A blog covering the health/care ecosystem and people.

This week, public health truths have collided with social media, the infodemic, and health citizenship. First, I read in Becker’s Health IT on February 16 that the peer-reviewed policy journal Health Affairs was prevented by a social media outlet from promoting its February 2022 issue themed “Racism and Health.” The company said the topic was too controversial to feature in this moment. “Google and Twitter are blocking its paid media ads to promote the content, flagging racism as ‘sensitive content,'” Molly Gamble explained in Becker’s. I myself used the blogging platform you’re on now to promote the February ’22 issue of

While love can’t solve all of the world’s problems, it is absolutely a basic human need and a positive force for health and well-being. For today’s Health Populi blog, I have curated a big hug-full of posts I’ve written over the years building the evidence base of love as a determinant of health. As a sidebar, the graphic you see here — my “WiFi Heart” — was purposefully commissioned to my web designer to incorporate elements of love and connectivity. Wishing you all the blessing of love in your life, in all of its glorious and health-ful forms…XO JSK My

The Future of Wellness in 2022 is, “shifting from a ‘feel-good’ luxury to survivalism as people seek resilience,” based on the Global Wellness Institute’s forecast on this year’s look into self-care and consumer’s spending on health beyond medical care — looking beyond COVID-19. GWI published two research papers this week on The Future of Wellness and The Global Wellness Economy‘s country rankings as of February 2021. I welcomed the opportunity to spend time for a deep dive into the trends and findings with the GWI community yesterday exploring all of the data, listening through my health economics-consumer-technology lens. First, consider

Health care must confront its role in the climate crisis, a JAMA viewpoint asserted on January 31, 2022. Dr. Kenneth Kizer and Dr. Kari Nadeau recommended that, “Instead of contributing to climate change, health care as an enterprise could become a model for environmental sustainability.” This ethos was called out at the recent COP26 UN Climate Conference which resulted in a portfolio of health care initiatives for providers, globally, to address climate change as a macro determinant of health. Consumers — now morphing into health citizens — also can (and should) play starring roles in doing what we can in daily

Aflac, our favorite duck-mascot-representing company, has launched the Close the Gap initiative featuring spokesman Deion Sanders, one of the good guys in the Football Hall of Fame. Recognizing the fact that nearly one-half of insured Americans don’t have enough in savings to pay for medical expenses, the company established the Aflac Care Index to educate and advocate for peoples’ health and financial security — including those people who have health care coverage. While U.S. consumers are facing historically high levels of inflation for household spending on food, petrol, and home goods, health consumers will be dealing with greater out-of-pocket spending based

One of the best parts of watching the biggest U.S. football game of the year are the ads which can provide great entertainment in-between touchdowns, time-outs, and referees’ video replays. This year, Ad Age provides us with an early inventory of some of the high-expectation commercials, including the usual suspects like Budweiser, Google, TurboTax, and Avocados from Mexico. For the first time, cryptocurrency brands will advertise on the  Super Bowl, too. But I’m most looking forward to seeing the 30-second spot from Hologic, the medical technology company. AdWeek wrote, quoting a Hologic press release, “As a leader in women’s health,

A new study from CIGNA and its subsidiary MDLive touts the cost-effectiveness of telehealth to improve health outcomes, reducing the need for unnecessary lab work, reducing duplication of care, and connecting patients with  high-performing providers. It is expected that one in three patient visits will be virtual, CIGNA quotes from an Accenture forecast. As more consumers used telehealth channels during the early phase of the COVID-19 pandemic, patients experienced virtual care. For many people, these visits matched or exceeded expectations compared with in-person encounters with clinicians, as well as satisfying on convenience and access values. How will virtual care play

People around the world have made health a “proactive priority,” most important to live a longer, healthier life, to avoid preventable diseases, to protect against disease, and to look and feel healthier, according to NielsenIQ’s latest health and wellness report. As the triangle here illustrates, NielsenIQ has turned Maslow’s Hierarchy of Needs upside down, shifting protective and physical needs to the top rung and altruistic — the “me-to-we” ethos — at the base. Note the translations of these needs, on the ride, into the “care” flows — moving from urgent care down to self-care, preventive care, innovative care, and selfless

Members of his congregation kept going to the hospital with diet-related issues, Reverend Dr. Heber Brown, III, realized. “I got tired of praying and hoping they made it and walked out,” Reverend Brown realized. And then… “God gave us an idea and vision to be proactive on the issue of health in our congregation,” Rev. Brown explained to us yesterday on Day 2 of Real Chemistry’s Health Equity Summit. This was the seed for the Black Church Food Security Network, planting a pragmatic vision for health and well-being weaving together local food, civic empowerment, economic development, and faith. “We had

Yesterday, we heard all about autonomous cars and sustainable mobility from Mary Barra, CEO of General Motors. Autos, TVs, and telecomms are the usual fare of the big stage speeches at the annual big show of consumer electronics. Gary Shapiro, President and CEO of CTA, introduced today’s CES keynote speaker, Robert Ford, as the “first-ever keynote speaker from health care” at CES, calling out the fact that Abbott’s Freestyle Libre System garnered one of CES 2022’s Innovation Awards. Ford is the Chairman and CEO of Abbott, one of the largest global life sciences companies. Ford let us know up-front that

The four top trends to watch for this week at CES 2022 are transportation, space tech, sustainable technology, and digital health, based on Steve Koenig’s annual read-out that kicks off this largest annual conference featuring innovations in consumer electronics. Last night, Steve discussed these trends for media attendees, of which I am one (gratefully) participating in #CES2022 virtually from the hygienic comfort and safety of my home health hub (more on that later in this post). All four of these mega-themes impact health and well-being in some way. “Space Tech?” you  might wonder. Yes. My friend Dorit Donoviel can be

One of my favorite Dr. Seuss characters is the narrator featured in the book, I Had Trouble In Getting to Solla-Sollew. I frequently use this book when conducting futures and scenario planning sessions with clients in health/care. “The story opens with our happy-go-lucky narrator taking  a stroll through the Valley of Vung where nothing went wrong,” the Seussblog explains. Then one day, our hero (shown here on the right side of the picture from the book) is not paying attention to where he is walking….thus admitting, “And I learned there are troubles of more than one kind, some come from

I cannot recall a season when so many health consumer studies have been launched into my email inbox. While I have believed consumers’ health engagement has been The New Black for the bulk of my career span, the current Zeitgeist for health care consumerism reflects that futurist mantra: “”We tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run,” coined by Roy Amara, past president of Institute for the Future. That well-used and timely observation is known as Amara’s Law. This feels especially apt right “now” as we enter 2022,

Most U.S. householders that experienced COVID-19 expect their 2021 December holidays will be impacted in terms of reducing their holiday gift or decor spending, canceling holiday travel plans to see family or friends, or canceling holiday events, according to the 2021 Aflac Health Care Issues Survey. Aflac polled 1,003 U.S. adults in September 2021 to gauge Americans’ financial health perspectives approaching the end of Year 2 of the COVID-19 pandemic in America. Families with children feel particularly strapped for the 2021 holiday season: while they will be less likely to reduce holiday spending, one-half are concerned about medical expenses compared with

Two pharmaceutical companies bubble up among the 20 fastest-growing brands for 2021 in Morning Consult’s report on the Fastest-Growing Brands of 2021. But the surprise in this year’s top 20 brand rankings was that five of them addressed consumers’ financial flows: Coinbase, AfterPay. Cash App, Mastercard, Chime, and Bitcoin. One year ago when I covered this study, I found  that the fastest-growing brands of 2020 had everything to do with the pandemic. They dealt with home entertainment, digital connectivity, hygiene, and indeed, health (with Pfizer and AstraZeneca the two pharma brands top-of-mind for consumers). In this year’s update, exploring consumers’

Most health care providers who were using telehealth by August 2021 felt optimistic about virtual care in a study from GoodRx on The State of Telehealth. GoodRx collaborated with the ATA on the 624 U.S. provider survey, which was complemented by a poll conducted among 1,024 health consumers for the patient perspective in September 2021. Looking at the two columns at the right side of the first bar chart, clinicians who have been using telehealth were more likely to feel optimistic about doing so than providers who were not. The most prevalent platforms providers used for telehealth engagement were via Zoom,

The pandemic has put health care top-of-mind for health citizens the world over. As the public health crisis continues its up-and-downticks around the globe, people are connecting health care to their national economies and politics, based on a global survey from the Pew Research Center, Citizens in Advanced Economies Want Significant Changes to Their Political Systems. For this analysis, the Pew research team assessed the views of some 2,600 health citizens living in 17 developed countries in February 2021. The study report was published in late October 2021. Shown in the first bar chart, the majority of people in at least

“The pandemic has shown that effective health spending is an investment, not a cost to be contained: stronger, more resilient health systems protect both populations and economies,” the OECD states in the first paragraph of the organization’s perennially-updated report, Health at a Glance 2021. This version of the global report incorporates public health data from the “OECD35,” 35 nations from “A” to “U” (Australia to United States) quantifying excess deaths experienced during the COVID-19 pandemic, the obesity epidemic, mental and behavioral health burdens, and health care spending, among many other metrics. The first chart illustrates that calculation of excess deaths,

The coronavirus pandemic put health care at the top of peoples’ minds all over the world. As important as health became to humans at the base of our Hierachies of Needs, in the U.S., health care industries fell to their lowest consumer satisfaction scores in two decades, we learn in the latest evaluation by the American Consumer Satisfaction Index report. I explore consumer-patient experience for hospitals, health plans and ambulatory care compared with other industries in the November 2021 Medecision Liberation blog, calling out the importance of two key factors that drove peoples’ positive perceptions of brands and products in

The most effective, engaging, and enchanting digital health innovations speak to patients beyond their role as health consumers and caregivers: digital health is at its best when it addresses peoples’ health citizenship. I had the great experience brainstorming the convergence of digital health, wearable tech, user-centered (UX) design, and health citizenship with João Bocas, @WearablesExpert, in a on his podcast. And if those topics weren’t enough, I wove in the role of LEGO for our well-being, “playing well,” and inspiring STEM- and science-thinking. João and I started our chat first defining health citizenship, which is a phrase I first learned from

“Americans remain in limbo between lives once lived and whatever the post-pandemic future holds,” the American Psychological Association observes in their latest read into Stress in America 2021, with this phase of the perennial study focused on Stress and Decision-Making During the Pandemic. The top-line: people face a daily web of risk assessment, up-ended routines, and endless news about the coronavirus locally and globally. While most people in the U.S. believe that “everything will work out” after the pandemic ends, the mental, emotional, and logistical daily distance between “now” and “then” brings uncertainty and indeed, prolonged stress. More Millennials, who

In the U.S., peoples’ expectations of their health care experience is melding with their best retail experience — and that’s taken a turn toward their digital and ecommerce life-flows. The American Customer Satisfaction Index Insurance and Health Care Study 2020-2021 published today, recognizing consumers’ value for the quality of health insurance companies’ mobile apps and reliability of those apps. Those digital health expectations surpass peoples’ benchmarks for accessing primary care doctors and specialty care doctors and hospitals, based on ACSI’s survey conducted among 12,274 customers via email. The study was fielded between October 2020 and September 2021. Year on year,

Most U.S. adults across political parties favor allowing the Federal government authority to negotiate for drug prices — even after hearing the arguments against the health policy. Drug price negotiation, say by the Medicare program, is a unifying public policy in the current era of political schisms in America, based on the findings in a special Kaiser Family Foundation (KFF) Health Tracking Poll conducted in late September-early October 2021. Overall, 4 in 5 Americans favor allowing the Federal government negotiating power for prescription drug prices, shown in the first chart from the KFF report. By party, nearly all Democrats agree

Before the coronavirus emerged, the top causes of death in developed countries were heart disease, cancers, diabetes, and accidents. Then COVID-19 joined the top-10 list of killers in the U.S. and the issue of pandemic preparedness for the next “Disease X” became part of global public health planning. But the biggest health threat to human life is climate change, according to a new report from the World Health Organization titled The Health Argument for Climate Action. It’s WHO’s special report on climate change and health, dedicated to the memory of Ella Kissi-Debrah — a child who died succumbing to impacts

A new look into Americans’ views on health privacy from Morning Consult provides a current snapshot on citizens’ concerned embrace of technology — worried pragmatism, let’s call it. This ambivalence will flavor how health citizens will adopt and adapt to the growing digitization of health care, and challenge the healthcare ecosystem’s assumption that patients and caregivers will universally, uniformly engage with medical tools and apps and technologies. More Boomers are concerned with health data app privacy than Gen Z consumers, as the chart illustrates. 46% of U.S. adults said that health monitoring apps were not an invasion of privacy; 32%

Years before we knew how to spell “coronavirus,” I gained Italian citizenship while retaining my U.S. citizenship. My family’s plan was to, soon thereafter, split time for work and life between the U.S. and the E.U. Then, COVID-19 emerged as a pandemic the world over, and the move to Brussels in January 2020 was quite short-lived. Now, the plan is in play and I’m writing this post from our home in Brussels, Belgium. Why Brussels? Among many smart reasons, the city is welcoming, our farm-to-table food style is doable, the walkability is brilliant, and the transportation options are accessible to

In 2020, Genentech launched its first study into health inequities. The company spelled out their rationale to undertake this research very clearly: “Through our work pursuing groundbreaking science and developing medicines for people with life-threatening diseases, we consistently witness an underrepresentation of non-white patients in clinical research. We have understood inequities and disproportionate enrollment in clinical trials existed, but nowhere could we find if patients of color had been directly asked: ‘why?’ So, we undertook a landmark study to elevate the perspectives of these medically disenfranchised individuals and reveal how this long-standing inequity impacts their relationships with the healthcare system

In the fourth quarter of 2021, U.S. hospital margins will still be lower than before the COVID-19 pandemic, Kaufman, Hall & Associates project in their latest read on hospital finances. Kaufman Hall has been monitoring hospitals’ financial health in the coronavirus era since March 2020, month-by-month. This new report looks into the Financial Effects of COVID-19: Hospital Outlook for the Remainder of 2021. This report was conducted on behalf of the American Hospital Association (AHA), who succinctly summarized the forecast saying, “COVID-19 [is] expected to drive continued hospital losses throughout 2021.” That projection is further couched in the concern that

When Dignity Health, the Catholic health care system, launched the “Hello humankindness” PR campaign in June 2013, well, they had me at “Hello.” When the project went live, Dignity Health’s President/CEO Lloyd Dean provided the rationale for the program, saying: “What’s missing in the public discourse about health care is the fact that while medicine has the power to cure, it’s humanity that holds the power to heal.” Dean pointed to two drivers shaping U.S. culture and the nation’s health care industry: The institutionalization of health care, and, The decline of civility in society. That was 2013. #HelloHumankindness sought to

The COVID-19 pandemic exacerbated food insecurity in the U.S., a situation that was already challenging for millions of American families before the public health crisis emerged. While several Congressional and administrative actions were implemented in 2020 and the first half of 2021, the issue of food insecurity — defined as being unable to acquire enough food due to insufficient money or resources — remains a tragic aspect of daily living for many Americans — and especially for children who live in households where jobs have been lost and incomes reduced. Nutrition security has also been a health risk where people

The Catholic Health Association (CHA) is urging Americans to “love thy neighbor” by getting the COVID-19 vaccine, Sister Mary Haddad wrote in an editorial published in Modern Healthcare, published on September 3, 2021. Sister Mary is CEO and President of CHA. “Some may suggest that there are moral and religious concerns to receiving the COVID-19 vaccine,” Sister Mary observed. “We strongly affirm the position of the leaders of the Catholic Church: the vaccines are morally acceptable and getting vaccinated is “an act of love.” she asserted. CHA launched a portal on the act of love, featuring lots of science-based articles

“CVS wants to be your therapist, too,” the Wall Street Journal reported on 31st August, discussing the plans of retail stores, Big Box and pharmacies, adding mental health services to their growing health/care portfolios. The coronavirus spawned an epidemic inside and beyond the pandemic throughout the U.S.: very clear and widespread mental and behavioral health impacts that have become a new and transparent normal in America. Enter CVS Health, joining retail health competitors such as Walgreens and Walmart, both of which have been growing services to help consumers access help to deal with anxiety, depression, and stress. The first chart

Financial Experience (let’s call it FX) is the next big thing in the world of patient experience and health care. Patients, as health consumers, have taken on more of the financial risk for health care payments. The growth of high-deductible health plans as well as people paying more out-of-pocket exposes patients’ wallets in ways that implore the health care industry to serve up a better retail experience for patients. But that just isn’t happening. One of the challenges has been price transparency, which is the central premise of this weekend’s New York Times research-rich article by reporters Sarah Kliff and

There is one health care public policy issue that unites U.S. voters across political party: that is the consumer-facing costs of prescription drugs. With the price of medicines in politicians’ and health citizens’ cross-hairs, the pharmaceutical and biotech industries have responded in many ways to the Rx pricing critiques from consumers (via, for example, Consumer Reports/Consumers Union and AARP), hospitals (through the American Hospital Association), and insurance companies (from AHIP, America’s Health Insurance Plans). The latest poll from the University of Chicago/Harris Public Policy and the Associate Press-NORC Center for Public Affairs Research quantifies the issue cross-party, finding that 74%

As connected devices proliferate within health care enterprises and across the health care ecosystem, cybersecurity risks abound. During the first year of the COVID-19 pandemic, the health care sector was profoundly affected by cyber-attacks on connected devices, we learn in the report, Rise of the Machines 2021: State of Connected Devices – IT, IoT, IoMT and OT from Ordr. For this annual report, Ordr analyzed security risks across over 500 deployments in healthcare, life sciences, retail, and manufacturing sectors for the 12 months June 2020 through June 2021. In health care, outdated operating systems present some of the greatest risks:

The COVID-19 pandemic digitally transformed most people living in the U.S., re-shaping consumers to work from home when possible, go to school there, and buy all manners of goods and services via ecommerce. In March 2021, Zoom conducted research into the question, “how virtual do we want our future to be?” posing that to thousands of citizens living in 10 countries including the U.S. As the first chart from the study illustrates, most people in America expect hybrid lifestyles, from fitness and retail to entertainment and education. And 7 in 10 U.S. health citizens want their health care to be

Simply put, is the equation, “Spend more, get less” a sustainable business model? Of course not. But that’s the simple math on U.S. health care spending and what comes from it, according to Mirror, Mirror 2021: Reflecting Poorly, a perennial report from The Commonwealth Fund that compares health system performance across eleven developed countries. The first table details the metrics that the Fund compares across the eleven peer nations, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. The metrics compared were access to care, care process, administrative efficiency, equity,

“You can trust us to help you find the right Medicare coverage for you and your lifestyle,” the tagline reads. What kind of organization would be behind this campaign: a healthcare navigator company, an insurance company, or a social services agency? In fact, it’s a grocery store called Hy-Vee, which launched the “Medicare Aisle” to help consumers living in the eight states in which the chain’s 240+ stores operate to sort through the daunting labyrinth of Medicare choices. “Hy-Vee is a trusted leader in the health and wellness space, and as a retail and specialty pharmacy provider, we are deeply

When we say the word “pharmacy,” we might picture the Main Street brick-and-mortar chain drugstore that dispenses medicines from behind the counter in the far back of the building, and sweet and salty snacks at the front by the cashier. In fact, “pharmacy” is the jumping off point for the expanding and increasingly beloved retail health ecosystem, J.D. Power found in the company’s latest 2021 U.S. Pharmacy Study. Each year, J.D. Power assesses consumers’ perceptions of pharmacies by category, including those retail chains along with supermarket operated, mass merchants, and mail order channels. This is the 13th year of the

There is no doubt that the COVID-19 pandemic motivated health care providers, payers, and patients to adopt digital tools and contact-less services, allowing people to deliver and receive medical care. Still, 18 months into the pandemic, now endemic and in its fourth wave of cases spiking around the world and in many parts of the U.S., some aspects of “digital transformation” seem not to have fully transformed American healthcare, we learn in HIMSS’s annual 2021 State of Healthcare Report. HIMSS collaborated with the organizations Trust  Accenture, The Chartix Group, and ZS on this year’s research. Nine in ten clinicians have recommended

The level of medical debt in America exceeded debt of other types in 2020. Furthermore, the flow of medical debt was greater among health citizens living in states that did not expand Medicaid as part of the Affordable Care Act, compared with patients who reside in Medicaid expansion states, according to an original research essay, Medical Debt in the US, 2009-2020 published in JAMA on 20 July 2021. The first line chart illustrates the trends in medical debt in collections by state expansion of Medicaid, with the bottom darkest line representing debt in collections in Medicaid expansion states from the

Cain Brothers is a 100+ year old financial services firm with a strong health care experience, now part of KeyBanc. A recent “House Calls” memo and podcast from two company analysts detailed the state of Medicaid, Motherhood and America’s Future: Giving Birth to Better Maternity Outcomes. Christian Pesci and David Johnson’s in-depth discussion detailed their bottom-line that, “maternity care in the U.S. is in crisis but poised for rapid evolution…(recognizing) that an uncoordinated system with misaligned incentives harms too many individuals, families, and communities.” They lay out the crisis as follows: Medicaid funds nearly one-half of births in the U.S.

“Self-care” took on new meaning and personal work-flows for people living in and through the coronavirus pandemic in the U.S. Acosta, the retail market research pro’s, updated our understanding consumers evolving as COVID-19 Has Elevated the Health and Wellness Trends of the Recent Years, results of a survey conducted among in May 2021. In the U.S., consumers’ take on self-care has most to do with healthy eating and nutrition (for 1 in 2 people), getting regular medical checkups (for 42%), taking exercise, relaxing, using vitamins and supplements, and getting good sleep. Healthy relationships are an integral part of self-care for

The ultimate health and wellbeing of an adult depends on the factors that shape us when we are children. A new, deep report from the OECD, Measuring What Matters for Child Well-being and Policies, spells out the many domains of experience that, together, bolster our whole health as we grow from child to adult. The first chart presents the OECD’s framework for measuring child well-being, calling out the nature of being “aspirational.” This re-look at children’s health data is aspirational because it is laying out how to best measure child well-being to set the bar higher for doing so. It addresses

The FDA’s approval of the first therapy to treat Alzheimer’s Disease in over twenty years brought attention to a not-yet-convened debate of U.S. health care costs and spending, innovation, and return-on-the-investment (as well as “for whom” do the returns accrue). In my latest post for Medecision, I explore different angles on the Aduhelm and Alzheimer’s discussion, covering: The macro- and micro-economics of Alzheimer’s and the $56,000 list price for the drug The FDA regulatory process and aftermath U.S. consumers’ bipartisan support for drug price regulation through Medicare negotiation and private/commercial sector adoption Congressional legislation addressing the price of medicines in

COVID-19 reshaped people around the world, one-half of whom are re-defining their personal purpose and life-goals. This sense of purpose extends to peoples’ willingness to buy or patronize companies who do not meet their needs for health, safety, sustainability and trust. For example, two in three of these people would switch travel brands if they felt health and safety weren’t up to par, discovered in Life Reimagined – Mapping the motivations that matter for today’s consumers, from Accenture’s Voices of Change series. In May 2021, Accenture polled over 25,000 consumers globally, in 22 countries, and found that one-half of people

Getting totally rid of the coronavirus isn’t likely, so we humans must accept the fact that SARS-CoV-2 will be endemic. The economic and healthcare system impacts of this were explored in the Post-Covid Healthcare Landscape, delivered by Fitch Solutions’ Jamie Davies and Beau Noafshar, leaders in the Pharmaceuticals, Healthcare, and Medical Devices groups. I welcomed the opportunity to learn from this team’s approach in weaving together the dynamic issues that help us to plan for the long-tail of COVID-19 and its impact on the economy and prospects for the health care industry and health citizens. The first graph illustrates the

One in two people in the U.S. with employer-sponsored health insurance worry that a major health event in their household could lead to bankruptcy, according to research gathered by West Health and Gallup in Business Speaks: The Future of Employer-Sponsored Insurance. Gallup and West Health presented their study in a webinar earlier this week; in today’s post, I feature a few key data points that particularly resonate as I celebrate/appreciate yesterday’s U.S. Supreme Court’s ruling on the Affordable Care Act (i.e., California v. Texas) combined with a new study published in JAMA Network Open, discussed below the digital fold in

Wherever you live in the world touched by the coronavirus pandemic, you felt (and were) stress-tested. Both you were, and your home was as well. In this year’s 2021 annual report by Deloitte into Connectivity & Mobile Trends, their report details How the pandemic has stress-tested the crowded digital home. This analysis was done, as it is every year, by the Deloitte Center for Technology, Media & Telecommunications. Deloitte’s Center commissioned an online survey among 2,009 U.S. consumers to gauge five generations of peoples’ perspectives on connected life in the context of COVID. The report covers the various life-flows of