More people are crossing borders for medical treatment. But is cross-border health care a good thing ? Willy Palm of Association Internationale de la Mutualité (AIM) addresses this question and describes the recent European Court of Justice cases that have made so-called "health tourism" more accessible.
Cross-border mobility of patients has become a very topical issue. Successive rulings of the European Court of Justice in the cases Kohll and Decker, and more recently in Smits-Peerbooms, have raised the expectations of patients for increased possibilities of medical treatment abroad. The rulings mean that this treatment abroad will be paid for by the patient’s own national health protection system.
The growing attention given to crossing a border for health care is an indicator of important developments affecting the health sector. Whereas for many years, health services developed in the relatively isolated context of national policy, the health sector is increasingly undergoing the influence of "internationalisation" and market integration at European level.
Restricted national budgets
National authorities are faced with political unwillingness to invest more in health care because of fears of compromising national competitiveness. At the same time, rising health care costs create problems at the national level with regard to accessibility, quality and affordability of health care delivery. Cost containment policies, launched by national governments to control public budgets, have shifted part of the costs to households. European social health insurance systems have introduced growth rate limits for public expenditure, increased co-payments, postponed cover for new techniques or the introduction of new drugs, and in some cases the insurance package itself has even been reduced. This is the case for dental care and physiotherapy coverage in the Netherlands, for example.
Underfunding of public health care has created quality problems and waiting lists. It has forced people to seek care in the private sector. Furthermore, the increasing shortages of skilled health professionals, which are occurring in several Member States, are adding to an already difficult situation. The prospects of an ageing society with increasing medical needs, especially in the field of long-term care, as well as ever-evolving medical science and technology making available new but costly treatments, do not suggest any future easing of the funding problems of national health systems.
Greater demand for "health tourism"
Even if people generally prefer to seek health care near their homes, the new combination of constraints and opportunities may encourage them to consider "health tourism". People are travelling more, and have more information about better or more immediate treatment alternatives available in other Member States. The information is provided either through the media, the internet or via more internationally-oriented health care providers*. The medical industry itself is keen to build on this new trend in well-informed health consumers. The rapid introduction of a new medical technology in one Member State would tend to increase pressure on other Member States. Furthermore, growing medical specialisation involving very costly clinical interventions is likely to result in the progressive creation of international centres of excellence, attracting patients from all over Europe.
Europeans’ fundamental right to health care was restated in the "Charter of fundamental rights of the European Union" in Nice on 7 December 2000. But national states are becoming less capable of delivering on this right. European citizens seem willing to try and guarantee this right for themselves through the European health care market. On this, the European Court of Justice is giving them a helping hand.
Impact of court rulings
Contrary to what might seem to be the case, the rulings of the Court of Justice were not primarily focused on granting European citizens the right to patients’ mobility at the expense of national health care budgets. However, they are inevitably seen this way because of the fierce and defensive political reactions they have provoked.
In the case of Mr Kohll and Mr Decker, both Luxembourg citizens, the European Court of Justice (ECJ) reviewed the rules on access to health care abroad in the light of the free movement of medical goods and services. Kohll and Decker wanted to be reimbursed for orthodontic treatment and the purchase of spectacles delivered by providers established outside territory. In its seminal judgements, the Court considered that by demanding prior authorisation for the reimbursement (on the basis of Luxembourg tariffs), the Luxembourg statutory health insurance rules had created an unjustified impediment to the free movement of goods and services within the European Union.
Although the Court confirmed that Community law does not detract from the power of the Member States to organise their own social security systems, it made clear that they must comply with Community law when exercising that power.
In the Smits-Peerbooms judgement, the Court confirmed that all medical care, either in-patient or out-patient, falls within the scope of free movement of the provision of services throughout the EU. This is not altered by the fact that the treatment service is not purchased directly but provided in kind by the Dutch sickness fund through contracted providers.
However, the Court also held that the condition of prior authorisation for hospital care abroad could be justified as a necessary and reasonable measure for guaranteeing a rationalised, stable, balanced and accessible supply of hospital services through planning and selective contracting, provided the applied authorisation criteria were objective and non-discriminatory vis-à-vis providers established in another Member State. But in establishing these criteria, the Dutch government has to take into account the position of international - rather than Dutch - medical science when defining the scope of services covered by the Dutch health insurance. Furthermore, Dutch non-contracted providers should not be treated differently from their foreign colleagues.
Whereas Member States generally apply very restrictive policies in terms of authorising health care abroad, the European Court of Justice forces them to review their position. This could be considered as a positive outcome. The incentive to develop a more proactive policy concerning cross-border access could eventually benefit patients. This might happen either through an opening up of national contracting systems or by the integration of foreign supply into national health care planning and procurement. For example, European hospital centres of excellence could constitute not only a more cost-effective but also a quality-effective way of ensuring highly specialised treatment to the whole EU population.
But the rulings have also produced some problems. First, since the judgements are not interpreted in the same way in all Member States, the new situation could result in inconsistent practices, and administrative and legal uncertainty. It could also lead to unequal treatment among Member States or even between citizens in one country. Confusion about the procedure for coverage of health care abroad has increased.
The Vanbraekel ruling has complicated the situation still further. Previously, it was the E112 system that afforded Europeans specialised treatments and hospital care abroad if authorisation had been agreed in advance. If consent was given, the patient would be reimbursed on the basis of the state tariffs of the country providing the treatment. The Vanbraekel ruling integrated the Kohll & Decker procedure into the E112 procedure. Since Kohll & Decker is based on the free movement of goods and services, prior authorisation is no longer required and rather than reimbursement necessarily being based on the rate of the state providing the care, the home state tariffs apply if they are higher than the ones normally applicable in the providing state.
Immediately after the rulings, rather over-enthusiastic press coverage in some Member State led to false expectations among patients. Despite the benefits, the Court rulings have deprived patients of some of the guarantees they enjoyed under the E112 procedure. For example, a patient seeking treatment abroad will now be obliged to make an advance payment on treatment costs, and the reimbursement rate will not relate to the actual expenditure incurred.
Need for information
It is therefore essential that access to health care abroad should be accompanied by correct and precise information about the price and costs involved in the treatment, the extent of social security coverage, the quality of care, and the medical competence and practices that the patient can expect. It is difficult to speak of free choice if the patient does not have a clear, accurate and prior view of the treatment available, the costs involved, and the level of reimbursement .
Complete deregulation of access to health care and free movement of patients throughout the EU is neither a realistic nor a desirable option. A "free market" cannot exist because patient choice will always be limited by language and cultural barriers and by the lack of complete information. New opportunities for health tourism will add to already over-strained health budgets. As stated in the recent Report of the High Level Committee on Health (1), "the Treaty rules governing free movement of goods and services can appear to be rather blunt tools which require careful handling". The implication here is that the possible benefits to individual patients have to be weighed against the search for equitable access to care for all and for a secure local supply of services.
References :
(1) European Commission, Health & Consumer Protection Directorate-General, The internal market and health services, Report of the high level Committee on health, 17 December 2001, 30 p.
* Global Op is a British company helping patients access hospitals and surgeons abroad. Website : www.globalop.co.uk
Info :
Willy Palm, Director
Association Internationale de la Mutualité (AIM)
50 rue d’Arlon
B-1000 Brussels
Belgium
Tel : +32 2 234 57 00, Fax : +32 2 234 57 08
E-mail : aim.secretariat@aim-mutual.org
Website : http://www.aim-mutual.org
