The internal market and healthcare services – a step too far?

1. The internal market and healthcare services – a step too far? The view from the insurers Willy Palm, AIM Director Brussels, 24 June 2005

2. Compulsory health protectionin the European Union (EU15) access to health care social insurance national health service Income ceiling no income ceiling categorial universal D A B DK P I NL F L IE GR UK E SW FIN Implication of mutual health funds in statutory protection

3. Voluntary protection in the EU (15) Implication of mutual health funds in voluntary protection access to health care social insurance national health service no income ceiling income ceiling categorial universal Statutory A B D DK P I F L NL IE GR UK E SW FIN Voluntary SUBSTITUTIVE SUPPLEMENTARY COMPLEMENTARY

4. EU non-life insurance directive (EEC 92/49) • Creating an internal (health) insurance market as of 1 July 1994 • Free settlement – Free provision of services • Single licensing - home country control • Harmonisation: prudential in stead of contract control • Exclusion: health insurance “forming a part of a statutory system of social security” • Article 54: general interest exception for VHI • “Ensure access to private or voluntary health cover regardless of age or risk profile.” • “where private insurance partially or completely substitutes to health cover provided by social security”

5. Draft Directive on services in the Internal Market • Scope? • Free establishment of service providers (permanent) • Prohibited requirements (art. 14) • Requirements “to be evaluated” (art. 15): mutual evaluation method • Free Service provision (temporary) • Country of origin principle (art. 16-19) • Assumption of medical costs in another Member State (art. 23)

6. I. Scope Directive • Council • Recital 14: The concept of service covers a wide variety of ever-changing activities, including (...) health and health care services; and household support services, such as help for the elderly. • Recital 16: According to the jurisprudence of the Court of Justice, the assessment of whether certain activities, in particular activities which are publicly funded or provided by public entities, constitute a ‘service’ has to be carried out on a case by case basis in the light of all their characteristics, in particular the way they are provided, organised and financed in the Member State concerned. The Court has thus recognized that the characteristic of remuneration is absent in the case of activities performed, for no consideration, by the State in the context of its duties fulfilment of its in the social, cultural, educational and judicial fields legal obligations, such as courses provided under the national education system, or the management of social security schemes which do not engage in economic activity. These activities are not covered by the definition in Article 50 of the Treaty and do not therefore fall within the scope of this Directive. • Gebhardt: This Directive shall not apply • 1a. to services of general interest performed and defined by Member States in fulfilment of their general interest obligations nor to services in the performance of which the service providers are subject to particular requirements imposed by Member States or the Community regarding the proper performance of certain general interest tasks, • 1c. to services which, while economic in nature, pursue a general interest objective and are thus subject to specific public-sector requirements, in particular: a) health and social security services and other social and welfare services;

7. Administrative simplification No duplication of formalities Single point of contact Information & assistance e-procedures Authorisation schemes Only if necessary for public interest and based on objective criteria No duplication of equivalent requirements and controls In principle for an unlimited period Transparent & efficient Prohibited requirements (art. 14) nationality or place of registered office Establishment in different MS Economic test Etc. Requirements to be evaluated (art. 15) Quantitative or territorial restrictions, specific legal form, shareholding, particular providers, minimum staff, fixed minimum and maximum tariffs, referral system, etc. Non-discriminatory, justified by general interest and proportional II. Free establishment

8. Country of origin principle (art. 16-19) Providers only subject to home state Home state control: mutual assistance Recital 47a: «application of COO in the field of health services is limited in scope given that many health services require an establishment (hospital) in the MS and cross border health services are the subject of important general derogations» Derogations Mutual recognition of professional qualifications (8): «disciplinary provisions of a professional or administrative nature directly linked to professional qualifications » Public health: prohibited services (16) + particular characteristics or risks (17) Case-by-case (exceptionnal): public health, health professions III. Free service provision

9. IV. Assumption of health care costs (art. 23) • Non-hospital health care: • not to be made subject to authorisation if covered under own social security system • conditions and formalities apply as in home state (e.g. referral, terms relating to dental care) • Hospital care = medical care which can only be provided in a medical infrastructure and normally requires accomodation: • authorisation is allowed if in conformity with general authorisation scheme conditions of the Directive • autorisation cannot be refused if: • treatment is covered in home state • treatment can not be given within a medically justifiable time-limit • Level of reimbursement: not less than that provided for by own social security system in respect of similar care provided on its territory

10. Scope Services Directive

11. Scope Services Directive

12. Scope Services Directive

13. High level reflection process on patient mobility and EU healthcare developments(2003) • More cooperation to better use healthcare resources • Sharing information on health care • Improving accessibility and quality • Reconciling national (health) policies with European (internal market) obligations • Improve legal certainty concerning cross-border access

14. Developing a shared vision on EU policy in health care

15. Access to health care in an internal market: Impact on statutory and complementary systems Conference background report at www.aim-mutual.org Luxembourg, 8 April