The 3-day hospital stay rule requires Medicare beneficiaries to complete at least three consecutive inpatient days to qualify for skilled nursing facility (SNF) coverage. Although intended to ensure that SNF services are reserved for patients needing short-term rehabilitation, this requirement can introduce inefficiencies and may lead to compromises in patient care. Patients who do not meet the requirement may be discharged to less clinical settings. However, hospitals may prolong stays unnecessarily to ensure eligibility and to avoid out-of-pocket costs.
In contrast, the rule may also prevent premature discharges under payment pressures. Reform has been limited due to economic and clinical factors. A natural experiment during the COVID-19 public health emergency (PHE), when the rule was waived and later reinstated on May 12, 2023, provides new insights. By comparing patients hospitalized after and before reinstatement, this current study investigates whether the rule influences short-term patient outcomes, hospital length of stay, and SNF discharge rates.
In this retrospective cohort study, data were collected from the American Hospital Association (AHA) surveys (2022-2023), Medicare Beneficiary Summary File (MBSF), and MedPAR. The MBSF provided demographic characteristics, MedPAR provided SNF claims and hospital data, and AHA provided hospital features. The cohort included Medicare beneficiaries aged ≥65 years with acute hospitalizations between January and November 2023.
A sub-cohort of patients discharged to SNFs was analyzed separately. The main exposure was the reinstatement of the 3-day rule on May 12, 2023. Outcomes included SNF duration, readmission, Medicare spending within 100 days, hospital stays ≥3 days, mortality, and SNF use within 30 days. Statistical analyses were performed using STATA version 18.0.
Within 28 days of May 12, 2023, a total of 332,044 hospitalizations occurred before (mean age = 78.3±8.3 years, female = 53.8%, White = 82.3%, dual-eligible = 16.3%) and 338,375 after (mean age = 78.2±8.3 years, female = 53.8%, White = 82.1%, dual-eligible = 16.3%) reinstatement. Common conditions included hip fractures (2.8%), heart failure (5.9%), and pneumonia (3.4%).
Hospital stays ≥ 3 days increased from 60.4% to 62.0%, with an adjusted change in probability of +1.13 percentage points (95% confidence interval [CI], 0.66–1.66; p < 0.001).
Subgroup analyses showed larger increases for hip fractures (+3.12 percentage points; 95% CI, 1.12–5.12; p = 0.002; relative change, 3.6%) and dementia (+2.20 percentage points; 95% CI, 0.62–3.78; p = 0.006; relative change, 3.1%).
Overall, reinstatement increased hospital stay duration but did not affect hospitalization costs, discharge patterns, or clinical outcomes.
This study’s limitations include its focus on immediate effects, potential confounding from policy changes, limited generalisability, and possible residual confounding.
In conclusion, this study highlights that reinstating the 3-day rule increased hospital stays ≥3 days, specifically among SNF patients, without impacting SNF use, outcomes, or spending, questioning its relevance and value in traditional medicine.
Reference: Chen Z, Trivedi AN, Rahman M, Kosar CM. Changes in inpatient and skilled nursing facility care after the Medicare 3-day rule reinstatement. JAMA Intern Med. 2026;186(4):446-454. doi:10.1001/jamainternmed.2025.7838
