Community action on cross-border healthcare Royal College of Physicians 17 January 2008 Robert Madelin Director General for health and consumer protection European Commission 1/19

Cross-border healthcare: Overview Background Why healthcare abroad? Challenges for cross-border healthcare Starting point for EU action What is not the aim of Community action What we do need to address Impact of Community action Timing 2/19

Background Regulation on Social Security (1971) European health systems more and more linked ECJ rulings on patient mobility ( ….) High Level reflection process on healthcare developments in the EU (2003) High Level Group on Health Services and Medical care (2004) HLG results: –Health Technology Assessment (2005) –Network of centres of reference (2006) –Health Systems Impact Assessment (2007) Removal of health services from the Services Directive (2006) Council conclusions on Common values and principles in EU healthcare systems (2006) Public consultation( ) 3/19

Why healthcare abroad? Patients prefer to be treated as close to home as possible (and only 2,14% of UK- citizens are waiting for care) Sometimes the healthcare patients need is better provided abroad –closer to home (in border regions) –lack of capacity –specialised care 4/19

Challenges for cross-border care Legal uncertainty about patient entitlements Lack of general framework for cross-border healthcare Inefficiency of Member States working independently; e.g. health technology assessment 5/19

Starting point for EU action Subsidiarity Common values Freedom of movement, in this context for patients, not providers 6/19

What is not the aim We do not touch upon the status quo as to Freedom of establishment The Commission will not change the EU’s so-called “Social security regulation” (1408/71) National benefit packages remain national competence The Commission doesn’t seek to create new rights, only to clarify those identified by the European Court of Justice 7/19

What we do need to address The public consultation showed the need for actions in three different fields: –bring clarity about entitlements for cross- border healthcare –reduce gaps/conflicts between Member States’ responsibilities –use the added value of European cooperation on healthcare 8/19

Avoiding gaps/conflicts between Member States’ responsibilities MS of treatment should be responsible for compliance with principles of: –quality and safety of care –information and assistance to patients –redress and compensation for harm –protection of privacy and personal data –equitable treatment of patients from home country and from other Member States Commission current internal thinking: 9/19

Clarity about entitlements for cross- border healthcare Increase choice for patients –greater clarity on the rights of patients seeking care abroad –systematically better information to patients to enable informed choices about their health –fair and quick procedures Allow national responses to prevent any unforeseen trends that could challenge the sustainability of a national healthcare system in one or other sector. Commission current internal thinking: 10/19

Sustainability of healthcare systems patients get repaid only what they would have got at home national planning rules remain applicable… provided that they are not discriminatory or a disguised removal of the Treaty rights safeguard:limits on hospital care abroad when the financial balance of the social security system or the maintenance of a balanced medical and hospital service open to all would be undermined. 11/19

Clarity about entitlements for cross- border healthcare Existing framework for coordination of social security (1408/71) remains in place, for patients: –who need urgent treatment during their stay abroad –who receive a prior authorisation from their home Member State under that system –who must as of right receive prior authorisation where they cannot receive the treatment they need in their home Member State without undue delay 12/19

Why Europe? We see clear European added value through cooperation on healthcare, to: Strengthen cooperation in border regions and through eHealth standards over the WWW Create a European network for sharing efforts on Health Technology Assessment Support Centres of reference Develop tools for Health Systems Impact Assessment Improve medical recognition of prescriptions issued in another MS 13/19

What is the impact of community action? 14/19

The options No further action Soft action (Guidance, recommendations, non binding cooperation, shared data collection) General legal framework A) prior authorization only when necessary to safeguard financial balance of the system B) prior authorization for all hospital care Detailed legal rules 15/19

The figures Option 1Option 2Option 3AOption 3BOption 4 Treatment costs € 1.6 million € 2.2 million € 30.4 million € 3.1 million € 30.4 million Treatment Benefits € 98 million € 135 million € 585 million € 195 million € 585 million Compliance Costs € 500 million € 400 million € 315 million € 300 million € 20 billion Administrative Costs € 100 million € 80 million € 60 million Social benefits 195,000 extra patients receive treatment 270,000 extra patients receive treatment 780,000 extra patients receive treatment 390,000 extra patients receive treatment 780,000 extra patients receive treatment 16/19

The impact for the EU For every patient treated earlier, a gain in EU-wide healthcare efficiency, AND of EU-wide well-being Patient-mobility remains limited (currently 1%); but impact for individual patients is high No significant impact on national budgets. Quality and safety of cross- border care improves More clarity for all about rules for reimbursement of care Patients have better access to the care they need 17/19

What about the poor? Clarity about the rules; no need to pay expensive lawyers to exercise your rights Regulation on Coordination of Social Security remains fully in place – so anyone who needs care abroad, gets it anyway as now Improvement of quality of all healthcare through European cooperation Countries can implement arrangements to avoid patients paying up-front if they wish 18/19

Thank you for your attention 19/19

The myths The UK is vulnerable and unique Wrong! The UK is not the only EU Member State with a National Health Service. Spain, Sweden, Finland, Denmark and Italy also have similar tax funded systems. Moreover, given the reductions in waiting times within the UK in recent years and the high proportion of citizens who consider that their health needs are already met within the UK (95%), there is no reason to expect a substantial impact in the UK. This directive leads to unsustainable health systems Wrong! People prefer to have healthcare as close to home as possible, and our surveys show that the vast majority of patients throughout the EU are content with the care provided by their domestic system – over 90% across the EU as a whole. And even most of those that are not content prefer to have their healthcare within their own country. And finally, there are no additional liabilities for the UK – the UK only has to pay for what the UK would have paid for anyway. 1/5

The myths This directive is a Bolkenstein directive through the back door Wrong! The 'Bolkenstein directive' focussed primarily on the possibility for health service providers and health professionals to provide their services abroad (ie: mobility of providers). This new directive on the application of patients' rights in cross-border healthcare focuses on the rights of patients to receive healthcare abroad (ie: mobility of citizens). This directive gives patients access to foreign private providers Wrong! This right has already been established under the case-law of the European Court of Justice. 2/5

The myths This directive creates a system where patients have to pay the difference between costs abroad and cost at home Wrong! This system has been already created by the Court. It’s up to the patient to decide to get treatment abroad. Under certain circumstances the treatment is only partly reimbursed. If a necessary treatment can’t be provided for without undue delay in their home country, the social security regulation already gives them the right to get treatment abroad and be fully reimbursed. This directive creates a right to receive healthcare abroad Wrong! The right to seek treatment in foreign hospitals was already established by the social security regulation, the internal market Treaty rules and the rulings of the ECJ. 3/5

The myths This directive is only interesting for people with money Wrong! It provides clarity about the rules for all; no need to pay expensive lawyers to exercise your rights. The regulation on Coordination of Social Security remains fully in place – so anyone who needs care abroad, gets it anyway as now. And it is up to national authorities how they implement it – if the UK wishes to put in place arrangements to avoid patients having to pay up front, they can. This directive extends the healthcare entitlements of the patient Wrong! It remains a national responsibility to decide what would be reimbursed and what would not be reimbursed and under which conditions. 4/5

The myths This directive makes it easier for doctors to practice abroad Wrong! This new directive focuses on the rights of patients to receive healthcare abroad (ie: mobility of citizens) and not on doctors practicing abroad; those rules remain as they are now. 5/5