Crossing borders

2013 will be a significant year for breaking down national barriers and making it easier for patients to seek medical treatment in other EU member states

For European healthcare, 25 October 2013 is a landmark date. It is the deadline by which the member states of the European Union have to put into national law the directive on patients’ rights in cross-border healthcare.

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That legislation is the device that seeks to break down national barriers to healthcare across Europe, making it easier for patients insured in one member state (the state of affiliation) to obtain treatment in another state (the state of treatment) – and, crucially, to get that treatment paid for by the state or insurance company where they are affiliated.

The law imposes obligations on each member state to put in place the necessary infrastructure to play either role: the state that provides the treatment or the state that foots the bill. The member state of affiliation will have to reimburse the insured person, if the treatment received abroad is regarded as reimbursable care in its own national legislation.

If the past practice is any guide, not many people will take advantage of the new law.

The market in cross-border healthcare in Europe is currently around €10 billion, less than 1% of overall healthcare spending. Most people will still want to be treated close to home and family. And for many, going abroad for treatment will remain a costly and complicated proposition, not least because the final version of the legislation did not – as the European Commission had initially proposed – require travel and accommodation costs to be covered.

Not covering such costs was the most obvious way for member states to lessen their obligations. There may be other ways of constraining cross-border treatment. Under the legislation, the member state of affiliation can require that patients get ‘prior authorisation’ before going abroad for treatment. The government can turn down such requests if it believes the other country presents a “safety risk” or that the treatment can be provided at home without an “undue delay”. But given that neither of those terms is precisely defined, those tests may be easy for governments to use to constrain their spending. The Commission will monitor the rejections, but has no power to overrule them.

Side-effects

Nobody really knows how the market might develop. Given the hurdles, patients are unlikely in the short term to flock great distances in large numbers for medical treatment. But the effects of the legislation may be felt more acutely by domestic patients. A side-effect of the directive is that it will force transparency in healthcare on an unprecedented scale.

“This will have a huge impact, not just on people crossing borders but for any EU citizen,” says Johan Hjertqvist of the patients’ campaign group Health Consumer Powerhouse. “Every government will now have to establish a user-friendly single point of information on the internet about patient rights.”

The law requires such information to be made available to those EU citizens who are contemplating treatment across borders. In practice, it will be available to everyone. Hjertqvist says that by requiring more information about the quality of care, the law is going to change fundamentally all healthcare, not just the cross-border versions.

For the first time, patients will be able to compare the offerings from hospitals in their own and other EU countries. They can see where there is a documented risk of hospital infections, for instance, or how experienced the doctors are. In theory, this should drive up quality and safety standards. If patients are given the ability and the incentive to opt out of a poor service, the pressure should grow on governments to improve their systems.

“Having this information provided in a clear and understandable way empowers patients and enables them to make an informed choice,” says Paola Testori Coggi, the Commission’s direct-general for health and consumers.

Greater information will benefit more than just patients. Another major part of the directive is the co-ordination of information between national health systems. The directive instructs member states to co-operate on standards and guidelines on patient safety and quality of healthcare. It contains a mandate for the Commission to define criteria for European ‘reference networks’ and ‘centres of expertise’ – specialists in certain diseases or areas of care. A stakeholder consultation by the Commission on how these reference networks should be developed is ongoing, and will close on 24 January.

Transferring data

The law is also supposed to ease the transfer of patient and medical data between member states. It sets up an eHealth Network to help national authorities to develop electronic health systems, such as patient records, that can be shared between member states. This group has already been set up, and has been tasked with helping to implement the Commission’s ehealth action plan coming out today (see above).

The law also requires the mutual recognition of prescriptions. Technically this is already required, but the Commission estimates that in half of all cases pharmacists refuse to fill a foreign prescription because they can’t understand it.

The directive standardises prescriptions, and the Commission hopes this will increase the success rate to 70%. An implementing directive setting this out was approved by member states last week.

How soon it will be until the full benefits are felt is uncertain. In a report issued last month on member states’ transposition of aspects of the law, the Commission found that few countries were making great progress. Those that are tend to be the ones that are already advanced in healthcare transparency such as the UK, Denmark and the Netherlands.

No member state has yet fully transposed the directive. “To what extent this will really support people who want to inform themselves, that remains to be seen,” says Hjertqvist. “I expect it will be a question of countries’ willingness. The countries that hate the idea of foreigners coming in for care will also be quite rude to their own citizens about providing them with information.”