What are sector boundaries?

“… the still far too high wall between outpatient and inpatient care”
German Advisory Council on the Assessment of Developments in the Health Care System, 2018 (our translation)¹

A wall running through care

People who are ill want to get well. Whether they are treated in a practice, a hospital, a rehabilitation facility or at home is secondary to them. For the German health system it is not. The system is organised in sectors: outpatient care by office-based physicians, inpatient care in hospitals, plus rehabilitation, nursing care and the public health service.

Each sector follows its own rules. Practice seats are planned by the self-governing bodies of statutory health insurance physicians, hospital beds by the federal states. Practices bill according to the uniform fee schedule, hospitals according to case-based lump sums (DRGs). Rehabilitation and nursing care are funded by other bodies. Each sector documents in its own systems. The result is boundaries that nobody drew on purpose, yet they shape every course of treatment.

One patient journey, five sets of responsibilities

GP practice
Referral; the findings come back by fax
Specialist practice
No timely appointment; the route leads through the emergency department
Hospital
Tests are repeated; the discharge letter follows later
Rehabilitation clinic
Medication was changed; the GP finds out late
Home with nursing care

Illustrative example: an older patient with heart failure. Each station plans, bills and documents on its own.

What the boundaries cost

Something is lost at every boundary: information, time, sometimes trust. Tests are repeated, medication plans do not match, and after discharge the GP practice often does not know what was changed in hospital. Legislators responded by making discharge management mandatory³, but an obligation to hand over is no substitute for shared care.

The scale of the problem shows in so-called ambulatory care-sensitive hospital cases: hospital treatments that good outpatient care could often prevent. A study commissioned by the Central Research Institute of Ambulatory Health Care counted around five million such cases, 27 per cent of all hospital cases. It considered more than 3.7 million of them avoidable with optimally coordinated care².

The invisible boundary: data

Even where organisations want to work together, they often fail at a boundary no one can see: their systems do not understand each other. In a comparison of 17 countries, Germany ranked 16th for the digitalisation of its health system in 2018⁴. A lot has happened since. Since 2025, an electronic patient record has been created for everyone with statutory health insurance unless they object, and since October 2025 practices have been required to use it⁵.

But a record alone does not create interoperability. A scanned doctor's letter in the record is better than a fax, but it is not machine-readable. Systems are only interoperable when they not only exchange data but also understand it in the same way. That requires common technical standards and a common clinical terminology. There is now a statutory procedure for setting them⁶. Every new project or app that invents its own data formats, however, draws the boundary anew.

Why good approaches get stuck

There is no shortage of ideas. As early as 2018, the Advisory Council proposed cross-sector planning and the same price for the same service, regardless of where it is provided^1,9. Hybrid DRGs, introduced in 2024, are a first step in this direction⁷.

Since 2016, Germany's Innovation Fund has supported more than 800 projects with around two billion euros, many of them on new, cross-sector forms of care. Yet half of the completed care projects received no recommendation for adoption into standard care, and even for the rest the road there is long⁸. Pilot projects end when the funding ends. The boundary remains.

Our approach: designing care from the patient journey

Sector boundaries cannot be abolished in a single project. But care can be designed to bridge them. We rely on four principles:

Plan from the patient journey. The starting point is not which sector is responsible, but where people get lost along the way.
Design the transitions. Every interface needs someone responsible for it and information that travels with the patient.
Interoperable from the start. We build nothing that creates new data silos. Open standards are not an extra for us but a prerequisite.
Plan the transfer. Anyone who wants a new form of care to last must clarify from the outset who will sustain it and what evidence that requires.

Our GesundheitsKompass Freiburg starts right there: it helps families find the right way through the system and connects services in the region across sector boundaries.

Sources

Advisory Council on the Assessment of Developments in the Health Care System (SVR). Bedarfsgerechte Steuerung der Gesundheitsversorgung. Report 2018, summary (in German). PDF
Central Research Institute of Ambulatory Health Care (Zi). Study on ambulatory care-sensitive hospital cases (Sundmacher et al.). Press release, 27 October 2015 (in German). versorgungsatlas.de
Section 39(1a) German Social Code Book V (SGB V) – discharge management. gesetze-im-internet.de
Bertelsmann Stiftung. #SmartHealthSystems – Digital Health Index, 2018. bertelsmann-stiftung.de
German Federal Government. FAQ on the electronic patient record (in German). bundesregierung.de
Section 385 SGB V – identification, specification and establishment of standards. gesetze-im-internet.de
Section 115f SGB V – special sector-equal remuneration (hybrid DRG). gesetze-im-internet.de
AOK-Bundesverband. Innovationsfonds. Gesundheit und Gesellschaft 4/2026 (in German). aok.de
Deutsches Ärzteblatt. Gesundheitswesen: Für eine Versorgung aus einer Hand. 2018 (in German). aerzteblatt.de