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

Mira Hartmann, Baptiste Haon, Lise Rochaix (), Jonas Schreyögg, Lasse Falk and Esra Eren Bayindir
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Mira Hartmann: Institut d'Études Politiques [IEP] - Paris, PSE - Paris School of Economics - UP1 - Université Paris 1 Panthéon-Sorbonne - ENS-PSL - École normale supérieure - Paris - PSL - Université Paris Sciences et Lettres - EHESS - École des hautes études en sciences sociales - CNRS - Centre National de la Recherche Scientifique - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement - ENPC - École nationale des ponts et chaussées - IP Paris - Institut Polytechnique de Paris
Baptiste Haon: GATE Lyon Saint-Étienne - Groupe d'Analyse et de Théorie Economique Lyon - Saint-Etienne - UL2 - Université Lumière - Lyon 2 - UJM - Université Jean Monnet - Saint-Étienne - UJM EPE - Université Jean Monnet (EPSCPE) - EM - EMLyon Business School - CNRS - Centre National de la Recherche Scientifique, PSE - Paris School of Economics - UP1 - Université Paris 1 Panthéon-Sorbonne - ENS-PSL - École normale supérieure - Paris - PSL - Université Paris Sciences et Lettres - EHESS - École des hautes études en sciences sociales - CNRS - Centre National de la Recherche Scientifique - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement - ENPC - École nationale des ponts et chaussées - IP Paris - Institut Polytechnique de Paris
Lise Rochaix: PSE - Paris School of Economics - UP1 - Université Paris 1 Panthéon-Sorbonne - ENS-PSL - École normale supérieure - Paris - PSL - Université Paris Sciences et Lettres - EHESS - École des hautes études en sciences sociales - CNRS - Centre National de la Recherche Scientifique - INRAE - Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement - ENPC - École nationale des ponts et chaussées - IP Paris - Institut Polytechnique de Paris
Jonas Schreyögg: UHH - Universität Hamburg = University of Hamburg
Lasse Falk: UHH - Universität Hamburg = University of Hamburg
Esra Eren Bayindir: UHH - Universität Hamburg = University of Hamburg

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Abstract: 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.

Date: 2026
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Published in European Journal of Health Economics, In press, ⟨10.1007/s10198-026-01923-6⟩

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Persistent link: https://EconPapers.repec.org/RePEc:hal:pseptp:halshs-05845440

DOI: 10.1007/s10198-026-01923-6

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