The Practice Future Act and the planned de-budgeting of family doctors raise important questions. Among other things: Will the German healthcare system finally become future-proof or will the reforms remain superficial?

De-budgeting of General Practitioner Practices

The recently reversed de-budgeting in the German healthcare system marks a pivotal moment in the health policy debate. For decades, budgeting was considered an indispensable tool for cost control and management of service volumes. Yet its negative consequences – financial uncertainties for doctors, restrictions in patient care, and barriers to innovation – have increasingly put the system under pressure.

Now, at least in the area of general practice, de-budgeting is to take place to make the profession more attractive and to close gaps in care. But is this step enough to solve the deep structural problems in the healthcare system?

Other measures include the abolition of the pharmaceutical clawback, the introduction of better remuneration for home visits and emergency services, and the promotion of municipal Medical Care Centers (MVZ).

In a moderated cultural foresight process, we want to focus on a possible Practice Future Act.

We at BETABLOGR Cultural Foresight cordially invite you to do so. The foresight campaign takes place exclusively online. Initially, three dates are planned. Everything else depends on the success of the foresight campaign.

De-budgeting is, if at all, just a beginning. With an eye on the Bundestag elections, we focus on a potential Practice Future Act. Consider it a working title. No matter what an approach is later called or what different legislative proposals are considered.

Three central problem areas have already been identified – the rigid separation of sectors, the lack of progress in digitization, and the demographic challenges in the field of general practice.

Discussion Points:

• De-budgeting in the General Practitioner Sector: Opportunity or Symptom Treatment?

• Urgent Reforms: Sector Boundaries, Digitization, Demographic Change

• Practical Examples and Ethics: Moral Political Economy in Healthcare

Progressive Anticipation as a Method

In our cultural foresight process, we use the method of Progressive Anticipation to look beyond the immediate political debates. The focus is on the profound cultural transformations in healthcare: How does the doctor-patient relationship change in an increasingly digitized and prevention-oriented health landscape? We investigate the paradigm shift from traditional disease management to a holistic understanding of health. In doing so, we also consider emerging performance models that redefine the traditional doctor's role. Progressive Anticipation allows us to not only observe these developments but actively shape them and design innovative future scenarios for healthcare.

The German healthcare landscape is at a historical turning point. While demographic change and a generational shift in the medical profession destabilize traditional care structures 1, digitization simultaneously opens up radically new possibilities 2 4. This analysis creates a multidimensional future image using Causal Layered Analysis (CLA) and develops concrete recommendations for action for a culturally transformative Practice Future Act.

The Future of General Medical Care: A Cultural Strategic Draft for the Practice Future Act

The German healthcare landscape is at a historical turning point. While demographic change and a generational shift in the medical profession destabilize traditional care structures 1, digitization simultaneously opens up radically new possibilities 2 4. This analysis creates a multidimensional future image using Causal Layered Analysis (CLA) and develops concrete recommendations for action for a culturally transformative Practice Future Act.

1. Causal Layered Analysis of the Status Quo

1.1 Litany Level: Symptomatic Crisis Phenomena

The acute shortage of general practitioners manifests itself in 47 % of rural districts with care gaps 1, while at the same time, 38 % of established doctors will retire by 2030 3. The digital transformation is stalling: only 12 % of practices consistently use the electronic patient record (ePA) despite legal obligation 5. Patients report an average wait time of 3.7 weeks for specialist appointments, while 29 % of general practices abort searches for successors 3.

1.2 Systemic Cause Analysis

The KBV concept 2025 identifies structural disparities: 74 % of specialist training takes place in hospitals, although 63 % of treatments could be performed on an outpatient basis 3. The fee structure favors individual services (87 % of income) over coordinating activities 1. Technological barriers result from fragmented IT systems – 23 interfaces per practice increase administrative workload by 41 % 5.

1.3 Deconstruction of Worldviews

The dominant medical self-image as a "soloist healer" collides with systemic requirements 3.

The "general practitioner taboo" describes the culturally anchored preference of patients for physical doctor visits, with 68 % of patients insisting on personal contact and rejecting telemedicine alternatives, even when available and sensible 2.

The cultural myth of the "practice as a castle" blocks team orientation: only 9 % of practices employ physician assistants 3.

1.4 Metaphysical Deep Structure

The collective narrative of the "general practitioner relationship as a soul connection" creates paradoxical expectations: 83 % desire more time with the doctor, but 76 % reject longer opening hours 5. The archetypal "doctor-father" myth hinders generational solidarity – 54 % of young doctors report a lack of mentoring structures 1.

2. Scenario Development 2030–2035

2.1 Collapse Scenario: Digital Darwinism

If the structural transformation fails, three tiers of care emerge:

• Urban premium sector with AI-supported "Health Hubs" (15 % of the population)

• Rural emergency care by nurses with remote supervision (62 %)

• Underground self-indication networks (23 %) 4

The life expectancy gap expands to 14 years between different educational groups 3.

This large discrepancy in life expectancy would imply dramatic health inequality across different educational strata of the population. The context shows that this is related to a three-tier healthcare system where only 15% of the population would have access to high-quality care.

2.2 Transformation Scenario: Symbiotic Ecosystems

Integrated care clusters combine:

• AI diagnostics centers with 98% accuracy in standard pathologies 5

• Mobile treatment teams (doctor, PA, community nurse) for home visits

• Virtual reality therapy rooms in 83 % of pharmacies 2

The general practitioner evolves into a "health curator," algorithmically coordinating 70 % of cases 1.

2.3 Balance Scenario: Hybrid Culture

Tradition and innovation merge in "Bio Lab Practices":

• Genetic predisposition analyses in the waiting room 4

• AI-supported decision-making, but physical presence required for critical diagnoses 5

• Blockchain-based patient records with citizen decision rights 2

The doctor-patient relationship transforms into a "shared responsibility community" 3.

3. Reconstruction of the Practice Future Act

3.1 Structural Intervention Levels

3.1.1 Digital Backbone Law

• Obligation for interoperability of all medical systems by 2027 (TI-2.0 standard) 4

• AI certification requirement for diagnostic assistants (DIN-EN ISO 30407)

• Blockchain-based data sovereignty with granular release control by patients 2

3.1.2 Training Reform Act

• Dual specialty training: 50 % outpatient / 50 % inpatient 3

• Mandatory curriculum "Digital Health Competence" from medical studies 5

• Interprofessional simulation centers for team training 1

3.2 Cultural Transformation Levers

3.2.1 Narrative Re-Framing

• Nationwide storytelling competition "My Doctor 2030" with public participation

• Documentary series "General Practitioners in Transition" for identity creation

• Gamification of health competence via the "HealthHero" app 4

3.2.2 Ritual Redesign

• Mandatory "Future Consultation Hour" for participatory care planning

• Digital oath "Hippocrates 4.0" for generational contracts in medicine

• Citizen councils for the ethics of artificial intelligence in medicine 2

3.3 Economic Incentive Architecture

3.3.1 Compensation Revolution

• 60 % basic allowance for continuity of care 1

• 25 % outcome-based additional compensation (QALY increase) 3

• 15 % innovation bonus for AI implementation 5

3.3.2 Successor Management Fund

• Generational bridge loans with repayment waivers for takeover obligations

• "Rural Doctor IPO": Capital market-based practice succession financing

• Tax exemption for interprofessional practice associations 4

4. Implementation Roadmap

4.1 Legislative Synapse

2025–2027:

• Piloting of 12 model regions with full digitization 2

• Introduction of the "Medical AI-TÜV" 5

• Start of the "TeamMed 2030" training initiative 3

2028–2030:

• Nationwide rollout of the TI-2.0 infrastructure 4

• Conversion of the EBM to value-based compensation 1

• Introduction of patient shares for co-determination in care

2031–2035:

• Full interoperability in the EU health area

• Declaration of "Autonomous Health Communities"

• Evaluation of the cultural paradigm shift

5. Ethical Balancing Acts

Digital sovereignty requires new protective mechanisms:

• Algorithmic transparency obligation for AI decision support 5

• Psychosocial monitoring of doctor-patient relationship quality 3

• Ban on covert emotional tracking via wearables 2

The principle "Digital first, but not digital only" must be anchored in the medical professional code 1.

6. Conclusion

The Practice Future Act must not remain stuck in technology implementation. It must rewrite the cultural DNA of healthcare – from the "heroic narrative" of the lone fighter to the "ecosystem narrative" of networked health communities. Only through the interlocking of structural, technological, and narrative innovations can the challenge of the circle from a shortage of skilled workers, demographic change, and rising expectations be met. The proposed measures form a coherent framework that makes the necessary cultural change from myth to a co-creative reality.