Elsevier

Health Policy

Volume 95, Issues 2–3, May 2010, Pages 103-112
Health Policy

Purchasing health services abroad: Practices of cross-border contracting and patient mobility in six European countries

https://doi.org/10.1016/j.healthpol.2009.11.016Get rights and content

Abstract

Objectives

Contracting health services outside the public, statutory health system entails purchasing capacity from domestic non-public providers or from providers abroad. Over the last decade, these practices have made their way into European health systems, brought about by performance-oriented reforms and EU principles of free movement. The aim of the article is to explain the development, functioning, purposes and possible implications of cross-border contracting.

Methods

Primary and secondary sources on purchasing from providers abroad have been collected in a systematic way and analysed in a structured frame.

Results

We found practices in six European countries. The findings suggest that purchasers from benefit-in-kind systems contract capacity abroad when this responds to unmet demand; pressures domestic providers; and/or offers financial advantages, especially where statutory purchasers compete. Providers which receive patients tend to be located in countries where treatment costs are lower and/or where providers compete. The modalities of purchasing and delivering care abroad vary considerably depending on contracts being centralised or direct, the involvement of middlemen, funding and pricing mechanisms, cross-border pathways and volumes of patient flows.

Conclusions

The arrangements and concepts which cross-border contracting relies on suggest that statutory health purchasers, under pressure to deliver value for money and striving for cost-efficiency, experiment with new ways of organising health services for their populations.

Introduction

Cross-border care in the form of patients obtaining treatment outside their country of residence can take various forms in the EU. The focus of this paper is on a specific type of patient mobility – namely when care is planned, purchased by statutory purchasers and delivered outside the country which funds it. Such an approach differs markedly from the case-by-case authorisations foreseen by EU Regulation 1408/71 on the coordination of social security systems and from individuals travelling for care on their own initiative, possibly reimbursed afterwards according to the Treaty-based rights on the free movement of services [1]. As opposed to these frameworks, the origin and procedures of the examined patient mobility are not necessarily rooted in EU legislation but in explicit contractual agreements between purchasers and providers.

‘Planned’ in this sense refers to the non-emergency character of the care, and to the planning which statutory insurers or health authorities undertake when contracting treatments outside the public system. In this way, systems open up to ‘external’ capacity – from providers abroad, and often in parallel from domestic non-public, for-profit providers.

These practices, and the concepts they rely on, are in contrast to the traditionally closed health systems. Since their inception, welfare systems have been constructed on geographical and membership boundaries which demarcate the territorial reach and the contributors/beneficiaries of a system [2]. The principle of territoriality implies that Member States use territorial elements in defining the scope of social security schemes, and when determining the qualifying conditions and the conditions of entitlement to benefits [3]. In terms of access to health services, it implies that in theory only individuals lawfully residing in the national territory can obtain health care from providers also established there [4]. Member States can thus control quality of care, protect the financial sustainability of the national system and ensure adequate planning of health care infrastructure and capacity [4]. While cross-border care takes place outside the domestic borders, contracting allows Member States to achieve these same three objectives even as patients leave the national territory. Cross-border contracting de-territorializes health services delivery but keeps quality, costs and planning under control.

The aim of the article is threefold. Firstly, to clarify the developments which have led national health systems to open up to foreign capacity. Secondly, to systematise the findings on cross-border contractual arrangements and to explain how purchasing and delivering health services ‘outside’ works in practice. The third aim is to identify the incentives behind cross-border contracting as well as its potential implications for systems involved.

Section snippets

Materials and methods

The article is a qualitative study which systematises and analyses the evidence on purchasing planned health care services from foreign suppliers to which patients are sent.

The material used originates from two sources: a study on contracted care in Belgian hospitals, based on in-depth interviews with stakeholders1

Results

We have found material on purchasers engaged in cross-border contracting in Denmark, England, Germany, Ireland, the Netherlands, and Norway. Before explaining how purchasing and delivering care outside the system function, the section briefly describes the policy background in which cross-border practices have taken place in the six countries. The national contexts provide clues to the rationales behind contracting.

Discussion

The limitations of the study should be made clear. The article is not exhaustive in terms of descriptions as the amount, quality, completeness and objectivity of data for each case vary. Contracting with foreign and/or for-profit providers is a constantly changing phenomenon not widely described in literature. Its politically or commercially sensitive character adds to the complexities of obtaining material. Some stakeholders decline to share information. For this reason, evidence of Portuguese

Conclusion

In an attempt to diversify providers and increase performance, statutory health purchasers make ‘public use’ of foreign and private health services. Patients travel and are treated within the framework of contractual agreements which allow quality of care, costs and domestic planning mechanisms to be kept in check. These are noteworthy variants of delivering services to a population. Experimenting with ways to purchase and organise care moves away from the idea of health systems being

Acknowledgements

This study would not have been feasible without the cooperation of a long list of people and organisations which contributed to the Belgian case-study [5] and the literature review on patient mobility [6]. We are most grateful for their help and availability. We would also like to thank our reviewers for precious comments, as well as Ms Maria Carlota Vieira and Prof Gilles Dussault, University of Lisbon, for their continuous efforts in contacting Portuguese municipalities, and in translating

References (55)

  • G. Botten et al.

    Trading patients – lessons from Scandinavia

    Health Policy

    (2004)
  • Palm W, Glinos IA. Enabling patient mobility in the European Union: between free movement and coordination. In:...
  • M. Ferrera

    The boundaries of welfare – European integration and the new spatial politics of social protection

    (2005)
  • R. Cornelissen

    The principle of territoriality and the community regulations on social security (Regulations 1408/71 and 574/72)

    Common Market Law Review

    (1996)
  • A.P. van der Mei

    Free movement of persons within the European Community. Cross-border access to public benefits

    (2003)
  • I.A. Glinos et al.

    Contracting cross-border care in Belgian hospitals: an analysis of Belgian, Dutch and English stakeholder perspectives

    (2005)
  • I.A. Glinos et al.

    A literature review of cross-border patient mobility in the European Union

    (2006)
  • D.M. Cutler

    Equality, efficiency, and market fundamentals: the dynamics of international medical-care reform

    Journal of Economic Literature

    (2002)
  • R Robinson et al.

    Introduction

  • J. Maarse et al.

    Market competition in European hospital care

  • M. Ferrera

    Introduction

  • D. Sindberg Martinsen

    The Europeanization of welfare – the domestic impact of intra-European social security

    Journal of Common Market Studies

    (2005)
  • A.M. Pollock et al.

    Independent sector treatment centres: evidence so far

    BMJ

    (2008)
  • Danske Regioner

    Sundhed – Suspension af det frie sygehusvalg

    Nyhedsbrevet Danske Regioner

    (2008)
  • Website of NTPF: http://www.ntpf.ie/home/ [accessed 6 November...
  • Nesse OJ. Norwegian patients in EU hospitals – the medical treatment abroad project. Paper prepared for the conference...
  • Ziekenfondsraad. Grensoverschrijdende zorg: arresten Decker en Kohll, Aan de uitvoeringsorganen ZFW en AWBZ,...
  • College voor zorgverzekering (CVZ) (Dutch Health Care Insurance Board). Circulaire 02/021 met betrekking tot...
  • Telephone briefing with officer in charge of health services purchasing CZ (Dutch health insurer). 4 March;...
  • Interview with officer in charge of external capacity and patient mobility. English Department of Health. London. 17...
  • Lowson K, West P, Chaplin S, O’Reilly J. Department of Health: evaluation of treating patients overseas: final report....
  • Interview with NHS Lead Commissioners. Guy's and St Thomas’ Foundation Trust. Brussels. 13 January;...
  • Official data from Corporate Development Guy's and St Thomas’, May 2005, and from the Belgian National Institute for...
  • Sundhedsguiden Media ApS. Udvidet frit sygehusvalg – behandlingsgaranti på 2 måneder (Extended free hospital choice –...
  • Ministry of Internal Affairs and Health (Now: Ministry of Health and Prevention). Resultater på sundhedsområdet (Result...
  • Y.A. Staalesen Strumse et al.

    The efficacy of rehabilitation for patients with rheumatoid arthritis: comparison between a 4-week rehabilitation programme in a warm and a cold climate

    Scandinavian Journal of Rheumatology

    (2009)
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