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

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.