CQL | The Council on Quality and Leadership

The DSP Crisis: Reimbursement Rates, Retention, and Research

Posted 2/27/19
By Carli Friedman | CQL Director of Research

Direct Support Professionals (DSPs) are critical for the community integration of people with intellectual and developmental disabilities (IDD). Not only are DSPs important to quality supports of millions of people in the United States, but a lack of staff can also keep people from going into and being integrated in the community. As such, DSPs are crucial to long term services and supports (LTSS) for people with IDD in the United States.

Medicaid reimbursement rates can serve as a significant gatekeeper to DSP retention. As a result, one way to better understand DSP utilization for people with IDD is through analysis of Medicaid Home and Community Based Services (HCBS) 1915(c) waivers, as they are the largest funding stream for LTSS for people with IDD. For these reasons, the aim of this study was to explore how states value the important services DSPs provide, particularly by how they prioritized DSPs’ work through projected service allocation. To do so, we analyzed Medicaid HCBS IDD waivers from across the nation (fiscal year 2015) to determine allocation of personal care services, which are typically provided by DSPs.

As our recent findings revealed, the average 15-minute personal care reimbursement rate was $4.57 per 15-minutes (equivalent to $18.26 an hour). Moreover, the average projected hourly personal care services reimbursement rate was $13.85. Reimbursement rates also varied widely by state (see figure).

Average Hourly Reimbursement Rates

Map of average hourly reimbursement rates by state

Not only were reimbursement rates for services provided by DSPs close to the federal minimum wage ($7.25), and below or near the poverty line for families of two or more, it is important to note that these reimbursement rates also must account for the other costs involved in agencies providing services, such as overhead – these rates are not all going directly to DSP salaries, but rather DSPs’ salaries represent only a fraction of these rates. For example, according to the Bureau of Labor Statistics (2017) as of May 2017 the national average wage for personal care workers was $11.59. These trends are problematic as research has indicated that low wages are one of the leading causes of DSP turnover.

Despite DSPs being central to promoting the quality of life of people with IDD, our findings revealed little standardization of personal care services in Medicaid HCBS waivers, including near minimum wage reimbursement rates for DSPs providing personal care services. People with IDD, providers, and allies can utilize the information in this study, as well as a plethora of existing research, to advocate for prioritization of DSP workforce issues. As DSPs are critical for community integration and quality of life, attention to DSP workforce issues will not only improve the lives of DSPs, but people with IDD as well!


Resources To Raise Awareness

CQL | The Council on Quality and Leadership has produced the following research and policy briefs to assist you draw attention to DSP workforce issues as well as advocate for changes. These can be useful in communication with various stakeholders, including policy makers, industry leadership, provider agencies, people receiving supports, families, and more.


The Value of Direct Support Professionals for People with Disabilities


The Value of Direct Support Professionals for People with Disabilities

Learn about the importance of DSPs in improving quality of life for people with disabilities and the crisis that DSPs face. Download>>



DSP Turnover: The Harmful Impact on People with Disabilities


DSP Turnover: The Harmful Impact on People with Disabilities

Find out how the high turnover rate of DSPs negatively affects quality of life for people with disabilities. Download>>



DSP Turnover: Who is most at risk?


DSP Turnover: Who Is Most At Risk?

Explore the factors that increase the likelihood that people with disabilities would experience DSP turnover. Download>>






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