Non-emergency medical transports between cost pressures and regulation: Why the industry faces a difficult year in 2027

Anyone currently transporting patients by taxi or rental car to dialysis, chemotherapy, or to the hospital looks to 2027 with growing concern. While personnel, energy and vehicle costs continue to rise, the legislator with the GKV Contribution Rate Stabilization Act has set new limits on remuneration increases. The industry fears that the gap between costs and revenues will continue to widen.

How large the challenges really are became evident at the first Action Day of the Association of Patient Transport Services for the Sick and Disabled in North Rhine-Westphalia (vdkbf). Representatives of transport services, taxi and rental-car associations gathered on September 19 in Ahlen to discuss the economic and legal consequences of the reform. At the center were two topics that at first glance have little to do with each other: the new remuneration framework for patient transports and the approval of special agreements in taxi traffic. In fact, according to the tenor of the event, both questions are closely intertwined.

The End of Cost Orientation

The kickoff was made by attorney Dr. Tim Unger with an analysis of the GKV Contribution Rate Stabilization Act, which came into force at the end of July 2026. The reform changes the rules by which health insurance funds and transport companies will negotiate remuneration for patient transport services in the future. Until now, negotiations were generally aligned with the actual costs of a company. The starting point were operating expenses, supplemented by a reasonable entrepreneur's profit. This business principle is now largely replaced by another metric: the so-called wage-sum change rate.

Behind the cumbersome term lies the development of earnings subject to contributions in the statutory social security system. Going forward, this key figure should set the framework for increases in remuneration. For the transport companies, this creates a problem: The development of the wage sum follows different dynamics than the actual costs of a taxi or rental-car operation.

Unger therefore spoke of a departure from the operational reality. Energy prices, insurance premiums, vehicle costs, workshop invoices, or collective-bargaining wage increases did not align with the development of the wage sum. Nevertheless, they are to play a decisive role in the future in determining whether a company can operate economically. The issue becomes particularly evident when looking at the years 2027 to 2029. The legislature has provided for reducing the already relevant change rate in this period by an additional one percentage point. For the year 2027, this yields an allowable remuneration increase of only 3.42 percent.

The Minimum Wage as a Calculation Example

How far this value might be from the actual business reality was shown by Unger using the minimum wage as an example. It rises at the beginning of 2027 from €13.90 to €14.60 per hour. That corresponds to an increase of around five percent.

Since personnel costs in medical transport regularly account for about 65 percent of total costs, the legally prescribed increase in remuneration is already not sufficient, in the lawyer's view, to compensate for the higher wage costs. The calculation he presented yields a remarkable result: Even merely adjusting to the higher minimum wage would require a remuneration increase of around five percent. Further cost increases for fuel, maintenance, insurance, or vehicle purchases are not yet taken into account.

For the companies this means an uncomfortable prospect. They would in the future have to budget remunerations whose growth lags behind the actual cost development. Over several years this could lead to considerable economic pressure.

A possible way out in the law

However, Unger does not see the industry as having no options for action. He referred to an exceptional provision in § 71 SGB V. According to it, the limitation of remuneration development does not apply if the necessary medical care cannot be guaranteed even after exhausting all efficiency reserves. This passage could play a central role in future remuneration negotiations. For it opens up the possibility to deviate from the statutory upper limits if companies can prove that the care would otherwise be endangered.

This argumentation finds support in the jurisprudence of the Federal Social Court. The court already clarified in 2022 that remunerations must not be so low that economic service delivery by a well-organized company becomes fundamentally impossible. For the businesses, this implies a new task. Those who want to demand higher remunerations must be able to document their actual costs in detail. Unger therefore recommended significantly expanding the business administration documentation. Not general demands for higher charges are decisive, but credible evidence of the concrete cost development.

Constitutional questions remain open

Moreover, the jurist also sees constitutional questions. If the statutory remuneration cap leads to economic operation being permanently impossible, interventions in the freedom of occupation under Article 12 of the Basic Law could be under discussion. This remains a legal assessment and not a judicial finding. Nevertheless, the debate shows that the reform could potentially have not only economic but also constitutional consequences.

The second arena: Special agreements in taxi operations

While Dr. Unger illuminated the financing of patient transports, Christian Linz, managing director of the Bavarian Taxi and Rental Car Companies Association, dedicated himself to a second field of conflict: the special agreements under § 51 paragraph 2 of the Passenger Transport Act.

Such agreements allow, under certain conditions, deviations from the regular taxi tariff. Among other things, a specific period, a minimum number of rides, or a minimum turnover are prerequisites. At the same time, the order of the transport market must not be impaired. Linz stressed that this regulation is often underestimated in practice. The crucial question is not only whether a contract is formally permissible. Much more important is what impact it has on the local market.

Munich judges place the market at the center

Therefore, a ruling of the Administrative Court of Munich from April 2026 attracted particular attention. The subject was a special agreement for patient transports in a southern Bavarian district. The court held that the effects of such an agreement on the local transport market must be examined much more thoroughly. In the judges' view, it is not enough to merely examine the formal requirements.

Notably, the reasoning is particularly noteworthy. The court sees the danger of tariff pressure and foreclosure of competition as relevant considerations. Thus, the economic impact of a special agreement comes more into focus.

In addition, the court explicitly distinguished between the "order of the transport market" and the general public transport interests. If this legal view prevails in higher instances, the approval practice for special agreements could change significantly. The proceedings are not yet concluded. An appeal has been filed against the ruling. Industry representatives expect a final clarification at the earliest in two years.