Out-patient Care Transition, Doctor Visits and Risks

The transition from in-patient to out-patient care is continuing in Germany. From Kalms Consulting (emphasis mine):

The German healthcare system is under pressure. In April 2026, the Health Finance Commission presented 66 proposals, approximately three-quarters of which are to be implemented by the Federal Ministry of Health. The exact details of the legislation are currently under discussion.

This includes a change in reimbursement for inpatient care. As early as 2023, cross-sector flat-rate reimbursements, so-called “hybrid DRGs,” were introduced, allowing both hospitals and contracted physicians in private practice to provide certain treatments.

To enable hospitals to provide additional outpatient treatments, so-called “short-term flat-rate payments” (Kurzzeitpauschalen) are to be introduced, which will allow treatments lasting 0–3 days for specific indications. These short-term flat-rate payments are to be reviewed annually and, if necessary, transferred to the AOP catalog or incorporated into a hybrid DRG.

The focus is on certain chronic conditions, from KBV (translated, emphasis mine):

To implement their legal mandate and to limit the scope of patients, the National Association of Statutory Health Insurance Physicians (KBV) and the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) have defined specific conditions for which general practitioners will be required to bill the standard care fee instead of the standard patient and chronic care fee. These conditions include certain thyroid disorders (hypothyroidism and autoimmune thyroiditis), lipid metabolism disorders (disorders of lipoprotein metabolism and other lipidemias), essential (primary) hypertension without a hypertensive crisis, and idiopathic gout. According to the Joint Federal Committee, these conditions generally do not require intensive care. A further requirement is that the patient only needs one disease-specific prescription medication and is between 18 and 74 years old.

The care fee includes the same services as the insured patient fee (GOP 03000), the chronic disease patient fee (GOP 03220), and the medication plan surcharge (GOP 03222). The difference is that it covers treatment for two quarters. It is therefore paid even if the patient only visits the practice in one quarter. If the patient consults the general practitioner again in the following quarter due to their chronic illness or other complaints, such as an infection, the care fee cannot be billed again, nor can the insured patient or chronic disease patient fees.

For patients who still require intensive care and who visit their general practitioner again in the quarter following the calculation of the care fee, or for whom a video consultation takes place, general practitioners may charge a surcharge. This is possible for a maximum of eight percent of the treatment cases for which the general practitioner billed the care fee in the previous quarter.

What’s interesting is that the new care fee is higher than the other fees combined, and it covers a pre-defined period, independent of how often a visit takes place or the reason for the visit, for that matter. That marks a movement away from reimbursing activities, such as doctor visits or medication prescription, and towards reimbursing for risk profiles. It also removes unnecessary administrative load from doctors - you have to enter patient visit details once instead of multiple times in those 6 months. Plus you get higher reimbursement. The downside of such risk-profile billing, is, well, the risk. Granted those decision are backed by analysing historical patient data to arrive at an optimal risk/benefit point, the risk still remains that patients come back more often or require more procedures than their profile suggests. 

All of this is good news, to be clear. Lowering the administrative load and streamlining care is how an efficient healthcare system should work. The difficult part, as any insurance company knows, is correctly assessing the risks. Failing to do so comes at a great cost and is only apparent years later; the price would be paid by doctors and patients alike.