Early Participation Patterns
During the 19 months since TTW began its rollout, SSA has mailed Tickets to more than 5 million beneficiaries. While only a tiny portion—less than 1 percent—of those beneficiaries has participated, the participation rate has been steadily increasing. In addition, participation rates among some Phase 1 subgroups and states exceed 1 percent and are as high as 2 percent. Thus, the participation patterns observed thus far leave room for cautious optimism. They suggest that, despite administrative start-up problems and the difficulty in recruiting providers, participation is slowly increasing and that rates might increase further if SSA can identify and replicate the factors that account for higher enrollments in some states and among some subgroups.
At the same time, it is clear that, while TTW has expanded beneficiaries’ choice of providers, most of the participation has been with SVRAs using the traditional payment system. Only 16 percent of Tickets are being used under the two new payment systems. The pattern suggests that TTW does not yet represent a dramatic break from the past. Instead, its progress so far represents the introduction of new choices and incentives whose ultimate effect will depend on the eventual level of participation and the extent to which ENs and SVRAs offer newer and more effective services.
This chapter presents early participation statistics on the dynamics of the rollout from its February 2002 start through August 2003, the last date for which data were available for the current analysis. We examine the number of eligible beneficiaries who have been sent Tickets, the share of such beneficiaries whose Tickets are in use (i.e., the "participation rate"), in-use Tickets by payment type and provider type, first-time assignments, and Ticket deactivations. We then consider the characteristics of eligible beneficiaries and examine how participation rates vary with those characteristics. We also consider how provider and payment type vary with the characteristics of beneficiaries with Tickets in use. We conclude the chapter with a synopsis of the findings. Appendix A presents tables that support the figures presented in this chapter.
A. ROLLOUT STATISTICS
1. Ticket Mailings and Eligible Beneficiaries with Tickets
SSA started to mail Tickets to beneficiaries in Phase 1 states as of February 2002, with the Phase 2 mailings starting in November 2002 (Figure IV.1). SSA staggered the mailings in both phases to avoid overloading the program manager and providers (see Chapter III, Section B). Most Tickets sent to beneficiaries in Phase 1 states were mailed during four months between February and June 2002. After that, mailings went to beneficiaries in New York (whose Ticket rollout activities were delayed) and to newly eligible beneficiaries. SSA staggered the Phase 2 mailings even more than the Phase 1 mailings because of the difficulties experienced by providers and others in Phase 1 states in handling the large number of beneficiary inquiries generated by the mailings. The initial Phase 2 mailings concluded in September 2003; mailings since then go to newly eligible beneficiaries.
The number of eligible beneficiaries who have tickets has increased over time, reflecting the cumulative number of Tickets mailed (Figure IV.2). Because of Ticket terminations, the number of eligible beneficiaries with Tickets in any given month is somewhat below the cumulative number of Tickets mailed. Tickets are terminated for those beneficiaries who leave the rolls for a reason other than work, typically because of death or conversion to retirement but sometimes because of medical, income, or compliance reasons. As of August 2003, 5.1 million eligible beneficiaries had been mailed Tickets--2.7 million in Phase 1 states and 2.4 million in Phase 2 states.
2. Participation Rate
As of the end of August 2003, about 19,600 beneficiaries in Phase 1 states were using Tickets (i.e., had assigned a Ticket to a provider and had not subsequently withdrawn it). An additional 6,500 beneficiaries were using Tickets in Phase 2 states. These numbers are small relative to the 5.1 million eligible beneficiaries with Tickets as of August 2003. The participation rate (percent of eligible beneficiaries with Tickets in use) was 0.74 percent in Phase 1 states and 0.27 percent in Phase 2 states (Figure IV.3).
After some initial ups and downs that reflect the rapidly growing number of Tickets mailed, the participation rate has increased steadily among beneficiaries in both Phase 1 and Phase 2 states. The rate in Phase 2 states is much lower but appears to reflect the more recent rollout of Tickets in those states. The August 2003 participation rate in the Phase 2 states is similar to the participation rate in the Phase 1 states in June and July 2002, when the initial Phase 1 mailings were nearing completion. Growth in the participation rate in Phase 1 states has continued steadily from the end of the initial mailings through August 2003. We would expect the experience in the Phase 2 states to be similar over the next 12 months.
3. Payment and Provider Type
A large majority of in-use Tickets are assigned to SVRAs under the traditional payment system. In August 2003, the share of in-use Tickets assigned under that system was 87 percent in Phase 1 states and 75 percent in Phase 2 states (Figure IV.4). This share has been rising for two reasons. First, we know from interviews of SVRA staff that it took some months for the agencies to obtain Ticket assignments from existing clients after they had received their Tickets. As a result, the number of Tickets in use under the traditional payment system in the early months of rollout likely understates the number of beneficiaries receiving services from SVRAs under that system. Second, evidence from the site visits and from statistics on new assignments and withdrawals indicates that ENs, as a group, are reducing the number of Tickets they are willing to accept.
Although Tickets are considerably less likely to be assigned under the outcome-only system than under the milestone-outcome system, evidence through August 2003 indicates that use of the outcome-only system is now growing relative to use of the milestone-outcome system (Figure IV.5). In fact, it appears that in Phase I states, the number of Tickets in use under the milestone-outcome system essentially stopped growing early in 2003 while the number under the outcome-only system continued its slow growth. Further, in Phase 2 states, the outcome-only system was used relatively more frequently than at the same point in the Phase 1 rollout. For Phase 2 states, 23 percent of all Tickets in use under either of the two new systems as of August 2003 were assigned under outcome-only versus 15 percent for Phase 1 states in November 2002, the comparable month in the Phase 1 rollout. As the evaluation continues, we will evaluate possible reasons for these differences.
Growth in the percentage of Tickets assigned to SVRAs (Figure IV.6) reflects growth in the percentage assigned under the traditional payment system (Figure IV.4). The percentage of in-use Tickets assigned to SVRAs is higher than the percentage assigned under the traditional payment system because SVRAs assigned some, albeit relatively few, Tickets under the two new EN payment systems. In August 2003, 91 percent of in-use Tickets were assigned to SVRAs in Phase 1 states and 81 percent in Phase 2 states.
Of all Tickets assigned to SVRAs in Phase 1 states at the end of August 2003, only 3.9 percent were under the milestone-outcome payment system and only 0.6 percent under outcome-only system. SVRAs in Phase 2 states had a larger share of Tickets in use under each of the new payments systems in the same month: 6.1 percent under milestone-outcomes and 2.8 percent under outcomes only. The difference is not a reflection of the later rollout in Phase 2 states; in November 2002, the comparable month of the Phase 1 rollout, 4.1 percent of in-use Tickets in Phase 1 states were under milestone-outcomes and 0.8 percent under outcomes only (see Appendix Table A.2).
4. First Assignments and DeactivationsThe above statistics focus on the number of Tickets that are in use during each month, but it is also important to look at the flow of Tickets into and out of in-use status. Specifically, we examine the number of Tickets that are first assigned in a given month and the net number deactivated. Almost all first assignments represent the first time that an individual beneficiary has placed a Ticket in use; the only exceptions are for the very small number of individuals who are assigning their second or third Ticket. Deactivations represent in-use Tickets that are unassigned or terminated for any reason, net of a small number of reassignments.
The evidence indicates that the number of in-use Tickets in Phase 1 states continues to grow on the strength of first assignments and the relatively small number of deactivations (Figure IV.7). In both Phase 1 and Phase 2 states, first assignments initially followed the pattern of mailings after a lag. In the Phase 1 states, new assignments dropped off to about 650 per month after completion of the initial rollout mailings (November 2002) but then picked up again in spring and summer 2003, reaching over 1,300 in May 2003. By August 2003, first assignments were down again but still above the low of 650. The data for the months after completion of the initial Phase 2 rollout mailing (November 2003) are not yet available. Net deactivations in the Phase 1 states were initially very low, grew to a peak of about 150 in March 2003, and then declined to under 70. One caution is in order, however: due to lags in the reporting process, some first assignments and deactivations in the most recent months might not have been reported or entered into the administrative files at the time we obtained the data for this report (October 2003). The declining numbers in June through August 2003 could thus be an artifact of the data system rather than a true downward trend.
To a large extent, the general characteristics of beneficiaries who are eligible for TTW resemble those of the overall beneficiary population. This similarity is due to the fact that more than 95 percent of beneficiaries are eligible so that the eligible and total populations are almost the same. The TTW participation rate varies substantially with the characteristics of eligible beneficiaries. In the Phase 1 states, rates are as high as two percent for some large groups, and well below the overall figure of 0.7 percent for others. An important issue for the evaluation will be to understand these differences and assess whether they indicate ways in which overall participation rates can be increased.
1. Characteristics of Eligible Beneficiaries
Characteristics of eligible beneficiaries in Phase 1 and 2 states are remarkably similar.2 In both state groups:
- A large majority of eligible beneficiaries receive DI. About 58 percent of beneficiaries are DI-only, another 11 percent are concurrent, and the remaining 31 percent are SSI-only.
- Eligible beneficiaries are almost evenly split between the sexes.
- Over half of eligible beneficiaries are age 50 or older, and only 22 percent are under age 40.
- Almost 40 percent of eligible beneficiaries have been receiving benefits for 10 or more years, and only 11 percent have been receiving benefits for 2 or fewer years.
- SSA lists a psychiatric disorder as the primary impairment for about one-quarter of eligible beneficiaries (27 percent in Phase 1, 23 percent in Phase 2). Musculoskeletal impairment is listed for another 17 percent in both phases, and mental retardation is listed for over 10 percent (11 in Phase 1 and 14 in Phase 2). SSA lists fewer than 10 percent of eligible beneficiaries as being in each of the remaining impairment categories.
One measurable way in which beneficiaries in the two Phases differ is in their preference for receiving notices from SSA in Spanish. Just 1 percent of beneficiaries in Phase 2 states prefer Spanish to English versus 4 percent in the Phase 1 states. This difference reflects the inclusion of Florida and New York in Phase 1 and the absence of any state with a comparably large Hispanic population in Phase 2.
2. Variation in Participation Rates
To understand the factors that drive participation, we estimated participation rates for several subgroups of Phase 1 participants. We focus on Phase 1 states because the states’ earlier rollout has given beneficiaries a longer chance to participate. The subgroups are defined by beneficiaries’ characteristics (including demographics and primary disabling conditions) and by their state of residence. Readers are cautioned that these simple cross-tabulations may mask the true determinants of participation because of covariation among characteristics. In a subsequent report, we will use more sophisticated analysis methods to study the relationships between participation and individual characteristics, holding other characteristics constant.
The most interesting finding from this analysis is that a few major subgroups participate at rates substantially higher or lower than the overall 0.7 percent rate. For example, young beneficiaries participate at higher rates than older beneficiaries. Those in the youngest age group (ages 18 to 24) have a participation rate of 2 percent in the Phase 1 states (Figure IV.8); however, the participation rate declines steadily with age and is only 0.1 percent for those ages 60 to 64. In fact, for the 53 percent of eligible beneficiaries who are over age 50, the participation rate is only 0.3 percent. As a result, while only 22 percent of eligible beneficiaries are under age 40, 45 percent of TTW participants fall in that age group.
We also found that the participation rate is much higher than average in some Phase 1 states and much lower in others—ranging from 0.3 percent in Florida, Oregon, and Massachusetts to 1.9 percent in Delaware (Figure IV.9). Interestingly, a few Phase 2 states already have participation rates that exceed those of some Phase 1 states, most notably South Dakota (1.2 percent). As the evaluation progresses, we will investigate why variation across states is so substantial. We have found that SVRAs differed greatly in their responses to the introduction of TTW, and it seems likely that such variation has contributed to differences in participation rates. It might also be that SVRAs varied substantially in the extent to which they served beneficiaries before TTW. In addition, it is likely that the explanation for variation in participation rates involves variation in significant other factors, such as the characteristics of beneficiaries, state policies and programs (including whether the state has a Medicaid buy-in program for people with disabilities), a state’s economy, the socioeconomic status of the state’s residents, and the state’s culture.
We also observed substantial variation in participation rates related to the primary impairment category that SSA records during the disability determination process (Figure IV.10). The category with the highest participation rate in Phase 1 states is severe hearing impairments (4.4 percent), but that group includes just 0.9 percent of eligible beneficiaries in those states. Impairment groups accounting for at least 5 percent of eligible beneficiaries and higher-than-average participation rates include those with primary impairments related to the nervous system, schizophrenia/psychoses/neuroses, major affective disorders, and mental retardation. Groups with at least 5 percent of eligible beneficiaries and lower-than-average participation rates include those with a primary impairment related to the musculoskeletal system and the circulatory system.
Participation rates increase with the length of time a beneficiary has been on the DI or SSI rolls until he or she reaches 24 months on the rolls. After that point, participation rates are relatively constant through month 120 (10 years) and then decline somewhat for those who have been on the rolls for longer (Figure IV.11). The figures suggest that many beneficiaries pass through a lengthy period in which they are adjusting to their new status as a beneficiary and, in many cases, their new medical condition before they are ready to attempt work. The figures could also point to new beneficiaries’ insecurity over benefits, as many will have spent months convincing SSA that they cannot work. Some DI beneficiaries might wait until they obtain Medicare benefits, which start only after beneficiaries have received cash benefits for 24 months.
The experience of the program through 18 months shows that the longer a beneficiary has a Ticket, the more likely that he or she will use it (Figure IV.12) up to some point. Over the first 10 months, the experience in Phase 2 states is similar to that in Phase 1 states, reinforcing a point made earlier: participation growth in Phase 2 states seems on track to approximate the experience in Phase 1 states. In the Phase 1 states, the rate in months 10 through 12 is actually higher than in months 13 through 15, although lower than in months 16 through 18. This pattern appears to be attributable, at least in part, to the pattern of TTW rollout in Phase 1 states. In particular, the vast majority of beneficiaries who have had their Tickets from 10 to 12 months in the Phase 1 states reside in New York, which experienced slower rollout; therefore, perhaps the figure for that period represents relatively high participation in that state.
Finally, we observed three other particularly interesting participation patterns in the Phase 1 states:
- The 4 percent of eligible beneficiaries that asked SSA to send them notices in Spanish participate at a substantially lower rate (0.2 percent) than the 95 percent of beneficiaries mailed notices in English (0.8 percent) in the Phase 1 states. This finding suggests that language is a barrier to participation for some, although it could also be related to the relatively low participation rate for all eligible beneficiaries in Florida.
- Concurrent beneficiaries participate at a rate that is higher than the rates for either SSI-only or DI-only beneficiaries. This finding could be related to the different incentives that beneficiaries and providers face but might also reflect variation in other characteristics across these groups, especially age.3
- Male and female beneficiaries have nearly identical participation rates.
3. Variation in Provider and Payment Type
For beneficiaries using Tickets in the Phase 1 states, both provider type and payment type vary substantially by state and by age. We did not find notable relationships between these variables and other characteristics.4
The percentage of in-use Tickets assigned to SVRAs varies from virtually 100 percent in Vermont to 55 percent in Arizona, with only three states exhibiting values less than 80 percent (Figure IV.13). The percentage of Tickets assigned under the traditional VR payment system follows a similar pattern, but there are a few exceptions because some SVRAs made more use of the new payment systems than others. Notably, while Vermont, Oklahoma, and Delaware rank first, second, and third in terms of percent of Tickets assigned to the SVRA, they also rank fourth, first, and seventh, respectively, for the percent assigned to one of the new payment systems. Only seven states have a substantial share of Tickets assigned under outcome-only payments; Vermont has the largest share, 27 percent, with only one other state having more than 10 percent (Oregon at 15 percent). We suspect that the variation is related to the same complex mix of factors that determine cross-state variation in participation rates, particularly the actions taken by SVRAs.
The likelihood that a Ticket is assigned to an EN increases with beneficiary age (Figure IV.14). Similarly, the likelihood that a Ticket is assigned under each of the new payment systems increases with age.
C. SYNOPSIS OF PARTICIPATION FINDINGS
As of August 2003, 5.1 million Ticket-eligible beneficiaries have been mailed Tickets in the Phase 1 and 2 states. The most interesting statistics on participation come from Phase 1 states, where the initial rollout mailings concluded in October 2002. Only 0.7 percent of eligible beneficiaries in those states were using their Tickets in August 2003, although the participation rate has been increasing steadily. Further, the vast majority (86 percent) of those assignments was to SVRAs under the traditional payment system. In addition, the number of Tickets assigned to SVRAs continues to increase in the Phase 1 states while the number assigned to ENs has leveled off. Of the two new payment systems, most Tickets are assigned under the milestone-outcome system rather than the outcome-only system.
There is a strong negative relationship between participation rates and age, with those in the youngest age group participating at a 2 percent rate and those in the oldest age group at a rate of 0.1 percent. Although they represent only 22 percent of eligible beneficiaries, 45 percent of Ticket participants are under age 40. We also found that provider and payment type vary with participant age; the percentages assigning their Tickets to an EN and using each of the new payment systems increase with age.
Participation rates also vary widely among Phase 1 states, from a low of 0.3 percent in three states to a high of 1.9 percent in one. A few Phase 2 states already have participation rates in excess of those in some Phase 1 states. Provider and payment type also vary widely across the Phase 1 states. The percentage of in-use Tickets assigned to SVRAs varies from virtually 100 percent to 55 percent, and the percentage assigned under the traditional payment system varies from 95 to 52 percent. A few states with particularly large shares of in-use Tickets assigned to SVRAs also have relatively large shares assigned to one of the new payment types, reflecting heavy use of one of the new payment types by each of the SVRAs in those states.
We also found that participation rates increase sharply with the number of months a beneficiary has been receiving disability benefits up to four years. Among impairment groups that constitute at least 5 percent of eligible beneficiaries, participation rates are relatively high for the groups with schizophrenia/psychoses/neuroses (1.1 percent), major affective disorders (0.9 percent), mental retardation (0.9 percent), and nervous system disorders (0.9 percent) and relatively low for musculoskeletal system (0.4 percent) and circulatory system (0.3 percent) disorders. One smaller impairment group, severe hearing disorders, has a participation rate that is much higher than any other (4.4 percent).
As mentioned in the introduction, subsequent reports will analyze these patterns in more detail, particularly the extent to which specific characteristics influence participation after controlling for the effects of other characteristics. We will also pay close attention to factors that explain why participation rates vary among states and whether those states provide lessons for increasing future participation.
1Back-up tables for the figures in this section appear in Appendix A, Tables A.8 through A.14. Return to text.
2All statistics pertain to beneficiaries eligible for at least one day during August 2003. Return to text.
3 Ticket payments are higher for both DI-only and concurrent beneficiaries than for SSI-only beneficiaries, and the value of payments relative to benefits is higher for concurrent beneficiaries than for DI-only beneficiaries. At an earlier stage of the rollout, an analysis of participation by title showed that, after controlling for age and other characteristics, concurrent and DI-only beneficiaries participate at the same rate, and both participate at a higher rate than SSI-only beneficiaries (Livermore et al. 2003; Appendix E). Return to text.
4 In assessing whether a relationship was noteworthy, we considered both the extent of variation in the two variables and the number of in-use Tickets in the relevant groups. The latter is small in many instances. For instance, we found that 20 percent of beneficiaries with digestive disorders used ENs compared with just 9 percent overall. Though this percentage is very high relative to values for other groups, those with digestive disorders represent only 0.7 percent of all beneficiaries with Tickets in use. Return to text.