Free Movement of Patients Directive: from autumn, Health Fund pays for treatment throughout Europe

Photo: Peeter Langovits

Estonian medical institutions are preparing to treat foreign patients, possibly resulting in higher health costs for locals. 

From autumn patients throughout the EU, including in Estonia, will have easier access to medical treatment in any member country, with the home country’s health insurance covering at least part of the cost.

Even now, health-insured Estonians can receive emergency or unavailable-in-Estonia treatment in other European countries at the Health Insurance Fund’s (HIF) expense. But from October 25th partially compensated consultations for hip replacements, for example in Finland or Germany, also become possible.

“Currently people are free to go, but they must pay for everything. Now, however, we are talking about treatment in other EU member states being included in the Estonian HIF price list, and appropriately compensated by HIF,” Heli Paluste, head of Health Department at the Ministry of Social Affairs explained.

In practice this means that if someone insured by the Estonian HIF is referred by a family doctor or medical specialist to a specialist in Germany, he will pay the initial bill. But afterwards he will be reimbursed by HIF on the basis of Estonian price list.

Still, HIF may not pay up immediately. If for instance the waiting list for hip replacement in Estonia is 18 months but paid treatment is quicker in Latvia, the Estonian HIF has the right to pay compensation only after a year and a half, in keeping with Estonian waiting lists. “Delayed payment is allowed if the financial stress due to patient movements proves excessive for HIF,” Ms Paluste added. “However, HIF has indicated that faster compensations may also be possible.”

If a hip replacement consultation or the surgery in Germany costs more than specified in the Estonian price list, the patient will have to pay the difference. But should a service, in Latvia for instance, be cheaper than on the Estonian HIF price list, only the actual cost is recompensed – Estonians cannot earn a profit on the difference.

“The patient shall fully pay all additional expenses such as transportation, housing outside the hospital etc.,” Anette Soosaar, head of the HIF foreign relations department, explained.

But in the view of Margus Ulst, board member of the Tartu University Hospital “On the one hand the new directive will theoretically give Estonians a chance to get partially paid treatment at the best Finnish or German hospitals. However, they might as well forget it right away, as ordinary people can never afford the price difference.”

Likewise, a Finnish patient, for instance, may come to Estonia for paid consultation or surgery. He pays himself, and is afterwards compensated in Finland by their health insurance, pursuant to their price list.

“Finland has no such price lists up to now, but budget-based health care financing instead. Now, however, they are required to create a price list, on the basis of which they will be recompensing foreign treatment for their citizens,” Ms Paluste pointed out.

Even though no-one predicts masses of foreigners flooding to Estonia for treatment, Tallinn medical establishments are nevertheless preparing for possible clients from Finland.

“It may be that come autumn, exports of medical services will be enhanced, especially private clinics. However, the main partner of HIF-related hospitals will still be HIF” thinks Mr Ulst.

“But we are preparing for the possibility, and we are able to communicate with patients in Finnish,” said Tõnis Allik, chairman of the board of North-Estonian Regional Hospital. “There are companies in Finland interested in providing services to patients wishing to be treated in Estonia. The patients would be able to call local Finnish companies, which would then find a suitable medical institution in Estonia. That would be easier than searching for Estonian options via the Estonian digital register,” Mr Allik added.

According to him, the regional hospital is currently in talks with one such company. “In Finland, the treatment waiting lists are comparatively long; therefore, offers of private ambulatory care are increasing. The Finnish health insurance fund (KELA) also pays for services by private medical institutions.”

But Mr Allik conceded that the new opportunities are unfair for domestic Estonian patients, as they will have to pay full price for paid treatment in Estonian medical institutions – meaning that should they opt for paid treatment abroad, HIF would at least partially compensate the costs, whereas it would not pay at all for treatment at home.

Minister of Social Affairs Taavi Rõivas acknowledged that the European directive for free movement of patients will not directly regulate free movement inside countries. Hinting at reducing the unfairness he added, “However, we are seriously considering the option to also facilitate patients’ movement within Estonia. We aim to trial it in one specialty, and should the results prove positive we are ready to extend it.”

The free movement directive grants patients greater choice within the European Union. However, every member state has the right to impose its own rules that accord with the local health care system. The main requirement is that the price must be the same for patients from any member state. For example, if an Estonian hospital has set the paid reception price at €35, it must be the same for both Estonians and Finns.

According to Mr Allik, this may – in case of Finnish interest in treatment in Estonia – push up the local prices.

Minerva Krohn, a Finnish doctor who has visited Estonia privately, believes that as the new rules come into force, more Finns may indeed start coming to be treated here. “Even now, Finns are partially compensated by KELA upon visiting Estonian dentists or opticians,” she said.

She thinks that from Finland’s state health care system perspective, patients coming to Estonia should not be a problem. However, Finnish private clinics will face extra competition. “Finns trust Estonian doctors, and if there is a good system here for registration via the internet, they may come,” Ms Krohn added.

According to Svea Laidinen who has lived in Finland for over 20 years, waiting lists for Finnish doctors are so long that in recent years she has preferred to come to Estonia for treatment. “In Finland, doctors are expensive and far away, you can’t get to them. Even to see a nurse, there is a long line,” said Ms Laidinen, praising Estonian doctors’ attitude towards patients.

Many elderly Finns purchasing medicines in Tallinn pharmacies said they had never been to a doctor here but experience with Estonian doctors in Finland has led them to trust Estonian doctors, and they would be willing to come for treatment in Tallinn.

According to Heli Paluste, it may become necessary to set limits for access by foreign patients, as a high volume of arrivals would create longer waiting lines for locals. Although foreigners would be unable to join state waiting lines paid by the Estonian HIF, hospitals might be tempted to take the opportunity to suggest paid treatment at more lucrative prices.

“The fear may arise that local patients will suffer. Foreign patients should not be given priority over locals. I don’t think that local contracts will be neglected because of foreigners, or local people’s treatment delayed,” Mr Allik said. “Paying patients should continue to be treated in available spare clinic time, as before."

In the future, a pan-European e-health system may develop. But for now, this doesn’t exist, and treatment abroad will rely on carrying paper files and health records.

Free movement rules also affect compensation for prescription medicine products in the home country. E-prescriptions cannot be used internationally, and prescriptions must be carried on paper.

To inform patients of cross-border treatment opportunities, all EU countries will establish contact points with information on rules that apply in the home country and directions to contact points abroad.

Summary of current treatment opportunities abroad for Estonians

•    Currently, a limited foreign treatment system applies in Estonia, with the HIF compensating health care services in other states under certain circumstances.

•    This applies if the needed medical service or an acceptable alternative with a minimum 50 per cent success rate are unavailable in Estonia.

•    Also, Estonian residents temporarily in another EU country are entitled to necessary medical care based on the European Health Insurance Card. Should a person not carry the EHIC, compensation may retrospectively be sought from HIF.

•    These rules will remain even after the cross-border directive become operative on October 25th, 2013.

Source: Anette Soosaar, foreign relations department, HIF