EU Cross-Border Care Directive
from the Primary Care perspective
Results of a simulation
Rita Baeten
Gothenburg, 3 September 2012
Overview of the presentation
1. Why a Directive?
2. What is the Directive on the application of patients’
rights in cross-border healthcare about?
3. A simulation on the Directive : forecasting potential
issues
4. Relevance from the primary care perspective
and conclusions
Directive on the application of Patients’
rights in Cross-Border Healthcare
WHY?
Court of Justice of the EU (CJEU)
• Health care provision is an economic activity
• EC Treaty provisions on the free movement of
services apply
• No discrimination of providers abroad
• Passive free movement: consumer goes to the
provider (=patient mobility)
• Care abroad to be reimbursed by the statutory
healthcare payers
Reimbursement of planned care
in another Member State
CJEU: Free movement
• Prior authorisation only
justified for hospital care
• All healthcare providers
qualify
• Reimbursement level and
conditions of MS where
socially insured
• Up front payment by
patient
Regulation 883/04 (E112)
• Prior authorisation
• Only providers providing
statutory care
• Reimbursement level and
conditions of the MS of
treatment
• Third party payment
system applies
=>legal uncertainty
– Tariffs, selection of providers, conditions
– Quality of care, information, ...
– Regulatory powers of health authorities
Policy reaction
1998: First Court cases (Kohll and Decker)
2004: High level group on health services and medical care
– Cooperation between Member states
– Addressing practical issues
2004: Proposal for a Directive on Services in the internal market
– Codification of CJEU rulings on reimbursement of care
– Freedom of establishment principles applied to healthcare
2006: Exclusion of healthcare from the services Directive
2008: Proposal for a Directive cross-border healthcare
– Codification of the case law on reimbursement of care
abroad
– Proposed in 2008, adopted in 2011,
– To be implemented by October 2013
Directive on the application of patients’
rights in cross-border healthcare
WHAT?
1. Rules on reimbursement of care provided in another
Member State (MS)
2. Measures ensuring proper conditions for receiving
care abroad (quality of care, information, ..)
3. Co-operation between MS
Rules on reimbursement
• Reimbursement levels and conditions of MS of
affiliation
• Regulation 883/04 on the coordination of social
security systems has priority
• Prior authorisation
– Allowed for hospital care and highly specialised care
• If subject to planning
– Cannot be refused when care cannot be provided
domestically with undue delay
Responsibilities of MS of
treatment
• Quality and Safety standards
• Information on availability and prices to be
provided by providers
• Systems for complaints, redress, professional
liability
• Remote access to or copy of medical record
Cooperation between MS
•
•
•
•
Basic duty of cooperation and mutual assistance
Exchange between national contact points
Agreements in border regions
Specific areas:
–
–
–
–
Mutual recognition of medical prescription
European reference networks of centres of excellence
ICT and e-health
Health Technology Assessment
Simulation on the Directive
24 November 2011
Objectives
• To understand the likely future impact of the
Directive in practice
• Forecast potential issues
• Insights on potential bottlenecks and different
ways of resolving them
• Focus on reimbursement issues
The Simulation: Concept
• 3 concrete cases
– Including key issues
– Specific questions for each stakeholder group
• 37 participants from 6 EU countries
– Belgium, France, Germany, The Netherlands, Luxembourg,
Spain
• 5 stakeholder groups
–
–
–
–
Patients
Statutory payers (mainly health insurers) (2X)
Public authorities
Healthcare Providers
The Simulation: Results
• Consensus on key issues
• But also important challenges
A selection…
Results
Conditions for reimbursement
• Statutory payers and public authorities:
– Impose same conditions as for care provided
domestically
• Healthcare providers:
– Would not adapt treatment procedures to the
requirements of foreign insurers
=>Patients risk not being reimbursed
Results
Tariffs and supplements
• Providers:
Would charge private tariffs (not the
“social insurance” tariffs)
• Payers:
Some would limit payments to the social
insurance tariffs of the MS of treatment
Results
Invoices
• How can payers know what care has
exactly been provided?
– Burden of proof lies with the patient
– Some providers are willing to adapt
invoices, against payment
Results
Prior authorisation
• Request it may become the general
rule
– Patients: “to be on the safe side”
– Payers: To specify reimbursement
Results
Information on treatment
• Who should provide information on
treatment options and quality and
safety?
– Patients: (treating and referring) doctor
– Providers: National contact points
– Who is accountable for provided
information?
Results
Language and translation
• Invoices, medical record, treatment
options
• Who has to pay: Patient
• Who is accountable ?
Results
Domestic impact
• Impact of European Reference Networks
– Pressure to reimburse care with an EU label
• Transparency :
– On tariffs, invoices, reimbursement level
• Information
– on quality, prices
Relevant issues for primary care
Patients can go abroad for primary care
• No prior authorisation for ambulatory care
• Some mobility in border regions
• More provider choice, including non contracted providers
abroad
• Different invoices
• Different prices
• INN prescribing of medicines
Relevant issues for primary care
Referring patients abroad
• Mainly for ambulatory care or in case of domestic waiting
lists
• Establishing contacts with providers
• Transfer of medical record (and language?)
• Differences in procedures, different guidelines,
pharmaceuticals
• Reimbursement conditions and levels to be taken into
account
• GP gatekeeper system potentially challenged
• Information to patients:
–
Differences in treatment, provider choice, costs
Conclusions
• Burden for patients under the Directive is very high
• No important movements to be expected
– When long waiting times
– In border regions
– For highly specialised care
• Differences between health systems to be taken into
account
• Domestic impact
– Information on quality,
– Transparency in prices,…
… And much more:
Jelfs, E. and Baeten, R. Simulation on
the EU Cross-Border Care Directive,
Final Report, OSE, EHMA, AIM, 2012
http://www.ose.be/files/publication/2012/C
rossBorderHealthcareSimulation_FinalRe
p_09052012.pdf