Opinion of the European Committee of the Regions – Implementation and future perspectives for cross-border healthcare

(2020/C 440/03)

Rapporteur: Karsten Uno PETERSEN (DK/PES), Regional Councillor, Region of Southern Denmark Reference document: Outlook opinion

POLICY RECOMMENDATIONS

THE EUROPEAN COMMITTEE OF THE REGIONS

Introductory comments

1. observes that cross-border patient mobility is a major policy issue. 34 % of EU citizens cite health as the most important policy topic in their region, an increase of 8 percentage points since 2015 and 10 percentage points since 2012;

2. emphasises that the local and regional dimension is absolutely key to cross-border healthcare. For a variety of reasons, many people living close to a border seek treatment in the neighbouring country. Border regions make up 40 % of the EU’s territory, with more than one in three Europeans living in such a region. Local and regional authorities provide a link between all the stakeholders involved (national, regional and local actors, hospitals, GPs, pharmacies, members of the public, etc.);

3. is of the view that cross-border patient mobility poses a series of questions — regarding, amongst other things, access to information on treatment abroad, continuity of care, exchange of information between healthcare professionals on either side of the border, disparities in healthcare and the types of care or treatment provided for a given medical indication, the ability of the healthcare system to prioritise and provide care on under the same conditions, and logistical and administrative challenges — that have an impact on the number of people wishing to make use of the opportunities for obtaining healthcare in another EU country under the cross-border healthcare directive;

4. expresses its satisfaction with the budget of the new EU4Health programme, which will make it possible to strengthen health security and increase preparedness for future health crises. It will be a robust stand-alone programme with increased funding in the next multiannual financial framework (MFF) (2021-2027), in order to properly address the challenges identified in the Commission’s programme for the current mandate, in particular regarding the fight against cancer, the prevention, early detection and management of chronic and rare diseases, anti-microbial resistance, access to affordable medicine and serious health threats (such as coronavirus epidemics), and to deliver an ambitious health policy with a focus on cross-border cooperation;

5. welcomes the fact that all Member States completed the transposition of the directive; remains concerned however about the compliance check and a sheer number of issues detected to date by the Commission; understands that the directive touches upon a large number of laws pertaining to healthcare organisation and governance, reimbursement mechanisms, information channels, patients’ rights and entitlements and professional liability;

6. in the light of the foregoing, welcomes the fact that the Commission’s first vice-president, Frans Timmermans, has asked the CoR, in a letter addressed to its president, to draw up an outlook opinion on the implementation of the directive on cross-border healthcare, which could help to improve enforcement and strengthen patient rights;

7. wishes to make it clear that this must be done in such a way as to ensure that the organisation, management, funding and delivery of healthcare services remain the prerogative of the EU Member States. Furthermore, the implementation of the directive should be seen in the light of the overall tasks to be undertaken by the competent health authorities in people’s best interests;

8. thanks all the RegHubs ( 1 ) and the stakeholders they consulted for their careful consideration of the survey and their insightful replies that informed this opinion;

COVID-19

9. believes that the COVID-19 crisis has made it clear that Europe needs more cooperation in the field of health;

10. echoes the call of the CoR president to set up a European Union Health Emergency Mechanism, closely linked to or integrated into existing EU structures for crisis management (i.e. the EU Solidarity Fund and the European Centre for Disease Control and Prevention) to better prepare the Union for any future pandemic crisis and to ‘support regional and local leaders to provide health services and materials to hospitals and schools, hire medical staff, buy medical devices and support intensive care services’;

11. also draws attention to Article 10 of the directive, on mutual assistance and cooperation, enabling Member States to ‘render mutual assistance’ and ‘facilitate cooperation in cross-border healthcare provision at regional and local level in border regions’ and is convinced that Member States should explore this opportunity more creatively to address pandemic situations as well;

12. recalls that, according to article 222 of TFEU, the Union and its Member States shall act jointly in a spirit of solidarity;

13. finds reassuring the solidarity shown in the hour of need when Member States took over patients from their overburdened neighbours to relieve the pressure of their intensive care capacities; firmly believes that this could be formalised in the future through a request for assistance under the directive;

14. recommends setting up ‘health corridors’ ( 2 ) between the border regions, making it possible for patients and health professionals to continue moving across the border during the lockdown to guarantee access to and provision of care;

15. points to digital cross-border solutions enabling e.g. imaging and remote analysis of samples (such as lung x-rays transferred for assessment abroad) as an example of a cost-effective and practical way to cooperate when there is a surge;

Increased patient mobility is not an end in itself

16. agrees with the European Parliament that only a tiny fraction of EU citizens make use of the opportunities offered by the directive, and that most patient mobility occurs across shared borders;

17. refers, in this respect, to the Commission’s report, which concludes that cross-border patient flows display a stable pattern, with people primarily choosing cross-border healthcare for reasons of geographical or cultural proximity;

18. draws attention to the Commission’s conclusion that patient mobility and its financial implications within the EU as a whole remain relatively low, and that the cross-border healthcare directive has not had significant budgetary consequences for the sustainability of health systems;

19. underscores that cross-border healthcare may be appropriate for certain groups of patients affected by rare diseases or for reasons of geographical proximity, especially in border regions;

20. welcomes the positive impact that the directive seems to be having on cross-border patient mobility, with figures showing a slight upwards trend since 2015. The number of prior authorisations has likewise been steadily increasing over the past few years, with more than twice as many requests being made and authorised in 2017 as in 2015 across the Member States;

21. points out that the regulations and the directive are not the only routes by which care may be provided in another Member State, as several of them have adopted bilateral and multilateral parallel procedures to address the particular needs of care in their border regions (BE, DK, SE, DE, CZ, EE, LU, HU, NL, PT, RO, FI and LT). Often predating the directive, these agreements generate significant flows of patients that are not captured in European statistics;

22. notes that the purpose of the cross-border healthcare directive is not to achieve the highest possible number of patients using care abroad; the arrangements offered by the directive have been designed to complement the basket of care services and products available regionally or nationally and to clarify the rights of European patients willing to access healthcare or treatment in another EU/EEA country; the number of users therefore cannot be interpreted as either a success or a failure of the legislation;

23. emphasises in this connection that any increase in cross-border patient mobility must be based on individual patient circumstances, and is not an end in itself;

Readily accessible information on health care under the terms of the directive

24. like the European Parliament, maintains that, if the directive is to be implemented successfully, it is crucial for patients, healthcare professionals and other stakeholders to be properly informed of the opportunities it affords for cross-border treatment;

25. therefore stresses that people must have easy access to information on the conditions for obtaining treatment in other Member States under the directive, so that they can make an informed choice if they are considering treatment abroad;

26. points out that since there are significant differences in how individual countries organise their health systems, including regional and local differences in some countries, health authorities should make sure that adequate arrangements are in place to provide the public with access to appropriate information;

27. draws attention to the fact that National Contact Points (NCPs) can have regional antennas or be integrated into the regional health systems’ websites or hosted on regional health insurers webpages; while these solutions may not necessarily increase the overall visibility of the NCPs, they may be more successful in providing citizens with information;

28. recommends that the Commission provide examples of good practice from different countries and from regional and local authorities on how best to disseminate information, so that the health authorities in the Member States can learn from the experience of health systems similar to their own;

29. stresses that, even if the Member States step up their efforts to make information available, there will still be major differences in patient mobility depending on the organisation of individual health systems and the services they deliver. The Commission’s report makes this clear. The main reasons why patients decide to seek cross-border treatment are swifter access to good quality care, cultural affinities and not least the possibility of saving money on treatment with a substantial proportion of own funding, such as dental treatment;

Additional administrative costs incurred for treatment abroad

30. notes that by far the major part of Member States’ health budgets is spent on the domestic market. The Commission calculates that, under the directive, the cost of cross-border healthcare across the EU as a whole amounts to only 0,004 % of the total annual health budget of the EU countries;

31. reiterates that only a tiny fraction of patients make use of treatment in another EU country under the directive. According to the most recent estimate by the European Court of Auditors, the number of reimbursement requests is in the region of 214 000 per annum, corresponding to approximately 0,04 % of the EU’s population. The vast majority of requests (over 210 000) are for reimbursement for treatment that does not require prior authorisation;

32. notes that reimbursement for out-patient services, which do not require prior authorisation (for example, dental care), is relatively low from a financial point of view in comparison with the additional information and administrative costs to health authorities incurred by implementing the directive;

33. stresses that in endeavouring to comply with all aspects of the directive and make it as straightforward as possible for people to seek treatment in another EU country, the Member State health authorities must also take into account the fact that by far the majority of EU citizens opt for healthcare that is delivered relatively close to their home or family. The organisation, quality and capacity of the Member States’ healthcare services must in principle, therefore, aim to enable people to be treated as close as possible to their place of residence or family;

34. notes that Member States’ spending on treatment in other EU countries is not just a matter of reimbursement. Administrative and information costs are also linked to treatment — money that could otherwise be spent on improving treatment in the Member States’ own health systems. When implementing the directive, the national health authorities should therefore take care to ensure that the very small proportion of patients wishing to receive treatment in another EU country does not place a disproportionate burden on resources in their own health systems;

Appropriate use of prior authorisation

35. takes note of the fact that Member States’ use of prior authorisation for hospitalisation or highly specialised medical treatment in another country has been identified as a barrier to cross-border patient mobility;

36. observes in this regard that, according to the Commission report, the impact on national health budgets of patients seeking access to cross-border healthcare is marginal, something that applies to all countries regardless of whether or not they have made provision for prior authorisation;

37. notes that the use of prior authorisation is deemed necessary by the majority of RegHubs (63 %) to ensure access to quality healthcare, as well as being key to avoid wasting resources (48 %) and to controlling costs at the regional level (44 %);

38. points out that recourse to the directive’s prior authorisation rules also offers financial certainty for patients, because before they receive treatment in another country their State of insurance guarantees that it will cover the cost of the treatment under the directive;

39. calls on the Member States to make prior authorisation as swift as possible so as not to delay treatment unnecessarily, while providing a realistic assessment of the estimated cost of the planned intervention;

40. highlights the much less-used mechanism of prior notification (Article 9(5) of the directive) found by the RegHubs to be a useful tool to provide patients with clarity and to support authorities in complying with their obligations, and invites the Member States to make more ample use of this voluntary arrangement;

41. draws attention to the mechanism of financial compensation, which Member States may implement in connection with prior authorisation, to introduce direct billing between competent institutions thus replacing upfront payment and reimbursement to patients (Article 9(5)) as a means to reduce the burden on patients and open up the possibility of seeking treatment abroad for less affluent societal groups;

42. following on from the above, recommends regarding the further implementation of the directive that recourse to the system of prior authorisation still be possible where the authorities in the Member States consider it necessary;

Further cooperation on the implementation of the directive

43. invites DG SANTE, in cooperation with the other relevant directorates-general, to follow up on this evaluation of the implementation of the Patient Mobility Directive and to collect, analyse and publish examples of cross-border healthcare activities and problems encountered by participating authorities;

44. requests adequate and long-term EU funding in the next programming period, especially but not exclusively through Interreg, including for the implementation of cross-border studies/projects aimed at removing specific barriers and at smooth cooperation;

45. notes that, whilst it does not specifically refer to the directive, the Memorandum of Understanding between the CoR and WHO nevertheless commits the CoR to promoting access to healthcare, health promotion and knowledge sharing, all of which are essential aspects of the directive;

46. invites the Commission to engage in a regular dialogue with the European Committee of the Regions, including the NAT commission and the Interregional Group on Health, on challenges and solutions with a view to improving the implementation of the directive on cross-border healthcare;

47. expresses its ongoing support for this much-needed European collaboration and stands ready to further advise and inform on best practice examples from the regions;

48. reiterates that diseases know no borders and that European health emergency solidarity should never stop at administrative or legal borders;

49. expects the forthcoming third implementation report from the European Commission to fully reflect the considerations of the European Committee of the Regions, as expressed in this opinion.

Brussels, 14 October 2020. The President of the European Committee of the Regions Apostolos TZITZIKOSTAS

(1) In November 2019, the European Committee of the Regions launched a consultation through its Network of Regional Hubs to investigate the implementation of the directive at territorial level. 27 regional hubs, representing 18 European countries, participated in the survey.

(2) France has set up such a ‘health corridor’ at the FR-ES border to enable the continuity of care in the Hospital of Cerdanya, whereas Luxembourg has looked into a specific derogation for the French healthcare workforce to assign them a special ‘settled’ status and keep them coming to work in the Grand Duchy.