[For discussion: Restructuring of medical specialist treatment using the example of ambulatory special medical care (ASV): Taking a critical look at its aims and implementation].

With the GKV-VStG act in 2012, the former section 116b SGB V was transformed into ambulatory special medical care (ASV). This system comprises the diagnosis and therapy of rare or complex diseases which are difficult to treat, in need of a special qualification of doctors, an interdisciplinary cooperation and/or special facilities. For the first time, a uniform regulatory framework was established for the participation of office- as well as hospital-based doctors in ambulatory care. There is no planning of demand or licensed permission. The Federal Joint Committee's instructions regulate the extent of care, the prerequisites of participation, scope of clinical services and reimbursement. The implementation is complex and has so far been very slow. The process is impeded by the legislative conflict between incentives for care providers and concerns about the uncontrolled evolution of expenditure. The procedure of furnishing the requested proof that the conditions of participation have been fulfilled is burdensome, creating yet another barrier to broad participation of doctors and institutions. Differences in competition between office-based physicians and hospitals have been reduced but not eliminated. Sectorial barriers are only partially reduced, existing structures provide alternative care. Improvement of care in rural areas, active involvement of patients and a genuine evaluation do not take place.