A long-standing Medicare policy intended to regulate access to nursing home rehabilitation may now be prolonging hospital stays for older adults—without improving patient outcomes or reducing costs—according to new research from Brown University.
Known as the “three-day rule,” the policy requires Medicare beneficiaries to spend at least three consecutive days admitted to a hospital before Medicare will cover care in a skilled nursing facility. The rule dates back to 1965, when hospital stays often lasted weeks and the requirement helped control post-acute care use.
Today, researchers say, it no longer aligns with modern medical practice.
“When the policy was created, hospital stays were much longer,” said Dr. Amal Trivedi, a study co-author and professor at Brown. “Now clinicians can assess the need for skilled nursing care far more quickly, making a rigid three-day threshold difficult to justify.”
The rule was temporarily suspended from March 2020 through May 2023 during the COVID-19 public health emergency. That pause allowed researchers to examine how the policy affects care when it is removed—and when it returns.
What changed when the rule came back
The study, published in JAMA Internal Medicine, analyzed more than 600,000 hospitalizations involving traditional Medicare patients in 2023.
After the three-day requirement was reinstated, the share of hospital stays lasting at least three days increased by more than 1% overall. Among patients later discharged to nursing home rehabilitation, that increase exceeded 5%. Within the first month, the policy resulted in at least 2,000 additional hospital days.
Researchers found no evidence that the rule reduced the use of skilled nursing facilities, its original purpose. Instead, hospitals appeared to keep patients admitted longer simply to meet Medicare’s coverage requirement.
No improvement in outcomes
Despite longer hospital stays, patient outcomes did not improve. The study found no change in 30-day mortality rates, hospital readmissions, or the number of days patients spent in nursing facilities.
“There were no observable savings for Medicare,” said co-author Cyrus Kosar, an assistant professor at Brown. “Instead, the policy shifts costs to hospitals and keeps beds occupied longer.”
Lawmakers have repeatedly considered repealing the rule but have hesitated amid concerns it acts as a safeguard against overuse of nursing facilities. The researchers say their findings suggest it may be time to reassess whether the policy still serves patients—or the healthcare system—effectively.
