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EU Cross-Border Care Directive from the Primary C are perspective Results of a simulation

EU Cross-Border Care Directive from the Primary C are perspective Results of a simulation. Rita Baeten Gothenburg, 3 September 2012. Overview of the presentation. Why a Directive? What is the Directive on the application of patients’ rights in cross-border healthcare about?

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EU Cross-Border Care Directive from the Primary C are perspective Results of a simulation

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  1. EU Cross-Border Care Directive from the Primary Care perspectiveResults of a simulation Rita Baeten Gothenburg, 3 September 2012

  2. Overview of the presentation • Whya Directive? • Whatis the Directive on the application of patients’ rights in cross-border healthcare about? • A simulation on the Directive : forecasting potential issues • Relevance from the primary care perspectiveand conclusions

  3. Directive on the application of Patients’ rights in Cross-Border HealthcareWHY? Court of Justice of the EU (CJEU) • Health care provision is an economic activity • EC Treaty provisions on the free movement of services apply • No discrimination of providers abroad • Passive free movement: consumer goes to the provider (=patient mobility) • Care abroad to be reimbursed by the statutory healthcare payers

  4. Reimbursement of planned care in another Member State CJEU: Free movement Regulation 883/04 (E112) Prior authorisation Only providers providing statutory care Reimbursement level and conditions of the MS of treatment Third party payment system applies • Prior authorisation only justified for hospital care • All healthcare providers qualify • Reimbursement level and conditions of MS where socially insured • Up front payment by patient

  5. =>legal uncertainty • Tariffs, selection of providers, conditions • Quality of care, information, ... • Regulatory powers of health authorities

  6. Policy reaction 1998: First Court cases (Kohll and Decker) 2004: High level group on health services and medical care • Cooperation between Member states • Addressing practical issues 2004: Proposal for a Directive on Services in the internal market • Codification of CJEU rulings on reimbursement of care • Freedom of establishment principles applied to healthcare 2006: Exclusion of healthcare from the services Directive 2008: Proposal for a Directive cross-border healthcare • Codification of the case law on reimbursement of care abroad • Proposed in 2008, adopted in 2011, • To be implemented by October 2013

  7. Directive on the application of patients’ rights in cross-border healthcareWHAT? • Rules on reimbursement of care provided in another Member State (MS) • Measures ensuring proper conditions for receiving care abroad (quality of care, information, ..) • Co-operation between MS

  8. Rules on reimbursement • Reimbursement levels and conditions of MS of affiliation • Regulation 883/04 on the coordination of social security systems has priority • Prior authorisation • Allowed for hospital care and highly specialised care • If subject to planning • Cannot be refused when care cannot be provided domestically with undue delay

  9. Responsibilities of MS of treatment • Quality and Safety standards • Information on availability and prices to be provided by providers • Systems for complaints, redress, professional liability • Remote access to or copy of medical record

  10. Cooperation between MS • Basic duty of cooperation and mutual assistance • Exchange between national contact points • Agreements in border regions • Specific areas: • Mutual recognition of medical prescription • European reference networks of centres of excellence • ICT and e-health • Health Technology Assessment

  11. Simulation on the Directive24 November 2011 Objectives • To understand the likely future impact of the Directive in practice • Forecast potential issues • Insights on potential bottlenecks and different ways of resolving them • Focus on reimbursement issues

  12. The Simulation: Concept • 3 concrete cases • Including key issues • Specific questions for each stakeholder group • 37 participants from 6 EU countries • Belgium, France, Germany, The Netherlands, Luxembourg, Spain • 5 stakeholder groups • Patients • Statutory payers (mainly health insurers) (2X) • Public authorities • Healthcare Providers

  13. The Simulation: Results • Consensus on key issues • But also important challenges A selection…

  14. ResultsConditions for reimbursement • Statutory payers and public authorities: • Impose same conditions as for care provided domestically • Healthcare providers: • Would not adapt treatment procedures to the requirements of foreign insurers =>Patients risk not being reimbursed

  15. ResultsTariffs and supplements • Providers: Would charge private tariffs (not the “social insurance” tariffs) • Payers: Some would limit payments to the social insurance tariffs of the MS of treatment

  16. ResultsInvoices • How can payers know what care has exactly been provided? • Burden of proof lies with the patient • Some providers are willing to adapt invoices, against payment

  17. ResultsPrior authorisation • Request it may become the general rule • Patients: “to be on the safe side” • Payers: To specify reimbursement

  18. ResultsInformation on treatment • Who should provide information on treatment options and quality and safety? • Patients: (treating and referring) doctor • Providers: National contact points • Who is accountable for provided information?

  19. ResultsLanguage and translation • Invoices, medical record, treatment options • Who has to pay: Patient • Who is accountable ?

  20. ResultsDomestic impact • Impact of European Reference Networks • Pressure to reimburse care with an EU label • Transparency : • On tariffs, invoices, reimbursement level • Information • on quality, prices

  21. Relevant issues for primary care Patients can go abroad for primary care • No prior authorisation for ambulatory care • Some mobility in border regions • More provider choice, including non contracted providers abroad • Different invoices • Different prices • INN prescribing of medicines

  22. Relevant issues for primary care Referring patients abroad • Mainly for ambulatory care or in case of domestic waiting lists • Establishing contacts with providers • Transfer of medical record (and language?) • Differences in procedures, different guidelines, pharmaceuticals • Reimbursement conditions and levels to be taken into account • GP gatekeeper system potentially challenged • Information to patients: • Differences in treatment, provider choice, costs

  23. Conclusions • Burden for patients under the Directive is very high • No important movements to be expected • When long waiting times • In border regions • For highly specialised care • Differences between health systems to be taken into account • Domestic impact • Information on quality, • Transparency in prices,…

  24. … And much more: Jelfs, E. and Baeten, R. Simulation on the EU Cross-Border Care Directive, Final Report, OSE, EHMA, AIM, 2012 http://www.ose.be/files/publication/2012/CrossBorderHealthcareSimulation_FinalRep_09052012.pdf

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