Medicaid‑Insured Children with Medical Complexity in a Rural State

To describe children with medical complexity (CMC) in Montana according to their clinical characteristics, rurality, and distance from specialty care, and to assess for disparities in geographic access to specialty care for American Indian children.

In this cross-sectional study, we categorized children in 2016-21 Montana Medicaid claims data using the Pediatric Medical Complexity Algorithm and compared the associations of medical complexity and demographic traits using chi-square tests. Using a database of providers, we calculated drive times from children's residences to the nearest pediatric subspecialist and calculated bootstrap confidence intervals for the difference in median driving distances by complexity and race.

Among 126,873 children, 23% lived in rural areas and 20% were reported as American Indian. In all, 10,766 children (8.5%) had complex chronic conditions (children with medical complexity, CMC), and 27,431 (21.6%) had noncomplex chronic conditions. Medical complexity was associated with age, race, ethnicity, sex, Children's Health Insurance Program enrollment, disability, and rurality. CMC had shorter median drive times to care than children with noncomplex medical conditions and children without chronic conditions (28 vs 34 and 43 minutes, 95% confidence intervals of differences 4-9 and 6-11). At each level of medical complexity, the median distance from care was greater for American Indian children than children of other races.

Although CMC tend to live closer to specialists than other children, many CMC live far from subspecialty care. American Indian children live farther from specialists than other children, regardless of complexity. Future work should support access to care for rural and American Indian CMC.