In recent years, measures have been taken in Germany to place a stronger focus on quality in the healthcare system. These measures were particularly reinforced by reforms such as the Hospital Structure Act (KHSG) or the establishment of the Institute for Quality Assurance and Transparency in Health Care (IQTiG). Ideas for strengthening the quality of care can also be identified in the context of current reform considerations, which focus on hospital care in particular.

An increased attention to quality issues is not only evident in Germany, but also in numerous other international healthcare systems [1]. However, the effects of a stronger focus on quality and an increase in the quality of care intended by the legislative reforms have not yet been realised sustainably in Germany [2].

An option for promoting quality orientation at the healthcare system level is to strengthen quality competition [3]. This is used in many international healthcare systems to improve the quality of care. Quality competition focuses on quality of service, not on price. The implementation of quality competition is a complex intervention. This is due to several factors: As an example, the concept of quality in healthcare is multifactorial [4] and health is a trust good whose quality is difficult to assess objectively due to the existing information asymmetries [5].

The instruments for strengthening quality competition include, in particular, quality measurement [5], public reporting [6,7], selective contracting [8], and pay for performance [9]. The use of these instruments primarily triggers reciprocal interactions between care providers and payers, such as selective contracting and pay for performance. But interactions between patients and care providers are also caused, e.g. the aim of an informed choice of care providers by patients as a result of public reporting.

Existing empirical evidence shows that the focused instruments are in principle useful for inducing quality competition. Often, they are used in the context of a managed competition approach [10,11]. However, the heterogeneity of the empirical evidence must be considered [12], [13], [14]. Because of this, in the case of quality competitive instruments, the design, the context of use, and an adequate regulatory embedding are crucial. This is particularly important in Germany since it´s a healthcare system based on the principle of solidarity.

This paper aims to provide guidance to health policy decision-makers and other interested stakeholders on quality competition. It presents between stakeholders empirically consented options and proposals on how to further develop quality competition. The investigations focus on outpatient and acute inpatient care in the context of statutory health insurance in Germany.