Monthly Archives: July 2017

Links: Bikes, jobs, why teen sex programs have fallen out of favor, hospitals, healthcare, and more!

* In parts of Indiana, the problem isn’t China. It’s too many jobs.

* Why is cycling so popular in the Netherlands?

* “Not quite half of American teens have had sex by 18. That’s actually low.” In other words, teens are more boring and phone-addicted than they once were. More seriously, this, along with increasing rates of contraception use, explains why teen-pregnancy prevention grant programs have faded from view.

* “Making cities denser always sparks resistance. Here’s how to overcome it.”

* “California lawmakers have tried for 50 years to fix the state’s housing crisis. This is why they’ve failed.”

* “A generational failure: As the U.S. fantasizes, the rest of the world builds a new transport system.”

* “Cuts threaten rural hospitals ‘hanging on by their fingernails.’” Isaac says he’s been reading the same article every couple of years for 30 years.

* “Why market competition has not brought down health care costs.” The history and analysis are good but I don’t buy the solution. I’d like to see mandatory price transparency, savings accounts, and (government-run) catastrophic insurance. Oddly, we are evolving towards a world where basically all insurance is catastrophic insurance. I think my deductible is now something like $5,000.

* “Get Able-Bodied Americans off the Couch: Nearly 95 million people have removed themselves entirely from the job market.” From the article: “According to the Kaiser Family Foundation, 41% of nondisabled adults on Medicaid do not have jobs. Thirteen million Americans 18 to 54 currently receive SSDI or SSI benefits.”

* “Big Foundations Double Down on Government Mistakes: What’s the trouble with ‘mission-related investments’? Who defines the mission.”

* Children of the Opioid Epidemic Are Flooding Foster Homes.

* Grid Batteries Are Poised to Become Cheaper Than Natural-Gas Plants in Minnesota.

* “A Conversation with Malcolm Gladwell: Revisiting Brown v. Board.” Extremely interesting and contrarian in an intelligent way that shows many familiar things in a light I’d never considered.

* “As opioid overdoses exact a higher price, communities ponder who should be saved.”

* Doctors think EMRs are hurting relationships with patients. We think so too. As I noted in this post, Isaac’s primary care provider thinks hand-charting was faster, better, and easier than digital charting is now.

* “Spending a Lot on Health Care Is the American Way: It’s a nation of consumers: Big houses, the latest gadgets, huge hospital bills.” Points rarely made about healthcare but useful throughout.

* Learning to Squat; unexpectedly found in The New Yorker. Note that few people squat, or ride bikes, or even walk around their neighborhoods, and that’s part of the reason U.S. healthcare spending is so high (pre the preceding link).

* A decade on, HPV vaccine has halved cervical cancer rate. The real tragedy is that vaccine compliance is so low.

* Are college costs finally declining, along with enrollments?

* “A promising new coalition looks to rewrite the politics of urban housing: An end to defensive planning could unleash huge change.”

* Tesla Model 3 first drive review. Or here is another variant, from The Verge instead of Motortrend.

* 34 criminal cases tossed after body cam footage shows cop planting drugs.

* Pigs are smart and sensitive, yet we continue to justify killing them for food.

* Harlem Nonprofit Plans to Offer Virtual Psychiatrist Visits in School Clinics.

* When you should call your program officer.

Everything complicated is hard, including writing grant proposals

I was just listening to Tyler Cowen’s conversation with Atul Gawande and noticed this part:

COWEN: Why do surgeons sometimes leave sponges behind in the bodies of patients who are being operated on?

GAWANDE: You zeroed in on one of my very first projects in creating intervention.

COWEN: Great paper.

GAWANDE: We had done a case control study of this problem of surgeons leaving sponges inside people, and got it published in the New England Journal [of Medicine], partly because of our whole method of going about solving this problem, which was, we studied 60 people who had sponges left inside them, compared to 240 people at the same institution at the same time with the same operation who didn’t have sponges left inside them.

I don’t want to focus on the interventions Gawande developed (he is the author of The Checklist Manifesto: How to Get Things Right, the title of which gives you a pretty big clue about one of those interventions); instead I want to focus on the fact that surgeons—who go to four years of undergrad, four years of med school, at least five years (in most cases) of residency—and who are highly motivated to not screw up procedures, because if they do people die—still manage to make seemingly elementary mistakes. Like forgetting a sponge in a patient.

Those mistakes happen, even to brilliant people, because as the cognitive load on a person increases, so does the tendency for error—even simple error. The same kinds of things happen, of course, in grant writing, although our “patients” are unlikely to die as a result. Still, the grant writing process is cognitively complex, which in part explains why so few people can become good grant writers. Interactions among the staff operating the program, the person writing the proposal, the funding agency, and the RFP are complex and can lead to errors. Even the nature of RFPs themselves lend themselves to error.

For example, I was just working on an HIV testing proposal for a client in a big Midwestern city. The narrative section of the proposal is limited to ten pages, with 1.5 line spacing, or about 7 single-spaced pages. The RFP, however, is 111 single-space pages. That’s right, the RFP is about 15 times longer than the allowed response. The possibility for error in such situations is enormous—it is cognitively difficult, and maybe impossible, to hold 111 pages of sometimes contradictory instructions, background on the applicant, and project design in one’s “RAM,” while also keeping to the max page length.

Part of our job as grant writers is to minimize error and understand where and why it might happen, so that we can prevent it to the maximum extent possible. Surgeons, who face life and death issues, don’t always manage to get the sponges out of people, even when they are very highly incentivized to do so. As such, it should not be surprising that the rest of us, who are doing cognitively complex tasks, also face major challenges in getting things right.

Everything is hard. Sometimes there is no way around that. If you’re old enough, you likely remember computers from ten or fifteen years ago that were slow and unreliable by today’s standards. Today, computers are probably more than a thousand times faster (transistor density tends to double every eighteen to twenty-four months) than they were 15 years ago. Yet Firefox is still kind of slow at times, Word still crashes, and various other programs have their foibles. One would expect computers to have transformed medicine, especially now that they’re so fast, yet every doctor hates their Electronic Medical Record (EMR) system. Isaac’s primary care physician uses eClinicalWorks and routinely complains about it being slower and less efficient than hand charting. He says finding the information he needs is harder with eClinicalWorks than it was when he charted by hand. In other words, he likes a millennia-old technology better than the latest software release.

We have faster computers, but EMRs still suck. We have faster computers, but Word still crashes. We have faster computers, but we also demand more of them. As hardware capabilities expand, we demand more of software. The software gets more complex and eats the gains from hardware speed. If I only ran programs from 10 or 15 years ago and made demands like those from that time, I could have a blazing-fast computer, but without the capabilities I like (like the ultra-high resolution 5K display on my iMac). Making software is hard, so it has problems and trade-offs.

The analogy to grant writing seems too obvious to belabor. I’ve also got to get back to the 10 page opus I’m extruding from the 111 page RFP; it’s too early for a cocktail.

Oh, and that story about the sponges? Gawande did come up with a technological fix for lost sponges: bar code each sponge and make sure that each sponge is “checked in” and “checked out.” That simple intervention means that virtually no sponges are lost in patients today. But not all problems lend themselves to technological fixes. Writing doesn’t.

“Backbone” grants for nonprofits, illustrated by the HRSA SAC and RWHAP Part C EIS programs

Human-service nonprofits face two basic challenges: keeping the lights on and providing integrated, case-managed services to meet client needs. Meeting the first challenge is obvious—if the nonprofit can’t cover basic costs like rent and salaries, the need for their services is irrelevant. The latter is trickier, since it usually takes a layer cake of grants, donations, and contracts to provide comprehensive services that really meet client needs.* To do this over the long term, it’s helpful to have at least one ongoing grant source that I’ll term a “backbone grant” for purposes of this post.

Two HRSA programs, both of which have RFPs on the street now, illustrate what backbone grants look like. In both cases, new applicants are eligible to compete with current grantees.

The Service Area Competition (SAC) provides three-year grants (often called “Section 330” or “Health Center” program grants) to Federally Qualified Health Centers (FQHCs) to provide primary health care to low-income patients. SAC grants are tagged for designated geographies called “service areas.” Hence the term “Service Area Competition or SAC;” we’ve written about the SAC grant process.

There are about 1,400 FQHCs right now, and every year a few dozen nonprofit health care providers receive a new FQHC designation, usually by receiving a New Access Point (NAP) grant. These days, FQHCs derive most of their revenue from Medicaid and other third-party payer reimbursements. Still, The Kaiser Family Foundation—a great source for health-related data—reports that Section 330 grants account for 18% of FQHC revenue. At first glance this might not seem like a lot, but imagine that your income was suddenly reduced by 18%—there goes Netflix, vacations, your rainy-day fund; you’ll be buying yoga wear at Target, not Lululemon. The same is true for FQHCs, which, like most Medicaid providers, operate on thin margins.** Thus, disaster would follow loss of Section 330 funding.

The second, Ryan White HIV/AIDS Program Part C HIV Early Intervention Services Program (RWHAP Part C EIS), provides three-year grants for outpatient primary health care and support services for low income, uninsured, and underinsured people living with HIV/AIDS (PLWH) in specified service areas. A range of nonprofit types receive RWHAP Part C EIS grants, including many FQHCs.

Not surprisingly, PLWH have very complex heath care and supportive services needs in addition to primary health care, as many also face challenges like injection drug use (IDU), other substance abuse, severe mental illness, homelessness, and so on. This makes providing case-managed integrated care to PLWH complicated and expensive. While grantees use multiple funding streams (e.g., Medicaid, other RW grants, etc.) to serve this hard-to-serve population, RWHAP Part C EIS grants are often the glue that holds the Rube Goldberg PLWH care system together. They’re the backbone grant. Without those grants, many fewer people would receive comprehensive HIV services—and they’d be more likely to transmit HIV to others.

We write many SAC and RWHAP Part C EIS proposals and know that many current grantees alternate between being indifferent and hysterical when the new funding cycle is announced. CEOs of FQHCs and similar large grantees often come to take backbone grants like these for granted (pun intended) because they’ve had the funding for years and think they’re entitled to the grant. This is a mistake.

Both programs, as well as many other similar backbone grant programs, force current grant grantees to complete with new applicants. While it’s not easy for a new applicant to “take away” a backbone grant, it can be done. We know, as we’ve helped clients do just this. We’ve also helped clients defend against new entrants to the market.

The CEO indifference towards the grant turns to hysteria when the CEO realizes the deadline is approaching and also realize they can’t receive a new backbone grant unless a technically correct and compelling proposal is submitted on time. HRSA uses peer reviewers and, from the reviewer’s point of view, applications from existing and new applicants are the same—it’s as if HRSA has never heard of the applicant, even if they’ve received the same grant for years. Victory is never final. Proposals need to meet some minimum quality threshold to be fundable. If they don’t meet that threshold, they may be rejected even if there are no other plausible providers in a given area.

The moral of this tale is twofold. If you’re a current grantee for a backbone program, don’t take your grant for granted. If you’re a new applicant, who wants to provide the service, by all means, go after the current grantee’s grant—they might stay in indifference mode and either turn in a lousy proposal or miss the deadline. It happens.


* Many grants and contracts don’t actually provide sufficient funding to do all the activities and accomplish all the goals funders require. Everyone knows this but no one talks about it. Except us.

** According to this analysis by FiveThirtyEight, state funding for colleges is down to the 8 – 20% range—which explains most of the cost of public-college tuition hikes over the last decade. For some reason, most state residents are demanding that colleges be better funded.