Preparing for the Ticket to Work: Market Leadership - It’s Ours to Lose
Dan O’Brien and Becky Cook
Oklahoma Dept of Rehabilitation Services (VR)
History of Milestones
1987
Grants to first supported employment providers
Hourly rate payment using Title VI-C formula grant funds
1992
First pilot of milestones
1997
All contracts converted
History of Milestones
Wrong financial incentives distorted services-unintended consequences.
Sought improved outcomes while containing costs
Collaborative planning key to success
Realistic operational definitions of outcomes
Sub-divide outcomes into incremental, observable steps
Payment % tied to each milestone
Payment % weighted towards end
Overview of Concepts
Based on incentive payments for quality results
Pays for increments of predefined outcome with integrated quality indicators
Payments based on average cost per outcome
Natural consequences; faster correction
Discourage "creaming"
Pay more for difficult-to-serve
Consider drop-outs & stop-outs
Overview of Concepts
Win-Win-Win
Consumers receive quick, quality service
Vendors receive adequate compensation, less regulation and greater flexibility
Funding agency purchases outcomes, not process
Bidding
Vendors develop program budget
Estimate the numbers who can be served
Estimate the number who will complete each Milestone (project the number of dropouts)
Plug the above figures into the weighting formula to arrive at a bid
Example of Milestone Structure
Determination of Needs - 10% of Bid $ 650
Vocational Preparation - 10% of Bid $650
Job Placement - 10% of Bid $ 650
4 Weeks Job Retention - 20% of Bid $1300
Stabilization on the Job - 20% of Bid $1300
Consumer Rehabilitated - 30% of Bid $1950
Total $6500
Job Retention milestones (paid by MH) - $400/Qtr.
Example of Quality Indicators
-Stabilization on the Job
Tenure on Job - 10 weeks minimum
Job matches the career goal
Job Coach has reduced job support to maintenance level, twice per month.
Worker/Consumer Satisfaction
Employer Satisfaction
Results
Time on Waiting List - reduced 53%
Time before placement reduced 18%
Assessed but not placed reduced 25%
Time from placement to success reduced by 45%
102% increase in # consumers succeeding
95% Succeeding in first job placement
30% increase in Placements - Mass.
VR Thinking Like a Business
We have prime positioning in an $80 B Market
Analyze the Market and Competition
GROWING our business using the Ticket:
Market our services to customers - Assertive Engagement
Develop and use choice based self-screening
Develop expandable networks of sub-contractors
Collaboratively plan with Vendors and Customers
Create incentives for VR staff to serve SSA beneficiaries
Ticket to Work Basics
TWWIIA Signed into Law Dec. 1999
Enhances Work Incentives and set up vocational voucher – the Ticket to Work
National Program Manager will manage Tickets and Employment Networks - TBA
Employment Networks (EN) the direct service providers must be approved by SSA
Some EN’s pre-selected-VR, One Stops ,AP’s
Includes Milestone Payments during 1st 9 Mos.
Only VR can choose the existing reimbursement system or the Ticket payment by individual
Ticket Implementation
Fall 2000 National Program Manager
August ? –First 12-14 Ticket States Announced
Sept. 2000 – Draft Ticket Regulations for Public Comment – Insert Your Comments Here!!!!
Dec. 2000 – Final Ticket Regulations
Jan 2001 – Ticket Implemented in 12-14 States
Jan 2002 – 20 additional states
Jan 2003 – Remaining States and Territories
Ticket to Work Voucher
Voucher worth 40% of estimated savings over 5 years off benefits
$18,000+ for SSDI
$12,000+ for SSI
Milestones+outcome payments
SSI Ticket Under-funded – ave. VR SSA Claim $11,000 (1999)
VR may be the only willing Provider for SSI recipients
SSA needs program to at least break even
that point is 2-4 years off of SSA rolls
Congressional Budget Office (CBO) Ticket Payment Fantasy
CBO’s estimate of the cost of the Ticket for Congress (Senate Fin.)
Milestone Payments = $1500
6 weeks Job Retention - $500
9 months of work at SGA/ 0 Benefits - $1000
Job Retention (Outcome) Payments for 60 months
SSDI = $275/mo. if over SGA ($700), check=$0
SSI = $175 per month at $0 Benefit Level, earnings over $1108 per month
Analyzing the Market/Competition
Empl. Network Risk Management
Employment Networks must manage Deferred Payment Risk to break even under Ticket
Option 1 - Identify and Target - Low Cost Clients
Option 2 - Forward Fund - use risk assessment
Option 3 - Only accept Ticket for individuals you intend to hire - ex. NISH, Goodwill, Employers
Option 4 - Bill third party for cost of services, ex. HCB Waiver – and/or regular Medicaid - personal assistance at work or case management
Option 5 - Join a publicly financed Employment Network –VR, One Stops, MH, DD
Forming a VR Funded Network
VR Agencies are positioned as the Market Leaders
Oklahoma DRS is piloting a VR sponsored Employment Network
Potential 200% growth of Case Service Funds at 3%-4% Ticket use rate
Need a system for Choice based Screening
Okla. Social Security SPI Project
To Inform consumers, advocates and MH Staff on the value of work in recovery and use of Work Incentives
Facilitate Medicaid buy-in Oklahoma
Pilot Ticket Implementation Issues:
Response Rate including the effect of assertive engagement
Equitable provider payment rates
Facilitating Choice - Report Card
Work out methodology for a VR sponsored Employment Network
OKLA DRS Pilot Structure
VR Contracts with competing Vendors
Issue OK Ticket at Work Incentive Meeting
NRC Vendor Performance Report Card
Consumer has choice of 2 Models (Clubhouse and IPS model) & 4 Vendors
Consumer Assigns Voucher to Vendor
Enrolled by VR – 6 Milestones total=$6,500 ave.
SSA funds used for Ongoing Support Payments Total=$4800 plus up to $2400 bonus for job with medical benefits
Marketing to the SSA Beneficiary: Selling Work
Four contacts before each meeting
Two by mail and two by phone
If they can’t or don’t attend, invite to next meeting or arrange a home visit
Held at an All you can eat Buffet
Consumer Trainers and Exemplars/Role Models explain value of work as part of recovery
Consumer Trainers review SSI/SSDI work incentives
IF we provide World Class service and choice why would anyone go anywhere else?
Choice based Customer Screening
The Work Incentive Meeting is an effective, inexpensive, choice/behavior based, self screening tool
Of about 400 randomly selected MH Consumers invited to a WI meeting 30% attended and 10% engaged with a vendor
Vendors who marketed their programs as providing quick, consumer focused job placement and support got majority of Tickets
Choice Based Self Screening
We must have a system to handle a huge increase in SSA Beneficiary interest
4 Step Self Screening Process
Recruiting by advocacy organizations by mail and phone – 100% of Ticket Holders
Work Incentive Meeting to brief beneficiaries on benefits of working and Work Incentives – 20-30% of beneficiaries choose to attend
Facilitated use of the One-Stops Core Services – 10% complete
VR Application and referral to CRP under Milestone contract - 5%
From Sharecropper to Partner
Vendors will bring Tickets to VR if they are full partners paid at Market based rates
We need the Vendor
Can recruit based on longstanding relationships
We don’t have the capability to hire large numbers of Job Coach’s or Personal Assistants
We need networks that can expand rapidly
Cheaper and faster to contract out
They need VR
They don’t have risk tolerance (funding) we do
Under Ticket we can manage the risk better
We can choose by individual whether to bill under existing reimbursement system or Ticket system
Collaboratively Planning Change
Executive authorizes change and timetable
Usually 3 to 6 months with 12 month pilot
Executive sets parameters
Ex. Can’t raise costs, must incentivize outcomes, must be consumer driven
assigns staff – must assign a "change agent"
delegates planning to stakeholder cross-functional team
30-50 diverse members
1/3 customers, 1/3 vendors and 1/3 Staff
Stakeholder Group Responsibilities
Design Milestone Payment System
Develop operational definitions for outcome(s)
sub-divide into incremental steps/Milestones
develop payment % for each step/Milestone
define quality indicators for Milestone payment
Review bidding/rate setting methodology
Vendor negotiated rate or bid, or
Ave. (regional) rate based on vendor costs
Design Choice based self screening system/methodology
Website Address:
www.onenet.net/~home/milestone
Email:
deobrien@aol.com (Dan O’Brien)
or