Case Studies of Eight Experienced TTW Providers
Previous chapters have shown that numerous organizations signed contracts with SSA to serve as ENs and many of these entities have begun providing services in Phase 1 and 2 TTW states. During summer and fall of 2002, Livermore et al. (2003) conducted case studies of 43 providers—the SVRA in each of the 13 Phase 1 states, 27 ENs across these states, and 3 national ENs—to describe the variability in their service approaches and the early implementation issues these providers faced. This chapter revisits the topic of EN operations one year later to see how their experiences under TTW are evolving. In August and September 2003, the evaluation team conducted follow-up telephone interviews with eight providers previously studied: AAA TakeCharge (TakeCharge), Arizona Bridge to Independent Living (ABIL), Career Consulting Services of America (CCSA), Employment and Employer Services, Inc. (EES), Glick and Glick, Integrated Disability Resources (IDR), Marriott Foundation Bridges from School to Work (Bridges), and the Oklahoma Department of Rehabilitation Services (DRS). We selected these ENs because they:
- Are relatively mature or experienced, having served Ticket holders since early in Phase 1
- Are among the ENs that have the highest number of Ticket assignments and they have received the highest total TTW payments1
- Represent a range of service models and business types (i.e., ENs and SVRAs acting as an EN, national and local, public and private, non-profit and for-profit)
Detailed write-ups of the experiences of the eight ENs are presented in Appendix B. The write-ups describe the ENs’ implementation and service delivery approaches, early implementation experiences, and implementation status at time of follow-up, blending information collected at both time points. Table V.1 presents selected characteristics of the eight ENs as well as background information that illustrates some of their key similarities and differences.
Payment Option Selected
Number of Payments Received
Number of Beneficiaries for Whom Payments Received
Total Amt. Received
At Initial Contact in 2002
|AAA TakeCharge||Private, for-profit||National||30||316||Outcome-only||23||5||$5,908|
|ABIL Employment Services||Private, nonprofit||Phoenix, AZ||100||117||Milestone-outcome||95||31||$35,580|
|Career Counseling Services||Private, for-profit||Wisconsin and Illinois||40||60-70||Milestone-outcome||26||11||$9,027|
|Employment and Employer Services||Private, for-profit||Chicago, IL||130||107||Milestone-outcome||39||16||$10,931|
|Glick and Glick||Private, for-profit||Formerly national; now only Florida||234||23||Milestone-outcome||52||18||$13,440|
|Integrated Disability Resources||Private, for-profit||National||28||137||Milestone-outcome||23||12||$6,899|
|Marriott Foundation Bridges from School to Work||Private, nonprofit||Chicago, IL||15||22||Milestone-outcome||22||4||$5,383|
|Oklahoma Department of Rehabilitation Services||Public, nonprofit (SVRA)||Oklahoma||367||1,125||Milestone-outcome||86||25||$26,983|
The remainder of this chapter presents a synthesis of the information obtained from the eight case-study ENs. We highlight similarities and differences in the ENs’ experiences using multiple examples and detailed descriptions to illustrate the main findings. The topics covered include: service models and targeted clients; outreach, screening, and Ticket assignments; prior related experience; payment system choice; relations with SVRAs and other organizations; factors affecting EN ability to help clients achieve positive outcomes; and both major and minor problems that the entities have had in operating successfully as ENs, in particular problems with financial viability. While the eight ENs are not representative of all ENs operating under TTW, their extensive TTW experience very likely means that other ENs with less experience may soon face some of the same issues.
A. SERVICE MODELS AND TARGETED CLIENTS
The selected ENs represent a wide range of service models in terms of the type and amount of assistance they provide. This diversity seems to reflect one goal of the Ticket Act—to foster an increasing variety of work-related services for disabled beneficiaries. An EN’s service model is, of course, inextricably linked with the types of beneficiaries it envisions serving; the two must correspond or else the program would not work. On this dimension, too, therefore, the ENs represent considerable diversity.
TakeCharge is a "do-it-yourself" EN. It offers no training or job placement services; beneficiaries are solely responsible for finding their own jobs. In fact, it offers no in-person services or direct interactions between beneficiaries and staff, although beneficiaries can get questions answered via e-mail. TakeCharge’s "services" consist entirely of information posted on its website. Thus, it might reasonably be described as an "online" or "virtual" EN. Clients who assign their Tickets to TakeCharge can access a password-protected portion of the website to take vocational tests that may help to narrow their choice of an occupation; learn about job hunting strategies, resume preparation, and job interviews; obtain information on occupations that are in demand in their local areas; locate government-subsidized training programs that can prepare them for high-demand occupations; consult with adaptive equipment experts who can help determine how to adapt a particular job or task to their specific conditions and abilities; and learn about government health care coverage issues such as how to resume Social Security benefits if needed and how to communicate effectively with SSA.
The key feature of TakeCharge’s service model is that it pays each client 75 percent of the Ticket outcome payments it receives from SSA on his or her behalf. This amounts to approximately $245 per month for DI beneficiaries and $150 per month for SSI-only recipients. The shared Ticket payments are intended to help clients stay in the workforce by providing money clients can use for transportation, child care, work clothes or any other expense associated with holding a job, advancing in a career, or running a business.
TakeCharge’s business model has remained consistent since it began operating as an EN under TTW. No changes were made during the year between the two interviews.
TakeCharge is clearly aimed at beneficiaries who need few or no services to get and keep a job that enables them to earn at least $810 per month (the level SSA has established for 2004 for indicating substantial gainful activity, SGA). The website notes that out-of-work beneficiaries should sign up with TakeCharge only if they intend to become financially independent of Social Security disability payments and believe they can find work on their own. Beneficiaries who are already working are told that TakeCharge is appropriate only if they intend to continue working and to increase their earnings to the point that monthly SSA cash payments will stop.
ABIL acts as a staffing agency, conducting job development, job search, and placement activities on behalf of its clients. When necessary, it acts as an advocate for clients, providing peer support and assisting them with any work issues or barriers they encounter. Staff conduct workshops to prepare clients for job interviews, emphasizing the importance of promptness and preparedness when interacting with potential employers. They make extensive use of the Internet to locate jobs and assist job seekers in submitting resumes. The EN does not assist clients with resume preparation or job search skills, nor do they provide rehabilitation, assistive technology, or other costly services. All that clients are required to do is attend the job interviews that have been arranged for them; those who fail to do so have their Tickets unassigned and returned to them.
ABIL selects participants who are ready and willing to work full-time. It does not accept Tickets from beneficiaries who want to work part-time or from home, or from individuals who need long-term training. Clients who require education, training or other resources to address employment barriers are referred to other providers such as One-Stop career centers or the Arizona SVRA.2 In deciding whether to accept a Ticket, ABIL does not concern itself with whether an individual is on SSI or DI or with the type and severity of an individual’s disability.
3. Career Consulting Services of America (CCSA)
CCSA provides job development and placement services to individuals with disabilities throughout Wisconsin and Illinois. It is staffed by a husband and wife team and funded through contracts with Wisconsin’s SVRA, the Veterans Administration, and other state agencies. CCSA works with individuals who are employment ready, that is, individuals who do not need extensive training or employment preparation. In addition to employer contacts, CCSA services include resume assistance, interview coaching, and acting as an employee advocate and liaison with employers. If CCSA staff identify service needs among prospective clients that it cannot provide (e.g., assistive devices or other equipment, vocational training), CCSA refers the individual to the SVRA.
Each applicant for services under TTW receives a letter describing both the CCSA’s and the individual’s responsibilities, and includes the individual work plan (IWP) and a release to obtain additional information about the beneficiary. Also included is a release permitting CCSA to obtain wage information, which must be completed as a condition of receiving services. This enables CCSA staff to contact employers directly, providing a copy of the release, and requesting that the employer send the wage documentation directly to CCSA. If the individual does not return those forms, another letter is sent. Only after the completed forms are returned does CCSA begins providing services.
Although the director was initially advised by other service providers not to participate in TTW, CCSA staff indicated that the organization has experienced excellent outcomes with Ticket holders. CCSA staff note that it has had an easier time placing SSA beneficiaries than it has had placing SVRA clients because the former appear more motivated to work. CCSA has placed its TTW clients in a variety of jobs, ranging from professionals and top-level executives to janitors and truck drivers. CCSA staff estimate that they currently have 60 to 70 Ticket assignments and the organization is eagerly accepting more.
4. Employment and Employer Services (EES)
EES developed a service model generally similar to the models of ABIL and CCSA. EES provides primarily job preparation and placement services. The EN offers weekly job club meetings where clients practice interview skills and discuss employment issues. Staff also provide services such as resume assistance, job search, and minimal computer training for beneficiaries seeking data entry and clerical positions. The EN does not provide vocational/job readiness training or long-term rehabilitation services.
In deciding whether to serve a potential TTW client, counselors assess their ability to work full-time in jobs that pay at least $7.00 per hour. EES will not accept Tickets from applicants looking for part-time work or judged unlikely to succeed in the workplace; these applicants are referred to a more appropriate service provider, such as the Illinois SVRA. Staff did not believe that participation in DI versus SSI affected a clients’ ability to succeed.
Glick and Glick, like the two ENs described immediately above, adopted a strategy of providing job placement assistance, including interview skills, resume development, and referral to potential employers. Staff determine potential matches by comparing the client’s skills and interests with an extensive database of available positions categorized by the location, skill requirements, job description, wages, benefits, and hours required. The company has this data source from the employee-recruitment business it operated before TTW existed and that it continues to operate now as its primary enterprise. However, as a national EN, Glick and Glick conducts all staff-client interactions by phone or mail. Staff schedule interviews for Ticket clients, inform Ticket clients of upcoming job fairs, and provide up to four or five job leads at a time. The EN does not focus on serving clients with any particular characteristics; the main issue is a beneficiary’s desire to work. As we will discuss later, the only change in Glick and Glick’s service model since it started operating was a change in scope for financial reasons, moving from a national EN to one serving only the state of Florida.
6. Integrated Disability Resources (IDR)
IDR is a multi-faceted job placement and support agency that primarily serves individuals on long-term disability who are referred by insurance companies. Working with a network of vendors across the country, IDR provides job placement, vocational rehabilitation, peer support, and other services as needed. IDR also assists beneficiaries with childcare, transportation and other support. Some services are provided directly by IDR staff, but a large network of experienced vendors provides the bulk of services under contracts with IDR.
IDR identified and recruited for TTW individuals it was already serving through its existing contracts with insurance companies—clients who receive private long-term disability and SSDI benefits. These beneficiaries seemed the most logical group to serve, and IDR anticipated a high success rate. IDR also expected to elicit referrals from provider agencies in the company’s national network of vendors, assuming that many of the smaller providers it works with would be unable to afford the up-front costs of providing services under the TTW payment schedule.
IDR also anticipated a small number of Ticket assignments from what staff refer to as "retail clients"—individuals who contact IDR after receiving their Tickets. To convince IDR’s Board of Directors to allow the firm to work with retail clients, staff had to conduct extensive modeling to show that the firm was likely to succeed with this population. The modeling had to demonstrate: that IDR had the ability to find employment for these clients; that the probability of job retention among these individuals was high; and that it would be feasible to track client earnings over 60 months. IDR did not anticipate that this group would represent a large client base without significant marketing. Despite minimal outreach efforts IDR ended up receiving a very high number of calls.
According to agency staff, extensive delays in receiving payments from SSA have made the program so costly to operate that IDR can only afford to accept Tickets from beneficiaries who it believes can be successfully placed with very low up-front costs. In addition, IDR is accepting fewer Tickets from its retail clients and is accepting no Tickets from those on SSI. IDR would like to accept a larger number of Tickets from beneficiaries who may require more costly, long term services, but feels it is not financially viable to do so at this time.
7. Marriott Foundation Bridges from School to Work
The Bridges program represents a substantially different service model than all the other ENs studied. Officials decided to begin functioning as an EN in order to tap into an additional funding source for the SSI youth that the Bridges program was already serving through its youth employment program funded by the Workforce Investment Act (WIA) and the Marriott Foundation. Bridges staff believed that as many as 50 percent of its WIA clients were potentially eligible for TTW. By aggressively recruiting SSA beneficiaries to participate in the youth employment program, Bridges hoped to use TTW funds to expand its services. Staff believed that TTW funds could be used to provide longer-term job retention and post-employment services to clients if Bridges could get them working at SGA. The program seeks to place TTW clients in full-time jobs that pay $7 to $8 per hour. Placements include hotel, laundry, fast food, janitorial, and clerical work. Their hope was that the WIA funds would serve beneficiaries for the first 18 to 24 months and TTW funding would be used to provide follow-up services.
Clients who assign their Tickets to Bridges usually begin with a 10-week employment preparation course that focuses on career exploration, job seeking and interviewing skills, and job retention strategies. But Bridges will place clients in jobs immediately if they must enter the workforce more quickly for financial or other reasons. After the preparation course, Bridges offers job placement assistance, job coaching, assistance with obtaining job accommodation, and counseling about SSA and other benefits. Bridges also provides limited funds for transportation and purchasing interview clothing or uniforms, and they refer individuals to other agencies that fund childcare or other services.
After job placement, Bridges provides an extensive level of employment-support services, because of the severity of clients’ disabilities. A staff member checks in with supervisors to monitor clients’ performance and conducts ongoing case management, asking beneficiaries to check in on a weekly, then monthly, basis. Beneficiaries also can call her cell phone any time. Bridges counsels beneficiaries about their concerns, including problems with coworkers, accepting direction from more than one supervisor, scheduling work and outside activities, marital and parenting issues, and housing problems. The program holds a celebration whenever a beneficiary reaches an important milestone, such as a year of employment.
Initially, Bridges planned to serve TTW clients ages 17 to 25 and even enrolled a few individuals over age 25 as space was available. However, WIA funding only permits the program to serve people age 21 and under, and TTW funding did not cover the up-front costs of serving older participants. Therefore, after the first six months, Bridges altered its strategy to serve TTW participants ages 18 to 21. Most Bridges clients have learning disabilities; a few have psychiatric or cognitive disabilities. In deciding which Tickets to accept, Bridges also considers whether a potential client appears willing to perform work above SGA and has experience and marketable skills such as food service, janitorial, and file clerking. Skills are important because Bridges is not a job-training program.
8. Oklahoma Department of Rehabilitation Services (DRS)
DRS is the Oklahoma SVRA and given that background it uses a service model that is distinctly different from the other ENs described above. DRS has no particular target group; it will serve all interested beneficiaries who meet state and RSA eligibility requirements for services. DRS operates like most SVRAs. Counselors provide client assessments and develop the Individualized Plan for Employment, and clients are often referred to one of the 58 community rehabilitation providers with whom DRS contracts for appropriate rehabilitation services. Such services can include anything from providing vehicle modifications and assistive technology to financing extensive training and education.
A few features of DRS may, however, make it unique in some respects from other SVRAs. DRS has participated in SSA’s State Partnership Initiative (SPI) since 1998. Its SPI model of delivering services has focused on providing benefits planning to Social Security disability beneficiaries. Under the SPI project, it has also used a performance-based milestone payment method with providers that was in place for many years prior to the implementation of TTW. While the SPI project was directed at SSI beneficiaries with mental illness, the focus on benefits planning and experience with a milestone payment structure has likely made agency staff more open to a performance-based service model and enabled DRS to implement this model more smoothly.
B. OUTREACH, SCREENING, AND TICKET ASSIGNMENTS
The Ticket assignment data presented in Table V.1 is, in some respects, only the proverbial "tip of the iceberg" in terms of the ENs’ efforts to elicit business and respond to Ticket assignment requests. In some cases, the ENs have dealt, in one way or another, with far more beneficiaries than the number of Ticket assignments might suggest. Finding beneficiaries who can be served appropriately under TTW can be a challenge. Additionally, the ENs’ Ticket caseloads have changed over time in ways that may not be fully captured by the two Ticket assignment statistics listed in Table V.1. Below we summarize the case-study ENs’ experiences in recruiting and screening potential clients that led to Ticket assignments as well as unassignments.
At one end of the continuum is AAA TakeCharge, which conducts no marketing or outreach. Potential clients learn about TakeCharge from the Program Managers’ website or mailings, as well as through word of mouth, and essentially refer themselves to the EN. The website clearly explains TakeCharge’s service model and the type of beneficiaries who are (and are not) ideally suited for this EN. Those who would be inappropriate are encouraged to seek services from a different provider. The director does answer e-mail inquiries, but TakeCharge does not screen applicants; those who send in an application form are accepted, assuming they meet basic Ticket program eligibility rules.
Between the first and second interviews, TakeCharge’s assigned Ticket caseload grew tenfold.
AAA TakeCharge has not developed procedures for unassigning Tickets because this would add another level of administrative burden that the EN does not have the resources to support. Thus, at present, a client may take steps to unassign his or her Ticket, but the EN will initiate no such steps regardless of a client’s activity level. This probably explains, in part, why the number of beneficiaries for which the EN has received payments is low relative to the number of Ticket assignments; many Tickets may be assigned to TakeCharge even though the clients are not active in the program in any real sense.
ABIL provides an example of an EN that has increased its outreach efforts over time and has also been involved in extensive screening of individual beneficiaries. At the time of the initial interview, ABIL had not done any active marketing of its program to Ticket holders. Nonetheless, due to various referrals, it was receiving 10 to 15 telephone inquiries a day. The EN had received a total of about 900 inquiries, but screening efforts had resulted in their accepting only about 100 Tickets.
Potential clients first undergo a 15-minute screening on the phone, during which they must show enthusiasm for work. About 15 to 25 percent of those who complete the initial phone screening are sufficiently interested to pursue the next step, an in-person, small-group orientation session. Potential clients are given two opportunities to attend the orientation session. Those who miss their appointed time twice are referred to other providers. During the orientation, potential clients are told about TTW and SSA work incentive provisions. ABIL staff members encourage attendees to shop around for other service providers before making a decision about where to assign their Tickets. About 50 percent of those who attend the orientation continue pursuing Ticket assignment with ABIL. The third step involves a 60- to 90-minute one-on-one meeting with the director, during which she talks with clients about their goals and skills and identifies any possible barriers that may emerge as they formulate a plan for employment. It is during this interview that the director decides whether ABIL will accept the beneficiary’s Ticket. Most that get to this stage are accepted, but sometimes before accepting their Tickets the director will require them first to address specific barriers to employment.
At the time of the recent follow-up interview, the total number of informational queries had risen to nearly 1,400, which had resulted in 220 IWPs being written. ABIL’s director mentioned having pursued two active marketing strategies. First, the EN had contracted with a public relations firm to produce an informational video about TTW and ABIL services that is shown occasionally on television. Second, the EN tried making cold-calls to Ticket-eligible beneficiaries, but this strategy was not deemed effective and thus abandoned. Too many beneficiaries, they found, did not even remember having received a Ticket (let alone what it was for), and others reacted negatively, figuring the EN staff to be telemarketers who wanted to sell them something.
CCSA does not conduct marketing or outreach, but relies on referrals from the Program Manager as well as calls from dissatisfied clients of local ENs. Initially, CCSA operated an 800 number, but shut it down because costs were prohibitive. CCSA has received as many as 20 calls per day on or near Ticket distribution dates. Initially, CCSA screened only for interest in working full time, but found that individuals interested in working full time were not necessarily good candidates for immediate return to work. Because of difficulty in job placement, CCSA began to screen out individuals with vision and hearing impairments, severe mental illness with active psychotic symptoms, and people over age 60. CCSA tends not to accept Tickets from married individuals with working spouses because of its belief that such individuals are likely to be less motivated to work than are individuals with less-generous or less-stable sources of support. CCSA also asks all callers about their trial work period and extended period of eligibility status.
Significant numbers of beneficiaries who have assigned Tickets to CCSA are not actively participating in services or looking for work. However, CCSA does not initiate unassignment of these Tickets. If the beneficiary requests unassignment, CCSA instructs the Ticket holder to submit a written request to the Program Manager.
EES reported no need to actively promote its services as an EN because so few other ENs were active in the Chicago area; indeed, they received more contacts from Ticket holders than they could handle. Initially, EES accepted most Tickets that beneficiaries wanted to assign, but later became more discerning, accepting only individuals deemed most likely to succeed under TTW based on the services EES could provide. Less-suitable candidates were referred to the Illinois SVRA, which, EES staff said, typically accepted the Tickets.
Glick and Glick’s intake experience was similar in some ways to the above-described programs. Like EES, it got so many calls initially—over 100 per day at first—based on the information provided by the Program Manager that it did not need to do any outreach or marketing. This had fallen to 10 or 15 per day by the time of the first interview. With experience and increased program knowledge, staff was able to reduce screening phone calls from half an hour to a few minutes. Staff sought to gauge motivation and interest, and candidates who were determined not to be a good match were told to contact another EN or their SVRAs. Staff noted that, as of November 2002, about 30 to 40 percent of the initial phone interviews resulted in a Ticket assignment; they had generated about 300 Ticket assignments from approximately 800 phone screens. Now, however, Glick and Glick staff are more rigorously screening Ticket holders. Its operations have been scaled back dramatically and it has only one-tenth as many assignments as a year earlier. At first, Glick and Glick unassigned Tickets only when clients clearly were not actively participating in the activities specified in their IWP, for example, missing multiple appointments, or in rare cases when they were verbally abusive toward a staff member. Later, however, Glick and Glick purposefully unassigned most of its Tickets, a decision we describe in detail later.
IDR devotes considerable resources to TTW. Staffing levels have increased in the past year as TTW has been implemented in additional states. A formal marketing plan was developed to encourage Ticket assignments from among IDR’s existing clientele. In addition, IDR works with its national network of vendors to encourage them to refer individuals on their caseloads to IDR’s TTW program. IDR has engaged in very limited marketing directed toward its retail clients. These beneficiaries become aware of IDR through information provided by the Program Manager or from others who have contacted the agency. Despite this lack of marketing, IDR continues to receive an overwhelming number of calls from Ticket holders, requiring them to assign a full-time staff member to answer these calls, provide detailed information on the Ticket program, and conduct initial screening activities.
IDR mails interested beneficiaries a questionnaire to determine if they can be appropriately served by the agency. The questionnaire addresses a beneficiary’s medical history, prior employment and educational experiences, and interest in work. The questionnaire specifically asks whether the beneficiary is interested in working at a level that will result in the individual losing his or her cash benefit. If the questionnaire reveals that the Ticket holder is interested in using the Ticket to work part-time but does not want to go off benefits, IDR is extremely reluctant to accept Ticket assignment.
IDR no longer accepts Tickets from SSI beneficiaries because they view them as too costly to serve given their limited employment histories and need for ongoing support. Screening procedures for SSDI beneficiaries now attempt to identify Ticket holders viewed as "job ready." IDR staff members believe that their TTW program is so costly to operate that it cannot provide vocational training or other costly upfront services. Based on the results of the screening questionnaire, IDR asks beneficiaries to participate in an individual interview. While this is time consuming and costly, it allows the agency to further explain the program and what is expected of participants. Once a Ticket holder has been accepted into the program, a counselor reviews all available information and begins developing an IWP. For some participants, IDR develop IWPs with the support of contract vendors.
Marriott’s Bridges program was distinct from the above ENs in that, although it did receive calls out of the blue, it also pursued a targeted recruitment strategy. Specifically, it generated some of its Ticket assignments from former clients whom staff knew to be SSI recipients. Staff instructed these clients to request their Tickets and assign them to Bridges. At the time of the first interview, staff were still in the process of identifying SSI recipients from among its clients served with its WIA funds. Prior to the initial interview, the EN had accepted about a dozen Tickets from clients not already on its caseload, and they subsequently stopped accepting Tickets from any individuals not eligible for services under WIA. More recently, feeling they were operating at about capacity level, staff stopped accepting any new Tickets. Callers get a phone message describing the program but are referred elsewhere.
The Oklahoma DRS has used an outreach and screening approach that is unlike that of any of the other five case-study ENs. It is on the opposite end of the continuum from AAA TakeCharge in terms of the extensiveness of its marketing, but quite similar to TakeCharge in its willingness to serve virtually all interested individuals.
In preparation for TTW, DRS set up a toll-free number and sent letters to all beneficiaries on the VR caseload, alerting them to TTW and describing its features. At the time of our first interview with them, DRS was preparing to send a mailing to all beneficiaries in the state to stimulate interest. The agency anticipated receiving 30,000 to 50,000 calls in response, but had received only 1,500 at the time of the first interview. A special, centralized group, the "Ticket Unit," fields and screens all TTW-related calls so as not to burden field counselors. While Ticket Unit staff tell callers about potential program benefits, they also invite all callers to Ticket orientation meetings, in-person presentations at local One-Stop career centers, a format viewed as more effective than telephone discussions. The presentation includes a slide show describing available work incentives and uses a variety of scenarios to illustrate the potential impact of work activity on SSA benefits. Interested beneficiaries complete an application to determine eligibility. Applications are processed in three to five days, and Ticket assignment takes another week; the whole process is almost one month shorter than for DRS’s usual eligibility determinations.
DRS will accept the Ticket of any eligible beneficiary who applies for services. At the initial visit in August 2002, DRS had approximately 225 milestone-outcome clients, which represented over 80 percent of Tickets assigned under this payment system to SVRAs in the 13 Phase 1 states. One year later, its Ticket assignment total had quintupled.
DRS does not have a policy of unassigning the Tickets of beneficiaries who do not appear to be making reasonable progress. Due to state budget shortfalls, however, DRS was forced to place many Ticket holders on a waiting list for services—many were on the waiting list for up to six months and could not proceed with writing IWPs. Staff recently reported that the backlog of Ticket holders has diminished; most have developed IWPs and are currently receiving services.
C. PRIOR RELATED EXPERIENCE OF ORGANIZATIONS AND STAFF
A major goal of the Ticket Act was to induce new providers to begin serving disability beneficiaries, perhaps giving them entrée to services they previously could not easily access. The case-study ENs encompassed diversity on this dimension—some were newly created, others had been in existence but were not necessarily working with SSA’s disability population.
The director of AAA TakeCharge had prior experience, with another organization, providing employment and placement services for persons with disabilities. However, she created her company specifically in response to the TTW program.
ABIL is an agency with a long history of services for persons with a variety of disabilities. ABIL is a Center for Independent Living that provides peer counseling, independent living skills training, housing, limited vocational preparation, and other services. ABIL is also the BPAO grantee in Arizona. However, to expand into Ticket operations, ABIL created a special new division, the Employment Services Division. A unique characteristic of ABIL is that it is primarily staffed by individuals with disabilities, thus they are especially adept at understanding what is required to find and maintain employment as well as establishing credibility with TTW clients.
As noted previously, CCSA is staffed by a husband and wife team and is funded with contracts through the Wisconsin VR agency, the Veterans Administration, and other state agencies. The director, a man with a disability, founded the company based on his own experience and frustrations in finding suitable employment. The organization participated in SSA’s Alternate Participant program, and experienced substantial difficulty collecting payments from SSA for services provided under that program. When first interviewed, the director anticipated encountering similar difficulties collecting payment under TTW and indicated that he will ensure that TTW participants will never constitute the majority of CCSA clients.
Though EES has existed since 1982, it is a new entrant into the field of disability services, drawn to this area by the initiation of TTW. It was a non-profit organization until 1989, when it converted to for-profit status. EES serves a variety of client populations. It operates three of the five Chicago-area One-Stop Centers and one suburban One-Stop Center, under contract with two Workforce Investment Boards: a Welfare-to-Work program and a program for dislocated workers. It also hired two staff members (counselors) with disability-related backgrounds—one had a background in mental health and the other is an occupational therapist.
Glick and Glick, like EES, was a pre-existing organization that decided to expand the scope of its operations into the TTW program. An employment agency operating since 1975, it has roughly 100 employees. Its core business is employment services; specifically, its clients are employers seeking to hire people whose characteristics would enable them to claim employer tax credits. Through one of its programs, Glick and Glick has worked with unemployed and disadvantaged populations, including persons with disabilities. The focus of its prior efforts, however, was to fill job vacancies on behalf of its employer clients. TTW represents somewhat of a departure from its previous activities in that the individual is the client, rather than the employer.
Until TTW was implemented, IDR served only individuals who were referred from major insurance companies for rehabilitation, job placement, and other return to work services. IDR staff noted that the services required by their long-term disability cases were virtually identical to those needed by those considered retail cases. From a service perspective, the employment services and supports provided to these two populations differed very little. The differences between the two groups primarily relates to available funding. For long-term disability clients, IDR can receive funding from both an insurance company and SSA, but when serving retail cases, the agency must rely exclusively on payments from SSA.
Marriott’s Bridges program also existed long before the creation of TTW, and was performing similar work for a portion of the Ticket-eligible beneficiary population. The program began in 1989 in Montgomery County, Maryland, and was replicated in Chicago in 1990. It focuses on youth ages 17 to 21 and the transition from school to work.
The Oklahoma DRS, as an SVRA, obviously had a strong connection with work-related services for disability beneficiaries long before TTW. To facilitate acting as an EN under TTW, DRS formed a "Ticket Unit" in its central office and ensured that all relevant staff were sufficiently trained on program details.
D. CHOICE OF PAYMENT PLAN
As shown earlier in Table V.1, seven of the eight case-study ENs operate under the milestone-outcome payment system; that is, all payments made on behalf of new clients will be made under that plan. Here, we try to provide some insight into their choices.
AAA TakeCharge chose the outcome-only payment system because it believed that system would be more easily understood by beneficiaries, that they would prefer getting 75 percent of a standard-sized, predictable monthly payment, more than getting 75 percent of milestone payments that would vary in size and timing. Beneficiary understanding is particularly important for the success of this EN, because of its do-it-yourself approach and its need to keep administrative costs to a bare minimum.
CCSA selected the milestone-outcome payment system because it would become eligible for milestone payments earlier than outcome payments. CCSA was also concerned about the requirement that clients must remain employed and that CCSA must document employment for five years to collect the full outcome payment.
Glick and Glick selected the milestone-outcome payment system because officials wanted to gauge the employment experiences of their early TTW clients before accepting what they believe to be a greater risk associated with the outcome-only payment system. This statement, and the statements of Bridges staff noted below, suggests that this EN, and perhaps others in the future, may switch to the outcome-only system if greater experience and data-driven analysis show it to be financially viable.
Two of the ENs changed their payment systems after initial selection. Initially IDR planned to use the outcome-only payment system with the expectation that the bulk of its Ticket assignments would come from its existing caseload. This population posed little risk because IDR was already receiving payments for serving these individuals. As it became obvious that the majority of its TTW customers would be retail clients, IDR switched to the milestone-outcome payment system. IDR perceives the outcome-only payment system to be riskier than the milestone-outcome system, and with no outside funding sources for these clients, IDR was hesitant to assume any more risk than was absolutely necessary.
The Marriott Bridges program initially chose the outcome-only system, but switched to the milestone-outcome system prior to the first interview in fall 2002. Program officials came to believe that the young beneficiaries they serve (all are ages 18 to 21) generally would not have enough employment stability to generate the full number of outcome payments—that is, they would not remain employed above the SGA level for five years. For example, some early clients moved away and stopped working relatively soon, and the program collected no payments on them. Realizing they could have collected milestone payments on those clients (and on others like them in the future), EN officials changed their selection to the milestone-outcome payment system, which they figured would produce more revenue. As a result of the switch, Bridges currently receives payments under both systems, depending on which was in place when a client assigned his or her Ticket. Now, however, the EN would like to switch back to the outcome-only system, because, officials said, they would like to collect the larger monthly payments on behalf of some two dozen clients who are working consistently over SGA. The EN will have to wait, however, until the required time period passes before it can change its payment plan a second time.
For Oklahoma’s DRS, the milestone-outcome payment system was a natural choice, officials said. Ten years earlier the agency had developed a milestone system for paying community rehabilitation programs. Under that system, community rehabilitation programs received up to eight milestone payments totaling $9,000 ($11,000 if the consumer was highly challenged) for each successful rehabilitation. The staff member who manages SSA reimbursement for the SVRA decides on a case-by-case basis whether to use the milestone-outcome option or the traditional payment system for each new Ticket assignment, depending on the agency’s past experience assisting individuals with similar characteristics. For clients who are expected to receive services totaling less than $5,000, DRS elects to be paid as an EN under the milestone-outcome payment system; for other, more-expensive cases they choose the traditional system. According to DRS staff, this flexibility has enabled DRS, acting as an EN, to receive payment for services that the agency would historically not have received under SSA’s traditional payment system. For example, by selecting the milestone-outcome payment system for individuals with mental retardation or developmental disabilities in supported employment, DRS might secure three or four milestone payments. The agency would likely not be able to receive traditional payments for these individuals, because they typically do not work up at SGA level for the nine-month period required by the traditional system.
E. RELATIONS BETWEEN ENs AND SVRAs
As TTW was being developed, it was unclear what relationships would develop between SVRAs and other ENs. The case-study ENs have not worked much with SVRAs, but we learned of some recent initial efforts to do so. Even if collaboration has been minimal so far, some frameworks are being established that could allow for more extensive relationships in the future.
In the past year, AAA TakeCharge entered into an agreement with the Wisconsin SVRA to serve their clients. Under the terms of the agreement, TakeCharge will decline Ticket assignment for Wisconsin clients expected to consume $10,000 or more in vocational rehabilitation services from the SVRA. These individuals will be served exclusively by the SVRA (or jointly between it and another EN). For individuals expected to consume less than $10,000 in SVRA services, TakeCharge will be free to accept Ticket assignment. For those clients, when Ticket outcome payments begin and for as long as they continue, the Ticket holder will receive $125 each month; TakeCharge will receive $45 a month for DI clients, $30 for SSI clients; and the SVRA will receive the balance of the payment. After developing the agreement, Wisconsin’s SVRA mailed a letter explaining the agreement to approximately 100 Social Security beneficiary clients believed to be working at SGA and above, or believed to have the potential to work at levels higher than SGA. TakeCharge and Wisconsin officials anticipated that at least half of the group would assign their Tickets to the EN, but only one or two dozen did so. TakeCharge’s director has discussed a similar agreement with the New York SVRA, but nothing had been finalized at the time of the second interview.
At the time of the initial interview, ABIL had established an agreement with the Arizona SVRA that would allow the EN’s clients to access long-term training and high-cost accommodations. This option has yet to be exercised, however, because ABIL still does not accept Tickets from beneficiaries with needs that would require services from the SVRA.
IDR explored the possibility of establishing a formal relationship with the SVRAs in Connecticut and Florida, but to date has not entered into any VR-EN agreements. Staff indicated that at one point IDR was close to developing a formal relationship with the Connecticut SVRA, but significant downsizing within the SVRA delayed negotiations and no discussions are underway at this time. IDR does not believe that entering into formal agreements with SVRAs is in its financial interest, and also indicated that negotiating these agreements consumes significant staff time.
CCSA has a contract with the Wisconsin SVRA, but the director did not believe the contract to be beneficial to his firm. The EN is sharing a number of Tickets with the SVRA, but specific payment arrangements have not been finalized. The director cited several problems, including (1) SVRA counselors and office directors do not understand the details of TTW, and (2) many of the SVRA counselors presume it is their responsibility to "grab the Ticket" before an EN can accept it, an attitude that alienates CCSA. The director sees one advantage in having the SVRA accept the Ticket: beneficiaries can obtain costly equipment or services from the SVRA that CCSA cannot provide.
For the other case-study ENs, typically their only connections with SVRAs consisted of recommending that individuals who need vocational training assign their Tickets to the local SVRA instead of the EN. Glick and Glick interviewees said they had considered the possibility of working with SVRAs, but had not signed any agreements mainly because as a national EN they thought it would be a major undertaking. Company officials also described wanting to maintain a clear distinction between their traditional business and their TTW placement efforts so that they could avoid giving SVRAs and other ENs the impression that they are attempting to "steal" those other agencies’ TTW clients, when they are really just doing job candidate recruitment under their main line of business. SVRAs are a source of job candidates Glick and Glick uses to fill vacancies for its employer clients. They want to avoid any perceptions that might undermine the success of their non-TTW programs.
Oklahoma’s DRS reported conducting fairly extensive outreach to potential ENs in the state. During the past year, DRS staff gave presentations about the TTW program at all 12 One-Stops in the state, inviting interested organizations to the nearest orientation session. Approximately two-thirds of the organizations reportedly applied to become ENs. DRS staff stated, however, that interest in the program has "fizzled," and few if any organizations are applying now. At present, DRS staff conducts bi-weekly orientation meetings in Tulsa and Oklahoma City, and in other locations as needed.
Oklahoma officials also developed a standard agreement form for ENs that wish to use DRS for their TTW clients. Under this agreement, an EN can purchase DRS services without having to pay for them up front. DRS reportedly accepts considerable risk that it will never be fully paid for services provided under these agreements. To date, the agency has no signed agreements with any ENs. Oklahoma officials note that ENs in the state realize that they can send their TTW clients to DRS for services regardless of the presence of a signed agreement and that DRS will serve them.
DRS staff believes, in general, that there will be a division of labor between SVRAs and other ENs. In particular, they expect that other ENs will tend to serve the "easy cases" and refer individuals with more complex and expensive training needs to SVRAs. In their opinion, this practice will not achieve one of the TTW’s goals—to provide individuals with more significant disabilities a choice of rehabilitation providers—but they concede that, overall, more individuals may potentially be served under TTW than under the old system.
F. RELATIONS WITH OTHER ORGANIZATIONS
Some interviewees mentioned having worked, even if briefly, with two other key players in the TTW and vocational rehabilitation system: Benefits Planning and Outreach Assistance (BPAO) programs and SSA field offices. Their experiences with these organizations were mixed, as summarized below.
BPAO Programs. Most of the ENs we spoke with had positive things to say about their local BPAO and said that the benefits planning program was one of the most beneficial components of TTW. Several ENs refer clients to the BPAO as part of their service packages. As noted previously, ABIL is also the BPAO grantee in Arizona and refers all its TTW clients to BPAO-sponsored orientations on work incentives. EES staff described referring beneficiaries to the local BPAO when they start to work. Glick and Glick staff originally referred to BPAOs Ticket holders who needed information about how employment would affect their benefits. After a bad experience with one BPAO, however, Glick and Glick decided to rely on its own staff or make referrals to SSA rather than a BPAO. CCSA refers clients to the BPAO if they have questions about how employment will affect their benefits. Oklahoma DRS counselors refer individuals with complicated cases (estimated at 5 to 10 percent of all cases), including all concurrent beneficiaries, to a BPAO for individualized benefits planning. DRS staff received training in work incentives from staff of the BPAO program (and also from the local SSA Employment Support Representative). IDR had expected that the BPAO would be in contact with SSA and have all of the necessary information for beneficiaries. In reality, IDR has found that the BPAO does not always have the information clients need, and that people end up having to contact SSA for assistance.
SSA Field Offices. The ENs reported a mix of low-level interaction with SSA field offices. ABIL’s director said her EN had established a strong working relationship with the SSA field office, despite her view that the field office had not been as involved in increasing awareness about TTW as she would have liked. Requests to use field office space for meetings with clients have been denied. EES staff reported difficulty in obtaining information about trial work periods from field offices. At first interview, Bridges staff stated the same complaint, but said they eventually resolved these issues by working with the Employment Support Representative working in the Chicago area. This EN also had a strange experience related to marketing. Field office staff had announced that EN marketing materials had to be approved, but when Bridges sent in copies of fliers and brochures about its services, they never heard back from the field office. Another time, when Bridges asked the field office for work history information on one client, the field office charged the EN $1 per page. Regardless of these incidents, however, Bridges staff told us they later were able to develop a better relationship with the SSA field office. Finally, Oklahoma’s DRS reported having close working relationships with local field offices.
G. FACTORS AFFECTING PROVIDER ABILITY TO ACHIEVE POSITIVE OUTCOMES FOR BENEFICIARIESThe case studies identified a variety of factors that reportedly help or hurt provider efforts to assist beneficiaries.
EN officials cited several factors that made it difficult (or, at least, more difficult than they may have originally expected) to assist some beneficiaries in obtaining and sustaining employment in ways that stood a good chance of leading to milestone or outcome payments. These factors generally correspond to the barriers to employment we described in Chapter I. It was not uncommon for the case-study ENs to report having to place some clients multiple times. In one extreme example, an EN reported placing one client seven times.
The Economy. Several ENs noted that the economy and its soft or shrinking job market has made it more difficult to place both TTW and other clients. CCSA’s director noted that the industrial sector has declined consistently for the past 36 months. EES reported that some beneficiaries placed in full-time jobs had their positions reduced to part-time; their subsequent lower earnings made them eligible once again for benefits and thus the EN was unable to collect any payments.
Beneficiaries’ Attitudes and Motivation. EES staff said that one reason its TTW clients take longer to place than its other clients is that the former take longer to envision themselves working. Helping them develop the necessary interest and confidence—overcoming fears and insecurities about their ability to find and keep a job—can require a substantial amount of personal counseling. A Bridges staff member noted that many of their clients lack motivation and a sincere desire to work. Similarly, Glick and Glick mentioned that some clients do not appear sufficiently interested in the program—after their initial enthusiasm about going back to work wanes, they do not return staff phone calls. Interviewees also said some beneficiaries are perhaps too specific or particular about the types of jobs they are willing to accept. ABIL’s director described how some clients have unreasonable or unrealistic expectations about the extent to which employers will accommodate their unique needs, and how others do not want to work full time—whereas most jobs are full time and full-time work is necessary in many cases for the individual to achieve earnings above the SGA level. CCSA’s director held a different viewpoint. He said that Ticket clients were easier to place than SVRA or Veteran’s Administration clients because they are motivated to work.
Beneficiaries’ Experience and Abilities. Glick and Glick representatives noted that many of the beneficiaries they had served had little work experience and could only qualify for entry-level positions paying minimum wage. Because the SGA level is adjusted upward annually based on inflation, they believed that it will be increasingly difficult for low-skilled beneficiaries to meet that standard.3 IDR no longer accepts Tickets from SSI beneficiaries, in part because of their minimal employment experience. According to ABIL’s director, sometimes the issue is over-qualification; some clients have had fairly extensive work experience or advanced skills that make them difficult to place in lower or entry level jobs that are more readily available. Other times placement is difficult because of the length of time experienced workers have been out of the labor force.
Discrimination. The director of CCSA believes that people with disabilities still encounter discrimination. In his experience, individuals with disabilities need twice as many contacts and ten times the number of interviews to get a job, relative to individuals without disabilities. He views his marketing role as very important; he needs to "sell" individuals to an employer and sell the employer to the individual. In conversations with employers, he does not make specific references to a disability, SSA, or the SVRA. He presents himself as someone in the legal or personnel profession. When submitting resumes to employers on behalf of clients, CCSA includes a notice to employers, warning that employment discrimination against individuals with disabilities is a violation of federal law. He believes that including warnings in various materials improves placement rates.
2. Helpful Factors
Interviewees were not just focused on the factors that negatively affected their ability to place Ticket holders in employment. Some cited factors that they believed helped them to assist beneficiaries in achieving positive employment outcomes. The director of ABIL identified several such factors: minimal EN competition in the service area; having a substantial funding base at start-up; a staff made up of people with disabilities who can easily relate to clients; focusing on placement services rather than VR services; and close organizational connections to other helpful entities such as a BPAO program, a Center for Independent Living, the SVRA, and SSA field offices. Having substantial prior job placement experience, such as Glick and Glick has, may also be an important factor. Having not just familiarity with the business in general, but also an extensive network of contacts with employers sounds intuitively significant. Glick and Glick representatives mentioned that after they started operating as an EN, whenever they received notice of a job opening, they would look first to their pool of TTW beneficiaries for a potential candidate, then proceed with their more traditional employee search process.
H. THE BIG ISSUE: FINANCIAL VIABILITY
Fundamentally, to be successful, ENs must cover their costs. But all eight of the case-study ENs, despite their diversity on numerous characteristics, had one thing in common: they all were losing money on their TTW operations. Despite the development of various, apparently well-functioning service models and the ENs’ generally positive expectations in summer and fall of 2002, TTW has not proven to be financially viable—thus far, at least, for these eight ENs.
It would be difficult to overestimate the seriousness of this matter for the future participation of these ENs—and possibly many others—in the TTW program. At the time of the fall 2003 interviews, 12 to 18 months after they started operating under TTW, the ENs’ situation looked rather bleak.
CCSA’s director believes he has a viable service model. Although he has received few payments thus far, he believes that in the near future, greater than 50 percent of his receivables will come from TTW. The program has the potential to be a major source of revenue for CCSA, with revenues ultimately outweighing costs, but he felt that the administrative issues associated with the program (described below) must be addressed.
EES is no longer accepting Tickets and plans to fully withdraw from the program. It is still submitting claims for payment for a few beneficiaries, but no longer considers itself to be participating in TTW. Before deciding to withdraw from TTW, EES tried several strategies to reduce costs. For example, EES downsized from two to one line staff members and also began providing services to groups, rather than individuals. Even with this added efficiency, however, EES corporate was subsidizing TTW services at an unacceptable level. The director estimated that EES spent $80,000 on the program, but brought in less than $10,000 in revenue. This EN would likely reactivate its program if changes are made that enable the organization to cover its costs.
At the time of the first interview, Glick and Glick representatives optimistically projected making a profit by January 2003, five months ahead of their original estimate. By August 2003, however, those profits had never materialized. The firm was expending a lot of resources on TTW and not recouping much of its costs—"shoveling money out the door," according to one interviewee. Glick and Glick was forced to substantially reduce its involvement in TTW. It is now serving only beneficiaries who reside in the state of Florida, retaining that state as a TTW service area because a large number of its Tickets were from Florida, and some of those clients had been showing success. In May 2003, the EN unassigned the Tickets of all beneficiaries not residing in Florida, including a number that Glick and Glick had placed in employment. The EN concomitantly reduced the number of TTW case workers from four to one. Like the EES director, Glick and Glick officials expressed hope that the program will be changed in a way that will make it profitable. Should that occur, Glick and Glick would be willing to participate once again as a national EN. They do not believe TTW will be successful, however, unless the requirements for submitting earnings information are significantly altered to reduce the EN’s administrative burden.
IDR representatives said that to date, the operational costs of the program have far exceeded the revenue collected through payments from SSA. The discrepancy between expenditures and revenues, they said, is in large part due to SSA’s inability to make timely payments to IDR for the outcomes achieved by its clients. The low return on the initial investment has made it difficult for IDR to raise additional capital from lending institutions to expand program operations. IDR has found it necessary to restrict its efforts to serve retail clients to no more than 25 percent of the caseload, and to stop serving SSI beneficiaries altogether because the payments from SSA do not adequately meet the agency’s up-front costs. Instead, IDR will concentrate its efforts on its long-term disability clients, which will enable it to cover service costs with insurance payments. Any payments IDR receives from SSA will be considered a "bonus."
ABIL’s director recently described the program as "horrendously expensive." The EN’s business plan over-estimated demand and under-estimated the administrative difficulties and related costs. The business plan projected more Ticket assignments and more placements. ABIL has invested about $500,000 in the last two years and has filed claims for about $50,000 in payments. ABIL has had to supplement TTW revenues with about $200,000 in general operating funds. The director estimates that ABIL needs $227,000 in payments (on behalf of about 100 Ticket holders) to continue operating. The interviewee stated that ABIL will likely be willing to support the program for another 12 months, but participation in TTW after that is doubtful if the program does not produce more revenue.
Representatives of Marriott’s Bridges program reported that program costs significantly outweigh revenues, creating losses that they cannot absorb much longer. Although they had originally viewed TTW as a five-year commitment, that estimate was based on higher anticipated revenues; if revenues do not increase, their participation in TTW will have to be discontinued.
The head of AAA TakeCharge said that, in general, administering TTW has involved more work and brought far lower returns than originally anticipated. Indeed, she said, despite her relatively low operating costs (TakeCharge has only two staff, both of whom work part time), the business has been losing money so far. Despite being in the red, the director plans to continue operating for the time being. She is close to her margin of profitability, which requires that she receive five or six outcome payments each month. She also feels an obligation to the Ticket holders whose Tickets she has accepted.
Oklahoma DRS officials estimated having spent about $1.2 million on services for the 575 beneficiaries it is serving as an EN under the milestone-outcome system, against just $26,000 in TTW payments. They expect to eventually realize $250,000 to $500,000 per year in Ticket payments, but it was unclear how this was expected to compare with future annual costs. Officials there appeared unconcerned about Ticket program revenues, probably because of the availability of other SVRA funding to pay for services.
Overall, the message is clear: all eight experienced providers we studied are experiencing serious financial difficulties in operating under TTW—problems so serious that they may not be able to continue functioning as TTW service providers, unless circumstances change dramatically and relatively quickly or they can continue to draw on non-TTW revenue sources. Next we turn to some of the specific causes interviewees identified as contributing to their TTW-related financial difficulties.
1. Process for Obtaining Payments
From the eight ENs’ perspective, the most problematic piece of the financial viability puzzle is obtaining payments; comments typically focused on the need to increase revenues, not to reduce higher-than-expected costs. Most payment-related complaints concerned the payment process, more so than the structure of the payment system (although structure is discussed separately, below),4 particularly difficulties obtaining acceptable documentation of workers’ earnings, getting the payment requests approved, and then receiving the payments they are owed.
The earnings documentation that virtually all ENs rely on is pay stubs from TTW clients. But, interviewees said, clients sometimes neglect or forget to turn in pay stubs altogether, and even when they do submit pay stubs, the stubs often do not contain the necessary information to meet SSA standards, such as the pay period start or end date. None of the approximately 20 clients who have submitted pay stubs to TakeCharge have provided problem-free documentation. ABIL offers beneficiaries a $25 stipend for each monthly pay stub, which reportedly helps, but the director considers tracking all the information to be a major administrative burden, a "nightmare," she said, resulting in large financial losses for her organization. She strongly dislikes having to hassle her clients for their pay stubs, adding unwanted stress in their lives; she would just as soon forgo trying to get payments for months when pay stubs are not received.
IDR staff feels very strongly that problems in the current payment process continue to jeopardize the entire TTW program. One staff member said, "This one issue is putting the entire program at risk." IDR estimates that it costs the agency $90 to $120 to collect a $279 payment from SSA. IDR further indicated that about 40 to 45 percent of program revenues are devoted to addressing pay stub issues. Participants are annoyed that they must submit pay stubs twice—once to the EN and once to the local SSA office. A few of IDR’s participants who were working full time unassigned their Tickets because they found the pay stub submission requirement intrusive.
CCSA requires clients to sign a release for any wage information, which is forwarded to employers with a request that the employer send the wage documentation directly to CCSA. The release includes language to the effect that the federal government requires CCSA to substantiate wages, and clients are required to provide copies of their pay stubs. In the written communication to both client and employer, CCSA includes a warning that failing to disclose wage information is a violation of federal law. The director said that he often has to go beyond simply requesting information; he needs to intimidate clients a bit to get them to send pay stubs.
EES officials had not had problems getting beneficiaries to submit pay stubs, but agreed that the earnings documentation requirements are a significant burden on providers and beneficiaries, one that reduces ENs’ ability to provide services. Bridges staff expressed similar sentiments, and Oklahoma DRS officials described the burdens of trying to keep track of pay stubs; they ultimately switched to using Unemployment Insurance data in most cases. Glick and Glick also found it very difficult and labor-intensive to obtain earnings information from placed workers, and pointed out an apparently important causal factor: neither employees nor employers have any incentive to provide proper documentation to the EN.
Problems continued even after EN staff had obtained the needed documentation. Most common were complaints about the length of time that it takes to receive payment. Bridges staff submitted their first payment request in May 2002, but did not receive payment until February 2003. Now, they said, it usually takes about three months. Glick and Glick were led to expect a turnaround of 60 to 90 days, but found that in reality it takes 90 to 120 days, and they said the Program Manager has been unable to explain the long turnaround time even for cases in which the documentation is correct. Representatives of AAA TakeCharge and ABIL also reported average turnaround times of three to four months, which they feel is far too long and must be rectified. According to one interviewee, the Program Manager has reportedly claimed that payment timeframes are largely out of its control, determined by SSA’s processing procedures. As noted previously, IDR believes that its negative cash flow is in large part due to SSA’s inability to make timely payments for the outcomes achieved by participants. The low return on the initial investment has made it difficult for IDR to raise additional capital from lending institutions to expand program operations.
CCSA’s director said that his EN has had a "terrible problem getting paid," and added, "SSA has a terrible system in place." CCSA has claims that are four months old that have not yet been paid. The director said, "Any other business would seek help from a collection agency!" The problem has not improved in recent months. It is his perception that the Program Manager processes and passes along CCSA’s invoices exactly as they are supposed to be processed, but SSA then sits on them, to the point where CCSA must conduct an investigation to determine what is happening with its payments. This problem occurs with initial milestone and outcome payments, as well as with subsequent payments. SSA does not provide adequate cooperation and support for ENs, he said, which he considers a very poor practice.
2. Structure of Payment Systems
Some critical statements related to revenues focused on the basic structure of the payment systems. The director of EES, which had selected the milestone-outcome payment system, said that even if payments were received promptly, they were simply too small to cover costs. In addition to supporting larger payments, she advocated for two new payments that would be made earlier than under the existing schemes: an initial payment upon completion of an IWP, to cover initial staff costs, plus one upon initial job placement; thereafter, the existing payment schedule could be followed. Additionally, she, as well as other EN interviewees, disagreed with the requirement that beneficiaries must reach zero-cash-benefits status before outcome payments could be made on their behalf to an EN. Her agency found that some clients were not able to sustain SGA consistently enough for EES to receive regular payments; others did reach SGA, but continued to receive benefits for several months during their trial work period. Glick and Glick representatives voiced the same concern about the zero-benefits rule. They felt they deserved some payment for the work they had done to get certain beneficiaries back to work, even though the individuals were still receiving cash benefits. Marriott’s Bridges program officials, like the EES director, felt that the payments (under both TTW payment systems) are too small to cover costs, a problem which they predicted will make it difficult for TTW ever to succeed on a large scale. These officials also expressed a desire for ENs to be allowed to select a payment system on a client-by-client basis, more like the level of flexibility granted to SVRAs. This flexibility would enable ENs to request outcome payments for clients who would more easily find employment with wages over SGA, while recouping some payments for clients who were not expected to quickly achieve this goal.
IDR thinks that the outcome payment system should be modified so that the payments take place over a shorter period of time—three years, for example. That EN argued that if a participant is still employed after three years, then he or she probably will remain employed for an extended period of time. The length of the outcome payment plan creates a problem when IDR is trying to raise capital. A bank considers payments expected 72 months in the future to be unlikely to be paid. In addition, IDR would like to devote more resources to serving SSI recipients, but feels that SSA needs to offer higher payments for them because they require more resources to place and support in employment.
It is difficult to disentangle, or rank the relative importance of, the many inter-related factors that have contributed to these eight ENs’ financial troubles. What accounts for the fact that expenditures have dramatically exceeded revenues, and what would be the ideal solution to this problem? For each EN, the story may be slightly different. In general, these ENs did not appear to have difficulty generating sufficient numbers of Ticket assignments. Slightly more problematic was the difficulty some ENs experienced in getting clients to move into employment at levels (in terms of income and duration) that would generate milestone and outcome payments. While some interviewees cited the poor state of the economy, Ticket holders’ skills and attitudes were also frequently cited. The latter issue seems a bit surprising, especially in light of the fact that most of the ENs had screened applicants to select those who appeared both willing to work and to require few services. A few questions arise: Do ENs need better skills or more experience in identifying clients most likely to succeed in the workforce? Or, do ENs have unrealistic expectations about being able to place disability beneficiaries in jobs despite offering few and relatively non-intensive services? Unfortunately, for ENs to improve their own skills or offer more intensive services would increase their costs, thus potentially putting them at even greater financial risk.
As mentioned earlier, interviewees facing financial difficulties focused mostly on increasing their revenue streams and on lowering the costs associated with processing payment claims. Recently announced changes to the procedures for reporting beneficiaries’ earnings and requesting payments may help to address ENs’ concerns about the payment process. The new Certification Payment Request Process (see Chapter III), however, was not in place at the time of our second interviews with the eight case-study ENs, so we do not know the extent to which EN officials believe it will ease their burdens and improve their overall financial circumstances. This issue will have to be addressed in future reports. But even if ENs begin to receive payments more easily and more quickly, many payment system issues still remain. As discussed in Chapter III, there is broad concern among ENs in general about the fact that TTW funding comes well after services have to be delivered and even then is stretched out over a five-year period. In addition, EN payments occur only for beneficiaries whose benefits have been reduced to zero, even if an EN’s efforts enable a beneficiary to work sufficiently to reduce, but not eliminate, benefits. These issues, too, will be an issue for additional future study.
I. OTHER PROBLEMS AND SUGGESTIONS
Obtaining payments may have been the biggest administrative challenge for the eight case-study ENs, but it was not the only problem they encountered. Below we describe several other concerns expressed by EN representatives. It should be noted, however, that most of these concerns arose early in the ENs’ experiences with TTW and appeared to be less significant at the time of the second interview.
Several EN interviewees called for changes in how TTW is marketed, saying that beneficiaries need much more information on the program. TakeCharge’s director believes that more Tickets would be assigned if SSA focused its TTW marketing activities. In her opinion, TTW marketing efforts have been too broad and have not focused on the 7 to 10 percent of the beneficiary population most likely to work their way off of benefits—those already working, but working at levels low enough to maintain benefits. In her opinion, information about TTW centers on getting a job and returning to work, rather than on increasing work levels among those already working. She believes that a targeted mailing to working beneficiaries, advertising the fact that support in the form of money (as opposed to return-to-work services) is available under TTW, might induce a significant proportion to use their Tickets, increase their work activity, and go off of benefits.
In addition to more-focused marketing, TakeCharge’s director would like the Program Manager to provide beneficiaries with more-descriptive and more-detailed information about ENs and how they operate. Currently, the Program Manager’s website does not list cash among the types of services that ENs may be providing, so an EN like TakeCharge must describe one of its core elements as "other." The Program Manager, she said, should expand the list of services from which ENs can choose.
The director of ABIL complained about an overall dearth of marketing by SSA. She said a national campaign, featuring extensive television and radio advertising, is desperately needed to market the program to Ticket-eligible beneficiaries.
During the initial interview, representatives of Glick and Glick mentioned a desire for SSA and/or the Program Manager to provide beneficiaries with more and better information about the TTW program early in the process, presumably as part of initial mailings. They felt they had to spend too much time explaining the program to beneficiaries who contacted them about using their Tickets. Bridges officials made a similar comment. Common misunderstandings include a belief that program participation is mandatory and that the Ticket automatically guarantees them a job, possibly with the EN itself. Potential clients also sometimes have concerns about how TTW will affect their SSA and health care program benefits.
Oklahoma DRS officials made similar comments about the problem of beneficiary confusion during the recent interview; the Program Manager provides only basic contact information, so ENs end up having to inform Ticket recipients about the program. They had different ideas from their non-SVRA peers, however, on what kind of marketing approach should be implemented. They pointed out that beneficiaries are often fearful of any communication from SSA, lessening the potential impact of any SSA-led marketing efforts. Similarly, they felt that the Program Manager did not need to be heavily involved in beneficiary outreach and education, partly because of inevitable delays in getting information to interested beneficiaries. Rather than a centrally operated, national level campaign, they supported a more local approach. They support having SSA provide funding to interested SVRAs and other ENs for state and local level outreach efforts, and had ideas about how such a program could be modeled after Oklahoma’s State Partnership Initiative.
Oklahoma DRS staff also made another unique statement relating to program promotion. They expressed a desire for the Rehabilitation Services Administration (RSA) to play a more active role in promoting TTW and assisting SVRAs to address ongoing policy problems. They quoted an RSA official as saying, "The Ticket is not our program," an attitude they feel is antithetical to successful implementation by SVRAs.
Glick and Glick staff expressed frustration over the fact that some beneficiaries do not even know under which program(s) they are receiving cash benefits—SSI, DI or both. Knowing about a beneficiary’s program participation is important, they explained, because under different programs, different pay documentation is needed, different earnings thresholds must be met to qualify for payment, and payment amounts differ. Thus, not knowing a beneficiary’s program status makes it difficult for an EN to develop expectations regarding the likelihood that a claim for payment will be accepted. Glick and Glick staff advocated for being able to get the needed beneficiary information from the Program Manager. At present, this is only permitted if the EN obtains a signed release from the beneficiary allowing the EN to obtain such information. The release must also be on file with the Program Manager. A similar procedure must be followed for an EN to obtain beneficiary information from SSA. CCSA noted that under the Alternate Participant program, it had direct access to SSA files. Under TTW, SSA will not provide ENs with basic information such as the nature of an individual’s disability. ENs must obtain information directly from the client or obtain the client’s permission to contact the local SSA field office.
Similarly, interviewees from Marriott’s Bridges program stated a desire for SSA to provide ENs with more information on the work history and benefit status of Ticket users—for example, whether they were in a trial work period. They reported success in overcoming this problem, however, by working with a local Employment Services Representative. EES staff also reported difficulty obtaining information about clients’ trial work periods from SSA field offices.
Oklahoma’s DRS had problems verifying earnings and cross-referencing individuals currently receiving VR services with those receiving a Ticket. DRS staff noted that about 20 percent of the addresses in the Program Manager database were incorrect, and roughly 40 percent of the addresses in DRS files are incorrect. Furthermore, DRS staff found that some individuals who have been issued a Ticket (and who have presented it to DRS for services) are not included on the CD-ROM. For these reasons, Social Security numbers are essential for cross-referencing. The CD-ROM provided by the Program Manager for this purpose did not contain the needed Social Security numbers.
Officials from Oklahoma’s DRS complained that the Program Manager is sometimes slow in confirming Ticket assignments; rather than wait, DRS has sometimes begun serving beneficiaries before receiving confirmations. They also said that the Program Manager sometimes informs them that a Ticket is unassignable, without providing a reason. Since that information is critical for determining whether to commence with services, DRS would appreciate getting full information, consistently. The director of TakeCharge said that, early on, when she was unclear about rules for unassigning Tickets, placing Tickets in inactive status, and the 24-month review process, the Program Manager was either unable or unwilling to give relevant advice. Glick and Glick representatives told of the considerable time and effort it took to get all the information they needed in order to fully understand a number of program details; they complained about getting incomplete, piecemeal information. Finally, IDR is concerned that the Program Manager has not maintained an updated list of active ENs and as a result beneficiaries are referred to ENs that are no longer accepting Tickets. Beneficiaries who contact IDR frequently indicate that they have contacted five to ten ENs prior to contacting IDR. Dealing with frustrated participants is challenging and takes considerable staff resources that could be used for other purposes.
Interviewees from Glick and Glick think that prior to becoming an EN they would have benefited greatly from a chance to speak with people from other organizations that had already implemented or were in the process of implementing TTW. They suggested that there could be great value in a forum that allows for and encourages information exchange among current and potential ENs. It could help, for example, with solving problems that commonly arise in implementing the program. Glick and Glick staff noted that they are now open to working with other ENs and potential ENs to exchange information on best practices and their own experiences with TTW.
Oklahoma’s DRS staff reported confusion over whether beneficiaries must sign the IWP (specifically SSA Form 1365) to formally assign the Ticket to their agency, and whether the date of Ticket assignment is the date an individual plan for employment is signed or the date Form 1365 is signed. They would appreciate formal SSA policy memoranda on such matters.
J. SUMMARY AND CONCLUSIONS
This chapter has presented the experiences and impressions of eight ENs that have served Ticket holders since the beginning of Phase I. The findings were based on initial interviews conducted during the summer and fall of 2002 and follow-up interviews conducted in August and September 2003. Although we interviewed only a small number of ENs, their impressions and experiences are important because they are among the ENs that have the largest numbers of Ticket assignments, have received the highest total TTW payments, and represent a range of service models and business types.
These ENs made a number of suggestions for improving the TTW program. SSA could implement some of the suggested changes fairly readily; indeed, in some cases, the Agency has already begun to do so. Implementing other suggestions would require a change in the Ticket Act or other Congressional action. We summarize the experienced ENs’ suggestions for program improvement below.
1. Changes that Could Be Implemented by SSA
Claims Payment. All eight ENs expressed frustration with the administrative process for requesting payments under both the outcome-only and milestone-outcome payment systems. They found the requirement to collect beneficiary pay stubs for 60 months beyond job placement particularly onerous. As noted in Chapter III, SSA has implemented a new Certification Payment Request Process to try to address this issue. The new process was not in place at the time of our second interviews, so none of the ENs had had any experience with it. Two of the ENs we spoke with after the new process was announced said they expected that it would significantly decrease their administrative burden. The new process also addresses another problem, at least after the EN has submitted the required three pay stubs: the need for beneficiaries to submit pay stubs to the EN as well as to SSA (for benefit and eligibility adjudication). While the new Certification Payment Request Process may address some ENs’ concerns, they would also like to see SSA address some remaining issues with the payment process, including reducing the length of time it takes to receive payments, clarifying what information must be shown on the pay stub to receive payments, and communicating reasons for denial of particular payments to the EN.
Marketing TTW. Several ENs called for changes in how TTW is marketed, saying that beneficiaries need much more information on the program, especially early during the roll-out period. Some ENs specified that marketing efforts, whether led by SSA or the Program Manager, should be focused on beneficiaries most likely to pursue employment, such as those already working part time and those under age 60. Some ENs also suggested that the Program Manager provide Ticket holders with more up-to-date information on which ENs are currently accepting Tickets. They felt that such marketing efforts would substantially reduce the time ENs must spend educating beneficiaries about the program, especially those who are unlikely to participate. As noted in Chapter III, SSA has recently taken steps to develop a campaign to market and publicize TTW. It will be some time, however, before a large-scale marketing effort is fully implemented.
Information about Beneficiaries. A number of ENs wished they could obtain more information about beneficiaries from the Program Manager or from the SSA field office, such as program status (SSI and/or DI), type of disability, work history, and months remaining in the Trial Work Period. One interviewee with experience under the Alternate Participant program said that providers had access to more information about beneficiaries under that program than ENs do under TTW.
Opportunities for EN Information Sharing. One EN expressed a desire for SSA to provide opportunities for communication between ENs, enabling them to share successful strategies and to solve common problems.
Clarify Ticket Assignment Date Policy for SVRAs. The Oklahoma SVRA suggested that SSA clarify, through a formal memorandum, whether beneficiaries must sign Form 1365 to formally assign the Tickets to the SVRA, and whether the date of Ticket assignment is the date an IPE is signed or the date the Form 1365 is signed.
2. Changes Requiring Congressional Action
While SSA could modify the milestone-outcome payment system in some ways that would not require Congressional action (e.g., providing additional milestone payments when the IWP is written or at job placement), most of the ENs’ suggestions concerning the payment structure would require Congressional action. Examples include setting higher payments for SSI recipients, allowing ENs to obtain payments for beneficiaries who still receive partial cash benefits, condensing the payment period from five years to three, and allowing ENs to select a payment system on a client-by-client basis. Potential modifications to the payment system, however, would need to be evaluated in light of the basic purpose of the Ticket Act: to enable beneficiaries to leave the SSA disability rolls for employment, with the costs for rehabilitation and job placement being more than offset by reduced federal government outlays for cash benefits.
1 As of early August 2003, these eight ENs collectively accounted for 52 percent of the total payments (approximately $220,000) SSA made to all ENs for Ticket beneficiaries. Return to text.
2 ABIL would like to expand its services to provide job training and assistive technology, but will not be able to do so unless and until its financial situation improves, an issue addressed later. Return to text.
3 The officials were implicitly suggesting that the minimum wage rises more slowly than the SGA level (currently $810 per month). This is typically the case because the minimum wage does not necessarily increase annually and is not tied to wage growth as is the SGA level. The current federal minimum wage rate of $5.15 per hour has been in place since 1997. Return to text.
4 It is not surprising that for these eight ENs, concerns about structure (payment size, for example) were less substantial than concerns about the payment process. These were ENs that initially believed they could make it financially under the TTW payment system and thus began accepting Tickets. Many other ENs interviewed last year voiced very strong complaints about the payment system structure; in fact, such concerns led many of them to decide against accepting any Tickets. Return to text.