The Hospital Reform Adjustment Act (KHAG) was intended to make hospital reform more practicable. For many hospitals, the decisive question remains unanswered: what specifically applies to their own site?
With the Hospital Reform Adjustment Act (KHAG), passed by the Bundestag in March 2026, the original hospital reform (KHVVG) was readjusted on key points. Availability payments will be deferred by one year and will not take full financial effect until 2030; 2026 and 2027 will be budget-neutral. The federal share of the Transformation Fund will increase from €25 billion to €29 billion. For hospital management, this initially sounds like relief. On closer inspection, however, the reform has not become calmer; it has become more complex.
More exemptions, more scope for interpretation
KHAG gives the federal states considerably more discretion, for example when assigning service groups to hospitals that do not fully meet the quality criteria otherwise required. Until the end of 2026, states can make such assignments even without the explicit consent of health insurers; thereafter, only in agreement with them. Binding nationwide criteria for classification as a specialist hospital are not to be developed until 30 September 2029. Until then, states will decide at their own discretion.
For hospital operators, this means that the relevant rules are no longer set out solely in federal legislation; they are also shaped by 16 different state-level interpretations. Those who rely exclusively on KHVVG or KHAG therefore know only part of the conditions that actually apply to their own site.
Outstanding issues affecting specific planning decisions
Several questions that are directly relevant to the investment and structural planning of individual hospitals have not yet been conclusively clarified:
- Exactly how availability payments from 2028 will be linked to case numbers and case mix, and which corridor will apply to deviations.
- Which specific criteria states will use to approve exemptions from quality requirements — the standards already differ noticeably.
- How the cooperation models between specialist hospitals newly introduced in KHAG will be assessed in practice, particularly with regard to related service groups.
- How the special arrangement in North Rhine-Westphalia, which is exempt from core KHAG requirements until the end of 2030, will be compatible with the federal rules in the long term.
These ambiguities are not a sign of insufficient care in the legislative process, but an expression of a political compromise between the federal government and the states. For individual hospitals, however, this does not change the need to make investment and structural decisions today, while some of their framework conditions will only become settled in the years ahead.
Why waiting is not a neutral option
A common response to regulatory uncertainty is to postpone decisions until there is more clarity. In hospital reform, this is risky because the deadlines continue to run regardless. State-specific applications to the Transformation Fund, assignment to service groups and preparation for the phased transition to availability funding all follow fixed timetables. Those who start too late lose not only time but also access to funding and room for manoeuvre that remain available to hospitals that act early.
The more effective approach is to distinguish between what is already certain today and what remains open — and deliberately work with scenarios for the latter rather than taking a wait-and-see approach.
Conclusion: reform competence becomes a leadership responsibility
Hospital Reform 2026 requires a new form of management from hospital leadership: ongoing monitoring of federal and state rules, active management of outstanding issues and the ability to make sound decisions under uncertainty. Those who take this task seriously gain an advantage that a wait-and-see approach cannot provide.