Crossing the border for health care: adding value for patients and health systems

Eurohealth  —  Vol.28  |  No.1  |  2022 51Eurohealth 28(1) CROSSING THE BORDER FOR HEALTH CARE: ADDING VALUE FOR PATIENTS AND HEALTH SYSTEMS By: Matthias Wismar, Robert Touret, Jonathan Clottes, Gabrielle Dubois, Apolline Damez-Fontaine, Vincent Rouvet and Ewout van Ginneken Summary: In the European Union, patients are able to receive health  care in another Member State. This has made life much easier  for people travelling, working, studying, and residing abroad and  provided options for patients facing long waiting times at home or  suffering from rare diseases. These opportunities have been especially  important during the COVID-19 pandemic, which has led to increased  demand for COVID-19 care as well as catch-up care following the  disruption to routine health services. As we are progressing towards  a European Health Union, we suggest where improvements to cross- border health care could be made. Keywords: Cross-Border Care, Border Regions, Bilateral Agreements, COVID-19 Matthias Wismar is Programme  Manager, European Observatory  on Health Systems and Policies,  Brussels, Belgium; Robert Touret  is Head of the Office of European,  International and Overseas Affairs,  Jonathan Clottes is Project  Manager, Gabrielle Dubois  is Project Manager and  Apolline Damez-Fontaine  is Project Manager, General  Directorate of Healthcare Services,  French Ministry of Solidarity and  Health, Paris, France; Vincent Rouvet is the General Director of  the Hospital of Cerdanya, Puigcerdà,  Spain; Ewout van Ginneken is  Berlin Hub Coordinator, European  Observatory on Health Systems  and Policies, Berlin University of  Technology, Germany.   Email: wismarm@obs.who.int Introduction Cross-border health care adds substantial value for European patients and citizens. It has been gradually developed since the beginning of the European Economic Community to ensure free movement in the European labour market. Cross- border health care rests on various legal frameworks. The two most important legal frameworks are: 1) the regulation on the coordination of social security systems (European Commission Regulation 883/2004); and 2) the patients’ rights directive (Directive 2011/24/EU) (see Box 1). Cross-border care received an important impetus when Directive 2011/24 on the application of patients’ rights in cross border health care passed in 2011 (Table 1 distinguishes between the regulation and the directive), though further progress towards implementation in practice and user-friendliness is necessary. Cross-border health care helps European patients who fall sick abroad, increases options to receive planned care in another European Union (EU) country, can help patients with rare diseases, and provides opportunities to develop cross-border collaboration between providers and payers. It also has the capacity to help alleviate health system pressures in times of crisis. Learning from experiences during the COVID-19 crisis, Europe is moving towards the creation of a European Health Union, in which EU countries work more closely together to protect the health of Europeans and to collectively respond to cross-border health crises (see the article by Mauer et al. in this issue on a European Health Union). In this context, cross- border health care must not be forgotten and warrants further attention. Eurohealth  —  Vol.28  |  No.1  |  2022 52 Eurohealth 28(1) The number of patients using cross- border health care is currently small Overall, the number of patients using cross-border health care under both legal frameworks – the regulation and the directive – appear small and the budgetary impacts are very limited. It is estimated that unplanned health care under the regulation amounts to around 2 million patients per year. Figure 1 provides an overview on the budgetary impact of cross-border health care under the regulation, which amounts to 0.4% of the total health care budget in the EU. For planned health care, the most prominent flows took place from France to Belgium, from Luxembourg to Germany, from Germany to Austria, from Germany to Switzerland, from Austria to Germany, from Luxembourg to Belgium, and from Belgium to Luxembourg. 2 The number of patients using cross-border health care under the regulation is difficult to assess and clear trends cannot be identified. There are many reasons for inaccuracies. There are severe data gaps  3 and some Member States do not make a distinction between planned care under the regulation and the directive. Moreover, some of the bilateral agreements for cross-border health care do not routinely report their data. The numbers of patients using the directive for cross-border health care and the costs reimbursed by the competent authorities is much smaller. In 2019, 290,890 cases were reported up from 232,054 in 2018. The growth occurred predominantly in cross-border care not requiring prior authorisation. These numbers are not directly comparable because of variations in the number of countries reporting each year. The total expenditure on all reimbursements reported by the Member States also rose in 2019 to €92 million up from €73.3 million in 2018. 3 The impact of the directive on national health budgets appears marginal estimated at only 0.004% of the EU-wide annual health care budget. 4 However, as mentioned above, the data are incomplete. How does the cross-border European care framework benefit EU citizens? It covers European patients who fall sick abroad EU nationals, who are crossing the border to live, work, study or retire can rely on the European Health Insurance Card (EHIC) when falling sick. It allows anyone who has health coverage in their country of origin to receive medical treatment in another Member State for free or at a reduced cost if that treatment becomes necessary during their visit abroad. Pre- existing chronic conditions which require care, such as kidney dialysis, are also covered. Students who study in another country can also use the EHIC for health care. Posted workers, who are sent by their employers for up to 24 months to another EU Member State can use the EHIC to obtain health care in the country of work, though their employer needs to request a form prior to the posting as a statement of the applicable legislation. The same is applicable for workers, who work in more than one country. Frontier workers, that commute on a daily or weekly basis to another Member State may choose between health care in their country of residence or country of work. This right is retained at retirement and extended to their families and their survivors. It increases the option to receive planned care abroad EU nationals can also ask for access to cross-border health care for planned procedures. This is particularly attractive when long waiting lists exist in the country of residence or if the health care facility may be closer to the place of Box 1: The legal framework for cross-border health care in the EU:  general principles for better access to care  The regulation on the coordination of social security systems (European Commission Regulation 883/2004) provides the legal framework for unplanned care and planned care organised by the competent authority (i.e. those with the power to perform the designated function, such as a sickness fund or national government). The coordination of social security systems was introduced to facilitate cross-border mobility for workers, which is a precondition for a European labour market. Therefore, the predecessor or the regulation on the coordination of social security systems, Regulation of the Council Number 3 on social security of cross-border workers, came into force almost in parallel with the creation of the European Economic Community. The regulation has been reformed several times and renamed but retained its function in guaranteeing cross-border social security. The patients’ rights directive (Directive 2011/24/EU) is more recent and establishes the right to seek health care in another Member State. It was passed after a long political process in 2011 with an implementation period of three years. It codifies a series of landmark rulings from the European Court of Justice (CJEU) on cross-border health care. The case law focused on demands of European citizens that the free movement of services also applies to health services and goods and therefore they derived from this an entitlement to access cross-border health care. 1 In a series of rulings, the CJEU followed these demands with the exception of ‘hospital care’, or what is now called ‘planned care’ allowing pre-authorisation through competent authorities. 1 Beyond codifying case law, the patient’s rights directive is of particular importance to the development of cross-border health care as it stipulates provisions with regards to ‘cooperation in health care’. The topics addressed are instrumental to the improvement and accessibility of cross-border health care for patients, e.g. assistance and cooperation, recognition of a prescription issued in another Member State, the European Reference Networks (ERNs), action in the area of rare diseases, eHealth, and cooperation on Health Technology Assessment (HTA). There is a host of other hard- and soft-law instruments surrounding the regulation and the directive. Their purpose is to specify, implement or explain the legal frameworks. Eurohealth  —  Vol.28  |  No.1  |  2022 53Eurohealth 28(1) residence. There is, however, always a requirement to seek prior approval under the regulation. But once authorisation has been granted, all financial aspects are taken care of by the competent authority, be it a sickness fund or a health authority. In case of undue delay, e.g. if care cannot be provided within a medical justifiable time, the pre-authorisation requirement is not applicable. EU nationals can seek cross-border health care on their own initiative under the directive. They are free to choose a provider across the border for a planned procedure. Some Member States, however, require pre-authorisation for the obtained care subject to specific conditions. In contrast to the previously mentioned process, the patient needs to pay in advance and can only claim reimbursement upon completion of the procedure. It can help patients with rare diseases who cannot access treatment at home Cross-border health care under the directive also provides substantial benefits for patients living with rare diseases at the European level. There are more than 6000 rare diseases, which affect 30 million European Union citizens. 5 While a number of countries have strategies or plans to address rare disease, the scarcity of cases and knowledge in this area makes a European approach necessary and cross-border cooperation is needed to promote better, faster and more accurate diagnosis. According to a survey conducted by Eurordis, which covered 8 rare diseases, 25% of patients waited from five to 30 years for a correct diagnosis, and during that time 41% received a misdiagnosis. 6 To help patients with rate diseases, the directive of 2011 led to the creation of 24 European Reference Networks (ERNs), including 900 highly specialized units from over 300 hospitals in 26 EU countries. 7 Through the pooling of medical expert knowledge, the ERNs provide common expertise thus offering patients potential benefits in terms of early diagnosis and improved treatment. Meanwhile, The Rare 2030 (Eurordis) foresight study, initiated by the European Parliament and supported by the European Commission, emphasises the importance of European cross-border cooperation and innovation in this area and will help guide a reflection on rare disease policy in Europe over the next decade. 8 Bilateral agreements have been developed to allow for cross-border collaboration across Member States and regions A mapping exercise commissioned by the European Commission in 2016/2017 9 identified 1,167 projects of which 423 projects were listed, showcasing a great Figure 1: Budgetary impact of cross-border health care under the regulation,  by type, 2019  Source:  2 Note: No data is available on prior authorised care from countries with prior-authorisation procedures from Germany. No data  is available on health care not requiring prior authorisation from Germany, Hungary, Luxembourg, the Netherlands. 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 Total cross-border health care Planned health care Health care provided to persons living in a MS other than the competent MS Unplanned health care Cr os s- bo rd er h ea lth ca re a s a sh ar e of to ta l he al th ca re s pe nd in g re la te d to b en efi ts in k in d 0.1% 0.3% 0.02% 0.4% % Table 1: Cross-border health care legal frameworks in comparison  Regulation on the coordination of social security Directive on patients’ rights in cross-border health care Countries included EEA and Switzerland  EU Member States, Iceland, Norway and Liechtenstein  Patients covered EU nationals, stateless people and refugees who reside in the  territory of a Member State Insured persons  Sectors covered Public health care Private and public health care  Services covered Unplanned necessary care and planned care organised  through the competent authority Planned and unplanned/necessary care initiated through  the patient  Expenditure covered Competent authority covers the expenditure incurred;  travel expenses are not covered Reimbursement of health care costs according to national  tariffs in country of affiliation; travel expenses are not covered  Note: After the United Kingdom’s withdrawal from the EU, British citizens can continue to use their EHIC card until expiry date or they can apply for the Global Health Insurance Card which covers  unplanned but not planned care in the countries covered by the regulation; Norway, Iceland and Liechtenstein joined the legal framework in 2015.  Eurohealth  —  Vol.28  |  No.1  |  2022 54 Eurohealth 28(1) variety in European collaboration in health care, social care and public health. These collaborations can provide concrete advantages for EU citizens. The projects not only address patient mobility but also target workforce mobility, sharing of knowledge and infrastructure, emergencies, and joint investment in medical infrastructure. The findings show that most activity takes place in central and western Europe between countries, particularly those with similar welfare traditions (e.g. Scandinavian countries), or a shared history (e.g. Italy and Slovenia or Italy and Austria). Furthermore, cross border collaborations can be aimed at overcoming gaps in regional provision, which occurs, for example, in the cross-border bi- national hospital of Cerdanya in the Pyrenees (see Box 2). This type of bilateral cooperation can take the form of cross-border framework agreements and conventions, as is the case for France. In France, those agreements are intended to provide a legal framework for the establishment of local cross-border health or medico-social cooperation agreements. The aim is to promote the development of cooperation in health or medico-social care between France and bordering countries and to ensure better access to quality care in border regions by: – guaranteeing continuity of care and faster recourse to emergency assistance – optimising the organisation of the health care offer and by encouraging the sharing of capacities (material and human resources) – encouraging the sharing of knowledge, practices, and human and material resources (see Box 3). These cross-border framework agreements are intended to complement the measures already provided for by Regulations 883/2004 and 987/2009, and by Directive 2011/24 EU on cross- border care. An example is TRISAN, a tri-national competence centre for cross-border collaboration between Germany, France and Switzerland in the Upper Rhine Region. TRISAN conducts studies, provides information, connects stakeholders for best-practice exchanges, and supports the cross-border cooperation project. 10 Several Member States have bilateral cross-border agreements for planned health care in place. They help to overcome temporary capacity shortages and the long waiting lists resulting from it. According to a study on the Franco-Belgian ZOAST-initiative (Zones Organisées d’Accès aux Soins Transfrontaliers), the largest share of inpatient interventions provided were gastroplasty for the treatment of obesity, stent placement, treatment of diaphragmatic hernia or hiatal hernia, therapeutic ureteroscopy, hip replacement, pacemaker, knee prosthesis, polysomnography, treatment of bilateral inguinal, femoral or obturator hernia and cholecystectomy. For outpatient and ambulatory care, the most common interventions involved ophthalmological operations, mainly for cataract. Can cross-border health care help COVID-19 patients and alleviate pressure on health systems? The COVID-19 pandemic has put great stress on EU Member States’ health systems, in some cases leading to situations in which acute beds, intensive care unit (ICU) beds and workforce were not sufficient to meet the surge in demand for COVID-19-related care. During the first wave of the pandemic in the spring of 2020, within a two month period, almost 300 European COVID-19 patients were treated in another Member State. Most transfers took place from the French Region of Grand Est, Northern Italy and the Netherlands to Austria, Germany, Luxembourg and Switzerland (see the article by Winkelmann et al. in this issue). These transfers were a measure of last resort aimed to help countries and regions on the brink of collapse due to capacity shortages. 11 Even though some of these initiatives were organised outside the European frameworks, they nevertheless serve as a reminder of the Box 2: The bi-national Hospital de Cerdanya /Hôpital de Cerdagne The AECT-HC/GECT-HC is a cross border hospital, situated in the Est Pyrenees. Its very name (AECT/GECT stands for European Grouping of Territorial Cooperation) speaks of its vocation as a bi-national instrument, devised to facilitate access to specialised medical care for a local population of around 33,000 (although this greatly increases during peak tourist seasons) inhabiting 50 municipalities on a 1340 km2 territory. The founding partners of the AECT-HC/GECT-HC are the public health care systems of France and Catalonia, Spain. The EU contributed 60% of the building costs through FEDER funds; CatSalut and ARS-Occitanie shared the rest, and funded 100% of the equipment. The facility is managed jointly by both health care systems with a yearly operating budget of €20 million. The project for a bi-national, shared hospital that is pivotal to a future cross-border health care network, was long in the making. It originated in 2005 with a declaration of intent signed by the French and Catalan authorities, and in 2007 the EGCT was registered. The need for a new hospital was particularly important for the local French population whose main reference hospital was in Perpignan, which was difficult to access through mountain roads or by the helicopter emergency medical service. Since its opening in September 2014, the centre offers access to 11 medical and surgical specialties to the local population and tourists in a small but modern local hospital that is well equipped. Through strategic alliances with sister organisations, in Catalonia and Occitanie, a further 15 specialities, comprising facilities for haemodialysis and (soon to be available) for chemotherapy treatments have also been made available. Eurohealth  —  Vol.28  |  No.1  |  2022 55Eurohealth 28(1) potential of cross- border care in crisis situations. Countries could explore the European frameworks better to facilitate the continued demand for COVID-19- related services as well as new demand for backlog care (see the article by van Ginneken et al.). Furthermore, several countries have been working together, with assistance from the EU and its frameworks, in providing emergency care for COVID-19 patients in the Interreg regions. For example, the Euregio Meuse-Rhine confronted with the pandemic set up a trilateral crisis management centre (Task Force Corona)*. Furthermore, the cross- border *  The Euregio fosters regional cross-border collaboration  on all economic, social, and cultural aspects. It was created in  1976, with judicial status achieved in 1991. Cerdanya Hospital between France and Spain cooperates with French hospitals to share intensive care capacity and personnel, working with the border police to ensure access for patients and health professionals. 12 What needs to be done to reap the full potential of cross-border care? Cross-border health care adds value for patients in many circumstances. At present, there is limited utilisation of cross-border care and the budgetary impact is negligible. The European Commission is carrying out an evaluation of the cross-border health care directive to assess its effects (see Box 4). However, there are pending issues that need to be addressed for cross-border health care to be realised in its full potential: ● EHICneedsimprovement: In 2019, there were close to 250 million EHIC cards issues amounting only to 53.1% of insured persons in the EU. The EHIC has also faced some acceptance problems with health care providers. 2 ● Betterinformationforpatientsand healthprofessionals: Patients and health professionals are not always informed on the options for cross- border health care, even in border regions. 14 The expansion of cross-border digital services for both patients and professionals will be important. Box 3: The case of Franco-German cross-border cooperation  before and during the COVID-19 crisis France has several cross-border framework agreements that allow, at the regional level, the directors of the Regional Health Agencies (Agences Régionales de santé, ARS) to sign local health cooperation agreements in order to promote patient care and the mobility of health professionals in border regions. ARS Grand-Est has four framework agreements for health cooperation between France and Belgium, Luxembourg, Switzerland and Germany. The Franco-German cross-border health cooperation framework agreement,* covers the border area of the former regions Alsace and Lorraine regions of the Grand-Est on the one hand, and the German Länders (States) of Baden- Württemberg, Rhineland-Palatinate and Saarland on the other. It aims to ensure better access to care for the populations of the border region, to guarantee continuity of care and faster access to emergency assistance, to optimise the supply of care and promote the sharing of professional knowledge and practices, and to facilitate crisis management. Further conventions have also been added in specific areas. For example, the field of cross-border emergency medical assistance, is the subject of several conventions between the ARS Grand-Est, the health structures concerned, the SAMU (Service d’Aide Médicale Urgente; Emergency medical service) and fire departments and the neighbouring Länder.† These specific conventions allow the emergency call centre responsible for the region to call on the emergency resources of the neighbouring region to shorten the response time or to compensate for the temporary unavailability of means. 13 *  Signed in 2005 and entered into force in April 2007. †   Between Alsace and Rhineland-Palatinate as well as between Alsace and   Baden-Württemberg both on 10 February 2009. When the COVID-19 crisis began, cross-border cooperation led the ARS Grand-Est and the Prefecture to reinforce their cooperation and to innovate actions on areas including contact tracing and the exchange of practices. Indeed, the Grand-Est region was very strongly affected at the beginning of the crisis in March 2020. Thanks to the solidarity provided by neighbouring countries, including Germany, transfers of patients in intensive care units were organised. Thus, between 22 March and 5 April 2020, 160 patients were transferred from France to neighbouring countries of the Grand-Est Region (Belgium, Luxembourg, Germany, Switzerland) or other EU countries (Austria), of which 74% of which were transferred to Germany.‡ In the same spirit, France has offered to receive patients in intensive care if the health situation so requires. Furthermore, in order to consolidate cross-border cooperation in light of the lessons learned from the COVID-19 crisis, ARS Grand-Est has proposed to develop a joint cross-border observatory on health data for the border areas § in order to facilitate a harmonised exchange between the parties. On the Franco-German border, with regard to the prospects offered by the Treaty of Aix,¶ this common desire to work on strengthening health cooperation would apply particularly to the cross-border living areas that are institutionally embodied by the Eurodistricts. ‡  Data from the ARS Grand-Est. §  Bassins de vie frontaliers. ¶   Treaty between the French Republic and the Federal Republic of Germany on Franco- German cooperation and integration, signed on 22 January 2019 and entered into force  on 22 January 2020. Eurohealth  —  Vol.28  |  No.1  |  2022 56 Eurohealth 28(1) ● Endfinancialriskforpatients: In many countries, the directive is implemented in a way that discourages patients to use it; in particular, it does not contain information on tariffs and levels of reimbursement. Patients therefore often prefer to use cross- border health care under the regulation. ● Improvecontinuityofcare: Cross- border hand-over and continuity of care remains a difficult task. In general, electronic patient records or paper records do not travel with the patient or is inadequately acknowledged. 15 The EU eHealth network has created the MyHealth@EU infrastructure to facilitate the transfer of medical records and by 2025 all EU countries are expected to be connected. ● Improveuser-friendliness: The legal provisions are complicated and deter potential patients from using cross- border health care. ● StrengtheningtheERNs: The ERNs had a promising start. With the expansion of the networks and the uptake of more patients with rare disease in the virtual panel consultations the question of additional investment in infrastructure and expertise needs to be answered. ● Strengtheningtheevidencebaseand monitoringofbilateralagreements: information on the prevalence and analysis on the effectiveness of bilateral agreements and a continuous monitoring would help to provide a stronger evidence base. ● Betterintegrateandsupportthe possibilityofhavingbilateral agreementswithintheEuropean framework: Similar to the agreements between France and some of its border countries, the measures provided are already complimented by the regulation and the directive mentioned above, while addressing local issues. Conclusion Cross-border health care adds value for patients and helps to provide timely access to high quality health care. This may be especially important during the COVID-19 pandemic which has led to increased demand for COVID-19 care as well as catch-up care following the disruption to routine health services. If we are to strive towards a European Health Union, we should continue to invest in cross-border health care by improving the user-friendliness, providing help for cross-border collaboration, strengthening the ERNs, and further expanding the cooperation of cross-border regions, Member States, and at European level. References 1   Wismar M, Palm W, Figueras J, Ernst K, Van  Ginneken E. Cross-border health care in the European  Union: mapping and analysing practices and policies.  Copenhagen: World Health Organization, on behalf  of the European Observatory on Health Systems and  Policies, 2011. 2   De Wispelaere F, De Smedt L, Pacolet J.  Coordination of social security systems at a glance  2020 Statistical Report. European Commission  Directorate-General for Employment, Social Affairs  and Inclusion, 2021. 3   Wilson P, Andoulsi I, Wilson C. Member State  Data on cross-border healthcare following Directive  2011/24/EU. European Commission, 2019. 4   European Commission. Report from the  Commission to the European Parliament and the  Council on the operation of Directive 2011/24/ EU on the application of patients’ rights in  cross-border healthcare. COM(2018) 651 final.  Available at: https://eur-lex.europa.eu/resource. html?uri=cellar:bc5ac6d2-bd7c-11e8-99ee- 01aa75ed71a1.0019.02/DOC_1&format=PDF 5   Nguengang Wakap S, Lambert DM, Olry A, et al.  Estimating cumulative point prevalence of rare 255  diseases: analysis of the Orphanet database. Eur J Hum Genet 2020;28(2):165 – 73. 6   EURORDIS. Survey of the delay in diagnosis for  8 rare diseases in Europe (‘eurordiscare 2’), 2007.  Available at: https://www.eurordis.org/sites/default/ files/publications/Fact_Sheet_Eurordiscare2.pdf 7   European Commission. European Reference  Networks, 2017. Available at: https://ec.europa.eu/ health/ern_fr 8   Rare 2030. Foresight in Rare Disease Policy.  Recommendations from the Rare 2030 Foresight  Study. The future of rare diseases starts today.  2021. Available at: http://download2.eurordis.org/ rare2030/Rare2030_recommendations.pdf 9   Bobek J, Schmidt AE, Bachner F, Röhrling I,  Seethaler J. Cross-border. Care – Study on  cross-border cooperation: capitalising on existing  initiatives for cooperation in cross-border regions.  Main Results, 2018. 10   TRISAN web site. Available at: https://www.trisan. org/ 11   Winkelmann J, Scarpetti G, Hernadez-Quevedo C,  van Ginneken E. How do the worst-hit regions  manage COVID-19 patients when they have no spare  capacity left? 23 April 2020. Available at: https:// eurohealthobservatory.who.int/monitors/hsrm/ analyses/hsrm/how-do-the-worst-hit-regions- manage-covid-19-patients-when-they-have-no- spare-capacity-left 12   European Commission. Communication from the  Commission: Guidelines on EU Emergency Assistance  on Cross-Border Cooperation in Healthcare related  to the COVID-19 crisis. Available at: https://eur-lex. europa.eu/legal-content/EN/TXT/?uri=celex%3A520 20XC0403%2802%29 13   France-Germany cooperation agreements  (Conventions de coopération France-Allemagne). Available at: https://www.cleiss.fr/docs/cooperation/ cc-france-allemagne.html 14   Beuken JA, Bouwmans ME, Verstegen DM,  Dolmans DH. Out of sight, out of mind? A qualitative  study of patients’ perspectives on cross-border  healthcare in a European border region. Patient Educ Couns 2021;104(10):2559 – 64. 15   Beuken JA, Verstegen DM, Dolmans DH, et al.  Going the extra mile – cross-border patient handover  in a European border region: qualitative study of  healthcare professionals’ perspectives. BMJ quality & safety 2020 ;29(12):980 – 7. 16   Cross-border healthcare – evaluation of patients’  rights web site. Available at: https://ec.europa. eu/info/law/better-regulation/have-your-say/ initiatives/12844-Cross-border-healthcare- evaluation-of-patients%E2%80%99-rights_en Box 4: Evaluation of the patients’  right directive  The European Commission is carrying out an evaluation of the cross-border health care directive to assess how the rules are working (or not working) in the interests of patients. 16 It will focus, in particular, on patients access to safe and high-quality health care in another country and how it encourages cooperation between national health care providers, also on rare diseases and ERNs. Following an extensive consultation of stakeholders across the EU including national and regional authorities, health professionals, health insurers, patient organisations and citizens, its report is expected to be published in the Spring of 2022.