A proposed EU directive would allow citizens to have a procedure anywhere in the EU and be reimbursed in their home state, even if the treatment can be had there, writes Gary Finnegan
A NEW EUROPEAN directive could see more Irish patients seeking medical care in other EU countries, but critics of the plan are warning it will disrupt how services are planned and funded.
The proposed directive allows patients to be treated anywhere in the EU and be reimbursed by their home country.
European citizens can already avail of medical services while on holiday or business using the European Health Insurance Card, and planned operations in other EU member states can be arranged if there is agreement between a patient’s own doctor and the doctor who will treat the patient.
This is commonly done in cases where a procedure is not available in the patient’s home country.
However, the new plan would place power in the hands of patients by allowing citizens to choose to seek treatment elsewhere in Europe, even if that procedure is available at home.
For in-patient procedures, prior agreement may still be required but day case patients could soon have the power to refer themselves to clinics anywhere in the EU and claim the costs back from their local health authority. The fine details of the plan are being thrashed out in Brussels this month.
The move follows several rulings by the European Court of Justice, which supported patients’ rights to travel for medical procedures. MEPs say the new directive will guarantee entitlement to medical and dental care across the EU, and reduce waiting lists.
Consumer groups have welcomed the plan, but there has been some concern that patients will have to pay upfront and cover their own travel expenses. It is also expected that patients will only be refunded the amount the operation would cost in their own country, rather than the fees they will actually pay out.
For example, an Irish patient undergoing surgery in Sweden would only be reimbursed the cost of that procedure in Ireland, even if the price is higher in Swedish hospitals.
In a submission to the Department of Health, Stephen McMahon of the Irish Patients’ Association said the directive has the potential to drive safety and quality standards across Europe, but he raised a number of practical concerns.
In particular, Mr McMahon warned against diluting the package of care currently available under the National Treatment Purchase Fund (NTPF). The NTPF pays for Irish patients – who are waiting more than three months for an operation – to be treated in private hospitals in Ireland and Britain. This can include travel expenses for the patient and a companion.
He added that the new law should not facilitate a health tourism industry at the expense of patients who choose to have treatment in Ireland.
“We feel it is inappropriate for the Department of Health and HSE to pay for foreign treatments out of existing budgets, which in turn deprives patients of their planned resources.”
Central to concerns expressed about the impact of the proposal is the uncertainty over how many patients are likely to avail of health services abroad.
The Department of Health said Ireland is not opposed in principle to the possibility of having a directive in this area, and is currently examining the implications of the proposal. However, in a statement, the department acknowledged it was difficult to estimate how many Irish patients would travel overseas for treatment, and how many European citizens would seek medical care in the Irish system.
“The potential impact of the proposed directive could be very significant for member states’ delivery of health services, and therefore it will be necessary to examine the text of the proposed directive to ensure that the intended legal clarity is achieved whilst unintended outcomes are avoided.”
The spokesperson said the main concern for Ireland was to balance the rights of patients who decide to travel abroad against the rights of the greater majority of patients, for whom this is not an option.
An impact assessment by the NHS in the UK has suggested the directive could cause additional administrative costs, but notes that patient mobility between the Republic of Ireland and Northern Ireland is currently less than one per cent.
Prof Charles Normand, the holder of the Edward Kennedy Chair in Health Policy at Trinity College, Dublin, also believes the numbers availing of treatment outside their own countries will be small.
“Traditionally, patient mobility has been much more common where people are used to travelling for shopping – like in areas of Holland, Belgium, France and Germany – where you have large populations living near borders.
“It’s not likely to be a huge part of the system here. What I think we will see is patients travelling for particular elective operations where there are long waiting lists.”
However, European Commission research reveals 79 per cent of Irish people say they would be willing to travel elsewhere in the EU for specialist care or to be treated more quickly, but three quarters of respondents complain that there is not enough information available on medical services in other EU member states.
Prof Normand believes the vast majority of patients will still opt to be treated as close to home as possible, despite the wider range of choices opening up across Europe. “There is some evidence that language is important. People want treatment where they can speak the language.”
He also suggests that the ability of hospital managers to plan services could be affected by the EU directive.
“It could be highly disruptive to planning if large numbers of people crossed borders, but it’s likely that language barriers will save national systems.”
Indeed, last year’s Eurobarometer research poll found that among Irish people who were unwilling to travel for healthcare, 69 per cent cited language differences as a disincentive, while 93 per cent said it would be inconvenient to leave Ireland for treatment.
Catherine Hartmann, executive director of the European Association of Hospital Pharmacists, believes the proposed directive should be changed to insist that patients seeking any treatment in another country must get agreement from hospital managers in advance.
“The only way you can plan your care is by arrangements between hospitals. Prior authorisation is essential given that the average cost of hospitalisation is €1,000 a day.
“I don’t know if politicians know the reality of hospital systems across Europe, and the impact it could have on underequipped and overworked staff.”
The European Commission has submitted the proposed directive to the Council and European Parliament.
MEPs discussed the issue at committee level on January 21st and are expected to vote at the end of April.
However, while the debate remains vigorous in Brussels, it is unlikely that the directive will come into effect until member states have been given time to prepare for its impact.
THE CURRENT SITUATION
The following is how things stand at present:
European Health Insurance Card– You are entitled to healthcare in countries of the European Economic Area and Switzerland if you become ill or are injured while on a temporary stay.
www.ehic.ie
Treatment Abroad Scheme (E112)– You can apply to the HSE for authorisation to travel to another EU country to receive medical care if a treatment is unavailable in Ireland or if it cannot be provided without "undue delay".
National Treatment Purchase Fund– If you are waiting for an operation in a public hospital for more than three months you may qualify for treatment in a private hospital paid for by the NTPF.
www.ntpf.ie
Directive will 'force the HSE to act to improve services at home'
IRISH MEP Colm Burke knows the value of travelling for healthcare better than most. In 1987 he was diagnosed with cancer of the brain stem.
A year later, he had an innovative treatment called stereotactic radiotherapy at a hospital in Sheffield.
Mr Burke says he had the benefit of being able to afford to pay for private care in the UK, but others are not so fortunate. "I could afford to travel, but what about those who cannot? We want a level playing field for everyone.
"When this directive comes into effect, Irish patients will be able to access healthcare in another EU member state and be reimbursed up to the amount that they would receive in Ireland. They will not need prior approval from the HSE, which is currently the case. This will ease pressure on the Irish health system, but it will also force the HSE to act to improve services at home, instead of footing the bill for treatment abroad."
He added that the directive aims to encourage European co-operation to improve the use of information technology in healthcare.
Ilaria Passarani, health policy officer at the European Consumers Organisation, welcomed the proposed directive but called for safeguards to ensure that patients would have access to follow-up medical care. She added that the organisation does not want health services to begin competing with one another for patients across Europe.
"Healthcare is not like any other services. We don't wish to see healthcare systems competing for patients, but we do hope this proposal will put pressure on national healthcare systems and encourage them to be more accessible, transparent, efficient, patient-centred and responsive to individual needs."
This view was echoed by Proinsias De Rossa MEP, who said the proposed directive was required to bring legal certainty regarding patients' rights to be reimbursed for medical treatment in other EU countries. The public service ethos of health policy should be preserved, he said, adding that policy cannot be rooted in a competitive market-based approach.