1.Background

Average life expectancy is increasing due to impro-vements in living standards, development of medical tech-nology, and interest in health¹⁾. In addition, due to the rapid decline in the birth rate and the increasing tendency of nuclear families, the aging of the population and the resulting nursing and care are emerging as a national task. Long-term care insurance (LTCI) is a system that pays insurance premiums and receives benefits for the nursing and care of persons with social activity restrictions that make daily life difficult and the elderly. Germany intro-duced nursing care insurance for the elderly for the first time in the world in 1995, separate from the health care insurance system²⁾, and Luxemburg and Japan started LTCI system in 1999 and 2000, respectively³⁾. Korea also recognized this situation and implemented LTCI system for the elderly in July 2008 after going through the pilot project from 2001 with reference to LTCI of Germany and Japan⁴⁾. Currently, Germany operates a social insurance method, and Korea and Japan operate a mixed method of social insurance and tax-based methods.

In Korea, the determination of a long-term care bene-ficiary is based on the long-term care certification grade for physical function, cognitive function, behavior change, nursing care, and rehabilitation areas when it is recognized that it is difficult to carry out daily life alone due to a disability of mental and physical function for a period of six months or more. Grades 1 and 2 can use the facility service, and grades 3, 4, and 5 and cognitive support grade (dementia) can use the home service in Korea. Providing long-term care benefits for the elderly in Korea is based on adequate benefit provision and home benefit priority pro-vision depending on user needs. Visiting nursing in LTCI for the elderly is the medical service provided to the elde-rly who have a health problem, where a care worker visits the beneficiary’s home and provides nursing, assistance in medical treatment, consultation on care, or oral hygiene according to the visiting nursing instructions from doctors, Korean medical doctors, and dentists. Although there was home nursing care service for discharged patients or visiting healthcare service for low-income and vulnerable groups performed at the public health center in the past, the services in LTCI were expanded to the elderly at home in need of care and patients with dementia, which is of institutional significance in that the target and scope of activities have been expanded⁵⁾.

Health problems that affect the elderly in Korea are mostly physical and functional problems, and it was found that 38.1% of the elderly aged 65 or older suffers from oral health problems⁶⁾. In general, in the elderly, salivary secre-tion decreases due to the effects of aging and medication, and periodontal diseases, tooth loss, xerostomia, dysma-sesis, dyslalia, and dysphagia are occurred⁷⁾. Oral health problems that affect the elderly are closely related not only to oral health-related quality of life but also to systemic health⁸⁾. Therefore, visiting oral health care services to improve oral function in the elderly and prevent oral diseases are required, and it is encouraging that oral hygiene work is included in LTCI for the elderly. Despite legal regulations to provide visiting oral health care ser-vices in Korea, finding practical examples of operations is difficult.

2.Objectives

This study aims to propose a method to activate the visiting oral health care services in Korea by comparing the visiting oral health care services of LTCI in Japan, where the visiting oral health care services are actively performed, with the system in Korea. Specific study obje-ctives are as follows. We plan to suggest improvements to visiting oral health services in Korea by comparing the general characteristics of LTCI in Korea and Japan, visiting oral health care services within LTCI, record forms used by LTCI, and personnel performing visiting oral health care services.

1.Study design

This descriptive survey study analyzed the secondary data such as statistics, laws, and related forms of each country to compare the oral hygiene of visiting nursing, which is implemented in LTCI Act in Korea, and oral hygiene mana-gement, which is implemented in LTCI in Japan.

2.Study data

This study extracted the most recent institutional documents among the extracted documents after entering search keywords of LTCI, oral health management, oral care, oral hygiene, Korea, and Japan on Google. Data from the Ministry of Health and Welfare (MOHW) and National Health Insurance Service (NHIS) are the central axis, and data from National Cancer Center⁹⁾ and a private research institute, Korea Insurance Research Institute¹⁰⁾ were also used when the relevant information in the MOHW was insufficient. Regarding visiting oral health care services in Korea, newspaper articles published by Korean Dental Association were also referenced if it was difficult to find related data as institutional documents. As Korean data, 2022 Handbook of Home Nursing Care Services for Medical Institutions¹¹⁾, Hospital-based Visiting Nursing Service Manual⁹⁾, LTCI Act, and statistical data from NHIS¹²⁾ were used as primary data. As Japanese data, data from the Ministry of Health, Labour, and Welfare¹³⁾ and data from the local government¹⁴⁾ and Japan Dental Hygie-nists’ Association¹⁵⁾ were used.

3.Study variables

Comparing the differences between Korean and Japa-nese insurance systems was considered a priority before comparing visiting oral health care services. Hence, sou-rces of long-term care benefits, copayment amount, mon-thly limit of long-term care benefits, and benefit recog-nition grade were investigated. For visiting oral health care services, service provider, service use cost, and service contents provided based on the record were investigated. The number of implemented cases was investigated to determine whether visiting oral health care services were implemented.

1.Comparison of general characteristics of long-term care insurance in Korea and Japan

As described in Table 1, the sources of LTCI in both Korea and Japan are a mixture of tax, which is public assistance, and social insurance, but Japan consists of 50% of tax and 50% of insurance premium, while Korea consists of 20% of tax and 80% of insurance premium. Exploring the copayment, the home benefit is 15%, and the facility benefit is 20% in Korea, and in Japan, there are 10∼30% of copayments depending on the income level, and benefit recipients of 90% or more pay only 10%. Thus, the level of copayment in Korea is high. The mon-thly limit of long-term care benefits in Korea varies depending on the grade, and the monthly limit for the most supported grade was 1,520,700 Korean Won (KRW) in 2021. Japan differs depending on the region, and based on Osaka, the grade that received the most support could receive a benefit of 362,170 Japanese Yen (JPY) in 2021, approximately 2.4 times as much as in Korea. Exploring the use procedure for long-term care services in Korea, NHIS performs an investigation and determines the care grade. In contrast, Japan’s procedure is community- oriented because applications are filed in the municipality, and the municipality investigates and reviews to determine the degree of need for care. Benefit recognition grade determination criteria are similar between Korea and Japan, but Japan can be considered prevention-oriented because it has new preventive benefits targeting mild cases.

Table 1

Comparison of Long-term Care Insurance between Korea and Japan

Category	Korea	Japan
Financial resources	Public assistance (Tax) 20%＋national insurance 80%	Public assistance (Tax) 50%＋national insurance 50%
Copayment	Home care: 15% Facility care: 20%	10∼30% according to income in 65＋ 10% over 40 and under 65＋with 16 specified illnesses
Insurer and manager	National Health Insurance Corporation	Local government
Care level	5 long-term care levels and 1 cognitive support level	5 levels of care need and 2 levels of cognitive support including prevention level
Care level criteria	Care score	Care time needed
Monthly limit in home care	1,520,700∼573,900 Korean Won in 2021 1,885,000∼624,600 Korean Won in 2023	362,170∼50,320 Japanese Yen in Osaka in 2021
Care plan	National Health Insurance Corporation	Care manager in local government

2.Comparison of visiting oral health care services in long-term care insurance

As seen in Table 2, visiting oral health care service providers in Korea are dental hygienists following the dentist’s visiting nursing instructions, and dental personnel can provide professional oral health care. It is not legally clear whether other long-term care workers can provide oral health care. To provide visiting oral health care services, oral hygiene care providers need visiting nursing instruction. The cost of issuing the visiting nursing instru-ction for visiting oral health care services is 21,520 KRW if the subject visits the dental clinic or hospital and 67,880 KRW if the dentist visits the home as of 2023. In addition, the visiting nursing service cost per visit is the diagnosis- related group payment system, 39,440 KRW for less than 30 minutes, 49,460 KRW for more than 30 minutes and less than 60 minutes, and 59,500 KRW for more than 60 minutes. Visiting care fees for other dental treatments do not exist in Korea except for oral health care.

Table 2

Comparison of Visiting Dental Care Service between Korea and Japan

Category	Korea	Japan
Visiting dental care service provider	Dentist, dental hygienist	Dentist, dental hygienist Nurse, speech-language-hearing therapist, and nursing facility staff can care daily oral health following dental hygienists’ instruction
Types of dental care service provided	Oral hygiene	Oral hygiene Oral function management
Dental treatment in home	Not possible	Some treatment and surgery, denture repair
Cost of visiting dental care service	Payment on time regardless of type of service 1. Cost of visiting nursing instruction by dentist -21,520 Won for a subject to visit a medical institution -67,880 Won for a dentist to visit a home 2. Cost of visiting nursing including dental health care service -39,440 Won for less than 30 mins -49,460 Won for more than 30 mins and less than 60 mins -59,500 Won for more than 60 mins in 2023	Payments to depend on the visit time and the number of patients in the same building 1. Cost of visiting dental treatment -830 points for 20 mins or more in a place with a patients -380 points for 20 mins or more in a place with 2 patients or more -218 points for 20 mins or less in the first visit 2. Cost of visiting nursing including dental health care service 1) Dentist (up to twice a mo) -516 points in a patient in a place -486 points in 2~9 patients in a place -440 points in 10 patients or more in a place 2) Dental hygienist (up to 4 times a mo) -361 points in a patient in a place -325 points in 2~9 patients in a place -294 points in 10 patients or more in a place 1 point is equivalent to about 10 Yen in 2022

In Japan, dental hygienists evaluate the situation in individual subjects’ oral health and set oral health care plans, and multiple occupations can jointly practice oral care. Japan has visiting care fees, and dental visit fees or visiting dental hygiene instruction fees can be calculated. In addition to oral health care services, some treatments, surgeries, and denture repairs can be performed in the visiting care. Visiting care fee varies depending on visiting treatment hours and the number of patients in the same building, and for one patient, it is 2,180 JPY (appro-ximately 21,000 KRW) for the first treatment of less than 20 minutes and 8,300 JPY (approximately 78,000 KRW) for more than 20 minutes. In 2021, long-term care insu-rance payment for one person was 5,160 JPY (approxi-mately 49,000 KRW) for dentists and 3,160 JPY (approxi-mately 30,000 KRW) for dental hygienists.

3.Comparison of the records of visiting oral health care services

As described in Table 3, the visiting nursing instruction for dentists is to record the dental plaque test, dental plaque care education, medication prescription, and visiting nursing services include professional tooth cleaning, scaling, periodontal treatment, treatment of wound stomatitis, pos-toperative care, mechanical tooth cleaning, fluoride appli-cation, denture care, and others (Supplementary Fig. 1). The visiting nursing record is designed to mark the oral care among nursing management and record the start, end, and total times (Supplementary Fig. 2). Korean record does not evaluate the oral function and focus only on oral hygiene.

Table 3

Comparison of Record Form of Visiting Dental Care Service between Korea and Japan

Category	Korea	Japan
Basic information	Name, resident registration number, level of long-term care, disease	Name, birthday, sex, type of food, aspiration pneumonia
Screening or oral examination	Chief complaints Patient’s oral health Only dentists	1. Oral hygiene: Oral malodor, tooth staining, denture staining, tongue coating 2. Oral function: Spilling food, slow tongue movement, wrong pipe, sputum, dry mouth 3. Oral disease: Total number of teeth, tooth disease (decay, fracture) periodontal disease, ulcer, denture problem 1 and 2 can be done by a dental hygienist or nursing staff or speech-language-hearing therapist, but only a dentist can do 3
Nursing instruction or plan	Plaque examination Oral health education: Plaque removal, toothbrushing method, use of floss or interdental brush Prescription Visiting nursing service by dental hygienist: Professional oral cleaning, interdental cleaning, dental scaling, fluoride application, periodontal treatment, denture cleaning, stomatitis treatment, postoperative care Only dentists	1. Patients -Objective: Dental disease (prevention or treatment), oral hygiene (improved self-care, periodic management by professionals), eating and swallowing function, type of food, nutrition, prevention of aspiration pneumonia -Service: Oral hygiene management, instruction of oral hygiene, denture cleaning, instruction of denture cleaning, instruction to improve oral function including eating and swallowing -Frequency of visits -Linkage with other occupations 2. Nursing staff -Objective: Screening by nursing staff, instruction for nursing staff, re-examination of oral hygiene by nursing staff, assessment by dental professionals, dietary environment and food type confirmation by dental professionals -Service: Oral hygiene management, Instruction of oral hygiene, denture cleaning, instruction of denture cleaning, instruction to improve oral function including eating and swallowing, technical advice for nursing staff, dietary environment and food type confirmation
Practice record	1. Start time, end time, total time 2. Oral hygiene care	1. Start time, end time 2. Working with dentist (Yes, No) 3. Practice: Oral hygiene, instruction of oral hygiene, denture cleaning, instruction of denture cleaning, instruction to improve oral function including eating and swallowing, instruction to prevent aspiration pneumonia

Japan’s oral health care service record is well organized. When evaluating subjects, not only oral hygiene but also oral function-related evaluations are conducted, and oral hypofunction has been included in insurance since 2018. Food form and aspiration pneumonia are recorded as basic information in the oral health care plan, and in the screening, halitosis, teeth staining, denture staining, and tongue coating are investigated for oral hygiene condi-tions. In addition, for the oral function status, spilling while eating, slowness of tongue movement, swallowing the wrong way, sputum, and dry mouth are investigated. The number of teeth, dental caries, fractures, periodontal diseases, mucosal problems, and denture problems are evaluated if necessary under the dentist’s judgment. The instruction plan consists of preventing or treating dental diseases, oral hygiene, eating and swallowing function, food form, nutrition status, and prevention of aspiration pneumonia. Implementation contents include oral hygiene management, guidance for oral hygiene management, denture cleaning, guidance for denture cleaning, guidance for oral functions such as eating and swallowing, and guidance for aspiration pneumonia, and the frequency of visits is also recorded. The implementation record is to record whether to accompany the dentist, technical instru-ction points for nursing care staff, tasks to be addressed, and special notes. Relevant records used in Japan are provided in Supplementary Fig. 3∼6.

4.Comparison of the number of implementations of visiting oral health care services

Despite the fact that LTCI was started in 2008 in Korea, the number of issued visiting nursing instructions from dentists was 10 cases in 2018, six in 2020, one in 2021, and a total of 17 cases for five years from 2017, according to the data from NHIS. Dental hygienists working in home care institutions were seven in 2017, 10 in 2018, seven in 2019, 14 in 2020, and 12 in 2021, and dental hygienists working in the facility is 0. The number of dentists working in care institutions is 0. In Japan, 22,007 dental clinics received visiting treatment fees, and 7,880 dental clinics received visiting dental hygiene instruction fees. The calculation for visiting dental hygiene instruction fee occurred a minimum of 4,294 times and a maximum of 5,585 times per month from April 2019 to March 2021¹⁰⁾.

1.Interpretation

As a result of comparing oral health care services by LTCI in Korea and Japan, visiting oral health care services in Korea has an insurance system and related fees at a level similar to Japan, but it seems that it is not actually operated. This study attempted to discover why visiting oral health care services are not working appropriately in Korea by comparing related data of Japan and Korea. We classified them into four factors. The first is the possibility of visiting treatment, the second is oral function evaluation and improvement service, the third is the monthly limit of LTCI benefits, and the fourth is linkage with other long term care providers.

Visiting care has been included in medical insurance since 1986 in Japan, and home medical institutions specializing in this have emerged. Unlike a house call requested by patients only when sick, visiting care was regularly visited at a set time, two to three times a month, and collaborated with nurses, pharmacists, and physical therapists. Collaboration in the long-term care home medi-cal team, such as visiting nursing, rehabilitation, and care guidance, has become more critical since LTCI was esta-blished in 2000. There is also a community center for connection between patient and doctor, and the center connects care managers, nurses, and social workers, and in addition to medical treatment, it also supports civil com-plaints^16,17). As of 2021, 5,270 community centers are operated in Japan. In contrast, Korea has not institu-tionalized visiting care. The basic plan for community integrated care was published in 2018, and a pilot project for visiting treatment fees for primary medical care and community care project for community integrated care are currently in progress. However, only medicine and Korean medicine were included in the pilot project for visiting care, and dentistry was not included. Thus, the fact that dental visiting treatment in Korea is not activated is thought to be the cause of low application for oral health care services in long-term care insurance. Nevertheless, researchers are constantly making suggestions for visiting oral health care service activation to participate the oral health project in the community project^18,19).

When comparing the record of oral health care services, the screening and instruction plans of Japan were more specific than Korea, and it seems judgment and guidance for oral function status were performed only in Japan. Japan defined frail as the intermediate stage between health and the need for long-term care²⁰⁾, and preventive mea-sures of nutrition, physical activity, and social partici-pation, including oral function, were suggested so that people can return to a healthy state before becoming nursing-requiring status. At the oral frail stage, the long- term care prevention seems essential in the community health project. Tanaka et al.²¹⁾ presented six items of the oral functional test: the number of natural teeth, chewing ability, articulatory oral motor skill for "ta", tongue pre-ssure, subjective difficulty in eating tough foods, and subjective difficulty in swallowing. A person who meets three or more of these is defined as oral frail and diagno-sed with oral hypofunction²²⁾. The rationale for active intervention by dentists and dental hygienists was esta-blished as oral hypofunction is included in the insurance item. Compared to this, it seems that there is no test or service for oral function in Korea because visiting oral health care services are focused on oral hygiene. Although visiting nursing includes nutrition management, it is not institutionalized, such as not being dealt with by dental professionals, and no fee for the oral function assessment is determined in Korea. It is thought that the dental community in Korea is still passive in the test for oral hypofunction, and it is not being implemented adequately.

The third is the difference in the monthly limit of long- term care benefits. The long-term care benefits in Korea has home benefits, such as visiting care, visiting bath, visiting nursing, day and night protection, and short-term protection, facility benefit that allows admission to medi-cal welfare facilities for the elderly, and cash benefit that can be received in cash such as family care expenses. Payment expenditure by NHIS for home benefits in 2016 was 73.8% for visiting care, 16.6% for day and night protection, 5.4% for welfare equipment, 3.5% for visiting bath, 0.6% for short-term protection, and 0.4% for visiting nursing, showing the utilization rate of visiting nursing was very low²³⁾. Visiting oral health care services in Korea belongs to visiting nursing. Compared to Japan, the monthly limit of Korea is approximately 40%, which is less than the amount of health care benefits people can receive. The number of people applying for visiting oral health care services to professional dental personnel is inevitably smaller in this environment.

Lastly, it is whether to connect with other fields, including medicine and nursing. Oral health is a crucial factor for general health, well-being, and quality of life among the elderly²⁴⁾, and the influence between oral health indicators and senility is recognized in other fields as well²⁵⁾. Exploring the visiting oral health care service in Japan, it seems that a dental hygienist visits up to four times a month to manage the subject’s oral cavity and guides the care workers in managing the subject’s oral health and function. According to Haresaku et al.²⁶⁾, although not all care workers were interested in oral health care, 20∼60% of them cooperated with oral health care, and more than 75% were willing to cooperate with implementation. If Korea also includes training for care workers who can continuously manage the subjects as a service item, rather than providing visiting oral health care services in the dental field alone, it will help improve the oral health and oral function of the subjects.

2.Suggestion

Fortunately, Korean politicians are lately showing interest in the fact that visiting oral health care services are not activated in LTCI^27,28). At this time, the dental commu-nity should actively support and promote visiting oral health care service so that oral health care service is guaranteed priority in the benefits and also need to take the initiative in preparing countermeasures. Moreover, this study suggests that the transformation of Korean dentists’ positive perception of visiting treatment, adding benefit items for oral function evaluation and improvement service, and coordination with other fields will help activate visi-ting oral health care services in Korea.

None.

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

This study did not receive IRB because it was a study that analyzed laws, government data, and records forms.

Conceptualization: Sang-Hwan Oh and Soo-Jeong Hwang. Data acquisition: Sang-Hwan Oh and Rumi Ni-shimura. Supervision: Sang-Hwan Oh. Writing-original draft: Soo-Jeong Hwang. Writing-review&editing: Sang- Hwan Oh, Rumi Nishimura, and Soo-Jeong Hwang.

The data and materials of this article are included within the article. The data supporting the findings of this study are available from the corresponding author upon reaso-nable request.