The editorial team at the Leading Medicine Guide took the opportunity to interview Dr. Björn Schmitz in his capacity as Chair of the Westfalen-Lippe State Association of the Professional Association of German Surgeons (BDC) and spokesperson for all BDC state association chairs, to learn more about the specific challenges of the hospital reform, its consequences, and the necessary adjustments.
Hospital reform is among the largest health policy restructuring projects in recent years—with far-reaching implications for structures, financing, medical training, and the future of surgical care. While policymakers promise efficiency, quality, and transparency, many hospitals, practices, and young physicians are facing profound changes that open up opportunities but also create considerable uncertainty. In this field of tension between political ambition and clinical reality, key questions arise for the surgical profession’s representative bodies and their assessment of the reform.
To implement reform requirements in a meaningful way in both rural and urban regions, flexible adaptation to local conditions is essential. This includes a precise analysis of regional needs in order to take into account care density, patient volumes, and specific requirements. Local hospital management teams and regional associations should be granted sufficient leeway to tailor requirements to their own structures.
“If you look at the hospital reform, you can certainly recognize a positive underlying attitude: The goal is to improve quality of care and create more streamlined, efficient structures. Centralization plays a major role in that. At the same time, however, it becomes difficult as soon as you take a regional perspective. Here I have to take a bit of a step back: I’m speaking not only as a state association chair, but above all as an additional voice for the regional representatives. And regional representatives—those are office-based physicians. Surprisingly, only a few people have so far considered that the hospital reform also significantly affects office-based colleagues. But first, a look at the underlying assumptions: In principle, I personally—and we as the BDC—yes, really all physicians—are in favor of reform, provided it improves medical quality and care for the population overall. Because the status quo shows: We spend an enormous amount of money, but in a European or global comparison we do not live longer as a result. The quality of the final years of life is not necessarily better than in other countries—it’s just significantly more expensive. And that raises the question of why that is. Now let’s look at the concrete example of hospital reform in North Rhine-Westphalia (NRW), where we have already gained some experience. The idea of centralization makes sense at first. Politically, however, it has been communicated in such a way that services—especially surgical ones—are centralized, creating a kind of black-and-white logic: What is done at the center is considered good; what happens outside is considered no longer good or should not happen at all. A simple example: A hospital that performs a large number of pancreatic procedures and is excellent at them is supposed to serve as a center. But that does not automatically mean that this hospital also performs inguinal hernia repairs perfectly. Nevertheless, these smaller procedures are politically swept into the centralization as well. This creates a pull toward large maximum-care hospitals, while smaller basic and standard-care hospitals are left behind. Their services will be reimbursed less in the future, so that hospital management can hardly operate these structures profitably. So on the one hand, services that are typically reimbursed at higher rates are taken away, and on the other hand, the remaining services—keyword: hybrid DRGs and shifting to outpatient care—are to be provided as outpatient services as much as possible, in some cases even outside the hospital” Dr. Schmitz explains, and continues:
“This inevitably leads to a loss of quality—and at the expense of patients. The maximum-care providers that are now supposed to take on many new service groups simply cannot do so in the short term: In addition to internal infrastructure, they lack staff, OR capacity, parking (for family members), and beds. The result is longer waiting times and patients being redirected. At the same time, patients at smaller hospitals that have previously offered high-quality basic and standard care may soon no longer be treated there because management says, ‘We can no longer make this financially viable—please go to an outpatient surgery center.’ The problem is: In many places, those centers do not even exist yet. And this is where office-based physicians come into play again. They cannot simply absorb the additional outpatient procedures that are now supposed to be outsourced en masse either. This results in a reduction in services provided, coupled with a reduction in reimbursement—and ultimately, that is precisely the stated goal of the reform”.
To prevent structural reforms from dismantling local surgical care instead of stabilizing it, a differentiated approach is required that takes into account both the political goals of the reform and actual care needs.
 in München.jpg "FOTO BDC Stand beim Deutschen Chirurgen Kongress (DCK 2025) in München")
Every reform must be planned realistically, but the hospital reform in NRW reveals structural problems. Dual financing—operating funds from health insurers and capital investment from the state—has been neglected for years. The states invested too little, forcing hospitals to finance capital needs from operating funds. That system is now collapsing, while needs analyses are continuously revised downward because services are no longer reimbursed adequately.
Dr. Schmitz explains this in more detail: “In practical terms, the reform means that large hospitals take on new services, while smaller basic and standard-care hospitals come under financial pressure. Policymakers made decisions independently of the sponsoring organizations, so everyone tries to secure the maximum benefit for themselves. A few emergency proceedings are still pending, but the reform is largely in effect: Payment follows the service groups, which severely restricts budget planning and hospital management. To keep smaller hospitals financially viable, political course-setting and financial support are needed. Otherwise, everything will concentrate in large hospitals, while investor-driven outpatient surgery centers take over what remains. Office-based physicians are often integrated into MVZs (medical care centers) or group practices and cannot close the resulting gaps. Supplying large hospitals can only be ensured through cooperation with other facilities. The hospitals in Münster and Essen show that networking works: Specialized hospitals handle complex procedures, while routine operations are performed via partner hospitals. The basis for this is regional, cross-operator budgets from the health insurers to enable cooperation and distribute resources fairly. The widespread mantra ‘volume equals quality’ falls short, because quality declines when only individual services are performed excessively often. Calculating case volumes for entire hospitals further exacerbates this problem. If you compare hospitals, you see a paradox: A hospital with eight surgeons and another with three can be rated the same on paper with similar case numbers, even though expertise is distributed very differently. At the same time, everyone keeps demanding more specialization—right or left of the liver, upper or lower abdomen—but a 24-hour on-call service of highly specialized surgeons is practically impossible. Specialists work during the day; at night, the generalist has to step in. I like to compare it to track and field: A sprinter, high jumper, or 400-meter runner is outstanding in their discipline, but not beyond it. The decathlete, on the other hand, can do many things well—and it’s similar in surgery. The general surgeon, defined as its own service group, reliably covers 80% of cases. Specialists such as visceral or trauma surgeons complement this, but they are not necessary everywhere for comprehensive coverage”.
Certain specialty areas have been strongly highlighted in the media—esophageal or pancreatic surgery—but for everyday patient care they are only a minor factor. The focus on specialization has far-reaching consequences, both for hospitals and for patients’ decisions.
Older, single individuals with limited mobility want a nearby hospital close to home. If they see that a hospital is no longer allowed to provide certain services, that can lead them to not go at all or to postpone surgeries.
“You could see this during the COVID period, for example: Many people stopped going to preventive appointments because they did not feel able to take on long journeys. These decisions are not always made consciously, but they have massive effects. The consequence is a spiral that particularly endangers smaller hospitals: Service groups are no longer granted, patients stop choosing the hospital, and that can lead to financial problems and, in the long term, even closure. Another issue is the shift to outpatient care, which can make sense in principle to relieve hospitals. In practice, however, it creates significant difficulties, especially for people who live alone or have limited mobility. The concept of hybrid DRGs leads to cases now being billed as ‘not inpatient = hybrid’—even though medically they are not truly outpatient. The problem also lies in organization: A hospital network could create surgical centers where office-based physicians and hospital doctors treat patients together. Patients would have to receive pre- and post-operative care, including emergency coverage and overnight options. But maintaining that capacity is expensive: beds, nursing staff, meals—all of that costs money that is not paid for outpatient services. Bureaucratic hurdles further worsen the situation. If a physician decides, for medical reasons, that a patient should remain inpatient, the insurer can deny it because the case is deemed ‘outpatient possible.’ Then every inpatient stay must be justified in detail, which is time-consuming and often only partially reimbursed. Central ORs with anesthesia and OR staff create high costs that cannot be covered with purely outpatient provision. The nursing burden also increases: Patients who used to be on the ward are now left to manage at home. The more care-dependent, the more labor-intensive the situation—and family members are often not able to take this on. Pre- and post-operative care is not covered for hospitals anyway, so in the end these patients may be left on their own” Dr. Schmitz observes thoughtfully.
Hybrid DRGs are bundled payments that reimburse certain procedures at the same rate—whether performed outpatient or with an overnight hospital stay. The goal is to save costs, but it often creates problems because medically necessary inpatient cases are not adequately financed.
Under the conditions of hybrid DRGs, another practical problem arises: A patient who is sent home after an inguinal hernia operation receives an emergency plan, but implementation is limited.
Dr. Schmitz illustrates: “In an emergency, the patient has to call emergency services themselves in order to be brought back to the hospital. Office-based colleagues provide only limited coverage at night, for example in acute problems such as a severely swollen knee or bleeding. Many emergencies are not noticed until hours later, which can put patients at risk. Comparisons with countries such as Denmark, Sweden, or the United States are misleading here. They have different structures: Patients often stay in a hotel next to the hospital, where medical staff provide follow-up care. In Germany, by contrast, patients go straight home without anyone ensuring follow-up care. Office-based physicians cannot compensate for these gaps—their practices are not twice as large, and the number of doctors is not doubled just because more surgery is being shifted to the outpatient setting. This chain of problems is hardly being recognized. In the reform process to date, surgery’s concerns have received little attention, as specialty associations were often broadly dismissed as lobbyists by the former federal minister and his advisory group. With the new minister of health, there have already been initial discussions, and parliamentarians are also showing understanding. Nevertheless, the reform is not yet complete, and political majorities are needed to push through adjustments. If that does not happen, there is a risk of a qualitative deterioration for patients: fewer available slots, longer waiting lists, reduced personal care, constrained training, more digital documentation, and strict budget orientation. In the end, so much revolves only around money, while caring for the patient moves into the background”.
Hospital CEOs are under enormous pressure: They are asking themselves whether they can continue operating a location at all under the current conditions. Even though the state classifies the facilities as necessary for meeting needs and calls for their continued operation, the business situation is often not sustainable. At the same time, paradoxically, there are state subsidies available when a hospital closes, which makes the situation even more absurd.
“Many management teams are therefore facing the difficult decision of how to continue running their facilities under these conditions. The idea of networking hospitals is also complex, especially when it comes to financial design. The DRG system does offer theoretical approaches here: regional DRGs or dynamic hybrid DRGs could be a solution (‘Diagnosis Related Groups’ is the bundled-payment system). A hospital could, for example, receive surcharges for overnight stays, nursing, or standby capacity without having to bill the entire case as inpatient. However, the problem with hybrid DRGs is that responsibility for patient overnight stays lies entirely with physicians, while reimbursement remains the same—regardless of whether the patient is discharged outpatient or must stay overnight as an inpatient. Hospitals cannot cover the costs of actual care this way. Policymakers are called upon here. Clear financial parameters are needed to stabilize basic and standard-care hospitals. As a professional-policy bridge, the BDC is therefore taking a very clear stance to point out these deficiencies and demand solutions” Dr. Schmitz makes clear.
High-quality and predictable residency training can only be ensured if reforms and financing models explicitly take into account the framework conditions for training and day-to-day clinical operations. Under rigid DRG conditions that reimburse services via case-based payments, there is a risk that time-intensive training measures will be seen as economically “unprofitable” and therefore neglected.
“Many hospitals feel as if they are heading into a black hole: No one knows exactly how the financial situation will develop, whether they will be able to hire the necessary surgeons, or how to train physicians well. The situation is highly dramatic. On the one hand, hospitals have to secure certain service groups and keep the corresponding specialists on staff. On the other hand, the question arises of who will train future physicians—especially for procedures that are increasingly performed outpatient or are taught only in service-group centers. Standard procedures such as inguinal hernia repair are carried out in practice by office-based specialists, who often do not have authorization to train residents. Residents cannot simply rotate through practices and learn the procedures—and the practices themselves rely on their own specialist workload. Rotation models across maximum-care providers, standard-care, and basic-care hospitals are conceivable in theory, but hardly feasible in practice. Highly specialized fields such as advanced visceral surgery can no longer be taught without years of rotation. This leads to a tragedy: Germany once had an extremely strong global reputation in medicine and hospitals, but the current development is jeopardizing that level. Seventy-five percent of all hospitals are currently operating in the red. Even flagship hospitals like Charité in Berlin, which provides top-tier medicine across all service groups in a networked manner and has sufficient physicians and nursing staff, are posting enormous losses in the hundreds of millions. These facilities meet all the goals of hospital reform, deliver cutting-edge medicine, and enjoy the highest international recognition—and yet they are not financially viable. Other hospitals in the region also operate at the highest level and still incur losses. The current reform does nothing to improve this situation” Dr. Schmitz criticizes sharply.
A professional association can ensure that political processes take surgical expertise into account by systematically acting as a bridge between policymakers, administrators, and clinical practice. The BDC is organized by federal states and state associations, with each state association having its own chair, and office-based physicians are represented as well.
“As the joint spokesperson for the BDC’s state association chairs and regional representatives, together with my colleague Prof. Dr. Carolin Tonus from Hamburg, I consolidate the interests of the surgical professional societies and present them in meetings, the presidium, and the executive board. We meet three times a year, regularly hold Zoom conferences and meetings, and consolidate the results, which are then carried forward into the political process. There is direct exchange with the Ministry of Health, the German Medical Association, elected officials, and payers. Demands are rarely enforced publicly through the media; the political path runs through intensive discussions and consensus-building. A current example is the debate about hospital financing. The health insurers want savings because they see hospitals as the largest cost item. Here, the BDC (together with the DGAV) steps in to explain positions and find solutions. For example, it was possible to successfully adjust the hybrid DRG rules for certain cases such as appendicitis, while complicated cases must remain inpatient. This requires intensive one-on-one discussions to push through medically sensible exceptions. The current reform is strongly oriented toward measurable metrics, such as the number of operations, and neglects ‘talking medicine,’ which cannot be quantified. The political perspective often follows management logics that fit medicine only to a limited extent: A hospital or an office-based physician is not a standardized product—regional differences and specific patient situations make a major difference” Dr. Schmitz explains, emphasizing:
“My wish for improving the system would be adequate hospital financing so that hospitals can operate at break-even without having to restrict medical services for financial reasons. Investments in construction, modernization, and staffing would have to be secured. My greatest wish remains patient-centered care: If hospitals close or procedures are restricted, waiting times increase significantly, and basic and standard care suffers massively. Patients cannot simply go abroad instead, and even those who could are often constrained financially or legally. In its current implementation, the reform therefore jeopardizes care for the population and leads to increasing strain on patients, physicians, and hospitals”.
For surgical care to be shaped once again more by medical priorities than by economic pressures, several structural adjustments would need to be implemented. How the situation develops from 2026 onward remains to be seen.
Dr. Schmitz comments: “At present, there are still no reliable figures. However, the Ministry of Labor, Health and Social Affairs is already publishing which facilities are permitted to continue offering certain service groups—and everywhere the numbers are negative. The sorting of these service groups will show how dramatic the situation will actually become. Initial reports already show that demand is rising sharply: With the same OR capacity, the same staff, and the same number of beds, some hospitals have 30% more requests in upper abdominal surgery and are already seeing initial waiting times. The dramatic consequences for patients who are not treated in time are therefore foreseeable. The legislature defines basic coverage within 20 minutes by car for 90%, i.e., for around 16.2 million people. What happens to the 1.8 million without an urban care area remains unclear. In practice, this is even more unrealistic: In urban areas, the drive takes significantly longer even on a Friday evening during rush hour, and the new federal reform, for example, also requires cooperating hospitals to be no more than two kilometers apart—a requirement that is hard to understand and whose data basis is unclear. Especially in rural regions east of NRW, the situation will become even more precarious: Physicians have to travel long distances to bring patients to obstetrics or basic-care centers. Under these conditions, basic and standard care will hardly be maintainable. Many physicians are forced by high requirements, liability risks, and limited resources to stop offering services. The reform thus threatens to massively restrict medical care for large parts of the population”.
Dr. Schmitz nevertheless ends our conversation on a positive, optimistic note: “Of course, the level of frustration due to political and organizational circumstances is high, but every day I try to achieve the best for the patient and my team. The goal is always good patient care, regardless of economic interests. If nothing else, if I manage not to put anyone on my team under pressure so that everyone can fully focus on caring for patients, that is a great success in this difficult time. I also engage outside the hospital, for example at ‘Career Evenings’ at high schools, to introduce interested graduating students to the medical profession. Likewise, many good projects are underway in Rotary networks. In doing so, I advocate passionately for making medicine overall more female, especially in leadership roles. Greater participation by women would benefit our field and hospital organization a great deal. At the moment, despite the high number of (female) medical licenses, few end up in direct patient care. Being a physician is still the most beautiful profession in the world, and I gladly experience that anew every single day. I also always end my talks with the same motto: ‘Stay confident,’ by Ingo Zamperoni. That is my conviction, which I have upheld for many years—despite all challenges, confidence remains a central driver”.
- Chief Physician, Department of General and Visceral Surgery and Proctology, Knappschaft Kliniken Kamen
- Focus on state-of-the-art diagnostics and therapy in abdominal surgery and proctology
- Clinical specialties: visceral surgery, hernia surgery, reflux procedures, endocrine surgery—especially thyroid surgery; specialization in minimally invasive (keyhole) surgery, including for complex procedures
- Specialized in wound care, particularly in the treatment of diabetic foot syndrome
- KV-authorized outpatient clinic for second-opinion procedures: diabetic foot syndrome & cholecystectomy
- Board-certified surgeon and visceral surgeon; advanced visceral surgery; emergency medicine; sports medicine; manual therapy; medical expert assessment
- MHBA degree connecting medical excellence with business/management expertise
