# Too complex, too busy, yet paid the same: why university tertiary hospitals need a new model

## TL;DR

Croatian university tertiary hospitals face unsustainable workloads and underfunding compared to smaller hospitals, leading to physician burnout and migration.

## Contribution

The paper proposes a pilot Workload Index model to adjust hospital reimbursement based on case complexity and academic responsibilities.

## Key findings

- Croatian tertiary hospitals have 3.4 physicians per 1000 inhabitants, below the EU average of 4.1.
- Burnout prevalence among Croatian physicians is 30–50%, with 7% seeking employment abroad in 2021.
- Countries like Germany and Canada use differentiated financing models for tertiary hospitals.

## Abstract

University tertiary hospitals in Croatia carry a disproportionate share of complex care, teaching, and research responsibilities, yet they are reimbursed under the same Diagnosis-Related Group framework as smaller secondary hospitals. This structural misalignment contributes to workforce strain, physician migration, and inefficiencies in patient flow, while challenging long-term system sustainability. This narrative review and policy analysis synthesizes biomedical literature, international policy reports, and national documents published between 2000 and 2024 to examine workforce shortages, burnout, migration patterns, financing models, and the Croatian context. Croatia reports 3.4 physicians per 1000 inhabitants compared with the European Union average of 4.1, while maintaining a highly centralized referral structure. Burnout prevalence among physicians is estimated at 30–50%, and in 2021 approximately 7% of Croatian physicians applied for certificates enabling employment abroad. Germany, France, the United Kingdom, Scandinavian countries, and Canada have introduced differentiated financing mechanisms that compensate tertiary hospitals for case complexity, referral flows, and academic responsibilities. A pilot Workload Index model is proposed to align reimbursement with case mix, teaching load, referral inflow, and occupational risk exposure. Linking financing to measurable workload indicators may support fairer resource allocation, workforce protection, and improved access to complex care within Croatia’s tertiary health services.