The report provides information on patient flows, the financial aspects of patient mobility and national contact points.

MS – 10/2018

Five years after the Directive’s entry into force, cross-border flows of patients show a stable pattern and are influenced by geographical or cultural proximity. In its report, the European Commission concludes that patient mobility and its financial dimension within the Union remain relatively modest and have no significant budgetary impact on the sustainability of health systems. 

What’s this about?

The general objective of the 2011 Directive on patients’ rights in cross-border healthcare (2011/24/EU) is to facilitate access to safe and high-quality healthcare in another Member State. To achieve this, patients are reimbursed for healthcare costs in another Member State up to the amount for a comparable benefit incurred in the country where they are insured. At the same time, Member States are still responsible for providing adequate healthcare services in their territory. 


Member States had to transpose the Directive by 25 October 2013. The Commission submits a report on the operation of this Directive every three years. 

Reimbursement of cross-border healthcare

Under the Directive, patients are reimbursed for treatment abroad, as if the treatment had been provided in their home country or in the Member State where they are insured. If a German patient seeks medical treatment in another EU country, their German health insurance fund will reimburse the costs of cross-border healthcare up to the maximum amounts that it would have assumed if the healthcare services in question had been rendered in Germany as a benefit in kind. Each health insurance fund in Germany has regulated the reimbursement procedure in its statute. Deductions can be made from the reimbursement amount for administration costs, a missing performance audit, as well as any additional foreseen payments. 


If persons from other EU countries receive medical treatment in Germany on the basis of the Directive, they do not need a German health insurance card nor a certificate of entitlement from their Member State under the EC Regulation, which ensures they are covered by the relevant health insurance fund in their country of origin. Therefore, they are treated as private patients, similar to German patients who do not have proof of entitlement to treatment. Thus, the fee schedules for private medical services are used to settle costs, as is the case in comparable domestic situations.  

Interaction between Directive and Regulation

In addition, there is another EU legal basis covering patient mobility in the EU. Persons who receive unplanned medical treatment in other EU countries, e.g. while on holiday, receive these benefits under the Regulations on the coordination of social security systems. 


The main difference between the Directive and the Regulation in terms of reimbursement is that, under the Regulation, patients are entitled to receive the same scope and manner of healthcare abroad as if they were insured by the social security system of the Member State where they receive treatment. In many cases, the amount of the reimbursement under the social security coordination Regulation is higher than under the Directive and generally does not require the insured person to pay upfront. 


In its report, the Commission concludes that the opportunities afforded by Regulation (EC) No 883/2004 under the European Health Insurance Card are used more than the opportunities offered by the Directive. 

Data on patient mobility

In principle, Member States are supposed to provide annual figures on their patient mobility under the patients’ rights Directive. In practice, however, the data situation looks difficult. One of the reasons for this is that Member States may not separate data and reimbursement applications for cross-border medical services under the social security coordination Regulation and the Directive. 

Financial impact

According to the Commission’s calculations, expenditure across the EU on cross-border healthcare incurred under the Directive amounted to 0.004% of the EU-wide annual healthcare budget. Based on the responses submitted by the Member States, a total of around € 65 million was spent across the Member States on healthcare under the Directive in 2016. The OECD estimates that healthcare expenditure in the EU countries is on average 10% of GDP. According to Eurostat, EU GDP for 2017 was €15.3 trillion. The cost of cross-border healthcare under the Regulations on the coordination of social security systems is about 0.1%. 


Taken together, both figures show that the vast majority of healthcare budgets is spent domestically. The impact on national health budgets as a result of patients who wish to access cross-border healthcare as a proportion of total domestic expenditure is negligible and without any major impact. 

Direction of patient mobility flows

Examining flows of patients who travel to access healthcare, the largest patient flows were from France to Spain and Germany, from Luxembourg to Germany, and from Ireland to the United Kingdom. 


The Commission sees two important trends from the current data on patient flows. Firstly, most patient mobility is between neighbouring countries. Around 50% of patients prefer to use health services near to their home or in a neighbouring country. In addition to geographic proximity, other criteria, such as collaboration between clinicians in border regions, also play a significant role. 


Secondly, the other 50% of cross-border treatment is made up of patients who travel throughout the EU to receive healthcare. The use of health services at a location of their choice may be driven by the desire to return ‘home’ for healthcare services in their country of birth, to be closer to a place where family members are based or to seek expertise that is not available in their own country. 

Information for patients at National Contact Points

The National Contact Points in the Member States, located in Germany at the GKV-Spitzenverband’s German Liaison Office for Health Insurance Abroad in Bonn, play an important role in providing information to citizens on request and raising general awareness of patient rights. In 2017, the National Contact Points received approximately 74,589 enquiries across 22 Member States and in Norway. According to the Commission, there needs to be more information about waiting periods and complaint procedures. There should also be more comprehensive information available on the NCP websites. 

The report from 2018 is available here

The report from 2015 is available here