A member state representative noted that the draft had clearly improved from its earlier versions, as the member state's right to establish a prior authorisation system for hospital care was now clearly stated. However, he noted that it was important to leave the definition of hospital and non-hospital care to member states.
He also argued that the proposal as such would considerably increase the administrative burden of member states. "It is justifiable to ask how big the administrative burden will be compared to the number of people actually crossing borders to seek care and to calculate how much tax payers' money is spent on maintaining an administration to serve those few," he added.
Irene Wittmann-Stahl, a health attaché at the Permanent Representation of Germany to the EU, said a lot of questions remained to be answered before the Council was able to form its opinion on the draft directive. These include:
- Legal certainty.
- Will ECJ jurisdiction be accepted as a starting point for the Directive or should one go back and make it stricter?
- Who should be protected? Individual patients or health care systems, which have the obligation and need to guarantee equal access to treatment?
- How about national steering capacity, which varies from one member states to another?
- At what stage are member states' rights are no longer respected? (cf. Article 152 of the Treaty guaranteeing the competence on organisation and delivery of health care to member states.)
- Despite Article 152, do member states accept that the four freedoms of internal market apply to health care as well?
- How about subsidiarity regarding patient mobility?
- Do member states agree that the directive creates more rights at EU level?
Pascal Garel, the chief executive of the European Hospital and Healthcare Federation (HOPE), is happy that the proposal is finally on the table and no longer in Commission corridors. He pointed to a number of potential problems in the proposal, namely the definition of hospital and non-hospital care, which varies from one country to another and could lead to problems as regards the need for prior authorisation.
He said the concept of continuity of care also needs better articulation and member states should be careful what they communicate to citizens in this regard. "The more precise the information, the better," said Garel. He also noted that the proposal's aim to provide citizens the opportunity to make informed choices is somewhat problematic as a lack of comparable EU level information on quality and safety data prevents such informed decisions.
In addition, he noted that equal access to care abroad will be compromised by the need for a patient to pay for the care first from his own pocket before being able to seek reimbursement.
In this regard, according to the Commission, nothing in the draft directive prevents member states from setting up schemes that would pay the costs of care upfront if they want to.
Finally, Pascal Garel believes that the new directive will introduce a lot of new administrative burdens. He also thinks it will not bring an end to court cases on the issue. On the contrary, the proposal could lead to an increased number of different types of cases unless member states establish extremely clear rules on the prior authorisation and conditions for reimbursement.
"We fear that this would not work out and the directive, which we welcome in principle, would not be able to bring the benefits nor to the patients nor to the service providers," said Marc Schreiner from the German Hospital Federation, challenging the whole Commission proposal and the way in which the draft proposes to reimburse the same or similar care received abroad according to national barometers for equivalent care.
Referring to the results of an EU-funded project [HealthBasket] which concluded that comparing health services in the EU 27 is not possible (as access to different care and their prices vary considerably), Schreiner argued that until we know exactly how much taxpayers' money goes to, for example, specific dental care or a hip replacement, it is not possible to establish a reimbursement system as laid down in the Commission proposal.
"The core problem of this directive is that as national health systems are not comparable, the reimbursement system can't work out and the directive would not help to initiate a cross-bordering supply of health services," said Schreiner. He also said that as we can't currently compare the health services, some have proposed the creation of baskets of treatments to which all citizens have a right all over Europe, and the price of which would be agreed upon. However, "this would clearly exceed the competence of the EU," he noted.
German hospitals hope to get more patients from other countries but in order to do so "a clear reimbursement system is need", he concluded.
As for the European Parliament's political groups, the Liberals and Democrats (ALDE) regard the proposal as "a first important step toward a free European patient area".
"Although it will not create new entitlements, this directive will make it easier for patients to exercise their rights and will ensure equal access to cross-border healthcare. For Liberals and Democrats, this long-overdue directive is a step towards the free movement of patients - a step we hope to make before the end of the Parliament's mandate," said ALDE Group Leader Graham Watson.
Meanwhile, the Greens/European Free Alliance has a rather different view on the proposal. "The draft proposal is not as positive as it might seem at first sight. Without doubt, there is a need for action concerning the legal right to reimburse treatment received abroad. However, while travelling to another member state might be an option open to some individuals, increased mobility is not a panacea that will ensure quality treatment for all patients. The proposal must be considered in the wider context of the privatisation of public healthcare. Positive sounding labels like "mobility" and "choice" must not be allowed to mask a potential liberalisation of healthcare services. We are at serious risk of seeing the market take over and undermine national systems," argued UK Green MEP Jean Lambert.
MEP Avril Doyle (EPP-ED, IE) argued that the directive was "a Charter for wealthy to opt for care abroad," as people need to pay for the care first themselves "which is not an option for the poor". Therefore, she said, it would lead to more inequality than equality.
The Confederal Group of the European United Left/Nordic Green Left argued that all issues addressed by the draft directive "must be solved within the existing framework of the coordination of social security schemes (Regulation 883/2004/EC). There is no need for a new directive based on an internal market approach to health care. We strongly oppose the re-introduction of 'Bolkestein' through the backdoor".
The European Public Health Alliance (EPHA) said it welcomes any Commission initiative "that would work to strengthen patients' rights and provide greater clarity on access to health services in Europe". The alliance calls on the Commission "to ensure that any proposal is in line with the common values and principles in health systems agreed by member states in 2006, and stresses the need to respect the principles of the universality of health services, access to good quality care, equality and solidarity." EPHA also welcomes a proposal that "would support member states in addressing existing inequalities within health systems".
The European Consumers Organisation (BEUC) particularly welcomes the establishment of national contact points "that will provide patients with information on essential aspects of cross-border health care, including procedures, reimbursements and means of redress in case of harm". However, the organisation urges further discussions on the system for prior authorisation for hospital care as "it must not lead to confusion and increased inequalities between the member states".
The European Hospital and Healthcare Employers' Association (HOSPEEM) argues that draft Directive goes "beyond the rulings of the ECJ, by making it very difficult for the member states to ask for prior authorisation for hospital treatment abroad". This could, according to the association have "serious consequences" for the organisation, financing and delivery of healthcare in EU-27. Therefore, HOSPEEM believes that "patients should be required to go through prior authorisation procedures in their home country before seeking hospital care abroad and asking to be reimbursed for this care."
The European Patients' Forum, an EU patient lobby, calls on the Commission and member states to ensure that "efficient administrative mechanisms for swift reimbursement are set up," in particular for economically disadvantaged patients. The forum also welcomes the establishment of national contact points and recommends that they are set up "in a transparent way and that quality information is appropriately disseminated across the country and regions". It also argues that "patient organisations, if adequately resourced, could play a useful support role and supplement the formal information received from health authorities".
Eucomed, the European medical technology lobby, urged more cooperation on eHealth and health technology assessment (HTA) between the EU 27. It argued that "medical technology helps in increasing the cost-effectiveness of medical care". "When implemented in a collaborative manner, eHealth is a particularly good example of medical technology contributing to increase the overall efficiency and cost-effectiveness of healthcare systems in Europe today," added Eucomed chief executive John Wilkinson.
Eucomed's views were endorsed by the Health First Europe, an alliance of patients, academics, healthcare experts and the medical technology industry. The alliance called on the EU "to facilitate the development and integration of eHealth into the provision of day-to-day healthcare services" and hoped the upcoming Recommendation on eHealth interoperability will clarify current legal uncertainties and lead to harmonised standards to speed up eHealth development.