|Implemented in this survey?|
In April 2009, the EU Commission sent a formal letter to the Danish government concerning the recognition of prescriptions and reimbursement for cross-border health care services. A formal letter is the first step towards actions before the Commission calls the European Court of Justice for breach of the Treaty. The Danish Parliament explained the contents of the letter .
Due to financial costs in a system with predominantly fixed global budgets, the Danish government has been reluctant to perceive health care as covered by the EU Treaty rules on free movement of services.
In 1999, the Danish Ministry of Health invoked an official investigation in order to analyze the impact of European Court decisions in cases C-158/96 Decker and Kohl and C-157/99 Smits and Peerbooms on the free movement of health care services . In the light of EU court rulings the Danish authorities found that health care services are not covered by the treaty rules on free movement of services in the Danish cases where there was no payment involved between the parties. The official investigation on the European Court of Justice (ECJ) rules done by the Ministry of Health led to a modification of the existing rules of reimbursement, which meant that only those health services where the patient incurred more than half of the cost were covered by the treaty rules on free movement of services .
Treatment at public hospitals, which are fully publicly financed, was then not considered as covered by the Treaty. Similarly, health care in general practice and in a specialist medical clinic were as well not considered as covered. The rules have since been gradually changed in order to bring the Danish regulations in line with the practice of the ECJ.
Treatment in hospitals
Danish legislation established in 1999 a general rule, which gave the competent authorities the power to refer patients to treatments abroad. It is left to the competent authorities to specify whether the patient is eligible for treatment abroad. In 2008, it was in line with the rulings of the ECJ that:
a) The regions must reimburse patient costs for treatment in hospitals in another EU Member State if the region cannot offer patients timely treatment according to the Danish waiting time guarantee .
b) Reimbursement of costs requires approval by the competent authorities prior to treatment.
c) The region will only refund an amount equal to the costs of either the same or a similar treatment offered by the public health system .
The Commission states in its letter that there is no compelling interest capable of justifying the possiblity of not recovering the costs in excess of the expenditures top a similar treatment in Denmark.
Treatment outside hospitals
The investigation of the rulings of the ECJ led to a change in the rules of reimbursement. Medical care in general practice and medical care in specialist clinics were then considered as covered by the treaty, but only for persons insured in group 2. In 2008 the rules of reimbursement to treatment in a specialist medical clinic was extended to include people insured in group 1 .
The rules of reimbursement for medical care in general practice in another EU country is still limited to individuals insured in group 2 of the health security. (Members in group 2 do not need a referral from a general practitioner to see a specialist in contrast to group 1 members, but the health insurance covers only a payment equal to the payment for group 1 members. Thus extra costs due to higer fees are paid for by group 2 members themselves. The group includes only 1 percent of the population while the rest is covedered as group 1 members with full coverage of specialist treatment. Once a year, it is possible to switch between the two insurance groups, with14 days notice ). Moreover, in the Danish legislation there is a general prohibition against disclosure of prescriptions issued by health professionals licensed in other EU countries (Excluding the Nordic countries) .
The Commission states in its letter that the ability for patients insured in group 1 to get refunds for costs to treatment outside the hopistal sector is non-existent and that a blanket ban for pharmacies to provide medicines on prescription issued in other Member States is contrary to the Treaty.
According to the Danish rules the competent authority will only refund an amount equal to the costs of either the same or a similar treatment provide by the public health system. In cases where the expenditures exceed the costs to at similar treatment provided by the public health system the reimbursement rate will not relate to the actual expenditure incurred. The Commission states in its letter that there is no compelling interest capable of justifying the possibility of not recovering expenditures in excess of the costs to a similar treatment in Denmark.
Regional Councils, Patient Associations
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The Danish Parliament has traditionally been reluctant to open up for treatment outside the country. The government continues this line with the unwillingness to change the existing rules for redemption of prescriptions. Further the government has not yet eased the rules for switching between health insurance group 1 and 2.
The Danish authorities have only reluctantly opened up patient access to treatment in other EU Member States. The rules that determine patients´ rights to reimbursement of expensens for treatment abroad have gradually changed. However, the rules have a significant economic aspect. The rules on reimbursement of the costs for treatment in other Member States are resource independent. Thus, the competent authority can not refuse to refund the cost of treatment if the patient meets the legal requirements for treatment abroad..
|Implemented in this survey?|
The approach of the idea is described as:
amended: The practice of the ECJ seems to be the driving force in the legislative development of patient rights to medical treatment.
|Ministry of health||very supportive||strongly opposed|
|Regional councils||very supportive||strongly opposed|
The government has stated its intention to make it easier to switch between health insurance group 1 and 2. However, the government has no intention of lifting the ban on redemption of prescriptions from countries within the EU.
|Ministry of health||very strong||none|
|Regional councils||very strong||none|
No rewiev is forseen.
It is expected that the government, however reluctantly, will change the rules for switching between health insurance group 1 and 2.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Easing access to seek treatment within the EU is expected to increase health care costs in total. However, it is expected that only few patients requiring highly specialized treatment will use this opportunity.
The ECJ rulings has forced the Member States to recognize the right to medical treatment within the EU increasing health care costs at the national level. However the ECJ rulings have also made an opening up of national and cross-border contracting with other health care providers. Thus it can be argued, that the ECJ regulation and the growing medical specialization involving costly clinical interventions for a small population of patients constitute a future basis for a few highly specialized European hospitals with a more cost-effective way of ensuring specialized treatment.
 Sundhedsministeriet: Notat vedrørende Kommissionens åbningsskrivelse om anerkendelse af recepter og om godtgørelse af udgifter til grænseoverskridende sundhedsydelser, 2009. Memorandum to the Health Commitee by the Ministry of Health concerning the formal letter from the EU Commission.
 Sundhedsministeriet: Redegørelse fra Embedsmandsgruppen til vurdering af konsekvenserne af EF-domstolens afgørelse i Decker/Kohl-sagerne, 1999. The official investigation of the impact of the ECJ decissions in cases C-158/96 Decker and Kohll and C-157/99 Smiths and Peerbooms.
 Bekendtgørelsen nr. 536 af 15.06.2000 om adgang til tilskud efter sygesikringsloven til varer og tjenesteydelser, der er købt eller leveret i et andet EU-/EØS-land. The modifications were implemented by law in 2000 in declaration no. 536 of 15.06.2000 on reimbursement of health care services provided in EU.
 See HPM Report from University of Southern Denmark, Survey 12, 2008.
 Bekendtgørelse nr. 1065 af 06.11. 2008 nu nr. 62 af 20.01.2010 om ret til sygehusbehandling. The modifications were first implemented in 2008 in declaration no. 1065 of 06.11.2008 now in declaration no. 62 of 20.01.2010 on righ to treatment in hospitals. For futher reading, see HPM Report from Universty of Southern Denmark, Survey 12, 2008.
 Bekendtgørelse nr. 1098 af 19.11.2008 om adgang til tilskud efter sundhedsloven til varer og tjenesteydelser, der er købt eller leveret i et andet EU-land/EØS-land. Declaration no. 1098 of 19.11.2008 on reimbursement of health care services provided in EU.
 Bekendtgørelse nr. 20.02.2007 om recepter. Declaration no. 20.02.2007 on prescriptions.
Assistant professor, Department of Law and Institute of Public Health.