Cost-benefit analyses of employment services for individuals with intellectual and developmental disabilities: A scoping review

1.1Economics of employment services

Cost analyses have been used for several decades as a method of summarizing the benefit of expenditure at achieving employment for individuals with disabilities (Cimera, 2000). In a literature review of research on supported employment programs from 1980–2000, Cimera (2000) found that cost-benefit analyses were conducted from both workers’ and taxpayers’ perspectives, with many presenting analyses from both perspectives. From worker’s perspectives, a majority of reviewed studies found that the financial benefits received by supported employees exceeded their cost, more than offset government subsidized benefits, and reported greater earnings than sheltered workshops (Cimera, 2000). Findings from a taxpayer perspective were more complex, with studies showing mixed results for the cost-benefit of supported employment in the short-term, but increasing in efficiency over time (Cimera, 2000). Cimera (2000) also found that supported employment, especially when using individual placements, was cost-efficient from both the worker and taxpayer perspectives.

More recent studies in cost-benefit of employment services for individuals with IDD have largely examined the macroeconomic impact by identifying overall trends by aggregating individuals nationally (e.g., Whittenburg et al., 2019) or by state (e.g., Bur-gess & Cimera, 2014). However, to date there have been no reviews conducted more broadly to examine the cost-efficiency of employment services for individuals with IDD beyond supported employment itself. Given the adoption of customized employment in recent policy (i.e., WIOA, 2014), increased emphasis on services for transition-age youth, and persistent use of sheltered workshops (Winsor et al., 2019), it is important to examine the cost-efficiency of employment services from a broader lens. Therefore, we approached the complex issue of cost-efficiency of services to promote CIE for individuals with IDD from two directions; macro- and microeconomic views.

Macroeconomic analyses, such as those used in previous reviews of cost-benefit literature provide important insights into the general efficiency of services relative to overall cost. The macroeconomic lens is necessary to evaluate the impact of different types of service delivery models (e.g., sheltered workshop or other segregated pre-vocational service versus integrated models such as supported employment) and examine benefits to various stakeholders, including the cost-benefit to service recipients, cost-benefit to taxpayers, and cost-benefit comparisons across types of employment service delivery models that lead to CIE outcomes. However, these macroeconomic analyses may gloss over salient details about the component pieces of employment services that lead to their ultimate success. Thus, it is also necessary to evaluate the microeconomics of individual vocational services and their impact on CIE. Microeconomic analysis considers factors such as the duration, intensity or installation of follow-up supports on CIE outcomes.

1.2Purpose of review

The purpose of this scoping review was to analyze and synthesize micro and macroeconomic analyses of various types of vocational services which promote the employment of individuals with IDD. Therefore, a dual-pronged approach to reviewing the literature was utilized—those related to macroeconomic analysis of the overall provision of services as well as microeconomic analyses of the specific type, duration, and intensity of vocational services provided to individuals. Information included in the review allowed for economic cost-benefit analyses to be considered from the perspective of different stakeholders (e.g., people with IDD and taxpayers). The following research questions were developed to guide the review;

2.1Inclusion and exclusion criteria

Articles eligible for inclusion were: a) empirical studies (e.g., quantitative and qualitative); b) focused on services provided in the United States; c) focused on youth and adults with IDD; d) examined some type of cost-benefit analysis of vocational services or their type, duration, or intensity; and e) investigated the impact on employment outcomes, including wages, hours, job retention, and employer benefits. Studies examining any type of analysis of cost-benefit were included regardless of methodology. Excluded articles focused on international contexts outside the U.S., conceptual papers, literature reviews, and those studies that were non-specific to individuals with IDD. While several studies have been conducted outside the U.S. which provide compelling analyses of cost-benefit in various international contexts, these were excluded so as to maintain a focus on evidence specific to the implementation of disability employment services in the U.S.

4.1Macro-analytic findings

Macro-economic studies included in the review revealed several important findings related to the provision of employment services to individuals with IDD. The first major finding is that supported employment proved to be more cost-beneficial than sheltered workshop services (Cimera, 2007; 2011; 2012). Furthermore, community-based services as a whole led to higher cost-effectiveness than sheltered workshops, specifically for individuals with ASD (Cimera & Burgess, 2011; Spreat et al., 2005). Additionally, not only is supported employment more cost-effective, but two studies indicated that training provided by sheltered workshops prior to CIE provided no cost-benefit (Cimera, 2011; 2012). In fact, individuals who had previously worked in sheltered workshops had worse employment outcomes than those who had no previous history of pre-tra-ining (Cimera, 2011; Cimera et al., 2012), thus soundly rejecting any possibility that sheltered workshops provide any pre-vocational benefit. In contrast, individuals who had previously received supported employment services and were placed in a new position were more cost-efficient than those who had no previous experience (Cimera, 2012). While supported employment was shown to be cost-effective across several studies, use of natural supports had no additional effect on cost-efficiency, underscoring the importance of well-trained employment specialists to the supported employment process (Cimera, 2001).

The second major finding from the macroeconomic literature relates to overall costs to serve individuals with IDD over time. Burgess and Cimera (2014) found that while wages earned by VR service recipients remained relatively flat over time, so did the costs to serve that group. Other literature pointed to an increase in cost-efficiency over time, finding that costs related to supported employment decreased over time (Cimera, 2007) and that this reduction in cost for supported employment was in contrast to static costs for sheltered workshops (Cimera, 2008).

Other emergent themes from the literature related to a diagnosis-specific focus of studies. Several studies reported findings specific to individuals with ASD (n = 12). Since 2000, the number of individuals with ASD receiving VR services increased subs-tantially—doubling between 2002 and 2006—and becoming employed at the third highest rate of any disability category by the end of the decade (Cimera & Cowan, 2009). However, despite these gains in overall rates of employment, individuals with ASD continued to earn less and work fewer hours than their peers with other types of disabilities (Cimera & Cowan, 2009). Furthermore, these wages and hours did not increase over time (Burgess & Cimera, 2014), even as the cost of VR services for those with ASD declined initially (Cimera & Cowan, 2009) and then remained steady (Burgess & Cimera, 2014).

Despite this overall lack of progress over the last two decades for individuals with ASD in terms of wages and hours, specific findings related to pathways to improved outcomes were identified. Provision of transition services for youth with ASD beginning at a younger age showed higher levels of cost-effectiveness (Cimera et al., 2013; 2014). Likewise, youth with ASD who received higher levels of education, including participation in postsecondary education were more cost-effective from a worker perspective and more cost-efficient from a taxpayer perspective in their earnings relative to VR service receipt (Whittenburg et al., 2019). This pattern of cost-effectiveness and cost-efficiency of postsecondary education was also consistent for individuals with ID.

Overall, macro-analytic findings clearly indicated that supported employment was more cost-beneficial than sheltered workshop services (Cimera, 2007; 2011; 2012), and that the cost-efficiency of supported employment increased over time (Burgess & Cimera, 2014; Cimera, 2007; 2008). Additionally, studies reviewed pointed to differential outcomes based on disability diagnosis—those with autism earned less than comparison groups. Finally, promising pathways to greater cost-efficiency were indicated based on earlier receipt of transition services and higher levels of post-secondary education (Cimera et al., 2014; 2013; Whittenburg et al., 2019)

4.2Micro-analytic findings

Findings from micro-analytic research provided more granular recommendations based on the specificity of services and their context. Overall, these findings pointed to the microeconomic effectiveness of individualized approaches to CIE like Project SEARCH+ASD Supports (PS+ASD) for transition age youth (Wehman et al., 2014; 2016; 2017; 2019) and supported and customized employment with long-term supports provided for working age adults (Brooke et al., 2018; Schaller & Yang, 2005). PS+ ASD studies presented a high level of evidence (using randomized control trial designs) to show efficacy of a specific intervention model for transition age youth based around internship rotations in community-integrated business settings (Wehman et al., 2014; 2016; 2017; 2019).

The most prominent emergent theme from mi-cro-analytic findings was that PS+ASD led to significantly improved outcomes for participants with ASD in terms of job placement, wages, and hours (Wehman et al., 2014; 2016; 2017; 2019). The PS+ASD intervention consists of embedded internship supervised by trained employment specialists (ES) employing ABA techniques to promote CIE in transition age youth. PS+ASD studies resulted in high levels of en-gagement in CIE with 73.4%of the treatment group (compared with 17%of the control group) gaining CIE, with a mean hourly wage of $9.61.

The second major finding from the micro-analytic research was that those vocational services and interventions that directly engaged with individuals in community integrated settings—and continued that support through stabilization—led to more cost-ben-eficial outcomes. Schaller and Yang (2005) found that both supported and customized employment led to VR closures in more than half of the sampled cases. Whereas supported employment resulted in a higher rate of closures than customized employment, customized employment resulted in higher wages and more hours in those who successfully secured emp-loyment (Schaller & Yang, 2005). McLaren and coll-eagues (2017) added evidence supporting the in-dividual placement model specifically, showing an association with increased wages, hours, rates of CIE, connection with vocational and mental health prov-iders, and independence. Finally, Brooke and colleagues (2018) found that providing long-term supports through employment specialists to employees with ASD led to long-term job stabilization, thus reducing the need for costly re-placement of emp-loyees.

Overall, the research analyzed regarding the cost, duration, and intensity of VR-funded services pointed to several key service types and patterns shown to lead to improved outcomes. These findings from the micro-analytic research underscore the importance of community integrated services to cost-benefit outcomes, both for transition-age youth (e.g., Wehman et al., 2019) and adults (McLaren et al., 2017). Supported employment was found to be a reliable means of accomplishing stable CIE for individuals across studies (e.g., Brooke et al., 2018; Schaller & Yang, 2005). Another important factor identified within the reviewed research is the provision of individualized supports based on evidence-based practice such as those provided within the PS + ASD framework (Wehman et al., 2014; 2016; 2017; 2019). Micro-analytic results also endorse the provision of long-term supports when required by individuals to sustain employment and job stability (Brooke et al., 2018). As a whole, micro-analytic research in this area provides support for individualized, community-integrated, and evidence-based approaches (e.g., supported employment; PS + ASD) to securing and maintaining CIE for individuals with IDD.

5.1Limitations of reviewed studies

Although the reviewed research provides many important insights into the cost-benefit of various vocational services for those with IDD, there are several key limitations of the reviewed studies that should be noted. First, a majority of studies used a secondary analysis of data from the Rehabilitation Services Administration Case Service Report (RSA-911) dataset. Although RSA-911 is composed of VR administrative data, this data may exclude other non-VR employment services and outcomes that may be relevant in evaluating the overall cost-benefit for individuals with IDD. Additionally, the majority of studies included in this review did not employ any type of experimental randomization or statistical control of intervention and comparison groups. Most studies used descriptive analysis overall; thus it is difficult to infer from the research included in this review how this cost-benefit may affect various demographic groups which historically have received poorer outcomes and service patterns (Eilenberg et al., 2019; Sung et al., 2015; Thoma et al., 2016). Finally, few included studies examined longitudinal data points beyond initial engagement in employment. Those that did examine long-term supports found that the provision of long-term support services led to positive employment outcomes (Brooke et al., 2018), thus meriting further investigation.

5.2Implications for research

As a result of these findings and limitations, there is a clear need for more robust research designs that more comprehensively investigate how employment service patterns are not only working for—but also failing—job seekers with IDD. In order to create meaning to the field, research must not only describe what is being done for the 20%, but also what remains to be fulfilled for the 80%. Most significantly, while research exists showing pathways to CIE for individuals with IDD, there are glaring questions about how those pathways operate in practical terms. For example, are those pathways equally open and accessible to all individuals who seek them? What barriers and facilitators exist that may impact individuals as they seek their preferred outcomes?

In order to better understand what pathways and approaches may serve as cost-efficient means of securing preferred outcomes, there is a need to break open the ‘black box’ of VR services and investigate which pieces and parts are essential to achieving those outcomes which are still out of reach for so many individuals with IDD. In order to accomplish this, more granular component analysis of VR service patterns is needed, both in terms of researching what is working as well as what is not—not only for individuals with IDD overall but also within various demographic groups that may experience systemic barriers to employment. Finally, more methodologically rigorous research designs are needed using experimental or statistical control through participant control matching to more rigorously evaluate findings presented in this review.

5.3Implications for practice

Findings of this review point to several important implications for practice as well. As with those discussed in previous sections, the foremost recomm-endation for practice should be to engage individuals with IDD in integrated and individualized vocational services that directly promote their engagement in CIE. Additionally, this review emphasized the impo-rtance of research-based approaches which incorporated job coaching, such as supported and customized employment. Overall, the findings of our review recommend the use of highly-trained ES who are able to implement research-based approaches to employment for individuals with IDD (i.e., supported and customized employment) in integrated employment settings. While the research overwhelmingly showed high levels of cost-effectiveness for use of supported and customized employment, individual placement in CIE led to even higher levels of cost-benefit.

Apart from these more global recommendations, there are several specific recommendations that emerge from the research. As mentioned previously, sheltered workshops show no evidence of cost-benefit compared to other alternatives in promoting CIE. As a result, employment service organizations should shift service models by retraining staff to provide integrated approaches such as supported and customized employment. Those employment service practitioners should also be mindful of findings recommending the cost-effectiveness of long-term supports to stabilize employees and increase prospects for expanded roles and promotion.

5.4Implications for policy

This review has a clear policy mandate—continue and expand legislative commitment to CIE and str-engthen investment in specific policies that promote CIE, while also phasing out those services that do not provide cost-effective pathways to emp-loyment—namely sheltered workshops and other segregated vocational service providers (e.g., adult day programs). This policy goal of CIE was clearly established through WIOA (2014), in alignment with previous legislative and judicial decisions (Olmstead v. L.C., 1999). However, given the disparate nature of policy informing the employment of individuals with IDD, significant and substantial alignment of policy is needed to accomplish these goals.

First, standardized measures of cost-benefit of employment services and outcomes should be established across both governmental and service agencies such as GAO, Department of Labor (DOL), and RSA and advocacy groups such as American Association on Intellectual and Developmental (AAIDD), TASH (disability advocacy organization), Association of People Supporting Employment First (APSE). Future federal and state policy related employment even indirectly (e.g., reauthorization of the Individuals with Disabilities Act, reform of Medicaid Home and Community based waivers) must be aligned with a prioritization of CIE. For example, WIOA’s Pre-ETS provisions have incentivized VR agencies to expand collaboration with school districts and engaging more directly with transition-age youth. In order to fully realize the potential of these initiatives, K-12 policy must be aligned with these desired outcomes and incentivized to participate in these collaborative partnerships (Taylor et al., 2019).