Wednesday, March 31, 2010

What comes next in healthcare reform?

The passage of House Bill 3590 was billed as a momentous event, the first moderately successful effort at universal healthcare in the United States. Unfortunately the passage of House Bill 3590 also sets the United States on a perilous economic path. The reason for this concern is that House Bill 3590 at its core by itself an incomplete bill. Opponents continually cite the $935-940 billion dollar price tag associated with the bill as economically crippling whereas proponents counter that the most recent CBO report estimates a $118-138 billion dollar reduction in the deficit over the next decade and another $1-1.2 trillion dollar reduction over the next decade after that. However, the CBO uses wildly optimistic assumptions and some mathematical incongruities (common in government accounting) to come to those conclusions. Even then despite the assumptions used, to suggest any level of accuracy in a prediction 20 years from now on an issue as dynamic as healthcare is foolishness regardless of whether the analysis yields a positive or negative economic prediction. For those that place their faith in these types of predictions, go down to the local automobile dealership and ask to see the latest model of the flying car.

Originally the primary objective behind healthcare reform was an intelligent and noble one, albeit with a misguided methodology (attempting to do so much in one single omni-bill was rather silly for the complicated and problematic issue that is healthcare). However, two elements influenced the original objective eventually resulting in House Bill 3590, which was the same bill passed by the Senate months earlier. First, it appears that the Obama Administration and a large number of Democrats in Congress arrived at the conclusion that due to the length and ferocity of the debate surrounding healthcare that to not pass anything would be viewed as an unrecoverable failure. Whether justified or not, not passing any type of bill related to healthcare reform would have resulted in a severe handicapping of President Obama’s remaining term, which would have made it difficult to undertake any future domestic policies. The very contemplation of such a situation is sad because the Republicans in Congress did nothing of significance to aid in the generation of a positive bill and appropriate healthcare reform. Therefore, there was desperation to pass something, regardless of whether or not it was proper to do so.

Second, the proper foundations were not established before addressing the issue of the uninsured. The 40+ million uninsured individuals in the United States has always been the sexy hot-button issue when citing the problems in the healthcare system. However, that problem cannot be solved in a long-term economically stable manner without addressing other problems first. The entire issue reminds one of the scene from Apollo 13 where Jack Swigert (Kevin Bacon) raised concern about coming in too shallow and Houston not informing them and Jim Lovell (Tom Hanks) replies that there are a thousand things that have to happen in order and Jack was talking about number 692 when they were only on number 8. Dealing with the uninsured was addressed much earlier than it should have been. Although it is not too late these earlier problems must now be addressed, otherwise all of the good feelings that have resonated among the supporters of House Bill 3590 will eventually give way in the face of a much bigger problem in healthcare than the uninsured. Below are the five most important problems in healthcare.

Problem – No permanent solution to Medicare reimbursement payments that currently do not increases appropriately;

Why this is Important – Since mid 2008 a number of medical institutions including the Mayo Clinic have turned away individuals on Medicare because the amount of money they receive through Medicare for treatment is not enough to cover costs associated in treatment. Thus the institution must either lose money or refuses care. Clearly if medical costs continue to rise especially those paid for by Medicare, which is a strong possibility due to the increasing poor health of seniors and those soon becoming seniors, more and more medical institutions will have to turn away Medicare patients.

Discussion of a Solution – Congress has tried many times to create a permanent solution, but has run into problems with ensuring adherence to Pay-go statutes. The fact is that there are too many seniors that require the services of Medicare on Medicare. Therefore, it is difficult to raise reimbursement rates without increasing the deficit or reducing costs (which would indirectly increases reimbursement rates). This new law institutes another temporary increase in reimbursement rates to cover the next couple of years, but nothing different or substantial. It also attempts to explore the possibility of bundling Medicare payments as a means to accomplish the indirect increase methodology by shifting the cost burden onto the medical institution and away from the government. For more information regarding why this problem persists see a previous post on healthcare here.

The attempted use of Medicare bundle payments aim to change the complexion of how medical services are reimbursed. Instead of receiving payment for each service rendered, hospitals are going to be paid a single lump sum payment for each individual. The idea is that the hospital will maximize intelligent care and be able to treat the patient for a much lower cost because the focus will be reducing wasteful and unnecessary tests and treatments because the total profit/loss will be based on outcome. In this payment environment running a battery of tests just because the patient wants them or just for the heck of it will be detrimental to the hospital/physician because each test is no longer reimbursed individually, the costs of those tests will come from the lump sum payment. Thus under the bundle system high volume will lose money not make money.

However, whether such a method works is entirely dependent on the size of the bundle payment. The Mayo Clinic is probably the most efficient healthcare provider in the country maybe even the world, and over the last couple of years it has been one of the medical institutions that has been forced to start turning away Medicare patients due to loss of funds through treatment. Basically Medicare reimbursement payments were so low that the most cost-effective treatment center in the country could not break even, let alone make money, when treating Medicare patients. Such a result demonstrates that using the Mayo Clinic for a reimbursement floor would be practical. If the Mayo Clinic cannot make money from the bundle payment, the payment is too low. However, the Mayo Clinic cannot be used as an inflexible floor because it is the best of the best due to its organization and personnel, which cannot be emulated across the country. Thus these bundles need to be higher than the floor because even high-quality medical institutions are not 100% accurate and a single miss could lose a lot of money.

Another potential problem with bundled payments is that their profitability is dependent on patient behavior. It is not the fault of the medical institution if a patient comes in with what originally appears to be a single-occurrence condition and after further examination that patient is diagnosed with an expensive and chronic condition. What is the medical institution supposed to do in such a situation, say ‘sorry you have such a detrimental condition, but we’ll lose money treating you, so we’re going to have to cut you loose…’? In addition, the patient may avoid medical attention for a small problem that later evolves into a much larger and more costly problem that the medical institution has to absorb. Thus to avoid these realities a medium system will have to be generated between 100% bundle and 100% fee for service if reimbursement rates are going to be sufficient enough that medical institutions can still afford to treat Medicare patients, but also avoid waste.

Problem – Lack of Primary Care Physicians;

Why this is Important – A lack of primary care physicians is a huge problem because the chief reason most economists believe insuring the uninsured is a win for cost control and the economy is that those uninsured individuals will now use their insurance for preventative care to reduce the probability that they develop higher cost ailments. However, if there are a lack of primary care physicians those newly insured individuals will have to go to the emergency room for preventative care, which is not the job of the ER and would create a greater bottleneck effect further reducing the efficiency of ERs and probably costing lives. A number of initiatives in the new law depend on preventative measures to reduce costs; however, with a lack of primary care physicians those preventative measures will become less probable. Thus without an increase in primary care physicians insuring the uninsured will actually increase total medical costs and the overall deficit and those that are already insured will have a higher expectation of cost due to a reduced ability to undertake preventative measures under a physician’s direct supervision.

Discussion of a Solution – The American Academy of Family Physicians predicts a shortfall of 40,000 primary care physicians by 2020.1 The new law attempts to combat that shortage by increasing funding for training programs (usually funded through Medicare funding), more scholarship and loans for those entering primary care or committing to primary care out of medical school or loan forgiveness for those that start a practice into a ‘high-need’ region. Unfortunately a vast majority of this new funding only appears to affect those entering medical school, which implies that any effort from this bill to increase the number of primary care physicians will be delayed by at least 6-10 years (due to completion of medical school and residency). Additionally the bill encourages medical schools to open new residence spots to increase the overall enrollment number because a number of talented individuals are still unable to enter medical school due to enrollment caps.

In addition to the delay the funding alone will probably not be enough to wean new students away from the monetary and time rewards that come from specialization (this contention assumes that the new funding does not end up violating the Stark Rules). Physicians that specialize in a particular field are paid more money and have to work fewer hours in a more homogenous environment; a little help with student loans is probably not going to drive most of them from a given specialty to primary care, which at its core is a more arduous job. In fact it is not common for the pay differential to be in the range of 100 – 250% more per year. Therefore, other attempts need to be made to increase the number of primary care physicians beyond simple salary concerns. The problem is in a capitalistic market it is difficult to influence such a change without triggering some form of lawsuit.

One possible means to create a specialist shift is to create statistical approval limits on medical care. Basically if a medical procedure does not aid in the diagnosis of a perceived condition in a statistically significant manner then the government or private insurance company has the option of not covering the procedure. The application of such a rule would reduce the number of unnecessary diagnostic tests and procedures, which in turn could reduce the overall salaries of the specialists that carryout those tests further closing the gap between primary care physicians as well as reduce overall medical care costs. However, the chief problem with this idea is fighting the suggestion that such statistical restrictions promote ‘rationing’ of medical care and the simple fact that the general public is not experienced in using statistics to make decisions and would probably not understand why one test is not covered by insurance as opposed to a similar test.

Due to the time required to train new physicians as well as any turn-around time to reverse the downward trend of medical school students selecting specialized fields over general practice field a more immediate strategy needs to be applied. The new law focuses on the application of ‘medical homes’ to reduce the influence of the current and short-term future shortfall. A ‘medical home’ is a facility that incorporates teams of physicians, nurses and other specialized personnel to provide general primary care services largely to patients suffering from chronic conditions. Under the umbrella of a ‘medical home’ physicians can combine their patient load and their resources in an attempt to expand hours and general preventative communication to hopefully increase the probability of lowering costs while maintaining at least the same level of care, if not improving it. Early test models of ‘medical homes’ work well enough, but there is no real information regarding how scalable they are or how they work in more isolated rural communities. Overall the trend delineating the reduction in primary care physicians did not just start a few years ago, it has been happening for quite some time. This was a problem that should have been addressed at least 5 years ago, sadly the late start means some significant growing pains.

Problem – Emergency Room Streamlining and Reform;

Why this is Important – The second element in increasing the probability that insuring the uninsured actually lowers healthcare costs is ER reform. Under this law soon 32 million individuals will have the ability to visit the ER without being stuck with the bill, so these individuals will more than likely visit the ER more often and sooner than they would normally. Quick side note – Most people incorrectly believe that an uninsured individual receives free medical care when going to an ER. This is not correct. The Emergency Medical Treatment and Active Labor Act of 1986 only obligates ERs to care for individuals regardless of ability to pay. These uninsured individuals that receive care from an ER still receive a bill for the services rendered. If they are unable to pay the bill then their credit score is negatively affected and if the hospital/physician so desires they can be sued for the amount. This billing is why individuals do not go to the ER for every little thing that may be wrong with them.

Most medical experts believe more frequent primary care physician or ER visits to be a good thing because most potential detrimental conditions will be caught at an earlier stage of development making them cost less to treat. However, if generic ER input and output streams remain the same, these more frequent ER visits by more individuals will significantly increase wait time and procedural costs to the ER either forcing an increase in medical costs or more ERs going out-of-business. The coverage breadth represented by this law most closely models that implemented by Massachusetts in 2006. In response to its ‘universal healthcare’ program, Massachusetts’s ERs have receive a much greater input and are having significant problems coping with the increase. It is reasonable to presume that such is the fate of other ERs across the nation unless steps are taken to neutralize this problem. Therefore, an essential element that must be addressed is streamlining both the input and output elements in an ER to reduce the influence of overcrowding as much as possible.

Discussion of a Solution – Addressing ER reform stems from one of two possible strategies, reducing the input or hastening the output. With regards to the input the shortage of primary care physicians is especially important in the issue of ER reform. Recall that the uninsured typically wait too long to go the ER to receive medical treatment largely due to the fact that they do not have insurance. However, even if these individuals were given insurance if there were still a lack of primary care physicians then there would only be a very small shift in the probability that these individuals would not go the ER because of the previously noted time discrepancy. In fact there may be reason to believe that insuring the uninsured without any change in the number of available primary care physicians will increase ER overcrowding because conditions can be treated in less advanced stages over a situation where the individual does not have insurance for a lower cost against the insurance company. Such a contention is supported by the results from Massachusetts.

A second possibility for reducing the rate of input is to integrate an electronic health record system into ERs. Such a system offers the potential to create a more effective triage system, which can reduce wait times as well as assuage tempers from other patients who feel they are getting short-changed. Any reduction by ER staff in having to deal with individuals they are not currently registering or treating can be better directed at those activities. The real solution behind altering the rate and total amount of the input in an ER has to do with many outside components that also need to be addressed in the medical world like lack of primary care physicians, streamlining medical records and diagnostic procedures and increasing application of prevention methods for patients.

The second component in overcrowding has to do with output speed. One of the reasons for the increase in ER crowding is a decrease in turnover due to a lack of available nurses. One of the only silver linings that may have come from the recession is an increased interest in nursing because of job availability. Nurses typically have to do more work than primary care or emergency care physicians, get paid even less and have to have a significant portion of the education that is required of a physician. With these conditions it is not surprising that the occupational field of nursing is prone to shortages. Regardless of any other factor, processing time is negatively influenced if there is no one to conduct the processing and aid in the in-patient care regardless of what technology is available or what the patients are suffering from.

Another important factor for the lack of turnover is the lack of beds for those that need to remain in the hospital for further observation and/or treatment. Obviously not everyone that comes into the ER has a condition that allows for a same day discharge. In fact common sense would imply that such a reality should not be the case for a number of individuals visiting the ER, especially the elderly. For example suppose someone is rushed to the ER after getting into an automobile accident, odds are that individual will need to stay at least one night in the in-patient unit. However, if there are no available beds in the in-patient unit that individual will have to stay in the ER or be moved somewhere else after the initial round of treatment, which will reduce the rate of recovery and contribute to over-crowding.

Problem – Organization and maintenance of medical records;

Why this is Important – With 32+ million new individuals acquiring health insurance, one can anticipate those individuals will make use of that insurance. For those that are healthy and were trying to save money by not having health insurance, their introduction into or the updating of their medical records takes a backseat to records representing individuals that were denied health insurance due to pre-existing conditions. It is reasonable to anticipate that these individuals will see physicians and hospital stays at a much higher rate than the more healthy individuals thus these individuals need to have organized medical records to ensure efficient administration of proper medical procedures. Most pundits have presumed that electronic health records (EHRs) will be incorporated into the healthcare infrastructure to accomplish this goal.

Discussion of a Solution – Despite the funds earmarked for EHRs from the American Recovery and Reinvestment Act of 2009 there are still questions regarding their mass implementation. There are two problems that surround EHR adoption. The first problem is the informational disconnect between those that provide the service of upgrading hospitals to an EHR system and those same hospitals. For example one of the largest healthcare software installation companies is EPIC. EPIC claims that over 90 million individuals are affected by their system based on the number of hospitals that have received its services. The concern is that such a statement seems to run counter to the findings that only approximately 17% of U.S. physicians use a minimally functional or a comprehensive electronic records system.2 So what is the difference in criteria between those in the academic community versus those in industry to classify a hospital as having a viable electronic healthcare record system? Until a universal standard between both parties and even the government itself is developed it will be difficult to identify what hospitals have what type of systems from a statistical perspective which will limit the rate of installation severely limiting the ability of hospitals to share information, which is one of the chief advantages cited by those that support the mass adoption of EHRs.

The second problem is that most physicians still do not use electronic record systems in full or even at the least simple basic EHRs. As mentioned above total level of EHR installation seems to depend on the definition used for ‘installation’. One of the most pervasive studies of installation through hospital surveys concluded that only 1.5% of hospitals have a comprehensive electronic-records system (all clinical units use it), an additional 7.6% have a basic system (at least one clinical unit), but in total only 17% of hospitals have the basic computerized provider-order entry for medications.2 A second study concluded that approximately 16.5% (16.41%) of all physicians use the most basic form of EHRs.3 Both studies concluded that a majority of that installation had occurred in large hospitals that employ at least 50 physicians.

The reason behind this choice needs to be identified because with the level of incentive money both the federal government ($44,000 per physician)3 and private institutions ($40,000 - $60,000 per physician)3 are providing, is money still the principle obstacle? It makes sense to presume that money still is the principle obstacle based on the installation pattern from the above studies. Larger hospitals are going to have greater financial resources available to pay for installation as well as save more time and money from the installation. However, this blog has made the argument before and still maintains that the lack of a cohesive easily assessable information network regarding the installation of EHRs is also a meaningful obstacle. Without an easy to understand pro-con comparison information portal that hospital administrators and physicians can reference, these individuals have to do more leg-work and research on their own adding to the opportunity costs and training time required for the installation and maintenance of an EHR system, especially for smaller practices that only include 1-5 physicians. There is no reason for the federal government to continue to wait on establishing this database as an independent objective auditor and evaluator of EHR services provided by private industry.

System instillation has become easier in the last few years due to widespread software licensing reducing costs and less rigid data entry parameters.3 Also the evolution of EHR systems with regards to additional features like bill creation, electronic prescribing and coding functions have made EHR systems more attractive relative to their costs.3 However, the evolution of EHR systems need to expand to include a larger diagnostic slant to aid in efficient record keeping regarding what has been attempted and recommendations for further treatment or diagnosis. These types of records will be critical to any successful attempt to bundle payments to quality of care because if an accurate record of care does not exist how can one be judged on value or quality of care offered? It is true that widespread adoption of a new currently unknown tracking strategy may replace EHRs, but so much hope and hype has been placed in EHR systems for streamlining care, it is unlikely that any new idea would become widespread in a reasonable amount of time.

This rationality is also why implementation to smaller networks of physicians and hospitals must occur. If bundling becomes the principle manner in which Medicare reimburses physicians smaller practices that do not possess at least a basic EHR system, if not the complete systems, will be placed at a significant disadvantage and may have to turn away Medicare patients creating ‘lack of treatment pockets’ in various communities, especially those in rural areas away from major hospitals. Other issues that need to be addressed are patient privacy (especially with the prevalence of computer hackers in modern times) and the possibility of some form of adaptor system that can ease communication between two different types of EHR systems. It is rational to conclude that not all hospitals will have the same EHR system (due to competition each system will have its own nuances and features), thus when moving information from one system to another a protocol must be in place to ensure the fewest number of errors in the transfer as possible.

Problem – Exponential increases in overall healthcare costs;

Why this is Important – The importance of this problem is self-explanatory. If healthcare costs continue to increase at their current rate, the healthcare system in the United States will collapse.

Discussion of a Solution – At the start of the discussion regarding healthcare reform the goal of reducing the overall costs in the future to a more manageable level was one of the primary goals. Unfortunately, strong ideas that have a high probability of providing cost controls have all but vanished from the newly passed bill. The new law attempts to reduce costs through three different methods. However, a critical analysis of these three methods does not instill much confidence that any of them will be overly successful, especially to the level that is required.

The first method thought to control costs in the future is the previously discussed bundle Medicare payments. As discussed above the idea is to shift the focus on patient care, but the bundle idea almost tries to suggest that a large amount of the waste in the medical care system is due to greedy doctors just trying to pad the bill. In reality these bundles seem to have almost as much of a chance at bankrupting the medical care facility than reducing overall healthcare costs. Even if successful, bundle payment will create significant treatment variance for patients and their respective hospitals as some patients will be quite cheap for the hospital to treat whereas others will be cripplingly expensive. Such variance may increase the probability that certain patients are refused care. For the bundle system to reduce long-term costs without significant disruption in care they will need to be carefully organized and highly classified with regards to what conditions are being treated and what new conditions can arise from the escalation of those conditions.

The second method thought to control costs in the future is the frequently mentioned health insurance exchange. Simple market principles drive the confidence in the ability of the exchange to reduce costs. The mindset is that one of the major reasons healthcare costs are so high is the lack of competition between insurance providers. In most states no more than 3 major insurance providers exist, thus if you do not like the premium price that you receive from Company A there is little you can do, but go without insurance. Thus, proponents believe that creating a new marketplace for insurance companies will expand the level of competition and force insurance companies to cater to its potential customers. Also with additional companies in the mix consumers will have more options available to identify the best available program for them, which will make their coverage more efficient more than likely reducing costs.

Unfortunately proponents only focus on the generic competitive marketplace when making these claims. Insurance is not a generic competitive marketplace. In the generic marketplace a supplier can make mistakes and still have the ability to recover because those mistakes are not crippling. In the insurance marketplace a bit of bad luck for both the customer and the company (a previously healthy individual develops cancer) can significantly impact the bottom line of the company. This feature of the insurance market makes it very difficult for new providers to emerge from scratch without significant backing. Here is another instance where the public option would have been a valuable tool because it could guarantee stability and longevity unlike any new private companies that emerge. Also with the new law stripping the ability of the insurance companies to reject the sickest individuals (not denial of care due to pre-existing conditions) the margin of error is further strained for the company.

Proponents seem to envision a world where 10+ insurance companies aggressively compete within a single state resulting in lower costs and maximization of care efficiency. Sadly this is not very probable as if companies cannot retain a significant amount of no/low cost customers they will go out-of-business. Under the current law it appears that the only way that multiple companies will be able to survive in a competitive environment is unified cooperation or collusion. Basically these companies decide as a group to evenly divide up all of the high cost customers so that no company is saddled with their unbalanced costs. However, such a design is highly improbable as remember capitalism is about competition not cooperation, if company A is on the ropes and needs company B to take some of its losses is company B really going to help? Overall one merely needs to look at the outcome of similar competitive measures in Vermont in the 70’s, where a multitude of insurance companies existed before competition whittled the number to single digits.

The third strategy for lowering medical costs is largely associated with the new tax on ‘Cadillac’ insurance plans. The idea behind the tax is to place a preemptive penalty on prospective waste. The general structure of the ‘Cadillac’ insurance plan is one with a high premium, but almost no deductible or co-pay thus encouraging use of medical services regardless of whether or not they are needed or statistically relevant. In addition, most of the expensive premiums that fund these plans are paid by employers, which receive a tax exemption further reducing their burden. However, the tax aims to forcibly change wasteful behavior through taxing insurance companies for plans that exceed $27,500 for a family or $10,200 for a single individual.

One of the chief problems is that this tax does not go into effect until 2018. In addition, the general target is too small because of an overestimation of waste through its use. Waste in the system is not confined to only plans that exceed the tax boundary. While it is true that there is a higher probability of waste in these plans, realistically most of the waste in medical treatment is volumetric spread-out over millions of insurance plans not concentrated in a few hundred super-plans. Also the tax could create a new twist on malpractice suits. Suppose that a patient elects not a receive procedure A that could predict severely detrimental condition A in order to avoid being taxed (because it makes rational sense that although the insurance company is liable for paying the tax, the cost of that tax will be passed on to the company or individual that holds the policy); later that individual develops detrimental condition A. It is highly likely that the patient will sue the physician for not detecting detrimental condition A. Can the physician cite tax avoidance as a meaningful defense?

As previously discussed limiting insurance coverage to diagnostic or therapeutic treatments that have demonstrated empirical statistical significance is another way to significantly reduce healthcare costs. Unfortunately although this method has been discussed in cost controls there are a lot of social barriers to applying such a method, especially with all of the confusion and misinformation concerning most of the more popular or mainstream techniques that would be removed from coverage under such a proposal. Sadly the most powerful weapon in using this technique would have been in the public option. The public option could impose the statistical restrictions where private insurance could choose to do the same or not use any statistical information to dictate coverage. Those that wanted to pay less, but have some popular, but ineffective treatment options not covered would go with the public option whereas those that wanted those procedures covered could sign up with the appropriate private insurer.

Another way to focus on waste reduction is to use preventative measures as a prerequisite for more advanced treatments. For example if an individual wants to receive treatment x they would need to demonstrate that they took an appropriate preventative measure like had a physical in the last 18 months. This method avoids the luck problem with the ‘Cadillac’ tax where an individual takes the proper precautions and still develops a chronic and expensive condition where the tax would further increase those costs because it would only apply to conditions that have a generalized cause and can be detected with a reasonable probability through general preventative measures.

Overall these are 5 important issues that must continue to be discussed in the coming years. To simply come to the conclusion that healthcare is solved now that this new law has passed would be a recipe for failure. Although the new law attempts to address some of these issues, none of the solutions are ironclad and most are still experimental. Steps that should be taken in the very near future are: 1) working with highly efficient organizations like the Mayo Clinic to define a general bundle pay scale that would reduce costs, but also allow for forgiveness of a small number of mistakes to avoid significant losses in treatment; this scale also must increase overall physician reimbursement; 2) generating an information portal so hospitals and physicians can more easily identify whether or not an existing EHR system would result in a more efficient/low cost practice; 3) have a serious discussion regarding the usefulness of incorporating statistical significance when covering a given medical procedure and how much money eliminating those statistically insignificant tests would save; 4) create a general reform structure for ERs and begin testing its application in ERs across the country;

Healthcare is a dynamic beast that must be carefully observed and analyzed so proper alterations can be made within the appropriate time guidelines. Otherwise, costs will continue to increase threatening the general stability and welfare of the United States and her citizens.


2. Jha, Ashish, et, Al. “Use of Electronic Health Records in U.S. Hospitals.” New England Journal of Medicine. 2009. 360:16 1628-1638.

3. Shea, Steven and Hripcsak, George. “Accelerating the Use of Electronic Health Records in Physician Practices.” New England Journal of Medicine. 2010. 362:3 192-195.

Wednesday, March 24, 2010

The Evolution of School Reform – Part 1: Students

One of the critical flaws in most school reform plans is the abject failure to address anything beyond the role of teachers. Teachers are an important part of the education experience and significantly influence the end educational result. However, to believe that all of the problems and solutions lie in the realm of the teacher is silly and frankly rather stupid and irresponsible. Sadly even those that should know better still place almost all of the focus on the teacher in the name of reform or improving school performance. Such emphasis can be seen in the following example, the opening paragraph of “Constructing 21st-Century Teacher Education” by Linda Darling-Hammond from Stanford University.1

“The previous articles have articulated a spectacular array of things that teachers should know and be able to do in their work. These include understanding many things about how people learn and how to teach effectively, including aspects of pedagogical content knowledge that incorporate language, culture, and community contexts for learning. Teachers also need to understand the person, the spirit, of every child and find a way to nurture that spirit. And they need the skills to construct and manage classroom activities efficiently, communicate well, use technology, and reflect on their practice to learn from and improve it continually.”

Unfortunately the above paragraph basically sums up the general view of teaching in the United States. Teachers need to know this, teachers need to know that, teachers need to respect this, teachers need to appreciate that… not once does the above paragraph or any part of the remaining article suggest that the other actors involved in the process of learning (the students, the administrators, the parents) have to compromise anything with respect to classroom performance. So the teacher has to be the hard working chameleon while everyone else should feel no responsibility to adjust or evolve his/her mindset to accommodate the teacher’s personal style. This attitude is a large reason why education in the United States has taken such a negative turn, no responsibility on the students, parents or the administration for their role in the process.

For example when an 8th grader can only read at a 4th grade level, reformers are quick to blame teachers for allowing the student to slip through the cracks. Of course such blame is easy and convenient for reformers because it does not require actually thinking about the issue. If people are willing to assign blame where is the blame for the administrators of the school who allowed that student to continue to advance in grade even when that student did not possess the adequate tools for advancement? Where is the blame for the parents of the student who elected to take so little genuine interest in their student’s education that they were unaware of his/her reading deficiencies? Most of all, where is the blame for the student? Why not chastise the student for going home and surfing the Internet or playing video games instead of cracking open a book and working on improving?

One of the continuing hot buttons of school reform is the periodic standardized test evidence that frequently demonstrates a trend of poor performance of 8th grade and 12th grade students from the United States versus those from other developed foreign countries. Although a lot has been made of the difference between foreign and domestic scores, a more pressing issue should be the change in ranking between 4th grade and these upper grade levels (8th and 12th). For instance when international comparisons are first made in 4th grade the United States is near the top in math, science and language. However, as the students age the rank of the United States wanes versus other nations, so the real question is where and why does this drop-off occur?

Clearly one cannot go running to the problems/gaps in technological integration because the standardized tests used to compile the information for these comparisons do not focus on creating a PowerPoint presentation or writing a program in C++. Thus, something must change either in the students, the instructors or both as these individuals move up the educational ladder. The important first question on this issue is: is it more a matter of the foreign students improving at a faster rate than U.S. students or do U.S. students on a relative level to their younger selves actually regress? Basically think of two cars in a race, does Car A maintain a relatively constant speed while Car B increases its speed or does Car A lose speed while Car B maintains a relatively constant speed?

The reason this question is important is if the answer is the former option school reform only requires some tweeks here and there to close this achievement gap. If the answer is the latter option, then school reform is more troublesome because clearly either the students, the teachers or both are creating an environment that is hurting student achievement relative to if that student attempted to learn alone. At this point in time there is little reason to believe that the latter option is the correct one.

Instead the former is the better bet due to the general static nature of most teaching as students progress in grade versus the dynamic nature of the students receiving that teaching. In 4th grade students have a lot less going on in their lives and the material is easier, so high-quality performance is more straightforward. In 8th and 12th grade other factors enter into the equation, most notably more difficult subject matter, increasingly complicated social interaction with peers (dating, etc.), expansion of extra-curricular activities (higher pressure sports teams, employment, etc.), which increases the difficulty of education. Thus if this reality does turn out to be the case, schools need to address the critical question of student motivation before anticipating any significant improvement in reform.

With the question of motivation in mind the simple fact is that despite the publicity and hype surrounding the role of teaching in school reform, the primary actors responsible for education are the students themselves. Contrary to popular belief, it is not the job of the instructor to motivate the student to learn. It is the job of the instructor to provide an environment where the potential to learn is enhanced, but the core motivational effort is the responsibility of the student. So why is it that teachers receive the blame for this lack of motivation and later the lack of results or learning pursuant to this lack of motivation? The most probable answer is that it is always easier for the students to blame the teacher over themselves for their educational failures and parents of course side with their children over the teacher in most to all instances. Proper placement of responsibility on this issue is a necessary step to enhancing student motivation. As long as society continues to create a scapegoat in teachers and pass the buck with regards to student motivation, the probability of properly motivating students will not significantly increase.

Another important step to closing this gap is students simply growing up. Like teachers students need to realize that education is not a passive activity, involving only simply sitting at a desk listening to the instructor lecture. Students need to actively participate in classroom discussions and activities, with the understanding that learning is not always easy and/or fun. For example when the instructor asks a question to the class every student in the room should raise a hand in anticipation of answering the question, not only one or two.

Of course the school as well as the teacher must aid the student. Returning to the statement of the 8th grader that can only read at a 4th grade level, how was this individual allowed to proceed to the 8th grade in the first place? Either the school did not realize that he/she could only read at a 4th grade level or the school did not care and merely passed the student up along the food chain hoping he/she would ‘get it’ at the next level. If the school does not have a rigorous literature program through composition or language classes then it is quite possible that an individual can move through the system with a low reading level because those skills are never thoroughly tested making them unnecessary, even in the eyes of the student. Unfortunately not knowing a problem exists is not an excuse for ignoring the problem. Therefore, schools need to institute a more rigorous assessment scale for subjects either within the curriculum or as a separate examination.

One could argue that the latter option is already covered by state standardized testing, thus including an additional school specific test could easily become a waste of time for teachers and students. Such an argument would have merit if the results of the standardized testing were handled in a more appropriate feedback manner. For example suppose student A and student B take standardized test D. Student A performs well measuring in the upper 10%, but student B performs poorly, especially in all reading comprehension and vocabulary sections. What is the general school based reaction to these results?

The reaction is the same in both instances, nothing. Schools tend not to address the results in any meaningful way. Most schools do not backtrack student B’s performance in language classes to determine whether or not he/she just had a bad test day or there is a legitimate problem. Student B’s parents typically do not ask the school to assign extra work or extra study focus so student B can work through the problem. Finally student B is rarely concerned about poor results. Such a reaction is either driven through the ‘it is just one test and I don’t need this stuff in real life’ philosophy (a philosophy that is rarely true, especially for language and communication skills) or the student does not want to admit to a problem because it could result in a lower level of self-worth and more homework in order to catch up with other students.

It is a significant problem if parents, the school and even the student realize there is a problem due to poor scores in class and/or standardized testing and nothing done about to address it. The rational behind this lack of action is a culture of equality or advancement. The stigma attached to holding a student back a grade due to poor performance is a powerful one. Such students are frequently the target of ridicule from peers and excessive worry from parents. However, the global picture is better served through the generation of a more prepared and more intelligent individual instead of one that graduates with peers of the same general age, but who still has holes in general skill sets. The issue of ‘he/she is just a late bloomer’ is rather passé and is irrelevant in a vast majority of situations where an individual would be held back a grade.

Therefore, both administrators and parents need to consider the fact that the advancement structure of an educational institution should be focused on making sure that the necessary skills and knowledge are imparted to the students and not be solely concerned with the emotional ramifications and stigma of being held back a year. In addition one must recall that the door swings both ways, it is also necessary to ensure those of greater intelligence are skipped ahead to an appropriate learning environment even if it is with those of greater age. There are few things more frustrating than learning in an environment that is too difficult or too easy for one’s own ability and talents.

An alternative to holding a student back a grade is the use of summer school; however, a large number of summer school programs are not nearly as rigorous as the normal school program and act more as a cover for both the parents and the school in convincing themselves that they are doing something to handle the problem. If summer school could become a viable alternative through overhaul and more specified focus of its coursework then it would provide a valuable alternative to holding a student back to ensure proper knowledge acquisition.

Returning to the point of motivation, increasing the probability of summer school or being held back a grade for inadequate performance may motivate students to work harder, but it should not be the only element to enhance motivation. A key part of motivation is the element of focus. When one is focused on a particular goal accomplishing elements essential to that goal are typically easier than accomplishing elements that are not viewed as important to that goal. Therefore, if one wishes to enhance motivation to learn, be it reading at a certain level or some other task, one possibility would be to incorporate its accomplishment into a meaningful goal structure for the student in question. At first such a statement may sound similar to some form of financial reward program for good grades. Not a chance as such programs do an incredible disservice to society by implying that if one wants to do anything one should expect to be paid to do it. These programs also instill a detrimental precedence of immediate or instant gratification typically sacrificing long-term meaningful gain for small very short-term gain.

Instead the goal motivation should be derived from career aspirations. For being such an important part of an individual’s life, schools do very little to promote career information or education. This is not to say that it is the responsibility of the school in any way, shape or form to fill this role, but it would prove advantageous to both the student and the school if these aspirations were explored in the proper capacity. The current basis for exploration of career issues within the primary education of a student largely involves the generic ‘what are your interests’ aptitude test which loosely attempts to categorize career possibilities based on these interests. There are also visits with the guidance counselor, but these trips are typically either due to poor behavior or at the behest of the student. Due to the reality that most students, especially at a young age, do not think far enough into the future to consider what they will do for a future career, these voluntary visits are unlikely.

What could schools do to improve career information availability? One of the best methods could be to take 2 hours each day for 4th or 5th graders and use that time to significantly explore career paths over the course of the school year with each discussion taking place over the course of 1-2 weeks. For example suppose the teacher wanted to discuss the legal profession, most notably a lawyer. The first day would involve a general background of the profession, what other professions it commonly interacts with, what type of skill set is required to succeed in the profession, what type of skill set generates an advantage in the profession, what type of education is required, etc. The second day and if necessary third day would involve the general terminology and analysis of examples of the profession in action. Depending on the complexity of the profession the next 1-3 days would explore the general principles of the profession using a role-playing exercise. The lawyer example could involve splitting the class into small groups of 4 students each giving them an example case and having them draft arguments to both the prosecution and defense sides of the issue later presenting them to the class in an oral presentation. A discussion regarding how other individuals felt about the arguments could occur after everyone was finished.

The idea behind these profession introductions would be to stimulate interest in a given profession(s) while also demonstrating the tools required to succeed in that profession. With the knowledge of what is required to undertake a future in a profession that they are interested in, students will hopefully be more motivated to study and work harder in class to acquire those tools. Establishing the goal system in this context creates a system that keeps the student interested without requiring additional funds from an already cash-strapped environment as well as not requiring a continually escalating reward structure due to attained tolerance levels.

For those that believe such a methodology would take too much time away from the instruction of other subjects, the incorporation of this methodology seems compatible enough with general knowledge in that any given profession requires language, communication, math, analysis and comprehension skills that would be appropriate to teach a 4th or 5th grader. Thus little time should be wasted in their adoption. It is true that incorporating such a system would be difficult in the interim largely because of lack of experience and familiarity from the teacher’s perspective, but these initial hurdles can be overcome through training programs. Overall the above suggestion is just one possibility designed to spur the motivational fire in students. However, despite the fact that school can lend a helping hand in motivation, it is important that society understand that the responsibility for educational motivation must be removed from the teachers and placed where it belongs, on the students otherwise positive large-scale school reform will be much more difficult. In the end the responsibility of whether or not a student learns something falls on the student.


1. Darling-Hammond, Linda. “Construction 21st Century teacher Education.” Journal of Teacher Education. DOI: 10.1177/0022487105285962

Wednesday, March 17, 2010

What needs to happen to improve education in the United States

This post will return to the issue of education reform, largely because there has been an abnormal increase in the number of articles written about it in mainstream news publications in the last two months. One of the saddest things that one experiences when reading these articles is that the authors seem not to genuinely care about actually reforming the education system in the United States, which make no mistake need reform, but instead they only care about their supposed method of reform. Of course such a mindset basically dooms any sense of legitimate and successful reform to failure because these individuals tend to block out the flaws in their method and demonize certain elements in the current system that do not deserve such scorn. Those who truly want to solve the problem need to systematically look at the system, identify the flaws and then act to remove those flaws instead of citing some little trendy example that seems to work, but could never be applicable as a real solution.

For example most of these new articles lament the ‘horrible’ state of education in the United States and gleefully cite charter school organizations like the Knowledge is Power Program (KIPP) or YES Prep as the model panacea. They dream that if only those horrid teacher’s unions could be abolished then everything would be perfect. Teachers would be judged on their performance using grades and standardized test scores giving ‘definitive’ proof of which teachers were competent and which should start looking for new jobs because without those pesky unions firing teachers would be as easy as adding 2 + 2. With the ability to fire teachers at the drop of a hat, teacher salaries could be increased attracting the best of the best to teach instantly improving the system and making the United States number 1 in the world again.

Alas, how unfortunate that reality must set in and awake Michelle Rhee and her allies from their perfect education world because such a dream world is far from perfect. The problem is that most reformers are so desperate for change they do not realize that the change they are seeking is in and of itself flawed. So where do the flaws lie in the ‘perfect’ dream of most reformers?

The first issue that many reformers seem to neglect is the very issue regarding the nature of teaching. Money is not the main attractor or detractor that determines whether or not an individual, who later would evolve into a good teacher, joins the profession in the first place. Most good teachers view the profession as a form of calling or an occupation of considerable importance. It is rational to believe that the substandard salaries that are given to most teachers may dissuade some from involving themselves in the profession, but to think that a dramatic increase in salary will magically flood applicant pools with individuals that are or will be effective teachers is less rational and more hopeful. The interesting issue is that an increase in salary may actually dilute the talent pool for quality teachers. A higher salary will indeed attract more applicants, but would those applicants have the appropriate drive and overall mindset to be an effective teacher?

The reason for the above concern is that the responsibility of teaching goes beyond what most people think. Frequent are the snipes about teachers only having to work 6-7 hour days and getting 3 months off in the summer; however, rarely is it mentioned that the quality teacher actually ends up working 12-14 hour days due to their involvement in running extracurricular activities for students and/or ensuring that the next day’s lesson is effective at instructing on the major points that need to be understood to master the given topic. Those 3 months off in the summer, good teachers spend them analyzing from a macro and micro perspective what went well the last year and what did not and for those things that did not go well what needs to change to foster improvement. Also if required these teachers, that reformers so highly value, attend workshops and training seminars to acquire new skills to ensure that their teaching efficiency does not decline with changing technology and changes in culture or society.

Of course those elements of teaching only involve the teacher. How does the requirement equation change if the pot is spiced up a bit by adding in the targets of the education? In most professions the working environment and clientele is rather homogenous as the given profession attracts and in some cases requires a certain personality to succeed. Thus person-to-person interaction is either very easy or very difficult, where those finding it very difficult quickly find themselves lacking a job. However, teachers have to interact with ‘clientele’ that run the gamut of personality traits including, but not limited to the eager to please ‘teacher’s pet’, the quiet and studious, the intelligent and arrogant, the apathetic and failing, the uncaring and rambunctious, etc.

Unfortunately that is not all. Teachers also have to interact with parents, which run the similar gamut of personality traits, but unfortunately do not always mesh up with the traits of their offspring. Add in other administration elements and a typical lack of funds due to local resident backlash against further increases to their property taxes and one can very easily see that good teachers require something much more than the offer of a large salary. Sadly most reformers do not seem to realize reality. They almost have the attitude that once the handshake acknowledging the acceptance of the job is complete the new teacher is magically imbued with the necessary traits to become a high quality, motivate the student no matter what, A or B grades for everyone instructor.

The focus on and adoration to quality programs like KIPP and YES Prep can probably be blamed for most of the delusions school reformers have about their solutions. The problem is that reformers look at a KIPP school and its successes, especially teaching Black and Latino students, who typically fair poorer on average in grades and standardized test scores in public schools. Then these same reformers look at what they regard as the gross failure of the public school system and come to the immediate conclusion that installing the KIPP school structure for the given public school will end the failure and facilitate success.

However, these reformers seem to neglect the simple fact of scales. For example the entire KIPP program consists of 82 schools [16 elementary (K-4), 55 middle (5-8) and 11 high schools (9-12)] with approximately 21,000 students whereas the entire public school system consists of over 64 million students. Even the least populous state of Wyoming has 4 times as many public school students (84,920) than the entire KIPP program. It is rational that a niche, which requires specialized talent can be very successful on a small scale, but cannot exceed a certain size and still hope for the same success with the same methodology. Such a niche is the KIPP program and similar programs, they look and operate great when they only involve 0.033% of the population; however, their model runs into significant problems when theoretically scaled up to meet higher population demands because of a simple lack of resources or time to meet those demands.

The cell phone stance is a great example of this point. The KIPP program advertises that teachers are instructed to carry cell phones so students can contact them to ask for help at any point in the day. Although on its face one may praise such an idea, the efficacy of such an idea changes dramatically with class size. The general 11-15 student KIPP class size allows for this idea, the standard 25-35 student class size for the generic public school significantly handicaps it.

The entire industry of charter schools falls under this niche umbrella. Outside of the very specialized programs like KIPP and Yes Prep, which are very small and almost need to be to generate their success, larger charter school systems have demonstrate no statistically significant improvement over the education offered at public schools despite their incredible support in the popular media. That niche characteristic is also why support for voucher programs as a means of school reform is such a joke. Voucher programs are so small that they will do nothing to help the flaws with the public school system and will actually be detrimental by pulling useful resources from the system. Suggesting that a voucher program is an element of positive reform for the education system in the United States is akin to suggesting that a bullet to the brain is a positive element for someone’s health.

Part of the problem with reformers is they are looking for solutions in the wrong places. If reformers are so eager to find a cut-and-paste example for education reform they should be looking at successful public schools instead of charter schools. The focus should be contained to the same genus. For example attempting to find a solution to the problems in the public school system in charter schools provides as little help as if a biologist trying to understand a disease in wolves looked at the uninfected local pig population instead of the uninfected local dog population. Unfortunately for reformers even looking at successful public schools will only generate broad based theories and possible solutions because of the eclectic and dynamic nature of public schools in general. However, these broad based solutions offer a place to start because one of the few things that reformers have gotten right is that reform is needed.

Before throwing around possible solutions to the myriad of problems reformers see with the education system, reformers tend not to ask the key question: what is the overall goal(s) of education? Until one develops an answer to that question proposing reforms is rather meaningless because the proposed reforms will not have a clear focus regarding their intended changes. So in order to get the ball rolling: what is the overall goal(s) of education?

Based on the actions and mission statements of various public and charter schools the intent is clearly to educate students attending the particular school; however, those statements do not go far beyond the nauseatingly general, similar in way to the generic medical student response of ‘I want to help people’ when asked why he wants to be a doctor. The problem with these broad statements is what do they really mean? There is a vast difference between providing the necessary level of education to be nuclear physicist and the education to be a radio broadcaster both in type of knowledge and amount of knowledge. For example despite the differences in type of knowledge the nuclear physicist needs to be able to think about certain issues and problems in a way that will never be required of the radio broadcaster. So if the goal is a focus on ‘education’ what type of ‘education’ should it be even in the most generic sense; the one required for the nuclear physicist or the one required for the radio broadcaster?

Overall despite all of the proclamations, it appears that most schools have one of two goals when it comes to education. First, instruct the students to the bare minimum thought to be required for the next grade level almost in a fashion of just getting rid of them. Second, instruct the student to a level required for college admission regardless of what particular level of college. Unfortunately neither of these goals are well defined with specifics, which makes it easy to claim success. Overall it is not difficult to get into college if one has the funds; if the only criterion for a successful educational experience is being accepted into college then attaining such a goal is relatively easy. However, such success may be relatively pointless, for there are many people that get into college that cannot think their way out of a paper bag. If advancing to the next grade level is the goal, success is almost guaranteed because individuals regardless of their true education level are almost never held back from advancing up the education ladder.

What would happen if education goals were better defined? Clearly a goal cannot be established for each individual or unique occupation because that would be silly and unproductive, but what about more defined general goals with specifics. To do this the first thing to do is ask the question: what is the first principle point of education, why were schools established in the first place? In a democracy for a country to reach its full potential its citizens must have the ability to analyze their situation and identify practical and reasonable solutions to any problems they encounter. Also citizens must realize that they are a single part of a much larger collective, thus it is important to consider the viewpoints and beliefs of other individuals and how they relate to society in general instead of characterize everything they do not agree with as a problem in society. It is the development of these abilities, which make up the origins and still remains the bedrock of the education system, thus it makes sense that these elements drive the goals of education. So how can these basic concepts be reconciled into a goal structure?

Although not the only way, one way is as followed:

Goals of Education –

1. Produce citizens that can make rational decisions, which will allow them to make positive contributions to society;

2. Produce citizens that can effectively form solutions to both qualitative and quantitative problems;

3. Produce citizens that can use both spoken and written word to effectively communicate their ideas and feelings to other individuals as well as understand and analyze the validity of the ideas and feelings of others;

4. Produce citizens that do not tolerate individuals that attempt to manipulate or deceive society for their own ends; further more produce citizens that do not tolerate those that practice and/or preach ignorance or idiocy for the sole purpose of satisfying their own personal beliefs;

To clarify the fourth goal, it is healthy and appropriate for well-meaning and intelligent individuals to debate on topics like the death penalty or legalization of certain drugs where there is legitimate evidence to support both sides of the argument. However, it is not appropriate and significantly detrimental to allow for the continuation of a ‘debate’ on topics that lack evidence to support one side, like discussions regarding whether or not climate change is driven by human activities. Arguing that human actions are not the primary driving force in climate change, to which there is no legitimate evidence of support, is akin to arguing that 2 + 2 is 6,891,957 instead of 4. Despite this simple and definitive reality the ‘debate’ of global warming still rages on. Thus the fourth goal seeks to ensure an end to these fruitless and time-wasting ‘debates’ because there really is nothing to debate.

So if those are the major general goals of educational institutions, what are the first steps to achieving them? The first goal can be achieved by acquiring a basic understanding of government/civics, history, contemporary social issues and math as well as detailed analysis of historical and practical cause and effect models and the methodology that was utilized in their development. The second goal can be achieved by extensive problem-solving analysis and the empirical practice of the scientific method on various topics. The third goal can be achieved through high quality language and grammar courses as well as a number of debates and discussions. Finally the fourth goal can be achieved through instant correction when a student makes a facetious argument and a follow-up challenge asking the two key questions to breaking the control of incorrect beliefs: 1. why do you believe such a thing? 2. what information/evidence would you have to see to convince you that your original opinion is incorrect?

Of course establishing goals and a general construct for achieving those goals is only the first step. There are many different elements that can still be debated on the grounds of whether or not they would enhance the efficiency of attaining these goals. That will be the motivation behind the next post regarding education, a critical analysis of how those elements need to be incorporated if they are going to be helpful to achieving the aforementioned goals of education. Overall if the education system is to improve reform will be necessary; however, to simply rest the outcome of reform on the illusionary laurels of generally flawed teacher evaluation methods and higher teacher salaries is a methodology that is doomed for failure when applied to the system as a whole.

Wednesday, March 3, 2010

A Brief Look into Biofuels

Research into biofuels has been rampant over the last decade largely driven by two factors. First, the ever-increasing specter of global warming demands that the world reduce emissions including those from the transportation sector. Second, regardless of when it occurs and there are a wide range of predictions, oil reserves will run out and a viable alternative infrastructure needs to be in place to ensure a smooth transition between oil/gasoline and these alternatives. Although it may be possible to ease the burden of this transition through mass deployment of electrical and hybrid vehicles, the prospects of mass distribution of electrical airplanes or ships are unlikely. Therefore, the pursuit of the next generation of liquid based fuel remains important.

Currently there are three major avenues of biofuel production each with their own strengths and weaknesses. Proper objective analysis of these strengths and weaknesses in relation to how the world transportation structure will develop in the future is critical to avoiding wasted time, money and effort. Issues that must be weighed are, but not limited to: emission reduction potential, cost, environmental damage, longevity, scalability and technological demands.

Food Stuffs Strengths:
• Technology already exists for production and scale-up;
• Limited energy required;
• Useful by-products such as dried distiller’s grain, bagasse and high quality (not crude) glycerin that can be used in other processes;

Food Stuffs Weaknesses:
• Requires quality soil and cultivated land;
• Due to the land requirement competes with food stock which can increase food prices;
• Inefficient process based on the total amount of energy absorbed by feed stock;
• Based on processing and production method, it may actually increase carbon emissions vs. gasoline when considering a lifecycle analysis;
• Profitability largely based on feed stock price;
• Synthesis ceiling determined by feed stock availability;
• Land requirement reduces longevity;

Algae Strengths:
• Largest efficiency rating of the three methodologies (oil per acre of land);
• High emission reduction potential due to CO2 consumption in addition to fuel replacement;
• Easy growth management;
• Low overhead;
• Low fresh water consumption;
• Increased potential through the use of waste water;
• Depending on the catalyst, potential to produce useful by-products, although does not appear to be in a quantity similar to food stuffs;

Algae Weaknesses:
• Limited growth and scale-up potential due to heavy CO2 feed requirement to maintain efficiency of production;
• Co-localization requirement for sound economics reduces longevity;
• Limited suitable and cost-effective locations for large processing facilities;
• Lack of scale-up potential for photobioreactors;
• Questions regarding oil extraction technique (although this issue is not a large concern);
• Lots of talk, but no viable commercial level processing scale yet;

Cellulose Strengths:
• Near limitless feed stock supply;
• Potential to grow feed stock supplies in poor soil on otherwise unusable agricultural land;
• Potential to recycle lignin by-product to reduce initial energy inputs, reducing overall CO2 required for production;

Cellulose Weaknesses:
• Exceedingly high energy costs which translate to higher production costs;
• Potential problems with ground cover harvesting with regards to erosion and soil replenishment;
• Very large capital costs for developed scale-up mass development infrastructure;
• Possible questions regarding CO2 reduction due to necessity of feed stock transport;
• No viable commercial level processing scale yet;

General Problems Across the Biofuel Spectrum:
• A vast majority of current and future vehicles would need to be retrofitted with additional accessories to properly operate higher than 20-25% biofuel/gasoline blends; biofuel cars are not currently mass marketed;
• Biofuels possess less energy than gasoline, thus higher biofuel blends will result in lower gas mileage;
• Current gasoline/oil transfer pipeline infrastructure is inappropriate to transport biofuels due to their tendency to absorb moisture dissolving impurities leading to corrosion of the pipe;

When weighing all of the pros and cons for the three different methodologies for biofuel production three conclusions, one for each methodology, can be drawn concerning its use on a global level.

For food stock based biofuels using corn, soybean or sugar beet/cane the process itself may be viable and even widely successful in countries like Brazil, but it does not appear to be sustainable in the long-term. Long-term sustainability is threatened largely by the requirement of high quality soil and agriculture to provide the necessary feedstock for the production of the biofuel. In addition the strain placed on modern fertilizer stocks also raises questions regarding production over the long-term from both a quantity and a cost standpoint.

In short food stock derived biofuels only appear viable in regions where motor vehicle use is small. The fact that mounting evidence demonstrating that biofuels produced from such food stocks may in fact result in a greater release of CO2 and other greenhouse gases begs the question, why continue production at all?

For algae based biofuels, the immediate future looks very promising with advantages in efficiency of production, additional CO2 consumption and low freshwater requirements for processing. However, the chief problem plaguing the future of algae based biofuels is their longevity in an emission-reducing environment. Currently the only viable means to generate economically acceptable biofuels from algae is to co-locate the algae growth region within an environment with excess CO2 far beyond what is currently the average atmospheric concentration. If the location could also provide waste heat and wastewater all the better. The best location has been identified as a coal plant.

Unfortunately in a future environment of emission reduction that excess CO2 from that coal plant will be short-lived as either the plant will be decommissioned to abide by future emission caps or the CO2 will be captured and sequestered. If such action occurs the coal plant is no longer a useful environment for enhanced algae growth limiting the total scale-up potential relative to associated cost. Some have proposed positioning the algae in the coal plant flue instead of using chemical sequestration, but such a process theoretically significantly hampers the total product that can be acquired from that biofuel.

Use of fertilizer to provide essential growth elements to algae is also a concern for the present and the future. Currently algae based biofuel is actually carbon positive instead of carbon neutral or negative because of the fertilizer requirements to stimulate enough growth for profitable scale-up. Although the demands for fertilizer can be somewhat eased by locating the growth region near a waste water facilities, at the moment it is unlikely to conclude that scale-up will be successful if fertilizer is removed to the point of carbon neutrality.

For cellulose-based biofuels, the chief problem is discovering and processing the necessary enzymes to facilitate the breakdown of the cellulose in the feedstock. However, even if those enzymes are discovered and can be produced at economically competitive rates, the question regarding the acquisition of feedstock still remains. Despite the proclamations of vast quantities of potential feedstock for a cellulose-based system, these statements only describe the potential not the feasible. Dedicated collection methodologies will have to be developed and carried out to ensure a continuous and environmental friendly amount of feedstock.

Although there is a fourth method for biofuel production, genetically engineering bacteria most notably E.Coli, both cost and efficiency elements of the process are still in the interim stages, despite initial successes, thus it would be unsuitable to discuss it on equal ground to the above three methodologies. On a side note this method of genetic engineering most closely mirrors the cellulose production pathway. Returning to the three major methodologies overall although there are still some sufficient obstacles ahead, from both longevity and emission reduction standpoints it appears that cellulose-based biofuel production has measure of superiority over the other two methodologies.