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“Fast Grants,” slow grants, HRSA grants, and COVID-19

In “What We Learned Doing Fast Grants,” Patrick Collison, Tyler Cowen, and Patrick Hsu do something I can’t recall ever seeing any funder, foundation or government, do: write a post-mortem on their giving process and describe what the process has taught them. Their second sentence says, “From the beginning, the institutional response has been lethargic.” I can’t recall ever seeing any funder, foundation or government, emphasize speed: most emphasize process. Speed is rarely a consideration in most grant making efforts—though it should be. Presumably grants are being made to address some critical issue, but what’s being left undone, based on slowness? Most federal grant proposals have an evaluation section, but few, if any, federal funders appear to evaluate themselves.

Most grants, from a funder’s perspective, are about signaling and covering one’s potential downside risk—a point I’ve seen few others make. That works sub-optimally, but seemingly well enough, in normal times. In times of crisis, though, the patterns and habits developed in normal times can be not only dysfunctional, but disastrous. I don’t think the average funder or applicant is much attuned to this issue, which makes me pessimistic about change. Yet the COVID-19 epidemic shows that the costs of overall bureaucratic lethargy is high:

we found that scientists — among them the world’s leading virologists and coronavirus researchers — were stuck on hold, waiting for decisions about whether they could repurpose their existing funding for this exponentially growing catastrophe.” Essentially, no one would, or could, make decisions. Tech companies have evolved the concept of the “directly responsible individual” (DRI): something that government strives not to identify. Without a DRI, no one can be blamed. Notice: “About 10 days after having the original idea, we launched.

The phrase “tech companies have evolved” is key here: evolution is built into the nature of private companies, because the badly managed ones die. One good thing about the nonprofit grant system is that a sufficiently dysfunctional nonprofit will also die, and grant making offers a feedback loop, however tenuous. Universities, though, rarely die. Do they reform? Some of the statements are grimly comical, like: “For example, SalivaDirect, the highly successful spit test from Yale University, was not able to get timely funding from its own School of Public Health, even though Yale has an endowment of over $30 billion.” So while I’ve been critical of government, and the authors are implicitly as well, universities don’t come out looking good either.

The authors report:

“We found it interesting that relatively few organizations contributed to Fast Grants. The project seemed a bit weird and individuals seemed much more willing to take the ‘risk’. (That said, a few institutions did contribute substantial amounts, and we’re very grateful to those that did.)”

I’m not aware of any large foundations that have attempted anything similar, although some likely have, and I don’t know about them. Most grant funding comes from the federal government and, because of the federal government’s sheer size, will for the foreseeable future. Foundations and corporate giving sources have their place—and it’s an important place, as Fast Grants demonstrates—but, barring some kind of major change, we’re unlikely to ever see such sources surpass government grants. The authors say: “[T]here are probably too few smart administrators in mainstream institutions trusted with flexible budgets that can be rapidly allocated without triggering significant red tape or committee-driven consensus.” They’re right.

If you’re interested in the behavior of institutions during the pandemic—which is to say, institutional failure during the pandemic—Michael Lewis’s book The Premonition: A Pandemic Story is excellent. Most government institutions were and perhaps are too used to “business as usual” to respond to business not as usual. FQHCs reacted better than most parts of government, but were hobbled by the usual problems of conflicting information and lack of access to personal protection equipment (PPE) in the early stages of the pandemic.

I’m unaware of any comprehensive accounting of the CDC’s actions or lack thereof during the pandemic, especially one that names names. Most of us know the CDC failed, but not the specifics of the organization’s internal workings. Fast Grants was and is an effort to compensate for government failures and slowness.

In non-emergency situations, science funding can work somewhat well. The Department of Energy’s ARPA-E programs have, going back for more than a decade, accelerated the transition towards low-carbon energy solutions (and we’ve written a lot of ARPA-E grants and SBIRs): but making those decisions slowly won’t kill hundreds of thousands of people, and leave millions hospitalized.

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The latest Service Area Competitions (SAC) from HRSA are here, and the FQHC Shuffle

2020 was a peculiar year for many reasons great and small, one of the small reasons germane to grant writers and Federally Qualified Health Centers (FQHCs) being that HRSA deferred Service Area Competitions (SAC), allowing FQHCs to skip the typical application, or re-application, process. For those of you unfamiliar with FQHCs, they’re the nonprofit healthcare providers that are designed to accept any patient, regardless of ability to pay, and that specialize in Medicaid patients, or helping the uninsured sign up for Medicaid. FQHCs and their counterparts, FQHC Look-Alikes, have significant advantages over typical nonprofit or for-profit primary healthcare providers in that they get higher reimbursement rates from Medicaid, protection from medical malpractice lawsuits, access to the 340B low-cost medication program, and a few other advantages—including eligibility for Section 330 grants via the SAC process, which offer between hundreds of thousands and millions of dollars per year in funding. Every (or almost every) geographical area in the country is supposed to be covered by a SAC and most FQHCs must submit a competitive SAC proposal every three years to keep their Section 330 grants.

Delaying SACs seemed like a reasonable idea during the pandemic, and their return is likely to herald some changes. We talk to lots of FQHCs, and it seems that some of the incumbents are weaker than they were, or discombobulated by the pandemic. Others, however, seem to have been strengthened, particularly those that moved expeditiously to telemedicine, which let them keep up their patient loads, while others have struggled with telemedicine. It’s often not apparent from the outside what’s happening on the inside of FQHCs. Some that may seem weak are likely strong, and vice-versa. That’ll make this SAC season unusual and interesting, and I’d not be surprised to see larger-than-average turnover in SAC grants. Because each SAC covers a specific geography, any new applicant is by definition trying to take over the designation from an existing grantee. We’ve heard the SAC process called “the FQHC shuffle.” Most FQHCs succeed in getting their SAC proposals approved and Section 330 grants renewed, but a significant portion don’t; most of us wouldn’t want to play a game we don’t think we’ll win.

We’ve worked with FQHCs on both sides of the SAC shuffle: incumbents worried about upstarts, and upstarts interested in taking over the incumbents’s service area and Section 330 grants. Losing a Section 330 grant can be an FQHC’s death knell: while SACs typically compose less than 20% of an FQHC’s budget, and often less than 10%, they often function as the glue holding the organization above the water level. Lose the SAC, and the overall revenue decline may be small, but that revenue may also be the revenue that keeps the organization in the black. During uncertain times like the present, an alert organization may be able to make progress that would be more difficult in other times.

Three of the eight planned FY ’22 SAC NOFOs have been issued so far: you can see whether your organization’s service area is up for renewal in HRSA’s massive SAC lookup table. The rest will be issued in the coming weeks or months. Is your FQHC or would-be FQHC ready to act?

Although the pandemic is receding, we’re still living in a strange time: the nonprofit winners have a lot of cash; some nonprofits, however, are gone. The next generation of nonprofit startups haven’t wholly started up yet. This is a propitious time to pursue change. We’ve been talking to a lot of callers about what’s happening in the present and what the future might hold.

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Telemedicine and the unstated reason it can save money for Federally Qualified Health Centers (FQHCs) and other providers

You may have read that Walgreens is is shuttering some of its in-store clinic, because the clinics are expensive to operate and, in addition, telemedicine services are taking off. Telemedicine competes with minute clinics, urgent cares, and some primary care offices; right now telemedicine is being vended through a variety of platforms, some of them independent of traditional medical providers (Teledoc is a relatively famous one), while others are affiliated with traditional providers, like FQHCs. The most interesting aspect of telemedicine services might be the one, unstated reason why they’re popular.

The official push towards telemedicine is justified by greater convenience and lower cost. So far, so good: those things are real, as is the nominal improvement in patient satisfaction, but the hidden reason is also revealing: a lot of in-person medical visits aren’t medically necessary and are generated by non-medical desires. Robin Hanson and Kevin Simler talk about this in The Elephant in the Brain: Chapter 13 describes how a lot of medicine seems to be generated by patients wanting reassurance from high-status people (doctors) and doctors wanting to enjoy the status that comes from people seeking out their expert knowledge. To be sure, “a lot of medicine” is not the same as “all medicine,” so you need not leave comments about broken bones being mended or cancers being treated.

A lot of medical office visits are costly for patient and doctor, so telemedicine can reduce the waste. In effect, telemedicine often ends up being triage: the distant provider tries to figure out whether something is genuinely wrong with the patient, and whether that thing needs to be seen in person. Almost all primary care providers have seen lots of patients who come in more for hand holding and an encounter with a sage doc than treatment of underlying condition. I haven’t seen studies describing exactly how many medical visits are really boredom, fear, craziness, improbable uncertainty, and the like, but anecdotally it seems to be high, and Hanson and Simler cite estimates in the 20 – 50% range. This is the sort of thing most of your healthcare provider friends won’t admit to strangers or acquaintances, but they may admit it to close friends or after a couple drinks. FQHC CEOs, who we work for, will sometimes admit this to us, their trusted grant writers (in our own way, we are the “trusted sages” in these conversations, reversing the roles).

So telemedicine can save money because it lets people with common colds, loneliness, and similar real or imagined ailments have a doctor, nurse practitioner, or physicians assistant tell them that they’re okay, bill them maybe less than they’d be billed for an in-person office visit, and then the provider can hang up and talk to another person who is also likely okay. Many people with chronic conditions also just need reassurance, direction to a specialist, or a prescription refilled. That can be done in a few minutes over the phone or via a videoconference. Because it’s socially undesirable and even unacceptable to admit that a lot of medicine is not what we typically think it’s about, not much can be done to substantially improve the system at current levels of technology, but offering telemedicine can be an improvement. HRSA has noticed something like this and is now pushing for FQHCs to offer telemedicine. Healthcare now consumed about 18% of GDP, in a $20 trillion economy, or about $3.7 trillion dollars. There’s enormous pressure on almost every player to try and lower costs as a consequence of these unbelievable numbers. One way or another, the average worker is paying about one in every five dollars earned into medicine—whether that dollar is paid to insurance companies, hospitals, or levels of government via taxes. Strangely, though, regulators are letting hospitals merge and form local monopolies and oligopolies, which is an important exception to the lower-cost trend. Telehealth, however, is right on trend.

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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.

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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.

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“Health insurance security” and FQHCs

I hesitate to post this, because it’s a bit more political than the topics we typically cover, but it’s explanatory more than partisan: “The 2018 Elections Were Not About Obamacare–They Were About Health Insurance Security.” In it, Bob Laszewski describes how “In March of 2016, there were 20.2 million people covered in the individual health insurance market,” but by “March of 2018 the count was 15.7 million.” Why? Because individual market “premiums and deductibles are sky high–for all but the lowest income participants.” Consider this data:

In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits.

That same family, but making too much for a subsidy, as 40% of families do, and a typical family in the affluent Virginia 10th, would have to spend $19,484 in premiums plus a $6,500 deductible, for a total of $25,984 in eligible costs before they would collect any meaningful benefits.

Those are shocking numbers, no? Yet we rarely see them, or numbers like them, in the larger media landscape. Many people have individual experiences of such things, including me; I’m covered by a small group employer plan, not an individual market plan, but my own deductible is now about $5,000. Two years ago, it was $4,500, and when I had a minor procedure to fix a toe I’d dropped a pan on, I spent $4,500 out of pocket almost immediately. Not only that, but when I saw podiatrists to get fee quotes on the procedure, most could not or would not give them to me. Even people who say they want to pay in cash often cannot find out how much a particular service will cost. When I inquired about the price of an office visit, most receptionists were confused but could eventually get an answer, and prices varied hugely, from as little as $40 to as much as $350. Why? I don’t know.

Oh, and the podiatrist billed my insurance for something like $12,000, beyond the $4,500 I paid, and she got $900 out of the insurance company. So her net benefit from the procedure was $4,500 in cash (from me) plus $900 from the insurance company. It is almost impossible to read this paragraph and not think, “Something is horribly wrong here.”

And I am not alone: almost anyone not covered by a very large employer plan, Medicaid, or Medicare has had similar experiences.

There is also an absurdly common misconception among normal people: that “insurance” is what matters for healthcare. Insurance is only part of the puzzle, but “insurance” is only as good as the healthcare we can access with it. Many doctors, for example, don’t accept Medicaid patients. So someone on Medicaid who counts as “having insurance” may not have access to care. Laszewski points out that many people “have insurance” (which is fine), but if the insurance never kicks in for the average person, then it is not functioning like true insurance, but not as the pay-all system that health insurance means to most Americans.

Federally Qualified Health Centers (FQHCs), which are federally funded nonprofits, have supersized in part because of the strange path of the US healthcare markets. Either by accident or design, FQHCs have become the default Medicaid providers in many parts of the country at the same time that the ACA significantly expanded Medicaid eligibility. Policy wonks in DC, along with some politicians, know that “insurance” is not the same as “health care” (as I myself said above). Even if politicians don’t know that, many of their constituents and voters who are on Medicaid know it. FQHCs are a partial solution, because they accept Medicaid patients and self-pays on sliding fee scales. FQHCs have also become front-line purveyors of Patient Navigation services (which link patients with Medicaid or ACA plans). Still, FQHCs usually do not have enough slots for everyone who seeks care, and waits can be long; FQHCs also often have trouble recruiting clinicians and in particular specialties like OB/GYN and psychiatrist.*

So the convoluted and intertwined health insurance and care access problems remain; the present situation likely cannot hold forever; and I do not know what will happen, politically speaking. But I would surmise that, if a family of four making $65,000 a year must pay $10,000 or more in true costs for healthcare before some manner of insurance kicks in, something has to give.

Single-payer is popular in some American political circles, though it’s not my preferred outcome and seems unfeasible financially; I’d rather see price transparency and mandatory health savings accounts coupled with true insurance for catastrophic care. Unfortunately, no one but me and a handful of healthcare wonks desire this outcome, or something adjacent. It’s hard to explain in a soundbite and normal voters have no idea what “price transparency and mandatory health savings accounts coupled with true insurance for catastrophic care” means. It doesn’t map well onto political ideologies. In healthcare, no one wants to talk about or admit to trade-offs. We write many grant proposals for FQHCs, but we never mention trade-offs. Seliger + Associates is a grant writing firm, so we’re firmly in the proposal world. All FQHCs should be in the proposal world when writing HRSA or SAMHSA or foundation applications. In the real world, however, just saying it’s so, doesn’t make it so. Trade-offs are real and pervasive. It may be socially undesirable to acknowledge them, but they are real.

The most likely political outcome will be more kludges on top of existing kludges. Fortunately, “price transparency” would fit this general paradigm. Unfortunately, there seems to be no political constituency for it. I cannot say what will happen next. I did not think Obamacare would happen, and I was wrong about that. I also did not realize that the feds would re-purpose FQHCs in the way that they have, as Medicaid providers, yet here we are. In healthcare, it seems, almost anything is, or has become, possible.


* This is largely due to barriers to entry imposed by existing doctors and especially the powerful American Medical Association. Many things could be done to increase the supply of doctors, including integrating med school into undergrad; shortening med school; allowing foreign doctors to practice without residency; or creating a special one-year residency for foreign doctors. None, however, are on the political horizon.

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HRSA makes it hard to target Ryan White Part C EIS “New Geographic Service Areas” applications

FQHCs and other HIV services providers have likely seen the recently issued HRSA “Ryan White HIV/AIDS Program Part C HIV Early Intervention Services Program: New Geographic Service Areas” NOFO and thought, “looks promising.” As usual, though, a potential applicant ought to first check the eligibility criteria. In this case, on page 3 the NOFO cryptically says, “[See Section III-1 of this notice of funding opportunity (NOFO), formerly known as the funding opportunity announcement (FOA), for complete eligibility information.]” Okay. That section says:

Newly proposed service areas must not geographically overlap with existing RWHAP Part C EIS service areas as defined in Appendix B in NOFO HRSA-18-001, HRSA-18-004, and HRSA-18-005.

Okay. So if you up those other NOFOs you’ll find a long table of current providers; the table isn’t organized in a coherent fashion, except by state. There’s no map or list of potentially qualifying zip codes, only a list of current providers and some poorly described service areas for their Ryan White Part C EIS grants. In many places, like big cities, it’s hard to tell which areas/neighborhoods might qualify as new service areas.

Still, the NOFO also listed a webinar, which occurred today. Despite knowing that bidders conferences are a usually waste of time, I participated anyway, and when the presenters finally finish regurgitating the NOFO I asked, “Will HRSA produce a map of areas that it currently considers underserved? That would help a lot, especially in dense urban areas like New York City.” The leader said, “No. The NOFA does not identify specific areas that are underserved. It’s up to the applicant to demonstrate need in a particular service area.” HRSA won’t produce a map showing allowed areas or even a map of currently served areas. Applicants just have to guess. Thanks, HRSA. Helpful as usual.

If you’re interested in the New Geographic Service Areas program and you read the Q & A when it’s released, you may find the question from yours truly. I sometimes tell students that formulating good questions can be as hard as giving good answers. In this case, the answer would’ve been more useful than the question—had it been forthcoming.

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HRSA sort of “Streamlines” FY ’18 Service Area Competition (SAC) NOFOs

As happens every year about this time, HRSA has been issuing Service Area Competition (SAC) Notices of Funding Funding Opportunities (NOFOs). As we’ve written before, HRSA requires Federally Qualified Health Centers (FQHCs—otherwise known as Section 330 grantees) to compete every three years against non-grantees to keep their Section 330 grants. About one-third of the approximately 1,400 FQHCs must submit a technically correct SAC proposal every year.

We’re in the early stages of the FY ’18 SAC derby and, while the process is more or less the same this year, we came across this, on page 3 of this year’s NOFOs:

The Project Narrative has been streamlined to reduce applicant burden, more closely align with Health Center Program requirements as defined by statute and regulation, and simplify the collection of information.

(Emphasis added.)

Sounds great in theory, but let’s take a closer as what passes for streamlining in HRSA-land. The term “NOFO” replaces HRSA’s longstanding practice of calling their RFPs Funding Opportunity Announcements (FOAs). Thus, HRSA has replaced one pointless three-letter acronym with a similarly pointless four-letter acronym. In they had to change the acronym, why not just use the more common acronym “RFP?”

The FY ’17 SAC FOAs were 73 single-spaced pages, while the FY ’18 NOFOs are 67 single-spaced pages (NOFO length does not include the 365 single-spaced Service Area Announcement Table). It also doesn’t include the 66-page, single-spaced HRSA SF-424 Two-Tier Application Guide (love the doc name). The Guide has intricate formatting instructions for all HRSA grant submissions but often conflicts with the instructions with particular NOFOs, like SAC. Then there’s the voluminous underlying regs for the Section 330 program, but counting these pages would like counting grains of sand on Santa Monica beach.

In summary, HRSA has shaved six pages off of the 498 pages of instructions, not counting regs, or a generous 1.2%! We must applaud HRSA for this Herculean streamlining effort!

To be fair to HRSA, some items previously required of all applicants, like floor plans, no longer must be submitted by current grantees. Also, current grantees don’t have to answer a few of the repetitive questions in the Program Narrative. Still, the SAC applications may not exceed 160 pages “when printed by HRSA.” Despite the digital application upload process, HRSA still prints and copies proposals for reviewers to read in hard copy—partying just like it’s 1999. This is a good reason to avoid color graphics in federal proposals, as most will be printed and copied in grayscale for reviewers.

For FY ’18, HRSA also still requires a two-step application process: the first step in a relatively simply application uploaded through grants.gov, while the second step is the fiendishly complicated online application through HRSA’s Byzantine Electronic Handbooks (EHB) system.

Without doing a deep dive into the SAC NOFOs, a couple of features remaining in the FY ’18 NOFOs illustrate why HRSA using the term “streamlined” might be euphemistic.

There’s a convoluted section of the Project Narrative called “Governance,” where applicants must explain how their governance structure meets complex Section 330 requirements. For current grantees—some of which have received SAC grants for decades—this is odd, since these applicant couldn’t have been funded before if they didn’t meet these requirements. Also, even current grantees must upload copies of their articles of incorporation and bylaws as attachments. One would think that after, say, four SAC grants, HRSA probably doesn’t need another copies of the Owatonna Community Health Center’s articles and bylaws (I made this up, but there probably is a FQHC in Owatonna, MN).

Also, in addition to the grants.gov application file, Abstract, Project Narrative, and Budget/Budget Narrative, the EHB application includes 13 required forms and 12 required attachments for all applicants, including existing grantees.

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Yes, it is possible for your FQHC to lose its HRSA Section 330 grant

If you’re a Federally Qualified Health Center (FQHC), you’ve probably seen announcements like this one, from the Federal Register: “Service Area Competition – Additional Areas (SAC-AA) – Honolulu, Hawaii; College Station, Texas; and Rock Springs, Wyoming.” Those announcements may seem curious: why announce for a strangely small number of additional service areas?

Answers vary. Sometimes it’s because the current FQHC Section 330 grantee has screwed something up badly enough to have its SAC grant yanked (though this is rare). More often, HRSA simply didn’t get any qualified applications for SAC grants in a certain geography, leaving a given area without a Section 330 provider needs for basic healthcare.

We’ve been told some funny stories about HRSA’s reaction to inadequate applicants. Our favorite probably involves an FQHC that called us on a Wednesday or Thursday about a SAC application that was due Monday. We were flabbergasted by this request and knew that a SAC FOA wasn’t on the street anyway. Our client explained what happened: She’d forgotten about the SAC deadline and failed to submit an application. HRSA did the initial review and realized that our client’s application was missing, and no one else had submitted for that rural service area.

HRSA probably isn’t supposed to extend the deadline for applicants who forget about the competition, but HRSA also doesn’t want healthcare gaps. So in the case of our client, HRSA called, told the client to get off their rear, and demanded a proposal by the following Monday. Our client panicked and called us.

We were able to complete the proposal on time (professional grant writer at work, don’t try this at home), and not surprisingly the client got funded. In short, depending on your FQHC’s relationship with HRSA, you can get wildly different outcomes from the same inputs. Our client got lucky. You may not be. We recommend attending to SAC deadlines and making sure you submit a complete, technically accurate proposal before the due date.

We’ve worked on SAC projects for insurgents attempting to take down the current grantee, and we’ve also worked on projects for the current grantee who suddenly realizes that they need a more serious application due to the threat of upstarts. Both kinds of projects are fun for us, albeit in slightly different ways. Both kinds of projects are also a reminder to FQHCs: SAC stands for “Service Area Competition.” Don’t get cocky. We’ve seen lots of cocky clients lose their primary funding streams via hubris, laziness, or both. Success is never final. There are no guarantees in grant writing, and you should know that you may have to compete for your dinner at any time.

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HRSA makes it harder for NAP applicants to shoot themselves in the foot

Many of you are working on HRSA New Access Points (NAP) applications, and this year HRSA made a revealing change on page 3 of the FOA:

Form 2: Staffing Profile will no longer collect salary or federal funding data to reduce duplication with the Budget Justification Narrative. Fields have been added to collect information on use of contracted staff.

The phrase “to reduce duplication” implies that previous applicants would enter one set of positions in the Staffing Profile and another inconsistent set of positions in the Budget Justification Narrative. Those kinds of errors often lead to rejected proposals—even when the applicant does much else right. HRSA, to its credit, is trying to reduce the potential for such errors by putting salary information in one place, instead of two (or twelve: with the feds, trying to find all the places that must match is often challenging).

We’ve written before about the importance of internal consistency in grant proposals. Internal consistency is one of the most important aspects of a proposal. The other day I met with a client who is a grant-world novice and who provided a recently finished proposal she had written for a technical project concept. We were to use her previous proposal as a starting point for the new proposal we were writing. As we went over the budget, budget narrative, and program narrative of her old proposal, I pointed out several key inconsistencies, and those inconsistencies had likely caused the proposal to lose enough points to become non-fundable. I stressed that internal consistency is more important than perfect fidelity between proposal and project implementation.

Why? Most grant programs have some amount of slack in project implementation—that is, grant applications are proposals, and the actual activities may change (slightly). If you do slightly different project activities or have a slightly different staffing plan, you’ll be fine. With NAP, for example, it’s common for applicants to change sites after they’re funded. They might change a nurse practitioner to a family doc or vice-versa. As long as the funded applicant ultimately opens up a new primary health center and deliver primary health care, they’re going to be okay.

But to get that far, NAP applicants need internal proposal consistency as much as they need to demonstrate site control, even if they snag a different site later. Otherwise they’re unlikely to get funded, making the site issue moot.