#### ![](media/image1.png){width="0.6666666666666666in" height="0.6944444444444444in"}**Ticket to Work and Work Incentives Advisory Panel**

> *Advice Report to the Commissioner\
> of the Social Security Administration:*
>
> *Design Issues Relating to\
> the Adequacy of Incentives Study*
>
> *June 18, 2002*

Table of Contents

Executive Summary [1](#__RefHeading___Toc7266711)

Message from the Panel [7](#__RefHeading___Toc7266712)

Summary of A Social Security Administration Report:\
Working Paper 003---Design of the Study of the Adequacy of Incentives\
for the Ticket to Work Program [9](#__RefHeading___Toc7266714)

Summary of Experts Roundtable, July 27, 2001
[11](#__RefHeading___Toc7266715)

Summary of Issues [14](#__RefHeading___Toc7266716)

Questions and Recommendations [19](#__RefHeading___Toc7266717)

Summary [33](#__RefHeading___Toc7266727)

Appendices [34](#__RefHeading___Toc7266728)

> 1\. Ticket To Work And Work Incentives Advisory Panel
>
> 2\. Design And Evaluation Committee
>
> 3\. List Of Experts, Experts Roundtable, July 27, 2001
>
> 4\. Public Commenters, July 27, 2001
>
> 5\. Individuals Providing Public Comment In Writing\
> Following July 27, 2001
>
> 6\. Staff, July 27, 2001
>
> 7\. Presenters, July 27, 2001
>
> 8\. References and Bibliography

[]{#__RefHeading___Toc7266711 .anchor}Executive Summary

The purpose of the Panel's Advice Report is to provide analysis and
recommendations regarding design of the Adequacy of Incentives Study
authorized by the Ticket to Work and Work Incentives Improvement Act of
1999. The Adequacy of Incentives Study was mandated by Congress to
evaluate how the Ticket to Work and Self-Sufficiency Program can be used
to increase employment among those with significant disabilities. The
Commissioner is required to report to Congress on recommendations for a
method or methods to adjust payment rates to Employment Networks to
ensure the participation of individuals with disabilities in four
specific groups. The Commissioner must implement the necessary adjusted
payment rates prior to full implementation of the Ticket to Work and
Self-Sufficiency Program. The statute requires that the Panel be
consulted during the development and evaluation of the study.

This Advice Report is based on relevant documents, including reports
from an Experts Roundtable and public testimony coordinated and convened
by the Design and Evaluation Committee of the Work Incentives Advisory
Panel in Washington, DC, on July 27, 2001. In addition, this Advice
Report is based on related research on employment of people with
significant disabilities and targets the four groups in the disability
population noted in the Adequacy of Incentives provision of the
legislation who are likely to be "involuntary nonparticipants." These
four groups are individuals with a need for ongoing support and
services, individuals who need high-cost accommodations, individuals who
earn a subminimum wage, and individuals who work and receive partial
cash benefits.

Summarized in this Advice Report are a report by the Social Security
Administration (Working Paper 003*, Design of the Study of the Adequacy
of Incentives for the Ticket to Work Program*, Huynh and O'Leary, July
14, 2001); key points from the July 27, 2001, Experts Roundtable; and
Panel and Experts Roundtable recommendations that will provide a
framework for additional research related to the Adequacy of Incentives.
The points offered in this Advice Report are intended to support and
enhance, not supplant, the overall proposal described by the Social
Security Administration's Office of Policy in Working Paper 003 and
discussed at the Experts Roundtable.

Panel Recommendations

The 13 recommendations offered here include recommendations from the
Panel related to the ongoing process for the Adequacy of the Incentives
Study. They are followed by recommendations from the Experts Roundtable
on nine specific issues raised by the Social Security Administration
(SSA) and/or the Panel.

Design Process of the Study

**Panel Recommendation 1:** An ongoing structure must be established for
review of emerging information, analysis of trends, and creation of
recommendations regarding modification of incentives and making use of
multiple evaluation methods.

**Panel Recommendation 2:** The Social Security Administration should
convene an Adequacy of Incentives Advisory Team, similar to the team of
consultants approach being used under the \$1 for \$2 research, for
ongoing technical support for the Adequacy of Incentives Study,
specifically related to the four targeted groups. This group should
consist of diverse individuals who have research background, knowledge,
and/or expertise in the successful employment of individuals in the four
groups. This group could include, but not be limited to, the experts
identified by the Panel for the Adequacy of Incentives Expert
Roundtable. These experts would be charged to further develop
recommendations from the Experts Roundtable for serious consideration by
the Social Security Administration. At least two members of the Adequacy
of Incentives Advisory Team should become members of the Technical
Evaluation Support Group, the technical group advising Social Security
Administration on overall Ticket evaluation, to ensure coordination of
the two research efforts.

**Panel Recommendation 3:** Given the impact of this and other studies
the Office of Policy conducts on the lives of people with disabilities
and their families, the Office of Policy should develop a policy and
practice for incorporating the input and experiences of consumers, their
families, and/or their representatives as it develops new research
designs, including the Adequacy of Incentives Study.

**Panel Recommendation 4:** As the Ticket to Work and Self-Sufficiency
Program is implemented, the Social Security Administration should
provide to the Panel, Congress, and the President ongoing interim
reporting on the participation of members of the four targeted groups in
the Ticket to Work and Self-Sufficiency Program.

**Panel Recommendation 5:** The Panel recommends that Congress approve a
technical amendment to require the Social Security Administration to
provide to the Panel, Congress, and the President ongoing interim
reporting on the participation of members of the four targeted groups in
the Ticket to Work and Self-Sufficiency Program.

**Panel Recommendation 6:** Ongoing data collected and outcomes
determined for the Adequacy of Incentives Study should be included in
the Social Security Administration's overall Ticket evaluation research.

**Panel Recommendation 7:** Due to delays in issuing the tickets, the
deadline for the Adequacy of Incentives Report to Congress should be
extended by the amount of time the ticket rollout has been delayed (13
months). The Panel recommends that Congress approve an amendment to
adjust the timeline for the Adequacy of Incentives Report so that it is
due 49 months, rather than 36 months, after the enactment date.
Implementation of the necessary adjusted payment rates should occur as
soon as practical following the release of the Adequacy of Incentives
Report but no later than 1 year after its release. Further, the Panel
requests preliminary progress reports on the Adequacy of Incentives
Study at 36 and 42 months after the date of enactment of the law.

Identifying the Four Groups

**Panel Recommendation 8:** While there is a need to take advantage of
what is known about the diagnostic categories with high proportions of
those most likely to fall into one of the four groups relative to work
capability, the Social Security Administration, in addition to
diagnostic data, should use other information, such as survey
information, information on earnings, onset date, and medical
improvement assessments. SSA should also go to outside data sources,
such as those identified in Expert Roundtable Recommendation 1 (below),
to identify members of the four target groups.

Survey Methodology

**Panel Recommendation 9:** The Social Security Administration has
proposed a survey to supplement its administrative data, improving its
ability to target the four groups. If the survey uses a telephone
protocol, the protocol should include two other elements. First, there
should be face-to-face home interviews if the phone survey fails for a
given respondent, except for cases of incorrect phone numbers, empty
residences, and so on. Second, if the potential respondent's disability
prevents effective participation in the survey, the interviewer should
use as a proxy another individual who knows the respondent well and,
preferably, who has communicated on the respondent's behalf in the past,
such as a parent, spouse, sibling, or supervisor in a group home.
Members of the Adequacy of Incentives Advisory Team (see Panel
Recommendation 2) should review the interview protocol used by the
contractor conducting the survey.

Supplementary Research

**Panel Recommendation 10:** Recognizing the need for research to
supplement what can be studied using Social Security administrative
data, SSA has proposed a program of supplementary research. It has
solicited the suggestions of the Panel for possible research topics to
supplement the research using SSA data. The Panel recommends the
following:

-   Review existing research on the four groups or related groups,
    including relevant behavioral demonstrations and field experiments.

-   Conduct or commission new research on these groups using State data
    or other Federal data.

-   Conduct or commission new research related to Employment Networks
    and other providers.

-   Review and consider best practices of successful programs relating
    to employment of those with significant disabilities.

-   Review best practice systems of results-based funding and/or
    individual milestones payments.

-   Conduct or commission a review of supported employment literature,
    research, and best practices.

-   Conduct or commission ongoing demonstration projects, modeling, and
    evaluation of the effectiveness of alternative incentives
    identified.

Employment Networks

**Panel Recommendation 11:** SSA should identify the data elements that
Employment Networks (ENs) should collect on whom they serve and do not
serve from the four functional groups identified in the statute. The
data should include descriptions of why a ticket is accepted or is not
accepted on the basis of the EN's perception of cost, degree of
difficulty, or lack of expertise on the part of the EN to provide the
necessary services. SSA should use a sampling of ENs rather than
requiring all ENs to collect the data. SSA should pay the ENs to offset
the administrative burden of management information system design.

**Panel Recommendation 12:** SSA should conduct or commission
qualitative research, including interviews and focus groups as
appropriate, to assess the adequacy of current incentives to large and
small providers, including community rehabilitation programs.
Information and recommendations should be collected regarding the amount
and timing of payments and other factors that affect potential
participation in the Ticket Program and integrated community employment
at minimum wage or higher levels for individuals in the four groups.

**Various and Diverse Populations**

**Panel Recommendation 13:** SSA should ensure that the data collected
include attention to national demographics such as rural and urban
settings, minority representation, and socioeconomic conditions across
the country.

Recommendations From the Experts Roundtable

The Panel convened an Experts Roundtable on July 27, 2001, as part of
its effort to bring expertise to bear in advising SSA on the design of
the Adequacy of Incentives Study. Following are the recommendations that
emerged from the Experts Roundtable in response to the nine questions
posed by the Social Security Administration and the Panel. The Panel
strongly urges the Social Security Administration to seriously consider
and further develop these recommendations in designing research related
to the Adequacy of Incentives Study and its context within the broader
evaluation of the Ticket to Work and Self-Sufficiency Program.

Identifying the Four Groups

**Roundtable Recommendation 1:** In addition to the administrative data
sets SSA has proposed using, use appropriate Federal databases (e.g.,
Office of Special Education and Rehabilitative Services, Rehabilitation
Services Administration, and Department of Labor); State databases
(e.g., State developmental disability agencies and State mental health
agencies); data from providers of day treatment, day activity programs,
sheltered workshops, and supported employment programs (e.g., data from
the Employment Intervention Demonstration Program funded by the Center
for Mental Health Services); and existing research studies in order to
identify and gather information from and about members of the four
groups. In addition, the Helen Keller National Center has data on 7,000
persons who are deaf and blind, some of whom are seeking employment.

**Roundtable Recommendation 2:** Oversample potential members of these
four groups who can be located in the administrative data from Social
Security, Office of Special Education and Rehabilitative Services,
Rehabilitation Services Administration, Medicaid, the Department of
Labor, and/or other Federal sources.

Outcomes of Interest

**Roundtable Recommendation 3:** Track basic employment outcomes (jobs,
wages, hours, choice, etc.) for members of the four groups once
identified.

**Roundtable Recommendation 4:** Gather information about access to and
use of the Ticket, with particular attention to whether nonparticipation
is voluntary or involuntary.

**Roundtable Recommendation 5:** Conduct or commission qualitative
research, including interviews and focus groups, to gather more
extensive information about participation, economic and other benefits,
and ways to attain improved incentives.

**Roundtable Recommendation 6:** Analyze the data collected related to
patterns of outcomes, cost/benefit, participation, and modifications of
incentives for members of these four groups compared with others making
use of the ticket.

Maximizing Outcomes

**Roundtable Recommendation 7:** The Social Security Administration
should ensure that studies of these four groups include attention to the
issue of the "mix" of funding, government programs, and other incentives
and disincentives that affect the employment of people with
disabilities. These studies should include analysis of how various
funding streams can be used together to enhance incentives to Employment
Networks and providers and result in employment for people in the four
groups.

Successful Efforts to Employ People With Significant Disabilities in
Community Employment at Minimum Wage Levels or Higher

**Roundtable Recommendation 8:** The Social Security Administration
should study the successes of supported employment programs,
Rehabilitation Services Administration Choice projects, and other
demonstration projects of the past decade for members of these four
groups.

Other Methods to Identify Members of the Four Groups

**Roundtable Recommendation 9:** The Social Security Administration
should consult other databases to identify members of the four groups.
Such databases should include other existing national samples as well as
State databases for persons with developmental disabilities, persons
with mental illness, persons with deafness and blindness, persons with
brain injuries, and persons with other disabilities.

Individualized Milestone Payments

**Roundtable Recommendation 10:** The Social Security Administration
should study the current and recent experiences of States that have
begun using results-based funding or some form of payment for
individualized milestones toward employment.

**Roundtable Recommendation 11:** The Social Security Administration
should conduct or commission cost/benefit analyses and create
demonstration projects on modifying the incentives to Employment
Networks and providers of services, showing how members of the four
groups can benefit from the Ticket and from employment that partially
reduces benefits.

Various and Diverse Populations

**Roundtable Recommendation 12:** The Social Security Administration
should ensure that the data collected include attention to national
demographics such as rural and urban settings, minority representation,
and socioeconomic conditions across the country.

Including Consumers, Family Members, and/or Their Representatives in the
Study Design and Implementation

**Roundtable Recommendation 13:** Given the impact of this and other
studies the Office of Policy conducts on the lives of people with
disabilities and their families, the Office of Policy should develop a
policy and practice for incorporating the input and experiences of
consumers, their families, and/or their representatives as it develops
new research designs, including the Adequacy of Incentives Study.

Including Employment Networks in the Study Design and Implementation

**Roundtable Recommendation 14:** The Social Security Administration
should gather data related to the costs to Employment Networks and
providers of services and the timeframes for providing access to the
Ticket and employment for members of these four groups.

**Roundtable Recommendation 15:** The Social Security Administration
should study the relationship between perceived disincentives and actual
incentives for Employment Networks and providers of services, including
incentives for small providers of services.

[]{#__RefHeading___Toc7266712 .anchor}Message from the Panel

In enacting the Ticket to Work and Work Incentives Improvement Act of
1999, Congress recognized that the Ticket to Work and Self-Sufficiency
Program would not be equally available to all individuals with
disabilities. In particular, some people with significant disabilities
might be involuntary nonparticipants. That is, they might be willing to
work but, because of their need for ongoing support and services,
high-cost accommodations, limited wages, and/or partial cash benefits,
as well as outside factors, they might not find an Employment Network
willing or able to take their ticket under the existing financial
incentives of the Ticket to Work and Self-Sufficiency Program.

To address this equity issue, Congress included a requirement in the
statute that the Social Security Administration identify and implement a
payment system that would allow this population to participate in the
Ticket Program. The Commissioner is required to report to Congress on
recommendations for a method or methods of adjusting payment rates to
Employment Networks to ensure equitable participation for individuals in
four specific groups. The Commissioner must implement the necessary
adjusted payment rates prior to full implementation of the Ticket to
Work and Self-Sufficiency Program. The statute requires that SSA consult
with the Panel during the development and evaluation of the
study---commonly referred to as the Adequacy of Incentives (AOI) Study.
The statutory language follows:

> Title I, Sec.101 (h)(C) REPORT ON THE ADEQUACY OF INCENTIVES---The
> Commissioner shall submit to the Congress not later than 36 months
> after the date of the enactment of the Ticket to Work and Work
> Incentives Improvement Act of 1999 a report with recommendations for a
> method or methods to adjust payment rates under subparagraphs (A) and
> (B), that would ensure adequate incentives for the provision of
> services by employment networks of---\
> (i) individuals with a need for ongoing support and services;\
> (ii) individuals with a need for high-cost accommodations;\
> (iii) individuals who earn a subminimum wage; and\
> (iv) individuals who work and receive partial cash benefits.
>
> The Commissioner shall consult with the Ticket to Work and Work
> Incentives Advisory Panel established under section 101(f) of the
> Ticket to Work and Work Incentives Improvement Act of 1999 during the
> development and evaluation of the study. The Commissioner shall
> implement the necessary adjusted payment rates prior to full
> implementation of the Ticket to Work and Self-Sufficiency Program.

The Panel has carefully considered issues related to equitable
participation in the Ticket Program. This has included consultation with
the Social Security Administration, other Federal agencies, and various
experts; opportunities for public comment; and Panel deliberations. The
Panel's Design and Evaluation Committee convened an Experts Roundtable
of nationally recognized experts, Social Security Administration
officials, and Panel members on July 27, 2001. The Roundtable addressed
the many complex issues involving the employment of individuals with
significant disabilities. The impact of the overall Ticket evaluation on
individuals in the four groups and the design of the AOI Study were
carefully considered. Subsequently, a well-known expert in the field,
Dr. David Mank, assisted the committee and Panel in drafting this
report.

This Advice Report represents the Panel's effort to bring expertise to
bear in advising the Social Security Administration on these complex
issues and the design of the AOI Study. It became evident during this
process that ongoing consideration and advice on this important topic
will be necessary. The Panel looks forward to continuing to address
these issues and provide advice as the Ticket is implemented and
research goes forward.

Summary of A Social Security Administration Report:

[]{#__RefHeading___Toc7266714 .anchor}Working Paper 003---Design of the
Study of the Adequacy of Incentives for the Ticket to Work Program

An overall design has been crafted by the Social Security Administration
for the Adequacy of Incentives Study that is based in part on Federal
databases and includes a process evaluation and an impact evaluation
(Huynh and O'Leary, 2001). Such research is required by the Ticket to
Work and Self-Sufficiency Program. Specifically, the Social Security
Administration is to assess the Adequacy of Incentives structure in
serving members of groups considered unlikely to participate and to
develop and test alternative incentives as necessary. The Act targets
four groups that are considered likely to be "involuntary
nonparticipants." These four groups are individuals with a need for
ongoing support and services, individuals who need high-cost
accommodations, individuals who earn a subminimum wage, and individuals
who work and receive partial cash benefits.

It is important that the Adequacy of Incentives design include specific
attention to these four groups from the beginning of the Ticket to Work
program evaluation process. As Huynh and O'Leary say, " ... it enables
us to ask: What data do we *want* to have when we get to the point of
implementing the evaluation, rather than what do we *have* at that
point" (Huynh and O'Leary, 2001, p. 2).

Working Paper 003 asks two important questions relative to this Advice
Report: Are incentives adequate for the target groups? And, if not, how
can incentives be modified to better serve these groups? The paper goes
on to describe the proposed process for the study of the Adequacy of
Incentives.

Data for addressing the Adequacy of Incentives will be drawn from
administrative data in the Social Security Administration and from
Internal Revenue Service tax files and possibly Center for Medicaid and
Medicare Services (formerly known as the Health Care Finance
Administration) data and Rehabilitation Services Administration data.
The intention here is to "compare the characteristics of those served in
the Ticket to Work program with the characteristics of the SSDI \[Social
Security Disability Insurance\] and SSI \[Supplemental Security Income\]
disabled populations." (p. 4) The authors also note that while the
administrative data will be useful, they are not likely to include
important information about ongoing publicly funded supports,
accommodations, and hourly wages earned. Because of the lack of some
needed data in the administrative data sets, the paper also proposed a
survey that would ask beneficiaries about work, wages, access to the
Ticket, access to vocational rehabilitation services, and other
questions. A phone survey is planned to attempt to collect these data,
supplemented by home interviews when information cannot be collected
over the phone. Issues with this approach are also discussed, including
sampling issues and survey subjectivity. For the purpose of determining
how to modify the incentives of the Ticket to Work, the authors propose
a theoretical modeling approach because, they argue, "testing
alternative incentives is ... not currently feasible given the limited
information ... on alternative incentives to test." (p. 8) The authors
expect the Social Security Administration administrative data to be
useful, but they note that its usefulness may be somewhat limited. In
addition, the survey noted earlier will be designed to help address the
issue of determining how to modify Ticket to Work and Self-Sufficiency
Program incentives. Issues of subjectivity and defining eligibility are
also noted and discussed related to possible modification of these
incentives.

Working Paper 003 also indicates that additional input is needed on
three specific questions: What are objective means of identifying the
groups? What are the outcomes of interest? What array of services should
be considered to maximize outcomes to members of these four groups?

[]{#__RefHeading___Toc7266715 .anchor}Summary of Experts Roundtable,
July 27, 2001

An Experts Roundtable was convened by the Design and Evaluation
Committee of the Work Incentives Advisory Panel on July 27, 2001, in
Washington, DC. The Panel assembled experts in several fields, with the
main focus being efforts to employ those with significant disabilities.
Lists of experts in attendance and of those providing public comment are
provided in the appendixes to this Report. The meeting provided the
opportunity for review and discussion of the design of the study on the
adequacy of incentives for individuals in the four groups noted. After
presentation of the study design by the Office of Policy and its
consultants, the experts offered comments in response to a series of
questions posed by both the Social Security Administration and the Work
Incentives Advisory Panel. Members of the public also had an opportunity
to share their thoughts and impressions on this topic through testimony.

While the overall design may represent important methods to begin to
assess the use of the Ticket to Work and Self-Sufficiency Program and
the Adequacy of Incentives, the following points summarize the concerns
and input of the Experts Roundtable, public testimony, and testimony
received in writing after July 27, 2001:

Expert Comments

-   The design should be formative in nature, immediately seeking ways
    to modify and test incentives rather than waiting for a period of
    time to conduct a summative evaluation to determine whether the
    design of incentives was adequate. The design should emphasize the
    question, What will it take for the incentives to be adequate for
    Employment Networks to serve members of the four groups?

-   There is a need for qualitative studies (in-person interviews and
    focus groups) in addition to quantitative studies.

-   There is a need for specific attention to collecting data regarding
    the issue of incentives to, and perceptions of, providers of
    services.

-   There is concern that the phone survey protocol, even supplemented
    by home interviews, will be inadequate because of communication
    barriers for some members of the four groups and lack of
    understanding of the nature of the Ticket to Work and
    Self-Sufficiency Program.

-   There is concern that the survey should be sensitive to minority and
    cultural issues as well as to geographical differences.

-   There is a need to use existing databases from supported employment
    data, State data from developmental disability agencies, and State
    data from mental health agencies.

-   There is ample evidence, based on the supported employment
    initiative, Rehabilitation Services Administration choice projects,
    and other projects, that individuals in these groups can work
    productively, although often part time.

-   Demonstration projects with members of the four groups are essential
    to show how the incentives could be modified to work with members of
    the four groups.

-   Evaluation of the Adequacy of Incentives should make use of the
    experience in States using results-based funding or milestone
    payments in the vocational rehabilitation system.

-   The evaluation design of the Adequacy of Incentives should be
    considered in the context of the other benefits and services
    received by members of the four groups.

Public Comments

-   The AOI Study is the only hope that persons with high support needs
    have for utilization of their tickets.

-   SSA must look beyond its own data banks to employment researchers
    who have spent years studying supported employment and the successes
    and the impact work has had on the lives of persons with high
    support needs.

-   Everyone needs to have the opportunity to work, regardless of
    disability. No one can be left behind.

-   The Ticket to Work Program is an extremely exciting opportunity for
    people with disabilities to gain employment while being in control
    of funding. It actualizes their role as customers, changing the
    perceptions and focus of the provider community and the general
    public. People with more severe disabilities may not be able to
    benefit from the Ticket to Work Program as it is currently designed.
    SSA and the Panel must analyze the types of supports needed by these
    individuals, the associated expenses, and the impact on the person's
    life style.

-   Because of the multitude of issues that surround individuals with
    significant disabilities, it is incumbent upon this process to take
    a broad view of both cost and benefit. Taking a narrow, econometric
    approach to the study may not reveal an effective payment strategy
    for these individuals---reducing potential outcomes that might be
    experienced otherwise.

-   A broad-based study will decrease reliance on Social Security and
    other benefits.

-   Individuals with disabilities can become employed and be successful
    with proper assistance. Without these intensive, individualized
    supports, though, these individuals are destined to remain on Social
    Security benefits and other public assistance programs.

-   In order to prevent failure of this program, input about the actual
    cost of supports needs to come from agencies that are proficient in
    serving individuals with disabilities, and *not* determined in a
    vacuum or through sterile research methodologies.

-   Expertise of people with disabilities, their families, and agency
    practitioners must be used in the research design.

-   SSA and the Panel must do nothing less than draw on the best
    information in the field to access the answers SSA needs to design
    payment strategies that will work for all persons who have a
    disability---especially those who have the most severe disabilities.
    This cannot be an academic debate about competing research
    methodologies; it should be about determining where the answers lie
    and designing a study that will lead to those answers.

-   The AOI Study potentially opens another avenue that is desperately
    needed to open employment for people with significant disabilities.

-   In Ohio, only 8 percent of people with severe disabilities are
    employed. In the proposed Ticket regulations, there is little
    incentive for providers to accept tickets from individuals who need
    intense and/or expensive supports. The AOI Study is needed to
    determine alternative payment strategies so these people can use
    their tickets and become employed with the needed supports.

    []{#__RefHeading___Toc7266716 .anchor}

Summary of Issues

The following represents a synthesis of the points derived from the
Experts Roundtable, public testimony, literature review, and Design and
Evaluation Committee discussions and provides the conceptual
underpinning for the Panel and Expert Roundtable recommendations made in
this Report.

1)  Individuals in these four groups are less likely to participate in
    the Ticket Program because they are less likely to stop receiving
    Social Security benefits altogether.

2)  Individuals in these four groups will be extremely difficult to
    identify in Federal databases because data on relevant dimensions
    defining these four groups are not directly collected in Federal
    databases. Some Federal data may allow inferences for some of the
    members of some of these groups (e.g., there may be relevant data
    from the Department of Labor regarding individuals earning
    subminimum wages; there may be relevant data on subsets of the four
    groups in Medicaid data and in data from the vocational
    rehabilitation system).

3)  It is likely that individuals in these four groups will require a
    greater degree of effort and long-term support for successful
    employment and may not be able to work enough hours or earn enough
    money to eliminate Social Security benefits (e.g., Mank, 1994;
    Wehman, 2001).

4)  Phone survey methodologies will be of limited utility for members of
    these four groups because of intellectual or other developmental
    disability, or communication difficulties based on disability, in
    addition to the issues of English as a second language and minority
    populations (including Native Americans), which will also affect the
    broader evaluation design (HSRI, 1999).

5)  There is a need for a "formative" evaluation approach and other
    research and evaluation designs for these four groups (which asks
    the question "Under what circumstances can and do members of these
    four groups participate?"), in addition to a summative evaluation
    about the extent to which members of these groups participate
    (Campbell and Stanley, 1963; Weiss, 1972).

6)  There will be major ongoing costs to Social Security as a result of
    widespread nonparticipation of people in these groups. Individuals
    in these groups are likely to receive a lifetime of benefits if they
    do not participate in employment (e.g., Braddock, 2001).

7)  There is widespread evidence that individuals who are part of these
    four groups can work successfully (although often part time) with
    individualized support structures (supported employment research and
    evaluation studies, Rehabilitation Services Administration "Choice"
    projects, etc.). These data are extremely relevant in considering
    the employment rates and potential of people in the four groups and
    in determining what Employment Networks need to assist individuals
    with significant disabilities to be employed (e.g., Mank, Cioffi,
    and Yovanoff, 1999; Mank, O'Neill, and Jensen, 1998; Revell, Inge,
    Mank, and Wehman, 1999; Sowers and Powers, 1991; Wehman, 2001).

8)  The research proposed by the Social Security Administration on the
    Adequacy of Incentives should be supplemented in part because Social
    Security administrative data do not include all the information
    needed to identify the four groups and in part because of
    communication issues associated with efforts to survey these groups.
    Promising sources of information include existing State and local
    databases as well as efforts to more directly collect new data
    relative to the individuals in these groups in addition to the
    adequacy of the incentives to the Employment Networks and providers
    of employment services (Campbell and Stanley, 1963; Weiss, 1972).

9)  The methodologies of the evaluation design must be considered in the
    complex context of a range of factors that affect the extent to
    which people with disabilities work and the extent to which the
    incentives in the Ticket Program are adequate. Additional factors
    that have an impact on the employment of people with disabilities
    include benefits management, provider availability and capacity in
    local areas, and vocational rehabilitation initiatives (Novak, Mank,
    Revell, and O'Brien, 1999; Wehman, 2001). The nature and funding,
    including milestone payments, of vocational rehabilitation services,
    long-term day services, and employment support services by State
    developmental disabilities agencies or State mental health agencies
    will also have an impact on employment. The nature of States'
    Medicaid Waiver programs and Medicaid Buy-In will influence
    employment. In addition, the extent to which long-term employment
    supports and services are funded or not funded in a given State will
    have an impact (e.g., Braddock, 2001; Butterworth, Gilmore, Kiernan,
    and Schalock, 1999).

10) "Purposeful" sampling will be useful for qualitative research and
    focus groups (Guba, 1978; McMillan and Schumacher, 1984). This
    strategy should include individuals in the four groups as well as
    Employment Networks and providers. The overall design proposed
    provides the broad structure for the large quantitative study of the
    Adequacy of Incentives. The four groups noted present specific
    challenges for the Adequacy of Incentives and for the study design.
    State samples provide a method for more closely identifying members
    of the four groups and for collecting more detailed information. In
    addition, they provide a context for creating studies specific to
    Employment Networks and providers in the specific context of the
    samples of individuals in the four groups.

11) There is a need to ensure that all methods used are designed with
    attention to geography, demographics, and economic conditions, as
    well as the representation and participation of Native Americans and
    other minority groups.

12) While the limits of the available administrative data have been
    noted, it must also be noted that available State databases and
    databases from national samples have limits related to the
    completeness and representativeness of the data. Thus, a combination
    of research, evaluation, and database methodologies is needed to
    create the most complete (albeit inherently imperfect) picture
    possible of the participation of members of these four groups and
    the modification of incentives.

13) While each of the research and evaluation strategies discussed in
    this Report has limits, it must also be recognized that the combined
    strategies discussed represent the best possible approach, given the
    limits, and should be implemented, because the cost of "doing
    nothing" is failing to provide any useful information about the
    participation of members of these groups and the modification of
    incentives.

14) These issues will not be fully resolved in the short run because of
    the weaknesses in the administrative databases, the need to create
    alternative evaluation designs for the evaluation of the Adequacy of
    Incentives, and the complex context of services and funding streams
    in which services are provided to members of these four groups. This
    complexity underscores the need for ongoing evaluation and reporting
    requirements in addition to the Adequacy of Incentives Study,
    report, and implementation requirements in the statute.

*Note that the appendices include references as well as a more complete
bibliography regarding employment initiatives and research related to
likely members of the four groups.*

[]{#__RefHeading___Toc7266717 .anchor}Questions and Recommendations

The analysis and input are considered here in the context of the three
primary questions posed by the Social Security Administration (questions
1--3 below) and six additional questions from the Panel (questions
4--9):

1)  What are objective means of identifying, through the Social Security
    Administration administrative data, the target populations as
    defined in the Ticket to Work and Work Incentives Improvement Act?

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15) What are the outcomes of interest?

16) What array of services should be considered to maximize outcomes to
    members of these four groups?

17) What experts and information resources should be considered
    regarding successful efforts to employ people with severe
    disabilities in community employment?

18) What other methods should be used to identify members of the four
    groups?

19) How can the Social Security Administration demonstrate how
    individualized milestone payments could be used?

20) How can the Social Security Administration ensure that various and
    diverse populations are represented in the study?

21) How can consumers, family members, and/or their representatives be
    included in the study design and implementation?

22) How should Employment Networks be consulted in the Adequacy of
    Incentives Study?

In addition, the Ticket to Work and Work Incentives Advisory Panel
believes that the ongoing process for the design of the Adequacy of
Incentives Study is critical to the success of the Ticket to Work and
Self-Sufficiency Program for members of these four groups. Thus,
recommendations about the ongoing process for study and reporting are
defined.

Panel Recommendations

Design Process of the Study

There are important issues concerning the plan for the evaluation of the
Adequacy of Incentives specifically related to the four groups in
question. Because it is agreed that the available administrative data
and the alternative strategies have limits in providing information
about members of the four groups, it will be necessary to define a
process for design and implementation of the study that is sensitive to
the need for current and ongoing information about participation and
about the adequacy of incentives to the Employment Networks and the
providers of services. Because the Act mandates attention to the
participation of these four groups and to the modification of incentives
in the interests of these four groups, the following overarching study
design principle recommendation is made:

**Panel Recommendation 1:** An ongoing structure must be established for
review of emerging information, analysis of trends, and creation of
recommendations regarding modification of incentives and using multiple
evaluation methods.

The following recommendations are intended to support the ongoing
evaluation design.

**Panel Recommendation 2:** The Social Security Administration should
convene an Adequacy of Incentives Advisory Team, similar to the team of
consultants approach being used under the \$1 for \$2 research, for
ongoing technical support for the Adequacy of Incentives Study,
specifically related to the four targeted groups. This group should
consist of diverse individuals who have research background, knowledge,
and/or expertise in the successful employment of individuals in the four
groups. This group could include, but not be limited to, the experts
identified by the Panel for the Adequacy of Incentives Expert
Roundtable. These experts would be charged to further develop
recommendations from the Experts Roundtable for serious consideration by
the Social Security Administration. At least two members of the Adequacy
of Incentives Advisory Team should become members of the Technical
Evaluation Support Group, the technical group advising Social Security
Administration on overall Ticket evaluation, to ensure coordination of
the two research efforts.

**Panel Recommendation 3:** Given the impact of this and other studies
the Office of Policy conducts on the lives of people with disabilities
and their families, the Office of Policy should develop a policy and
practice for incorporating the input and experiences of consumers, their
families, and/or their representatives as it develops new research
designs, including the Adequacy of Incentives Study.

**Panel Recommendation 4:** As the Ticket to Work and Self-Sufficiency
Program is implemented, the Social Security Administration should
provide to the Panel, Congress, and the President ongoing interim
reporting on the participation of members of the four targeted groups in
the Ticket to Work and Self-Sufficiency Program.

**Panel Recommendation 5:** The Panel recommends that Congress approve a
technical amendment to require the Social Security Administration to
provide to the Panel, Congress, and the President ongoing interim
reporting on the participation of members of the four targeted groups in
the Ticket to Work and Self-Sufficiency Program.

**Panel Recommendation 6:** Ongoing data collected and outcomes
determined for the Adequacy of Incentives Study should be included in
the Social Security Administration's overall Ticket evaluation research.

**Panel Recommendation 7:** Due to delays in issuing the tickets, the
deadline for the Adequacy of Incentives Report to Congress should be
extended by the amount of time the ticket rollout has been delayed (13
months). The Panel recommends that Congress approve an amendment to
adjust the timeline for the Adequacy of Incentives Report so that it is
due 49 months, rather than 36 months, after the enactment date.
Implementation of the necessary adjusted payment rates should occur as
soon as practical following the release of the Adequacy of Incentives
Report but no later than 1 year after its release. Further, the Panel
requests preliminary progress reports on the Adequacy of Incentives
Study at 36 and 42 months after the date of enactment of the law.

Identifying the Four Groups

The Social Security Administration should not rely on diagnostic data
alone in attempting to identify the four groups of interest to Congress.
Such efforts will yield less than perfect outcomes. Using standard
diagnostic categories that would include but not be limited to
developmental disability, mental retardation, psychiatric disability,
and multiple disabilities (such as deaf and blind or blind and cerebral
palsy) as a major identification tool for the four groups fails to
recognize the wide heterogeneity within these categories. The categories
that would "most likely" include a significant portion of the population
in the four target groups would also include a number of individuals who
do not fall within the target groups. Likewise, individuals in the
target groups may be found in other diagnostic categories that would not
be expected to include them. Moreover, supplementing existing data
through surveys is problematic because a high proportion of the
population of interest will have disabilities that impede survey
participation.

**Panel Recommendation 8:** While there is a need to take advantage of
what is known about the diagnostic categories with high proportions of
those most likely to fall into one of the four groups relative to work
capability, the Social Security Administration, in addition to
diagnostic data, should use other information, such as survey
information, information on earnings, onset date, and medical
improvement assessments. SSA should also go to outside data sources,
such as those identified in Expert Roundtable Recommendation 1, to
identify members of the four target groups.

Survey Methodology

**Panel Recommendation 9:** The Social Security Administration has
proposed a survey to supplement its administrative data, improving its
ability to target the four groups. If the survey uses a telephone
protocol, the protocol should include two other elements. First, there
should be face-to-face home interviews if the phone survey fails for a
given respondent, except for cases of incorrect phone numbers, empty
residences, and so on. Second, if the potential respondent's disability
prevents effective participation in the survey, the interviewer should
use as a proxy another individual who knows the respondent well and,
preferably, who has communicated on the respondent's behalf in the past,
such as a parent, spouse, sibling, or supervisor in a group home.
Members of the Adequacy of Incentives Advisory Team (see Panel
Recommendation 2) should review the interview protocol used by the
contractor conducting the survey.

Supplementary Research

**Panel Recommendation 10:** Recognizing the need for research to
supplement what can be studied using Social Security administrative
data, the SSA has proposed a program of supplementary research. It has
solicited the suggestions of the Panel for possible research topics to
supplement the research using SSA data. The Panel recommends the
following:

-   Review existing research on the four groups or related groups,
    including relevant behavioral demonstrations and field experiments.

-   Conduct or commission new research on these groups using State data
    or other Federal data.

-   Conduct or commission new research related to Employment Networks
    and other providers.

-   Review and consider best practices of successful programs relating
    to employment of those with significant disabilities.

-   Review best practice systems of results-based funding and/or
    individual milestones payments.

-   Conduct or commission a review of supported employment literature,
    research, and best practices.

-   Conduct or commission ongoing demonstration projects, modeling, and
    evaluation of the effectiveness of alternative incentives
    identified.

Employment Networks

**Panel Recommendation 11:** SSA should identify the data elements that
Employment Networks (ENs) should collect on whom they serve and do not
serve from the four functional groups identified in the statute. The
data should include descriptions of why a ticket is accepted or is not
accepted on the basis of the EN's perception of cost, degree of
difficulty, or lack of expertise on the part of the EN to provide the
necessary services. SSA should use a sampling of ENs rather than
requiring all ENs to collect the data. SSA should pay the ENs to offset
the administrative burden of management information system design.

**Panel Recommendation 12:** SSA should conduct or commission
qualitative research, including interviews and focus groups as
appropriate, to assess the adequacy of current incentives to large and
small providers, including community rehabilitation programs.
Information and recommendations should be collected regarding the amount
and timing of payments and other factors that affect potential
participation in the Ticket Program and integrated community employment
at minimum wage or higher levels for individuals in the four groups.

Various and Diverse Populations

**Panel Recommendation 13:** SSA should ensure that the data collected
include attention to national demographics such as rural and urban
settings, minority representation, and socioeconomic conditions across
the country.

Recommendations From the Experts Roundtable

Following are the recommendations that emerged from the Experts
Roundtable in response to the nine questions posed by the Social
Security Administration and the Panel. The Panel strongly urges the
Social Security Administration to seriously consider and further develop
these recommendations in designing research related to the Adequacy of
Incentives and its context within the broader evaluation of the Ticket
to Work and Self-Sufficiency Program.

Identifying the Four Groups

Summary of Comment

Public comment regarding identifying members of the four subgroups noted
the importance of including people with Down syndrome, people with
significant disabilities, and people who are deaf and blind. Information
was shared about databases on those who are deaf and blind. In addition,
comment included the importance of ensuring that the Ticket is available
in the transition years from school to adult life. Public comment also
emphasized the importance of ensuring that the Ticket incentives are
modified in the interest of people whose Social Security benefits may
not be eliminated.

Discussion

Information from the original design of the study, the Experts
Roundtable, and the public testimony show that there will be difficulty
in identifying individuals in these four groups in the Federal
administrative data available. As a result, it will be necessary to add
methods to locate these individuals in order to collect data about use
of the Ticket. It is clear that many of the individuals in these four
groups are now eligible for, or receiving, services via State
developmental disability programs or mental health agencies. Those
receiving services and likely to be eligible for the Ticket are likely
to be found in day activity programs, day treatment programs, sheltered
workshops, supported employment, and other appropriate databases.
Because there are important questions about the availability of Federal
data, State sources of information will be needed in order to find and
understand the participation or nonparticipation of people from the four
groups. Sources that can provide information to locate members of the
four groups will include State mental retardation and developmental
disability agencies; State mental health agencies; providers of
sheltered work, day activity, and day treatment programs; providers of
supported employment services; and some State vocational rehabilitation
agencies. Existing supported employment databases in some States could
be very useful. Other databases may be of use, such as available data
about people with deafness and blindness and data related to community
rehabilitation facilities that serve people in these four groups.
Through such sources, it will be possible to identify relatively large
samples of people who fit the descriptions of each of the four groups.

Identifying samples will depend in part on the availability of
State-level data regarding people in the four groups. Some States will
have databases that make such analysis possible; other States may have a
limited ability to provide such data. These data will be useful for
several kinds of studies. First, identifying a relatively large sample
in each State will allow specific tracking to note the participation or
nonparticipation of people in the four groups. In addition,
identification of people in the four groups will allow data to be
collected from the individuals and their families. In light of the
communication issues, it can be expected that it will be necessary, at
least in part, to conduct face-to-face interviews and to talk to some
family members or significant others regarding participation. The
information collected should include the needed disability and
demographic information as well as information about knowledge of the
Ticket, availability of the Ticket, and access to Employment Networks
and providers of service. In addition, it may be possible to gather
information about interest in and the feasibility of full-time or near
full-time work in order to possibly work enough to eliminate Social
Security financial benefits. While such samples will not be random
samples from a national perspective, they will provide additional
information needed for the Adequacy of Incentives Study.

It must be noted that such State and other databases have serious limits
in their completeness and the extent to which they represent in totality
the members of the four groups. The four groups, as defined in the Act,
have never before been defined in quite this way. As a result, no
existing databases can be expected to be complete or representative of
the four groups. Because of this, a combination of national
administrative data and State and other data should be used to construct
the best possible understanding of the groups and the best possible
understanding of the incentives to Employment Networks and providers in
providing access to the Ticket to members of the four groups. This
approach is supported by the Experts Roundtable and by the public input
provided to the Panel.

**Roundtable Recommendation 1:** In addition to the administrative data
sets SSA has proposed using, use appropriate Federal databases (e.g.,
Office of Special Education and Rehabilitative Services, Rehabilitation
Services Administration, and Department of Labor); State databases
(e.g., State developmental disability agencies and State mental health
agencies); data from providers of day treatment, day activity programs,
sheltered workshops, and supported employment programs (e.g., data from
the Employment Intervention Demonstration Program funded by the Center
for Mental Health Services); and existing research studies in order to
identify and gather information from and about members of the four
groups. In addition, the Helen Keller National Center has data on 7,000
persons who are deaf and blind, some of whom are seeking employment.

**Roundtable Recommendation 2:** Oversample potential members of these
four groups who can be located in the administrative data from Social
Security, Office of Special Education and Rehabilitative Services,
Rehabilitation Services Administration, Medicaid, the Department of
Labor, and/or other Federal sources.

Outcomes of Interest

Summary of Comment

Public comment related to outcomes supported the emphasis on basic
employment outcomes, including wages and integration in the workforce.
However, commenters also indicated that it is important to emphasize
that the Ticket should increase choices and control by people with
disabilities and their families. Commenters also expressed concern that
a phone survey will not be adequate to gather outcome and participation
data from the people in the four targeted groups. Commenters also agreed
that qualitative methods for collecting data would be needed in addition
to quantitative methods. In addition, one commenter emphasized the use
of existing databases that include people with significant disabilities.
Experts and commenters agreed that an essential outcome is the
opportunity for individuals in the four groups to use a ticket to obtain
successful employment. There was agreement that successful employment
should be defined as real work in integrated settings in the community
at minimum or higher wage, based on individual choice and control.

Discussion

There are two levels of outcomes of interest: the individual outcomes of
interest and the broad program outcomes of interest. The individual
outcomes of interest include type of job, wages earned, hours worked,
job retention, and the process (and timing) of gaining access to the
Ticket through the Employment Networks and providers of services. When
members of the four groups do not use or have access to the Ticket, the
Social Security Administration will need to know the reasons why
individuals are not participating: Is it voluntary or involuntary
nonparticipation? It will be important to know if the Ticket Program
increases choices of employment services for individuals. It will also
be important to know if partial reduction of benefits is possible and
helpful to individuals. At a broad program level, it will be important
to understand the patterns of participation, outcomes, costs, and
incentives that may be adequate to produce desired outcomes.

**Roundtable Recommendation 3:** Track basic employment outcomes (jobs,
wages, hours, choice, etc.) for members of the four groups once
identified.

**Roundtable Recommendation 4:** Gather information about access to and
use of the Ticket, with particular attention to whether nonparticipation
is voluntary or involuntary.

**Roundtable Recommendation 5:** Conduct or commission qualitative
research, including interviews and focus groups, to gather more
extensive information about participation, economic and other benefits,
and ways to attain improved incentives.

**Roundtable Recommendation 6:** Analyze the data collected related to
patterns of outcomes, cost/benefit, participation, and modifications of
incentives for members of these four groups compared with others making
use of the ticket.

Maximizing Outcomes

Summary of Comment

Public comment on the array of services emphasized the need for
flexibility in how the Ticket Program is used to ensure that members of
the four groups have access to the Ticket. Commenters noted that there
are a number of best practice programs around the country that can
provide information about successful employment of people with
significant disabilities. Commenters also noted that the Ticket Program
should supplement and not supplant other services received by members of
the four groups. In addition, comment included attention to the
importance of ensuring that the Ticket Program incentives were adequate
for the providers of services. Finally, comments focused on the need to
understand results-based funding and milestone payment programs for
employment outcomes.

Discussion

A third important question concerns the array of services that should be
provided to members of these four groups. In considering essential
services and supports, it is important to recognize that a large number
of people who typically would fall into one of the four groups have
become successfully employed through an array of services and supports.
It is critical that the study include an evaluation of the array of
services and supports that led to successful employment. The experiences
of the supported employment initiative, the Rehabilitation Services
Administration Choice projects, and the milestone payment systems in
vocational rehabilitation will be especially relevant in this regard. In
addition, the combination of services (vocational rehabilitation,
developmental disabilities programs, mental health programs, Medicaid,
etc.) received by some members of these four groups will be important to
understand. For people in these four groups, there are other macro and
micro factors that relate to the opportunity to work. Such factors
include benefits planning, assistance and outreach projects,
availability (and payment methodology, for example, fee-for-service vs.
results-based funding) of vocational rehabilitation funds, availability
and structure of long-term employment support funds (via mental
retardation/developmental disability and mental health agencies), use of
Medicaid funds, Plan for Achieving Self-Support and Impairment-Related
Work Expense use, housing allowances and funding, and the perception of
disincentives to employment. Factors such as these already complicate
work decisions for people in these four groups and have an impact on
their unemployment or underemployment. In addition, issues of continued
health care coverage and States' use of the Medicaid Buy-In process will
have an impact on employment. Analysis of the Adequacy of Incentives
will depend in part on analysis of this complex context and of possible
interaction effects. There are also related questions about combining
funding sources in the interest of employing these individuals. Another
area for analysis is the extent to which those eligible for tickets are
sufficiently motivated to work.

**Roundtable Recommendation 7:** The Social Security Administration
should ensure that studies of these four groups include attention to the
issue of the "mix" of funding, government programs, and other incentives
and disincentives that affect the employment of people with
disabilities. Studies should include analysis of how various funding
streams can be used together to enhance incentives to Employment
Networks and providers and result in employment for people in the four
groups.

Successful Efforts to Employ People With Significant Disabilities in
Community Employment at Minimum Wage Levels or Higher

Summary of Comment

The public comment about experts and information resources to consider
focused on initiatives in the past 10 to 15 years that have emphasized
employment for people with severe disabilities. These initiatives
include supported employment, the Rehabilitation Services Administration
Choice projects, and other demonstration projects, including those for
persons with mental illness as well as persons who are deaf and blind.

Discussion

Public comment and the discussion of the Experts Roundtable emphasized
that members of the four groups have benefited from employment
initiatives in the recent past. Evidence of these successful strategies
is described in some detail in the supported employment literature, in
reports regarding projects to create greater choice and control in the
vocational rehabilitation process, and in a number of demonstration
projects that have been created in the past 15 years. Evidence of such
projects is summarized in a number of books and published research
reports noted in the bibliography. While these initiatives have not
solved the widespread unemployment or underemployment of people in the
four groups, there is ample evidence that these people can work if they
are provided with creative and individualized supports. Study of these
successes can help inform the process of discovering how to modify
incentives related to the Ticket.

**Roundtable Recommendation 8:** The Social Security Administration
should study the successes of supported employment programs,
Rehabilitation Services Administration Choice projects, and other
demonstration projects of the past decade for members of these four
groups.

Other Methods to Identify Members of the Four Groups

Summary of Comment

Public comment supported the concern about administrative data and the
planned phone surveys as a way to gather information from members of the
target groups. Comment included an emphasis on the need to consult other
databases that may be from States, regions, or national samples of
persons likely to be members of the four groups.

Discussion

There is concern that administrative data will not be adequate to locate
members of the four groups. As a result, commenters and the Experts
Roundtable emphasized the need to use other databases to find people in
the four groups in order to gather information about their participation
and about ways to modify the incentives of the Ticket. Owing to the
heterogeneity of the population with disabilities, large samples and
information specifically needed to analyze key subgroups would be
especially useful.

**Roundtable Recommendation 9:** The Social Security Administration
should consult other databases to identify members of the four groups.
Such databases should include other existing national samples as well as
State databases for persons with developmental disabilities, persons
with mental illness, persons with deafness and blindness, persons with
brain injuries, and persons with other disabilities.

Individualized Milestone Payments

Summary of Comment

Public comment and the Experts Roundtable cited the recent experiences
in Massachusetts, Oklahoma, and other States with creating milestone
payments in the interest of employment for people with disabilities and
including members of the four groups.

Discussion

Results-based funding and milestone payment systems are emerging in at
least a dozen States across the country (e.g., Massachusetts and
Oklahoma) in the interest of increasing employment for people with
significant disabilities, some of whom are members of the four groups.
These experiences can provide information about effective means of
funding providers of services to create employment outcomes. They can
also provide a framework for creating demonstration projects that make
use of emerging payment mechanisms in combination with best practices
for employment programs.

**Roundtable Recommendation 10:** The Social Security Administration
should study the current and recent experiences of States that have
begun using results-based funding or some form of payment for
individualized milestones toward employment.

**Roundtable Recommendation 11:** The Social Security Administration
should conduct or commission cost/benefit analyses and create
demonstration projects on modifying the incentives to Employment
Networks and providers of services, showing how members of the four
groups can benefit from the Ticket and from employment that partially
reduces benefits.

Various and Diverse Populations

Summary of Comment

Input related to diversity issues included the need for attention to the
unique differences of minorities related to gaining access to
employment. Concern was also expressed about regional differences
nationwide and about Native American people.

Discussion

Because of the diversity in the country, it will be important to ensure
that the study design is sensitive to a range of diversity issues.
National demographics should be considered in the design and
implementation of the study, with particular attention to rural and
urban settings, minority representation, and emerging economic issues.

**Roundtable Recommendation 12:** The Social Security Administration
should ensure that the data collected include attention to national
demographics such as rural and urban settings, minority representation,
and socioeconomic conditions across the country.

Including Consumers, Family Members, and/or Their Representatives in the
Study Design and Implementation

Summary of Comment

Input related to participation in the study design process noted the
need for people with disabilities and families to be included. Others
commented that research methodology used should be accessible and not
limit participation.

Discussion

Because participation or nonparticipation in the Ticket Program will
profoundly affect people with disabilities and their families, as well
as the overall success of the program, it is important that they clearly
be a part of the process for design, implementation, and ongoing
tracking of the Adequacy of Incentives evaluation.

**Roundtable Recommendation 13:** Given the impact of this and other
studies the Office of Policy conducts on the lives of people with
disabilities and their families, the Office of Policy should develop a
policy and practice for incorporating the input and experiences of
consumers, their families, and/or their representatives as it develops
new research designs, including the Adequacy of Incentives Study.

Including Employment Networks in the Study Design and Implementation

Summary of Comment

Input regarding the role of Employment Networks and providers emphasized
the need for the incentives to be clearly adequate from a financial
standpoint for both large and small providers. Commenters noted that the
Ticket payment schedule might be too far in the future for providers to
believe the incentive will be adequate. There was also some concern
about the possibility that Employment Networks would experience an
excessive reporting burden if they were not told in advance---before
being contracted---about the extent of information needed. It was
further suggested that Social Security Administration consider random
sampling of Employment Networks to obtain this information and consider
providing a financial incentive for participation in gathering this
information.

Discussion

As tickets are released and Employment Networks begin service to
beneficiaries, it is critical to ensure that a stream of information and
data is steadily collected and analyzed relative to how Employment
Networks serve beneficiaries in these four categories. To do this
effectively, the Social Security Administration should identify up front
what specific data need to be collected, to enable ENs to incorporate
the data collection into their database design. To further facilitate
accurate and timely collection, SSA should consider asking for the data
from a representative sample of ENs rather than from all ENs and should
pay a reasonable fee to participating ENs to cover the cost of the
administrative burden. In addition to collecting data on those served by
an EN, data should be collected on those whose tickets the EN did not
accept. It is expected that some ENs will reject tickets on the basis of
the perception, real or imagined, that people in the four targeted
groups will ultimately cost more to serve than is available in the
outcome/milestone payment program. Surveys and focus groups could be
used to garner recommendations from ENs as to what they believe
sufficient incentives to be. Incentives could be measured in terms of
time, money, and difficulty (e.g., availability of certain services in
rural areas, coordination with the One-Stop Career Centers for job
skills training funds, cooperation with the State vocational
rehabilitation agency). Social Security should compare data among ENs to
determine whether or not there is consistency among and between ENs in
terms of whether they accept tickets, costs they claim to incur for
various services, and perceived difficulty in serving consumers in the
four targeted groups.

**Roundtable Recommendation 14:** The Social Security Administration
should gather data related to the costs to Employment Networks and
providers of services and the timeframes for providing access to the
Ticket and employment for members of these four groups.

**Roundtable Recommendation 15:** The Social Security Administration
should study the relationship between perceived disincentives and actual
incentives for Employment Networks and providers of services, including
incentives for small providers of services.

[]{#__RefHeading___Toc7266727 .anchor}Summary

This Advice Report provides a framework for recommendations related to
the design of the Adequacy of Incentives Study. This guidance is
intended to enhance and supplement, not supplant, the overall design
proposed by the Social Security Administration in order to understand
the impact of the Ticket Program for members of the four noted groups
and to determine how incentives can be modified to promote access to
employment services and supports for all beneficiaries of Social
Security Administration disability benefit programs.

[]{#__RefHeading___Toc7266728 .anchor}

APPENDIX 1:

TICKET TO WORK AND WORK INCENTIVES ADVISORY PANEL

Sarah Wiggins Mitchell, R.N., M.S.W., J.D., Chair\
President and Executive Director\
New Jersey Protection and Advocacy, Inc.

Richard V. Burkhauser, Ph.D.\
Professor of Policy Analysis\
Chair, Department of Policy Analysis and Management\
Cornell University\
Ithaca, NY

Kristen E. Flaten, M. Div.\
Employment Consultant\
Lifetrack Resources\
St. Paul, MN

Thomas P. Golden, M.S., C.R.C.\
Extension Faculty\
Program on Employment and Disability\
School of Industrial and Labor Relations\
Cornell University\
Ithaca, NY

Frances Gracechild\
Executive Director\
Resources for Independent Living, Inc.\
Sacramento, CA

Christine M. Griffin, J.D.\
Executive Director\
Disability Law Center\
Boston, MA

Larry D. Henderson\
Executive Director\
Independent Resources, Inc.\
Wilmington, DE

Jerome Kleckley, M.S.W., C.S.W.\
Director\
Hospital Services\
Eastern Paralyzed Veterans Association\
Jackson Heights, NY

Stephanie Smith Lee\
Governmental Affairs\
National Down Syndrome Society**\
**Oakton, VA

Bryon R. MacDonald\
Public Policy Advocate\
World Institute on Disability\
Oakland, CA

Stephen L. Start\
President and CEO\
S.L. Start Associates\
Spokane, WA

Susan Webb\
President\
Webb Transitions, Inc.\
Phoenix, AZ

Appendix 2:

DESIGN AND EVALUATION COMMITTEE

Thomas P. Golden, M.S., C.R.C., Chair\
Extension Faculty\
Program on Employment and Disability\
School of Industrial and Labor Relations\
Cornell University\
Ithaca, NY

Richard V. Burkhauser, Ph.D.\
Professor of Policy Analysis\
Chair, Department of Policy Analysis and Management\
Cornell University\
Ithaca, NY

Kristen E. Flaten, M. Div.\
Employment Consultant\
Lifetrack Resources\
St. Paul, MN

Stephanie Smith Lee\
Governmental Affairs\
National Down Syndrome Society\
Oakton, VA

Bryon R. MacDonald\
Public Policy Advocate\
World Institute on Disability\
Oakland, CA

Susan Webb\
President\
Webb Transitions, Inc.\
Phoenix, AZ

Appendix 3:

LIST OF EXPERTS

EXPERTS ROUNDTABLE, JULY 27, 2001

Peter Blanck\
Professor of Law, Director\
Law, Health Policy and Disability Center\
University of Iowa\
Iowa City, IA

Crystal R. Blyler, Ph.D.\
Social Science Analyst\
Center for Mental Health Services\
Rockville, MD

Jane Burke, M.S.\
Research Specialist and Project Manager\
University of Illinois at Chicago\
Mental Health Services Research Program\
Chicago, IL

Claire T. GhiLoni\
Director\
Statewide Employment Services\
Massachusetts Rehabilitation Commission\
Boston, MA

Richard L. Horne, Ed.D.\
Senior Policy Advisor\
Presidential Task Force on Employment of Adults With Disabilities\
Washington, DC

William E. Kiernan, Ph.D.\
Director\
Institute for Community Inclusion\
Boston, MA

John Kregel\
Associate Director -- VCU RRTC**\
**Virginia Commonwealth University\
Richmond, VA

David Mank\
Director\
Indiana Institute on Disability\
Bloomington, IN

Constance Pledger, Ph.D.\
Project Officer\
NIDRR\
U.S. Department of Education\
Washington, DC

Ronald E. Rucker\
President and CEO\
VIA of the Lehigh Valley, Inc.\
Allentown, PA

Priscilla Sanderson\
Director\
American Indian Research and Training Center**\
**Arizona University Affiliated Program\
Institute for Human Development\
Northern Arizona University\
Flagstaff, AZ

Robert Silverstein\
Director\
Center for the Study and Advancement of Disability Policy\
Washington, DC

Sue Swenson\
Commissioner\
Administration on Developmental Disabilities\
U.S. Department of Health and Human Services\
Washington, DC

Appendix 4:

PUBLIC COMMENTERS, JULY 27, 2001

Dr. William Halleran\
U.S. Department of Education\
Washington, DC

Jim Larson\
President and CEO\
Morningside\
Olympia, WA

Susan Goodman\
Director of Governmental Relations\
National Down Syndrome Congress**\
**Oakton, VA

Jan Hoyme\
Employment Link\
Boulder, CO

Jamie Ruppman\
Director of Governmental Affairs\
TASH**\
**Washington, DC

Joseph McNulty\
Director\
Helen Keller National Center\
New York, NY

Appendix 5:

INDIVIDUALS PROVIDING PUBLIC COMMENT IN WRITING

FOLLOWING JULY 27, 2001

Barbara Carroll\
The Arc of Tuscaloosa County

Brenda D. Carson\
United Cerebral Palsy of Greater Birmingham, Inc.

Sue Gunn\
Region VII Community Rehabilitation Regional Continuing Education
Program

David L. Horne\
Oklahoma Association for Persons in Supported Employment

Diane Kaatz\
Wildwood Programs

Ed Kaler\
Mid-Coast Mental Health Center

Robert A. Lawhead\
Boulder, CO

Debra Martin Luecking\
University of Tennessee

Brenda McComb\
Alabama Department of Mental Health and Mental Retardation

Celane McWhorter\
Association for Persons in Supported Employment

Paul Mendez\
National Association of Workforce Development Professionals

Leslie K. Paull\
Ohio Developmental Disabilities Planning Council

Susan Rinne\
Options for Better Living, Inc.

Carol Rydell\
Advocate

Steve Savage\
Indiana Association for Persons in Supported Employment

Yvonne Swanson\
Human Technologies Corporation

Peggy Todd\
University of Missouri at Columbia

Appendix 6:

STAFF, JULY 27, 2001

Social Security Administration Staff

Steve Fear

Minh Huynh

Howard Iams

Deborah Morrison

Paul O'Leary

Advisory Panel Staff

Marie Strahan, Executive Director

Gordon Richmond

Theda Zawaiza

Ilene Zeitzer

Appendix 7:

PRESENTERS, JULY 27, 2001

Jane Burke, M.S.\
Research Specialist and Project Manager\
University of Illinois at Chicago Mental Health Services Research
Program\
Chicago, IL

Gina Livermore\
Research Associate\
Cornell Center for Policy Research\
Washington, DC

Paul O'Leary\
Project Director\
Office of Policy\
Social Security Administration\
Washington, DC

Priscilla Sanderson\
Director\
American Indian Rehabilitation Research and Training Center\
Arizona University Affiliated Program\
Institute for Human Development\
Northern Arizona University\
Flagstaff, AZ

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