The negotiating teams of the CDU, CSU and SPD finalised the coalition agreement on 9 April 2025. As outlined in our article commenting on the “Health and Nursing Care” working group’s outcome paper published on 31 March 2025, it was clear that the group wanted to push ahead with reform. In the following, we discuss the extent to which the coalition agreement incorporates the outcome paper.
A. Key plans in the coalition agreement
- SHI funding identified as the main problem: Compared to the outcome paper of the “Health and Nursing Care” working group, the coalition agreement focuses more on the question of how measures can be financed from tax revenues. Plans such as the unconditional continuation of the Pact for the Public Health Service (Öffentlicher Gesundheitsdienst) only appear in a watered-down form. The coalition identifies stabilising contribution rates for statutory health and long-term care insurance as its top healthcare priority, but the agreement does not contain any specific measures for achieving this. The coalition agreement no longer includes the plan – outlined in the outcome paper – to use taxes to fully fund the non-cost-covering statutory health insurance contributions for benefits recipients, thereby tackling the structural deficit currently suffered by the SHI funds. The same applies to the reimbursement of the EUR 5.22 billion withdrawn from the compensation fund during the coronavirus pandemic, as announced in the outcome paper, which would have stabilised the financial situation of long-term care insurance. The new coalition wants to improve the financial position of SHI funds by increasing income through raising employment levels and reducing expenditure. But the coalition agreement does not contain any specific structural reforms; instead, an expert commission is to be established to evaluate the healthcare policies by spring 2027 and propose individual measures.
- New primary care physician model: The previously announced primary care physician model has been included in the coalition agreement. In future, patients will be obliged to visit a general practitioner or paediatrician of their choice before consulting a specialist. Exceptions will apply in the case of appointments with gynaecologists and ophthalmologists and for patients with serious chronic illnesses. Under this new model patients will be guaranteed an appointment with a specialist, to be scheduled by the respective regional association of SHI-accredited physicians (Kassenärztliche Vereinigung). If the relevant association is unable to schedule a timely appointment, outpatient hospital treatment will also be permitted. This option already exists under sections 76(1a), 75(1a), sentence 7 Social Security Code, Book V (Sozialgesetzbuch V, “SGB V”), but is hardly ever used. The coalition agreement does not answer the questions already raised as to whether this primary care physician model will – due to the sometimes limited availability of general practitioners – create a new bottleneck in care or how specialists will be persuaded to offer appointments that the regional association can allocate to patients. The same applies to the question of what can be done to encourage hospitals to provide routine outpatient treatment in such cases. It remains to be seen how this will play out in practice.
- Investor-operated ambulatory healthcare centres and hybrid DRGs still up in the air: Even after the outcome paper, it was still unclear how the coalition parties envisage the future of investor-operated ambulatory healthcare centres. The coalition agreement does not provide any clarity either. It merely mentions the possibility of enacting a law regulating investor-operated ambulatory healthcare centres, focussing on ensuring “transparency regarding the ownership structure as well as proper utilisation of the contributions”. It will be necessary to closely monitor whether the restrictions on investor-operated ambulatory healthcare centres, as previously announced by Professor Lauterbach, will be pursued further in the next legislative period and, if so, whether they will stay within constitutional limits. The same applies to the further development of sector-independent flat fees per case (hybrid DRGs). Specific details on how this service and remuneration model will be put into practice are also lacking, and it has been slow to get off the ground.
- Fee system changes: The planned adjustments to doctors’ fees have found their way into the coalition agreement, with the fee system to be modified to incorporate annual flat fees as a means of curtailing unnecessary visits. This will offer greater flexibility than the current system of quarterly fees and will reduce the number of unnecessary doctor-patient contacts, improving access for new patients. It would be prudent for legislators to make sure that these changes do not cause significant disparity between certain specialist medical fields. The changes to the fee system will be accompanied by efforts to enhance health professionals’ skills, particularly by offering broader access to training. This initiative is the coalition’s response to the limitations in the current professional development regime, which it recognises as an impediment to resolving the shortage of doctors.
- Increased involvement of the federal states and removing budget caps for necessary specialist care: Federal state involvement in accreditation committees is to be bolstered by granting states a deciding vote, enabling them to plan for their needs at a more granular level. This would weaken the regime of self-administration in the healthcare sector – something that the previous government had also agreed to do in its coalition agreement, albeit in softer form. However, it raises the question of whether state authorities are to be permitted to use that deciding vote to exert substantive control or direction over a functional self-administration body beyond their statutory oversight mandate. The agreement is less specific about plans to remove budget caps for necessary specialist care in underserved regions; this option is to be investigated, it says. The proposed scheme to balance out overserved and underserved regions is more tangible, and the coalition agreement defines oversupply to mean 120% of requirements. Here, too, it is important to ensure that the deductions do not cause significant disparity within the profession.
- Social insurance contributions from on-call doctors and emergency care reform: The black-red coalition has agreed to establish statutory provisions exempting doctors from the regional associations of SHI-accredited physicians’ on-call service from paying social insurance contributions – an issue that caused considerable uncertainty throughout the health insurance system following a restrictive Federal Social Court ruling during the last legislature. A corresponding regulation was included in the Cabinet draft of the Act to strengthen Municipal Healthcare Provision (Gesundheitsversorgungsstärkungsgesetz, “GVSG”), but did not make it into the truncated version of the act passed by the Bundestag due to the premature end of the traffic light coalition. The coalition also plans to draw on previous drafts on emergency care reform that failed to materialise and bring them to fruition; however, the 100-day target that the working group specified in its outcome paper is missing from the coalition agreement.
- Pharmacies: The coalition agreement largely corresponds to the outcome paper as far as pharmacies are concerned. The profession of pharmacist is to become a “healthcare profession”, which could lead to conflicts between pharmacists and SHI-accredited physicians. The financial burden on local pharmacies is to be reduced, with health insurance funds to be denied the option of refusing to pay prescription costs for formal reasons. This indicates that the coalition parties do not consider the list of formal reasons that cannot be used to justify such a refusal in section 129(4d) SGB V (as amended by the Act to improve the Supply of Medicines and avoid Shortages (Arzneimittel-Lieferengpassbekämpfungs- und Versorgungsverbesserungsgesetz)) to be sufficient to protect pharmacies. The ban on prompt payment discounts is to be lifted and the fixed basic dispensing fee per package increased to EUR 9.50. This may be increased further to up to EUR 11.00 depending on the coverage rate, especially in rural areas. The fee is to be negotiated between pharmacists and the National Association of Statutory Health Insurance Funds. Red tape – such as documentation obligations – is to be reduced, and the requirements for local and mail-order pharmacies standardised, especially as regards cold chains and obligations to provide proof. The ban on third-party ownership, which significantly restricts investment in pharmacies and participation in revenue-based fees, is to remain in place.
- Hospital reform: The hospital reform initiated under the previous government is set to be completed by summer 2025. Responsibility for granting exemptions to ensure continued access to essential clinical services – such as internal medicine, surgery, gynaecology, obstetrics and emergency care – is to remain with the federal states. The criteria for designating specialised hospitals are to be revised, although no further details have yet been provided. There is concern that these exceptions may dilute the reform’s objective of improving structural quality through a greater concentration of services, as the states may seek to preserve existing hospital structures. The current system of primary care delivered by general practitioners is to be maintained, with targeted improvements in specific areas. Funding gaps for hospitals’ immediate transformation costs incurred in 2022 and 2023 will be covered through the newly established special infrastructure fund. This fund will also absorb the share originally intended to be financed by the SHI system. This replaces the previously planned – yet constitutionally controversial – shared financing of the hospital transformation fund through the health fund, which would ultimately have placed the burden on SHI members. Starting 1 January 2027, service group allocations will be based on the 60 service groups defined in North Rhine-Westphalia, along with an additional group for special trauma care. Depending on the results of the evaluation, both the composition of service groups and the allocation of physicians to these groups (with 38.5 hours considered full-time) may still be adjusted. As with other elements of the reform, it remains to be seen how this will affect the goal of improving the quality of hospital care. Billing will be based on the InEK grouper for these service groups. The convergence phase is to be extended from two to three years, with 2027 intended as a revenue-neutral year for all hospitals. After that, the standby financing model (Vorhaltevergütung) will be introduced in two stages.
- Joint government/state commission to pursue nursing care reform: The coalition agreement provides only sparse details of the parties’ ambitious plans for nursing care reform. For example, it is still unclear how short-, medium- and long-term measures will ultimately be balanced. To address this, a joint government/state working group at ministerial level – with input from national associations representing cities, towns and municipalities – is expected to draft concrete proposals for structural reform by the end of 2025. The agenda set out in the coalition agreement (which includes streamlining and consolidating services, better support for family caregivers, and capping out-of-pocket contributions) hints at the scale of the challenge the commission faces. In the short term, laws on nursing skills, nursing assistance, and the introduction of the “advanced practice nurse” (APN) role are to be finalised, building on previous legislative drafts. The so-called “basic healthcare contract” (kleiner Versorgungsvertrag) is also to be put on a sound legal footing. The originally planned 100-day deadline has now been dropped.
- Cutting red tape and increasing digitalisation in healthcare: The coalition partners plan to reduce bureaucracy, one specific measure being to introduce a EUR 300 de minimis threshold in auditing payments to physicians in independent practice. This was originally included in the Cabinet draft of the GVSG but fell victim to the premature end of the traffic light coalition. Greater digitalisation in healthcare will also be pursued. This year, for example, the electronic patient record is to be rolled out in stages, with mandatory use and penalties for non-use. There are also plans to introduce a “nationwide alternative allowing structured initial assessment via digital means and telemedicine”. This wording could also allow doctors to use AI to take patient histories, as a standard service, something which is already offered by private providers.
- Health research: Barriers in clinical research are to be removed and regulations harmonised with other EU countries, e.g. in CAR T-cell therapy. Data use at the Health Data Lab is also to be improved and a Register Act drawn up, violations of which are to be strictly penalised in order to protect sensitive health data.
B. Conclusion
The coalition partners have set ambitious health policy goals for the next four years, in particular the introduction of a mandatory primary care physician model. But the coalition agreement has little to show in terms of innovative ideas or concrete solutions for the healthcare sector, nor any real suggestions for tackling fundamental structural reform. The ongoing (and challenging) questions concerning the long-term financial sustainability of the SHI system have not been answered, but have merely been put off for the time being. Many of the measures outlined in the coalition agreement remain unclear, as it primarily sets out legislative intentions and general objectives, with only a few concrete initiatives. Healthcare sector stakeholders should therefore closely monitor the upcoming reforms in the new legislative period. The Gleiss Lutz team will be happy to advise.
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