In one of the early scenes in the hit HBO Max show “The Pitt,” an elderly patient with Alzheimer’s is admitted to the hospital — against a physician’s guide — rather than a nursing home. The reason: A Medicare rule that requires patients to stay in the hospital for at least three days before insurance covers care at skilled nursing facilities, according to Zoey Chen GS, a PhD candidate in Health Services Research.
In a recent study led by Chen, Brown researchers confirmed what some clinicians have long suspected — this three-day rule is associated with longer hospital stays and does not reduce Medicare spending or improve short-term health outcomes.
The rule, introduced in 1965, was implemented to ensure Medicare coverage to patients whose hospitalization required long-term treatment at nursing facilities. At the time, nursing homes typically offered custodial care and long-term stays were common.
SNF care typically includes rehabilitation-based treatments such as physical therapy or wound care, said co-author Amal Trivedi, professor of policy and practice, health services and medicine. These services are generally considered outside the scope of Medicare, which is usually reserved for short-term services.
According to the study, the three-day rule was waived during the COVID-19 pandemic. After two years, the rule was reinstated, providing Chen and her co-authors with a clean data set to determine the rule’s impact on inpatient and post-acute care.
The researchers found that patients used SNF care at similar rates when the three-day rule was suspended as when it was in place. But when the rule was active, a significantly larger proportion of patients stayed in the hospital for at least three days, suggesting they were staying just long enough to qualify for coverage.
The researchers concluded that the extra days were used to meet this “kind of rigid or arbitrary three-day threshold,” Chen said.
Cyrus Kosar, assistant professor of health services and policy and practice and another co-author of the study, also emphasized the harm caused by the rule’s rigidity.
“You have these one-size-fits-all policies, but every clinician you talk to will talk about how this is so much of a nuisance,” he said. “Every clinician has an experience with some patient who does not need to stay three days and should go to” a SNF.
The study also found that these extra hospital days have concrete consequences, as patients waiting three days take up beds that could be used by patients who actually need them. The longer hospitalization also led to an increased risk of adverse events such as infection or delirium.
But reforming the rule is challenging, as the rule is designed to “prevent overuse” of costly SNF care, Chen said. But she noted that this study “provides a very important first step towards making a change” since it demonstrates that the rule does not save Medicare money.
The rule has remained unchanged even though “our current health care delivery system is so different from what it was back in 1965,” Chen said.
Lewis Lipsitz, a professor of medicine at Harvard Medical School and director of the Hinda and Arthur Marcus Institute for Aging Research, said that the diagnostic and treatment process at hospitals now occurs within the first day or two of a patient’s stay.
“Keeping people for a third day is excessive, unnecessary and often detrimental,” Lipsitz said.
But he cautioned against the continued reduction of hospital stays.
“We already have a lot of incentives in place to reduce unnecessary hospitalizations and reduce lengths of stay,” he said.
Lipsitz said that his primary concern is an increase in rehospitalizations if the rule was permanently disbanded, and more research should be done to ensure patients are not prematurely discharged.
Chen also said she plans to conduct further research on how the three-day rule may affect different patient populations.
Health care plans in the private sector have already waived the three-day rule.
“This might be the moment,” to reform the rule for the public sector of Medicare, Trivedi said.
“We should be basing eligibility for going to a SNF based on patients’ clinical needs and their functional status, and less on arbitrary rules,” he said.
