Despite increasing levels of awareness about rights to cross-border medical treatment under the EU Directive, European patients are still not travelling in large numbers to other Member States for healthcare. Ian Youngman, healthcare and insurance industry analyst, examines the latest official report from the European Commission.
The latest report on the impact of the EU Directive on cross-border healthcare was published this September. Coming from the European Commission to the European Parliament and the European Council, it has the snappy title of ‘Commission report on the operation of Directive 2011/24/EU on the application of patients’ rights in cross-border healthcare’.
The report finds that cross-border patient mobility within the EU shows only a slight upwards trend over the last three years. This may be due partly to the gradual improvements in the information available to citizens regarding the Directive and a better awareness of patient rights as a possible consequence. After five years since the launch of the Directive, the report concludes that cross-border patient flows are showing a ‘stable’ pattern, mostly driven by geographical or cultural proximity.
More specifically the report found:
No major budgetary impact on national health systems
Since the adoption of the Directive, no further European court rulings were considered a requirement to ensure these rights. However patient mobility and its financial dimensions within the EU remain relatively low, and the Directive has not resulted in a major budgetary impact on the sustainability of the national health systems.
The report shows that patients are, however, increasingly aware of their rights under the Directive. In the last reporting period (2015-2018), the National Contact Points (NCPs) have been trained and supported to carry out proactive day-to-day interaction with citizens. The quality of information through dedicated national websites and other means has also improved.
The Directive has created a framework for cooperation between health systems, especially in areas of ‘Health Technology Assessment’ and eHealth. In addition, 24 thematic European Reference Networks (ERNs) for rare, complex and rare-prevalence diseases have been established, bringing together more than 900 highly specialised healthcare units in 300 plus hospitals across the EU. There are also more than 200 virtual panels on patient cases operating under the ERNs.
Cross-border patient mobility barriers have been removed
In terms of patient numbers, cross-border patient mobility within the EU has slightly increased in the last three years, as citizens have more access to information.
Six EU Member States (plus Norway) have no ‘prior authorisation’ system for choosing and reimbursing for healthcare received in another Member State. This has given patients from these countries greater freedom to choose, so reducing the administrative burden.
Other countries had in place authorisation barriers that can reduce the number of patients taking advantage of the Directive.
Some Member States for example required patients to provide a certified translation of their medical documentation to obtain their reimbursement. This sworn translation can represent a disproportionate obstacle to free movement of services, as in several countries the cost of the translation can be higher than the reimbursement of the outpatient service.
One Member State introduced a high minimum threshold (€15) for reimbursement – an amount that roughly equalled average reimbursement tariffs for outpatient healthcare in that Member State.
Another Member State required a certificate from the foreign NCP attesting that the healthcare to be provided within its territory would be compliant with the necessary safety and quality standards in place. A written confirmation was also required from the healthcare provider on its availability to grant the requested healthcare in the period indicated by the applicant for prior authorisation.
All three barriers above have now been removed.
Requests for reimbursement remain generally low
In accordance with Article 20 of the Directive, Member States report on an annual basis on their patient mobility under Directive 2011/24/EU. These reports cover healthcare with or without prior authorisation, requests for information about healthcare, healthcare provided, reimbursements made and reasons for which healthcare was reimbursed, or not.
The report gives a high-level overview of the data received in 2015, 2016 and 2017. Some data, however, includes cases of healthcare reimbursed under the social security coordination rules. This is because not all Member States are able to maintain a strict separation between the data on reimbursements for healthcare and reimbursements under bilateral cross-border agreements.
Prior authorisations
Data on prior authorisation was received in 2015 from 23 Member States and Norway; in 2016, from all 28 Member States plus Norway and Iceland; and in 2017 from 26 Member States. The aggregated data reported by Member States on the number of requests in 2015, 2016 and 2017 show that such requests remain generally low, although this is rising. A steady increase has occurred since 2015, with more than twice as many requests being made and authorised in 2017 as in 2015 across the Member States.
Authorisations
In 2015, Member States issued 55,000 authorisations for planned treatment abroad.
Requests not subject to prior authorisations
The total number of requests for reimbursement for treatment not subject to prior authorisation was relatively low in all three years as a share of total patient care and has remained very steady. In 2015, the total number of requests granted was 180,704 across 19 Member States plus Norway; in 2016, the number of requests granted over 22 Member States amounted to 209,568; and in 2017 the total number of requests granted was 194,292 across 20 Member States. Adjusting for the number of countries reporting data, this shows that EU citizens’ use of the rights granted under the Directive had no significant growth or reduction over the three years of the reporting period.
Enquiries
In 2017 a total of 74,589 enquiries to NCPs were received across 22 Member States and Norway, compared to 2016 when a total of 69,723 enquires were counted across 28 Member States and Norway, and in 2015 when a total of 59,558 requests were received in 19 Member States.
Cross-border patient flows – mostly from France to neighbouring countries
Looking at flows of patients travelling for healthcare after receiving prior authorisation, the greatest flow was from France to Spain. Where authorisation was not required, the greatest flow was from France to Germany. These patterns have not changed significantly between 2015 and 2017.
For the years 2015 and 2017, when France was not able to provide data on patient mobility with prior authorisation, Luxembourg to Germany and Ireland to UK were amongst the most common cases of patient mobility.
For treatment without prior authorisation, flow maps show a clear pattern where France has the greatest number of travelling patients, with the three most common countries for healthcare provision being Spain, Portugal and Belgium in all three years.
After patients travelling from France, the next most frequent cases of patient mobility were patients travelling from Denmark to Germany; followed by Poland to Czech Republic and Norway to Spain. Additional data from Denmark indicates that the bulk of this patient mobility is for dental care
For both types of treatment over the last three years most of the patient mobility has been between neighbouring countries. Patients prefer to receive healthcare near their home if possible, and that if they do elect to travel, they prefer to travel to a neighbouring country.
Half the patient mobility is accounted for by movements from France to its neighbouring countries, the other half of the flow is made up by small numbers of patients travelling throughout the EU to receive care, both to neighbouring countries and to countries further away.
Issues of proximity drive 50% of patient mobility, and possibly also collaborations between clinicians in border regions, a very significant part of which may also reflect patients’ desires to receive healthcare in a place of their choice. Such choice may be driven by a desire to return ‘home’ to a country of birth for healthcare, or to bring a relative closer to a place where a family member can care for them, or it may be driven by a desire to find expertise not available in their home country.
IMTJ assessment
The surge in cross-border EU medical tourism predicted and hoped for by certain some experts and associations has not occurred.
This is a true ‘consumer choice’ model, as the patient is not directed by a country (a wasted effort by countries targeting national bodies) or even a hospital or doctor.
What we know little or nothing about is why a patient from country A goes to hospital X in country B. Although, it’s worth noting that 50% of the reasons a country is chosen is because it’s next door.
Possibly, the main surprise from the report is that the largest supplier of patients is France. This is, perhaps, because the French are already accustomed to the complex bureaucracy of their own health and insurance system, making the EU system seem less daunting.
Could it be that, despite the promise of being reimbursed for treatment costs, the low take-up is simply down to most patients not wanting the added complication of organising and paying for travel and accommodation? What does this mean for actual numbers of EU medical tourists who also need to pay for the treatment? This report finding should serve as a reality-check for organisations targeting the European cross-border patient.
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