HÄPPI: How GPs can care for more patients with delegation and digital tools

While a first proposal for future patient management is coming from Berlin, Baden-Württemberg began this in 2008. There, more than three million insured individuals voluntarily participate in "GP-centered care," or HZV for short. This leads to fewer hospital stays and fewer complications in chronic diseases, among other benefits. This is the result of a long-term evaluation by Goethe University Frankfurt and Heidelberg University Hospital, which has been scrutinizing AOK Baden-Württemberg's HZV every two years since 2011.

Nationwide, nearly 11 million people are enrolled in HZV – more than in private health insurance. Those who participate commit to first going to their GP in case of illness. The GP knows the patients, their medical history, their daily lives, and coordinates further care. In return, the practices do not receive a fee based on individual services but a lump sum for the entire care provided. This creates different incentives than the classic KV system: consultation is worthwhile, overtreatment and mis-treatment are not.

Who is managing the care?

According to the draft bill from the Federal Ministry of Health, which has not yet been officially published, a new digital entry point for care is to be introduced. By February 1, 2028, at the latest, the electronic patient record (ePA) will have a dedicated functional area through which insured individuals will be directed for initial assessment by the appointment service centers of the statutory health insurance physicians' associations to book a treatment appointment. By 2029, contracted physicians must issue and retrieve referrals digitally and transmit them via the telematics infrastructure (TI). The Association of General Practitioners in Baden-Württemberg (HÄVBW) wants the GP practice to remain in the management function. The professional association calls on the federal government to consistently build upon HZV for the planned mandatory primary care system.

At the same time, the AOK Federal Association wants to curb HZV contracts. From the perspective of the chairwoman of the Association of General Practitioners, however, it is "completely absurd to demand the expansion of a primary care system on the one hand and to want to scrap the only established primary care system, HZV, on the other." After all, nearly 11 million patients nationwide voluntarily participate in HZV – many of them AOK insured individuals who, according to the association, use the model with high satisfaction. All innovations of recent years – from the team practice model to the modernization of the remuneration system – have emerged from HZV, not from standard care.

To make general practitioner care fit for the future, the association, together with Heidelberg University, developed the HÄPPI concept (Hausärztliches Primärversorgungszentrum – Patientenversorgung Interprofessionell). In addition to doctors and medical assistants (MFA), the concept involves academically trained non-medical healthcare professionals – such as Physician Assistants or Primary Care Managers – working in a team; digital solutions support the processes. The goal is to enable practices to care for more patients and to prepare them for the challenges of demographic change. What began in Baden-Württemberg is now also being piloted in Bavaria and Rhineland-Palatinate.

In HZV, delegation is not a new concept; the "Versorgungsassistentin in der Hausarztpraxis" (VERAH), or assistant in GP practice, has existed for a long time. She is an experienced medical assistant who, after further training while working, independently makes house calls, treats wounds, and coordinates care for chronically ill patients under delegation. Her work is specifically remunerated in the HZV contract. Current evaluation data show that HZV practices with a VERAH demonstrably achieve better results – including fewer uncoordinated specialist contacts and fewer avoidable hospital admissions.

Dr. Susanne Bublitz explains in an interview with heise online how this looks in practice, which digital tools really help – and why the plans of Federal Health Minister Nina Warken to make the electronic patient record the central health app miss the mark. The GP from Pfedelbach is a board member of the Association of General Practitioners in Baden-Württemberg and has introduced HÄPPI in her practice. She talks about delegation, digitalization – and a 60-minute hold loop.

Federal Health Minister Nina Warken wants to develop the electronic patient record into the central health app, which will also handle digital initial assessments and appointment brokering. How realistic is that?

Currently, this question is hardly relevant – a look into the ePA in a doctor's practice quickly shows that. The ePA is currently either empty or nothing more than a large data dump – filled with PDFs from the practice management system, without structure.

Take a hospital discharge letter: there are four doctors in our practice, and we receive almost all discharge letters four times, and then twice more because there's a preliminary and a final report. This means we have the same document eight times. If hospitals eventually use the ePA actively, the letter will end up in the ePA eight times, depending on the circumstances.

This creates a huge collection of documents that cannot be searched and contains no structured data or diagnoses. Yet, this prior knowledge is crucial for coordinating care effectively. It makes a big difference in a GP practice whether a young woman calls with chest pain or Mr. Müller, 76, with a pre-existing heart condition. In the best-case scenario, you can find this information by searching through a doctor's letter, but even there, the data is not structured. Therefore, I have no imagination as to how management is supposed to work on this basis. The recently published draft bill for the new Digitalization Act also provides no answer to this, even though the ePA is supposed to become a digital entry point for care from 2028 onwards.

Is she poorly advised?

I understand why the idea seems attractive: a digital system that quickly guides people and directs them to the right care sounds charming. However, it ignores the reality of care provision, and it's important to make it clear: a digital initial assessment is not primary care. It is well-documented that management via digital initial assessment is only sensible in certain situations.

In which specific situations?

In emergencies or acute care outside of practice hours. Imagine it's Saturday morning, you have a burning sensation when urinating and want to go to the emergency service. One symptom, one illness. In that case, the digital initial assessment can work excellently. The patient is told: no fever, no flank pain, no pre-existing urinary tract diseases, not pregnant? Then you can wait, take a painkiller, drink plenty of fluids, and go to your GP on Monday or be referred to the responsible on-call practice. This sensibly relieves emergency rooms and helps patients.

But introducing a digital initial assessment before every appointment in standard care, instead of going to your known GP, makes no sense and provides no proven added value. In general practice, patients come to the practice with an average of 3.5 consultation reasons. This morning, I had patients with four or five concerns multiple times. Which of these do you want to assess digitally, and where will the patient then be directed? General practice is relationship-based medicine, and often the actual task is to put all the puzzle pieces together and place them in the overall context.

Can you give a concrete example?

Yesterday, a patient came in complaining of dizziness and mental overload at work. He also wanted to check his vaccination status and discuss whether his severe disability ID would be extended for his chronic leukemia, allowing him to retire early.

Sending patients through an app that spits out a specialist referral for every concern doesn't get us anywhere. In the end, many will still end up back in the GP practice – either because they have acute complaints for which a specialist appointment in three months is useless, or because they simply need a vaccination. It would be much better to integrate the digital initial assessment into our practice, not before it: as a tool connected to our patient data that helps us manage concerns within the practice. How urgently does someone need to come in? Does the concern really need to go to the doctor, or is a consultation by a VERAH or a Physician Assistant sufficient? Or perhaps even a digital health service? This would improve care within the practice.

What happens if these things aren't coordinated within the practice?

Then the holistic view of the patient is lost. Imagine the patient with the urinary tract infection receives the advice five times in six months via a central health app: Drink plenty, take ibuprofen – and it gets better each time. Each occasion might be considered resolved on its own. What's missing is what we call "experienced medical history": What are the underlying causes? What needs to be ruled out?

The sixth time, the patient comes to me – and I know nothing. If a person is treated for each issue individually, a PDF is placed in the ePA that we GPs are unaware of, and therefore no one takes care to medically contextualize how the issues are related, then "Continuity of Care" is lost. And studies clearly show that this continuity is fundamental for good care.

Has anyone told Ms. Warken this yet?

With the goal of introducing a mandatory primary care physician system, the federal government has initiated a political change of direction – and that is right and important, but also a major challenge. The crucial question now is how to get there. We are naturally involved in this process to convey the requirements of good primary care.

The KBV has made its own proposal: Digital initial assessment should not be integrated into the ePA. What do you think of that?

The KBV is pursuing a similar concept – only the management is to be handled via 116 117 instead of the ePA. There, you will receive your prescription if needed, and essentially, very little will change from the status quo. Instead of acting like a primary care system, the concept seems like Swiss cheese to me – it's full of holes.

Gynecologists are supposed to manage, the GP is supposed to manage, there's an exception for every chronic illness. But many patients have multiple chronic illnesses. Where are they supposed to go then? If management is done a little bit everywhere, then we will simply have more initial contacts, more interfaces, more communication effort. The system will become more chaotic, not better – especially for the patient, who will no longer know where to go with which concern.

GPs are calling on the federal government to build upon HZV for the primary care system. A battle for interpretive authority has ensued, including within the National Association of Statutory Health Insurance Physicians (KBV).

True. That's not surprising – management always involves responsibilities and financing. Our position is clear: primary care needs a stable coordinating base, and that lies in the GP practice, where patients are known and information converges.

For example: Gynecological practices often have waiting times of months. At the same time, patients with lower abdominal pain regularly come there who simply have a urinary tract infection – a condition that a GP practice can resolve immediately. Good management means that the gynecologist has time for those who truly need it – and the patient with the urinary tract infection is treated faster.

What distinguishes the HZV model from the KV system?

The role of the GP practice is fundamentally different. In HZV, it takes over coordination and is remunerated with a lump sum. In return, we ensure the primary care of our patients and do what is medically necessary. In the KV system, however, billing is done based on individual services, which creates misincentives. Consultation is difficult to bill, surgery is easier.

For example: In the KV system, for an ultrasound, I have to take photos of both kidneys, the liver, the gallbladder, the spleen, and all other organs – and all this just to meet the billing requirements for the individual service of ultrasound. In HZV, I receive a surcharge for maintaining the equipment and performing the necessary examinations. If someone comes with right lower abdominal pain, the first thing I'm interested in is whether the appendix is inflamed. That's a matter of two minutes. In the KV system, it takes ten times as long and provides no additional medical information. This is overtreatment, which is expensive for the system and offers no added value to the patient.

What do you say to the concern that patients are being disempowered by these and similar models?

This concern is often the consequence of management being portrayed as "gatekeeping" – as a bouncer for the specialist, limiting freedom of decision. But that's a fallacy: management doesn't mean patients decide less. It means there is a clear first point of contact that offers orientation, assesses risks, and supports those affected in deciding which path is sensible. And in fact, most people choose to do so themselves, for example in HZV, because they realize it's the better path for them.

And looking at everyday life, it becomes clear why: many people today experience the opposite of self-determination. They struggle through unclear responsibilities, long waiting times, and contradictory information. In my view, well-organized primary care strengthens autonomy because decisions become more informed and because someone helps navigate the system. HZV data clearly show that this leads to better care and thus better health for patients.

What role do VERAH and Physician Assistants play in your daily work?

A very significant one. We have delegated tasks to VERAH for many years – house calls, wound care, management of stable chronic conditions. That was already a paradigm shift back then: away from "everything goes through the doctor" towards a targeted division of tasks within the team – to where the respective expertise is available. Interestingly, NäPA (the non-physician practice assistant) only exists in the KV system since VERAH demonstrated in HZV how it works. Competition stimulates business, after all.

With HÄPPI, we are now taking it a step further and integrating academically trained personnel – Primary Care Managers, Physician Assistants, Community Health Nurses, and others. This allows us to care for significantly more patients with the same number of doctors. According to the Bertelsmann study from March 2026, we could achieve up to 200 percent of the previous care capacity through consistent delegation. This strengthens primary care within the existing framework.

And what does it cost and who pays?

That's the crucial question. There are many good concepts that everyone likes, but interest ends when it comes to financing. If we want to seriously implement delegation, digital processes, and new professional roles broadly, we need reliable financing for them. The KV system offers no solution for this, as everything is geared towards personal doctor-patient contact, i.e., the highly personal service provision by the doctor, and delegated services can therefore largely not be billed.

Many concepts and pilot projects are therefore permanently dependent on third-party funding – from the innovation fund, from foundations, or other subsidies. In HZV, we are taking a different approach. For HÄPPI, we negotiated a surcharge with AOK Baden-Württemberg, which is tied to conditions. This creates incentives for practices to implement innovations and offers them predictable and stable framework conditions in return.

What financial support is available for digitalization in practices?

For the TI components, there is a fixed reimbursement price, the TI flat rate. However, this is far from cost-covering, as it does not account for the costs incurred by TI failures. We also pay for all costs for digital service providers, for appointment brokering tools, for messengers, for AI-supported documentation – out of our own pockets. Hospitals have entire IT departments and digital budgets; there is financial support from the hospital transformation fund. Practices are expected to undergo this transformation immediately, both in terms of personnel and finances.

And what about interoperability between the systems?

That's a huge problem. The practice management systems often only allow certain providers in. If I end up working in four different interfaces, I have four digital input channels that I have to process analogously. That's not digital transformation – that's digital extra effort.

A few years ago, I acquired a digital telephone concierge to relieve medical assistants of phone duties. In reality, we realized how many calls had previously gone unnoticed. On the first day, we suddenly had 600 calls. One provider told us at one point that we were essentially a call center with an attached GP practice. But that also shows how digital solutions can strengthen accessibility – and how important it is for digital solutions to be fully integrated into practice processes.

How do you communicate with patients digitally today?

We have an integrated messenger in our practice management system that we offer to our HZV patients for asynchronous communication. When I arrive in the morning, there are already 30 messages. I always have one or two employees who process them from home. This makes the workplace more attractive: if an MFA's child is sick, she can work from home. This sounds like an exception, but it's the norm for us. And this is exactly what we need to compete with hospitals for personnel.

What are these solutions still missing?

An integrated AI that handles initial assessments in the practice to support the aforementioned routing to the correct level within the practice. If a patient writes "I have a headache," that doesn't help me initially. Then my MFA has to manually ask for details. An AI system in the messenger that already conducts the initial anamnesis in the chat, prepares the results for us, and directly books the appointment from the online appointment calendar would be helpful. That's where we need to get to.

What about the KIM system – the e-mail service connected to the telematics infrastructure – and the TI messenger TIM?

A good communication platform for exchange between healthcare providers is extremely important for care – and that's often lacking right now. For example, I've been trying to reach an oncologist since January with whom I have a mutual patient. I've called several times, written twice via KIM, sent two faxes. Yesterday, I was on hold for 60 minutes and then gave up.

This shows that communication options are often not well integrated into workflows. Whether TIM can help here remains to be seen – the messenger is not yet widespread enough to serve as a reliable communication platform.

Why does the HZV concept work?

The HZV, as a primary care physician system, is conceived from the care process itself and implemented in such a way that care coordination by GP practices is also possible within it. Care coordination is not a series of individual services by doctors, on which the KV system is built. Care coordination is time-consuming. In HZV, there is a flat-rate remuneration for the team's work. With HÄPPI, we are taking the next step in our primary care concept: How do we want to work in the future, and what is possible?

The federal government doesn't need to reinvent the wheel. It can build on what has grown over 18 years and is scientifically proven to work. A primary care system becomes better when it is simple, reliable, and understandable for patients – and when responsibility lies where care can be coordinated: in the GP practice.

What would be your specific request to policymakers?

First: a transformation fund for practices, analogous to the Hospital Future Act. Second: open interfaces in practice management systems, so that digital tools that work and offer added value can also be used in practices.

The development and introduction of digital management tools should be consistently carried out with practical care settings – with pilot projects, evaluations, and a clear focus on implementability. Unfortunately, in the past, we in practices have often had to implement unfinished and ill-conceived digital solutions – this naturally does not foster enthusiasm for new digital concepts.

If we get management and digitalization right, everyone benefits in the end: patients through more orientation and targeted care, teams through better working conditions, and the system through fewer unnecessary contacts and healthier people.

(mack)