Undersupply in the German healthcare system – the underestimated problem

Short Paper #1

The German healthcare system is in a deep crisis. For those with statutory health insurance, appointments with specialists are only available after months, if at all. Privately insured patients are given preferential treatment because their treatment in doctor's offices is reimbursed more than twice as much as under statutory health insurance. Transitions between levels of care (outpatient practices, hospitals, nursing facilities) are becoming increasingly difficult, and costs are rising rapidly. In terms of quality and patient safety, Germany ranks at best in the middle of the pack internationally. Digitalization – touted as a panacea – sometimes increases bureaucracy rather than helping. Added to this is a significant and long-standing shortage of skilled workers in all professional groups. Team-based collaboration between the professions is inadequate. There is a shortage of hundreds of thousands of nursing staff, while the cost of a nursing home place is now only affordable for the wealthy. Over the past 20 years, there has been much discussion in Germany about the "combined under- and over-provision." But now another issue is on the agenda: under-provision, the inaccessible care for large sections of the population. In 2000, the German Council of Experts defined under-provision as "care that meets an individual, professionally and scientifically recognized need but is either denied or not made available within (reasonable) reach." Under-provision creates a new situation. Our statement therefore aims to bring this new issue to the forefront of public discussion. Drawing attention to under-provision seems all the more important given the considerable reluctance to address this topic in professional and scientific circles. While a few years ago the focus was on patient orientation and patient-reported outcomes, today, in keeping with paternalistic concepts, the talk is of patient management and optimization.

>> The paper presented here is divided into seven sections. The first chapter clarifies terms based on the groundbreaking report of the German Advisory Council on Over-, Under-, and Inappropriate Treatment in 2000/2001. The focus here was on the concept of (objective) need, which exists when a professionally or scientifically proven (net) benefit is evident.
Chapter 2 briefly critiques this understanding, which has dominated the past 20 years, in light of current developments. In particular, it presents some evidence that healthcare decisions can be justified not only by considerations of benefit, but also by societal preferences and political priorities. From this perspective, the issue of undersupply is not a purely clinical and scientific issue, but also a political one.
Chapter 3 systematizes the concept of undersupply. Patients often have no access to treatment because they are not informed about it, cannot reach appropriate practices, or the treatment is not offered (access issues). In other cases, patients do have access to treatment, but it is provided incorrectly (a very common combination: undersupply and misprovision). Finally, there is also the third case: patients generally have access and the service is provided adequately, but due to dysfunctional structural characteristics of the healthcare system, it is restricted or provided as a non-indicated service (e.g., services from the IGeL catalog of treatments not covered by health insurance companies). There is considerable overlap between these three cases, but they nevertheless form the systematic framework for the following three chapters.
The access problem is discussed in Chapter 4 for five selected topics:
• In primary care, a dominant area in terms of the number of patient contacts, there is a severe shortage of staff. There is a shortage of doctors in the outskirts of major cities and especially in rural areas, where a significant shortage of doctors has occurred. Access problems exist, especially for patients with multiple chronic conditions.
• The lack of cooperation with specialist medical care is also having a negative impact, where it is particularly difficult for patients insured by statutory health insurance (GKV) to obtain appointments, despite the establishment of appointment service centers. They are blocked by rebookings, and the distribution of practices here is even more concentrated in urban centers than that of general practitioners.
• The recently introduced reimbursement reform will increase the volume incentives for scalable services in hospitals, but at the same time, there is a risk of under-provision for patients with multiple illnesses. The reasons for this are primarily the planned under-provision of the reserve budget and active risk selection. With a fixed reserve budget, high-risk patients with comorbidities are an economic risk, and access to care may become more difficult for them.
• In nursing, staff shortages are a key problem, but so are collaboration and the division of responsibilities.
• Pharmaceutical supply has received considerable public attention. Important areas are systematically neglected by the pharmaceutical industry. Many medications, such as those used for pediatrics and basic care, are often difficult to obtain, while so-called "orphan drugs" for rare diseases command exorbitant prices.

Chapter 5 deals with the combined under- and mis-provision of care, which occurs when access to care is hindered because services are provided but do not meet professional standards. It is increasingly observed that central professional requirements from quality and patient safety practice, which have been generally agreed upon in recent years, are no longer being taken into account. For example, comparisons between hospitals are completely meaningless if they are conducted in large "performance groups," as planned in the Hospital Transparency Act and the KHVVG, because in this case, differences in quality can no longer be distinguished from random or other factors ("confounders"). This quality and safety shift, which affects numerous other issues (e.g., low-threshold recording of safety-relevant events, attributability of events), has been observed since the Corona crisis and must be understood as a conceptual, not just isolated, departure from these fundamentals of a quality improvement approach.

Undersupply as a systemic characteristic is the subject of Chapter 6. Fundamental structural deficiencies in the organization of medical care and the health insurance system provoke undersupply, despite the availability of adequate services. The main issues addressed are the strict separation of outpatient and inpatient care, the lack of cooperation among healthcare professionals, and the dual system of statutory and private health insurance (SHI, PHI). This chapter forms the transition to Chapter 7, which is dedicated to potential solutions.
There was much discussion within the author group about the extent to which this paper should, in addition to a systematic presentation of the problem, also address more comprehensive concepts for addressing deficits related to undersupply. Ultimately, however, we decided to gradually address the question of development perspectives in subsequent papers, which we hope will attract as much interest as—hopefully—this first short paper from the Health Group (which turned out to be not so short after all).
Introduction
We're finding that the German healthcare system is sick. Hundreds of legislative changes over the past decades have failed to deliver any real breakthroughs. Rather, all sectors have been overwhelmed with ever-increasing, uninspiring changes, without any improvement in intersectoral coordination and cooperation. The bureaucracy has become increasingly confusing with regard to documentation requirements and is now extremely time-consuming for employees—time that is lacking for direct patient care.
Navigating the system is not possible without expert support. Patients and relatives feel left alone with many problems. Cross-sector service requirements are difficult to understand and too complicated to initiate. Appointments from general practitioners to specialists take too long and require considerable patience. Privately insured patients receive appointments much more quickly, which leads to resentment and incomprehension.1 Relatives and patients themselves describe a deterioration in treatment processes, particularly in transitions between sectors, especially in Germany.2 Patient safety has remained at the same low level for years, with approximately 20,000 preventable deaths and a great deal of (predominantly voluntary) effort; an unacceptable state of affairs.3 The implementation of the electronic patient record, which could improve transparency and security, receives too little support for the clientele, who are overwhelmed by it, and is fraught with numerous technical deficiencies.
Bottlenecks in primary care and specialist medical care exist, particularly in rural areas. Team-based specialist nursing support from community health nurses and district nurses is rare. At the same time, chronic diseases, multimorbidity, and the need for care are increasing with the high number of older people. In 2021, 5 million people in need of care were registered; by 2050, this number will rise to 6.8 million. Currently, it is estimated that there will be 5 million family caregivers. The shortage of skilled workers in the healthcare professions will increase, as many of today's workers will retire in the next 10 years. Of the 1.25 million nursing staff working in various sectors, there is already a shortage of 300,000, and an additional 250,000 will retire by 2034. Many nursing homes can no longer accommodate those in need of care due to a lack of skilled workers, so hospitals are increasingly serving as contact points for people who actually only need care. The financial co-payment for those in need of inpatient care was 2,350 euros in July 2024, an insurmountable hurdle for many families that cannot be overcome without support.
Against this backdrop, the "Health Authors' Group," which convened just over a year ago, is initially focusing its work on the overarching topic of undersupply. With this "Short Paper #1," the authors lay the foundation for further analyses and proposed solutions, clarify the terminology, review the available information (without claiming to be exhaustive), assess the relevance of the problem, and—based on a root cause analysis—make suggestions for its resolution.

1. Undersupply: Clarification of terms
With the 2000/2001 SVR report, the concepts of over-, under-, and misprovision became a central component of the health policy debate.4 The focus was on the pair of concepts of over- and misprovision, i.e., the assumption that in the German supply-oriented health care system, services are provided that do not meet the necessity requirement or the prohibition of excess5 and, moreover, exhibit an unfavorable balance between positive and negative effects. Underprovision was not identified as a pressing problem, apart from particular perspectives; this issue was more likely to be located in health systems with state or purely market-based coordination (e.g., UK, USA).
This situation has changed fundamentally in recent years, although critical analysis has not addressed the issue of under-provision with the same intensity and focus as was the case 25 years ago with the issue of over-provision and inadequate provision. This reluctance is remarkable, as the issue of under-provision is highly topical in patient reports and media reports6, and corresponding statements from associations and self-governing bodies are also increasing. In the area of professional, scientific, and especially health policy discussion, however, a "deafening silence" prevails; rather, it is suggested that the issue of under-provision is based on a misguided sense of entitlement or is an expression of hidden economic interests (which may, of course, be true in individual cases).
In the context of healthcare, the term "undersupply" is closely linked to the issues of need, benefit, and thus also evidence. The SVR defines:
“Care for an individual, professionally and scientifically recognized need that is refused or not provided within (reasonable) reach, even though services with sufficiently proven health benefits and an acceptable benefit-cost ratio are available, is undersupply.”7

In addition to the "recognized need," services must be "available with sufficiently proven health benefits," otherwise undersupply would not be objectively verifiable. Historically, this reference was possible and realistic because, in previous years, the emergence of evidence-based medicine provided, for the first time, a method that could identify the professional and scientific knowledge necessary for benefit assessment, assess its validity, and transparently synthesize it (e.g., through systematic reviews and meta-analyses). In this sense, "eminence-based decision-making" through statements and specialist conferences could be supplemented and superseded, placing evaluations and allocation decisions on a different foundation.
Typically, undersupply does not occur in isolation, but in combination with oversupply:
“Care services that go beyond the individual needs and are provided without or without sufficiently assured (additional) health benefits (e.g., out of ignorance, complacency, for marketing purposes, or for income reasons) are medical overprovision.”8
as well as with inadequate care:
“Incorrect care is any care that causes avoidable harm, or any provision of services whose harm or potential harm significantly exceeds their (possible) benefit.”9
From this perspective, undertreatment can also be understood as mistreatment, “since lost benefit [from failing to treat, MS] means avoidable harm.”10

2. Undersupply: conceptual clarification and need for development
The equation "studies => evidence for net benefit => allocation decision at the system level" is generally suitable for determining needs-based care and thus for determining excess or insufficient care. However, the EBM concept includes decisions that take individual circumstances into account, which makes the assessment of under- or over-provision more difficult. This distinction between allocation decisions at the system level and individual treatment decisions naturally becomes less important the more treatment methods are concerned with clear evidence and favorable financial conditions that make studies appear easily feasible. However, the distinction is more problematic, for example, for treatment methods with professional acceptance but (still) insufficient study data, especially when the generation of good evidence encounters obstacles (particularly with non-pharmacological treatment methods such as physiotherapy, etc.).
To facilitate the discussion, the SVR introduced the concept of “objective need”:
“An objective need for a treatment method for a medically verifiable disease exists if it has a positive net benefit based on professional and scientific evidence.”11

An objective need for an intervention therefore exists when, based on the best available evidence in the individual case, it is explicitly expected to have a positive benefit-harm ratio. This need encompasses the content, timing, location, and quality of the intervention. Establishing this objective need and thus providing a benchmark for assessing under- or over-provision is becoming increasingly difficult. This particularly affects the differentiation between treatment preferences (also known as "subjective need") and treatment decisions based on a positive benefit assessment with sufficient external evidence ("objective need"). Consequently, the levels of evidence-based practice, where the patient's treatment preferences and the professional experience of the practitioners play a central role, and evidence-based health policy (allocation decisions in the Federal Joint Committee, G-BA) are increasingly diverging.
At least five external factors contribute significantly to this, threatening the benefit-based concept of professional and system decisions:
1 Through the revival of the "cookbook medicine" argument from the 1990s, the EBM method of identifying knowledge, its evaluation, and synthesis (systematic reviews and meta-analyses) is described as inhibiting innovation and, together with the reference to its alleged paternalistic nature ("your doctor cannot decide freely"), is presented as substandard medical care;12
2 controlled clinical studies are to be replaced by analyses of large amounts of data (“big data”), in which even the fundamental scientific requirement of ex-ante definition of precise questions is relativized (“end of theory approach”);13
3 The emergence of “personalized medicine” has promoted such a pronounced differentiation of patient groups that not only has the orphan drug regulations of the German Social Code (SGB V) been applied (simplified approval),14 but the “n=1 approach” has also fundamentally questioned the usefulness of studies with double-blind randomization designs;15
4 Patient associations, some of which are openly supported by companies with commercial interests, have increasingly been involved in the decision-making process, describing the rigorous methodology of evidence generation as too cumbersome and slow, or demanding faster access to new or alternative treatment methods;16
5 Through health policy interventions in the last two legislative periods, the obligation to provide justification for therapies and interventions at the system level has been increasingly leveled out, as was paradigmatically evident in the "Healthy Heart Act" with its scientifically unproven population screening for hyperlipidemia followed by drug treatment.17

These developments lead to a relativization or even a loss of benchmarks, lowering the threshold for objective need and resulting in an "inflation" of undersupply. If the relevance of an evidence-based benefit assessment is questioned and no longer enjoys universal acceptance or appreciation, there is a risk that the concept of undersupply will cease to be a reference point in the health policy debate.
This is a controversial issue in health policy terms because it conceals the actual undersupply and prevents it from being adequately addressed. Against this background, the topic of "undersupply" not only appears to be of high political relevance, but also faces the challenge of re-evaluating and expanding its theoretical foundations. In particular, a stronger goal- and problem-orientation of the term is needed, which ultimately amounts to a complementary evaluation at the level of appropriateness and political preference.

3. Systematics of undersupply
First, however, a systematic structuring of the concept of undersupply is required. The following cases must be distinguished:
• Patients do not have access to treatment, either because they are not informed about it, cannot reach it or the treatment is not offered (access problem);
• Patients have access, but the treatment is provided incorrectly (misprovision);
• Patients generally have access, the service is provided adequately, but due to dysfunctional structural characteristics of the health system, the services are scarce or would not have been indicated at all (could have been avoided, e.g. due to a lack of prevention, lack of cooperation).
There is some overlap between these three forms, especially since they often occur together.

3.1. Lack of access as a cause of undersupply (see Chapter 4)
If access to healthcare services is limited, this is usually expressed by the difficulty of obtaining an appointment for treatment, especially in the area of outpatient specialist care. Three cases can be distinguished, which are further discussed in Chapter 4 for several areas of care:
1 Patients are denied access to a service that they could easily access and that is offered because they are not informed about the service's availability or because they are unaware that it is indicated.18 While health insurance funds, the associations of statutory health insurance physicians, and the Independent Patient Advice Center are obligated to inform patients about health services and their indications, deficits remain (the issue of health education). The IQWiG has provided the information platform www.gesundheitsinformation.de, and there are also a number of disease- or disease-group-specific forums.
2 Patients want to use services but are unable to access them. This is the classic access problem, which is typical for healthcare systems as a whole (especially in the US) and for regional or population-based care concepts, and is described by so-called area indicators. The following subtypes are distinguished:
2a Geographical dimension: Access is not possible because patients cannot reach the care due to distance and/or transport infrastructure. In recent years, this situation has become apparent in many regions through the closure of doctor's offices, nursing homes, hospitals, and even pharmacies. It plays a major role in the needs planning of care structures (e.g., hospital care), especially as a counterweight to centralization, which is assumed to improve quality due to the volume-outcome relationship, and where any possible quality gain should not be offset or reversed by a deterioration in accessibility.
2b. Financial dimension of the access problem: The service is accessible and known to the patients, but they cannot use this service for economic reasons (e.g., due to a lack of insurance coverage19).20 This form of access-related undersupply was in the past and still is today one of the main problems of health care in the USA.
2c. The social dimension, to be distinguished from this, describes healthcare as a problem of the social status of patients, which includes not only social class, but also educational level, housing, and employment situation. This represents one of the most important deficits in today's healthcare policy, in which health and illness are increasingly individualized and social factors have been completely lost sight of (see neglect of social aspects in non-pharmacological prevention during the coronavirus epidemic).
2d. In addition, there are structural conditions, primarily in the cooperation and coordination of treatment among the various actors in the healthcare system (there are overlaps with section 3.3). All care options are available, but patients do not receive the indicated care because the interaction between the practitioners is not coordinated.
2e. Navigational undersupply begins with point 2d and describes an undersupply characterized by the (understandable) inability of patients to navigate the high complexity of healthcare.21 This begins with the scheduling of appointments, "because you don't know anyone," and, in the context of the growing problem, affects not only patients insured by statutory health insurance, but also those "not networked" privately insured.

3.2. Quality deficits and other forms of inadequate care (see Chapter 5)
Care with negative net benefit, as the short definition suggests, is a complex topic. In the past, misprovision was always discussed in connection with overprovision, with the compound term "combined overprovision and misprovision" considered a ubiquitous diagnosis. Currently, however, the combination of misprovision and underprovision is coming into focus. In the context presented here, on the one hand, misprovision is relevant, which is caused by underprovision due to faulty care that does not meet medical standards. On the other hand, misprovision occurs when indicated care is substituted or supplemented by elements of overprovision (e.g., the enforced use of IGeL services as an entry barrier for appointment scheduling).
1 Underprovision due to quality deficits can only be briefly described here. In Germany, the quality discussion and the availability of quality indicators still focus on acute illnesses requiring surgical treatment; deficiencies in the treatment of multimorbid chronically ill patients are therefore neither measured nor subject to improvement approaches (e.g., MRI for back pain). In both cases, it should be noted that such forms of inadequate care prevent patients from receiving adequate services.
2 Underprovision resulting from the replacement of appropriate services with elements of overprovision (combined overprovision and underprovision) is more common than is generally assumed. Overprovision ties up working time and, as a result, impairs access to treatment services. So-called IGeL services are often strongly recommended to patients, but there are also increasing reports that such examinations and services are cited as entry requirements for regular treatment. Since these services must be paid for by the patients themselves, they represent a barrier to access to actual treatment, quite apart from the aspects of inadequate care that arise from such services (e.g., false-positive findings from incorrectly administered screening tests).

3.3. Structural characteristics of the healthcare system (see Chapter 6)
Even when patients are informed, the services are generally offered, and patients have access to them, undersupply can occur due to shortages at the system level. The most well-known case is the state-run NHS in Great Britain, which has been so devastated by austerity measures that long waiting times arise even for urgent treatments. However, such forms of undersupply must also be expected in Germany, for example, in the provision of pharmaceuticals, insofar as systemic issues (the system of price negotiations) are responsible.
The second case refers to undersupply, which occurs even when such a shortage does not exist, but which, due to dysfunctions, prevents the care from reaching the patient. This situation is (also) present in the German healthcare system, where, primarily, sectoralization leads to a situation where, despite generally existing access, sufficient financial resources, and the availability of treatment services, satisfactory care and quality of care are still not achieved. This situation is further exacerbated by the inappropriate duality in the insurance system (described in more detail in Chapter 6).

4. Undersupply from the perspective of access
4.1 Outpatient area
Family medicine plays a central role in the continuous care of patients. Although the number of physicians in Germany has doubled since the 1990s, it has only grown slightly in general medicine. The number of practicing physicians in Germany rose from 237,750 in 1990 to 428,474 in 2023, almost doubling.22 While the total number of physicians has increased significantly, the proportion of family doctors has increased comparatively slightly. Furthermore, the proportion of family doctors over 60 is particularly high, indicating an increased need for young professionals.23 According to the National Association of Statutory Health Insurance Physicians (KBV), the average age of practicing family doctors is over 55, and approximately one-third of practicing family doctors will retire within the next ten years. In many rural areas, this proportion is even higher. The shortage of junior doctors means that the remaining general practitioners must care for even more patients, which in turn can lead to overload and a potential deterioration in the quality of care.24 The extent to which the significantly increased number of physicians will affect physician care time is difficult to estimate. According to the KBV, factors such as bureaucracy, changing living and working patterns, and a declining number of practices mean that, despite the increased number of physicians, less physician time is available.25
The need for young primary care physicians is being exacerbated by another development: the number of people aged 65 and over has risen from 12 million in 1991 to 18.7 million in 2022.26 With increasing age, the likelihood of developing multiple chronic diseases (multimorbidity) increases, which increases the need for continuous primary care.27 If one considers that primary care physicians should actually increasingly assume coordination functions (“gatekeepers”), the shortage becomes even more apparent.
Patients have to bear the consequences of reduced doctor time: 77 percent of the population have experienced personally or through a family member in recent years that they had to accept long waiting times for a doctor's appointment, and 43 percent have experienced that it was difficult to find a doctor who would even accept them as a patient.28 Rural and structurally weak regions are particularly affected by this.
Ultimately, the access problems reported in the Allensbach study particularly affect people with chronic illnesses and multimorbidity. Primary care is the first point of contact for health concerns and the coordination of further medical treatments. Ensuring continuous basic care will become more difficult in structurally weak regions.
At the same time, there is an overconcentration of specialists in urban areas, while rural regions are disadvantaged.29 This leads to regional inequalities that not only affect the availability of medical care but also contribute to a general deterioration in health care in these areas.

4.2. Specialist medical care
Outpatient specialist care in Germany is an important component of the healthcare system for treating patients with complex or rare diseases.30 Nevertheless, despite fully utilized capacities, demand is often inadequately met, which is due to structural and organizational deficiencies. The reimbursement system often favors shorter, standardized treatment cases over time-consuming, specialized services.31 This makes it difficult for area specialists to focus on particularly complex clinical pictures. The unequal distribution of specialists and the structural deficiencies in the reimbursement system contribute to the fact that patients with complex or rare diseases have difficulty receiving timely specialized treatment. This is particularly true in rural regions where the density of specialists is lower.32
The undersupply of specialist medical care is now evident in many regions and is primarily reflected in the lack of access to appointments and the creation of access barriers by linking these to additional services (financed by the patient themselves and not limited by budgets), either non-indicated or from the IGeL sector.33 Press reports about a lack of specialist appointments are numerous34, continue to rise, and are increasingly linked to fee demands.35
In many cases, adequate appointment scheduling cannot be achieved via the KVs, which were obliged to set up so-called appointment service points (telephone number 116117) in accordance with the provisions of the Care Strengthening Act of 16 July 2015 (Section 75 (1a) SGB V).36 Although a regional access component was introduced here for the first time (travel time for general specialist care 30 minutes, for “special and separate” care 60 minutes), the reduction of the concept of access to travel time (today also found, for example, in the intended emergency reform) means that more extensive aspects of access (e.g. transport infrastructure, patient mobility) are still missing, even though these were already mentioned in Section 6 (5) of the corresponding agreement at the time.37 Patient representatives and, for example, For example, the Bertelsmann Foundation pointed out that the actual deficits (e.g. unequal distribution of specialists) were not positively influenced by this regulation.38 Furthermore, appointments in the dental field and in psychotherapy were excluded from the regulation.
As mentioned at the beginning, there is also a significant dependence on insurance status (see footnote 1). Several studies have empirically determined a significantly longer waiting time for statutory health insurance (GKV) patients than for private patients.39 However, a gradual deterioration in access for private patients has also been evident in recent years, as a study by the Wahlen research group commissioned by the KBV (Confederation of German Health Insurance Associations) in 2017 showed.40 Furthermore, the access issue must be distinguished from the quality of indication and care: Private patients often feel threatened by over-provision due to the lucrative reimbursement structures.41
The main cause of undersupply in the specialty medical field is the focus on short-term efficiency rather than sustainable care. Due to economic pressure, less time-consuming but potentially less effective treatment approaches are often pursued.42 Many specialists' consultation hours are full, which is often related to inefficient patient flow management. Patients with minor complaints block appointments, while seriously ill patients sometimes have to wait months for treatment. This is exacerbated by rigid appointment scheduling practices and insufficient use of delegation options.
Another problem lies in a lack of geographical distribution: Specialists are often concentrated in urban centers, while rural and economically disadvantaged regions remain underserved.43 This leads to long travel distances and delays for patients who need timely specialized treatment. Furthermore, care is fragmented and there is a lack of integrated approaches in which general practitioners and specialists cooperate more closely to manage care.
4.3. Hospital reform
Hospital reform was at the heart of the diverse legislative activities of the last federal government. The Hospital Transparency Act (KHTrGes) was enacted on March 27, 2024, and the Hospital Care Improvement Act (KHVVG) passed the Bundesrat (Federal Council) on November 22, 2024. However, the Emergency Care Reform Act must be considered a failure due to the premature end of the coalition.
The main content areas can be summarized as follows:
• Hospital planning 1: transition from the classification into basic, standard and maximum care in three levels with special allocations (§135d para. 4);
• Hospital planning 2: transition from case number-related planning at the level of specialist departments to planning according to service groups (KHVVG §135e);
• Treatment costs: Reduction of the DRG share in financing to a revenue share of 40% in favour of a reserve budget that is allocated according to the number of cases (and contains security elements);
• Investment costs: Planning of a transformation fund of 50 billion euros, half of which will be financed by the states and half by the statutory health insurance (private health insurance not taken into account; Section 12b KHG (KHVVG));
• Linking the performance groups with quality parameters that relate to the quantity of services and other criteria (KHVVG §§135e,f);
• Transition from a care mandate based on security (KV) and public services (hospital) to care based on statistical assumptions (Section 6a Paragraph 4 KHG (KHVVG) and Section 123a Paragraph 1 Emergency Reform Act (draft));
• Transfer of the creation of quality parameters and their validation as indicators from the Federal Joint Committee (G-BA) to the executive branch (BMG)
(KHVVG § 135e para. 3);
• Attempt to establish a cross-sectoral supply
supply structure (cross-sectoral supply centers according to
§ 115g) with, however, continued sectoral remuneration (KHEntgG § 6c in conjunction with §18 KHG);
• Overemphasis on digital tools at the expense of human/personal interaction.

In addition to the well-known criticisms
• Continuation of the volume incentive despite reduction of the DRG budget to 40%,
• Centralization and bureaucracy,
• Interference with the federal powers of the federal states,
• Failure of a truly cross-sectoral integration, as the financing of the §115g centers continues to come from the hospital budget and secure financing is therefore a long way off,
• Disempowerment of the G-BA in the area of quality assurance,
• questionable financing of structural change (transformation fund) through social insurance instead of taxes,
• Non-consideration of privately insured persons and salary portions above the assessment ceiling or from capital income in the financing of the transformation fund
In connection with the undersupply problem, the following points should be emphasized:
1 There is a classic access problem in both general hospital care and emergency care (see Chapter 3). Hospital care will be thinned out to such an extent that internal medicine and general surgery services can be reached “for a significant portion of the population” in a maximum of 30 minutes (probably by car in sunny weather), and the other service groups in a maximum of 40 minutes (Section 6a, Paragraph 4 of the Hospital Health Act (KHVVG). In emergency care, the figures are 95% of the population in 30 minutes (Section 123a, Paragraph 1 of the Emergency Reform Act (E)). Regardless of the rather unsound wording “significant portion,” the draft Emergency Reform Act leaves open what should happen to the remaining 5% of the population in the event of an emergency (4 million inhabitants, after all). Overall, there will be a deterioration in access to inpatient and emergency care, as we already know in the outpatient sector. In the public’s perception, this development is already underway, although the majority clearly favors (moderate) Accept a loss of quality.44
2 On the one hand, the volume incentive is continued (the DRG system remains effective because the allocation of reserve budgets and service groups is based on minimum quantities), and on the other hand, undersupply is reinforced by a previously unknown remuneration incentive in this form. The reason lies in the gradual reduction of the reserve budget when cases decrease by more than 20%. With a constant budget, hospital management is therefore exposed to pressure, on the one hand, not to increase the number of cases (additional services are not compensated for), but on the other hand, to keep the number of cases in the affected service groups low, but not to allow it to fall below 80%.45 In short: It is worthwhile to maintain reserve budgets at -19% of services and to keep away patients who would jeopardize this target.
3 The intention of the KHVVG in particular is to achieve quality improvement. A detailed discussion of this intention must take place elsewhere, but in summary, it can be stated that basic knowledge from quality and patient safety practice is disregarded here. Even individual DRGs, which are far more narrowly defined and specific than any of the 65 service groups, are not suitable for quality comparisons due to their lack of medical homogeneity (although the private hospital industry would like to dispute this given their intervention options). In any case, it remains problematic for the service groups, with their extensive spectrum, to develop reliable and valid quality parameters or even indicators that can reflect the quality of these groups. There will, of course, be comorbidity correction and risk adjustment, but with such broad groups, it is impossible to identify the confounders (the distorting factors) with such precision that differences in outcomes (e.g., complication rates) can truly be attributed to the quality of service provision and not to regional peculiarities, characteristics of the healthcare landscape, ethnic composition, etc. Implementing risk adjustment, which could lead to truly comparable service groups within the meaning of the law, would require extraordinarily large models, for which numerous other parameters would have to be collected and integrated, and the documentation effort would increase enormously. Incompletely adjusted quality comparisons, however, inevitably lead to inappropriate care, i.e., under-provision, in the sense that the indicated care for patients is not guaranteed.
4 There is also a far more important aspect, as the allocation of performance groups and reserve budgets is linked to minimum quantities, which not only represents a quantity incentive (see above), but also an enormous incentive for risk selection
This incentive for risk selection through the reserve budgets adds to the well-known, similar incentive through the DRGs, which is effective in the 40%igen DRG budget share. For both forms of financing, it makes economic sense, on the one hand, to prefer patients without risk factors, i.e., to engage in risk selection. As a consequence, this risk selection leads to a comparative under-provision of patients with a worse risk profile. On the other hand, it presents an opportunity, particularly for broadly positioned (private) providers, to convert even poor results in low-risk patients into unremarkable results through targeted gaming by increasing their comorbidity through targeted documentation. The actually observed parameters can thus be aligned with the expected ones and subsequently appear "qualitatively unremarkable." In this sense, these two points, i.e. the under-provision of patients with a worse risk profile together with the simultaneous incentive to gaming when the quality of care for patients with a low risk profile is poor, result in a perfect case of combined under-provision and misprovision (see Chapter 3.2).

4.4. Undersupply of care
Demographic change in Germany has shown a continuous increase in the number of people in need of care since 2019. The Statistical
The Federal Statistical Office46 already describes the increase (also due to the broadening of the definition of long-term care needs) as of December 31, 2023, with 5.7 million people affected. Forecasts predict a further one million people in need of care by 2040.
In total, the people in outpatient and inpatient long-term care, as well as the 17.2 million patients who require occasional care and are cared for in hospitals each year, are currently cared for and supported by 1.7 million professional nurses.47 Overall, the German Nursing Council estimates that 31 million people are directly or indirectly dependent on care. Without the approximately 7.5 million family caregivers in the outpatient and inpatient long-term care sector, the health and care system would not be sustainable.
However, family-based care, especially in the middle and upper classes, is often vulnerable to "grey care markets," especially in the case of 24-hour services provided by so-called "live-ins," primarily from Eastern Europe. Their financing, including care allowances and private contributions, is often associated with confusing downsides.48 Unlike in Austria, there is also no information available in this country regarding the qualifications of live-ins, such as regular home visits by qualified caregivers. The statement in the coalition agreement of November 24, 2021 (p. 81) of the "Ampel" government, "We are creating a legally secure basis for 24-hour care in the family setting," has so far not been followed up, and, based on current status, there is little improvement in sight in the ongoing coalition negotiations.
Despite comprehensive family support, there are increasing examples of underprovision in both outpatient and inpatient care, for example, when the need for care increases in intensity and family members require support in providing care.49 Underprovision is often evident in long waiting times or even rejections of new care recipients. The reasons are usually both a shortage of skilled workers and the increasing closure of care facilities.
• Since 2023, 1,097 care providers (outpatient and inpatient) have ceased operations due to bankruptcies or closures due to a shortage of skilled workers.50 Last year alone, 143 outpatient care services filed for bankruptcy.51 In Germany, there are no centrally collected statistics on how frequently outpatient care services have to refuse to accept care cases. However, there are indications of longer waiting lists, which indicate more difficult access to care services for those affected, although there are regionally varying supply deficits.
• In the outpatient sector, the proportion of those in need of care among those with statutory insurance is particularly high in eastern Germany and in parts of North Rhine-Westphalia, Hesse, and Saarland.52 For example, in 2023, approximately 15.7 to 17.1 percent of insured persons in the Brandenburg districts of Barnim, Prignitz, and Ostprignitz-Ruppin were in need of care.53
• The nursing care placement density in 2019 was 169.9 per 1,000 people in need of care, below the national average, suggesting inadequate inpatient care provision. In contrast, the proportion of insured people in need of care in regions such as Munich, Freising, and Rosenheim was only 3.4 to 3.7 percent.54

Regional differences also exist in inpatient long-term care. An analysis by the Scientific Institute of the AOK (WIdO)55 showed that the quality of care in nursing homes can vary. For example, in parts of Lower Saxony, Rhineland-Palatinate, and Eastern Bavaria, more people were admitted to hospital with dehydration than the national average. The occurrence of pressure ulcers was also more common in some regions, such as Rhineland-Palatinate, North Rhine-Westphalia, and Thuringia. According to Schwinger et al.56, the Innovation Committee of the Federal Joint Committee assumed in 2022 that 44% of hospital days were due to the treatment of patients in need of care. The five most common reasons for treatment (according to discharge diagnoses) for nursing home residents in the hospital, according to the analyses of the project "Needs-based care of nursing home residents by reducing nursing home-sensitive hospital cases (PSK)" based on routine statutory health insurance data, are heart failure, pneumonia, femur fractures, volume depletion, and diseases of the urinary system. In relation to the study population, this corresponds to one fifth (20.51 TP3T) of all hospital stays (n = 191,174 cases).57
Potentially avoidable hospital stays in long-term inpatient facilities are attributed in the article to a deterioration in general health (35% of cases) or to falls, accidents, or injuries (34% of cases). "While almost every person in need of care has at least one contact with a contracted physician per quarter, around 28% of those in need of care remain without contact with a specialist, and 15% of those in need of care received PRISKUS active ingredients or antipsychotics." (Explanation for high fall and injury rates – author's note).58
In hospitals, the shortage of nursing staff is also leading to restrictions. For example, current evidence from the regulation of minimum staffing levels (PpUG)59 shows that understaffing occurs in care-sensitive areas (141% in day and night shifts), resulting in wards being closed, operations being cancelled, and nursing deficits. Although there are no comprehensive statistics on the exact frequency of such restrictions, various reports and studies indicate significant problems. Intensive care units are also affected, based more on reports than on documented data.60
According to forecasts by the Federal Statistical Office, the total demand for professional nursing staff is expected to rise to 2.15 million by 2049 compared to 2019. At the same time, the number of nursing staff is expected to be up to 690,000 below the required number, which will further exacerbate the undersupply.
The federal government is called upon to implement significantly more preventive measures in a timely, strategic action plan. Personal health education as a lifelong learning process, such as institutional prevention and health promotion, helps delay and prevent the need for care, and significantly reduce it over the demographic trend.

4.5. Undersupply of pharmaceuticals
The "supply bottlenecks" of pharmaceuticals represent another example of an already manifest undersupply and have led to considerable public uncertainty, especially since these generally concern basic medicines (e.g., the unavailable "fever syrup" for children).61 Historically, the problem goes back over 10 years. In 2015, the basic drug pyrimethamine (treatment for toxoplasmosis and an important drug for AIDS patients) was acquired by the company Turing and its price increased by a factor of 50, which led to an economically mediated restriction of access.62
This was followed by medications such as tamoxifen or melphalan (basic oncology drugs), painkillers such as ibuprofen, but also essential medications such as insulin, antibiotics (e.g., the important reserve combination piperacillin/tazobactam), narcotics, or even antidotes for deadly snakebites.63 Today, according to the Federal Institute for Drugs and Medical Devices (BfArM) and the Federal Statistical Office, there are access problems for a total of 506 medicines.64
However, the term "supply bottlenecks" does not fully describe the problem, as it is usually not a disruption of supply or supply chains, but rather a result of economic disincentives in the production or supply of medications. This dysfunctionality of the pharmaceutical market is actually surprising, because approval and inclusion in the statutory health insurance system in Germany have so far been relatively rationally structured through the benefit-based decision-making processes of the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWiG). The regulations under the 2011 German Drug Reorganization Act (AMNOG), with the assessment of the additional benefit after 12 months, particularly compared to the "appropriate comparator therapy" (Section 35a, Paragraph 1, Sentence 2 of the Social Code Book V), are paramount in this regard. Section 35b of the Social Code Book V also opened up the possibility of taking appropriateness considerations into account (side effects, quality of life, "reasonableness of cost coverage"). However, the regulation on “rare diseases” (Section 35a, Paragraph 1, Sentence 11 of the Social Code Book V) created the option of circumventing the benefit assessment for individual patient groups and for numerically small sub-groups (orphan diseases) that could be identified using modern methods and of creating high-price segments, since these patient groups were excluded from the benefit assessment.
This "orphanization" also indirectly impacted the generics market, as it made new pricing concepts common in the pharmaceutical market. The production of "old molecules" no longer appeared profitable enough compared to the high-price segments and was partially discontinued or scaled back. Of course, rebate procedures, on the one hand, and the international division of labor, which left only a few production sites worldwide for certain medications, also played a role here. The President of the Federal Institute for Drugs and Medical Devices (BfArM), Karl Broich, summarized this situation in an interview with a rather critical undertone as follows: "The cheapest medications are often too cheap. They would have to cost more to make supply chains more secure. Conversely, one could discuss whether particularly expensive medications are always worth this high price."65
The health policy measures taken to date to address these deficits have been of limited effectiveness and cast doubt on the political will. On December 16, 2022, the Federal Ministry of Health published a key issues paper66 proposing "structural measures in the generics sector (...), in particular measures to diversify supply chains, to introduce location criteria for supply, and to identify and prevent supply bottlenecks at an early stage." For pediatric medicines whose availability is considered risky by an advisory board at the Federal Institute for Drugs and Medical Devices (BfArM), no further discount agreements would be permitted, and the price cap could be set at 1.5 times the current fixed price. Furthermore, discount agreements should incorporate location criteria (European production preferred), and pharmacies would be compensated for their additional effort. These recommendations were subsequently incorporated into the "Medicinal Shortage Control and Supply Improvement Act" (ALBVVG) of July 26, 2023, which also establishes an "early warning system" at the Federal Institute for Drugs and Medical Devices (BfArM) and introduces a mandatory stockpiling requirement. The European regulations currently being discussed go in the same direction. However, given the high number of reported "supply bottlenecks" (Federal Institute for Drugs and Medical Devices, see above), these regulations cannot be said to have had any effect to date.67
The overall assessment even suggests a questionable incentive structure in an environment characterized by an increase in the pharmaceutical costs of the statutory health insurance since 2000 from 19.41 to 50.41 billion euros in 2023.68 Currently, 0.07% of prescriptions lead to 12.7% of pharmaceutical expenditure, 1.2% to 24% of costs, i.e. 1,27% are responsible for more than a third of the costs.69 The high-price sector is leading accordingly, while innovation is stagnating: according to the “AMNOG Monitor,” as of March 4, 2025, of 1,792 procedures to demonstrate an additional benefit (for 480 medicinal products), only 1,2% had been concluded with the statement “significant additional benefit,” 12,5% with “considerable,” 13,0% with “minor,” but 18,6% with “unquantifiable,” and 53,6% with “no additional benefit.”70 It is therefore foreseeable that attempts will increase in the generics market, either to achieve a relaxation of fixed prices through scarcity (by inclusion in the BfArM risk list) or to enforce massive price increases through the establishment of monopolies.

5. Undersupply: Focus on inadequate supply
5.1 Current situation
If access to treatment methods is available but the treatment is not provided adequately, for example, if problems arise in the treatment process or the treatment outcome is compromised by complications, this is referred to as inadequate care (see Chapter 3.2). Since in this case, an unfavorable benefit-benefit ratio exists and the care required is not provided, undersupply also exists. This situation primarily affects quality and patient safety issues.
The quality and safety findings of healthcare can only be described in excerpts here.71 Characteristic of the situation is the observation that, internally, the German healthcare system is always portrayed as particularly good, while in international comparison, Germany ranks average or even at the bottom. In a new Commonwealth study by the internationally renowned quality researcher Donald Blumenthal (Sept. 2024), Germany ranked second to last, ahead of the lagging USA (deficits primarily in coordination and treatment outcomes).72
To add a single quantitative statement: Based on a comprehensive analysis of national and international studies, it must be assumed that in hospital care alone, which currently comprises approximately 17 million cases per year, approximately one percent of these patients suffer an avoidable adverse event, i.e., one attributable to an error, corresponding to approximately 170,000 patients. The leading causes are nosocomial (hospital-acquired) infections, as well as drug- and medical device-related adverse events.73

5.2. Concept of quality and safety: initial situation
However, this unsatisfactory situation described above has been exacerbated in recent years by far more radical developments, especially in connection with the coronavirus pandemic and other crises. Key findings from national and international expert discussions in the field of quality and patient safety are suddenly being called into question. We are currently in a situation in which we must not only identify and resolve quality problems in the sense of under- and mis-provision, but also adapt to "tectonic" shifts in the framework conditions and contexts of meaning. To address these
In order to be able to describe the Quality and Safety Shift, the key elements are briefly summarized in terms of a status quo ante:74
(A) the neutral definition of quality is based on the “requirements” to be negotiated in each case, which arise from objective needs, perspective of observation and structural relevance, and in relation to which quality “characteristics” are assessed,75
(B) the normative definition of patient safety, in contrast, results from the “absence of adverse events” and, furthermore, from the willingness of institutions and systems to perceive, change and ultimately innovate,76
(C) the complex nature of healthcare is the starting point for all conceptual considerations, which is also evident in the emergence of patient safety-relevant events,77
(D) the description of quality and safety must pay particular attention to the attributability of quality problems, i.e. the reference to the treatment that has taken place and not, for example, to the progression of the disease;78
(E) With regard to statistical requirements, the methods of recording quality and safety must be clearly differentiated from one another, distinguishing between the scientific approach (experiment), the quantitative recording in the everyday treatment of large collectives, the monitoring approach of the indicator concept and the so-called generating methods that serve to gain knowledge in the area of the so-called unknown unknowns (e.g. CIRS or surveillance methods in the pharmaceutical sector).79
(F) the use of patient-reported outcomes is a central element of a modern understanding of quality, i.e. the results of treatment that can only be reported by patients (in connection with patient-centered treatment),80
(G) the rule-based identification, evaluation and synthesis of scientific studies must be observed (evidence-based medicine and the methods of health services research based on it),81 and
(H) The comprehensive body of knowledge on the effectiveness of interventions must be used as a basis for quality improvement measures, as these are themselves complex in nature in a complex context and can therefore only be effective if they are composed of several, carefully coordinated individual interventions (so-called double complexity of complex multicomponent interventions).82

In other words, until a few years ago, everyone agreed: quality depends on "agreements" and reflects what is crucial (primarily from the patient's perspective); quality and patient safety must be described methodically and precisely (according to professional standards); healthcare is a complex process with many unexpected outcomes; and, last but not least, interventions "for the good of the whole" require careful planning; unexpected "paradoxical" effects are to be expected here as well. In other words, everything is as politicians, experts, and scientists experience it every day—only those outside the field assume simple linear action-reaction relationships.

5.3 The quality and safety shift: Corona and the polycrises
Then came the coronavirus pandemic, and with it the so-called polycrisis. The current challenges posed by the coronavirus pandemic, the war in Ukraine, global warming, and political polarization are of such a powerful nature that some previously vigorous debates, such as those on the importance of patient safety, quality indicators, or patient orientation, could almost seem irrelevant. Of course, the profound impact of the coronavirus pandemic cannot be discussed solely in the field of quality and patient safety, and pre-existing conflicts (e.g., measurement methods) are often played out. Nevertheless, these and newly emerging conflicts, in their interaction, have gained such relevance that one can truly speak of a changing of the times.83
This will be briefly illustrated using the example of the above-mentioned quo ante elements.
• The definition of quality (A) refers to the perspective taken from which the "requirements" are formulated. The coronavirus epidemic, in particular, has led to a change of perspective here, because the potentially infectious patient represents not only a problem of individual treatment, but also a societal problem of infection epidemiology (since the quality problem, the infection, is transmissible). The way societies deal with this differently – the spectrum in the case of coronavirus ranged from Australia to Sweden – ultimately provides insight into the inner constitution of a society. Other crises such as climate and war are also emerging, and the language alone reveals this: the term "triage" originates from military medicine, but is now casually used to describe the organization of emergency rooms ("door-to-triage time" until the decision on further treatment is made84). As a consequence, it should be noted that quality problems are no longer discussed so much from an individual perspective (e.g., treatment outcome), but increasingly as population and societal issues. While the patient perspective had previously held undisputed precedence, the coronavirus epidemic gave rise to a greater focus on incorporating not only the individual but also the regional, population, and societal perspectives into the formulation of the constitutive concept of "requirement." In principle, this development cannot be rejected outright; in particular, in the case of coronavirus, the population and societal perspectives were of crucial importance, for example, in assessing the course of the disease, as the regional impact of coronavirus varied greatly and fluctuated over time. However, an explicit approach should be taken here and, going beyond existing quality concepts,85 adequately reflect the diversity of perspectives.86 Subsequently, a very critical discussion must be held regarding the extent to which this can be done at the expense of the patient perspective, thereby risking underprovision (see (F)). If older and vulnerable people are not given special protection, if children are disadvantaged in their development without scientific basis, if patients have to die alone against their express wishes, then one has to suspect that the patient orientation that was long upheld in Sunday speeches was very carelessly sacrificed, which led to under-provision on a large scale.
• The definition of patient safety (B) is normatively oriented, in contrast to the concept of quality. However, in recent years, the primum nil nocere principle has been relativized; one example of this is the lack of recording of vaccine side effects during the coronavirus pandemic. The basic principle for patient safety practice, however, must be the low-threshold recording of possible adverse drug events. The list of safety-relevant deficits is endless (abandonment of clinical scores, "preventive early intubation," in-patient/outpatient care gaps, etc.).
• Only briefly (since the reference to undersupply is only indirectly given): The relapse into linear top-down models of “governance” in the “war against the virus” is in stark contradiction to organizational models that had long been developed in the field of quality and safety and in organizational theory for the management of large systems (complex nature of health care (C)).
• The failure to attribute events (D) (e.g., lethality or infection fatality rate) has massively contributed to inadequate care and thus to undertreatment (quarantine conditions!) of patients who merely showed SARS-CoV-2 colonization, and no effort was made to properly differentiate between these two. The damage caused by this undertreatment and inadequate care has not yet been addressed.
• Managing an epidemic situation requires, first and foremost, reliable data (E). The unwillingness to conduct a cohort study must be viewed as a breach of the most important principles of scientific practice. But even beyond such precise studies, it is essential to ensure that the most important data on comorbidities and other host characteristics are also collected in quantitative "everyday recording" (ideally comparable to the RKI data). This has not been done and results in disadvantages for all patient groups that have not yet been recorded in detail. Indicator sets were not even considered; the same applies to generating procedures analogous to the CIRS concept for identifying vulnerabilities (see vaccination adverse events under (D)).
• Patient orientation (F) and especially the consideration of patient-reported outcomes (PRO) have fallen behind. Of course, this was also a pre-existing conflict, as there has always been heated debate about whether the "institution" (i.e. the hospital, the professional groups, the healthcare sector) is in the dominant position or whether it should be the patient and their needs (so-called patient-centeredness). Hundreds of conferences have been held in recent years that aimed to "put the patient at the center," whether with regard to their wallet (maximizing benefits may cost money) or with a view to a humanistic understanding of the individual in their needy situation. Today, however, patients have to be happy to be admitted for treatment at all; hardly anyone dares to discuss quality deficits or safety-related incidents. "I have a splinter in my eye," said the master carpenter, "draw a card, but you might not be seen until tomorrow" - inhumanity has taken hold overnight.
• The replacement of human contact with digitalized interactions leads to a serious deterioration and accordingly leads to a specific form of undersupply (digital impoverishment due to the displacement of human contact). In addition, IT-related adverse events occur (including outages, e.g., due to hackers).
• The scientific validation (G) of findings regarding quality and safety, as well as interventions to improve the situation, is based centrally on methods of EBM and health services research, even if this validation is not always easy to achieve due to its anchoring in everyday care. As explained in Chapter 2, the generation of evidence is increasingly subject to questioning, which has a massive impact on the quality sector because it makes it impossible to independently describe the "medical standard" and thus the existence of under-provision (or over-provision).
• Knowledge of the "double complexity" (H) of care and intervention is central to any measures to improve quality and safety. Without such concepts, the identification of meaningful measures remains vague. During recent crises, it was therefore repeatedly observed that perhaps well-intentioned interventions led to completely different effects than expected (e.g., screening of returning vacationers, curfews, vaccination campaigns combined with coercion). Far from a fatalistic attitude that one can then no longer implement any (complex) interventions in complex systems, it is important to point to the extensive empirical and theoretically sound knowledge on this topic, which has been completely ignored.87

However, this aspect of the leveling of the concept of benefit during the coronavirus epidemic—and this is where we come full circle—has enormous implications for the definition of undersupply. As explained in Chapter 2, it is traditionally justified by the concept of objective need, which is based on the concept of benefit. One of the consequences could be that benefit is defined more normatively.
In this context, particular attention should be paid to patients and their rights. These were strongly emphasized by law just a few years ago (see the Patient Rights Act of 2013), and of course, everything possible was done to save patients' lives during the coronavirus pandemic. Nevertheless, restrictions on visits and freedom of movement remained the order of the day, even when older people, for example, expressed a clear desire to maintain contact with the outside world, even at the risk of infection. The issue of mandatory vaccination has also cast doubt on the principle of bodily integrity, including the issue of information provided before COVID-19 vaccination.88 Health and care workers are unwittingly serving as mouthpieces for "Patient Reported Outcomes" when they report increased, sometimes dramatically increased, aggression and despair among patients, not to mention the fate of the dying.

5.4. Concept of quality under stress
In summary, under-provision due to inadequate care in Germany is not only a deficit constellation in the sense of inadequate process and outcome quality, but is facing a conceptual crisis that threatens successful improvement strategies. Patient orientation has been sacrificed to a dominant societal perspective, principles of quantification and control are increasingly disregarded, and the complexity of crises and epidemics in particular has not been addressed according to the rules of implementation science and practice. The path to a quality improvement approach as it was formulated just a few years ago,89
appears to have become more impassable and longer than anyone could have ever imagined. The problem of undersupply due to inadequate care is one of the main problems of the coming years.

6. Undersupply as a system property
In statutory health insurance, insured persons are entitled to medical services based on the generally accepted state of medical knowledge (Section 2, Paragraph 1 of the Social Code Book V). There are significant deficiencies in the implementation of this principle, particularly in outpatient medical care:
• Access to outpatient care in rural areas is significantly hampered by the insufficient number of medical practices, their great distances from patients' homes, and a lack of public transportation. This applies to both primary care and specialist care. Primary care practices are completely overwhelmed, and outpatient specialist care is virtually nonexistent in sparsely populated areas.
• In cities, outpatient care suffers from the neglect of general medicine, but especially of primary care specialists (pediatrics, gynecology, conservative ophthalmology, urology). While there is generally a sufficient number of specialist practices in urban areas, they are not distributed according to need within the planning regions.
• There are long waiting times in specialist practices, especially for new patients. The lack of transparency in scheduling appointments is a much-complained annoyance, even in areas with good medical care. It is one of the factors contributing to the overcrowding of hospital emergency rooms and the fact that five million patients are treated as inpatients each year who could actually be cared for by doctors' offices as outpatients.

These phenomena of undersupply have their roots
• in the dual system of statutory health insurance and private health insurance,
• in the sectorally organized management of supply
• as well as developments in the working culture of the medical profession.

6.1. Perverse incentives created by the dual health insurance system
Private health insurance spends more than twice as much per insured person on outpatient care as statutory health insurance, with these additional expenditures mainly occurring in outpatient care (2020: medical care: + 52.41%, remedies/physiotherapy: + 49.05%).
Private health insurance (PKV) and subsidized hospitals pay the same fees as statutory health insurance (GKV). For treatment by a senior physician and more comfortable accommodations, supplementary insurance is required, which also has 6 million statutory health insurance members. Statutory health insurance and private health insurance also pay the same prices for pharmaceuticals. Medical practices have different net income depending on their specialty, the amount of which is closely correlated with private billings (see table in the appendix).
• General practitioner practices have a net income of €192,000, with a share of statutory health insurance reimbursements of 86.6%. Pediatricians are at the same level, with an income of €200,000 and a share of statutory health insurance reimbursements of 83.4%.
• Ophthalmology practices have remarkably high revenues (€308,000), but these revenues are very unevenly distributed among them. While several conservative ophthalmology practices are experiencing financial difficulties, surgical ophthalmologists are among the top earners. About one-fifth of ophthalmology practices have annual revenues exceeding €1 million, with an average revenue of more than €400,000. This is due not only to private liquidations, but also to comfortable special reimbursements from statutory health insurance providers, for example, for cataract and glaucoma surgeries.
• The relatively low share of GKV income for orthopaedists and surgeons can also be explained by special income as GUV referral doctors, whose remuneration is significantly higher than that of the GKV.

These revenue differences between physician groups also lead to an uneven distribution of physician practices across neighborhoods in cities and metropolitan areas. In neighborhoods with a high proportion of civil servants and privately insured patients, the density of care is significantly higher than in less affluent districts. Demand planning and the licensing of physician practices by the KVen and the GKV associations have not even begun to eliminate these discrepancies.

6.2. Undersupply through the system of individual practices
In rural areas, these commercial factors are less responsible for the serious gaps in primary outpatient care. The problems there lie primarily in the overburdening of existing general practitioner practices and the accessibility of the few specialist practices. The needs-based planning tools of the statutory health insurance system cannot solve the care problems in rural areas. A complete reorganization of the cooperation between physician practices, social services, non-medical professionals, and hospitals is required.
The long waiting times in specialist practices, especially for statutory health insurance members, are rooted not only in the dual health insurance system and the privileges of private patients, but also in changing attitudes among the younger generation of physicians regarding the balance between work and private life. They primarily align their working hours with their own needs. Caring for a core group of patients takes priority over new patients. The still prevailing system of individual practices promotes this trend. Countermeasures are only possible through cooperative practice structures and networks.

7. Perspective
Over the past 20 years, the term "undersupply" has primarily been related to the concept of benefit and, from this, to the need for health care services. Undersupply occurs when measures whose benefits can be supported by studies are not available or are not offered. However, it is becoming apparent that, in the context of the general discussion on deficits in public infrastructure, the provision of basic services in the health sector will also assume a more normative significance. Against this background, undersupply would encompass the withholding of benefit-based health services, but would also have to be measured against societal expectations regarding the design of health care.
Undersupply, it must be clear, will not disappear so easily once it has become established as a problem. The US Public Health and
Family practice expert Mark Murray put it this way 25 years ago: "...in a particular service it takes a month to see a dermatologist, and it has 'always' taken a month." It remains as it is because it always has been.91
So two things are important: on the one hand, structural solutions are needed, and on the other hand, we must counteract a hidden agenda that might say something like: We have always been concerned with over-provision, now we can safely expect the population to accept a little under-provision, and we can also save money that way.
There is general agreement that the biggest structural problem in the German healthcare system is its sectoral organization and financing. Despite numerous initiatives for "integrated care" dating back to the 1992/93 Health Structure Act (at that time, the introduction of the first flat-rate fees was accompanied by outpatient surgery and pre- and post-hospital care), sustained and effective integration has failed due to persistent sectoral egoism driven by separate budgets. Effective action to combat undersupply would therefore have to start at this point.
Of course, it can be argued that the sectoral structure is not the only problem. Substantive issues also need to be discussed, such as the one-sided focus on interventions rather than prevention, or the preference for surgical methods as opposed to care and, where appropriate, only monitoring of chronic multiple diseases. Of particular importance here is the fact that the health policy debate often lacks a clearly formulated goal orientation, which, while obscured by polypragmatism, is not conducive to further development. Furthermore, the question of the quality of care and its safety has not been satisfactorily resolved, especially in international comparison given the level of financial resources deployed. Likewise, there are no well-established concepts for improved collaboration between professional groups, which are supposed to cooperate but fail to do so due to a lack of incentives and opportunities (including legal ones). Ultimately, needs planning, already hampered by the individual sectoral perspectives, is underdeveloped, both in the outpatient and inpatient sectors.
Possible solutions may lie in regionalized care models that rely more heavily on networks between general practitioners and specialists to direct patients to the right specialists and avoid overloading certain regions. Reimbursement structures must be adapted to changing needs, with particular attention paid to placing greater emphasis on chronic diseases and less on individual services in the area of (surgical) interventions. Access to the specialty sector should be reserved for patients who have a valid indication for it, and gatekeeper models that strengthen primary care coordination should be more widely applied. Although suboptimal structures should generally not be allowed to degrade into "poorly digitized structures" through technical tools, the targeted use of telemedicine and digital communication is useful to bridge regional disparities and facilitate access to specialists for patients in structurally weak areas.
In particular, the following points must be considered:
• Integrated care: Inter- and intraregional care deficits can only be eliminated by establishing cross-sectoral care networks and promoting multidisciplinary medical care centers. The former are a priority in rural areas, while the establishment of medical care centers (possibly with contractual relationships with hospitals) takes priority in cities and metropolitan areas.
• The involvement of self-directed healthcare professionals is urgently needed to ensure primary care, particularly in rural areas and socially disadvantaged areas of large cities. Model projects such as IT-supported outreach care by qualified nurses in Mecklenburg-Western Pomerania and Brandenburg ("AGnES") must be integrated into standard care. The Innovation Fund project from Rhineland-Palatinate, "HandInHand": Implementation of nursing experts in standard care, can also be recommended.92
• Given that the need for care will increase significantly in the coming years, the federal government is called upon to implement significantly more preventive measures in a timely, strategic action plan. Personal health education as a lifelong learning process, such as institutional prevention and health promotion starting in daycare and school, will help delay and prevent the need for care, and significantly reduce it in demographic terms.
• New housing and living models must be considered in housing construction. Nearly everyone wants to grow old in their own home and not die in a residential facility. Projects that are suitable for enabling people with and without assistance needs, with and without financial needs, in retirement and during university, to age with dignity, health, and security through social integration in a self-chosen environment and community.
• There is neither a medical nor an economic justification for the dual system of statutory health insurance and private health insurance, as even the Council of Economic Experts has stated. However, its transition to a unified health insurance system (“citizens' insurance”) is fraught with legal pitfalls. This applies in particular to the legally unresolved question of who actually “owns” the private health insurance pension reserves, and to what extent. While transferring individual reserves to the health fund would be an economically and socially “sound” solution in the event of a switch from private health insurance to statutory health insurance, the private health insurance sector would certainly challenge its constitutionality. The politically simpler solution is the gradual dissolution of the current assistance system for civil servants and their transfer to the group of persons subject to compulsory statutory health insurance.

Consequently, underprovision cannot be avoided or eliminated solely by increasing capacity; rather, a strategic approach is needed that considers regional needs, reduces bureaucracy, and promotes collaboration between general practitioners, specialists, various professional groups, and the patients themselves. However, a clear and credible commitment from stakeholders is required that underprovision is not viewed as a hidden strategy for cost reduction. This is not always easy, because overprovision, misprovision, and underprovision continue to exist side by side in our healthcare system, often even closely intertwined.

*: The Health author group consists of Prof. Dr. med. Matthias Schrappe, Hedwig François-Kettner, Franz Knieps, Univ.-Prof. Dr. phil. Klaus Kraemer, Hartmut Reiners, Prof. Dr. med. Martin Scherer, and Dr. med. Thomas Voshaar. The short paper #1 was written with the collaboration of Prof. Dr. med. Jürgen Windeler.