Dr. med. Volker Fackeldey heads the renowned Hernia Center at Maindreieck in the Klinik Kitzinger Land, which under his leadership has developed into a major institution for abdominal wall hernias in the Würzburg area and beyond. As early as 2013, it was recognized as one of the first centers in Germany as a Center of Excellence for Hernia Surgery – proof of the highest quality in patient care.
Dr. Fackeldey pursues a consistently individualized approach: Each hernia is treated according to a tailor-made surgical concept ("tailored approach"), as also advocated by the German Hernia Society. The specialist in general and visceral surgery as well as special visceral surgery also holds additional qualifications in sports medicine, proctology, chiropractic therapy, and European coloproctology (EBSQ). His comprehensive scope of practice includes hernia surgery as well as procedures involving the gallbladder, intestines, and appendix, as well as incontinence treatment.
In hernia treatment, Dr. Fackeldey masters all common procedures – from minimally invasive techniques such as TAPP and IPOM to open techniques like Shouldice and Lichtenstein, as well as specialized methods for incisional hernias. A particular focus is on the use of cutting-edge technologies such as 3D laparoscopy, which enables especially precise, gentle, and almost scar-free procedures. The center’s technical equipment, featuring a 3D video tower and innovative instruments, underscores its high standards of quality. Scientifically, Dr. Fackeldey is active in several national professional societies and expert panels and maintains ongoing exchange with colleagues to stay abreast of the latest research developments.
The Hernia Center is also a popular observation center for medical colleagues from across the German-speaking region. Patients benefit from excellent follow-up care, including a free follow-up examination six months after surgery upon request. Dr. Fackeldey stands for modern, responsible medicine at the highest level and offers patients with abdominal wall hernias a reliable point of contact at one of Germany’s leading facilities.
He views the impact of current changes in the healthcare system with concern – especially for smaller hospitals – a topic the editorial team of Leading Medicine Guide discussed with him.
The healthcare reform brings far-reaching changes to the entire healthcare system – but the effects are particularly noticeable for small and medium-sized hospitals. The aim of the reform is to make medical care future-proof, ensure quality, and control costs. However, facilities with limited financial and personnel resources are increasingly under pressure. Many smaller hospitals fulfill important care functions in rural or structurally weak regions, but now face the challenge of meeting new requirements in areas such as quality assurance, digitalization, or staffing standards – without jeopardizing their financial viability. The reform thus raises fundamental questions: How can these hospitals survive without losing their role in providing local care? And how can the balancing act between economic efficiency and patient welfare be managed?
The current healthcare reform presents significant challenges for small and medium-sized hospitals providing basic and standard care. Particularly problematic is the introduction of new service groups and the associated shift to standby flat rates, as these are often tied to structural requirements such as certain case numbers, a high density of specialists, or specific technical equipment that many smaller facilities cannot meet.
“The specific challenge for small and medium-sized hospitals is simply to survive. After a law was passed by the Bundestag and Bundesrat last year, there was hope for planning security. But the current coalition agreement states that this law is to be revised by summer, creating new uncertainty. Several hospitals in the region have already closed or are about to, which is politically intended. The law will make it possible for many small facilities not to survive. Even though there are good approaches, the implementation of the law under the current Health Minister Karl Lauterbach is often catastrophic. A concrete example of these shortcomings is the regulation of service groups. It was decided that not all hospitals may provide every service. For example, a service group for deep rectal resections in cancer cases was introduced. The original plan was that only certified centers would be allowed to perform these procedures to ensure quality. But Lauterbach chose to base it on the quantity of procedures performed. Now, hospitals in a region must perform at least 15 percent of the total number of these procedures, regardless of their certification. This ignores the fact that in small hospitals often only 1–2 surgeons perform these complex procedures, whereas large hospitals have many colleagues. The number of surgeries should be evaluated per surgeon and not just per hospital,” says Dr. Fackeldey at the beginning of our conversation, and continues:
“Another problem is the planned implementation of the service groups. In North Rhine-Westphalia, a politically supported process was carried out by Karl-Josef Laumann (Minister for Labor, Health, and Social Affairs of the State of North Rhine-Westphalia), in which regional conferences discussed which hospitals may continue to offer which services. Nevertheless, there are numerous legal complaints in NRW. In the future, this will largely be decided by the MDK (Medical Service of Health Insurance), which will lead to further conflicts. The problem is also evident in professional society certification, which is intended to ensure high-quality care. Lauterbach’s focus on quantity in allocating service groups does not consider the importance of individual expertise and experience of surgeons, which could be ensured through certifications by professional societies and oncology centers. Another major issue is the new G-BA resolution (Federal Joint Committee, the most important decision-making body in the German healthcare system): To perform oncological colorectal surgery, hospitals will soon have to carry out 20 rectal and 30 colon operations per year. If a hospital loses the deep rectal resection, it also loses the colon. This means that only a few hundred hospitals in Germany would be allowed to perform these procedures, which would massively overload the remaining clinics. The capacities would not be sufficient to meet demand, and medium-sized hospitals would be excluded from care.”
The separation of billing systems between inpatient and outpatient care has a significantly negative impact on the efficiency and economic viability of small and medium-sized hospitals.
This artificial system boundary often means that medical services are not provided where it would be most sensible and economical for patients, but rather where billing is technically possible or better remunerated. Hospitals that are fundamentally capable of performing certain outpatient procedures efficiently and with high quality are prevented from doing so by the current demarcation – for example, because they do not have a statutory health insurance accreditation or because outpatient billing in the inpatient sector is structurally disadvantaged.
Dr. Fackeldey explains: “Billing in the healthcare system has become very complex and includes three main types: outpatient billing according to the EBM, the Hybrid-DRG (a cross-sector billing model), and inpatient billing. It has become apparent that mistakes are made at various levels – both politically and within the hospital itself. Even though mismanagement and wrong decisions play a role in many facilities, this is sometimes not sufficiently addressed. A concrete example is the Hybrid-DRG, introduced last year. It results in a revenue loss of more than half a million euros for the department. Originally, the Hybrid-DRG was a subsidy for office-based colleagues, who received significantly more money for the same operation and could also bill additional services such as pre- and post-operative care separately. Hospitals, like ours, receive only a flat rate, which is significantly lower – about 800 to 1000 euros less for, say, an inguinal hernia. With the number of procedures performed here, this amount adds up considerably. Some procedures, like umbilical hernia repair with local technique, are better remunerated, but overall, the department generates significantly less revenue due to these regulations.”
Another mistake affecting the clinic is the absence of a statutory health insurance physician position, i.e., a Medical Care Center (MVZ) for surgery. This was clearly a poor decision, as an MVZ would allow the clinic to better position itself in outpatient billing and thus generate additional revenue. This is particularly important for small and medium-sized hospitals, which must better structure their outpatient care to offset deficits.
“In the future, the so-called standby flat rate will be introduced, DRGs (Diagnosis-Related Groups) will continue to be reduced, and flat rates will be paid for maintaining capacities. However, it is expected that these flat rates will be insufficient and tied to the number of inpatient cases. Clinics must treat as many cases as possible this year to receive a good standby flat rate for 2027. I find this approach incomprehensible. By 2027, we will have completely different cost structures and different service groups. Services provided today may no longer be permitted and would be excluded. At the same time, new services may be added by then that are not currently allowed. This means another massive bureaucratic burden. I therefore fundamentally consider the planned linkage with this year’s DRG revenues to be wrong. Another problem for the clinic is the aftereffects of the COVID period. Some departments struggle to reach pre-pandemic figures. However, our own department is well-positioned and benefits from a large catchment area and cooperations such as with the Leading Medicine Guide,” emphasizes Dr. Fackeldey.
Ambulatory care, especially in smaller hospitals, is often insufficiently implemented, although this would be an important step to better position themselves in the healthcare market.
“Some hospitals have already acquired statutory health insurance physician positions and founded MVZs to optimize outpatient care, as has been done in our clinic in internal medicine, anesthesiology, or gynecology. However, this opportunity was missed in surgery – a wrong decision by the hospital administration. This decision costs the department a significant amount annually and denies the advantage of a better revenue situation and closer integration of outpatient and inpatient care. The lack of an MVZ means that patients come to the hospital who actually do not need to be treated there, which in turn burdens the cost structure. In a hospital with an MVZ, this outpatient area could be better organized. An MVZ requires its own premises and must be clearly separated from the inpatient area. Staffing resources must also be split, meaning senior physicians would no longer hold full-time positions in the hospital but would have to divide their time. Although this division of resources leads to organizational challenges, the long-term benefits outweigh them,” Dr. Fackeldey makes clear and comments on the over-bureaucratization:
“Another major problem is the bureaucratic hurdles in the healthcare system. Documentation requirements and associated tasks take up a lot of time that should actually benefit patients. Despite the hospital being well digitalized, there is often a lack of interfaces between different systems. Thus, data must be entered multiple times, which is not only inefficient but also leads to additional effort. Data protection is, of course, important, but the lack of system integration makes work more difficult and causes unnecessary extra work. The slow progress in introducing an electronic patient record is hindering. Despite decades of announcements, there are still no functioning solutions that allow for easy exchange of patient data between doctors. This is especially problematic in complex diseases where quick, uncomplicated communication between various specialties is necessary to optimally help the patient.” In sum, these factors mean that many smaller hospital locations can hardly remain financially viable. The danger of a growing thinning out of inpatient care in rural areas is therefore real and imminent.
Service groups and new reimbursement models play a central role in assessing the future viability of medium-sized hospitals – they largely determine which facilities will be allowed to provide certain medical services in the future and how these services will be financed.
Dr. Fackeldey explains: “For real progress in the healthcare system, the fundamental problem of reimbursement must be addressed, as hospitals have a different cost structure than practices. Hospitals have not received inflation compensation for years, creating a structural deficit. An important legislative proposal stipulates that hospitals can better position themselves in the outpatient sector if they apply for authorization. However, this process depends on the Associations of Statutory Health Insurance Physicians (KVen), which often pursue their own interests. A legal regulation is needed that automatically grants hospitals authorization for their specialist departments. Moreover, hospitals lack a strong lobby in my opinion, while private practitioners and health insurance companies are better networked. Hospitals are often seen as cost drivers, which weakens their position in political discussions – even though private practitioners also contribute to the high number of surgeries,” and he adds:
“Despite the financial pressure on both sides, the aim of the legislation to reduce surgeries is understandable. The goal is to perform only medically necessary procedures and to strengthen conservative treatment approaches – in line with international standards where significantly fewer surgeries are performed. Hospitals that do not meet the required criteria, such as specialist density, case numbers, or technical equipment, risk being excluded from key areas of care. This jeopardizes their financial viability and their role as local healthcare providers, especially in rural regions. Medium-sized hospitals, which function as a bridge between basic and maximum care, are particularly affected. The new reimbursement models, with standby flat rates, mark a departure from the volume-based DRG system: hospitals receive payments for providing structures, regardless of case numbers. This offers opportunities – for example in emergency care or obstetrics – but depends critically on the amount and conditions of these flat rates. If they are too low or too restrictive, economically weak hospitals will come under even greater pressure.”
The current healthcare reforms certainly offer opportunities for smaller hospitals, particularly through specialization and cooperation. One of the key opportunities available to these hospitals is to specialize in certain treatment areas or medical services.
One possible solution for smaller hospitals could be merging with neighboring clinics. Such a merger would allow the facilities to specialize in certain medical fields and thus leverage synergies. “Currently, one clinic is in merger negotiations with a neighboring clinic to increase efficiency. Both clinics will reduce their bed capacities and attempt to optimize their structures. However, the problem with this merger is that many parallel structures are to be maintained despite the intended consolidation. This is due to political requirements that make it difficult to restructure the clinics economically. Ideally, surgical services would be concentrated in one clinic, while the other clinic specializes in other areas such as geriatrics. However, political and administrative obstacles currently hinder such restructuring. The merger itself could give the participating clinics a chance to work more efficiently and survive in the long term. But the current course might merely prolong the ‘closure process’ without achieving real improvements. This is particularly problematic as both facilities are struggling with deficits of several million euros and the planned structural changes contribute little to solving the underlying financial problems,” explains Dr. Fackeldey.
If hospitals in rural areas are closed, it often means that patients have to travel long distances to receive necessary treatment. In many cases, this could be 50 to 70 kilometers, which poses a significant challenge for elderly or ill patients.
Dr. Fackeldey adds: “A sensible solution could be to structure the existing hospitals so that they only provide the most essential services such as emergency medicine and basic surgical and internal care, while specialized treatments are concentrated in larger centers. This is also the basic approach of the law. Nevertheless, these hospitals should still be allowed to continue providing existing competencies. Another important point is that many elderly and ill people are unable to organize their medical care themselves. This often leads to the emergency services being called, which further strains these resources. Another possibility would be to convert closed hospitals into care facilities to meet the growing demand for care places and ensure patient care. There is also a significant shortage of personnel in the care sector, which exacerbates the situation. Therefore, closer cooperation between healthcare and care facilities may be necessary to overcome these challenges.”
The current situation in the healthcare system shows that the coming years will be extremely challenging for both hospitals and the healthcare system as a whole.
“The coming years will be extremely difficult and demanding, marked by many hospital closures. Right now, it is mainly a matter of perseverance in order to be among the survivors. Church-run and public hospitals are particularly affected because counties will face significant financial challenges in the coming years and will often no longer be able to contribute the necessary millions. The coming years remain uncertain, especially due to unclear developments in legislation. A transition period until 01.01.2028 has already been announced, and until then it remains unclear how the situation will evolve. This means that planned mergers and structural decisions are being delayed because no clear information is expected before summer. As for young doctors, this uncertainty also negatively affects their career prospects. Many aspiring physicians are facing the challenge that hospitals cannot give them any firm commitments because it is unclear how things will proceed. This uncertainty and lack of planning lead to frustration and discourage many young doctors from continuing their careers in hospitals,” says Dr. Fackeldey.
The challenges facing the German healthcare system are manifold, especially for smaller hospital sites in rural areas. There is an urgent need for reforms that enable better financial resources and sustainable structuring of hospitals.
“Germany often lacks team spirit and collaboration, which is certainly also due to mentality. In comparison, Scandinavian countries like Denmark do better by focusing more on cooperation and less on self-congratulation. Another problem in the current legislation is the capping of the nursing budget, which leads to many care-related costs being shifted back to the general hospital budget. A doctor’s budget, which could sensibly relieve hospital finances, is also lacking. The nursing budget introduced a few years ago is even to be restricted again. To improve the cost structure, it would make sense to introduce a standby flat rate that is calculated independently of DRG revenue. Especially for an emergency department in a rural area that must be open around the clock, the costs are high and should be fully covered, rather than only partially. If such an emergency department is needed, it should also be fully financed, without being dependent on other DRG revenues,” states Dr. Fackeldey, emphasizing another key point:
“Small hospital sites in rural areas should be developed into large polyclinics with beds and a wide range of outpatient services. They must automatically be granted authorization for outpatient activity without being dependent on self-governing bodies. Another reform need lies in inflation compensation: while employees received adjustments, hospitals were left with the additional costs, causing massive underfunding. However, there are positive signals from politics. Specializations of small hospitals are difficult within the framework of service groups because high personnel requirements – such as five cardiologists in interventional cardiology – financially overwhelm small facilities. Cooperations and mergers can be sensible if well implemented. The basic structure of the new law seems to be in place; the introduction of service groups is fundamentally sensible, provided quality criteria are the focus rather than pure quantity. Clinics that provide good care and are certified should continue to be allowed to offer these services. However, the motivation of staff remains crucial, and this is currently a major challenge given the widespread frustration.”
Thank you very much, Dr. Fackeldey, for this political discourse!
