The integration of dietitians into the German Health Care system has changed over the years. Legal developments lead to new working fields even in financially tight times.
The German Health System is based on the principle of social insurance. The majority of all residents are obliged to join the social insurance. The social insurance in Germany consists of the health insurance, the pension fund, accident insurance, long-term care insurance and public unemployment insurance. A basic role in the German health care system plays the statutory health insurance. 90.5 percent of all citizens have to enter a statutory health insurance.
The statutory health insurance pays for
- hospital treatment
- costs for medicines as well as remedy (speech therapy for example) or aids (wheelchair for example)
- dentures and dental treatments
- Treatments by registered physicians
- other benefits such as sickness benefits, cures or administrative expenses
The Federal Joint Committee (G-BA) is the highest body of common self-government in the health system in Germany and decides on all deliverables of the health insurances.
The profession of the dietitians has a long history in Germany. Nevertheless, dietetic counselling has just little relevance in the German Health system. Just about 3% of all hospitals have nutrition support teams. 12,000 -15,000 dietitians work all over Germany. About 70% work in hospitals, 30% work at least part-time as freelancers. Due to the force of cost-effectiveness, more and more pressure is put on the clinic sector and dietitians have to fight for their jobs there. A shift to the ambulant sector might follow and legal changes might help.
Dietetic Counselling by Prescription
In contrast to physiotherapy, speech therapy or occupational therapy dietetic counselling in the ambulant sector did not belong to the mandatory service of the statutory health insurance. After years of legal claims initiated by the VDD the responsible authority (G-BA) decided in 2017 that CF patients and patients with congenital metabolism disorders like PKU will receive dietetic counselling by prescription. Dietetic counselling was the first remedy that was just accepted in the long list of remedies on the base of an evidence validation. As for the G-BA the evidence of dietetic counselling (not of dietetic therapy) was not clear for several indications like cancer for example, they just accepted those two indications because without dietetic therapy the patients will suffer major complications or death and studies would be unethical. Other indications were not integrated into the validation process due to multimodal therapeutic approach.
We hope that this is a start to change the health policy to easy access for all patients to qualified dietetic counselling. At the moment patients with other diagnoses have to ask their physician for diagnosis, search for a dietitian, receive a cost estimate, hand it over to the health insurance and ask if they can (voluntarily) refund the costs (partly). If they will, patients can start the treatment, pay and receive the money partly back. If not, they have to decide if they can afford to pay privately or not to receive advice. In respect to an easy access the VDD is very happy about the two diagnoses as remedy but hopes to improve the situation of the patients by further indications. Political lobbying is a big task of the VDD: to give evidence about the success of dietetic counselling and the financial benefit for the health insurances on the long run.
In 2015 the so called prevention law included prevention activities like group programs and nutrition counselling for healthy people to the service of the statutory health insurances. Programs for different groups like children, elderly people or pregnant woman on the fields of physiotherapy and nutrition are run by the health insurances. A hot topic is the activities for employers. Companies have to spend a certain amount of money for preventive activities. The VDD is very active in this field and offers its members a network for cooperation. The head of the network works on the development of consumer orientated conceptions (including nudging in the cafeteria, education of staff responsible for the food, hydration programs and nutritional information and further more), negotiates with health insurances and big companies and makes contracts. Members of the network receive assignments and benefit from the overhead.
Changes in the law have opened up new working areas for the dietitians workforce. The next step will be to revise the education standard of dietitians and adapt it to the European competence standards. As Germany has a strong history in dual education this will be a hard task but the VDD hopes to tackle it.
President of the German Association of Dietitians (VDD e.V.)