South Korea implemented long-term care insurance on July 1, 2008, in response to rapid aging and shifts in social structure, aiming to alleviate the caregiving burden on families. This program has seen substantial growth in scope; by the end of December 2023, over 1 million beneficiaries were registered. There are 22,097 home care benefit providers and 6,269 institutional care benefit providers, with the total benefits from long-term care insurance amounting to 14.5 trillion KRW [1]. Despite this expansion, there remains some dissatisfaction among beneficiaries regarding the limited scope of benefits. Additionally, families of those in institutional care have expressed the need for improved end-of-life care services to enhance the quality of the services provided [2].

According to the 2019 long-term care survey, 68% of the beneficiaries were aged 80 or older, a figure that rose to 72.2% by 2022 [2,3]. Given Korea’s aging population, this proportion is expected to continue rising significantly. The demographic profile of long-term care insurance beneficiaries indicates a need for services that address the nursing, care, health, and medical needs of older adults at the end of their lives. Instead of focusing solely on life-prolonging treatments, there is an urgent need for a comprehensive approach to end-of-life care. This approach should include emotional, social, and spiritual support to assist older adults and their families in managing the effects of end-of-life diseases and their consequences. Such support is crucial to alleviate pain and discomfort in the terminal phase and to prepare for a comfortable death, while also providing daily living support and physical care [4]. Despite the clear need for end-of-life care services, long-term care insurance in Korea currently does not cover these services. Therefore, this article aims to propose measures and tasks to restructure long-term care insurance to include end-of-life care.

Article 23 of the Long-Term Care Insurance Act defines the types of long-term care benefits as benefits for home care services, institutional care benefits, and care allowances for special cases. Benefits for home care services include home visit care, home visit bathing, home visit nursing, day and night care, short-term respite care, and other related services. Care allowances for special cases encompass family care benefits in cash, exceptional care benefits in cash, and nursing expenses at a long-term care hospital. Furthermore, Article 14 of the Enforcement Rule of the Long-Term Care Insurance Act specifies that expenses related to food, upper-grade hospital rooms, hair and aesthetics, and other necessities of daily life are considered non-benefits. These expenses, as prescribed and notified by the Minister of Health and Welfare, are to be covered by the beneficiaries.

To understand the current status of end-of-life care within the framework of long-term care insurance, I reviewed the services outlined in the Notice on the Standards for Providing Long-Term Care Benefits and Calculating Methods of the Benefit Expenses. Providers of home care benefits are mandated to deliver long-term care services that support beneficiaries in living with their families and sustaining their daily activities at home.

Institutional care benefit providers are mandated to offer a range of services, including meals, oral care, bathing, defecation care, and transportation assistance. Specifically, they must ensure the provision of 1) regular meals at least three times a day, tailored to the nutritional needs, preferences, and health conditions of the beneficiaries, 2) a weekly bathing service, 3) hygiene care that encompasses defecation and oral care to help beneficiaries maintain cleanliness, 4) transportation assistance and adjustments to body position, taking into account the physical health conditions of the beneficiaries, and 5) additional services that support daily living activities. Furthermore, providers are required to offer programs aimed at maintaining and enhancing the physical and cognitive functions of beneficiaries, as well as regular counseling to support psycho-emotional stability. Nurses should be primarily assigned to manage the health care of beneficiaries. Additionally, it is necessary to either appoint contracted doctors for regular examinations at least twice a month or to collaborate with contracted medical institutions to ensure the provision of adequate medical services, thereby preventing any deterioration in the mental and health status of the beneficiaries (Table 1) [5].

Table 1 . Home-Based Benefits in Korean Long-term Care Insurance..

Benefit	Service
Home-visit care	Long-term care benefits provided by a long-term care Institution, where home visits are made to the beneficiary to support his or her physical activities and household chores
Home-visit bathing	Long-term care benefits providing baths by a long-term care agent, where home visits are made to the beneficiary with bathing equipment
Home-visit nursing	Long-term care benefits providing nursing, assistance in medical treatment, consultation on nursing or oral hygiene by a long-term care agent under the instructions of a nurse or directions on visiting nursing
Day and night care	Long-term care for the beneficiary for a certain period per day at a long-term care institution to support physical activities and to provide education and training on the maintenance and improvement of physical and mental functions
Short-term respite care	Long-term care for the beneficiary for a certain period within the range designated by the Ministry of Health and Welfare at a long-term care institution to support physical activities and to provide education and training on the maintenance and improvement of physical and mental functions

Current laws and public notices do not specify that long-term care insurance benefits should cover services related to end-of-life care. Similarly, these benefits do not extend to non-covered services. Additionally, visit care and medical services provided by institutional care providers do not encompass terminal care or treatments necessary at the end of life. Although counseling for psycho-emotional stability is broadly defined, it is challenging to infer that it includes counseling specific to end-of-life care.

Japan operates a long-term care insurance system similar to that of Korea, which includes medical fees for end-of-life care services. As beneficiaries often spend their final days in long-term care facilities, the number of these facilities offering end-of-life care services is on the rise. However, it has been observed that some facilities transfer beneficiaries nearing the end of life to medical institutions. To address this issue, specific fee items related to long-term care services are implemented. In the long-term care insurance system, fees such as the “end-of-life care addition,” “terminal care addition,” and “medical linkage addition” are applied to support end-of-life care for those with high medical dependency. The “end-of-life care addition” and “terminal care addition” are specifically applied to special nursing homes and health facilities for older adults, respectively. The additional fees are categorized based on the timing relative to death: “30 days to 4 days before the day of death,” “2 days and 1 day before the day of death,” and “the day of death.” With the 2018 revision of long-term care insurance fees, the “end-of-life care addition” for special nursing homes was updated. The medical care system saw improvements, and fees were differentiated by introducing “end-of-life care addition (II),” which applies if care is provided in the facility until the actual end of life. Additionally, “home visit fees” are applicable if a medical institution provides home visits for terminal cancer patients at a special nursing home or for patients whom a special nursing home cares for until their end of life. A “home visit terminal care fee” is also available if a medical institution provides home visits for terminal cancer patients at a special nursing home [6].

In Germany, the Supreme Federation of Sickness Fund (Der GKV-Spitzenverband) oversees the evaluation of long-term care institutions. One of the criteria used in these evaluations is the quality of services related to supporting the deceased and their families, which falls under the broader category of internal organization quality management. This category includes key questions such as: “Are there written regulations for the support of the deceased and their families?” “Are there regulations for cooperation with external facilities and a designated point of contact for these facilities?” “Are the needs of the deceased and their families during health crises and at the time of death documented?” “Is the patient’s statement of intent or advance directive communicated to the staff and adhered to when necessary?” and “Is direct information provided to the family upon the death of an older adult, in accordance with the family’s wishes?” [7]. Although the long-term care system in Germany does not recognize end-of-life care as a distinct benefit type, the assessment system encourages long-term care facilities to offer services that support death with dignity for residents.

The examples from Japan and Germany demonstrate that end-of-life care can effectively improve the quality of life in long-term care settings. However, it is crucial to tailor these approaches to the specific circumstances of each country [8]. In Korea, the long-term care insurance system needs to be restructured to incorporate end-of-life care. This restructuring should aim to broaden the range of services covered, enhance service quality, and support dignified death. A phased approach is essential for integrating end-of-life care services into the long-term care insurance system, and I propose several alternatives for consideration.

The first possibility is to introduce new benefits under the long-term care insurance for home care. Currently, home care benefits encompass home visit care, home visit bathing, home visit nursing, day and night care, short-term respite care, and welfare devices, with a monthly cap determined by the long-term care rating. It is proposed to add a special end-of-life benefit, allowing beneficiaries nearing the end of their lives to receive an increased monthly cap, thereby enabling additional access to home visit care or home visit nursing. Furthermore, it is worth considering the integration of home-based medical center services with the existing home care benefits.

Regarding the establishment of new benefit items, it is important to note that there are currently no clear criteria for setting benefits under long-term care insurance, along with a demand for various home care benefits. The 2022 Long-Term Care Survey revealed that families of home care beneficiaries are seeking additional services such as meal and nutrition, home visit medical care, vehicle support, and home renovation [2]. Given these findings, prioritizing the establishment of an end-of-life care benefit appears to be a practical challenge for the government. More fundamentally, within the current long-term care insurance framework, the National Health Insurance Service evaluates long-term care needs during the eligibility survey and develops an individual long-term care use plan, which is then implemented by the long-term care institution. However, the existing eligibility survey does not assess needs related to end-of-life benefits. Therefore, it is necessary to explore options for incorporating end-of-life care needs into both the eligibility survey and the individual long-term care use plan.

The second option is to introduce an additional fee to be incorporated into the premium for long-term care insurance. Currently, the benefits of long-term care insurance are disbursed at a fixed hourly rate for home care and a fixed daily rate for sanatoriums, senior citizen medical treatment facilities, and communal living homes. Notably, there are no provisions for end-of-life services in either public notices or relevant legislation. Given that long-term care insurance benefits are not varied and are disbursed at a fixed rate, it is challenging to categorize end-of-life services as a distinct benefit type. Consequently, a more feasible short-term solution might be to implement additional fees similar to those used in Japan. However, introducing such fees necessitates a discussion on the staffing criteria for institutions eligible to claim these additional fees.

The third possibility involves incorporating an assessment of end-of-life needs and related services into the evaluation of long-term care benefits. Establishing new benefit items or adjusting fees in the short term is not feasible. Given that long-term care institutions are evaluated every three years under Article 38 of the Enforcement Rule of the Long-Term Care Insurance Act, and receive additional payments based on these evaluations, it is proposed that assessment indicators relevant to end-of-life services be included. Institutions providing these services should receive extra points, highlighting the significance of end-of-life care in long-term care and promoting improvements in service quality.

Previous studies in Japan have shown that home-dwelling older adults nearing the end of life with long-term care insurance are significantly more likely to die at home compared to those without such insurance [9]. Additionally, the costs associated with physician-led home visit care were found to be lower than those for hospital care at the end of life [10]. These findings highlight the need to restructure long-term care insurance to better support end-of-life care. Given the challenges of completely overhauling or introducing long-term care insurance under the current conditions in Korea, implementing a pilot project is a practical approach. Moreover, empirical studies are essential to gather data on the effectiveness of end-of-life care provided through long-term care insurance. The impact of this care can be assessed in various dimensions, including the quality of life of beneficiaries, the incidence of home deaths, the satisfaction of beneficiaries’ families, and medical costs.

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2024.27.4.167.

No potential conflict of interest relevant to this article was reported.