Monthly Archives: September 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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