For decades, Medicare’s “three-day rule” has dictated crucial thresholds in the rehabilitation trajectory for older Americans after hospitalization. Instituted in 1965 to manage the use of skilled nursing facilities (SNFs), this rule mandates that patients must spend at least three consecutive days in a hospital inpatient setting before Medicare will approve coverage for subsequent skilled nursing care. Originally conceived at a time when hospital stays routinely spanned nearly two weeks, the rule has persisted despite dramatic shifts in healthcare delivery, patient length of stay, and clinical practice protocols.
Recent research emerging from Brown University’s School of Public Health critically challenges the ongoing utility of this policy in contemporary clinical settings. Drawing on a comprehensive dataset encompassing over 600,000 hospital admissions of traditional Medicare beneficiaries in 2023, researchers undertook a rigorous statistical analysis to assess the real-world effects of reinstating the three-day inpatient stay requirement after its suspension during the COVID-19 public health emergency. This natural experiment provided a rare analytical window to disentangle the policy’s effects on hospital length of stay, utilization of skilled nursing facilities, and broader economic and patient-centered outcomes.
Findings published in JAMA Internal Medicine reveal that contrary to the rule’s original intent—to curb unnecessary use of post-acute skilled nursing care—the three-day stipulation does not demonstrably reduce SNF utilization among Medicare patients. Instead, the reinstatement correlates almost immediately with a measurable increase in inpatient hospital days, signaling that hospitals are extending stays, not for clinical necessity, but to meet the bureaucratic threshold essential for Medicare reimbursement of nursing facility services. Within just the first month of policy reactivation, this translated to at least 2,000 additional hospital days, amplifying inpatient bed occupancy and potentially exacerbating systemic pressures on hospital infrastructure.
Dr. Amal Trivedi, a health services expert and study co-author, contextualizes these findings within broader healthcare trends. She notes that modern hospital practices emphasize expedited patient assessment and shorter lengths of stay, with many admissions lasting only one or two days. The three-day inpatient rule, rooted in mid-20th-century assumptions about hospitalization duration and post-acute care needs, now appears misaligned with streamlined clinical workflows and rapid triage capabilities. The persistence of a rigid chronological barrier seems to compel hospitals into unnecessary inpatient extension, underscoring a disconnect between regulatory frameworks and contemporary care delivery realities.
The policy’s impact reaches beyond mere administrative inconvenience. Extended hospital stays impose considerable risks on elderly patients, including heightened susceptibility to nosocomial infections, functional decline from prolonged immobility, and psychological distress linked to institutionalization. Moreover, longer inpatient durations occupy beds that could otherwise serve new acute-care patients, thereby constraining hospital throughput and amplifying wait times—all of which runs counter to efficient healthcare system operation and patient welfare.
Crucially, the study found no evidence that these longer inpatient stays improve patient outcomes. Metrics such as 30-day post-discharge mortality rates and rates of hospital readmission within the same period remained unaffected by the reinstatement. Similarly, patients did not compensate by spending fewer days in skilled nursing facilities post-hospitalization, indicating that the prolonged hospital stay merely supplanted rather than streamlined post-acute rehabilitation care. This raises vital questions about the policy’s cost-effectiveness and impact on Medicare spending patterns.
Economic analyses further illuminate the unintended consequences of the rule. While policymakers have regarded the three-day requirement as a fiscal gatekeeper aimed at preventing unwarranted spikes in Medicare spending on SNFs, the data suggests that it instead shifts costs onto hospitals by artificially inflating inpatient days. Since hospital care is substantially more expensive than skilled nursing, this policy may paradoxically exacerbate healthcare expenditures rather than constrain them, challenging long-held assumptions about its budgetary prudence.
Congress has intermittently debated repealing or modifying the three-day rule, yet these initiatives have historically faltered amid concerns regarding potential surges in Medicare spending and the role of the policy as a control mechanism for post-acute care demand. Earlier relaxations of the rule have demonstrably driven sharp increases in skilled nursing facility utilization, fueling apprehension that eliminating the restriction could overload these facilities and strain Medicare’s financial sustainability. This research offers a nuanced evidence base for reconsidering these entrenched positions by spotlighting the indirect costs and clinical ramifications of maintaining the status quo.
Zihan Chen, the study’s lead author and a doctoral student specializing in health services research, emphasizes that their ongoing work seeks to rigorously quantify not only utilization patterns but also patient health trajectories and systemic efficiencies under diverse post-acute care policies. The COVID-19-induced suspension of the rule created an unprecedented natural experiment enabling the disentanglement of policy effects from confounding patient health variables, shedding new light on how outdated regulations may unintentionally distort care delivery.
This research underscores a broader imperative within healthcare policy and system design: the continuous re-evaluation and evidence-based updating of legacy regulations to ensure alignment with evolving clinical standards, patient needs, and cost structures. Formal reconsideration of the three-day inpatient prerequisite could foster more responsive, patient-centered transitions from hospital to skilled nursing care, reduce unnecessary inpatient days, and optimize allocation of healthcare resources.
As population aging accelerates and post-acute rehabilitation demand grows, balancing access, cost containment, and quality outcomes presents a complex policy challenge. The findings from Brown University’s analysis provide timely, data-driven insights, challenging longstanding assumptions and prompting calls for modernization of Medicare’s skilled nursing coverage criteria. This could catalyze changes that better serve elderly patients by enhancing care efficiency while safeguarding public funds.
In sum, the three-day rule’s enduring legacy appears more problematic than protective in today’s healthcare environment. By generating longer hospital stays without improving patient recovery or reducing Medicare costs, it exemplifies how historic policies can become inadvertent obstacles to optimal care. Policymakers, practitioners, and researchers alike must harness emerging evidence to recalibrate such frameworks to contemporary realities, ultimately promoting health, system efficiency, and sustainable funding.
Subject of Research: Not applicable
Article Title: Changes in Inpatient and Skilled Nursing Facility Care After the Medicare 3-Day Rule Reinstatement
News Publication Date: 9-Feb-2026
Web References:
https://dx.doi.org/10.1001/jamainternmed.2025.7838
References:
Chen, Z., Trivedi, A., Kosar, C., et al. (2026). Changes in Inpatient and Skilled Nursing Facility Care After the Medicare 3-Day Rule Reinstatement. JAMA Internal Medicine. DOI:10.1001/jamainternmed.2025.7838
Keywords: Hospitals, Nursing homes, Rehabilitation centers
