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Europe in health: the impact of ECJ decisions on healthcare systems
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Transcript of Europe in health: the impact of ECJ decisions on healthcare systems
Association Internationale de la Mutualité
Europe in health: the impact of ECJ decisions
on healthcare systems
Willy Palm
AIM Director
Palma de Mallorca, 15 June 2004
Association Internationale de la Mutualité(AIM)
(www.aim-mutual.org)
Access to quality health care
Solidarity
Selfgovernance
Social profit
Compulsory health protectionin the European Union (EU15)
D
NL
Income ceiling
A B
L
no income ceiling
social insurance
DK
IE
I
SW FIN
national health service
access to health care
E
P
UKF
Implication of mutual health funds in statutory protection
categorial universal
GR
Voluntary protection in the EU (15)
Statutory
Voluntary
A B
F L
no income ceiling
D
NL
income ceiling
social insurance
DK
IE
E
P I
GR UK
SW FIN
universal
national health service
access to health care
categorial
Implication of mutual health funds in voluntary protection
SUBSTITUTIVE
COMPLEMENTARYSUPPLEMENTARY
Health systems and EU law
Public health
Health care
Social security
FREE MOVEMENT
Health systems and EU law
Public health
Health care
Social security
FREE MOVEMENT
Health systems and EU law
Public health
Health care
Social security
Social security coordination
Insured person identity details
Application specific dataApplication
specific data
Card related details
“Another piece of Europe in your pocket”
A health insurance card which will, on top of all other objectives, foster intra-EU mobility
FREE MOVEMENT
Health systems and EU law
Public health
Health care
Social security
Free settlement of healthcare providersFree movement of
medical goods
limitations justified on grounds of
public policy, public
security or public health
Article 152 EC Treaty
1. A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities.
Community action, which shall complement national policies, shall be directed towards improving public health, preventing human illness and diseases, and obviating sources of danger to human health. Such action shall cover the fight against the major health scourges, by promoting research into their causes, their transmission and their prevention, as well as health information and education.
(…)
5. Community action in the field of public health shall fully respect the responsibilities of the Member States for the organisation and delivery of health services and medical care. In particular, measures referred to in paragraph 4(a) shall not affect national provisions on the donation or medical use of organs and blood.
Association Internationale de la Mutualité
Basic principles of the ECJ rulings
Social security and health care are competence of Member States but it does not preclude respecting Community law
Free movement of goods and services applies to health care, regardless of the type of care (in- or outpatient) and the type of coverage (reimbursement – benefits in kind)
Prior authorisation is an obstacle to free movement
Can be justified to:1) Preserve the financial
equilibrium of the social security system
2) Maintain a balanced medical and hospital service and accessible to all
3) Maintain medical capacity and expertise on the national territory, essential for public health
As far as It is necessary and
proportional The criteria used are
objective and non discriminatory
Patient mobility
Prior authorisation is justified:
importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care
Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment
Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history
Prior authorisation is not justified:
no spectacular increase of cross-border mobility to be expected
Cover remains subject to levels and conditions as defined by the home state
Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria)
in-patient careSmits-Peerbooms
Van Riet
out-patient careKohll-Decker
Müller-Fauré
Patient mobility
Prior authorisation is justified:
importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care
Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment
Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history
Prior authorisation is not justified:
no spectacular increase of cross-border mobility to be expected
Cover remains subject to levels and conditions as defined by the home state
Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria)
in-patient careSmits-Peerbooms
Van Riet
out-patient careKohll-Decker
Müller-Fauré
How to distinguish?
Patient mobility
Prior authorisation is justified:
importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care
Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment
Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history
Prior authorisation is not justified:
no spectacular increase of cross-border mobility to be expected
Cover remains subject to levels and conditions as defined by the home state
Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria)
in-patient careSmits-Peerbooms
Van Riet
out-patient careKohll-Decker
Müller-Fauré
Should I wait or should I go?
Patient mobility
Prior authorisation is justified:
importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care
Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment
Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history
Prior authorisation is not justified:
no spectacular increase of cross-border mobility to be expected
Cover remains subject to levels and conditions as defined by the home state
Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria)
in-patient careSmits-Peerbooms
Van Riet
out-patient careKohll-Decker
Müller-Fauré
How solid is this justification ground?
Patient mobility
Prior authorisation is justified:
importance of hospital planning to guarantee rationalised, stable, balanced and accessible supply of quality care
Can only be refused if same or equally effective treatment is available without undue delay in a contracted estalishment
Undue delay: take into account actual medical condition (incl. degree of pain and nature of disability) and medical history
Prior authorisation is not justified:
no spectacular increase of cross-border mobility to be expected
Cover remains subject to levels and conditions as defined by the home state
Member States are allowed to fix reimbursement amounts to which cross-border patients are entitled (provided they are based on objective, non-discriminatory and transparent criteria)
in-patient careSmits-Peerbooms
Van Riet
out-patient careKohll-Decker
Müller-Fauré
How low can we go?
Watts case (UK)
Mrs. Watts (72) waiting for an urgent hip replacement surgery by the NHS Oct. 2002: classified as routine case – consultant’s
waiting lists is approx. 1 year Patient’s PCT: undue delay > NHS plan targets = 12
months Feb. 2003: Mrs. Watts reprioritised as a “soon case” (3-
4 months) because of deterioration of her clinical condition
Operation performed in France on 7 March 2003 Referral to ECJ: Reimbursement for costs incurred
Association Internationale de la Mutualité
Increased impact from EU economic law
Health care is economic but obstacles may be justified by reasons of general interest (Kohll-Decker & co)
Social security is non economic but social security institutions can be seen as enterprises(Poucet-Pistre, Höfner-Elser)
Purchasing of health care must observe public procurement rules (Tögel)
Competition rules may apply unless they obstruct tasks of general (economic) interest (art. 86.2 ECT)
Commission/France (C-496/01)
Clinical laboratories Administrative autorisation: requirement of business seat
in France Refusal of reimbursement of services provided by foreign
laboratories
Appreciation of the Court: contrary to the principle of free service provision Conditions imposed by France are not justified by the
objectif of public health protection
AOK e.a./Ichthyol-Gesellschaft Cordes
Sickness funds are no enterprises Participating to management of social security system
= an exclusively social function, which is founded on the principle of national solidarity and is entirely non-profit-making.
No influence on benefits “Solidargemeinschaft”: risk structure compensation Competition element (premiums) serves the specific
goal of good management of social security determining the ceilings for certain medicines = not
economic Social security management task imposed by law No proper interest
High level reflection process on patient mobility and EU healthcare developments
(2003) Develop a shared European vision on
how EU can contribute to national health policy objectives
More cooperation to better use healthcare resources
Sharing information on health care High Level Group on health service and
medical care
Conclusions
Indirect impact of EU integration
How to balance (national) social and public health objectives against (EU) internal market principles?
Need for a genuine (integrated) health policy at EU level
Communication on social and health services of general interest (2005)