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31 January 2025 | Policy Analysis
The Hospital Care Improvement Act came into force on 1 January 2025 -
05 November 2022 | Country Update
Proposal for expansion of day treatment in hospitals and reductions in inpatient hospitalizations
5.3. Primary care
Ambulatory health care is mainly provided by private for-profit providers, including physicians, dentists, pharmacists, psychotherapists, midwives and allied health professionals, such as physiotherapists, speech and language therapists, occupational therapists, medical pedicurists and technical professionals. Ambulatory physician care includes primary care (family physician care) which is mainly provided by GPs and secondary care provided by office-based specialists, whereas hospital services and tertiary care usually only take place in inpatient care settings (see section 5.4 Specialized care).
Patients have free choice of physicians, psychotherapists, dentists, pharmacists and urgent/out-of-hour care services. Although patients covered by SHI may also choose other allied health professionals, access to reimbursed care is available only upon referral by a physician. About 42% of all SHI- affiliated physicians work as family physicians and in primary care. Although GPs are usually the patient’s first point of contact with the health system, they are not official gatekeepers (see also section 5.2 Patient pathways). However, GPs’ coordinating competences have been strengthened in recent years (see below).
According to data from the Federal Association of SHI Physicians, 44% of the 402 118 active physicians working in Germany in December 2019 (i.e. 177 826) worked in SHI-contracted ambulatory care. Of these, 127 636 worked as SHI-accredited physicians (including non-medically qualified psychotherapists), 40 828 as salaried physicians and further 9362 as hospital physicians who are authorized to provide specialized outpatient care. Solo practices are still the dominant setting in primary care, but over the last decade there has been a trend towards more group practices and GPs working in interdisciplinary medical care centres (Medizinische Versorgungszentren – MVZ). Between 2009 and 2018 the number of solo practices providing family care decreased by 16.5%, while the number of GPs working in group practices and medical care centres increased by 3% and 117% respectively (Kassenärztliche Bundesvereinigung (KBV), 2019d). Thus, the number of salaried GPs at medical care centres or in group practices has increased more rapidly than the number of SHI-accredited GPs working on a self-employed basis (Bundesministerium für Gesundheit (BMG) 2020i).
In 2019, of the 149 710 ambulatory care physicians (excluding non-medically qualified psychotherapists), 63 097 (42%) were working as family physicians, of whom 34 757 were qualified in general practice (i.e. held a specialist qualification in general practice), 4203 worked as practitioners (physicians without any specialist qualification practising family medicine), 16 305 were family internists (specialists in internal medicine) and 7832 were paediatricians (see Table5.1). The number of GPs decreased slightly (by 1%) between 2010 and 2019, whereas the number of practitioners without a specialization in general medicine decreased by 38%. Between 2010 and 2019 the number of all physicians working in family medicine increased by 4% compared to the total number of specialists, which increased by 11% (see Table5.1). This trend is also confirmed in a report by the Advisory Council to Assess Developments in Health Care (Sachverständigenrat im Gesundheitswesen – SVR), which highlights that the relationship between family physicians and specialists is subject to increasing sub-specialization (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, 2014b). While before the turn of the millennium 60% of all ambulatory care physicians had still been involved in family care and 40% in specialist care, the ratio has reversed by 2019.
Table5.1
In the early 2000s the federal government launched several initiatives to improve the status of family physicians. After physicians with a specialization in internal medicine and paediatricians were legally offered the opportunity to work as family physicians (Hausärzte) instead of specialists (Fachärzte) (§73 SGB V), the share of family physicians temporarily increased.
Since then, family physicians and specialists have had different reimbursable service profiles, different reimbursement pools and separate representation in the assemblies of delegates and the executive boards of the Regional Associations of SHI Physicians (see section 3.7.1 Paying for health services). The SHI Care Structures Act (2012) further strengthened ambulatory care and introduced financial incentives for physicians – and particularly for family physicians – to work as SHI-affiliated doctors in undersupplied and rural areas, e.g. by lifting quantity-based limitations like the practice-based volume of standard services that could be delivered and through the introduction of surcharges for special services (see section 3.7 Payment mechanisms and Chapter 6 Principal health reforms). Despite these efforts, a shortage of GPs is still noticeable in rural areas and the provision of family physician care in the community is not necessarily guaranteed. Fig5.2 shows that the supply of family physicians in more rural areas does not reach 100% of the needs-based planning ratios established by the Federal Joint Committee, while other areas exceed supply up to 207% in 2018.
Fig5.2
According to OECD data on Germany, there were 9.9 outpatient contacts per capita in 2018, which is considerably higher than the EU average of 7.5 (OECD/European Observatory on Health Systems and Policies, 2019; OECD, 2020d). However, this is likely to be an underestimation as national surveys estimate higher numbers. The calculations of the Central Institute for SHI Physician Care (Zentral-Institut für die kassenärztliche Versorgung – ZI) identified 17.1 visits per person in ambulatory care, albeit the data refer to the year 2007 (Riens et al., 2012). In fact, the actual number of contacts with ambulatory physicians is difficult to determine. This is due to changes in the reimbursement mechanism of ambulatory care physicians in 2008 and the definition of a “case”, i.e. a treatment case is registered only once per quarter, even if the patient contacts the doctor several times per quarter.
Context
Germany’s health system is characterized by strong sector boundaries between inpatient care (hospitals) and outpatient care (mainly office-based physicians). Hospitals are primarily paid through case payments (diagnosis-related groups, DRGs). The DRG system and general budget constraints have put hospitals under increasing financial pressure, evoking societal and media debates about access to and quality of hospital care. Additionally, the quality of inpatient care differs widely between hospitals. So far, hospital planning, a task of the 16 federal states, does not systematically include quality criteria.
Impetus for the reform
In 2022, the Government Commission for Modern and Needs-based Hospital Care proposed a comprehensive hospital reform, including
- a partial substitution of the DRG-based hospital payment system with flat fees,
- linking hospital planning and remuneration to the existence of certain hospital structures and processes with so-called service groups, and
- categorizing hospitals into different levels of care based on which service groups they can offer (see the policy analysis “Proposal for fundamental reform of hospital remuneration” from 12 December 2022).
In 2023, the legislative process started with the Hospital Care Improvement Act (Krankenhausversorgungsverbesserungsgesetz).
Main purpose of the reform
According to the Ministry of Health, the reform intends to
- improve treatment quality in hospitals,
- secure access to care, especially in rural areas,
- foster integrated, cross-sector healthcare, and
- relieve hospitals of bureaucracy and economic pressure.
Content
With the reform, the main content includes the introduction of the following policies:
- 65 service groups: Hospitals must meet certain requirements for staffing, equipment, and departments to apply for a service group (for example, general internal medicine, stroke unit). The respective federal state assigns these groups, which determine reimbursement.
- A new reimbursement model: The DRG-based hospital payment system has been partly replaced with flat fees. Reimbursement for inpatient operating costs will ultimately include three components: nursing staff, flat fees, and residual DRGs, derived for every service group based on average costs. The share of the flat fees depends on nursing costs and variable material costs.
- Intersectoral care facilities: A new hospital form, intersectoral care facilities, will be able to provide outpatient physician care, outpatient and short-term inpatient care for older people, outpatient hospital services (for example, day surgery), and some inpatient treatments (at least covering geriatrics and general internal medicine). The aims are to secure access to basic services, especially in rural areas, and to lower sector boundaries.
- A so-called transformation fund: Between 2026 and 2035, hospitals can apply for investments from a transformation fund with €50 billion to meet the requirements to apply for one or more service groups, mergers and closures of hospitals, or conversions into intersectoral care facilities.
- Staffing levels: For physicians (as in place for nurses) and assessing the need for staffing levels for other professional groups like midwives or physiotherapists.
- Measures to lessen bureaucracy: For example, regarding accounting procedures.
Implementation
The act passed parliament in October 2024, got approved by the federal states in November, and entered into force on 1 January 2025. Federal states will assign service groups to their hospitals in 2025 and 2026. The conversion of the remuneration system will take place between 2027 and 2029.
Authors
On 22 September 2022, the Government Commission for a Modern and
Needs-Based Hospital Sector made its second recommendation and proposed
expanding hospital day treatment. The main aim is to address hospital
staff shortages, which the Commission considers one of the main causes
of hospital capacity constraints.
Due to the considerable
medical progress, inpatient monitoring of patients at night or on
weekends is not always necessary for many examinations, interventions,
and treatments previously performed on an inpatient basis. However, many
of these procedures require extensive and complex medical structures
that only a hospital can usually provide [1].
Therefore, from 1 January 2023 at the latest, hospitals should be allowed to carry out all previously fully inpatient treatments as day treatments, if clinically appropriate, so the staff freed up can be deployed elsewhere in the hospital. The Commission also recommended mapping the day treatment in hospitals in the DRG system [1].
5.3.1. Coordinating primary (and secondary) care
Since 2004 sickness funds have been obliged to offer their insured the option of enrolling in a GP-centred model (Hausarztzentrierte Versorgung) (§73b SGB V) and some provide a bonus for complying with the gatekeeping rules. Participation in these models is voluntary for both providers and the insured. According to data from the German Association of General Practitioners (Deutscher Hausärzteverband), 17 000 GPs participate in “GP-centred care models” and about 5.4 million insured had subscribed in 2020 (Deutscher Hausärzteverband, 2020).
To improve the coordination of services provided by family physicians and specialists, structured treatment programmes, called DMPs, were introduced in 2003. DMPs aim to organize the treatment and care of chronically ill patients across the boundaries of individual service providers, in line with individual patients’ requirements, and in a more efficient manner. Health care services for patients registered with one or several DMPs are provided using evidence-based guidelines. In contrast to integrated care, which is aimed at cross-sector patient care, DMPs primarily aim at coordinating different services at the ambulatory care level and include rules for intra-sectoral treatment (e.g. referral to hospital treatment). The DMPs are based on a uniform contract between all sickness funds in a region and the regional physicians’ association as well as a number of hospitals. Measures for quality assurance include standardized documentation, feedback reports to physicians, patient information and reminder systems (see Box5.3).
Box5.3
