Archive

Archive for the ‘RAND Corporation’ Category

Continuity of Care and the Cost of Treating Chronic Disease

July 21, 2014 Comments off

Continuity of Care and the Cost of Treating Chronic Disease
Source: RAND Corporation

Strengthening coordination of care in the U.S. health care system is a priority for policymakers and the medical community. Poor coordination of care can drive up costs and harm patient health, especially for patients with chronic illnesses who see many different providers across many different settings. Some new models of care, such as the patient-centered medical home, focus on improving coordination as a way to provide affordable, high-quality care. Are these new models having the desired effect?

To answer this question, RAND researchers studied one important aspect of care coordination: continuity of care — the extent to which a patient’s care visits occur with the same provider. Researchers reviewed insurance claims data to gauge the association between continuity of care, costs, and patient outcomes during episodes of care for Medicare patients with one or more of three chronic diseases: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus (DM).

Researchers used a continuity of care (COC) index to measure the number of providers and/or practices involved in a patient’s care during a 365-day episode of care. The index ranges from 0 (each visit involved a unique provider) to 1 (all visits were billed by a single provider). An increase in the COC index reflects either fewer providers involved in a patient’s care or a concentration of visits among fewer providers.

Findings from this study show that modest improvements in continuity of care correlate with sizable reductions in service use, complications, and costs:

  • Higher levels of care continuity for CHF, COPD, and DM patients were consistently associated with lower rates of hospitalizations, emergency room visits, and complications.
  • An 0.1-unit increase in the COC index (which ranges from 0 to 1) was associated with episode-of-care costs for CHF, COPD, and DM patients that were on average 5 percent lower.
About these ads

Iran’s Influence in Afghanistan: Implications for the U.S. Drawdown

July 18, 2014 Comments off

Iran’s Influence in Afghanistan: Implications for the U.S. Drawdown
Source: RAND Corporation

This study explores Iranian influence in Afghanistan and the implications for the United States after the departure of most American forces from Afghanistan. Iran has substantial economic, political, cultural, and religious leverage in Afghanistan. Kabul faces an obdurate insurgency that is likely to exploit the U.S. and international drawdown. The Afghan government will also face many economic difficulties in future years, and Afghanistan is highly dependent on international economic aid. Additionally, the biggest problem facing Afghanistan may be political corruption. Iranian influence in Afghanistan following the drawdown of international forces need not necessarily be a cause of concern for the United States though. Although Tehran will use its cultural, political, and economic sway in an attempt to shape a post-2016 Afghanistan, Iran and the United States share core interests there: to prevent the country from again becoming dominated by the Taliban and a safe haven for al Qaeda.

This study examines Iran’s historic interests in Afghanistan and its current policies in that country, and explores the potential implications for U.S. policy. The research is based on field interviews in Afghanistan, the use of primary sources in Dari and Persian, and scholarly research in English.

The Future of Driving in Developing Countries

July 17, 2014 Comments off

The Future of Driving in Developing Countries
Source: RAND Corporation

The level of automobility, defined as travel in personal vehicles, is often seen as a function of income: The higher a country’s per capita income, the greater the amount of driving. However, levels of automobility vary quite substantially between countries even at similar levels of economic development. This suggests that countries follow different mobility paths. The research detailed in this report sought to answer three questions: What are the factors besides economic development that affect automobility? What is their influence on automobility? What will happen to automobility in developing countries if they progress along similar paths as developed countries? To answer these questions, the authors developed a methodology to identify these factors, model their impact on developed countries, and forecast automobility (as defined by per capita vehicle-kilometers traveled [VKT]) in four developing countries. This methodology draws on quantitative analysis of historical automobility development in four country case studies (the United States, Australia, Germany, and Japan) that represent very different levels of per capita automobility, in combination with data derived from an expert-based qualitative approach. The authors used the latter to assess how these experiences may affect the future of automobility in the BRIC countries: Brazil, Russia, India, and China. According to this analysis, automobility levels in the four BRIC countries will fall between those of the United States (which has the highest per capita VKT level of the four case studies) and Japan (which has the lowest). Brazil is forecasted to have the highest per capita VKT and India the lowest.

Why Is Veteran Unemployment So High?

July 17, 2014 Comments off

Why Is Veteran Unemployment So High?
Source: RAND Corporation

According to official statistics, the unemployment rate of young military veterans ages 18-24 reached 29 percent in 2011. This report seeks to put that statistic in perspective by examining the historical time-series of veteran unemployment, comparing the veteran unemployment rate to that of non-veterans, and examining how veteran unemployment varies with time since military separation. Between 2000 and 2011, younger veterans were, on average, 3.4 percentage points more likely to be unemployed than similarly situated younger non-veterans. However, this difference between veteran and non-veteran unemployment falls rapidly with age and time since military separation. The report concludes that the best available evidence supports the hypothesis that relatively high rates of veteran unemployment reflect the fact that veterans, especially younger veterans, are more likely to have recently separated from a job — namely, military service — and, consequently, are more likely to be engaged in job search, which takes time, especially during periods of slow economic growth. The available evidence lends little support to the hypothesis that veterans are inherently disadvantaged in the civilian labor market. Limiting unemployment benefits available to recently separated veterans would likely reduce the length of unemployment spells, but the net effect of such a policy action on the long-term federal budget is unclear. There is very limited evidence on the effectiveness of other federal policies aimed at facilitating the transition of veterans into the civilian labor market.

Effects of Heath Care Reform on Disability Insurance Claiming

July 15, 2014 Comments off

Effects of Heath Care Reform on Disability Insurance Claiming
Source: RAND Corporation

The Affordable Care Act (ACA) will fundamentally change the conditions that influence Americans to apply for federal disability insurance benefits. Because disability insurance confers health insurance in addition to cash benefits, it is an attractive option for many individuals with work-limiting disabilities. At the same time, leaving employment to apply for disability insurance benefits (a requirement for application) can be risky for those who obtain health insurance through their employers, making it a relatively unattractive option for others. By enabling access to affordable private health insurance and expanding access to subsidized public health insurance, the ACA alters the calculus of disability claiming decisions. Whether it will lead to more or fewer applications for disability benefits is not obvious. Research summarized here offers empirical evidence that, on net, disability applications are likely to decrease.

There is great interest in this issue because the numbers of disability beneficiaries have swelled in recent years relative to the number of workers paying into the system, leading the Board of Trustees of the Federal Disability Insurance Trust Fund to predict that the system will run out of funds by 2016.

It is too soon, of course, to know what the actual effects of national health reform will be on disability applications. But a recent RAND study has examined data from Massachusetts, which implemented reforms in 2006 that share the key features of the ACA, including creation of an insurance exchange as a source of lower-cost individual coverage and expansion of Medicaid (subsidized coverage for low-income individuals). Using administrative data from the Social Security Administration (SSA), the researchers analyzed changes in application rates for the two federal disability insurance programs — Supplemental Security Insurance (SSI) and Social Security Disability Insurance (SSDI) — in Massachusetts before and after the reform, statewide and by county, and compared changes to those in neighboring states and counties.

We summarize what the researchers expected to find in the data, what they actually found, and the implications of their results for national health reform.

The Future of the Army’s Civilian Workforce: Comparing Projected Inventory with Anticipated Requirements and Estimating Cost Under Different Personnel Policies

July 14, 2014 Comments off

The Future of the Army’s Civilian Workforce: Comparing Projected Inventory with Anticipated Requirements and Estimating Cost Under Different Personnel Policies
Source: RAND Corporation

In keeping with the coming drawdown in military end strength, the Department of Defense is planning to scale back its civilian workforce over the next several years. After reaching nearly 295,000 full-time employees in fiscal year (FY) 2010, the size of Army’s civilian workforce has started to fall. It is necessary to manage this drawdown so that sufficient people remain available in key positions. The authors projected the future supply of Army civilians under various scenarios and examined how the Army might manage supply to meet projected demand, by bringing together workforce supply and demand models. The RAND Inventory Model was used to project the supply of Army civilians, by command and occupation, based on historical patterns of internal transfers and separations, and various scenarios for future hiring. The supply projections were matched with demand projections from RAND’s Generating-Force-to-Operator model, which translates budgets for the Army’s operating force into projected changes in the institutional Army, to estimate the numbers of new hires or force reductions needed to meet the demand for civilians. The findings suggest that meeting future targets will require reducing hiring rates below historical levels but that substantial hiring will still be needed in most commands. If demand drops considerably below current projections, larger cuts would likely be required. Workforce cost is projected to change largely in line with the number of personnel. If requirements based on the FY 2014 President’s Budget are met by FY 2017, nominal costs are projected to remain approximately constant, with expected civilian pay raises offsetting workforce reductions.

Armed and Dangerous? UAVs and U.S. Security

July 9, 2014 Comments off

Armed and Dangerous? UAVs and U.S. Security
Source: RAND Corporation

Armed drones are making the headlines, especially in their role in targeted killings. In this report, RAND researchers stepped back and asked whether these weapons are transformative. The answer is no, though they offer significant capabilities to their users, especially in counterterrorism operations as has been the case for the United States. Will they proliferate? Yes, but upon a closer look at the types of systems, only a few rich countries will be in a position to develop the higher technology and longer range systems. U.S. adversaries and others will likely find weapons such as aircraft and air defenses more cost and militarily effective. Their proliferation will not create the kinds of global dangers that call for new arms control efforts, but the risks to regional stability cannot be dismissed entirely, as is the case of any conventional weapon. How the United States will use these weapons today and into the future will be important in shaping a broader set of international norms that discourage their misuse by others.

License Plate Readers for Law Enforcement: Opportunities and Obstacles

July 3, 2014 Comments off

License Plate Readers for Law Enforcement: Opportunities and Obstacles
Source: RAND Corporation

Law enforcement agencies across the country have quickly been adopting a new technology to combat auto theft and other crimes: automated license plate reader (LPR) systems. These systems can capture the image of the license plate of a passing vehicle and compare the plate number against official “hotlists” that show an array of infractions or reasons why it may be of interest to authorities. But because LPR technology is relatively new in the United States, opportunities and obstacles in its use in law enforcement are still under exploration. To examine issues about this technology, RAND conducted interviews with law enforcement officers and others responsible for procuring, maintaining, and operating the systems. Champions of LPR technology exist at many levels, from tech-savvy officers who use it every day, to chiefs who promote it, to other officials and policymakers who believe LPR technology is a significant force multiplier for police departments. Challenges exist, however, to realizing more widespread acceptance and use of the technology. Chief among these are privacy concerns related to the retention and potential misuse of LPR data, technical and bureaucratic impediments to sharing data among law enforcement agencies, and constraints on the availability of staffing and training needed to support LPR systems.

How Do We Know What Information Sharing Is Really Worth? Exploring Methodologies to Measure the Value of Information Sharing and Fusion Efforts

June 27, 2014 Comments off

How Do We Know What Information Sharing Is Really Worth? Exploring Methodologies to Measure the Value of Information Sharing and Fusion Efforts
Source: RAND Corporation

Since the terrorist attacks of September 11, 2001, the sharing of intelligence and law enforcement information has been a central part of U.S. domestic security efforts. Though much of the public debate about such sharing focuses on addressing the threat of terrorism, organizations at all levels of government routinely share varied types of information through multiagency information systems, collaborative groups, and other links. Given resource constraints, there are concerns about the effectiveness of information-sharing and fusion activities and, therefore, their value relative to the public funds invested in them. Solid methods for evaluating these efforts are lacking, however, limiting the ability to make informed policy decisions. Drawing on a substantial literature review and synthesis, this report lays out the challenges of evaluating information-sharing efforts that frequently seek to achieve multiple goals simultaneously; reviews past evaluations of information-sharing programs; and lays out a path to improving the evaluation of such efforts going forward.

Improving Dementia Long-Term Care: A Policy Blueprint

June 25, 2014 Comments off

Improving Dementia Long-Term Care: A Policy Blueprint
Source: RAND Corporation

In 2010, 15 percent of Americans older than age 70 had dementia, and the number of new dementia cases among those 65 and older is expected to double by the year 2050. As the baby boomer generation ages, many older adults will require dementia-related long-term services and supports (LTSS). This blueprint is the only national document to date that engages local, state, and national stakeholders to specifically focus on policy options at the intersection of dementia and LTSS.

The authors undertook five major tasks that resulted in a prioritized list of policy options and research directions to help decisionmakers improve the dementia LTSS delivery system, workforce, and financing. These were to (1) identify weaknesses in the LTSS system that may be particularly severe for persons with dementia; (2) review national and state strategies addressing dementia or LTSS policy; (3) identify policy options from the perspective of a diverse group of stakeholders; (4) evaluate the policy options; and (5) prioritize policy options by impact and feasibility.

Stakeholders identified 38 policy options. RAND researchers independently evaluated these options against prespecified criteria, settling on 25 priority options. These policy options can be summarized into five objectives for the dementia LTSS system: (1) increase public awareness of dementia to reduce stigma and promote earlier detection; (2) improve access to and use of LTSS; (3) promote high-quality, person- and caregiver-centered care; (4) provide better support for family caregivers of people with dementia; and (5) reduce the burden of dementia LTSS costs on individuals and families.

This policy blueprint provides a foundation upon which to build consensus among a larger set of stakeholders to set priorities and the sequencing of policy recommendations.

Hackers Wanted: An Examination of the Cybersecurity Labor Market

June 24, 2014 Comments off

Hackers Wanted: An Examination of the Cybersecurity Labor Market
Source: RAND Corporation

There is a general perception that there is a shortage of cybersecurity professionals within the United States, and a particular shortage of these professionals within the federal government, working on national security as well as intelligence. Shortages of this nature complicate securing the nation’s networks and may leave the United States ill-prepared to carry out conflict in cyberspace.

RAND examined the current status of the labor market for cybersecurity professionals — with an emphasis on their being employed to defend the United States. This effort was in three parts: first, a review of the literature; second, interviews with managers and educators of cybersecurity professionals, supplemented by reportage; and third, an examination of the economic literature about labor markets. RAND also disaggregated the broad definition of “cybersecurity professionals” to unearth skills differentiation as relevant to this study.

In general, we support the use of market forces (and preexisting government programs) to address the strong demand for cybersecurity professionals in the longer run. Increases in educational opportunities and compensation packages will draw more workers into the profession over time. Cybersecurity professionals take time to reach their potential; drastic steps taken today to increase their quantity and quality would not bear fruit for another five to ten years. By then, the current concern over cybersecurity could easily abate, driven by new technology and more secure architectures. Pushing too many people into the profession now could leave an overabundance of highly trained and narrowly skilled individuals who could better be serving national needs in other vocations.

Countering Others’ Insurgencies: Understanding U.S. Small-Footprint Interventions in Local Context

June 12, 2014 Comments off

Countering Others’ Insurgencies: Understanding U.S. Small-Footprint Interventions in Local Context
Source: RAND Corporation

This study examines the counterinsurgency strategies and practices adopted by threatened regimes and the conditions under which U.S. “small-footprint” partnerships are likely to help these governments succeed. The report’s findings are derived from a mixed-method research design incorporating both quantitative and qualitative analysis. Simple statistical analyses are applied to a dataset of counterinsurgencies that have terminated since the end of the Cold War (72 in all), and more in-depth analyses are provided of two recent cases of U.S. partnerships with counterinsurgent regimes, in the Philippines and Pakistan. The quantitative analysis finds that the cases of small-footprint U.S. operations that are commonly touted as “success stories” all occurred in countries approximating a best-case scenario. Such a verdict is not meant to deny the importance of U.S. assistance; rather, it is meant to highlight that similar U.S. policies with less promising partner nations should not be expected to produce anywhere near the same levels of success. The majority of insurgencies have taken place in worst-case conditions, and in these environments, counterinsurgent regimes are typically unsuccessful in their efforts to end rebellion, and they often employ violence indiscriminately. The case studies of the Philippines and Pakistan largely reinforce the findings of the quantitative analysis. They also highlight the challenges the United States faces in attempting to influence partner regimes to fight counterinsurgencies in the manner that the United States would prefer. The study concludes with policy recommendations for managing troubled partnerships.

Dementia’s Mounting Toll on the U.S. Economy

June 11, 2014 Comments off

Dementia’s Mounting Toll on the U.S. Economy
Source: RAND Corporation

Dementia costs Americans hundreds of billions of dollars per year, and the annual cost could top half a trillion by 2040 due to the “graying” of the U.S. population. This infographic shows the soaring economic costs and caseload of dementia.

Satellite Anomalies: Benefits of a Centralized Anomaly Database and Methods for Securely Sharing Information Among Satellite Operators

June 3, 2014 Comments off

Satellite Anomalies: Benefits of a Centralized Anomaly Database and Methods for Securely Sharing Information Among Satellite Operators
Source: RAND Corporation

Satellite anomalies are mission-degrading events that negatively affect on-orbit operational spacecraft. All satellites experience anomalies of some kind during their operational lifetime. They range in severity from temporary errors in noncritical subsystems to loss-of-contact and complete mission failure. There is a range of causes for these anomalies, and investigations by the satellite operator or manufacturer to determine the cause of a specific anomaly are sometimes conducted at significant expense.

Maintaining an anomaly database is one way to build an empirical understanding of what situations are more or less likely to result in satellite anomalies, and help determine causal relationships. These databases can inform future design and orbital regimes, and can help determine measures to prolong the useful life of an on-orbit spacecraft experiencing problems. However, there is no centralized, up-to-date, detailed, and broadly available database of anomalies covering many different satellites.

This report describes the nature and causes of satellite anomalies, and the potential benefits of a shared and centralized satellite anomaly database. Findings indicate that a shared satellite anomaly database would bring significant benefits to the commercial community, and the main obstacles are reluctance to share detailed information with the broader community, as well as a lack of dedicated resources available to any trusted third party to build and manage such a database. Trusted third parties and cryptographic methods such as secure multiparty computing or differential privacy are not complete solutions, but show potential to be further tailored to help resolve the issue of securely sharing anomaly data.

Racial and Ethnic Differences in Exposure to Suicide Prevention Messaging, Confidence in One’s Ability to Intervene with Someone at Risk, and Resource Preferences

May 29, 2014 Comments off

Racial and Ethnic Differences in Exposure to Suicide Prevention Messaging, Confidence in One’s Ability to Intervene with Someone at Risk, and Resource Preferences
Source: RAND Corporation

Report assesses differences in racial and ethnic groups’ exposure to suicide prevention messaging, preferences for suicide crisis services, and confidence in their ability to intervene with persons at risk of suicide.

Healing Medical Product Innovation

May 28, 2014 Comments off

Healing Medical Product Innovation
Source: RAND Corporation

No matter how it’s tallied—in total, per capita, or as a percentage of gross domestic product—U.S. spending on health care outstrips that of any other nation. Many experts identify costly new technology as the biggest driver of health care spending. Previous studies aimed at reining in spending on technology have focused on changing how existing medical technologies are used. But what about also encouraging the creation of technologies that could improve health and reduce spending, or that provide large-enough health benefits to warrant any extra spending? A recent RAND study focused on policies that could help change which medical products—drugs, devices, and health information technologies—get invented in the first place.

To spur inventors to create medical products that lower health care spending and promote health, policymakers need to address the perverse financial incentives that lead inventors and investors in the opposite direction. Currently, large profits are most often available from creating increasingly expensive products that boost spending, whether or not they also substantially improve health. In contrast, inventors face relatively weak incentives to create products that would help decrease spending.

The RAND research team developed ten high-priority policy options that could change the costs, rewards, and risks that inventors and investors face. We synthesized information from scientific, trade, and popular literature; conducted interviews with more than 50 national experts from a variety of fields; sought input from a panel of accomplished technical advisors; and developed illustrative case studies of eight medical products.

Effects of Employer Health Insurance on Disability Insurance Claiming

May 28, 2014 Comments off

Effects of Employer Health Insurance on Disability Insurance Claiming
Source: RAND Corporation

A new RAND study offers rigorous analysis of the effect of employer-provided health insurance on workers’ decisions to leave the workplace and apply for disability insurance when they become disabled. Specifically, it tests whether individuals who rely on their employers for health insurance are more likely to continue working after the onset of a disabling health condition than are those with other health insurance options, such as coverage from a spouse’s employer.

The study finds that employer-provided insurance has a strong influence on a certain type of newly disabled worker — those who largely retain their physical functional capacity and whose disability is expected to have high medical costs, such as cancer. These workers are 23 percent more likely to continue to work in the years immediately following disability onset (see the figure) if they rely on their employer for health insurance than are those with the option of obtaining health insurance through a spouse. Workers with these types of health problems represent 20 percent of newly disabled workers aged 51 or older.

By contrast, there is little evidence of employment lock for other types of workers with disabilities, such as those with more severe disabilities or lower expected medical costs. The researchers hypothesize that the reason most workers do not continue to work to retain their employer-based insurance is that they may be physically or mentally unable to work: i.e., the effort cost of work is so large that it outweighs the influence of other factors, such as retaining health insurance. Another reason could be that the value of health insurance may be low for some conditions.

At the same time, researchers do not find evidence of an effect on disability claiming, even among workers with low-severity and high-cost conditions: i.e., they do not find that workers who decide to stay employed would have applied for disability insurance benefits if they had other options for their health insurance.

Effects of Military Service on Earnings and Education Revisited; Variation by Service Duration, Occupation, and Civilian Unemployment

May 20, 2014 Comments off

Effects of Military Service on Earnings and Education Revisited; Variation by Service Duration, Occupation, and Civilian Unemployment
Source: RAND Corporation

The overriding objective of U.S. military compensation policy is to attract and retain the force necessary to meet the nation’s national security objectives. Whether and how military service affects earnings and an individual’s likelihood of completing college (one determinant of future earnings) has implications for military policies related to compensation, recruiting, and retention. Estimating the effect of military service is complicated by the fact that veterans are likely to differ from nonveterans in ways that are correlated with subsequent economic outcomes but are not observable to the researcher. This report builds on earlier work to understand how military service affects earnings, especially how these effects differ by the number of years of service and their military occupational specialties while serving. The authors also sought to understand how external factors and policies affect these impacts. To do this, they examined how economic conditions in the civilian labor market when individuals exit active duty affect postservice earnings, and they studied the effect on earnings of an Army recruiting program, Partnership for Youth Success, designed to promote enlistment but with the potential to ease the financial transition from military to civilian life.

Air Attack Against Wildfires: Understanding U.S. Forest Service Requirements for Large Aircraft

May 16, 2014 Comments off

Air Attack Against Wildfires: Understanding U.S. Forest Service Requirements for Large Aircraft
Source: RAND Corporation

An aging fleet of contracted fixed-wing airtankers and two fatal crashes in 2002 led the U.S. Forest Service to investigate how to recapitalize its fleet of airtankers. The Forest Service asked RAND for assistance in determining the composition of a fleet of airtankers, scoopers, and helicopters that would minimize the total social costs of wildfires, including the cost of large fires and aircraft costs. The research team developed two separate but complementary models to estimate the optimal social cost-minimizing portfolio of initial attack aircraft — that is, aircraft that support on-the-ground firefighters in containing a potentially costly fire while it is still small. The National Model allocates aircraft at the national level, incorporating data on ten years of historical wildfires, and the Local Resources Model provides a more nuanced view of the effect of locally available firefighting resources, relying on resource allocation data from the Forest Service’s Fire Program Analysis system. Both models favor a fleet mix dominated by water-carrying scoopers, with a niche role for retardant-carrying airtankers. Although scoopers require proximity to an accessible body of water, they have two advantages: shorter cycle times to drop water and lower cost. Two uncertainties could affect the overall optimal fleet size, however: future improvements in the dispatch of aircraft to fires and the value attributed to fighting already-large fires with aircraft.

Data Flood: Helping the Navy Address the Rising Tide of Sensor Information

May 16, 2014 Comments off

Data Flood: Helping the Navy Address the Rising Tide of Sensor Information
Source: RAND Corporation

In the U.S. Navy, there is a growing demand for intelligence, surveillance, and reconnaissance (ISR) data, which help Navy commanders obtain situational awareness and help Navy vessels perform a host of mission-critical tasks. The amount of data generated by ISR sensors has, however, become overwhelming, and Navy analysts are struggling to keep pace with this data flood. Their challenges include extremely slow download times, workstations cluttered with applications, and stovepiped databases and networks — challenges that are only going to intensify as the Navy fields new and additional sensors in the coming years. Indeed, if the Navy does not change the way it collects, processes, exploits, and disseminates information, it will reach an ISR “tipping point” — the point at which its analysts are no longer able to complete a minimum number of exploitation tasks within given time constraints — as soon as 2016.

The authors explore options for solving the Navy’s “big data” challenge, considering changes across four dimensions: people, tools and technology, data and data architectures, and demand and demand management. They recommend that the Navy pursue a cloud solution — a strategy similar to those adopted by Google, the Intelligence Community, and other large organizations grappling with big data’s challenges and opportunities.

Follow

Get every new post delivered to your Inbox.

Join 856 other followers