This brief reviewed two areas of relatively high-cost utilization among Medicaid enrollees: acute care inpatient stays and institutional long-term care facility stays. Although the information for this analysis (2012) predates Medicaid expansion under the Affordable Care Act, a detailed examination of the Medicaid utilization subset within rural populations suggests disparities that may require further examination.

Inpatient utilization: Overall, the likelihood of any hospitalization was similar across all Medicaid enrollees (9.3% rural, 9.2% urban), despite the absence of hospitals in many rural counties. Findings regarding inpatient utilization must be viewed carefully, particularly for persons who qualify for Medicare and are in the aged and disabled categories. Hospitalizations paid by Medicare are not in the data unless Medicaid covers deductibles and copays; thus it is possible that hospital stays are undercounted. Nonetheless, several points stand out. The hospitalization rate among American Indian/Alaska Native enrollees was higher than that for other beneficiaries, reaching 11.3% in isolated rural areas. Further analysis is recommended to identify geographic areas in which this population group is particularly at risk and determine diagnoses contributing to high hospitalization rates. A second area of concern surrounds lower hospitalization rates among rural enrollees who qualified for Medicaid in the "other" category, which is principally composed of individuals covered under the Breast and Cervical Cancer Prevention Act of 2000. Whereas 16.2% of urban enrollees were hospitalized, the rural value was 14.9%. The possibility of a disparity in rural cancer detection and treatment merits further exploration. Finally, enrollees covered by managed care plans were less likely than those covered through fee-for-service Medicaid to be hospitalized, and rural/urban hospitalization rates were more similar within the managed care population.

Institutional long-term care facility utilization: Data available in the Medicaid Analytic eXtract (MAX) file pertain only to institution-based services, not home- and community-based services. With that limitation, points of interest for future research include: The higher likelihood of nursing facility use among rural than urban enrollees (2.0% vs. 1.5%) may be due to the higher proportion of rural residents who qualify for coverage as aged or disabled individuals. The long lengths of stay among persons who use nursing facilities (NFs), nearly 9 months, suggests that many of these individuals experience severe medical need. However, it is possible that some rural institutional care use is associated with an absence of home- and community-based alternatives. This topic is recommended for further study.

Average lengths of stay in NFs and intermediate care facilities for individuals with intellectual disabilities were similar among patients covered by fee-for-service and managed care plans. However, average lengths of stay in psychiatric/mental health facilities were markedly shorter for rural managed care patients (1.5 months among full-year enrollees) than for rural fee-for-service patients (2.8 months among full-year enrollees). Whether this difference stems from more effective transitions to community-based care for enrollees covered by managed care or from inadequate inpatient treatment remains to be resolved. Again, further study is warranted.