What Is Health Economics?

For many of you, this article provides your first exposure to the study of health economics. Perhaps the ongoing controversy regarding health care reform or the prospect of a career in the health care field motivated you to learn more about health economics. Or perhaps you need only three more credits to graduate. Whatever the reason, we are sure you will find health economics to be challenging, highly interesting, and personally rewarding.

The study of health economics involves the application of various microeconomics tools, such as demand or cost theory, to health issues and problems. The goal is to promote a better understanding of the economic aspects of health care problems so that corrective health policies can be designed and proposed. A thorough understanding of microeconomic analysis is essential for conducting sound health economics analyses. If you lack a background in microeconomics, don’t worry. This article is intended to help you learn and apply basic microeconomic theory to health economics issues. Before long, you will be thinking like a health economist!

The tools of health economics can be applied to a wide range of issues and problems pertaining to health and health care. For example, health economics analysis might be used to investigate why 25 of every 1,000 babies born in Turkey never reach their first birthday, whereas all but 3 of every 1,000 babies born in Japan live to enjoy their first birthday cake. The tools of health economics analysis might also be used to examine the economic desirability of a hotly contested merger between two large hospitals in a major metropolitan area. The burning question is: Will the merger of the two hospitals result in lower hospital prices due to overall cost savings or higher prices due to market power?

Health economics . . . studies the supply and demand of health care resources and the impact of health care resources on a population.

Notice that health economics is defined in terms of the determination and allocation of health care resources. This is logical, because medical goods and services cannot exist without them. Health care resources consist of medical supplies, such as pharmaceutical goods, latex rubber gloves, and bed linens; personnel, such as physicians and lab assistants; and capital inputs, including nursing home and hospital facilities, diagnostic and therapeutic equipment, and other items that provide medical care services. Unfortunately, health care resources, like resources in general, are limited or scarce at a given point in time, and wants are limitless. Thus, trade-offs are inevitable and a society, whether it possesses a market-driven or a government-run health care system, must make a number of fundamental but crucial choices. These choices are normally couched in terms of four basic questions, discussed next.

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Special Note for Elderly People

Since older people can be quite dehydrated, with tight, inflexible tissues, they must be extra careful. Be very gentle, and be sure not to stretch so hard that it causes a searing or burning sensation.

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> Take your shoes off before stretching.

> Since the fascial stretches aren’t used to release spinal compression, there’s no special benefit to doing them just before bed. You can do them at any time of the day.

> It’s essential to make sure that all the components of each stretch are in place. The positions of the head, feet, hands, and so on lock down specificparts of the fascial chain. If any part of this chain isn’t held in tension, you won’t properly stretch the particular fascia you’re focusing on.

> Relax your face. Clenching the jaw actually distracts from your ability to focus on the area being stretched. The only muscles that should be tight are the ones you’re contracting to hold the position.

> The instruction to keep the head in neutral position is not the same as chin-tucking the head. It simply means that the chin is level—not tilted up or down—and the head itself is not tilted to either the right or the left.

> Since everyone’s body is different, you need to play around slightly with each stretch to make it work for you. I explain in the instructions how to make small adjustments to modify the stretch for your unique body. I also tell you what the stretch should feel like, and you can use that as a guide for experimenting. Remember, you will not get this feeling the first time you do a stretch. Just keep adjusting until you do.

> For the sake of simplicity, you should always do a fascial stretch on both sides of the body, even if one side is tighter than the other. There are two reasons for this. First, stretching the more flexible side first prepares your body mentally for stretching the other side, giving you confidence that the stretch is achievable on the tight side. Second, the nonactive side of the body learns the ropes from the side that’s stretching and can release more when its turn comes. So stretching the flexible side first actually makes it easier to stretch the tight side.

You can do this stretch either seated or standing. Hold your right arm out along your side, about 15 inches away from your hip. Bend the wrist backward and rotate the arm so the inside crease of your elbow faces up and away from your body.

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Never Stretch When You’re Cold

Another general rule is to never stretch an area that’s cold. Before stretching, you need to warm up and get your blood flowing. The body contains miles of tiny arteries, most of which stay closed unless you have moved enough to open them up and fill them with blood. After just a few minutes of movement, these baby blood vessels will open. The muscles they bring blood to grow warm and loosen up, allowing all that water you’re drinking to get into the fascia. That’s why the best time to stretch is after a workout, when all these arteries are open. Be sure to warm up the specific part of the body you plan to stretch.

If you don’t do regular workouts, just do some very simple movements:

> Windmill your arms.

> Rotate your torso.

> Do neck rolls.

> Touch your toes (bending forward as far as you can comfortably).

> Make circles with your knees.

> Jog slowly in place for thirty seconds. (If you can’t jog, hold on to a chair and march in place.)

> Do calf raises. (Holding onto a chair, come up onto the balls of your feet and then lower your heels slowly to the floor.)

All you need are 10 to 15 rhythmic repetitions on each side, just to loosen yourself up—a total of two minutes of nonstop movement. The key is that you must sweat slightly. If you don’t break a sweat, you’re not warmed up enough, and you need to repeat a couple of the warm-up movements for

an extra minute or so.

Timing the Stretches

You don’t need to hold fascial stretches for an uninterrupted sixty-secondperiod. For most people, this would be quite difficult. So you break each fascial stretch into two sections, with a rest in between. After the rest, in the second part of the stretch, you can go farther. Here’s the basic timing for all but two of the stretches:

> Hold for twenty seconds.

> Rest for ten seconds.

> Hold for thirty seconds.

The first twenty seconds is essentially a warm-up for the following thirty-second hold. Most people need five to ten seconds just to get into position, so don’t worry if the first hold doesn’t seem to be doing much. On the second hold, you’ll get into position much faster, and—here’s the key—you should make a greater effort. The thirty-second hold does the majority of the work. During this part, strive for an additional 5 percent of stretch beyond what you got in the first part. This requires a mental focus on expecting and working toward that small extra increment of movement. Even after you’ve stretched as much as you can, you can always go another 1 percent—so strive for that as well. If you don’t challenge yourself to your end point, you won’t get the full benefit. Keep asking, is it still releasing? Just remember you are listening to your body, not trying to force it. When it says no, that’s where you must stop.

At the beginning, put a clock with a second hand in front of you to time your stretch-rest-stretch intervals. After a while, you won’t need it because you’ll know how long twenty seconds is. Besides, with the fascial stretches, these time periods are basically just guidelines. The actual time you need depends on how well hydrated you are and the amount of injury and scarring in the part of the body you’re stretching. If your fascia is unhealthy, you need a longer hold to stretch it enough to get a good release. As you come to understand how the stretches work, you might decide to add a few extra seconds to your hold time, but always remember to be gentle and not force your tissue beyond that sense of slight discomfort. As your fascia gets healthier, your hold times can be shorter. You’ll be able to get into position immediately, so you can hold a few seconds less.

As you hold, there will be a moment when you suddenly feel the muscle fibers separating as the muscle opens and releases. When this happens, hold right there as long as you still feel this opening—being gentle yet firm at the same time. When the sensation of opening stops, let go. The optimal timing is slightly different for everyone. Once again, you must listen to your body—it will tell you. You might hold for thirty seconds, twenty-eight, or forty. What’s important is to consciously use the second hold period for the main therapeutic work.

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The Fascial Stretches

Like the spinal stretches, the fascial stretches are quite different than any other stretches you may have done. But your body will quickly become used to them. You’ll develop a practical understanding of how they work and learn to adjust each one so it’s maximally effective for your own body.

Say you’re used to stretching your hamstrings (back-of-thigh muscles) the way everyone does: propping your leg up on a bench and leaning forward over it with a rounded back. Although you are getting some stretch in your hamstrings, you’re also getting a pull in the mid- and lower back, which diffuses the stretch—it doesn’t focus precisely on the hamstrings. By contrast, the Ming Method hamstring stretch feels much more profound, because it’s intensely localized in the hamstrings.

After you’ve done the hamstring stretch a few times, you’ll notice real changes. When the hamstrings are tight with their fascia all bunched up, there’s excess tension in the tendons. In response, the little GPS computers shut the muscles off to prevent you from tearing something. But once a few stretching sessions have reshaped those muscles, the hamstrings start contracting properly, the GPS system kicks in and starts working right, and the muscles are stronger. Your body becomes more responsive to mental commands, you feel lighter on your feet, and you are less tired. If you’re a runner, your times improve.

General Instructions for Fascial Stretching

The fascial stretches are done differently than the spinal stretches. Instead of holding for one sixty-second period, you hold for two shorter periods with a rest in between (totaling sixty seconds in all). This makes them easier to do.

Don’t Overstretch

The most important rule to remember when doing fascial stretches is that if you overstretch a muscle, you can tear it. Keep in mind that these are very scientific, efficient stretches. You put your body in a position that gives one targeted muscle an extremely vigorous, focused stretch. To avoid injury, you absolutely must start out very slowly and gently. Here’s how to keep your stretching safe:

> The muscle being stretched should not hurt. If the experience is extremely uncomfortable, especially if you feel searing or burning pain, you’re pushing too hard.

> If the stretch is totally comfortable, you’re not pushing hard enough.

> You want an experience that’s exactly in between the previous two descriptions: definitely a little uncomfortable, but not really painful.

> When you put your body in the preparatory position for a stretch, never take any of the movements (e.g., turning your head, rotating your torso, pulling your shoulder blades together) to the limit. Go only to 80 percent of your ability, and save some flexibility for the stretch itself. If you try to push farther a muscle that’s already at its max, you may injure yourself.

My advice is: always err on the side of caution. Take each stretch just to the point where you’re slightly uncomfortable and hold right there, gently, for the remainder of your stretch time. Then stop and save any further effort for the next day. Each day, increase the stretch ever so slightly—in increments so small that they’re barely perceptible. Ride the line between slightly uncomfortable and too easy, and you’ll be in just the right place. Advanced practitioners of yoga and Pilates, gymnasts, professional dancers, and others whose disciplines create an understanding of the dynamics of stretching can start out somewhat more aggressively. But remember even advanced practitioners can injure themselves if they stretch too forcefully.

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It’s Not Enough Unless You Vibrate!

Remember that real exertion is essential to stretching successfully. Especially at the beginning, you must work hard enough to make your body vibrate at least a little. Some people shake like crazy. That’s a good sign—it means that you’re maximizing the intensity of your muscle contraction, which is necessary for adequate spinal decompression. As you get stronger and your body comes to understand what it’s doing, you won’t vibrate as much, which indicates that your body is accepting the posture. This learning process occurs for every stretch. If you slack off for a while, the vibration will return until you’re up to speed again.

Another caution: once you’ve become used to the stretches, it’s easy to slip into a halfhearted way of doing them. For example, if you’re extending your arm, remember that you’re not just casually holding it out there. You’re pushing as hard as you possibly can, as though you need to save yourself by keeping a heavy weight from crushing you. This goes for extending the legs, head—everything. You need this powerful exertion to activate Sherrington’s law. If you do the stretch only halfheartedly, you won’t create the separation between vertebrae that you’re aiming for.

First try it sitting upright. Begin by tucking your chin into the bottom of your neck, as though you’re making a double chin. The goal is to move your chin toward the notch at the bottom of your neck. It won’t actually reach that notch, because you don’t want your head to tilt forward. Instead, move your head slightly backward until the back of your neck flattens out. The challenge is to keep your head in a straight line with your spine while tucking your chin directly into your neck. This is what elongates the back of the neck, which is the goal of the head position.

Once your chin is tucked, imagine the top of your head moving away from your shoulders.

It helps to think of your spine and skull as one unit, with the skull a natural extension of the spine. Imagine a hook on top of your head and someone pulling your head toward the ceiling.

People tend to drop their jaw by opening their mouth, instead of tucking their chin in. This is incorrect. Keep your lips together, but don’t clench your jaw. Remember that all you’re doing is pressing your head back.

Now lie on your back and try the head position again, bringing your chin toward the notch at the bottom of your neck. To do this, your head has to come up off the floor. Focus on keeping your spine in a straight line from the top of your head to your sacrum (the triangular bone at the bottom of your spine), and you will find the distance between your head and the floor that’s right for your body.

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Timing the Stretches

Hold all the spinal stretches for a full sixty seconds. This is done for two reasons: First, you need to hold the fascia in tension for a certain length of time to reshape it. Second, the spinal stretches actually create suction that draws water into the fascia and the spinal disk, and this takes the full sixty seconds to occur. If you can’t hold for an entire minute at the beginning, start at forty-five seconds, thirty, or even fifteen, and work up to sixty gradually.

The sixty-second total includes the time it takes you to settle into position, so start counting as soon as you begin getting into the stretch. Beginners need twenty to thirty seconds to do this, but don’t worry—it’s been factored in. As you gain experience, you lock into position within five to ten seconds, so the amount of actual therapeutic time increases.

There are a number of ways to keep time. I stretch next to a clock with a second hand and check it periodically. You can use a timer, or count inside your head. One patient told me that she counts her breaths.

“Flashing In and Out”

You’ll find that some spinal stretches are easy, and you can hold them for sixty seconds after only two or three sessions. Other stretches are difficult and take longer to master. The general principle is that the spinal stretches you find the hardest are the ones you need to work on the most. In fact, this is how you diagnose your own problem. Since each stretch releases a particular region of the spine that’s related to a specific part of the body, the difficulty of each stretch tells you whether there’s a problem in the general area it relates to. Then you can use the fascial stretches to find out which specific muscles in that part of the body are affected.

Most people can’t hold the spinal stretches for sixty seconds when they first try them—in fact, thirty seconds is a long time to hold at the beginning. I’ve discovered that dancers, women, and thin people in general can do the stretches more easily than older people, overweight people, those with a lot of injuries, and men. Men are generally less flexible than women and usually have a body type—especially a stocky or muscular build—that makes it harder to hold a stretch. When I started out, I couldn’t do the Low Back Stretch for more than twenty seconds, and it’s still challenging for me. For people who are not very flexible or have difficulty getting down on the floor, I’ve included easier versions of most of the stretches, which can be done on a chair or cushion until you develop the ability to do the regular versions.

Another important point: even once a stretch has become easy for you, do not expect yourself to hold it perfectly for the full sixty seconds. Your goal is to maintain each piece of the position throughout that minute, but the truth is that no one, other than a professional dancer, can really do this. Instead, once you’re in position, run your tape loop in your mind, continually scanning your body and adjusting each part in turn, maintaining the position to the maximum of your ability. I call this “flashing in and out.” Say your right foot relaxes instead of staying flexed. When it comes up on your tape loop, you notice this and flex that foot again. Expect to lose pieces of the stretch even as you strive to maintain as much of it as you can. Just keep scanning and recorrecting yourself. Time for making these changes is built into the sixty seconds.

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General Instructions for Spinal Stretching

Begin the spinal and fascial stretches on the same day. You don’t have to do both kinds at the same time, although you can if that’s convenient for you. But you should do all the stretches in your program every day. Here are several basic guidelines:

• Stretch on a relatively soft surface, such as a carpet with a fair amount of cushioning or an exercise mat that’s about ฝ-inch thick—not on a hard surface such as a wood floor. Take your shoes off.
• Your body should be moderately warm before you stretch. “Moderately warm” means that if you feel cold or even chilly, you’re not warm enough. Your body should feel loose. Don’t stretch right after you’ve come in from the cold! Do the stretches in a warm room, with a sweatshirt on. When you have the opportunity, it’s especially effective to stretch after using a sauna or hot tub, or even after taking a hot bath or shower. Drink a cup of water right after the shower or sauna, wait a few minutes so the water can pass through your digestive tract, and then stretch. Other good moments are after a massage, when your fascia is already softened up, and when you’re warm after a workout.
• The ideal time of day to do the spinal stretches—especially if you have chronic or severe pain—is right before you climb into bed at night, because being horizontal helps maintain the spaces the stretches create between vertebrae. As soon as your body is upright, the spine starts to compress, but when you’re lying down, it stays open. Let’s say I have lower-back compression that’s causing an ankle problem. I do the Low Back Stretch and go straight to bed. Because I’m horizontal all night, the nerves in my lower back remain uncompressed, sending stronger signals to the leg and foot, buying time for healing to occur in the joint. By the end of the next day, my lower back will be compressed again, but if I stretch regularly every night, little by little my ankle will heal.
•  Always do spinal stretches that affect the higher parts of the body before those that affect the lower parts. Thus neck stretches come before mid-back stretches, which come before lower-back stretches.
• If you can, stretch in front of a mirror. Since you won’t have Ming Chew correcting your position, you need something to give you feedback. You can also try a mental device I use. I keep an endless tape loop running in my mind: Are my legs straight? Are my feet flexed? The instructions for each stretch include a “Tape Loop,” which gives you the cues to scan for as you do the stretch. Keep the tape loop going in your mind for the entire sixty seconds. 

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