Commission report on the operation of the Directive 2011/24 on the application of patients’ rights in cross-border healthcare Health and Food Safety Directorate General Healthcare Systems Unit Balázs Lengyel - SANTE. D2

State of play of transposition Patient mobility Information to patients and National Contact Points Cross-border cooperation Conclusions

I . State of play of transposition The transposition deadline for the Directive was 25 October 2013; Transposition check: Completeness check – almost finished 26 infringements launched Compliance check – ongoing Red lines identified: Unreasonably low reimbursement tariffs; Prior authorisation - Lack of transparency or incorrect use of PA; Restriction on reimbursement Unreasonable administrative requirements; Overcharging incoming patients

II. Patient mobility - Prior authorisation PA must be necessary and proportionate, and may not constitute an unjustified obstacle; Article 8(7) of the Directive requires MS to “make publicly available which healthcare is subject to prior authorisation” Assessment of the MS transposition: Majority of MS legislation doesn't specify clearly: overnight stay; and or highly specialised care; Some MS overuses PA; At least 14 MS, it is unclear which treatments exactly are subject to PA;

II. Patient mobility – Reimbursement and administration Reimbursement tariffs 3 MS reimbursement tariffs are based on tariffs for private or non-contracted providers, which is lower than the rate for public or contracted providers; Administrative procedures: 3 MS require patients to demonstrate medically necessity of healthcare; 12 MS require a referral from GP; 5 MS insist that the referral must be from a professional in their country; 4 MS require official translation

II. Patient mobility – patient flows The data collection exercise will be discussed with MS on the next NCP meeting (2 December 2015) Pilot data collection for 2014; 26 MS provided data; MSs have difficulties making distinction between the Directive and the Regulation; Data collection was influenced by late and different transposition dates; Patient flows are low; 17 MS who introduced PA were able to provide data on requested treatments. 560 applications of which 360 were granted. Reimbursement not subject to PA in FI, FR and LU were more than 550 000 (together with the Regulation); Other MS altogether reported almost 40 000 cases of which DK reported 31 000 alone.

III. Information to patients and National Contact Points (1) We asked citizens whether they would be willing to travel to another EU country to receive medical treatment. A third said they would be willing to do so. The main reasons given for this choice were: 1) to receive treatment that is not available in their country; 2) to receive better quality treatment; 3) To receive treatment more quickly.

III. Information to patients and National Contact Points (2) Only 10% of respondents across EU28 were aware of the existence of an NCP in their country. Certainly more can be done and this ties into health literacy concerns. A prominent role for patient organisations, for sure. All MS established NCP however, 2 out of 10 citizens feel that they are informed about their cross-border rights and 10% knew about the existence of NCP

III. Information to patients and National Contact Points (3) Awareness about rights amongst patients is a real issue. A recent Eurobarometer study on patients’ rights carried out last year found that patients face difficulties grappling with their entitlements to healthcare, even at home. On average, only half of the respondents say they feel well informed about their rights to treatment in their home country. And 1 in 5 respondents on average say they feel well informed about their rights to treatment in another EU MS, with huge variations by MS, as seen in the bar chart.

IV. Cross-border cooperation European Reference Networks Networks bringing together specialised centres across Europe helping citizens to better access highly specialized and complex healthcare and to disseminate information and expertise Health Technology Assessment eHealth Cross-border healthcare in border regions Recognition of prescriptions

V. Conclusions 1. Patients mobility for planned healthcare remains low; Late implementation by MS Low awareness of patients' rights on cross-border healthcare Obstacles in MS legislation Extensive use of PA or lack of clarity treatments require PA; Unreasonably low reimbursement tariffs; Burdensome administrative requirements 2. Information to patients more transparency on healthcare services in EU; Directive provides a framework for NCP to improve information to patients; 3. Directive created frameworks for cooperation between MS, ERN, HTA, E-health and cooperation between cross-borders The level of use of planned care is far below the potential levels suggested by the number of people indicating in the Eurobarometer survey;

Thank you for your attention! SANTE. D2 European Commission Health and Food Safety Directorate General Healthcare Systems Unit