Longer hospital stays, no patient benefit

A protracted-standing Medicare coverage meant to handle rehabilitation companies in nursing properties might hold older Individuals in hospitals longer than crucial with out bettering affected person well being or saving Medicare cash, new analysis finds.

Established in 1965, the rule was supposed to handle using expert nursing amenities, which offer short-term medical and rehabilitative care to Medicare beneficiaries. Often called the “three-day rule,” it requires sufferers to spend not less than three consecutive days within the hospital earlier than Medicare will cowl care in a nursing facility. Expert nursing amenities are used as a post-hospital profit by one in 5 Medicare beneficiaries after hospitalization, and Medicare pays a median of about $15,000 for every keep.

When the coverage was created, typical hospital stays had been shut to 2 weeks, and requiring three inpatient days might have helped guarantee acceptable use of post-acute care. At present, hospital stays are far shorter, and hospitals can shortly assess sufferers’ want for expert nursing care. In that context, it has been troublesome to justify a inflexible three-day threshold.”

Dr. Amal Trivedi, research co-author, professor of well being companies, coverage and apply and of drugs at Brown College

From March 2020 to Might 2023, the rule was suspended in response to the COVID-19 public well being emergency. The pause gave researchers from Brown’s College of Public Well being a uncommon alternative to analyze the scientific and financial impacts of the coverage.

The evaluation revealed in JAMA Inside Drugs checked out greater than 600,000 hospital stays involving conventional Medicare sufferers in 2023. The findings led the researchers to query whether or not it could be time to rethink if the three-day requirement nonetheless is sensible in trendy scientific apply.

“We discovered that the rule doesn’t cut back expert nursing care use amongst sufferers who’re admitted to the hospital, as was its unique objective, however as a substitute led to longer hospital stays to satisfy requirement for protection,” mentioned lead research creator Zihan Chen, a Brown doctoral pupil in well being companies analysis.

As quickly because the rule was reinstated, as an example, the proportion of hospital stays lasting not less than three days amongst all conventional Medicare sufferers admitted to hospitals elevated by greater than 1%. For individuals who later went to nursing-home rehab, the rise was greater than 5%. Inside the first month alone, the reinstatement of the rule resulted in not less than 2,000 further hospital days, based on the research.

“Collectively, this strongly means that the coverage itself – relatively than modifications in affected person well being or scientific want – drove the longer hospital stays,” Trivedi mentioned.

The longer hospital stays did not result in higher well being outcomes for sufferers, based on the research. In reality, additional days within the hospital usually enhance the chance of different problems, like infections or practical decline, they usually hold hospital beds that might be used for different sufferers occupied, the researchers famous.

Dying charges within the 30 days after discharge did not change after the rule was introduced again; nor did a sufferers’ means to keep away from one other hospital keep inside that very same time. And sufferers did not spend fewer days in nursing properties due to the elevated hospital time, mentioned Cyrus Kosar, a co-author on the research and assistant professor of well being companies, coverage and apply at Brown.

“There have been no modifications to discharge charges or days of care, which signifies that the three-day rule doesn’t generate observable financial savings for Medicare and as a substitute passes prices to hospitals,” Kosar mentioned.

The researchers famous that Congress has repeatedly sought to repeal the rule, however every try has stalled amid issues it acts as a filter for using expert nursing amenities and fears that eradicating it might considerably enhance Medicare spending. Previous efforts to take away or chill out the rule certainly led to sharp will increase in Medicare-covered expert nursing use.

“These elements have made policymakers cautious about any reform,” Chen mentioned.

They’re additionally among the many causes the analysis crew plans to proceed inspecting the rule and exploring whether or not there are alternatives for change.

“Rigorous analysis helps us perceive what these long-standing insurance policies are literally doing right now – how they form care supply, affected person experiences and system effectivity – to allow them to be up to date to higher serve sufferers whereas utilizing public sources properly,” Chen mentioned.

 The research was funded by the Nationwide Institute on Growing older (P01AG027296 and R01AG089051).