Tag Archives: Healthcare

Links: The online ad bubble, funny RFPs, college grads and job training, the nature of behavioral health, and more!

* “The new dot com bubble is here: it’s called online advertising.” One could alternately ask, “What do we really know about the effectiveness of digital advertising?” The answer seems to be, “Not much.” The idea that many companies throw away tens or hundreds of millions of dollars annually, and in some cases more, seems barely believable.

* One of my favorite recent RFPs is for “Strengthening U.S.-Ukraine Business Relations while Addressing Social Issues through ‘Serious Game Jam.'” That’s from the Dept. of State, and it has $100,000 to “introduce U.S. companies to the Ukrainian gaming industry and promote good corporate governance by creating a platform for U.S. developers to collaborate with their Ukrainian counterparts on tackling social issues through ‘serious games.'”

* You may have heard that 41% of college grads are working jobs that don’t require the degree. What should this do to our view on college for everyone, as a panacea to our economic woes? In other education news, “U.S. Higher Education Has a Foreign Money Problem“—but this is mostly the rich, highly marketed schools. Having been a part of higher ed for a long time, I favor a much stronger push towards apprenticeships and vocational education. Lots of people don’t like sitting still and doing abstract symbol manipulation, and we should stop pretending that those personality traits are key to a meaningful life.

* “The evidence for evidence-based therapy is not as clear as we thought.” That shouldn’t, for now, stop you from citing CBT, MET, etc. in your SAMHSA proposals. It still seems, however, that we don’t really know what makes therapy work or how it should work: we’re still leaping in the dark. Colorado, however, looks like it will, in November, decriminalize psychedelics, and a number of research projects are using psychedelics for therapy.

* Owning a car hurts your health. “Beijing has limited the number of new car permits it issues to 240,000 a year… Those permits are issued in a monthly lottery with more than 50 losers for every winner.” Older winners gained more than 20 pounds, compared to the control group of non-winners. Given COVID-19 social distancing and fears, it may be a while until mass transit gains its recent luster.

* Book Review: Just giving. I was surprised by the first quarter of the review and didn’t see the shift coming, although in retrospect I should have.

* Why the US sucks at building public transit. If we could get better at this, we could slash many households’s transit costs and thus free up more money for anything and everything else. Except for endless COVID-19 news, which is scaring most people off of public transit, even though wearing masks on public transit appears to prevent COVID from spreading.

* “Why Japan is obsessed with paper.” I have complained periodically about American publishers not being obsessed with paper at all, and the crappy paper quality used in most books. The New York Review of Books books are among the notable exceptions.

* “In the Future, Everything Will Be Made of Chickpeas.” One hopes. A pressure cooker helps.

* “In Philanthropy, Race Is Still a Factor in Who Gets What, Study Shows.” This is the New York Times, after all.

* For over a decade, the Permian Basin in Texas and New Mexico has been the epicenter of the American oil boom. Now, it’s the epicenter of its demise. I’ve read versions of this article a couple times already. The Permian Basin could be going back the back economic times that served as the backdrop for the book, movie, and great TV series, Friday Night Lights.

* Can genetic engineering bring back the chestnut tree? If so, that would be great news: chestnuts produce lots of cheap food and good wood. And, then there’s Jurassic Park style dinosaurs. Maybe they’ll love to eat genetically engineered chestnuts.

* The Early Days of China’s Coronavirus Coverup. If not for Chinese censorship, the rest of the world might have been much better prepared.

* The new language of telehealth. Maybe.

* “Exclusive: Tesla’s secret batteries aim to rework the maths for electric cars and the grid.” Maybe. It does seem that nickel and low-cobalt batteries are coming. The second-life systems are also hugely impressive: one rarely appreciated reason to pick electric vehicles is that their batteries can be repurposed for grid storage when the car itself reaches end-of-life. Here is one story on how “Millions of used electric car batteries will help store energy for the grid.”

* Cities are transforming as electric bike sales skyrocket. It is now possible to buy very good electric bikes for $1,500 retail and less-good ones for about $1,000. In this case, COVID-19 terror should help.

* The pandemic is bringing us closer to our robot takeout future?.

* MacOS 10.15: Slow by design. Thankfully I haven’t “upgraded,” although this is not an actual upgrade. We have written periodically about how we use Macs at Seliger + Associates, but we may need to re-think that usage given Apple’s direction.

Less obvious things that impact human services during the coronavirus pandemic

The news about coronavirus focuses rightly on life and death and the struggles of hospitals, as well the need for social distancing and the suspensions of large gatherings. Emergency measures that last for a few weeks are one thing, but it looks like this crisis may continue for several months. While the media is generally doing a good job of crisis coverage, some aspects of particular interest to nonprofit human services providers are being narrowly covered at best.

For example, arrests by the LAPD are dropping, and many court systems are deferring or dismissing non-felony cases, since no one wants coronavirus to rip through jails. It’s hard to say what lowered policing and low-level case dismissal means: maybe many arrests were bogus in the first place. But maybe they weren’t, and we’re likely going to see substantially increased crime as people adjust to this new normal—most big city cops aren’t arresting people, even for such fairly serious crimes as burglary and car break-ins. It’s also possible that petty crime—and even crime in general—will decline because would-be criminals are at home and either don’t want to get coronavirus themselves, or they know most people are holed up at home, and many of those holed up at home are armed. It’s beyond the purview of our knowledge and subject matter to discuss this in detail, but there’s also a lively debate about whether most crime is premeditated versus simply persons seeing what they perceive as opportunity and then acting on it.

Some incarcerated persons are already being released early; released arrestees and, more importantly, recently released prisoners need something productive to do and to earn legitimate income—which usually means case-managed job training and placement of some kind. We’ve written many funded proposals for services for ex-offenders and, even in good times, this is not an easy population to work with. The unemployment rate is likely 10% and may spike as high as 20% in the coming months, further complicating matters. In the short term, however, there’ll be huge need, and likely lots of grant money available, to provide these services. Training and placement, alway challenging, will be hard, given social distancing, but some nonprofits have to try, perhaps with sufficient social distancing measure and/or tele-case management.

Another issue: thousands of 12-Step Program meetings, like Alcoholics Anonymous, are being cancelled—and these programs are based mostly on in-person peer support. Behavioral health provides will have to suspend in-person individual and group sessions, leaving millions more with SUD/OUD and/or severe and persistent mental illness (SPMI) more or less on their own. Add the incredible stressors of job/income loss, stay-at-home orders, and the like to addiction and mental health issues, and a huge human toll is likely. We’ve seen estimates that 10% of the US population has mental health or substance abuse challenges that are mitigated by in-person support. Most people don’t get the same effects from digital communications tools that we do from in-person interaction. Still, this is an opportunity for nimble nonprofits to seek foundation and government grants to establish or scale-up tele-behavioral health services.

Lots of people have realized that shuttered movie theaters may never recover; fewer people are thinking openly about what we ought to be doing with the most vulnerable persons who are facing serious disruptions, on top of the obvious coronavirus disruptions.

Links: Healthcare and how it’s eating the world, education, homelessness and weird public policies, the nature of the good life, and more!

* “The Pedagogical Lessons and Tradeoffs of Online Higher Education.” Education and healthcare both seem to lack silver bullets, although we keep looking for them. See also us on the need to boost apprenticeships and vocational education. This is based in part on my experiences teaching college students.

* “The U.S. Furniture Industry Is Back—but There Aren’t Enough Workers: Companies expanding American production due to consumer preferences and tariffs are finding a dearth of skilled workers.”

* “As Homelessness Surges in California, So Does a Backlash.” Who could have predicted that homelessness is part of the regulatory environment that precludes the building of homes?

* “Apple Commits $2.5B to Ease California Housing Crunch.” Unfortunately, money is not the big problem here—zoning policies that prevent new housing from being constructed is the problem. Until we decide that more housing is a good idea, more money is mostly going to be used to bid up the prices of existing housing. Oregon, for example, has legalized townhomes statewide, and California should be doing the same. We’ve worked on some homeless-service proposals, but it’s depressing to see California raise a bunch of money that then can’t be used efficaciously because of their zoning policies.

* “The Key to Electric Cars Is Batteries. Chinese Firm CATL Dominates the Industry.” Have not seen this triangulated from other sources, however.

* Unraveling an HIV cluster.

* “Why It’s So Hard to Buy ‘Real Food’ in Farm Country. An exodus of grocery stores is turning rural towns into food deserts. But some are fighting back by opening their own local markets.” Seems like an Onion story, but seemingly not.

* “San Francisco Board of Supervisors questions $900K/unit cost for Sunnydale ‘affordable’ housing.” Until we do zoning reform, we can’t build affordable housing, as noted above. Meanwhile, southern California is little better: “Some of Los Angeles’ homeless could get apartments that cost more than private homes, study finds.”

* $30 million in grants to fund nuclear fusion research. That’s cool.

* Air Pollution Reduces IQ, a Lot. If you are worried about human welfare, attacking air pollution is key. Normal people can do this, too, by choosing low-emissions vehicles.

* Medical billing: where all the frauds are legal. We’ve heard that many healthcare providers, including FQHCs, are forced to be medical billers first, and everything else second, or third, or worse. In related news, A CT scan costs $1,100 in the US — and $140 in Holland.” You’ve heard it before, but: price transparency now. What’s stopping this? “Doctors Win Again, in Cautionary Tale for Democrats: Surprise billing legislation suddenly stalled. The proposal might have lowered the pay of some physicians.” There are few if any easy wins.

* Why white-collar workers spend all day at the office. It’s a signaling race. Most writers know we have 2 – 4 decent hours a day in us for real writing, for example.

* “California population growth slowest since 1900 as residents leave, immigration decelerates..” This is purely a political and legal problem, which means it’s very solvable. Also, “‘Garages aren’t even cheap anymore:’ Bay Area exodus drives lowest growth rate in years.” California is a gerontocracy ruled by zombie homeowners who bought their properties decades ago, pay low property taxes on them, and now block anyone else from building anything, anywhere.

* Magic mushroom compound psilocybin found safe for consumption in largest ever controlled study.

* AI and adaptive learning in education. This could and should be a big deal.

* “Denser Housing Is Gaining Traction on America’s East Coast: Maryland joins Virginia with a new proposal to tackle the affordable housing crisis. And it’s sweeping in its ambition.”

* Dan Wang on science, technology, China, and many other matters of interest.

* Letting nurse practitioners be independent increases access to health care? See also my post, Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school. Healthcare fields seem to have near-infinite job growth, which is useful knowledge for job-training programs.

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.

“Health insurance security” and FQHCs

I hesitate to post this, because it’s a bit more political than the topics we typically cover, but it’s explanatory more than partisan: “The 2018 Elections Were Not About Obamacare–They Were About Health Insurance Security.” In it, Bob Laszewski describes how “In March of 2016, there were 20.2 million people covered in the individual health insurance market,” but by “March of 2018 the count was 15.7 million.” Why? Because individual market “premiums and deductibles are sky high–for all but the lowest income participants.” Consider this data:

In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits.

That same family, but making too much for a subsidy, as 40% of families do, and a typical family in the affluent Virginia 10th, would have to spend $19,484 in premiums plus a $6,500 deductible, for a total of $25,984 in eligible costs before they would collect any meaningful benefits.

Those are shocking numbers, no? Yet we rarely see them, or numbers like them, in the larger media landscape. Many people have individual experiences of such things, including me; I’m covered by a small group employer plan, not an individual market plan, but my own deductible is now about $5,000. Two years ago, it was $4,500, and when I had a minor procedure to fix a toe I’d dropped a pan on, I spent $4,500 out of pocket almost immediately. Not only that, but when I saw podiatrists to get fee quotes on the procedure, most could not or would not give them to me. Even people who say they want to pay in cash often cannot find out how much a particular service will cost. When I inquired about the price of an office visit, most receptionists were confused but could eventually get an answer, and prices varied hugely, from as little as $40 to as much as $350. Why? I don’t know.

Oh, and the podiatrist billed my insurance for something like $12,000, beyond the $4,500 I paid, and she got $900 out of the insurance company. So her net benefit from the procedure was $4,500 in cash (from me) plus $900 from the insurance company. It is almost impossible to read this paragraph and not think, “Something is horribly wrong here.”

And I am not alone: almost anyone not covered by a very large employer plan, Medicaid, or Medicare has had similar experiences.

There is also an absurdly common misconception among normal people: that “insurance” is what matters for healthcare. Insurance is only part of the puzzle, but “insurance” is only as good as the healthcare we can access with it. Many doctors, for example, don’t accept Medicaid patients. So someone on Medicaid who counts as “having insurance” may not have access to care. Laszewski points out that many people “have insurance” (which is fine), but if the insurance never kicks in for the average person, then it is not functioning like true insurance, but not as the pay-all system that health insurance means to most Americans.

Federally Qualified Health Centers (FQHCs), which are federally funded nonprofits, have supersized in part because of the strange path of the US healthcare markets. Either by accident or design, FQHCs have become the default Medicaid providers in many parts of the country at the same time that the ACA significantly expanded Medicaid eligibility. Policy wonks in DC, along with some politicians, know that “insurance” is not the same as “health care” (as I myself said above). Even if politicians don’t know that, many of their constituents and voters who are on Medicaid know it. FQHCs are a partial solution, because they accept Medicaid patients and self-pays on sliding fee scales. FQHCs have also become front-line purveyors of Patient Navigation services (which link patients with Medicaid or ACA plans). Still, FQHCs usually do not have enough slots for everyone who seeks care, and waits can be long; FQHCs also often have trouble recruiting clinicians and in particular specialties like OB/GYN and psychiatrist.*

So the convoluted and intertwined health insurance and care access problems remain; the present situation likely cannot hold forever; and I do not know what will happen, politically speaking. But I would surmise that, if a family of four making $65,000 a year must pay $10,000 or more in true costs for healthcare before some manner of insurance kicks in, something has to give.

Single-payer is popular in some American political circles, though it’s not my preferred outcome and seems unfeasible financially; I’d rather see price transparency and mandatory health savings accounts coupled with true insurance for catastrophic care. Unfortunately, no one but me and a handful of healthcare wonks desire this outcome, or something adjacent. It’s hard to explain in a soundbite and normal voters have no idea what “price transparency and mandatory health savings accounts coupled with true insurance for catastrophic care” means. It doesn’t map well onto political ideologies. In healthcare, no one wants to talk about or admit to trade-offs. We write many grant proposals for FQHCs, but we never mention trade-offs. Seliger + Associates is a grant writing firm, so we’re firmly in the proposal world. All FQHCs should be in the proposal world when writing HRSA or SAMHSA or foundation applications. In the real world, however, just saying it’s so, doesn’t make it so. Trade-offs are real and pervasive. It may be socially undesirable to acknowledge them, but they are real.

The most likely political outcome will be more kludges on top of existing kludges. Fortunately, “price transparency” would fit this general paradigm. Unfortunately, there seems to be no political constituency for it. I cannot say what will happen next. I did not think Obamacare would happen, and I was wrong about that. I also did not realize that the feds would re-purpose FQHCs in the way that they have, as Medicaid providers, yet here we are. In healthcare, it seems, almost anything is, or has become, possible.

* This is largely due to barriers to entry imposed by existing doctors and especially the powerful American Medical Association. Many things could be done to increase the supply of doctors, including integrating med school into undergrad; shortening med school; allowing foreign doctors to practice without residency; or creating a special one-year residency for foreign doctors. None, however, are on the political horizon.

Preventive care doesn’t save money, bankruptcies aren’t widely caused by lack of insurance, and FQHCs

Preventive Care Saves Money? Sorry, It’s Too Good to Be True” tells you everything you need to know in the headline, though you should of course read the article. The point is important because a lot of Health Resources and Services Administration (HRSA) funding for Federally Qualified Health Centers (FQHCs) is premised on the idea that more primary preventive care will save money and slow the seemingly inexorable rise in healthcare costs. There’s an intuitive, seductive logic to the argument: it seems like it should be true that prevention is superior to treatment.

But we, collectively, don’t actually know if most healthcare is good for most people most of the time. The Robin Hanson and Kevin Simler book The Elephant in the Brain has a chapter on medicine that demonstrates most medical care is actually wasted and unnecessary. We still pursue costly, low-importance care for status reasons that are too long to describe in this post, but interested readers are directed to the book. The idea that preventive care doesn’t reduce costs and may do little to improve health is congruent with the Hanson-Simler idea that most healthcare is not actually about health.

In other healthcare news, at least one expert wonders: “Are Hospitals Becoming Obsolete?” One hopes so: many are dysfunctional and won’t reveal prices to patients, leading to wild cost inflation and the “mystery bill” phenomenon many of us, myself included, have been subjected to. In healthcare, it seems that the prices are the problem, and most healthcare players are working to maintain price opacity. At the same time, there’s very little political or media noise about this issue.

Americans read and hear a lot about insurance issues and almost none about prices and transparency. Mandating price transparency would be a huge win for patients and, maybe, for cost. Yet politicians of all stripes show little interest in this obvious (and very cheap) policy choice. I don’t know why. I have only a very small platform, but I’m going to use it to propose price transparency. Small-scale studies like “Research finds nearly 8-fold price differences at Minnesota hospitals” show that the price of healthcare varies enormously. But it’s hard if not impossible for patients to gather information about pricing (as I discovered recently).

When you get a shockingly high mystery bill, just try getting an explanation about why the price is the price. I have. Good luck. Hospital bureaucracies are enough to make one wonder if single payer really is next: the healthcare experience for many Americans is already so close to the DMV, why not just go all the way?

I’m not advocating for single payer as a political position: this is a non-political space devoted to analyzing grant writing, grant source research, and grant makers. But it is worth analyzing how the world works, how that relates to larger political questions, and what those larger questions mean for practitioners on the ground.

In the first section of this essay I wrote about primary preventive healthcare access doesn’t appear to lower costs. That’s a common idea that doesn’t appear to be true; there are other things we think we know that just aren’t true. During the ACA debate, for example, many claimed the medical bills bankrupted vast numbers of people. Turns out it just ain’t so:

The fraction of bankruptcies caused by medical events is just 4 percent. And even among those bankruptcies, it seems that medical bills may be less of a problem than the other things associated with an illness, such as lost labor income. […]

That jibes with what’s evident in the bankruptcy data since Obamacare passed. If medical bills really were driving so many people into bankruptcy, then we would have expected filings to plummet after 2013, when millions of people gained health insurance coverage. Instead we see a smooth decline from the recession-era peak.

So if we’re worried about poverty, as many of us in the nonprofit world are, health insurance access may not be the most important way to tackle that issue. The data on bankruptcy filings from 2013 to the present are particularly compelling. It may be that lost income is the bigger issue for people who get sick. Or some other factor may be at work. It’s hard to know.

Perhaps the best way to save money and improve health as an individual is to quit eating sugar and get sufficient exercise. Those things would also be good for the larger society, but “we” (the mandarin know-it-alls like myself and those who dictate healthcare policy) have no way to make that happen. Despite decades of effort—much of it misguided, granted—we have no way of improving people’s habits on the macro level. It turns out that “American Adults Just Keep Getting Fatter:” “New data shows that nearly 40 percent of them were obese in 2015 and 2016, a sharp increase from a decade earlier, federal health officials reported Friday.” Obesity is not a perfect proxy for health, but it’s a useful starting point.

Much of this essay won’t make it into the proposals we write for FQHCs and other primary care providers. Proposals are about mythology, not actuality, unless the funder specifically demands reality (most don’t). But it’s good for applicants to keep the grant world and proposal worlds straight. Reading widely and deeply is still one of the open secrets of good grant writers—and good writers of all kinds. The information is out there. Whether you choose to access it is up to you.

“Your methods are unorthodox”

As GWC readers know, getting information about state and local grants is often tricky. Every state and municipality is different, and, like foundations, few if any make any effort at standardization or the user experience; most just assume that the usual suspects will apply for grants, and consequently they end up forming de facto cartels. In theory, too, all government grant information is also public information, but that’s a little like the theory that DMV employees are public servants who work on behalf of taxpayers: connecting theory to practice can be hard or nonexistent—naive visitors to the DMV learn.

Anyway. I spent some time attempting to get into the Wisconsin “Division of Public Health Grants and Contracting (GAC) Application” page, which is stashed behind a password wall for no reason I can discern. In the process I ended up emailing “Yvette A Smith,” a contracting specialist, to request access, and in reply, she told me that “Your request is unorthodox.” While not quite as good as “Your methods are unsound,” I did actually laugh out loud; I do like to imagine I’m the grant-world equivalent of Captain Willard talking to Colonel Kurtz in Apocalypse Now.

And Yvette is right: our methods are unorthodox and we do disturb the fabric of the grant/proposal world. That’s part of the reason we’re effective.

Still, I had no idea that there’s an orthodoxy in the State of Wisconsin. And if there is, what is that orthodoxy? Is it John 16:10 that describes how users should access GAC Application information? Or does orthodoxy emerge from other texts?

Alas, I didn’t inquire that far, and I also never quite got access to the GAC Application Page, but I was able to find the information I needed elsewhere. Still, I did learn just a little about the quality of governance in Wisconsin. A famous paper looks at “Cultures of Corruption: Evidence From Diplomatic Parking Tickets,” and the authors find that “diplomats from high corruption countries (based on existing survey-based indices) have significantly more parking violations, and these differences persist over time.” I wonder if my own experiences interacting with local and state governments are similar: the worse the quality of random bureaucrats, the worse the overall level of governance.

Links: ACA news, job training news, “Walrus Haulout” grants, money and jobs and social services, and more!

* “Aetna Joins Rivals in Projecting Loss on Affordable Care Act Plans for 2016: Health insurer will review how it will continue its public exchange business in existing states.” This is essential reading for FQHCs, and note: “In addition, Medicaid-focused insurers continue to do well.” It’s interesting to contemplate Tyler Cowen’s 2009 post, “What should we do instead of the Obama health reform bill?“, in light of recent news.

* My favorite recent grant program: “Re-announcment of the Community Training and Video Production for Walrus Haulout Public Education Video.

* A new Tyler Cowen book is coming out in February; the link goes to the post describing the book (and how to get a free copy of another book), and here is a direct Amazon link to The Complacent Class: The Self-Defeating Quest for the American Dream.

* “ How The Cures For Cancer Snuck Up On Us,” good news all round.

* “How The West Was Won,” which is actually about how and why “Western” culture took over the world because a) it’s popular and b) it’s not so much Western per se as the result of technologically oriented development.

* “You Should Read More Romance Novels: The libertarian case for bodice rippers,” file under “headlines I could not have imagined reading.”

* The pre-order page for Tom Wolfe’s new novel, The Kingdom of Speech. If Wolfe writes it you ought to read it. EDIT: Read it; you can safely skip this one. The research and really entire worldview are not so good.

* “Why Police Cannot Be Trusted to Police Themselves,” a point that seems increasingly obvious.

* “It turns out that putting money directly into the pockets of low-income parents, as many other countries do, produces substantially larger gains in children’s school achievement per dollar of expenditure than does a year of preschool or participation in Head Start.” Attention UPK legislators!

* “Israel Proves the Desalination Era is Here: One of the driest countries on earth now makes more freshwater than it needs,” an important point and one I didn’t realize.

* Mark Manson: “Is It Just Me, Or Is the World Going Crazy?

* “How to Write a Novel,” amusing throughout and it seems that many quality authors use many different systems (or lack of systems). There is not one, single route to good end product.

* Oliver Sacks: “Me and My Hybrid,” from 2005, and his points still stand today.

* GM delivers 100,000th Chevy Volt in the US alone.

* “US fertility rate falls to lowest on record” as Americans fail to reproduce themselves, driving the need for more immigrants (remember this data when you hear some kinds of political rhetoric). And: “More Old Than Young: A Demographic Shock Sweeps the Globe.” And: “Europe’s ageing population is set to wreak havoc with the economy.”

* “The Next Generation of Wireless — “5G” — Is All Hype: The connectivity we crave — cheap, fast, ubiquitous — won’t happen without more fiber in the ground.”

* L.A. isn’t a suburb. It needs to stop being planned like one. There’s still some truth in Dorothy Parker’s observation about LA being “72 suburbs in search of a city.”

* “Can 42 US, a free coding school run by a French billionaire, actually work? Just across the bridge from Facebook HQ, a radical education experiment is underway.”

* “Why Tokyo is the land of rising home construction but not prices:”

Here is a startling fact: in 2014 there were 142,417 housing starts in the city of Tokyo (population 13.3m, no empty land), more than the 83,657 housing permits issued in the state of California (population 38.7m), or the 137,010 houses started in the entire country of England (population 54.3m).

A social bonus, too: “In Tokyo there are no boring conversations about house prices because they have not changed much. Whether to buy or rent is not a life-changing decision.” I would love to never have those boring conversations ever again, yet they seem everywhere around me.

* NSA attacked Pro-Democracy Campaigner, demonstrating (yet again) the ills of secret proceedings and near-unlimited power.

* The race for a Zika vaccine.

* “The case for making New York and San Francisco much, much bigger.”

* Mark Zuckerberg’s charity sells $95 million of Facebook stock.

* “Aging out of drugs: Most addicts just stop using in time, without needing costly treatment. Why?” An important question for anyone providing drug treatment services or seeking SAMHSA grants.

* “It’s the first new U.S. nuclear reactor in decades. And climate change has made that a very big deal.” Nuclear power is still, oddly, underestimated; note that New England and Germany, both places with lots of superficial climate change worry, are now emitting more carbon dioxide than they used to—because they are phasing out nuclear plants and failing to replace them.

* “Making bicycles in Detroit is an uphill climb.” My bike came from REI and was made in China.

* “Cycling Matches the Pace and Pitches of Tech.” Probably a bogus trend story, but I like riding so I hope not.

* “‘I’ve done really bad things’: The undercover cop who abandoned the war on drugs: Neil Woods used to risk his life to catch drug dealers. But as gangs responded with escalating violence and intimidation – some even poisoning users who talked to the police – he started to see legalisation as the only solution.”

Meaningful Use Regulations, CMS, HRSA FQHCs and the Stalled Push to Electronic Medical Records (EMRs)

According to Mother Jones, the United States has spent billions on electronic medical records (EMRs)* and we’ve got little to show for it. Digitizing healthcare records was supposed to save time, money, and lives. It hasn’t. That news resonates with us because we’ve written dozens of proposals, mostly for Health Resources and Services Administration (HRSA) and Centers for Medicare & Medicaid Services (CMS) RFPs that either explicitly or implicitly require a discussion of our clients’ use of EMR systems. These clients are usually hospitals, Federally Qualified Health Centers (FQHCs) or other primary care providers. From them we’ve heard numerous heard off-the-record stories about the fiascos that ensued for providers that have implemented EMRs. For example, we worked for a hospital in Southern California that interfaced with a much larger, nationally known hospital that attempted to implement a comprehensive EMR system. The large, famous hospital eventually scrapped a $30 million EMR system because the doctors simply refused to use it.

There seems to be no good solution to the EMR problem. EMRs have been touted for at least the last 15 years as a tech-based way of improving patient outcomes, while reducing healthcare costs or at least bending the cost curve downward (as health policy wonks like to say). EMRs got a got big push with huge amounts of EMR funding included in the 2009 “Stimulus Bill.” The advent of the Affordable Care Act (“ACA,” or, colloquially, “ObamaCare”) escalated the EMR drive. Various Federal and state agencies advocated and then effectively mandated EMRs.

But this well-meaning concept has at best moved sideways. HealthIT.gov promulgates the wonderfully bureaucratically named “Meaningful Use” regulations, which use a combination of incentives (e.g., higher Medicare/Medicaid reimbursements) and threats. The carrots are offered and the threats enforced primarily by CMS. Everyone is supposed to get to Stage 1 of Meaningful Use (data capturing and sharing) on a supposedly smooth trajectory to Stage 3 (improved outcomes). Stage 3 turns out to be like the intergalactic instantaneous travel through spacetime. We’ve yet to find an hospital, FQHC or other client that has reached Stage 3. Most are stuck at Stage 1, with a few bravely claiming Stage 2. We’ve never seen a client hit Stage 3, though they may be out there, perhaps in a galaxy far far away.

The problem is that EMRs are trying to map the extraordinary complexities of the real world into software. The complexity can be seen in the new International Classification of Diseases, ICD-10 Codes, published by our old friend CMS. ICD-10 codes are used by medical providers and billers to track patients and payments, based on the code or codes of the patient’s particular situation. When we talk to FQHCs, they invariably say that coding errors are among their major problems. ICD-10 has an astounding 68,000 individual codes, compared to only 14,000 codes in the previous ICD-9. In recent years, humans have invented or discovered an enormous number of new ways to get hurt. No one can remember more than a few hundred of these mysterious codes, which are easy to mistype into an EHR and/or be misunderstood by harried doctors and mid-level practitioners. The complexity of the codes, combined with human diversity and frailty, inherently generates huge numbers of mistakes.

Folks with too much time on their hands have published various funny ICD-10-CM codes. Some choice ones (we are not making these up) include: “V97.33XD: Sucked into jet engine, subsequent encounter;” Y92.146: “Swimming-pool of prison as the place of occurrence of the external cause” (how many prisons have swimming pools?); and my personal favorite, “R46.1: Bizarre personal appearance.” You can tweet your favorite bizarre ICD-10 codes to @healthcaredive.

Ask your doctor about their EMR system and you’ll likely here a lot of invective. I live with a doctor and so have heard the horror stories from her and her colleagues. Isaac’s primary care physician (PCP) hates EMRs but is more or less forced to use eClincalWorks, an EMR system that is also popular with our FQHC clients. Epic is another popular one. Still, however you feel about whether EMRs is efficacious or horrible or brilliant or whatever, pretty much every healthcare-related proposal has to mention EMRs, statistics, and tracking. That could be as minor as a project that works on childhood obesity or as major as a hospital chain implementing some new facet of EMRs.

Anyway, EMRs are a specialized case of a more general problem described in “Why Software Fails: We waste billions of dollars each year on entirely preventable mistakes.” EMRs, like other forms of software, have numerous moving parts and numerous human users. Anyone working in or around EMRs needs to read “Why Software Fails.” At Seliger + Associates, we expect to keep writing about EMRs for FQHCs and similar clients for years if not decades to come. In the real world, doing EHRs right is simply a Hard Problem—so hard that it deserves capital letters. EMRs are almost impossible to do “right” and yet have to be done right. They’re so hard that we don’t have a solution. “Why Software Fails” explains why a solution may not exist, no matter how badly HRSA or CMS wants one. As the Soviet Union discovered, mandates from above, no matter how strong, do not automatically translate into fixing problems from below.

* EMRs are alternatively referred to as Electronic Health Records (EHRs), particularly in HRSA and CMS RFPs. In ones types “EHR” into Word, or any other word processor, and the autocorrect feature will change it to “HER.” This in annoying, but does result in some unintentionally funny typos. When finished with proposal draft involving EHRs, always do a find and replace for “HER”.

The HRSA Health Infrastructure Investment Program (HIIP) Illustrates Why It’s Hard to Handicap Chances of Getting a Grant

Anyone who’s been to a race track or Vegas knows that the odds of a given race or sporting event are being constantly updated by pros who seem to know how to handicap future events. Prospective clients often ask me to handicap their chances of winning a grant competition (and we’ve written before about why grant writing is not like the Olympics). Trying to handicap a particular grant competition is like trying to handicap a horse race in which you don’t know the horses, riders, or venue until after the race is completed. If grant writing was really like a horse race, you’d just pick the cutest horse or jockey with the best colors and hope for the best.*

A prospective client raised the odds issue on Friday, regarding the recently issued Health Resources and Services Administration (HRSA) Health Infrastructure Investment Program (HIIP) FOA. HIIP has $150,000,000 available, with about 175 grants up to $1,000,000, for Federally Qualified Health Centers (FQHCs). FQHCs are sometimes called “Section 330 grantees” and provide primary health care to publicly (Medicaid) and uninsured patients. HIIP is a great opportunity for FQHCs: there’s a lot of money up for grabs, the grants are large, and the money is for facility improvements (facility improvements are always hard to fund).

Not surprisingly, we’ve received a number of inquiries from FQHCs. On Friday, a FQHC CEO in rural Montana called. I learned a bit about his agency and provided a fee quote. Then he popped the question: “So, what are my chances of being funded?” As I was starting my standard reply to this standard question, he interrupted. He said he didn’t think his chances were very good, because “thousands of FQHCs would apply.”

I said that’s not true, since there aren’t that many FQHCs. We got into a bit of a tiff over this, so I double checked after the call. The Henry J. Kaiser Family Foundation says there were only 1,202 FQHCs as of 2013. I would’ve guessed closer to 1,000, but the numbers are in the same ballpark. While new FQHCs are created every year, there are likely less than 1,300 today. Thousands of FQHCs can’t apply for HIIP because not that many exist. My caller was trying to talk himself out of applying.

Let’s try estimating the likely competition.

For various reasons, not every FQHC will want to apply for a HIIP grant. Some are already happy with their current facilities, while others are undergoing leadership changes. Let’s assume that 1,000 FQHCs want to apply and that HRSA will ultimately make about 175 grants. This would mean around a 20% chance of any given application being funded, which is pretty good odds in submitting a grant proposal or buying a lotto ticket.

But, of the hypothetical 1,000 or so applicants, many will not finish their applications, so perhaps 700 applications will actually be submitted. Of these, a fair number, say 100, will be technically incorrect and will not even be scored. Now the pool is down to 600. Many of these will be poorly written, fail to demonstrate need, etc., and will not score high enough to be funded. Let’s assume that 350 – 400 score high enough to be funded.

Now the odds are close to one in two!

Still, grant handicapping is more complex than this simple analysis. Of my theoretical 400 potential grantees, some will be urban, some rural, some will serve special populations (e.g., homeless, Native Americans, etc.). Some will serve African Americans, some Hispanics and so on. Since, like all governmental funders, HRSA is a semi-political entity, the organization wants to spread the sugar. Even if the top 200 applications, based on points alone, were somehow clustered in the Northeast, applicants in other areas would still be funded.

My 400 possible grantees are actually competing against similar applicants, rather than all applicants, because not all applicants are equal in the eyes of HRSA administrators. If your FQHC is the only highly scored applicant that serves rural Native Americans, your chances of being funded could be 100%. If your FQHC serves a general population in a large city like New York or LA, you might be one of ten possible grantees in that city. HRSA will likely make multiple awards in a given big city, but not ten. Now your odds could be one in three. This particular exercise can be played ad infinitum, but it doesn’t mean much because no one outside of HRSA knows the organization’s subjective priorities in advance and because you don’t know who else is going to apply.

Not knowing who else is going to apply really counts. If four other FQHCs similar to yours operate in a given region, they may all say they’re going to apply—just to scare you, or intimidate you, or impress you, or for any number of other reasons. Will they? Maybe, maybe not. You can’t control them, and we recommend that you not be dissuaded by their rhetoric. They may claim to have juice with power players in Washington, or any number of other advantages. You don’t know and can’t know if they’re telling the truth.

My advice to all callers is the same: if your agency is eligible and you want to provide the service, you should disregard real or imagined odds and apply. The logic is similar to seeking a new job. In most cases, you don’t know the other job applicants. Most people apply for jobs they want to do in places they want to live. Say you’re a highly qualified lion tamer and there is a great job open at a circus in Seattle. You should only apply if you like rain, coffee, and tech / nerd culture. If you like sunshine, Cubano sandwiches, and salsa dancing instead, wait for a circus opening in Miami.

The same is true for HIIP: FQHCs who need facility improvements should complete technically correct and compelling proposals that are submitted on time. Worrying about the odds is an interesting but pointless enterprise.

* This is actually the way I bet at horse races, which is why I’m not much of a gambling man.