An historic vote in the European Parliament
on 19 January paves the way for residents to seek health care anywhere in the European Union, expanding rights that will particularly help patients with rare diseases seeking advanced treatments, people living along borders where the nearest hospital is across the line, or those who work in one country but want to get treatment near family members in another country. The directive passed a second reading in the European Parliament in Strasbourg, so the new rules will apply across the EU in about two years' time.
When a hospital stay is required, the directive says health services can request prior authorisation from doctors in the patient's home country. The prior authorisation clause is intended as a safeguard against any unexpected surge in foreign patients. According to a parliament report, "the aim is absolutely not to encourage cross-border healthcare as such, but to ensure its availability, safety and quality".
Health systems are primarily the responsibility of EU member states, but in some cases, as confirmed by several European Court of Justice (ECJ) rulings since 1998, EU citizens may seek health care in other member states, with the cost covered by their own health systems. This can occur in instances where healthcare is better provided in another member state, for example, for rare conditions or specialised treatment. It may also be the case in border regions, where the nearest appropriate hospital may be in another European country.
Health services were excluded from the general Services Directive in spring 2006, despite many ECJ rulings that they are an economic activity and that Community law applies to them. To provide clarity and legal certainty on the issue as well as support for co-operation between national health systems, the European Commission
decided to establish a EU framework to ensure cross-border access to healthcare services.
According to the EU executive, the current scale of cross-border mobility amounts to 1% (€10 billion) of overall EU-27 states public health spending (€1,000 billion). And the Commission estimates the cost increase under the new rules will be just €30 million a year.
The European Parliament adopted the cross-border directive in April 2009, but it had been stalled ever since at the European Council, where health ministers have struggled to pass the deal, and where MEPs, health ministers and individual governments all had their own –often highly contrasting views on the eventual shape of the legislation. The Cross-border Health Care Directive is now expected to come into effect in 2013. Exactly when it will come into operation in each country is uncertain, as several countries opposed to the principle and agreed detail are notorious for not implementing EU laws until several years after deadlines (e.g. an EU directive on timeshare holidays has a deadline of February 2011, but Spain will not pass its law until at least late 2012). But while the directive mandates a kind of EU universal health coverage, it is not universally supported. Portugal, Austria, Poland and Romania rejected it in the European Council, and Slovakia abstained.
UK Conservative MEP Marina Yannakoudakis says, ‘’Cross-border health care can be a very useful tool in patient care, giving choice to the patient and taking pressure off national health systems in areas where a backlog exists.” To discourage health tourism, patients will only be reimbursed at home-country rates; so if a treatment costs more in another country the patient will have to pay the difference. There are other safeguards; in cases where the treatment is very expensive or the patient must stay in a hospital, the patient must get prior authorisation from their own national health system. The directive also includes an exemption for long-term care and organ transplantations. Although the United Kingdom supports the proposal, Nigel Farage, leader of the UK Independence Party, says, ‘The rules will turn the UK’s NHS into a bureaucratic nightmare. Extra staff will be needed to chase up getting the money we are owed from countries such as Romania.”
The European Consumers' Organisation (BEUC) is unhappy that bureaucracy (either ingrained or deliberate) will make the theory unworkable in some countries, with delays and form filling stopping patients accessing their rights. Ophelie Spanneut of BEUC says,
“We are bewildered by the time limit. The vague time frame may lead to inequalities between counties and ultimately force health ministries to define what is reasonable before the European Court of Justice. We suggested a simple time limit of a response to a patient request within 15 days, but the final version allows individual countries to "set out reasonable time limits" to reply.” Under the directive, a request can only be refused if the treatment could quickly be obtained in the patient's current country, or if there are doubts about the qualifications of the physician. Each country must establish at least one national contact point for patients to get information about health providers, reimbursement procedures, and when prior authorisation is needed. Patients can choose between public or private doctors. The Standing Committee of European Doctors was disappointed by the lack of information available to patients before treatment and that vulnerable or disabled patients will not receive special consideration. But the group is pleased to see a call for increased international compatibility on health technologies to share patient information, plus more references to data protection.
German MEP Dr. Peter Liese welcomes the agreement, saying it would improve access to treatment for patients and cut hospital waiting lists, but concedes that parliament has been unsuccessful in securing some of its demands during the protracted negotiations with the other EU institutions. These included a clear definition of "undue delay" and the possible grounds under which a member state can refuse a patient's request for treatment abroad. I accept that it is a compromise but it is better to have a compromise than nothing at all. The directive is unlikely to lead to a dramatic increase in cross-border healthcare but will appeal to patients who have spent considerable time on a waiting list or live near the border of another country. I live in Germany, near the border with eastern France so it will be easy for me to go for treatment in Strasbourg. At present, the waiting list for hip replacement in the UK is over 12 months, so a British person waiting for a hip replacement will be able to go for an operation in France and be reimbursed for the bulk of the cost by the NHS in Britain. The directive is long overdue and will profit all patients. It will definitely give patients more rights and is to be welcomed. Patients' rights will be more transparent and easy-accessed across Europe. Waiting lists in countries like the UK and Germany will fall as more patients go to another member state for treatment. I am confident the directive will have a positive impact on healthcare systems in member states with shorter waiting lists and improved quality of medical treatment. As the member state of residence in question has to reimburse the costs that would be incurred for the same treatment in their own country, I expect the responsible authorities will strive to keep the earnings and patients in their own country."
There are many amendments from what the European Council agreed. Ones that stand out are-
* Costs incurred by the individual over and above the level reimbursed by the Member State of affiliation shall be borne solely by the person, unless the Member State of affiliation decides also to reimburse the person for the costs incurred in excess of that level.
* Each country must list and advise the European Commission of healthcare that may be subject to prior authorization.
* A Member State may provide for a system of prior authorisation if the absence of prior authorisation could seriously undermine or be likely to undermine either the financial balance of the Member State's social security system; and/or the planning and rationalisation carried out in the hospital sector to avoid hospital overcapacity, imbalance in the supply of hospital care and logistical and financial wastage, the maintenance of a balanced medical and hospital service open to all, or the maintenance of treatment capacity or medical competence on the territory of the concerned Member State.
* Prior authorisation application systems must be made available at a local/regional level and must be accessible and transparent to patients. The rules for application and refusal of prior authorisation must be public and available in advance of an application so that the application can be made in a fair and transparent way.
For full details of the Second Reading and how it differs from the previous European Council position see here