Ticket to Work Evaluation (January 2006)

CHAPTER 8
EN Cost and Revenue

The difficulty in recruiting providers to become ENs has inhibited TTW rollout and expansion. Even after ENs enroll in the program, most do not accept Tickets. The initial evaluation report included information from interviews with some experienced ENs that had several Ticket assignments and had received several payments. Their experience indicates that financial viability has been a problem in that program expenditures have far exceeded program revenues. This chapter explores the issue of whether the TTW program, as currently structured, offers ENs a financial incentive that is strong enough to encourage them to participate actively in the program.

To conduct the analysis, we developed a framework for analyzing the financial incentives offered to ENs by the TTW program. For instance, we examined the ENs’ aggregate costs and revenues for Tickets assigned during the first year of TTW. Costs were approximated on the basis of information collected in EN interviews and from published data from other providers. Revenue data were obtained from SSA administrative records, and we include two years of payment data for the 2,570 Tickets that were assigned to ENs between the start of TTW in February 2002 and February 1, 2003.¹

Overall, the analysis suggests that TTW has not given providers enough of a financial incentive to secure their participation in the program. The low financial return on their investment during the first two years after Tickets were assigned stems primarily from the fact that providers have been able to generate payments for only a small fraction of the beneficiaries whose Tickets they accept, and the payment streams from these assigned Tickets have tended to be small. In addition, ENs have incurred costs for serving beneficiaries who do not ultimately generate payments, including many who contact ENs to get information but do not assign their Ticket.

The average EN experience, however, masks the wide variation between providers. For example, a few ENs have generated payments for more than 30 percent of the Tickets they have accepted. But even at that success rate, it appears that TTW provides a low net financial incentive to ENs because the payment streams have been relatively small even for the more successful ENs.

Looking to the future and assuming no changes to the payment systems, it would take a large change in beneficiary behavior for ENs to overcome the deficit we observed in the first two years of experience. More specifically, ENs will not be able to break even unless they can generate payments for many more of the beneficiaries they serve and generate more payments from those beneficiaries. For example, we estimate that each beneficiary who assigns a Ticket would have to generate 10 to 22 payments. To see the magnitude of the required change, it is important to consider that beneficiaries who assigned their Tickets during the first year of TTW generated an average of only 0.86 payments in the 24 months following assignment. In other words, fewer than 15 percent of all beneficiaries generated any payment in the first two years after assignment; of those generating payments, they accounted for only about 16 payments each during the first two years.

We cannot be certain whether changes of the required magnitude are feasible. Such changes seem unlikely based on the early experience with TTW whereby the proportion of beneficiaries generating payments declined during the two years following assignment. Nevertheless, there is evidence from the SVRA system that it can take 26 months or more of assistance before many beneficiaries earn enough to move to zero-benefit status. Therefore, given that the data in this analysis reflect only the 24 months after assignment, it is possible that ENs may see some gains in the future.

We assigned dollar values to the activities that ENs typically perform in serving beneficiaries (Figure VIII.1) and compared the costs we estimated with the actual revenues we observed for beneficiaries who assigned their Ticket to an EN during the first year of TTW rollout. EN costs stem from the five major activities shown in Figure VIII.1: (1) outreach, (2) intake, (3) initial services, (4) follow-up services, and (5) payment tracking. Outreach covers efforts to generate a flow of potentially interested clients. At the simplest level, outreach activities may be just answering telephone calls from beneficiaries who receive Tickets and want more information. Beyond that, ENs may develop a Web site, make presentations to groups that include or advise beneficiaries, or work with their SVRA or other possible referral sources. While specific outreach activities vary considerably from one EN to the next, our general sense from the 29 ENs we interviewed is that no more than half of the beneficiaries contacted through any of these efforts will express a concrete interest in assigning their Tickets to the EN.²

Click for Figure VIII.1. Summary of Core EN Activities in Ticket to Work (Opens in new window)

For beneficiaries who express an interest in assigning their Ticket, the EN conducts an intake assessment to determine whether it wants to accept the Ticket and provide beneficiaries with the information they need to decide whether to assign their Ticket to that EN. When beneficiaries decide to assign their Ticket, the EN must develop an IWP and submit it to the TTW Program Manager. ENs have varying success at this stage, but it appears that many have discussions with 10 beneficiaries for every Ticket they accept. When outreach and intake activities are taken together, ENs appear to incur costs for 20 or more beneficiaries for each Ticket assignment.

Once a Ticket is assigned, ENs help beneficiaries find a job in which they can earn enough money to generate a milestone or an outcome payment. This activity involves a variety of services, including job search and placement, counseling in skill-building, and case management. In addition, some ENs may provide financial incentives for employment and retention. The intensity and number of services provided vary within and across ENs according to beneficiary needs and interests. However, all ENs provide some level of service for beneficiaries who do not go on to work at a level that generates a payment.

On the other hand, if a beneficiary does generate a payment, the EN incurs additional costs for tracking the beneficiary’s progress and for providing any additional counseling or other services that the individual may need to retain his/her job. Furthermore, ENs must pay staff to obtain pay stubs from the employers of beneficiaries. TTW regulations require ENs to submit the stubs to the Program Manager as part of a request for payment so that SSA can be assured that the beneficiaries left the rolls because of work, and the EN staff must collaborate with the Program Manager to ensure that all requirements are met so that payment is received without significant delay.

To cover the various costs and generate a profit, ENs must generate revenue from milestone or outcome payments or find some other revenue source. This is true even for nonprofit ENs, which must at least cover their costs if they are to remain viable.

ENs operating under the outcome-only system receive payments for each of up to 60 months in which a beneficiary’s earnings are high enough to reduce his/her SSI or DI benefits to zero. For a DI Ticket holder, an individual outcome payment under this system was $336 in 2004, and for SSI-only Ticket holders, it was $199. ENs operating under the milestone-outcome payment system may receive up to four milestone payments when the beneficiary’s earnings are above the SGA level for a certain number of months in a 12- to 15-month period, with each milestone larger than the last. For DI Ticket holders in 2004, the first milestone payment received by ENs was $286, and for SSI-only Ticket holders, it was $169. ENs operating under the milestone-outcome system will also receive outcome payments for months in which a beneficiary’s earnings are high enough to reduce his/her benefit payments to zero. Each outcome payment under the milestone-outcome system is reduced by 1/60 of the total milestones paid. Once a beneficiary generates an outcome payment, the EN cannot collect any further milestone payments but may continue to collect up to 60 outcome payments for that beneficiary. In 2004, outcome payments under the milestone-outcome system ranged from $229 to $286 for DI Ticket holders (depending on the number of milestones achieved) and from $136 to $169 for SSI-only Ticket holders.

We estimated revenue flows on the basis of the experience of beneficiaries who assigned their Ticket to an EN during the first year of TTW rollout. Payment data are available for all of these beneficiaries for the first 24 months following Ticket assignment. The population of beneficiaries who had been mailed Tickets by January 2003 includes all beneficiaries in Phase 1 states and 20 percent of Ticket-eligible beneficiaries in Phase 2 states. For the first two years after assignment, we calculated monthly revenues as the inflation-adjusted average payment achieved per Ticket assigned.³ We made separate calculations for the SSI-only and DI beneficiaries. Our analysis focuses on the milestone-outcome system because only a small number of Tickets for which we have at least 24 months of payment data were assigned under the outcome-only system (6 for SSI-only beneficiaries and 22 for DI beneficiaries).

To assess the financial incentives TTW gives providers to participate in the program, we started by examining the net revenue ENs generated for an early cohort of TTW participants. We estimated net revenue by approximating the average costs ENs incur to recruit and serve beneficiaries and then used SSA administrative data to measure the revenue received.

1. EN Costs

Using the preceding assumptions about costs, we estimated typical EN costs as follows:⁴

• Outreach and Intake Costs. For simplicity, we combined outreach and intake costs so that they would include all the resources required for an EN to get one Ticket assignment. Interviews with ENs suggest that 15 minutes per call is a reasonable estimate for the time required to address beneficiary inquiries. It also appears that it requires an average of approximately three hours of staff time to conduct the intake assessment, develop an IWP, and complete a Ticket assignment. As noted, it appears to require 20 initial contacts and then 10 intake assessments to generate one assignment. Staff labor for these activities was valued on the basis of published data on the compensation of vocational rehabilitation counselors (Bureau of Labor Statistics 2003).⁵ Given this level of effort, we estimate that ENs incur costs of $782 per Ticket accepted in order to conduct outreach and intake.
  
  
• Initial Services. There are no accurate data on the costs ENs incur to move beneficiaries into employment. We therefore decided to approximate the costs on the basis of expenditures reported by mid-cost SVRAs to close an SSI or DI beneficiary’s case.⁶ Specifically, our mid-cost SVRAs reported costs of $1,507 per Ticket assigned by DI beneficiaries and a slightly higher figure of $1,529 for SSI-only beneficiaries. The costs reflect the mix of services provided to all beneficiaries, even those who do not find work and generate a milestone or outcome payment.⁷ The experience of some providers suggests that the estimate may be low, and we return to this issue when we present overall results.
  
  
• Follow-Up Services. Evidence of the cost of ongoing employment supports for Ticket recipients who have started to work is scant because few of the ENs we interviewed had yet needed to provide such services. We therefore assumed that a full-time employee could handle the follow-up service needs of about 100 beneficiaries per year or that about 1 percent of an employee’s time is required to perform these services. We assumed that ENs would provide these services only to beneficiaries who began to work and generate a milestone or outcome payment. Furthermore, because an EN can collect up to 60 outcome payments on a beneficiary who leaves SSA benefits due to work, we assumed that services would continue until beneficiaries stopped generating outcome payments. Given the low rates at which we observe beneficiaries generating payments (discussed in the next section), we estimate that follow-up services during the first two years after assignment will cost ENs $26 per DI Ticket accepted and $19 per SSI-only Ticket accepted. The higher cost for SSI Tickets reflects the fact that ENs are slightly more likely to generate payments for that group than for the DI group.
  
  
• Payment Tracking. Early in the TTW program, ENs devoted considerable resources to collecting pay stubs and submitting payment requests. We assumed that these costs would decline over time as ENs gained experience and as a result of the administrative changes made by SSA. In our framework, therefore, we assumed that it would take an average of one hour of staff time for each payment (milestone or outcome) an EN obtains for a beneficiary. Given that assumption and the observed payment rates, we estimate that payment tracking will cost ENs $15 per DI Ticket accepted and $11 per SSI-only Ticket accepted.

An EN’s total costs for each Ticket that it accepts include the cost of services (such as information, referral, and assessment/screening) provided to several Ticket holders who do not eventually assign their Ticket to the EN as well as the cost of services to beneficiaries who do assign their Ticket. Beyond that, if a beneficiary goes on to generate a payment (and not all do), the EN incurs some intermittent cost of follow-up services provided to that beneficiary and the administrative cost of tracking the payment from the Program Manager. The costs we used are estimates, but our analysis indicates that even a substantial change in costs (even at magnitudes higher than 50 percent) will not change the main conclusions.

2. EN Revenues for an Early Participant Cohort

Revenues in the first two years after assignment were measured by using SSA administrative data on payments to ENs (excluding any payments to VRs with contracts to act as ENs). The data indicate that few of the Tickets assigned in the year after TTW rollout generated any payment at all within two years, and those that did generate a payment did not tend to do so in multiple months.

Table VIII.1 presents the percentage of assigned Tickets that generated a payment in the first and second years following assignment as well as the share of those Tickets that generated at least one outcome payment. Nearly 16 percent of DI Tickets assigned to an EN and 10 percent of SSI-only Tickets generated payment in the first year after assignment. In the second year after assignment, the likelihood that a Ticket would generate any payment to an EN is half as high as it was in the first year, but Tickets generating outcome payments made up a larger share in the second year than they did in the first year. It appears that, during the first two years following assignment, Tickets that generate a milestone payment are more likely to do so in the first year, and ENs may expect that a portion of the Tickets that generate outcome payments in the second year will continue to do so in future months, although each Ticket holder that has reached outcome status may not generate an outcome in each month.

Under the milestone-outcome system, about 17 percent of Tickets assigned to an EN by DI beneficiaries generated at least one payment within 24 months of when the Ticket was assigned, and nearly 11 percent of Tickets assigned by SSI-only beneficiaries generated at least one payment within the two-year period. This means that ENs had to serve approximately six DI beneficiaries or nine SSI-only beneficiaries before a beneficiary generated a payment. Of the small fraction of beneficiaries with assigned Tickets who generate any payment, a smaller proportion generated a payment in any given month. To illustrate this pattern, Figure VIII.2 shows the proportion of Tickets that generated at least one payment under the milestone-outcome system that generated any payment in each month during the two years after assignment. Only about one in four Tickets that ever generated a payment to an EN generated a payment in a given month. In the months shortly after assignment, Tickets were more likely to generate a payment, but the likelihood of payment 18 months after assignment was relatively low. This trend suggests that, of the Tickets generating any payment at all within two years, most do so only in a few months, and the number of Tickets that consistently generates payments in several months is likely to be small.

^aPayment data on all Tickets assigned to ENs in first year of TTW operations.

Thus, the average revenue that ENs received from assigned Tickets was small during the first two years following assignment. For DI beneficiaries in the cohort that assigned their Tickets during the first year of TTW, we estimate that ENs generated payments worth an average of just $352 per Ticket ($214 in the first year and $138 in the second year).⁸ SSI payments are smaller so the revenue flow for SSI-only beneficiaries was smaller, even though these beneficiaries tended to generate more payments. We estimate that ENs generated an average of just $127 per SSI-only Ticket accepted ($83 in the first year and $44 in the second year).

Click for Figure VIII.2. Percentage of Tickets Generating Payment in Each Month Among Tickets That Generate at Least One Payment (Opens in new window)

3. EN Net Revenue for an Early Cohort

Our analysis of costs and revenues indicates that, on average, ENs are not likely to have recovered the cost of serving beneficiaries within two years of accepting a Ticket (Table VIII.2). The revenue streams from the few beneficiaries who generate payments do not appear to be sufficient to pay for the costs of all the contacts with and services provided to beneficiaries who do not generate payments. Specifically, our model predicts that, over the two years following assignment, ENs would incur costs of approximately $2,300 for each Ticket they accept. However, revenue generated by the Tickets hardly begins to offset service costs.

The low estimates of revenue reflect two factors: (1) the low likelihood that an assigned Ticket will generate any payment and (2) the fact that Tickets that do generate payments do not consistently do so in every month. That is, the payment per Ticket accepted is equivalent to the total payments received times the likelihood that an accepted Ticket will generate any payment. We observed that only 11 to 17 percent of Tickets assigned under the milestone-outcome payment generated any payment in the two years following assignment, thus creating a very low cash flow. The small average revenues do not compensate the EN for the service costs they incur. Thus, two years after a Ticket is assigned, we estimate that an EN will have experienced a loss of nearly $2,000 (for DI/concurrent beneficiaries) to more than $2,200 (for SSI-only beneficiaries).

Note: All revenues and costs discounted to date of Ticket assignment using the January 2004 prime rate of 4 percent per year.

To determine whether this early experience might improve for later enrollment cohorts, we examined the payment pattern associated with milestone-outcome Tickets within one year of assignment for assignments that occurred in the second year after Ticket rollout (Figure VIII.3). We compared this pattern to the payment pattern for Tickets assigned in the first year after Ticket rollout (Figure VIII.2). Among the later assignments, about 16 percent of DI beneficiaries and about 9 percent of SSI-only beneficiaries generated a payment within one year of assignment. These overall rates are similar to the rates observed in the earlier assignment data, although the monthly percentages of these Tickets that generated any payment are lower overall than the monthly rates for Tickets assigned earlier. For both DI and SSI-only beneficiaries who generated a payment in the second year after rollout, the payment rates in months 8 through 11 were already as low as those observed in the last four months of the second year after assignment for beneficiaries who assigned in the first year after rollout.

Click for Figure VIII.3. Percentage of Tickets Assigned in the Second Year After TTW Rollout That Generate Any Payment in Months 0–11 That Generate Payment in Each Month (Opens in new window)

The early experience may improve if a larger share of beneficiaries served by ENs ultimately generates at least one payment and if each beneficiary begins to generate more payments. In addition, ENs could reduce their service costs if they could screen beneficiaries before assignment, asking for information (such as goals, motivation, and employment history) that might help determine which beneficiaries were most likely to become employed. If ENs enrolled only those beneficiaries who were highly likely to generate a payment, they might spend less to provide services to clients who do not ever reach zero-benefit status. However, the preliminary evidence from a later cohort of Ticket assignments does not suggest that monthly payment rates will increase much.

Two years after Ticket assignment, ENs have found themselves in an unfavorable financial position with regard to TTW. In this section, we examine what it would take for ENs to break even in TTW and discuss whether such steps are realistic. As in the section above, we will focus on the milestone-outcome system because the outcome-only payment system is used so infrequently that there is little available evidence to assess likely payment flows.

To compensate for the estimated net loss of approximately $2,000 on each Ticket accepted under existing payment rules, ENs must begin to receive payments on more Tickets that they accept, and each Ticket must generate more payments. Our assumptions about the cost of staff time and the amount of time needed both to provide follow-up services and track payments yield an estimate that each payment will cost about $60 to produce. If we assume that a beneficiary generates two milestone payments and then begins to generate outcome payments, the outcome payments would total $161 and $272 for an SSI-only and a DI beneficiary, respectively.⁹ So, net of the costs of producing that payment, an EN could expect to gain about $100 for each additional outcome payment received for an SSI-only beneficiary and $210 for each additional outcome payment received for a DI beneficiary. To recover its net loss of approximately $2,000 to $2,200 for the first two years after assignment, an EN must receive approximately 22 more payments per Ticket assigned by an SSI-only beneficiary and 10 more payments per DI Ticket. These payments would be in addition to the payments already received by an EN.

To illustrate the magnitude of the change required for an EN to break even, it is useful to consider a case where an EN generates payments only for those beneficiaries who generated a payment during the first two years. In that case, the 17 percent of DI beneficiaries who generated a payment during the first two years would have to generate an average of 56 more payments in order for the EN to break even. For the 11 percent of SSI beneficiaries who generated a payment during the first two years, each would have to generate 202 more payments. The DI scenario is barely feasible because the total number of outcome payments possible is 60; the SSI scenario is clearly infeasible. Thus, generating more payments only among those beneficiaries who generate a payment during the first two years is not going to be enough. ENs will have to generate payments for more of the beneficiaries from whom they accept Tickets as well as generate more payments from all of those who generate any payment. Furthermore, if, as some providers have indicated, our rough approximations underestimate any of the costs, ENs would need to generate even more payments to offset the higher costs.

The payment data indicate that, so far, few beneficiaries generate many payments and that the payment stream is declining in the second year after Ticket assignment, with a smaller percentage of beneficiaries who generated any payment actually generating a payment in a given month during the second year. Based only on this early experience, ENs may not see TTW as a self-financing line of business.

^aPayment data on all Tickets assigned in the second year following TTW rollout.

On a positive note, some emerging evidence from SVRAs indicates that many beneficiaries receiving vocational rehabilitation services require more than two years of services before they reach zero-benefit status.¹⁰ As a result, we might see a turnaround in the payment profile for the early cohort that is just now completing its second year of services. However, it is not clear whether ENs will have the cash flow to sustain their services if they must wait for more than two years to break even.

Furthermore, even though these early findings are discouraging, the outlook for TTW is brighter if the program is viewed as a supplement to other funding intended to promote employment among people with disabilities. If an EN has other sources of income to fund TTW services, the milestone and outcome payments may provide an additional incentive to serve Ticket-eligible beneficiaries. For example, if an EN must fund only the intake and payment-tracking costs from its Ticket revenues, then the EN could, in theory, earn a substantial profit.

It is likely that ENs will become profitable only if beneficiary behavior and Ticket regulations change; moreover, neither of these changes is likely to be sufficient on its own. ENs could boost their own net revenues by decreasing costs or increasing revenues or doing both simultaneously. Some policy-oriented changes can lower EN costs and increase the real value of payments, but no such changes seem likely to help ENs generate consistent profits unless ENs also manage to increase the likelihood and frequency of payments.

One option is for ENs to try to reduce their service costs well below $2,000 per Ticket accepted. However, if ENs try to keep service costs low, beneficiaries who face substantial barriers to employment may have difficulty assigning their Ticket, perhaps resulting in a decrease in already low TTW participation rates. Furthermore, the ENs we interviewed were generally trying hard to identify potentially successful participants, and it is unclear whether they can do so better than at present.

Another option for ENs is to improve screening processes so that they accept Tickets from individuals who are most likely to become successfully employed. This option would reduce costs spent on beneficiaries who are unlikely ever to generate a payment. Increasing the success rate of Ticket holders also brings in more payments to the EN, which increases the amount of funding available for services. A few ENs have generated payments for more than 30 percent of Tickets they accept. Further, ENs could work with SVRAs to serve beneficiaries who had already been prescreened by the SVRA. Such a joint effort might be structured in a way that allows the SVRA to provide some of the more expensive initial services by using other funds while ENs provide long-term employment support funded by TTW revenue.

Finally, while it appears difficult for ENs to become profitable if they rely on TTW as their only source of revenue, the financial picture would be brighter if they could turn to other funding sources to pay for some beneficiary services. In that case, the need to generate payments would still exist, but it would be less urgent. But treating TTW as just a supplemental funding source is likely to limit its ability to achieve its goals of greatly expanding the number and variety of providers who will assist beneficiaries.

¹ The purpose of this analysis is to determine whether ENs that participate in TTW find that the program is financially viable; therefore, we focus on non–SVRA ENs, and the revenue data we examine excludes SVRA Ticket assignments under the two new payment systems. Return to Text.

² The EN interviews are described in detail in Chapter V. Return to Text.

³ Two payment dates were available in the administrative data: one that corresponded to the month in which the outcome or milestone was achieved, and one that represented the date payment was received by the EN. We use the earlier of the two, the date on which an event prompting a payment was achieved, in order to eliminate payment processing delays from our analysis. Return to Text.

⁴ In making these cost and revenue projections for ENs, we tried to select values that would illustrate the financial performance of a provider that was already established and no longer had to deal with start-up costs or the costs of operating at very small scale. We also adjusted all the cost and revenue estimates to net out inflation and express the results in January 2004 dollars. Furthermore, any costs and revenues that occur more than 12 months after assignment are discounted at the January 2004 prime rate of 4 percent per year. Return to Text.

⁵ This hourly wage represents salary only and was multiplied by 1.61 to account for fringe benefits, supplies, and supervisory time. The adjustment factor comes from a detailed cost study performed by staff of the Minnesota State Partnership Initiative project (Minnesota Work Incentives Connection 2003). Application of the factor yielded an inflation-adjusted estimate of $22.34 per hour for labor. Return to Text.

⁶ We determined the median cost of closing a case for non-blind beneficiaries in each SVRA and then used the median of those median costs to approximate the cost an EN would incur to assist a beneficiary. For SSI cases, median-cost SVRAs were Tennessee and Colorado. For DI cases, median-cost SVRAs were Oregon and New York. Return to Text.

⁷ These tabulations are based on an analysis of FY2002 RSA 911 data on service costs for closed cases in which beneficiaries had signed an Individualized Plan for Employment. Return to Text.

⁸ Ticket revenue is discounted to the date of Ticket assignment at 4 percent per year, the prime interest rate in effect in January 2004. Return to Text.

⁹ This analysis is based on 2004 dollars; therefore, we use the 2004 payment rates to determine the value of payments. Outcome payments under the milestone-outcome system depend on the number of milestones a beneficiary reaches. Return to Text.

¹⁰ This analysis of SVRA data is in an unpublished SSA report. Return to Text.