Outdated Medicare Rule Delays Care, Wastes Resources

New study finds three-day hospital stay requirement before nursing home coverage does not improve patient health or save Medicare money

Published on Feb. 10, 2026

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A long-standing Medicare policy that requires patients to spend at least three consecutive days in the hospital before Medicare will cover care in a nursing facility may be outdated and ineffective, according to a new study by researchers at Brown University's School of Public Health. The study found that the "three-day rule" does not reduce skilled nursing care use, but instead leads to longer hospital stays without improving patient outcomes or generating savings for Medicare.

Why it matters

The three-day rule was established in 1965 when typical hospital stays were close to two weeks, but today hospital stays are much shorter. Researchers say the rigid three-day threshold is difficult to justify in modern clinical practice and may be delaying care and wasting healthcare resources.

The details

The study analyzed more than 600,000 hospital stays involving traditional Medicare patients in 2023. When the three-day rule was reinstated after a pandemic-related pause, the proportion of hospital stays lasting at least three days increased by more than 5% for those who later went to nursing-home rehab. This resulted in at least 2,000 additional hospital days within the first month, without improving patient health outcomes or generating savings for Medicare.

  • The three-day rule was established in 1965.
  • From March 2020 to May 2023, the rule was suspended in response to the COVID-19 public health emergency.
  • The study analyzed more than 600,000 hospital stays involving traditional Medicare patients in 2023.

The players

Amal Trivedi

A professor of health services, policy and practice and of medicine at Brown University, and a co-author of the study.

Zihan Chen

A Brown doctoral student in health services research and the lead author of the study.

Cyrus Kosar

An assistant professor of health services, policy and practice at Brown and a co-author of the study.

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What they’re saying

“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. 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.”

— Amal Trivedi, Professor of health services, policy and practice and of medicine at Brown University (JAMA Internal Medicine)

“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.”

— Zihan Chen, Brown doctoral student in health services research (JAMA Internal Medicine)

“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.”

— Cyrus Kosar, Assistant professor of health services, policy and practice at Brown (JAMA Internal Medicine)

What’s next

The researchers plan to continue examining the three-day rule and exploring whether there are opportunities for change, as 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.

The takeaway

This study suggests that the three-day rule, which was established over 50 years ago when hospital stays were much longer, is now outdated and may be delaying care and wasting healthcare resources without improving patient outcomes or generating savings for Medicare. Rigorous evaluation of long-standing policies is important to ensure they are serving patients and the healthcare system effectively in the modern era.