MEDICINE, LAW & SOCIETY
Vol. 9, No. 2, pp- 101 - 120, October 2016
Different Approaches to Cross Boreder Mobility of
Patients in the European Union in Czechia, Slovakia
and Poland
FILIP K *
Abstract Czechia, Poland and Slovakia are neighbour countries with
similar history and socioeconomic conditions. They share heritage of
socialized healthcare. Nevertheless, they adopted different policies
Accession to coordination of social security establishing assistance
for tourists was smooth. Providers offer quality care for good prices.
Foreign patients come to all three countries. Right for
reimbursement of treatment intentionally sought across borders was
created by the Court of Justice already before their accession.
Neve
Czechia supported it, Slovakia abstained and Poland refused.
Numerous Poles seek treatment abroad and ask for its
reimbursement, while implementing legislation barely complies and
authorities are tight-fisted. Few Slovaks do it in accordance with
rules adopted with cautiousness. Czechs ignore this opportunity
despite official benevolence. Quality of healthcare, various pricesetting
and peculiarities of public financing explain this difference.
KEYWORDS: European Union Free movement of services and
goods Medical tourism Public financing of healthcare
rights
CORRESPONDENCE ADDRESS Masaryk
University -60177 Brno, email: Filip.Krepelka@law.muni.cz.
DOI 10.18690/24637955.9.1.101-120(2016)
ISSN 2463- University of Maribor Press
Available online at http://journals.um.si.
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F. K epelka: Different approaches to cross-border mobility of patients in the
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1 Introduction
While being teacher of both law of the European Union and healthcare/medical
law, I am continuously interested in European integration of healthcare.
Considerable specifics of the East persist despite integration of Central European,
Baltic and Balkan countries it this supranational structure. There are different
political, economic and social conditions in these countries. Some ones are relics
even perpetuated.
Research projects addressing integration often focus situation in the elder member
states, especially those ones in its core along Rhine.1
Therefore, I was glad to be
Regulation in the European Union; A Policy-Cycle Study of Complex Decision
2
supported by the Danish Research Council. The
project addressed political aspects of healthcare integration starting with the caselaw
of the Court of Justice establishing right for reimbursement of non-urgent
healthcare found in the other member states stabilized with the Directive
-border Healthcare.
Coordinator of the project Dorte Sindbjerg-Martinsen with Karsten Vrangbaek
point out that even Denmark as an elder member state with national healthcare
service system is distant from efforts tailored for the member states with public
health insurance (Martinsen & Vrangbaek, 2008). Nikolay Vasev and Karsten
Vrangbaek described the participation of new member states at the beginning as
various modes of compliance with the case-law and the Directive (Vasev,
Vrangbaek & Krepelka, 2016).
Czechia, Poland and Slovakia are neighbours with shared history and similar
economic, political and social conditions. Nevertheless, Czechia supported the
Directive, Poland refused it and Slovakia abstained. The last two countries feared
outflow of money with outgoing patients and indeed face it.
I find information in the two countries thank knowledge of their languages. It is
insufficient to rely on English summaries and presentations. I had also an
opportunity to discuss the topic of cross-border healthcare with experts in
Slovakia and with legal scholars in Poland.
I thank for opportunity to present detailed results of the research in journal
Slovenia is another new member state with heritage of nationalized healthcare also
involved in cross-border healthcare.
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2 Integration of healthcare in the European Union
Free movement of patients started with journeys for privately paid treatments.
This movement was unhindered. There is little justification for control of nationals
undergoing treatment abroad. Relaxation and cessation of migration controls made
it impossible. Liberalization was thus confirmed accidentally due to restrictions of
related payments in Luisi and Carbone.3
Freedom was guaranteed thanks European integration even for individuals seeking
treatment restricted in their home member states such as abortion4
and assisted
reproduction.
The European (Economic) Community addressed medical aspects of migration
among growing number of the member states with regulations for coordination of
social security 1408/71, later replaced with regulation 883/2004.
Migrant workers, self-employed persons and their family members nationals of
the member states enjoying broad migration rights, but later also resident aliens shall
enjoy publicly financed healthcare in host member state. They pay taxes and
contributions there. Commuters and family members left in home member state
can opt and enjoy coordinated financing respectively.
Real benefit of integration is public financing of urgent treatment of tourists.
Reimbursement channels developed within the legal framework. Its ubiquity is
symbolized with standardized European Health Insurance Card (EHIC) issued
now for half billion Europeans.5
Public financing of medical treatment sought and found in other member state
than state of affiliation was and is feasible for countries lacking capacities for
specialties or facing shortcomings. Mentioned framework established one channel
for it. Other arrangements are not excluded.
While interpreting free movement of services and goods, the Court of Justice
established in Kohll6
and Decker7
an individual right for public financing of
treatment and medical device intentionally sought in the other member states.
This approach was questioned by the member states fearing destabilization of
healthcare and claiming their competence to organize and finance it.
Despite it, the Court sustained in subsequent judgments8
Vanbraekel, Millerand
Petru
right for reimbursement of non-urgent treatment sought and found abroad despite
various models of public financing. Nevertheless, safeguards for hospitalizations
and expensive treatments were recognized by the Court facing extraordinary
pressure of the member states.
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which further softened requirements of the Court of Justice (Hatzopoulos &
Hervey, 2012). It required implementation with national legislation until October
2013. We can thus estimate first outcomes of this effort.
3 Implementation of the case-law and the Directive
3.1 Czechia
Above summarized case-law was respected by Czech public health insurance
funds with tacitly agreed policy under auspices of the national contact point
were granted in most cases. No action was brought to the courts until 2013 when
one specific case was pending.9
As mentioned, Czechia supported the Directive. Transposing legislation was
adopted in April 2014 with amending
(the Act of Public Health Insurance).
Seven months delay was caused with cabinet crisis and early election. The
substance was uncontroversial. Competence to enact the list of treatments
requiring prior authorisation is curtailed.10
No list was adopted since then. Czechia
thus joined few member states enabling any reimbursement without prior
authorization.
(CMU, Centre for Interstate Payments) renamed in
2016 (KZP, Chancellery of Health Insurance)11
established by public health insurance funds under auspices of the Ministry of
Healthcare after the accession in 2004 for interstate payments according to the
regulations developed into excellent institution assuming also role of the national
contact point despite long lasting lack of legislative recognition.
3.2 Slovakia
There was scarce information about impact of case-law after the accession of
Slovakia. The funds balanced permissive and restrictive approach towards
sporadic requests.12
They escaped both media coverage and judicial review.
Slovakia transposed the Directive with detailed amending
o (Act on Health Insurance) with
considerable impact on related and simultaneously adopted ministerial decree
specifying list of treatments whose reimbursement requires prior authorization
with
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The national contact point for realization of rights resulting from the Directive and
for coordination is which is
national supervisory authority for healthcare.13
3.3 Poland
Case-law of the court of Justice was argued by many Poles in actions against
denial to reimburse. Nevertheless, administrative courts often refused actions of
patients claiming reimbursement of treatment sought, found and paid in the other
member states. Argumentation reveals limited significance of the case-law of the
Court of Justice.14
The situation reversed in the period for implementation of the Directive known
simply as dyrektywa transgraniczna (cross-border directive) and after its elapse.
The Directive was swiftly applied according to settled case-law establishing its
direct effect towards state few months after the implementation deadline.15
Poland implemented the Directive with considerable delay in November 2014
after intense deliberation with amendment16
of
ych (Act on Healthcare Services
Financed by Public) adopted in 2004.
Unsurprisingly, related legislative provisions and adopted decree define treatment
whose reimbursement requires prior authorization extensively as any
hospitalizations, expensive pharmacotherapy plus numerous diagnostic methods.
Procedure for reimbursement is cumbersome. Limits are fixed with legislation17
for annual expenditures of the Narodowy fundusz zdrowia for various regimes of
cross-border healthcare sought by Poles abroad.
Central administration of the Narodowy fundusz zdrowia is designated as authority
for coordination and the national contact point.18
4 Mobility of patients
4.1 Czechia
Great Britain was described to be in splendid isolation in 19th
century due to its
refrain from alliances with European countries albeit it was centre of international
trade. Czechia is not closed hermetically as regards cross-border movement of
medical services.
The number of Czechs treated abroad reached thousands per year during last
decades. Czechs realized in the first years of free travelling that urgent treatment
abroad can be exorbitantly expensive. Travel insurance has become routine
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solution. The number of foreigners treated in Czechia is even bigger. Millions
tourists visit Prague annually. Thousands need medical help due to sudden illness
or injury.
Several tourists from other European countries enjoy reimbursement of their
healthcare according to mentioned rules. Many injured and ill tourists rely further
on their travel insurance due to its advantages such as instant phone and e-mail
assistance in case of disease and injury, reimbursement of prices claimed by
providers above reimbursed public rates, coverage of healthcare provided by
providers uncontracted for public financing and expensive repatriation. Many
Czechs abroad also prefer this way.19
Immigration and emigration has also consequences for public financing.
Residence has become criterion for affiliation instead of citizenship. Immigrants
are included an expatriates excluded. Citizens of the non-member states with
medium and long-term residence are excluded from public health insurance. Their
mandatory insurance is the most important commercial insurance in Czechia.
However, it has considerable exclusions. Urgent treatment must is provided to
uninsured foreigners and unpayable debt emerges. Ombudsman and human right
activists criticize the exclusion.20
On the opposite, Czechs can return easily to the
system providing comprehensive care for free with restoration of their residence in
Czechia. They can be perceived as free-riders while they escape contributions.
The biggest money transferred among authorities relates to commuting workers both
Czechs abroad and citizens of the other member states commuting to Czechia
- affiliated in the member states of their employment, but treated in their country
of residence. However, I suggest ignore the phenomenon while addressing crossborder
movement of patients. These people are treated in their home state. Solely
money for it crosses border.
Medical tourism emerged during last decades. Several providers started to offer
their medical services for paying patients for treatment unavailable, restricted or
ka,
2011) and advanced surgery can be mentioned. Czechia started to promote itself
as destination for medical tourism.21
No significant outflow of rich patients paying for excellent healthcare is apparent.
Even the richest patients are treated mostly in Czechia. Private clinics emerged
and provide care of excellent quality cheaper than abroad.
Otherwise, Czech hospitals remain rather egalitarian. People of all social strata
meet there. Healthcare shall be equal for every insured. Real equality is
questioned. Many believe that bribes are necessary for good care. It is difficult to
distinguish corruption from presents given by patients symbolizing gratitude for
care provided by underpaid physicians and nurses. Independent experts claim that
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expensive innovative treatments are often denied to patients incapable to
investigate options and communicate with physicians.22
Public health insurance funds are capable to spend exorbitant sums on individual
patients without coercion.23
This generosity does not stop at borders. The funds
agree numerously in the last decade with financing of special treatment abroad if
unavailable in Czechia. Specific genetic testing, innovative cancer treatment and
complicated surgery available are financed to Czech patients selected according to
medical necessity and perspectives. This care is mostly found in Germany. They
form an episode of healthcare provided in Czechia. Demand usually requires
recommendation of leading physicians maintaining international contacts.
Influx of patient within the framework is bigger. Slovaks seek treatment in
Czechia. Their interest is often accepted by their public health insurance funds.
Czech healthcare has good reputation in Slovakia. Czech physicians contributed to
improvement of local healthcare during the 20th
century. Many Slovaks work or
have relatives in Czechia. By the way, Czech hospitals employ many Slovak
physicians and nurses. Czech and Slovak are mutually intelligible languages.
According to information of physicians, dozens of Britons seek treatment financed
by their government in Czechia. Seeking capacities abroad relieving waiting lists
in the National Healthcare Service achieved thus central Europe.
The number of foreign patients paying directly for their treatment in Czech
hospitals, level of urgency, type of their treatment, and sums paid by them are not
summarized by authorities. As mentioned, there are providers oriented at foreign
clientele. However, no general hospital highlights foreign privately paying
patients as crucial for its business.
Nobody investigated whether foreign patients paying in Czechia for their
treatment enjoy reimbursement of their expenditures by private insurers or the
authorities of their countries. Impact of the Directive and its implementation in
other member states on influx to Czech hospitals is thus hard to estimate.
4.2 Slovakia
Slovaks are not deprived from treatment abroad. Slovak health insurance funds
approve planned healthcare abroad to number of their clients.24
That number of requests for reimbursement after implementation of the Directive
is significant. Three public health insurance funds existing in 2015 bargain on
rates to be paid. They question from time to time whether particular treatment is
reimbursable. Fraud was identified in some cases and suspected in others.25
Migration of Slovak patients26
and related outflow of public money, however,
does not spark any debate in Slovakia.
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4.3 Poland
It is difficult to estimate international mobility of Polish patients. According to
opinions expressed in media and in conferences, thousands seek treatment abroad
and many other contemplate it. The Directive can boost outflow of patients from
Polish hospitals.
Czech healthcare belongs to prominent destinations of Polish patients. Influx of
Polish patients to Czech hospitals and clinics is also significant. It was noticed in
both Czechia and in Poland. Among others, cataract and glaucoma is treated by
providers located in Ostrava agglomeration close to conurbation.
Healthcare abroad is sought also for abortions restricted in Poland and unavailable
even if permitted. Despite reputation of pro-choice country, Slovak providers
serve more Polish women seeking abortion than Czech ones.
5 Incentives for mobility and obstacles to it
5.1 Czechia
Czech patients started to sue their healthcare providers for damages. Malpractice
is reported frequently to the police and result sometimes into criminalisation of
physicians and nurses. Judges are thus confronted with medical law.
Healthcare becomes battlefield of human right activism. (LLP,
League of Human Rights)27
is prominent organization. Its activists are educated
and trained graduates of law and social sciences. Nevertheless, they focus on
autonomy and liberty of patients: extensive compulsory vaccinations, alleged
manipulations in psychiatry and restrictions of planned home births and coercive
practices in hospital births.
There is, however, no tradition of adjudication on access to treatment and its
affordability. It has not been clear for decades whether hospital denying treatment
or the competent public health insurance fund shall be sued.
Reimbursement of treatment sought and found in the neighbour countries as part
of fair healthcare is no priority for human rights organizations. They would be
surely familiar with the case-law, with the Directive and its implementation.
Newspapers informed several times about actions on behalf of patients denied
expensive treatment. Nevertheless, the funds usually reacted with permissive
approach. Czech courts thus do not get an opportunity to develop any
methodology of identification of medical services to be reimbursed.
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No tradition of litigation made argumentation with the case-law improbable.
Specialized legal scholars, attorneys specialized in medical litigation, experts on
healthcare management and competent officials knew about the first judgements
already before accession. Follow-up judgments were also considered. The issue
was presented at conferences about European integration and medical law. It was
mentioned together with overviews of reimbursement of urgent treatment
according to rules for coordination of social security. This issue was addressed in
professional journals. Clients would surely find attorneys to argue.
Unsurprisingly, interest of judges suffering from chronic overload with cases of
increasing diversity and complexity, quickly changing legislation and unstable
interpretation for the case-law was zero.
Czech patients are not accustomed to pay for treatment and then to ask for
reimbursement. Contemporary healthcare emerged from transformation of the
national health service of socialist Czechoslovakia financed with block grants.
Privatized ambulances and commercialized public hospitals are contracted by
public health insurance funds covering their clients. Healthcare is largely for free.
ailed.
Few rich people pay for treatment of superior quality or unfinanced innovative
treatment offered by private providers. Private insurance companies do not offer
policies covering better better care, because sufficient demand was not identified.
Several hospitals considered the Directive and its implementation in the member
states as an opportunity to extent their services and increase yields.28
We can
doubt that such assistance is really provided. It is generally feasible to cooperate
with local attorney or adviser instead studying laws and communicating with
foreign authorities.
The number of people asking for reimbursement of planned healthcare in the other
member states is expected to increase. Young Czechs travel frequently and some
work abroad. They master foreign languages. Number of them has experience
with foreign healthcare. However, these migrants often realize that Czech
healthcare has surprisingly good performance.
Seeking for alternatives restricted at home assisted birth in private settings
rejected vigorously by ob-gyn community can be also an impulse.29
Eventual increase of outflow of Czech patients will be surely gradual. Public
health insurance funds will be thus capable to cope with it.
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5.2 Slovakia
Slovakia provides healthcare of slightly inferior quality. Migration of Slovaks is
bigger than in Czechia. There is constant immigration for jobs and studies to
Czechia. Incentives for seeking treatment abroad are thus better.
5.3 Poland
Publicly financed healthcare in Poland has considerable shortcomings. Waiting
lists, so-called kolejki (queues) are commonplace for many treatments.
Poland has significant sector serving privately paying patients. Shortcomings
result from limited public financing. Personnel, equipment and material are
available. Economic elites pay for healthcare in greater extent.
Millions of Poles migrated abroad during last two decades for jobs, many
accompanied with families. We can assume that such long-term migration makes
many people familiar with healthcare abroad thanks residence and affiliation to
system of social security of host member state. Familiarity with healthcare abroad
can serve even relatives which have never migrated.
6 Different political attitudes towards implementation of the Directive
6.1 Czechia
The right-centre cabinet downplayed its Eurosceptic stance with textbook-like
economic liberalism in case of the Directive. Domestic healthcare was expected
attractive for incoming patients. There was little fear of outflow of money.
However, no studies of impact on Czech healthcare and its public financing were
realized.
Hospital managers and physicians know that foreign patients unaffiliated with
Czech health insurance funds are entitled to urgent care which reimbursed to the
providers by national institutions. They know that travel insurance provide
guarantees for other cases. They now foreign patients paying out of pocket. They
are aware that urgent treatment of uninsured poor foreigners can result in unpaid
bills. Nevertheless, they know little about promotion of patient mobility in the
European Union with the case-law and the Directive.
There was limited interest shown by ministers and deputies for cross-border
healthcare and its public financing. Certainly, widespread ignorance of Czech
politicians to promotion of patients in the European Union should not be
explained exclusively with its negligible impact. Political parties ignore important
issues. Their capacity to recognise problems and to ascertain measures is
perfunctory. Membership is little and declining. Parties lack expertise. Seeking
politicians capable to discuss the position of his/her party on the topic was thus
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unsuccessful. Central administration is fragile. High-ranking officials fluctuate.
Expertise is compromised with underpayment. Mismanagement is frequent.
Both (Association of hospitals of the Czech
Republic) joining university and state hospitals and
(Association of Czech and Moravian Hospitals) joining
smaller hospitals did not published any opinion on the Directive and it
implementation. (Czech chamber of physicians) with
compulsory membership was similarly ignorant.
There are several rival patient organizations. They informed about the possibility
of treatment abroad. Nevertheless, their membership and audience is old-aged.
Elder patients are disinterested in any treatment abroad. Similarly, association of
patients suffering from particular diseases did not highlight cross-border
healthcare as solution or alleviation. 30
Public health insurance funds still identified eventual threat and lobbied in the
Chamber of Deputies and in the Senate for adequate statutory definition of
treatment which can be subject of prior authorization.31
6.2 Slovakia
It is difficult to ascertain attitude towards the Directive and its implementation in
Slovakia. Political parties presented no opinion on it. Information for patients
provided by patient organizations does not go beyond summary of the Directive
and referrals to legislation.
6.3 Poland
Opposition of Polish government towards the Directive confirm chronic problems
in Polish healthcare (Krysiak, 2015). Polish government officials including the
then prime minister Donald Tusk - did not conceal dissatisfaction with expected
outflow of public money to the other member states. They expressed lack of
enthusiasm for the implementation (Lisowska, 2014).
Unsurprisingly, several deputies of the Sejm, senators, or Rzecznik praw
obywatelskich (ombudsman) sided with unsatisfied patients. Failure to implement
the Directive was highlighted by Polish patient organizations. The issue was
covered by media to extent and intensity unseen in Czechia. Good knowledge of
the issue even in Internet blogs and promotions. Legal assistance is offered by
talented young attorneys presenting their in-depth expertize in the issue.32
Unsurprisingly, implementation of the Directive was rather defensive, based on
consideration of significant costs by government and particular authorities.33
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7 Shared and different in Central Europe
Central European, Baltic and Balkan new member states differ widely as regards
controversial treatments. Nothing divides Poland and Czechia than stance towards
abortions. Most Czechs are decisively pro-choice. Surprisingly, Slovakia has
similar reality despite higher religiosity. Restrictive approach in Poland and
attempts to ban abortions entirely reveals considerable cleavage in attitude in
neighbour post-socialist nations.
Persistent statism and paternalism in many post-socialist countries is reflected
more in resistance towards patient autonomy unseen in other countries. Postsocialist
countries require extensive vaccination. They suppress home births and
assistance at them, as revealed in judgments of the European Court for Human
Rights Ternovszky v. Hungary34
and 35
and management of healthcare. Professionals pushed for privatisation which
prevailed in other sectors. Public institutions were also commercialized. On the
other hand, population requires public financing. The three countries adopted
different methods for balancing these demands.
7.1 Czechia
Limbo of politicians and experts is restricted to cross-border issues. Financing and
organization of healthcare in general is sensitive issue.
Contributions of employees, employers, individual businessmen fluctuate in
accordance due to economic cycle and efficacy of collection of contributions.
Contributions of the state for economically inactive clients stagnate. They are
redistributed among the funds.
Competition of public health insurance funds expected originally was suppressed
within one decade. Fluctuation among the funds does not bring significant
advantages. The funds - seven in 2016 shall follow the same policy resulting in
equalized coverage of population. Unsurprisingly, plurality of funds is questioned
from time to time. Nevertheless, politicians were too weak to introduce single
national fund. Fears of excessive power were voiced.
Public health insurance funds vary on development and maintenance of network
of healthcare providers. Hospitals, clinics, institutions of special care and selfemployed
physicians perceive different policies.
Current public financing developed from fee-for-service towards plethora of
lump-sums reflecting number of patients, required equipment and vigilance. There
are complicated combinations of lump-sums and fees-for-service. Ceilings,
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limitations and exclusions emerged. There is considerable differentiation among
types of providers. Financing based on diagnosis-related-groups (DRG) was
introduced but compromised with unreliable data.
Elaborate mathematical formulas with countless variables and coefficients are
now used for distribution of money to Czech hospitals, clinics and practitioners.
Czech hospitals engage increasingly experts capable to bill their activities to
public health insurance funds at the best and to avoid penalizations.
Complexity, lack of transparency and suspicion of manipulation in favour of
providers close to politicians attract judicial review. Annual ministerial decrees
were thus repeatedly evaluated by the Constitutional Court asked by groups of
deputies and senators supporting disadvantaged ones. The Court warned with
postponed - abolition of the decree for 2013.36
This pricing has consequences also for cross-border mobility. We can debate
whether rates reimbursed to few patients enjoying non-urgent healthcare abroad
are fair according to expectations of the case-law and the Directive. List of
treatments and their prices for calculation of compensation by those liable for of
injuries and illnesses and for non-contracted providers of urgent treatment shall be
used. However, these rates differ widely from real expenditures thanks additional
lump-sum component.
Similarly calculated prices hardly covering costs render unattractive recruiting of
patients from the other member states. Few privately paying patients in Czech
hospitals enjoyed special treatment with higher prices for it. The principle of equal
treatment37
seems to block free movement of patients under such conditions.
Certainly, it is circumvented with charging higher prices for allegedly superior
care. We can debate whether higher prices can be justified solely with complicated
communication with foreign patients.
Czech legislation on public health insurance does not specify medical treatments
covered by public health insurance funds to hospitals, practitioners and other
healthcare providers in favour of their clients.
Innovative treatments are introduced thanks initiative of leading physicians and
managers. Hospitals accept red figures with an effort to become the first and the
best or cross-financing is tolerated. International multicentre clinical trials are also
impulse for improvement.
They methods are generally welcomed if they are cheaper than existing healthcare.
Financing of expensive novel treatment starts after bargaining of leading hospitals
as designed centres of specialized care, public health insurance funds and the
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Ministry. There is specific monit
It can be thus unclear whether particular innovative treatment intentionally sought
and found abroad shall be reimbursed. However, it is largely theoretical problem
because few patients are willing to pay considerable sums in advance and then ask
for reimbursement.
Plurality of public health insurance funds provides for rather prudent and
sometimes creative management of public money.38
Officials of the funds know
that failure to guarantee expected standard of healthcare to their clients can cause
exodus to other funds and its destabilization. Non-profit nature contributes to
generosity including sporadic demands for reimbursement of healthcare sought
abroad.
7.2 Slovakia
Slovakia adopted similar model of plural public funds as Czechia. It attempted to
commercialize healthcare further decade ago enabling private funds to organize
public health insurance. Courageous measures were adopted. Contracts between
funds and providers shall be published. Competition among providers has been
encouraged with methods of calculation. Strict public supervision with rather clear
standards was introduced.
Shortcomings of healthcare contrasting profits resulted in their suppression by
subsequent cabinets. Investment disputes followed. The number of funds dropped
to three and the fund established by the state is clearly dominant. Nevertheless,
many features of reform survived.
The transition from socialism to democracy and market economy was gradual
outcome of chronic regime crisis in Poland than in Czechoslovakia.
Poland introduced system of regional kasy chorych ( ).
Establishment of competing funds was expected. Nevertheless, shortcomings
resulted into crisis. This crisis addressed with centralization. Narodowy fundusz
zdrowia (NFZ, National Health Fund) was established for contracting various
public and private providers of healthcare.
Among the three countries, Poland has the most centralized system of public
financing of healthcare. It eases introduction of some measures and reflection of
the development. Nevertheless, chronic insufficient financing, monopsony and
recurrent government interventions contribute to poor performance of Polish
healthcare.
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115
8 Identification of push and pull factors
Performance of national healthcare seems to be decisive for patient mobility.
Czech healthcare provides better treatment - ranked 13th
among 35 countries in
Euro Health Consumer Index 2015 if compared with other post-socialist countries
including neighbour Slovakia ranked 24th
and Poland ranked 34th
.
) 39
Healthcare in the two neighbour countries is thus unattractive for Czechs. On the
contrary, Czech healthcare is attractive for both Slovak and Polish patients.
Satisfactory performance of Czech healthcare together with public financing
excluding negotiation of patients with public authorities, lack of better and cheap
care abroad and language barrier explain relative isolation of Czech healthcare.
Benevolence towards few Czechs requesting reimbursement of non-urgent
treatment sought and found in the other member states prevents eventual tensions
and downplays attention to opportunity to seek healthcare abroad.
Germany and Austria ranked 7th
and 12th
respectively provide better
healthcare. However, medical treatments are labour-intensive services. Prices thus
reflect higher wages. Healthcare is thus unattractive despite efforts of healthcare in
adjacent L to attract Czech patients due to huge co-payment for most Czech
patients widely satisfied with Czech healthcare.40
Language barrier is obstacle for many cross-border activities in the European
Union. It is widely perceived as significant for cross-border movement of patients
and even unsurmountable. (Nunez, 2012) Indeed, cross-border movement is
significant among countries without language barrier, especially if other factors
emerge, as case of small Luxembourg without available treatment on its territory
and cheaper treatment in neighbourhood.41
It is hard to estimate whether Czech patients are less fit for communication with
physicians, providers and administrative personnel abroad more than patients from
other member states. Knowledge of foreign languages is poor. Nevertheless,
identified obstacles and grounds for negligible resort to reimbursement largely
coincides with factors highlighted also by researchers examining situation in West
Europe. (Legido-Quigley et al., 2012)
Shortcomings of Polish and Slovak healthcare waiting lists, widespread
unavailability of innovative treatments, and perfunctory quality of many other
treatments - seem to be impulse for several patients to seek treatment abroad.
Czechia becomes attractive destination thanks neighbour position and low prices if
compared with other member states.
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9 Conclusions
Even authors of the Directive recognize that thin minority of patients will further
seek treatment abroad.42
Nevertheless, even marginal outflow of money to other
member states can be sensitive. Considerable restrictions were thus accepted.
We can debate whether outflow of patients with public money for their treatment
can also push into improvements of domestic healthcare. Approximation of
classification of treatments and methods for calculations was also expected.43
Nevertheless, Scepticism about impact of the Directive is appropriate. The Court
of Justice discovered right for reimbursement of healthcare intentionally sought
and found abroad as emanation of free movement of services and goods not until
1998. Decades of building of common market were necessary until the first
impulse for healthcare integration beyond coordination for migrants and urgent
treatment. The member states showed considerable fears. Nevertheless, judicial
impulse was strong enough to be downplayed. Legislative refinement was
perceived as the best option by most of them including Czechia, with considerable
exception of Poland and Slovakia. Finalization, however, requires another decade.
The model was developed cautiously to survive. European nations enjoy further
different healthcare. Any significant solidarity among the member states is not
expected, contrary to different approach towards mobility of students requiring
hospitality towards incomers.
We shall thus ascertain cautiously whe
(Vollaard, Bovenkamp & Martinsen, 2016) emerges. It is far from significant
federal contribution to healthcare which is fundament of federal legislative
interventions in the United States of America. (Obinger, Leibried & Castles, 2005)
New member states in central Europe form surely periphery of such union.
Notes
1
In case of patient mobility and cross-border healthcare, among others (Glinos, Baeten &
Maarse, 2010)
2
See http://pliticalscience.ku.dk/research/healthcare_regulation_in_the_european_union/
(retrieved 2016-06-08)
3
Judgment of the Court of Justice of 31.1.1984 G. Luisi and G. Carbone v. Ministero del
Tesoro, reference for a preliminary ruling Tribunale civile e penale di Genova (Italy),
286/82 and 26/83, ECR 00377.
4
Attempts to ban travel for abortion by Irish authorities in Attorney General v. X (1992)
IESC 1, 1 IR 1 resulted into adoption of the Thirteen Amendment of the Constitution of
Ireland guaranteeing freedom to travel abroad as rule deprioritizing protection of the
unborn.
5
2003/752/EC: Decision No 190 of 18.6.2003 concerning the technical specifications of
the European health insurance card, L 276, 27/10/2003 p. 0004-0018.
MEDICINE, LAW & SOCIETY
-border mobility of patients in the
European Union in Czechia, Slovakia and Poland
117
6
Judgment of Court of Justice, 28. 4. 1998 R. Kohll v. Union des caisses de maladie,
reference for a preliminary ruling of Cour de cassation (Luxembourg), C-158/96, I-01931.
7
Judgment of the Court of Justice, 28. 4. 1998, N. Decker v. Caisse de maladie des
itral des assurances
sociales (Luxembourg) C-120/95, I-01831.
8
For detailled analysis of the case-
9
Interview with an official of the public health insurance fund involved (Prague, 13.10.
2013)
10
Prior authorization can be required solely for reimbursement of treatments addressed by
another Cabinet decree defining maximal waiting periods for some treatments.
11
http://www.kancelarzp.cz, http://www.cmu.cz
12
Interview with official of , 17. 9. 2014.
13
For detailled information of presentation. http://www.udzs-sk.sk
14
Numerous cases can be found in database of judgments of the Naczelny sad
administracyjny (the Superior Administrave Court) a regional administrative courts
http://www.orzeczenia.nsa.gov.pl if judgments of the Court of Justice are inserted in fullsearch
tool. The courts were largely reluctant to apply free movement of services as
interpreted by the Court of Justice, but accepted argumentation for correction of refusal of
prior authorization in cases of treatment unavalable in Poland.
15
The first judgment concerned cataract surgery found in Czechia after waiting for such
treatment in Poland for several years, see (Pachocki, 2014).
16
Ustawa o zmianie ustawy o swiadczeniach opieki zdrowotnej finansowanych ze srodkow
publicznych, Dz. Ust. 2014/1491.
17
Limits and reserves fixed in Art. 11 of ustawa 2014/1491 (above) are fixed for years
2014-2023. Sums are considerable, surpassing 1.000.000.000 PLN per year, which is
magnitude two of Czech expenditures.
18
NFZ differentiates at institutional level urgent treatment, planned treatment according to
the regulation and treatment reimbursed according the Directive and its implementation, the
latter managed by Krajowy punkt kontaktowy do spraw transgranicznej opieki zdrowotnej
(country contact point for cross-border healthcare), see http://www.kpk.nfz.gov.pl/pl/.
19
Surprisingly, private insurers do not attempt to reduce expenditures with recovery of
claim towards public health insurance funds for reimbursment of urgent treatment in
20
21
See Internet presentation of Czech healthcare offering treatment for foreigners in
English, German and Russia supported by grants of ministries of healthcare and regional
development http://www.medicaltourism.cz.
22
23
Figures are from time to time presented jointly by public health insurance funds.
Haemophiliacs with rare adverse effects are the most expensive. There is considerable
disparity among funds.
24
56.394.373 CZK (approximately 2.000.000 EUR) was transferred as financing for 829
planned treatments of Slovaks to Czech hospitals (CMU Yearbook 2014) through channels
expected by the coordination regulations.
25
Interview with official of (17. 9. 2014), that correctional
operation of cornea improving vision were declared frequently as cataract surgery despite
Austria was declared as sudden. Similar phenomenon was reported in Slovenia (discussion
at conference Cross-border delivery of healthcare in the EU. Rijeka, 2012).
118 MEDICINE, LAW & SOCIETY
F. K epelka: Different approaches to cross-border mobility of patients in the
European Union in Czechia, Slovakia and Poland
26
I was informed by Slovak student in Brno about specific orthopaedic surgery she
underwent in specialized Czech hospital because her orthopaedist in Slovakia refused to
provide due to lack of experience. Public health insurance fund promised to reimburse
significant part of her expenditures according to an individual calculation.
27
See http://www.llp.cz. Disinterest can be explained with limited political impact of any
advocacy in the field.
28
One regional hospital in vicinity of Poland discussed the feasibility of assistance to their
potential Polish patients. Another private hospital in Brno oriented at superior healthcare
advertises the assistance with administration in the member state of affiliation to the social
security.
29
It can be debated whether article 8 (2)(c) of the Directive would allow for restriction of
reimbursment of home births if discouraged by Czech legislation restricting assistance of
midwives.
30
http://www.pacienti.cz, other
organizations are largely defunct. The list of organizations of patients suffering from
particular diseases and disabilities can be found at http://www.sukl.cz/sukl/pacientske-
organizace.
31
Their independence from the Ministry of Healthcare can be demonstrated with such
lobbying aimed at deputies of both government and opposition parties.
32
http://www.blogprawapacjenta.com.pl http://gazetaprawna.pl)
33
For detailed political analysis see (Vasev & Vrangbaek, 2014)
34
Judgment 67545/09 of 14. 10. 2010.
35
Judgment 28859/11 and 28473/12 of 11. 12. 2014, but referred to the Grand Chamber.
36
37
Article 18 TFEU, Judgment of the Court of Justice of 3. 10. 2010, A. Ferlini v. Centre
hospitalier de Luxembourg reference for preliminary ruling
Luxembourg , C-411/98, I-08081.
38
Among the three countries, Czechia is the closest to Bismarck model praised repeatedly
39
ffecting
Poland deserves discussion due to its moral relevance.
40
See initiative JuSani (http://jusani.de) of Saxonian healthcare providers. Web pages
established in 2013 stagnate and promised tools for seeking of providers in both northern
part of Bohemia and Saxony were not established. There is no information about expected
cooperation of hospitals.
41
See (Bocquet, Smit, Couffignal & Lair, 2009).
42
Recital 39 of the Directive.
43
See (Riedel, 2016).
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