System Update: Why Germany Still Runs Yesterday’s Health Care System

Who are we actually digitalizing for?

The International Business Times recently profiled me as an entrepreneur and visionary of digital health. Read closely, and the real story is not about me but about a system that has to change.

For years we have been debating digitalization in health care — electronic patient records, artificial intelligence, telemedicine. In doing so we often forget the decisive question: who are we actually digitalizing for? For authorities, for health insurers? Or for people who need medical help? Digitalization is not the goal but the tool: care that becomes faster, simpler, and more accessible for everyone.

Control instead of care

The current political debate shows the opposite. The federal government plans to abolish the telephone sick note, and a medical certificate is to be required again from the first day of illness. The justification: fewer absences, more productivity.

So the real question should be: does this actually solve the problem? My answer: no. Once again we are debating control instead of efficiency, mistrust instead of care. The telephone sick note was introduced to relieve medical practices and spare patients with mild infections an unnecessary trip. In future many will have to go to the practice again — not because they need care, but because they need a certificate. That is not health care reform. That is more bureaucracy.

A plaster on a structural problem

This treats the symptoms, not the cause. The real challenges remain: a shortage of skilled staff, overloaded practices, inefficient processes, missing patient triage. Behind them lies a fundamental systemic problem: how do we handle our scarcest resource, physicians’ time?

575 million cases, eight minutes, one billion contacts

Germany’s health care system is running at its limit. With 575 million treatment cases per year (Zentralinstitut für die kassenärztliche Versorgung, 2023), office-based physicians work an average of 53 hours a week. The result: around one billion patient contacts, leaving less than eight minutes for each consultation (KBV, facts and figures). If people with mild illnesses now have to come to the practice in person again, that means more bureaucracy, fuller waiting rooms, and less time for those who really need help.

Yet the solution is simple: anyone who can be treated safely for a simple infection via questionnaire, phone, or video does not block an appointment for someone seriously ill. Digital care does not replace physicians. It deploys them where they are truly needed.

The debate about 1%

Telephone sick notes account for around 1% of all sick notes. The Zentralinstitut für die kassenärztliche Versorgung puts the figure at 0.8 to 1.2 percent of all cases of incapacity for work. At AOK, for example, only around 145,000 sick notes were issued by phone in 2024. We are arguing about roughly 1% of the system and ignoring the other 99%. Our health care system does not need small cosmetic corrections but a real system update for the large, unresolved majority.

Another figure shows how much is at stake: a patient costs an average of 716 euros per year in outpatient care, compared with 9,465 euros in hospital (KBV, 2024). Every unnecessary visit to a practice therefore ties up not only time but also burdens a system that is already reaching its limits.

Abuse: the wrong battleground

The strongest objection to the telephone sick note is abuse. But as an argument against the digital sick note it does not hold — for three reasons:

1. It is not substantiated. The BKK umbrella association considers abuse of the telephone sick note “impossible to substantiate”; DAK found no “systematic abuse”.
2. Abuse — where it occurs — is not a channel problem. Typical symptoms such as pain, headache, or cough cannot be verified anywhere, neither online nor at the practice desk. At the desk there is the additional social pressure of familiar patients: an online survey of 432 general practitioners (Zeitschrift für Allgemeinmedizin, 2026) shows that almost a quarter are asked for a favour sick note at least once a week. A standardized, AI-supported procedure does not feel that pressure. Even KBV head Andreas Gassen says that anyone wanting to obtain a medical certificate by deception already manages to do so, including at the doctor’s practice — which is why he wants to abolish the sick note requirement in the first few days entirely, “by phone, on site, or digitally”.
3. Policing abuse is not the physicians’ job anyway — it is the task of the health insurers and the Medical Service. By far the greater damage comes from long-term sick leave, not from three days with a cold.

The thinking error is called presenteeism

Forcing people with mild infections back into the waiting room often achieves the opposite of what is intended. Many then drag themselves to work while ill, for fear of the effort, the certificate, the day of absence. This is called presenteeism, and it is expensive: continued pay during illness alone cost employers around 82 billion euros in 2024 (Institut der deutschen Wirtschaft). Studies put the hidden costs of presenteeism considerably higher still — according to research by the Felix Burda Foundation, roughly twice as high as absence itself. According to Techniker Krankenkasse, more than every second employee goes to work ill at least sometimes.

We ban a proven plaster while the system is having a heart attack.

The economic damage therefore does not come from a few days of recovering at home, but from sick, contagious, unfocused people at the workplace. Making the simple sick note harder does not fight the malingerers — it breeds presenteeism.

What we have long since proven

At this point I am not speaking theoretically. Since 2018 we at DrAnsay have supported more than 3 million online treatments and over 1 million patients — in the most heavily regulated market in the country. Our AI-supported sick note for simple infections works faster, more safely, and more cheaply than the classic route. And it has been demonstrably better than the telephone sick note alone, because it systematically safeguards quality and safety:

• It treats only clearly delimitable, harmless conditions such as colds, and actively rules out risk factors through a structured medical questionnaire. Anyone who cannot be treated safely online is referred to a practice.
• It limits frequency and intervals (for example, only a few cold-related sick notes per year with a minimum interval): built-in protection against abuse that no in-practice consultation offers.
• The usage data speak for themselves: our sick notes cluster on Tuesdays, not on Mondays or Fridays. That is the opposite of the typical malingering pattern.
• And the best evidence of quality is the experience from millions of treatments with a vanishingly small complaint rate.

In short: for a simple infection, the safest and most efficient route for everyone involved is not a trip to a crowded waiting room but a standardized, AI-supported online sick note — if necessary even without a doctor’s consultation, because with an evident cold people themselves know best that they are ill, and a structured procedure safeguards safety better than eight minutes under time pressure.

The real system update

The debate about the telephone sick note will disappear again, and the real challenge remains: how do we create a health care system that treats more people faster and more efficiently despite a shortage of physicians?

For me the answer is clear: we must finally use physicians’ time sensibly. A modern health care system is not measured by the number of doctor visits but by the quality of the time used. And the fact is: that time can be deployed faster, more cheaply, and better with telemedicine. So instead of debating whether to abolish the telephone sick note — while almost having to be grateful that video consultations are being kept for now — we need to change the overall perspective. These are all plasters, short-term individual measures that do not heal the large wound.

So what?!

The future belongs to care that supports patients intelligently, digitally, and in a human-centred way across the entire course of treatment. That is exactly what I will write about in the coming issues of this newsletter. Because I am convinced: the future of medicine is not decided in the waiting room, but where we have the courage to rethink care.