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 HealthcareWHY?

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 reaction1998: 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 Directive24 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 ?

ResultsDomestic 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/CrossBorderHealthcareSimulation_FinalRep_09052012.pdf