Understanding Access to Hospice Care

在美国，四分之三的人死于慢性病，通常是在经历了数月或数年的身心折磨之后最近的证据19-22表明，接受涉及患者身体、社会心理和精神健康以及护理人员健康的多领域服务对患者和家庭应对严重疾病的重要性。然而，卫生保健系统常常不能满足患有晚期疾病的患者及其家属的需要，他们经常经历不适当的疼痛和症状管理，42-46严重的照顾者负担和压力，47,46以及对护理的总体不满。

Three-quarters of individuals in the United States die from chronic illnesses,40 often after suffering both physically and psychologically for months or years.41 Recent evidence19-22 establishes the importance to patients and families coping with serious illness of receiving services across multiple domains that address the patient's physical, psychosocial and spiritual well-being, as well as the caregiver's well-being. However, the health care system has often failed to meet the needs of patients suffering from advanced illness and their families, who frequently experience inadequate pain and symptom management, 42-46 significant caregiver burden and stress,47,46 and overall dissatisfaction with care. Hospice was developed to address the multidimensional needs of patients suffering from serious illness and their families that were not being met by the traditional medical system. Hospice consists of services that focus on the physical, emotional, social, and spiritual needs of patients and their families including medical services, pain and symptom management, spiritual counseling, social services, and bereavement counseling. Services are palliative, rather than curative, and the majority of hospice care is provided in the patient's home.18 The population enrolled with hospice is rapidly diversifying as greater understanding of its benefits, particulariy for older adults with chronic illnesses, becomes wide-spread. Almost two-thirds of individuals enrolled with hospice are age 75 years or older.18 Individuals with a terminal diagnosis of cancer comprise 46% of all individuals enrolled with hospice, followed by those with end-stage heart disease (12%) and dementia (10%).18 The Tax Equity and Fiscal Responsibility Act of 1982 authorized Medicare to reimburse for hospice care under the Medicare Hospice Benefit (Table 1). In order for individuals to be eligible for hospice they must have a life expectancy of 6 months or less if the disease follows its usual course and must be willing to relinquish Medicare reimbursed services focused on life prolongation or cure. In order for hospices to receive reimbursement for hospice care they must be certified by Medicare.50 Medicare is the primary payor of hospice and approximately 94% 18 of hospices are Medicare certified. Certification requires satisfying several "conditions of participation 50 related to the availability of hospice services and the types of personnel that must be employed by the hospice. Reimbursement for hospice under Medicare is on a per diem basis according to four categories depending on the intensity of care delivered: routine home care, continuous home care (i.e., home care provided during periods of patient crisis), respite care (i.e., inpatient care for a short period to relieve the caregiver) and general inpatient care (i.e., inpatient care for patients unable to remain at home).51 More than 95% of hospice care reimbursed by Medicare is for routine home care.35