At the start of the first week of sessions after the summer recess, the German Association for Managed Care (BMC) called for a fundamental structural change in healthcare provision. In a position paper (1) and a regulatory proposal (2), the cross-sectoral association suggested creating a new, sector-independent care area, for which the functional mechanisms of value-based care should be enshrined in the German Social Code. The proposal was discussed in a digital spotlight session by BMC Chairman Prof. Dr. Lutz Hager and Dr. Regina Klakow-Franck (until June 2023 Deputy Director of the IQTIG Institute), who initiated the BMC paper.

This discussion paper, like everything else, has its precursors and is also the result of a long discussion process. It addresses the fundamental question, which has been raised for many years (and remains unanswered), of how structural changes could be made to healthcare provision in Germany in order to finally overcome the sectoralization of care. While this paper is not identical to the AOK joint paper "Health Regions: Shaping Sector-Independent Care" published in April 2024 (3), it does move in a similar direction.
The paper originated from the BMC working group "Value-Based Care," launched several years ago under the chairmanship of Dr. Nicolas Busch (Boston Consulting Group) and Dr. Alexander Schellinger (Siemens Healthineers AG). However, the regression analysis model developed by AOK Nordost for the financial efficiency of physician networks (Arete model) and the "Quattro" quality monitoring system, with a focus on value-based care, also likely played a role in its content. The working group's work was further published in 2024 in the BMC book "Gemeinschaftsprojekt Gesundheit" (Joint Project Health), subtitled "How Value-Based Care is Reinventing Healthcare" (4). Two contributions were particularly groundbreaking: "What Comes After Outpatient and Inpatient Care? Perspectives on Hybrid Healthcare" by Prof. Dr. med. Djordje Nikolic.
(consus.health – Part of Accenture) and „Value-Based Care: Approaches to a results orientation and its remuneration” by AOK-Nordost employees Beatrix Bender, Stephanie Sehlen and Harald Möhlmann (retired for a year).
Presumably, the challenge now will be to skillfully combine these approaches to avoid fragmentation in the political debate. This will also require gaining more allies willing to change the ineffective and inefficient structures that have been built and entrenched over many decades. The stated goal is not only to overcome the separation between outpatient and inpatient care, but also, and above all, to establish a patient-centered approach oriented towards value-based care (VBC).
to design patient-centered care.
How this can be achieved was explained in a spotlight presentation by BMC Chairman Prof. Dr. Lutz Hager and Dr. Regina Klakow-Franck, Deputy Director of the IQTIG until June 2023 and since then an independent healthcare consultant. „Our goal and our idea is to open a new chapter and insert a new chapter into the German Social Code, Book V (SGB V),” Hager began the presentation of the discussion paper „A New Chapter for Healthcare: Sector-Independent Care with Value-Based Care“ (1). He added: „And to all those who might find our proposal a bit too far-reaching, and to those who say, ”Now they’ve gone mad,’ I say: How else do you intend to achieve your goal? How else do you intend to permanently and systematically anchor patient-centeredness and patient benefit in the healthcare system?”
The key message of the well-attended online event was that it was finally time to "further develop the fundamental mechanics of the German Social Code, Book V (SGB V)." According to Hager, if this doesn't happen, there's a risk that numerous reforms will only scratch the surface. The current healthcare system, with its inadequate integration, its significant fragmentation, and its diverse reimbursement mechanisms, would simply be "adding yet another garden shed to the already crooked house of the SGB V" with each reform – more is usually all that can be achieved in a single legislative period. But that's not what will drive the necessary system development. Hager stated: "Our demand and our suggestion is that patient-centered care shouldn't be created in a vacuum with the motto 'We'll manage somehow,' but rather given a solid legal foundation based on the principles of value-based healthcare."„
Klakow-Franck: „to tackle the regulatory framework itself”
The German Healthcare Management Council (BMC) envisions a fundamental redesign with its proposal, not just a minor adjustment, as Dr. Regina Klakow-Franck, Deputy Director of the Institute for Quality and Transparency in Healthcare (IQTIG) until June 2023, explained. According to her, legislators have long recognized that the greatest potential for quality improvement and increased efficiency lies in eliminating sectoral boundaries. She noted that legislators have attempted many measures in the past to improve care, particularly at the interface between outpatient and inpatient settings: for example, through the introduction of integrated care contracts, with specific care models such as disease management programs designed to coordinate care for chronic illnesses along a treatment pathway across sectoral boundaries, or with outpatient specialist care (ASV) to promote cross-sectoral integration of care. Klakow-Franck added: "Unfortunately, all of this has ultimately resulted in an ever-expanding patchwork of inconsistent care at the interface between outpatient and inpatient settings."„
This is precisely the problem facing the innovation fund introduced almost ten years ago, which was actually intended to support pilot projects that went beyond standard care. "While we have seen many successful pilot projects that have been recommended by the innovation committee for inclusion in standard care, unfortunately, not a single project has yet made the leap directly into standard care," explained Regina Klakow-Franck.
For these reasons, the BMC has concluded, as a last resort, that it is now necessary to "address the regulatory framework itself," because the existing conditions are clearly not designed to accommodate cross-sectoral forms of care. Therefore, the core of the BMC's proposal is to establish a patient-centered care model as the new guiding principle.
to incorporate this principle into the German Social Code, Book V (SGB V). Klakow-Franck: „We call this an update of the quality and efficiency principle, in order to actually create a new regulatory framework for a sector-independent organization of care and thus a new sector-independent care sector.”
Of course, the "brilliantly formulated" principle of economic efficiency should remain in its original form – at least with regard to the first clause, which states that services offered within the statutory health insurance system should be sufficient, appropriate, and economical. Nevertheless, this principle has become outdated because it is no longer clear what the concept of needs-based care or the phrase "must not exceed what is necessary" means. She advocated for clarifying, in the planned update of the quality and economic efficiency principle, what constitutes sufficient, appropriate, and medically necessary care today. This is precisely the kind of care whose patient benefit is evidence-based. Therefore, the new guiding principle of care in the German Social Code, Book V (SGB V), is centered on patient benefit. If this is the case, then, according to Klakow-Franck, all healthcare services must naturally be organized around patient benefit.
To achieve this, the BMC proposes a new regulatory framework, based on the fundamental architecture of the then-revised version of Section 116b of the German Social Code, Book V (SGB V). At the same time, however, the mistakes of the outpatient specialist care system should not be repeated. Instead, the contractual flexibility of cooperation options should be explicitly maintained by avoiding overly rigid requirements for service providers regarding organizational forms and cooperation possibilities.
by: MVF editor-in-chief Peter Stegmaier

According to BMC, several chapters of the German Social Code, Book V (SGB V) need to be amended or rewritten to implement value-based care in the healthcare setting.

1. Update for the quality and efficiency requirement:

Amendment to Section 2 Paragraph 1 SGB V (Benefits):
The services must have demonstrable benefits for patient care, measured against patient-relevant endpoints along the care pathway.
Amendment to Section 12 Paragraph 1 of the German Social Code, Book V (principle of economic efficiency):
Services that are not beneficial to patients or are uneconomical cannot be claimed by insured persons, may not be provided by service providers, and may not be approved by health insurance funds; when assessing the cost-effectiveness of care, particular consideration must be given to improvements in health status, extension of life expectancy, and improvement in quality of life.

2. Introduction of a sector-independent supply area

The regulatory framework for outpatient specialist care (ASV) according to Section 116b of the German Social Code, Book V (SGB V) covers the essential dimensions of the framework that must be considered when designing this new area of care and implementing individual services. This defines uniform guidelines for agreeing on specific services, which must be aligned with the fundamental principles of value-based care. Within this framework, the specific services can be flexibly designed with regard to the scope of treatment and cooperation partners based on selective contracts according to Section 140a of the SGB V (Special Care). Innovative forms and services of care (process and product innovations) should be able to be integrated into standard care more quickly in the future, provided there is demonstrable evidence of their effectiveness. Therefore, a systematic transfer option based on a methodologically revised, standardized, and accelerated review process is also important.

Specific design of the new supply area (excerpt)
1. Purpose and scope of treatment: Sector-independent care should be patient-oriented, interdisciplinary, and quality-assured. It encompasses services along the entire treatment pathway – even beyond standard care – and may include innovative diagnostic and treatment methods as well as nursing care services according to Book XI of the German Social Code (SGB XI).
GOAL: To enable comprehensive, integrated care that creates real patient benefits.
2. Contractual Partners: All contracted physicians and hospitals and cooperative partnerships approved under Section 108 of the German Social Code, Book V (SGB V), are eligible to participate in the sector-independent care sector, provided they have concluded contracts with health insurance funds for sector-independent care. Additional contractual partners can be included in the contracts to form cooperative partnerships. Population-based contracts are also possible.
GOAL: To create contractual flexibility for interdisciplinary, multi-professional and inter-institutional collaboration.
3. Quality Requirements: Requirements for structural, process, and outcome quality must be met. Structural and process quality is ensured through sector-independent treatment and care teams, patient-centered care, and the consistent use of digital tools. Outcome quality is demonstrated through outcome measurements based on patient-relevant endpoints. There is a requirement to publish evaluation results.
GOAL: To enable fair and transparent contract competition that is primarily aimed at improving the quality, efficiency and cost-effectiveness of the supply.
4. Remuneration and Financing: The new sector-independent care sector envisions a modular remuneration system. Wherever possible, service packages should be bundled into diagnosis-specific treatment or care lump sums. Implementation will be phased in. The starting point can be bundled payments agreed upon within the framework of contracts between health insurance funds and cooperative networks. In addition, it is possible for remuneration components to be paid out depending on the impact of care (pay for results), which will be measured through accompanying evaluations. The distribution of remuneration is carried out independently within the cooperative network. To finance the new sector-independent service sector, health insurance funds will be obligated to allocate a specific amount per insured person to contracts for sector-independent care.
GOAL: To provide a sustainable, integrated remuneration system alongside value-based, sector-independent healthcare provision.