Major shortcoming: hospital emergency services would remain structurally underfunded
This is now the third attempt to pass legislation reforming Germany’s emergency care system—an urgent initiative that can no longer be delayed. The need has once again become very clear in January, with hospital emergency departments severely overcrowded. However, the problem is not new: for years, acute emergency care has been characterised by inadequate patient flow management and excessive pressure on hospital emergency departments.
The draft bill published at the end of November 2025 addresses a critically important interface between outpatient (ambulatory) care and inpatient (hospital) care. Any effective reform must therefore be organisationally, structurally, and technically compatible with both sectors, including quality assurance requirements, in order to achieve the necessary integration and networking. In several key areas, the current draft does not meet these requirements.
Lack of a Coherent and Fair Financing Model
For many years, hospitals’ services in ambulatory emergency care have been severely underfunded and have significantly contributed to hospital deficits. A major flaw of the draft bill is that it does not propose fair financing for these services in the future. According to the draft, these services would continue to operate at a loss even within the new system.
Remuneration would remain inadequate and continue to be based on the Uniform Value Scale (EBM – Einheitlicher Bewertungsmaßstab), the fee schedule used for office-based physicians in statutory health insurance. Under Germany’s statutory duty of care (Sicherstellungsauftrag)—which is assigned to the Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, KVs) and would be further expanded under the draft—these bodies would continue to hold significant influence over the financing of hospital-based ambulatory emergency services. This is despite the fact that KVs have been unable for years to deliver these services adequately, a situation unlikely to improve given the increasing shortage of physicians, particularly in rural areas.
Ultimately—and this is implicitly acknowledged in the draft—hospital resources will continue to be relied upon, as has long been common practice. The German Association of Hospital Managers (VKD – Verband des Klinikmanagements Deutschlands) has therefore repeatedly called for the statutory duty of care for ambulatory emergency services to be transferred to the federal states (Länder) and for health insurance funds to be legally obliged to reimburse these services on a full cost-recovery basis when provided by hospitals and their Medical Care Centres (MVZ – Medizinische Versorgungszentren).
Additionally, Integrated Emergency Centres (INZ – Integrierte Notfallzentren) require a dedicated budget that is distinctly separated from hospital funding. This budget should cover material costs, staffing expenses, and standby (readiness) costs.
Remuneration for Initial Triage in Hospitals Without an Integrated Emergency Centre
Allowing hospitals without an Integrated Emergency Centre to continue treating emergency patients aligns with the general obligation not to turn patients away. In these cases, payment would be linked to a mandatory initial clinical assessment (triage) confirming that it would not be reasonable to refer the patient to a nearby Integrated Emergency Centre.
This initial assessment must be reimbursed in all cases. It remains to be seen whether this payment will be sufficient. From VKD’s perspective, adequate compensation is essential, as this mechanism would be the only way to cover the short-term closure of emergency departments.
Digital Infrastructure Treated as a Secondary Issue
The draft legislation does not clearly define how the digital infrastructure required for a complex, networked emergency care system is to be established. Yet achieving the reform’s goals is only possible if all stakeholders use interoperable digital systems that allow effective communication.
Despite the introduction of the electronic patient record and partial digitalisation within hospitals, Germany remains far from this aim. According to the draft, digitalisation would apparently only happen once the new structures are already in place. This sequence would significantly complicate communication between providers. Instead, digital infrastructure and structural reform must be developed simultaneously in a coordinated, step-by-step manner, rather than one after the other.
Emergency Capacity and Crisis Preparedness Must Be Considered
Hospital capacity is already being reduced through ongoing “cold” structural changes and increasing focus on centralised sites. As a result, reserve capacity for major incidents, disasters, and mass casualty events is being diminished.
The Hospital Care Improvement Act (KHVVG – Krankenhausversorgungsverbesserungsgesetz) does not address preparedness for such scenarios. However, crisis preparedness impacts all sectors of the healthcare system and is especially important for emergency care. It must therefore be explicitly included in emergency care legislation.
Implementation Timelines Are Unrealistically Short
Overall, the proposed implementation deadlines are far too tight. Many of the necessary prerequisites—such as IT infrastructure, site planning decisions, and binding guidelines from the **Federal Joint Committee (G-BA – *Gemeinsamer Bundesausschuss*)**—are not yet in place.
To prevent failure at the implementation stage, these timelines need to be extended.
Original Press Release: This is a translated version of the original German press release. To view the original text, Click Here (German).
Image Credit: VKD
