A blog covering the health/care ecosystem and people.

The FDA is delaying the public posting of calorie counts, a policy that President Obama’s administration had pioneered for public health and wellness. Menu labeling has applied to grocery stores, gas stations, convenience stores, movie theaters and sports stadiums that sell prepared food. “Health and Human Services Secretary Tom Price said the menu labeling requirements would be ‘unwise and unhelpful’ as currently written, and added that the FDA is looking for ways to make the rules ‘more flexible and less burdensome.'” Former FLOTUS Michelle Obama took on the issue of healthy food and fitness for America’s children. Except for keeping her White

The top healthiest eating communities tend to circle the perimeter of the map of the lower 48 U.S. states. In these towns, more than 72% of health citizens report healthy eating. These areas are located in California, Florida, and Massachusetts, among others. Areas with the lowest rates of healthy eating are concentrated generally south of the Mason-Dixon Line, in places like Arkansas, Kentucky, and Mississippi, and other states. In these places, fewer than 57% of people eat healthy. Eating healthy foods in moderation is a mighty contributor to personal and public health, discussed in the report, State of American Well-Being

For us mere humans, behavior change is hard. Changing health behaviors is really tough. Enter Dr. James Prochaska, who has been at the forefront of researching and understanding human and health behavior for several decades. He’s the father of the Transtheoretical Model of Behavior Change (TTM). I have the honor today to listen live to Dr. Prochaska’s talk at the Health Integrated EMPOWER conference in St. Petersburg, Florida, where I’ll be addressing attendees on the new health consumer tomorrow. “Empower,” indeed. Dr. Prochaska is all about how people have good intentions to make good health decisions, but we all slip and

Just as consumers use TripAdvisor, Zagat, OpenTable, and their Facebook pages to review restaurants, hotels, automobiles, and financial services companies, many patients – now health consumers in earnest – have taken to reviewing healthcare services in social networks. Finding reliable, understandable information about healthcare quality and prices is very challenging for most consumers. Are healthcare reviews on social networks statistically valid? An analysis of consumer ratings for New York State hospitals on Yelp, the social network, were positively correlated to objective scores of hospital quality, according to the research published in Yelp for Health: Using the Wisdom of Crowds to

Consumers love their supermarkets, fast food shops, retailers, delivery services, and banks. These industries rank highest in the 2017 Temkin Experience Ratings, my go-to source for understanding consumer service Nirvana. Health insurance companies and internet service providers (ISPs) are at the bottom of the Temkin Ratings, as shown in the first chart. Note that health plans range from a score approaching 70 to under 50, illustrating the very wide range of consumer experience from okay-to-good, too very poor. The top-ranked health plan was Kaiser Permanente, with a rating of 67%; Health Net was ranked the worst of the health plans

3 in 4 Americans’ health care costs have risen in the past few years. Two-thirds of Americans want to lower their costs, but don’t know how to do that. A survey from Amino released this week, conducted by Ipsos, has found that one in five people could not afford to pay an unexpected medical bill without taking on debt, and another 18% of Americans could only afford up to $100 if presented with an unexpected medical bill. This medical debt side effect more likely impacts women versus men, the less affluent, the unmarried, and those with no college degree. While

The future of wellness combines: Connected (you) Social IRL (in-real-life) Banishing bad (de-tabooing what’s traditionally seen as “bad”) Humanizing data, and The end of experts. These insights come from adidas, whose team developed a forecast of the future of fit, announced at the 2017 South-by-Southwest Festival in Austin this weekend. I had the honor of participating in this forecast and shepherding the SXSW panel on The End of Experts: Crowdsourcing Your Wellness at the adidas meet-up held over the weekend. The future of fit and wellness is Connected, because we are growing to understand that balancing many elements in our daily

The truest form of health reform and consumer-directed health care isn’t in a high-deductible health plan or a health savings account, and it doesn’t come out of Washington DC or your employer’s health benefits office. It comes from you in the form of self-care and DIY healthcare. In this case, think “inspired by sport, powered by you.” I’ll be participating on a panel at this weekend’s South-by-Southwest Festival in Austin, Texas, along with three wellness innovators: Nick Buettner of the Blue Zones project, Mary Liz McCurdy of Google, and John Wilbanks from Sage Bionetworks. Together, our quartet will brainstorm the

Geography is destiny, Napoleon is thought to have first said. More recently, the brilliant physician Dr. Abraham Verghese has spoken about “geography as destiny” in his speeches, such as “Two Souls Intertwined,” The Tanner Lecture he delivered at the University of Utah in 2012. Geography is destiny for all of us when it comes to our health and well-being, once again proven by Gallup-Healthways in The State of American Well-Being 2016 Community Well-Being Rankings. The darkest blue circles in the U.S. map indicate the metro areas in the highest-quintile of well-being. The index of well-being is based on five metrics, of consumer self-ranking

The plane has left the Orlando airport, and I’m looking back at the past week at the 2017 annual meeting of HIMSS, the annual health IT conference that has been my pleasure and (foot) pain to attend for the past two+ decades (for real). Walking the exhibition floor, I encountered some new flavors of imaging that went way beyond bits and bytes, data and technology. These images spoke to me of health, vitality, and life. I’m sharing them with you here, with no intention of selling you company products or services but simply sharing some images that speak to these

  “Digital technology can provide a bridge to the healthcare system via sensors, tools, and trackers for people who are living their lives each day,” I explained to the social media team at Philips, which is morphing as an organization to being all digital health, all-the-time. (Here’s what I learned about Philips and digital health in January 2017 after meeting with Jeroen Tas at the CES in Vegas). Here’s the larger discussion, shared with several of my fellow members of the HIMSS Social Media Ambassador family. I’ll be meeting with Philips’ leadership at HIMSS, the annual health IT conference that

Health care is the top concern of American families, according to a Monmouth University Poll conducted in the week prior to Donald Trump’s Presidential inauguration. Among U.S. consumers’ top ten worries, eight in ten directly point to financial concerns — with health care costs at the top of the worry-list for 25% of people. Health care financial worries led the second place concern, job security and unemployment, by a large margin (11 percentage points) In third place was “everyday bills,” the top concern for 12% of U.S. adults. Immigration was the top worry for only 3% of U.S. adults; terrorism and

Americans are more than five times more likely to skip medication doses or not fill prescriptions due to cost than peers in the United Kingdom or Switzerland. U.S. patients are twice as likely as Canadians to avoid medicines due to cost. And, compared with health citizens in France, U.S. consumers are ten-times more likely to be non-adherent to prescription medications due to cost. It’s very clear that more consumers tend to avoid filling and taking prescription drugs, due to cost barriers, when faced with higher direct charges for medicines. This evidence is presented in the research article, Cost-related non-adherence to prescribed

Health and money are the two issues about which Americans have set New Year’s resolutions, according to the Harris Poll, Americans Look to Get Their Bodies and Wallets in Shape with New Year’s Resolutions. The top goals U.S. consumers have set for 2017 are to: Eat healthier, 29% of all U.S. adults Save more money, 25% Lose weight, 24% Drink more water, 21% Pay down debt, 17% Spend more time with family and friends, 15% Get organized, 15% Travel more, 15% Read more, 14% Improve relationships, 14%. There are some marked differences between American men versus women across these resolutions;

Among many health disparities which mar healthcare quality in the United States, there’s another one to add to the list: health and healthcare information access. Access to health care is underpinned in large part on a health consumer’s access to information about available health care services, their location, price, and if the patient is very fortunate to glean, quality. As people take on more responsibility for managing their health care utilization and financing in America, their access to information that is easy-to-find, clear, comprehensive and current is critical to personal and public health outcomes. But consumers are dissatisfied with the

Health citizens in America will need to be even more mindful, critical, and engaged healthcare consumers in 2017 based on several factors shaping the market; among these driving forces, the election of Donald Trump for U.S. president, the uncertain future of the Affordable Care Act and health insurance, emerging technologies, and peoples’ growing demand for convenience and self-service in daily life. The patient is increasingly the payor in healthcare. Bearing more first-dollar costs through high-deductible health plans and growing out-of-pocket spending for prescription drugs and other patient-facing goods and services, we’re seeking greater transparency regarding availability, cost and quality of

“Because health is personal” is the tagline at the 2016 Connected Health Conference being held at the Gaylord Resort in National Harbor in metro Washington, DC. “Personal,” “Connected,” and “Health” are the three words that comprise the adjectives in the Personal Connected Health Alliance, the host of this conference. PCHA was formed through the merger of HIMSS, the health IT association, and Continua, the organization advocating for health technology “interoperability” — the ability for digital and communications technologies to communicate with each other, to remove friction from health data exchange. This week, PCHA announced that it will bring the Wireless-Life Sciences Alliance into

Several market forces are converging that boost patients’ ability to engage in their health and self-care, including peoples’ growing adoption of smartphones, demand for self-service and DIY lifestyles, and Americans’ growing responsibility as health consumers. Health consumers are using a growing array of self-health tools, enabled through digital technologies. However, these tools aren’t yet engaging some of the very people who need them the most: high-need, high-cost patients. Research into this situation is discussed in the December 2016 Health Affairs article, Many Mobile Heaath Apps Target High-Need, High-Cost Populations, But Gaps Remain, published in the December 2016 issue of Health Affairs. For

“Thanksgiving.” Merriam-Webster’s dictionary defines the word, first, as “the act of giving thanks.” Second, it’s “a prayer of expressing gratitude.” And, third, the word means a public acknowledgment or celebration of divine goodness. We each have our stories about how a loved one’s life has ended. If we’re lucky, that beloved person had a good death: in sleep, perhaps, or simply of old age with no hospital events or trauma. Then there are the Rest-of-Us who have the stories of long and painful endings, in institutional settings and costly, futile care. When you’re already in the situation of making tough health

“The patient is the best sensor,” asserted Jamie Heywood, founder of Patients Like Me, during the perennial meeting sponsored by PwC, the 180° Health Forum. This event featured several panels of PwC’s curated group of so-called “provocateurs” in healthcare, and I was grateful to be one of nine selected for the event. Heywood joined Dr. Leanna Wen, Baltimore City Health Commissioner, and me in a panel called, “Strange Bedfellows or Soul Mates? The New Dating Game in Health.” The theme of our collective brainstorm was how collaborations across the ecosystem could help make health and healthcare better. The drawing is

I attended CES Unveiled in New York this week, which is a preview of what will be featured at the CES in Las Vegas in January 2017. CES, previously known as the Consumer Electronics Show, is celebrating a 50 year anniversary, having been born in Manhattan in 1967 when transistor radios, stereos, and black-and-white TVs were all the rage. Today, CES is the world’s largest innovation event, and the longest-lived. 10 of the original 1967 exhibitors still show at CES, including 3M, Philips, Sharp, SONY, Toshiba, and Westinghouse, among others. Meet George Jetson, who might have been an attendee at

It’s the 9th of November, 2016, and Donald Trump has been elected the 45th President of the United States of America. On this morning after #2016Election, Health Populi looks at what we know we know about President Elect-Trump’s health policy priorities. Repeal-and-replace has been Mantra #1 for Mr. Trump’s health policy. With all three branches of the U.S. government under Republican control in 2018, this policy prescription may have a strong shot. The complication is that the Affordable Care Act (aka ObamaCare in Mr. Trump’s tweet) includes several provisions that the newly-insured and American health citizens really value, including: Extending health

60% of Americans are currently trying to lose weight. So it shouldn’t be a surprise that when asked, “what’s the most serious health problem in the United States?” Americans say it’s obesity, tied with cancer, and ahead of heart disease and diabetes. Overweight and obesity are top-of-mind for most Americans, according to research conducted by the American Society for Metabolic and Bariatric Surgery (ASMBS) and NORC at the University of Chicago. This research has created two reports which can be accessed at the link. The survey, conducted among 1,509 consumers in August and September 2016, found that Americans’ understanding of

“Today’s primary care won’t work tomorrow,” given the shortage of primary care providers (PCPs) and the need to do more in healthcare with fewer resources in the emerging value-based economy. So let’s re-imagine primary care models, PwC asserts, and makes the case in their report, ROI for primary care: Building the dream team. What’s the financial impact of this dream team on healthcare providers? It’s potentially $1.2 million in savings for every 10,000 patients served, PwC calculates. Historically, physicians have been loath to share their work with non-physicians because of how doctors have been paid — on the basis of fee-for-service,

Notwithstanding the head of the AMA recently referring to digital health technologies as “snake oil,” it appears that one-half of physicians is keen on digital health. And scale, not age, matters when it comes to doctors using digital health tools. The American Medical Association (AMA) surveyed physicians on their use of digital health tools, finding that primary care physicians (PCPs) and doctors working in larger and more complex practices tend to be more digital. In Physicians’ motivations and requirements for adopting digital clinical tools, the AMA’s digital health study, “Physicians are optimistic about digital health innovation and its game-changing potential

Healthcare is going direct-to-consumer for a lot more than over-the-counter medicines and retail clinic visits to deal with little Johnny’s sore throat on a Sunday afternoon. Entrepreneurs recognize the growing opportunity to support patients, now consumers, in going shopping for health care products and services. Those health consumers are in search of specific offerings, in accessible locations and channels, and — perhaps top-of-mind — at value-based prices as defined by the consumer herself. (Remember: value-based healthcare means valuing what matters to patients, as a recent JAMA article attested). At this week’s tenth annual Health 2.0 Conference, I’m in the zeitgeist

The number of hospitals offering patients electronic access to their health information grew seven times between 2013 and 2015. Electronic health records access has gone mainstream in America, according to the latest findings by The Office of the National Coordinator for Health Information Technology (ONC-HIT). The data are detailed in Electronic Capabilities for Patient Engagement among U.S. Non-Federal Acute Care Hospitals: 2012-2015, an ONC Data Brief. Two in three U.S. patients can now view, download, and transmit their personal health information, shown in the bar chart. This hockey-stick growth, from 10% in 2013 to 69% in 2015, results from the

Consumers are open to technology-enabled healthcare, but look to providers to ensure quality and privacy of patients’ personal health information, according to Will Patients and Caregivers Embrace Tech-Enabled Healthcare?, based on the Deloitte 2016 Survey of US Health Care Consumers. Seven in 10 consumers would use at least one of the technologies Deloitte served up in its study, with telemedicine at the top of the list: 49% of people favor telemedicine for post-surgical care, 48% for chronic disease management, 36% for care while traveling, and 32% for minor health issues. While Millennials are generally keener across-the-board for tech-enabled health care,

Health is everywhere: where we live, work, play, and learn, as I’ve often written here on Health Populi. While I’ve also analyzed the market for medical tourism over the past twenty years, this week I’ve learned that it extends to the cruise travel industry along with hospitals and clinics around the world. I had the pleasure of meeting up this week with Hannah Jean Taylor, Manager of the Mandara Spa on Norwegian Cruise Line‘s ship, The Norwegian Breakaway. This vessel accommodates nearly 4,000 passengers who enjoy the services of over 1,600 staff members in the hotel, entertainment, and operational crews.

People living in only 1 in 10 homes with broadband are “very interested” in connected health services, like a personal health coach, a remote health monitoring app that connects to and notifies a healthcare provider, or a clinician collecting vital signs virtually. This finding comes out of a survey from Parks Associates. This is a relatively low consumer demand statistic for digital health, compared with many other surveys we’ve mined here on Health Populi. While these are not apples-to-apples comparisons — note that Parks Associates focus on broadband households — a recent study to consider is Accenture’s consumer research published in March

In the past week, the patient engagement/empowerment community marked two major events: the achievement of 400 painted patient stories in The Walking Gallery, and the loss of one of our tribe — Jess Jacobs. Jess passed away from complications of a complex condition called POTS (Postural Orthostatic Tachycardia Syndrome), made even more complicated by the fragmented, institution-focused (vs. patient-focused) healthcare she received. Jess documented many of her interactions with her health care providers, largely located in the Washington, DC, health care community, on social media–leaving a legacy and evidence on exactly how not to do patient care. You can experience

A majority of U.S. hospitals could enable patients digital access to their personal medical records in 2015. Specifically, nearly all US hospitals offer patients the opportunity to view their medical records online in 2015. Eight in 10 hospitals were able to download patient information from their medical record as well as enable patients to request a change to that record, according to a Trendwatch report from the American Hospital Association (AHA), Individuals’ Ability to Electronically Access Their Hospital Medical Records, Perform Key Tasks is Growing. Over the past several years, hospitals have made significant capital investments in buying, adopting, and

When consumers consider the many stakeholder organizations in healthcare, a majority trust pharmacists first, then doctors and dentists. Hospital and health insurance execs, and members of Congress? Hardly, according to a survey from Meyocks, a marketing consultancy. Meyocks conducted the survey via email among 1,170 US adults, 18 years of age and older. This survey correspondends well with the most recent Gallup Poll on most ethical professions, conducted in December 2015. In that study, pharmacists, nurses and doctors come out on top, with advertisers (“Mad Men”), car salespeople, and members of Congress at the bottom, as shown in the second

Health care payment responsibility continues to shift from employers to employee-patients, More of those patients are morphing into financially burdened health consumers, according to TransUnion, the credit agency and financial risk information company, in the TransUnion Healthcare Report published in June 2016. Patients saw a 13% increase in their health insurance deductible and out-of-pocket (OOP) maximum costs between 2014 and 2015. At the same time, the average base salary in the U.S. grew 3% in 2015, SHRM estimated. Thus, deductibles and OOP costs grew for consumers more than 4 times faster than the average base salary from 2014 to 2015.  In

About two-thirds of health consumers would be open to virtual health care options for non-urgent situations, according to the 2016 Connected Patient Report from Salesforce Research. Salesforce conducted the survey with the Harris Poll online among 2,025 U.S. adults in June 2016. 1,736 of these health consumers had health insurance and a primary care physician. Among the many findings in the report, Salesforce found that: In terms of communications and relationship… The vast majority of consumers with primary care physicians are very satisfied with them (91% of people with PCPs) However, one-third of people with a PCP believe their physicians would

Today is Financial Wellness Day. Do you know how financially well you are? Let me take a crack at that answer, even though I haven’t seen your bank account (which you may not even have as over 20% of people in the US are, as financial services companies would call you “un-banked” or “under-banked”.) You have some level of fiscal stress, ranging from a little to a lot. You aren’t taking all of your summer vacation your employer extends to you. You’re spending around $1 in every $5 of your household budget on health care. And your sleep isn’t as

The top award at the annual Cannes Lions International Festival of Creativity for best pharmaceutical advertising campaign went to Philips, the company that’s placing a big corporate bet on digital health.  The campaign was called Breathless Choir, and it left me, well, breathless (in a good way). Watch it now. This is how health/care advertising should be done. This inspires health and patient engagement, social connections, and sound self-care principles. Evidence shows that singing in the right way can bolster lung capacity — just what these patients, all dealing with some sort of respiratory condition, must do to enhance their quality

Hippocrates is often quoted as saying, “Let food be thy medicine and medicine be thy food.” While some researchers argue that Hippocrates knew the difference between ‘real’ medicine and clinical therapy, there’s no doubt he appreciated the social determinant of health and wellness that food was 1,000 years ago and continues to be today. Taking a page, or prescription note, from the good doctor’s Rx pad, food retailers, healthcare providers, local food banks, and State healthcare programs are working the food-as-medicine connection to bolster public health. One approach to food-as-medicine is promoting the purchase of fresh fruits and vegetables — the

The top health-related activities among U.S. adults include routinely taking vitamins and supplements, and prescription medicines, according to Frost & Sullivan’s report, Are We Engaged Yet? Their response to the titular question lies in in the subtitle: “US consumers appear confused or ambivalent about what it means to be proactive or engaged in their health.” 1 in 2 U.S. adults says they’re “somewhat engaged” in their healthcare, according to Reenita Das’s write-up on the study in Forbes magazine. She notes that: Consumers with higher incomes have more confidence in their access to health care services and quality of care Budget-constrained consumer

Cost ranks first among the factors of selecting health insurance for most Americans across the generations. As a result, most consumers are likely to shop around for both health providers and health plans, learned through a 2016 Xerox survey detailed in New Insights on Value-Based Care, Healthcare Attitudes 2016. The younger the consumer, the more important costs are, Xerox’s poll found, shown in the first chart. Thus, “shopping around” is more pronounced among younger health consumers — although a majority people who belong to Boomer and Greatest Generation cohorts do shop around for both health providers and health insurance plans —

Hospital margins can increase 50% if health providers offer patients a better customer experience, Accenture calculates in the paper, Insight Driven Health – Hospitals see link between patient experience and bottom line. Specifically, hospitals with HCAHPS scores of 9 or 10, the highest recommendations a patient can give in the survey, more likely enjoy higher margins (upwards of 8%). The Hospital Computer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered by the Centers for Medicare and Medicaid Services (CMS) and measures patients’ exeperiences in hospital post-discharge. The correlation, simply put, is “Happy Patients, Healthy Margins,” Accenture coined in

Faced with the increasing financial responsibility for healthcare payments, and a desire to manage pain and disease via “natural” approaches, more U.S. consumers are seeking and paying for non-conventional or naturopathic therapies — complementary and alternative medicine (CAM). Health and Healing in America, The Harris Poll conducted among U.S. adults, learned that two in three Americans see alternative therapies as safe and effective. 1 in 2 people see alternative therapies as reliable. And most people believe that some of these treatments, like chiropractic and massage therapy, should be reimbursed by health insurance companies. Seven in 10 Americans have used alternative

Where you live in America determines what you might pay for healthcare. In this health economic scenario, as Napoleon is rumored to have said, “geography is destiny.” If you’re searching for low-cost health care, Ohio may just be your state of choice. The map illustrates these health care disparities across the U.S. in 2015, when the price of a single service could vary by more than 200% between one state and another: say, Alaska versus Arizona, or Wisconsin compared to Florida. Even within states, like Ohio, the average price of a pregnancy ultrasound in Cleveland ran nearly three times that received in

The top reason people in America over 50 don’t fill a prescription is the cost of the drug, according to the AARP 2015 Survey on Prescription Drugs. Eight in 10 people 50+ think the cost of prescription drugs is too high, and 4 in 10 are concerned about their ability to afford their medications. Thus, nearly all people over 50 think it’s important for politicians (especially presidential candidates) to control Rx drug costs. Older consumers are connecting dots between the cost of their medications and direct-to-consumer prescription drug advertising: 88% of the 50+ population who have seen or heard drug

In the U.S., spending on prescription medicines reached $425 bn in 2015, a 12% increase over 2014. For context, that Rx spending comprised about 14% of the American healthcare spend (based on roughly $3 trillion reported in the National Health Expenditure Accounts in 2014). We can expect double-digit prescription drug cost growth over the next five years, according to forecasts in Medicines Use and Spending in the U.S. – A Review of 2015 and Outlook to 2020 from IMS Institute of Healthcare Informatics. The biggest cost growth driver is specialty medicines, which accounted for $151 bn of the total Rx spend

Older workers and retirees in the U.S. are most pleased with their healthcare experiences and have the fewest problems accessing  services and benefits. But, “younger workers [are] least comfortable navigating U.S. healthcare system,” which is the title of a press release summarizing results of a survey conducted among 1,536 U.S. adults by the Harris Poll for Accolade in September 2015. Results of this Accolade Consumer Healthcare Experience Index poll were published on April 12, 2016. Accolade, a healthcare concierge company serving employers, insurers and health systems, studied the experiences of people covered by health insurance to learn about the differences across age

Patient engagement is the new imperative in health care, writes Editor-in-chief Alan Weil in his introduction to the April 2016 issue of Health Affairs. It is appropriate and right that Judith Hibbard of the University of Oregon served as the theme adviser for the issue: she’s the innovator of the Patient Activation Measure and has frequently published her research in Health Affairs. Her own bottom-line: that the higher the patient activation, the less health care costs the health plan. (See a recent post on her research here on Health Populi). This issue of Health Affairs is a comprehensive primer on the

There’s an annual $1.5 trillion in revenues for the legacy healthcare system at stake by 2025, at risk of transferring to new entrants keen to please consumers, streamline physician practices, and provide new-new health insurance plans. A team from PwC has characterized this challenge in their strategy+business article, The Coming $1.5 Trillion Shift in Healthcare. Based on their survey of healthcare industry stakeholders and analyzing their economic model, the PwC team developed three scenarios about the 2025 healthcare market in the U.S. These are supply-driven, demand-driven, and equilibrium. The exhibit details each of these possible futures across various industry stakeholder

8 in 10 Americans would like one trusted person to help them figure out their health care, according to the Accolade Consumer Healthcare Experience Index Poll, conducted by The Harris Poll. The study gauged how Americans feel about their healthcare, especially focusing on employer-sponsored health insurance. One-third of people (32%) aren’t comfortable with navigating medical benefits and the healthcare system; a roughly percentage of people aren’t comfortable with their personal knowledge to make financial investments, either (35%). Buying a car, a home, technology and electronics? Consumers are much more comfortable shopping for these things. Consumers say that the most onerous