Have illness, will travel?

The cross-border healthcare directive comes into effect in 2013, but will it lead to greater choice for all patients?

Patients should be able to get healthcare treatment from anywhere in the EU from late 2013. At least, this is the idea behind the cross-border healthcare directive, which is likely to make it into the European Union’s official journal in the next few days, after years of legal arguments and political wrangling.

Relatively few people are expected to take advantage of the law. Current cross–border care is worth €10 billion, less than 1% of current healthcare spending, according to the European Commission. But for the EU institutions, the principles at stake meant the law was worth the long and arduous battle. The law codifies when patients are entitled to obtain reimbursement for healthcare obtained abroad, with the aim of ensuring that people no longer need to fight for their rights in court.

The directive also introduces greater co-operation between member states on rare diseases, assessment of new health technology, and e-health. Although these initiatives are voluntary or light-touch, the Commission sees the mere existence of a legal base for co-operation as an important milestone.

Grey areas

The law is less ambitious than the Commission and European Parliament had originally wanted, and not universally popular – four national governments voted against it, and one abstained.

It also leaves several grey areas. Most significantly, before going abroad for treatment, patients must get “prior authorisation” from their home country; their request could be turned down if the home authorities believe there is a safety risk or that the treatment can be provided at home without “undue delay”. But it is not clear what “undue delay” really means, although case law suggests it will have to be medically justifiable.

Another unanswered question is exactly how national authorities will be able to reach considered judgments about the inadequate safety of another country’s hospitals and healthcare. How will a health authority in Ireland, for example, be able to ascertain the quality of services in Romania?

A request from the Parliament for home governments to reimburse patients not only for the costs of treatment, but also for travel costs and hotel bills, was turned down. For MEPs, this raises the concern that the directive could reinforce existing health inequalities, by allowing the wealthiest to benefit, while others cannot.

Cost barriers

Nicola Bedlington, director of the European Patients’ Forum, says that overall the directive is “good news for patients”, although her organisation was disappointed with some parts of it: the lack of guaranteed reimbursement of travel costs is “clearly going to be a barrier” for some patients.

But she is pleased that the Commission will be obliged to monitor rejected applications and believes this will help hold governments to account. Patients’ organisations also have a role in promoting the directive, she says: “There is a job for patients’ organisations in terms of reminding governments of their commitments in Brussels.”

A new network on e-health will aim to help national authorities develop electronic health systems, such as patient records, that are capable of ‘talking to each other’, even if member states resisted any mandatory obligations, fearing the costs.

Officials also believe that the new law can drive up quality and safety standards, by enshrining the patient’s right to opt out of a poor service, and by requiring governments to publish quality and safety standards.

National governments now have 30 months to put the provisions into national law. The lack of practical experience in such a venture makes it impossible to say whether the directive represents the limits of a common European health policy, or is the beginning of a much more far-reaching process.

As Bedlington remarks, the law “is a stepping stone”.