1. EU Cross-Border Care Directive from the Primary Care perspective Results of a simulation Rita Baeten Gothenburg, 3 September 2012

2. Overview of the presentation 1.Why a Directive? 2.What is the Directive on the application of patients’ rights in cross-border healthcare about? 3.A simulation on the Directive : forecasting potential issues 4.Relevance from the primary care perspective and conclusions

3. Directive on the application of Patients’ rights in Cross-Border Healthcare WHY? Court of Justice of the EU (CJEU) Health care provision is an economic activity EC Treaty provisions on the free movement of services apply No discrimination of providers abroad Passive free movement: consumer goes to the provider (=patient mobility) Care abroad to be reimbursed by the statutory healthcare payers

4. Reimbursement of planned care in another Member State CJEU: Free movement Prior authorisation only justified for hospital care All healthcare providers qualify Reimbursement level and conditions of MS where socially insured Up front payment by patient Regulation 883/04 (E112) Prior authorisation Only providers providing statutory care Reimbursement level and conditions of the MS of treatment Third party payment system applies

5. =>legal uncertainty –Tariffs, selection of providers, conditions –Quality of care, information,... –Regulatory powers of health authorities

6. Policy reaction 1998: First Court cases (Kohll and Decker) 2004: High level group on health services and medical care –Cooperation between Member states –Addressing practical issues 2004: Proposal for a Directive on Services in the internal market –Codification of CJEU rulings on reimbursement of care –Freedom of establishment principles applied to healthcare 2006: Exclusion of healthcare from the services Directive 2008: Proposal for a Directive cross-border healthcare –Codification of the case law on reimbursement of care abroad –Proposed in 2008, adopted in 2011, –To be implemented by October 2013

7. Directive on the application of patients’ rights in cross-border healthcare WHAT? 1.Rules on reimbursement of care provided in another Member State (MS) 2.Measures ensuring proper conditions for receiving care abroad (quality of care, information,..) 3.Co-operation between MS

8. Rules on reimbursement Reimbursement levels and conditions of MS of affiliation Regulation 883/04 on the coordination of social security systems has priority Prior authorisation –Allowed for hospital care and highly specialised care If subject to planning –Cannot be refused when care cannot be provided domestically with undue delay

9. Responsibilities of MS of treatment Quality and Safety standards Information on availability and prices to be provided by providers Systems for complaints, redress, professional liability Remote access to or copy of medical record

10. Cooperation between MS Basic duty of cooperation and mutual assistance Exchange between national contact points Agreements in border regions Specific areas: –Mutual recognition of medical prescription –European reference networks of centres of excellence –ICT and e-health –Health Technology Assessment

11. Simulation on the Directive 24 November 2011 Objectives To understand the likely future impact of the Directive in practice Forecast potential issues Insights on potential bottlenecks and different ways of resolving them Focus on reimbursement issues

12. The Simulation: Concept 3 concrete cases –Including key issues –Specific questions for each stakeholder group 37 participants from 6 EU countries –Belgium, France, Germany, The Netherlands, Luxembourg, Spain 5 stakeholder groups –Patients –Statutory payers (mainly health insurers) (2X) –Public authorities –Healthcare Providers

13. The Simulation: Results Consensus on key issues But also important challenges A selection…

14. Results Conditions for reimbursement Statutory payers and public authorities: –Impose same conditions as for care provided domestically Healthcare providers: –Would not adapt treatment procedures to the requirements of foreign insurers =>Patients risk not being reimbursed

15. Results Tariffs and supplements Providers: Would charge private tariffs (not the “social insurance” tariffs) Payers: Some would limit payments to the social insurance tariffs of the MS of treatment

16. Results Invoices How can payers know what care has exactly been provided? –Burden of proof lies with the patient –Some providers are willing to adapt invoices, against payment

17. Results Prior authorisation Request it may become the general rule –Patients: “to be on the safe side” –Payers: To specify reimbursement

18. Results Information on treatment Who should provide information on treatment options and quality and safety? –Patients: (treating and referring) doctor –Providers: National contact points –Who is accountable for provided information?

19. Results Language and translation Invoices, medical record, treatment options Who has to pay: Patient Who is accountable ?

20. Results Domestic impact Impact of European Reference Networks –Pressure to reimburse care with an EU label Transparency : –On tariffs, invoices, reimbursement level Information –on quality, prices

21. Relevant issues for primary care Patients can go abroad for primary care No prior authorisation for ambulatory care Some mobility in border regions More provider choice, including non contracted providers abroad Different invoices Different prices INN prescribing of medicines

22. Relevant issues for primary care Referring patients abroad Mainly for ambulatory care or in case of domestic waiting lists Establishing contacts with providers Transfer of medical record (and language?) Differences in procedures, different guidelines, pharmaceuticals Reimbursement conditions and levels to be taken into account GP gatekeeper system potentially challenged Information to patients: –Differences in treatment, provider choice, costs

23. Conclusions Burden for patients under the Directive is very high No important movements to be expected –When long waiting times –In border regions –For highly specialised care Differences between health systems to be taken into account Domestic impact –Information on quality, –Transparency in prices,…

24. … And much more: Jelfs, E. and Baeten, R. Simulation on the EU Cross-Border Care Directive, Final Report, OSE, EHMA, AIM, 2012 http://www.ose.be/files/publication/2012/C rossBorderHealthcareSimulation_FinalRe p_09052012.pdf