Expert Interview with Dr. Volker Fackeldey, M.D.

The hospital reform is taking place against the backdrop of a healthcare system already under pressure from staff shortages, hospital closures, and financial difficulties. While the federal and state governments argue over jurisdiction, hospitals providing primary and standard care, in particular, are facing existential uncertainty. In many regions, the planned structural guidelines seem out of touch with reality—and are heightening concerns that medical care in the future will be available not based on need, but on where one happens to live.

“The introduction of service groups can improve the quality of care because it is based on clear qualitative criteria and concentrates elective procedures more heavily in specialized centers. However, a nuanced approach is necessary for primary, routine, and emergency care. While elective surgeries—such as hip replacements or oncological procedures like the treatment of colon cancer—demonstrably yield better outcomes in certified centers and longer travel distances are acceptable for patients, this does not apply to emergency care close to home. Here, structures must be maintained that ensure rapid and high-quality treatment. Germany has too many hospitals overall, but political control through statutory requirements carries risks: Even high-quality hospitals can come under pressure if regional characteristics are not taken into account. It would make sense to have a healthcare planning system that is based on geographic conditions and clearly defines which hospital should assume which responsibilities. Examples from individual regions also show that hospital closures are often only noticed once care has already collapsed—while other facilities are rightly shut down due to poor quality,” explains Dr. Fackeldey, emphasizing:

“For patients, this means that elective procedures should always be performed where there are high case volumes and certified expertise. For emergency and primary care, on the other hand, accessible facilities must remain in place that are medically sound and of assured quality. The challenge lies in balancing specialization and local care in such a way that stable, high-quality structures are established in the long term.”

The idea that patients can travel longer distances to specialized centers without experiencing any disadvantages is only partially realistic. In healthcare, it is clear that distance is a medical risk factor. Older people, those with chronic illnesses, or those with limited mobility, in particular, quickly fall behind due to additional kilometers—treatments are delayed, follow-up appointments are missed more often, and symptoms are reported later. Longer distances also place a strain on emergency medical services: transport times increase, vehicles are tied up for longer periods, and response times come under pressure—with direct consequences for time-critical emergencies.

Without regional differentiation, tiered requirements, or separate funding for standby costs, there is a risk of centralization that will further thin out coverage across the region and weaken the security of care. It will be crucial whether the reform is implemented with sufficient regional differentiation so that quality goals are not achieved at the expense of the security of care.

Standby flat rates are fixed payments that hospitals receive for maintaining key primary and emergency care facilities around the clock—regardless of how many patients are actually treated. They therefore finance readiness, not individual services. These include emergency rooms, intensive care units, specialists on 24/7 call, and certain basic departments. The goal is to stabilize the financial footing of hospitals that are indispensable for regional care but could not cover their costs through the DRG system alone. The flat-rate maintenance payments are thus intended to ensure comprehensive care coverage and prevent key facilities from having to close for economic reasons.

If smaller hospitals come under structural or financial pressure as a result of the reform, this creates a complex risk for emergency and primary care that manifests not only in isolated bottlenecks but also in the gradual destabilization of entire healthcare regions.

“The problem arises where a hospital does not provide high-quality services in specialized areas but nevertheless plays an important role in local emergency care. If such a hospital closes, the question arises as to how local primary, routine, and emergency care can continue to be guaranteed. Service groups can help clearly allocate responsibilities: Primary care providers should take on the basic services necessary for emergency and routine care, while complex procedures—such as hip replacements or oncological surgeries—take place in centers with a high level of expertise. Hospitals with very low case volumes in such areas are considered unsustainable in the long term and should transfer their specialized services to larger or certified facilities. However, political implementation often takes the form of blanket market consolidation rather than systematic healthcare planning. A regional analysis that determines where specific hospital structures are actually needed would be sensible. Instead, the current course of action is leading to the closure of some hospitals without first defining how care is to be organized across the region. A look at other countries shows that a lower density of hospitals does not necessarily mean poorer outcomes. Examples such as the Netherlands illustrate that a more centralized structure can work, even if elective procedures there sometimes involve longer wait times. What remains crucial is that primary and emergency care be reliably accessible and that specialized services be provided where quality is demonstrably highest. However, the political reluctance to date to clearly define regional structures makes sustainable and realistic planning more difficult,” states Dr. Fackeldey.

From a medical perspective, the proposed quality criteria make sense in principle because they are intended to promote a stronger focus on outcomes, clearer minimum standards, and the concentration of complex procedures at experienced facilities. Minimum volume requirements, structured process guidelines, and defined staffing requirements can indeed help reduce complication rates and make the quality of outcomes more measurable. Especially for highly specialized procedures, the evidence is clear: experience and routine improve outcomes.

“An assessment of the quality criteria for hospitals reveals that the originally planned requirements were watered down during the reform process. Experts criticize this because lower requirements inevitably lead to poorer treatment outcomes and thus send the wrong message to the public. At the same time, certain care models—such as the affiliated physician system—are coming under increasing criticism, as economic incentives often take precedence over medical quality goals in this context. Under the new reimbursement structures, private-practice surgeons benefit significantly in some areas, while hospitals are experiencing substantial revenue losses. With the increasing shift toward outpatient care, the logic of care delivery is also changing. In the future, many procedures are to be performed on an outpatient basis or within the framework of hybrid DRGs. While these models allow for short inpatient stays, they often do not cover the actual costs incurred by hospitals. Should the hybrid DRG be phased out in the future, outpatient reimbursement rates would have to increase significantly to prevent financial losses for hospitals. At the same time, hospitals must adapt their structures: Hospitals that perform inpatient surgeries will also need outpatient capacity in the future—for example, through their own locations within medical care centers (MVZs), coordinated staffing structures, and flexible spatial layouts. Some hospitals that embraced this integration early on are already operating more financially stably today. For patients, these changes will have little impact on the process, and care may even benefit: follow-up treatments can be better managed at medical care centers, chronic wounds can be treated over a longer period, and the transitions between inpatient and outpatient care will be more clearly defined. The decision as to whether a procedure is performed on an outpatient basis or with a short inpatient stay ultimately rests with the treating physicians and is easily manageable in practice. “Hospitals that establish these structures early on demonstrate that an integrated outpatient-inpatient model can work—even if the organizational effort seems high at first,” explains Dr. Fackeldey.

Hybrid DRGs are uniform flat rates that apply to both outpatient and short-stay procedures. They are intended to remove treatments that do not strictly require an inpatient stay from the traditional DRG (Diagnosis-Related Groups) system and prioritize outpatient care over inpatient care. The flat rate remains the same—regardless of whether the patient goes home the same day or stays in the hospital for up to two days. For hospitals, this means that reimbursement is no longer based on the length of stay, but exclusively on the procedure itself. The goal is to expand outpatient services, avoid unnecessary inpatient stays, and at the same time manage care in a medically sound manner.

If smaller hospitals are allowed to perform fewer surgeries, this will have a significant impact on the training of young doctors. They need to perform a wide variety of procedures to gain confidence and be able to work effectively as specialists later on. If this practical experience is lost, they will lack precisely what can only be learned in the real-world setting of a hospital.

If, as a result of the reform, certain procedures are performed only in larger centers, surgical training will be concentrated in a few hospitals that are already under high work pressure and have limited capacity to expand their training programs.

Dr. Fackeldey explains: “The current reforms are having a noticeable impact on medical continuing education. In the future—similar to the situation in Switzerland—there will no longer be any single hospital that fully covers all aspects of continuing education. Doctors will have to rotate within regional networks: from primary and general care providers to specialty or high-level care providers and back again. This also applies to university hospitals, which, while teaching complex procedures, offer little routine experience in day-to-day surgery. These rotation models are intended to ensure that the next generation of physicians gains both highly specialized and broad-based practical experience. Organizationally, this will be challenging, but it is considered sensible from a professional standpoint. At the same time, the financial uncertainty facing many hospitals is currently complicating staff planning. Some hospitals are hesitant to hire young doctors because it is unclear whether the facility will remain open in the long term. Nevertheless, day-to-day practice shows that the medical job market remains stable: Graduates generally have no trouble finding positions, as hospitals cannot maintain operations without a sufficient number of board-certified specialists and resident physicians. Minimum requirements for the number of board-certified specialists within service groups, as well as the need to ensure 24/7 coverage, make medical staff indispensable. This is creating a system that relies more heavily on rotation, regional cooperation, and clear quality requirements. For continuing medical education, this means more structure and greater diversity; for hospitals, however, it also presents organizational and economic challenges.”

The current uncertainties surrounding hybrid DRGs and the unresolved financing of standby costs are creating a situation in which medical decisions must increasingly be made under economic constraints—and this is particularly critical in regions where the reform is already causing structural pressure.

“The economic pressure on hospitals has intensified further over the past year. New cost-cutting measures, incomplete inflation adjustments, and capped nursing budgets are placing an additional burden on hospitals. Many hospitals are now operating at a significant loss—a situation that is apparently being accepted politically in order to accelerate structural adjustments. At the same time, it remains unclear how key elements of the reform, such as flat-rate standby fees or integrated emergency centers, are to be implemented in practice. This uncertainty makes planning considerably more difficult. The situation in emergency departments is particularly problematic. Reimbursement does not even come close to covering actual costs, while the number of patients continues to rise—including a significant proportion who actually belong in outpatient care. Even large hospitals are facing financial difficulties as a result, and smaller clinics even more so. To reduce the economic pressure, reliable funding for basic and routine care would be crucial. An adequate flat-rate subsidy could ensure that hospitals can fulfill their legal obligations without incurring permanent losses. At the same time, hospitals would need to assess which service areas make sense from both an economic and a quality perspective and which should be better outsourced to specialized centers. However, cost-efficiency must not mean skimming profits from the healthcare system—rather, the goal should be stable care that combines medical quality with economic rationality,” Dr. Fackeldey notes, adding:

“Hybrid DRGs are actually intended to enable cross-sector, medically sound reimbursement. In practice, however, it is unclear how stable the funding will actually be, how the distinction between outpatient and inpatient care will be drawn, and how hospitals are supposed to maintain the necessary personnel and infrastructure resources if this provision is not reliably reimbursed. For many hospitals, this creates a dilemma in which medically appropriate inpatient treatments become economically unattractive, while outpatient procedures—regardless of the individual risk profile—appear financially preferable. This increases the risk that patients will be steered toward care pathways that are driven less by clinical necessity than by reimbursement logic. This is particularly problematic in hospitals that are already under pressure: When case numbers decline, service groups are eliminated, and at the same time the financing of basic infrastructure remains uncertain, the incentive grows to shift procedures as much as possible into those categories that secure short-term revenue. Added to this is the fact that the financing of standby costs—that is, the structures indispensable for ensuring reliable 24/7 care—remains unresolved. Without reliable, case-volume-independent funding, small and medium-sized hospitals are caught in a downward economic spiral that directly impacts patient care: emergency departments become unstable, on-call services are scaled back, and staff leave. In this situation, every medical decision automatically becomes a business decision, because every additional service carries the risk of generating losses.”

To ensure that the reform does not lead to further centralization at the expense of rural areas, structural adjustments are needed that take the unique characteristics of rural regions seriously and stabilize primary and emergency care there, rather than gradually eroding it. First and foremost, realistic funding for the costs of maintaining these services is crucial. Without this basic funding, these services will inevitably be drawn into an economic downward spiral that weakens rural areas.

“A strong clinical perspective is still lacking in the key decision-making bodies of the healthcare system. Many consider hospital advocacy groups to be too weak because, while they voice criticism, they rarely present concrete, constructive alternatives. Instead of solution-oriented proposals, a culture of opposition dominates, further paralyzing reform processes. This pattern is evident not only in the hospital sector but also in many political debates: resistance forms even before the details are fully known, while viable alternative models are lacking—a structural problem that hinders reforms. At the same time, it is clear that even within hospitals, operations are not always managed in a professional and forward-looking manner. Poor decisions made by executive boards often go unpunished because supervisory boards—frequently appointed for political reasons—have little grasp of the complex workings of the healthcare system. At the same time, the question arises as to why Germany continues to maintain such a large number of health insurance plans. Countries like Austria demonstrate that a small number of efficiently organized plans are sufficient and that significant administrative costs could be saved. Consistent digitization could further amplify this effect. “Structural reforms are necessary not only at the political level but also within the institutions themselves in order to use resources more effectively and make the system sustainable for the future,” explains Dr. Fackeldey.

In many regions, hospitals are faced with the question of how to distribute specialized services effectively. When individual hospitals have built up a high level of expertise in certain areas—such as joint replacement or colorectal surgery—while other facilities operate without clear areas of specialization, closer collaboration makes sense.

Dr. Fackeldey comments: “Possible options include both regional networks, in which hospitals remain independent and coordinate services among themselves, and joint centers that consolidate specialized procedures. Both models can work, provided they are strategically planned and implemented with high quality standards. The underlying concept aligns with the principle of service groups: Not every hospital should offer everything, but rather what it can reliably provide to a high standard. Complex and elective procedures belong in hospitals with high case volumes and proven expertise, while primary and general care providers should focus on local, community-based care. In practice, however, this logic often fails due to entrenched structures and the desire of many hospitals to provide as many services as possible themselves. At the same time, there is a risk that quality criteria will be diluted and that hospitals will perform procedures for which they are not optimally equipped. In the long term, there is no alternative to clear specialization. Minimum volume requirements in areas such as joint replacement, vascular surgery, or complex visceral surgery are intended to promote precisely this development. If hospitals are willing to pool services and share responsibility regionally, this can result in a healthcare system that is both high-quality and economically viable.”

The current reform package is only the first step toward a more comprehensive reorganization of the hospital landscape. The truly decisive structural changes are not expected until the main law is enacted, which will definitively establish the service groups, minimum volume requirements, and financing mechanisms. Until then, regional assessments will serve as an initial basis: They analyze how hospitals in individual areas are positioned, which care functions they can fulfill, and where there are excess or insufficient capacities. These analyses are useful because they highlight regional characteristics and provide initial guidance.

“In the next step, policymakers will determine which hospital is assigned which service groups. At the same time, new minimum volume requirements are to be introduced or existing ones significantly increased—for example, in joint replacement, vascular surgery, or obstetrics. These requirements are intended to further drive specialization and concentrate complex procedures more heavily in centers with a high level of expertise. For many hospitals, this means additional pressure, as they will no longer be allowed to offer certain services in the future. Particularly in the field of spinal surgery, the question arises as to whether rising minimum volume requirements could lead to more surgeries. From a medical standpoint, however, the opposite is expected: If fewer hospitals are permitted to perform surgeries and capacities are limited, conservative treatment will once again take center stage. At the same time, patients must adjust their expectations, as not every condition can be resolved surgically in the short term. An international comparison shows that Germany already performs too many procedures in this area. Greater centralization could therefore contribute to more medically sound determination of indications,” explains Dr. Fackeldey, and with that, we conclude our conversation.

Director of the Hernia Center at Maindreieck at Klinik Kitzinger Land, a nationally recognized center for complex abdominal wall hernias.
Responsible for the Department of General, Vascular, and Visceral Surgery at the same clinic where the Hernia Center is organizationally based.
Application of minimally invasive hernia procedures (TAPP, IPOM, fundoplication) as well as open techniques such as Shouldice, Lichtenstein, Sublay, and component separation according to Ramirez.
Implementation of a differentiated, patient-specific “tailored approach” in accordance with current guidelines.
Qualifications in general, visceral, and specialized visceral surgery, as well as additional training in sports medicine, proctology, chiropractic therapy, and coloproctology (EBSQ).
Scientific involvement through active participation in surgical professional associations and expert committees.
Treatment of the full spectrum of hernias, including incisional, hiatal, and parastomal hernias.
Use of modern 3D laparoscopy and high-resolution endoscopic systems.
Participation in external quality assurance programs (Herniamed) and structured postoperative follow-ups.
Management of an established training center for hernia surgery with high demand in German-speaking countries.

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