Telemedicine and the unstated reason it can save money for Federally Qualified Health Centers (FQHCs) and other providers

You may have read that Walgreens is is shuttering some of its in-store clinic, because the clinics are expensive to operate and, in addition, telemedicine services are taking off. Telemedicine competes with minute clinics, urgent cares, and some primary care offices; right now telemedicine is being vended through a variety of platforms, some of them independent of traditional medical providers (Teledoc is a relatively famous one), while others are affiliated with traditional providers, like FQHCs. The most interesting aspect of telemedicine services might be the one, unstated reason why they’re popular.

The official push towards telemedicine is justified by greater convenience and lower cost. So far, so good: those things are real, as is the nominal improvement in patient satisfaction, but the hidden reason is also revealing: a lot of in-person medical visits aren’t medically necessary and are generated by non-medical desires. Robin Hanson and Kevin Simler talk about this in The Elephant in the Brain: Chapter 13 describes how a lot of medicine seems to be generated by patients wanting reassurance from high-status people (doctors) and doctors wanting to enjoy the status that comes from people seeking out their expert knowledge. To be sure, “a lot of medicine” is not the same as “all medicine,” so you need not leave comments about broken bones being mended or cancers being treated.

A lot of medical office visits are costly for patient and doctor, so telemedicine can reduce the waste. In effect, telemedicine often ends up being triage: the distant provider tries to figure out whether something is genuinely wrong with the patient, and whether that thing needs to be seen in person. Almost all primary care providers have seen lots of patients who come in more for hand holding and an encounter with a sage doc than treatment of underlying condition. I haven’t seen studies describing exactly how many medical visits are really boredom, fear, craziness, improbable uncertainty, and the like, but anecdotally it seems to be high, and Hanson and Simler cite estimates in the 20 – 50% range. This is the sort of thing most of your healthcare provider friends won’t admit to strangers or acquaintances, but they may admit it to close friends or after a couple drinks. FQHC CEOs, who we work for, will sometimes admit this to us, their trusted grant writers (in our own way, we are the “trusted sages” in these conversations, reversing the roles).

So telemedicine can save money because it lets people with common colds, loneliness, and similar real or imagined ailments have a doctor, nurse practitioner, or physicians assistant tell them that they’re okay, bill them maybe less than they’d be billed for an in-person office visit, and then the provider can hang up and talk to another person who is also likely okay. Many people with chronic conditions also just need reassurance, direction to a specialist, or a prescription refilled. That can be done in a few minutes over the phone or via a videoconference. Because it’s socially undesirable and even unacceptable to admit that a lot of medicine is not what we typically think it’s about, not much can be done to substantially improve the system at current levels of technology, but offering telemedicine can be an improvement. HRSA has noticed something like this and is now pushing for FQHCs to offer telemedicine. Healthcare now consumed about 18% of GDP, in a $20 trillion economy, or about $3.7 trillion dollars. There’s enormous pressure on almost every player to try and lower costs as a consequence of these unbelievable numbers. One way or another, the average worker is paying about one in every five dollars earned into medicine—whether that dollar is paid to insurance companies, hospitals, or levels of government via taxes. Strangely, though, regulators are letting hospitals merge and form local monopolies and oligopolies, which is an important exception to the lower-cost trend. Telehealth, however, is right on trend.

Links: Freedom for nonprofits, fun RFPs, car-free LA, insurance weirdness, grant $ spent at strip clubs, and more!

* “Jeff Bezos is quietly letting his charities do something radical — whatever they want.” “[Bezos] has given them life-changing money with virtually no restrictions, formal vetting, or oversight, according to Recode’s interviews with eight of those funded by him and others familiar with his donations.” This is what giving looks like when it’s supposed to be about getting the work done, rather than increasing the status and stature of the funder; note that almost no funders operate this way. This is also somewhat closer to how many VCs operate: they give money to the entrepreneur and tell the entrepreneur to implement more or less as she sees fit. We’ve also written about narrative as Amazon’s competitive advantage.

* “New federally funded clinics in California emphasize abstinence and ‘natural family planning.'” What could go wrong? But, importantly, we also wrote a bunch of Community-Based Abstinence Education (CBAE) grants back in the day, and they were an interesting lesson in how to write “evidence-based” applications when the evidence seemed to point in the opposite direction of what the RFPs required.

* “Baseline Inventory and Assessment of Newly Acquired Lands” is the title of an actual RFP in the Federal Register. I also like this, from grants.gov: “Batty about Bats program.” This program is meant to “increase public education about bats, white nose syndrome, and the importance of bats to the environment.” In Tucson I lived near an underpass that was famous for also being a bat house, which could be better than living near a frat house.

* “Car-Free in L.A.? Don’t Laugh.” There are two major spending categories—housing and transportation—that can be substantially reduced with existing technologies, provided the politics can be solved. Healthcare and education cost rises, however, seem to be due to Baumol’s cost disease and for that reason are likely resistant to substantial reform. But housing (typically the largest cost for a given individual or family) and transportation can both be made far less expensive.

* Insured price $2,758, cash price $521. Perhaps our policy makers ought to do something about this?

* “‘It’s going to be a crisis’: D.C. may be left without a halfway house for men returning from federal prison.” Another story that’s fundamentally about zoning, NIMBYs, and land costs.

* “American With No Medical Training Ran Center For Malnourished Ugandan Kids. 105 Died.” This is the space where “good intentions” meet “lack of knowledge.”

* Give later?

* Is the AIDS Healthcare Foundation fraudulently misusing savings from a federal drug-discount program designed to help poor patients? I have no idea about the merits of this story. Still, it is one of the rare mentions of the 340(b) program I’ve seen in the larger media, although we mention 340(b) in just about every proposal we write for FQHCs—which means we write about 340(b) “a lot.”

* Simple cash transfers might be the optimal way to reduce severe global poverty.

* “A Gates-funded program meant to keep low-income students pushed them out instead.” The author observed on Twitter, probably correctly, “I kind of always beat the same drum when it comes to education policy: we don’t really know how to turn money into results and most programs fail.” Nonetheless, I predict more confident predictions about improving education policy. Confident predictions of success are also an important element of grant proposals.

Plus, “Fail” is a bit tricky when it comes to grants: most grants have multiple purposes, including PR cover and employment, beyond their putative purpose (many high-flying Silicon Valley types miss this distinction and so find grant-funded programs very strange).

* Why is California seeing housing starts decline by 20% amid a housing shortage? These kinds of stories explain why, adjusted for cost of living, California is the most impoverished state in the nation.

* “The Fastest Growing Jobs in America Don’t Require a College Degree.” This is heartening in some ways (college is not the apotheosis of human existence) but also points to some of the bad public policies of the last two decades. We need more work in apprenticeships and less in traditional four-year degrees.

* “Malaria breakthrough as scientists find ‘highly effective’ way to kill parasite.” This is likely to be bigger news than anything else you read this month, if it’s true.

* Health insurance coverage was down in 2018, according to the Census. Does anyone else remember the sound and fury accompanying the Affordable Care Act (ACA)? The way it dominated headlines and generated millions, if not billions, of words, from all kinds of people with all kinds of writing skills and knowledge? And yet it’s turned out to neither be the major blessing supporters hoped nor the catastrophe its opponents feared.

* Greedy hospitals fleecing the poor. And not just the poor, either, as I’ve unhappily discovered.

* “‘Out here, it’s just me’: In the medical desert of rural America, one doctor for 11,000 square miles.” Unfortunately, without comprehensive reform of the medical training and credentialing systems, this is unlikely to change. Most doctors are ritzy cosmopolitan types who want to live in or near big cities and can afford to do so. They didn’t go through four years of undergrad, four years of med school, and then three or more of years residency only to live somewhere they don’t want to live.

Right now, this problem is partially being made up for by fly-in doctors who, at great expense, fly into rural areas or hospitals, work a couple days or a week, then fly home.

* “The Atavism of Cancel Culture: Its social rewards are immediate and gratifying, its dangers distant and abstract.”

* Death By 1,000 Clicks: Where Electronic Health Records Went Wrong.

* “Drexel engineering professor ‘blew $190k in federal grant money on strip clubs, sports bars and iTunes over 10-year period.’” This is not how you’re supposed to manage your grant, in case you’re wondering.

Funders sometimes force grantees to provide services they don’t want to: FQHCs and Medication Assisted Treatment (MAT)

We often remind clients that those with the gold make the rules. Accepting a government grant means the applicant must sign a grant agreement, in which the applicant agrees not only to provide wherever services were specified in the proposal, but also abide by a myriad of regulations and laws. While many applicants will tussle with a funder over the budget, there’s rarely any point in trying to modify the boiler plate agreement—just like one can’t modify Apple or Facebook’s Terms of Service.

In addition to the specific terms of the grant agreement, grantees quickly become subject to other influences from the funder—when the Godfather makes you an offer you can’t refuse, you know that eventually you’ll be told to do something you’d otherwise not much want to do. While a federal agency is unlikely to place a horse’s head in a nonprofit Executive Director’s bed, the grantee might end up having to provide an unpalatable service.

A case in point is HRSA’s relatively recent (and divisive) endorsement of Medication Assisted Treatment (MAT) for treating opioid use disorder (OUD). Since HRSA is the primary FQHC funder, it is essentially their Godfather and has great influence over FQHCs. In the past few years, HRSA has strongly encouraged FQHCs to provide MAT. The CEOs of our FQHC clients have told us about HRSA pressure to start offering MAT. It seems that, even after several years of cajoling, only about half of our FQHC clients provide MAT, and, for many of these, MAT is only nominally offered. Other clients see offering MAT as a moral imperative, and we’ll sometimes get off the phone with one client who hates MAT and then on the phone with another client who sees not providing MAT as cruel.

“MAT” generically refers to the use of medications, usually in combination with counseling and behavioral therapies, for the treatment of substance use disorders (SUD). For OUD, this usually means prescribing and monitoring a medication like Suboxone, in which the active ingredients are buprenorphine and naloxone. While Suboxone typically reduces the cravings of people with OUD for prescribed and street opioids (e.g., oxycontin, heroin, etc.), it is itself a synthetic opioid. While MAT replaces a “bad opioid” with a “good opioid,” the patient remains addicted. Many FQHC managers and clinicians object to offering MAT for OUD, for a variety of medical, ethical, and practical reasons:

  • Like its older cousin methadone, as an opioid, Suboxone can produce euphoria and induce dependency, although its effects are milder. Still, it’s possible to overdose on Suboxone, particularly when combined with alcohol and street drugs. So it can still be deadly.
  • While MAT is supposed to be combined with some form of talking or other therapy, few FQHCs have the resources to actually provide extensive individual or group therapy, so the reality is that FQHC MAT patients will likely need Suboxone prescribed over the long term, leaving them effectively addicted. We’re aware that there’s often a wide gap here between the real world and the proposal world.
  • Unless it’s combined with some kind talking therapy that proves effective, MAT is not a short-term approach, meaning that, once an FQHC physician starts a patient on Suboxone, the patient is likely to need the prescription over a very long time—perhaps for the rest of their life. This makes the patient not only dependent on Suboxone, but also dependent on the prescriber and the FQHC, since few other local providers are likely to accept the patient and have clinicians who have obtained the necessary waiver to prescribe it. Suboxone users must be regularly monitored and seen by their prescriber, making for frequent health center visits.
  • As noted above, prescribed Suboxone can, and is often, re-sold by patients on the street.
  • Lastly, but perhaps most importantly, most FQHC health centers prefer to look like a standard group practice facility with a single waiting room/reception area. Unlike a specialized methadone or other addiction clinic, FQHC patients of all kinds are jumbled together. That means a mom bringing her five-year old in for a school physical could end up sitting between a couple of MAT users, who may look a little wild-eyed and ragged, making her and her kid uncomfortable. Since FQHCs usually lack the resources for anything beyond minor paint-up/fix up repairs, there is simply no way around this potential conflict.

Given the above, many FQHC CEOs remain resistant to adding the challenges of MAT to the many struggles they already face. Still, the ongoing pressure from HRSA means that most FQHCs will eventually be forced to provide at least a nominal MAT program to keep their HRSA Program Officer at bay. The tension between a typical mom and her five-year old against a full-fledged behavioral and mental health program is likely to remain, however. Before you leave scorching comments, however, remember that we’re trying to describe some of the real-world trade-offs here, not prescribe a course of action. What people really want in the physical space they occupy and what they say they want in the abstract are often quite different. You can see this in the relentless noise around issues like homeless service centers; everyone is in favor of them in someone else’s neighborhood and against them in their own neighborhood. Always pay attention to what a person actually does over a person’s rhetoric.

Don’t split target areas, but some programs, like HRSA’s Rural Health Network Development (RHND) Program, encourage cherry picking

In developing a grant proposal, one of the first issues is choosing the target area (or area of focus); the needs assessment is a key component of most grant proposals—but you can’t write the needs assessment without defining the target area. Without a target area, it’s not possible to craft data into the logic argument at is at the center of all needs assessments.

To make the needs assessment as tight and compelling as possible, we recommend that the target area be contiguous, if at all possible. Still, there are times when it is a good idea to split target areas—or it’s even required by the RFP.

Some federal programs, like YouthBuild, have highly structured, specific data requirements for such items as poverty level, high school graduation rate, youth unemployment rates, etc., with minimum thresholds for getting a certain number of points. Programs like YouthBuild mean that cherry picking zip codes or Census tracts can lead to a higher threshold score.

Many federal grant programs are aimed at “rural” target areas, although different federal agencies may use different definitions of what constitutes “rural”—or they provide little guidance as to what “rural” means. For example, HRSA just issued the FY ’20 NOFOs (Notice of Funding Opportunities—HRSA-speak for RFP) for the Rural Health Network Development Planning Program and the Rural Health Network Development Program.

Applicants for RHNDP and RHND must be a “Rural Health Network Development Program.” But, “If the applicant organization’s headquarters are located in a metropolitan or urban county, that also serves or has branches in a non-metropolitan or rural county, the applicant organization is not eligible solely because of the rural areas they serve, and must meet all other eligibility requirements.” Say what? And, applicants must also use the HRSA Tool to determine rural eligibility, based on “county or street address.” This being a HRSA tool, what HRSA thinks is rural may not match what anybody living there thinks. Residents of what has historically been a farm-trade small town might be surprised to learn that HRSA thinks they’re city folks, because the county seat population is slightly above a certain threshold, or expanding ex-urban development has been close enough to skew datasets from rural to nominally suburban or even urban.

Thus, while a contiguous target area is preferred, for NHNDP and RHND, you may find yourself in the data orchard picking cherries.

In most other cases, always try to avoid describing a target composed of the Towering Oaks neighborhood on the west side of Owatonna and the Scrubby Pines neighborhood on the east side, separated by the newly gentrified downtown in between. If you have a split target area, the needs assessment is going to be unnecessarily complex and may confuse the grant reviewers. You’ll find yourself writing something like, “the 2017 flood devastated the west side, which is very low-income community of color, while the Twinkie factory has brought new jobs to the east side, which is a white, working class neighborhood.” The data tables will be hard to structure and even harder to summarize in a way that makes it seem like the end of the world (always the goal in writing needs assessments).

Try to choose target area boundaries that conform to Census designations (e.g., Census tracts, Zip Codes, cities, etc.). Avoid target area boundaries like a school district enrollment area or a health district, which generally don’t conform to Census and other common data sets.

Foundation and government grant applicants: It’s “Hell yes” or “No.”

Derek Sivers has a rule for many things:

No ‘yes.’ Either ‘HELL YEAH!’ or ‘no.’” He says, “When deciding whether to do something, if you feel anything less than ‘Wow! That would be amazing! Absolutely! Hell yeah!’ — then say ‘no.’

That principle applies to other fields: are you going to get the job? If the employer really wants you, they are going to be very “hell yes,” and they are going to start courting you. With any reply other than “hell yes,” keep looking. Don’t stop looking till the contract is signed—and don’t be surprised when the employer is a whole lot more excited about you the day after you sign up with another outfit. Same is true in dating: don’t stop lining up leads unless and until that special person says HELL YES! This is also true in applying for most grant funding: assume it’s a “no” until proven otherwise.

We’ve had lots of clients over the years who have been encouraged by foundations that are eager to cultivate applications but seem decidedly less eager to actually cut the check (CTC). Talk is cheap, but the CTC moment has real costs—in pro hoops and grant seeking. Foundations are prone to delaying that magic moment, if possible. Foundations, like many of us, like the flattery and attention that comes with dangling cash in front of people who desire said cash. Note that I’m not arguing this behavior is fair or appropriate—just that it’s common. Foundation officers seemingly enjoy the flattery that comes with nonprofits’s seduction attempts.

To a lesser extent, some government funders at the federal, state, and local level also engage in the dangling CTC approach, but government rules often discourage excess promises from government officers to applicants. If your agency has applied for a government grant, you’re unlikely to hear anything until you get the hell yes email (notice of grant award) or the “thanks for a lovely evening” email (thanks, but no grant this time around). Still, if a funder, government or foundation, requests more information about your proposed budget or asks if you’ll accept a smaller grant, you’ll almost always eventually get the desired response. Few funders will bother with info requests unless they are likely to fund you.

As a rule, though, your default assumption should be that the funder is not going to fund you until they want to fund you. This is a special case of the Golden Rule. Your assumption should be “no deal:” don’t waste time anticipating a promised deal that may not happen. Spend that energy improving your services and pursuing other funding opportunities. Many foundations also like giving out the last check to make the project happen, rather than the first one, so keep chasing early grants—even small ones.

Links: Don’t steal the grant money, where the jobs are, fun grant programs, ameliorating homelessness, and more!

* Don’t embezzle grant funds. If your organization gets grant funding but can’t carry out the proposed services, just admit it and give the money back—or at least stop taking the money. This ought to go without saying and without federal prosecutors getting involved. And, an excellent way of meeting the local US Attorney is to steal grant funds. Some grantees find themselves unable to execute the grant-funded activity, and, while that isn’t optimal, it is okay.

* We have a massive truck driver shortage, and pay is increasing, albeit too slowly, given that shortage. Contrary to the hype, we still appear to be quite far from automating trucking and many other in-demand jobs.

* “There’s a high cost to making drugs more affordable for Americans.” Almost no one is talking about this. We can likely force the cost of today’s drugs and treatments lower—but at the cost of not having new drugs and treatments tomorrow. This seems like a poor tradeoff to me, although that’s a philosophical point. The interesting thing is that no one advocating for price controls admits the tradeoff.

* “Resistance to Noncompete Agreements Is a Win for Workers.” This is an area where the left and right are aligned: the left worries about worker rights, and the right (putatively) worries about free markets. Banning both is a win for left or right.

* My favorite recent grant program: “Supporting Economic Empowerment in the Pakistan Film Industry.” We really want to be hired to write a proposal for this one!

* “Fears grow over ‘food swamps’ as drugstores outsell major grocers: With CVS selling more groceries than Whole Foods and Trader Joe’s combined, researchers fear food ‘deserts’ are becoming ‘swamps’ of processed food.” Another handy proposal term. Both Isaac and I have noticed the expanding food selection at local drug stores.

* More Millennials Are Dying ‘Deaths of Despair,’ as Overdose and Suicide Rates Climb. See also the book Lost Connections.

* “Americans Need More Neighbors: A big idea in Minneapolis points the way for other cities desperately in need of housing.” Obvious but needs to be repeated, as bad land zoning is at the root of many problems in individual cities and America as a whole today. We feel some of the effects when we work on projects like Prop HHH proposals in Los Angeles. If it’s not possible to build a sufficient amount of new housing, then many actors are going to bid up the price of existing housing, and homeless service providers are rarely the top bidder.

* “Los Angeles Is in Crisis. So Why Isn’t It Building More Housing? Rising rents are feeding a surge in homelessness.” The Atlantic is now on the beat Seliger + Associates has been covering for years. These links are congruent with the links immediately above.

* “An Addiction Crisis Disguised as a Housing Crisis: Opioids are fueling homelessness on the West Coast.” Or, as I’d put it, “Both at once, and interacting with each other.”

* The Machiavelli of Maryland: Edward Luttwak is adviser to presidents, prime ministers – and the Dalai Lama. Hugely entertaining, and via MR.

* “Why Transparency on Medical Prices Could Actually Make Them Go Higher.” I’ve long been a price-transparency proponent, but maybe I’m wrong.

* “Housing crisis: Why can’t California pass more housing legislation?” This is much of the reason homelessness is increasing in California: it’s almost illegal to build housing for humans.

* “Why mention the Affordable Care Act (ACA) when Democrats can debate shiny new Medicare-for-all?” I post this not for the political valence but for the discussion of what has and has not changed in healthcare over the last decade; in many ways, there’s been less change than both ACA proponents hoped for and opponents feared.

* Why Are U.S. Drivers Killing So Many Pedestrians? “If anything else—a disease, terrorists, gun-wielding crazies—killed as many Americans as cars do, we’d regard it as a national emergency.” Maybe the automotive era was a terrible, murderous mistake.

* “Progressive Boomers Are Making It Impossible For Cities To Fix The Housing Crisis: Residents of wealthy neighborhoods are taking extreme measures to block much-needed housing and transportation projects.” Not far from what you’ve been reading here for years, but the news is getting out there.

* “Live carbon neutral with Wren: Offset your carbon footprint through a monthly subscription.” Many people wonder what they as individuals can do. Here is one answer.

* “The numbers are in: SF homeless population rose 30% since 2017.” While people are slowly but surely linking SF’s terrible zoning rules with its extraordinary homelessness challenges (just like L.A.), the city isn’t moving fast enough to make real changes. Interesting fact: about one in 100 San Francisco “residents” lack a place to live. And there is purported to be more dogs than kids living in SF.

* “FBI investigating tattooed deputy gangs in Los Angeles County Sheriff’s Department.” This is almost unbelievable, but here it is.

* The radical case for teaching kids stuff. Relevant to those of you running early childhood education programs like Head Start and UPK.

* “Seliger + Associates enters grant writing oral history (or something like that).” This is a favorite essay, as since then we’ve seen, many times, our own phrases and proposal structures come back to us, like ships in a bottle dropped at sea that then wash up on our shores.

Why we like writing SAMHSA proposals: the RFP structure is clear and never changes

We wrote our first funded Substance Abuse and Mental Health Administration (SAMHSA) grant about 25 years ago, and there’s something notable about SAMHSA: unlike virtually all of their federal agency sisters, SAMHSA RFPs are well structured. Even better, the RFP structure seemingly never changes—or at least not for the past quarter century. This makes drafting a SAMHSA proposal refreshingly straightforward and enables us, and other competent writers, to (relatively) easily and coherently spin our grant writing “Tales of Brave Ulysses.” The word “coherently” in the preceding sentence is important: RFPs that destroy narrative flow by asking dozens of unrelated sub-questions also destroy the coherence of the story the writer is trying to tell and the program the writer is trying to describe. SAMHSA RFPs typically allow the applicant to answer the 5Ws and H.

A SAMHSA RFP almost always uses a variation on a basic, five element structure:

  • Section A: Population of Focus and Statement of Need
  • Section B: Proposed Implementation Approach
  • Section C: Proposed Evidence-Based Service/Practice
  • Section D: Staff and Organizational Experience
  • Section E: Data Collection and Performance Measurement

While SAMHSA RFPs, of course, include many required sub-headers that demand corresponding details, this structure lends itself to the standard outline format that we prefer (e.g., I.A.1.a). We like using outlines, because it makes it easy for us to organize our presentation and for reviewers to find responses to specific items requested in the RFP—as long as the outlines make sense and, as noted above, don’t interrupt narrative flow. In this respect, SAMHSA RFPs are easy for us to work with.

In recent years, SAMSHA has also reduced the maximum proposal length (exclusive of many required attachments) from 25 single-spaced pages to, in many cases, 10 single-spaced pages. Although it’s generally harder to write about complex subjects with a severe page limit than a much longer page limit, we’re good at packing a lot into a small space.* A novice grant writer, however, is likely to be intimidated by a SAMHSA RFP, due to the forbidding nature of the typical project concept and the brief page limit. In our experience, very long proposals are rarely better and are often worse than shorter ones.

We haven’t talked in this post about what SAMHSA does, because the nature of the organization’s mission doesn’t necessarily affect the kinds of RFPs the organization produces. Still, and not surprisingly, given its name, SAMSHA is the primary direct federal funder of grants for substance abuse and persistent mental illness prevention and treatment. With the recent and continuing tsunami of the twin co-related scourges of opioid use disorder (OUD) and homelessness, Congress has appropriated greater funding for SAMHSA and the agency is going through one of its cyclical rises in prominence in the grant firmament. Until we as a society get a handle on the opioid crisis, SAMHSA is going to get a lot of funding and attention.


* When writing a short proposal in response to a complex RFP, keep Rufo’s small luggage in Robert Heinlein’s Glory Road in mind: “Rufo’s baggage turned out to be a little black box about the size and shape of a portable typewriter. He opened it. And opened it again. And kept on opening it–And kept right on unfolding its sides and letting them down until the durn thing was the size of a small moving van and even more packed.” The bag was bigger on the inside than the outside, like a well-written SAMHSA proposal.

Washington Post’s story on rural health care ignores Federally Qualified Health Centers (FQHCs) — huh?

Eli Saslow recently wrote a 3,500-word Washington Post story about rural healthcare in “Urgent needs from head to toe’: This clinic had two days to fix a lifetime of needs.” Although it reads like a dispatch from Doctors Without Borders in Botswana, Saslow is describing rural Meigs County TN. Rural America certainly faces significant unmet healthcare needs, but this piece has a strange omission: it doesn’t mention Federally Qualified Health Centers (FQHCs).

The Tennessee Primary Care Association reports over 30 Federally Qualified Health Centers (FQHCs) operating over 200 health clinics in the state, most in rural areas—including at least four in or near Meigs County! FQHCs are nonprofits that receive HRSA Section 330 grants to provide integrated primary care, dental care, and behavioral health services to low-income and uninsured patients. FQHCs also accept Medicaid and, in rural areas, are usually the main primary care providers, along with ERs.

Federal law requires FQHCs to provide services under a sliding-fee scale, with a nominal charge for very-low-income patients—in theory, at least, FQHCs never turn patients away due to lack of ability to pay. Similarly, federal law requires ERs to treat everyone, regardless of income and/or insurance status. Unlike ERs, however, FQHCs provide a “medical home” for patients. There are over 1,400 FQHCs, with thousands of sites, both fixed and mobile, to better reach isolated rural areas like Meigs County. We should know—we’ve written dozens of funded HRSA grants for FQHCs, including many serving rural areas like Meigs County.

The story’s hero is Rural Area Medical (RAM), a nonprofit that appears to set up temporary clinics under the free clinic model. Free clinics emerged from the runaway youth health crisis of the late 60s, starting in the Summer of Love in San Francisco—I was on the board of a free clinic over 40 years ago and understand the model well. While there are still over 1,400 official free clinic sites, free clinics largely depend on volunteer medical staff, may not accept Medicaid, and have insecure funding because they rely on donations (often from their volunteers) to keep the lights on. To operate, a free clinic must necessarily devote much of its resources away from direct services to maintaining volunteers and fundraising, like any nonprofit that depends on volunteer labor (think Habitat for Humanity).

Unlike FQHCs, free clinics patients don’t have a designated primary care provider (PCP), since a given doc or NP might be volunteering or not on a given day—like an ER, free clinic patients lack a true medical home. Free clinics aren’t generally eligible to participate in the federally subsidized 340B Discount Pharmacy Program, so patients don’t have access to long-term, low-cost medications. Free clinics, while once the only source of healthcare for many uninsured, have now mostly been overtaken by FQHCs, much as the days of the independent tutor ended with the coming of public schools. We’ve worked for a few free clinics over the years, and most were struggling to stay open and provided erratic services. Their executive directors could feel which way the wind is blowing and consequently many were trying trying to become FQHCs.

I wonder: has RAM applied to become an FQHC and open a permanent site in Meigs County? I don’t know anything about Meigs County, and it’s possible that the local FQHCs are incompetent or poorly run and could use some new competitors. HRSA just had a New Access Points (NAP) competition, with over $200 million to found and fund new sites. If the the healthcare situation is dire in Meigs County, applying for NAP grant makes much more sense than setting up shop for a weekend. Does RAM refer patients to local FQHCs? That may be a more efficacious long-term solution than the superman approach of flying in, saving the day, and flying out (imagine if education worked the same way, with itinerant teachers stopping by to give a lecture on geometry one day, Shakespeare’s sonnets the next, and the gall bladder the day after).

The original story is great as human interest, but it doesn’t go into root causes. Some consulting organization created the “Five Whys” strategy or methodology, which holds that, for any given problem, it’s often not useful to look at a single moment or cause of failure or inadequacy. Rather, systems enable failure, and for any given failure, it’s necessary to look deeper than the immediate event. Some of the other underlying problems in this story include the American Medical Association (AMA), which controls med school slots, and the individual medical specialty associations, which control residency slots. The U.S. has been training too few doctors and doing an inadequate job getting those doctors into residency for decades. Detail on this subject is too specific for this piece, but Ezekiel Emanuel has a good article on the subject; med school needs to be integrated with undergrad and needs a year lopped off it. The way medical training works right now is too expensive and too long, creating physician shortages—especially in the places that need physicians most. The supply-demand mismatch raises the costs of physician services and mean that physicians charge more for services than they otherwise would.

Rural areas have also faced decades of economic headwinds, with young adults moving to job centers, leaving an aging-in-place population that needs many support services; declining tax base from manufacturing leaving for emerging countries; the opioid epidemic; and so on. While I wouldn’t expect Saslow to fully cover such factors, context is missing and at least a passing reference to FQHCs would make sense.

Another piece of the evaluation puzzle: Why do experiments make people unhappy?

The more time you spend around grants, grant writing, nonprofits, public agencies, and funders, the more apparent it becomes that the “evaluation” section of most proposals is only barely separate in genre from mythology and folktales, yet most grant RFPs include requests for evaluations that are, if not outright bogus, then at least improbable—they’re not going to happen in the real world. We’ve written quite a bit on this subject, for two reasons: one is my own intellectual curiosity, but the second is for clients who worry that funders want a real-deal, full-on, intellectually and epistemologically rigorous evaluation (hint: they don’t).

That’s the wind-up to “Why Do Experiments Make People Uneasy?“, Alex Tabarrok’s post on a paper about how “Meyer et al. show in a series of 16 tests that unease with experiments is replicable and general.” Tabarrok calls the paper “important and sad,” and I agree, but the paper also reveals an important (and previously implicit) point about evaluation proposal sections for nonprofit and public agencies: funders don’t care about real evaluations because a real evaluation will probably make the applicant, the funder, and the general public uneasy. Not only do they make people uneasy, but most people don’t even understand how a real evaluation works in a human-services organization, how to collect data, what a randomized controlled trial is, and so on.

There’s an analogous situation in medicine; I’ve spent a lot of time around doctors who are friends, and I’d love to tell some specific stories,* but I’ll say that while everyone is nominally in favor of “evidence-based medicine” as an abstract idea, most of those who superficially favor it don’t really understand what it means, how to do it, or how to make major changes based on evidence. It’s often an empty buzzword, like “best practices” or “patient-centered care.”

In many nonprofit and public agencies, evaluations and effectiveness are the same: everyone putatively believes in them, but almost no one understands them or wants real evaluations conducted. Plus, beyond that epistemic problem, even if evaluations are effective in a given circumstance (they’re usually not), they don’t necessarily transfer. If you’re curious about why, Experimental Conversations: Perspectives on Randomized Trials in Development Economics is a good place to start—and this is the book least likely to be read, out of all the books I’ve ever recommended here. Normal people like reading 50 Shades of Grey and The Name of the Rose, not Experimental Conversations.

In the meantime, some funders have gotten word about RCTs. For example, the Department of Justice’s (DOJ) Bureau of Justice Assistance’s (BJA) Second Chance Act RFPs have bonus points in them for RCTs. I’ll be astounded if more than a handful of applicants even attempt a real RCT—for one thing, there’s not enough money available to conduct a rigorous RCT, which typically requires paying the control group to follow up for long-term tracking. Whoever put the RCT in this RFP probably wasn’t thinking about that real-world issue.

It’s easy to imagine a world in which donors and funders demand real, true, and rigorous evaluations. But they don’t. Donors mostly want to feel warm fuzzies and the status that comes from being fawned over—and I approve those things too, by the way, as they make the world go round. Government funders mostly want to make congress feel good, while cultivating an aura of sanctity and kindness. The number of funders who will make nonprofit funding contingent on true evaluations is small, and the number willing to pay for true evaluations is smaller still. And that’s why we get the system we get. The mistake some nonprofits make is thinking that the evaluation sections of proposals are for real. They’re not. They’re almost pure proposal world.


* The stories are juicy and also not flattering to some of the residency and department heads involved.

Links: Housing, grant size, the perils of EMRs, the nature of energy, addiction and treatment, and more!

* Death by a thousand clicks: How electronic medical record (EMR) systems went wrong. We’ve written so many proposals involving EMR systems, and yet it seems they’ve had little if any positive impact on the overall landscape, in terms of health or cost.

* “California Has a Housing Crisis. The Answer Is More Housing.” One of these obvious things, yet here we are.

* “When It Comes To Applying for Grants, Size Doesn’t Matter (Usually).”

* “A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills. I spent a year writing about ER bills. Zuckerberg San Francisco General has the most surprising billing practices I’ve seen.” Remember how we wrote about the need for price transparency? This is another specific instance of that general point.

* Waymo’s CEO says autonomous cars “will always have constraints.” They are not a panacea for urban transit and are not going to be here in the next five years, and they will likely be weather-dependent.

* Is fusion power much closer to becoming reality than is commonly anticipated? If so, it will solve or substantially ameliorate the world’s energy problems, along with the geopolitical conflicts fueled by the world’s desire for oil.

* “Firms Learn That as They Help Charities, They Also Help Their Brands.” This is firmly “dog bites man” story instead of a “man bites dog” story, but there it is.

* “California will sue Huntington Beach over blocked homebuilding.” Good news.

* “Most People With Addiction Grow Out of It,” something not widely appreciated in the larger culture and a factoid we never include in the many SUD/OUD treatment proposals we write.

* Public Education’s Dirty Secret. Congruent with my experiences.

* “Is the Revolution of 3D-Printed Building Getting Closer?” Let’s hope so, as that would likely substantially decrease construction costs.

* Japanese urbanism and its application to the Anglo-World.

* “Climeworks: The Tiny Swiss Company That Thinks It Can Help Stop Climate Change.” Not just the usual.

* From Literature to Web Development: My first 6 weeks at Lambda School.

* * “A Radically Moderate Answer to Climate Change.” You may be getting tired of reading about nuclear power, yet we still seem as a culture not to be paying attention to it. See also “Nuclear goes retro — with a much greener outlook.”

* “This is Roquette Science: How computerized arugula (aka roquette) farms take over the world.”

* How to Create Reality: “So a funny thing happened on Twitter this week, which almost changed the world a little bit. Someone sent me a beautiful 3-D mockup of a fictional, car-free city of 50,000 people, set in the scenic nook of land* between Boulder, Colorado and Longmont, where I live.”

* “Science, Small Groups, and Stochasticity.” In short, we are doing the structure of science wrong.

* “The corporations devouring American colleges.” Colleges are businesses with extremely good PR and marketing arms.

* “The Streets Were Never Free. Congestion Pricing Finally Makes That Plain..” Seems obvious to me.

* “The antibiotics industry is broken—but there’s a fix.”

* “The 2008 financial crisis completely changed what majors students choose.” How could it not?

* “Lambda, an online school, wants to teach nursing.” Good. Competing with existing schools is a feature, not a bug. See also that other link about Lambda School, above.

* Most of America’s Rural Areas Are Doomed to Decline. Basically, agriculture now accounts for perhaps 2% of the workforce; manufacturing accounts for less than 15% of the workforce, and even as manufacturing has increased in value produced, it hasn’t much increased in jobs.

* “Considerations On Cost Disease‘s” money shot:

So, to summarize: in the past fifty years, education costs have doubled, college costs have dectupled, health insurance costs have dectupled, subway costs have at least dectupled, and housing costs have increased by about fifty percent. US health care costs about four times as much as equivalent health care in other First World countries; US subways cost about eight times as much as equivalent subways in other First World countries.

I worry that people don’t appreciate how weird this is.