Tag Archives: Well-Being

Well-Being – Real Time Revisited

NOTE: This post revisits a post titled “Well-Being Real Time”. The original post was May, 2014, and can be found at: http://johncreid.com/2014/05/well-being-real-time/.

Well-Being – Real Time Revisited

Well-being is arguably the central mega-trend of the 21st century. As we look to the future, we have an obligation to “unpack” this dense concept, and find its essential component parts.

We describe these components here as “ACE” – ACT, CARE, and EAT. The wish we have for ourselves and for others is to be well. “Be Well” is our salutation and our call to actions.

How far out are we looking?

The future is now. ACE is here – together with real time measuring and monitoring. ACE is our pathway to greater and greater levels of personal well-being.

ACE measuring and monitoring will be supported by all elements of the quantified self movement. FitBit, Apple Watch, and so many other new monitoring devices will allow us to to bring personal well-being into a real-time modality.

ACE represents three pillars, each deceptively simple:

A – ACT: ACT is short for activity. The call to action is “stay active”. Well-being activity has physical activity at its center, but the pillar also embraces social activity, and activities of the mind. Staying active is a critical element of being well.
C – CARE: CARE is short for well-being care. The call to action is “care for yourself” and “care for others.”Well-being care of course has health care at its center, but there is so much more. e.g. genomics, massage, essential oils, acupuncture, etc. “Caring for myself” and “Caring for others” are elements of this pillar. “Preventive care” regular check-ups, colonoscopies after age 50, mammograms, pre-natal care for expecting mothers, etc.
E – EAT: EAT is short for eating and drinking. The call to action is “Eat well.” Well-being eating is the exploration of how what we eat and drink contributes to our well-being.

As simple as these pillars appear, each is complex: deep enough for a life-time of focus. Each represents bodies of research, skills, capabilities, and areas of professional endeavor. All together, these pillars represent pathway that each of us will follow as we attain greater and greater levels of personal well-being.

Discussion:

ACT

A – ACT (walking, running, calories burned etc)

Staying active is a critical element of being well. Well-being activity has physical activity at its center: sports, walking, lifting, climbing, yoga, and all of the other activities that light up a FitBit. The pillar also embraces activity of other kinds, e.g. social activity, and activities of the mind.

CARE

Well-being care is all about promoting health. Of course, it has health care at its center, but there is so much more. e.g. mental health, addictive behaviors, massage, genomics, essential oils, acupuncture, etc.

“Caring for myself” and “Caring for others” are elements of this pillar. “Preventive care”, eldercare and aging, palliative care are included, but so are regular check-ups, colonoscopies after age 50, mammograms, pre-natal care for expecting mothers, etc.

The ability to routinely monitor vital signs at home or at the office will be a part of this pillar. Lab work – including saliva, blood, and stool samples, will be more real time, more regular and less expensive. These trends will be one of the keys to progress in the care pillar. On the innovation side of this pillar will be many technologies, but breakthroughs in genomics will certainly be high on the list. Telemedicine is another innovation that will alter access to well-being care.

Predictive modeling will be more relevant than never. Am I headed for pre-diabetes? If so, what evidence shows me a path to avoid that condition?

CARE-MMEDS (what MEDS I take, what compliance I have, etc)

CARE-RResting Metabolic Rate (calories burned at rest)

CARE-VVITALS (pulse, BP, etc)

CARE-LLABS (blood testing, etc)

CARE-SSleep (duration, deep sleep, etc)

EAT

EAT is short for eating and drinking. The call to action is “Eat well.”

Well-being eating is the exploration of how what we eat and drink contributes to our well-being. Naturally, there is a social element, where eating and drinking together makes the experience more fulfilling. There is a physiological element, having to do with ingestion, osmosis, calories, glucose and glycogen, enzymes, etc. There is a psychological element, related to the feelings of satiety, or hunger, or thirst, and their related cravings. There is a sensory element, where sweet and sour contrasts, aromas, and their related metaphorical associations, play a part.

Eating delicious food and drink with friends is certainly a component. But achieving a balanced diet, with moderation as a central tenant,

On the one hand, this pillar is ancient. For thousands of years, elders have taught daughters and sons how to cook well. and cooking techniques have evolved

On the other hand, this pillar is ripe for innovation. The new breakthrough science related to the micro-biome is a part.

EATS (what I eat and drink, especially calories)

Implications

Monitoring all components of ACE (MEDS, Activity, Resting Metabolism,VITALS, EATS, LABS, Sleep) is now going to accelerate at an exponential rate.

There will be three settings where ACE monitoring will accelerate:

Employees in Workplaces: Employers will offer employees routine monitoring as part of employee benefits and/or health insurance.
Residents in Communities: Communities will offer residents routine monitoring as one of their amenities. Wellbeing facilities and programs will become as important as golf courses and swimming pools. Look for HOA’s,Condo and Coop associations, and subdivision developers to increasingly view MARVELS as critical to “place-making”.
Clients of service-providers: Hotels, spas, assisted-living centers, nursing homes, and many others will increasingly offer MARVELS monitoring as one of their base services.

The Privacy Imperative will be the critical success factor for all of these pushes into the future. It is foundational.

Without it, there will be no progress.

With it, personalized, real-time care will flourish. Each individual will be able to opt-in to his care-coaching community (and to opt-out whenever they choose), and get the extraordinary benefits that such a community can provide.

Want to talk to your well-being coach? FaceTime them, and they – with your permission – will help you sort out what’s going on with you.

Feel like you might need a check-in with a doctor? Send them an email – with your ACE history embedded in it, or get them on the phone or FaceTime, and see if they need you to come in.

The future is now.

BEWELL Centers will be everywhere. Look for:

DWELL CENTERS (part of BEWELL Centers) – for community ACE measuring and monitoring support. Target population is neighbors in the community.

Employee BEWELL CENTERS (part of BEWELL Centers) – for employees in workplaces ACE measuring and monitoring support. Target population is employees in the workplace.

CLIENT BEWELL CENTERS (Part of BEWELL Centers – for service-providers ACE measuring and monitoring support.Target population is clients of the service provider.
(Walgreens and CVS are already moving aggressively in this direction>

References:
The Privacy Imperative
LABS revolution
LABS By Disease
Quantified Self Movement

Neo.Life

This beta site NeoLife link beyond the splash pagee is tracking the “neobiological revolution”. I wholeheartedly agree that some of our best and brightest are on the case. Here they are:

ABOUT
NEO.LIFE
Making Sense of the Neobiological Revolution
NOTE FROM THE EDITOR
Mapping the brain, sequencing the genome, decoding the microbiome, extending life, curing diseases, editing mutations. We live in a time of awe and possibility — and also enormous responsibility. Are you prepared?

EDITORS

FOUNDER

Jane Metcalfe
Founder of Neo.life. Entrepreneur in media (Wired) and food (TCHO). Lover of mountains, horses, roses, and kimchee, though not necessarily in that order.
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EDITOR
Brian Bergstein
Story seeker and story teller. Editor at NEO.LIFE. Former executive editor of MIT Technology Review; former technology & media editor at The Associated Press
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ART DIRECTOR
Nicholas Vokey
Los Angeles-based graphic designer and animator.
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CONSULTANT
Saul Carlin
founder @subcasthq. used to work here.

EDITOR
Rachel Lehmann-Haupt
Editor, www.theartandscienceoffamily.com & NEO.LIFE, author of In Her Own Sweet Time: Egg Freezing and the New Frontiers of Family

Laura Cochrane
“To oppose something is to maintain it.” — Ursula K. Le Guin

WRITERS

Amanda Schaffer
writes for the New Yorker and Neo.life, and is a former medical columnist for Slate. @abschaffer

Mallory Pickett
freelance journalist in Los Angeles

Karen Weintraub
Health/Science journalist passionate about human health, cool researcher and telling stories.

Anna Nowogrodzki
Science and tech journalist. Writing in Nature, National Geographic, Smithsonian, mental_floss, & others.
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Juan Enriquez
Best-selling author, Managing Director of Excel Venture Management.

Christina Farr
Tech and features writer. @Stanford grad.

NEO.LIFE
Making sense of the Neobiological Revolution. Get the email at www.neo.life.

Maria Finn
I’m an author and tell stories across multiple mediums including prose, food, gardens, technology & narrative mapping. www.mariafinn.com Instagram maria_finn1.

Stephanie Pappas
I write about science, technology and the things people do with them.

David Eagleman
Neuroscientist at Stanford, internationally bestselling author of fiction and non-fiction, creator and presenter of PBS’ The Brain.

Kristen V. Brown
Reporter @Gizmodo covering biotech.

Thomas Goetz

David Ewing Duncan
Life science journalist; bestselling author, 9 books; NY Times, Atlantic, Wired, Daily Beast, NPR, ABC News, more; Curator, Arc Fusion www.davidewingduncan.com

Dorothy Santos
writer, editor, curator, and educator based in the San Francisco Bay Area about.me/dorothysantos.com

Dr. Sophie Zaaijer
CEO of PlayDNA, Postdoctoral fellow at the New York Genome Center, Runway postdoc at Cornell Tech.

Andrew Rosenblum
I’m a freelance tech writer based in Oakland, CA. You can find my work at Neo.Life, the MIT Technology Review, Popular Science, and many other places.

Zoe Cormier

Diana Crow
Fledgling science journalist here, hoping to foster discussion about the ways science acts as a catalyst for social change #biology

Ashton Applewhite
Calling for a radical aging movement. Anti-ageism blog+talk+book

Grace Rubenstein
Journalist, editor, media producer. Social/bio science geek. Tweets on health science, journalism, immigration. Spanish speaker & dancing fool.

Science and other sundries.

Esther Dyson
Internet court jEsther — I occupy Esther Dyson. Founder @HICCup_co https://t.co/5dWfUSratQ http://t.co/a1Gmo3FTQv

Jessica Leber
Freelance science and technology journalist and editor, formerly on staff at Fast Company, Vocativ, MIT Technology Review, and ClimateWire.

Jessica Carew Kraft
An anthropologist, artist, and naturalist writing about health, education, and rewilding. Mother to two girls in San Francisco.

Corby Kummer
Senior editor, The Atlantic, five-time James Beard Journalism Award winner, restaurant reviewer for New York, Boston, and Atlanta magazines

K McGowan
Journalist. Reporting on health, medicine, science, other excellent things. T: @mcgowankat

Rob Waters
I’m a journalist living in Berkeley. I write about health, science, social justice and policy. Father of 1. From Detroit.
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Yiting Sun
writes for MIT Technology Review and Neo.life from Beijing, and was based in Accra, Ghana, in 2014 and 2015.
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Michael Hawley
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Richard Sprague
Curious amateur. Years of near-daily microbiome experiments. US CEO of AI healthcare startup http://airdoc.com
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Bob Parks ✂
Connoisseur of the slap dash . . . maker . . . runner . . . writer of Outside magazine’s Gear Guy blog . . . freelance writer and reporter.

CREDIT: https://medium.com/neodotlife/review-of-daytwo-microbiome-test-deacd5464cd5

20th Century History on Health Care and Insurance

A historian’s take on health care and insurance in the US:

Key points:

Health care in the US is primarily driven by an “insurance company model”.’
There actually was a “medical marketplace” in early 20th century.
One of the best in that marketplace was a “prepaid physician group” with profit sharing for docs.
Truman proposed universal health care.
A.M.A. fought government intervention.
A.M.A. decided that the best way to keep the government out of their industry was to design a private sector model: the insurance company model.
In the insurance company model, insurance companies would pay physicians using fee-for-service compensation.
Thus, physicians became allied with insurance companies – both striving to keep government out of health care. Fee for service was their chosen model.
The model worked to expand coverage: from 25% of the population in 1945 to about 80 percent in 1965.
Elderly did not get covered as well. Congress stepped in with Medicare in 1965.
Because of rising prices, insurers gradually took over. “To constrain rising prices, insurers gradually introduced cost containment procedures and incrementally claimed supervisory authority over doctors. Soon they were reviewing their medical work, standardizing treatment blueprints tied to reimbursements and shaping the practice of medicine.”
Innovation in lacking. Concierge medicine experiments show some promise, like Atlas is Wichita.

=============
JCR comments:
It’s always easier looking backward. If only 25% of the population have health insurance, it seems eminently sensible that driving that number up to, say, 80% would be a high priority goal.

That’s what America did: it adopted a high priority goal to increase health insurance coverage from 25% to 80%. It’s chosen method was a fee-for-service reimbursement model – the “insurance model”. We put insurance companies in the driver’s seat, and we encouraged them to work with employers and physicians groups.

They were the middle man:

Insurers made sure that their employer clients had the benefits they needed to attract employees, at a cost that was practical.
Insurers also made sure that their physician partners supplied the services that they needed, at prices that were practical.

So, with the insurer-as-middle-man-model, we achieved our goal of enrolling 80%, up from 25%. 80% of the American population had health insurance in 1965.

So – what’s wrong with that?

It’s mostly very good. But…

Looking backward, it is obvious now that what is wrong: it is the remaining 20%. These are the unemployed – or the seniors – or the ones who have such ugly health attributes that their health costs are truly exorbitant.

While America was getting the 80% “squared away”, the 20% were left to fend for themselves. They overran emergency rooms; they took beds in charity hospitals; they died.

In 1965, we adopted Medicare and Medicaid. Medicare addressed the 20% who were seniors.
Medicaid addressed the 20% who were poor, such as:

Low-income families
Pregnant women
People of all ages with disabilities
People who need long-term care

Most of this happened over time, not in 1965. State offerings vary.

In 1997, we adopted CHIP for children. This addressed the 20% who were kids. 11 million kids got coverage. They were from families with too much income to qualify for Medicaid.

in 2003, we adopted MMA “The Medicare Prescription Drug Improvement and Modernization Act of 2003”. Under the MMA, private health plans were offered, approved by Medicare “Medicare Advantage Plans’. An optional prescription drug benefit was offered (“Part D”)

In 2011, the Affordable Care Act was adopted.

So, the key question for today is: why is our health care system such a mess. Read on:

=============
CREDIT: NYT https://www.nytimes.com/2017/06/19/opinion/health-insurance-american-medical-association.html?emc=edit_th_20170619&nl=todaysheadlines&nlid=44049881&_r=0

The Opinion Pages | OP-ED CONTRIBUTOR
How Did Health Care Get to Be Such a Mess?
By CHRISTY FORD CHAPINJUNE 19, 2017
The problem with American health care is not the care. It’s the insurance.
Both parties have stumbled to enact comprehensive health care reform because they insist on patching up a rickety, malfunctioning model. The insurance company model drives up prices and fragments care. Rather than rejecting this jerry-built structure, the Democrats’ Obamacare legislation simply added a cracked support beam or two. The Republican bill will knock those out to focus on spackling other dilapidated parts of the system.

An alternative structure can be found in the early decades of the 20th century, when the medical marketplace offered a variety of models. Unions, businesses, consumer cooperatives and ethnic and African-American mutual aid societies had diverse ways of organizing and paying for medical care.

Physicians established a particularly elegant model: the prepaid doctor group. Unlike today’s physician practices, these groups usually staffed a variety of specialists, including general practitioners, surgeons and obstetricians. Patients received integrated care in one location, with group physicians from across specialties meeting regularly to review treatment options for their chronically ill or hard-to-treat patients.

Individuals and families paid a monthly fee, not to an insurance company but directly to the physician group. This system held down costs. Physicians typically earned a base salary plus a percentage of the group’s quarterly profits, so they lacked incentive to either ration care, which would lose them paying patients, or provide unnecessary care.

This contrasts with current examples of such financing arrangements. Where physicians earn a preset salary — for example, in Kaiser Permanente plans or in the British National Health Service — patients frequently complain about rationed or delayed care. When physicians are paid on a fee-for-service basis, for every service or procedure they provide — as they are under the insurance company model — then care is oversupplied. In these systems, costs escalate quickly.

Unfortunately, the leaders of the American Medical Association saw early health care models — union welfare funds, prepaid physician groups — as a threat. A.M.A. members sat on state licensing boards, so they could revoke the licenses of physicians who joined these “alternative” plans. A.M.A. officials likewise saw to it that recalcitrant physicians had their hospital admitting privileges rescinded.

The A.M.A. was also busy working to prevent government intervention in the medical field. Persistent federal efforts to reform health care began during the 1930s. After World War II, President Harry Truman proposed a universal health care system, and archival evidence suggests that policy makers hoped to build the program around prepaid physician groups.

A.M.A. officials decided that the best way to keep the government out of their industry was to design a private sector model: the insurance company model.

In this system, insurance companies would pay physicians using fee-for-service compensation. Insurers would pay for services even though they lacked the ability to control their supply. Moreover, the A.M.A. forbade insurers from supervising physician work and from financing multispecialty practices, which they feared might develop into medical corporations.

With the insurance company model, the A.M.A. could fight off Truman’s plan for universal care and, over the next decade, oppose more moderate reforms offered during the Eisenhower years.

Through each legislative battle, physicians and their new allies, insurers, argued that federal health care funding was unnecessary because they were expanding insurance coverage. Indeed, because of the perceived threat of reform, insurers weathered rapidly rising medical costs and unfavorable financial conditions to expand coverage from about a quarter of the population in 1945 to about 80 percent in 1965.

But private interests failed to cover a sufficient number of the elderly. Consequently, Congress stepped in to create Medicare in 1965. The private health care sector had far more capacity to manage a large, complex program than did the government, so Medicare was designed around the insurance company model. Insurers, moreover, were tasked with helping administer the program, acting as intermediaries between the government and service providers.

With Medicare, the demand for health services increased and medical costs became a national crisis. To constrain rising prices, insurers gradually introduced cost containment procedures and incrementally claimed supervisory authority over doctors. Soon they were reviewing their medical work, standardizing treatment blueprints tied to reimbursements and shaping the practice of medicine.

It’s easy to see the challenge of real reform: To actually bring down costs, legislators must roll back regulations to allow market innovation outside the insurance company model.

In some places, doctors are already trying their hand at practices similar to prepaid physician groups, as in concierge medicine experiments like the Atlas MD plan, a physician cooperative in Wichita, Kan. These plans must be able to skirt state insurance regulations and other laws, such as those prohibiting physicians from owning their own diagnostic facilities.

Both Democrats and Republicans could learn from this lost history of health care innovation.

Christy Ford Chapin is an associate professor of history at the University of Maryland, Baltimore County, a visiting scholar at Johns Hopkins University and the author of “Ensuring America’s Health: The Public Creation of the Corporate Health Care System.”
Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter.

=============
Brian Hudes Comment:

I saw this one, as well.  The author lost credibility for me.   Ironically, what the author clearly doesn’t realize is that she is making an argument for the Kaiser Permenante model.  However, she unfairly and without any data makes the following claim: 

“Where physicians earn a preset salary — for example, in Kaiser Permanente plans or in the British National Health Service — patients frequently complain about rationed or delayed care”

Here’s a more balanced and comprehensive assessment supported by third party research:

Health Care Members Speak

==========

RECENT COMMENTS
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I’ve worked in marketing for both healthcare insurance and a healthcare/hospital system. It’s ridiculous how much money is spent selling a…

Gallup reports on 2016 Well-being

Gallup/Healthways 2016 Report

This report, part of the Gallup-Healthways State of American Well-Being series, examines well-being across the nation, including how well-being varies by state and which states lead and lag across the five elements of well-being. The five elements include:
• Purpose: liking what you do each day and being motivated to achieve your goals
• Social: having supportive relationships and love in your life
• Financial: managing your economic life to reduce stress and increase security
• Community: liking where you live, feeling safe and having pride in your community • Physical: having good health and enough energy to get things done daily

In 2016, the national Well-Being Index score reached 62.1, showing statistically signif- icant gains from 2014 and 2015. Also in 2016, Americans’ life evaluation reached its highest point since 2008, when Gallup and Healthways began measurement. Now 55.4% of American adults are “thriving”, compared to 48.9% in 2008. Other positive trends include historically low smoking rates (now at 18.0%, down from 21.1% in 2008); historically high exercise rates as measured by those who report they exercised for 30 minutes or more, three or more days in the last week; and the highest scores recorded on healthcare access measures, with the greatest number of Americans covered by health insurance and visiting the dentist. Americans are also reporting the lowest rates of healthcare insecurity since 2008, as measured by not being able to afford health- care once in the last 12 months.

All national well-being trends are not positive, however; chronic diseases such as obesity (28.4%), diabetes (11.6%), and depression (17.8%) are now at their highest points since 2008. The percentage of Americans who report eating healthy all day during the previous day is also at a nine-year low.

Georgia ranked 29th – middle of the pack. Georgia improved – up from 35th.

Georgia showed a wide variation in sub-components. Georgia scored in the highest quintile on Social Rank (“having supportive relationships”), second quintile on Purpose Rank (“liking what you do each day”), third quintile on Physical (“having good health”), fourth quintile on Community ((“like where you live”), and fifth quintile on Financial (“managing your economic life”).

8 Health Habits

CREDIT: NEW YORK TIMES ARTICLE POSTED BELOW
===============SUMMARY=============

Weigh yourself often.
Learn to cook
Cut back on sugar.
Live an active life. 

Eat your veggies.
Practice portion control.

Adopt a post-party exercise routine. 
 

Find a job you love.

============ JCR NOTES ==========

As we enter 2017, I am in the mood for simplifying well-being, which is why I like this list above. But I want to cross-check it against what I know.

For example, I long have asserted that “MARVELS” are critical to well-being. MARVELS stands for MEDS (M), ACTIVITY (A), RESILIENCE (R), VITALS (V), EATING (E), LABS (L), AND SLEEP (S).

I still believe this. But it is complicated – can it be simpler?

The article suggests – correctly – that in your 20’s, “what’s important now” is developing and maintaining an active, healthy lifestyle. It emphasizes E (a healthy diet, moderate alcohol consumption and no smoking), and A (regular physical activity).

Just for fun, what if the most simplistic acronym was “EAT”, which stands for:

E – eating, drinking, smoking ………….(what you put into your body)
“be mindful about what you put in your body, by tracking it, and enjoy taking increasing control over this by developing related habits such as learning to cook or juicing”
A – activity, including rest and sleep ….(what you do with your body)
“Be mindful about what you do with your body by staying active and getting plenty of rest”
T – track E and A ….
“Develop quantified self habits that track E and A and regularly verify that your body is operating normally”

So I might restate “what is important now” for people in their 20’s:

You want to fully enjoy your life in your 20’s – without putting your 30’s,, 40’s and beyond at risk – develop AHL (active, healthy living) habits that you enjoy, so that they have a good chance of being with you the rest of your life. stay lean and well-rested during your 20’s. To get that way, eat and drink well, don’t smoke,

Tracking:

Daily (get a routine, like taking a shower): M, A, E, and M. (Track what you put in your body (E) and what you do with your body (A and S) daily.

Simple checklist is this. Today, did you:
“Take MEDS as prescribed” (were you in compliance?)?
“Smoke?”
“Eat your veggies?”
“use sugar, especially alcohol, in moderation?”
“stay active with activities that can be life habits?”

Monthly: V (Track your vital signs, including body weight and body mass monthly.)

Annually: L (Track your lab results annually, and more frequently if results are out of normal range). L includes genomes – so do them once, and annually if V or L is out of normal range.

==============KEY STUDY===========

Staying healthy in your 20s is strongly associated with a lower risk for heart disease in middle age, according to research from Northwestern University. That study showed that most people who adopted five healthy habits in their 20s – a lean body mass index, moderate alcohol consumption, no smoking, a healthy diet and regular physical activity – stayed healthy well into middle age.

===============ARTICLE=============
The 8 Health Habits Experts Say You Need in Your 20s
By TARA PARKER-POPE OCT. 17, 2016
If you had just one piece of health advice for people in their 20s, what would it be?
That’s the question we posed to a number of experts in nutrition, obesity, cardiology and other health disciplines. While most 20-year-olds don’t worry much about their health, studies show the lifestyle and health decisions we make during our third decade of life have a dramatic effect on how well we age.
Staying healthy in your 20s is strongly associated with a lower risk for heart disease in middle age, according to research from Northwestern University. That study showed that most people who adopted five healthy habits in their 20s – a lean body mass index, moderate alcohol consumption, no smoking, a healthy diet and regular physical activity – stayed healthy well into middle age.
And a disproportionate amount of the weight we gain in life is accumulated in our 20s, according to data from the Centers for Disease Control and Prevention. The average woman in the United States weighs about 150 when she’s 19, but by the time she’s 29, she weighs 162 pounds – that’s a gain of 12 pounds. An average 19-year-old man weighs 175 pounds, but by the time he hits 29 he is nine pounds heavier, weighing in at 184 pounds.
But it can be especially difficult for a young adult to focus on health. Young people often spend long hours at work, which can make it tough to exercise and eat well. They face job pressure, romantic challenges, money problems and family stress. Who has time to think about long-term health?
To make it easier, we asked our panel of experts for just one simple piece of health advice. We skipped the obvious choices like no smoking or illegal drug use – you know that already. Instead we asked them for simple strategies to help a 20-something get on the path to better health. Here’s what they had to say.

Weigh yourself often. 
- Susan Roberts, professor of nutrition at Tufts University and co-founder of the iDiet weight management program 
Buy a bathroom scale or use one at the gym and weigh yourself regularly. There is nothing more harmful to long-term health than carrying excess pounds, and weight tends to creep up starting in the 20s. It is pretty easy for most people to get rid of three to five pounds and much harder to get rid of 20. If you keep an eye on your weight you can catch it quickly.

Learn to cook. 
- Barbara J. Rolls, professor and Guthrie Chair of Nutritional Sciences at Penn State 
Learning to cook will save you money and help you to eat healthy. Your focus should be on tasty ways to add variety to your diet and to boost intake of veggies and fruits and other nutrient-rich ingredients. As you experiment with herbs and spices and new cooking techniques, you will find that you can cut down on the unhealthy fats, sugar and salt, as well as the excess calories found in many prepared convenience foods. Your goal should be to develop a nutritious and enjoyable eating pattern that is sustainable and that will help you not only to be well, but also to manage your weight. 
(Related: The foods you should stop buying and start making yourself) 


Cut back on sugar. 
- Steven E. Nissen, chairman of cardiovascular medicine at the Cleveland Clinic Foundation 
I suggest that young people try to avoid excessive simple sugar by eliminating the most common sources of consumption: 1) sugared soft drinks 2) breakfast cereals with added sugar and 3) adding table sugar to foods. Excessive sugar intake has been linked to obesity and diabetes, both of which contribute to heart disease. Sugar represents “empty calories” with none of the important nutrients needed in a balanced diet. Conversely, the traditional dietary villains, fat, particularly saturated fat, and salt, have undergone re-examination by many thoughtful nutrition experts. In both cases, the available scientific evidence does not clearly show a link to heart disease. 

Live an active life. 
- Walter Willett, chairman of the nutrition department at the Harvard School for Public Health 
While many people can’t find time for a scheduled exercise routine, that doesn’t mean you can’t find time to be active. Build physical activity into your daily life. Find a way to get 20 or 30 minutes of activity each day, including riding a bike or briskly walking to work. 
(Related: Learn how to run like a pro.) 


Eat your veggies. 
- Marion Nestle, professor of nutrition, food studies and public health at New York University 
Nutrition science is complicated and debated endlessly, but the basics are well established: Eat plenty of plant foods, go easy on junk foods, and stay active. The trick is to enjoy your meals, but not to eat too much or too often. 

Practice portion control. 
- Lisa R. Young, adjunct professor of nutrition at New York University 
My tip would be to not to ban entire food groups but to practice portion control. Portion control doesn’t mean tiny portions of all foods – quite the opposite. It’s okay to eat larger portions of healthy foods like vegetables and fruit. No one got fat from eating carrots or bananas. Choose smaller portions of unhealthy foods such as sweets, alcohol and processed foods. When eating out, let your hand be your guide. A serving of protein like chicken or fish should be the size of your palm. (Think 1-2 palms of protein.) A serving of starch, preferably a whole grain such as brown rice or quinoa should be the size of your fist. Limit high-fat condiments like salad dressing to a few tablespoons – a tablespoon is about the size of your thumb tip. 

Adopt a post-party exercise routine. 
- Barry Popkin, professor of global nutrition at the University of North Carolina at Chapel Hill 
If you engage in a lot of drinking and snacking, ensure you exercise a lot to offset all those extra calories from Friday to Sunday that come with extra drinking and eating. We found in a study that on Friday through Sunday young adults consumed about 115 more calories than on other days, mainly from fat and alcohol. 


Find a job you love. 
- Hui Zheng, associate sociology professor, population health, Ohio State University 
Ohio State University research found that work life in your 20s can affect your midlife mental health. People who are less happy in their jobs are more likely to report depression, stress and sleep problems and have lower overall mental health scores. If I can give just one piece of health advice for 20-year-olds, I would suggest finding a job they feel passionate about. This passion can keep them motivated, help them find meaning in life, and increase expectations about their future. That in turn will make them more engaged in life and healthier behaviors, which will have long term benefits for their well-being.

Human connection lies at the heart of human well-being.

See NYT article below: if these facts are anywhere close to right, a community-based BeWell Center has an opportunity to do a whole lot of good by simply being an organizer of volunteer outreach. Low or no cost, big impact, great from a philanthropy POV. Meals on Wheels, elderly check-ins, classes, etc. “Research confirms our deepest intuition: Human connection lies at the heart of human well-being.”

“Social isolation is a growing epidemic — one that’s increasingly recognized as having dire physical, mental and emotional consequences. Since the 1980s, the percentage of American adults who say they’re lonely has doubled from 20 percent to 40 percent.

About one-third of Americans older than 65 now live alone, and half of those over 85 do. People in poorer health — especially those with mood disorders like anxiety and depression — are more likely to feel lonely. Those without a college education are the least likely to have someone they can talk to about important personal matters.
A wave of new research suggests social separation is bad for us. Individuals with less social connection have disrupted sleep patterns, altered immune systems, more inflammation and higher levels of stress hormones. One recent study found that isolation increases the risk of heart disease by 29 percent and stroke by 32 percent.
Another analysis that pooled data from 70 studies and 3.4 million people found that socially isolated individuals had a 30 percent higher risk of dying in the next seven years, and that this effect was largest in middle age.”

Research confirms our deepest intuition: Human connection lies at the heart of human well-being.

“Direct Primary Care”

Its pretty clear that a coalition of “direct primary care” providers is pushing Congress to recognize subscription services as a service reimbursable under Medicare.

I believe they are differentiating themselves from “concierge” care, for political reasons. The coalition says concierge care is $2000-$5000, instead of under $2000. One of the main advocates for direct primary care says that it does not seek third party reimbursement, while concierge services might.

“The Primary Care Enhancement Act of 2016” has been brought to the Ways and Means Committee, where is was referred in September, 2016 to the Health Sub-Committee.

Sponsor: Rep. Paulsen, Erik [R-MN-3] (Introduced 09/13/2016)
Committees: House – Ways and Means
Latest Action: 09/19/2016 Referred to the Subcommittee on Health. (All Actions)

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Direct primary care could get a big boost next year. Under the federal health care law, these practices will be able to operate in state-based health insurance exchanges. However, insurers on exchanges must offer a basic benefits package that includes hospital, drug and other coverage, so direct primary care practices will likely team up with other health plans.
If you’re considering a direct primary care practice, get a list of provided services and talk with a physician in the practice. Also, some practices that are similar to concierge care may accept insurance but charge a monthly fee for extra services. For options in your area, visit the Web site of the Direct Primary Care Coalition (www.dpcare.org).

======================
The Primary Care Enhancement Act of 2016  proposes to amend the tax code so consumers can use their health savings accounts (HSAs) to pay physicians in direct primary care (DPC), bypassing insurance. H.R. 6015 would also enable Medicare enrollees to pay for direct primary care using Medicare funds, rather than pay out of pocket.

======================
http://www.dpcare.org

Senators Bill Cassidy, MD (R-LA) and Maria Cantwell (D-WA) have introduced bipartisan legislation which clarifies that DPC is a medical service for the purposes of the tax code regarding Health Savings Accounts. The bill also creates a new payment pathway for DPC as an alternative payment model (APM) in Medicare. “Co-sponsors are important. They show Senate leaders that there is widespread support for the legislation,” said Sen. Cassidy when he addressed the DPCC Fly-in Sept. 24. We need your help today to ensure that S.1989 moves forward.  Please contact your Senators and urge them to co-sponsor the Primary Care Enhancement Act today.

On the Move in the States with DPC
16 States Move to Clear Regulatory Hurdles for DPC 
Legislation  defines DPC outside of Insurance.
 
As of June, 2016, 16 states have adopted Direct Primary Care legislation which defines DPC as a medical service outside the scope of state insurance regulation. 
 
The DPCC has developed model legislation to help guide legislators and their staffs on the best way to accomplish  this important reform. Click here to see the model bill.
States With DPC Laws:

• Washington – 48-150 RCW
• Utah – UT 31A-4-106.5
• Oregon – ORS 735.500
• West Virginia – WV-16-2J-1
• Arizona – AZ 20-123
• Louisiana – LA Act 867
• Michigan – PA-0522-14
• Mississippi – SB 2687
• Idaho – SB 1062
• Oklahoma – SB 560
• Missouri – HB 769
• Kansas – HB 2225
• Texas – HB 1945
• Nebraska – Leg. Bill 817
• Tennessee – SB 2443
• Wyoming – SF0049

Current as of June, 2016

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Direct Primary Care is an innovative alternative payment model in primary care model embraced by patients, physicians, employers, payers and policymakers across the United States.The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. In DPC unwanted fee-for-service incentives are replaced with a simple flat monthly fee. This empowers the doctor-patient relationship and is the key to achieving superior health outcomes, lower costs and an enhanced patient experience.
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http://medicaleconomics.modernmedicine.com/medical-economics/news/bill-could-allow-health-saving-account-use-dpc

Direct primary care physicians charge patients a monthly fee for care and access to a package of services rather than by fee-for-service or insurance. The subscription model can grant patients increased access to doctors, discounted drugs and laboratory services. 
According to Meigs, the proposed law will allow people with high deductible plans to use their HSA to pay for primary care, given that people with high deductible insurance plans can use their insurance for catastrophic coverage and hospitalizations, and cost-effectively tap their HSAs for primary care.  

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Direct primary care and concierge medicine: They’re not the same

Direct primary care and concierge medicine: They’re not the same
SAMIR QAMAR, MD | PHYSICIAN | AUGUST 24, 2014
Samir Qamar
Direct primary care (DPC) and concierge medicine are rapidly growing models of primary care. Though the terms are used interchangeably, both are not the same. Such liberal use of terms, many times by even those within the industry, confuses those who are attempting to understand how these primary care models operate. As former concierge physician for the Pebble Beach Resorts, and subsequent founder of one of the nation’s largest direct primary care companies, I have attempted to differentiate the two based on extensive personal knowledge and experience.

First, concierge medicine. Born in the mid 1990s, this practice design was first created by wealthy individuals who were willing to “bypass” the woes of the current fee-for-service system by paying a subscription to access select primary care physicians. This access consists of same-day appointments, round-the-clock cell phone coverage, email and telemedicine service, and sometimes, as in my previous practice, house calls. Although some high-end practices charge as much as $30,000 a month, most charge an average monthly fee of $200.
In return, to allow such unrestricted access, physicians limit their patient panels to several hundred patients at most, a significant drop from the typical 2,500-plus panel size most doctors are used to. Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “access fee” is only for “non-covered” services. This results in two subscriptions paid by patients — the concierge medicine fee, and the insurance premium. Importantly, a few concierge practices do not bill insurance for medical visits, as the monthly fees cover both access and primary care visits.
Direct primary care started in the mid 2000s, and was created as an insurance-free model to serve a new patient population: the uninsured. In DPC, patients, and now their employers, are also charged a monthly fee, but the fee can be as low as $50 per month and there is typically no third-party payer involvement. Consumers pay physician entities directly (hence, direct primary care), and because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.

Patient panels can be as high as 1,500 patients per doctor, and there is typically no physician cell phone access or house call service. Similar to higher-priced concierge practices, DPC practices also allow for longer patient visits and telemedicine. The most important characteristic of DPC practices, however, is that insurance claims are not filed for medical visits.

Direct primary care’s definition, therefore, is any primary care practice model that is directly reimbursed by the consumer for both access and primary medical care, and which does not accept or bill third party payers.
Confusion arises from similarities that exist in both models, such as decreased patient panels, monthly subscriptions, and longer visits. There is added confusion when a DPC physician offers house calls or email access, typical of concierge practices. Confusion is maximized when a physician is by definition practicing direct primary care, yet calls the practice a “concierge practice.” Similarly, a concierge practice may decide to abstain from participating in third party payer systems, and thus would also be a DPC practice.
The distinction is important because direct primary care is explicitly mentioned in the Affordable Care Act, while concierge medicine is not. Several state laws have also recognized direct primary care as medical practice models, and non-insurance entities. In addition, the term “concierge medicine” causes visceral reactions in select social and medical circles, drawing criticism such as elitism and exacerbation of physician shortage.
Adslot’s refresh function: googletag.pubads().refresh([gptadslots[1]])

In summary, not all direct primary care practices are concierge practices, and not all concierge practices are direct primary care practices. The terms are not synonymous, and even the basic fundamentals of either model do not overlap. The key to differentiation is whether or not a third party payer is involved. If not, then the model is a direct pay, or direct primary care model, no matter what the fees.
Samir Qamar is CEO, MedLion and president, MedWand. He can be reached on Twitter @Samir_Qamar.

Latest on well-being convenience

I just had a great experience at a CVS Minute Clinic, which I documented here:

JCR Experience with CVS Minute Clinic

It’s been awhile since I revised this mega-trend, so here is an update.

So CVS has been busy. They changed their name to CVS Health, threw tobacco out of their store, and set out to create 900 “Minute Clinics”. These were intended to provide consumers with highly convenient access to nurse practitioners who were armed with the latest in diagnostic tools and online diagnostic protocols.

The latest? CVS now has 800 Minute Clinics in 28 states plus DC.

Walgreens now has 400 clinics. Their press recently has raised questions about whether they are rethinking their corporate strategy.
 
Seattle-based Arivale arrived on the scene in 2015, announcing their intention to revolutionize this space by brings LABS to the foreground, especially through genomics. What caught my eye then was the background of the CEO, Clayton Lewis, who was in genomics from the beginning with Genentech, and Lee Hood, who is a thought-leader in the area.
 
The latest? Well, the update on Arivale is this: they did indeed raise $40 million, and they now have a year’s experience with their “pioneers”. The pioneers are individuals who opted into this intensive longitudinal tracking. The pioneers were offered well-being coaches as well. There originally were 170 pioneers, and there now are over 1,000.

Learnings:

1. the Company says that well-being coaches are a winner. People like them and they say they really help keep them on track.  
2. They are finding that it is difficult (impossible) to keep people focused on long-term risks.
3. They are finding that “experiences” – avoiding bad experiences and promoting good “experiences” is proving useful as a way to motive the pioneers.
 
References:
I wrote about my own vision for this subject here, in 2014:

JCR 2014 Predictions
 

 I wrote about Walgreens here:
2011 post on Walmart with Updates

I Wrote about Arivale here:
2015 post on Arivale

….and here are the two co-founders, on stage in March, 2016:
Lee Hood and Clayton Lewis
 
… an astute 2016 synopsis of what Arivale has learned is here:
 
2016 synopsis of Arivale learnings
 
…and a March 2016 article provides an update, including the acquisition of the Institute for System Biology:
March 2016 Article on Arivale

A good summary on Walgreens and CVS overall is here:

Walgreens and CVS Summary

 

CVS Minute Clinic

I have written before about the trend toward convenience well-being centers (like convenience stores but for all things health and wellness-related). Every big box – most especially Walmart, CVS, and Walgreens – wants their store to be the convenience store for well-being. See all posts tagged BeWell or Well-Being.

There is a retail component – and CVS is an example of best practice. And there is a back-end component. Iona Heath and Arivale are examples there of best practice.

In any event….

Yesterday, with my daughter insisting I had pink eye, I decided to check out the CVS Minute Clinic in my neighborhood. I had a great experience.

There was the usual “set-up/registration” time. It was acceptable and on-line – at a kiosk outside the clinic rooms themselves. Took me about 10 minutes to tell them about me. At the end of registration, they asked online whether I wanted to be in line to see a clinician. I said yes.

There was no wait! Amazing. Not sure how this could be – but true.

The clinician was a “nurse practitioner”. That worried me until I watched her work with all her online and in-clinic diagnostic tools. She gave me a viral pink eye test – negative. So all that was left was the possibility of bacterial pink eye. For this possibility, I needed to take seven days of drops.

How to get the drops? She offered to provide a prescription at the store. I said “yes, please”, and she literally called the pharmacy next to her, and said ‘Josh, I need 7 days of drops in five minutes. Can you handle that. Josh said yes, and I was on my way – so simple!

So here is what I also loved. She took all vitals, she checked my ears and eyes with a laser light (or whatever it is called), she even checked my eyesight! But I am sure she would not have done all these things if I had said I was busy.

So what’s up with this trend? Here’s one mom’s take:

One Mom’s Take on CVC Minute Clinics

I left convinced that a good nurse practitioner could handle 95% of my medical needs – saving the tough stuff for my primary care physician.

References:

Here is my July 11, 2015 blog post about CVS Minute Clinics – printed here in its entirety:

This update about CVS is from today’s NYT:

Strategic Summary:

CVS is placing a very big bet, and my guess is it is right:

That the future consumer of health care in the US will:
– rarely have a primary care physician
– have “high deductible” insurance (so they will be very tough buyers)
– demand services closer to home (convenience is a premium)
– demand services with great frequency of visits (shorter waits, no hassle)
– value convenient treatment for routine illnesses, basic screenings and vaccinations.

So these consumers still need a “front end” to the health care system that allows them to get what they need, when they need it – when it is routine. They also want to crisis services, and other backend services – arranged when the need arises. They think CVS is the answer to those consumers. They want to be the one-stop shop for those consumers.

Their push to retail clinics can be seen in their 900 MinuteClinics and plan to have 1500 by 2017. A typical CVS clinic staffed by nurse practitioners sees 35 to 40 patients a day; those patients pay $79 to $99 for minor illnesses and injuries, and most insurance plans are accepted. Analysts estimate each clinic typically brings in $500,000 a year..

And … just a few months ago …they bought all of Target’s 1900 pharmacy locations. Assuming that some of these become clinics, there could there be even more retail clinics in the future.

So they want to be the one-stop-shop for a consumer’s health, with a front end that is both behind the counter (traditional pharmacy) and in-front-of-the-counter (the store with lotions and magazines and diagnostic equipment etc).

On the back end, they want to best prices for everything that is health-oriented. They also are partnering with Rush University in Chicago to make sure that more-critical needs are serviced properly.

Highlights:

– The Company started in 1963 as Consumer Value Stores (Lowell, Massachusetts)
– CVS under CEO Larry Merlo (who came to CVS when they acquired People’s Drug) has moved aggressively to rebrand the company as a health company. This move began in 2004, when they bought Eckerd Drug.
– They now have 7800 stores, and 900 “MinuteClinics” within their stores …. and plan to have 1500 soon.
– “Its MinuteClinics diagnose and treat patients, and its pharmacies dispense medicine to more than two million prescriptions a day. It negotiates the price of medicines and helps 65 million people navigate drug coverage under their insurance plans.”

Last year, the company changed its name from CVS Caremark to CVS Health.

Acquisitions history is:

2004: The shift toward health care started in 2004, when CVS acquired Eckerd Stores and Eckerd Health Services, giving CVS a foothold in administering drug benefits to employees of big corporations and government agencies.

2006: CVS acquired MinuteClinic, a pioneering in-store health clinic chain that was offering treatment for routine illnesses, basic screenings and vaccinations.

2007: $21 billion merger between CVS and Caremark, which gave birth to the country’s leading pharmacy benefits manager.

2012: CVS struck a deal with the medical products distributor Cardinal Health to form the country’s largest generic drug sourcing operation.

2012: $2.1 billion acquisition of Coram, a business that allows CVS to dispatch technicians to patients’ homes to administer pharmaceuticals through needles and catheters.

2015: In May, it paid $12.7 billion to acquire Omnicare, which distributes prescription drugs to nursing homes and assisted-living operations.

2015: In June, CVS announced it would buy Target’s pharmacy and clinic businesses for $1.9 billion and left open the possibility of pursuing further deals. Once the Target deal closes, CVS will operate about 9,600 retail stores, or about one out of seven retail pharmacies, according to Pembroke Consulting.

= = = = = = = = = =
Article begins here:

How CVS Quit Smoking and Grew Into a Health Care Giant

Michael Gaffney’s throat was scratchy for days, and lemon tea was not helping. So he dropped into a MinuteClinic above a CVS store in Midtown Manhattan on a lunch break. Within minutes, a nurse practitioner tested him for strep throat (negative), suggested lozenges and a regimen (ample fluids, no spicy food), collected a co-payment ($25 cash) and sent him on his way.

“That was quick,” said Mr. Gaffney, 26, an account executive for Indeed.com, who, like millions of Americans, does not have a primary care physician, even though he is covered by health insurance. He has been meaning to find a doctor since moving to New York last year, but his sore throat did not seem serious enough to warrant what was sure to be a time-consuming search and a long wait for an appointment.

The CVS MinuteClinic, on the other hand, was just blocks away from his office. “I waited longer for my bagel this morning,” he said.

With 7,800 retail stores and a presence in almost every state, CVS Health has enormous reach. And while shoppers might think of CVS as a place to pick up toothpaste, Band-Aids or lipstick, it is also the country’s biggest operator of health clinics, the largest dispenser of prescription drugs and the second-largest pharmacy benefits manager. With close to $140 billion in revenue last year — about 97 percent of that from prescription drugs or pharmacy services — CVS is arguably the country’s biggest health care company, bigger than the drug makers and wholesalers, and bigger than the insurers.

Even before the Affordable Care Act created millions of newly insured customers in the almost $3 trillion health care industry, CVS saw that there were more profits to be made handling prescription drugs than selling diapers. But while its transformation from drugstore to health care company began a decade ago, CVS has more recently taken on a new advocacy role, that of a public enemy of cigarettes.

Last year, CVS became the first major pharmacy chain to stop selling tobacco, a business that brought in $2 billion a year. And on Tuesday, CVS said that it would resign from the United States Chamber of Commerce after revelations that the chamber and its foreign affiliates were engaged in a global lobbying campaign against antismoking laws.

Its stand against smoking has allowed CVS to make alliances with health care providers and rebrand itself fully as a health care company. But with smoking rates on a steady decline, and cigarettes sales slumping, CVS also saw that future profits lie not with Big Tobacco but in health and wellness.

Taking the high road for health has its challenges. For one thing, it means new competitors in a rapidly changing industry. And, for a major retailer with tens of thousands of products on its shelves, it leads to an uncomfortable question: If we cannot sell cigarettes, what does that mean for potato chips?

Road to Growth

The Consumer Value Store started as a scrappy discount health and beauty outlet in Lowell, Mass., in 1963. Four years later, the small chain opened its first in-store pharmacies, and those became the core of the company — and its growth — for years. Larry Merlo, the chief executive, is a pharmacist by training and came into the company when it bought People’s Drug, a drugstore chain based in a suburb of Washington.

In a phone interview, Mr. Merlo spoke mostly in corporate platitudes, but when the conversation turned to the subject of pharmacists, he spoke passionately about pharmacists’ role in delivering health care.

“Hypertension, diabetes, osteoporosis,” he said. “It’s the same story — people don’t take their medication as prescribed.”

Pharmacists, who see patients more frequently than doctors do, can make sure patients stay on their drug regimens, he said, keeping them out of the hospital and saving the health care system billions of dollars down the road.

“I think back to my own personal experience,” he said. “Sometimes, it’s as simple as answering questions to get people to stay on their prescription therapies.”

Mr. Merlo said the company stood out in the breadth of products and services it offered: Its MinuteClinics diagnose and treat patients, and its pharmacies dispense medicine to more than two million prescriptions a day. It negotiates the price of medicines and helps 65 million people navigate drug coverage under their insurance plans.

The shift toward health care started in 2004, when CVS acquired Eckerd Stores and Eckerd Health Services, giving CVS a foothold in administering drug benefits to employees of big corporations and government agencies. Two years later, CVS acquired MinuteClinic, a pioneering in-store health clinic chain that was offering treatment for routine illnesses, basic screenings and vaccinations. CVS also expanded its very profitable specialty pharmacy business, which focuses on expensive drugs to treat complex or rare diseases like cancer or H.I.V.

Then in 2007 came the $21 billion merger between CVS and Caremark, which gave birth to the country’s leading pharmacy benefits manager. Three years ago, CVS struck a deal with the medical products distributor Cardinal Health to form the country’s largest generic drug sourcing operation. It followed up with a $2.1 billion acquisition of Coram, a business that allows CVS to dispatch technicians to patients’ homes to administer pharmaceuticals through needles and catheters.

The acquisitions keep coming. In May, it paid $12.7 billion to acquire Omnicare, which distributes prescription drugs to nursing homes and assisted-living operations. Just weeks later, CVS announced it would buy Target’s pharmacy and clinic businesses for $1.9 billion and left open the possibility of pursuing further deals. Once the Target deal closes, CVS will operate about 9,600 retail stores, or about one out of seven retail pharmacies, according to Pembroke Consulting. Last year, the company changed its name from CVS Caremark to CVS Health.

The growth of CVS comes at a time when the way Americans get access to and pay for health care is evolving quickly. Surveys show that many of the estimated 30 million people who gained insurance coverage last year under health care reform do not have a primary health care physician or do not use one. Many, too, opted for high-deductible health plans and are expected to become picky with the dollars they spend, and less tolerant of the opaque pricing that is still the industry’s norm. And consumers in general are starting to demand more convenient, on-demand access to health care, closer to home.

In that fast-changing world, CVS’s strategy is to be a one-stop shop for health care.

“Say you have diabetes, and you go into a pharmacy to get your insulin, how great is it if, in the same aisle, there’s a cookbook for people with diabetes?” said Ceci Connolly, managing director of PwC’s Health Research Institute. “And maybe there’s some foods that are already approved for you, and a place to check your feet, and a clinician to check your eyes,” she said.

“Consumers are saying: I want all of that at a place near my house that’s open on Saturdays, when it’s convenient for me. I want that place to post prices. It’s in CVS’s interest to pull in more and more pieces of that puzzle.”

A typical CVS clinic staffed by nurse practitioners sees 35 to 40 patients a day; those patients pay $79 to $99 for minor illnesses and injuries, and most insurance plans are accepted. Analysts estimate each clinic typically brings in $500,000 a year, representing just a fraction of CVS’s revenue. Still, the clinics are an important part of the company’s health care proposition.

Other retailers are also getting into the business. The number of retail clinic sites grew to 1,800 locations nationwide in 2014 from 200 in 2006, though they still represent just 2 percent of primary care encounters in the United States, according to a report published this year by Manatt Health, a health advisory practice, and the Robert Wood Johnson Foundation. But CVS is by far the leader. Walmart, which charges just $40 a visit, has fewer than 100 clinics, compared with the more than 900 in CVS’s portfolio. Walgreens, the second-largest, has half as many clinics as CVS. And CVS plans to add more, reaching 1,500 by 2017, the company has said.

Whether these clinics provide the best kind of care is a question sometimes raised by doctors in more traditional practices, like Robert Wergin, president of the American Academy of Family Physicians and a doctor in Milford, Neb.

“These retail clinics, they’re run by competent folks, and they probably have some role to play,” he said. “But you’re being seen at a clinic next to the frozen food section by a stranger. And if you go back for a follow-up, you’re going to get seen by someone else.”

For employers and insurers, however, the clinics offer a way to reduce costs for noncritical conditions. A study by researchers at the RAND Corporation estimated that more than a quarter of emergency room visits could be handled at retail clinics and urgent care centers, creating savings of $4.4 billion a year.

Reducing health care spending, however, may turn out to be complicated.

“You might imagine that they keep people out of E.R., so that’s one way you could save money,” said Martin Gaynor, professor of economics and public policy at Heinz College, Carnegie Mellon University. “On the other hand, just because they’re more convenient, people might go and obtain care in circumstances where they otherwise would not have sought care.”

CVS might have more sway reducing health care costs in its role as a middleman between drug companies and patients with drug benefits. The company is expected to start shifting the balance between end users on one hand, and drug manufacturers and wholesalers on the other.

CVS and other large dispensing pharmacies — Walgreens, Express Scripts, Rite Aid and Walmart — made up about 64 percent of prescription-dispensing revenue in the United States in 2014, according to Pembroke Consulting. That year, CVS was also the leading provider of specialty drugs in North America, with $20.5 billion in revenue, representing 26 percent of the total market.

“Scale is a big factor in pharmacy,” said Joseph Agnese, senior equity analyst at S&P Capital IQ. “There’s a lot of pricing pressure from drug manufacturers and one way for retailers can come back at them is to become larger, and become a more significant purchaser of drugs.”

Dr. Gaynor of Carnegie Mellon said, however, that cost reduction varied greatly by type of drug. “If there’s a drug that is very important for CVS to carry, and there are no alternatives, they aren’t going to have a lot of negotiating power,” Dr. Gaynor said. “But of course, the bigger CVS gets, the more they can move product, the more important it becomes.”

The company’s size also creates significant competition issues, says David A. Balto, an antitrust lawyer and former policy director at the Federal Trade Commission who often represents independent pharmacies. CVS’s ownership of Caremark could restrict consumers’ access to rival pharmacies, he said, and CVS’s acquisition of Omnicare, already a dominant player in long-term care, could reduce competition in that industry.

“There are tremendous concerns when you see someone becoming so terrifically large,” Mr. Balto said. “The acquisitions might conceivably be efficient, but whether those efficiencies are passed on to consumers really depends on the level of competition in the market.”

Quitting Cigarettes

Helena B. Foulkes, who leads CVS’s retail business, swept past the sales counter at a newly renovated CVS in downtown Manhattan. Where cigarette packs once lined up in neat rows, now there were nicotine gum and patches to help smokers quit. (There are no e-cigarettes either, much to the chagrin of that industry, which had hoped CVS would embrace its products as a lower-risk alternative.)

Ms. Foulkes, who lost her mother to lung disease, leads the retail business, which is starting to change to fit the company’s health care bent better.

The move to forgo $2 billion in annual tobacco sales has bolstered CVS’s health care bona fides. The White House lauded CVS’s move. “Thanks @CVS_Extra, now we can all breathe a little easier,” Michelle Obama wrote in a Twitter post. The praise seemed to give Mr. Merlo a jolt of confidence. At a TEDx talk this year in Winston-Salem, N.C., he declared: “CVS kicks butts across the U.S.”

“When we exited the tobacco category, it was the most important decision we’d made as a company,” Ms. Foulkes said. “That decision really became a symbol both internally and externally for the fact that we’re a health care company.”

It also made economic sense. Adult smoking rates have dropped to 18 percent in 2014, from 43 percent in 1965, according to the Centers for Disease Control, and experts predict that rate to dip below 10 percent in the next decade. Ditching cigarettes allows CVS to trade a small — less than 2 percent of revenue — and shrinking part of its business for an instant enhancement of its credentials in the faster-growing health and wellness space.

In October, CVS announced that its Caremark arm would require some of its customers to make higher co-payments for prescriptions filled at pharmacies that still sold tobacco products — in effect driving more traffic to the now tobacco-free CVS pharmacies. While that move encourages pharmacies to quit selling tobacco, it also raised the ire of an antitrust law research firm, which called the announcement “a smokescreen” that masks higher costs for those who fill prescriptions at competing pharmacies.

“CVS’s use of its market power to bludgeon consumers and rivals into ending tobacco sales is not a legitimate form of competition,” the American Antitrust Institute said in a statement. It has urged the Federal Trade Commission to investigate.

In general, CVS’s new anti-tobacco stance has helped it forge affiliations with regional hospitals. Before CVS went tobacco-free, negotiations with local health systems were awkward, Mr. Merlo said during a recent analyst conference call.

“That question would always come up — ‘You guys sell tobacco products, don’t you?’ — and that literally sucks all the energy out of the room,” Mr. Merlo said. But since the company stopped selling tobacco, he said, “We’ve been able to accelerate partnerships with leading health systems across the country.”

A new partnership with Rush University Medical Center in Chicago will involve patient referrals and shared electronic health records. Anthony Perry, vice president for ambulatory care and population health at Rush, said that traditional health care providers and companies like CVS could be natural allies.

“Take people with high blood pressure. That’s the type of thing you manage steadily over time, and you work on things like diet and exercise, and lifestyle changes, and if those things don’t work, you get into the world of medications,” he said. “What we asked was: If we’re going to do a series of visits with somebody, might they be able to do some of that closer to home?”

The flip side, he said, is that CVS can refer people with more serious ailments, but no primary care doctor, to Rush. “So CVS can now say: You need to see a primary care doctor, and we can connect you.”

The anti-tobacco stand has had other effects. Notably, the company has had to start thinking about other unhealthy items on its shelves. If it is a company that promotes health, can it also sell sugary sodas and candy bars?

The downtown Manhattan store where Ms. Foulkes walked the aisles is one of 500 locations that CVS is remodeling to emphasize healthy fare.

“I was in Long Island the day after the tobacco announcement, and I ran into a store manager who said: ‘I’m so proud of the company,’ ” she recalled. “But he also said, ‘I’m hearing customers now saying, why don’t you have healthier food?’ ”

“Customers quickly made the leap. They expected more from us,” she said.

Ms. Foulkes pointed to a prominent snack corner at the front of the store.

“What you’ll see in our stores are brands that convey healthy without being overly edgy. It’s Chobani yogurt, it’s Kind bars, it’s lots of proteins and nuts,” she said. “Health for the masses.”

At this point, there are no plans to stop selling high-fat or high-sugar snacks, still a big part of CVS stores’ sales. But they might be harder to spot.

When asked where the Oreos were, she smiled. “You’ll find them, but you’ll have to look for them.”