In This Issue

March 2011 | Bradford H. Gray

With patient safety a continuing policy concern, could ideas besides using checklists be adapted from commercial aviation? The answer is yes, according to Geraint Lewis, Rhema Vaithianathan, Peter Hockey, Guy Hirst, and James Bagian in the first article of this issue of The Milbank Quarterly. In “Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety,” Lewis and his colleagues describe fifteen safety practices from aviation that might be adapted to health care.

After describing these practices, which are cited in the article’s title, the authors offer a framework for assessing potential safety initiatives based on issues such as compliance and administrative costs. In addition, they discuss behavioral distortions that could result from these new patient safety initiatives, as well as why physicians might resist them. Lewis and colleagues conclude that although these ideas have promise, they nonetheless require careful evaluation and monitoring before being promoted or adopted systematically.

Although transferring patients among service providers often is necessary, it can lead to medical errors and other problems with patients’ care. The next article in this issue, “Dropping the Baton: Specialty Referrals in the United States” by Ateev Mehrotra, Christopher Forrest, and Caroline Lin, reviews the research on transitions to and from medical specialists. The authors summarize and assess the research about the referral decision, care coordination and information transfer, and access to specialty care. The propensity of primary care physicians to refer patients to specialists varies widely, and shortcomings in information transfer and care coordination are commonplace. Mehrotra and colleagues end by describing promising ways of improving the specialty referral process.

The next article in this issue analyzes a much discussed potential consequence of insurance coverage expansions in the 2010 U.S. health reform legislation: the increased demand for primary care services. In “Expansion of Coverage under the Patient Protection and Affordable Care Act and Primary Care Utilization,” Adam Hofer, Jean Marie Abraham, and Ira Moscovice analyze data from the Medical Expenditure Panel Survey to estimate how the use of primary care physicians will change when the health reform law is implemented. Then, using data about uninsured people in each state, they predict changes by state in the number of primary care visits and estimate the number of additional primary care physicians that will be needed.

The reform legislation will expand coverage by both private insurance plans and public programs. One of the policy issues in such a mixed system is whether the rate-setting power of public programs will result in higher costs paid by private payers. This is the topic of “How Much Do Hospitals Cost Shift? A Review of the Evidence” by Austin Frakt. The fact that hospitals charge private payers more for services than is paid by Medicare is well known. Whether such price discrimination, which is common in many industries, is actually cost shifting depends on whether the higher charges to private payers are a response to shortfalls in Medicare and other public programs. Here Frakt focuses on the articles published since Michael Morrisey wrote about a similar project (Morrisey 1993, 1994, 1996).

After presenting data on the payment-to-cost ratios for Medicare, Medicaid, and private payers since 1980 and reviewing the history of payment policies during that time, Frakt discusses and summarizes the theoretical and empirical work on this topic. The theoretical analyses focus on hospitals’ market power, which influences whether they can raise their prices at will, and on whether hospitals are profit maximizers, which influences whether the prices they charge private payers are affected by the prices they charge public payers. The empirical literature provides evidence regarding hospitals’ possible responses to public payments. Frakt concludes that the amount of cost shifting during the period studied has, at most, been modest and that hospitals’ future pricing policies for private payers may be influenced more by changes in their market power resulting from consolidation than by changes in prices charged to public payers.

The final article in this issue is “Maximizing the Impact of Systematic Reviews in Health Care Decision Making: A Systematic Scoping Review of Knowledge-Translation Resources” by Duncan Chambers, Paul Wilson, Carl Thompson, Andria Hanbury, Katherine Farley, and Kate Light. The knowledge-translation resources that are their focus are the organizations that make the results of systematic reviews of research evidence accessible and useful to interested policymakers. Besides describing twenty such knowledge-translation resources, they examine seven empirical studies that have assessed the usefulness of efforts to make the results of systematic reviews accessible to policymakers. Several of these studies reported some success in influencing policymakers, but none looked at cost effectiveness. Although Duncan and his colleagues also were concerned about possible publication bias (i.e., the tendency for only success stories to reach print), such evaluation studies are an important step in improving the use of research by policymakers.

Bradford H. Gray
Editor, The Milbank Quarterly


Morrisey, M. 1993. Hospital Pricing: Cost Shifting and Competition. EBRI Issue Brief. May.

Morrisey, M. 1994. Cost Shifting in Health Care: Separating Evidence from Rhetoric. Washington, DC: AEI Press.

Morrisey, M. 1996. Hospital Cost Shifting, a Continuing Debate. EBRI Issue Brief. December.

Author(s): Bradford H. Gray

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Volume 89, Issue 1 (pages 1–3)
DOI: 10.1111/j.1468-0009.2011.00618.x
Published in 2011