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The cross-border healthcare directive
The impact of the implementation for
the national healthcare systems
Xavier Brenez
General Manager
National Federation of Independent
Health Insurance Funds
www.mloz.be
2
Title
1. Is cross-border healthcare in Europe
something new?
2. What is the impact of the implementation
for the different stakeholders?
3. What is the result of the implementation
process for the national healthcare
systems?
4. Conclusions
Structure
1. Is cross-border healthcare in
Europe something new?
Xavier Brenez
General Manager
National Federation of Independent
Health Insurance Funds
www.mloz.be
4
Title 1. Is cross-border healthcare in Europe
something new?
No, it’s already a reality:
Regulations 883/2004 and 987/2009 (S2/E112)
Decisions of European Court of Justice in the cases Decker & Kohll, Vanbraekel, …
Cross-border projects between member-states: To facilitate patient mobility
To facilitate collaboration between hospitals
Contracts between foreign actors and national hospitals
And now: the Directive…
5
Title 1. Is cross-border healthcare in Europe
something new?
So long tradition BUT until now:
Increasing complexity
Key role of mutual societies to inform patients
Legal uncertainty for patients
Not all member-states apply European jurisprudence
Lack of data on cross-border healthcare
European Commission: “less of then 1% of public
spending on health care”
No planned cross-border healthcare for social
reasons allowed
F. e. to be close to family
2. What is the impact of the
implementation for the different
stakeholders?
Xavier Brenez
General Manager
National Federation of Independent
Health Insurance Funds
www.mloz.be
7
Title 2. Impact implementation for stakeholders ?
The patient:
Uniform rules:
For procedures for prior authorisation
For procedures for reimbursements
In case of damage or medical error
National contact points for information
No discrimination in tariffs, in public and private
hospitals
Foreign patients benefit same tariffs as inhabitants of
country of treatment!
Possibility to buy medicines and medical
products/devices with prescription form country of origin
8
Title 2. Impact implementation for stakeholders ?
The health insurers:
Information campaign to guide patients through
complexity of rules
New rules for prior authorisation and for reimbursement,
with operational impact (IT, procedures, …)
Legal base to reimburse healthcare by private providers
Collection of data on cross-border healthcare
9
Title 2. Impact implementation for stakeholders ?
The national authorities:
Creation and management of National Contact Points
Make sure healthcare providers provide relevant
information to help individual patients to make an
informed choice
Participation in European network for
eHealth
Health Technology Assessment
Monitoring impact of incoming and outgoing patients
10
Title 2. Impact implementation for stakeholders ?
The providers:
In general:
Provide clear information
Like: the availability, information on quality and safety of the
healthcare, clear invoices, clear information on prices, …
Private providers: billing same tariffs to everybody
Doctors: prescribing differently for purchase of
medicines or medical products devices abroad
Pharmacies: accepting foreign prescriptions
Hospitals: participation in network of references
3. What is the result of the implementation
process for the national healthcare
systems?
Xavier Brenez
General Manager
National Federation of Independent
Health Insurance Funds
www.mloz.be
12
Title Strenghts (1)
More precise definition of procedures on national level
Example 1: maximum delay for treatment of demand for
authorisation
Example 2: provider from other member state can motivate
demand.
Rules also apply to private providers: important impact
on reimbursements
Legal base to reimburse healthcare provided by private
providers
Forbidden to bill higher tariffs to foreigners
Until 25/10: overbilling foreign patients, especially for urgent medical
care in touristic areas
From 25/10 on: same tariffs for foreign and national patients in private
hospitals
13
Title Strenghts (2)
Finally more data on cross-border healthcare
For the first time: fact & figures on European
level
More collaboration between member states
Healthcare systems should profit from network
for eHealth and HTA
14
Title Weaknesses (1)
Complex legal framework
2 legal instruments – 2 possible procedures
Regulation vs directive
Difficult to explain to citizens and difficult to
apply for mutual societies
Some principles of regulation principles of
directive
Absurd situations!
15
Title Example: pensioned person living
in another members state – annexe 3
Belgium Competent country
Spain Country of residence
S1 (E121)
SED - E127
Italy EHIC
S2 (E112)
Reimbursements urgent
medical care – public provider Reimbursements urgent
medical care – private provider
Authorisation directive
16
Title Weaknesses (2)
Most member-states are still busy with the implementation
Big differences between countries
Source of discussion between competent institutions
Transparency of information: Information to be provided by healthcare providers:
Art. 4: …relevant information to help individual patients to make an informed choice, including on treatment options, on the availability, quality and safety of the healthcare they provide in the Member State of treatment and that they also provide clear invoices and clear information on prices, as well as on their authorisation or registration status, their insurance cover or other means of personal or collective protection with regard to professional liability.
Little action to implement this principle…
17
Title Weaknesses (3)
No European document in case of authorisation
Risk of being considered as a private patient
Still no room for social criteria for planned cross-
border healthcare
Reasonable in today’s Europe?
Rare diseases:
Little use has been made of possibilities in directive
Not on agenda
Maybe via reference networks in future?
18
Title Opportunities
On national level: reviewing and modernizing all
existing instructions concerning cross-border
health care
Regulation and directive
Urgent and planned medical care
EHIC and S2
Reimbursement and Authorisation Procedure
Stakeholders: reviewing and optimizing internal
procedures and information to members
Programs, guidelines, correspondence to insured
persons, …
19
Title Threats (1)
Message « No borders for European patients »:
Still a lot of risks: no reimbursement in certain cases:
Medical care doesn’t exist in country of origin
No reimbursement tariff exists in country of origin
Conditions for reimbursements are not fulfilled
Supplementary fees are not reimbursed
Important challenge to inform the general public
Responsibility of mutual societies
20
Title Threats (2)
Financial impact of directive?
In certain members-states (like Croatia): only
reimbursement if public provider
Now also obliged to reimburse if private provider abroad
Will providers be informed properly and on time?
Example: pharmacists about foreign prescriptions
Will private providers respect the principles of the
directive?
Will the overbilling of foreign patients stop?
Support for cooperation at regional and local level:
a bit of a paradox if it serves to avoid the complexity of directive/regulation…
4. Conclusions
Xavier Brenez
General Manager
National Federation of Independent
Health Insurance Funds
www.mloz.be
22
Title Conclusions
More legal security for the citizens?
YES, but financial risks
Coherent legal framework?
Not completely – increasing complexity
Better and more information for citizens?
….to be continued
Impact on national healthcare systems?
In the long run: YES, more transparency
Financial impact: to early to say
Challenges left after 25/10/2013?
YES! Most member-states will be busy with the
implementation in the coming months
