Directive on Patient Mobility
UEHP – The European Union of private hospitals - is an Association, which boasts 4000 private hospitals and over one million employees in 15 European Member States. The majority of these hospitals work in agreement with public health systems and can thus receive the same patients with corresponding conditions and rights. The UEHP as a European association aims to promote significant values for both patients and health operators in the European Union, such as the patient’s free choice of the place of his or her treatment, the patient’s right to quality and safety of healthcare, the health professional’s freedom to practice. As well, considering equal and fair competition as a factor of effectiveness and quality, the financial durability of health systems.
Proposal of Directive on Patient’s rights on Cross-boarder Healthcare
The UEHP welcomed the Proposal for a directive on the rights of patients in cross border health care. The new text adopted by the European Commission indicates that the interest in the mobility of patients is rightly linked to the definition of fundamental rights in the construction process of a People’s Europe.
In reference to the values that are common to European healthcare systems - enshrined in the Declaration of Member States’ Ministers of Health and approved by the European Council - the UEHP recommends, priority attention be given to the patient’s right of free choice and access, with particular consideration to health and its likely evolution, as required by the European Court of Justice. It should not be forgotten that the demand for access to health care often concerns treatments and therapies that are not available in the sick person’s country of origin, and for which there is no possibility of timely execution in his home country, even under conditions of urgency.
The concern of Member States to ensure a balance of national health systems is certainly legitimate, but according to the principle of subsidiary, the responsibility of ensuring a quality health service lays within each Member State, based on universal access, which would make patients’ large-scale mobility superfluous. The patient’s condition is, in fact, what should be given priority attention.
Therefore, with respect to the possibility of limiting the flow of patients allowed to receive treatment in another EU country, the UEHP points out that the European Parliament has repeatedly urged Member States to use the whole supply, public and private, available at national level. In this regard, it is interesting to note the provision in the draft Directive, which states that the rules laid down shall apply to health care “regardless of their public or private nature.”
In conclusion, impartial and effective use of the whole wealth of expertise and facilities, public or private, available at national level, would limit the use of services in other EU countries, without imposing regulatory barriers to European citizens’ freedom of choice. In fact, this right is among the basic guidelines of the EU, together with the guarantee of high quality and security of health care service and fair competition between providers on both national and Community level.
A Community legal framework concerning Services of General Interest is necessary in order to guarantee optimal legal safety in connection with the basic conditions of benefits of Healthcare services, which must ensure certain fundamental social values of "welfare" such as quality and equal access, whilst respecting the principles of competitiveness. In this prospect it is important to define in a Mobility Directive certain fundamental criteria such as
- Citizen’s freedom of choice
- Adequate and rapid delivery of requested services
- Quality and safety Healthcare
- Independence of Quality Control Organisations at a National Level
- Equity of all health providers, whether public or private.
- Utilisation of the entire National Health service offer, accredited Public and private healthcare providers
- Competitiveness amongst a plurality of Healthcare providers.
- Resources allocation based on optimisation criteria in relation to expenses/profit.
The definition of these basic principles at a community level respect the principle of subsidiary, according to which the services of the various systems and regimes thus organisation, remain the responsibility of the Member States. Indeed there would have to be an agreement of national authorities to guarantee:
- Equal access conditions for citizens and the accreditation agreement of health service providers
- Transmission of objective information, symmetrical and detailed, in regards to the entire European and National Health care offer.
- Continuous improvement in quality through arrangements on rules and fair controls by independent institutions
- Financing of services on the basis of precise and homogenous remuneration criteria for the public or private health care accredited providers.
Remarks on Fundamental Questions
Directive Field of Application
The exclusion of sanitary services in the field of application within the Internal Market Directive required clarification. UEHP considers that the field of application of the last proposal for a Directive presented by the Commission was subsequently reduced. UEHP thus, recognises the importance of the question raised and knows the need of a precise regulatory framework for sanitary services however, criticises the fact that the question is limited to patient mobility and that it has remained static without having brought new elements to the discussion.
In this respect UEHP shares the observations presented by the French Presidency of the EU: « the jurisprudence of the ECJ related to the freedom of movement of services and healthcare services, covers a broader field since they are also concerned, for example, the acts of the authorised professionals or the supply of medical devices. The field of application of the Regulation 883/2004 is also broader since it includes all services of the legal system of health insurance. ... Yet the Directive proposal called for codification of the entire jurisprudence of the ECJ relating to the reimbursement of Cross-boarder health care. In this context, the presidency proposes to broaden the field of application of the directive and to include health care : All healthcare services and treatments provided or prescribed by a healthcare professional legally exercising in the country of treatment. ”The Legal security’s priority is to aim to consider the jurisprudence of the Court of justice related to Patient mobility in order to classify within a more general and coherent framework the principles established in specific cases. Transparency must be guaranteed not only on the level of freedom of choice and access to services by the European citizens, but also with regards to the freedom of service of the professionals and the healthcare structures, not forgetting freedom of enterprises which is fundamental within this framework. It is also necessary to take into account the current private sector’s offer within the framework of national systems (or it is important to guarantee the performance of services as a plurality of public and private structures) and at a European Level, locating the centres of reference in the EU.
Definition of Health services and of hospital care
UEHP reaffirms the position adopted in agreement with other European Organisations1: “A group of experts should work with Member States and the Commission to develop a common-sense framework for defining hospital care that neither restricts nor extends the intended scope of prior authorisation. The question of who defines hospital care is significant. If the Directive’s proposed definition is adopted some hospital activity may be excluded (in particular some day case surgery). However, if Member States are given sole responsibility for defining hospital care there may be inconsistencies that hinder patient mobility. It is therefore important that a consensus is reached around definitions of hospital care that provides clarity for patients and Member States alike.”
In particular UEHP believes that in the definition of hospital assistance it is important to remind that many treatments, in particular specialised ones, must necessarily be provided within the framework of hospital admittance so that the safety of the patient is fully guaranteed. Concerning healthcare establishments, it is necessary to consider the role and the positioning of the private healthcare sector within a mixed national health care system (where private and public healthcare sectors are both operating) present in various Member States. Besides, it is necessary to recognise that the accredited private healthcare establishments provide services of general interest. For this reason, from a regulatory point of view, they are comparable to public health care structures particularly because they allowed Patient’s free choice and the possibility to access these establishments also in member states outside the patient’s country of origin.
Consequently UEHP considers the fundamental importance, that healthcare and hospital treatment is framed within a broad scope of services of general interest and that in that context, equality between the public and private institutions is reaffirmed.
The citizen’s fundamental rights, such as health, have to be legally guaranteed at a European level, particularly concerning equity of access and freedom of choice of the healthcare professional and structures in the European Union. Through this perspective, a chart of patient’s rights ought to have ethical and political value, but also legal and obligatory content.
Consequently a Directive must precisely state that freedom of choice is the basic principle, except the safeguard clause notified or justified by member states. Notably, the cross-boarder freedom of choice allows patients to avoid long waiting lists, in compliance with the judgements of the European Court of Justice.
Preliminary authorisation and reimbursements
Concerning preliminary authorisation, the proposition limits reimbursements of treatments received in other Member States ought to be limited to health care covered by the National Health System. This statement seems restrictive, in relation to the jurisprudence of the European Court of Justice. In fact the fundamental criteria to access the health system of another state ought to be only a justified health-care necessity, and the professional validity of the care, as recognised by the International Community of Healthcare Professionals. Every National law must precisely state in their standard rules of Social Security or within a framework of healthcare services, the basis of non-discriminatory reimbursement, which would be applied at the time of the provision in another Member State.
Regarding Social Security Institutions, it is important to establish common rules, between the centres which demand compulsory Social Security from the patient and centres which function on a basis of National Health Services, notably, for what concerns the financial aspect of compensation of healthcare treatments received in other member states. Incentives in favour of competition must thus be introduced in the financial side of health services, not only by the side of services offered.
Quality and Security of care
The Patient’s freedom of choice is a fundamental element for Quality. In fact it stimulates competitiveness by encouraging the national health systems to ameliorate their performance in the services offered to finally become competitive in Europe. The EU’s Social internal cohesion would improve, promoting quality, security and accessibility of healthcare services at a common European level. Having said that, it would allow the EU to obtain a certain internal equilibrium, reducing the risks of overcrowded waiting lists of various Systems and meanwhile safeguarding a satisfying protection in Health. Patients must have access to information, meaning to say, that they must know if an accreditation system exists or if a hospital is accredited and disposes an evaluation system of Quality and Risk management. Mobility involves the respect of essential levels of consistent quality in all the EU member states, to finally safeguard patient security. The authorities of the hosting countries must respect the same Quality and security guarantees for treatments, both for national and foreign patients.
The related aspects of quality treatments can be favoured by voluntary initiatives, which aim to ameliorate this Quality (Indicative clarification of Quality measures, exchange of good practice, « benchmarking » procedures, etc.). However, it is necessary that healthcare professionals and healthcare establishments are subject to Quality control, anticipated by National law, lead by the third party independent organisations. It could also be foreseen, the obligation to organise Quality evaluation and risk management programmes in every member state.
Authority and Service provider’s Responsibility
In what concerns Clinical errors, the responsibility is defined by national law, which is normally imputed to the practitioner and in certain particular cases, to the treatment team responsible, thus the service providing structure, which would be charged with the responsibility of compensation. In case of the use of these services in a foreign country (see patient mobility), the service provider has the same responsibility towards the foreign patient and the residential patient, according to the laws applied in the country where the health services are provided. When the patient returns to his country, if this occurs, the Foreign Service provider has to allocate the remaining treatment to a colleague. This will transfer the control and the vigilance to a new service provider under safeguarding authority surveillance of the patient’s country. We could foresee a compulsory insurance so as to cover the related responsibilities and the compensations
All the subjects involved have the right to obtain clear information regarding access to health providing services in other member states, according to their appropriate demands. The authorities must be informed of the dimensions and formation of the offered and demanded services, as well as for the quality standards and security guarantees of the country itself. The purchasing body must be informed of the prices and the quality of services. The service providers must be informed of the accreditation conditions (convention), the remuneration criteria and the predicted flow of patients, so as to be capable of plan the services, which would be offered. The patients must be informed of the different treatment possibilities, the healthcare delivery conditions and how to access complaints in case of prejudice.
Migration flow of patients
The cross-boarder free choice allows the patient to avoid long waiting lists, in compliance with the judgements of the European Court of Justice. None the less, the flow of patients from one country to another does not reach great scales, so considerable that it can increase the waiting time for patients in their own country. The impact of cross-boarder healthcare does not appear to carry risks to a national system’s equilibrium, in relation to financial sustainability, because impact of the benefit received in another Member State on the global public health expenditure does not currently exceed 1%. In light of this, it is necessary to know certain data on patient flow to enable the clever programming of an appropriate offer. Generally, citizens prefer to be treated close to their residence, which implies that the number of foreign patients (who wish to seek treatment in another Member State) is not so large that it could undermine the balance of a Quality national service accessible to all patients. Within this context, it is necessary to evaluate the differences between the national systems, taking into consideration the contribution of the private sector in the pursuit of better efficiency, performance, accessibility and financial management of healthcare services. In particular the value of the private healthcare offer would allow the shortening of waiting lists, thus avoiding an exaggerated increase of patient flow towards other member states, yet, without creating obstacles in mobility or freedom of choice. As recommended by the European Parliament, it is appropriate to optimally use both public and private health services available in a member state, in order not to increase, in an excessive manner, the need for foreign treatment. In this specific case, we are speaking of the accredited private structures, which operate within the interior national health system or else in agreement with compulsory social insurance.
Uehp asks to respect those important principles:
- The patients right to freedom of choice for best quality of services
- The classification of healthcare services in the framework of services of general interest, essential principle in all internal market activities, and particularly required for an efficient cross border healthcare.
- The Directive should apply to provision of healthcare regardless of how it is organised, delivered and financed or whether it is public or private, as both private and public healthcare institutions equally provide services of general interest.
With our best regards,
The European Union of Private Hospitals
1 Standing Committee of European Doctors (CPME) European Federation of Nurses Associations (EFN) European Health Management Association (EHMA) European Patients’ Forum (EPF) European Public Health Alliance (EPHA).