1. Association Internationale de la Mutualité Europe in health: the impact of ECJ decisions on healthcare systems Willy Palm AIM Director Palma de Mallorca, 15 June 2004

2. Association Internationale de la Mutualité (AIM) (www.aim-mutual.org) Access to quality health care Solidarity Selfgovernance Social profit

3. Compulsory health protection in the European Union (EU15) D NL Income ceiling AB L no income ceiling social insurance DK IE I SWFIN national health service access to health care E P UKF Implication of mutual health funds in statutory protection categorialuniversal GR

4. Voluntary protection in the EU (15) Statutory Voluntary AB FL no income ceiling D NL income ceiling social insurance DK IE E PI GRUK SWFIN universal national health service access to health care categorial Implication of mutual health funds in voluntary protection SUBSTITUTIVE COMPLEMENTARY SUPPLEMENTARY

5. Health systems and EU law Public health Health care Social security

6. FREE MOVEMENT Health systems and EU law Public health Health care Social security

7. FREE MOVEMENT Health systems and EU law Public health Health care Social security Social security coordination

8. Insured person identity details Application specific data Card related details Another piece of Europe in your pocket A health insurance card which will, on top of all other objectives, foster intra-EU mobility

9. FREE MOVEMENT Health systems and EU law Public health Health care Social security Free settlement of healthcare providers Free movement of medical goods limitations justified on grounds of public policy, public security or public health

10. Article 152 EC Treaty 1. A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities. Community action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health. Such action shall cover the fight against the major health scourges, by promoting research into their causes, their transmission and their prevention, as well as health information and education. (…) 5. Community action in the field of public health shall fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care. In particular, measures referred to in paragraph 4(a) shall not affect national provisions on the donation or medical use of organs and blood.

11. Association Internationale de la Mutualité Basic principles of the ECJ rulings Social security and health care are competence of Member States but it does not preclude respecting Community law Free movement of goods and services applies to health care, regardless of the type of care (in- or outpatient) and the type of coverage (reimbursement – benefits in kind) Prior authorisation is an obstacle to free movement Can be justified to: 1) Preserve the financial equilibrium of the social security system 2) Maintain a balanced medical and hospital service and accessible to all 3) Maintain medical capacity and expertise on the national territory, essential for public health As far as It is necessary and proportional The criteria used are objective and non discriminatory

12. Patient mobility Prior authorisation is justified: importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history Prior authorisation is not justified: no spectacular increase of cross- border mobility to be expected Cover remains subject to levels and conditions as defined by the home state Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria) in-patient care Smits-Peerbooms Van Riet out-patient care Kohll-Decker Müller-Fauré

13. Patient mobility Prior authorisation is justified: importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history Prior authorisation is not justified: no spectacular increase of cross- border mobility to be expected Cover remains subject to levels and conditions as defined by the home state Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria) in-patient care Smits-Peerbooms Van Riet out-patient care Kohll-Decker Müller-Fauré How to distinguish?

14. Patient mobility Prior authorisation is justified: importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history Prior authorisation is not justified: no spectacular increase of cross- border mobility to be expected Cover remains subject to levels and conditions as defined by the home state Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria) in-patient care Smits-Peerbooms Van Riet out-patient care Kohll-Decker Müller-Fauré Should I wait or should I go?

15. Patient mobility Prior authorisation is justified: importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history Prior authorisation is not justified: no spectacular increase of cross- border mobility to be expected Cover remains subject to levels and conditions as defined by the home state Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria) in-patient care Smits-Peerbooms Van Riet out-patient care Kohll-Decker Müller-Fauré How solid is this justification ground?

16. Patient mobility Prior authorisation is justified: importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history Prior authorisation is not justified: no spectacular increase of cross- border mobility to be expected Cover remains subject to levels and conditions as defined by the home state Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria) in-patient care Smits-Peerbooms Van Riet out-patient care Kohll-Decker Müller-Fauré How low can we go?

17. Watts case (UK) Mrs. Watts (72) waiting for an urgent hip replacement surgery by the NHS Oct. 2002: classified as routine case – consultants waiting lists is approx. 1 year Patients PCT: undue delay > NHS plan targets = 12 months Feb. 2003: Mrs. Watts reprioritised as a soon case (3-4 months) because of deterioration of her clinical condition Operation performed in France on 7 March 2003 Referral to ECJ: Reimbursement for costs incurred

18. Association Internationale de la Mutualité Increased impact from EU economic law Health care is economic but obstacles may be justified by reasons of general interest (Kohll-Decker & co) Social security is non economic but social security institutions can be seen as enterprises (Poucet-Pistre, Höfner- Elser) Purchasing of health care must observe public procurement rules ( Tögel) Competition rules may apply unless they obstruct tasks of general (economic) interest (art. 86.2 ECT)

19. Commission/France (C-496/01) Clinical laboratories Administrative autorisation: requirement of business seat in France Refusal of reimbursement of services provided by foreign laboratories Appreciation of the Court: contrary to the principle of free service provision Conditions imposed by France are not justified by the objectif of public health protection

20. AOK e.a./Ichthyol-Gesellschaft Cordes Sickness funds are no enterprises Participating to management of social security system = an exclusively social function, which is founded on the principle of national solidarity and is entirely non- profit-making. No influence on benefits Solidargemeinschaft: risk structure compensation Competition element (premiums) serves the specific goal of good management of social security determining the ceilings for certain medicines = not economic Social security management task imposed by law No proper interest

21. High level reflection process on patient mobility and EU healthcare developments (2003) Develop a shared European vision on how EU can contribute to national health policy objectives More cooperation to better use healthcare resources Sharing information on health care High Level Group on health service and medical care

22. Conclusions Indirect impact of EU integration How to balance (national) social and public health objectives against (EU) internal market principles? Need for a genuine (integrated) health policy at EU level Communication on social and health services of general interest (2005)