Germany Approves 2026 Hospital Flat Rate Catalog Amidst Contentious Negotiations
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The German Hospital Association (DKG) announced an agreement on the 2026 flat rate catalog, a system that has underpinned inpatient treatment billing in German hospitals as 2004. Reached in collaboration with the umbrella association of statutory health insurance (GKV-SV) and the association of private health insurance (PKV), the agreement comes after what stakeholders describe as notably difficult negotiations.
Shifting Focus to Outpatient Care
A key driver of the complexity was the late definition of the hybrid DRG catalog, which differs substantially from the established flat-rate case catalog – known as the aG-DRG catalog. While the aG-DRG catalog focuses on inpatient treatment, the hybrid DRG system extends to both inpatient and outpatient services. This expansion reflects a broader push to incentivize outpatient care and alleviate pressure on hospital resources.
The newly adopted aG-DRG catalog represents the standard per-case flat-rate system for inpatient hospital treatment. Notably, it separates services covered by hybrid drgs, as services covered by hybrid DRGs could not be together accounted for in the inpatient DRG system.
Expansion of Hybrid DRGs and Coordination Challenges
The scope of the hybrid DRG system is undergoing a substantial expansion. The number of cases covered is projected to increase from approximately 270,000 to around one million treatments utilizing this new remuneration system. This significant growth necessitates increased coordination between hospitals and payers, as highlighted by the recent publication of the new remuneration catalogs by the institute for the Remuneration System in Hospitals (InEK).
“the expansion of the hybrid DRGs to one million cases is a long-overdue step towards needs-based care,” stated a deputy chairwoman of the National Association of Statutory Health Insurance Funds. “In order to keep health care affordable for those paying contributions, we must consistently promote outpatient care.” The sentiment underscores a belief that shifting medically appropriate services to outpatient settings will reduce costs and minimize unnecessary inpatient hospital stays.
Negotiations Marked by Controversy
Despite the agreement, the process was not without friction. A senior official from the DKG characterized this year’s proceedings as “extremely controversial,” citing a significant role played by the arbitration panel of the expanded evaluation committee.
this resulted in considerable debate surrounding the selection of services and the calculation of appropriate remuneration levels among the self-governing partners. The DKG also voiced concerns regarding the committee’s understanding of the interconnectedness between the aG-DRG and hybrid DRG remuneration catalogs.
from the DKG’s perspective,the central aG-DRG remuneration system should operate independently of decisions made regarding the hybrid DRG in the future. The organization advocates for the outpatient provision of hospital services to be managed by the existing contractual partners for inpatient care,leveraging the expertise of InEK to develop short-stay flat rates tailored to the overall system.
Legal Framework for Flat Rates
The process for determining the aG-DRG catalog is currently governed by § 17b KHG, which outlines the foundation of the per-case flat-rate system used to reimburse inpatient hospital treatment via diagnosis-related flat rates (G‑DRGs). Each treatment case is categorized into a DRG based on diagnoses, procedures, and severity.
This legislation also mandates the annual development and adaptation of these flat rates by the self-governing partners to reflect evolving medical and economic conditions. Moreover, § 17b KHG provides the framework for removing individual cost components from the flat rates, a strategy previously implemented with nursing staff costs through the PflegeÂperÂsoÂnalÂstärÂkungsÂgeÂsetz (PpSG). As January 1, 2020, nursing staff costs have been financed through a separate nursing budget.
The Hybrid DRGs were introduced on January 1,2024,and are regulated under § 115f SGB V. Their purpose is to streamline billing for specific outpatient procedures and encourage a shift towards outpatient treatment, thereby easing the burden on hospitals. The aG-DRG system remains applicable to all inpatient services not encompassed by the Hybrid DRG catalog.
