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Tomas Aubell, Cosmea Pflege on building a sustainable home care group in Germany

Germany’s home-care market is highly fragmented. Although an ageing population continues to support long-term demand, providers have faced pressure from rising wages, reimbursement reforms and affordability constraints.

HBI spoke with Tomas Aubell, CEO of Cosmea Pflege, a German network of ambulatory care services, about the company’s approach to acquisitions, integration and the challenges shaping the future of home care in Germany.

Cosmea provides home-based care services including nursing, personal care, day care, housekeeping support and inclusion services for children. The company operates around 25 care units across six German federal states.

The company began acquiring care units in 2019 before deliberately slowing its acquisition programme for several years to focus on integration and strengthening its operating model.

“In the meantime, we ended up repaying all our debts. We’ve now become more of a ‘boring’ small enterprise — very little financial debt, highly cash-positive, and with organic growth across all care units,” Aubell told HBI.

Home care also proved to be a relatively accessible market compared with other healthcare segments.

“In a lot of other segments, purchase prices were very high — we were still in the post-boom before COVID, where multiples had exploded,” he says. “For some reason, home care was never a target of investor-led buyouts, because you don’t buy hard assets — you just buy people. That’s much tougher to manage.”

Cosmea has since grown to annual revenue of almost €40 million.

Cosmea’s approach to M&A

 Germany’s home-care market comprises around 15,000 providers. Aubell estimates Cosmea’s national market share at roughly 0.1%, leaving significant scope for consolidation.

“I don’t think our task now is to be everywhere, but rather to become stronger where we already are – to maybe reach 10% market share in our sub-regions,” Aubell tells HBI.

The company prioritises acquisitions close to its existing operations, arguing that regional density creates far greater synergies than expanding into new territories.

“It’s a lot of hassle to buy something far away.”

Cosmea targets small to mid-sized care providers generating €1–3 million in annual revenue—large enough to have professional structures but small enough to integrate efficiently. The company plans around €10 million of acquisitions this year, although Aubell says the limiting factor is integration capacity rather than capital.

The business focuses on three priorities: care quality, staff retention and regulatory compliance.

“Across Europe, and increasingly worldwide, populations are ageing and it’s getting harder to win and retain employees. So, when you build a group, you have to become a place where people actively want to work,” he says.

“It has forced us, over the years, to learn how to handle things in a cost-efficient way. Take occupational safety or data protection: the real question is how you stay compliant, while still running the business efficiently.”

For now, Cosmea is prioritising growth within Germany rather than international expansion, citing the complexity of operating across different federal states with varying regulations, pricing systems and salary structures.

“We don’t yet have the scale to justify that complexity — we’d rather go deeper where we are.”

 Centralisation and standardisation

Centralising administrative functions has been a key part of Cosmea’s operating model. Finance, HR, IT, recruitment, bookkeeping, legal reporting and marketing are managed centrally rather than within individual care units.

According to Aubell, bringing these functions in-house also avoids the VAT costs associated with outsourcing professional services.

“We’re much better off doing these services ourselves. We’ve built systems around exactly what we need.”

Digital workflows automate invoice approvals, payments and reporting, allowing a lean central organisation to support multiple legal entities. Employees are also encouraged to broaden their responsibilities over time rather than remain in narrowly defined administrative roles.

“We train people on the working processes by having one software – the software dictates, in a service-capital model, how you have to work.”

“People who started with simple bookkeeping now help prepare annual reports, manage collections and take responsibility for several legal entities.”

Every acquired business is migrated onto Cosmea’s operating platform, software and brand.

“We tell people before they sell to us that they’ll switch to our systems. We have to standardise certain things if we want cost control, quality and transparency.”

The company also continues to digitise its back office, although Aubell sees automation and AI as tools for reducing administrative work rather than replacing caregivers.

“Everything that helps our people spend less time behind a desk and more time with patients is valuable.”

Regulation a key challenge

Despite favourable demographics, Aubell believes recent reimbursement changes have made the German home-care market significantly harder to navigate. Providers received higher reimbursement to offset sharp wage increases, but many patients did not see equivalent increases in insurance coverage.

“The underlying need for care has increased, but many people simply can’t access the same volume of services.”

As a result, he expects steady rather than rapid growth.

“People often talk about huge demographic growth, but I think we’ll see low single-digit growth, driven by a combination of modest volume increases and inflation.”

Despite these challenges, Aubell remains optimistic about the long-term outlook. He argues that the fundamental demand drivers remain intact and that the key opportunity lies in consolidating Germany’s fragmented home-care market. However, he stresses that successful consolidation requires more than acquisitions, warning that investor-led portfolios lacking a shared culture, clear operating model and strong leadership will struggle to maintain quality over the long term.

We would welcome your thoughts on this story. Email your views to Hemani Vipul Sheth or call 0207 183 3779.