Barefoot running and correcting your stride

As a FIT professional at Fleet Feet, I receive an increasingly greater demand for "barefoot running shoes" (how's that for an oxymoron?). Normally, customers are specifically looking for Vibram Five-Fingers, but the Nike Free is still a popular choice.  Most commonly, people saunter into a "Chi Running" class or read something featuring the "Pose Method" of running, or, my personal favorite, read Christopher McDougal's book Born to Run,, then coming looking for shoes that will help them apply what they have learned.  If you think I'm going overboard with links, then I accomplished my goal!  There is a ton of writing being done on the topic of barefoot running as well as methodologies that claim to make running easy, pain-free, and even comfortable!  

The truth of the matter is that running is a natural movement with which we have fallen out of touch.  Over millions of years of evolution (in case you haven't been able to tell from past posts, I love evolutionary biology!), the environment selected for minor tweaks here and there to our bodies.  As a result, we developed the ability to walk upright, freeing our arms to carry stuff (or pump to help us move our legs faster); an extremely complicated structure known as the foot; and a perfect arrangement of tendons, ligaments, and tissues that enabled us to walk or run whenever we needed to escape danger, hunt, move stuff, or have fun.

This is the barefoot runners' argument: evolution gave us a body that was not meant to wear shoes!  Many indigenous tribes and communities around the world have maintained near-barefoot practices.  The Tarahumara are a group of Mexican indians that lives off of ultra-distance running and booze, and they are virtually injury-free.  McDougall's book (mentioned above) centers around this tribe of amazing athletes who insist on wearing no more than a piece of leather and straps.

http://isiria.files.wordpress.com/2009/04/tarahumara.jpg

While this is true, evolution never intended for us to walk around on uniform concrete all day long.  The many bones in the foot enable it to adapt to uneven, rough terrain, meaning modern barefoot people - who wore shoes for the first 30 years of their lives - are probably doing more harm than good by diving into barefootedness.

Having said that, many people find that (slowly!) transitioning to barefoot running (or at least using as minimalistic a shoe as possible) helps them become not only a more efficient runner but also less prone to injury.  The reason can be found if we look at the evolution of the running shoe:

1832 - Englishman Wait Webster patents a process wherever a thin, rubber sole can be attached to a canvas upper
1860 - A croquet shoe is developed using Webster's process.  These shoes are noiseless when worn, hence "sneaker".
1890s - These shoes quickly began very popular as children's shoes.
1917 - The first popular sneaker is released in the U.S.  The company is called "Keds", which is likely a combination of "Kids" + "peds". Also, Converse introduces it's high-top basketball shoe.
1964 - Phil Knight and Bill Bowerman found Blue Ribbon Sports.  They begin selling Onitsuka Tiger shoes out of Knight's car at track meets.  Onitsuka Tiger eventually becomes Asics.  BRS eventually becomes Nike.
1974 - Bowerman experiments with waffle irons and creates the waffle sole.  He markets a new shoes called the Waffle Racer.

After the introduction of the Waffle Racer, the running shoe industry exploded.  Shoes became more complicated as time went on.  Currently, it's nearly impossible to buy a regular running shoe without a big chunky rubber heel, which enables us to land on our heel with each step.  To strike on the heel, you must lengthen your stride.  Don't believe me?  Try it yourself.  Go find an empty sidewalk and take off your shoes.  Walk a few paces, paying close attention to your feet.  You will notice that your natural walking pace is programmed for a mid-foot strike, not a heel strike.  Now, mark off about 20 yards on the sidewalk.  Jog first with your shoes on between the markings, counting every stride.  Repeat barefoot.

If you are indeed a heel-striker, you will count more paces during that drill barefoot than while wearing shoes.  Without the plushy heel, we naturally correct our gait by shortening our stride, transitioning our body weight forward over the feet, and landing on the mid- or forefoot as opposed to the heel.

Mastering this technique will make you efficient without losing the running shoes.  My buddy Dustin runs in Vibram Five Fingers occasionally, and, while he'll be the first to let the good vibes roll regarding minimalistic shoes, he confesses that the thin soles allow even the tiniest stone to jab into your plantar fascia. So I still like to wear my shoes.  A longer stride is inefficient because it is often accompanied by locking out of the knee.  When you land on a locked out knee, it acts to break your forward momentum.  There's no fluidity to this motion, as you'll see in the video below:



The alternative is to lean slightly forward at the hips and allow your body to almost fall forward. Your feet are forced to shuffle forward in order to keep you from falling on your face. That's pretty much it! If you watch elite runners, their heels never hit the ground because they don't over stride. They land on their mid- or forefoot, and their cadence is very fast (90-98 strides with each foot per minute!)

Another benefit to running (or just walking around your house) barefoot is that it strengthens the many muscles in your feet.  The 26 bones of the foot are controlled by a bunch of muscles that are required to do very little work from the day we begin walking due to our over-reliance on shoes.  Allow your feet to breathe, and I think that you'll find that you'll be less prone to injury.  Decreasing stride length = eliminating heel strike = lower impact running. By the way, flip-flops don't count!  There's still a nice chunk of rubber under your foot! 

My suggestions for improving your running are simple:
1) Slowly transition through very short distances if you wish to begin barefoot running.  If nothing else, go to a high school football field and run a few lengths of the field without shoes on after your workout.  Practice shortening your stride and landing mid- to forefoot.
2) Once you understand the basics, don't over think running.  The beauty of the motion is that it should feel natural. As Matt Fitzgerald says, Run Unconscious!
3) Take your shoes off around the house and in your yard.
4) Aim for a higher cadence rather than a longer stride when you're trying to go faster.  If you already are running with a high cadence, check out some of Joe Friel's writing (blog linked below) for drills to increase your stride length while maintaining mid- to forefoot striking.

Some more resources:
http://www.therunningfront.com/natural-running/beware-of-barefoot-running-injuries/
http://www.joefrielsblog.com/
http://running.competitor.com/
http://www.runningbarefootisbad.com/
http://www.barefootrunning.fas.harvard.edu/
http://therunningbarefoot.com/
http://www.mediafire.com/file/3zj3ndtddje/minimalist
http://thedianerehmshow.org/shows/2010-07-12/running-america

Happy running!

Send me questions if you got 'em: m.aspiration@gmail.com

Developing the "kick"

In 1983, Jeff Smith was leading the New York City Marathon at mile 26.  Rod Dixon, in second place, had been closing in on him since mile 20.  At mile 26, Smith looked over his should, only to see a possessed Dixon speeding past him.  At mile 26!  In the ensuing 0.2 miles, Dixon's legs churned, taking him straight to the finish line, increasing in speed the whole way.



This incredible drive by Dixon at the end of the marathon is something I like to refer to as "the kick". Developing the kick takes time and patience in your training. It's normally the result of regular fast, explosive workouts that focus on building anaerobic endurance.

Jeff Dixon is historically a miler, meaning he was a short-distance racer turned marathoner. Through regular speed work sessions, he managed to maintain his anaerobic engine in addition to improving his long course endurance.

Anaerobic work ranges from heavy weightlifting to short-distance sprints. If you're a runner, this obviously means running sprints. But you can build the kick in swimming or cycling in similar fashion - short, powerful repetitions.

Anaerobic work has benefits beyond developing the kick, a useful component of endurance sports competition. It also revs up your metabolism and builds muscle. As a runner, if you were to focus your time primarily on speed work at the track, you would look more like exhibit A as opposed to exhibit B:

Don't get me wrong. I don't think one body type is better than the other, but, physiologically speaking, the anaerobic giants tend to have more muscle mass, and aerobic runners, who would observe decreased performance from extra, heavy muscle mass, tend to be thinner.  Long-distance guys don't need the explosive power garnered from big muscles.

Anyways, "the kick" is one of the most incredible things to watch in sports.  When you see somebody turn on the jets at the end of a long event, you can't help but admire them.  It's so hard to develop the kick, but the result is well worth the price.

How to Fix the U.S. health care system...at least partly

Anybody that claims that they have the solution to the U.S. health care dilemma is crazy.  I won't try to provide a secret recipe for health care reform, but I do think that there are some important facets of other health care systems around the world that should be implemented into our own system.

1) Insurance companies should be prohibited from making profits off of peoples' health.  Shareholders?  Gone.  Their primary function must be to keep people healthy.  There really isn't any way around this.  Health care costs money, so when you deny people coverage, you conserve more of it for your shareholders.  This must end, no questions asked.

2) Insurance companies can't refuse coverage based on pre-existing conditions.  In fact, they shouldn't be able to refuse coverage to anybody, period, if that person is willing to pay them for insurance.

3) To make sure that people don't abuse #2, everybody that can afford it must pay into insurance.  If everybody pays, then premiums are lower because costs are distributed across a larger population.

4) It should be illegal for pharmaceutical companies to spend so much of their budgets on marketing.  Currently, U.S. pharmaceutical companies spend about 24% of their budgets on marketing their drugs, which is over ten percent more than they spend on research and development.

5) A special advisory commission comprised of health professionals should negotiate all prices for any procedure, treatment, drug, test, and other health care service. These prices should be fixed nationwide for any patient, provider, and insurance company.  Insurance companies should focus on expanding their client list rather than on finding reasons to deny reimbursement to their clients.  Since prices are fixed, they have to pay no matter what, so they'll increase their income by enticing more people to sign on with them, and then by keeping those people healthy.

6) Prevention should become our primary objective.  This includes improving access to locally, sustainably produced food; better public health regulations (e.g. reduced air pollution, access to safe drinking water, vaccinations); steep taxes on all processed foods except restaurants that meet certain established dietary guidelines; steep taxes on cigarettes and alcohol; the encouragement of tests and screenings for cancer, diabetes, cardiovascular disease, etc.; and improving access to fitness facilities and programs.

7) Taxes collected from processed foods, cigarettes, and alcohol will help to fund health insurance for those below the poverty line, senior citizens, veterans, military personnel and their dependents.

8) A separate advisory committee established by the government should make recommendations for which screenings and test should be done on which populations and how often they should be done to produce the best results.

9) Physicians must regain the power to choose whichever treatment they see fit for their patients.  The commission suggested in point #5 will outline a fee schedule for every treatment imaginable (as long as they see a benefit in covering it), and the physician may choose whichever drug or procedure that they think would be most effective.

10) Medical schools should be free to the student.  In 2009, the average debt incurred by U.S. medical students was $156,456.  This is the figure achieved after graduation.  Add on 15-30 years of interest, and you're looking at a second mortgage on a very fancy house.  It's simply too difficult to pay off medical school loans on a primary care physician's salary.  If school was free, many more people would choose fields in internal medicine, which is currently desperate for more doctors, and which also happens to be the field in which prevention could reign supreme.

11) The USDA needs to revise its dietary guidelines, and these guidelines should be followed strictly in our schools.  Even with the recent 2006 USDA Food Pyramid Revision, it's suggested that we eat more carbs than necessary and not enough healthy fats and protein.   Processed carbohydrates should be forbidden on the food pyramid.  All of the carbohydrates that we need should come from fruits, vegetables, nuts, and legumes, as far as I'm concerned.  Soft drinks, candy, and pastries should absolutely not be allowed to be served in grades K-12.

12) Government subsidies should be reserved for organic produce and raising free-range, hormone-free, grass-fed livestock.  Evidence for the health benefits grass-fed beef and dairy; free-range poultry products; wild fish; and organic produce is overwhelming.

13) Brace yourself for this last one.  Every U.S. citizen needs to start taking personal responsibility for their health.  While there is probably some connection between genes and disease, the diseases that are most taxing to our health care system (those associated with metabolic syndrome) can be largely avoided through a healthy diet and frequent exercise.  Get your kids outside rather than buying them electronics to keep them busy.  Get yourself outside with your kids!  If you are young and feel healthy, start incorporating regular exercise into your life to maintain and improve your fitness.  The most important thing that we can all do is to educate ourselves about food.  Cook your meals at home rather than resorting to fast food every day, and slowly incorporate more produce into your diet.  Lastly, take it on yourself to pressure the government and school boards to fix the school lunches and physical education programs at your local schools.  There are countless things you can do to live a healthier life.  You know what to do.  


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Considering the huge disparities in our nation's health when compared to other developed countries, it would be absurd to think that we can't do any better.  Our health care expenditure is nearly twice the next highest in the world, yet we get shockingly poorer results.  Health care costs continue to rise faster than we are able to accommodate them, due to constantly improving technology.  The most important reason to reform ourselves drastically is that people are dieing from diseases that were entirely avoidable in the first place.   When people do get sick for fault other than their own (e.g. genes, accidents, and natural disasters), we should have a system in place to help them out. 

Global Health Care Systems - Canada

http://www.who.int/whr/2000/en/whr00_annex_en.pdf

Notes on Canada's health care system: 

1. Taxpayer-funded national insurance program, which is titled Medicare (sound familiar?)

2. The system covers all hospital and psychiatric care.

3. Private health care providers, government financing.

4. Canadians generally love the program.

5. Medicare guarantees everybody health care who needs it while maintaining better health stats than the U.S.

6. Canada's system is going bankrupt though.  It hasn't been increasing its expenditures to match the rise in health care costs.

7. There is a lack of doctors due to poor compensation; Canada is also working to reduce the number of medical students because the system can't afford to pay so many doctors.

8. Service is available for all persons with acute illness, accident, and emergencies, but non-life-threatening problems may require a long wait.

9. Some people never even get to see specialists because of the long waiting lists.  They either get their care elsewhere, or they just give up on the pursuit.

10. Waiting periods differ between provinces and according to your particular needs.

11. Reports of Canadians fleeing to the U.S. for medical care aren't backed up by statistical research.  The actual number of such cases is tiny.

12. Those whose urgently need care will get it, but those who can wait must wait, and they seem to do it without much complaint.

13. Each province has its own Medicare plan, so Canada's system isn't a single-payer system. Some provinces require co-payments, others cover 100% of the cost.  However, the system works like single-payer system since the federal government provides most of the funding and sets regulations for the provinces (Canada Health Act of 1984).  Rules laid out in the Act are, for the most part, simply advised, but if provinces don't follow the rules, they forfeit their ability to receive government subsidies, which no province can afford.  So, the rules are effectively laws.

14. The basic principles of the Act are: a) administration must be done on a non-profit basis; b) each plan must pay for all "medically necessary" treatments; c) every resident within a province must have equal access to health care services; d) the plan must pay for services received anywhere in the country and often in foreign countries as well; e) patients must be charged the same fee, regardless of age or illness

15. Most Canadians pay nothing when they visit their doctor, nothing for screenings or tests, and nothing for vaccinations. Preventive dental care isn't covered, but dental surgery is covered when performed in a hospital.  Ambulance services are covered in most provinces.  Mental health care is largely covered, but expect a very long waiting list.  

16. Prescription drugs are much cheaper in Canada, but they aren't covered at all by insurance, except for the poor, senior citizens, and chronically ill persons, except for "lifestyle" drugs such as Viagra.

17. Two-thirds of Canadians have private, supplemental insurance to cover thing that aren't covered by Medicare (e.g. dental, private hospital rooms, prescription drugs, etc.) 

18. Private insurance won't, however, shorten your waiting time.  

19. Since Medicare covers all of the expensive stuff in Canada, private insurance is very cheap.

20.  To avoid a flight from Medicare, it's illegal for patients or private plans to pay for any medical service covered by Medicare.

21.  A physician must choose to be accept Medicare or provide private services - they can't do both.

22. The problem with this model is that there is no way to get around waiting lists, even if you would pay dearly for otherwise Medicare-covered services.

23. To respond, there is increasing pressure on the Canadian government to spend more money on health care and to train more doctors. 

24. Physicians are paid must less than American doctors.

25. All patient records are digital.

26. Medical schools cost about half the price of American med schools.

Global Health Care Systems - UK

 

http://www.who.int/whr/2000/en/whr00_annex_en.pdf

Notes on the UK's health care system:

1. Nobody pays any part of a medical bill.
2. No insurance premiums, no co-payment.
3. There are private health insurance plans, but virtually nobody uses them.

4. Health care system is financed through heavy taxation.

5. There are numerous treatments and medications that aren't covered by the National Health Service (NHS).

6. The UK system is infamous for its long waiting lines.

7. No billing, no paperwork since everything is covered by the government, so it's surprisingly cost-efficient.

8.  Lower child mortality, longer life spans, and better recovery from major diseases.

9. The system only pays for what it deems necessary medical care.

10. The government owns the hospitals, compensates health care professionals, buys medicines, and pays the bills.  

11. This is the "socialized medicine" model.  The same system we use to provide medical services to Native Americans, veterans, and military personnel and their dependents. 

12. Physicians can still see patients on the side and charge their own fees, but few people take advantage of private services outside of the NHS network.

13. The NHS is the largest  employer in Europe (over a million full-time employees).

14. The only fee is for prescription drugs ($10), but this fee is waived for children, senior citizens, pregnant women, and the chronically ill.  Patients are, however, often required to pay for eyeglasses, contact lenses, false teeth, and some dental bills.

15. Government regulations are vast in an effort to contain costs.

16. A major reason for the cost-efficiency is the lack of billing offices and the bureaucracy required to review insurance claims that exists in the U.S.

17. General practitioners (GP) are private businesspeople, but most are paid solely by the government.

18. Every UK citizen must register with a GP.  To see a specialist, you must be referred by a GP.  This "gatekeeper" system is utilized to a large degree by U.S. insurance companies, and it is very effective at controlling costs.

19. GPs receive a set fee for each person that chooses them as their practitioner. Thus, there is an economic incentive to have more people, but more people means more treatments and procedures because the NHS pays GPs per patient enrolled, regardless of whether they come in for treatment.  For this reason, prevention is always first priority, since less people coming in for treatment means less resources used.

20. There are tons of campaigns promoting preventive behavior.

21. Waiting lines for specialist care are the biggest complaint in the UK system.   

22. Anything life-threatening doesn't require a long wait.

23. Primary and preventive care is not rationed. 

24. The NHS controls its budget by covering only certain medications, tests, and procedures.  This type of rationing also takes place in the U.S., but decisions are made by insurance companies behind closed doors.In the UK these negotiations are constantly in the news, open to public critique.  The agency within the NHS that makes these decisions is called the National Institute for Health and Clinical Excellence (NICE).

25. The UK's health care system operates on very egalitarian principles: how can we provide the best care to the most people.

26. Physicians make house calls.

27. Annual physicals are considered pointless.  They prefer to do screenings and tests for disease, but only those that would be considered appropriate according to your family history and other factors affecting your potential for disease.

28. If your complaint isn't detrimental to your quality of life, you probably won't get any treatment, unless you want to wait along time and pay for it yourself.

29. About 60% of physicians are GPs (35% of physicians are GPs in the U.S.).  This is because GPs in the UK normally make more than specialists, since they make more money if they see more patients.  Many GPs also see patient privately on the side. 

30. GPs earn additional income through the Index of Quality Indicators, which pays GPs for good performance.  This replaces the fee-for-service model so common in the U.S. Doctors are simply paid more for taking the necessary steps to keep their patients healthy.

31. Malpractice insurance is much cheaper in the UK than in the U.S.

32. In the UK, anybody sued for malpractice is off the hook if they can prove that they were following NICE guidelines.  This also leads less GPs to practice defensive medicine, suggesting multiple screenings and test simply to cover their behind like in the U.S.

Global Health Care Systems - Japan

http://www.who.int/whr/2000/en/whr00_annex_en.pdf

Notes about Japan's health care system:

1. No waiting, no gatekeeper, no rationing, and a very high level of patient choice
2. Prices are low as a result of a rigid cost-containment system that benefits the patient at the expense of the doctors and hospitals

3. Even the best, most prestigious doctors are accessible at virtually no cost to the patient.

4. Japan's system is largely private.  

5. Competition between doctors, clinics, and hospitals is fierce.  Everybody claims their treatments or procedures are more effective.  There are billboards and ads (this one a cure for sweaty hands) everywhere in the cities.

6. The Japanese use more medical care than any other country.  They average 14.5 hospital visits per year, three times the U.S. average.

7.  Nearly all Japanese physicians make house calls.

8. The Japanese gets twice as many cat scans per year as Americans, 3x as many MRI scans.

9.  Patients enjoy twice as many hospital beds per capita as American patients.

10. The Japanese spend 36 nights per hospital visit as compared to 6 nights in the U.S.

11. Japanese women spend 8-10 nights in the hospital after giving birth, compare this to 1-3 days for American women. 

12. Japanese are much less likely to take advantage of invasive surgeries.  Physicians don't recommend it anyways because it's so expensive, and they receive high compensation.  The Japanese also have cultural hesitations about going through surgery, they prefer to take advantage of less drastic options. 

13. Drugs are usually preferred to surgery. The Japanese pop twice as many pills as Americans.

14. Despite incredibly cheap access to patients, the Japanese actually require less medical care than Americans.  There is less obesity, lower rates of blood-borne diseases, and less illicit drug use.

15. Health care costs are steady or even declining.

16. Medical providers' income is much lower than in most developed countries.

17. Patients are required to pay 30% of their medical bills as a co-payment, insurance picks up the remaining 70%.  Co-pay is lower for children and senior citizens.  There is a monthly limit on co-payment; nobody has to pay more than $650 per month.

18. Insurance plans cannot refuse coverage, regardless of preexisting conditions, and they cannot deny a claim.

19. Insurance companies are nonprofit entities; providers are private. 

20. Japan has over 3500 different insurance plans to chose from.  Three major categories: 1) plans set up by large companies to cover their employees, premium split 55:45 employer:employee, no government subsidies, companies subsidize premiums for pensioners, some companies (e.g. Honda, Toyota) even maintain their own hospitals; 2) in smaller companies, employer/employee split premium but with help from government subsidies; 3) Citizens Health Insurance plan, which covers retirees and the self-employed; individual and local government split the premium

21. Everybody is required to buy into health insurance.  If you don't choose one, you'll be assigned one by local government.  If you don't pay your premiums, you'll be hounded by collection agencies.  If you get sick, you're required to pay up on all past over-due premium payments before insurance will foot your bill.  If you're unemployed or unable to pay your premiums, the local government pays your premiums and bills instead.

22. When a worker loses his job, the government steps in to cover the employer's share of his premium.

23. Even the richest are required to buy into insurance. 

24. In Japan, you don't get to choose your insurance plan.  Rather, you are given a plan by your employer or the local city government.  Patient choice rests around physician, clinic, and hospital selection.

25. The Ministry of Health and Welfare negotiates all prices with providers.  Prices are set for every doctor, clinic, and hospital in Japan regardless of how luxurious or rural.  All fees for every procedure imagineable are published in a book called the Shinryo Tensu Hyakumihyo (Quick Reference Guide to Medical Treatment Points). Prices are renegotiated every two years.

26. Costs remain low  because of extremely poor compensation to physicians and hospitals.  Doctors don't get rich in Japan, they are average earners, "comfortably middle class".  Being a physicians, however, gives you sky high social class.

27. Multi-payer system that works like a single-payer system because of the strict fee schedule. Hospitals and doctors compete for customers, but fees are set.  This is like phone service in the U.S.

27. Doctors often drive innovation of cheaper, more efficient technology because they want to be able to make more money for the same procedures.
28. Many hospitals and clinics are on the verge of bankruptcy.
29. The list of procedures and treatments that are paid for by insurance is vast.  U.S. critics cite a lack of coverage for pregnancy-related care, but the government gives pregnant a maternity grant of $3000 to cover prenatal care, delivery, and postnatal care to mother and child.
30. There is a Confucian obligation for physicians to use their skills to treat people without expecting payment.

Global Health Care Systems - Germany

 

http://www.who.int/whr/2000/en/whr00_annex_en.pdf

Notes on Germany's health care system

1. World's first national health care system
2. Health care is guaranteed to anybody residing in the country, legal or not.
3. Benefits include doctors, dentists, chiropractors, physical therapists, psychiatrists, hospitals, opticians, prescription drugs, nursing homes, health club memberships, physician-recommended vacations trips to the spa, and numerous others.
4. Ample supply of hospitals and doctors, so there's no queue for treatment. Waiting time for elective/non-emergency surgery and emergency care is less than in the U.S.
5. Patients can choose any doctor or hospital, and insurance must pay the bill.
6. There are over 200 insurance plans that you can choose from.  These different plans compete for your business despite fixed prices for services and treatments.
7. Insurance plans are known as "sickness funds".  They are private entities.
8. Health care providers are private businesspeople working in private clinics.
9. German hospitals are normally charity-run non-profits, but there is an increasing number of for-profit hospitals as well.
10. The private insurance companies negotiate prices with the private clinics and hospitals, and these negotiations are almost entirely government-independent.  There is much less government regulation than in the U.S.

11. Germany's system is understandably very expensive.  In an effort to control costs, Germany strictly controls payments to physicians.  They use a "digital health card" (die elektronischen Gesundheitskarte), which, like in the French system, eliminates a lot of overhead by eliminating administrative costs that go into billing, clerical work, maintaining medical records, etc.  The U.S. hasn't even totally switched over to electronic medical records, let alone a card that you use for all things medical.
12. Patients are only responsible for co-payments for covered services and treatments.
13. Because Germany's system covers non-surgical procedures, alternative therapies are always given as options in addition to heavy drugs and surgeries.

14. Premium is a fee that usually equates to around 15% of your paycheck (similar to income tax int he U.S.), split between you and your employer.  This is about the same amount taken from U.S. paychecks for medicare and medicaid, but then we pay an additional percentage for our healthcare.
15. Physicians complain about poor compensation. But government and sickness funds are constantly trying to reduce costs.  Health care reform is constantly being proposed, but the basic system has remained untouched.
16. Germans are required to pay into health care.
17. Price negotiations are differ regionally, prices are then fixed for every physician and hospital in a specific region.

18. Sickness funds are nonprofit (no shareholders!).  There is thus no incentive to deny coverage.  All plans are required to pay any claim submitted.  This is also good for cost control because they don't have to pay for the claim-review system for which we pay so dearly in the U.S.

19. If you lose your job, the government jumps in to cover your premium.  You thus are covered through the same plan while you look for a new job, regardless of the time during which you are unemployed.

20. It's very easy to switch insurance plans.

21. Competition between plans is tough.  A basic care package is required, and the premium is the same no matter which plan you have (percentage of pay), so plans compete by offering perks like quick claim payment, exotic therapies, and free neonatal nursing care. 

22. Insurance plan competition is driven by executives' desire to insure more people and thus make more money (think U.S. care insurance)

23. Richest families are excused from mandated insurance coverage.  They  may choose to buy private coverage from for-profit companies.7% of population takes this route.  These alternatives plans may cover fancier facilities or care provided by famous physicians.  

24. Co-payments are tiny (around $13 per quarter year)

25. Germany malpractice insurance is very cheap, but litigation is very rare.

26. Other than co-pay, no money changes hands at the point of care.

27. In 2002, a round of health care reforms installed caps in certain regions on patient expenditures per year or the number of patient visits reimbursed per year.