Letters to the Editor / JAMDA 16 (2015) 527e534
Nursing Homes and Their Contracted Doctors: Korean Experience
Table 2 Major Accompanied Diseases of the Long-Term Care Insurance Recipients by June 2014
To the Editor: The Korean elderly population is rapidly increasing; currently, approximately 13.4% of the population is 65 years or older,1 and this proportion is expected to reach 37.0% by 2050, which will give Korea the second-highest elderly population proportion among Organisation for Economic Co-operation and Development countries, after Japan.2 Since 2008, the Korean government has provided a national long-term care insurance (LTCI) program.3,4 Accordingly, there has been huge growth in the number of existing nursing homes and residents, from 128 nursing homes with 7864 residents in 2001 to 4079 nursing homes with 103,973 residents in 2013.5 Senior citizens who are 65 years or older and citizens who are younger than 65 years but have chronic senile diseases are eligible for LTCI services. If the eligible participants apply for LTCI services, a social worker and/or nurse from the National Health Insurance (NHI) Corporation agencies visits applicants to assess their capacity for activities of daily living (ADLs) according to the assessment criteria defined by LTCI law. LTCI recipients are finally classified into 5 categories according to the care needs of local LTCI committees taking account of the doctor’s note. They must be at least within category 3 to be admitted to a nursing home. LTCI is funded by the NHI. The NHI and the government are responsible for 80% (institutional services) to 85% (in-home services) of the expense of long-term care services (Table 1).6e9 One of the key challenges facing this program is that national LTCI and NHI are separate entities in Korea. Therefore, medical care in nursing homes is not reimbursed by LTCI. In reality, more than 95% of long-term care beneficiaries require medical services after being institutionalized in nursing homes (Table 2). To address these issues, long-term care facilities, by regulation, must contract with physician(s) or form agreements with local hospital(s), or both; the number of contracted doctors was reported to be 1166 as of the end of 2013.10 However, this regulation does not apply to group homes with a maximum capacity
Table 1 Application, Acceptance, and Benefit Rate of Long-Term Care Service in Korea
Elderly population Applicants for LTCI Application rate*, % Accepted elderly Acceptance ratey, % Beneficiaries Benefit ratez
533
2008 July
2010 December
2012 December
2014 June
5,028,357 272,662 5.4 146,643 82.1 134,249 91.5
5,436,969 759,339 14.0 315,994 67.8 281,119 89.0
5,914,202 643,409 10.9 341,789 68.9 307,773 90.0
6,335,294 709,308 11.2 393,927 71.0 350,607 89.0
Cited from major statistics in long-term care insurance. Available at: http://www.nhis. or.kr/cms/board/board/Board.jsp?searchType¼ALL&searchWord¼&list_start_date¼ &list_end_date¼&pageSize¼&branch_id¼&branch_child_id¼&communityKey¼ B0163&pageNum¼1&list_show_answer¼N&boardId¼28&act¼VIEW. Accessed Mar ch 12, 2015. *Applicants for LTCI divided by Elderly population. y Accepted people divided by Applicants for LTCI. z Beneficiaries divided by Accepted people.
Disease
No. of patients
Percentage
Dementia Stroke Dementia þ stroke Hypertension Diabetes Osteoarthritis Lower back pain, sciatica Dyspnea Hearing loss Cataract, glaucoma Sequelae after accidents, fracture Cancer Others Total
108,572 84,580 26,138 3,469 5,633 33,324 37,975 2,197 509 4,560 31,081 5,962 49,927 393,927
27.6 21.5 6.6 0.9 1.4 8.5 9.6 0.6 0.1 1.2 7.9 1.4 12.7 100
Cited from Major Statistics in Long-Term Care Insurance. National Health Insurance Corporation; 2011. Available at: http://www.nhis.or.kr/cms/board/board/Board.jsp? searchType¼ALL&searchWord¼&list_start_date¼&list_end_date¼&pageSize¼&bra nch_id¼&branch_child_id¼&communityKey¼B0163&pageNum¼1&list_show_ans wer¼N&boardId¼28&act¼VIEW. Accessed March 12, 2015. Note: Each recipient registers their most representative diseases.
of fewer than 10 residents (Table 3). Contracted doctors who specialize in family medicine, internal medicine, rehabilitation medicine, neurology, psychiatry, oriental neuropsychiatry, and other geriatric-related specialties are by regulation preferentially recommended. According to a survey by Park et al,11 private practitioners accounted for 57.8% of these contracted physicians. Approximately 69.0% of them had contracts with 1 or 2 nursing homes and 5.6% of them had contracts with 10 or more nursing homes. The specialties of the contracted doctors were family medicine (20.2%), internal medicine (18.4%), neurology (8.8%), general surgery (7.9%), psychiatry (7.0%), and oriental internal medicine (4.4%), among others. By regulation, contracted physicians must visit the facilities at least once every 2 weeks to clinically examine the residents and to order physiotherapy or nursing treatment, or to provide referrals to a hospital. However, they are not allowed to provide any direct medical services to the residents except for prescriptions, as these places are not designated as medical care facilities by law. Nurses or nurse’s aides on duty must evaluate the health status of every newly institutionalized resident, including consciousness, respiration, digestive function, and ADLs. They should also check vital signs, body weight, and medicines taken by the residents on a daily basis.12 Geriatric hospitals provide another distinct form of long-term care in Korea. They deliver various medical services like subacute to long-term care, palliative care, and rehabilitation medical services; as of early 2014, 1337 geriatric hospitals existed in Korea. Those hospitals are reimbursed by the NHI.12 The overlap in the roles played by nursing homes and geriatric hospitals remains a major issue. This is manifested in their similar patient composition, with dementia and stroke being the most prevalent conditions.13 In 2013, the Ministry of Health and Welfare published guidelines for contracted doctors working for nursing homes, but that is not enforceable. The Ministry of Health and Welfare also is seeking to develop and implement an education and qualification program for these doctors.
534
Letters to the Editor / JAMDA 16 (2015) 527e534
Table 3 Requirements for the Workers of Long-Term Care Facilities in Korea Long-Term Care Facility
Physicians (attending or contracted) Nurse or nurse’s aides Physical therapist Social workers Registered long-term caregivers Dietitians
Group Home
No. of Residents 30
No. of Residents 10w29
No. of Residents 5w9
1 1 per 25 residents 1 per 100 residents 1 per 100 residents 1 per 2.5 residents 1, only if the residents are 50 or older
1 1 As needed 1 1 per 2.5 residents Not required
Not required 1 1 1 per 3.0 residents Not required
Cited from Korea Institute for Health and Social Affairs, Standards of care for elderly welfare facilities and staffing standards (Article 22, paragraph 1, Revised Aug 29, 2013), Elderly Welfare Law Enforcement Rules, Health and Welfare Ordinance No. 203.
References 1. Statistics Korea. Available at: http://kosis.kr/statisticsList/statisticsList_01List. jsp?vwcd¼MT_ZTITLE&parentId¼A. Accessed March 12, 2015. 2. Organisation of Economic Co-operation and Development. Health at a glance 2013. Available at: http://dx.doi.org/10.1787/health_glance-2013-en. Accessed March 12, 2015. 3. Yoon J. The long-term care insurance system and the role of hospital care in Korea. Healthcare Policy Forum 2008;6:28e39. 4. Kwon S. The introduction of long-term care insurance in South Korea. Eurohealth 2009;15:28. 5. National Health Insurance Service. Available at: http://www.nhis.or.kr/cms/ board/board/Board.jsp?searchType¼ALL&searchWord¼&list_start_date¼&list_ end_date¼&pageSize¼&branch_id¼&branch_child_id¼&communityKey¼ B0160&pageNum¼1&list_show_answer¼N&boardId¼16&act¼VIEW. Accessed March 12, 2015. 6. Ha JH. Health care policy for older Koreans. In: Choi SJ, Bae JN, Min KH, et al., editors. Ageing in Korea, today and tomorrow. 3rd ed. Seoul, Korea: Federation of Korean Gerontological Societies; 2013. p. 130e139. 7. Seok J. Public long-term care insurance for the elderly in Korea: Design, characteristics, and tasks. Soc Work Public Health 2010;25:185e209. 8. Long-Term Care Insurance. Available at: http://www.longtermcare.or.kr/portal/ longtermcare/main.jsp. Accessed March 12, 2015. 9. Kang I, Park C, Lee Y. Role of healthcare in Korean long-term care insurance. J Korean Med Sci 2012;27:41e46. 10. National Health Insurance Service. 2013 Long Term Care Insurance Statistical Yearbook. Seoul, Korea: National Health Insurance Service; 2014. 11. Park JH, Won CW, Cho KH, et al. Research on improvement of institutional contracted doctors in nursing home. The report of Ministry of Health and Welfare. Gyeonggi-do: Ministry of Health and Welfare; 2011. Korea. No. 2011;11-1352000-000645-01:1e198. 12. Won C. Elderly long-term care in Korea. J Clin Gerontol Geriatr 2013;4:4e6. 13. Ga H, Won C. Perspective on long term care hospitals in Korea. J Am Med Dir Assoc 2013;14:770e772.
Sunyoung Kim, MD Department of Family Medicine College of Medicine Kyung Hee University Kyung Hee Medical Center Seoul, Korea Department of Medicine The Graduate School Ewha Womans University Seoul, Korea Chang Won Won, MD, PhD Department of Family Medicine College of Medicine Kyung Hee University Kyung Hee Medical Center Seoul, Korea Hyuk Ga, MD, PhD Department of Family Medicine Institute of Geriatric Medicine Incheon Eun-Hye Hospital Incheon, Korea
http://dx.doi.org/10.1016/j.jamda.2015.03.024
Nursing Homes and Their Contracted Doctors: Korean Experience
Table 2 Major Accompanied Diseases of the Long-Term Care Insurance Recipients by June 2014
To the Editor: The Korean elderly population is rapidly increasing; currently, approximately 13.4% of the population is 65 years or older,1 and this proportion is expected to reach 37.0% by 2050, which will give Korea the second-highest elderly population proportion among Organisation for Economic Co-operation and Development countries, after Japan.2 Since 2008, the Korean government has provided a national long-term care insurance (LTCI) program.3,4 Accordingly, there has been huge growth in the number of existing nursing homes and residents, from 128 nursing homes with 7864 residents in 2001 to 4079 nursing homes with 103,973 residents in 2013.5 Senior citizens who are 65 years or older and citizens who are younger than 65 years but have chronic senile diseases are eligible for LTCI services. If the eligible participants apply for LTCI services, a social worker and/or nurse from the National Health Insurance (NHI) Corporation agencies visits applicants to assess their capacity for activities of daily living (ADLs) according to the assessment criteria defined by LTCI law. LTCI recipients are finally classified into 5 categories according to the care needs of local LTCI committees taking account of the doctor’s note. They must be at least within category 3 to be admitted to a nursing home. LTCI is funded by the NHI. The NHI and the government are responsible for 80% (institutional services) to 85% (in-home services) of the expense of long-term care services (Table 1).6e9 One of the key challenges facing this program is that national LTCI and NHI are separate entities in Korea. Therefore, medical care in nursing homes is not reimbursed by LTCI. In reality, more than 95% of long-term care beneficiaries require medical services after being institutionalized in nursing homes (Table 2). To address these issues, long-term care facilities, by regulation, must contract with physician(s) or form agreements with local hospital(s), or both; the number of contracted doctors was reported to be 1166 as of the end of 2013.10 However, this regulation does not apply to group homes with a maximum capacity
Table 1 Application, Acceptance, and Benefit Rate of Long-Term Care Service in Korea
Elderly population Applicants for LTCI Application rate*, % Accepted elderly Acceptance ratey, % Beneficiaries Benefit ratez
533
2008 July
2010 December
2012 December
2014 June
5,028,357 272,662 5.4 146,643 82.1 134,249 91.5
5,436,969 759,339 14.0 315,994 67.8 281,119 89.0
5,914,202 643,409 10.9 341,789 68.9 307,773 90.0
6,335,294 709,308 11.2 393,927 71.0 350,607 89.0
Cited from major statistics in long-term care insurance. Available at: http://www.nhis. or.kr/cms/board/board/Board.jsp?searchType¼ALL&searchWord¼&list_start_date¼ &list_end_date¼&pageSize¼&branch_id¼&branch_child_id¼&communityKey¼ B0163&pageNum¼1&list_show_answer¼N&boardId¼28&act¼VIEW. Accessed Mar ch 12, 2015. *Applicants for LTCI divided by Elderly population. y Accepted people divided by Applicants for LTCI. z Beneficiaries divided by Accepted people.
Disease
No. of patients
Percentage
Dementia Stroke Dementia þ stroke Hypertension Diabetes Osteoarthritis Lower back pain, sciatica Dyspnea Hearing loss Cataract, glaucoma Sequelae after accidents, fracture Cancer Others Total
108,572 84,580 26,138 3,469 5,633 33,324 37,975 2,197 509 4,560 31,081 5,962 49,927 393,927
27.6 21.5 6.6 0.9 1.4 8.5 9.6 0.6 0.1 1.2 7.9 1.4 12.7 100
Cited from Major Statistics in Long-Term Care Insurance. National Health Insurance Corporation; 2011. Available at: http://www.nhis.or.kr/cms/board/board/Board.jsp? searchType¼ALL&searchWord¼&list_start_date¼&list_end_date¼&pageSize¼&bra nch_id¼&branch_child_id¼&communityKey¼B0163&pageNum¼1&list_show_ans wer¼N&boardId¼28&act¼VIEW. Accessed March 12, 2015. Note: Each recipient registers their most representative diseases.
of fewer than 10 residents (Table 3). Contracted doctors who specialize in family medicine, internal medicine, rehabilitation medicine, neurology, psychiatry, oriental neuropsychiatry, and other geriatric-related specialties are by regulation preferentially recommended. According to a survey by Park et al,11 private practitioners accounted for 57.8% of these contracted physicians. Approximately 69.0% of them had contracts with 1 or 2 nursing homes and 5.6% of them had contracts with 10 or more nursing homes. The specialties of the contracted doctors were family medicine (20.2%), internal medicine (18.4%), neurology (8.8%), general surgery (7.9%), psychiatry (7.0%), and oriental internal medicine (4.4%), among others. By regulation, contracted physicians must visit the facilities at least once every 2 weeks to clinically examine the residents and to order physiotherapy or nursing treatment, or to provide referrals to a hospital. However, they are not allowed to provide any direct medical services to the residents except for prescriptions, as these places are not designated as medical care facilities by law. Nurses or nurse’s aides on duty must evaluate the health status of every newly institutionalized resident, including consciousness, respiration, digestive function, and ADLs. They should also check vital signs, body weight, and medicines taken by the residents on a daily basis.12 Geriatric hospitals provide another distinct form of long-term care in Korea. They deliver various medical services like subacute to long-term care, palliative care, and rehabilitation medical services; as of early 2014, 1337 geriatric hospitals existed in Korea. Those hospitals are reimbursed by the NHI.12 The overlap in the roles played by nursing homes and geriatric hospitals remains a major issue. This is manifested in their similar patient composition, with dementia and stroke being the most prevalent conditions.13 In 2013, the Ministry of Health and Welfare published guidelines for contracted doctors working for nursing homes, but that is not enforceable. The Ministry of Health and Welfare also is seeking to develop and implement an education and qualification program for these doctors.
534
Letters to the Editor / JAMDA 16 (2015) 527e534
Table 3 Requirements for the Workers of Long-Term Care Facilities in Korea Long-Term Care Facility
Physicians (attending or contracted) Nurse or nurse’s aides Physical therapist Social workers Registered long-term caregivers Dietitians
Group Home
No. of Residents 30
No. of Residents 10w29
No. of Residents 5w9
1 1 per 25 residents 1 per 100 residents 1 per 100 residents 1 per 2.5 residents 1, only if the residents are 50 or older
1 1 As needed 1 1 per 2.5 residents Not required
Not required 1 1 1 per 3.0 residents Not required
Cited from Korea Institute for Health and Social Affairs, Standards of care for elderly welfare facilities and staffing standards (Article 22, paragraph 1, Revised Aug 29, 2013), Elderly Welfare Law Enforcement Rules, Health and Welfare Ordinance No. 203.
References 1. Statistics Korea. Available at: http://kosis.kr/statisticsList/statisticsList_01List. jsp?vwcd¼MT_ZTITLE&parentId¼A. Accessed March 12, 2015. 2. Organisation of Economic Co-operation and Development. Health at a glance 2013. Available at: http://dx.doi.org/10.1787/health_glance-2013-en. Accessed March 12, 2015. 3. Yoon J. The long-term care insurance system and the role of hospital care in Korea. Healthcare Policy Forum 2008;6:28e39. 4. Kwon S. The introduction of long-term care insurance in South Korea. Eurohealth 2009;15:28. 5. National Health Insurance Service. Available at: http://www.nhis.or.kr/cms/ board/board/Board.jsp?searchType¼ALL&searchWord¼&list_start_date¼&list_ end_date¼&pageSize¼&branch_id¼&branch_child_id¼&communityKey¼ B0160&pageNum¼1&list_show_answer¼N&boardId¼16&act¼VIEW. Accessed March 12, 2015. 6. Ha JH. Health care policy for older Koreans. In: Choi SJ, Bae JN, Min KH, et al., editors. Ageing in Korea, today and tomorrow. 3rd ed. Seoul, Korea: Federation of Korean Gerontological Societies; 2013. p. 130e139. 7. Seok J. Public long-term care insurance for the elderly in Korea: Design, characteristics, and tasks. Soc Work Public Health 2010;25:185e209. 8. Long-Term Care Insurance. Available at: http://www.longtermcare.or.kr/portal/ longtermcare/main.jsp. Accessed March 12, 2015. 9. Kang I, Park C, Lee Y. Role of healthcare in Korean long-term care insurance. J Korean Med Sci 2012;27:41e46. 10. National Health Insurance Service. 2013 Long Term Care Insurance Statistical Yearbook. Seoul, Korea: National Health Insurance Service; 2014. 11. Park JH, Won CW, Cho KH, et al. Research on improvement of institutional contracted doctors in nursing home. The report of Ministry of Health and Welfare. Gyeonggi-do: Ministry of Health and Welfare; 2011. Korea. No. 2011;11-1352000-000645-01:1e198. 12. Won C. Elderly long-term care in Korea. J Clin Gerontol Geriatr 2013;4:4e6. 13. Ga H, Won C. Perspective on long term care hospitals in Korea. J Am Med Dir Assoc 2013;14:770e772.
Sunyoung Kim, MD Department of Family Medicine College of Medicine Kyung Hee University Kyung Hee Medical Center Seoul, Korea Department of Medicine The Graduate School Ewha Womans University Seoul, Korea Chang Won Won, MD, PhD Department of Family Medicine College of Medicine Kyung Hee University Kyung Hee Medical Center Seoul, Korea Hyuk Ga, MD, PhD Department of Family Medicine Institute of Geriatric Medicine Incheon Eun-Hye Hospital Incheon, Korea
http://dx.doi.org/10.1016/j.jamda.2015.03.024
