1. Tension between the Competence of the Member States to Organize and Finance Health Care and Liberalization Efforts of the European Union Filip Křepelka (krepelka@law.muni.cz) Masarykova univerzita, Brno, CZ

2. Case-law for liberalization and its justification Every expert on EU and health care law heard repeatedly about Kohll / Decker, Smits + Peerbooms, Vanbraekel, Watts, Leichtle etc. etc. Free movement of services applied and related principle of equality applied on reimbursement of health care sought and found abroad. Stability recongized in acceptation of previous consent for reimbursment of hospitalization.

3. Codification of case-law in the directive 2010/24/EU Suprisingly, the member states represented in the Council, the European Parliament as elected supranational body and the European Commission agreed on codification of above-mentioned case-law requiring public reimbursement of health care sought and found abroad. Lengthy text mentions numerous principles, tasks and policies is compromise between liberalization efforts and concerns of the member states. Economic liberalization is overshadowed with rhetorics of rights of patients.

4. Different models of financing recognized in case-law and in the directive? Judgment Smits + Peerbooms confronted with contracted health care providers selected by public health care insurance funds on national territory – understandably, if health care of residents shall be assured. Judgment Watts confronted with national health service – health care provided by provider owned and managed directly by the government (national, regional, local). The European Court of Justice recognizes existence of these models and confirms rights of the member states to operate these models.

5. Pricing of health care Pure reimbursement model: every single health care treatment has its own price. Public health care financing in models of health care providers contracted by public health care insurance funds or similar institutions, however, tend to restrict such payments and resort to lump-sums, motivation payments. Institutions of national health care are also financed with Mixture of various methods tries to curtail expenditures.

6. Inherent preference for reimbursement system Free movement of services applied for reimbursment. Contractation between patient and health care provider including agreement on price and separate reimbursment (albeit often hidden thanks) Prevalent model in France, Belgium and Luxembourg, including the European Union institutions located in these countries. Same amount of money as in home country shall be reimbursed if healthcare sought and found abroad.

7. Urgent health care for tourists + allowed health care sought abroad Coordination of social security for migrants (now regulation 883/2004, former regulation 1408/71) establishes. Prevalent model of public health care financing in six founding member states in the first decades of the European Economic Community was public reimbursement of health care contracted by pacients and health care providers. Money are paid directly to patients similarly as pensions and allowances.

8. Different approach in coordination of health care Regulations for coordination of social security expect interinstitutional reimbursement based on prices of public reimbursment in the member state where the health care provider is active. The member states are need to establish lists of prices for such reimbursment if mixed pricing as applied. Most countries have price lists for calculation of compensation of health care expenditures if injury or illness can be attributed to negligence or intent and person or entity can be made liable for such expenditures. In reality, these prices are often different from real pricing. Rates applied on foreign public insurance funds are lower. Compensation prices can contain punitive damages.

9. Pressure for change for to reimbursment system? The member states are pushed to switch for reimbursment system at least as regards health care sought and found abroad in accordance with the case-law and the directive mentioned. Price lists for many treatments must be established. Average hypothetical domestic prices must be calculated to avoid unnecessary privileging of foreign providers on the one hand and their discrimination which can be questioned with law of the European Union.

10. Minor and complementary reimbursement system