For EU patients, doctors with borders

High costs, bureaucracy and lack of awareness limit single health market.

A push by the European Union to allow patients to travel throughout the bloc for medical treatment without big hassles or costs is off to a sluggish start, benefiting mostly the well-off and highly informed.

High costs, bureaucracy and lack of awareness are the biggest roadblocks for the sick to navigate when trying to use their rights under the cross-border initiative, according to patients’ groups and European Commission officials.

Adopted in 2011 by the EU institutions, the initiative sought to clarify patients’ rights to health care services outside their home country. But the way some EU member countries are implementing the directive may be making matters worse.

“Some countries have very elaborate systems of prior authorization; others seem to use a lower level of reimbursements than they should and others have different administrative requirements,” the EU Health Commissioner Vytenis Andriukaitis said earlier this month at an event on the topic.

When asked which countries are laggards, he declined to name them.

Patients’ rights organizations say there have been cases where EU countries set the level of reimbursement based on the cost of private instead of public treatment, creating artificially low reimbursement. The cost factor is keeping patients from taking advantage, advocates say.

“The financial barriers are really seen as a major threat when it comes to equity of access,” said Kaisa Immonen-Charalambous from the European Patients’ Forum.

Rich countries, poor countries

Ideally, a health care provider in one country should be able to recover its costs from the national system in the country where the patient is insured.

But this is still a faraway dream for EU patients.

The country where the patient pays his or her social security decides the level of reimbursement the patient gets back, based on what the treatment costs in that country’s public system.

This opens a rift, and wildly varying use, between patients living in poorer EU countries and those living in richer ones.

The reimbursement level for medical procedures in Croatia and Poland, for example, is much lower than in other EU countries.

Croatians are not generally using the directive because the health care provided by the older EU members, and even some newer ones, like Slovenia, is more expensive than in Croatia, the head of the country’s national contact for cross-border health, Dubravka Pezelj Duliba, told POLITICO.

But the cheaper medical services in Croatia attract Slovenians and Italians, who go there mostly for dental treatment, she said. “So in some way cross-border health care is health tourism.”

There were some 250 requests for reimbursement for health care received by Croatians abroad in the 18 months since the law started to apply, Pezelj Duliba said. But most of them were related to unplanned health care used abroad.

The number of requests is higher in Poland, with some 2,000 applications for reimbursement received since November 2014, when the measure went into effect there. Some 1,200 were reimbursed, an official with the Polish National Health Fund told POLITICO.

In crisis-stricken Greece, the National Organization for Health Care Services Provision only dealt with one demand of reimbursement from the beginning of this year.

By contrast, French authorities handled last year almost 160,000 requests for reimbursement for health care services provided in other EU countries and the European Economic Area. More than half were reimbursed, totally and partially, according to the French National Center for Treatment Abroad.

Finding equivalence

For the Greek and Polish authorities, one major challenge in deciding to reimburse is identifying the service provided abroad and finding its equivalent in their own national system.

Vasiliki Koukou, who works with the Greek national contact, said that lately, this has become easier through better communication between national contacts.

They can also use the Commission’s Internal Market Information System platform, which links up national, regional and local authorities across borders, she said.

The EU cross-border directive adds to a series of existing rules. The European health insurance card allows patients to access unplanned, emergency-type treatment if they fall sick while on holiday or during a temporary stay in another EU country.

Another set of regulations on the coordination of national social security legislation applying since May 2010 gives people right to seek health care abroad in special cases, such as when a treatment for a rare disease is not accessible in their country.

Under the 2010 rules, the patient has to request authorization from national authorities before pursuing such a treatment.

The cross-border directive is meant to work without prior authorization, in most cases to help patients avoid long waiting times for a specific treatment or fulfill unmet medical needs, such as dental care.

That is the theory, anyway.

Gatekeeping

In practice, patients still have to request prior approval in some specific cases.

For example in Croatia, they need authorization from the Health Insurance Fund to seek hospitalization or procedures performed with expensive equipment, such as CT scans, MRIs or endoscopies.

The fund received three requests for prior authorization last year; they were all rejected.

“Because it was estimated that that kind of health care can be done within Croatian health system in a timely manner,” said Pezelj Duliba.

The rejection is also a way to protect the public investment in medical equipment, she said. If Croatian patients start going abroad, the equipment would be under-used.

In Poland, which began implementing the directive a year later than required, there was only one request for prior authorization so far.

It was refused “because the patient could be given such treatment in Poland within a time limit that is medically justifiable,” the Polish official told POLITICO.

Another major problem from the patients’ point of view is that the costs reimbursed are in the majority of cases only covering the treatment. The patient still has to pay out of pocket for travel and accommodation.

Where’s my baby?

A mother living in Brussels told the story at this month’s cross-border health event attended by Andriukaitis, of having her baby prematurely when traveling in London for a few days. The baby then had to be transferred to Brussels under medical surveillance, but without her.

The mother had to arrange her own travel between the two countries.

“I went to the hospital in Brussels and said: I think you have my baby,” she told the group.

While the directive does not apply to emergency cases such as this one, the costs of a parent accompanying their child for treatment in another member state needs to be covered in the future, according to Andriukaitis.

“I encourage member states to work across sectors to help fix these issues,” he said.

By late 2014, only five percent of the 28,000 people interviewed for a Eurobarometer survey had used medical treatment abroad. Only two percent had actually planned for it.

Lack of information and awareness of the directive is one of the reasons for these very low figures, according to Andriukaitis. Plus, the quality of information patients get about it varies significantly among EU countries, he said.

National contact points to inform patients have been set up across Europe, but they range from properly staffed information centers to a simple email address with little follow-up.

And there is some confusion among the national contacts themselves about whether they should be encouraging patients to go abroad or not.

A paragraph in the directive says that its application should not result in patients being encouraged to receive treatment abroad, said Siniša Bošnjak from the Slovenian national contact point.

“This is strange, because we need to give patients all the information they need, but we need to do it in a way that we don’t encourage them to go abroad,” he explained.

All of these challenges are likely to find their way in the first report on the implementation of the directive, which DG Health is expected to present in September.

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