Obtaining health care in the appropriate setting is crucial for older patients

Through the next decade, 10,000 members of the Baby Boomer generation will turn 65 years of age every day. Recently, I took care of Paul, a 78-year-old man with mild cognitive impairment and gait instability, who had fallen.

His X-rays were standard, but he still had significant difficulty walking. His caregiver was overwhelmed, and my ability to discharge him home safely was brought into question. Would he “bounce back” after a worse fall next time? Or could he benefit from a short-stay at a Skilled Nursing Facility (SNF) to regain his strength? As a geriatrics researcher and emergency medicine physician, I see patients similar to Paul every day. 

To qualify for SNF coverage, federal regulations specify that Medicare beneficiaries, like Paul, must meet the “3-day rule” before SNF admission. The 3-day rule requires the recipient to have a medically necessary 3-day-consecutive inpatient hospital stay. It does not include the day of discharge, or any pre-admission time spent in the emergency room (ER) or outpatient observation status.

If the patient is discharged to an SNF on hospital day three, the patient is often required to pay out-of-pocket for the extended care services unless they have long-term care insurance or a supplemental insurance plan. Similarly, if a patient does not have a qualifying diagnosis and is placed under “observation” status during the hospitalization, they are also responsible for the subsequent SNF costs. Governmental reports estimate uncovered SNF stays following an observation hospitalization cost Medicare beneficiaries over $10,000 out-of-pocket expenses.

Obtaining health care in the appropriate setting is crucial. If a patient is not going to benefit from hospitalization, then efforts should be made to get them the necessary attention at the SNF. The prolonged, unnecessary time within the hospital exposes patients to risk, including hospital-acquired infections. Patients should not be required to stay in the hospital additional days if it is not beneficial to their overall care. 

So what is the rationale behind the 3-day rule? In 1965, Lyndon Johnson signed into law the Medicare and Medicaid programs as part of the Social Security Act. At that time, there was concern that the government would end up paying for long-term institutional care.

Any shift towards payment for custodial care — any non-medical care that helps individuals with primary daily care, such as eating and bathing — could have significant financial implications regarding the new programs. In Congress at that time, representatives feared that people would go into the hospital for one day, pay their deductible, and get transferred to an SNF with the government responsible for the bill. Others proposed the need for a five-day stay before a nursing home to “avoid abuse’.” The 3-day rule was seen as a compromise.

For many, the most desired approach would be to get rid of the 3-day rule altogether. As a middle ground, Medicare Advantage programs have previously waived the 3-day rule, resulting in appropriate decreases in-hospital length of stay without increased SNF utilization.

As a second option, counting all the time spent in a hospital toward the SNF requirement, including the ER, outpatient observation status, and inpatient — would be a welcome change to advocate lawmakers. In December 2017, Rep. James Renacci (R-Ohio) introduced the Creating Access to Rehabilitation for Every Senior (CARES) Act to address the 3-day rule.

Still, the legislation stalled within the House Committee on Ways and Means. Given our continued aging population and the financial implications of the 3-day rule, this growing issue should be readdressed within the U.S. Congress.

Unfortunately, I was forced to admit Paul to the hospital after his fall. He contracted a hospital-acquired infection and ended up staying 7 days before being discharged to an SNF. Instituted nearly 50 years ago, the 3-day rule is outdated. 

In the 1970s, hospitalizations lasted over two weeks, with the requisite 3-day stay before post-acute care seemingly more reasonable. Today, inpatient stays last four to five days on average, with costs rising above $4,000 per day. 

The 3-day rule prevents timely and coordinated care for older adults needing rehabilitation in the appropriate setting, exposes them to unnecessary risk, and is a cost to patients and the broader health care system. The goal is to offer the right care for the right patient in the right location

Cameron Gettel, M.D., is a practicing emergency medicine physician at Yale University School of Medicine with expertise in geriatrics, transitions of care, and long-term care. Follow him on Twitter at @CameronGettel.