Introduction

Dementia is a major epidemic disease of the 21st century in the world. Dementia is one of the major issues in public health globally. By the Alzheimer’s Disease International report, over 46million people live with dementia worldwide in2015(Table 1)[1], and this number will increase to 131.5 million by 2050. Also in Korea, the estimated prevalence of dementia was 8.7%(0.47million) in 2010, the number will reach the1 million marks in 2024, it will become a15.1%(2.71 million) by 2050(Table 2)[2]. Among Koreans aged 65 or older, 725,000 are estimated to be suffering from dementia in 2017.

Table 1. Prevalence of dementia in the world over time

Source. Alzheimer’s Disease International, 2015

Table 2. Prevalence of dementia in Korea by age over time

Sources. National Dementia Institute of Korea, 2016

Methods

The aim of this paper was to introduce and review the current status, major issues and problems, and policy implications for prevention and care management of dementia in Korea.

Results and Discussions

Demographics and epidemiology of dementia

In the last fifty years, South Korea’s economy has grown very rapidly. It is now a high-income country, with GNI per capita of $27,090[3]. It has a population of 50 million and is the world’s15th largest economy.

South Korea has experienced very rapid aging since the year 2000; between 2000 and2015 it experienced the fourth-fastest rate of aging in the world, and between 2015 and 2030it is expected to be the second-fastest aging country in the world[4]. The percentage of the population aged 65 or more was estimated to be12.8%(6.54 million) in 2015 and is projected to reach 35.6%(18.18 million) by 2045(Figure 1)[5].

Figure 1. Prevalence of dementia by metropolitan cities and provinces, Korea, 2016​​​​​​​

​​​​​​​Figure 1. Trend of the population aged 65 in Korea over time

Using data from the 2012 Nationwide Survey on Dementia Epidemiology of Korea(NaSDEK)and the 2010 Census, the prevalence of dementia in 2012 was estimated to be of 9.18%by the National Dementia Institute. Applying age and gender standardized dementia rates to the national population projections, in 2015 there would be over 648,000 people with dementia.

The World Alzheimer Report 2015 estimates were lower, suggesting that in 2015 there were just over 478,000 people with dementia in Korea, increasing to just over a million by2030[1].

cost of dementia

In Korea, the number of patients with dementia is increasing, and dementia management costs are increasing rapidly. Itis estimated that the management cost per dementia patient increased from 18.1 million won in 2010 to 20.33 million won in 2015(Ministry of Health and Welfare, 2011). In 2013, the service cost for long-term care services per capita was 9.27 million won for facility service and 3.74 million won for in-home service. In2016, it increased to 11.4 million won for facility service and 3.97 million won for in-home service (Health Insurance Policy Institute, 2016). The cost of dementia management across the country is expected to increase from 13.2 trillion won in 2015 to 105.5 trillion won in 2050.

It is a mental and economic burden that individuals or households are responsible for the treatment and care of patients with dementia. The annual cost of dementia patients is estimated to be about 20.3 million won, including medical expenses, drug costs, nursing costs, long-term medical expenses, transportation costs, and time costs[6]. In particular, the long-term medical care costs are 10.23 million won per patient. Many people are at risk of suffering psychological and economic suffering from the onset of dementia of the person or family.

Dementia brings about an enormous expenses in Korea. In 2013, the annual cost of dementia in Korea was estimated to be about US$ 10billion. It was about 0.7% of its GDP[7].

The importance of the costs of dementia as a share of GDP is expected to rise to about 2%by 2050. The costs of caring for a person with dementia in Korea were estimated to be US$19,104 in 2015(Figure 2)[7]. 38% were direct health costs, 17% were direct long-term care costs, and 45% were indirect costs, including the opportunity costs of unpaid family care and productivity losses in the total costs of dementia. The costs of caring for people with severe dementia were found to be 2.7 times higher than for people with mild(questionable) dementia[8].

Figure 2. Cost of dementia care and the number of dementia patients over time in Korea

National Dementia Plans in Korea

Dementia is becoming the most feared disease in Korea, it is more feared than cancer in older age groups, and is the 2nd most fared disease after cancer in younger age groups.

Against dementia, Korea developed three national Dementia Plans in 2008, 2012, and2016.

The 1st plan was came into effect in 2008and focused on prevention, early diagnosis,development and coordination of infrastructures and management, and improving awareness.The 1st National Dementia plan included the implementation of National Long-term CareInsurance, providing the funding to ensure that every person has timely access to relevant services and support. The National DementiaEarly Detection(NDeED) program was also introduced, in which all older adults in Korea have access to dementia screening and can access post-diagnostic services including reimbursement for medication if needed. As a result, diagnosis rates have increased to 75%.

The 2nd plan was launched in 2012, addressed the same priorities but had a stronger focus on supporting family members. In 2012 the dementia Management Act(DeMA) established a statutory basis for organization of the NationalDementia plans.

Under the Dementia Management Act, the government is required to produce a comprehensive plan for dementia every 5 years. The Act also orders that the government should register the dementia patients and collect statistics on epidemiology and the management of the dementia conditions. This has introduced to the ‘Nationwide Study on the Prevalence dementia in Korean elders 2008’[9], the ‘Study on Dementia Prevalence 2012’[10], and the forthcoming ‘Study on Dementia Prevalence2016’. The Act also built institutions to coordinate dementia treatment, care, and support.

The Dementia Management Act of Korearequired the operation of the National Institute of Dementia and Metropolitan/ProvincialDementia Centers to make and carry out dementia management plans throughout thenation[11].

The National Institute of Dementia(the SeoulNational University Bundang Hospital) has a central management center and coordinates regional Dementia Center in the 17 regions(13 have been established so far, 4 more are expected to open before the end of 2016).The Dementia Centers provide education to healthcare professionals and conduct research, as well as building and carry out local awareness campaigns, including the Dementia Partnersprogramme[11].

Dementia Centers have specialized programs for each region. Another program is running the Regional Dementia Council. These councils advise and support local government to create and operate regional dementia management plans. Provincial councils meet quarterly and are inclusive of numerous organizations and people.Metropolitan Dementia Councils meet six times a years and includes government officials and welfare service providers.

The Act also mandates to establish DementiaCounselling Centers in every public health center and the National Dementia Helpline.

The 3rd National Dementia Plan of 2016aims to build a dementia-friendly community to ensure people with dementia and their carers live well. This plan focus on community-based prevention and management of dementia, convenient and safe diagnosis, treatment, and care for people with dementia, the reduction of the care burden for family caregivers of people with dementia, and support for dementia research through research, statistics andtechnology[2]. Key performance indicators(KPI)of the 3rd National Dementia Plan were showed in Table 3[12].

Table 3. Key performance indicators(KPI) of the 3rd National Dementia Plan in Korea.

Health and medical care services

The first National Dementia Plan was started as a result of concerns about the low-level of diagnosis of people with dementia: in 2008 up to 67% of people with dementia had not beendiagnosed[13]. This plan introduced the NationalDementia Early Detection program (NDeED), which enables all older people to access to dementia screening and access post-diagnostic services(including the reimbursement of medication if this is prescribed). The NDeEDprogramme has resulted in a substantial increase in diagnosis rates. As part of the drive to enhance awareness and timely diagnosis of dementia, a self-screening digital app “CheckDementia” has been made available, as well as a National Dementia Helpline and guidelines to help people reduce their risk of dementia[6]. Out of 6 million people over the age of 65, 2millionpeople are screened for dementia. One-third of them go onto the next stage and get a diagnosis at a government-run center, and the other two thirds either do not have sufficient symptoms for a diagnosis, or go to private centers, or do not seek further help. In the end, 25% of those screened are diagnosed with dementia[6].

Based on data from National Health Insurance claims, the total number of people who used in/outpatient medical and pharmaceutical services for dementia treatment under the national health Insurance was 377,901 in 2014, the total value of benefits was $912 million(USD)[14].

The Dementia Counselling Centers, set up in every local Public Health Center, provide early dementia screening. This service is financed by the National Health Promotion Fund and local government and in 2015 it was used by52,000 people[15]. However, people living in metropolitan cities had better continuation rates than those in other areas, which may reflect regional variation in treatment accessibility and clinical practice[16].

Long-term care insurance(LTCI) system in Korea

In 2008, Korea introduced a mandatory longterm care health insurance scheme after 7 years of preparation, covering all older people(over the age of 65) and also younger people(under the age of 65) with particular conditions such as dementia and stroke. In the world, 5countries choose this type of insurance system only(Germany, Luxembourg, Netherlands, Japan, Korea). Basically, The system of Korea is similar with japan. Every working person from the age of twenty contributes to LTCI. The need for the introduction of the LTCI system arose through an increasing elderly population and a change in family structures, this impacted the medical costs of people living with chronic illnesses. The healthcare system and LTCI coexist in Korea. Long-term care is financed through insurance contributions(60~65%) and government subsidy(20%) with the person covering the rest(15~20%). The long-term care insurance(LTCI) scheme is run by the national health Insurance Scheme(NHIS), which added an additional contribution to the existing health scheme and the government provides additional funding from taxation.

Eligibility is assessed by the local NHIS offices.To deliver care services to people, an assessmentprocess is undertaken, nurses and social workerswork together to assess the needs of the person and give them a grade of 1(more serious) to 5(less serious).

Public health security for dementia in Korea are provided in accordance with the elderly long- term eligibility level. Although the elderly long-term care eligibility level is divided into1~3 stages by 2008~2013, it had been pointed out that it was difficult to obtain a grade for mild dementia because the evaluation was based on physical function. In 2014, the 5th grade of mild dementia was newly established and the elderly long-term care eligibility level was revised to 1~5 grades. If someone get a longterm care status, he can receive government support for a monthly salary of ₩ 830,000 to ₩125,000 per month.

Initially, people are assessed on functions such as ability to perform activities of daily living(ADL) or instrumental activities of daily living(IADLs), which meant that people with dementia were often not considered eligible.People are provided with a care plan and can then choose to go into a care home or choose another care system such as home care.It was estimated that approximately 27% of people with dementia in need of care had been excluded from services under the LTCI[17]. This situation has now been addressed and there is now an additional “special grade for dementia” eligibility.

This has been enhanced by the DementiaSupport Policy which aims to provide support specifically to people who have mild dementia with no or little physical impairment. Support can includes day and night care, cognitive stimulation training by trained staff, and respite for caregivers[18].

Those who are eligible for LTCI benefits can contract directly with provider agencies, and benefits are mostly provided in kind. The basic packages of care are set by national guidelines which to define the maximum amount of benefits for each category. Residential care or nursing home care is provided by long-term care facilities, licensed nursing homes, retirement homes, and licensed residential establishments. Home care or community care includes support for ADL needs at home, bathing service, nursing care at home, and daycare services.

Cash benefits are only available to those in remote areas or islands where there is no formal care provision. When cash benefits are used, these are of lesser value than benefits in kind.Quality assurance is based on staff qualifications and staffing ratios. People who want to work as care workers are required to complete an a240-hour training course and pass a national qualification examination[19].

In 2013, over 115,000 people for whom dementia was reported as the ‘primary disease’ were beneficiaries of LTCI. They represented34% of the total number of LTCI beneficiaries.Of these, 63,000 were in care homes and 52,000received home care benefits, representing, respectively, 50% and 25% of the total number of beneficiaries.

Of the 615,000 dementia patients in 2014, only 240,000 dementia patients received long-term care benefits after receiving the long-term care classification of the elderly(grade 1-4).Only 5,133 patients who received the 5th grade of dementia were rated special. Approximately380,000 people with dementia were classified as out-of-grade and were not receiving long-term care insurance benefits from the country. Currently, private insurance companies sell mainly dementia-guaranteed products for risk management. Life insurance companies are paying premiums for three or more patients who are severely ill according to the ClinicalDementia Rating (CDR).

Non-life insurance companies are only guaranteed for the elderly long-term care grades 1-4, while the fifth-class and out-of-class subscribers do not pay insurance premiums(Figure 4).

Figure 4. Service utilization of dementia patient in 2016, Korea.

President Moon's Plan against Dementia, 2017.

The infrastructure and manpower for supporting Korean patients with dementia are both insufficient. In 2016, 17 local autonomous dementia centers, 45 regional dementia centers and 253 regional dementia counseling centers are operating in basic autonomous organizations.

Among the workforce of the national dementia counseling center, there are 677 persons, including doctors, nurses, mental health specialists and social workers, and the number of dementia patients per one person is 957persons. A total of 332,000 persons in longterm care institutions related to dementia were found to be 513.2 persons per 1,000 people with dementia.

In 2017, Moon‘s government will introduce the “National Dementia Responsibility System,” which guarantees most of the burden caused by dementia. The “National Dementia ResponsibilitySystem” presented as a presidential election pledge mainly focuses on strengthening national support for dementia costs and expanding related infrastructure.

This plan includes that the introduction of a ceiling on self-pay for dementia diseases, expansion of the application of dementia care standards through alleviating the support criteria for long-term care insurance for mild dementia, expansion of dementia support centers, expansion of national and public dementia care facilities. It is expected that the new system will drastically reduce the burden of dementia patients and their families, and the national management system of dementia will be firmly established.

Moon's government will inject a 160 billion won ($143 million) extra budget to set up 205new dementia care centers nationwide, the ministry said. There are 47 centers currently under operation, 25 of which are located in Seoul. Another 60 billion won will be spent to establish clinics specialized in dementia care within public hospitals.

Some 20 million won is estimated to be spent on a dementia patient annually, according to to2015 data. Considering the number of patients, the total cost, estimated at 13.2 trillion won, accounts for some 0.9 percent of the country's gross domestic product. The figure will increase to 106.5 trillion won, which is equal to some 3.8percent of the GDP by 2050.

Moon also promised to introduce a 10 percent cap on the financial burden placed on those insured against dementia, a rate similar to those applied to four major age-related diseases cancer, cardiac disorders, cerebrovascular diseases and other rare incurable diseases. Nonetheless, the plan is expected to have many difficulties in securing concrete funding.In the meantime, Korea has accomplished many accomplishments by establishing many measures related to dementia and promoting related projects in a short time, but there are still many challenges. Kim et al. (2017)introduced key policy strategies in six categories(Table 5)[21].

Table 5. Key policy strategies for dementia care in Korea​​​​​​​

·Minimizing the incidence of dementia by linking major NCDs management project

·Strengthen dementia-friendly community and improve awareness on the dementia·Strengthen community dementia response capacities for dementia care and care

·Promotion of dementia policy based on human rights of dementia patients and carer

·Strengthening support for dementia research and technology development for establishment of evidence-based policies

·Establish and strengthen international cooperation system

And other policy issues and tasks are summarized as follows. The routine collection of data provides an opportunity to monitor the degree to which needs are being met and inform future policies. Korea has made important commitments to improve the quality of life of elderly with dementia and address their care, treatment and support needs, through the development of national dementia policy, ensuring universal coverage for both health and social care, and ensuring that the needs of people with dementia were considered in athletic eligibility criteria. We should consider the establishment of a user-based dementia management system with wider coverage and the consideration of the ‘care pathway’. The current dominance of fee-for-service payments for healthcare and lack of a gate-keeping role for primary care providers is resulting in incentives for mostly private providers to induce demand for care that may not be necessary or cost-effective, and in people being exposed to large out-of-pocket payments. To ensure the sustainability of the National Health InsuranceSystem, it has been argued that it necessary to consider a stronger gate-keeping role for primary care and increase the role of prospective payment and capitation[19]. We should improve the balance and coordination between treatment,care and welfare services, using evidence-based planning and quantification of outcomes.With an aging population and an increase in dementia prevalence, the number of people using the benefits of the LTCI has increased over the past eight years, as has the number of care facilities and home care centers. The challenge for the LTCI are how to improve thequality of the services. We also highlight the need for better coordination between health and social care. With respect to long-term care, it may be necessary to strengthen the regulatory management and monitoring systems, which are considered to be inadequate, as they allow opportunistic and sometimes illegal behavior by service providers and the provision of care of poor quality[17]. It is also recognized that the support of people with dementia in long-term care facilities requires a better management system and improved professional education[18]. Particularly, we need a standardized dementia education manual, knowledge/information system for nurses, social workers, and doctors as well as the general peoples for dementia. Metropolitan, provincial and regional dementia council face many challenges currently include difficulty in recruiting members, a lack of shared priorities, and a lack of understanding of the roles of the council. We are therefore grappling with how we can invigorate the regional dementia councils and how we can support nonprofit organizations such as Korean Association for Dementia, who provide services to people with dementia and their families. And also, creating a dementia-friendly community should be the end goal of these groups led by itsmembers[3]. Media can play an important role of highlighting dementia and facilitating the attitudes and understanding need for dementia-friendly communities.

Currently, Korea is implementing and planning LTCI system rapidly, however there still many concerns on the needs of the elderly peoples.

Figure 5. Structure and functions of new dementia care centers of Korea

Figure 6. Management system of dementia care center project of Korea

Figure 7. Organization and major project of dementia care center

Figure 8. Framework of National Dementia Responsibility System, President Moon's government

Figure 9. Framework of national dementia R & D plan, Korea, 2018

Summary

Dementia is a major epidemic disease of the21st century in the world. Dementia is one of the major issues in public health globally. Also in Korea, the estimated prevalence of dementia was 8.7%(0.47 million) in 2010, the number will reach the 1 million mark in 2024, it will become a 15.1%(2.71 million) by 2050. Among Koreansaged 65 or older, 725,000 are estimated to be suffering from dementia in 2017.

Against dementia, Korea developed three national Dementia Plans in 2008, 2012, and2016. The 1st plan came into effect in 2008and focused on prevention, early diagnosis, development and coordination of infrastructures and management, and improving awareness.

The 2nd plan was launched in 2012, addressed the same priorities but had a stronger focus on supporting family members. In 2012the Dementia Management Act established a statutory basis for the organization of theNational Dementia Plans. Under the DementiaManagement Act, the government is required to produce a comprehensive plan for dementia every 5 years. The Act also orders that the government should register the dementia patients and collect statistics on epidemiology and the management of the dementia conditions. The Dementia Management Act of Korea required the operation of the NationalInstitute of Dementia and Metropolitan/Provincial Dementia Centers to make and carry out dementia management plans throughout the nation. The Act also mandates to establish dementia Counselling Centers in every public health center and the National DementiaHelpline.

The 3rd National Dementia Plan of 2016aims to build a dementia-friendly community to ensure people with dementia and their carers live well. This plan focus on community-based prevention and management of dementia, convenient and safe diagnosis, treatment, and care for people with dementia, the reduction of the care burden for family caregivers of people with dementia, and support for dementia research through research, statistics and technology.

In 2017, Moon‘s government will introduce the “National Dementia Responsibility System,” which guarantees most of the burden caused by dementia. This plan include that the introduction of a ceiling on self-pay for dementia diseases, expansion of the application of dementia care standards through alleviating the support criteria for long-term care insurance for mild dementia, expansion of dementia support centers, expansion of national and public dementia care facilities. In the meantime, Korea has accomplished many accomplishments by establishing many measures related to dementia and promoting related projects in a short time, but there are still many challenges.