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“You Can’t Shovel Tens Pounds of Shit in a Five Pound Bag:” The New York Times Ignores CHCs, Section 330 Providers, and HRSA

In “For Many New Medicaid Enrollees, Care Is Hard to Find, Report Says,” Robert Pear discovers something that has long been obvious to our many Community Health Clinic (CHC) clients: having insurance doesn’t mean you can see a doctor. Many if not most doctors won’t see Medicaid patients. CHCs, however, are a class of primary care organization designed specifically for Medicaid patients and the uninsured. We’ve written numerous Health Resources and Services Administration (HRSA) proposals for CHCs, and everyone one of those proposals is supposed to expand access to care. This year’s New Access Point (NAP) program, for example, has $100 million available. Pear apparently does not know that CHCs exist and are funded through HRSA mostly to serve Medicaid patients.

The bigger problem regarding real-world healthcare is the number of doctors. Any discussion about the difficulty of finding care that doesn’t mention the limits on the supply of doctors is specious at best. There have been around 100,000 residency slots since the 1980s. Medical schools stopped expanding long ago. These facts are well-known to experts. Physician Assistants and Nurse Practitioners are to some extent filling in the gap, but in most states they still must practice under a doctor.

Our CHC clients’ biggest problem is rarely recruiting patients—when you subsidize goods or services, people consume more—it’s finding doctors. CHCs usually serve a high-need, difficult-to-treat population. Consequently, physicians often prefer to seek higher pay and lower stress jobs. Although there are lots of people trying to go to medical school—in Educating Physicians: A Call for Reform of Medical School and Residency, the authors note that 42,000 people applied for 18,000 medical school spots, and that at least 30,000 were likely qualified to become doctors—med school and residency act as bottlenecks to this process.

You can give every person health insurance without ensuring that they’ll actually get care, much like you can give everyone a degree without ensuring they have a brain. In the United Kingdom, care gets rationed through wait times. In the U.S., a similar dynamic is happening via provider shortages. While it is laudable that the Affordable Care Act (ACA) significantly increased the number of Americans covered by Medicaid, the landmark legislation did little to increase the number of providers to serve the newly insured. Or, as they used to say in the old days, you can’t shovel ten pounds of shit into a five pound bag. It’s a vulgar phrase but applicable to this article and the overall challenge of helping the newly insured actually access affordable, quality healthcare.

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So, are Seliger + Associates’s grant writing fees too high, too low, or just right?

Last Monday, the executive director of a Community Health Center (CHC) in a western city called me for a HRSA New Access Points (NAP) proposal fee quote—a fairly routine call. I gave him the quote, told him how we do what we do oh-so-well, and he agreed to hire us. As my kids liked to say when they were in high school, “it’s all good.” Just before I signed off, however, our new client startled me by asking, “By the way, how come your fees are so cheap?”

Wow! This query surprised me, as I always thought our fees were relatively high compared to our alleged competition. So, I did a little riff on how we price jobs. I also offered to raise the fee, if he wanted to feel like he was buying the best, but he declined. In our view the fee is about right for this kind of assignment with about eight weeks to complete.

On Tuesday, I was on the loading dock checking in a new shipment of gerunds when the phone rang. I put down my bailing hook, took off my work gloves, and answered. It was a call back from a national nonprofit in Washington D.C. that wants to outsource their grant writing functions. I had talked to an underling the previous week, and she was calling back with the big boss man to grill me about what we do, how we do it, and what we charge. I spent a half hour giving my standard pitch and fielding rapid fire questions with aplomb. After 20 years of pitching, I’ve pretty much heard every possible permutation of questions and have ready answers. The queso grande, however, was going at me hammer and tongs and was giving me the verbal equivalent of what Elmore Leonard calls the Big Yard stare.

I thought I was doing all right when he said, “How come your fees are so high? You’re three times as expensive as the other grant writers we’re interviewing.” On Monday, we’re too cheap and on Tuesday, we’re too expensive! I said that he was in the Mercedes dealership and must have gotten lost on him way to the Hyundai dealership across the street. I told him what we think of our competition—which is not much, based on the websites we’ve seen and the proposals we’ve been given by clients. Finally, I reminded him that our fees are cleverly hidden in plain sight on our website. If he was looking for the 99-cent store of grant writers, he was wasting our collective time.

The interview ended shortly thereafter. I guess he thought I was going to collapse in the face of pressure and give him a two-thirds discount.* As John Wayne said in my favorite Western, The Searchers, “That’ll be the day.”

These two anecdotes show that one person’s cheap consultant is another person’s expensive grant writer. We post our fee ranges on our website in part to avoid sticker shock. Most of our competitors, however, either post nothing about fees or write in vague generalities. I assume this is because they don’t know what their time is worth or charge by the hour.** We’ve been in business for 20 years, so we must be hitting the sweet spot of pricing—or we would have disappeared along the way, as so many of our would-be competitors have.

When you’re seeking hundreds or thousands or millions of dollars in grants, you can hire a consultant because they’re cheap or you can hire a consultant because they’re good. But when the difference in fees is a couple of thousand dollars, and the difference in outcomes is measured in hundreds of thousands or millions of dollars, you know who to call.

* He might also already have another grant writer he wants to hire, or he might be engaging in some weird interpersonal battle with his employee, or have some other consideration in mind. We don’t know enough to know what’s really going on, but in many situations nominal price considerations are actually a cover for other motivations. We’ve written about one example of this in “Why Seliger + Associates Never Responds to RFPs/RFQs for Grant Writing Services,” which we noted that “RFQs/RFPs for professional services are easily wired, with ‘wired’ meaning that one firm is going to get the contract regardless of who submits a response.”

** Charging by the hour makes sense in some circumstances—we sometimes work on an hourly basis—but for many assignments a flat-fee arrangement better aligns our interests and our clients’ interests. Many would-be grant writers charge by the hour because they know they can’t actually complete a full proposal, even if they say they can and will. For us, charging a flat fee for many assignments signals that we’re going to get the job done.

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$700,000,000 in the Affordable Care Act Capital Development Fund: Building Capacity and Immediate Facility Improvements Programs — See, I Told You The Feds Weren’t Broke

HRSA just issued two Funding Opportunity Announcements (“FOAs”) for the Affordable Care Act Capital Development: Building Capacity Grant Program and the Affordable Care Act Capital Development: Immediate Facility Improvements Program”. The first program has $600,000,000 available and the second has $100,000,000. These are significant grant opportunities for existing Section 330 grantees, which include Community Health Centers (CHCs), Migrant Health Center (MHCs), Health Care for the Homeless (HCHs), and Public Housing Primary Cares (PHPCs) providers.

If your agency is a Section 330 provider, you should definitely apply for one or both programs, which will fund facility improvements—an otherwise difficult project concept. Even if your organization is not eligible, you should take heart because it means there are many grant opportunities out there as long as you go fishing for grants. Also, the funding authorization for these two HRSA gems is in the Affordable Care Act (“Obama Care”), and no further congressional budget action is needed. As I’ve blogged about before, there are approximately 50 discretionary grant programs funded in the Affordable Care Act, which will continue to become available in coming months. In most case, the applicants do not have to be Section 330 providers.

Ever since the Great Recession hit, I’ve had to remind readers that the Federal government continues to make billions of dollars in competitive grant funds available across thousands of discretionary grant programs. When you’re right, you’re right, and I’m right.

If you are a Section 330 provider, keep in mind that HRSA uses a two-step application process involving a fairly simple initial application submitted through our old friend In this case the initial application is due October 12. The second, much more complicated application is submitted through a HRSA portal called Electronic Handbooks (EHBs). The EHBs deadline for these two programs is November 22, which is a thoughtful two days before the Thanksgiving holiday. Of course, HRSA won’t actually let you see the EHBs application kit until the application is submitted, adding needless complexity to an already complex process.

Writing a HRSA proposal is not a good idea for a novice grant writer or the faint of heart. But we’ve written many funded Section 330 and other HRSA proposals and know the arcana of the HRSA pack of tarot cards well. We’re tanned and fit from a summer of boogie boarding and bike riding in Surf City and ready to write.