Understanding Access to Hospice Care

在美国，四分之三的人死于慢性病，40通常是在遭受数月或数年的身体和心理痛苦之后。41最近的证据19-22证实，对于患有严重疾病的患者和家庭来说，接受多个领域的服务非常重要，这些服务涉及患者的身体、心理和精神健康以及照顾者的健康。然而，卫生保健系统往往不能满足晚期疾病患者及其家人的需要，他们经常经历疼痛和症状管理不足，42-46名照顾者负担和压力很大，47-46名患者对护理总体不满意。 临终关怀的发展是为了满足重病患者及其家人的多层面需求，而这些需求是传统医疗系统无法满足的。临终关怀包括关注患者及其家人的身体、情感、社会和精神需求的服务，包括医疗服务、疼痛和症状管理、精神咨询、社会服务和丧亲咨询。临终关怀服务是治标不治本的，而且大多数临终关怀是在病人家中提供的。18随着对临终关怀益处的更多了解，尤其是对患有慢性病的老年人的认识日益广泛，登记参加临终关怀的人口迅速多样化。在登记参加临终关怀的个人中，几乎三分之二的人年龄在75岁或以上。18确诊为癌症的人占登记参加临终关怀的所有人的46%，其次是终末期心脏病(12%)和痴呆症(10%)。18 1982年的《税收公平和财政责任法》授权联邦医疗保险根据联邦医疗保险临终关怀福利报销临终关怀费用(表1)。为了使个人有资格获得临终关怀，如果疾病按照正常过程进行，他们的预期寿命必须在6个月或更短，并且必须愿意放弃专注于延长生命或治愈的医疗保险报销服务。为了让临终关怀机构获得临终关怀补偿，它们必须经过Medicare的认证。50 Medicare是临终关怀的主要付款人，大约94%的临终关怀机构获得了Medicare认证。认证要求满足与临终关怀服务的可用性和临终关怀所必须雇用的人员类型有关的几个“参与条件”。医疗保险下的临终关怀根据提供的护理强度按日报销四类：常规家庭护理、持续家庭护理(即在病人危急期间提供的家庭护理)、暂缓护理(即短期住院护理以减轻照顾者的痛苦)和普通住院护理(即对不能留在家中的病人的住院护理)。 由联邦医疗保险报销的95%以上的临终关怀是用于常规的家庭护理。

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