Association Internationale de la Mutualité Europe in health: the impact of ECJ decisions on healthcare systems Willy Palm AIM Director Palma de Mallorca,

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)