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Sweden reveals myth of EU healthcare 'freedom'

20 Jul 2012, 10:04

Published: 20 Jul 2012 10:04 GMT+02:00

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When it was first introduced in 2004, the EU's European Health Insurance Card was hailed as a major step forward in facilitating the free movement of people throughout the European Union.

By flashing the blue credit card-sized document, any EU citizen in need of medical care would be ensured their treatment would be covered by the public health care system, regardless of whether they were in their home country or visiting another EU member state.

But the recent case of Johanna, a Swedish woman residing in Germany who was left with 130,000 kronor ($18,500) in medical bills after she gave birth prematurely while visiting family in Sweden, shows that the system doesn't always work, especially for mobile Europeans who divide their time between more than one EU country.

“Someone has to take responsibility. If you’re an EU citizen, it shouldn't be a problem to receive healthcare,” Moderate Party MEP Christoffer Fjellner tells The Local.

Fjellner's frustration stems from what he sees as failings in the EU health system that in dealing with the medical needs of mobile EU citizens – precisely the sort of people whose lives were supposed to be made easier by a more harmonized system across member states.

In many ways, Johanna – whose case was highlighted recently by the TT news agency – embodies the modern "EU citizen": born in an EU country (Sweden), working in another (Germany) for an employer based in yet another (the UK).

But because she was pregnant when she moved to Germany, health authorities there said she had a "pre-existing condition" and thus wasn't covered by Germany's public health insurance system.

And after her baby came six weeks early during a visit to Sweden, Johanna was shocked when she received a bill from the Swedish hospital for more than 120,000 kronor for the delivery and two weeks of neo-natal care that health authorities in Sweden, Germany and the UK refused to cover.

“It’s idiotic to let people suffer and force them to borrow money to pay bills," says Fjellner, who has devoted significant time toward issues related to mobility and healthcare access within the EU.

According to him, existing legislation on the matter is clear but huge problems remain in how the rules are implemented in Sweden and elsewhere.

In theory, EU legislation entitles citizens carrying an EU health insurance card to emergency healthcare in any EU member state without having to pay more than the standard patient fees which apply in their country of residence.

Even without the card, EU citizens can get reimbursed later by the agency which manages the country's health insurance system, which in Sweden is the National Social Insurance Agency (Försäkringskassan).

The rules are somewhat different when it comes to planned medical procedures, however.

For example, patients are allowed to receive medical treatment in another EU country if there are long queues to receive medical treatment in their country of residence. Again, patients don't need to pay any other fees than they would pay at home.

But obtaining reimbursement is not always straightforward and, despite the legislation, there are several cases in Sweden where people's requests to have their medical expenses covered have been denied by the National Social Insurance Agency, forcing people to take their cases to court.

Some of these cases at the administrative court include a woman who went to Finland to receive a treatment not used in Sweden, a radiological scan to identify an illness. Another person was treated in France, but not reimbursed because the method used was not recognized amongst Swedish practitioners.

The agency's point person on international healthcare issues, Andreas Stjernberg, explains that part of the issue stems from differences of opinion about what counts as medically accepted and internationally recognized methods of treatment.

“If you have a broken left arm we don’t accept a treatment that results with you also having your right arm put in plaster," he says, taking up a case involving emergency care.

"The diagnosis should be treated in the same way it's treated in Sweden. If the method is not the same, you won't be reimbursed."

But Fjellner disagrees with the Swedish health insurance agency's interpretation of EU rules.

“This is a misinterpretation of the law that states that you can be treated for an internationally recognized diagnosis. The method used is irrelevant,” Fjellner explains.

“It doesn’t matter what treatment is used.”

And Fjellner is not alone in criticizing the agency, which was forced to adjust how they interpret the rules following a slew of complaints last year about reimbursement denials.

"We implemented changes in March 2012. Previously, the medical treatment needed to be identical to the one carried out in Sweden, but now that definition is broader,” says Stjernberg.

The EU Commission representation in Stockholm also agrees that information and procedures for reimbursements in Sweden under the EU healthcare system need to be improved.

“We get around thirty calls from desperate people each month," says the Sigrid Jonason of the EU Commission's offices in Sweden.

"People complain and tell us they have been waiting over three months for the national insurance agency to reimburse them."

This is something Fjellner also recognizes as a problem, and is quick to point out that Sweden's national insurance agency is not as efficient as it should be.

“There is no reason why the national insurance agency can’t pay you earlier or even before,” he says.

But the agency's Stjernberg counters that his colleagues are doing everything according to legislation requiring to review each case before deciding if someone should be reimbursed or not.

In addition, most cases are dealt with expediently.

“Between April and June around 62 percent of the cases were cleared within sixty days,” he says.

Despite gradual improvements in how Sweden's national insurance agency handled reimbursement claims, Fjellner blames hospitals for adding to reimbursement confusion when it comes to seeking planned care in another EU country.

“The big problem is that hospitals decide not to tell people that they are entitled to treatment in another country,” Fjellner explains.

Another obstacle to patient's EU-mandated freedom of choice when it comes to healthcare, according to Fjellner, is the difficulty patients have if they need treatment only offered in certain parts of the country.

Cancer patient and Stockholm resident Therese Vesterlund, whose case was highlighted recently in the Dagens Nyheter (DN) newspaper, has been unable to get the treatment she wants.

While health authorities in several Swedish counties have approved the drug Yervoy for treating melanoma, the Stockholm County Council (Stockholms Länstinget) has yet to do so, meaning Vesterlund's only option is to pay for the treatment out of pocket.

Gunilla Gunnarsson, a cancer treatment coordinator at the Swedish Association of Local Authorities and Regions (SALAR), points out that each county in Sweden has the power to decide what treatments are available.

Story continues below…

“Every county sets their own priorities. That’s why different counties offer different healthcare options,” she explains.

But Fjellner nevertheless remains critical of the system, arguing that everyone should be given full freedom of choice when it comes to accessing healthcare within the EU and within Sweden.

He claims Swedish healthcare providers are refraining from fully informing patients about their options due to concerns about costs.

“A county sometimes decides not to treat someone for cancer not because there is no treatment but because the medication is too expensive,” he says.

“This is the sad truth, but it happens."

And Göran Stjärnstedt, head of healthcare at SALAR, agrees, adding that having a doctor refer a patient from one county to another, while theoretically possible, is a rarely used option as it pits the care in one county against another.

"Since the 1990s, patients have been able to apply for medical treatment in another county, but it’s not easy and it’s unlikely that doctors would admit that another county offers better treatment,” Stjärnstedt explains.

Cost considerations also play a part in Swedish health providers' reluctance to let patients know they can also seek treatment in other EU member states.

“A leg operation in Austria will be double the cost. That’s enough reason why a county or the national insurance agency will not pay up,” he explains.

Despite the system's current shortcomings, Stjärnstedt is optimistic that things will improve as patients in Sweden and elsewhere in the EU become more accustomed to exercising their rights.

"It's of course hard for a patient to assert his or her right, but I hope more people will do that in the future. That's what we're pushing for," he says.

Salomon Rogberg

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Your comments about this article

11:25 July 20, 2012 by libertarianism
Thank you Christoffer Fjellner, Salomon Rogberg, and TL!!
11:44 July 20, 2012 by azimuth
"Great" Swedish healthcare system at its pinnacle of idiocy...
11:53 July 20, 2012 by krattan
Hardly only a Swedish problem. It's also a EU problem.
12:03 July 20, 2012 by krrodman
This health care mess is no different than the financial crisis. The EU is a economic association that pretends to be a real political union. In fact there are different rules for every aspect of life in every country. Health care is the newest example of the folly of the EU as it now stands.

A United States of Europe was an idea created by utopian politicians after the devastation of WWII. They were well aware that the people of Europe were not ready for a real political union so they created an economic union as a first step toward political union. Well, the economic union is imploding and will not survive without the creation of a true political union that will have the power to create uniform rules across Europe. Are the people of Europe ready for a real political union? Are Swedes ready to allow a Congress in Brussels have authority over Parliament in Stockholm? The French? The Germans? Not a chance.

The EU is doomed.
12:08 July 20, 2012 by texaslass
Is it possible to purchase a private medical insurance plan that covers the costs of the melanoma drug or whatever treatment that the county does not cover? Does anyone know if something like this available and what are the options?

If private medical insurance is available, and it covers treatments that the county does not provide, then perhaps it is a good idea to purchase a supplemental insurance plan.
12:49 July 20, 2012 by occassional
In other news, Sweden's parliament debated on granting free healthcare to all illegal immigrants and asylum seekers. Yeah. Way to go.
13:07 July 20, 2012 by cogito
Dear TL: Keep this Salomon Rogberg around. And thank you Mr. Rogberg for a well-written and researched article.

Where to start...?

"The diagnosis should be treated in the same way it's treated in Sweden. If the method is not the same, you won't be reimbursed." (spokesman for National Health Insurance Agency).

So, the diagnosis made with antiquated equipment in Sweden determines the method.

"the methods are not the same..." Yes, that's why those who are able to travel prefer to seek the methods practiced in France, Germany, Spain, Italy, Greece, the USA....
13:14 July 20, 2012 by inthenovel
Amazing that a Swedish-born woman would have to pay this yet an illegal person here gets it free.

Sweden's medical system, according to WHO, has really gone down the toilet anyway and is not what it used to be. They tell you it is free yet the price for visits keeps increasing.
13:18 July 20, 2012 by tes85
Swedish citizen... and had her baby in Sweden yet still charged for it?! that sounds bizarre even if she resides in another country!
16:12 July 20, 2012 by hjoian
EU law is very clear,but as the article mentions,interpretations of it are varied. Sweden is almost as bad as the UK when it comes to breaking EU law, when it suits its own purpose. Only people knowing their rights and using the EU court to uphold it will ensure everyone gets to be treated fairly....its just a pity you have to fight for it!
17:28 July 20, 2012 by Timien
Today I can only say unfortunately that nothing surprises me.

Having been really ill for more than two years and getting nowhere with the Doctors in Sweden who refused to believe I was ill, I paid £300. (3010kr) to see a top Neurologist in the UK at the leading hospital of Neurology in London.

The Neurologist and his team were horrified as to how I was being treated in Sweden, the lack of treatment and refusal to refer me to a Neurologist for help. Having read the evaluations carried out on me in Sweden he was amazed at how the Swedish doctor and Vårdcentralen staff had come up with the diagnosis they had.

Having carried out his own evaluations he promptly informed me what he suspected was actually wrong and told me all the tests that needed to be carried out and if I did not receive the right treatment would end up severely disabled.

On return to Sweden I made another appointment with my doctor who told me he didn't believe that I'd had the appointment and only on proof would he refer me to a Neurologist.

I contacted the Vårdcentralens Area Regional Manager and explained the situation only to be told, and I quote "If you don't like the treatment here you are free to find another Vårdecentralen."

So not only has my health really gone downhill, I am still not properly diagnosed after 2 years, the staff at the Vårdecentralen are all trying to cover their backs with lies and Forsäkringskassan is demanding that I change jobs, retrain and return to work even though Arbetsförmedling who have read all my medical notes have said that there is no way I will be able to work for many years, if ever again and with my medical situation as it is, I am actually unemployable.

As you can imagine this has led to a 2 year battle with Forsäkringskassan in trying to get sick pay /pension and having to try and deal with all of this when you are severely ill has been an absolute nightmare.

Now Patientsnämnden (The Patients Ombudsman) has advised me to report it all to Socialstyrelsen (The Govenment Dept for Social Health).

People are today suffering needlessly as people don't care and sadly those that do are not in a position to do anything about it!

Re-imbursement from Försäkringskassan for the consultants £300. fee ..... what do you think!
19:08 July 20, 2012 by krrodman

What do I think???

I think the doctors at Vardecentralen are going to get a medal from the National Health Service for saving money.
19:33 July 20, 2012 by libertarianism
Re 11, I'm sorry for all you've suffered and wish you continued healing. You're not alone in the nightmare. :( Please continue to share your story, so that more people become aware of these abuses. Perhaps a lawyer can help with your FK claim? There are lawyers who specifically do this now.

Fyi, during my own prolonged search for care in Sweden, I changed doctors several times with no success, of course. Long story short, I was eventually forced to leave the country for help. When I returned with a diagnosis and test results, etc, they still refused to provide any treatment or to even recognize the diagnosis. Someone advised I turn to the Patientnämnden. The Patientnämnden said there should be a meeting with one of their representatives, myself, and the head of the Vårdcentral. He however refused!! And so the Patientnämnden told me they were dropping my case. I told them I had never received help and that I still didn't have medical care, but they just ignored me. I was again forced to leave the country... and the nightmare has gone on and on...

These people truly don't care. They are glad to ignore you and let you die. It's one of the most horrible feelings in the world, and it is a very very sick element of Swedish society.
09:56 July 21, 2012 by Timien
@ Krrodman

You are probably right in the mean time I am still very ill and getting nowhere and like many other people are being wrongly diagnosed and when you are entitled to seek medical care elsewhere within the EU then you should be re-imbursed not ignored. At the end of the day its pretty disgusting that I needed to go outside Sweden to find out what my illness is in the first place.

@ Libertarianism

Thanks for sharing your story and I am sorry to hear that like me you did not receive help.

It's time people in Sweden woke up to the way people are being treated and the endless number of people being denied treatment because there are no central rules and regulations that the whole country must adhere to.

Instead administrators that have no medical background are able to make decisions in Försäkringskassan as to how ill you are and can over turn a doctors decision as to your capability of work, or surgery managers trying to keep their budgets down not allowing certain drugs to be available to patients or the lack of looking into a patients medical situation.

Unfortunately today if a test comes back OK then you aren't sick. In the old days a doctor would look at the result and say, "Ok it wasn't that so what test do we need to do next?" Today it's "OK well you are fit for work" rubber stamped HEALTHY even if the person is very ill. It's frightening that in 2012 with all the medical knowledge and equipment and medication we have today people are dying needlessly and going without the correct medical care due to just plain ignorance and nonchalance!!

And you are totally right, they don't care and it is one of the most horrible feelings in the world and an extremely appalling element of Swedish society.
20:14 July 22, 2012 by Eyeswideopen
Part of the problem is surely that you won't see the types of comments expressed in The Local appearing in the local or national media. A free press is a pillar of democracy, but it doesn't fully exist here, perhaps in any Scandanavian country because of cultural reasons. Everyone must tow the government line, publically expressed dissent is not welcome, people who repeatedly won't accept this are ignored - passive aggression - or ostracised. This means there is no honest, profound debate, true transparency and more importantly accountability.

In the case of health, there should be a health Ombudsman who investigates such cases described by other contributors - an impartial body without ties to the government or the industry.

But until the Swedes themselves start speaking up more and demanding space in mainstream media to air their grievances, the teflon-coated systems will remain impervious to their concerns.
14:32 July 23, 2012 by rohermoker
everything provided has a cost, and detais about how and how the fee are paid. Food and water is a most basic human need, does the govn't porvide that "free" to everyone?
21:35 July 23, 2012 by anticommie
LOL and people wonder why Americans are fighting to stop this kind of barbaric health care system from coming to the states. This is what you get when the government runs your life, bare minimum.

Its also fascinating you pay so much for it through taxes and have no way to stop funding a bad provider, here in the states you just dont go back to shitty doctors and they either go out of business or go to work in government health areas.

No thanks socialism sucks for everyone.
07:45 July 24, 2012 by Ian C. Purdie - Sydney
Advanced Sweden?

Once again revealed to the world as hypocritical BS. Not the vibrant, progessive liberal society formerly portrayed and believed world-wide.

Wikileaks revealed the "rendition" of people [among many other things from corrupt politicians].

Which has led to? The insane persecution of the "messenger", Sweden has proven a more craven lackey than my native Australia.


You can't get medical care right!

Thumbs down.

@21:35 July 23, 2012 by anticommie

Grow up, you're at least 50 years behind the times, you're likely living in an age before you were born, stop believeing outdated propaganda. You'll possibly go blind.
12:25 July 28, 2012 by jostein
Healthcare is a commodity. It can therefore not be a right. Unless you make nurses and doctors into slaves.
20:54 July 28, 2012 by MitchXXX
Comment: As far I can see Sweden belongs to EU only to use the benefits of the membership like trading and the huge market. When it comes to the saving the rights given under the EU legislations like right of work, free movement and settlement, access to Medicare and public services for citizens of other EU members the Swedish administration has clear instructions to ban it using administrative tactics and tricks like requiring unnecessary papers and proofs, not answering the service phones for inquiries, taking its time for indefinite periods, or just denying for no reasons. Also the private and the public sector is using the knowledge of Swedish language as an excuse to keep away well educated and qualified foreign labor saving the job places only for native Swedes. Now they felt so powerful that they do it even to Swedish citizens living abroad. If it goes like this in few years Sweden will have the image abroad of a chauvinistic country far away from the democracy and freedom shared as a common values among EU. It is a shame I think if it is true.I don't want to believe this is the real face of Sweden hidden behind the Mask.
16:47 August 1, 2012 by oldonpalouse
I have heard these stories for years. My mother-in-law left to die of cancer by lack of treatment in Gothenberg, nine month wait for an X-RAY, ERs turning away injured people, etc.

Reality is, the cost of cradle to grave medical care is too expensive for any country. It is dishonest to claim otherwise, in any country.
00:24 August 5, 2012 by Taxalien
Be very afraid if you become sick in Sweden. There may be no emergency services or any specialist healtcare available.

Such is Sweden.
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