Tag Archives: FQHCs

Who are the HRSA peer reviewers? An anecdote from the New Access Points (NAP) Program

Federally Qualified Health Centers (FQHCs) know that the Health Resources and Services Administration (HRSA), like some other federal agencies, uses peer reviewers for proposals. That can lead to some entertaining coincidences and collisions. We were recently hired by a client who had previously served on a review panel for the last New Access Points competition. In talking with him, I mentioned that we’d written a funded NAP proposal about a year ago for a client in an unusual location. It turned out that our new client had been on the review panel for that proposal (which, fortunately, was funded).

Peer review can in effect shrink the size of the grant world. Peer reviewers also (usually) know something about the programs and processes being discussed, which isn’t necessarily the case with staff reviewers. In some funding agencies, like the Department of Labor, peer reviewers generally aren’t used; if there aren’t enough reviewers, the DOL may grab staffers from other federal agencies to review proposals. That implies grant writers should explain more about basic ideas, rather than assuming that reviewers actual understand the program they’re reviewing. So for staff-reviewed proposals, it’s a good idea to explain more than might be necessary in peer reviewed proposals, since the staffers may not be up-to-date on, say, prisoner reentry common practices, or the finer parts of the parole system.

Because of the small-world effect in peer-reviewed proposals, it can be particularly important to turn in high-quality proposals, because you never know when your proposal is going to act as an inadvertent resume. If you’re part of the Greater Seattle FQHC and someone from the Greater Nashville FQHC reads and likes your proposal as a reviewer, you may much later get a call from them offering you a job.

Don’t underestimate the power of “avoiding social embarrassment” in the list of motivations underlying human behavior.

Links: Vaccines work, legalizing drugs, energy progress, prosecutors and prostitutes, and more!

* “Vaccine Has Sharply Reduced HPV in Teenage Girls, Study Says.” This one verges on the obvious, but it’s worth reiterating. Vaccines really are a public health free lunch. FQHCs take note.

* I don’t know if this story is on the level, but: “How schools around the country are turning dead Microsoft PCs into speedy Chromebooks.” See also our post on Geek Heresy and how technology is not going to magically save schools.

* Scientists are floored by what’s happening in the Arctic right now.

* Good signs in the fight against pointless drug prohibition: Mayor wants to open supervised injection facility for heroin in NY city.

* “A Long Game:” How California cities became as screwed up as they are, and how to fix them.

* “Here’s How Electric Cars Will Cause the Next Oil Crisis;” one hopes so!

* “There is a better way to parent than the nuclear family” should be obvious; see also The Anthropology of Childhood.

* “The rechargeable revolution: A better battery: Chemists are reinventing rechargeable cells to drive down costs and boost capacity.”

* Why America abandoned nuclear power (and what we can learn from South Korea); could also be titled, “How to reduce the cost of nuclear power.”

* “Can NATO and the EU survive Donald Trump, French nationalists, and a ‘Brexit?’” A scarier article than I ever imagined reading. We are our own worst enemies.

* The headline is too polite, but: Left-Leaning Economists Question Cost of Bernie Sanders’s Plans. This is likely to be of particular interest to FQHCs.

* Kofi Annan on why it’s time to legalize drugs.

* “The forgotten survivors of AIDS,” a shocking and moving story, or rather set of stories, that you should probably not read if you’re at work.

* “After Cash: All Fun and Games Until Somebody Loses a Bank Account.” The drive towards cashless societies baffles me, since it further concentrates an enormous amount of power in the hands of unaccountable, indifferent, power-mad bureaucrats, while enabling already pervasive government and big business snooping.

* “Prosecutor known for fighting prostitution charged with paying for sex hundreds of times;” the phrase “victimless crime” comes to mind.

* Good news (well, the bringing-killers-to-justice part is good, the death part is not): “A toddler got meningitis. His anti-vac parents gave him an herbal remedy. The toddler died. Now his parents are on trial.”

* Self-driving cars may still be decades out.

In grant writing, you don’t have to be great; you only have to be better than the other guy

You don’t need to submit the perfect grant application (assuming the “perfect application” even exists); you just need to be better than the other guy.

A story: Years ago we we wrote a string of funded grants for a majority-minority California city. The city was not particularly well run and some of its workers were indicted for corruption. But the feds kept pouring money into the city because, while it was messed up, it was still better run than other majority-minority cities at that time. The city wasn’t going to win any good government awards, but it was less corrupt than the alternatives. So the proposals we wrote got funded because the feds wanted to fund a majority-minority city somewhere west of the Mississippi and there weren’t (and still aren’t) many choices.

This pattern repeats itself. A couple years ago we wrote a funded HRSA Service Area Competition (SAC) proposal for a Federally Qualified Health Center (FQHC) in a medium-sized city.* In and of itself this isn’t interesting, because we write lots of funded HRSA proposals. This FQHC client, however, failed to tell us that, as we wrote the first draft, some of their officers were being indicted on corruption charges. Our FQHC client had competition from another large, local nonprofit, which applied for the same SAC grant.

Given our client’s legal problems, we figured they’d never get their SAC grant renewed. We were wrong.

We later discovered why HRSA funded our client: The other SAC applicant was facing corruption charges too, and it had a big federal grant pulled. Our HRSA client kept getting funded because, it was probably the lesser of two evils, and HRSA had to fund someone. Without a SAC grantee in the city, at least 15,000 Medicaid patients would’ve had nowhere to go for primary care.

What makes this story even more fun is the the second nonprofit was also a former client, albeit for a non-HRSA grant. And, of course, the second client also didn’t tell us about their corruption woes when we were writing their proposal.

One sees this general principle in other areas. Tech workers, for example, are now increasingly fleeing Silicon Valley. San Francisco’s draconian land-control policies mean that expanding housing supply is almost impossible. Restricting supply in the face of rising demand causes prices to rise. Silicon Valley’s situation is uniquely insane on the national stage, as this article describes.

Seattle—while not exactly a paragon of good, fast local governance—is allowing more housing units to be built than San Francisco, and it’s even building underground light rail services that are getting done on-time and under-budget. Light rail construction is going so well that residents want more transit tunneling. There is also no income tax in Washington State, which makes Seattle a much less expensive place to live than the Bay Area. Consequently, tech companies and tech workers are leaving California for Seattle—not because Seattle is perfect, but because it’s better and more functional than its southern neighbor. Even highly paid tech workers are voting with their wallets and feet.

Analogies to dating are so obvious that I won’t belabor them here, although I will say that Briefly noted: Date-onomics: How Dating Became a Lopsided Numbers Game is an excellent take on the subject.

Potential clients often ask us whether they should apply for a particular grant. We can never tell them definitively, but we do say that if they don’t apply, they definitely won’t get funded. We’ve seen numerous apparent underdogs get funded because they applied and the presumed favorites didn’t, or because they applied and the presumed favorites messed up their application, or because they applied and the funder was sick of the presumed favorite. To get funded, you don’t necessarily have to be the “best,” whatever that may mean. You only have to be better than the other guy.


* At least one Section 330 SAC grant is available for virtually every geographic area in the United States; those grants are used to fund primary healthcare services for predominantly low-income people. Without them, many large FQHCs would not be able to operate. Funded FQHCs must compete to keep their Section 330 funding about every three years when HRSA issues a new SAC RFP for their area.

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

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

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

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

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

Let’s try estimating the likely competition.

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

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

Now the odds are close to one in two!

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

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

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

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

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


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