Wiener Joshua M, Tilly Jane
The Urban Institute, 2100 M Street, NW, Washington, DC 20037, United States of America.
Int J Integr Care. 2003;3:e24. doi: 10.5334/ijic.81. Epub 2003 May 7.
End-of-life care financing and delivery in the United States is fragmented and uncoordinated, with little integration of acute and long-term care services.
To assess policy issues involving end-of-life care, especially involving the hospice benefit, and to analyse model programs of integrated care for people who are dying.
The study conducted structured interviews with stakeholders and experts in end-of-life care and with administrators of model programs in the United States, which were nominated by the experts.
The two major public insurance programs--Medicare and Medicaid--finance the vast majority of end-of-life care. Both programs offer a hospice benefit, which has several shortcomings, including requiring physicians to make a prognosis of a six month life expectancy and insisting that patients give up curative treatment--two steps which are difficult for doctors and patients to make--and payment levels that may be too low. In addition, quality of care initiatives for nursing homes and hospice sometimes conflict. Four innovative health systems have overcome these barriers to provide palliative services to beneficiaries in their last year of life. Three of these health systems are managed care plans which receive capitated payments. These providers integrate health, long-term and palliative care using an interdisciplinary team approach to management of services. The fourth provider is a hospice that provides palliative services to beneficiaries of all ages, including those who have not elected hospice care.
End-of-life care is deficient in the United States. Public payers could use their market power to improve care through a number of strategies.
美国临终关怀护理的资金筹集与服务提供分散且缺乏协调，急性护理和长期护理服务几乎没有整合。
评估涉及临终关怀护理的政策问题，尤其是与临终关怀福利相关的问题，并分析针对临终患者的综合护理模式项目。
该研究对临终关怀护理的利益相关者、专家以及美国模式项目的管理人员进行了结构化访谈，这些管理人员由专家提名。
两大主要公共保险项目——医疗保险和医疗补助——为绝大多数临终关怀护理提供资金。这两个项目都提供临终关怀福利，但存在一些不足，包括要求医生预估患者有六个月的预期寿命，坚持让患者放弃治愈性治疗（这对医生和患者来说都很难做到的两个步骤），以及支付水平可能过低。此外，针对疗养院和临终关怀机构的护理质量举措有时会相互冲突。四个创新型医疗系统克服了这些障碍，为生命最后一年的受益人提供姑息治疗服务。其中三个医疗系统是接受按人头付费的管理式医疗计划。这些提供者采用跨学科团队服务管理方法，整合了健康、长期和姑息治疗。第四个提供者是一家临终关怀机构，为所有年龄段的受益人提供姑息治疗服务，包括那些未选择临终关怀护理的人。
美国的临终关怀护理存在不足。公共支付方可以利用其市场影响力，通过多种策略改善护理服务。
