The Hospital Readmissions Reduction Program.

To the Editor: Zuckerman et al. (April 21 issue)1 found that hospital readmissions for conditions targeted for penalties fell by 3.7 percentage points, whereas stays in observation units rose by 2.1 percentage points, yet they concluded that these two trends were not related because observation stays were rising even before the penalties were in place. Instead, the authors attribute continuously rising observation rates to hospitals’ confusion over the criteria used in audits of inpatient stays. It seems unlikely that confusion over these regulations continued to increase for many years, leading hospitals to sacrifice billions by billing for observation stays rather than for more lucrative admissions. More likely, hospital executives realized that, on balance, avoidance of readmission penalties by relabeling inpatient stays as “observation” was the most lucrative strategy. The authors also overinterpret their statistics as showing no correlation between readmissions and observation stays. In fact, they, like previous analysts,2 found a weak positive correlation (P = 0.07) — indicating a 93% likelihood that falling readmissions and rising observations were related. Finally, their analysis ignores other potential gaming strategies — for example, upcoding coexisting conditions to improve riskadjusted rates and shifting inpatient-type care to emergency departments.