116117, Appointment Backend & Co: Dispute over division of tasks begins

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With the primary care physician system announced in May 2025 by Health Minister Nina Warken, general practitioners are to act as "navigators" in the future, directing patients to the right medical care. The kickoff event focuses on the objective already enshrined in the coalition agreement of a "comprehensive possibility for structured initial assessment via digital channels with telemedicine." The nationwide telephone number 116117 for the medical on-call service, which already has such functions, could become the central point of contact for patients – increasingly also with AI.

The National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) warns against exaggerated expectations. "The primary care physician system is not a panacea," says Andreas Gassen, Chairman of the KBV, in an interview with the Catholic News Agency. The hope for cost savings is unrealistic, as medical progress and rising salaries will lead to higher expenses anyway.

The Union and SPD parties want to introduce a binding system in which patients primarily go to a general practitioner's office, which then refers them to specialists if necessary – and with an appointment within a specific timeframe. The restructuring is described as a "major operation" – also because it intervenes in a huge healthcare system. According to the KBV, there are 578 million treatment cases and one billion patient contacts with specialists and general practitioners per year in the 98,500 practices nationwide. Warken is aiming for a first draft bill in the summer.

The social association VdK, while supporting better orientation for appointments, warns against sanctions: "Anyone seeking help needs help, not punishment," said President Verena Bentele, according to dpa. She also criticizes: "The cause of too many doctor contacts is not widespread 'doctor hopping,' but a system geared towards profit maximization that is poorly coordinated." With private health insurance companies, according to VdK, a two-tier healthcare system already exists. The German Patient Protection Foundation also warns of an "outpatient medical care chaos" and criticizes that there is no answer to how people inexperienced with digital technology will be integrated.

First to the General Practitioner or Pediatrician

According to dpa, appointments with gynecologists and ophthalmologists will be excluded from the primary care physician principle. For children, pediatricians are to be the first point of contact. For certain severe chronic illnesses, "suitable solutions" are to be found – such as annual referrals or the possibility for a specialist internist to take on the role of a controlling primary care physician. If a practice cannot arrange an appointment, patients should also be able to "go to specialists in a clinic" – this is intended to represent a "guarantee of appointments." Medical associations also demand that the free choice of doctor not be abolished. To create acceptance, steering instruments are already being discussed. There is talk of a bonus for patients who adhere to the system's recommendations and a fee for directly seeking a specialist.

In October 2025, the National Association of Statutory Health Insurance Physicians argued for a tariff model with co-payments: an additional specialist tariff (200 to 350 euros annually) should allow insured persons to go directly to a specialist in the future without a referral or digital initial assessment, while the additional revenue should be used to fully reimburse additional appointments outside the budget. This is also the case in other countries.

On the health insurance side, steering is increasingly understood as digital routing. The Association of Statutory Health Insurance Funds (GKV-Spitzenverband) (PDF) proposes a standardized navigation tool in its concept "Primary Care: Access and Digitally Supported Care Navigation." This tool is intended to assess the need uniformly for treatment, identify the appropriate care pathway, and determine urgency "within the framework of a low-threshold initial contact (digital or analog)"; in addition to medical care, possible pathways mentioned by the GKV include "other health professions," "direct transfer to emergency care," "digital care models," and "options for self-treatment."

Digital Appointment Booking

Central to the GKV concept is the link to appointment scheduling: the tool should "directly enable (digital) appointment booking" and be "mandatorily and immediately" connected to a digital appointment scheduling system based on a nationwide directory of appointments. Prospectively, it should be connected to the ePA; collected data should be structured and transferred to the ePA so that all relevant findings, diagnoses, and treatment recommendations converge there. Among other things, the GKV-Spitzenverband proposed that one could enter complaints in a health insurance app and find out whether a doctor's visit is necessary or if a pharmacy could help – this should also include a neutral platform with available practice appointments. This inevitably raises the question of who operates the appointment backend. Many bookings are already handled by the large private platform Doctolib. With a nationwide appointment directory and a neutral platform, a competition for the contract to supply the central infrastructure is therefore likely to emerge.

The Spitzenverband Digitale Gesundheitsversorgung (SVDGV) demands that digital solutions not only be integrated but defined as a prerequisite. In its position paper (PDF) "Rethinking Primary Care Digitally – Digital Before Outpatient Before Inpatient," it states: "Digital solutions are not an additional offer, but a fundamental prerequisite for realizing the primary care system." The association wants to establish an "initial digital access" as an independent channel through which patients can receive "an initial medical assessment" after describing their symptoms – "either via telephone hotlines or through certified digital technologies such as AI-supported structured initial assessment." For referral to specialist care, the SVDGV relies on platforms, "which also include appointment management systems," and demands that these must be "interoperable, technology- and provider-open."

"Political Power Struggle Pre-programmed"

The question of who should take over the steering of patients is causing much discussion. Timo Frank from the Gematik's care department speaks of a political power struggle in a LinkedIn discussion round: "I believe the political power struggle is pre-programmed, it will happen." Jan Zeggel, a health expert, points to the different terminology: "Personally, I find that one sees it very clearly, while the doctor-affiliated organizations speak of a primary care physician system," the term primary care system has been established in the Federal Ministry of Health. I believe this clearly shows where we are now in the context of reforms, where the negotiation lines are also running accordingly."

Stefan Spieren, a general practitioner and digitalization pioneer, explains in the LinkedIn discussion: "When we explain to patients what added value they have, regardless of the system they come through, whether they are just standing in my practice and say 'I want it now' or whether they are on the phone or have an online appointment. [...] The patient must first understand why we are doing what we are doing. [...] And if the patient sees advantages, we know from ourselves: I always do what [...] brings me the most advantages."

Many Services Are Not Reimbursed

Another problem is the reimbursement of digital services. "It stands and falls with the reimbursement system. That is our problem. [...] As a doctor, I only live from the fact that this insurance card, to put it plainly, has been inserted into this card reader. I am not paid for quality. As perverse as it sounds, the more cards have been inserted into my card reader, the better it is for what I see in my bank account," says Spieren.

Frank emphasizes the necessity of a joint solution: "Fundamentally, however, we should agree to guide the patient to the right place, at the right time, to the right level of care. And it doesn't really matter whether the 116 117 does it by phone, digitally, or the health insurance company does it. The crucial thing is whether the end result is an offer that benefits the patients."

Spieren's appeal: "We must understand that it cannot go on like this, but that we must let ourselves be guided or guide patients and fit in there." This is only possible if doctors do not go away empty-handed. Those involved agree that a radical cost reduction or a perfect platform will not happen overnight.

The Kassenärztliche Vereinigung Westfalen-Lippe (KVWL) also demands that additional steering and appointment efforts are not free of charge. The head of KVWL, Dirk Spelmeyer, warns that reform and savings proposals are "strikingly often formulated at the expense of outpatient contract medical care," even though this is "the backbone of our healthcare system." Through the Terminservice- und Versorgungsgesetz (TSVG), the KVen were tasked with ensuring faster access to specialists – and "delivered." This "additional effort" must be "fairly compensated" – also against the background that services worth around 2.7 billion euros (2024) already provided nationwide have not been paid, which corresponds to "over 40 million appointments" in the specialist field.

Spelmeyer also calls for politics to "commit to the system of outpatient medical care" and prevent private service providers from draining money from the system without taking on care responsibility – and advocates for making the medical profession more attractive as an entry barrier for young professionals, given "budgets" and "recoupments."

(mack)