Objective. This study examines conversion to Medicaid as a payment source among a cohort of newly admitted nursing home residents. Data Source. The longitudinal data used came from regular assessments of residents in the National Health Corporation's 43 for-profit nursing homes in Missouri, Kentucky South Carolina, and Tennessee. This information system tracked all residents who were discharged, providing a comprehensive record that may have spanned multiple admissions. Study Design. Using survival analysis methods, Cox regression, and survival trees, we contrasted the effect of state, initial payment source, education, age, and functional status on the rate of spend-down to Medicaid. Data Extraction Methods. New-admission cohorts were created by linking an admission record for a newly admitted resident with all subsequent assessments and follow-up records to ascertain the precise dates of any payment source changes and other discharge transitions. Principal Findings. For the 1,849 individuals who were admitted as self-payers and who were still in the nursing home at the end of one year, there is a 19 percent probability of converting to Medicaid. All analytic methods revealed that education, age, and state of residence were predictive of spend-down among residents who were admitted as self-payers. Conclusions. Our results confirm the effect of education as an SES indicator and state as a proxy for Medicaid policy on spend-down. Future research should model the effects and duration of intervening hospitalizations and other transitions on Medicaid spend-down among new admissions.
