Eszter Füzéki, Winfried Banzer
Department of Sports Medicine, Goethe University, Frankfurt
Primary care physicians in Germany are potentially in a pivotal position to provide physical activity counselling and exercise referral for their patients. The preventative prescription scheme dates back to the late 1970s. This scheme called “green prescription” (Grünes Rezept), however, could not be established as exercise referral scheme in primary care on a regular and systematic basis. After the German Medical Association (Bundesärztekammer), the German Association for Sports Medicine and Prevention (Deutsche Gesellschaft für Sportmedizin und Prävention) and the German Olympic Sports Federation (Deutscher Olympischer Sportbund) had developed the standardized national quality criteria of Physical Activity on Prescription in a joint effort, the German Medical Association has adopted them in 2011 and now recommends them to the Medical Associations of the Federal States for implementation. These national criteria establish a framework, but given the federal structure of Germany, schemes are not implemented in a uniform or centralized way. The federal states rather develop their own delivery methods according to local possibilities and needs. Exercise as a therapeutic means in the rehabilitation phase of a large number of chronic conditions as well as for people with disabilities is a legally established part of health care. The current legal and financial bases as well as the level of institutionalised support for the prescription of physical activity and exercise within health care are markedly different in the areas of prevention and therapy, respectively. While patients with chronic conditions are entitled to
receive free exercise as a means of therapy (within certain limitations), no such “right” exists in the area of prevention. Exercise referrals rely on group offers with defined high standards in organised sports, making use of easily accessible sport clubs which are a traditional part of community life. Rigorous scientific evaluations are needed to provide guidance on how to further develop Germany´s exercise referral schemes.
Niedergelassene Ärzte in Deutschland sind potenziell in einer Schlüsselposition, um Patienten zu körperlicher Aktivität und Bewegung zu beraten und ihnen diese zu verschreiben. Das erste präventiv orientierte «Rezept für Bewegung» (Grünes Rezept) wurde bereits in den späten 1970er Jahren initiiert. Das Grüne Rezept konnte jedoch die Verschreibung von Bewegung in der Primärversorgung nicht systematisch verankern. Nachdem die Bundesärztekammer, die Deutsche Gesellschaft für Sportmedizin und Prävention und der Deutsche Olympische Sportbund gemeinsam standardisierte nationale Qualitätskriterien für das «Rezept für Bewegung» entwickelt hatten, wurden diese 2011 von der Bundesärztekammer verabschiedet und den Landesärztekammern zur Umsetzung empfohlen. Die nationalen Kriterien schaffen einen Rahmen, angesichts der föderalen Struktur Deutschlands wird aber das «Rezept» nicht zentralisiert oder einheitlich eingesetzt. Jedes Bundesland adaptiert es nach seinen jeweiligen Möglichkeiten und Bedürfnissen. Sport als therapeutisches Mittel ist in der Rehabilitationsphase vieler chronischer Erkrankungen sowie für Menschen mit Behinderungen ein gesetzlich festgeschriebener Bestandteil der Gesundheitsversorgung. Aktuell zeigt sich ein deutlicher Unterschied bei der rechtlichen Grundlage, der Finanzierung, sowie der institutionalisierten Unterstützung für die Verschreibung von körperlicher Aktivität und Bewegung zwischen Prävention und Therapie. Während Patienten mit chronischen Erkrankungen mit einigen Einschränkungen berechtigt sind, kostenfreie Bewegungstherapie in Anspruch zu nehmen, besteht ein ähnliches Anrecht auf dem Gebiet der Prävention nicht. Durch die Einbindung der flächendeckenden und traditionell verankerten Sportvereine bilden die qualitativ gesicherten Gruppenangebote des organisierten Sports eine Basis sowohl für den präventiven als auch für den therapeutischen Ansatz. Rigorose wissenschaftliche Untersuchungen sind notwendig, um die Bewegungsberatung und -verschreibung in der ärztlichen Praxis in Deutschland weiterentwickeln zu können.
Primary care in Germany
Primary care practitioners play a major role in outpatient care in Germany. Primary care practitioner-focused care (hausarzt-zentrierte Versorgung) is described in paragraph 73 of the German Social Security Code Volume V. Primary care practitioners in Germany are, similarly to their counterparts in other Western countries, in a crucial gate-keeper’s position in the health care system. They are seen as reliable sources of health information and typically maintain long-term relationships with patients. About 90% of the population see a primary care physician at least once a year (Streich 2002). Primary care is equally accessible for and utilized by socially vulnerable populations (Smythe et al. 2004). In the following paragraphs we will outline the role of outpatient physicians in exercise referral and physical activity counselling in Germany.
Exercise as means of therapy and rehabilitation
Exercise as a therapeutic means in the rehabilitation phase of a large number of chronic conditions as well as for people with disabilities is a legally established part of health care (Social Security Code Volume IX, Par. 44, Sec. 1.). All outpatient statutory health insurance physicians (Vertragsärzte) can prescribe 50 (in certain well-defined cases 120) sessions of group-based supervised exercise. As a general rule, patients are entitled to this prescription only once in a lifetime; the offer is seen as “help to self-help”, with the ultimate goal of patients maintaining sufficient levels of activity by themselves, beyond the period covered by the prescription. Exercise groups are offered for specific diseases, and only group offers meeting the quality standards relating (among other criteria) to instructors’ qualifications, group size, medical supervision during courses, emergency services and insurance as established in a framework agreement (BAR 2011) are eligible. Exercise offers within this scheme are free of charge for patients. Physicians receive no special reimbursement; exercise referral is covered as part of a per-patient lump-sum. Statutory health insurance funds (gesetzliche Krankenkassen) spent € 134 million on exercise therapy and functional training in 2010, an increase of 31% since 2009.
Physical activity and exercise in prevention
The German Social Security Code Volume V, Par. 73, Sec. 1 requires that primary care services delivered by physicians include “the initiation or implementation of preventive and rehabilitative measures, as well as the integration of non-physician support and accompanying services into therapy”, though without specifying the nature of these measures and services. In contrast to exercise as a means of therapy, physical activity counselling and exercise referral for prevention are factually voluntary, given this rather soft legal basis.
The German Exercise on Prescription Scheme in the area of prevention dates back to the late 1970s. The scheme called “green prescription” (Grünes Rezept), however, could not be established in primary care on a regular and systematic basis. After the German Medical Association (Bundesärztekammer), the German Association for Sports Medicine and Prevention (Deutsche Gesellschaft für Sportmedizin und Prävention) and the German Olympic Sports Federation (Deutscher Olympischer Sportbund) had developed the standardized national quality criteria of Physical Activity on Prescription in a joint effort, the German Medical Association adopted them in 2011 and now recommends them to the Medical Associations of the Federal States for implementation. Primary care physicians (niedergelassene Ärzte) are encouraged to refer their healthy but inactive patients (adults and children) to already existing group exercise offers with the quality seal “Sports Pro Health” (“Sport Pro Gesundheit”) in local sports clubs. Certified “Sports Pro Health” offers must fulfil the following criteria: target group oriented courses, limited group size, qualified instructors, standardized structural organization, preventive health check up for participants and permanent quality control.
The national exercise referral criteria establish a framework, but given the federal structure of Germany, schemes are not implemented in a uniform or centralized way; the federal states rather adopt their own delivery methods according to local possibilities and needs. Currently 9 of the 16 federal states of Germany operate a scheme (Bavaria, Berlin, Bremen, Hamburg, Hesse, Rhineland-Palatinate, North Rhein-Westphalia, Schleswig-Holstein and Thuringia). Supporting materials such as posters, booklets, and flyers have been developed in all federal states using the logos of the three bodies behind the scheme and the “Sports Pro Health” logo to ensure brand recognition. Beyond this, federal states are free to use logos of their local partners, such as the sports federations and medical associations of their respective federal states. The German exercise referral scheme in the area of prevention is entirely voluntary; physicians receive no compensation for their referral and patients are not entitled to reimbursement. Depending on the offers patients opt for, the costs might nonetheless be covered up to 80% by their health insurance funds, as defined by The Social Security Code (Volume V, Par. 20). In 2011 statutory health insurance funds (gesetzliche Krankenkassen) spent € 204 million on courses for primary prevention, including exercise, diet, stress management and addiction prevention (MDS 2012). Around three quarters of all primary prevention courses were group exercise offers. Currently, health insurance funds cover a maximum of two courses per person per year. To be eligible for coverage, courses must have a defined duration, usually no more than 12 weeks. To date it has not yet been systematically assessed how many exercise referrals were initiated by physicians or the patients themselves, respectively. Beyond this coverage, no institutionalised funding or support is provided for the development and maintenance of the necessary structures, supporting materials and capacity building. In this regard, federal states and local communities must rely on their own resources and means.
Exercise referral in the federal state of Hesse
The exercise referral scheme “Rezept für Bewegung” in the German Federal State of Hesse is part of the network Sports and Health in Hesse, initiated in 2006 by the Sports Federation of the State of Hesse (Landessportbund Hessen). The overall goal of the network is to encourage all people in all age groups to become more active in general and not only in structured exercise programs. Members of the network are communities, local authorities, sports clubs, and primary care physicians. A major role of the network is to enhance the profile of sports and physical activity issues at the local and regional political level, and to create a link between politics, health care providers and sports clubs. The network also aims at improving the public visibility of physical activity and health related issues through organizing lectures and participating in community health fairs and other events. A side effect of the network have been the improved qualification of exercise instructors. The network launches new projects, coordinates existing ones and aims at enhancing the impact of activities through synergies. Local regional networks are initiated by local regional sports umbrella organisations (Sportkreise). Communities provide political and financial support, know-how and sports facilities, and they function as door-openers for sports clubs.
Physicians interested in the project screen their patients for levels of physical activity and refer them to existing programs in the local sports clubs. The network provides support to participating physicians through the organisation of continuing professional development courses relevant for physical activity counselling. The network also compiles and regularly updates a directory of available programs of the sports clubs. This directory along with prescriptions and posters is made available to physicians. Also, a searchable internet database has been developed to facilitate referral. Currently further supporting materials, including a manual for physicians, are being developed by Goethe University Frankfurt, the German Medical Association, the German Association for Sports Medicine and Prevention and the German Olympic Sports Federation.
Résumé and future directions
Currently, the legal and financial bases as well as the level of institutionalised support for prescribing physical activity and exercise within health care are markedly different between the areas of prevention and therapy. While patients with chronic conditions are entitled to receive free exercise as a means of therapy (within the limitations described above) and the necessary infrastructure is part of the health care system, no such right or structures exist in the area of prevention. One common aspect is the referral to already existing offers of organised sport, in line with the strong German tradition and ubiquitousness of sports clubs. A major strength of this approach are the high standards of these offers guaranteed by quality assurance. Given the fact, however, that some patients might not wish to exercise in groups or might have limited access to such offers, not only exercise referral but also physical activity counselling should be encouraged within the health care system.
Until now, no rigorous scientific evaluation of physical activity counselling or exercise referral has been conducted in Germany. Such an evaluation seems to be essential before schemes can be further developed.
Eszter Füzéki, M.A. Gesundheitsförderung – und
management, Johann Wolfgang Goethe-Universität
Institut für Sportwissenschaften, Abteilung Sportmedizin
Ginnheimer Landstrasse 39, 60487 Frankfurt am Main
Deutschland, Tel +49 69 798 24443
- BAR (2011). Rahmenvereinbarung über den Rehabilitationssport und das Funktionstraining [Framework agreement on exercise in rehabilitation and functional training]. Bundesarbeitsgemeinschaft für Rehabilitation BAR, Frankfurt am Main. http://www.kbv.de/media/sp/Rehasport_Funktionstraining.pdf, accessed 22.05.2014.
- MDS (2012). Präventionsbericht 2012. Leistungen der gesetzlichen Krankenversicherung: Primärprävention und betriebliche Gesundheitsförderung. Berichtsjahr 2011 [Prevention report 2012. Performance of the statutory health insurance funds in prevention and occupational health promotion in 2011]. Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen e.V. (MDS), Essen. http://www.mds-ev.de/media/pdf/MDS_Praeven-tionsbericht_2012.pdf, accessed on 22.05.2014.
- Smythe J., Abholz H.H., Alves B., Blane D., Borgers D. (2004): Soziale Ungleichheit im Zugang zur ambulanten Behandlung in England und Deutschland [Social inequality in access to outpatient care in England and Germany]. Zeitschrift für Allgemeinmedizin 80: 58–62.
- Streich W. (2002): Qualität in der ambulanten Versorgung [Quality of outpatient care] In: Gesundheitsmonitor 2002 [Health Monitor 2002], Böcken J., Braun B., Schnee M. (eds). Bertelsmann Verlag, München.