A Qualitative Exploratory Study on the Service Delivery System for the New Long-Term Care Insurance System in Korea

ABSTRACT

To cope with the rapid growth in its aging population, the Korean government introduced a new social long-term care insurance (LTCI) system for elderly people beginning in July 2008. This study aims to understand how National Health Insurance Corporation (NHIC) staff and home-visiting service providers experienced and evaluated the new service delivery system. A total of 26 semistructured in-depth interviews were conducted with NHIC staff primarily responsible for the functional assessment of the elderly and the home-visiting service providers responsible for providing direct services to elderly clients. In summary, interviewees had negative experiences with the new service delivery system such as difficulties in carrying out their roles. The findings suggest that Korea's new LTCI service delivery system faces challenges and that a more active role for the Korean government, especially regarding the introduction of a proper care management system, is needed to address the issues. Future research with larger sample sizes is needed to examine and understand the issues in detail.     

Home care development in Korea and Germany: The interplay of long-term care and professionalization policies

The aim of the study was to compare the effects of long-term care and professionalization policies on the development of home care infrastructure and the care workforce in reference to long-term care insurance systems adopted in Germany and Korea. A comparative analysis of the effects of the two policy systems allowed us to examine distinct forms of marketized home care service expansion. In both countries, the opening-up of care markets has brought about a significant expansion of home care services through the active participation of mainly for-profit providers. However, a trade-off between the rate of expansion, the quality of care services, and the stability of care infrastructure has emerged. The market-based expansion of home care services has resulted in difficult employment and working conditions for care workers in both countries. The country-specific organization of home care and related professionalization approaches has led to the development of a well-trained care workforce with less precarious conditions in Germany but not in Korea. Despite this difference, less well-trained care workers experience precarious employment in both countries.     

Organization and Supply of Long‐term Care Services for the Elderly: A Bird's‐eye View of Old and New EU Member States

This article provides an overview of the organization of formal long‐term care (LTC) systems for the elderly in ten old and 11 new EU member states (MS). Generally, we find that the main responsibility for regulating LTC services is centralized in half of these countries, whereas in the remaining countries, this responsibility is typically shared between authorities at the central level and those at the regional or local levels in both institutional and home‐based care. Responsibilities for planning LTC capacities are jointly met by central and non‐central authorities in most countries. Access to publicly financed services is rarely means tested, and most countries have implemented legal entitlements conditional on needs. In virtually all countries, access to institutional care is subject to cost sharing, which also applies to home‐based care in most countries. The relative importance of institutional LTC relative to home‐based LTC services differs significantly across Europe. Although old MS appear to be experiencing some degree of convergence, institutional capacity levels still span a wide range. Considerable diversity may also be observed in the national public–private mix in the provision of LTC services. Lastly, free choice between public and private providers exists in the vast majority of these countries. This overview provides vital insights into the differences and similarities in the organization of LTC systems across Europe, especially between old and new MS, while also contributing valuable insight into previously neglected topics, thus broadening the knowledge base of international experience for mutual learning.     

Long-term care reform in Korea: lessons from the introduction of Asia's second long-term care insurance system

Korea was the second Asian country to introduce universal long-term care insurance in an attempt to meet the challenges posed by its ageing population. This article presents an overview of the key issues that were involved in designing and implementing the new Korean system and the lessons that have been learned. Although the government reformed the long-term care system, a number of new challenges have emerged, such as its limited coverage and the unethical behavior of service providers. These problems appear to be closely associated with the scheme's initial design flaws and the government's passive responses to these problems.     

Design limitations of long-term care insurance schemes: A comparative study of the situation in Spain

Social and demographic changes are gradually transforming the way Western societies cope with old‐age dependency, in particular the provision of long‐term care (LTC). In response to the need for formal care services and financing instruments, this study examines a range of both private and public insurance tools. As a general rule, LTC insurance is markedly underdeveloped. Furthermore, in southern European countries, the role of the public sector in LTC is unclear compared with its role in other, related welfare areas such as healthcare. The study examines the financing alternatives for LTC insurance, taking as its benchmark the Spanish LTC financing reform. It briefly examines some existing, publicly funded LTC financing tools and explores the potential role of private LTC insurance, arguing that it has an active part to play alongside compulsory mainstream insurance schemes and self‐insurance alternatives. As in other European countries, Spanish social attitudes show a preference for some kind of general entitlement to publicly funded schemes, although this preference is subject to significant regional heterogeneity.     

The Development of Korea's New Long-Term Care Service Infrastructure and Its Results: Focusing on the Market-Friendly Policy Used for Expansion of the Numbers of Service Providers and Personal Care Workers

One of the main reasons for reforming long-term care systems is a deficient existing service infrastructure for the elderly. This article provides an overview of why and how the Korean government expanded long-term care infrastructure through the introduction of a new compulsory insurance system, with a particular focus on the market-friendly policies used to expand the infrastructure. Then, the positive results of the expansion of the long-term care infrastructure and the challenges that have emerged are examined. Finally, it is argued that the Korean government should actively implement a range of practical policies and interventions within the new system.     

Analysis and Advocacy in Home- and Community-Based Care: An Approach in Three Parts

A new chapter in health policy presents both challenges and opportunities for aging policy analysts and advocates concerned with long-term care. Millions of long-term care recipients and providers live today in a pubic policy netherworld, one principally associated with Medicaid. I suggest here that moving policy forward will entail three key steps: (a) to overcome structural lag in key home and community-based care (HCBC) policy arenas; (b) to reverse a contemporary pattern of risk-shifting from institutions to individuals; and (c) to inform and empower caregivers to have their own pressing needs recognized. Recent developments in Washington provide new optimism on these fronts. Voluntary long-term care and community-based care (LTC/HCBC) proposals are on the table within the broad context of health care reform. Whether they remain will be, in large, part a function of how far we have moved along the fronts described: modernizing policies, recognizing risks, and activating neglected policy constituencies.     

Long-term Care in China: Issues and Prospects

One of the major socioeconomic challenges China faces is the rapid aging of its population. China is now an aging society, even though it is still regarded as a middle-income economy. Coupled with the market-driven reform of social services and rapid erosion of family support, the provision of affordable and accessible social care services to older people has already become an urgent issue for the government to address. Looking into the future, the formulation of a sustainable position on long-term care (LTC) will increasingly become the major focus of social policy. This article sets out the background to the demographic shifts resulting in the emerging need for LTC in China. It analyzes the issues facing LTC services and reviews their prospects, including the structure, operation, financing, and interfacing of residential and community-based home care services.     

Long-term care insurance and bequests as instruments for shaping intergenerational relationships

The growing demand for long-term care (LTC) causes the relationship between children and their parents to gain increased importance for society. Parents may create incentives for children to provide LTC through bequests, or they may purchase LTC insurance. While these instruments have been analyzed separately in the literature, this article shows that optimal LTC insurance must be small in the presence of bequests. Thus, the failure of private LTC insurance to diffuse into middle-class households may be explained by the fact that the bequest instrument is fully available to the current generation of parents, who for the first time since 1914 are in a position to bequeath an intact stock of capital in major industrialized countries.     

Choices, Policy Logics and Problems in the Design of Long–term Care Systems

Establishing a public, comprehensive, independent, mainly community–based long–term care system, separate from medical care and social services, can lead to the provision of more effective and consumer–oriented services, and also to a more appropriate mix of public/private financing. Of the two main approaches to financing long–term care (LTC), a tax–based model is more flexible in providing benefits according to the individual's need, since income levels and the family's ability to provide care will be taken into consideration, while a social insurance model is more rigid because the individual's rights are more explicitly defined. The latter system is likely to provide more opportunities for choice, including decisions about the mix of health and social services. Policy–makers must decide which approach to take after weighing the positive and negative aspects of each, and the existing organizational infrastructure. Decisions must also be made on the practical issues of coverage, fairness, form of benefits, service delivery patterns, relationship with medical and social services, and controlling costs. With increasing pressure to contain public sector expenditures and improve efficiency, the focus of care will gradually shift from medical care to LTC, and within LTC, from institutions to housing. How to make this process proactive and planned, instead of ad hoc and reactive, is the challenge for public policy.     

Balancing Long-term Care in Japan

This article discusses Japan's long-term care (LTC) from the perspective of balancing the provision and financing of care. Specifically, this article provides an overview of the long-term care insurance (LTCI) system in Japan and analyzes the current state of Japan's LTC with current statistical data as to whether the supply meets the demand for care by frail elders and their families.     

Two-sided intergenerational moral hazard,long-term care insurance,and nursing home use

Two-sided intergenerational moral hazard occurs (i) if the parent’s decision to purchase long-term care (LTC) coverage undermines the child’s incentive to exert effort because the insurance protects the bequest from the cost of nursing home care, and (ii) when the parent purchases less LTC coverage, relying on child’s effort to keep him out of the nursing home. However, a “net” moral hazard effect obtains only if the two players’ responses to exogenous shocks fail to neutralize each other, entailing a negative relationship between child’s effort and parental LTC coverage. We focus on outcomes out of equilibrium, interpreting them as a break in the relationship resulting in no informal care provided and hence high probability nursing home admission. Changes in the parent’s initial wealth, LTC subsidy received, and child’s expected inheritance are shown to induce “net” moral hazard, in contradistinction to changes in child’s opportunity cost and share in the bequest.     

Supplemental home care and topping‐up: A shift from service universalism towards a new and privatised public service model?

How does a public service model based on service universalism react to the introduction of market principles of topping up? In a recent so‐called Free Municipality Scheme (an experimental scheme that allowed for greater operational autonomy locally in an effort to reduce state bureaucracy), a number of Danish municipalities were for the first time ever allowed to compete with for‐profit providers of home care in selling supplemental home care services paid entirely by the user. The take‐home message from this experience is that the introduction of supplemental home care entails challenges and eventually wider implications for the public service model, on an economic, organisational and cultural level. Supplemental services represent a new and potentially powerful combination of market and state logics that eventually redirects away from the universalist welfare state and towards a new and increasingly privatised public service model – a model where the service level is determined by the user's capacity to purchase and pay for services. The introduction of such services therefore implies a change of the potential of the Nordic welfare state to ensure equal access regardless of class and income.     

Choice,Competition and Care – Developments in English Social Care and the Impacts on Providers and Older Users of Home Care Services

This article critically examines recent changes in markets for home (domiciliary) care services in England. During the 1990s, the introduction of competition between private (for‐profit and charitable) organizations and local authority providers of long‐term care services aimed to create a ‘mixed economy’ of supply. More recently, care markets have undergone further reforms through the introduction of direct payments and personal budgets. Underpinned by discourses of user choice, these mechanisms aim to offer older people increased control over the public resources for their care, thereby introducing further competitive pressures within local care markets. The article presents early evidence of these changes on:

• The commissioning and contracting of home care services by local authorities and individual older people.
• The experiences and outcomes for individual older people using home care services.

Drawing on evidence from two recent empirical studies, the article describes how the new emphasis on choice and competition is being operationalized within six local care markets. There are suggestions of small increases in user agency and in opportunities for older people to receive more personalized home care, in which the quality of care‐giving relationships can also be optimized. However, the article also presents early evidence of increases in risk and costs associated with the expansion of competition and choice, both for organizations providing home care services and for individual older service users.     

Promoting Personalization in Social Care Services for Older People

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Promoting personalization in social care services for older people

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Raising the Quality of Home Care: A Study of Service Users' Views

Raising standards is one of the key objectives of the British government's Modernizing Agenda. The quality of life of vulnerable older people who are being maintained at home is fundamentally dependent on the quality of the home‐care services they receive, so raising standards of home care is clearly central to this agenda. This paper draws on a small‐scale study of service users and providers to examine the aspects of quality of home care of importance to older people, their experiences and barriers to improvement. Six key aspects of quality were investigated: reliability, continuity, flexibility, communication, staff attitudes and skills and knowledge. If performance indicators are to have the desired effect, more work needs to be done to ensure they reflect key aspects of quality from the user perspective. We identify potential areas for improvement in commissioning and organization but these all have resource implications that will need to be met if home care is to realize its full potential in maintaining and improving quality of life for older people.     

From Official Supervision to Self‐monitoring: Privatizing Supervision of Private Social Care Services in Finland

In October 2011, a new Act on Private Social Care Services came into force in Finland. The Act included a provision on a ‘self‐monitoring plan’. According to the provision, providers of private social care services are required to draw up a self‐monitoring plan and to follow its realization. The plan must be kept publicly on view so that clients and their relatives can also keep an eye on the realization of self‐monitoring. In this article, self‐monitoring is first explained and then briefly analyzed against the background of a wider theoretical discussion on accountability. It is argued that the introduction of client involvement in the supervision of private social care services represents a new mechanism of accountability that is typical of the Post‐Keynesian welfare state. Because public authorities are no longer able to supervise the growing number of private social care service providers, the responsibility has been partly shifted to service providers themselves as well as to clients. However, it is argued that the idea of self‐monitoring lends itself poorly to ‘delegated’ private social care services, i.e. to services that are outsourced to private service suppliers. Supervision of private social care service providers should not be too eagerly delegated to service providers themselves, or to clients, because we are here dealing with the constitutional right to adequate social care services. Client involvement also involves numerous practical problems, as shown at the end of the article.     

Reconciling Cash and Care: Home Care Charges and Benefit Checks in Social Services

Correspondence to Pete Alcock, Health and Community Studies, Sheffield Hallam University, Collegiate Cresent, Sheffield S10 2BP Summary This article contains the report of a small research projecton the development of welfare rights checks for home care clientsin social services departments. Welfare rights take-up activityhas become an important feature of provision by local authoritysocial services departments, frequently targeted on particulargroups of clients known to experience problems in claiming fullbenefit entitlement. Users of home care services are such aclient group. Take-up work with home care clients is also, however,a product of the impact of community care policy changes andof financial pressures on local authority social services. Thesehave resulted in the introduction of charges for home care servicesby many authorities, and the use of rebates from such chargesto protect low income service users. Welfare rights work hasthus become an important feature of the reconciliation of thesenew charging policies with the continued service needs of poorhome care clients. The research examined a successful take-upinitiative, linked to home care charges, in Sheffield and contrastedthis with similar activities in other authorities throughoutthe UK. The conclusion is reached that levels of non-take-upof social security benefits are particularly low amongst homecare clients and that benefit checks can secure significantadditional income for them, which may also have the indirecteffect of increasing the income to social services departmentsfrom the charges for home care services.     

Introducing social insurance for long‐term care in Taiwan: Key issues

Nadash P, Shih Y.‐C. Introducing social insurance for long‐term care in Taiwan: Key issues Taiwan will shortly complete its comprehensive social safety net, which includes national health insurance, retirement security, and unemployment insurance, by introducing long‐term care (LTC) insurance – putting it ahead of the many countries that rely on a patchwork of policies to address the need for LTC. The program, to be implemented in 3 to 5 years, will cover all citizens on a primarily social insurance basis. The range of LTC policy options considered is discussed, particularly how to structure the program, how to finance and regulate it, and how to develop its inadequate LTC infrastructure and workforce. Particularly thorny issues include the choice of social insurance, the feasibility of cash benefits, and how to address Taiwan's heavy reliance on foreign workers. Taiwan's increasingly democratic character, along with high levels of public support for the program, creates significant pressure on politicians to deliver on their promises to implement LTC reform. Key Practitioner Message: ?Emphasizes the importance of policy learning from other environments; ?Highlights the need for a strong regulatory and provider infrastructure for delivering long‐term care services; ?Emphasizes the need for training, support, and appropriate regulation of the long‐term care workforce.