Only less than a half of people know what they can claim within their national healthcare system. Paul Belcher from the European Public Health Alliance clearly expresses it: „Patients do not know yet what advantage cross-border healthcare brings.“ Foto: Wikimedia/ZD koláž

Does planning of medical care abroad pay off? EU Directive versus reality

Rampant bureaucracy and lack of information – these are the main reasons, why EU citizens do not seek cross-border healthcare. Notwithstanding medical treatments in other EU countries can be cheaper.


Already in 2011 The European Commission issued the Directive on the application of patiens‘ rights in cross-border healthcare. The aim was to support patients‘ mobility within the EU and to clarify their rights to healthcare outside the country where they pay their healthcare insurance. According to the Directive, EU citizens can choose the country where they are going to receive medical treatment.

Nevertheless it clearly ensues from the latest Report on the operation of the Directive that patients rarely use this opportunity. Although the Directive should have been implemented by all of Member States in 2013. So what prevents EU citizens from having their teeth treated or having their eye operations done in neighbouring countries?

Denmark reimburses healthcare abroad the most

The major obstacles are placed in the way of patients by health systems of their domiciliary countries. They often require prior authorization for planned treatment abroad. If a home state does not authorize a certain medical intervention planned abroad for its citizen he/she has to pay for that alone, as the Report points out the potential problem.

As well as nearly wherever in healthcare, money is the most decisive issue in this area, particularly in reimbursing for medical treatment. In optimal case, patient’s cross-border healthcare should be reimbursed by the patient’s home state. However this situation is rather far from the reality because a home Member State itself determines how much money a patient will be reimbursed with respect to the cost of a medical treatment in a local public health sector. That is why wealthier countries utilize opportunities for cheaper healthcare abroad more than their poorer neighbours. An example can be frequent visits of Italian patients at dentists‘ in Croatia.

Only 20 states in Europe keep statistic data for cross-border healthcare of their citizens. There were 40.000 applications for reimbursement for health treatments, having been planned in advance and undergone by patients in another Member State, recorded in 2014. These cases did not concern unplanned treatments or emergencies occurring usually on holidays. Nearly 75% of all applications for reimbursement for healthcare in the EU were applied by patients in Denmark. The possibility of reimbursement of cross-border healthcare is also plentifully used by Frenchmen, Luxembourgers and Finns. On the contrary Austria, Bulgaria, Cyprus, Estonia, Greece and Portugal did not reimburse a treatment abroad even to a single patient. For example: In recently so much watched Greece, only one Greek has applied for reimbursement this year – unsuccessfully.

Reimbursed treatments must be beforehand approved of

Although there are 85% applications for cross-border healthcare reimbursed on average, patients do not tend to make use of this opportunity. They are most frequently deterred by the slow process in which they must first apply for prior approval of their treatments and afterwards for reimbursement. Many patients beforehand give up such a double clash with bureaucracy and so therefore they loose the possibility of reimbursement for the cost of care.

The Report criticizes that it is not clearly defined in many Member States what kinds of care they reimburse to their citizens. E. g. a half of EU states require patients to obtain permission for treatment in case of healthcare connected with hospitalization or in case of „highly specialized treatment“. However, a majority of countries do not define at all what treatments belong to the sort of specialized care. By information of Healthcare Insurance Companies, such an unclear definition leads to excessive number of applications for approval of medical treatments abroad. Only seven countries do not require any prior authorization from their citizens. These states are Austria, Estonia, Finland, Lithuania, Netherland, Sweden and Czech Republic.

Some countries do not consider prices in public health system as a base for determination of reimbursement for cross-border healthcare, but the reimbursement tariff for patients is based on the costs at private health sector (which is lower than the rate for public providers). So patients get back less money. Other countries require that a treatment of a patient at a specialist’s abroad should be approved of by his/her GP. A frequent obstacle is also requirement for professional translation of medical documentation.

Patients do not know about the possibility of reimbursement

Lack of information is another obstacle hindering from easier using cross-border healthcare. According to a Eurobarometer survey, 78% citizens of the EU have no information about what sort of medical treatment abroad they are entitled to get reimbursed by their home states. It is not surprising, however. For example: only less than a half of people know what they can claim within their national healthcare system.

Paul Belcher from the European Public Health Alliance clearly expresses it: „Patients do not know yet what advantage cross-border healthcare brings.“

There are „National Contact Points“ (NCP), founded in Member States with the goal to contribute to better patients‘ awareness. Czech Republic has such a Point working under the Centre for International Reimbursement. The insured can get to know what everything they can claim abroad on Some NCPs in other countries are based and administered in the Ministry of Health, other in the healthcare insurer and other in independent bodies. The European Commission points out that there are big differences in activity among single NCPs. Those least active do not solve more than 10 inquiries a month. The most active NCPs are those in Germany and Finland solving hundreds inquiries.

According to the European Patients‘ Forum, National Contact Points are entirely essential for successful utilization of cross-border healthcare. Forum recommends that each Point should have „a checklist“ ready for any applicant for cross-border healthcare, including information about an individual plan of treatment, expenses and possibilities of their reimbursement.

The EU strives for the unification of medical information

The Directive on the application of patiens‘ rights in cross-border healthcare also enables the mutual recognition of medical prescriptions between Member States. Such a prescription should contain not a particular name of pharmaceutical product but an international designation of adequate effective substance.

The Directive also supports formation and development of the European Reference Networks (ERNs). These Networks should associate healthcare providers and Centres of Expertise (in particular in the area of rare diseases).

By assumption, the networks should mutually exchange information and experience between EU countries. During 2016 healthcare experts will suggest what specialized networks will be particularly established and developed.

A similar role has a network to eHealth. This has already adopted guidelines on patiens‘ data and health documentation and electronic prescriptions.

Unfortunately this case of the Directive demonstrates that EU Member States do not often respect too much the decisions that they agreed to. Governments undertook to implement the Directive by autumn 2013. However, a majority of Member States have done it only in 2015. Almost 2-year delay is another reason why reimbursement for cross-border healthcare is minimally used.

Gita Zenknerová, translation – pk-