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One of the greatest concerns of patients is to seek treatment in the quickest, most efficient and safest way possible. To achieve this, many European citizens need to seek health care in other member states than their own either because health care is better provided, or because they live in border regions where the nearest appropriate facility is situated in another country, or even because the treatment they seek is not provided in their own country due to lack of expertise (a common phenomenon for patients with rare diseases) or due to ethical reasons.

Author / translator

One of the greatest concerns of patients is to seek treatment in the quickest, most efficient and safest way possible. To achieve this, many European citizens need to seek health care in other member states than their own either because health care is better provided, or because they live in border regions where the nearest appropriate facility is situated in another country, or even because the treatment they seek is not provided in their own country due to lack of expertise (a common phenomenon for patients with rare diseases) or due to ethical reasons. The mobility of patients raises several questions such as…

- Who should pay for cross-border care and when?
- How can patients be informed about where the best treatment is available?
- Should they get approval by their own health system prior to receiving the treatment abroad?
- What happens when patients seek for an organ transplant? Who gets priority in the waiting lists?
- What about travel expenses for patient, relatives, post treatment and medicines needed?

The European Commission recently proposed a directive for cross border health care trying to clarify some of these issues. The directive addresses both the need to support cross-border care, especially for rare diseases and treatments for which there is no other choice and strengthen telemedicine through networks of centres of expertise and harmonized e-health tools. Making a law for all patients, in all medical situations, in all Member States is difficult. The question remains – how will Europe manage to ensure an equal access and quality of treatment for all its citizens?

Created 22 January 2010
Last edited 20 June 2018
Topics Ethics, Health, Politics

Policy positions

Policy position 1

Cross border health care is available for all patients with no authorisation needed. The state reimburses the costs of treatment, travel and accompanying persons directly and upfront. No investment on e-Health.

Policy position 2

Cross border health care is available for all patients, but authorisation from the state is required. The state reimburses the cost of treatment and travel for patient only. No investment on e-Health.

Policy position 3

Cross border healthcare is possible for patients only if treatment is not available in their country of residence. Only direct costs of the treatment are reimbursed. No prior authorisation is needed. The state invests some in e-Health initiatives.

Policy position 4

Cross border health care is minimised. It has to be authorised by the state for special cases and only direct costs of the treatment are reimbursed, after it has taken place. If a treatment is not approved (for ethical reasons) in residence country it is not reimbursed for treatment abroad. The state makes e-Health major priority to minimise cross border health care.

Story cards


My name is Joao and I am Portuguese. A few years ago I went to the doctor for a check-up when he told me that I had to urgently do a specialised examination that was only available in Sweden. I had to travel urgently and didn’t wait for state authorisation. With my results I received the bill from the health centre. I claimed reimbursement from my healthcare system but I was refused it because my examination was not classified and because I was lacking reimbursement decision. Not only did I have to cover the costs for travelling to treat my disease, but I also had to pay out of my own pocket for the examination.

Joao Gomes

I am Maria, I live in Greece and I am 78. I was paralysed from a stroke in 2004. For two years I had to go under several visits to hospitals very troublesome for me and my kids, especially since living in a small village. Since 2006 a home-based service run by a team of experts, was offered to me through virtual visits. This has resulted in significant improvements in my quality of life, in half visits to the hospital and has been a big economical help. This system though runs only in my region and is in experimental phase. How long should other people like me wait for these treatments?

Maria Papanikolaou

My name is Ovidio; I am Rumanian, 20 years old. Recently I was diagnosed with cancer and the doctor said that I needed to do bone marrow transplantation. It was very difficult to find here a matching donor but my doctor found a transplant in France for €5000. The health care system here accepted for me to go but according to the law I need to pay upfront by myself. Even if I find the money, the reimbursement from the state will be up the amount that would be paid had I obtained that treatment here. This is not proper reimbursement, since in Romania this treatment is much cheaper than in France.


I am Elain, I am British and 46 years old. I have had numerous unsuccessful IVF treatments and already paid over £30,000 on this. I am now applying for treatment at clinics in Bulgaria, Romania and Spain where there is no legal age limit for IVF treatment. In England, having a baby is impossible for me as after the age of 40 a woman is not allowed to do IVF treatment. Many of my relatives are upset I still want a baby. Most of them have children though and have no idea how I feel. I am very healthy, as is my husband, we have the right to have a child and we will try to have one soon.

Elain McGlade

Our son Ulrich was diagnosed with NBIA a very rare, inherited, neurological movement disorder. In Germany there is one network for patients with NBIA but there is no European NBIA patient group network. Sometimes we are contacted by patients outside Germany who seek desperately for more information on the disease, treatments, or doctors, but there is not much we can do. I wish it existed a more constructed way for us to be able to communicate with people in other countries and be able to collaborate and help each other by exchanging useful contacts and medical information...

Achim Heckl

My name is Sheena, I am Danish. I have needed a liver transplant for the past year; I have been trying to book an appointment for a surgery but I will need to wait several more months before I do the operation. The hospital close to my house accepts a large number of patients from a neighboring city across the border. These people are on the same list as me making the waiting time even harder. I feel that this is not fair; I pay taxes in this country and I expect to be treated first before foreign patients. How long shall I wait until I get my treatment?

Sheena Laursen

My name is Sara; I live in Italy, I have a 4 year old daughter suffering from a rare immunodeficiency disorder. The doctor recently told us that a new treatment exists in Germany. The health care system will reimburse for the treatment, but going abroad would mean travelling and staying over for several months with her. Also, we will have to pay additional costs for translation of documents, interpreting, etc. We will need several operations and medicines. We will not be able to claim this money back. This brings us to a very difficult economic situation, but how can someone judge anything over the life of his child?

Sara Antonioni

My name is Carlos; I work for the public authority in Valencia. We have realised the very heavy impact of the cross border health care in our region. Currently more than 500,000 Britons - most of whom are over 50 - and other European citizens that currently live in the Valencia region are placing an impossible burden on our country's health service. It is costing us an extra €1bn annually to look after a million new residents.This is a heavy burden on our shoulders and we cannot keep up with the current situation. I realise my community also benefits from these people, but the burden on the health system is still very difficult for us.

Carlos Soares


Importance of telemedicine

With telemedicine someone can get health care services from abroad without either him or the doctor leaving the country (e.g diagnosis of physical malformations present at birth is possible by sharing of photos and symptoms between doctors in different countries)

Who is liable for errors in cross border health care?

Although healthcare is intended to benefit patients, sometimes patients suffer harm through errors. Who is responsible then in cross border healthcare? Who compensates the patients? Whose liability rules apply?

Ethical issues in different countries

When a woman can only seek for fertility treatment outside her country (due to different age limits) who decides on whether she is entitled on reimbursement? Whose ethical rules apply?

Lack of a transparent legal framework

Patients have encountered problems in seeking cross border healthcare due to different rules across countries. For example, the legal status of stem cell therapies varies across Europe.

Prior authorisation needed

Prior authorisation when cross border health care is needed is often complex, long and arbitrary especially for rare diseases which are unknown by many health care professionals and authorities and thus marginalised in healthcare systems.

Cost implications from travel

Rare disease patients are often not independent enough to travel without assistance. In addition to the healthcare expense, the travel costs for two individuals and the loss of income during the trip must also be added to the overall cost.

Special rules for rare diseases

Whatever the rule is for cross border health care rare disease patients must be reimbursed for a treatment abroad, even if it is not foreseen in their country without prior authorisation.

Role of centres of expertise

Rare disease patients are often marginalised in classic healthcare systems designed for non-rare diseases. The restructuring of the system that manages frequent diseases can be accomplished through the Centres of Expertise.

Rare diseases and prior authorization

How can costs be reimbursed up to the level of the home country for patients with rare diseases if the home country system does not include or take account of this disease/treatment?

Source of information

Who has the responsibility to provide information on treatments to citizens that consider receiving health care in another country? The EU? Member States? Health care professionals?

Equality in services

Is it not discrimination to not treat patients coming from another EU country equally to nationals of the country in which they are treated?

Priority in lists?

With the current system patients from other Member states are integrated in waiting lists for a treatment on the same basis. Is it fair that domestic patients have to wait in the queue with foreign patients?

Patients favor proximity

Patients often find travelling for treatment unpleasant (survey in Finland showed that 90% of elderly citizens refuse referral even within Finland even though this would mean shorter waiting time).

Responsibilities of a member state

Today healthcare providers are not obliged to accept patients from abroad for planned treatment if this would endanger their capacity for treatment (lack of medicines etc.) or medical competence in their country

Pre payment from patient needed

The current European directive sets out a framework for wealthier and well-informed European citizens, because everything is built around pre-payment and later reimbursement

Mobility of patients should follow mobility of records

Mobility of patients throughout Europe means mobility of their medical records and a system to track their treatment and its follow-up…

Open market system on health care - oppositions

A completely open system in the health care market is opposed by some Member States with high and expensive healthcare system, as they fear that this could lead to a lowering of standards.

The right to quality care

It is not only about the right to care, but about the right to quality care. How can standards of care be put in place and monitored on a regular basis and assessed? By whom?

Cross border health care a necessity for rare diseases

With over 6,000 rare diseases, it is impossible for each EU country to develop care for every disorder. Rare disease patients may need access to reimbursed medical expertise where it exists for free more than other EU citizens.

Seeking medicines for rare diseases abroad

Despite a centralised approval for rare diseases medicines, reimbursement and availability differ within EU. When people seek treatment abroad that is not covered by their own country how can reimbursement be secured?

Reasoning for prior authorisation

Prior authorisation for treatment and waiting lists may be used as planning tools for the health care budget in order to streamline patient flows and manage it in an efficient way.

Differences in health care systems in Europe

One way to limit spending on cross border healthcare is to limit reimbursements only to non-hospital care. Different health systems throughout the EU define hospital and non-hospital care differently, making standard reimbursement procedures complicated.

Waiting for authorisation

The authorisation processes from the healthcare system for cross-border healthcare is often long. Consequences to the patients include increased psychological burden as well as adverse medical consequences, even a risk of death.

Right for treatment abroad – ethical questions

Should treatment that is restricted in the country of residence for the patient for ethical reasons (such as genetic testing) be equally restricted for these citizens in other Member States?

Do we need a Directive on Cross-border care?

Many bilateral cross border healthcare cooperation currently exists. Imposing a “one size fits all” structure for cross border health care via a directive may restrict cross border activities that are currently very beneficial to patients...

Is eHealth widespread in Europe?

eHealth is not yet widely recognised across the whole healthcare sector as a significant part of the core health policies, strategies, and services.

Right to healthcare

Rights to healthcare are recognised in the EU Charter of Fundamental Rights. According to EU Court of Justice, free movement applies to health services, regardless of organisation and finance at national level.

The European health insurance card

It entitles someone needing treatment during a stay in another Member State to the same benefits insured in his country. Treatment costs for an illness or injury that someone had before travelling or private health care are not covered.

What is cross border provision of health services?

It is the delivery of health services from one Member State into another. Such services can include direct services, such as face-to-face consultations, or remote services, such as telemedicine.

What is patient mobility?

A patient moving for medical care (diagnosis, treatment, etc.) to a healthcare provider in another Member State than the one of residence.

What is the European ombudsman?

He/she receives complaints from any EU citizen or legal person concerning improper administration in the activities of the Community institutions or bodies. If citizens have complaints regarding health care (e.g. access to cross-border care) they can contact him/her.

Respect of the internal market

Even though Member States are primarily responsible for health services, they must comply with Community Law, particularly for the internal market enabling goods, services, persons and capitals to circulate freely within the EU.

Travelling abroad for treatment

In May 2007 the Eurobarometer reported that 54% of European citizens were willing to travel to another EU country for medical treatment.

Border regions

The nearest hospital for citizens in border regions is usually the one in a neighbouring Member State. 1/3 of the EU population lives in border areas

What is reimbursed in cross border health care?

Reimbursement in patient’s own country is often lower than the cost for treatment abroad. The difference between these two is borne by the patient.

Lack of information

Eurobarometer survey showed that 30% of EU citizens are not even aware of the possibility to receive healthcare outside their country of affiliation.

Why Europeans seek treatment abroad? (Eurobarometer)

91% of responders said due to inability for treatment at home, 78% due to better quality of treatment abroad. 69% would travel for treatment by a renowned specialist and 64% in order to reduce waiting time for treatment while 48% for cheaper treatment.

Recognition of treatment

With current EU laws if a Member State does not include a treatment as part of the entitlement of their citizens, then patients can’t get reimbursed if treatment is purchased abroad

Rare diseases patients and cross border health care

According to the European Organisation for Rare Diseases survey of 6,000 patients, 1.8% of them sought care across borders. If this is representative of the estimated 30 million rare disease patients in Europe, it represents a considerable need for cross-border care.

Cross border health care: Draft EU Directive

- Patients to be reimbursed for care entitled to in their country
- Upfront payment
- Reimbursement on the amount they would have been reimbursed if received the treatment in country of affiliation
- they pay for additional costs
- no financial advantage

What do centres of expertise for rare diseases do?

They improve access to quality care by bringing together experts for the management and care of one or a group of rare diseases. As they can’t and don’t exist for each rare disease in each country, patients need to travel to centres across borders.

Organ transplants availability in Europe

56,000 patients in EU are currently waiting for an organ donor. Every day 12 people die waiting for transplantation. Organ donation rates range from 34.6 donors per million people in Spain to 6 in Greece and 0.5 in Romania.

Costs of cross border health care in EU

Cross-border mobility amounts to 1% (€10 billion) of overall EU-27 public health spending (€1000 billion).

Medicines in Europe

There is no common system in Europe for the provision and reimbursement of medicines. The availability varies across Europe and shortages can occur in some countries. This is especially true for orphan drugs for rare diseases.

No European standards for quality

There are no European minimum standards for many aspects of healthcare and there are big variations in the way national health systems ensure quality. The provision of health care is a national competence.

Language barriers

The cost for necessary translations related to a treatment abroad and recognition of prescriptions is not well defined by the current EU legislation

Differences in prices of health services

As with quality, price of health services can vary considerably from one Member State to the next

Differences in definitions on medical and social care

Member States have different definitions of medical care, psychological care, nursing care, social care and even "necessary treatment".

What is eHealth?

Any healthcare practice supported by electronic processes and communication, including information networks, electronic health records, telemedicine services, portals, and other information-communication-technology based tools assisting disease prevention, diagnosis, treatment and monitoring.

Seeking for fertility treatment abroad

20,000 to 25,000 cross-border fertility treatments are carried out each year. There are currently thousands of women seeking help to get pregnant abroad

European Networks of Centres of Expertise (ERN)

They are the physical or virtual networking of knowledge and expertise at national Centres of Expertise in Europe. Their goal is the improvement in the quality and management of care of one or a group of rare diseases.

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