Will New Changes Save Ticket to Work?

By E.J. Brown

The future of occupational therapy in rehabilitation is pretty certain, but the context of that treatment is going to enlarge as cost containment on a federal level continues and the profession moves toward its new brand-Living Life to Its Fullest. The element of participation with others in occupation is at the heart of this new paradigm.

Vocational occupation is a primary ADL. Yet the role of worker is often denied to those with disabilities because of their inability to get to a job, operate the equipment of the workplace and/or communicate fully with co-workers. Many people with disabilities have made their own careers despite these handicaps. Still more may be able to do so with a little more help from the system.

That was the premise when Congress passed the Ticket to Work program in 1999. The program offered beneficiaries of Supplemental Security (SSI) and Disability Income (DI) payments the opportunity to access services that would increase their ability to get and keep mainstream jobs, eventually earning their own keep.

But after six years of operation, the program has pretty much failed to meet that goal. As of September 2006, the Social Security Administration (SSA) had rolled out 12 million tickets to people across the country who qualified for them. But a federally commissioned $1.8 million study undertaken in May of that year by Mathematica Policy Research and Cornell University and completed last month shows that of 1.4 million beneficiaries-about 15 percent-who have indicated that they want to enter the workforce and support themselves, fewer than 2 percent are actually using their tickets. And of that number, more than 40 percent are not using the services to find new or better jobs, but to enhance their ability to live independently.

Occupational therapy is one of the services these people reported using most, along with counseling and obtaining adaptive equipment. But most of these people were already receiving some kind of vocational services already, through their state vocational rehab departments (SVRAs). And in fact, although Congress' intent was to motivate private providers to get into the program, very few have.

There are fewer than 1,400 Employment Networks (ENs) in operation, and as of 2004, only a third of them had taken any tickets. Ninety-one percent of people using their tickets were doing so through state-run offices.

There have been many reasons not to become involved with, or open, ENs. Private providers received little payment through the system until their clients has been working for more than six months, and in fact, there is no way to track that they are indeed working. It is up to the beneficiaries to report their earnings documentation back to their providers so that the providers can request payment. This, the report admits, makes it financially risky for any business other than one already highly solvent to even participate.

The government set up this system by reducing beneficiary payments as the recipient began to earn money, intending to use that money to pay private providers. It hasn't worked, for obvious reasons. SVRAs are already state funded and don't have to worry about financial survival.

As a result of the Mathematica report and testimony to Congress regarding the deficits of its overall approach to getting beneficiaries to exit the SSI and DI systems, the SSA announced on May 20 that it is issuing new rules for TTW:

• Individuals who are expected to medically improve will become eligible for the program.

• EN payment systems have been modified to create greater financial incentives for private providers to participate.

• The value of the ticket will be increased to offer a better combination of services.

• TTW will be better aligned with the Work Incentives Planning and Assistance Program, the Protection and Advocacy for Beneficiaries of Social Security Program and other SSA work incentive programs.

You can access the final rule and its effective date of operation on the Federal Register at www.regulations.gov. There's more information about the Ticket to Work initiatives at The Work Site at www.socialsecurity.gov/work.

ADVANCE will continue to update you on changes to this program. Put together well, it could comprise a major practice area for OT in the future.

Until reimbursement becomes more stable, however, we are not advocating that OTs get involved in a major way. We do suggest that occupational therapists make their voices heard about the content and direction of Ticket to Work to Social Security Commissioner Michael J. Astrue, Commissioner of Social Security, P.O. Box 17703, Baltimore, MD 21235-7703.

E.J. Brown is editor of ADVANCE