A wide range of outpatient specialities can be linked to a diagnostics and/or primary care back bone, building a complete ambulatory ecosystem linked by telehealth. Thanks to employers paying, this is a reality in Finland with Terveystalo and in Poland with Lux-Med and Medicover. Similar hub and spoke models are also the norm in the United Arab Emirates. But can it be done elsewhere and who is doing it? We name the highly ambitious operators and their platforms across the main European countries.

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The model is being pursued aggressively by imaging group Affidea in several geographies. Where it has mass-scale, for example in Italy, it is adding primary care and other specialities. Indeed Affidea, which is currently being sold, is partly marketing itself as a platform from which a big private equity player could then invest a further billion plus euros on further outpatient expansion beyond its core imaging business.

In Germany much of the excitement around the growth of imaging and radiology is also about the possibility of building further into broader outpatient models. Med360 is perhaps the best example of this. It already has 20 surgery, 6 nuclear medicine, five neurology, 11 radiotherapy, six back pain and 30 imaging centres plus centres for cardiology, rheumatology and gynae.

In France, the for-profit hospital groups are diving into outpatient.

But perhaps the most ambitious play in French outpatient services is Doctegestio, which told us back in 2018 it wanted to grow to €1bn by 2022. In January it combined its Amapa arm (which is focused on home help, medicalised homecare and care homes) with Doctegestio (hospitals, outpatient, dentistry) into a single platform called Avec. The coverage is far from nationwide, but this is the first time we’ve seen a single platform of this scale covering both care and healthcare services in France.

Vivalto Sante is also building a similar platform.

The broader outpatient sector is also being targeted aggressively in Italy by Alliance Medical and others who are building centres which cover imaging, lab tests, primary care and outpatient specialisations. Lifenet Healthcare, an operator set up in 2018 by Nicola Bedin, one of the architects behind the growth of San Donato into a €1.4bn behemoth, is following a similar route with its nine businesses offering everything from imaging and dentistry through to ophthalmology, sports medicine and centres with 30 different specialist doctors. Group revenue came to €45m in 2019.

In Switzerland, the last few months have seen the creation of two competing telehealth platforms aimed at connecting primary care to hospital providers. Compass Sana is a new partnership between telehealth operator Medbase and Hirslanden, the largest for-profit Swiss hospital chain and part of Mediclinic International. Meanwhile, hospital and outpatient grouping CSS, telehealth platform Medi24, insurer Visana and pharmacy group Zur Rose have come together to form Well.

Scale models that clearly work remain rare, thanks partly to the way payors are siloed. Normally it is only when you find payors who are responsible for both care and healthcare that you find operators offering those same payors a wide range of services. This is what marks out the big Finnish and Swedish players who offer a vast array of services to Swedish counties and municipalities and to Finnish municipalities, with portfolios covering everything from dentistry and primary care through to nursing homes and homecare.

So where do synergies exist and where are they much less obvious? In Germany, lab group operators amedes and Medicover have aggressively acquired women’s health specialist doctor seats because of the sheer volume of tests that they prescribe. Medicover dived into the market after being outbid by amedes for endocrinology chain Medivision in 2014. At the time a source told us: “We liked the business model so much that we decided to compete.”

Proving synergies really do exist is not always easy. There are certain sectors which are clearly complementary. Medipass, which runs imaging and radiotherapy outsourcing in the UK and France, told us that, once it recognised that 90% of its MRIs were oncology-related, it made sense to market both services to oncology departments. Infravia has created a similar merger.

And in Germany, women’s health and labs has clearly worked well together. So should fertility centres, with their heavy testing load.

But other synergies are much harder to find. Unilabs runs both imaging and labs, but there are few obvious synergies between the two diagnostic modalities. They are very different technically, although histopathology slides are read as images and so can go on the same teleradiology platform. Most of Unilabs’ imaging business is in outsourcing. And the outsourcing of lab and imaging modalities are almost never combined by hospitals or healthcare systems into a unified tender. A doctor who prescribes lab tests to Unilabs wouldn’t normally be able to move their imaging prescriptions to the company.

An ecosystem may look good on paper, but they need to be local to be strong. Unless you have all your assets in a particular location – be they primary, imaging, hospitals and care homes – you won’t see real synergies. Telehealth does have the capacity to change that to an extent, but the patient is still going to want a local imaging centre or ambulatory surgery facility.

And policymakers may well wake up to some of the inherent conflicts of interest baked into all this. An ecosystem works well for an employer or payor who is paying a per capita fee per month for access to services. But it is easy to see how such an ecosystem could be exploited on a DRG or cash payment activity model with doctors encouraged to refer patients for tests that are not really necessary to increase sales. This was pointed out to us many years ago by a major lab group and competitor of amedes and Medicover!