EU schemes set up to encourage patients to cross borders for treatment have enjoyed little take-up. Jon Sussex looks at the reasons why

Patients in the European Union may hope to bypass waiting lists by travelling to another country for treatment, or perhaps to receive types of care unavailable at home, but the numbers that do so are small.

Despite expectations of rapid growth following the April 1998 Kohll and Decker rulings of the European Court of Justice, cross-border healthcare in the EU remains small-scale. The funders of healthcare might be attracted by lower prices in other countries, but if so they have had little success in steering patients towards them.

A recent article in HSJ showed a wide range of prices charged for elective procedures across Europe and looked forward to increasing crossborder patient flows in consequence.

1The experience of the EU's 'Euregio' projects suggests, however, that even concerted efforts to increase such flows come up against barriers. The NHS's experience with the internal market suggests some of the reasons for this. Also, piecemeal judgements by the European Court and the lack of a clear EU policy are adding uncertainty.

The inter-regional programme of the EU has set up projects in border areas - referred to as 'Euregios' - with the aim of making it easier for people living near the border of an EU member state to access health services that are provided nearby but in another EU country. A study of three such projects shows how difficult this can be.

2The Euregio Meuse-Rhine project tried to make it easier for residents in this Belgian-Dutch-German border area (see map) to access hospital care across borders. Two Belgian hospitals (in Liège and Genk), one German (Aachen) and one Dutch (Maastricht) were involved. In the latest stage of the project, since April 1997, the health insurers have agreed that everyone living in the Euregio qualifies for basic medical care (excluding very expensive treatments) at the provider of their choice, including those across the border.

The Netherlands has a primary care doctor gatekeeping system, so Dutch patients still need to be referred to a foreign hospital by a doctor. Both doctors and patients were informed of the new arrangements.One of the Dutch insurers, CZ Groep, set up contracts with the German and Belgian hospitals to provide for its insurees. But in the first two years of the project only 600 patients resident in the Netherlands sought care in Belgium or Germany, and 20 per cent of these were German nationals living in the Netherlands. The reluctance of local doctors was a factor.

The January 1997-May 1999 project in the Euregio Rhine-Waal on the Dutch-German border sought to help residents on the German side gain access to certain specialties provided at the University Hospital of Nijmegen in the Netherlands. The specialties were renal transplant, open heart surgery, neonatal intensive care, dermatology, radiotherapy and trauma care. For many people the nearest German providers were much further away than Nijmegen. But the number of German patients crossing to Nijmegen during the project was estimated as representing less than 1 per cent of potential patient need for specialist care, and crossborder care accounted for only 0.35 per cent of the total yearly budget of the Nijmegen hospital.

Some of the German doctors' reluctance to refer patients to the Netherlands was apparently due to not wanting to take income away from German providers. Arguably, if the project had been set up also to ease the flow of Dutch patients to German hospitals, some of this reluctance may have been avoided. The geographical distribution of hospital services in the area makes it unlikely, however, that flows from the Netherlands to Germany would have been significant.

The third Euregio example highlights the problems that can arise when cross-border patient flows appear to threaten the viability of the 'home' hospital in a region. The Euregio Scheldemond straddles the Dutch-Belgian border in Flanders. It includes a Dutch population separated from the rest of the Netherlands by the Wester Schelde estuary, whose natural hinterland is therefore across the border to the south in Belgium. The Scheldemond project started formally at the end of 1997, following two years of prior co-operation, with the aim of improving cross-border access to healthcare.

The plight of the relatively small hospital at Terneuzen in the Dutch part of the Scheldemond region is of particular interest. Terneuzen has been losing business to larger and more specialised Belgian hospitals, but it has strategic political importance. In order to keep some hospital infrastructure in Dutch Flanders, Terneuzen is unlikely to be permitted to become merely a satellite facility of a Belgian hospital. The Dutch system of block contracting provides little information on costs per case or procedure to compare with Belgian hospital charges.

These three projects cover areas where cultural differences between populations either side of the national boundaries are small. But barriers remained which kept cross-border healthcare small (see box).

The judgement in the Kohll case explicitly noted that a member state's need to maintain a balanced medical and hospital service open to all could provide a justification for denying EU citizens the right to be reimbursed for unauthorised, nonemergency hospital-based care obtained abroad.

The advocate general has reiterated this view in his opinion on the Smits-Geraets and Peerbooms cases now before the court. Unlike Kohll and Decker, these cases explicitly concern requests for reimbursement for hospital care obtained abroad without prior authorisation by the payer.

Also, while care obtained abroad under the existing EC Regulation 1408/71 is reimbursable at tariffs prevailing in the country where the care is obtained, the Kohll and Decker rulings provided for reimbursement at tariffs prevailing in the member state in which the patient is insured. Consequently, member states fear financial consequences that would arise from additional demand for services.

This might happen, for example, where patients travel to avoid a domestic gatekeeper system, or to circumvent waiting lists at home.

Finally, there are the as yet unresolved legal and administrative questions about whether, and if so how, the European Court judgements apply to all types of member states' health systems. The Kohll and Decker rulings were for the Luxembourg system of restitution insurance, where patients first pay licensed providers for medical services and are then reimbursed the costs of their treatment by their insurer. The other main type of insurancebased healthcare is a benefits-in-kind system, as in the Netherlands and Germany.With this, affiliation to a health insurance fund provides a patient with access to contracted medical professionals without direct payment for services. Further cases have been referred to the European Court by Dutch courts expressly to determine whether the Kohll and Decker rulings apply to the Dutch system of financing healthcare.

The opinion of the advocate general in the SmitsGeraets and Peerbooms cases suggests that the Dutch benefits-in-kind system, unlike the restitution system in Luxembourg, does not constitute a 'service' under the terms of the EU treaties, since no direct payment or reimbursement of money is involved. If upheld by the European Court, this view implies a two-track system under which patients in some healthcare financing systems would have a right to movement across national boundaries not afforded to patients in other systems. As yet untested is the possible legal and administrative application of Kohll and Decker principles to tax-based, benefits-in-kind systems, which now make up majority practice among EU member states.

It seems improbable that such a two-track system could be countenanced politically. But a political solution to apply throughout the EU is not yet in sight. A single European market in healthcare still seems a long way off.

Key points

Expectations of significant numbers of patients crossing borders within the EU for treatment have not materialised.

This is despite the establishment of projects in border regions designed to increase the number of patients going outside their own country for treatment.

Doctors'reluctance to refer patients outside their own country may be a factor in this.

There are still legal and administrative uncertainties about reimbursement for care in another country.

Barriers to cross-border care Patient and doctor unfamiliarity with the cross-border healthcare system.

Satisfaction with the 'home'healthcare services.

Bureaucracy costs involved in accessing, and then being reimbursed for, care in another country.

Uncertainty about cost and quality differences.

Desire not to threaten the financial stability of the healthcare infrastructure in the 'home' country.

Jon Sussex is associate director, Office of Health Economics