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<p>As medical innovations become increasingly complex and costly, ensuring equitable access within fiscally constrained health systems is a key policy objective. This study assesses the spatial equity relevance of the Add-on List, a supplementary payment mechanism in the context of Diagnosis-Related Group-Based Financing by examining how regional utilisation patterns of selected high-cost hospital technologies align with equity-relevant structural correlates. The policy is assessed based on its institutional design and the type of technology addressed. A cross-country comparative analysis is conducted between the Add-on List mechanisms in Germany and France. The German model, characterized by intra-budgetary add-on payments, is expected to be associated with less equitable regional utilisation patterns than the extra-budgetary approach adopted in France. Additionally, the Add-on List is expected to be less strongly associated with lower regional inequity for resource-intensive technologies, with the diffusion of specialized healthcare professionals and infrastructure playing a more determinant role. Given differences in institutional objectives and policy logics between German <i>Zusatzentgelte</i> and the French <i>Liste-en-sus</i>, results are interpreted within each national context rather than as a direct effect comparison. Using the Multiple Inequality Index (MII) and applying decomposition analysis at the NUTS 2 level, the study evaluates access disparities for the Stent Retriever, as a resource-intensive technology, and Cetuximab / Panitumumab as a resource-non-intensive technology. Findings are consistent with the interpretation that spatial accessibility correlates are relatively more salient for resource-non-intensive technologies, while infrastructure and specialist diffusion are essential for resource-intensive technologies. We do not identify causal effects of add-on payment design. Findings suggest that more equitable access to resource-non-intensive technologies may be more compatible with the Add-on List context, while complementary investments in infrastructure and specialised human resources may be essential for resource-intensive technologies. Payment mechanisms alone are most likely insufficient to reduce access disparities. </p>

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The add-on list cannot do it all: a comparative economic evaluation of equity impacts in the German and French inpatient care sectors

  • 期刊论文

  • 发表日期：

    2026年4月22日

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  • Mira Hartmann,
  • Baptiste Haon,
  • Lise Rochaix,
  • Jonas Schreyögg,
  • Lasse Falk,
  • Esra Eren Bayindir

摘要

As medical innovations become increasingly complex and costly, ensuring equitable access within fiscally constrained health systems is a key policy objective. This study assesses the spatial equity relevance of the Add-on List, a supplementary payment mechanism in the context of Diagnosis-Related Group-Based Financing by examining how regional utilisation patterns of selected high-cost hospital technologies align with equity-relevant structural correlates. The policy is assessed based on its institutional design and the type of technology addressed. A cross-country comparative analysis is conducted between the Add-on List mechanisms in Germany and France. The German model, characterized by intra-budgetary add-on payments, is expected to be associated with less equitable regional utilisation patterns than the extra-budgetary approach adopted in France. Additionally, the Add-on List is expected to be less strongly associated with lower regional inequity for resource-intensive technologies, with the diffusion of specialized healthcare professionals and infrastructure playing a more determinant role. Given differences in institutional objectives and policy logics between German Zusatzentgelte and the French Liste-en-sus, results are interpreted within each national context rather than as a direct effect comparison. Using the Multiple Inequality Index (MII) and applying decomposition analysis at the NUTS 2 level, the study evaluates access disparities for the Stent Retriever, as a resource-intensive technology, and Cetuximab / Panitumumab as a resource-non-intensive technology. Findings are consistent with the interpretation that spatial accessibility correlates are relatively more salient for resource-non-intensive technologies, while infrastructure and specialist diffusion are essential for resource-intensive technologies. We do not identify causal effects of add-on payment design. Findings suggest that more equitable access to resource-non-intensive technologies may be more compatible with the Add-on List context, while complementary investments in infrastructure and specialised human resources may be essential for resource-intensive technologies. Payment mechanisms alone are most likely insufficient to reduce access disparities.