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The DSP Crisis: Reimbursement Rates, Retention, and Research

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

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!

Featured Research

CQL | The Council on Quality and Leadership has also produced two research studies regarding DSPs, HCBS reimbursement, and quality of life.

This article is a summary of the following journal manuscripts:

  • Friedman, C. (2018). Direct support professionals and quality of life of people with intellectual and developmental disabilities. Intellectual and developmental disabilities, 56(4), 234-250.
  • Friedman, C. (2019). State utilization of direct support professionals in Medicaid HCBS waivers. Intellectual and Developmental Disabilities, 57(1), 1-13.