The analysis of overprovision in the German healthcare system highlights structural and cultural drivers as well as reform approaches.
The overprovision in the German healthcare system is a complex phenomenon, characterized by structural misincentives, cultural norms, and institutional frameworks. A post shared on LinkedIn describes the case of a patient with nine MRI and two CT scans of the lumbar spine with unchanged findings Li. It illustrates the discrepancy between diagnostic effort and medical benefit. This analysis examines the underlying mechanisms of overprovision as a systemic cause and reviews the plausibility of key figures. We also assess the potential impact of the Hospital Care Improvement Act (KHVVG) of 2024/2025 in its currently initiated form.
Epidemiology of Overprovision: Numbers and Their Interpretation
Imaging as a Paradigm of Overdiagnosis
Germany, with 142 MRI scans per 1,000 inhabitants (2016), has one of the highest usage rates worldwide—a figure that increased by 71% between 2006 and 2016 9 14. These numbers correlate with the described case, in which a single patient underwent eleven radiological examinations over eight years. The cost per MRI of the lumbar spine ranges between €395 (outpatient) and €608 (inpatient), which in this case led to total costs of €4,355–6,680 9 14.
Critically, there is a lack of evidence for repeated examinations in stable findings: international guidelines recommend primarily conservative therapies for nonspecific back pain without neurological deficits 7. The high frequency of imaging procedures thus reflects less medical necessity and more systemic incentive structures.
Doctor-Patient Interaction Under Time Pressure
With an average of 10 doctor visits/year, Germany significantly exceeds the OECD average (6.6) 11 16. At the same time, consultations in Germany only last 7.6 minutes—compared to 22.5 minutes in Sweden 15. The duration information stems from 2017 but has presumably changed little since then. Besides, they are average values.
This discrepancy promotes a transactional treatment style. Short interactions favor technical interventions (“activism”) over empathetic anamnesis taking 5 7. In the case example, this could explain the successive consultation of eight neurosurgeons, each time offering fresh diagnostic certainty without addressing the underlying somatoform disorder.
Cultural Drivers: Logic of Escalation and Medicalization
Economized Medicine and Performative Service Provision
The German DRG system (Diagnosis-Related Groups) rewards quantity-driven action. As many as 40% of chief physicians state that economic conditions force high case numbers 5. This “logic of escalation” transfers market economy principles to medicine, where they lead to the institutionalization of overprovision. For economist Tomáš Sedláček, the harm in modern, liberal societies stems from a logic of perfection and escalation, the idea of being even better, which also applies to the healthcare sector: In linking institutionalization and optimization, moral responsibility has shifted from the individual to institutions 12.
This is exemplarily shown in thyroid surgeries: 90% of the 70,000 annual procedures occur without proof of malignancy 1. Simultaneously, the prescription of stomach acid blockers increases by 70% without adequate indication 1 7. Both phenomena demonstrate how economic incentives (surgery lump sums, pharmaceutical sales) overshadow clinical decisions.
Patient Role in the “Consumer Paradigm”
The “medicalization of everyday life” transforms patients into health consumers, who, through frequent doctor switching (“doctor shopping”), seek supposedly optimal care 3 7. In the described case, this manifests in the combination of somatoform disorder, pension claims, and repetitive diagnostic searches—a pattern reinforced by lack of gatekeeping function and uncoordinated care 7 12.
Structural Deficits or from Planning Reality to Reform
Hospital Landscape Between Overcapacity and Insolvency
Germany's 1,874 hospitals (2024) with only 67% bed occupancy reflect a fragmented care landscape 2 6. This system promotes competition over cooperation: Clinics cover broad ranges of services to maximize case numbers, even with a lack of expertise 6 8. The consequence is quality loss—for example, in ovarian surgeries, where only 10% of operations show actually malignant findings 1.
The KHVVG 2024/2025: Ambivalent Reform Approaches
The hospital reform aims for a bundling of service groups (65 specialities) and quality orientation through minimum volumes 2 6 13. Core elements include:
Regional planning: Hospitals must provide verifiable expertise to offer certain service groups 2 8.
Provision fees: Financing is oriented towards population needs instead of historical case numbers 13.
Transformation fund: €50 billion by 2035 for structural adjustments 8 13.
Critical remains the implementation of digital interoperability. Despite reference to the Hospital Future Act (KHZG), specific requirements for telemedical networking are lacking 4 8. Furthermore, centralization threatens to exacerbate rural care deficits—a conflict that was controversially discussed in the Federal Council 8 13.
The Dialectic of Safety and Harm
Iatrogenic Risks of Repetitive Diagnostics
Repeated imaging in stable findings generates pseudo-objective safety, while simultaneously triggering iatrogenic disease careers through incidental findings (e.g., incidental tumors) 3 7. In the case of MRI overdiagnosis described above, the nine MRIs likely exacerbated the somatoform disorder through reattribution of bodily symptoms—an effect well documented in studies on overdiagnosis of chronic pain 3 5.
Economization of the Doctor Role
The deprofessionalization due to economic pressure is evident in the dominance of “RVU time” (Revenue per User) over medical indication 12. Chief physicians remain caught between ethical responsibility and budgetary constraints—a dilemma, as already mentioned, that 40% of them cite as the main driver of unnecessary procedures 5.
From System Change to Cultural Transformation
Evidence-Based De-Implementation
Initiatives like Choosing Wisely 17 address overprovision through …
Guideline update: Explicit non-recommendations for ineffective measures 1
Shared Decision Making: Participatory decision-making using decision aids 7
Peer review processes: Clinical case conferences for indication review 3
Structural Reform Through the KHVVG
The reform could reduce overprovision by:
Service groups: Specialization reduces quality risks in high-risk interventions 2 6
Quality criteria: Minimum volumes for oncological centers prevent opportunistic surgery 13
Digital documentation: Electronic case files reduce duplicate examinations 4
At the same time, remain implementation risks: The lack of coupling of the KHVVG to the Digital Health Care Act (DVG), passed years ago, limits data utilization, while the transformation fund, without clear governance capabilities of the federal states, could accelerate insolvencies 8 13.
Overprovision as a System Property
The analyzed case is symptomatic of a healthcare system characterized by complementary misincentives from providers and demanders. The logic of escalation of free markets meets here a cultural-historical belief in feasibility, equating medical progress with maximal intervention.
The KHVVG 2024/2025 addresses important structural deficits but remains a compromise between politics and self-administration in its current form. Sustainable changes require in parallel:
Cultural change in the medical profession through ethics curricula for resource responsibility
Patient education for health literacy through national awareness campaigns
Selective contracts between health insurers and guideline-certified centers
Only the synthesis of structural reform and cultural transformation can release German medicine from the paradigm of overprovision—towards precision-oriented, patient-centered care.
