A blog covering the health/care ecosystem and people.

With our HealthConsuming “health is everywhere” ethos, this post updates some of the most impactful recent retail health developments shaping consumers’ health/care touchpoints beyond hospitals, physicians, and health plans. For inspiration and context, I’ll kick off with Roz Chast’s latest New Yorker cartoon from the February 3rd 2020 issue — Strangers in the Night, taking place in a Duane Reade pharmacy. Roz really channels the scene in front of the pharmacy counter, from Q-tips to vitamins and tea. And it’s hummable to the tune of, well, Strangers in the Night. Check out the 24-hour pharmacist under the pick-up sign. Now,

Tonight, President Trump will present his fourth annual State of the Union address. This morning we don’t have a transcript of the speech ahead of the event, but one topic remains high on U.S. voters’ priorities, across political party – prescription drug prices. Few issues unite U.S. voters in 2020 quite like supporting Medicare’s ability to negotiate drug prices with pharmaceutical companies, shown by the October 2019 Kaiser Family Foundation Health Tracking Poll. Whether Democrat, Independent, or Republican, most people living in America favor government intervention in regulating the cost of medicines in some way. In this poll, the top

In America, earning lower or middle incomes is a risk factor for having trouble accessing health care and/or paying for it. But most Americans, rich or not, believe that it’s unfair for wealthier people to get better health care, according to a January 2020 poll from NPR, the Robert Wood Johnson Foundation and Harvard Chan School of Public Health, Life Experiences and Income Equality in the United States. The survey was conducted in July and August 2019 among 1,885 U.S. adults 18 or older. Throughout the study, note the four annual household income categories gauged in the research: Top 1%

The new year will see a “looming tsunami” of high prices in healthcare, regulation trumping health reform, more business deals reshaping the health/care industry landscape, and patients growing do-it-yourself care muscles, according to Top health industry issues of 2020: Will digital start to show an ROI from the PwC Health Research Institute. I’ve looked forward to reviewing this annual report for the past few years, and always learn something new from PwC’s team of researchers who reach out to experts spanning the industry. In this 14th year of the publication, PwC polled executives from payers, providers, and pharma/life science organizations. Internally,

There’s something like cognitive dissonance as I prepare my 2020 Health Populi TrendCast of what to expect in the health/care ecosystem in the new year. One of my key pillars for health-making is food-as-medicine, and that opportunity in this moment resonates in this holiday season with Dickens’ “Best of Times, Worst of Times” context-setting that kicks off Great Expectations. In the “best of times” part of the food+health equation, we recognize the growing role of grocery stores, food-tech and food manufacturers in the health/care landscape. A current example comes from Kroger, partnering with Ascension’s health system in Tennessee, enhancing the organization’s

Patients’ experiences with the health care industry fall short of their interactions with other industries — namely online retail, online banking and online travel, a new survey from Cedar, a payments company, learned. Survata conducted the study for Cedar among 1,607 online U.S. consumers age 18 and over in August and September 2019. These study respondents had also visited a doctor or hospital and paid a medical bill in the past year. One-third of these patients had a health care bill go to collections in the past year, according to Cedar’s 2019 U.S. Healthcare Consumer Experience Study. Among those people

SelfCare is health/care, particularly as patients, everyday people, take on greater responsibility for clinical decisions and paying for medical services. We’re convening today through Sunday in Indianapolis with GMDC, the Global Market Development Center and Retail Tomorrow to brainstorm the current and future prospects for SelfCare, health and wellness in the hands, hearts, and homes of consumers. To bolster the message and engage with industry stakeholders, GMDC collaborated with the Hamacher Resource Group to develop a SelfCare Roadmap, an interactive tool that provides insights into twelve conditions where consumers typically looking to DIY their health using over-the-counter medicines, supplies and

Marc Iskowitz, Executive Editor of MM&M, warmly welcomed me to the Haymarket Media soundproof studio in New York City yesterday. We’d been trying to schedule meeting up to do a live podcast since February, and we finally got our mutual acts together on 6th August 2019. Here’s a link to the 30-minute conversation, where Marc combed through the over 500 endnotes from HealthConsuming‘s appendix to explore the patient as the new health care payor, the Amazon prime-ing of people, and prospects for social determinants of health to bolster medicines “beyond the pill.” https://www.pscp.tv/MMMnews/1eaJbvgovBYJX Thanks for listening — and if you

This year, an employer-sponsored PPO for a family of four in the U.S. will cost $28,386, a 3.6% increase over 2018, according to the 2019 Milliman Medical Index (MMI). Based on my annual read of this year’s Index, the PPO costs roughly the same as a new Dodge Charger or a year attending the engineering school at Alfred University. The Milliman MMI team has updated the methodology for the Index; the chart shown here is my own, recognizing that the calculations and assumptions beneath the 2019 data point differ from previous years. The key points of the report are that:

If you heed the mass media headlines and President Trump’s tweets, the U.S. has achieved “the best economy” ever in mid-July 2019. But if you’re working full time in that economy, you tend to feel much less positive about your personal prospects and fiscal fitness. Nearly nine in 10 working Americans believe that medical costs will rise in the next few years as they pondering potential changes to the Affordable Care Act. The bottom line is that one-half of working people are more concerned about how they will save for future health care expenses. That’s the over-arching theme in PwC’s

In reading the July/August issue of Eating Well magazine this week, I came across this ad which I scanned for you to see yourself: “We believe in food as medicine.” Signed, Kroger Health. Here’s the introductory text in the full-page ad: “As Kroger Health, our vision is to help people live healthier lives. And now, more than ever, through our experts, innovation, and technology, we’re uniquely positioned to bring that vision to life,” the copy read. “We know food,” the text continued, as part of The Kroger Co. which is the largest grocery chain in the U.S. celebrating 135 years

People over 50 in the U.S. that are likely to vote in the 2020 Presidential election are keenly interested in lowering the cost of prescription drugs, according to a survey conducted by AARP in February and March 2019. Most people over 50 take prescription drugs daily; one-third take two or three Rx’s regularly, and one in five older people take six or more prescription medicines regularly. Thus, prescription drugs are part of most older Americans’ daily life-flows and household spending considerations. About two-thirds of older people who are likely to vote say that Rx prices are “unreasonable,” including 67% of

Pharmaceutical company executives are testifying in the U.S. Congress this week on the topic of prescription drug costs. One of those medicines, insulin, cost a patient $5,705 for a year’s supply in 2016, double what it cost in 2012, according to the Health Care Cost Institute. Know that one of these insulin products, Lilly’s Humalog,  came onto the market in 1996. In typical markets, as products mature and get mass adoption, prices fall. Not so insulin, one of the many cost components in caring for diabetes. But then prescription drug pricing doesn’t conform with how typical markets work in theory.

Today, the number of searches on Google using the phrase “self-care” reached a high, shown in the line graph I created on Google Trends and marked up in red. A Google search overall yielded over 2 billion results. I started this search when the Great Recession began in the U.S. in December 2007, and tracked “self-care” searches to today, 15 March 2019. I ran this little test because I’m speaking on Monday 18 March at the annual meeting of the Consumer Healthcare Products Association. CHPA was founded in 1881 as the “Proprietary Association.” In 1989, over 100 years later, the

Across generations, from younger to older patients, cost, transparency and convenience drive consumer satisfaction, Accenture’s latest health consumer survey found. I had the opportunity to brainstorm the study’s findings in real-time on the day of survey launch, 12 February, with Dr. Kaveh Safavi, Brian Kalis, and Jenn Francis at HIMSS19. Our starting point was the tipping-point statistic that over 50% of people in the U.S. have chosen to use a non-traditional health care setting. Those non-traditional sites of care include walk-in and retail clinics, outpatient surgery centers, virtual health (whether on the phone, on video or via mobile apps), on-demand services,

Most patient visits to doctors result in a prescription written for a medicine that people retrieve from a pharmacy, whether retail in the local community or via mail order for a maintenance drug. This one transaction generates a lot of data points, which individually have a lot of importance for the individual patient. Mashed with other patients’, prescription drug utilization data can combine with more data to be used for population health, cost-effectiveness, and other constructive research pursuits. At HIMSS19, there’s an entire day devoted to a Pharma Forum on Tuesday 12 February, focusing on pharma-provider-payor collaborations. Allocating a full

Today, as Congress kicks off hearings about the cost of prescription drugs in the United States, IQVIA published its 2019 report on The Global Use of Medicine in 2019 and Outlook to 2023. The top-line of the research is the robust pharma market growth will be driven by two factors, and limited by two others: spending in the U.S. and emerging markets (coined “pharmerging” by IQVIA) will push up spending, while limiting factors on growth will be increasing generics and expiration of brand patents. The U.S. will continue to be the number 1 prescription drug spender in the world to

All health/care is retail now in America. I say this as most people in the U.S. who have health insurance must take on a deductible of some amount, which compels that insured individual to spend the first dollar on medical services up until they meet their financial commitment. At that point, health insurance kicks in, and then the insured may have to spend additional funds on co-payments for general medicines and services, and coinsurance for specialty drugs like injectables and high-cost new therapies. The patient is a consumer is a payor, I asserted today during my talk on the expanding

Today is Boxing Day and St. Stephens Day for people who celebrate Christmas, so I share this post as a holiday gift with well-wishes for you and those you love. The tea leaves have been brewing here at THINK-Health as we prepared our 2019 forecast at the convergence of consumers, health, and technology. Here’s our trend-weaving of 4 C’s for 2019: costs, consumerism, cyber and care, everywhere… Health care costs will continue to be a mainstream pocketbook issue for patients and caregivers, with consequences for payors, suppliers and ultimately, policymakers. Legislators inside the DC Beltway will be challenged by the

  American consumers are now viewing their phones an average of 52 times daily, with 39 percent of consumers believing they use their smartphones too much. In fact, 60 percent of 18 to 34-year-olds admit to smartphone overuse, the highest level of any age group. However, 63 percent of the respondents reported trying to limit their smartphone usage, roughly half succeeding in cutting back. Smartphones also are helping blur the lines between work and leisure with 70 percent of respondents using personal smartphones at least occasionally for after-hours work. Furthermore, voice technologies are “making noise,” according to Deloitte in A New Era

The future of healthcare is not about being sick, Prof. Dr. Koen Kas believes. Having spent many years in life sciences in both research and as an entrepreneur, Koen now knows that getting and staying healthy isn’t about just developing medicines and med-tech: optimally, health requires a tincture of delight, Koen advises in his breakthrough, innovative book, Your Guide to Delight. Healthcare must go beyond traditional user-centered design, Koen’s experience has shown, and aspire toward design-to-delight. The concept of “delight” in healthcare, such as we experience in hospitality, grocery stores, and entertainment, is elusive. I’ve observed this, too, in my

The prices of medicines prescribed in outpatient settings rose, on average, 10.3% in 2018. Wages increased about 2.6%, and consumer prices, 1.3%, based on the 2019 Segal Health Plan Cost Trend Survey. Segal forecasts that medical cost trends will moderate for 2019, lower than 2018 rates. But to the patient, now feeling like a consumer dealing with high-deductibles and the growing sticker shock of specialty drug prices, a so-called “moderate” trend still feels like a big bite in the household budget. Specifically, specialty drug trend is expected to be 14.3% in 2019, compared with 17.7% in 2018 — still several

Consumers who have long purchased over-the-counter medicines, anti-dandruff shampoo, whitening toothpaste, and cosmetics-with-benefits at food, drug and mass merchant retailers are switching to other places to shop for health, new data from AT Kearney and GMDC have found. The two organizations have collaborated to launch a new  benchmarking study into health-beauty-wellness (HBW) sales, launched this weekend at the GMDC HBW Conference in Orlando. Overall, 2017 to 2018 year-on-year, HBW sales were flat-to-no growth, notwithstanding the consumer and influencer buzz around the categories.       This study uncovered some very important trends underneath the macro numbers that tell a story

Patients are the new healthcare payors, and as such, taking on the role of health consumers. In fact, health and wellness consumers have existed since a person purchased the first toothpaste, aspirin, heating pad, and moisturizing cream at retail. Or consulted with their neighborhood herbalista, homeopathic practitioner, therapeutic masseuse, or skin aesthetician. Today, the health and wellness consumer can DIY all of these things at home through a huge array of products available in pharmacies, supermarkets, Big Box stores, cosmetic superstores, convenience and dollar stores, and other retail channels – increasingly, online (THINK, of course, of Amazon — more on

Most Americans have been surprised by a medical bill, a NORC AmeriSpeak survey found. Who’s responsible? Nearly all Americans (86% net responsible) first blame health insurance companies, followed by hospitals (82%). Fewer U.S. patients blamed doctors and pharmacies, although a majority of consumers still put responsibility for surprise healthcare bills on them (71% and 64% net). Most of the surprise bills were for charges associated with a physician’s service or lab test. Most surprise charges were not due to the service being excluded from a health plans provider network. The poll was conducted among 1,002 U.S. adults 18 and over

Most Americans are healthcare cost-conscious, concerned about various kinds of healthcare expenses, data from McKinsey’s research has found presented in Healthcare consumerism 2018: An update on the  journey. McKinsey’s consumer research identified four themes: affordability as a pressing consumer concern; lack of continuity of care for many consumers; growing demand for digital convenience and access; and, greater willingness to partake in health care programs that lower costs, if made available. Personal and household concerns about healthcare costs is top-of-mind for U.S. consumers, as I’ve pointed out in previous studies such as Kaiser Family Foundation’s look at top “pocketbook issues,” here on

All sectors who are stakeholders in the healthcare ecosystem aren’t created equal, Accenture explains in their report, Healthcare’s future winners and losers. Observing the influx of new flavors of entrants like Amazon and Google, start-ups like Iora Health, Oscar and FetchMD, begs the question: how will legacy healthcare system players fare? Who will survive, and what will be the success factors that bolster long-term viability? To answer that question, Accenture points to three market trends that set “new rules” in healthcare: Blurred lines, which are the grey areas and adjacencies between technology, service, finance, and retail The middle of nowhere,

While Amazon and Google get lots of positive PR and media attention as major healthcare industry disruptors, don’t forget about two big “W’s,” Walgreens and Walmart, in the healthcare innovator mix. I recently read The Four in which Scott Galloway explains the dominance of Amazon, Apple, Google and Facebook in consumers’ everyday lives. These four tech-behemoths each have their particular designs on healthcare innovation, or disruption in the eyes of, say, Epic and Cerner working on health IT systems, or GE and IBM if you’ve been pioneers in health data or big-iron information technology. Then in the past week, the

America’s agricultural roots go deep, from the native Patuxet tribe that shared maize with Mayflower settling Pilgrims in southern New England, to biodynamic and organic winemakers in Sonoma County, California, operating today. In 2016, 21.4 million full- and part-time jobs were related to agriculture and food sectors, about 11% of total U.S. employment. Farming is an integral part of a nation’s food system, so the Union of Concerned Scientists developed the 50-State Food System Scorecard to gauge the state of farming and food in the U.S. on several dimensions: diet and health outcomes, farming as an industry and economic engine,

Taking a page out of Hippocrates, “let food be thy medicine and medicine be thy food,” consumers are increasingly shopping for groceries with an appetite for health, found in research published this week by the International Food Information Center cleverly titled, An Appetite for Health. The top line: over two-thirds of older adults are managing more than one chronic condition and looking to nutrition to help manage disease. Most consumers have that “appetite for health” across a wide range of conditions, with two rising to the top as “extremely important:” heart health and brain function. Other top-ranked issues are emotional/mental

“We are at a remarkable point of cancer treatment,” noted Murray Aitken, Executive Director, IQVIA Institute for Human Data Science, in a call with media this week. 2017 was a banner year of innovative drug launches in oncology, Aitken coined, with more drugs used more extensively, driving improved patient for people dealing with cancer. This upbeat market description comes out of a report on Global Oncology Trends 2018 from the IQVIA Institute for Human Data Science. The subtitle of the report, “Innovation, Expansion and Disruption,” is appropriately put. The report covers these three themes across four sections: advances in therapies,

One-third of Americans are following a specific eating pattern, including intermittent fasting, paleo gluten-free, low-carb, Mediterranean diet, and Whole 30, among dozens of other food-styles in vogue in 2018. It’s mainstream now that Americans are shopping food for health, with eyes focused on heart health, weight, energy, diabetes, and brain health, according to the 2018 Food & Health Survey from IFIC, the International Food Industry Council Foundation. But underneath these healthy eating intentions are concerns about the cost of nutritious foods, IFIC reports. And this aspect of home health economics can sub-optimize peoples’ health. Consider the first graph on consumers’

In the U.S., trust in the healthcare industry declined by 9 percentage points in just one year, declining from 62% of people trusting — that’s roughly two-thirds of Americans — down to 53% — closer to one-half of the population. I covered the launch of the 2018 Edelman Trust Barometer across all industries here in Health Populi in January 2018, when this year’s annual report was presented at the World Economic Forum in Davos as it is each year. The Edelman team shared this detailed data on the healthcare sector with me this week, for which I am grateful. Check

As the nation battles an obesity epidemic that adds $$ costs to U.S. national health spending, there are many opportunities to address this impactful social determinant of health to reduce health spending per person and to drive public and individual health. In this post, I examine a few very current events in the food-as-medicine marketspace. Big Food as an industry gets a bad rap, as Big Tobacco and Big Oil have had. In the case of Big Food, the public health critique points to processed foods, those of high sugar content (especially when cleverly marketed to children), and sustainability. But

Chronic diseases are what kill most people in the world. In the U.S., the chronic disease burden takes a massive toll on both public health and mortality, accounting for 7 in 10 deaths in America each year. That personal health toll comes at a high price and proportion of national health expenditures. A new alliance between Livongo and Cambia Health seeks to address that challenge, beginning with diabetes and scaling to other chronic conditions. Livongo has proven out the Livongo for Diabetes program, which has demonstrated positive outcomes in terms of patient satisfaction and cost-savings. The plan with Cambia is

The most beloved company in America is Amazon, according to the 2018 Harris Poll Reputation Quotient Rankings which were published on 22nd March 2018. This was the third year in a row that Amazon garnered the top position in this corporate reputation poll, which gauges consumers’ views on workplace environment, social responsibility, emotional appeal, financial performance, vision and leadership, and products and services. Mr. President, why pick on Americans’ favorite brand? The brand defines the 2018 consumer’s benchmark for a best-retail experience, which is what people increasingly expect across the various interactions they have throughout a day. [As a sidebar,

Albertsons, the grocery group with popular brands like Acme, Safeway, and Vons, announced a merger with Rite Aid, the retail pharmacy chain. The deal has been discussed as Albertsons’ move to succeed in light of growing competition from Amazon and Whole Foods, the proposed CVS/Aetna merger, and Walgreens’ possible purchase of AmerisourceBergen (finalizing its acquisition of over 1,900 Rite Aid stores). If played out well, the combination could become an important player in the evolving U.S. health/care ecosystem that brings a self-care front-door closer to consumers, patients and caregivers. “The new company is expected to serve more than 40 million

Las Vegas is known for glitzy neon lights brightly shining along the strip and casinos without clocks reminding us of the time, stimulating us to stay awake at all hours of day or night. But inside the Sands Convention Center are a couple dozen technologies and connected things designed to put us to sleep, which is a growing digital health category at the annual CES. Form factors for sleep-things at CES 2018 include masks, beds, lights, apps, and even a huggable sleep “robot.” Why is sleep seeing such a huge influx on the consumer tech-supply side? Because there’s growing, mainstream

As 2018 approaches, consumers will gather healthy New Year’s Resolutions together. Entering the New Year, most Americans are also dealing with concerns about healthcare costs, cybersecurity, and caring – for physical health, mental stress, and the nation. Healthcare costs continue to be top-of-mind for consumer pocketbook issues. Entrenched frugality is the new consumer ethos. While the economy might be statistically improving, American consumers’ haven’t regained confidence. In 2018, frugality will impact how people look at healthcare costs. 88% of US consumers are likely to consider cost when selecting a healthcare provider, a Conduent survey found. Physicians know this: 81% of

It takes more than enrolling in a high-deductible health plan (HDHP) for someone to immediately morph into an effective health care “consumer.” Research from Dr. Jeffrey Kullgren and his team from the University of Michigan found that enrollees in HDHPs could garner more benefits from these plans were people better informed about how to use them, including how to save for them and spend money once enrolled in them. The team’s research letter was published in JAMA Internal Medicine on 27 November 2017. The discussion details results of a survey conducted among 1,637 people 18 to 64 years of age

  A response to Amazon’s potential moves in healthcare and pharmacy…strategic positioning for the post-Trump healthcare landscape…vertical integration to better manage healthcare utilization and costs…these, and other rationale have been offered by industry analysts and observers of the discussions between CVS and Aetna, for the former to acquire the latter. “A pharmacy chain buying a health insurance company?” many have asked me over the past few days. These inquiring minds include people who work both inside and outside of health/care. I ask back: in 2017 and in the future, “What is a pharmacy? What is a health plan?” See the

THINK: money and love. To find health, working-aged people seek financial stability and good relationships, according to the Consumer Health POV Report from Welltok, meQuilibrium, and Zipongo, featured in their webinar broadcast today. The online consumer survey was conducted among 2,000 full-time working U.S. adults in August 2017, segmented roughly into thirds by Boomers (37%), Gen Xers (32%), and Millennials (31%). Much lower down the priority list for healthy living are managing food, sleep, and stress based on the poll. Feeling stress is universal across most consumers in each of the three generational cohorts, especially related to work and finance.

Driven by price increases, costs for the prescription drug benefit carve-out will increase 11.6% this year, based on Segal Consulting’s survey report, High Rx Cost Trends Projected to Be Lower for 2018, published today. The report is accessible on the Segal Co. website. While the Segal team expects prescription drug (Rx) benefit plan cost trends to be “less severe” in 2018, Rx cost increases is a top priority for many sponsors of health plans as their rate of increase far exceeds those for inpatient hospital claims or physician expense. Drug costs continue to be the fastest-growing line item in health

The average cost of an employer=sponsored health plan for a family reached $18,764 in 2017. While this premium grew overall by a historically relative low of 3.4%, employees covered under that plan faced an increase of 8.3% over what their plan share cost them in 2016, according to the 2017 Employer Health Benefit Survey published today by the Kaiser Family Foundation. [Here’s a link to the 2016 KFF report, which provided the baseline for this 8.3% calculation]. Average family premiums at the workplace rose 19% since 2012, a slowdown from the two previous five-year periods — 30% between 2007 and 2012, and

Cost is the number one driver among consumers declining satisfaction with pharmacies, J.D. Power found in its 2017 U.S. Pharmacy Study. Historically in J.D. Power’s studies into consumer perceptions of pharmacy, the retail segment has performed very well, However, in 2017, peoples’ concerns about drug prices negatively impact their views of the pharmacy — the front-line at the point-of-purchase for prescription drugs. In the past year, dissatisfaction with brick-and-mortar pharmacies related to the cost of drugs and the in-store experience. For mail-order drugs, consumer dissatisfaction was driven by cost and the prescription ordering process. Among all pharmacy channels, supermarket drugstores

  Patients want their doctors to know what their personal costs for medicines are; 42% of patients also believe their doctor is aware of how much they spend on prescription drugs. However, 61% of these people have not talked with doctors about drug prices. Nor do most doctors have access to this kind of information at the individual patient level. One important tactic to addressing overall healthcare costs, and managing the prescription drug line item in those costs, is discussed in Doctors and Pharmacists: An Underused Resource to Manage Drug Costs for Older Adults, a report on a survey sponsored

The business and mission of pharmacies are being re-shaped by several major market forces, most impactful being uncertain health reform prospects at the Federal level — especially for Medicaid, which is a major payor for prescription drugs. Medicaid covered 14% of retail prescriptions dispensed in 2016, according to QuintilesIMS; Medicare accounted for 27% of retail prescriptions. “But if affordability, accessibility, quality, innovation, responsiveness and choices are among the standards that will be applied to any future changes, pharmacy has strong legs to stand on,” Steve Anderson, president and CEO of the National Association of Chain Drug Stores, said in the PoweRx Top 50

Wellness is at the grocery store, the vast majority of U.S. health citizens say. 8 in 10 U.S. shoppers are concerned about the nutritional content in the food they eat. As grocery shoppers look for more fresh and less processed foods, grocery stores are seen as trusted allies for meeting wellness needs. Grocers are coupling the growth of more healthy packaged foods in the middle of the store with more fresh and prepared food options that consumers see as healthier than restaurant meals, according to U.S. Grocery Shopper Trends 2017 from FMI (the Food Marketing Institute) and Hartman Group. While

“Helping people on their path to better health” is the mission-mantra of CVS Health. Re-branded from its previous identity as CVS/pharmacy, the organization convened a Health Innovation Summit with its vendor partners whose products fill the front-of-store shelves to empower, inspire and support consumers to manage health and wellness for themselves and their families. I was grateful for the opportunity to provide the first talk for the day, setting the context for the evolving retail health/care landscape with the consumer at the center. The consumer is, at any point in a 24-hour day: a person wearing many hats (a worker,