Hospice Underutilization in the US: The Misalignment of Regulatory Policy and Clinical Reality
Hospice Underutilization in the US: The Misalignment of Regulatory Policy and Clinical Reality
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DOI：
10.1016/j.jpainsymman.2018.08.005
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发表时间：
2018-11-01
影响因子：
4.7
通讯作者：
Fine, Perry G.
中科院分区：
文献类型：
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作者：
Fine, Perry G.
经过美国 Medicare 临终关怀福利三十年半的经验，尽管在症状管理、患者和家属满意度以及医疗保健成本降低方面取得了出色的质量成果，但受益人在生命最后一年中只有 12% 至 15% 的日子是在称为临终关怀的极具成本效益的跨学科协调高级疾病护理模式中接受护理。尽管造成这种情况的原因有很多，包括难以承认患者、患者家属和医生的死亡率，但临终关怀机构整体利用率低和中位住院时间极低（反映入院较晚）的一个重要原因可以归因于医疗保险受益人中大多数主要死亡原因的预后确定变得越来越困难且高度可变。 Medicare 是美国大多数临终关怀的付款人，需要受益人提供六个月或更短时间的预后证明才能获得临终关怀支持。在进入临终关怀医院时，两名医生必须根据临床状况预测患者在未来六个月内死亡的可能性大于生存的可能性。除了预后的不确定性构成及时临终关怀转诊的障碍之外，医疗保险和医疗补助服务中心及其付款承包商还制定了强大且昂贵的回顾性审查流程，当患者的寿命超过预期预后时，该流程会对临终关怀机构进行惩罚。繁重的行政负担和经济惩罚性的审查做法进一步延迟或限制了符合条件的患者获得护理的机会，因为认证医生和机构担心审查和审计的财务和法律影响，不愿意接受护理，除非患者明显处于死亡过程中。本文将回顾相关历史，并解决获得医疗保健福利的核心问题，该福利建立在一项政策上，该政策要求的预后确定性远高于任何临床医生可以合理确定的水平，并且没有考虑到临终关怀对绝症患者改善预后的有利影响。这一限制重病患者获得高价值优质护理的临床难题对于美国医疗保险人群具有深远的意义，并且也与所有复杂且受监管的卫生系统以及其资格标准基于预测的其他护理模式具有潜在的相关性。 (C) 2018 年美国临终关怀和姑息医学学会。由爱思唯尔公司出版。保留所有权利。
After three and a half decades of experience with the Medicare hospice benefit in the U. S., despite excellent quality outcomes in symptom management, patient and family satisfaction, and reduction in health care costs, only 12% e15% of beneficiaries' days during the last year of life are spent being cared for within the highly cost-effective interdisciplinary coordinated advanced illness care model known as hospice. Although there are many reasons for this, including difficulties in acknowledging mortality among patients, their families, and physicians, a significant cause of low overall hospice utilization and intractably low median lengths of stay, reflective of late admissions, can be attributed to increasingly difficult and highly variable prognostic determinations for most of the leading causes of death among Medicare beneficiaries. Medicare is the payer for most hospice care in the U. S. and requires certification of a prognosis of six months or less for a beneficiary to access hospice support. At the time of admission to hospice, two physicians must predict that a patient is more likely to die in the next six months than survive, based on clinical status. In addition to prognostic uncertainty constituting a barrier to timely hospice referral, the Centers for Medicare and Medicaid Services and its payer contractors have developed a robust and expensive retrospective review process that penalizes hospices when patients outlive their expected prognosis. The administratively burdensome and financially punitive review practices further delay or limit access to care for eligible patients as certifying physicians and agencies, fearful of the financial and legal repercussions of reviews and audits, are hesitant to take patients under care unless they are clearly in the dying process. This article will review pertinent history and address the core problem of access to a health care benefit built on a policy that requires far greater prognostic certainty than any clinician can reasonably ascertain and fails to take into consideration the favorable impact hospice care has on terminally ill patients in improving prognosis. This clinical conundrum that limits access of seriously ill people to high-value quality care is of profound importance to the U. S. Medicare population and also one with potential relevance to all complex and regulated health systems and to other models of care whose eligibility criteria are based on prognostication. (C) 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.