Five Questions With: Dr. Amal Trivedi

"We carried out this study by focusing on Medicare Advantage plans which have the flexibility to waive the three-day stay requirement."

Dr. Amal Trivedi is associate professor of health services, policy and practice and associate professor of medicine at Brown University. He recently authored a study showing that when Medicare Advantage plans waive their three-day stay requirement before patients are eligible for skilled nursing care, hospital days per year are lessened and risk of hospital-acquired complications went down.

PBN: To what extent are Medicare rules simply antiquated?
TRIVEDI
: Medicare enacted the three-day stay policy almost 50 years ago. A lot has changed in healthcare since the 1960’s. The average length of stay in the hospital was 2 weeks in 1965; it is about 5 days in 2015. That trend, combined with my clinical experience as a hospitalist, suggests that it would be reasonable for hospitals to evaluate and safely discharge a patient to a skilled nursing facility in less than three days.

PBN: Your study points to the likelihood that waiving the three-day-stay rule saves health systems money and improves outcomes. Will your research be exploring that more, in terms of quantifying those two things?
TRIVEDI
: Our study focused on Medicare Advantage plans, which have the flexibility to waive the three-day stay requirement. It is unclear to what extent our findings generalize to the traditional Medicare program. That’s where we would like to go next.

PBN: Can you talk about how the three-day rule led to unintended consequences and the difficulty of avoiding those when drawing up health insurance plans, both public and private?
TRIVEDI
: The three-day stay policy was designed to prevent inappropriate use of skilled nursing facilities. Three days was thought to be the minimal amount of time required for a hospital to evaluate and treat a patient and to ensure a safe transfer. Our study suggests that, at least among Medicare Advantage patients, the three-day stay policy may lengthen the amount of time spent in a hospital among patients who could be sent earlier. This could be a problem because each day in the hospital carries some risk of a complication, like an infection or blood clot. We only want patients staying in a hospital when it is medically necessary.

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PBN: Why do you think it is that researchers have not looked at the benefits of waiving this rule for the last two and a half decades?
TRIVEDI
: With the exception of a one-year period after the 1988 Medicare Catastrophic Coverage Act of 1988, the three-day stay policy has been in place continuously since the mid-1960s. That’s what has made it challenging to study this question over the past 25 years. We carried out this study by focusing on Medicare Advantage plans which have the flexibility to waive the three-day stay requirement. We compared outcomes in those that did with those that didn’t.

PBN: Are you pleased with the response to your paper so far – what are you hearing?
TRIVEDI
: We have had a number of inquiries from media outlets and provider organizations expressing interest in our study and wanting to learn more about our findings. We think the research is relevant to Medicare beneficiaries and the providers who care for them. We hope it will promote further study of the consequences of waiving the three-day stay requirement.

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