

I talked until I was hoarse. And he didn’t interrupt. He just held me and listened. It was far more therapeutic than I thought possible. I took a couple of deep breaths when I was done and closed my eyes, reveling in the relief coursing through me. And I tried very hard not to think about what Loki’s reaction would be.

It was a long time before he said anything.

“I’m proud of you.” He said it simply, as if it was just another fact of life. “It takes great courage to face your inner demons.”

I swallowed thickly, trying to comprehend what he was saying. “But... I’m broken.”

“No, you’re not. You’re a work in progress,” he corrected, loosening his grip and turning me in his lap until I was facing him. “That does not mean you are broken.”

I felt the tears form again, but these weren’t tears of sadness. They were a product of relief, pure and simple. This... this wasn’t rejection. This was validation. This was acceptance. This was... new.

His hands cradled my face, his expression serious. “I don’t want you to feel as if you need to hide from me. I will help you through this. You will get through this.”

I gave him a small smile and nodded. It was amazing how empowering it was to have someone in your corner. I had never known anything like it. I knew that I didn’t want to walk this path alone anymore. And I didn’t have to. Loki had made that much clear.

“Thank you,” I whispered.

“You don’t have to thank me. I will always be there for you. You are stuck with me, I’m afraid.”

I gave a little giggle and met his eyes. They were no less intense, but they were shining brightly. He smiled at me before leaning in and planting a sweet kiss on my lips. It was soft and slow. It was the reassurance that I needed.

It was perfect.

Everything was going to be okay. Loki was right; I was going to get through this. And I was going to do it with him at my side.

It was more than I could have hoped for.

[dailyaudiobible]

08/15/2020 DAB Transcript

Nehemiah 9:22-10:39, 1 Corinthians 9:19-10:13, Psalms 34:1-10, Proverbs 21:13

Today is the 15th day of August welcome to the Daily Audio Bible I am Brian it's great to be here with you as we seal another week up and continue to move forward because the only way is forward. And, so, this week, yeah, we live into this week and then it becomes a part of our history and we start over again with a shiny sparkly week that we get to live into. But now we are at the conclusion of the week so let's take that final step for this week. We’re reading from the English Standard Version this week and we’re back in the book of Nehemiah. Today chapter 9 verse 22 through 10 verse 39. And just by way of reminder we’re in the middle of a prayer, the law has been read to the people, great repentance is happening, a great revival is happening, and we’re in the middle of a prayer.

Prayer:

Father, we thank You for Your word and we are grateful again at the end of another week, we are grateful again that You have brought us this far. We’re still here. The days go by and they add up to weeks and we realize we’re still here, You are still sustaining us, You are still guiding and directing us. We…we would have lost it all, including our minds by now without You, and yet You are here Fathering us, being patient with us, helping us grow and mature. And, so, we acknowledge this as we end another week. You have been faithful, and You have given us what we need, and You have instructed us, and our role is to trust You. And, so, as we release this week, we trust You, and as we look into the new week, we trust You. There is no safer thing to do. There is no safer place to be. Everything else is in our own strength and we are not strong enough. But You are the most-high God our Father and we trust You. And, so, come Holy Spirit well up from within, lead us into all truth, lead us forward in the name of Jesus we ask. Amen.

Announcements:

dailyaudiobible.com is the website, its home base, it's the home of the Global Campfire. So, be sure to check it out if you haven't. Be familiar with it.

The Prayer Wall lives there and a fantastic resource. Day or night no matter where you are in the world somebody's praying and you can always reach out and you can always participate. If you can't sleep, go there. Find out what people are asking for prayer for, pray for them. If the burdens of your life are keeping you up, maybe that’s a place to go and offer your story so that others might shoulder the burden along with you. So, that is a fantastic resource in the Community section. Check that out.

If you want to partner with a Daily Audio Bible you can do that at dailyaudiobible.com. There is a link on the homepage. My heart is full of gratitude as it is on a daily basis, gratitude and awe that, yeah, this…that we just have the gift of each other, that this can happen and that…that this is happening is overwhelming sometimes. So, thank you for your partnership. There’s a link on the homepage. If you’re using the Daily Audio Bible app you can press the Give button in the upper right-hand corner or the mailing address, if you prefer, is PO Box 1996 Spring Hill Tennessee 37174.

And if you have a prayer request or encouragement, you can hit the Hotline button in the app, which is the little red button at the top or you can dial 877-942-4253.

And that's it for today. I’m Brian I love you and I'll be waiting for you here tomorrow.

Community Prayer and Praise:

Hey, family this is Dave from Colorado I was wondering if I could ask for some prayers for my nephew Richie. He is right about 40 years old and his girlfriend Tammy, they’ve been together probably like 20 years something like that. She was on a waiting list for several years for kidney, you know, attached to the dialysis machine and not really able to go too far from home, but she finally got the kidney and that was January last year and then, you know, things are looking better. She was able to go to the mountains for the day or go camping, you know, she was just starting to kind of enjoy life. Anyway, yesterday morning God decided to bring her home during her sleep. I guess I suppose it was painless but my nephew he is just devastated and so are her kids so if you could pray for them that would…that would be awesome. I appreciate that. And also, White as Snow, I heard your call last week and it sounds like not only you don’t have to struggle with all those doors anymore but kind of sounds to me like God opened one of them and got you in a little better position. Anyway, I just wanted you to know you’re going to be in my daily prayers now. You know, as a fellow truck driver I know what it’s like out there on the road. Anyway, I guess that’s it for today. I love you all family and I appreciate you all so much. We’ll talk to you later.

Good morning DAB family this is Rebecca from North West Arkansas. I’m calling to pray for Jude from Maryland that has gone to the hospital for COVID symptoms. You called in and you’re going to the hospital and you wanted to pray for other people and I just think that is precious and I just wanted to pray for you. Dear Father we pray right now that You would put Your hands on Jude, and that he would heal her completely, that You would give her Your Holy Spirit and the strength of Your Holy Spirit in her. Help her feel that and help her know that You’re with her. Be with her doctors and nurses. I pray that You would protect all the doctors and nurses that are taking care of COVID patients right now and that You would give them strength, give them what they need physically and help them have the rest they need. Lord I pray that You’ll also be with all the children going back to school and be with their teachers. I pray that You would protect them from this virus and help them to learn in a health and safe environment. Lord thank You so much for DAB and thank You for Brian and his family and all those who participate in making this a wonderful podcast. We love You and we thank You Father and we praise You in Jesus’ name. Amen.

Hello Daily Audio…Audio Bible family this is Theo I was led by God to this…to this site and to this Prayer Wall. Thank you, Pastor for everything that you’ve done. I’m new to this, just a few days old to this site, and I absolutely have fallen in love with it. Thank you for the brothers and sisters that have been praying for me since I’ve posted my prayer request on the Prayer Wall. And I’ve attempted to reach out to others that need prayer also. And just continue to pray for me for protection and healing. And I really need it. And I just want to say how much this has changed my life and my walk with Christ. And I just want to say that I appreciate everything that every…everyone is doing just loving and caring for each other. So, I just want to say thank you very much. And as I said in the Prayer Wall, a little bit of love and a lot of prayer goes a very long way and I greatly appreciate it. Thank you very much. God bless you.

Hi family at Shannon from Texas and I need some prayer today. I know God transcends time. S,o the simplest thing happened this morning and I am losing it because I feel like I’m just losing it because of everything that’s going on. I lost a credit card and I feel like the world falling apart. So, I know that this little thing is pushing me over the edge like this…I am just not doing well. So, I’ve been taking care of a sweet little six-month-old baby boy that screams constantly. I’ve been finding myself just getting angry over prayers that are answered and just hope deferred. So, please pray that I find that card and that I just…just for me overall. Thank you. Love you.

Hello Daily Audio Bible family this is Sunset Cindy in Washington I am a first-time caller. I just started listening to DAB and actually last month, July 17th and I am so thankful that my cousin, shout out to my sweet cousin for suggesting this. She could tell I was struggling with some, you know, loneliness and isolation and things that are happening during this COVID crisis that were in and out it’s so helping me to focus on other things, focus on the things of the Lord and give me an opportunity to hear His word and listen to people all around the world. It is astonishing the connection I feel with all of you. And I just wanted to pray for Valerie who’s also a new listener. I was listening today it’s August 12th. She is calling in to say she’s trying to catch up as I am also trying to catch up. I would love to catch up with all the rest of you. I know I’ve got a long way to go. It’s August and I…I…but I’m almost through January as well. So, I’m just praying for her. And also, Jude I heard you call in about going to the hospital and praying for your COVID symptoms that you would be well and 100% and all of the medical providers that are helping with this crisis. I would also like to have the family pray for my immediate family. I have a family member who’s in…extreme anxiety attacks are happening to his mental…you know it’s just really affecting him mentally…

Hi family this is __ in __ South Africa my message today is for Valerie. Valerie, I heard you call in today on August 12th and I just wanted to say welcome. I always get so excited when I hear a new voice on…on DAB and it’s just, yeah, it’s just amazing to have you as part of the family. So, yeah, 2 and ½ weeks you’re in there, you’re going and I just pray that God would...would sustain you and help you to…to reduce the number of ebbs that you mentioned, ebbs and flows, and increase the number, the amount of flowing daily hours of routine and with purpose. I’ve been listening to DAB for about 10 months. It’s just changed my life in so many ways. It’s just blown me away and just continuing to do so daily. It’s hard work listening and…and concentrating and I’ve been writing notes and trying…I’ve got hundreds of questions because the Bible is a tricky book but it’s just wonderful to…to be able to…to learn daily to be able to enjoy Brian’s incredible teaching and the way…his explanation of Scripture and I just pray for…for enormous joy for you and purpose and focus as you continue on this journey and pray for strength and comfort for you and, yeah, just once again thank you for phoning in. It’s wonderful to hear your voice and I pray that God would bless you richly on this journey. Lots of love. Bye.

[ellymackay]

3 Reasons Why You’re Still Tired After 7-9 Hours of Sleep

3 Reasons Why You’re Still Tired After 7-9 Hours of Sleep was initially published on https://www.ellymackay.com/

This week we’re going to be diving into a question I get nearly daily, and one you may be asking yourself: why am I still tired after a full night of sleep?

Chances are you’ve heard the standard advice: get seven to eight hours of sleep per night for optimal health. It’s bad enough that for some of us that’s hard to achieve. First of all, most of us don’t know where to start–something as simple as a sleep calculator and taking my chronotype quiz can be helpful.

But something that’s frustrating? Making every effort to get those seven to eight hours of sleep and still waking up exhausted and relying on caffeine to combat daytime sleepiness.

I’ll explain why the seven to eight hours of sleep guidelines doesn’t work for everyone; the reasons behind why you’re always tired, and some natural sleep remedies to boost your energy.

Where Do Sleep Guidelines Come From?

The first thing we need to tackle is the 7-9 hours of sleep. Chances are someone’s recommended this to you, whether it’s your primary care physician, a friend, or just advice you’ve come across after battling daytime fatigue.

The guidelines were established by the National Sleep Council, which routinely revisits sleep recommendation guidelines for everyone from babies to teenagers and adults.  The latest guidelines came out in 2015.

But it’s more complex than that: while these are guidelines, sleep experts such as myself have continued to see, time and time again, that those recommendations don’t fit everyone.

Why 7-9 Hours of Sleep Doesn’t Work For Everyone

Sometimes I wish one set of guidelines, one sleep aid, or a single tip could help all clients fight insomnia, wake up refreshed, and enjoy optimal health. That isn’t the case: for some, a drug free cooling band like my favorite from EBB is helpful for calming racing thoughts at night. Others might benefit from this Remzy weighted blanket for comfort and relaxation

68 percent of us have sleep issues at least once a week, according to a 2016 Consumer Reports survey of 4,000 Americans. So it makes sense that, while seven to nine hours of sleep may work for the average adult, it doesn’t work for everyone.

A narrative review of sleep guidelines published in The Nature of Science and Sleep found that observational and self reporting biases made it difficult to truly know how long people were sleeping. The 2018 recommendation was that more in depth, controlled and longitudinal studies will be needed to better understand how much sleep is associated with the most health benefits.

Finally, individuals are…individuals. We all have different sleep patterns, based on an internal biological clock, or what I call a chronotype. Our chronotypes affect the time of day we perform our best work, get our best workout in, and sleep. Because of this, a standard seven to nine hours doesn’t ensure waking up feeling rested.

Why More Sleep Isn’t Always the Answer

Of course, while you may find that you can get by with one less hour of sleep, or need one more, most adults will need within an hour of those professional sleep guidelines. So when a client asks why they’re still tired after 12 hours of sleep, I start becoming concerned, sleeping too much can have its own serious side effects.

The truth is, while up to 35 percent of Americans are considered chronically sleep deprived (less than seven hours of sleep per night),that isn’t the only problem. Many of us are getting seven to nine hours of sleep, and even more, but especially for those suffering from a true sleep disorder, your risk for depression and other life issues is still high.

3 Common Reasons Why You’re Always Tired (And What To Do)

If seven to nine hours of sleep isn’t working (and then some) here are the most common reasons why you’re still feeling tired:

Problem: You’re Not Sleeping as Much as You Think.

This is a common problem, not unlike going on a diet: unless you’re tracking your sleep, it can be easy to lose track of just how many hours you’re getting.

You can have the best intentions and end up staying up late looking at emails instead of going to bed when you planned (if you do look at electronics at night, I recommend using blue light blocking glasses so you won’t disrupt your body’s production of melatonin).

Another reason you may not be getting as much quality sleep as you think is ambient light. Consider using an eye mask so that all light is blocked, especially if you have a bed partner who uses a light in bed or if your work requires sleeping during daylight hours. This is the eye mask I use and recommend for my patients. I also love the Dep Slep sleep hoodie with a built in eye mask.

Solution: Track Your Sleep

You don’t have to be a sleep expert like me to track your sleep. While sleep centers can monitor your sleep, you can also opt for the lower cost solution of a sleep tracker (my go to is the SleepScore Max ).

For many people I recommend a sleep tracking device because you’ll get information not only how many hours you sleep, but how much of that is deep sleep. Research has shown that lack of deep sleep is tied to everything from obesity and diabetes to disorders, heart problems, and impedes sleep’s benefits for brain health.

Problem: You Have Sleep Apnea

This sleep issue is directly related to not being aware of how much sleep you’re getting, and why a sleep tracker can be helpful. If you or your partner snores, there’s a high probability that you may be suffering from sleep apnea.

I’ve written extensively on sleep apnea and its negative impact on your health, and that’s because it’s so prevalent: more than 18 million Americans suffer from sleep apnea, a disorder characterized by obstructed breathing at night.

If you do have undiagnosed sleep apnea, one of the most common symptoms is daytime sleepiness, no matter how many hours you’re logging. That’s because sleep apnea regularly disrupts deep sleep, which is vital for tissue growth and repair.

Solution: Seek Sleep Apnea Treatment

Suspect you might have sleep apnea? Take my Snore Score Quiz to get started. If you snore at all, it’s worth getting checked because undiagnosed sleep apnea can not only cause you to always feel tired, but also lead to serious cardiovascular conditions, like high blood pressure, abnormal heart rhythm, and even heart attacks.

The good news is that sleep apnea is treatable. The most effective treatment is a CPAP machine. For some, oral mouthpieces can be used to open up airways at night.  Lifestyle changes such as losing weight and reducing alcohol consumption; and, in rare cases, surgery can also be helpful.

Always consult a medical professional and avoid self diagnosing.

Problem: You’re Fighting Your Chronotype

The third reason why you’re always tired after a full night’s sleep deserves a whole article, but for now I’ll leave it to this: you’re fighting your chronotype.

There are many things we do throughout our days–from when we get up to what we eat and our stress levels–that drain our energy even after a night of restorative sleep. While we all have days where we struggle to stay awake, sleep deprivation causes chronic lack of concentration and harms both our physical and mental health.

From drinking caffeine at the wrong time to eating dinner too early (or too late), little habits that fight our biological clock make it harder to fall asleep, stay asleep, and power through our day.

Solution: Adjust Your Routine For Your Unique Needs

This is in some ways the hardest solution to follow, because it takes time, patience, and trial and error.

Your first step to optimizing your energy is to find out when exactly your body thrives when it comes to eating, sleeping, and even exercising and socializing. To do that, take my Chronotype Quiz.

From there, you can learn ways to reorient your day. By doing so, you’re making the very most out of those seven to nine hours of sleep and you’ll start feeling more energized as your body adjusts.

As a send off, I’ll leave you with this: feeling tired all the time is something we seem to have accepted as a society, but it shouldn’t be. You deserve to live your best life possible. And you don’t need to succumb to the dangers of relying on energy drinks to get through your day.

Until next week, sweet dreams.

The post 3 Reasons Why You’re Still Tired After 7-9 Hours of Sleep appeared first on Your Guide to Better Sleep.

from Your Guide to Better Sleep https://thesleepdoctor.com/2020/07/25/3-reasons-why-youre-still-tired-after-7-9-hours-of-sleep/

from Elly Mackay - Feed https://www.ellymackay.com/2020/07/25/3-reasons-why-youre-still-tired-after-7-9-hours-of-sleep/

[anxiousamberleigh-blog]

i’m basically an alien

I have a genetic mutation

I have the Methylenetetrahydrofolate Reductase (MTHFR) mutation. Methylenetetrahydrofolate Reductase is an enzyme in the human body that is responsible for methylation, which is a metabolic process that switches genes on and off, repairs DNA, and does many other things. Methylation also helps convert both folate and folic acid (vitamin B9) into 5-MTHF, which is its usable and active form. 

Essentially what this all means in normal verbiage is that my body has a hard time processing folate and folic acid, which increases my chances of developing a vitamin deficiency later in life, especially a deficiency in one or more of the essential B vitamins. So, I have a prescribed medical food pill called Deplin that I take every day that contains high concentrations of needed vitamins. I also take a methylated vitamin that contains doses of B vitamins. I take these vitamins in addition to a daily vitamin, probiotics, and vitamins for my immune system and gastrointestinal systems. 

Not surprisingly, this genetic mutation can cause a wide range of health complications, such as: heart disease, Alzheimer’s disease, diabetes, depression, anxiety, attention deficit disorders, gastrointestinal disorders, etc. All complications that not-so coincidentally run in my family. Personally, I have Generalized Anxiety Disorder, Panic Disorder, Irritable Bowel Syndrome (IBS), and acid reflux. In addition to the medications/vitamins I take for my genetic mutation, I also take Prozac for anxiety and depression, xanax for panic attacks (as needed), and mirtazapine for anxiety/depression and for sleep because I started getting panic attacks in the middle of the night during my freshman year of college. 

I have come to terms with the fact that I am not “normal,” and I’ll probably never be. I have come to terms with my anxiety and my genetic mutation and I have accepted them as apart of me. I have come a long way and I am proud of myself for that. I have been diagnosed with anxiety for 2 years and I tested positive for the MTHFR gene mutation about a year ago. After my freshman year of college I decided to go off of my antidepressant (then Lexapro) because it just was not working anymore and I had lost faith in medication. I thought I was strong enough to not be on medication, and sadly, I was wrong. Withdrawal was a bitch, excuse my language. Withdrawal was hands down the hardest thing I’ve gone through. Once the withdrawal symptoms went away, I actually felt okay. Then, I moved into my first apartment and started my sophomore year of college. The fall semester went terribly. I don’t know how else to explain it. I had to drop a class, I ended up having 13 absences in just one class because I was terrified to leave my apartment. I was spiraling downwards. Luckily I had a good support system of my parents, my friends, and my amazing boyfriend (God bless him; I thank God for you every day, babe). I decided to go back on medication in September/October of the fall semester. My doctor put me back on Lexapro and it was Hell. First of all, the initial symptoms of Lexapro were nothing like the first time I started Lexapro. The first time, I had mild symptoms, but this time I felt like I got hit by a truck. My anxiety was worse, my stomach hurt, I felt nauseous, I felt sick on every aspect. After a month with no progress, I went to my doctor to try a new medication. In November I was put on Prozac, and life has been great ever since. The initial side effects were tolerable, and after some time I noticed my anxiety lessening. I finished off the fall semester the best I could after dropping a class, and I got a 2.7 GPA for that term. I was devastated but I knew I received the grades I technically had deserved. My professors were understanding and empathetic with what I was going through, and they did the best they could to help me. It is now summer, and the spring semester went amazing. I took 11 hours of classes (just under full-time), joined a sorority, made new friends, got over my fear of public transportation, maintained a healthy and committed relationship, got two dogs, and made lasting memories. And now, I ended last semester with a 3.36 GPA (even while taking Organic Chemistry!!), I am on the executive board of my sorority, I am happy, and I am excited for what’s in store for my future.  

#mentalhealthawareness #MTHFR #geneticmutation #anxiety #college #progress

[baburaja97-blog]

New Post has been published on Vin Zite

New Post has been published on https://vinzite.com/a-prescription-for-the-health-care-crisis-2/

A Prescription For the Health Care Crisis

With all the shouting going on about America’s health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it—people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they’ve encountered it, when people who’ve spent entire careers studying it (and I don’t mean politicians) aren’t sure what to do themselves.

Albert Einstein is reputed to have said that if he had an hour to save the world he’d spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.

Though I’ve worked in the American health care system as a physician since 1992 and have seven year’s worth of experience as an administrative director of primary care, I don’t consider myself qualified to thoroughly evaluate the viability of most of the suggestions I’ve heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.

THE PROBLEM OF COST

No one disputes that healthcare spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is, therefore, an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we’ve spent on health care has been rising.

Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we’ve been getting for each dollar we spend.

WHY HAS HEALTH CARE BECOME SO COSTLY?

This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can’t attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country’s GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).

Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.

Is it because of monstrous profits the health insurance companies are raking in? Probably not. It’s admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it’s unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren’t likely different by any order of magnitude).

Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it’s hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs were approximate $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must, therefore, be considered significant, it still remains only a small percentage of total health care costs.

Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it’s hard to imagine it’s shrunk to any significant degree since then.

In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and health care providers themselves.

Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they’re treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don’t have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we’ve figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we’re great at doing in the United States is making technology available.

Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What’s not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies—but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn’t important—just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.

Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.

A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:

1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depend on their training and the intangible exercise of judgment.

2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their subspecialty colleagues but obtain similarly and sometimes even better outcomes.

3. Fear of being sued. This is especially common in Emergency Room settings but extends to almost every area of medicine.

4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.

Gawande’s article implies there exists some level of utilization of health care resources that’s optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).

How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient—the “sweet spot”—in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately, or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks don’t mean every physician knows it or provides them. Data clearly show many don’t. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.

But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next—

WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?

According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families—Implications for Reform, growth in health care spending “can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care.” When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you’d be spending 60% of your income on health care but that as a result, you’d enjoy, say, a 30% chance of living to the age of 250, perhaps you’d judge that 60% a small price to pay.

This, it seems to me, is what the debate on health care spending really needs to be about. Certainly, we should work on ways to eliminate overutilization. But the real question isn’t what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?

People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don’t realize that we’re already rationing at least some of it. It just doesn’t appear as if we are because we’re rationing it on a first-come-first-serve basis—leaving it at least partially up to chance rather than to policy, which we’re uncomfortable defining and enforcing. Thus we don’t realize the reason our 90-year-old father in Illinois can’t have the liver he needs is because a 14-year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14-year-old girl doesn’t). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we’re so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).

So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980’s (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn’t want to give up.

But how do we decide whether we’re getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn’t provide great clinical benefit—demented patients score higher on tests of cognitive ability while on it but probably aren’t significantly more functional or significantly better able to remember their children compared to when they’re not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.

Who’s best positioned to judge the value to society of the benefit of an innovation—that is, to decide if an innovation’s benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public’s views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone’s imagination).

THE PROBLEM OF ACCESS

A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance—emergency rooms—which has significantly impaired the ability of our nation’s ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors’ appointments, long wait times in doctors’ offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.

GUIDELINES FOR SOLUTIONS

As Freakonomics authors Steven Levitt and Stephen Dubner state, “If morality represents how people would like the world to work, then economics represents how it actually does work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there’s always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.

Here then is a summary of what I consider the best recommendations I’ve come across to address the problems I’ve outlined above:

1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It’s harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging cross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn’t be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group’s higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory “open enrollment” period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that’s driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of “good” and “bad” insurance that’s currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a “public option” insurance plan open to all, I worry that if it’s significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another’s health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a “public option” remains comparable to private options, the very people it’s meant to help won’t be able to afford it.

2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn’t have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that’s true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let’s not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.

3. Decrease overutilization of health care resources by doctors. I’m in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what’s truly best for their patients? The idea that external bodies—whether insurance companies or government panels—could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients’ welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient’s consideration, as long as they’re careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn’t). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients’ welfare, meaning doctors’ salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn’t seemed to promote shoddy care when doctors feel they’re being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.

4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:

* Making available the right resources for the right problems (so that patients aren’t going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the “sweet spot” with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we’ve been seeing for the last decade).

* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don’t actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tell them it’s just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should—we’d just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).

* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can’t have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current “pre-pay for everything” model does.

CONCLUSION

Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, skyrocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don’t have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to anyone is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don’t allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.

[netmaddy-blog]

A Prescription For the Health Care Crisis

New Post has been published on https://netmaddy.com/a-prescription-for-the-health-care-crisis/

A Prescription For the Health Care Crisis

With all the shouting going on about America’s health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it—people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they’ve encountered it, when people who’ve spent entire careers studying it (and I don’t mean politicians) aren’t sure what to do themselves.

Albert Einstein is reputed to have said that if he had an hour to save the world he’d spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.

Though I’ve worked in the American health care system as a physician since 1992 and have seven year’s worth of experience as an administrative director of primary care, I don’t consider myself qualified to thoroughly evaluate the viability of most of the suggestions I’ve heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.

THE PROBLEM OF COST

No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we’ve spent on health care has been rising.

Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we’ve been getting for each dollar we spend.

WHY HAS HEALTH CARE BECOME SO COSTLY?

This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can’t attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country’s GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).

Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.

Is it because of monstrous profits the health insurance companies are raking in? Probably not. It’s admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it’s unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren’t likely different by any order of magnitude).

Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it’s hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.

Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it’s hard to imagine it’s shrunk to any significant degree since then.

In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and health care providers themselves.

Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they’re treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don’t have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we’ve figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we’re great at doing in the United States is making technology available.

Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What’s not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies—but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn’t important—just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.

Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.

A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:

1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depending on their training and the intangible exercise of judgment.

2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.

3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.

4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.

Gawande’s article implies there exists some level of utilization of health care resources that’s optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).

How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient—the “sweet spot”—in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn’t mean every physician knows it or provides them. Data clearly show many don’t. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.

But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next—

WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?

According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families—Implications for Reform, growth in health care spending “can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care.” When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you’d be spending 60% of your income on health care but that as a result you’d enjoy, say, a 30% chance of living to the age of 250, perhaps you’d judge that 60% a small price to pay.

This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn’t what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?

People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don’t realize that we’re already rationing at least some of it. It just doesn’t appear as if we are because we’re rationing it on a first-come-first-serve basis—leaving it at least partially up to chance rather than to policy, which we’re uncomfortable defining and enforcing. Thus we don’t realize the reason our 90 year-old father in Illinois can’t have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn’t). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we’re so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).

So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980’s (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn’t want to give up.

But how do we decide whether we’re getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn’t provide great clinical benefit—demented patients score higher on tests of cognitive ability while on it but probably aren’t significantly more functional or significantly better able to remember their children compared to when they’re not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.

Who’s best positioned to judge the value to society of the benefit of an innovation—that is, to decide if an innovation’s benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public’s views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone’s imagination).

THE PROBLEM OF ACCESS

A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance—emergency rooms—which has significantly impaired the ability of our nation’s ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors’ appointments, long wait times in doctors’ offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.

GUIDELINES FOR SOLUTIONS

As Freaknomics authors Steven Levitt and Stephen Dubner state, “If morality represents how people would like the world to work, then economics represents how it actually does work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there’s always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.

Here then is a summary of what I consider the best recommendations I’ve come across to address the problems I’ve outlined above:

1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It’s harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn’t be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group’s higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory “open enrollment” period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that’s driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of “good” and “bad” insurance that’s currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a “public option” insurance plan open to all, I worry that if it’s significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another’s health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a “public option” remains comparable to private options, the very people it’s meant to help won’t be able to afford it.

2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn’t have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that’s true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let’s not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.

3. Decrease overutilization of health care resources by doctors. I’m in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what’s truly best for their patients? The idea that external bodies—whether insurance companies or government panels—could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients’ welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient’s consideration, as long as they’re careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn’t). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients’ welfare, meaning doctors’ salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn’t seemed to promote shoddy care when doctors feel they’re being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.

4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:

* Making available the right resources for the right problems (so that patients aren’t going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the “sweet spot” with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we’ve been seeing for the last decade).

* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don’t actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it’s just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should—we’d just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).

* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can’t have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current “pre-pay for everything” model does.

CONCLUSION

Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don’t have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don’t allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.

[hopefulphantomwonderland-blog]

New Post has been published on Pagedesignweb

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A Prescription For the Health Care Crisis

With all the shouting going on about America’s health care crisis, many are probably finding it difficult to concentrate, much less understand the cause of the problems confronting us. I find myself dismayed at the tone of the discussion (though I understand it—people are scared) as well as bemused that anyone would presume themselves sufficiently qualified to know how to best improve our health care system simply because they’ve encountered it, when people who’ve spent entire careers studying it (and I don’t mean politicians) aren’t sure what to do themselves.

Albert Einstein is reputed to have said that if he had an hour to save the world he’d spend 55 minutes defining the problem and only 5 minutes solving it. Our health care system is far more complex than most who are offering solutions admit or recognize, and unless we focus most of our efforts on defining its problems and thoroughly understanding their causes, any changes we make are just likely to make them worse as they are better.

Though I’ve worked in the American health care system as a physician since 1992 and have seven year’s worth of experience as an administrative director of primary care, I don’t consider myself qualified to thoroughly evaluate the viability of most of the suggestions I’ve heard for improving our health care system. I do think, however, I can at least contribute to the discussion by describing some of its troubles, taking reasonable guesses at their causes, and outlining some general principles that should be applied in attempting to solve them.

THE PROBLEM OF COST

No one disputes that health care spending in the U.S. has been rising dramatically. According to the Centers for Medicare and Medicaid Services (CMS), health care spending is projected to reach $8,160 per person per year by the end of 2009 compared to the $356 per person per year it was in 1970. This increase occurred roughly 2.4% faster than the increase in GDP over the same period. Though GDP varies from year-to-year and is therefore an imperfect way to assess a rise in health care costs in comparison to other expenditures from one year to the next, we can still conclude from this data that over the last 40 years the percentage of our national income (personal, business, and governmental) we’ve spent on health care has been rising.

Despite what most assume, this may or may not be bad. It all depends on two things: the reasons why spending on health care has been increasing relative to our GDP and how much value we’ve been getting for each dollar we spend.

This is a harder question to answer than many would believe. The rise in the cost of health care (on average 8.1% per year from 1970 to 2009, calculated from the data above) has exceeded the rise in inflation (4.4% on average over that same period), so we can’t attribute the increased cost to inflation alone. Health care expenditures are known to be closely associated with a country’s GDP (the wealthier the nation, the more it spends on health care), yet even in this the United States remains an outlier (figure 3).

Is it because of spending on health care for people over the age of 75 (five times what we spend on people between the ages of 25 and 34)? In a word, no. Studies show this demographic trend explains only a small percentage of health expenditure growth.

Is it because of monstrous profits the health insurance companies are raking in? Probably not. It’s admittedly difficult to know for certain as not all insurance companies are publicly traded and therefore have balance sheets available for public review. But Aetna, one of the largest publicly traded health insurance companies in North America, reported a 2009 second quarter profit of $346.7 million, which, if projected out, predicts a yearly profit of around $1.3 billion from the approximately 19 million people they insure. If we assume their profit margin is average for their industry (even if untrue, it’s unlikely to be orders of magnitude different from the average), the total profit for all private health insurance companies in America, which insured 202 million people (2nd bullet point) in 2007, would come to approximately $13 billion per year. Total health care expenditures in 2007 were $2.2 trillion (see Table 1, page 3), which yields a private health care industry profit approximately 0.6% of total health care costs (though this analysis mixes data from different years, it can perhaps be permitted as the numbers aren’t likely different by any order of magnitude).

Is it because of health care fraud? Estimates of losses due to fraud range as high as 10% of all health care expenditures, but it’s hard to find hard data to back this up. Though some percentage of fraud almost certainly goes undetected, perhaps the best way to estimate how much money is lost due to fraud is by looking at how much the government actually recovers. In 2006, this was $2.2 billion, only 0.1% of $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year.

Is it due to pharmaceutical costs? In 2006, total expenditures on prescription drugs was approximately $216 billion (see Table 2, page 4). Though this amounted to 10% of the $2.1 trillion (see Table 1, page 3) in total health care expenditures for that year and must therefore be considered significant, it still remains only a small percentage of total health care costs.

Is it from administrative costs? In 1999, total administrative costs were estimated to be $294 billion, a full 25% of the $1.2 trillion (Table 1) in total health care expenditures that year. This was a significant percentage in 1999 and it’s hard to imagine it’s shrunk to any significant degree since then.

In the end, though, what probably has contributed the greatest amount to the increase in health care spending in the U.S. are two things:

1. Technological innovation.

2. Overutilization of health care resources by both patients and health care providers themselves.

Technological innovation. Data that proves increasing health care costs are due mostly to technological innovation is surprisingly difficult to obtain, but estimates of the contribution to the rise in health care costs due to technological innovation range anywhere from 40% to 65% (Table 2, page 8). Though we mostly only have empirical data for this, several examples illustrate the principle. Heart attacks used to be treated with aspirin and prayer. Now they’re treated with drugs to control shock, pulmonary edema, and arrhythmias as well as thrombolytic therapy, cardiac catheterization with angioplasty or stenting, and coronary artery bypass grafting. You don’t have to be an economist to figure out which scenario ends up being more expensive. We may learn to perform these same procedures more cheaply over time (the same way we’ve figured out how to make computers cheaper) but as the cost per procedure decreases, the total amount spent on each procedure goes up because the number of procedures performed goes up. Laparoscopic cholecystectomy is 25% less than the price of an open cholecystectomy, but the rates of both have increased by 60%. As technological advances become more widely available they become more widely used, and one thing we’re great at doing in the United States is making technology available.

Overutilization of health care resources by both patients and health care providers themselves. We can easily define overutilization as the unnecessary consumption of health care resources. What’s not so easy is recognizing it. Every year from October through February the majority of patients who come into the Urgent Care Clinic at my hospital are, in my view, doing so unnecessarily. What are they coming in for? Colds. I can offer support, reassurance that nothing is seriously wrong, and advice about over-the-counter remedies—but none of these things will make them better faster (though I often am able to reduce their level of concern). Further, patients have a hard time believing the key to arriving at a correct diagnosis lies in history gathering and careful physical examination rather than technologically-based testing (not that the latter isn’t important—just less so than most patients believe). Just how much patient-driven overutilization costs the health care system is hard to pin down as we have mostly only anecdotal evidence as above.

Further, doctors often disagree among themselves about what constitutes unnecessary health care consumption. In his excellent article, “The Cost Conundrum,” Atul Gawande argues that regional variation in overutilization of health care resources by doctors best accounts for the regional variation in Medicare spending per person. He goes on to argue that if doctors could be motivated to rein in their overutilization in high-cost areas of the country, it would save Medicare enough money to keep it solvent for 50 years.

A reasonable approach. To get that to happen, however, we need to understand why doctors are overutilizing health care resources in the first place:

1. Judgment varies in cases where the medical literature is vague or unhelpful. When faced with diagnostic dilemmas or diseases for which standard treatments haven’t been established, a variation in practice invariably occurs. If a primary care doctor suspects her patient has an ulcer, does she treat herself empirically or refer to a gastroenterologist for an endoscopy? If certain “red flag” symptoms are present, most doctors would refer. If not, some would and some wouldn’t depending on their training and the intangible exercise of judgment.

2. Inexperience or poor judgment. More experienced physicians tend to rely on histories and physicals more than less experienced physicians and consequently order fewer and less expensive tests. Studies suggest primary care physicians spend less money on tests and procedures than their sub-specialty colleagues but obtain similar and sometimes even better outcomes.

3. Fear of being sued. This is especially common in Emergency Room settings, but extends to almost every area of medicine.

4. Patients tend to demand more testing rather than less. As noted above. And physicians often have difficulty refusing patient requests for many reasons (eg, wanting to please them, fear of missing a diagnosis and being sued, etc).

5. In many settings, overutilization makes doctors more money. There exists no reliable incentive for doctors to limit their spending unless their pay is capitated or they’re receiving a straight salary.

Gawande’s article implies there exists some level of utilization of health care resources that’s optimal: use too little and you get mistakes and missed diagnoses; use too much and excess money gets spent without improving outcomes, paradoxically sometimes resulting in outcomes that are actually worse (likely as a result of complications from all the extra testing and treatments).

How then can we get doctors to employ uniformly good judgment to order the right number of tests and treatments for each patient—the “sweet spot”—in order to yield the best outcomes with the lowest risk of complications? Not easily. There is, fortunately or unfortunately, an art to good health care resource utilization. Some doctors are more gifted at it than others. Some are more diligent about keeping current. Some care more about their patients. An explosion of studies of medical tests and treatments has occurred in the last several decades to help guide doctors in choosing the most effective, safest, and even cheapest ways to practice medicine, but the diffusion of this evidence-based medicine is a tricky business. Just because beta blockers, for example, have been shown to improve survival after heart attacks doesn’t mean every physician knows it or provides them. Data clearly show many don’t. How information spreads from the medical literature into medical practice is a subject worthy of an entire post unto itself. Getting it to happen uniformly has proven extremely difficult.

In summary, then, most of the increase in spending on health care seems to have come from technological innovation coupled with its overuse by doctors working in systems that motivate them to practice more medicine rather than better medicine, as well as patients who demand the former thinking it yields the latter.

But even if we could snap our fingers and magically eliminate all overutilization today, health care in the U.S. would still remain among the most expensive in the world, requiring us to ask next—

WHAT VALUE ARE WE GETTING FOR THE DOLLARS WE SPEND?

According to an article in the New England Journal of Medicine titled The Burden of Health Care Costs for Working Families—Implications for Reform, growth in health care spending “can be defined as affordable as long as the rising percentage of income devoted to health care does not reduce standards of living. When absolute increases in income cannot keep up with absolute increases in health care spending, health care growth can be paid for only by sacrificing consumption of goods and services not related to health care.” When would this ever be an acceptable state of affairs? Only when the incremental cost of health care buys equal or greater incremental value. If, for example, you were told that in the near future you’d be spending 60% of your income on health care but that as a result you’d enjoy, say, a 30% chance of living to the age of 250, perhaps you’d judge that 60% a small price to pay.

This, it seems to me, is what the debate on health care spending really needs to be about. Certainly we should work on ways to eliminate overutilization. But the real question isn’t what absolute amount of money is too much to spend on health care. The real question is what are we getting for the money we spend and is it worth what we have to give up?

People alarmed by the notion that as health care costs increase policymakers may decide to ration health care don’t realize that we’re already rationing at least some of it. It just doesn’t appear as if we are because we’re rationing it on a first-come-first-serve basis—leaving it at least partially up to chance rather than to policy, which we’re uncomfortable defining and enforcing. Thus we don’t realize the reason our 90 year-old father in Illinois can’t have the liver he needs is because a 14 year-old girl in Alaska got in line first (or maybe our father was in line first and gets it while the 14 year-old girl doesn’t). Given that most of us remain uncomfortable with the notion of rationing health care based on criteria like age or utility to society, as technological innovation continues to drive up health care spending, we very well may at some point have to make critical judgments about which medical innovations are worth our entire society sacrificing access to other goods and services (unless we’re so foolish as to repeat the critical mistake of believing we can keep borrowing money forever without ever having to pay it back).

So what value are we getting? It varies. The risk of dying from a heart attack has declined by 66% since 1950 as a result of technological innovation. Because cardiovascular disease ranks as the number one cause of death in the U.S. this would seem to rank high on the scale of value as it benefits a huge proportion of the population in an important way. As a result of advances in pharmacology, we can now treat depression, anxiety, and even psychosis far better than anyone could have imagined even as recently as the mid-1980’s (when Prozac was first released). Clearly, then, some increases in health care costs have yielded enormous value we wouldn’t want to give up.

But how do we decide whether we’re getting good value from new innovations? Scientific studies must prove the innovation (whether a new test or treatment) actually provides clinically significant benefit (Aricept is a good example of a drug that works but doesn’t provide great clinical benefit—demented patients score higher on tests of cognitive ability while on it but probably aren’t significantly more functional or significantly better able to remember their children compared to when they’re not). But comparative effectiveness studies are extremely costly, take a long time to complete, and can never be perfectly applied to every individual patient, all of which means some health care provider always has to apply good medical judgment to every patient problem.

Who’s best positioned to judge the value to society of the benefit of an innovation—that is, to decide if an innovation’s benefit justifies its cost? I would argue the group that ultimately pays for it: the American public. How the public’s views could be reconciled and then effectively communicated to policy makers efficiently enough to affect actual policy, however, lies far beyond the scope of this post (and perhaps anyone’s imagination).

THE PROBLEM OF ACCESS

A significant proportion of the population is uninsured or underinsured, limiting or eliminating their access to health care. As a result, this group finds the path of least (and cheapest) resistance—emergency rooms—which has significantly impaired the ability of our nation’s ER physicians to actually render timely emergency care. In addition, surveys suggest a looming primary care physician shortage relative to the demand for their services. In my view, this imbalance between supply and demand explains most of the poor customer service patients face in our system every day: long wait times for doctors’ appointments, long wait times in doctors’ offices once their appointment day arrives, then short times spent with doctors inside exam rooms, followed by difficulty reaching their doctors in between office visits, and finally delays in getting test results. This imbalance would likely only partially be alleviated by less health care overutilization by patients.

GUIDELINES FOR SOLUTIONS

As Freaknomics authors Steven Levitt and Stephen Dubner state, “If morality represents how people would like the world to work, then economics represents how it actually does work.” Capitalism is based on the principle of enlightened self-interest, a system that creates incentives to yield behavior that benefits both suppliers and consumers and thus society as a whole. But when incentives get out of whack, people begin to behave in ways that continue to benefit them often at the expense of others or even at their own expense down the road. Whatever changes we make to our health care system (and there’s always more than one way to skin a cat), we must be sure to align incentives so that the behavior that results in each part of the system contributes to its sustainability rather than its ruin.

Here then is a summary of what I consider the best recommendations I’ve come across to address the problems I’ve outlined above:

1. Change the way insurance companies think about doing business. Insurance companies have the same goal as all other businesses: maximize profits. And if a health insurance company is publicly traded and in your 401k portfolio, you want them to maximize profits, too. Unfortunately, the best way for them to do this is to deny their services to the very customers who pay for them. It’s harder for them to spread risk (the function of any insurance company) relative to say, a car insurance company, because far more people make health insurance claims than car insurance claims. It would seem, therefore, from a consumer perspective, the private health insurance model is fundamentally flawed. We need to create a disincentive for health insurance companies to deny claims (or, conversely, an extra incentive for them to pay them). Allowing and encouraging aross-state insurance competition would at least partially engage free market forces to drive down insurance premiums as well as open up new markets to local insurance companies, benefiting both insurance consumers and providers. With their customers now armed with the all-important power to go elsewhere, health insurance companies might come to view the quality with which they actually provide service to their customers (ie, the paying out of claims) as a way to retain and grow their business. For this to work, monopolies or near-monopolies must be disbanded or at the very least discouraged. Even if it does work, however, government will probably still have to tighten regulation of the health insurance industry to ensure some of the heinous abuses that are going on now stop (for example, insurance companies shouldn’t be allowed to stratify consumers into sub-groups based on age and increase premiums based on an older group’s higher average risk of illness because healthy older consumers then end up being penalized for their age rather than their behaviors). Karl Denninger suggests some intriguing ideas in a post on his blog about requiring insurance companies to offer identical rates to businesses and individuals as well as creating a mandatory “open enrollment” period in which participants could only opt in or out of a plan on a yearly basis. This would prevent individuals from only buying insurance when they got sick, eliminating the adverse selection problem that’s driven insurance companies to deny payment for pre-existing conditions. I would add that, however reimbursement rates to health care providers are determined in the future (again, an entire post unto itself), all health insurance plans, whether private or public, must reimburse health care providers by an equal percentage to eliminate the existence of “good” and “bad” insurance that’s currently responsible for motivating hospitals and doctors to limit or even deny service to the poor and which may be responsible for the same thing occurring to the elderly in the future (Medicare reimburses only slightly better than Medicaid). Finally, regarding the idea of a “public option” insurance plan open to all, I worry that if it’s significantly cheaper than private options while providing near-equal benefits the entire country will rush to it en masse, driving private insurance companies out of business and forcing us all to subsidize one another’s health care with higher taxes and fewer choices; yet at the same time if the cost to the consumer of a “public option” remains comparable to private options, the very people it’s meant to help won’t be able to afford it.

2. Motivate the population to engage in healthier lifestyles that have been proven to prevent disease. Prevention of disease probably saves money, though some have argued that living longer increases the likelihood of developing diseases that wouldn’t have otherwise occurred, leading to the overall consumption of more health care dollars (though even if that’s true, those extra years of life would be judged by most valuable enough to justify the extra cost. After all, the whole purpose of health care is to improve the quality and quantity of life, not save society money. Let’s not put the cart before the horse). However, the idea of preventing a potentially bad outcome sometime in the future is only weakly motivating psychologically, explaining why so many people have so much trouble getting themselves to exercise, eat right, lose weight, stop smoking, etc. The idea of financially rewarding desirable behavior and/or financially punishing undesirable behavior is highly controversial. Though I worry this kind of strategy risks the enacting of policies that may impinge on basic freedoms if taken too far, I’m not against thinking creatively about how we could leverage stronger motivational forces to help people achieve health goals they themselves want to achieve. After all, most obese people want to lose weight. Most smokers want to quit. They might be more successful if they could find more powerful motivation.

3. Decrease overutilization of health care resources by doctors. I’m in agreement with Gawande that finding ways to get doctors to stop overutilizing health care resources is a worthy goal that will significantly rein in costs, that it will require a willingness to experiment, and that it will take time. Further, I agree that focusing only on who pays for our health care (whether the public or private sectors) will fail to address the issue adequately. But how exactly can we motivate doctors, whose pens are responsible for most of the money spent on health care in this country, to focus on what’s truly best for their patients? The idea that external bodies—whether insurance companies or government panels—could be used to set standards of care doctors must follow in order to control costs strikes me as ludicrous. Such bodies have neither the training nor overriding concern for patients’ welfare to be trusted to make those judgments. Why else do we have doctors if not to employ their expertise to apply nuanced approaches to complex situations? As long as they work in a system free of incentives that compete with their duty to their patients, they remain in the best position to make decisions about what tests and treatments are worth a given patient’s consideration, as long as they’re careful to avoid overconfident paternalism (refusing to obtain a head CT for a headache might be overconfidently paternalistic; refusing to offer chemotherapy for a cold isn’t). So perhaps we should eliminate any financial incentive doctors have to care about anything but their patients’ welfare, meaning doctors’ salaries should be disconnected from the number of surgeries they perform and the number of tests they order, and should instead be set by market forces. This model already exists in academic health care centers and hasn’t seemed to promote shoddy care when doctors feel they’re being paid fairly. Doctors need to earn a good living to compensate for the years of training and massive amounts of debt they amass, but no financial incentive for practicing more medicine should be allowed to attach itself to that good living.

4. Decrease overutilization of health care resources by patients. This, it seems to me, requires at least three interventions:

* Making available the right resources for the right problems (so that patients aren’t going to the ER for colds, for example, but rather to their primary care physicians). This would require hitting the “sweet spot” with respect to the number of primary care physicians, best at front-line gatekeeping, not of health care spending as in the old HMO model, but of triage and treatment. It would also require a recalculating of reimbursement levels for primary care services relative to specialty services to encourage more medical students to go into primary care (the reverse of the alarming trend we’ve been seeing for the last decade).

* A massive effort to increase the health literacy of the general public to improve its ability to triage its own complaints (so patients don’t actually go anywhere for colds or demand MRIs of their backs when their trusted physicians tells them it’s just a strain). This might be best accomplished through a series of educational programs (though given that no one in the private sector has an incentive to fund such programs, it might actually be one of the few things the government should—we’d just need to study and compare different educational programs and methods to see which, if any, reduce unnecessary patient utilization without worsening outcomes and result in more health care savings than they cost).

* Redesigning insurance plans to make patients in some way more financially liable for their health care choices. We can’t have people going bankrupt due to illness, nor do we want people to underutilize health care resources (avoiding the ER when they have chest pain, for example), but neither can we continue to support a system in which patients are actually motivated to overutilize resources, as the current “pre-pay for everything” model does.

Given the enormous complexity of the health care system, no single post could possibly address every problem that needs to be fixed. Significant issues not raised in this article include the challenges associated with rising drug costs, direct-to-consumer marketing of drugs, end-of-life care, sky-rocketing malpractice insurance costs, the lack of cost transparency that enables hospitals to paradoxically charge the uninsured more than the insured for the same care, extending health care insurance coverage to those who still don’t have it, improving administrative efficiency to reduce costs, the implementation of electronic medical records to reduce medical error, the financial burden of businesses being required to provide their employees with health insurance, and tort reform. All are profoundly interdependent, standing together like the proverbial house of cards. To attend to any one is to affect them all, which is why rushing through health care reform without careful contemplation risks unintended and potentially devastating consequences. Change does need to come, but if we don’t allow ourselves time to think through the problems clearly and cleverly and to implement solutions in a measured fashion, we risk bringing down that house of cards rather than cementing it.

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12 Healthy Healing Foods From the Bible

Why does our society seem to seek every way to overcome sickness and disease other than looking in the best Instruction Manual that’s been around for thousands of years? Why do we avoid the simplicity of the basics when it comes to our health? The “basics” I refer to are eating healthy foods, getting regular exercise and adequate sleep.

Of course, the best instruction manual I am referring to is the Bible and there must be hundreds of books out there educating us on the importance of adequate exercise and sleep. Yes, there are scads of books on what to eat, too, but if they tell you to eat something that seems to contradict what the Bible says is OK, you probably should do some serious research before incorporating it into a regular eating plan. 

There are actually some diet/eating plans being promoted that in the long run, may not be very healthy. What a shame if you lose weight, for example, and then have a heart attack because you were eating way too much meat or didn’t get adequate nutrition.

Do I even need to mention some things you should obviously avoid if you want to experience optimum health? Folks, as much as I hate to list anything, this is what I see around me in abundance: fried foods, sugar in just about everything it seems, artificial sweeteners, meals heavy in meats with few vegetables and fruits, almost all cooked, (very little raw foods), and diet drinks.   

The foods listed in this report are by no means all the “healthy” foods mentioned in the Bible. They should, however, provide you with some guidance in your food choices.

1. Apples. Song of Solomon. Apples are considered to be the “all around health food.” They are high in flavonoids, fiber and Vitamin C. Some of the apple’s healing powers include: A.      They lower both bad cholesterol and high blood pressure

B.      The juices in apples are highly effective virus fighters

C.      They help stabilize blood sugar, an important factor in controlling diabetes

D.      They suppress the appetite without robbing the body of necessary nutrients

E.       Depending on the need, they prevent constipation or help treat diarrhea

One caution: conventionally grown apples may be highly sprayed with pesticides and coated with wax. Purchase organically grown apples when possible.

2. Barley. Deuteronomy 8:8, Ezekiel 4:9. Barley’s high fiber content can help keep us regular, relieve constipation and ward off a wide variety of digestive problems. It also may help block cancer. Barley is full of beta glucans, a type of fiber that can lower the risk of heart disease by reducing the levels of artery-clogging LDL.

3. Coriander (Cilantro). When the children of Israel wandered in the desert and received manna from the sky, they described it as looking like coriander seed. Since then coriander has been called “the healer from heaven.” Coriander is recommended for indigestion, flatulence (excessive gas) and diarrhea. Externally, it’s used to ease muscle and joint pain. Recently, scientists began looking at coriander as an anti-inflammatory treatment for arthritis. Other research has demonstrated that it reduces blood sugar levels, an indication that it may prove to be a useful sugar management tool for diabetics.

4. Fish. Luke 24:42-43. Fish is low in cholesterol and contains healthy polyunsaturated fats. Fish is a rich source of protein, potassium, vitamins and minerals with only a moderate amount of sodium. Eating fish: * Thins the blood

* Protects arteries from damage

* Inhibits blood clots (anti-thrombotic)

* Reduces blood triglycerides

* Lowers LDL blood cholesterol

* Lowers blood pressure

* Reduces risk of heart attack and stroke

* Eases symptoms of rheumatoid arthritis

* Reduces risk of lupus

* Relieves migraine headaches

* Fights inflammation

* Helps regulate the immune system

* Inhibits cancer in animals and possibly humans

* Soothes bronchial asthma

* Combats early kidney disease

The key to the healing powers of fish lies in the omega-3 fatty acids. These are particularly concentrated in cold-water fish such as anchovies, bluefish, herring, lake trout, mackerel, sable fish, whitefish, flue fin tuna, salmon and sardines. Note: in deciding between “healthy” and “unhealthy” fish, you can get specific instruction from Lev. 11:9. Eat only fish which have both fins and scales.

5. Garlic. One of the world’s oldest healing foods. By the time of Moses, garlic was already being used as an anticoagulant, antiseptic, anti-inflammatory and anti-tumor agent, as well as a relief for flatulence, a diuretic, a sedative, a poultice and as a cure for internal parasites. Research suggests that garlic may help protect against heart disease and stroke by lowering blood pressure. It contains allylic sulfides, which may neutralize carcinogens. In fact, garlic has been linked to lower rates of stomach cancer, too. It is heart-friendly, with scores of studies showing its astonishing ability to fight hypertension, prevent blood clots and lower cholesterol.

6. Fruits, Berries, Grapes. Numbers 13:23, II Samuel 16:1-2. Grapes were the first thing Noah planted after the flood. Grapes were eaten fresh, dried and eaten as raisins just as we do today, and pressed into cakes. However, most of the crop of the vineyards was made into juice, wine and vinegar. A cup of raw grapes contains only 58 calories, 0.3 grams of fat, zero cholesterol and vitamins A, B and C. Grapes also contain important minerals such as boron, calcium, potassium and zinc. 

Grapes may be helpful in preventing osteoporosis, fighting tooth decay, heading off cancer and fighting off viruses. Other health-giving fruits include figs, melons, and pomegranates.

7. Legumes. 2 Samuel 17:28-29, Genesis 25:34. As reported in the book of Samuel, beans were among the highly nutritious foods sent to feed King David’s hungry army and restore their strength for the hard times ahead. Beans have a lot of soluble fiber, which helps lower LDL and reduce blood pressure. The fiber also helps keep blood sugar levels stable, stave off hunger, and even reduce the insulin requirements of people suffering from diabetes.

Beans are a great source of protein as well as being packed full of vitamin C, iron and dietary fiber. Beans help lower blood pressure and reduce the “bad” cholesterol that today’s research has shown to be the cause of so much devastating heart trouble — a rarity centuries ago. Beans contain chemicals that inhibit the growth of cancer. They help prevent constipation, can stop hemorrhoids and other bowel-related problems from developing, and help cure them if they do.

8. Nuts, including almonds, pistachio nuts and walnuts. Song of Solomon 6:11, Gen. 43:11. Botanists today believe that Solomon’s “garden of nuts” referred to in Scripture was a rich grove of walnut trees. At the time, walnuts were prized for the oil they produced, which was regarded as only slightly inferior to olive oil. The fact that walnuts were a delicious treat and highly nutritious was an added bonus. Nuts contain the right mixtures of natural ingredients whose benefits include cancer prevention, a lower risk of heart disease and help for diabetics. The oil found in walnuts is considered helpful because it is one of the “good guy” polyunsaturated fats and tends to lower blood cholesterol levels. Note: it’s best to avoid roasted nuts since they have been found to carry carcinogens, which could lead to cancer growth, so buy your nuts raw.

9. Olives. The olive was one of the most valuable and versatile trees of biblical times. It is mentioned frequently throughout the Bible. Probably the most famous reference to olive oil and its healing powers is in the parable of the good Samaritan, in which the Samaritan cares for a beaten and robbed traveler, treating his wounds with oil and wine. Olive oil, mixed with wine, was even used to soften and soothe bruises and wounds. Known benefits of olive oil include:

* Lowers blood cholesterol            

* Reduces LDL (bad) cholesterol levels

* Retards cancer growth

* Reduces the wear and tear of aging on the tissues and organs of the body and brain

* Reduces gastric acidity

* Protects against ulcers and aids the passage of food through the intestines, helping to prevent constipation

* Reduces the risk of gallstones

* Aids normal bone growth

One CAUTION: olive oil has a slight laxative effect, so add it to your diet gradually.  One TIP: the more pure the olive oil, the better, so spend a little extra and get Virgin Olive Oil.

10. Onions. Numbers 11:5. Like its cousin, garlic, the onion is noted as a cure-all. And the folk healers hold it in high regard as far back as 6000 years or more. At least 3000 years before the birth of Christ, onions were treasured both as food and for their therapeutic value — particularly in the treatment of kidney and bladder problems. Some facts about onions:   

* Taken internally as a tonic to soothe intestinal gas pains

* Taken internally to alleviate the symptoms of hypertension, high blood sugar and elevated cholesterol

* Some people attribute their long life to a diet that includes high concentrations of onions and yogurt

* The juice of an onion and a syrup made from honey has been used to treat coughs, colds, and asthma attacks

* A tonic of onions soaked in gin has been prescribed for kidney stones and to eliminate excessive fluids

* Modern herbalists recommend onion syrup as an expectorant (it helps eliminate mucus from the respiratory tract)

* Onions can raise the good and lower the bad cholesterol

* Onions can slow blood clotting, regulate blood sugar, break up bronchial congestion and possibly prevent cancer

* Onions possess a strong antibiotic that kills a variety of bacteria

* Have been used externally as an antiseptic and a pain reliever

11. Wheat. Jeremiah 41:8, Ezekiel 4:9. Wheat was the “staff of life.” Biblical people ate their grain boiled and parched, soaked and roasted, and even ate it green from the stalk. It was pounded, dried or crushed to be baked into casseroles, porridges, soups, parched grain salads and desserts. Ezekiel’s bread was intended to be a survival food during the dark days of the Babylonion conquest because it contained wheat, barley, beans, lentils, millet and spelt. Wheat bran is high in insoluble fiber. The fiber protects us against constipation. It helps prevent intestinal infections, hemorrhoids and varicose veins. It also improves bowel function and guards us against colon cancer.

12. Wine. I Timothy 5:23. John 4:46. Making wine from grapes is one of the most ancient arts and the beverage of choice in the Bible. According to Genesis, one of the first things Noah did after the flood was plant a vineyard so he could make wine. Researchers are now rediscovering what the physicians of the Bible knew centuries ago. In moderation, wine has a profound impact on our health and healing. Just a single glass of wine a day may be enough to raise the good cholesterol by 7% and help the body put up a barrier to a variety of cancers.

Wine appears to help stop heart disease and cancer. A study at the University of Ottawa in Canada concluded that there is a clear link between wine consumption and lower rates of heart disease. Countries where more than 90% of alcohol is consumed in the form of wine have the lowest rate of heart disease deaths.

A British study of 100 men and women discovered that a single glass of wine or sherry everyday increased the HDL or good cholesterol. When the group abstained from drinking wine, the HDL level decreased.

Red wine also seems to increase the body’s defenses against cancer. White wine may carry some of the same therapeutic benefits, but research so far seems to indicate that red wine is the most effective cancer blocker. Note: be sure to drink only in moderation. Ephesians 5:18.

As you can see, the Bible lists a lot of foods, foods that are actually available to us today, that we could be consuming to prevent illness, serious diseases and many trips to the doctor. Good health is not that difficult, but you do have to work at it a bit. It’s a balance of what you eat, exercise, sleep, avoiding stress, taking vitamin supplements. And strange as it may seem, the Bible is actually a complete instruction Manual for all of this.

In conclusion, the 12 healing foods listed here are only a partial list of healing foods found in the Bible. However, this report provides abundant evidence that God has placed on this earth, many health-giving foods for our consumption. A person who makes a serious effort to daily eat some of these health-giving foods, while avoiding health-destroying foods, certainly can expect to reap the benefits of a healthier body.