The Centrum Gastroenterologie Bethanien (CGB) in Frankfurt am Main is one of the largest outpatient facilities in Germany for diseases of the gastrointestinal tract, liver, and pancreas. With over 25,000 endoscopic procedures performed annually, it ranks among the largest gastroenterology centers nationwide. Prof. Dr. med. habil. Fabian Finkelmeier and Assoc. Prof. (Priv.-Doz.) Dr. med. habil. Mate Knabe are two of the five partners who significantly shape the center’s strategy and development. Both have many years of clinical and scientific experience and are recognized experts in their respective fields.
Prof. Dr. Finkelmeier specializes in oncological gastroenterology and hepatology. He brings extensive experience in the diagnosis and treatment of liver diseases as well as gastrointestinal tumors and is particularly committed to advancing outpatient gastroenterological and oncological care.
Assoc. Prof. Dr. Knabe, in turn, focuses on interventional endoscopy and is considered one of Germany’s leading specialists in this field. His expertise includes, among other things, the endoscopic removal of early cancers in the gastrointestinal tract, endosonographic diagnostics, as well as complex therapeutic endosonographic procedures and interventions on the bile ducts and the pancreas. As an experienced endoscopist, he is especially at the forefront in the interdisciplinary management of cancers of the digestive tract.
Both physicians place great emphasis on individualized, patient-centered care – from the first consultation through follow-up. Together with a team of ten other highly qualified specialists, including Dr. med. Kai Miesel, Dr. med. Stephan Haaß, Dr. med. Jörg Ungemach, Dr. med. Stephan Vetter, Dr. med. Sibylle Ehrlich, Dr. med. Shakila Terai-Chun, Dr. med. Sandra Blößer, and Dr. med. Nora Schweitzer-Klusmann, the center offers a broad spectrum of diagnostic and therapeutic services covering the entire field of interventional endoscopy and gastroenterology. This ranges from standard upper and lower endoscopies to advanced ultrasound and puncture techniques, to the management of chronic inflammatory bowel diseases, as well as complex tumor diagnostics and treatment.
Close collaboration with Bethanien Oncology, Bethanien Radiology, and the Bethanien Surgical Center ensures comprehensive, one-stop care – efficient, coordinated, and at the highest medical standard. Short pathways, structured processes, and personal physician attention are always paramount. With this clear focus on quality, interdisciplinarity, and patient orientation, the Centrum Gastroenterologie Bethanien has established itself as a reliable point of contact for complex gastrointestinal issues – both regionally and beyond.
How a shift to outpatient care can work in the field of gastroenterology and what prerequisites are needed was the subject of a conversation the Leading Medicine Guide editorial team had with Professor Dr. Finkelmeier and Assoc. Prof. Dr. Knabe.
Gastroenterology has been undergoing a marked shift toward increasingly outpatient care for several years. Advances in diagnostics, minimally invasive techniques, and optimized treatment concepts now make it possible to deliver many gastroenterology services outside the inpatient setting – safely, efficiently, and with the patient in mind. Particularly in endoscopy, the management of chronic inflammatory bowel diseases, and oncology, the focus of services is increasingly moving to the outpatient sector. This development not only benefits patients; it also presents the healthcare system with new challenges and opportunities in cross-sector care.
In today’s gastroenterology, many services can be delivered safely and effectively in the outpatient setting.
„Gastroenterology is one of the specialties that are particularly well suited to a stronger shift to outpatient care – especially in light of current health policy efforts in Germany to provide more medical services outside the inpatient sector. Many common procedures in endoscopy, such as preventive exams like upper endoscopy or colonoscopy, have long been established on an outpatient basis. Beyond that, interventional endoscopy can increasingly be meaningfully transferred to the outpatient sector. The treatment duration for these procedures is generally short, complication rates are low and predictable. Often, a brief period of post-procedure monitoring is sufficient, so that patients can be discharged the same day – provided they return to a safe home or supervised environment. In many such cases, procedures still performed on an inpatient basis offer neither a medical advantage for the patient nor an economic benefit for the healthcare system. A large proportion of one- to two-day stays could be avoided without compromising treatment quality or safety. At the request of the Federal Ministry of Health, our specialty society systematically analyzed which gastroenterological services can be provided on an outpatient basis. It became clear that virtually all common endoscopic procedures can in principle be performed outpatient – with only a few exceptions in which inpatient treatment remains necessary for medical reasons. At the same time, it must be noted that current reimbursement structures often make outpatient services economically unattractive. Many procedures are therefore performed inpatient because they are better reflected in the DRG system than in the AOP catalog. The existing billing pathways for ambulatory surgery (AOP) currently cover only part of the services, such as colonoscopy. With the introduction of the so-called Hybrid DRG, a new reimbursement model for certain outpatient services, a first step has been taken to enable more complex procedures – like endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP) – outside the inpatient sector. Gastroenterology is one of the first specialties to be included in this model – an important signal for the further development of outpatient care“, explains Prof. Dr. Finkelmeier at the beginning of our conversation.
The question of reimbursement plays a central role in the discussion about shifting medical services to the outpatient sector. It would be counterproductive to neglect this aspect, because every hospital faces the economic challenge of operating sustainably. Therefore, there must be clear, transparent, and fair framework conditions under which it can be decided how a medical institution provides its services – and can thus remain economically viable.
Prof. Dr. Finkelmeier comments: „From a health policy perspective, it certainly makes sense to rely more on outpatient care models, as Germany provides an above-average number of inpatient services in international comparison. This entails substantial costs: for buildings, energy, staff, accommodation, and the entire infrastructure. A large portion of these expenditures could be reduced through targeted expansion of outpatient care – explicitly without cutting nursing staff or quality. For hospitals, this would mean, prospectively, that bed capacity would need to be reduced, which depending on your viewpoint may have advantages or disadvantages for the healthcare system. For such a transformation to succeed, however, the reimbursement system must also be adapted accordingly. Particularly in interventional medicine – whether in gastroenterology, cardiology, or other internal medicine disciplines – there are high costs for technology, materials, and specialized structures. These expenditures must be adequately reflected in the outpatient sector so that services can be provided there in a financially sustainable way. While the DRG system in inpatient care is often better geared to complex and cost-intensive services, the outpatient sector frequently lacks the possibility of adequate refinancing. In privately run practices, investments and ongoing costs must be covered independently – without the financial leeway that sometimes exists in inpatient care. For the shift to outpatient care not only to be politically desired but also practically feasible, we need a reimbursement system that meets these requirements. Only then can a high-quality, economically stable, and patient-centered outpatient care be established in the long term“ and adds:
„Current reimbursement systems are not sufficient to implement the outpatient shift to the necessary extent. There is a lack of clear and sustainable financial frameworks that both create incentives and realistically reflect the actual costs of outpatient services. While the Hybrid DRG is viewed by many experts as a sensible interim solution to facilitate the transition from inpatient to outpatient care and to enable corresponding shifts in service delivery, a structural reform of reimbursement systems is indispensable in the long term. At the same time, the fundamental question arises as to who should provide these outpatient services in the future: hospitals, which are becoming increasingly active in the outpatient sector, or office-based practices? In many areas, the required structures to perform certain procedures on an outpatient basis at a high level are not yet in place. Health policy measures have created an initial incentive, but the infrastructural prerequisites – personnel, technical, and organizational – are still lacking in many places. These now need to be purposefully developed to not only enable the outpatient shift, but also to implement it at high quality. In terms of staffing, the core requirements for an outpatient intervention do not differ substantially from those for an inpatient procedure: You need experienced specialists, well-trained nursing staff, and appropriate spatial and technical equipment. Emergency care must also be ensured. Unlike in the inpatient setting, however, resource-intensive nursing, monitoring, and accommodation structures are not required – which basically lowers operating costs, but at the same time raises the bar for organization and safeguards in an outpatient environment“. 
Assoc. Prof. Dr. Knabe comments: „An important aspect is integrating outpatient services into a cross-sector care concept. To provide outpatient services at a high medical standard, you need more than a technically well-equipped practice – you need structural embedding in a medical network that enables clinical standards. In facilities like the Bethanien Center, this principle is already a reality. Various specialties work closely together here: an oncology practice, a surgical practice, as well as cardiology partners – all at an excellent professional level. This interdisciplinary integration not only creates medical quality but also safety, for instance if complications occur during an intervention. In such cases, there can be an immediate response – for example, with imaging diagnostics by the radiology practice, which functions just as smoothly as in a traditional hospital setting, even though this is formally an outpatient care environment. Many solo practices cannot replicate such structures – especially when they operate in isolation and without a clinical backbone. In such an environment, outpatient care for more complex cases would often not be feasible or safe. At the same time, as the outpatient shift increases, the question arises as to how daily inpatient workflows will change“.
If a significant share of the less complex cases is treated on an outpatient basis in the future, the wards will primarily be left with patients who have severe or complex conditions – and that in turn means a significantly higher need for intensive nursing and care.
„This aspect is indeed being taken into account in the current health policy discussion. The goal is not to burden nursing staff further, but to allocate resources more sensibly. If outpatient structures prevent patients from being admitted, wards can be downsized or merged. This creates available nursing capacity that can be concentrated on those patients who actually need inpatient treatment. This concept has already been implemented at Bethanien: What is now the practice used to be a regular ward that was completely rebuilt and converted into an outpatient facility. The nursing staff who used to work there are now distributed across other wards – wherever the need is greatest. The result is a double benefit: outpatient care is strengthened without weakening inpatient care. On the contrary – by targeted relief, clinics can focus more on caring for severe cases. And economically, it also makes sense for the hospital, since outpatient cases are handled by specialized partners, while inpatient care remains focused on the treatments that are truly necessary“, says Assoc. Prof. Dr. Knabe. 
The so-called “Ambulantisierungsfördergesetz” is an umbrella term for a variety of health policy measures and reforms launched in recent years to strengthen outpatient care in Germany. These include, for example, the Hospital Care Improvement Act (KHVVG), new nursing structure regulations, the MDK Reform Act (Medical Service of the Health Insurance Funds) as well as rules concerning the so-called AUG presumptions (clarification of unclear genesis). Much of this, however, has not yet been fully implemented – particularly with regard to the Medical Service (MDK) and the associated restructuring.
„In practice, the impact of the law has so far been very inconsistent. Federal states like North Rhine-Westphalia are far advanced in implementation. There, a comprehensive restructuring of the hospital landscape has already taken place, including the introduction of so-called service groups. Only institutions that meet certain qualitative and structural requirements are still granted service mandates – for example, in surgery. Hospitals that do not meet these prerequisites or have only low case volumes are simply no longer permitted to offer certain services. This has far-reaching effects on the care offering but is quite consistent from a systemic point of view. Other federal states, however, are much more restrained. In Hesse, for example, there is currently intense debate about what the future distribution of service groups should look like. Decisions have not yet been made in many places. Nevertheless, the restructuring of the hospital landscape is already noticeable. Many institutions are reorganizing entire departments, and gastroenterology is also affected. Inpatient gastroenterology services are often barely cost-covering from a business perspective, leading many hospitals to downsize these departments or integrate them into other structures. The result: a large portion of these services is increasingly being shifted to the outpatient sector. Gastroenterology in particular exemplifies how the system is shifting – where exactly it is headed, however, is still open at this point. Much is in flux and highly dependent on the respective federal state. While some regions already issue concrete stipulations, there is still great uncertainty elsewhere. One thing is certain: Over the next two to three years, it will become clear where things are going. Many stakeholders – hospitals, specialty societies, federal states – are currently engaged in intensive discussions about who should assume which responsibilities in the future“, emphasizes Prof. Dr. Finkelmeier, and Assoc. Prof. Dr. Knabe adds by way of explanation:
„A central problem in this transformation process is the lack of flexibility in medical decision-making. In practice, many physicians experience that they must provide services on an outpatient basis even when, from a professional standpoint, they consider inpatient care necessary. If a procedure is formally defined as outpatient, there is hardly any leeway – even if a physician explicitly recommends inpatient monitoring in the report. Decisions are often made purely according to the catalog, without taking individual clinical judgment into account. This lack of differentiation between the legal text and medical reality is increasingly becoming a problem within the new structures – and shows that the outpatient shift requires not only structural but also regulatory fine-tuning“. 
Despite the increasing shift to outpatient care, patient safety in Germany remains ensured. So-called context factors provide safeguards: If there is, for example, a bleeding or another relevant complication, inpatient admission can – or must – take place. These medical criteria often automatically apply, especially for older, multimorbid patients. In such cases, care is well secured.
Assoc. Prof. Dr. Knabe emphasizes: „However, it becomes problematic when none of these context factors are present in the case of a medically complex procedure. Then there is no longer any decision-making freedom for physicians – even if inpatient monitoring would be advisable from a professional point of view. In practice, admission still occurs, often in the interest of patient safety. But afterward, the inpatient service is often not recognized or reimbursed by the payers. There are rejections by the Medical Service (MDK) on the grounds that the procedure was listed as outpatient in the catalog or that the extent of inpatient treatment was not justified – a so-called inappropriate admission. This leads to financial losses for the institutions. To mitigate such situations, a great deal of effort goes into documentation“.
Prof. Dr. Finkelmeier clarifies possible consequences: „If more than a certain proportion of inpatient cases are deemed inappropriate admissions – the threshold is usually around 35 percent, varying by federal state – repayments to the MDK and penalties may result. This system is intended to prevent economic misincentives, but in practice it imposes a considerable burden on medical institutions. The threshold for inpatient admissions is thus artificially raised“.
A good option is to create outpatient structures with clinic-adjacent monitoring. After complex procedures, such as removal of large polyps, patients are initially observed for several hours. Only when stable are they discharged – or they remain inpatient after all.
„With us, all patients receive an emergency number through which an experienced specialist can be reached directly around the clock. This allows complications to be assessed quickly and, if necessary, managed immediately – at least in urban areas where emergency services can be on site within minutes. In rural areas, however, the situation is different. Distances are longer, and the on-call medical service is often more thinly staffed“, says Assoc. Prof. Dr. Knabe, and Prof. Dr. Finkelmeier notes: „At the same time, care needs are increasing: Many elderly people live alone and feel insecure or overwhelmed after a procedure. However, a patient’s wish to be admitted is not sufficient on its own. There must be a medically justifiable need. This is particularly problematic for very elderly people living alone – for example, when there are no relatives who could ensure aftercare at home. While functioning models of cross-sector care are already emerging in urban centers, implementation remains a challenge in rural regions. The structural differences in the healthcare system – for example between urban and rural areas – are significant and have not yet been adequately addressed. There is an urgent need for further solutions to ensure safe outpatient care across the board beyond metropolitan areas“.
Shift to outpatient care and cross-sector collaboration
The ongoing shift to outpatient care is fundamentally changing the collaboration between specialist practices and hospitals. In integrated models such as the affiliated-physician system or cross-sector care concepts, the boundaries between outpatient and inpatient care are increasingly blurring. Specialists accompany their patients continuously – from diagnostics and outpatient therapy to inpatient treatment and follow-up. This continuity strengthens quality of care and increases patient satisfaction. Closer integration also brings new requirements: coordinated communication structures, digital interfaces, and clear allocation of responsibilities between outpatient and inpatient partners. This allows patient flows to be better managed, inpatient stays to be reduced, and even complex disease courses to be managed efficiently – especially for chronic and specialized indications such as in gastroenterology.
The notion that more outpatient services will automatically allow more patients to be treated falls short – many outpatient structures are already working at their limits. In many specialty practices, it is a daily challenge to prioritize patients who truly need urgent care. Appointments are scarce, demand is high, and comprehensive coverage is often not feasible.
„Some practices therefore use structured procedures to quickly assess the urgency of referrals. The aim is to use limited resources as sensibly as possible – for example, by deprioritizing patients with repeated, low-yield requests in favor of complex or acute cases. At the same time, it is becoming clear that the outpatient–inpatient system is in a phase of restructuring. Traditional solo practices are increasingly being replaced by larger medical care centers (MVZs), operated either privately or by hospitals. Cooperation between office-based physicians and inpatient institutions is on the rise. One example is our close collaboration with Markus Hospital in Frankfurt, a maximum-care provider with 800 beds. There, office-based surgeons operate who also regularly work in the affiliated practice – a cross-sector connection that enables seamless treatment pathways“, says Assoc. Prof. Dr. Knabe regarding future developments.
Prof. Dr. Finkelmeier comments in this context on the situation of patients who may live farther from the nearest hospital: „Even though patients with limited mobility may initially face hurdles, centralization and specialization are seen as a clear long-term advantage: higher quality of care, lower complication rates, and shorter lengths of stay. Especially in a country with comparatively short distances like Germany, this approach seems sensible – also in view of the growing shortage of skilled professionals. By pooling expertise and resources more strongly, staff can be deployed more efficiently, ultimately improving overall treatment quality“, and Assoc. Prof. Dr. Knabe reinforces the idea of centralization: „In the end, it is more sensible to accept, for example, a 100-kilometer trip to the treating physician if that physician has the necessary expertise“.
Bethanien is something special – an outpatient colorectal center with history and a clear ethos. It stands out for its highly qualified medical team, close integration of outpatient and inpatient care, and state-of-the-art diagnostics and therapies on site. 
„Bethanien was the first certified outpatient colorectal center in Germany. And in fact, the whole concept arose out of necessity. Sure, there are now countless certified colorectal centers, but an operation that is entirely outpatient – like here – as far as we know, that hadn’t existed elsewhere. It was established here before our time, many years ago. And to this day it is truly unique. What also sets Bethanien Hospital apart is a management team that has driven and supported this overall concept with absolute determination for years. Always decisive, with short lines of communication, and always in the patient’s best interest. This pragmatism is not a given in a complex system like healthcare. It’s not just an attitude; it’s a culture. And I believe that applies to all the practices here. We decide many things simply over lunch. If we want to change something, we do it. Immediately. It’s implemented the very next day. Elsewhere you first have to go through five committees and get 17 signatures – and when the board finally decides something two years later, it’s already outdated. This speed, at a high level – that’s what defines Bethanien“, says Assoc. Prof. Dr. Knabe enthusiastically.
If the shift to outpatient care is meant seriously, it must also be enabled.
„When we talk about the bigger picture – the further development of outpatient care – there are essentially two major issues: First, financing. How all of this will be funded in the long term is still completely open. That’s where policy makers come in. And second – just as important – training. At the moment, training depends entirely on hospitals. And things are not going smoothly there. Due to centralization, service groups, and all these structures, training is effectively shrinking. Many hospitals can no longer provide adequate training. Specialist certifications? Often no longer fully attainable. That is a huge problem. We have both outpatient and inpatient structures here – actually ideal. But training in the outpatient sector? That is barely envisaged in the system. And that is absurd, because the majority of cases and everyday clinical pictures – the ones you need for learning – are found in practices“, criticizes Prof. Dr. Finkelmeier, and his position is supported by Assoc. Prof. Dr. Knabe:
„In hospitals you only see the very severe cases. How is one supposed to learn properly under those conditions? That’s a real blind spot. In theory, training would be permitted, but in practice it is extremely time-consuming, complicated, and hardly feasible. And that needs to change – otherwise the outpatient shift will not work in the long run. Many hospitals are currently no longer hiring permanent staff. Why? Because they don’t know how things will continue – financially, structurally. Everything is somehow up in the air, decisions are being postponed, and it’s practically impossible to plan. That also affects training. It’s like a spiral: if fewer people are trained, assistants will soon be lacking. Then specialized staff will be missing, then beds will have to be closed, then the level of care will drop. And we are already facing a shortage of physicians. This has not been fully thought through yet. Responsibility lies not only with political decision-makers but also with the medical bodies. So far, too little is happening. It needs to move faster. Otherwise, the system will eventually falter. But – and this is also important – we shouldn’t only complain“.
Here, Prof. Dr. Finkelmeier concludes our conversation on a very positive note: „At Bethanien here in Frankfurt am Main, we truly have an exceptional situation. A constellation that works really well. And that shows: It’s possible – if you want it. You can implement things quickly, at a high level, with a lot of humanity. And that is a genuine privilege“.
Many thanks to Prof. Dr. Finkelmeier and Assoc. Prof. Dr. Knabe for this lively and candid discussion about the shift to outpatient care!
