Tag: Service Area Competition

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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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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’s Service Area Competition (SAC) Soaks Up Some Sun in Miami, While Brownfields Grants Are Available in California

This week’s Grant Alert e-mail newsletter has a curious RFP: a single HRSA Service Area Competition (SAC) grant is available to Miami-area nonprofits. You might remember SAC because we wrote “HRSA Service Area Competition (SAC) Grants: How to Defend Your Turf or Deftly Lift a HRSA Grant from an Unsuspecting Grantee” back in June, when the general competition was underway.

The fact that a second competition is being held exclusively for Miami could mean a couple of things:

1. Whoever got the Miami grant screwed it up and had their funding pulled. If so, the local Miami paper should be on this story but probably isn’t.

2. None of the Miami applications were fundable, but for whatever reason HRSA wants to fund Miami.

3. HRSA somehow came up with extra money, perhaps through a Congressional appropriation or earmark, for Miami money.

4. Something even more devious is going on behind the scenes that we’re not aware of.

Of those, number 1 is the most plausible. This also means that Miami-area nonprofits who want to get on the SAC Section 330 bandwagon have an unusual opportunity to do so, because no one is defending that turf at the moment.

The other set of RFPs in this week’s newsletter are three Brownfields programs that should be of special interest to California public agencies and nonprofit affordable housing developers that are interested in developing Brownfields sites. The grants should generate more interest than usual because the California legislature recently eliminated redevelopment agencies, along with tax-increment financing and the 20% set-aside of tax increment funds for affordable housing that was previously required. In this face of this sea change, Brownfields grants have become a much more attractive way of defraying development costs than they were previously.

If you’re part of a city in California, you should be thinking about this RFP.

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Project GEESE is Project NUTRIA At a Table Near You. Also, HRSA’s Service Area Competition (SAC) FOA is out

According to the New York Times, “the city’s too fertile and apparently pesky geese will soon face a grim fate, but will not go to waste: They will go to feed hungry Pennsylvanians.” I’m not making this up.

The idea might sound familiar to Grant Writing Confidential readers. Isaac wrote a post called “Project NUTRIA: A Study in Project Concept Development,” which describes how to conceptualize project development while parodying some of the crazy concepts we see bandied about. A nutria, for those who don’t know, is basically a very big rat, and they were apparently terrorizing Seattle not long ago. So Isaac suggested that low-income and/or homeless individuals be trained to capture the nutria and turn them into food.

This was (mostly) a joke.

The New York Times article, however, indicates that something quite similar is actually happening. No word on whether there’s a job training element to the proposed project or an acronym. If whoever runs this program needs an acronym, we’re willing to contribute one gratis: Project GEESE (Geese Expeditiously Evicted and Served to Everyone). You could change “Evicted” to “Eviscerated.” No word yet regarding whether any of the unsuspecting geese will force fed first to produce foie gras, which I’ve eaten once and would not care to eat again.

Furthermore, you may want to take a gander at this article article from a different source, which claims that “Due to strict New York guidelines regulating the processing and distribution of goose meat, local authorities finally decided to send them off to Pennsylvania, which already has an established protocol for distributing slaughtered geese.” Who knew? So there’s a bureaucratic perspective to this feathered tale as well.

In other acronym-related news, the Health Resources and Services Administration’s (HRSA) Service Area Competition (SAC) Funding Opportunity Announcement (FOA) has been announced, which you should celebrate by asking WTF took so long and ordering some BBQ.

EDIT: In “Why Soup Kitchens Serve So Much Venison,” Henry Grabar reports that “a growing percentage of [venison served to the homeless and needy] comes from the suburbs of American cities, at the unlikely but unmistakably American intersection of bow hunting, pest control and hunger relief.” There are too many deer and too many hungry people, and they intersect here.

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Is it Collaboration or Competition that HRSA Wants in the Service Area Competition (SAC) and New Access Points (NAP) FOAs?

HRSA just issued a Funding Opportunity Announcement (FOA, which is HRSA-speak for RFP) for the Service Area Competition (SAC). SAC FOAs are issued each year for different cities and rural areas in which HRSA has existing section 330 grantees, including Community Health Centers (CHCs), Migrant Health Center (MHCs), Health Care for the Homeless (HCHs), and Public Housing Primary Cares (PHPCs). Without going too far inside baseball, as section 330 grantee contracts expire, HRSA groups them together and forces them to reapply while encouraging other organizations to complete for the contracts. Hence the word “competition” in SAC.

SAC applicants are required to respond to a section of the FOA called “Collaboration” by describing “both formal and informal collaboration and coordination of services with other health care providers, specifically existing section 330 grantees, FQHC Look-Alikes, rural health clinics, critical access hospitals and other federally-supported grantees.” I’m guessing that if your organization is applying to take the contract away from the current Section 330 grantee, that grantee is probably not going to be in much of a mood to collaborate with your application and give you a letter of support.

To put a requirement for “collaboration” in a FOA that uses the term “competition” in its title demonstrates HRSA’s cluelessness. A particularly fun aspect of the SAC FOA is that HRSA pats itself on the back by stating in the Executive Summary that “For FY 2011, the HRSA has revised the SAC application in order to streamline and clarify [emphasis added] the application instructions.” The instructions are 112 single-spaced pages and the response is limited to 150 pages! And there a two-step application process involving an initial application submitted through our old friend Grants.gov, as well as a second application with a second deadline through a HRSA portal called Electronic Handbooks (EHBs). That’s what I call streamlining and clarifying. I would hate to see the results if HRSA tried to complicate and obscure the application process.

HRSA has another FOA process underway for the New Access Points (NAP) program, which I recently wrote about in “The Health Resources and Services Administration (HRSA) Finally Issues a New Access Points (NAP) FOA: $250,000,000 and 350 Grants! (Plus Some Important History).” A quick search of the FOAs reveal that the term “collaboration” is used at least 32 times in the NAP FOA, compared to 8 times in the SAC FOA. I suppose collaboration is four times as important in writing a NAP proposal that in writing a SAC proposal. For those with inquiring minds, the word “competition” is not used at all in the NAP FOA. As far as I can tell, HRSA does not let NAP applicants know that, if they are successful, they will eventually have to compete to keep their contract, while simultaneously committing to collaborating with their competitors. Since I have written many NAP and SAC proposals, I know how to thread this word needle by writing out of both sides of my Mac. But novice grant writers and new HRSA applicants will find this a challenge.

For more of my reasoning on the essential pointlessness of requiring grant applicants to profess their undying commitment to collaboration, see “What Exactly Is the Point of Collaboration in Grant Proposals? The Department of Labor Community-Based Job Training (CBJT) Program is a Case in Point.”