Medicaid has recently released a Final Rule (Federal Register, Vol. 81, No. 88) for Medicaid Managed Care.

By definition, Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Medicaid Managed Care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and Managed Care Organizations (MCOs) that accept a set per member per month (capitation) payment for these services.

When States agree to accept funding for Medicaid from the Federal Government, part of the agreement is to determine the type of delivery system in which beneficiaries will receive care. Historically, this was fee-for-service (FFS). However, FFS delivery systems encourage volume billing – i.e. every service a physician performs when a client is in his care is reimbursed at a 1-to-1 rate, thus financially encouraging behaviors that lead to performing non-necessary services. This type of delivery model places the burden of risk on the payer – in this case, you and I as taxpayers.

However, Managed Care models typically use a reimbursement rate that shifts the risk from us to the physicians (or hospitals, networks, etc.,). Capitation payments, typically function (there are caveats to everything, bear with me) as a means to pay a provider a set amount per patient, regardless of the number of services the physician performs. For instance, a physician may receive $180 for every client in his care, every month, regardless of services rendered to those clients. The idea is some healthy patients may not utilize $180 worth of services whereas; some patients may utilize more than $180 worth of services. There are a series of checks and balances here that need constant monitoring to ensure patients are not underserved and physicians are not underpaid.

In 2013, there were 45.9 million Medicaid beneficiaries (73.5%) receiving care through a Managed Care model. Additionally, (in 2015), some 2.7 million children (73%) also received services through Managed Care models. To provide some perspective, the U. S. population in 2015 was approximately 320 million, so roughly 15% of all U. S. residents were in a Medicaid Managed Care setting.

Medicaid’s Final Rule was written to:

• Reform the Managed Care Delivery Systems
• Improve Quality of Care
• Improve the Beneficiary Experience
• Increase Accountability and Transparency
• Reduce Fragmentation of Care

Key components that were addressed in the rule making were:

• Payments for IMDs
• Addressing In-lieu of Services
• Modernization of typically antiquated systems – Digital handbooks for clients, new rules on network adequacy management, etc.,
• Coordination between Long-Term Services and Supports with Primary Care
• Rules outlining clarity and transparency in rate setting
• Including providing data that contains better encounter data
• And the flexibility to minutely adjust rates without a new actuarial certification annually
• Provides new parameters for the CHIP program that were historically lacking. These parameters bring the CHIP program more in line with the provisions that administer traditional Medicaid MCOs.

This final rule is a great first step at clearing away the fog that has existed for years surrounding Medicaid Federal Regulations. Items like ‘in-lieu of services’ and ‘IMDs’ were traditionally reinforced through flimsy policy papers, or State Medicaid Directors Letters, or even worse, internal CMS emails from division heads. The rules seemed to be applied with little or no consistency, and varied on a State-by-State basis. Now, some topics that were a source of past administrative tension between Federal and State agencies can be relieved with clearly defined guidance. States will continue to try and shift away from FFS models into Managed Care (as they are easier on the budget), and as more States expand their Medicaid programs, we can expect to see more and more of the population placed into these delivery systems.

North Carolina legislature passed House Bill 2 (2016), and the bill effectively restricts transgender persons from using the restroom in accordance with the sex they identify with. And while that provision in of itself is monstrous, other, smaller segments of the bill have larger, more far reaching implications. But to understand those, lets first talk about the fallacy in the arguments used to pass such a bill:

Critics of Charlotte's ordinance said it could have allowed men who may be sexual offenders to enter a woman's restroom or locker room by claiming a transgender identity.

John Rustin, president of the North Carolina Family Policy Council, testified before the Senate, saying that the Charlotte ordinance "means men could enter women restrooms and locker rooms -- placing the privacy, safety, and dignity of women and the elderly at great risk."

Gov. McCrory agreed in a statement he wrote after signing the bill.

"The basic expectation of privacy in the most personal of settings, a restroom or locker room, for each gender was violated by government overreach and intrusion by the mayor and city council of Charlotte," he said. "As a result, I have signed legislation passed by a bipartisan majority to stop this breach of basic privacy and etiquette which was to go into effect April 1 (Source)."

North Carolina is now at risk of losing $4.5 billion of federal funding, according to a statement from the Human Rights Campaign, which claimed the new law is in "direct violation" of Title IX, a federal non-discrimination act.

Trump recently released his seven point plan for health care reform in the U. S., and I wanted to offer some initial thoughts to his different elements. Some points contained multiple sub-points, so I broke them out into individual elements.

1.    Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to.

I’m fine with any candidate that wants to repeal Obamacare, but the elimination of the Affordable Care Act in its entirety solely for the purpose of eradicating the individual mandate is like burning down your house to get rid of a rat. The ACA has bridged gaps in the consumer-corporate partnership that went long unfulfilled; gaps such as an end to pre-existing conditions, a standardized set of basic health benefits, access to preventative care, and premium equity.

Premium equity may not initially appear as a cornerstone of the ACA, but under Trump’s plan, this is a term that will become mainstream within a matter of months if the ACA is repealed. Premium equity, in its most basic definition, is the equitable distribution of premiums across cohorts. Essentially, if you have diabetes, and I am a healthy man, we pay the same premium for the same level of coverage. This prevents insurance companies from gouging high-risk clients.

2.   Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.

This plan worked so well with credit card companies. This is a weak argument, as none of us know exactly how the removal of this barrier will affect insurance carriers, it is a similar comparison. Credit card companies used to be previously subjected to laws that required the interest rates be based on the location the credit card bank was headquartered. This law was jettisoned by the Supreme Court, and South Dakota passed State Laws eliminating the maximum interest rates, and consumers have been swimming in credit card debt since. 

 

Would insurance carriers capitalistically benefit in the same manner of credit card companies? One thing’s for sure: insurance costs will absolutely not go down, just as credit card interest rates and consumer debt did not go down. It’s not in the interest of shareholders.

3.   Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system.
 

This ties in to my main argument against the ACA from previous posts. Health Insurance is NOT Health Care. If Trump is going through the effort of repealing the ACA, why not replace it with a more cost-effective system?

 

Medicare operates at a much lower administrative cost than private plans, and has a slower growth rate than private insurance premiums. What does this mean? If two identical consumers received the same type of coverage, utilized the same benefits, and were similar in every way, the consumer who claimed his insurance premiums as a tax deduction would cost more than the consumer who received Medicare coverage.

 

If Republicans were truly for government cost containment and efficiency, they would repeal the ACA and implement Medicare for all.

4.   Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions?

I’m not going to speak much to this, but the marriage between your employer and health insurance is an antiquated relic from World War II. Medicare-for-all would divorce us from being slaves to our jobs for health coverage. Again, not only would the Federal Government save on the costs of health care, but businesses would no longer be able to deduct the cost of insurance from their taxes.

 

5.    As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance.

This is a bit of an empty statement that offers no resolution to ‘the cracks.’

6.   We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.

What basic options are being referred to here? States have only recently been granted the authority to expand Medicaid coverage beyond extremely limited groups, and only about half of States have chosen this expansion. In States that have not chosen to expand Medicaid coverage at the expense of their own constituents being left without insurance (Texas for example, has approximately 1 million uninsured individuals who fall outside of Medicaid coverage and below the minimum amount for Federal premium assistance).

7.   Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate.

This provision has some merit. I would argue these funds typically go into a 401k-style savings account that can be subject to large amounts of risk.

8.   Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.

This is a legitimate recommendation, and subject to many of the harsh criticism the ACA received from Democrats and Republicans alike.

9.   Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure.

As a person who has personally had State Medicaid budgetary oversight responsibilities, I would contend most States are ill-equipped to manage block grants. However, that is a highly subjective and anecdotal response. Part of what makes the Medicaid program unique is the partnership between the State and Federal government. It creates an informal system of checks and balances, as one agency monitors the other. Block grants would systematically remove this system of checks and balances. However, we have no long-term case studies of a State implementing block-grant funding, so I would be open to a trial.

 

For those of you unfamiliar with the term and funding principles, States typically request assistance in paying for Medicaid services from the Federal government. In exchange for payment, the Federal government regulates how those funds can be spent (what services are appropriate, and for which populations). Block grant funding is essentially a lump-sum annual check to the State to spend the funds how that State sees fit.

10.   The state governments know their people best and can manage the administration of Medicaid far better without federal overhead.
 

I think I covered this above.

11.   States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources.

States have the incentive now to eliminate fraud, waste, and abuse. The State and Federal government dually fund Medicaid programs. State dollars are currently at risk to FW&A, and the incentive currently exists to save State dollars.

12.   Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products.

This needs further explanation. Are these ‘barriers’ the FDA? If so, we have a prime example currently unfolding of what happens when these barriers are removed from society in the dietary supplement market.

13.   Congress will need the courage to step away from the special interests and do what is right for America.

This is a no-brainer. The same could be said for the environment, economy, and every other aspect of our nation. In 1994, the FDA’s regulation of supplements was basically neutered. “Between 1994 and 2008, the number of dietary supplement products on the market increased from 4,000 to 75,000. In the first 10 months of 2008, the FDA received nearly 600 reports of serious adverse events (including hospitalization, disability, and death) from these products and 350 reports of moderate or mild adverse events. However, the FDA believes that these reports are drastically underreported and estimates that the annual number of all adverse events is 50,000.”

 

Is this the same outcome we desire as a society with the pharmaceutical industry?

14.   Though the pharmaceutical industry is in the private sector, drug companies provide a public service.

Yes, which lends to why it is regulated as such.

15.   Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.

Just like Chinese goods? The FDA regulates the conditions, purity, source, and a number of other variables for drugs manufactured in the U. S. This regulation is often referred to as cumbersome and costly, but would you feel safe taking anti-psychotics if these measures can be bypassed? 

Why Super-Tuesday Matters to Health Care:

A look at each candidate’s platform on health care

Hillary Clinton

Hillary Clinton’s platform calls for the proliferation of the ACA, while making incremental changes.

These changes would include placing Federal Limits on the price of prescriptions, reducing the costs of premiums while increasing the coverage of insurers, and pushing for the expansion of Medicaid in the remaining hold-out States.

As of publishing, her party has not released detailed plan information to crosswalk how these reforms will be financed.

Bernie Sanders

Bernie Sanders supports a single payer, Medicare for all. His plan addresses the cost-per-capita spending issue of the United States by divorcing insurance from employment, and providing a basic set of Medicare coverage for all citizens.

His estimates place the plan on a course that reduces costs by $6 trillion over the current ACA – Health Insurance Hybrid model.

The plan is financed through a combination of factors including progressive income tax rates, household income tax increases, and employer taxes. While household taxes would increase, his plan estimates to save the average U. S. household $5,000 annually in premium payments, a savings larger than the 2.2% tax increase on average.

Donald Trump

Donald Trump has no plan on his official website, nor does he address health care in his ‘issues’ panel on his site. However, if you sift through his Twitter account and other media outlets, you can glean a semblance of ideas from his speaking engagements. Some of those highlights include:

• Replace the ACA with a Health Savings Account
• Reduce the amount of vaccines to reduce / avoid autism
• Retain Medicaid and Medicare
• He did, however, when running as a Democrat/Reform party, advocate for Universal Health Care.
• Wants to allow insurers to sell insurance across State lines. 

Cruz and Rubio?

Cruz makes no effort whatsoever to address health care in his ‘issues’ section of his website. He has advocated for the repeal of ‘Obamacare,’ but has no legitimate plan to replace it.

Senator Rubio wants to either repeal ‘Obamacare’ or at the minimum, repeal the individual mandate. Rubio advocates giving families a ‘$500’ tax credit to pay for health care in any way they see fit. 

In 2016, Colorado, of all States, could jettison the Medicaid expansion, but not in a way you would expect. Instead of reverting back to the days of inescapable insurance gaps and junk coverage like some Red States have pursued, Colorado’s “purple (1)” initiative would provide comprehensive coverage to individuals. From Kaiser Health News:

Seniors would stay in the Medicare system, and those in Tricare, the military health system, could keep that insurance. And anybody would be free to buy private coverage from a private insurer, though they would still have to pay for ColoradoCare. It would work like a single-payer plan, in the sense that everybody pays in, and everybody would be automatically covered, one way or another

This initiative would be funded through the redirection Medicaid funds, along with increased employer payroll and individual taxes. 

To finance the project, Colorado employers would pay nearly 7 percent in a payroll tax. Employees would pay 3 percent or more of their gross pay toward the health plan. The self-employed would need to pony up 10 percent of their annual net income (to cover the employee’s contribution plus the employer’s contribution — analogous to the formula used to calculate federal self-employment tax). All in all, supporters say, these proposed tax hikes would raise around $25 billion, and save residents money in the long run.

However, opponents of universal care have quickly mobilized to denounce the initiative, and while their criticism is suspect, I don’t know that I necessarily disagree with it (for different reasons). One vocal opponent is Tammy Neiderman: 

The proposed system would also put 4,000 brokers out of work and lead to longer waits for care, according to Tammy Niederman, representative of a trade group for health insurance brokers.

“This will inevitably ration care,” Niederman says. “There’s no way to put in a universal system that doesn’t do that.”

I tend to disagree with Niederman on both points. Brokers will still be necessary, but for different reasons. Like most nations with socialized medicine, consumers still have the option of purchasing insurance for Cadillac care. Brokers could still find employment for distribution of these plans. Would the State still need 4,000 of these jobs? Probably not. 

As for rationing care, I tend to disagree. Care is currently rationed everywhere. The U. S. has historically suffered from a shortage of physicians (Source), and Colorado is no exception (Source). However, this mentality of ‘because a resource is scarce, and I want mine, other people shouldn’t get theirs’ is not only selfish, but borderline disgusting. The solution to healthcare shortages should not be limiting care to people who cannot afford it, but more along the lines of incentivizing physicians for participation in healthcare and increasing access to school for future physicians. 

Ida Hellander, M.D., David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H., constructed a quick pros and cons of the colorado single-payer initiative, and I agree whole-heartedly with their initial assessment:

Strengths of ColoradoCare

1. The proposal if implemented would cover all, or nearly all of Colorado’s uninsured – apparently (and laudably) including the undocumented.

2. The proposal includes some useful cost-control features, notably the creation of an annual budget, and the ability to negotiate lower prices with pharmaceutical companies.

3. The plan allows for a free choice of primary care doctor.

4. The financing plan is more progressive than the current system.

5. ColoradoCare's organizers have mounted an impressive campaign with considerable mobilization.

Weaknesses of ColoradoCare

1. Multiple payers would persist – probably including private insurers. As a result, it sacrifices much of the administrative savings that could be realized through a true single- payer reform because providers would have to maintain much of their current cost-tracking and billing apparatus in order to apportion costs among the multiple payers. Published cost estimates for ColoradoCare overstate the savings that could be achieved through single payer, and do not take into account the additional costs entailed by ColoradoCare's failure to adopt a full single-payer structure.

2. The initiative makes no mention of how hospitals or other institutions would be paid – apart from a rhetorical nod favoring ACOs. It makes no mention of global budgeting, separating operating and capital payments, or other constraints on hospital capital spending. Global budgeting is critical to achieving administrative savings; separating operating and capital payments is a bedrock of effective health planning, which is essential for long-term cost containment.

3. The initiative would not ban for-profit hospitals or other providers, despite clear evidence that they inflate costs and compromise quality. For-profit ACOs (indistinguishable from HMOs in most respects) might also flourish.

4. The initiative specifies that patients would have a free choice of primary care physicians, but makes no mention of whether the choice of specialist or hospital could be restricted.

5. While the plan would outlaw deductibles, the Board could impose copayments.

6. While the 10 percent tax rate would apply to both the rich and poor (including those with incomes below the poverty line), income over $350,000 would not be taxed.

7. The campaign's anti-government rhetoric is problematic. 

8. Rather than specifying critical aspects of the plan, the initiative leaves many of these to be decided later by the Board. Delaying such decisions has often favored corporate interests, who can intervene after the popular mobilization required to pass a reform has subsided. In the case of the ACA, corporate lobbying during the rule-making process attenuated cuts in Medicare HMO overpayments; reduced promised funding for public health and community clinics; effectively neutered limits on insurance overhead; and watered down the mandated benefit package. In Vermont, the broad-brush program initially passed by the legislature was whittled down in the detailed design stage, leading to rising cost estimates and ultimate rejection by the governor.

According to CMS, we will exceed the $10,000 per-capita threshold in 2015. 

Lastly, the elephant in the room is the $25 billion price tag this initiative arrives with. It seems as if ColoradoCareYes is perfectly comfortable with this price tag, and accepts it as an inevitable. The real question, and it’s the same question I pose to all of the Affordable Care Act reformation, is – Why do we accept this cost of care? Both ColoradoCare and the ACA have done very little (nothing) to address the rising cost of healthcare. According to a study conducted by the Commonwealth Fund, the costs of health insurance is unaffordable for a quarter of all working-aged adults. 

And what are we paying for?

We spend more on healthcare than any other nation (per-capita) more for health at no advantage:

1. How did we arrive at the $25 billion dollar price tag.
2. Elaborate on Section 7 of the proposed ballot measure: 
   (2) COLORADOCARE SHALL PHASE IN PAYMENT REFORMS AND A UNIFIED BILLING SYSTEM. (3) COLORADOCARE SHALL USE PAYMENT MODELS THAT OPTIMIZE QUALITY, VALUE, AND HEALTHY OUTCOMES FOR BENEFICIARIES.

There are a slew of other issues that need addressing, such as plans for fraud prevention, legal authorities for recover and overpayment, quality assurances, access standards, etc., but those can be addressed at a later date. 

Like most of you, I'm highly addicted to podcasts. Serial, in particular, has been interesting this season. For those of you who do not know, Serial covers a singular story through a number of episodes, and in the process, conducts interviews, separates facts from fanfare, and manages to sift through the broken pieces of a story to find some meaning and truth. All of those things are subjective, but it's probably as close to investigative journalism as we'll experience in our lifetimes. It's a free podcast. If you have some time, it's worth a listen. 

This season, the focus has been primarily on Bowe Bergdahl. For those of you unfamiliar with the story, it's about a Sergeant in the Army who abandons his post and is captured by the Taliban. 

From his wiki:

Robert Bowdrie "Bowe" Bergdahl (born March 28, 1986) is a United States Army soldier who was held captive by the Taliban-aligned Haqqani network in Afghanistan from June 2009 until his release in May 2014.^[3][4][5][6] The circumstances under which Bergdahl went missing and how he was captured by the Taliban have since become subjects of intense media scrutiny.

Bergdahl was released on May 31, 2014, as part of a prisoner exchange for five Taliban members who were being held at the detention center at Guantanamo Bay. This exchange and the ceremony announcing it, held in the White House Rose Garden, generated controversy in the United States. On December 14, 2015, the U.S. Army announced that Bergdahl would be tried by general court-martial on charges of desertion and misbehavior before the enemy.^[7]

While there is a ton of political discourse as to the authenticity of his actions, I want to focus on a small piece of the story that no one seems to be discussing. Bowe continually states he pulled this stunt as a whistleblower effort to uncover the poor leadership and conditions he served under. On multiple occasions, he states he did not know of any other ways to draw attention to their deteriorating situation, and in retrospect, is a bit remorseful that he didn't follow proper channels to air these grievances. While the merits of his actions are debatable, and I'm taking no sides, it is utterly devastating to hear someone say their command is bereft of upwards communication. 

This lesson is not lost on healthcare. In both Medicaid and Medicare, whistle-blowing is a positive behavior. Remember, all of our tax dollars are funding the cost of care for MCare/Caid recipients, so anything we can do to curb those costs without limiting access is a boon for all parties involved. Each of us are stakeholders in public health, whether we think about it or not. 

Another important point to illustrate is the different between fraud and waste. Fraud has a criminal intent. Waste could be inadvertent. The determination between he two is made outside of our reporting. What I mean by this is, if you work for a provider and suspect mis-billing or wrong doing, you can report it without the mental burden of trying to determine which category the act falls into.

However, some see this as a deterrent to report at all. What if you discover an accidental coding issue that's been ongoing for some time, resulting in an overpayment? Self-reporting is not admission of fraud. It's the identification of overpayments. And typically, if no fraud is found, those overpayments are recouped through various methods. 

Billing agents and physicians should never be deterred from reporting suspected fraud, waste, abuse. HHS's website has a number of outlets to report Medicaid or Medicare fraud:

Anyone suspecting Medicaid fraud, waste, or abuse is encouraged to report it.  The first touch point should be the Program Integrity contact in the State Medicaid Agency for your individual state.  The State By State Fraud and Abuse Reporting Contacts document was last updated October 2014, and includes the contact information for the State Medicaid Agencies (SMA), and the Medicaid Fraud Control Units (MFCU).  Another reporting option is to visit CMS' State Contacts Database which requires entering the State, Contact Type, and Organization Type.  Lastly, the Office of Inspector General's (OIG) National Fraud Hotline is:

Dial: 1-800-HHS-TIPS

(1-800-447-8477)

Or visit their website at: Office of Inspector General - Report Fraud

Medicare does offer financial incentives to whistleblowers, up to $1,000. While they did try to increase this to 15% of the amount recovered, up to ~$10million, that provision was retracted by CMS after a negative public reception. However, the $1,000 bonus does remain in effect. Additionally, the Office of the Inspector General (link above) has an anonymous form (or hotline) to report fraud. 

Thank you for reading, and if you have any comments, please be sure to add them below. Also, re-share this to anyone on LinkedIn, Facebook, or Twitter as you see necessary!

Purpose in 140 Characters: 

Create a blog dedicated to educating on the basics of the American Healthcare System, while providing some personal conjecture and thoughts. 

Purpose in 140 Words:

The more I speak with the public, both healthcare professionals and in general, the more I realized the American Healthcare System is operated behind a curtain of mystery, invisible to the average person. My intent is to slowly draw back Oz's curtain, revealing the interlocking mechanisms that churn Emerald City's healthcare. 

I am, by no means, an expert. The mechanisms which turn our convoluted, fragmented healthcare system take years of experience to understand, and I've just started my journey. However, the more we read, write, and process, the better we understand. So this is my outlet for those tools of understanding. 

Who would benefit from subscribing to this blog?

Anyone interested in how our healthcare system works. Professionals currently in the industry looking for tips, thoughts, and reminders about Medicaid or Medicare rules, deadlines, and processes. Lastly, anyone who, out of pity, wants to support my professional endeavors. 

What type of subject matter do you intend to write about?

Ideally, I would like to alternate between current events and educational materials. For instance, I may post my thoughts on gun crime statistics as a health epidemic in one post, followed by a small lesson on capitated rate setting the next. All very captivating, I'm sure. 

Lastly, who are you and why should I read your work?

I am a current Health and Human Services employee, but my posts here are in no way the reflection of Health and Human Services, or those of the Centers for Medicare and Medicaid Services. I've spent time as a criminal investigator in the greater-Houston area, investigating Medicare and Medicaid Fraud. I spent four(+) years working with the State of Colorado implementing the Affordable Care and Patient Protection Act and Medicaid expansion. Lastly, I currently work in Medicare fee-for-service contracting. I've dabbled in a bit of everything, and I have a genuine enthusiasm for the American Healthcare System. I mean, it's a unicorn in a haystack, after all. It's a public/private fragmented venture; a beautiful mess. Let's look at it one shard at a time.