A blog covering the health/care ecosystem and people.

  Consumers have grown accustomed to Amazon, and increasingly to the just-in-time convenience of Amazon Prime. Today, workers who sign onto employee benefit portals are looking for Amazon-style convenience, access, and streamlined experiences, found in the Aflac Workforces Report 2016. Aflac polled 1,900 U.S. adults employed full or part time in June and July 2016 to gauge consumers’ views on benefit selections through the workplace. Consumers have an overall angst and ennui about health benefits sign-ups: 72% of employees say reading about benefits is long, complicated, or stressful 48% of people would rather do something unpleasant like talking to their ex or

Existing healthcare industry players – the stakeholders of hospitals, physicians, pharma/life sciences, medical device manufacturers, and health plans – are operating in a whirlwind of change. While there are many uncertainties in this period of transition, there’s one operational certainty: learn to do more with less payment. That’s due to the growing pursuit of payors paying for value, not on the basis of volume or what’s “done” to a patient in care delivery. At the same time, another force re-shaping healthcare is interest and focus on wellness and health management. Combined with the growing health economic value proposition, wellness and

  1 in 3 consumers track health or fitness via an app, wearable technology, or smartwatch, according to GfK’s global survey on Health and fitness tracking published in September 2016. The key reasons people monitor health or fitness are to maintain or improve physical condition/fitness (for 55%) and to motivate oneself to exercise (for 50%), across the 16 countries GfK surveyed. Improving energy level, feeling motivated to eat and drink more healthfully, improving sleep, making tracking part of a daily routine, losing weight, and being more productive were cited as reasons to health-track by at least one-fourth of health citizens

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

More U.S. patients are faced with spending more out-of-pocket for health care services, to meet high-deductible health plans and rationally spend their health savings account investments. As rational economic men and women, some are seeking care outside of the United States where many find transparently priced, high-value, lower-cost healthcare. Check out the table from the Medical Tourism Association, and you can empathize with cash-paying patients looking for, say, gastric bypass surgery or a heart valve replacement. My latest column in the Huffington Post discussed this trend, which points first to the Cleveland Clinic — a top-tier American healthcare brand that’s

It takes a couple to bend the health care cost curve when you’re senior in America, according to the EBRI‘s latest study into Differences in Out-of-Pocket Health Care Expenses of Older Single and Couple Households. In previous research, The Employee Benefit Research Institute (EBRI) has calculated that health care expenses are the second-largest share of household expenses after home-related costs for older Americans. Health care costs consume about one-third of spending for people 60 years and older according to Credit Suisse. But for singles, health care costs are significantly larger than for couples, EBRI’s analysis found. The average per-person out-of-pocket spending for

Walmart is already in the healthcare business, serving 140 million customer visits weekly, millions of whom fill prescriptions at the store pharmacy, seek personal care in the health and beauty aisles, track blood pressure using a Higi health kiosk, and shop for healthier foods in the grocery aisles. The world’s largest company on the Global Fortune 500 list hosted a Retail Health Summit in June, the details of which have been published in . The Summit, produced by Dan Mack’s Mack Elevation Forum and , convened stakeholders from across the retail health landscape: including over-the-counter medicines, personal care, aging-at-home, caregiving, genomics, disease

Some of the fastest-growing mobile phone apps help people manage life-tasks every day, like getting real-time directions when driving, finding dates, getting rides, and tracking health, according to The 2016 U.S. Mobile App Report from comScore. The chart from the comScore Mobile Metrix survey illustrates some popular apps well-used by people on smartphones, with one of the fastest growth rates found for the Fitbit app — 1,524% growth over two years, from June 2014 to June 2016. In comparison, the Uber app visits increased 828% in the period, half as fast, and the Tinder app, 220%. Some key topline results of

There are many signposts in the marketplace pointing the way toward the new retail health/care for consumers. They include: Food and exercise as the new medicine Loneliness as the new smoking as a health risk Prevention as the new sustainability Home as the new long-term care locus Balancing humanity and technology, the analog and the digital, and Retail as a center of the new healthcare ecosystem. Read more about the 7 Signs of the Retail Health Revolution,  published by Drug Store News. This graphic-rich publication was based on a speech I gave at a recent retail health summit convened with healthcare’s

When it comes to health care, more American voters trust Hillary Clinton to deal with health issues than Donald Trump, according to the Kaiser Health Tracking Poll: August 2016 from the Kaiser Family Foundation (KFF). The poll covered the Presidential election, the Zika virus, and consumers’ views on the value of and access to personal health information via electronic health records. Today’s Health Populi post will cover the political dimensions of the August 2016 KFF poll; in tomorrow’s post, I will address the health information issues. First, let’s address the political lens of the poll. More voters trust Hillary Clinton to do

Mylan, the marketer of the EpiPen, dropped the price by 50% this week. This response was due in large part to pressure that outraged parents’ call-outs on social media put on the company. Tara Parker-Pope in the NY Times Well blog pointed this out in her column, How Parents Harnessed the Power of Social Media to Challenge EpiPen Prices. Online petitions, patient and parent social networks, and patient activists’ ability to leverage social media are the new tools of health and patient engagement. EpiPen is a must-have medicine for people who deal with serious allergy and asthma conditions, many of

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 developed world, patient disengagement has become the new killer disease — not the lack of diagnostic devices, trained physicians or efficacious treatment options,” argues Andrea LaFountain, PhD, in her book, How Patients Think. Disbanding prescription drugs in advance of doctors’ instructions, postponing lab and diagnostic tests, and avoiding daily blood glucose testing when managing diabetes are just some examples of “how patients think” about health care and the many tasks involved in caring for oneself and the health of loved ones. But better understanding how patients think — technically speaking, the cognitive neuropsychology underneath the thinking — can

If you’re retiring in 2016, you’ll need $260,000 to cover your health care costs during your retirement years. In 2015, that number was $245,000, so retiree health care costs increased 6% in one year according to Fidelity’s Retirement Health Care Cost Estimator. The 6% annual cost increase is exactly what the National Business Group on Health found in their recently published 2017 Health Plan Design Survey polling large employers covering health care, discussed here in Health Populi. The 6% health care cost increases are driven primary by people using more health services and the higher costs for many medicines — specifically, specialty

Large employers are taking more control over health care costs and quality by pressuring changes to how care is actually delivered, based on the results from the 2017 Health Plan Design Survey sponsored by the National Business Group on Health (NBGH). Health care cost increases will average 5% in 2017 based on planned design changes, according to the top-line of the study. The major cost drivers, illustrated in the wordle, will be specialty pharmacy (discussed in yesterday’s Health Populi), high cost patient claims, specific conditions (such as musculoskeletal/back pain), medical inflation, and inpatient care. To temper these medical trend increases,

Rationing has long been seen as a common practice in national, single-payer health systems like the UK’s National Health Service and Canada’s national health insurance program (known as “Medicare”).  However, over half of U.S. physicians say they ration care to patients. In a peer-reviewed column in the Journal of General Internal Medicine published in July 2016, Dr. Robert Sheeler and colleagues at the Mayo Clinic, University of Iowa, and University of Michigan, found that 53% of physicians surveyed personally “refrained” in the past six months from using specific clinical services that would have provided the “best patient care” due to cost.

Personal fitness equipment is getting connected in the growing Internet of Things ecosystem (IoT), and fitness enthusiasts are getting more digitally connected well beyond their wristband tracking device. , a healthy living portal, looked into fitness consumers’ digital habits and found a health-engaged cohort that’s online in the Web 1.0 world — sharing workout tips in social media communities but not so much product information. Product information is still learned Old School-wise, via product websites, traditional magazines, from peers and word-of-mouth (offline), and trying new gear out at the gym in real time. This survey was conducted among HellaWella’s readers,

When a person dons a piece of wearable technology, they first look to engage with some aspect of health or fitness before they seek entertainment. To satisfy that demand side of the market equation, we’re seeing a stream of devices, platforms, and corporate strategies trying to reach the wearable tech consumer. Today, Philips announced its expanding strategy for digital health, launching devices to help people, in Philips’ words, measure, monitor, and stay motivated for personal health. The company is offering a health smartwatch, a weight scale, an ear thermometer, and two blood pressure monitors (for wrist and upper arm), all

The average hospital cost per day in the U.S. is $5,220. In Switzerland it’s $4,781, and in Spain that inpatient day looks like a bargain at $424. An MRI in the U.S. runs, on average, $1,119. In the UK, that MRI is $788, and in Australia, $215, illustrated in the first chart. Drug prices are strikingly greater in the U.S. versus other developed nations, as shown in the first chart for Xarelto. If you live in the U.S. and have a television tuned in during the six o’clock news, chances are you’ve seen an ad for this drug featuring Arnold

The promise of digital, connected health to engage all health citizens cannot be fully realized until people have access to the new social determinant of health: broadband connectivity. The World Health Organization considers social determinants of health inputs like education, safe drinking water, nutritious food, safe neighborhoods for walking, employment and transportation access. Together, these factors bolster personal/individual and public health. See the map of the U.S., and note whee the concentrations of aqua blue are. These are areas that lack broadband access. Telehealth and other digital health tools can get health care to under-served people in under-served geographic areas….where broadband

The bad news: mortality rates haven’t improved much and obesity rates rose in one-third of communities. The good news: public health gains can be made in resource-poor communities with the right health policies, based on research from The Commonwealth Fund, Rising to the Challenge, the Fund’s Scorecard on local health system performance for 2016. The top-line of this benchmark report is that health care in the U.S. has, overall, improved more than it’s declined. Among the big levers driving health care improvement in the past year have been the further expansion of health citizens covered with insurance through the Affordable

J.D. Power, the company best known for evaluating consumers’ experiences with automobiles, published its 2016 Fitness Band Device Satisfaction Report this week. The bar chart summarizes overall satisfaction with activity tracking wristbands, led by Samsung with the highest index score, followed by Garmin. Below the average index were LG, Fitbit, and Jawbone. Samsung’s top grade translates into J.D. Power’s methodology as “among the best” fitness bands, based on a 1,000 point scale. Samsung’s high ranking was earned based on particularly strong scores for customer satisfaction in comfort, reliability, and ease of use. Garmin’s customer service was also highly rated, along

Investing information technology dollars in telehealth and mobile platforms, patient engagement, and cybersecurity are major focuses for leading IT-savvy hospitals in America, according to the 2016 Most Wired survey of healthcare organizations, released in July 2016 sponsored by Hospitals and Health Networks and Health Forum, a division of the American Hospitals Association. This survey, in its 18th year, has become an important benchmark measuring the adoption of information technology tools and services among American hospitals and health systems. The complete list of Most Wired hospitals for 2016 can be found here. The most popular telehealth services offered by the Most Wired hospitals are

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

Millions of U.S. patients have more financial skin in the American health care game. But are they behaving like the “consumers” they are assumed to be as members in consumer-directed health plans? Not so much, yet, explained John Park, Chief Strategy Officer at Alegeus, during a discussion of his company’s 2016 Healthcare Consumerism Index. This research is based on an online survey of over 1,000 U.S. healthcare consumers in April 2016. Alegeus looks at healthcare consumerism across two main dimensions: healthcare spending and healthcare saving. As the chart summarizes, consumers show greater engagement and focus on buying a TV or car, choosing

There’s a lot of talk about the growing platform economy. If well-designed platforms get adopted in healthcare, they may help our ailing healthcare systems get better. The quality, safety, and convenience of healthcare in America suffer from a lack of patients’ personal health data being essentially locked in data siloes. The diagnosis is lack of data “liquidity:” the ability for our health information generated in various touch points in the healthcare system and in our personal lives each day to move outside of the locations where the bits and bytes were first created: to our clinicians, researchers, health providers, and to

Virtually all employers who offer health coverage to workers extend health benefits to all full-time employees. 94% offer health care coverage to opposite-sex spouses, and 83% to same-sex spouses. One-half off health benefits to both opposite-sex and same-sex domestic partners (unmarried). Dental insurance, prescription drug coverage, vision insurance, mail order prescription programs, and mental health coverage are also offered by a vast majority (85% and over) of employers. Welcome to the detailed profile of workplace benefits for the year, published in 2016 Employee Benefits, Looking Back at 20 Years of Employee Benefits Offerings in the U.S., from the Society for Human

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

“Gas ‘N’ Health Care” is one of my most-used cartoons these days as I talk with health/care ecosystem stakeholders about the growing and central role of consumers in health care. You may be surprised to learn that the brilliant cartoonist Michael Maslin created this image back in 1994. That’s 22 years ago. When I first started using this image in my meetings with health care folks, they’d all giggle and think, ‘isn’t that funny?’ Legacy health care players — hospitals, doctors, Pharma, and medical device companies — aren’t laughing at this anymore. At a Costco a 20 minutes’ drive from

#PrayForOrlando The club Pulse, site of the biggest mass gun shooting in U.S. history, was named to honor one of the co-owner’s brothers, who succumbed to AIDS in 1991. In today’s Health Populi, I soberly ponder the lost lives in the Orlando massacre of people who joyfully convened in a safe haven to celebrate life, liberty, and their pursuits of happiness. Over fifty people ended up dead, and there will be more mortalities as the health workers at Orlando Regional Medical Center continue to fight the post-trauma battle to save gunned-down lives. We define “health” broadly in Health Populi and

Two news items published in the past week point to the yin/yang of cancer survivorship and the high prices of cancer drugs. The good news: a record number of people in the US are surviving cancer, according to the American Cancer Society. That number is 15.5 million Americans, according to a study in the cancer journal CA. Note the demographics of cancer survivors: One-half are 70 years of age and older 56% were diagnosed in the past ten years, and one-third in the past 5 years Women were more likely to have had breast cancer (3.5 mm), uterine cancer (757,000),

There’s growing recognition of the role of food in health, on both the supply side of grocers, food growers and consumer marketers; and, among consumers who are, increasingly, shopping for food with health on their minds. 8 in 10 consumers in the U.S. enter a grocery store thinking about the health attributes of what they’re about to choose from the aisles that are stocked with more gluten-free, GMO-labelled, and organic products, according to the 2015 Deloitte Pantry Study. Our physicians have begun to “prescribe” food, especially as the collective BMI of Americans has reached medically catastrophic levels. See this forecast from

If you had exactly $25,826 in your pocket today, would you rather buy a new Chrysler 200 sedan, send a son or daughter to a year of college at Wake Forest University, or pay for your family’s health care in an employer-sponsored preferred provider organization? Welcome to the annual 2016 Milliman Medical Index (MMI), one of the most important health economic studies I’ve relied on for many years. This year’s underlying question is, “Who cooked up this expensive recipe?” posed in the report’s title. The key statistics in this year’s MMI are that: Healthcare costs for a typical family of four

6 in 10 people in the US would like to replace the Affordable Care Act with a national health insurance program for all Americans, according to a Gallup Poll conducted on the phone in May 2016 among 1,549 U.S. adults. By political party, RE: Launch a Federal/national health insurance plan (“healthcare a la Bernie Sanders”): Among Democrats, 73% favor the Federal/national health insurance plan, and only 22% oppose it; 41% of Republicans favor it and 55% oppose it. RE: Repeal the ACA (“healthcare a la Donald Trump”): Among Democrats, 25% say scrap the ACA, and 80% of Republicans say to do

Nearly 1 in 2 people own at least one wearable device, up from 21% in 2014; one-third of people own more than one such device that tracks some aspect of everyday life, according to PwC’s latest research on the topic, The Wearable Life 2.0 – Connected living in a wearable world, from PwC. Wearable technology in this report is defined as accessories and clothing incorporating computer and advanced electronic technologies, such as fitness trackers, smart glasses (e.g., Google Glass), smartwatches, and smart clothing. Specifically, 45% of people own a fitness band, such as a Fitbit, the most popular device in this

“Health comes to your local store,” explains the recently-launched portal, GoHealthEvents. This site is a one-stop shop for health consumers who are seeking health screenings and consults in local retail channels like big box stores, club stores, drug stores, and grocery stores. Events covered include cholesterol, diabetes, heart health, nutrition, osteoporosis, senior health, vaccinations and immunizations. By simply submitting a zip code, a health consumer seeking these kinds of services can identify where and when a local retailer will provide it. I searched on my own zip code in suburban Philadelphia, and found the following opportunities taking place in the

This cool network map is brought to us by Onalytica, which is in the business of identifying online social network digerati — the Who’s Who of social/digital influential people across a whole range of industries. Because you’re reading Health Populi, I’m showing you their latest map of digital health influencers (which includes, humbly, me pictured around 5 o’clock on the map in the lower southeast corner). I’m number 15 with an influence score of 9.32. This pales in comparison to the top influencer, the wonderful Dr. Bertalan Mesko, MD, PhD, the medical futurist based in Hungary. @Berci is his Twitter

Pressures on the pharmaceutical industry are coming from every stakeholder touchpoint, driving companies to merge, set prices high for short-term gains, and (finally) put more resources toward providing patients services. Let’s call out just a few of the events from the past couple of weeks which, together, paint the current rocky landscape for pharma and life science companies: Last week on April 28th, termed “healthcare’s $45 billion day,” three big M&A deals hit the financial markets: Abbott sought to acquire St. Jude Medical (worth $30 bn alone), AbbVie looked to buy Stemcentrx for just under $6 bn, and Sanofi tagged

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

Who better than a financial services institution based in Silicon Valley to assess the state of digital health? Few organizations are better situated, geographically and sector-wise, than SVB Analytics, a division of Silicon Valley Bank based in, yes, Silicon Valley (Santa Clara, to pinpoint). The group’s report, Digital Health: Opportunities for Advancing Healthcare, provides an up-to-date landscape on the convergence of healthcare and technology. SVB Analytics defines digital health as “solutions that use digital technology to improve patients’ health outcomes and/or reduce the cost of healthcare.” The report provides context for the digital health market in terms of health care costs,

Financial stress impacts health, relationships, and work productivity and attendance for employees in the U.S. It’s the American worker’s trifecta, a way of life for a growing proportion of people in the U.S. PwC’s 2016 Employee Financial Wellness Survey for 2016 illustrates the reality of fiscally-challenged working women and men that’s a national epidemic. Some of the signs of the financial un-wellness malaise are that, in 2016: 40% of employees find it difficult to meet their household expenses on time each month 51% of employees consistently carry balances on their credit cards (with a large increase here among Baby Boomers

American workers are feeling financial stress and uncertainty, struggling with health care costs, and seeking support for managing finances. 75% of employees feel financially insecure, with 60% feeling stressed about their financial situation, according to the 2016 Workplace Benefits Report, based on consumer research conducted by Bank of America Merrill Lynch. The overall feeling of financial wellness fell between 2013 and 2015. 75% of U.S. workers don’t feel secure (34% “not very secure” and 41% “not at all secure”), with the proportion of workers identifying as “not at all secure” growing from 31% to 41%. Financial wellness was defined for this

How can digital technologies enable self-healthcare in novel ways? This was the theme of a meeting sponsored by Pfizer Consumer Healthcare and hosted by Google, with the title, “Advancing Consumer Health through New Technology and Next Generation OTC Healthcare” held on 12th April 2016 at Google offices in Manhattan’s Chelsea neighborhood. Pharmaceutical brand drugs switching to over-the-counter packaged goods, the Cellscope Otoscope used by parents checking their young children’s earaches, connected shoes and earbuds for athletic enhancement, and omni-channel retail shopping….these are a few of the signals we see emerging to enable consumers’ to drive healthy behaviors, wellness and self-healthcare. Speakers

Faxing in health care ranks higher in patient data information sharing than using secure email, online portals, health information exchange (HIE), or leveraging electronic health records. Welcome to the American healthcare system in 2016, as described in a market spotlight published by IDC, The Rocky Road to Information Sharing in the Health System. IDC’s survey research among healthcare providers forecasts the “rocky road” to information sharing. That rocky road is built for medical errors, duplication of services, greater healthcare costs, and continued health il-literacy for many patients. “The holy grail of interoperability — lower-cost, better-quality care with an improved experience for

April 7 is World Health Day, and the World Health Organization (WHO) has named #diabetes the big public health challenge for 2016. What’s striking about this year’s World Health Day is the “Stay Super” public health ad campaign that WHO has developed featuring figures of super-people. THINK: Superman and Wonderwoman meet Doctors Welby, Kildare, and McDreamy. I’ve included several of the posters in the blog today to show how engaging health messaging works well when it works. The materials can be downloaded at this link. This week also saw the publication of America’s Health Rankings, spotlighting the impact of unhealthy behaviors.

Consumers are extremely price-sensitive when it comes to shopping for health insurance. The cost of health insurance premiums, deductibles and copays, prescription drug coverage and out-of-pocket expenses rank higher in the minds of health insurance shoppers than the list of doctors and hospitals included in a health plan for health consumers in 2015. The Employee Benefit Research Institute (EBRI) surveyed 1,500 workers in the U.S. ages 21-64 for their views on workers’ satisfaction with health care in America. The results of this study are compiled in EBRI’s March 2016 issue of Notes, Views on Employment-based Health Benefits: Findings from the 2015 Health

The most prestigious occupation in America is being a doctor, agreed by 90% of U.S. adults. 90% of them would also encourage their child to pursue a career in medicine. Politician? 70% of parents would discourage a child from pursuing that career path, according to The Harris Poll’s survey on occupational prestige. The top-prestige professions are: Doctor, agreed by 90% Scientist, 83% Firefighter, 80% Military officer, 78% Engineer, 76% Nurse, 76% Architect, 72% Emergency medical tech, 72% Veterinarian, 71% Police office, 67%% Teacher, 65% Entrepreneur, 65% Chef, 62% Athlete, 62% Lawyer, 62% Musician, 61%. All other professions fell below 60%

As patients continue to grow health consumer muscles, their ability to vote with their feet for health care services and products grows. That’s why it’s crucial for health care providers to understand how patients perceive their quality and service levels, explained in Patient Experience: It’s Time to Rethink the Consumer Healthcare Journey, a survey report from GE Healthcare Camden Group and Prophet, a brand and marketing consultancy. 3 in 4 frequent healthcare consumers say they are frustrated with their services. One-half of less-frequent patients are frustrated. Patients and physicians are on different pages when it comes to evaluating the health care