Large Bills Research Articles

Financial distress, health literacy, numeracy, and treatment receipt by race/ethnicity amongst breast cancer survivors.

e18554 Background: Low-income and minority women are less likely to receive breast cancer treatments and have higher mortality rates compared with other women.We examined economic hardship, health literacy, and numeracy by race/ethnicity and whether these factors were associated with differences in receipt of recommended treatment. Methods: We conducted a telephone survey in 2018-2020 of adult women diagnosed with stage I-III breast cancer between 2013-2016 at three centers in Boston and New York. We asked women about treatment receipt and factors contributing to decision-making. We used X2 and Fischer exact tests to examine associations between economic distress, health literacy/numeracy, and treatment receipt by race/ethnicity. Results: Among 326 respondents (AAPOR cooperation rate 63-80% across sites), 55% were Non-Hispanic (NH) White, 23% were NH Black, and 14% Hispanic; 15% were Medicaid-insured. Due to item non-response, sample sizes ranged from 294-315 per question. A substantial proportion of women, and particularly Black and Hispanic women, reported economic distress, worse finances over time, and low literacy/numeracy (Table). Overall, 7% (n = 22) did not initiate at least one recommended treatment. Although we observed no differences in treatment by race/ethnicity (p = 0.70), those not initiating recommended treatment(s) reported more worry about paying large medical bills (52% vs. 27%) and covering visit costs (27 vs. 10%); p < .05 for both. Conclusions: In a diverse sample of breast cancer survivors, financial distress was common, particularly for non-White participants; non-White women also had lower literacy/numeracy. Although we observed some associations of these factors (but not race/ethnicity) with less receipt of recommended treatments, because few women declined treatments, understanding the scope of impact is limited. However, our results highlight the importance of up-front and longer-term assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures on financial distress and the focus on health literacy/numeracy among a diverse population.[Table: see text]

Ecological adaptation and birdsong: how body and bill sizes affect passerine sound frequencies

AbstractThe avian bill is finely adjusted to foraging ecology and, as part of the vocal tract, it may also affect sexual signals such as songs. Acoustic theory predicts that larger bills lower the resonant frequency of vocal tracts, allowing larger-billed species to emphasize lower sound frequencies. Theory also predicts that identical changes in bill gape allow singing over a wider frequency bandwidth in larger-billed species. We tested these associations between bill size and sound frequencies of song, controlling for body mass, across ca. 1000 taxonomically-diverse passerines. Phylogenetically informed analyses indicated that both bill and body sizes are negatively related to the sound frequency of songs, with additive effects of similar strength. Analyses of reduced datasets, to decrease bill-body size associations, indicated that the effect of bill size remains identical and is thus not an artefact of its covariation with body size. Sound frequency bandwidth was only related to body size but not bill size, perhaps because large bills may allow greater modulation of frequency but also hinder fast bill movement. Since the bill has a major role explaining species differences in birdsong sound frequency, it can be a magic trait that promotes reproductive isolation as a consequence of ecological divergence.

Effects of financial toxicity on prescription drug use and mental well-being in cancer patients

BackgroundIn the US, medical costs for cancer patients have grown from $27 billion in 1990 to $174 billion in 2020. The increased financial strain that cancer patients and survivors endure is referred to as financial toxicity. ObjectiveTo quantify the relationship between indicators of financial toxicity and health utilization and quality of life in patients ever diagnosed with cancer. MethodsAdult cancer patients and survivors in 2017 were identified using the Medical Expenditure Panel Survey. Multiple logistic regression models were used to quantify the relationship between three financial toxicity exposures (concern for keeping an income, paying large medical bills, and going into debt or borrowing money) and two discrete outcomes of being able to purchase prescriptions and often worrying that cancer would worsen or come back. ResultsThis study assessed 609 respondents. After survey weighting was applied, that represented 16,215,673 individuals. Patients who reported concern for keeping an income were at 2.91 (95% Confidence Interval [CI], 1.16 to 7.31) and 2.97 (95% CI, 2.01 to 2.67) times increased odds to report avoiding purchase of prescriptions and worry of cancer status, respectively, versus those who did not. Patients who reported worry about paying large medical bills were at 4.46 (95% CI, 2.15 to 9.24) and 2.80 (95% CI, 1.98 to 3.96) times increased odds to report avoiding purchase of prescriptions and worry of cancer status, respectively, versus those who did not. Patients who reported borrowing money or going into debt were at 3.04 (95% CI, 1.19 to 7.76) and 2.42 (95% CI, 1.54 to 3.18) times increased odds to report avoiding purchase of prescriptions and worry of cancer status, respectively, versus those who did not. ConclusionsFinancial toxicity is associated with decreased prescription utilization and quality of life in the form of excessive worry among cancer patients including cancer survivors.

The evolution of the traplining pollinator role in hummingbirds: specialization is not an evolutionary dead end.

Trapliners are pollinators that visit widely dispersed flowers along circuitous foraging routes. The evolution of traplining in hummingbirds is thought to entail morphological specialization through the reciprocal coevolution of longer bills with the long-tubed flowers of widely dispersed plant species. Specialization, such as that exhibited by traplining hummingbirds, is often viewed as both irreversible and an evolutionary dead end. We tested these predictions in a macroevolutionary framework. Specifically, we assessed the relationship between beak morphology and foraging and tested whether transitions to traplining are irreversible and lead to lower rates of diversification as predicted by the hypothesis that specialization is an evolutionary dead end. We find that there have been multiple independent transitions to traplining across the hummingbird phylogeny, but reversals have been rare or incomplete at best. Multiple independent lineages of trapliners have become morphologically specialized, convergently evolving relatively large bills for their body size. Traplining is not an evolutionary dead end however, since trapliners continue to give rise to new traplining species at a rate comparable to non-trapliners.

No Surprises Act Brings New Billing Rules, Disclosures; Doctors Sue

No Surprises Act Brings New Billing Rules, Disclosures; Doctors Sue

Second Records of the Caspian Tern Hydroprogne caspia in Lebanon 2022

Caspian Tern Hydroprogne caspia is a monotypic, cosmopolitan species occurring in North America, North Europe, Africa, Madagascar, Asia, Australia, and New Zealand. There are only three European populations of approximately 4,500 breeding pairs along the coasts of the Caspian, Black, and Baltic Seas. It’s the largest of the terns, with a wingspan averaging. It has a body length of 48 - 56 cm, a weight of 570-780 gram and a wing span of 127-140 cm. Its size, stout red bill, and lack of a deeply forked tail distinguishes it from other white terns found in the state. Its black cap, large red bill, and tern-like habit of flying slowly with its bill pointed downward separates it from the gulls. The low harsh call of the Caspian tern sounds similar to karrr or kraa-ah and is given frequently while in flight. The orange feet of immature birds distinguish them from fall-plumaged adults which have black feet. Recently it was recorded for the first time in Lebanon in 15th of September 2021 and the second record was made in 18th of January 2022, both records were made by Michel Sawan in north Lebanon.

First Records of the Caspian Tern Hydroprogne caspia in Lebanon 2021

Caspian Tern Hydroprogne caspia is a monotypic, cosmopolitan species occurring in North America, North Europe, Africa, Madagascar, Asia, Australia, and New Zealand. There are only three European populations of approximately 4,500 breeding pairs along the coasts of the Caspian, Black, and Baltic Seas. It’s the largest of the terns, with a wingspan averaging. It has a body length of 48 - 56 cm, a weight of 570-780 gram and a wing span of 127-140 cm. Its size, stout red bill, and lack of a deeply forked tail distinguishes it from other white terns found in the state. Its black cap, large red bill, and tern-like habit of flying slowly with its bill pointed downward separates it from the gulls. The low harsh call of the Caspian tern sounds similar to karrr or kraa-ah and is given frequently while in flight. The orange feet of immature birds distinguish them from fall-plumaged adults which have black feet. Recently it was recorded for the first time in Lebanon in 15th of September 2021 at Cheikh Zennad, Akkar District, North Lebanon by Michel Sawan.

Effects of climate on bill morphology within and across Toxostoma thrashers

Bird bills possess an important thermoregulatory function as they are a site for environmental heat exchange. Previous studies have demonstrated that birds in warmer climates have larger bills than those living in colder climates, as larger bills can dissipate more heat. Because this dry heat transfer does not incur water loss, it may be additionally advantageous in water‐restricted habitats. Here, we examine the influence of climate on bill morphology in Toxostoma thrashers, a group of 10 North American species that varied in bill morphology and occupied climate niche, with several species inhabiting arid climates. Past examinations of thrasher bill morphology have only considered foraging, leaving unanswered the role of climate in morphological divergence within this group. We photographed 476 Toxostoma museum specimens encompassing all 10 species and calculated bill measurements from the photos using a MATLAB‐based program. For each species, we calculated occupied climate niche using data from WorldClim describing temperature and precipitation. We found no reliable significant relationships between climate variables and bill morphology across species, suggesting that other factors such as foraging behavior may be more important in shaping bill morphology in this genus. Within species, we found three Toxostoma species have significant relationships between bill morphology and climate that follow Allen's rule. However, we also found the relationships between climate and bill morphology varied in strength and direction across species. Notably, we found a negative relationship between maximum temperature of the hottest month and bill surface area in LeConte's thrasher, which occupies the hottest and most arid climates of the thrashers. This adds to the evidence that Allen's rule may reverse in extremely hot climates when the bill may become a heat sink instead of a heat radiator. These results demonstrate the importance of considering the generality of ecogeographical rules across lineages that occupy extreme climates.

Rejection of vaccination against the COVID-19 virus will increase morbidity and mortality

It has been about two years since the first COVID-19 epidemic began,now it coincides with the fifth peak of epidemic infection in some countries. Over the years we have experienced many ups and downs of this virus(1, 2). It has been about two years since the first COVID-19 epidemic began,now it coincides with the fifth peak of epidemic infection in some countries. Over the years we have experienced many ups and downs of this virus(1, 2). Some people are still with us, but unfortunately, some have left us in the middle of their lives, and they have become victims of the COVID-19 pandemic(3). A virus that when it got into the world of people, many said: "It does not last long and when it reaching warm seasons of the year, it will die prematurely and does not survive." However, the virus has survived to this today. Efforts have been made around the world to shine the bright rays of hope and life in the shady cornerscreated by it(4, 5). One of these constructive efforts is to obtain a vaccine against COVID-19. COVID-19 vaccination rates have still not been optimal in some countries(6, 7). While China, India, and the United States have had the highest vaccination rates (over 100%) since August 4, 2021, the statistics are disappointing in some other countries(8). For example, approximately 1.16% of Iranians received vaccinations at the same time(6-8). This is not sufficient to achieve so-called herd immunity, and hospitals have become more crowded due to the serious spread of the more contagious type of delta. In addition to the lack of appropriate vaccines due to economic sanctions following the political tensions in some countries,such as Iran(9, 10), the reasons for refusing free injections and neglecting preventive measures are also different(5). The covid-19 virus survived and mutant and increased mortality. However, still, some people don't hear and look at these facts. The efforts of medical staff across the globe have not yet been properly heard(5). What remains are the challenges that have endangered human life on earth, and we seem to be counting it down. These barriers must be identified in a short time. The workload of medical staff has grown significantly. In addition, journalists and the press have come to their aid, reporting and promoting the views of professors, experts, and heads of the health care system in the press, and enlightenment efforts have reached the point where politicians are talking about COVID-19 in election campaigns(11). Although an unknown and difficult path has been taken so far, it seems that this path is still ahead(7). In addition to government agencies, removing these barriers requires residents' campaigns to get vaccinated for their health, for their grandparents, for their neighbors, or to use free incentives(5, 12). Failure to do so will result in significant health costs for governments and economies.Failure to get COVID-19 vaccination in most cases leads to hospitalization and usually leads to large bills. These expenses will be higher for the uninsured person. It also enhances the likelihood of re-globalization pandemic with its mutant strains(13).

Investigating alternative power generation strategies for local municipalities that are tied to the national grid

Escalating electrical energy usage and costs over the past few years has resulted in large utility bill expenses that municipalities are struggling to pay-off to National Energy Suppliers. Furthermore, some energy suppliers are struggling to meet the demand for more energy due to a variety of factors. The challenge therefore exists in identifying viable alternative power generation strategies for local municipalities to reduce their current electrical energy expenses or to provide limited power to their community when disconnected from the National Grid. An environmentally friendly renewable energy strategy method could be used to supplement the current energy requirements of a municipality during months of high energy demand. The main focus of this study will be on a small town in the Free State province of South Africa, called Koffiefontein. A battery-based solar PV system was designed in the Homer software and chosen as the renewable energy strategy to supplement the current energy needs of Koffiefontein due to its performance and cost effectiveness. The initial implementation cost of the system is $ 42 995 649.95. The cost of energy for the PV system suggested for Koffiefontein houses is $ 0.40/kWh with the yearly electricity production of 27 661 kWh. The payback period of the system is 45.3 years. The municipality needs to consider installing battery-based solar PV system to supply businesses in Koffiefontein during their high demanding hours and during load shedding as the system indicates an affordable cost of energy with high yearly production.

The Effect of Monthly Cost‐Sharing Limits on Out‐of‐Pocket Costs for Privately Insured Patients

Research ObjectiveDespite the Affordable Care Act increasing access to health insurance for millions of previously uninsured Americans, underinsurance is a persistent problem. A key contributor to underinsurance is growing enrollment in high deductible health plans for those on the health insurance exchanges and in employer‐sponsored health plans. Because annual deductibles do not reflect the economic realities of how people are paid or how they pay for other expenses, it is worthwhile to consider alternatives to annual cost‐sharing limits as an option for improving access to care.Study DesignWe used the 2018 IBM MarketScan® Commercial Claims and Encounters database to assess changes in patient out‐of‐pocket and plan spending under either a $250 or $500 in‐network monthly out‐of‐pocket maximum. We also estimated spending assuming uncapped out‐of‐network costs or with $500 or $1,000 monthly out‐of‐network out‐of‐pocket maximums. We calculated the percentage of enrollees who would benefit from each scenario and share of total costs shifted back to plans as a percentage of total health care spending under each scenario.Population StudiedThose under age 65 who were enrolled for the full year, excluding those in HMO or POS with capitation plans.Principal FindingsEnrollee annual mean and highest month mean out‐of‐pocket costs decreased in all scenarios. For in‐network care, annual mean out‐of‐pocket costs fall by $380 (49%) under a $250 monthly cap and by $269 (35%) under a $500 monthly cap. For out‐of‐network care, annual savings averaged 35% and 22% under the $500 and $1,000 out‐of‐network caps, respectively. When considering savings for the highest month of out‐of‐pocket costs, representing peak burden of cost‐sharing, we estimated mean patient spending decreases between 48% and 68% (from $480 under the status quo). The percentage of enrollees benefitting from these monthly caps ranges from 23% to 37% and the portion of total health care costs shifted from enrollees back to plans ranges from 4% to 7%. The latter estimate reflects potential increases in premiums expected as a result of such a policy change, absent any behavioral effects on health care use.ConclusionsInstead of a large annual deductible, plans could spread the annual deductible over the year to improve affordability for patients. Patients with acute illnesses could get necessary care without facing a deductible that is more than their monthly take‐home pay, and those with chronic needs would be better able to spread their costs throughout the year instead of facing a single large bill at the beginning of every year. There may be some increases in so‐called inefficient health care use, commonly referred to as moral hazard, due to lower cost‐sharing; however, there is a practical limit to the amount of care that can be scheduled within one month. Conversely, under the current annual cost‐sharing limits, patients who reach their out‐of‐pocket maximum early have the opportunity to use care with no cost‐sharing for a substantial portion of the year.Implications for Policy or PracticeMonthly cost‐sharing limits could improve affordability of care for those in high‐deductible health plans.

Formation of Macro- and Microrefugia Explains Morphological Divergence of the Eurasian Jay Garrulus glandarius in the Japanese Archipelago

The Eurasian Jay Garrulus glandarius is a highly polytypic bird species composed of 34–36 subspecies. The contribution of formation of glacial refugia to the evolutionary process that generated its tremendous diversity has not been studied. We investigated the contribution of microrefugia to the subspeciation process of the Eurasian Jay in the Japanese archipelago. By assessing genetic diversity and reconstructing a mitochondrial phylogenetic tree, we asked whether divergence of a subspecies on a peripheral island (Sado Island) from the subspecies on the mainland of the Japanese archipelago (Honshu and Kyushu, hereafter mainland) occurred via formation of a microrefugium outside the mainland macrorefugia. We also assessed morphological differences between the Sado Island and mainland jay populations. We tested whether the observed morphological differences can be explained by adaptation of the Sado Island population to a species-poor microrefugium. Genetic analyses inferred that the Sado Island population survived in a refugium outside the mainland macrorefugia from around the late Middle to Late Pleistocene. The morphology of the Sado Island jay population was characterized by greater trait variance, larger body size, and a disproportionately large bill when compared with the mainland population. These results are consistent with the expected patterns of morphological evolution in microrefugia with reduced species diversity. We suggest the importance of ecological release in a microrefugium on Sado Island for the evolution of geographical variation of the Eurasian Jay in the Japanese archipelago. This is the first study to assess the significance of microrefugia for the diversification of the Eurasian Jay.

Health reforms in the United States: The outlook after Biden's first 100 days

The November 2020 election of Joe Biden, coupled with the election of a Congress controlled by the Democratic Party, has the potential to dramatically alter the direction of health policy in the United States. Donald Trump failed to repeal the Affordable Care Act (ACA) but he managed to whittle down aspects of coverage protection. Historically, the first 100 days of a presidency are a bellwether of accomplishments to come. During this period Biden reversed several of Trump policies through both executive orders and a large economic stimulus bill. The stimulus bill substantially increased premium subsidies to encourage people to purchase health insurance coverage, albeit with funding guaranteed only for a two-year period. Larger accomplishments, such as making these enhanced premium subsidies permanent, reining in prescription drug spending, enacting a public health insurance option to compete with private insurers, and improving public health and health equity, will require further legislation. The political environment in the U.S. is now extraordinarily contentious. Each of these proposed initiatives faces major political hurdles and the window of opportunity for enacting each of these goals very well may be brief.

The case against eliminating large denomination bills

When large denomination bills are preferred in illegal activities, what is the optimal policy response? We construct a dual currency model where illegal activity can be reduced by modifying the payment environment. In our model, legal (goods) traders are indifferent between small and large bills, but illegal (goods) traders face a lower transaction cost of using large bills in comparison to small bills because it is easier to conceal. We show that eliminating large bills can reduce illegal trade and its associated social cost. However, this pooling equilibrium is sub-optimal because the government can collect more seigniorage by allowing illegal traders to use large bills with a lower rate of return. When the transaction cost of using small bills for illegal traders is sufficiently large, a separating equilibrium, where legal traders use small bills and illegal traders use large bills, can maximize welfare by making an implicit transfer from the illegal traders to the legal traders.

Surprise Billing—A Flashpoint for Major Policy Issues in Health Care

This Viewpoint discusses the unexpected large billing that can occur when a patient receives care from an out-of-network physician or center (surprise billing)—its root causes and recent legislation that will provide some patients with protection, but not all.

A Systematic Review and Scoping Analysis of Smoking Cessation after a Urological Cancer Diagnosis

Smoking cessation after a urologic cancer diagnosis significantly benefits patients. It is not well known how often patients quit after diagnosis or how urologists intervene to support patients' smoking cessation efforts. To examine rates of smoking cessation after diagnosis among patients with urologic cancers and to assess how often patients are given advice and support to quit smoking in the urology setting. Following the PRISMA guidelines, a systematic review was conducted of the available studies on smoking cessation after a urologic cancer diagnosis during April 2020 by a trained medical librarian using the MEDLINE, PsycInfo, Embase, and Cochrane CENTRAL databases. Studies were included based on three independent reviews and if they met a priori inclusion/exclusion criteria. In total, 2568 records were identified, 31 of which were included for final analysis. Four studies (patient n=587) reported outcomes related to the prospective implementation of a smoking cessation program with patient-level quit rates ranging from 3.2% to 47.3%. Twenty one studies reported outcomes of passive (no directed, active intervention) smoking cessation after the diagnosis of a urologic cancer (patient n=3669) with widely varying quit rates. In general, the quality of included studies was poor. There was no standardization of the measurement or timing of outcomes and few studies included validated survey instruments or biochemical confirmation of cessation. Seventeen studies included data on whether patients received advice to quit smoking after diagnosis. The proportion of patients in each study who were told to quit ranged from 2.8-78.3%. There are few smoking cessation interventions that have been prospectively implemented and reported in the urology literature and studies on quit rates after diagnosis are limited. The paucity of quality data and lack of smoking cessation interventions being used in routine urologic oncology care underscores the need for more rigorous study and implementation of evidence-based practices in this area.

Energy-efficient approach to lower the carbon emissions of data centers

Data Centers require enormous amounts of electrical energy to operate. The resultant emissions in the form of heat, directly, and carbon, indirectly, are cause for concern among Data Center managers and owners. In the past, and in many contemporary instances as well, Data Center managers have struggled to rein in large energy bills as operational activities increased. This paper attempts to address the problems without affecting operational efficiency of Data Centers and while maintaining high standards of system uptime. The latter is made possible by observing a set standard of Power Usage Efficiency and through rationalizing power consumption of equipment and Data Center infrastructure itself. Our research has shown that it is possible to control power consumption, and thus bring about savings in terms of electric bills paid, even when the count of servers in Data Centers racks increase from four to seven. Experiments conducted in the course of our research indicate to maintain a high quality of Data Center operational state and keep power consumption under control even in the wake of rising user numbers. The resultant savings in electrical units consumed, shall ultimately contribute in a small yet meaningful way towards a smaller carbon footprint and a greener planet.

Surgically Treated Severe Odontogenic Infections: A Large Cost to the United States Hospital System and Patients

Objectives This purpose of this study was to analyze the cost of surgically treated severe odontogenic infections to both the patient and the hospital system. Materials and Methods This retrospective chart review assessed data of patient hospital charts surgically treated for severe odontogenic infections in the operating room and admitted for greater than one day. Hospital charts of consecutive inpatients admitted from the ED to the University of Texas Southwestern Medical Center and Parkland Memorial Hospital for treatment from January 1st 2016 to December 31st 2020, were reviewed. Patients with infections of non-odontogenic origin were excluded. The specific outcome measures included total hospital stay cost, amount not collected, hospital charity adjustments, insurance type, length of stay, number of infected spaces, number of operating room visits, imaging ordered, and preadmission antibiotics. Results Data from 144 consecutive hospital charts were analyzed. The total billed cost of stay across all study years was $6,888,326.52, the average billed cost per hospital stay was $47,835.60, and the amount not collected was $2,864,857.82. Of the total billed cost, $2,107,692.15 was covered by hospital charity. Only $777,276.43 (11.3%) of the total $6,888,326.52 billed was collected by the hospital. Conclusions Patients that are treated for severe odontogenic infections incur a large hospital bill that could have been avoided. Often, a very small percentage of this bill is collected by the hospital.

“Repayment-by-Purchase” Helps Consumers to Reduce Credit Card Debt

Many consumers struggle to repay their credit card debt, in part because paying small portions of large bills often feels fruitless. We introduce a novel credit card payment option – repayment-by-purchase – and examine its influence on both the amount consumers’ repay and their perception of progress toward reducing their debt. With typical repayment, consumers simply enter the amount they wish to pay toward their total balance – often the minimum required payment. With repayment-by-purchase, in contrast, consumers can select specific purchases (e.g., a coffee at Starbucks, a utility bill) that they wish to repay, and make payments specifically directed toward “eliminating” these purchases. Five studies reveal that repayment-by-purchase increases awareness of what is being repaid, which increases perceptions of progress toward reducing debt, which in turn encourages higher repayment. In a large field experiment, credit card customers who were given the opportunity to allocate their payment toward specific purchase categories paid 12.18% more toward their debt balance than a control group. These findings advance our practical understanding of how consumers can be encouraged to pay more toward credit card debt and offer conceptual insight into how both increased awareness and perceived goal progress enhance consumer motivation to get out of debt.

IoT-Based Electricity Bill for Domestic Applications.

This work proposes a real-time electricity bill for quantifying the energy used in domestic facilities in Mexico. This bill is a low-cost tool that takes advantage of the IoT technology for generating an easy reading real-time bill allowing the customers to constantly review and administrate their energy consumption. Using low-cost sensors and the electronic board Particle® Photon, an energy meter is proposed. The presented prototype is extremely compact and satisfies safety measures to be used by anyone in a domestic installation. The measurement data is displayed and processed in real-time, and an appropriate algorithm determines the accumulated kWh. The energy consumed is displayed using an Html interface of easy interpretation for the customers, given recommendations about their consumption habits and some alarms in case of abnormal or high consumption. As a reinforcement measure for avoiding large consumption bills, the system is programmed to send messages to the user, remembering if the estimated consumption is large.