A blog covering the health/care ecosystem and people.

Without trust, people do not engage with health care providers, health plans, or life science companies….nor do many people accept “science fact.” I explore the sad state of Trust and Health Care. published in the Medecision Liberate Health blog, with a positive and constructive call-to-action for health care industry stakeholders to consider in re-building this basic driver of well-being. That is, trust as a determinant of health. Edelman’s 2022 Trust Barometer came out in January 2022, coinciding as it annually does with the World Economic Forum’s meeting in Davos, Switzerland. Every year, WEF convenes the world’s biggest thinkers to wrestle with the

“Social distancing is great. Medical distancing? Not so much,” I observe in Medical Distancing in America: A Lingering Pandemic Side Effect., my essay published this week in Medecision’s Liberate Health blog. Since we learned to spell “coronavirus,” we also learned the meaning and risk-managing importance of physical distance early in the COVID-19 pandemic. But medical distancing became a corollary life-flow of the physical version, and for our collective health and well-being, it hasn’t been good for our health in ways beyond keeping our exposure to the virus at bay. For health care providers — physicians, hospitals, ambulatory clinics, diagnostic centers —

Health is the cornerstone to our core needs, thereby the cornerstone to trust.” This was one lens on the latest 2022 Edelman Trust Barometer published earlier this month. But trust is in short supply when it comes to consumers openness to share their personal information we learn through a new study published in JAMA, Consumer Willingness to Share Personal Digital Information for Health-Related Uses. For some historical context, the authors (all affiliated with the University of Pennsylvania [medical school or Wharton (business school)] start with HIPAA, the Health Insurance Portability and Accountability Act which served up privacy protections based on

In October 2021, the Consumer Technology Association (CTA) announced that Robert Ford, CEO and President of Abbott, would give a keynote speech at CES 2022, the world’s largest annual convention of the technology industry. “This marks the first time in CES history that a healthcare company will take the mainstage for a keynote at the show,” CTA’s press release stated. I covered this announcement in the Health Populi blog at the time, and today want to double-down on the significance of Ford’s leading presence at #CES2022. When announced, the news was a signal that health care and the larger tech-enabled

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

As we see the medical and acute care sector moving toward health and wellness, there’s a sort of equal and opposite reaction moving from the other end of the continuum of health/care: that is, wellness and fitness companies blurring into health care. Let’s start with the news about CrossFit and 23andMe, then synthesize some key market forces that will help us anticipate more ecosystem change for 2022 and beyond. CrossFit announced the company’s launch of CrossFit Precision Care, described as primary care that provides personalized, data-driven services for “lifelong health,” according to the press release for the program. The service

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

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%

Rising costs, generational shifts, digital transformation, and fast-growing investments in new health care models and technologies are forcing change in the legacy health care, noted in the State of Consumerism in Healthcare 2021: Regaining Momentum, from Kaufman, Hall & Associates. As the title of Kaufman Hall’s sixth annual report suggests, health care consumers are evolving — even if the traditional healthcare system hasn’t uniformly responded in lock step with more demanding patients. Kaufman Hall analyzed 100 health care organizations in this year’s consumerism survey to assess their readiness to embrace consumer-centric strategies, understand how the industry prioritizes these approaches, evaluate

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

In the U.S., patients have assumed the role of health care payors with growing co-payments, coinsurance amounts, and deductibles pushing peoples’ out-of-pocket costs up. This has raised the importance of price transparency, which is based on the hypothesis that if patients had access to personally-relevant price/cost information from doctors and hospitals for medical services, and pharmacies and PBMs for prescription drugs, the patient would behave as a consumer and shop around. That hypothesis has not been well proven-out: even though more health care “sellers” on the supply side have begun to post price information for services, patients still haven’t donned

“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

We’ve long know that “the patient” has been an under-utilized resource in the U.S. healthcare system since Dr. Charles Safran testified with that statement to Congress way back in 2004…an era where bipartisanship for health IT was a real thing. Today, with the insights of Alexandra Drane (Founder of ARCHANGELS) and Dr. Nirav Shah (of Stanford University), we know that caregivers are among the most over-utilized resources in the U.S. healthcare system — overused, over-stressed, under-paid, detailed n How Health Systems Can Care for Caregivers, published in the NEJM Catalyst July 2021 issue. In this study, Drane and Shah analyze

In the COVID-19 pandemic, health care spending in the U.S. increased by a relatively low 6.0% in 2020. This year, medical cost trend will rise by 7.0%, expected to decline a bit in 2022 according to the annual study from PwC Health Research Institute, Medical Cost Trend: Behind the Numbers 2022. What’s “behind these numbers” are factors that will increase medical spending (the “inflators” in PwC speak) and the “deflators” that lower costs. Looking around the future corner, the inflators are expected to be: A COVID-19 “hangover,” leading to increased health care services utilization Preparations for the next pandemic, and

The hearts and minds of nurses are fertile and inspirational sources and engines for health care innovation. This past weekend, and for the second time, I had the privilege and opportunity to be a panelist for the perennial hackathon meet-up of Nurse Hack 4 Health, sponsored by Microsoft, Johnson & Johnson, Sonsiel, and DevUp. This round, the hackathon attracted hundreds of nurses from at least 20 countries and 30 U.S. states. Even a few students attended, a growing trend as academia recognizes the shortage of workers trained to solve thorny problems of the world. In health care, right here, right

While the “in-person” visit to a doctor or medical professional continues to rank first as consumers’ most-trusted information source, the virtual doc or clinician rose in trust during the COVID-19 pandemic, according to Euromonitor’s latest read on Consumer Health: Changes in Consumer Behaviour during COVID-19 . The first four most-trusted sources for health information in 2021 remained the same short-list from 2020: doctors in-person, pharmacists, nutritionists and dieticians, and government or NGOs. But fifth place slipped from family and friends to the pharma industry, and sixth in line went to virtual doctors or medical professionals rising from 9th place in

The coronavirus pandemic accelerated digital transformation of organizations, including health care providers. But another patient side-effect of COVID-19 has been the digital transformation of many patients, documented by data gathered by Rock Health and Stanford Center for Digital Health and analyzed in their latest report explaining how the public health crisis accelerated digital health “beyond its years,” noted in the title of the report. Rock Health and Stanford commissioned an online survey among 7,980 U.S. adults from early September to early October 2020 to gauge peoples’ interest in and utilization of digital health tools and telehealth. Rock Health has conducted a consumer digital

At the start of CES 2021, I had the opportunity to catch up with Karsten Russell-Wood, Portfolio Marketing Leader, Post Acute & Home, Connected Care at Philips. We brainstormed just as CES 2021 was going to “open,” virtually, for the consumer electronics conference’s first all-virtual meeting. Philips, a longtime major exhibitor at CES, created an entirely new online experience for the CES attendees – a sort of virtual gallery of different exhibits that are accessed from a single point in a “room” with various entry points. One of the company’s key messages for CES 2021 was health care delivered outside

In 2020, the COVID-19 pandemic drove U.S. consumers to increase spending on electronics, notably laptops, smartphones, and desktop computers. But the coronavirus era also saw broadband households spending more on connecting health devices, with 42% of U.S. consumers owning digital health tech compared with 33% in 2015, according to research discussed in Supporting Today’s Connected Consumer from Parks Associates. developed for Sutherland, the digital transformation company. Consumer electronics purchase growth was, “likely driven by new social distancing guidelines brought on by COVID-19, which requires many individuals to work and attend school from home. Among the 26% of US broadband households

From appointment scheduling to checking in, payment and clinical encounter follow-up, patients now expect digital experiences across the health care continuum….and really great ones, like they get from Amazon and other platforms that earn high net promoter scores. That is the big message from the 2020 Healthcare Consumer Experience Study published by Cedar, based on the input of 1,502 U.S. adults who paid a medical bill between October 2019 and October 2020. The timing of this study coincided with the start of the COVID-19 pandemic in the U.S. through at least seven months of American patients’ experiences in 2020. Two-thirds

When it comes to patients, health care providers have been hit hard in two ways in the wake of the COVID-19 pandemic. Hit #1 has been the direct negative impact of the coronavirus on health care volumes and patients not utilizing hospitals and doctors’ services, avoiding physical encounters in health care sites Hit #2 has been the negative impact of patient experience for those health consumers who sought health care services during the pandemic — and had a negative response to the encounter. Accenture explored this phenomenon in their latest report, Elevating the Patient Experience to Fuel Growth. In the

One in two U.S. adults say their concerns about personal health and wellness increased in the past year: in particular, stress and anxiety, and sleep and eating habits. Despite spending more time at home due to the COVID-19 pandemic, few people believe they live in a “healthy home.” The vast majority of consumers are concerned about some aspect of their home’s health, like air or water quality, according to Healthy Home Technologies , a report published in October 2020 by the Consumer Technology Association (CTA), convener of the annual CES. For the research, CES interviewed 1,500 U.S. adults in late

One universal experience health systems around the globe have witnessed in the first months of the coronavirus pandemic has been the dramatic pivot to telehealth and virtual care platforms. The latest report from Philips Future Health Index series attests to that, and to clinicians’ general recognition that telehealth has been crucial in the early phase of the crisis. However, younger doctors’ experience with telehealth has led to them being more bullish on the value of the modality than older physicians, Philips learned. Philips conducted 500 interviews with doctors in China, France, Germany, Singapore, and the United States to assess their

COVID-19 is re-shaping all industries, especially health care. And the pharma industry is challenged along with other health care sectors. In fact, the coronavirus crisis impacts on pharma are especially accelerated based on how the pandemic has affected health care providers, as seen through research from Accenture published in Reinventing Relevance: New Models for Pharma Engagement with Healthcare Providers in a COVID-19 World. For the study, Accenture surveyed 720 health care providers in general practice, oncology, immunology, and cardiology working in China, France, Japan, the United Kingdom, and the U.S., in May and June 2020. Top-line, Accenture points to four

The pandemic has become a sort of forcing function on all aspects of daily living, include health care. Deloitte’s latest wave of health care consumer market research updates the COVID-19 impacts on the U.S. health care landscape and asks the question in the study report’s title: “Are consumers already living the future of health?” For the general survey of U.S. Health Consumers, Deloitte polled 4,522 U.S. adults 18 and older online in February and March 2020. Deloitte conducted an additional 1,510 interviews with consumers in April to gauge peoples’ perspectives on the pandemic, health and well-being. In the Great Lockdown

The coronavirus pandemic accelerated many trends and new workflows for patients and consumers, and health care providers, too. The convergence of basic needs like hygiene and safety, financial and health security, and living-working-learning-and-cooking-at-home has turbocharged a migration of more acute care delivered at home. I explore this growing concept in my latest essay on Medecision’s Liberation blog, How the Pandemic Is Accelerating the Hospital-At-Home Concept. The key points are that: Hospital-at-home services (H-a-H) combine home visits with virtual care and remote monitoring Think: advanced home care, enabled through virtual health technologies and wrap-around services both clinical and scaled social determinants

The phrase, “burden of health care,” has two usual meanings: one, to do with the massive chronic care burden, and the other, involving costs. There’s a third area of burden in U.S. health care — the onerous patient experience in finding and accessing care, assessed in the 2020 Change Healthcare – Harris Poll Consumer Experience Index. Two in three U.S. consumers feel like “every step of the healthcare process is a chore.” That burdensome patient experience leads to one in two people in America avoiding seeking care, the poll found. That’s not just self-rationing health care due to costs, but due

You’ve heard the one about three characters walking into a bar. A new collaboration between United Airlines, Cleveland Clinic and Clorox reminded me of that scenario, and that in the age of the coronavirus pandemic, collaboration can bolster our health. In the era of COVID-19, people — consumers. patients managing chronic conditions, and caregivers (whether for younger or older loved ones) — are concerned about contracting the virus. In U.S. states where governors mandated shelter-at-home for much of the first half of 2020, millions of people have become conditioned to physically distance, wear face coverings, and #StayHome. In particular, workers

There’s a gap between the supply of digital health tools that hospitals and health systems offer patients, and what patients-as-consumers need for overall health and wellbeing. This chasm is illustrated in The future of the digital patient experience, the latest report from HIMSS and the Center for Connected Medicine (CCM). The big gap in supply to patients vs. demand by health consumers is highlighted by what the arrow in the chart below points to: managing payments and paying bills. Nowhere in the top 10 most commonly provided digital tools is one for price transparency, cost comparing or cost estimating.  In the

One in two people over 50 bought a piece of digital technology in the past year. Three in four people over fifty in America now have a smartphone. One-half of 50+ Americans use a tablet, and 17% own wearable tech. The same percentage of people over 50 own a voice assistant, a market penetration rate which more than doubled between 2017 and 2019, AARP noted in the 2020 Tech and the 50+ Survey published in December 2019. For this research, AARP worked with Ipsos to survey (online) 2,607 people ages 50 and over in June and July 2019. Across all

The topline of this year’s annual Gallup Poll into honesty and ethics of professions finds nurses sustaining their reign as the top trusted profession in America. But it’s also important to point out that four of the top five most ethical professions are people working on the front lines of health care: doctors (#3), pharmacists (#4) and dentists (#5). Engineers rank second this year after nurses, edging ahead of doctors and pharmacists who typically have ranked 2nd and 3rd each year in the past decade. One of these years, pharmacists’ reputation fell as the profession was associated with being a

The top two health care concerns facing Americans are out-of-pocket costs and prescriptions drug costs, according to a poll published today in Morning Consult. Apropos to my title of this post, the survey was sponsored by the Bipartisan Policy Center, whose mission is to promote, cross-party affiliations, “health, security and opportunity for all Americans.” Health care is the top issue driving voters’ choices in the 2020 elections for most Americans. The economy follows second with 44% of voters, then immigration with 33% of Americans keen on the issue. For overall healthcare reform, the plurality of Americans prefer improving the current system

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,

“What’s the evidence on the role of the arts in improving health and well-being?” asks a report from the World Health Organization‘s Europe region team (WHO-Europe). There’s a lot of proof supporting arts-as-medicine, WHO details in this paper, which synthesizes research published in over 3,000 studies. The first chart illustrates the logic model that bridges arts to health in three segments: “Components” of arts programs, including but not limited to cognitive stimulation (e.g., learning a new arts skill such as painting, drawing or journaling), social interaction (e.g., participating in theatre), physical activity (e.g., dance), and evocation of emotion (e.g., listening

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

“Digital transformation” is the corporate strategy flavor of the moment across industries, and the health are sector isn’t immune from the trend. As this 13th year of the annual Health 2.0 Conference kicks off this week, I’m focused on finding digital health innovations that engage people — consumers, caregivers, patients, health citizens all. This year’s conference will convene thought leaders across a range of themes, and as is the Health 2.0 modus operandi, live demo’s of new-new things. As Health 2.0 kicks off today in pre-conference sessions, there is useful context described in a new report from the American Hospital

Health care system financing, delivery, and workflows widely vary across nations around the world. Philips surveyed health care professionals and consumers living in 15 countries, from North America to Asia, and found that these health systems share one over-arching objective: to provide quality care with improved experiences for both patients and healthcare professionals. Being Philips, what underpins that quality and experience is technology; Philips explored telehealth, AI, digital health records (DHRs), and other digital health tools that can engage patients. Philips published results from this global study in The Future Health Index 2019, themed “Transforming healthcare experiences, exploring the impact

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

Today is July 15, and my email in-box is flooded with all flavors of Amazon Prime’d stories in newsletters and product info from ecommerce sites — even those outside of Amazon from beauty retailers, electronics channels, and grocery stores. So I ask on what will probably be among the top ecommerce revenue generating days of all time: “What could health care look like when Amazon Prime’d?” I ask and answer this in my book, HealthConsuming, as chapter 3. For context, this chapter follows two that explain how patients in the U.S. have been morphing into health consumers based on how health

There are many forms of magic inspired by Disney, the company. There’s the obvious attraction, the Magic Kingdom, that was Walt’s original destination vision, “imagineered” in 1932. Then there are other kinds of magic. The one I’m deep into in the moment is inspiration, ideation, and “reimagineering” my own thinking about work, legacy, and social justice. I’m grateful to have had the opportunity to spend much of this week at the inaugural Disney Institute Women’s Leadership Summit. The Institute convened about 300 women (and a handful of brave “He-for-She” men keen on diversity) in Orlando to learn about and brainstorm

Most U.S. healthcare providers are spending more time, effort and capital with an eye to engaging with patients-as-consumers, a trend quantified in the report, the 2019 State of Consumerism in Healthcare: The Bar is Rising from Kaufman Hall, summarizing results from this year’s healthcare consumerism index survey conducted among about 200 healthcare providers. “Legacy organizations will need premier-level consumer capabilities to compete in today’s increasingly consumer-centric environment,” Kaufman Hall recommends. Providers identified the key capability gaps for consumer-centric care as improving the consumer experience, offering a variety of facility-based access points, utilizing digital tools for health engagement, providing price transparency,

The supply side of digital health tools and tech is growing at a hockey-stick pace. There are mobile apps and remote health monitors, digital therapeutics and wearable tech from head-to-toe. Today in America, electronic health records (EHRs) are implemented in most physician offices and virtually all hospitals. Chapter 5 of my book, HealthConsuming: From Health Consumer to Health Citizen, details the promise of digital health: wearable, shareable and virtual. Today, we can also call on Alexa to remind us to take medications, play nostalgic music when we are lonely, check our physical activity status with Fitbit, and query WebMD about

Have you read the life changing magic of tidying up, or Spark Joy, books by Marie Kondo? Her new Netflix series, Tidying Up with Marie Kondo debuted on January 1, and has enjoyed passionate early viewership by consumers in America who are among the world’s major hoarders. If you opened any pop culture magazine or newspaper in the past week, you probably saw the results of a PR blitz promoting KonMari, the trademarked name for Marie’s clean-out method. As an example, the Wall Street Journal discussed the phenomenon in Ben Zimmer’s profile, “A Guru of Organizing Becomes A Verb” published this weekend

I had the pleasure once again of attending Shelly Palmer’s annual kick-off breakfast where he level-sets our expectations for CES two hours before the tech halls open. Shelly is a consumer tech expert and leads the Palmer Group; comments on Fox 5 in NYC, CNN, and CNBC; writes a weekly column in Advertising Age; composes music; and he’s a Renaissance Man who’s a generous sharer of knowledge with a great sense of humor and humanity. Shelly is one of my trusted touchpoints for all-things-consumer-tech. His message at the start of #CES2019: this year, the show is about connectivity and partnership.

Most patients wish their doctors would have a conversation with them about non-medical issues. The Doctor-Patient Conversation, a survey conducted for the Samueli Foundation by the Harris Poll, examined how patients feel about their health, healthcare, and relationships with physicians. The Samueli Institute, has several missions including integrative health with a focuses on evidence-based practices for healing, wellbeing and resilience. Patients are keen to learn about non-medication alternatives, like food-as-medicine, meditation, and acupuncture. But most doctors base their conversations with patients on purely medical options like lab test results and surgical procedures. The top issues doctors discuss with patients are

Information is power in the hands of people. When it’s open in the sunshine, it empowers people — whether doctors, patients, researchers, Presidents, teachers, students, Everyday People. Welcome to the era of Open Source Healthcare, not only the “about time” for patients to own their health, but for the launch of a new publication that will support and continue to evolve the concept. It’s really a movement that’s already in process.     Let’s go back to some definitions and healthcare basics to understand just why Open Source Healthcare is already a thing. When information access is uneven, it’s considered

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

With the acquisition of GreatCall, a mature player in the aging-tech space, Best Buy is doubling down on consumer health technology@retail. This week at Best Buy. the electronics retailer,  it’s out with CDs and in with technology for aging at home. The company announced that it would buy GreatCall for $800 million. A snippet from the announcement from Best Buy’s press release is shown in the first diagram, noting that GreatCall’s membership is approaching 1 million subscribers who use mobile phones and connected devices, “providing peace of mind to their loved ones.” Beyond the obvious “falling and I can’t get