A paper by Hernandez and colleagues recently published in the Journal of Arthroplasty blames the Medicare 3-day rule for lengthier hospital stays among some patients with total knee arthroplasty (TKA) compared with others.1 They found a 30.4% longer average hospital stay among Medicare recipients compared with privately insured patients: 3.0 days versus 2.3 days, respectively (P <.05). There were no differences between the 2 groups in age, gender, Charlson Comorbidity Index scores, body mass index, and American Society of Anesthesiologists score.
The paper quotes an earlier study as support,2 positing that in the 2011 study “patients who underwent a TKA with private insurance had the shortest stays in the hospital but those with Medicare or Medicaid presented with [the] longest stays, up to an increase of 8.8% secondary to the 3-day rule.” However, the 2011 study showed the factors associated with the longest hospital stays were higher patient comorbidity level and low surgeon volume. The older study also used multilevel linear regression models to account for a range of variables, while the new study instead used a one-way ANOVA test, independent sample t test, and chi square to analyze the data.
The new study involved patients treated at the Rothman Institute in Egg Harbor Township, NJ. In a telephone interview, the lead author, Victor H. Hernandez, MD, MS, said that their protocol stipulates that patients should be sent home or to a rehab/skilled nursing facility as quickly as possible.
One requirement for patients to qualify for Medicare coverage for a stay in a skilled nursing facility is that they must previously have spent at least 3 consecutive days as a hospital inpatient.3
“Based on our results, it seems that patients with Medicare insurance who need to be discharged to an inpatient rehab facility will stay longer in-hospital, secondary to the 3-day rule, and this can result in higher costs for the health system,” said Hernandez, Assistant Professor, Arthroplasty & Joint Reconstruction, Department of Orthopedics, Miller School of Medicine, University of Miami, who has spent time working at the Rothman Institute.
He and his coinvestigators focused on 800 people who underwent TKA between January and December 2011. Of the patients in the study, 478 were discharged home after surgery, and 322 were sent directly to an inpatient rehabilitation facility. For patients requiring inpatient rehabilitation, the average length of stay was 0.72 days longer among those with Medicare versus those with private insurance.
The study concludes that revising the 3-day rule could not only reduce prolonged hospitalization and improve patient care, but also decrease costs to the patient and federal government.
- Hernandez VH, Ong A, Post Z, et al. Does the Medicare 3-day rule increase length of stay? (published online June 12, 2015). J Arthroplasty. doi:10.1016/j.arth.2015.06.008. http://dx.doi.org/10.1016/j.arth. 2015.06.008. Accessed July 20, 2015.
- Styron JF, Koroukian SM, Klika AK, et al. Patient vs provider characteristics impacting hospital lengths of stay after total knee or hip arthroplasty. J Arthroplasty. 2011;26(8):1418-1426.e1-2.
- Your Medicare coverage: skilled nursing facility (SNF) care. Medicare.gov website. www.medicare.gov/coverage/skilled-nursing-facility-care.html. Accessed July 17, 2015.