Large Bills Research Articles

Self-Reported Financial Difficulties Among Patients with Multiple Myeloma and Chronic Lymphocytic Leukemia Treated at U.S. Community Oncology Clinics (Alliance A231602CD).

To estimate the proportion and correlates of self-reported financial difficulty among patients with multiple myeloma (MM) or chronic lymphocytic leukemia (CLL). 23 U.S. community and minority oncology practice sites affiliated with the National Cancer Institute Community Oncology Research Program (NCORP). 521 patients (≥18 years) with MM or CLL were consented and 416 responded to a survey (completion rate=79.8%). Respondents had a MM diagnosis (74.0%), an associate degree or higher (53.4%), were White (89.2%), insured (100%) and treated with clinician-administered drugs (68.0%). Observational, prospective, protocol-based survey administered in 2019-2020. Financial difficulty was assessed using a single-item standard measure, the EORTC QLQC30: "Has your physical condition or medical treatment caused you financial difficulties in the past year?" and using an 'any-or-none' composite measure of 22 items assessing financial difficulty, worries and the use of cost-coping strategies. Multivariable logistic regression models assessed the association between financial difficulty, diagnosis, and socioeconomic and treatment characteristics. 16.8% reported experiencing financial difficulty using the single-item measure and 60.3% using the composite measure. Most frequently endorsed items in the composite measure were financial worry about having to pay large medical bills related to cancer and difficulty paying medical bills. Financial difficulty using the single-item measure was associated with having MM versus CLL (adjusted odds ratio [aOR], 0.34; 95% CI, 0.13-0.84; P=.02), having insurance other than Medicare (aOR, 2.53; 95% CI, 1.37-4.66; P=.003), being non-White (aOR, 2.21; 95% CI, 1.04-4.72; P=.04), and having a high school education or below (aOR, 0.36; 95% CI, 0.21-0.64; P=.001). Financial difficulty using the composite measure was associated with having a high school education or below (aOR, 0.62; 95% CI, 0.41-0.94; P=.03). U.S. patients with blood cancer report financial difficulty, especially those with low socio-economic status. Evidence-based and targeted interventions are needed.

A new multi-function smart electricity measurement device

Algeria's national gas and power provider is called Sonelgaz. It is in charge of producing, distributing, and transmitting power throughout the nation. Sonelgaz has encountered several difficulties in effectively supplying electricity to consumers and keeping track of their usage over the years. One of the primary problems is that client consumption is not accurately metered. Algeria has a large number of old power meters that don't give precise readings of the real electrical usage. Customers receive inaccurate bills as a result of this. It also makes it more challenging for Sonelgaz to monitor usage trends and detect power thieves. Poor metering infrastructure has led to disputes between Sonelgaz and customers over excess bills. In recent years, the idea of a smart power meter has become increasingly popular all around the world. Traditionally, readings must be taken in the meter reading room. As a result, tracking and keeping tabs on your electricity usage is a time-consuming and annoying chore. Furthermore, a lot of us worry about our large electricity bills at the end of the month, therefore, we have to periodically check the energy meter. However, what if we could track how much electricity we consume from anywhere in the world? In this paper, we will develop a new multi-function smart electricity measurement device using an ESP32 microcontroller and the mobile Blynk app. The smart electricity measurement device displays the voltage, current, power factor, and power consumption in real time. In addition, it displays the cost of electricity in dollars and the total energy consumed in kWh, saving you both time and money. The consumer's electricity will be remotely off if the bills are not paid.

A smart energy monitoring system using ESP32 microcontroller

Gaza's electrical deficit has resulted in the rise of new energy suppliers that sell power from private generators at higher prices. Consumers have challenges because they cannot tell whether their energy originates from the utility or private generators, resulting in unexpectedly large bills owing to a lack of an electronic monitoring system. This study fills this gap by developing a low-cost IoT energy monitoring system that provides real-time information on energy use (hourly, daily, and monthly) to assist consumers in managing their usage and expenditures. An ESP32 microcontroller is used in the system to gather data from energy meters, analyze it, and deliver updates to users via WhatsApp over a secure Wi-Fi connection via the Blynk platform. Experimental findings show that the system accurately captures voltage, current, active power, and cumulative power consumption and transmits this information to customers in real time.

Implementations of The Digital Madrasah

The demands of the times demand the world of education to be able to adapt and use technological developments in an effort to improve the quality of learning. The current development of information technology provides its own challenges in the world of education especially madrasah. Basically, the madrasah is an important Islamic educational institution in Indonesia, where its existence has proven to have marked a generation of nations with deep religious insights and the soul of nationalism. Therefore, the educational institutions of the Madrasah must be able to adapt to such massive technological developments. The madrasas must be capable of utilizing and integrating technology in teaching activities so that it becomes relevant and contextual with the development of the times. The aim of this research is to take stock of the efforts made by MTsN 1 Makassar in transforming into a digital madrasah, to find out the supporting factors and obstacles in implementing the digital madrasah policy. This type of research is qualitative descriptive. The results of the research describe the efforts made at MTsN 1 Makassar in transforming into a digital madrasah starting from the planning stage of both activity planning and budget planning, strengthening the quality of SDM by forming the learning revolution team 4. Supporting factors are the large number of digital flatforms that are open access, the support of the parents of the students and the factors that hinder are the price of relatively expensive digital devices, large electricity bills and a less stable internet network.

Characteristics of migrant workers admitted from the emergency department.

Emergency department (ED) admissions for non-work-related injuries and illnesses in the migrant worker (MW) population in Singapore are not well studied. We aimed to examine ED triage acuity and bills associated with admissions among MW for non-trauma, workplace injury (WI) trauma, and non-workplace injury (NWI) trauma. In this retrospective observational study, we included all work permit holders admitted to hospital via the ED of three public hospitals from 1 May 2016 to 31 October 2016. Data obtained from medical records included demographics, triage acuity and bill information. There were 1,750 unique patients accounting for 1,788 admissions. The median age was 33 (interquartile range 27-40) years, with a male predominance of 67%. Trauma accounted for 33% (n = 595) of admissions, and of these, 73% (n = 433) were due to WI. Admissions for NWI, as compared to WI, were more likely to present as high acuity P1 cases (43% vs 24%, P < 0.001), be conveyed by ambulance (49% vs 24%, P < 0.001) and result in trauma team activations (29% vs 7%, P < 0.001). More NWI admissions (22%, 36/162) exceeded the insurance claim limit under prevailing healthcare policies, as compared to WI admissions (3%, 13/433). Migrant workers are admitted to hospital for non-trauma conditions more frequently than for trauma. Non-workplace injury trauma may be severe. Non-trauma and NWI admissions can result in large bills that exceed mandatory insurance coverage. Recent changes to healthcare policy governing MW to allow copayment of large bills and better access to primary care are timely.

Disclosures 7: Parents who initiate request for disclosure, part 1

A few years back, a registrar posed the following situation on scr‐l: The technology department at his institution told the registrar they had received an “interesting call” from a mother requesting the phone records for her child. She wanted to know 1) who her student was calling and 2) who was calling her student. She also wanted to know the dates and times connected to each call. According to the mother, the student had a large phone bill and she wanted to know why. The registrar said the college sends the phone bills to students (which prompted the mother's call when her student asked her to pay the bill). The registrar also wasn’t sure if “phone records” were education records that fell under FERPA.

Disclosures 7: Parents who initiate request for disclosure, part 1

A few years back, a registrar posed the following situation on scr‐l: The technology department at his institution told the registrar they had received an “interesting call” from a mother requesting the phone records for her child. She wanted to know (1) who her student was calling and (2) who was calling her student. She also wanted to know the dates and times connected to each call. According to the mother, the student had a large phone bill, and she wanted to know why. The registrar said the college sends the phone bills to students (which prompted the mother's call when her student asked her to pay the bill). The registrar also wasn’t sure if “phone records” were education records that fell under the Family Educational Rights and Privacy Act.

Determination of Community-Based Health Microinsurance Premiums Based on Health Costs

Low-income households are faced with the financial risk of paying large medical bills when a member of the household falls ill. This health-related risk can affect household welfare because meeting medical expenses has the potential to reduce income capacity. Community-based health insurance is seen as one mechanism for vulnerable low- and middle-income households to overcome barriers and to improve access to health care and financial protection. This research was conducted to determine the calculation of community-based health microinsurance premiums based on health costs and determine the average willingness to pay insurance premiums. The determination of the premium is calculated based on the pure premium and other costs. Data obtained based on surveys and data provided by health facilities. Based on the results of the research, the pure individual premium is IDR 92,297.12 per year. The total individual premium calculated based on pure premium and other costs is IDR 275,256.80 per year. If the premium is paid monthly, a premium of IDR 22,938.07 per month will be obtained. Then the average value is obtained WTP or willingness to pay IDR 38,368.42 per month. The average value of the willingness to pay is greater than the total monthly health micro insurance premium that has been determined.

Decomposing racial differences in financial hardship among older cancer survivors.

6598 Background: Despite Medicare coverage, financial hardship is a prevalent issue among older cancer survivors, particularly among those belonging to a racial/ethnic minority. Sociodemographic, clinical, and area-level factors may mediate this relationship; however, no studies have assessed the extent to which these factors contribute to disparities. Methods: Surveys assessing financial hardship after cancer were completed by 721 patients age 65y+ of Black or white race completing primary cancer treatment for breast, prostate, colorectal, prostate cancer or lymphoma at University of Alabama at Birmingham between 2000 and 2019. Financial hardship included material, psychological, and behavioral domains. Material hardship included ever 1) borrowing money/going into debt, 2) filed for bankruptcy, 3) worried about paying large medical bills, and 4) made any other financial sacrifices due to cancer. Psychological hardship was measured by asking if participants were ever worried about paying large medical bills related to cancer, its treatment or effects of treatment. Behavioral hardship was measured by asking if participants were unable or delayed in obtaining medical care, tests, treatments or prescriptions in the last 6 months. Non-linear Blinder-Oaxaca effect decomposition methods evaluated the extent to which individual-level sociodemographic, clinical, and area-level factors contributed to racial disparities in financial hardship. Results: Median age at survey was 78 (IQR = 73-82), majority were female (53%) and non-Hispanic White (84%). The most common cancers were breast (34%) and prostate (27%), followed by lung (17%), lymphoma (9%) and colorectal (14%). Ninety percent were diagnosed at an early stage and median time from diagnosis to survey was 8y (IQR = 5-12). There were no significant clinical differences between Black and white patients. Overall, 22% reported any financial hardship; 14% material, 3% behavioral, and 14% psychological. Black, compared to White participants reported significantly (p &lt; 0.001) higher rates of overall (39% v 18%), material (29% v 11%), and psychological (27% v 11%) financial hardship. Notably, Black patients had higher rates of being unable to cover cancer-related costs (23% v 7%), worrying about paying large medical bills (27% v 11%), and having to borrow money or go into debt (9% v 3%). Overall, the observed characteristics explained 81% of racial differences in financial hardship among cancer survivors, primarily by differences in income (24%), cancer diagnosis and stage (22%), and area deprivation (15%). Conclusions: These results identify primary contributors to racial disparities in financial hardship among older cancer survivors, which can be used to develop interventions aimed at eliminating inferior healthcare outcomes experienced by certain racial groups, inform policy, and allocate resources to those at greatest risk for financial hardship.

Financial toxicity and quality of life among people with chronic myeloid leukemia on tyrosine kinase inhibitors.

e18918 Background: Costs associated with treatment of Chronic Myeloid Leukemia (CML), along with out of pocket (OOP) expenses related to cancer care, put CML patients at risk for financial toxicity (FT). Although FT is considered a side effect of many cancer treatments, little is known about how FT affects quality of life among CML patients treated with Tyrosine Kinase Inhibitors (TKIs). In this study, we examined the association between FT, demographic factors, and health related quality of life (HRQOL). Methods: A secondary analysis was conducted using data from a parent study examining adherence trajectories in people with CML treated with TKIs. Descriptive, bivariate, and multivariate analyses were used to describe the sample, assess demographic and disease-specific FT correlates, and assess the predictive value of FT on HRQOL. FT was assessed by the Comprehensive Score for Financial Toxicity (COST Facit V2; higher scores were better) along with the Medical Expenditure Panel Survey (MEPS). HRQOL was assessed using the EuroQol 5-Dimension (EQ-5D-5L) single summary index score. Results: Of the 118 participant sample, about half were male (52%), White (57%), married (53%), and currently employed (59%) with a mean age of 49. Most had some college credit (76%). Many reported making financial sacrifices because of cancer costs (42% reduced spending on vacation/leisure activities, 31% delayed large purchases, 24% reduced spending on basics like food and clothing, and 27% used savings set aside for other purposes). Most (62%) reported ever being worried about having to pay large medical bills related to their cancer and 15% reported borrowing money or going into debt to cover cancer care costs. About half (51%) reported never discussing OOP costs for cancer care with their doctor. Overall, participants reported low FT (mean = 25, standard deviation = 11), but approximately 26% of respondents noted FT levels associated with significant financial burden (COST &lt; 17.5). In bivariate analyses, greater FT was associated with Black race, not married/partnered status, unemployed, high school education or less, and lower income. FT was not significantly associated with gender or age. In multivariable models, FT was significantly associated with HRQOL index (β = 0.011, SE = 0.002, P &lt; 0.001) after adjusting for individual characteristics. Age (β = -.003, SE = 0.001, P = 0.01) and education (β = .125, SE = 0.05, P = 0.027) also seemed to be important correlates of HRQOL index. Conclusions: Financial concerns are a common worry for individuals receiving treatment for CML. The association between FT and HRQOL suggests a need for assessing and addressing FT as part of routine care of people with CML who are taking TKIs. Further work is needed to understand the longitudinal experience of FT of people with CML on continuous treatment to help identify individuals who are most in need of intervention across the treatment continuum.

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors.

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors. During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity. The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed. In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Increased suicidal ideation and suicide attempts in COVID-19 patients in the United States: Statistics from a large national insurance billing database

Emerging research suggests suicidality may have increased during the COVID-19 pandemic. This cross-sectional study aimed to advance understanding of suicide risk during the pandemic through novel use of a large insurance database. Using logistic regression across time-points, we estimated the effect of exposure to SARS-CoV-2 infection on rates of suicidal ideation and suicide attempts in infected individuals versus uninfected controls during the pandemic (March 2020 - September 2021). In uninfected individuals, we estimated the effect of exposure to the pandemic period versus the pre-pandemic control period (January 2017 to February 2020) on suicidality rates. We also investigated within-pandemic temporal patterns of suicidality. All patients with data in the UnitedHealth Group claims during those intervals were included. ICD-10 codes defined suicidality measures. There were 525,312,717 (62.3% over age 45, 57.7% female) included encounters. From the pandemic subsample (32.8%), 1.7% were COVID+. Adjusted odds ratios showed that COVID+ patients were significantly more likely to have suicidal ideation and suicide attempts than COVID- patients. Among COVID- patients, adjusted odds of suicidality were significantly lower during versus prior to the pandemic. Results were unfortunately limited by the absence of data on deaths by suicide. Further research should examine how SARS-CoV-2 infection may influence suicidality.

Congress Takes a Positive Swing at an Unsung Public Health Crisis: Preventing Pressure Injuries in Veterans Affairs Facilities.

Congress Takes a Positive Swing at an Unsung Public Health Crisis: Preventing Pressure Injuries in Veterans Affairs Facilities.

Acute stress and restricted diet reduce bill-mediated heat dissipation in the song sparrow (Melospiza melodia): implications for optimal thermoregulation.

We used thermal imaging to show that two environmental factors - acute stress and diet - influence thermoregulatory performance of a known thermal window, the avian bill. The bill plays important roles in thermoregulation and water balance. Given that heat loss through the bill is adjustable through vasoconstriction and vasodilation, and acute stress can cause vasoconstriction in peripheral body surfaces, we hypothesized that stress may influence the bill's role as a thermal window. We further hypothesized that diet influences heat dissipation from the bill, given that body condition influences the surface temperature of another body region (the eye region). We measured the surface temperature of the bills of song sparrows (Melospiza melodia) before, during and after handling by an observer at 37°C ambient temperature. We fed five birds a restricted diet intended to maintain body mass typical of wild birds, and we fed six birds an unrestricted diet for 5months prior to experiments. Acute stress caused a decrease in the surface temperature of the bill, resulting in a 32.4% decrease in heat dissipation immediately following acute stress, before recovering over approximately 2.3 min. The initial reduction and subsequent recovery provide partial support for the hemoprotective and thermoprotective hypotheses, which predict a reduction or increase in peripheral blood flow, respectively. Birds with unrestricted diets had larger bills and dissipated more heat, indicating that diet and body condition influence bill-mediated heat dissipation and thermoregulation. These results indicate that stress-induced vascular changes and diet can influence mechanisms of heat loss and potentially inhibit optimal thermoregulation.

Complications, Adverse Drug Events, High Costs, and Disparities in Multisystem Inflammatory Syndrome in Children vs COVID-19

Multisystem inflammatory syndrome in children (MIS-C) causes severe inflammation of multiple organ systems after SARS-CoV-2 infection. During the pandemic, surveillance reporting of MIS-C was voluntary, with likely underreporting. For a rare syndrome like MIS-C, numerous data are needed to explore the disease in greater detail. To use large all-payer billing data and the new International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) code for MIS-C to compare outcomes across MIS-C and COVID-19 over all 4057 hospitals in 31 states. A retrospective cross-sectional study of all COVID-19 and MIS-C hospitalizations in individuals younger than 21 years from 31 states was conducted, using Agency for Healthcare Research and Quality 2021 Healthcare Cost and Utilization Project data. Analyses were conducted from February 1 to October 20, 2022. Fifty complications, adverse medication events, costs, and the Social Vulnerability Index. There were 4107 individuals with MIS-C (median age, 9 [IQR, 5-13] years; 2443 [59.5%] male; 1384 [38.1%] White) and 23 686 individuals with COVID-19 without MIS-C (median age, 15 [IQR, 5-18] years; 12 878 [54.4%] female; 4605 [44.1%] White), with 1.48 (95% CI, 1.35-1.62) MIS-C hospitalizations per 100 000 children per month, ranging from 0.97 hospitalizations per 100 children for White and 1.99 hospitalizations per 100 children for Black children. Outcomes worsened as the number of organ system dysfunctions increased from 2 to 8 organs. Deaths associated with MIS-C increased from less than 1% to 5.8% (95% CI, 3.3%-8.4%) and from less than 1% to 17.2% (95% CI, 11.7%-22.7%) for COVID-19 (P = .001). Adverse medication events associated with MIS-C increased from 4.9% (95% CI, 3.8%-6.0%) to 17.8% (95% CI, 13.7%-22.0%) and from 1.2% (95% CI, 1.0%-1.3%) to 13.4% (95% CI, 8.4%-18.3%) for COVID-19. The median length of stay for MIS-C increased from 4 (IQR, 2-5) to 8 (IQR, 5-12) days and from 3 (IQR, 2-5) to 16 (IQR, 7-23) days for COVID-19. Median costs for MIS-C increased from $16 225 (IQR, $9244-$26 822) to $53 359 (IQR, $35 920-$86 882) and from $6474 (IQR, $3741-$12 103) to $98 643 (IQR, $30 675-$204 956) for COVID-19. The percentage of MIS-C cases that were in Black children doubled from 16.2% to 31.7% (P = .001) as organ dysfunction increased, remaining unchanged with COVID-19. Hospital stays for MIS-C increased by 1 day (P = .01) for Black patients compared with White patients, with Black patients moving from the bottom to top quartile of socioeconomic vulnerability, with no disparity with COVID-19. In this cross-sectional study, MIS-C was more common and severe than previously reported, with more racial disparities in outcomes than were seen in patients with COVID-19. The findings of this study suggest that relying on mean outcomes for MIS-C from past studies can be misleading, since outcomes and disparities varied widely with the number of multiorgan dysfunctions.

Options for change: Restructuring California’s residential inclining rates for a better electricity future

Local distribution companies (LDCs) regulated by the California Public Utilities Commission use mandatory inclining rates (MIR) to bill their residential electricity customers. However, MIR hinder the California electricity industry’s provision of clean and reliable service at affordable rates. Hence, we consider the following options to restructure MIR: (1) adopting a flat energy rate and revised customer charges; (2) replacing the flat rate in (1) with time-of-use (TOU) rates; (3) replacing the TOU rates in (2) with real-time pricing; (4) replacing (3) with a Hopkinson tariff with reliability differentiation. Our assessment of these options recommends sequential implementation (1), (2) and (4), thus lessening the potentially large and adverse bill impacts on some residential end-users caused by a drastic rate design change. Our recommended implementation sequence is (2) and (4) when the potentially large bill impacts of TOU pricing on the small and poor end-users with relatively high peak kWh consumption are to be mitigated by income-based customer charges.

Design and Implementation of Smooth Renewable Power in Cloud Data Centers

The renewable power has been widely used in modern cloud data centers, which also produce large electricity bills and the negative impacts on environments. However, frequent fluctuation and intermittency of renewable power often cause the challenges in terms of the stability of both electricity grid and data centers, as well as decreasing the utilization of renewable power. Existing schemes fail to alleviate the renewable power fluctuation, which is caused by the essential properties of renewable power. In order to address this problem, we propose an efficient and easy-to-use smooth renewable power-aware scheme, called Smoother, which consists of Flexible Smoothing (FS) and Active Delay (AD). First, in order to smooth the fluctuation of renewable power, FS carries out the optimized charge/discharge operation via computing the minimum variance of the renewable power that is supplied to data centers per interval. Second, AD improves the utilization of renewable power via actively adjusting the execution time of deferrable workloads. Extensive experimental results via examining the traces of real-world data centers demonstrate that Smoother significantly reduces the negative impact of renewable power fluctuations on data centers and improves the utilization of renewable power by 250.88%. We have released the source codes for public use.

Should more effortful utterances map to more elaborate signals?

Many songbirds tune the frequency of their whistled vocalizations by varying the length of their vocal tract. To do this, they must open their bills wider to produce higher tones and then close them again for lower pitches. The time course of frequency variation in such a bird's song, thus, maps directly to the time course of motor effort by its bill. In 2016, Podos et al. described frequency excursion as “for any given song or song segment, the sum of frequency modulations both within and between notes on a per-time basis.” As predicted from the previous work, birds with larger bills are constrained to produce less frequency excursion than birds with smaller bills. After reviewing this result, I will elaborate on ways to extend the idea of a map between motor effort and signal characteristic from one-to-one to many-to-many.

Racial and ethnic differences in cost-of-care conversations among older adults

ABSTRACT Background The rapidly growing racially diverse ageing population in the United States presents unique challenges for the country’s social, economic, and healthcare systems. Rising health care costs, increased patient cost-sharing, and limited financial resources make this generation of older Americans susceptible to large medical bills or debt, which disproportionally impacts older adults who are from racial/ethnic minority communities. Cost of care (CoC) conversations between patients and healthcare providers is one recommended approach for containing healthcare costs and alleviating patients’ financial burden of care. Method The current study used focus group methods to qualitatively explore the contextual factors that influence CoC conversations in a diverse sample of older adults (N = 27). Three focus groups were held with non-Hispanic White (n = 10), Black/African American (n = 9), and Hispanic (n = 8) participants. Thematic analysis yielded four broad themes. Results The results suggest that CoC conversations do not occur with physicians. The facilitators of CoC conversations included positive provider affect, rapport/relationship building, and communication. Barriers included lack of physician training, wait time, lack of focus on the patient, language, provider preferences, fear of physicians, and religion. There were significant differences in the facilitators and barriers across racial/ethnic groups. Conclusions It is critical for physicians to have the tools and training to successfully discuss CoC with older patients. Cultural competency training and provider awareness of patient preferences and expectations may be important when it comes to enhancing rapport and increase the likelihood of these important conversations within racial/ethnic minority communities.

Nationalization of the private sector labor force, quotas, matching and public jobs, an illustration with Saudi Arabia

We analyze how quotas of foreign workers and subsidies on national labor can increase the private sector employment of nationals in an economy with a large proportion of expatriates and a large government wage bill. We use two alternative partial equilibrium models of the labor market: one has a market-clearing wage, and the other represents matching and job search directed towards either the public or the private sector. The models are calibrated on Saudi Arabia. We show that when the quotas of foreign workers are binding, they reduce the impact of labor subsidies on the employment of nationals. In addition, we find that in the matching model subsidies on the labor of nationals have a larger effect on employment than in the market-clearing wage model, because the highly attractive public sector flattens the wage curve. We also find that labor subsidies financed by expat levies or public job cuts have modest employment effects and require a very large fiscal adjustment. Finally, we show that a domestic energy price reform, where only a fraction of the fiscal proceeds are used for labor subsidies, can substantially reduce unemployment.