Shifting suitable services into outpatient care is medically and economically plausible. It only works when financing, investment, staff and responsibility move with the service.

Policy has moved, but implementation remains incomplete

Since 2024, Germany has used hybrid DRGs for selected procedures. The 2026 catalogue contains 904 OPS codes and 69 hybrid DRG groups. Payment is sector-neutral for the covered procedures.

This is meaningful progress, but a larger code list alone does not create sustainable outpatient capacity.

The expenditure structure shows the scale of the sectors

Germany spent EUR 538.2 billion on health in 2024. EUR 71.2 billion was attributed to medical practices and EUR 131.6 billion to hospitals. These figures are not prices for identical services, because hospitals provide different severity levels and maintain inpatient, emergency and intensive-care infrastructure.

They nevertheless illustrate that ambulatory expansion is a structural change, not a simple savings exercise.

A procedure cannot be moved in isolation

Patient selection, diagnostics, consent, anesthesia, qualified staff, suitable rooms, hygiene, material, monitoring, follow-up and complication pathways belong to the service.

Moving only the intervention while leaving adjacent responsibilities unresolved creates a new interface rather than better care.

Equal payment does not remove delivery risk

Hybrid DRGs cover the immediate context of a procedure and include material costs. A single payment must be distributed among participating providers.

Economic feasibility therefore depends on case mix, staffing, material, utilization and operational quality. The stronger 2026 differentiation by severity is useful, but must be tested against real delivery costs.

Investment logic differs

German hospitals are legally financed through a dual model: states are responsible for investment costs and insurers for operating costs. Outpatient practices and MVZs largely finance equipment, conversions, digital systems and staff development from revenue or credit.

Additional outpatient activity therefore requires a credible answer to investment and planning certainty.

Staff and patient suitability must be included

More outpatient procedures require physicians, anesthesiology, assistants, operating-room staff and administrative support. These people are not automatically available.

Not every technically ambulatory procedure is appropriate for every patient. Comorbidity, anesthesia risk, mobility, social support and access to urgent help remain essential.

Conclusion

Outpatient before inpatient is a sensible principle when the right patient can be treated safely and sustainably in the right setting.

Financing, capital, staff, quality assurance, follow-up and responsibility must move with the service. Otherwise, policy merely transfers the problem between sectors.

Sources