Makes patients stay in the hospital when they might not need to
By Carl Dimitri, Senior Writer, School of Public Health,
Established in 1965, the rule was intended to manage the use
of skilled nursing facilities, which provide short-term medical and
rehabilitative care to Medicare beneficiaries. Known as the “three-day rule,”
it requires patients to spend at least three consecutive days in the hospital
before Medicare will cover care in a nursing facility. Skilled nursing
facilities are used as a post-hospital benefit by one in five Medicare
beneficiaries after hospitalization, and Medicare pays an average of about
$15,000 for each stay.
“When the policy was created, typical hospital stays were close to two weeks, and requiring three inpatient days may have helped ensure appropriate use of post-acute care,” said study co-author Dr. Amal Trivedi, a professor of health services, policy and practice and of medicine at Brown University. “Today, hospital stays are far shorter, and hospitals can quickly assess patients’ need for skilled nursing care. In that context, it has been difficult to justify a rigid three-day threshold.”
From March 2020 to May 2023, the rule was suspended in
response to the COVID-19 public health emergency. The pause gave researchers
from Brown’s School of Public Health a
rare opportunity to investigate the clinical and economic impacts of the
policy.
The analysis published
in JAMA Internal Medicine looked at more than 600,000 hospital stays involving
traditional Medicare patients in 2023. The findings led the researchers to
question whether it may be time to reconsider if the three-day requirement
still makes sense in modern clinical practice.
“We found that the rule does not reduce skilled nursing care
use among patients who are admitted to the hospital, as was its original
purpose, but instead led to longer hospital stays to meet requirement for
coverage,” said lead study author Zihan Chen, a Brown doctoral student in
health services research.
As soon as the rule was reinstated, for instance, the
proportion of hospital stays lasting at least three days among all traditional
Medicare patients admitted to hospitals increased by more than 1%. For those
who later went to nursing-home rehab, the increase was more than 5%. Within the
first month alone, the reinstatement of the rule resulted in at least 2,000
additional hospital days, according to the study.
“Together, this strongly suggests that the policy itself —
rather than changes in patient health or clinical need — drove the longer
hospital stays,” Trivedi said.
The longer hospital stays didn’t lead to better health
outcomes for patients, according to the study. In fact, extra days in the
hospital often increase the risk of other complications, like infections or
functional decline, and they keep hospital beds that could be used for other
patients occupied, the researchers noted.
Death rates in the 30 days after discharge didn’t change
after the rule was brought back; nor did a patients’ ability to avoid another
hospital stay within that same time. And patients didn’t spend fewer days in
nursing homes because of the increased hospital time, said Cyrus Kosar, a
co-author on the study and assistant professor of health services, policy and
practice at Brown.
“There were no changes to discharge rates or days of care,
which indicates that the three-day rule does not generate observable savings
for Medicare and instead passes costs to hospitals,” Kosar said.
The researchers noted that Congress has repeatedly sought to
repeal the rule, but each attempt has stalled amid concerns it acts as a filter
for the use of skilled nursing facilities and fears that removing it would
significantly increase Medicare spending. Past efforts to remove or relax the
rule indeed led to sharp increases in Medicare-covered skilled nursing use.
“These factors have made policymakers cautious about any
reform,” Chen said.
They are also among the reasons the research team plans to
continue examining the rule and exploring whether there are opportunities for
change.
“Rigorous evaluation helps us understand what these
long-standing policies are actually doing today — how they shape care delivery,
patient experiences and system efficiency — so they can be updated to better
serve patients while using public resources wisely,” Chen said.
The study was funded by the National Institute on Aging
(P01AG027296 and R01AG089051).
