The upcoming end of the COVID-19 public health emergency also means the end of several healthcare waivers, including one on Medicare's three-day rule. In response, both providers and healthcare organizations are pushing back on the rule's return, arguing that it will further overcrowd hospitals and strain healthcare staff, Cheryl Clark writes for MedPage Today.

Hospital overcrowding is getting worse

According to Abhi Mehrotra, an emergency physician and vice chair of emergency medicine at the  University of North Carolina Hospitals, hospitals are currently facing significant overcrowding that is straining healthcare staff and impacting patient care.

Currently, between 60% and 70% of his hospitals' ED beds were occupied last week by patients "waiting to go someplace else, either into the hospital for a medical reason, or into a state psychiatric facility, or other kind of hospitalization for behavioral health purposes."

"We are definitely over capacity and crowded on the inpatient side, and that has led to emergency department boarding and ED overcrowding," Mehrotra said.

Mehrotra also noted that "the patients have changed" since more people are being brought to the ED by families when they can't care for them. These patients have behavioral or cognitive issues, and "they need other resources and placement but there's no medical diagnosis to admit them," he said.

In San Diego, Scripps Health has been tracking "avoidable bed days" (ABDs), or days in which patients are medically stable enough to be discharged but remain in the hospital because there was no safe, appropriate setting for them to be transferred to.

Between Oct. 16, 2022, and April 15, 2023, Scripps identified 18,301 ABDs affecting 1,958 patients across its five hospitals and behavioral health unit. In total, there was an average of 101 ABDs per day.

According to Scripps president and CEO Chris Van Gorder, the current overcrowding at hospitals is "the worst [he's] seen in [his] healthcare career."

"Because of low state and federal reimbursement for their patients, [skilled nursing facilities] SNFs, long-term care, and behavioral health facilities are not taking these low-pay and sometimes, complex patients and we are ending up with beds that are tied up for months and longer," Gorder said.

Providers push back on the return of Medicare's 3-day rule

With the COVID-19 public health emergency slated to end May 11, many emergency physicians are concerned about the end of the waiver for Medicare's three-day rule for discharging patients to SNFs.

Under the waiver, hospitals were allowed to bypass a rule requiring traditional Medicare beneficiaries to spend three full days in acute care before Medicare will cover their SNF care after being discharged. This allowed patients to be discharged directly to a nursing home once they were stable enough and still have their SNF stay covered.

However, once this waiver ends, patients will have to be hospitalized for at least three days before they can get their SNF stay covered by Medicare. Patients who don't meet this requirement will have to pay out-of-pocket. Some SNFs may also choose not to accept beneficiaries who don't meet the requirement.

According to emergency physicians, the return of the three-day rule will likely pressure hospitalists to keep these patients in acute care beds for the required three days, even if they don't need to be there.

"Patients need to meet criteria in order to be admitted in the first place," said Jeffrey Davis, director of regulatory and external affairs for the  American College of Emergency Physicians. "But sometimes when a patient needs only 1 or 2 days, they're going to try to keep them there for 3 days so they qualify if they need SNF coverage."

Because of this, inpatient units will fill up more quickly, hospital beds will be occupied for longer, and more patients will be boarded in EDs, which will tax ED staff even more.

"Our worry is if they reinstate this [three-day rule], it will make matters even worse, because when the inpatient beds are full, this backs up and locks up whole lines of patients," Davis said.

Vincent Mor from the  Brown University School of Public Health agreed that the return of the three-day rule could lead to more patients taking up hospital beds unnecessarily. Depending on the hospital's size, "you could have as many as 10 to 15 extra bed days waiting for that third day to finish," he said.

He also added, "If the emergency doctors are concerned about it, it's because they're admitting people who they may not need to admit."

Currently, Leading Age, an organization that advocates for long-term and other senior care providers, has petitioned  HHS Secretary Xavier Becerra to permanently extend the waiver for the three-day rule.

Although the rule was originally intended to protect certain patients from inappropriate discharges, it may no longer be necessary. According to Leading Age, recent Medicare audits show that the waiver did not negatively impact patient outcomes.

In a statement, the organization said the "antiquated" three-day rule was "onerous for patients and providers and reimplementing it will create hardships for older adults and families who need access to care." (Clark, MedPage Today, 4/27)