The EU is trying to clarify citizens' rights to healthcare outside their own country but a draft directive raises a host of questions about payment and reciprocal responsibilities.
The directive would move the EU on from today's health agreement, which provides automatic reimbursement for emergency treatment for EU citizens wherever they may be. Until 2006, travellers had to take the E111 form with them to qualify for emergency care. It's estimated that 1% of the EU's total healthcare costs are incurred by people being treated outside their home country: that's about £8bn, and much of it is explained by movements across particular borders, between Germany, the Netherlands and Belgium and between Germany and Austria.
In future, the EU envisages a union-wide health economy in which would-be patients could travel to seek care in the knowledge their home healthcare system would cover (some of the) costs.
The proposals are an attempt to clarify patients' rights following European Court of Justice rulings. In a landmark case in 2006, Yvonne Watts successfully argued that Bedfordshire primary care trust should cover the £4,000 cost of a hip replacement operation she had sought in France, because otherwise she would have faced "undue delays".
Payments
The directive would entitle patients to receive non-urgent healthcare in any of the 27 EU countries and be reimbursed up to the amount their care would have cost to provide at home. So for UK patients, if treatment was no more expensive than it would have been under the NHS, they could reclaim the full cost of healthcare received in other EU member states, although they would normally have to pay for their own travel and subsistence.
Treatments unavailable at home will not be reimbursed. So if the National Institute for Health and Clinical Excellence has not approved certain drugs, patients would have to meet the full cost if they received them abroad. Similarly, spa treatments and massages available in some countries' health systems would also not be covered.
Patients will still need to get a hospital referral from their GP first. Afterwards, they would be free to seek outpatient treatment abroad without any need for authorisation. But for care involving an overnight stay, they may need permission to have treatment abroad. If the numbers of patients going abroad would "seriously undermine" the stability and smooth running of services, member states could insist patients obtain prior authorisation to receive healthcare in another country.
This would require clear evidence that preventing treatment abroad would damage national health systems and authorisation could not be refused if patients would face excessive delays.
Major problems lie ahead, especially over the calculation of costs. States with social insurance systems such as Germany and France will find it relatively easy to calculate reimbursements. Others would have to establish tariffs and systems to calculate what citizens are entitled to claim back. In the NHS, indicative prices exist for some procedures (at least in England) but not for others. "What would be the level of reimbursement for care," asks Anna Dixon, director of policy at the King's Fund, citing non-hospital treatment for which there are no tariffs; block contracts are the norm, so it is much harder to calculate a price per item.
It's not just the NHS which lacks the database the directive would require. Spanish health is financed through local taxation and central government funding. Delivery is devolved to the 17 regions. Denmark finances healthcare through taxation set at 8% of income. The bulk of this is then distributed to five regions, with the rest going to 98 municipalities.
Costs vary as they do in different parts of the UK. An implication of the EU move is that Scotland and Wales and Northern Ireland would have to calculate how much patients should be reimbursed. Scotland has tariffs for some elective procedures, while Wales and Northern Ireland have none.
The growing prevalence of day patients who are admitted to hospital for minor surgery but do not stay overnight will also be problematic. The directive also only distinguishes between in- and outpatient care, so it is not clear whether day patients would need authorisation to go abroad or not.
Discrimination
The directive could lead to allegations of discrimination. Why should NICE rulings be applied to patients from England if a non-approved therapy is available in, say, France? If patients have to pay upfront for their care in a Belgian hospital, this could mean that only those who have the money would be able to go abroad for treatment. Health systems would have to establish mechanisms to pay each other directly; with many countries operating devolved health services, the complications are endless.
The EU seems to want to establish free choice for patients - a political proposition that is highly contentious in some countries. The directive proposes that patients receiving care abroad could have more expensive care and pay the difference themselves. That trespasses on a hot political debate in England about top-ups.
As things stand private patients must pay the full amount for care. But if the directive allows them to receive rather more or better quality healthcare abroad and be reimbursed for what they would have received in the NHS, it will become increasingly difficult to argue that the same principle should not apply at home.
The clinical professions are accredited differently in the various countries; there are different minimum standards of care. What happens if a patient's treatment abroad goes wrong?
Perhaps anxieties are overblown. If the directive becomes law, it may have few takers. According to the website treatmentabroad.com, last year only 28,000 people from the UK received elective surgery and other non-urgent hospital treatment abroad. As each patient typically spent over £3,000, it would have cost nearly £97m to reimburse them.
Health collaboration is strong in certain areas. Strasbourg has arrangements with Liège and Luxembourg to exchange trainees, teaching, research and patients; Maastricht, Aachen and German speaking Belgium also treat each other's patients, as do hospitals either side of the Italian/Slovenian border. Keith Pollard, director at Treatment Abroad, says some medical tourism is also common to countries where care is cheaper, such as from Germany and Austria to Hungary.
A recent study by McKinsey argues that globally, 40% of those travelling abroad for healthcare do so to get access to the latest treatments and technologies. A third seek better quality care than they would find at home (particularly those from developing countries) while many simply want quicker access to orthopaedics, general surgery or cardiology.
Treatment Abroad says for UK patients, anxiety about MRSA is an important factor behind the decision to go abroad, alongside waiting lists and the cost of private healthcare in the UK. In countries with long waiting lists such as Northern Ireland, Wales and Spain, the directive could in theory help to cut them.
There may be financial benefits for lower-cost health regimes. "If you go to a country that is cheaper, the NHS will be quids in because it reimburses at that rate," says John Bowis, one of London's representatives in the European Parliament. Hungary is already popular among patients from northern Europe for dentistry.
The directive might strengthen private insurers such as Bupa and PPP. They already operate internationally, so would be in position to advise local health systems about healthcare in other EU states. And they may also move into providing "navigation" services, helping patients and GPs choose where to go for foreign care.
Pollard estimates that around half those who have gone abroad for treatment used an agent and half went under their own steam. "The market is very fragmented," he says. "There are a lot of one- to three-man bands acting as go-betweens." The directive would create opportunities for bigger players to set up medical tourism intermediary services, be they travel operators such as Thomson or insurance giants.
