1. Introduction 1

2. Policy context 1

  2.1. Directive 2011/24/EU on cross-border healthcare 1

  2.2. Responsibilities of the Member States 2

  2.3. Broader EU framework for cross-border healthcare 5

  2.4. Why modernise the rules for cross-border healthcare? 7

3. Overview of the study 7

  3.1. Study objectives  7

  3.2. Study methodology 9

  3.3. Study limitations 10

4. Evolution of cross-border healthcare under the Directive 11

  4.1. Evolution of the number of cross-border healthcare cases 11

  4.2. Evolution of the cost of cross-border healthcare 13

  4.3. Benefits of cross-border healthcare 17

5. Challenges to cross-border healthcare in the EU 18

  5.1. Summary of challenges identified 18

  5.2. Right to access healthcare abroad 20

  5.3. Reimbursement 24

  5.4. Recognition of prescriptions and prior authorisation 26

  5.5. Enhancing cooperation and interoperability 28

  5.6. Quality, safety, and continuity of care 31

  5.7. Previous recommendations 33

6. Roadmap for EU action 39

  6.1. Pillar 1 – Empower patients to access cross-border healthcare 40

  6.2. Pillar 2 – Enable effective cross-border healthcare delivery 52

  6.3. Pillar 3 – Build interoperable and future-ready systems 56

  6.4. Synthesis assessment of policy options 62

7. Conclusions  64

REFERENCES 67

ANNEXES 70

  ANNEX I: Interview programme  70

  ANNEX II: Workshop 76

Table of figures

  Figure 1 – Study steps 10

  Figure 2 – Adjusted data on CBHC requests under the Directive (2016-2024; EU-27) 13

  Figure 3 – Reimbursement costs (2016-2024) (N=12 Member States) 14

  Figure 4 – Prior notification 23

  Figure 5 – Prior authorisation 26

  Figure 6 – Three pillars for strengthening cross-border healthcare in the EU 40

Table of tables

  Table 1 – Responsibilities of the Member State of treatment and of affiliation 3

  Table 2 – Key differences between the Directive and the Social Security Regulations 5

  Table 3 – Overview of the number of CBHC cases received and granted (2016-2024) 12

  Table 4 – Total health expenditure and CBHC expenditure, (2016-2024; EU27) 15

  Table 5 – Summary of challenges and their drivers 18

  Table 6 – Summary of previous recommendations and current status 33

  Table 7 – Policy option 1 41

  Table 8 – Policy option 2 44

  Table 9 – Policy option 3 47

  Table 10 – Policy option 4 49

  Table 11 – Policy option 5 52

  Table 12 – Policy option 6 54

  Table 13 – Policy option 7 57

  Table 14 – Policy option 8 60

  Table 15 – Synthesis assessment of policy options 62

  Table 16 – Overview of the interviews conducted 70

  Table 17 – Overview of the workshop participants  76