Health Policy 108 (2012) 27–36 Contents lists available at SciVerse ScienceDirect Health Policy journal homepage: www.elsevier.com/locate/healthpol Analysing arrangements for cross-border mobility of patients in the European Union: A proposal for a framework Helena Legido-Quigley a,∗ , Irene A. Glinos b,c , Rita Baeten d , Martin McKee a , Reinhard Busse e a b c d e London School of Hygiene & Tropical Medicine, London, UK European Observatory on Health Systems and Policies, Brussels, Belgium Maastricht University, Maastricht, The Netherlands European Social Observatory (OSE), Brussels, Belgium Department of Health Care Management, Berlin University of Technology, Berlin, Germany a r t i c l e i n f o Article history: Received 26 February 2012 Received in revised form 20 June 2012 Accepted 4 July 2012 Keywords: Cross-border health care EU Patient mobility Conceptual framework a b s t r a c t This paper proposes a framework for analyzing arrangements set up to facilitate crossborder mobility of patients in the European Union. Exploiting both conceptual analysis and data from a range of case studies carried out in a number of European projects, and building on Walt and Gilson’s model of policy analysis, the framework consists of five major components, each with a subset of categories or issues: (1) The actors directly and indirectly involved in setting up and promoting arrangements, (2) the content of the arrangements, classified into four categories (e.g. purchaser–provider and provider-provider or joint crossborder providers), (3) the institutional framework of the arrangements (including the underlying European and national legal frameworks, health systems’ characteristics and payment mechanisms), (4) the processes that have led to the initiation and continuation, or cessation, of arrangements, (5) contextual factors (e.g. political or cultural) that impact on cross-border patient mobility and thus arrangements to facilitate them. The framework responds to what is a clearly identifiable demand for a means to analyse these interrelated concepts and dimensions. We believe that it will be useful to researchers studying cross-border collaborations and policy makers engaging in them. Crown Copyright © 2012 Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction The vast majority of health care is obtained from providers located in the same country as their patients. Patients are often unwilling to travel significant distances even in their own country and prefer to be treated as near to home as possible; near their family; in a language they understand; with familiar procedures; on a pathway that will assure continuity of care, including appropriate aftercare. This applies both to emergency care (for reasons of ∗ Corresponding author. E-mail address: helena.legido-quigley@lshtm.ac.uk (H. Legido-Quigley). perceived safety) and to elective treatment (for convenience, both for the patient him/herself and for visiting relatives). This means that unless there are good reasons (e.g. to obtain needed treatment more quickly, cheaply, or of better quality), any suggestion that patients should have to travel for treatment is unlikely to be well received. However, in some situations in the European Union, the most appropriate or the most accessible health care happens to be in another Member State. “Cross-border patient mobility” is the most commonly used expression within the EU to describe a social phenomenon that involves people crossing a border to receive health care. The expression encompasses a diverse set of interrelated concepts that vary in their importance in different contexts and settings. Cross-border patient mobility 0168-8510/$ – see front matter Crown Copyright © 2012 Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.healthpol.2012.07.001 28 H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 is part of the wider concept of cross-border health care, which also encompasses the mobility of professionals and services such as a blood sample or an image taken from a patient in one country but analysed in another country. The processes involved in accessing health care across borders can be purely individual decisions, outside any organised arrangements (which are not considered in this paper), or they can be facilitated by “arrangements” between different actors. It is the processes involved in the latter which we are interested in understanding. For these arrangements, which are predominantly, but not necessarily based on formal contracts, we propose a framework that can help to analyse the arrangements and provide an understanding of how the various concepts relate to one another and with the environments in which they operate. The proposed framework can be used as a tool for both research (retrospective analysis) and for policy and planning (prospective analysis) [1]. The development of such a framework is timely as European cross-border care patients will soon be covered by the Directive on the Application of Patients’ Rights in Cross Border Health Care [2], which will enter into force in 2013. This seeks to facilitate cross-border health care by providing patients with information, defining what treatment they are entitled to, what reimbursement they will be eligible for, and what costs they will have to meet themselves [3]. This Directive, which encapsulates successive rulings by the European Court of Justice brought by patients seeking care in another EU Member State, establishes a legal framework for all patients travelling abroad to receive treatment in circumstances not otherwise covered by bilateral agreements and current social security legislation [4]. 2. Methodology This paper exploits conceptual analysis and data from a range of case studies carried out previously by the authors in the context of a project (Europe for Patients) funded by the European Commission’s 6th framework programme [5–7], another one (HealthACCESS) funded by the European Commission’s Dircetorate General for Health and Consumer Protection [8] and by current research taking place under a 7th framework programme project (Evaluating Care Across Borders, or ECAB) that aims to facilitate Europe’s citizens making informed choices about whether to seek health care in another Member State. It complements earlier and ongoing work by the authors on the various types of cross-border patient mobility [8–11]. The methodology of Europe for Patients consisted of two literature reviews, on cross-border patient mobility [5] and on patients’ needs, levels of satisfaction and expectations in those cases where they have received treatment in another EU Member State [6], and five case studies which collected information on cross border patient mobility in Ireland/Northern Ireland, Belgium/the Netherlands and Belgium/England; Slovenia/Austria, Estonia/Finland, and Spain [7]. The methodology of HealthACCESS consisted of an analysis of six types of hurdles facing patients seeking access to health care within ten countries participating in the project and then identified via Internet searches and expert consultation all cross-border arrangement among those countries, in each case looking at existing documents to identify the hurdle(s) addressed; it was complemented by an analysis of routine data to estimate the numbers of patients moving among the ten countries [8,9]. The methods of ECAB consisted of seven case studies on hospital collaboration in European border(Finland/Norway, Denmark/Germany, the regions Netherlands/Germany, Belgium/France, Austria/Germany, Romania/Hungary, and Spain/France). Each case consisted of a stakeholder analysis exploring the purpose of hospital collaboration; actors’ incentives to engage in cross-border collaboration; and the role of the EU in supporting such initiatives. The research on hospitals was only one part of the larger ECAB project. 3. The development of the proposed framework The starting point of this framework is the model of policy analysis developed by Walt and Gilson [1]. This model links four elements: the substantive content of the policy, the actors involved, the processes in which this policy is formulated and developed, and the contextual factors that help to frame the policy. Walt and Gilson, in a seminal publication from the mid-1990s argue that health policy is increasingly characterized by conflict and uncertainty rather than by consensus and suggest that it is important to look beyond the content or the technical aspects of health care reforms. The complex and time-consuming developments at EU level in the field of (cross-border) health care, including more than a decade of rulings by the European Court of Justice and three years of negotiations between Member States, the Commission and the European Parliament, signify the degree of conflict and uncertainty and the difficulties facing policy-making in this area. Walt and Gilson’s model has been adapted to take account of the characteristics of the phenomenon we are studying. Even though the processes involved in arrangements to facilitate cross-border patient mobility match the criteria for what is normally understood by public policy, i.e. a process involving decisions taken by political actors to achieve certain objectives by way of certain means [12], it cannot be understood purely as a “public policy” since it does not always have a predominant political character. While decision-making and goal-selection are present in most if not all cross-border care settings, these decisions and objectives are not necessarily defined by political actors but rather by health care actors such as third-party payers (e.g. health insurers), providers (e.g. hospitals), health care professionals and, last but not least, the patient making use of the arrangement. Cross-border patient mobility can be initiated in situations where explicit policies are in place (e.g. when public authorities set up arrangements allowing patients to go abroad in the event of waiting lists or lack of certain services in the national health care system) but can equally arise in situations where there is no explicit pre-existing policy. There are several obvious examples: academic hospitals that seek benefits from co-operation across a border by exchanging know-how and patients; health insurers that enter into direct contracts with foreign health care H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 Table 1 A framework for understanding cross-border mobility of patients. Component Categories or issues Actors Providers Third-party payers/purchasers Public authorities (as planners and regulators) Brokers and facilitators Indirectly: patients Content Third-party payer/purchaser–provider arrangements Provider–provider or joint cross-border providers arrangements Border area emergency care Purchaser–purchaser collaboration Institutional framework Legal framework Cross-border health policies Characteristics of the health care systems Tariffs and payment mechanisms Quality assurance frameworks Patients’ rights Processes/changes How is the cross-border health care initiated, developed, implemented and evaluated? How is the process changing, and why? What factors have stimulated/inhibited the process? Contextual factors Political factors Cultural and linguistic factors The nature of borders providers to offer their insured members faster access to health care; or patients guided by facilitators to go abroad (e.g. for dental treatment or aesthetic surgery). The components of the framework will be adapted to fit the purpose of our analysis. In order to encapsulate all the concepts falling under “arrangements to facilitate crossborder patient mobility” we explore (Table 1): • the actors directly and indirectly involved in setting-up and motivating cross-border care arrangements; • the content of the different arrangements, classified into categories; • the institutional framework of cross-border care arrangements (including the underlying European and national legal frameworks). This is a new component introduced into the policy framework so as to cover all the specific institutional factors that influence particular cross-border arrangements and explain the differences between one initiative and another; • the processes that have led to the initiation and continuation, or cessation, of arrangements to facilitate cross-border patient flows; • the contextual factors that impact on cross-border patient mobility and thus arrangements to facilitate them. 29 these different levels and reflects how actors and the other components interact across them. The following sections present what we understand by each of the components, illustrated with examples from research previously carried out by the authors. It is important to recognize that although the components are presented as separate entities, all components are interrelated. Thus, processes involved in arrangements on cross-border mobility of patients cannot be understood without considering the roles that different actors play in arranging or initiating a cross-border initiative. Contextual factors influence actors’ decisions and the establishment of institutional frameworks and they can have a marked impact on processes. The relationship between institutional frameworks and actors is reciprocal. Actors can influence the introduction of an institutional framework and, on the other hand, actors behave according to a set of rules and procedures which are embedded in institutions. We have avoided ranking the importance of each of the components, as they vary according to the specificities of the cross-border arrangement, yet we have placed actors at the centre of our analysis. Actors at organisational, regional, national and European level are the main drivers for change and the active players in assuring the success or failure of cross-border health care arrangements in the European Union. For example, in Ireland contextual factors influenced the decision to establish health care collaborations across borders. For many years the two Health Departments on the island had only limited contact. Greater cross-border care was seen primarily as a means to facilitate dialogue between divided communities. Thus, the health arrangements were grounded in broader political agreements, including the 1998 Good Friday Agreement that included health although only as a very peripheral issue [13]. The arrangements were then institutionalized through funding from the European Interreg Programme. This strengthened collaboration and communication between those on different sides of the border. These arrangements were characterised by positive feedback loops; greater contacts fostered more initiatives. Given that they were embedded in a broader political process, they extended to tackling social deprivation and improving education. This illustrates the interconnectedness between context, actors, processes and institutional frameworks. In this particular example, contextual factors influenced the actors’ decisions, which in turn facilitated the creation of new institutional arrangements. Actors were influenced by the institutional arrangements as, following their establishment, it was necessary to collaborate with their counterparts in the other side of the border, something that was unlikely otherwise. These arrangements then triggered other crossborder heath care processes. 4. Actors As set out above, however, the list of components fails to capture the complexity of patient mobility. The five interrelated elements involved all act on several levels – European, national, regional and organisational. Consequently, it is necessary to think of this framework as having an additional cross-cutting, spatial dimension which encompasses Our understanding of an arrangement involves a structure or mechanism set up to allow the movement of patients across borders; arrangements often involve deliberate and structured cooperation between two or more health care actors located in different systems, but may also 30 H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 involve actors in solely one country as e.g. when national legislators grant rights to patients to seek care abroad. We understand actors to include all those who influence directly or indirectly the decision to set up an arrangement to facilitate cross-border patient mobility or contribute to making it work. These include (i) health care providers, (ii) third-party payers/purchasers, (iii) regulators/public authorities and (EU) policy-makers, and (iv) brokers (individuals and organisations that facilitate links between the involved parties) and, usually only indirectly, patients (or potential patients). Although patients usually do not directly take part in setting up the arrangements which allow them to go abroad [14,15], their motivations for seeking care abroad are relevant to the framework. If patients do not see the need or benefit to cross borders for care, the arrangements have no function. Glinos and colleagues systematically analysed 100 references on patient mobility from across five continents. Based on the evidence, they concluded that patients’ motivations fall into four key types: the availability of care (whether in terms of quantity or types of services), affordability of care, perceived quality, and familiarity with providers and/or the system [10]. Busse et al. [8,9] have identified six – later expanded to seven – hurdles facing patients seeking access to health care within countries, and asked whether these hurdles can be circumvented by cross-border care [8,9]: The first step regards the coverage for health care – an issue not amenable to cross-border mobility. The second hurdle relates to benefits covered under their primary scheme, which is only partially amenable to cross-border care. The remaining five are in no particular order of precedence: Cost-sharing policies may threaten equity of access; geographical distribution of services may pose a threat to accessibility in spite of equal entitlement (a reason cited in reports of 76 of 132 cross-border arrangements existing in 2006 [8]; a lack of contracts between (public) third-party payers and health care providers or a lack of choice among existing providers may block actual access to certain providers; capacity limitations and/or intra-organisational factors can also act as barriers to access, mainly through waiting lists (cited in 63 of the 132 cross-border arrangements in 2006 [8]); and, last but not least, personal preferences to utilising a service, which is influenced by gender, socio-economic and cultural factors. These five often motivate patients to cross borders to access health services (e.g. because they have to wait for a shorter time, pay less than in their home system) and, for other actors, to set up cross-border arrangements. Different types of health care providers can be involved in cross-border health care. They may include institutional providers (hospitals or emergency care services) or individual providers (general practitioners and specialist doctors). They may have public, private not-for-profit or private for profit status, and may be publicly funded or primarily rely on private payments. Third-party payers/purchasers engaging in cross-border health care arrangements can also be of different types: public health insurers (sickness funds), private insurance companies, or purchasers within tax-funded systems, all of which may commission care abroad for individuals or groups of patients and decide on procedures and conditions for funding care received abroad (including granting prior authorisation). Regulators/public authorities, such as ministries of health and regional/local health departments, as well as policy-makers are also involved in the process of cross-border health care as they define the legal aspects of health care provision, set limits around the national benefit basket, and conclude framework agreements with other Member States. Additionally, brokers and facilitators are emerging to play a role in crossborder health care; they can have a commercial profile, such as companies that take a commission for introducing the patient and provider to each other and arranging the cross-border treatment, or they can be not-for-profit bodies, such as social insurers in the receiving country, who simply assist with making cross-border mobility function more smoothly by, for example, helping cooperating partners overcome practical problems and differences in national practices and supervising invoices. 5. Content of the cross-border arrangements to facilitate cross-border patient mobility The content of cross-border arrangements for facilitating cross-border mobility differs greatly. Busse et al. [8] have proposed classifying them into four categories: (1) arrangements between third-party payers/purchasers (in one country) and providers (in another), (2) arrangements among providers or for joint cross-border providers (typically, hospitals located in border areas), (3) border area emergency care, and (4) purchaser–purchaser collaboration where administrative arrangements are designed to facilitate access to care abroad, but not actually involving the purchase or provision of care. 5.1. Third-party payer/purchaser–provider arrangements Agreements between third-party payers/purchasers in one country and providers in another can reflect several rationales, however two stand out, although usually operating in conjunction with each other. The first is the presence of ‘organisational’ hurdles to access on the purchaser side (for example, the presence of waiting lists). The second is the ability (and the incentive) for purchasers and providers to behave in a market-like manner (most straightforwardly, where purchasers are concerned, to shop around for the best deal, and where providers are concerned, to maximise revenue). In that respect, the presence of significant price differentials between countries is both a driver and a barrier (especially in relation to longer-term relationships, rather than to ‘spot’ purchases), depending on the location of the purchaser and provider, respectively. This barrier may, in part, explain the absence, or underdevelopment, of this type of arrangement between purchasers in the new EU Member States in Central and Eastern Europe, and providers in countries such as Germany, where prices are high relative to the prices faced at home. There are many purchaser–provider arrangements in place, but seem to be particularly concentrated between providers in Belgium and purchasers in The Netherlands. In 2006, there were some 21 arrangements in place which see patients from the Netherlands H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 going to Belgium to receive treatment [8]. All addressed waiting time and other access-to-service problems. The presence of so many arrangements reflects issues such as problems of under-capacity, the existence of a market, and the desire to place downward pressure on provider prices locally, with purchasers using benefit-in-kind systems [16]. Purchaser–payer arrangements are not limited to border areas though, as in the case of the German Techniker Krankenkasse with, in early 2012, 126 contracted hospitals in eight EU countries (73 in Italy) demonstrates (Caroline Wagner, personal communication). Of the 132 arrangements identified in the HealthACCESS project in early 2006, the majority (71) fell into this category [8]. 5.2. Provider–provider or joint cross-border provider arrangements Cross-border arrangements involving agreements between provider institutions, primarily aimed at sharing infrastructure and/or personnel, also exist. Across the German-Austrian border, hospitals in Simbach (Germany) and Braunau (Austria) have been collaborating since 1994 when the closure of a surgical ward in the German hospital prompted German sickness funds to ask the Austrian hospital to act as emergency unit for trauma patients requiring surgery. Since then, cooperation has intensified (in 2009 the Austrian hospital treated some 500 in-patient and 2000 ambulatory German patients) and has also involved Austrian patients being treated at the German hospital during refurbishment works at Braunau [17]. Cooperation between provider institutions located on different sides of a border is not simply about sharing existing infrastructure, but also planning provision in order to avoid duplication and thus waste. For example, on the island of Ireland, joint planning in both jurisdictions has been seen as a means to assure the viability of a hospital in the border region by extending the catchment population across the border [18]. On the initiative of the Belgian and French sickness funds, six organized zones of access to cross border care (ZOAST) have been set up at the Belgian-French border since 2008, based on a French-Belgian bilateral framework agreement between national public authorities [19]. They encourage the development of complementarity among provider facilities and patient movement across the border – that is, its overall aim is to develop a local, integrated health economy that straddles the border. Of the 132 arrangements identified in the HealthACCESS project in early 2006, 39 fell into this category [8]. Taking an even wider definition, all arrangements where joint infrastructure is set up across a border (e.g. where a hospital serves border-region populations of two countries or where an existing one is designated to serve border-region populations of both countries) can be considered under this heading. 5.3. Border-area emergency care The oldest arrangements in this category are those which relate to planning for major disasters in border areas (although these happen to be among the newer arrangements too). For instance, an agreement of this type has 31 been in place between France and Germany since 1977. These ‘planning’ arrangements are not strictly of the health care type, but can include a health care component. This would relate to issues such as responsibility for response, for casualty reception, and so on. Related to this type of arrangement, but with a clearer health care focus, are arrangements involving the shared use of emergency and ambulance services. This type of arrangement is especially prominent in the Netherlands–Germany–Belgium border regions (both bi-lateral and tri-lateral arrangements exist), but also, for example, between Austria and Germany (a shared emergency helicopter service with equal financial and organisational input from both countries), and between the Republic of Ireland and Northern Ireland (which has a history of informal cooperation on the use of emergency services going back to the 1940s). Of the 132 arrangements identified in the HealthACCESS project in early 2006, 10 fell into this category [8]. 5.4. Purchaser–purchaser collaboration Schemes aimed at facilitating access administratively to care abroad exist to enable the other formal arrangements – or simply rights codified under EU law (see below) – to function more effectively. There are several such arrangements in place, one of the main ones being ‘Health Card International’. This is a ‘smart card’ arrangement between German and Dutch sickness funds and providers in the Mass-Rhine region which allows members to access specialist, hospital and pharmaceutical care across the border without having to seek prior authorisation. 6. The institutional frameworks impacting on cross-border care There is a set of institutional frameworks, including legal frameworks and characteristics of the health systems of the countries involved, which influence the scale, nature of mobility and the attitudes and behaviour of actors. 6.1. The legal frameworks As cross-border health care involves the consumption of health care services outside the borders of the Member State where the patient is affiliated to the social security system, it implies that a legal mechanism is in place to allow patients to obtain treatment abroad – and reimbursement for it. Such derogations from the principle that health care be consumed within national territory can take various forms and the legal frameworks on which it is based can be set at European level, at national level or as bilateral agreements between two Member States. Often it involves national policies, including legal frameworks, although framed by the more general EU legal principles. Consideration of European Union structures involves looking at how EU legislation has impacted on cross-border health care arrangements involving patient mobility. Here we distinguish between two main frameworks. Firstly, in 1971 the EU established a mechanism by which individuals can obtain health care in another Member State, based on what is now Regulation 883/04. Many of the 32 H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 arrangements to facilitate cross border patient mobility are based on the provisions of this Regulation. Secondly, through a series of judgments since 1998 the European Court of Justice (ECJ) has had a major impact in the way it has interpreted the Treaties and applied their principles to cross-border health care. In the seminal linked cases of Kohll and Decker, the Court stated that patients could use internal market provisions to gain access to health care in other Member States. Other ECJ rulings with an impact on cross-border health care have followed, confirming that the Treaty provisions on freedom of movement of goods and services means that an individual’s health care system must pay if a patient looks elsewhere in the EU for treatment, in particular because of “undue delays”. Many of the arrangements involving an agreement between a third-party payer/purchaser and a provider resulted from national interpretations of this EU case law, in particular in benefit in kind systems [20]. The Directive on the Application of Patients’ Rights in Cross Border Health Care, which will enter into force in 2013, aims to codify these rulings and provides flanking measures which should allow patients to make informed decisions about cross-border health care. National legislation can set out conditions and criteria for obtaining planned treatment in another Member State. A country can choose to grant its citizens entitlements which go beyond the provisions of the EU legislation, whilst applying the procedures set in the EU frameworks or other procedures. In this sense, EU legislation defines the minimum which patients are entitled to in terms of cross-border health care. Countries where funding of care is based on reimbursement typically base their initiatives to relax access to cross border care on the procedures defined in Regulation 883/04. For instance, Luxembourg has arrangements in place to allow its patients highly specialised treatments abroad because the Luxembourg health system, due to its relative small size, is not able to provide all types of care domestically. In Belgium, a Royal Decree specifies that the population living in defined border-regions has access to care abroad and thus may be exempted from the territoriality principle [21]. The Health and Disease Insurance Act furthermore allows further relaxation of access to cross border care in nationally approved local arrangements [22]. Other countries such as Germany, Denmark and the Netherlands have seen adaptations to national legislation, allowing domestic purchasers to contract with providers in other Member States, thereby implicitly allowing patients access to care abroad [20]. Legal issues can prove challenging in concluding contracts between a provider in one Member State and a purchaser in another one. Legal provisions in two countries are often not directly compatible and contractual negotiations can become long and tedious procedures, as experienced by several Belgian hospitals with cross-border contractual arrangements with the English NHS [23]. In the cooperation between the Austrian Braunau hospital and the German Simbach hospital, Austrian regional health authorities – responsible for the safety and standards of treatment provided to Austrian patients – have insisted that Austrians be treated by Austrian health professionals at the German hospital [17]. 6.2. Cross-border health policies There is considerable variation in Member States’ approaches and in the extent to which policies to promote or facilitate cross-border health care have been formulated and implemented at regional or at national levels. In some countries, patient mobility attracts little political attention or even awareness. In other countries where patient mobility is higher on the political agenda, important initiatives are being promulgated by national governments. This can occur in two different scenarios. First, where there is a long tradition of cross-border health care initiatives at regional level creating complementarities in healthcare provision between the countries, often in rural areas. In such cases national policies aim to streamline the locally emerging initiatives and to define responsibilities clearly. France, for example, has concluded bilateral framework agreements with its neighbours (in particular Belgium and Germany), defining the authorities authorised to set up arrangements between providers and defines the regions at both sides of the border where the agreement applies. For example, the framework agreement between the government of the Belgian Kingdom and the French Republic on healthcare cooperation in border areas was signed in 2005, ratified by France in 2007, and by Belgium in 2010. Secondly, when there is lack of provision in the national system either due to insufficient capacity, leading to waiting lists (as has been the case in England, Ireland, Norway and the Netherlands [10]) or due to a conscious decision not to provide specific services (typically in small countries such as Luxembourg or Malta, because the service would not be viable), national health authorities can opt to send patients abroad. EU policies can also play an important role. On the border between Spain and France, a hospital is planned in the mountainous border region of Cerdanya to cater for the needs of the local Spanish and French populations, with substantial financial and political support from the EU totalling some D23 million from the European Regional Development Fund [24]. In border regions, a crucial factor in the development of health care projects is whether there is sufficient will from local and regional actors for these initiatives to take place. Another issue is how cross-border co-operation is seen by the relevant national authorities and whether they give a project (political) backing or not. The literature on cross-border care suggests that co-operation pursued by regional actors across borders may be seen as undermining a country’s territorial integrity and so may be resisted by central state authorities [5]. Much depends on the extent of centralisation of governance of the health systems in the countries involved. There are examples across the European Union that show how health care co-operation can be initiated successfully by regional authorities, such as the co-operation between Southern Jutland (Denmark) and German hospitals [25]. For these arrangements to work, authorities responsible for the funding of care have to be involved or to create the framework in which they can function. This is illustrated at the French-Belgian border where French local authorities conclude contracts with Belgian providers and sickness funds, in conformity with the Bilateral Framework agreement concluded between the national authorities [19]. H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 6.3. Characteristics of the involved health systems When seeking to understand cross-border health care it is necessary to consider the organisational structures and procedures of both health care systems (the sending and the receiving Member State) to see how they can influence cross-border arrangements. Different organisational characteristics can hinder the process of co-operation and can lead to “clashes” between systems, but can also stimulate cross-border health care arrangements. Aspects of health care systems that can impact on patient mobility and cross-border arrangements include: differences in tariff-setting; the existence of contractual practices; differences in payment mechanisms of providers; the existence of a gate-keeper system; whether the system reimburses expenses or provides benefits in-kind; the presence of over- or under-supply of services; the role of commercial actors in the system; differences in the organisation of after-care; and whether health care has been devolved to lower tiers. For example, Belgian providers’ financial interest in treating more patients has meant that they welcome Dutch patients who come from a system where waiting lists and under-capacity have received great attention from the media, the public and politicians. Furthermore, Dutch insurers have commercial incentives to look for ‘deals’ across the borders. 6.4. Tariff setting and payment mechanism Differences in price levels can constitute both an important driver and a hurdle for cross-border health care when institutional purchasers make contracts with providers abroad, such as German sickness funds contracting with Czech health facilities or Dutch insurers which are attracted by lower tariffs in Germany and Belgium, in particular because the prices in the Netherlands include investment costs, as opposed to Belgium and Germany which thus effectively subsidize foreign patients. The same problem arises across the German–Austrian border as Austrian tariffs include infrastructural costs [17]. An example of a similar unresolved issue involves the ambulance services in Belgium and the Netherlands. The Dutch ambulance services are more expensive than in Belgium because they include the costs of medical treatments. This is to the detriment of Belgian patients as Belgian sickness funds do not reimburse the costs of transportation by a Dutch ambulance to a Belgian hospital [5]. Reflecting differences in their health systems, countries may have very different methods of calculating costs and setting prices and tariffs, which complicates inter-system comparisons and requires extra efforts to “translate” the specificities of the systems. Payment methods might also differ according to whether a fee for service system or all-in pricing is used. A final issue at the European level relates to the funding opportunities for the arrangements themselves that are provided by the European Regional Development Fund, in particular through its INTERREG programmes, which promote European integration through cross-border cooperation and exchanges. Interreg projects have often created the opportunity for a cross-border co-operation initiative in health care involving patient mobility to get 33 started and, in many cases, consolidated. As an example, all cooperation initiatives at the French-Belgian border have been set up by local actors, under INTERREG programmes. 6.5. Quality assurance frameworks A condition for safe and well-functioning cross-border patient mobility is that patients can be assured that the care they will receive in the foreign country is of satisfactory quality. Our previous work in this area identified two steps that must be taken for this to happen [26,27]. The first step in assessing quality involves determining what policies exist at national level. The second step relates specifically to the process of cross-border care. Clearly, this varies, to some extent, according to the type of patient mobility being considered. While everyone in Europe ought to be reassured that the key elements of a high quality system are in place, issues relating to continuity of care or doctor-patient communication will differ. Following treatment abroad, most patients will return to their country of origin where they may need after-care. Ways of assuring quality of health care for those moving between countries include the development of shared protocols; controls prior to setting up arrangements; the transfer of patient files; and the development of common medical documentation. The Danish “Extended Free Choice of Hospitals” scheme involves a programme of quality assurance with a system of evaluation and accreditation of facilities including foreign providers. The German St. Franziskus hospital (located ca. 5 km from the border) provides radiation therapy to Danish cancer patients living in the border-region and follows Danish quality guidelines for these cross-border treatments [21]. Common quality assurance protocols have been established between the Teaching Hospital Centre in Nice, France, the authorities in the Italian provinces of Imperia and Savona, and the Research Centre on Cancer in Genoa, Italy. Quality assurance can also involve controls prior to setting up arrangements: English and Dutch purchasers rigorously checked Belgian hospital facilities before setting up contracts with them [23]. 6.6. Patients’ rights Depending on the country’s legal and cultural tradition, approaches to patient rights vary greatly in the extent to which they are incorporated into laws, charters, and nonbinding aspirations [28], with implications for cross-border patient mobility. The new Directive seeks to clarify some of these rights in a cross-border context and should be understood in conjunction with national legislation on this topic. The way in which patients’ rights on access to care, for instance, are defined at national level can have a major influence on providing health care abroad. For example in Norway, since 2004, a law on patient rights lays down that if the target date for treatment (set individually for each patient) is not respected in the region of residence or if there is lack of medical competence in Norway, the patient has the right to be treated abroad before that target date [29]. Similar legal provisions exist in Denmark guaranteeing that the patient receives treatment within a 34 H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 specified maximum period of time and in theory that sending patients abroad is an option if waiting times cannot be respected by domestic providers [30]. 7. Processes The establishment of cross-border health care arrangements is a dynamic process involving conception, initiation, formulation and development, and on the practical level negotiation, communication, implementation and evaluation. By visualising cross-border health care as a process, one can hopefully form a more complete picture of the mechanisms involved. They are rarely straightforward and rational, instead often involving trial and error, with pilots being set up, which then may or may not be extended to other providers, regions can be redefined and eligible treatments can change over time. Changes can be the result of citizens putting pressure on policy makers, but also technical and legal problems can change the initiatives. Actors who feel threatened (e.g. hospitals loosing patients) can exert pressure to stop or limit the flows, others can discover that the cross border arrangements offer them a strategic position in the national system, which then becomes an additional motive to continue and expand cooperation. It is important to recall that processes do not take place independently of actors. As Walt notes; “the analysis of the policy process is interwoven with an exploration of which actors are involved, and how far each may be exerting influence on policy” [31]. We are not only interested in policy processes but at least as much in cross-border interactions between actors which launch and put into practice crossborder health care and how these change over time. An analysis of the processes, the changes and the factors that have stimulated or inhibited cross-border health care allows us to understand thoroughly what problems exist, what solutions have been found and what remains to be done. Additionally, processes can explain why derived outcomes fail to emerge [1]. Cross-border health care cooperation involves a process of learning and of adapting to the relevant circumstances. Yet, cross-border care arrangements can also lead to new processes. From this perspective, it is important to consider how cross-border health care and patient mobility impact on the health care systems involved – for example by creating new pressures, by introducing new medical practices or financial procedures, or by changing power balances between actors on the domestic health care scene. For instance, Cross-border care can encourage the introduction of selective contracting mechanisms in systems where they did not exist previously or can create more room for commercial actors and for commercial behaviour of existing actors in the publicly funded system; Dutch patients bypass national gate-keeping practices when accessing Belgian providers [32]. By examining the processes which lead to patient mobility and cross-border health care and the processes which these phenomena give rise to over time, we can more easily grasp the reasons for and the consequences of patient mobility in its entirety. 8. Contextual factors Contextual factors here refer to those external factors that can influence the nature and scale of cross-border health care. There are many ways of categorising such factors. The most commonly used typology is the one provided by Leichter [33] which includes Situational factors, Structural factors, Cultural factors and International or exogenous factors. For the present purpose the following main categories have been identified through the empirical research carried out by the authors [5,11]: political factors, cultural and linguistic factors and the nature of borders. These map on to all of Leichter’s categories but have been arranged in a way that best represents the issues to be taken into account when exploring cross-border patient mobility in the European Union. 8.1. Political factors Political factors include both short-term events and longer-term developments that impact on public opinion or stakeholders attitudes, both of which shape the policy agenda or the introduction and design of policies. Here we refer to policy makers and stakeholders who use the cross border arrangements to achieve other goals, including reforms to national health care systems but also in other policy domains. These can act at local/regional, national and European level and, in some cases, they can be decisive for the development of a cross-border initiative. At national level, cross-border health care can reach the political agenda when it is seen as a possible solution to a domestic problem. For example, when long waiting lists are perceived as a problem by the population or when they are seen to be a result of a failure of domestic providers to meet needs, the responsible third-party payers – health insurers or health authorities – may seek to purchase treatment abroad. Ostensibly this is to overcome a lack of domestic capacity but there often seems to be an underlying intention of challenging what are seen as unresponsive domestic monopolies or cartels. Where the latter is the case, as in England or Ireland, such initiatives are short-lived [34,35]. They appear to be more sustained where there is a real concern about domestic capacity, as in Norway [29]. Cross-border health care may also arise as a consequence of wider policies to develop structures that cross frontiers. Again, the motives may be mixed. In a few cases there is an underlying desire to build cultural and social links between communities, exemplified by the situation in Ireland where cross-border co-operation is to a considerable extent driven by the agenda for peace and reconciliation in the aftermath of several decades of inter-communal violence [34]. These considerations are especially common where there are communities divided by an international border but who share strong cultural and often linguistic links, as in co-operation between neighbouring regions in Italy and Austria [36]. 8.2. Cultural and linguistic factors Cultural factors can play an important role by influencing whether actors are willing to cooperate and whether H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 patients are willing to travel abroad for treatment. Habits, traditions, language, expectations and familiarity with the country and health care system can either hinder or facilitate cross-border health care. A recent study from the Dutch–German border region shows how familiarity with local health professionals and national health systems motivates patients living abroad to seek health care in their home city, and that survey respondents were willing to travel hundreds of kilometres to see their usual doctor [37]. A Danish study into the use of cross-border health care facilities in Germany by Danish patients revealed that the closer people lived to the border, the less reluctant they were to go for treatment in Germany [25]. Reluctance to being treated abroad thus appears to diminish as people become more familiar with the neighbouring country and with its language so that “the foreign appears less foreign” in the border-region between the two countries. However, willingness to be treated abroad is not only determined by proximity to the border. In Ireland, reluctance by patients to travel abroad was seen as one of the main constraints to achieving the policy goal of promoting cross-border health care (to circumvent domestic waiting lists) whilst in countries such as the Netherlands and Luxembourg it appears that going abroad for care is a more widely accepted phenomenon – even when this might imply travelling considerable distances [34]. This highlights how “borders” can mean different things depending on the situation. 8.3. The nature of borders There are great differences in terms of the ease with which national borders can be crossed in Europe. In some cases, neighbouring countries are divided by sea, a situation that has shaped the relationship between the United Kingdom and France throughout history. Others are divided by high mountain passes, such as Italy and Austria. However, in other places borders are almost imperceptible, indicated only by a change in the road signs. Borders may also be more or less easy to cross in terms of administrative hurdles such as authorisation procedures. Finally, borders can have different meanings to different people, depending on whether they are perceived to be difficult to cross, thus discouraging cross-border movements and exchanges, or whether instead the population living close to the border is familiar with “the other side”, feels it is easy and comfortable to cross the border and does not experience the border as a dividing line. People’s perception of the border will be closely linked to affinities or dissimilarities in terms of culture and language. These differences have led us to distinguish between rigid borders and fluid borders, which respectively hinder and facilitate cross-border health care. 9. Conclusion The proposed framework presented in this paper seeks to represent the main issues that need to be considered when studying cross-border arrangements for mobility of patients. We believe that it will be useful to researchers studying cross-border arrangements and policy makers and other actors engaging in them. It originates from 35 the authors’ substantial body of research in this complex field over many years and responds to what is a clearly identifiable demand to provide a means to analyse these interrelated concepts and dimensions. The conceptual framework has several limitations. First, as with any framework, it is difficult to delineate a complex phenomenon or divide it into components and categories. Second, some categories can be placed into more than one of the five components. For example, cross-border health policies have been placed within the component on institutional frameworks. However, one could argue that cross-border health policies constitute a regional or local level action within the legal framework. Furthermore, rather than defining cross-border health policies as a category of institutional frameworks, it could be included within an additional spatial dimension. However, we considered cross-border health policies as a category that fitted better within the component of institutional frameworks as it lacks a legal mandate. Third, frameworks are ideal type categorizations so there will be some scenarios that are not completely captured by this framework and others that do not fit the framework. While we wanted our framework to have a spatial dimension, we were also aware that different elements could exist at different levels. Thus, some actors will not appear in all the levels envisaged. For example, it is very unlikely that European-level actors will be other than regulators or brokers. Notwithstanding this limitation, we believe that the spatial dimension was needed to emphasize the levels at which arrangements operate. The usefulness of the conceptual framework for analyzing arrangements set up to facilitate cross-border mobility of patients in the European Union is twofold. First, it provides the reader with an overview of the different issues at organisational, regional, national or EU level involved in cross-border mobility of patients although we acknowledge that each issue cannot be exhaustively covered here. It can be used for retrospective analysis to learn about the actors, processes and contextual features that make each situation different. It can also be used for prospective analysis in particular for those who are interested in recognising opportunities for change or for those who intend to initiate a cross-border arrangement. The proposed framework can also be used to undertake comparative analysis by collecting information on each of the headings or/and subheadings of the framework as they apply to the different types of arrangements to facilitate cross-border patient mobility. Second, by providing the first overview of issues that need to be considered, it will encourage researchers to take some forward through more in-depth analyses. This can be done in several ways. One way is to apply concepts from other disciplines, such as power relations or social capital which focus on the role of interactions, or by combining this framework with perspectives that focus on institutions and interests of groups to for example explain how the EU affect cross-border patient mobility. Other analysts might look at how processes of change came about in cross-border health care by using different policy process models such as the Advocacy Coalition Framework (ACF) [38] as a lens to investigate how networks of actors and 36 H. Legido-Quigley et al. / Health Policy 108 (2012) 27–36 their ideas change over time or undertake a network analysis to understand different loci of power. Finally, research can focus on the bottom-up processes and explore how collaborations are initiated at a local level, for example in a hospital, or instead adopt a top-down perspective looking at the negotiations that take place at European or national levels to elucidate which networks are influential in shaping the policy debate. Any of these approaches, combined with this framework or some of its components, would enhance understanding of the motivations of actors to engage in these collaborations; how the arrangements are implemented, formulated and evaluated; and what are the factors influencing their success or failure. Acknowledgement This project was undertaken within the European Union 7th Framework Programme EU Cross Border Care Collaboration (EUCBCC) Contract no: 242058. References [1] Walt G, Gilson L. Reforming the health sector in developing countries: the central role of policy analysis. Health Policy and Planning 1994;9(4). [2] European Parliament and Council of the European Union, Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients’ rights in cross-border healthcare, 2011, Official Journal of the European Union: Brussels. [3] NHS, Patient choice beyond borders: implications of the EU Directive on cross-border healthcare for NHS commissioners and providers, in Briefing2011, NHS European Office: Brussels. [4] Legido-Quigley H, Passarani I, Knai C, Busse R, Palm W, Wismar M, et al. Cross-border healthcare in Europe: clarifying patients’ rights. BMJ 2011;342:364–7. [5] Glinos IA, Baeten R. A Literature review of cross-border patient mobility in the European Union. Brussels: Observatoire social European, asbl; 2006. p. 114. [6] Legido-Quigley H, McKee M, Glinos IA, Baeten R. Drivers of patient and professional mobility. London: London School of Hygiene and Tropical Medicine; 2006. p. 179. [7] Rosenmöller M, McKee M, Baeten R, editors. Patient mobility in the European Union: learning from experience. Copenhagen: European Observatory on Health Systems Policies; 2006. [8] Busse R, Wörz M, Foubister T, Mossialos E, Berman P. Mapping Health Services Access: National and Cross-Border Issues (HealthACCESS) Final Report. Dublin/Brussels: European Health Management Association; 2007. [9] Busse R, Van Ginneken E, Wörz M. Access to healthcare services within and between countries of the European Union, in CrossBorder Healthcare in the EU: Mapping and Analysing Practices and Policies. In: Wismar M, et al., editors. WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen. 2011. p. 47–90. [10] Glinos IA, Baeten R, Helble M, Maarse H. A typology of cross-border patient mobility. Health Place 2010;16(6):1145–55. [11] Legido-Quigley H, Glinos I, Baeten R, McKee M. Patient mobility in the European Union. BMJ 2007;334:188–90. [12] Jenkins W. Policy analysis: a political and organizational perspective. New York: St. Martins Press; 1978. [13] The Centre for Cross Border Studies. [cited 2012 12th June]; Available from: http://www.crossborder.ie/. [14] Glinos I. Cross-border collaboration, in Cross-Border Healthcare in the EU: mapping and analysing practices and policies. In: Wismar M, et al., editors. WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen. 2011. p. 217–54. [15] Seminaire: “Coopération Transfrontalière Sanitaire”. 2002. Lille. [16] Glinos IA, Baeten R, Maarse H. Purchasing health services abroad: practices of cross-border contracting and patient mobility in six European countries. Health Policy 2010;95:103–12. [17] Kostera T, Burger R. Regional restructuring and European Prospects: cross-border hospital cooperation between Austria and Germany, in Cross-border hospital collaboration in the EU. In: Glinos I, Wismar, M, editors. WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen, in press. [18] Jamison J, Legido-Quigley H, Mc Kee M. Cross-border care in Ireland, in patient mobility in the European Union- learning from experience. In: Rosenmöller M, McKee M, Baeten R, editors. European Observatory on Health Systems and Policies: Copenhagen. 2006. p. 194. [19] Kiasuwa R, Baeten R. Cross-border hospital collaboration in the region of the Ardennes, at the French-Belgian border. In: Glinos I, Wismar, M, editors. Cross-border hospital collaboration in the EU, WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen, in press. [20] Baeten R, Vanhercke B, Coucheir M. The Europeanisation of National Health Care Systems: creative adaptation in the shadow of patient mobility case law, R.p.N. In: OSE Paper Series. 2010. p. 30. July 2010, Editor. [21] Royal Decree 3 July 1996 executing the statutory Sickness-and Invalidity Insurance Act BS/MB 31 July 1996, 1996. [22] Coordinated Act of 14 July 1994 concerning the statutory sickness and invalidity insurance BS/MB 27 August 1994, 1994. [23] Glinos IA, Baeten R. Cross-border care in Belgian Hospitals: an analysis of Belgian, Dutch and English stakeholder perspectives. Observatoire Social Europeen: Brussels 2005:44–5. [24] Sanjuan J, Gil J. The creation of a new health care facility: the Cerdanya joint cross-border hospital. In: Glinos I, Wismar, M, editors. Crossborder hospital collaboration in the EU, WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen, in press. [25] Augustin U, Panteli D, Busse R. German radiation therapy for Danish cancer patients – a 13-year long border-region success story, in Cross-border hospital collaboration in the EU. In: Glinos I, Wismar, M, editors. WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen, in press. [26] Legido-Quigley H, McKee M, Nolte E, Glinos IA. Assuring the Quality of Health Care in the European Union: A case for action. Observatory Studies Series N 122008 World Health Organization on behalf of the European Observatory on Health Systems and Policies: Copenhagen. [27] Legido-Quigley H, Glinos IA, Walshe K, van Beek B, Cucic C, McKee M. Quality and safety, in cross-border healthcare in the EU: mapping and analysing practices and policies. In: Wismar M, et al., editors. WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen. 2011. p. 121–58. [28] Nys H, Goffin T. Mapping national practices and strategies relating to patients’ rights, in cross-border healthcare in the EU: mapping and analysing practices and policies. In: Wismar M, et al., editors. WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen. 2011. p. 159–216. [29] HELTEF, Evaluering: Pasienterfaringer I kjøp av helsetjenester i utlandet, 2003, HELTEF: Nordbyhagen. [30] Retsinformation. 2012 [cited 2012 21st of February]; Available from: https://www.retsinformation.dk/Forms/R0710.aspx?id=129917. [31] Walt G. Health policy: an introduction to process and power. Zed Books Ltd; 1994. [32] Baeten R. Past impacts of cross-border health care, in Cross-Border Healthcare in the EU: Mapping and Analysing Practices and Policies. In: Wismar M, et al, editors. WHO on behalf of European Observatory on Health Systems and Policies: Copenhagen. 2011. p. 255–87. [33] Leichter HM. A Comparative Approach to Policy Analysis. Health care policy in four nations. Cambridge: Cambridge UP; 1979. [34] Jamison J, Legido-Quigley H, McKee M. A solution in search of a problem? - Cross-border health co-operation in Ireland. Armagh, Northern Ireland.: Centre for Cross Border Studies; 2005. p. 38. [35] Glinos IA, Baeten R, Boffin N. Cross-border Contracted Care in Belgian Hospitals, in Patient Mobility in the European Union: Learning from Experience. In: Rosenmoller M, McKee M, Baeten R, editors. European Observatory on Health Systems and Policies: Copenhagen. 2006. p. 97–118. [36] HOPE. Hospital Co-operation in Border Regions in Europe. Leuven: Standing Committee of the Hospitals of the European Union; 2003, 88. [37] Glinos IA, Doering M, Maarse H. Travelling home for treatment and EU patients’ rights to care abroad: Results of a survey among German students at Maastricht University. Health Policy 2012, published online 20 Jan 2012. [38] Sabatier P, Jenkins-Smith H. Policy Change and Learning: An Advocacy Coalition Approach. Boulder: Westview Press; 1993.