3-Day Hospital Stay Rule for Nursing Homes Fails to Improve Outcomes, Cut Costs, as Researchers Question ‘Rigid’ Thresholds
•February 10, 2026
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Why It Matters
The findings expose a costly, ineffective Medicare requirement, prompting urgent reconsideration of post‑acute care coverage rules that affect hospital finances and patient pathways.
Key Takeaways
- •Rule added ~1.1% more three‑day stays overall
- •No change in SNF discharge rates or Medicare spending
- •Hospital stays lengthened, especially for hip fracture, dementia patients
- •30‑day readmission and mortality unchanged
- •Researchers recommend waiving rule to reduce costs
Pulse Analysis
The three‑day hospital stay rule, enacted in 1965, was designed when average inpatient stays approached two weeks, ensuring that only patients with genuine post‑acute needs qualified for Medicare‑covered skilled nursing care. Over the past decades, advances in surgical techniques, care pathways, and discharge planning have compressed lengths of stay to under a week for most conditions. Yet the rule persisted, creating a regulatory mismatch that forces hospitals to extend admissions solely to meet a coverage threshold, potentially inflating costs without clinical justification.
The JAMA Internal Medicine analysis leveraged the natural experiment created by the policy’s temporary COVID‑19 waiver and subsequent reinstatement. By comparing over 600,000 acute‑care episodes before and after May 12, 2023, researchers observed a modest rise—1.13 percentage points—in the proportion of stays reaching three days, with a pronounced 5.57‑point increase among patients ultimately discharged to SNFs. Despite these longer stays, discharge rates to skilled nursing facilities, 30‑day readmission, mortality, and overall Medicare expenditures remained statistically unchanged, indicating that the rule fails to achieve its cost‑containment or quality‑improvement objectives.
For policymakers, the study underscores the need to align Medicare post‑acute coverage with modern clinical realities. Waiving the three‑day requirement could eliminate unnecessary inpatient days, reduce hospital overhead, and streamline patient flow to appropriate care settings. However, past attempts to relax the rule sparked concerns about unchecked SNF utilization, suggesting that any reform must be paired with robust utilization management and value‑based payment models. Stakeholders—including hospital administrators, Medicare Advantage plans, and SNF operators—should monitor upcoming CMS proposals, as shifts in this long‑standing threshold could reshape the economics of post‑acute care nationwide.
3-Day Hospital Stay Rule for Nursing Homes Fails to Improve Outcomes, Cut Costs, as Researchers Question ‘Rigid’ Thresholds
The 3-day hospital stay rule – long opposed by nursing home providers – is linked to longer hospital stays without improving outcomes or reducing costs, according to a new study.
Its reinstatement over the past two and a half years was associated with prolonged stays but no reduction in skilled nursing facility (SNF) use or savings, the study published in JAMA Internal Medicine Monday found.
“These findings suggest that the policy imposes additional costs on hospitals while failing to lower Medicare spending on hospitalized patients,” researchers said. “More generally, results raise questions regarding the value and continued relevance of a broadly applicable 3-day inpatient stay rule in the traditional Medicare program.”
Previous efforts to reform the 3-day hospital stay rule were hindered by uncertainty about the clinical and economic effects of expanding SNF coverage and by limited opportunities to study a rule that had largely remained unchanged since its introduction in 1965.
The temporary suspension of the policy during the COVID-19 pandemic and its reinstatement after the public health emergency ended on May 12, 2023, provided a unique opportunity to study its impact, researchers noted.
“In this study, we leveraged a natural experiment created by a federal policy change,” the researchers noted.
The rule requires patients to spend at least three consecutive days in the hospital before Medicare covers care in a nursing facility, but researchers now say its provisions may be outdated.
“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,” said study co-author Dr. Amal Trivedi, a professor of health services, policy and practice and of medicine at Brown University. “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.”
Policymakers should reconsider keeping the rule in place, researchers concluded.
“Our study indicates that once a patient was admitted to a hospital, the 3-day rule has minimal impact on downstream skilled nursing facility (SNF) use. Therefore, policymakers may consider waiving the 3-day rule for inpatient admissions as a feasible starting point for reform with minimal fiscal and health impacts,” they said, emphasizing that the results were limited to the inpatient setting.
However, they also noted that past attempts to relax the rule increased Medicare-covered SNF use, making policymakers cautious about reform
This cohort study examined more than 600 000 traditional acute care hospitalizations, using Medicare beneficiaries data from January through November 2023.
Specifically, researchers investigated whether the 3-day rule reduced SNF discharges or instead lengthened hospital stays to meet coverage requirements, and whether these effects influenced short-term patient outcomes and Medicare spending.
The study found that the likelihood that a hospitalization lasted at least three days increased by 1.13 percentage points overall. Among patients who were ultimately discharged to SNFs, the increase was much larger – a 5.57 percentage point rise in hospital stays.
Despite these longer hospitalizations, the policy change did not significantly alter the discharge rates to a SNF. There were also no meaningful changes in short-term health outcomes, including 30-day rehospitalization rates or mortality. Similarly, Medicare spending and the total number of SNF days used did not differ significantly after the rule was reinstated. Subgroup analyses showed that the increase in 3-day hospital stays was particularly pronounced among patients hospitalized for hip fractures and those with dementia, groups that are commonly discharged to post-acute care.
Moreover, hospitals may have extended inpatient stays to ensure patients qualified for Medicare-covered SNF care, researchers said.
Taken together, the results indicate that reinstating the 3-day rule led to longer inpatient stays without achieving its presumed goal of limiting SNF utilization or reducing Medicare spending. Instead, the policy appears to have imposed additional costs and burdens on hospitals while failing to improve patient outcomes or meaningfully constrain post-acute care use.
“The temporary waiver allowed us to identify changes associated with the 3-day rule by comparing outcomes between individuals who were subject to the rule because they were hospitalized immediately after the end of public health emergency with those hospitalized immediately before, when the rule was still waived.”
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