Cross-Subsidization in Nursing Homes: Explaining Rate Differentials among Payer Types

Are Medicaid patients being subsidized by other residents in nursing homes? This article employs cross-sectional data on nursing homes and residents in a multiproduct empirical cost analysis to obtain the benchmark magnitudes of patient service costs needed to assess the issues. The estimated cost function provides evidence that Medicaid reimbursement rates are lower than the average incremental cost of care for Medicaid patients in approximately one quarter to one third of Florida nursing homes. One possible explanation for this apparent cross-subsidization, considered here, is that patients pay a premium in self-insured rates early in their residency to fairly cover the expected future losses if they later convert to Medicaid. Based on the empirical frequencies of patient transitions to different payer status over the length of the nursing home stay, it is shown that the apparent cross-subsidization is explained, to a large extent, by an intertemporal conversion surcharge.