Rae Woods (01:27):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods, you can call me Rae.

(01:39):
It is no secret that the delivery system is strapped, and any opportunity for financial stabilization or revenue diversification is top-of-mind for every provider executive. We've been tracking a growing trend here. More and more health systems are partnering internationally. It's not just the med tech or the life sciences firms going global anymore, health systems are looking overseas to advance their core business objectives.

(02:08):
Today I want to talk about why global partnerships are accelerating, how organizations are leveraging these partnerships successfully, and whether all of you should be pursuing global partnerships.

(02:19):
To do that, I've invited advisory board international experts, Paul Trigonoplos and Isis Monteiro. Hey Paul, hey Isis. Welcome to Radio Advisory.

Paul Trigonoplos (02:28):
Happy Tuesday.

Rae Woods (02:31):
The two of you study international research. Does this mean you get to travel to fun places? Does this mean that you get to visit some of the countries that you are studying and trying to understand?

Isis Monteiro (02:45):
Yeah, I actually just got back from my first international work trip. Delivered an onsite in Sudbury, Ontario. And then we went to Toronto for the Roundtable.

Rae Woods (02:55):
Nice. Paul, I feel like you're all over the place now.

Paul Trigonoplos (02:59):
Yeah, it was more before the pandemic, but I do have a long trip to Australia coming up, which will be good and tiring.

Rae Woods (03:09):
That seems both exciting and tiring. And maybe I should start this conversation by admitting my own bias, or frankly my own just lack of knowledge when it comes to the international healthcare system, and when it comes to international partnerships.

(03:24):
I will tell you, when I think about partnerships, I think about two organizations, maybe. And perhaps our audience is thinking the same thing. Everyone is thinking, oh yeah, I remember when Cleveland Clinic built a multi-specialty hospital in 2015 in Abu Dhabi, right? Classic growth strategy. We want to get into new markets, we want to get into profitable markets. But I have a feeling that you're going to tell me that that's not actually what we're talking about when we talk about international partnerships.

Isis Monteiro (03:53):
Yeah, absolutely. So when we first started looking into this, and started this research about a year or so ago, the question that we were originally trying to answer is, what are health systems doing to generate or diversify the revenue abroad? And two things immediately stood out to me.

(04:10):
The first is that going overseas doesn't actually generate a huge amount of revenue, and the second is that it's pretty hard to find examples of health systems that are going at it alone, and standing up a new site or a new clinic completely on their own. So that's part of the reason why we took this international partnership angle for this research.

Rae Woods (04:30):
And it sounds like once you started it, you realized, oh my gosh, there's a lot of interest here. There's a lot of interest in global partnership even with those kinds of constraints you mentioned, that a lot of folks aren't going at it alone, and that the revenue isn't as obvious as maybe we would think, if you're just thinking about the Cleveland Clinic.

(04:46):
Why though, are we seeing more questions about are partnerships the right answer, and more interest in global partnerships in general?

Isis Monteiro (04:55):
Yeah. So I think coming out of Covid, health systems definitely realized the growing interdependencies between them and other organizations abroad, and that we have a lot of similarities between us. Also, things like economic development and a growing middle class of patients, potential patients within certain markets. Also have policy shifts increasing private sector participation. Paul, if you want to speak to that a bit.

Paul Trigonoplos (05:20):
Yeah. I mean on the one side of the policy shifts is coverage. So take India for example. In 2018, 2019, India announced the largest public coverage in the world, I think to that date. So in a year they started covering about 550 million people. That's a lot of demand, and that's a lot of demand on infrastructure that needs a lot of partnerships to stand it up, things like that.

(05:46):
And then the other side of that is private participation. With the growing middle class, you're seeing a lot more, especially in Europe, willingness to pay out of pocket for some services or for coverage, which does open up opportunities for US systems to get in the door.

Rae Woods (06:03):
So it sounds to me like there was this aha moment of perhaps we're more alike than we think. And we've tested this through the global stressor that was the pandemic, and so there's just more interest in how can we extend partnerships.

(06:18):
But then it also sounds to me like there is some actual urgency for doing it right now. Paul, is that what you're talking about when you talk about some of the policy shifts, and coverage shifts, and just increasing demand on systems that are going to need help?

Paul Trigonoplos (06:34):
I think there is urgency in the opportunity, to your point. But I think more than that, the urgency comes from the competition that is starting to take place around the world. And Isis can probably speak more to that.

Isis Monteiro (06:49):
So it's not just competition from other providers, but it's other non-provider organizations as well, like private equity that's stepping into the space. But it's also that governments are investing and building up their domestic capacity to deliver those services at home. So foreign reliance on external aid is decreasing as well.

Rae Woods (07:14):
So the number of opportunities is closing at the same time that there is more interest.

Isis Monteiro (07:18):
Absolutely.

Rae Woods (07:19):
And more proof points for these opportunities. So there's more interest in global partnerships, but the opportunity to actually act on it is a window that is closing. Hence we're seeing a lot of activity right now.

Paul Trigonoplos (07:31):
Especially in countries that you would imagine would be sort of safe havens for this type of work. So a lot of Middle Eastern countries, namely. I mean, those countries have built up their health systems over the last few years to the point where there's not really much running room left. So places like Cutter or the UAE, their systems are really good now. They don't need that many partners.

Rae Woods (07:58):
What do we mean when we talk about partnership opportunities? Is there a way that we can, I don't know, categorize the kinds of things that we're seeing, the kinds of opportunities? Because where I started from I know is not the end, which is just growing into new markets. How do you want us to think about the kinds of partnerships that are out there?

Isis Monteiro (08:16):
Absolutely. So when we were doing this research, some themes started coming up across the kinds of objectives that health systems are trying to achieve through international partnerships. And these include things like recruiting and retaining staff, delivering on their mission to expand access to and quality of care. Reducing supply chain costs, that's a little bit less common, but we can go into that.

(08:41):
Advancing innovation and research. And then of course, generating new revenue is an objective as well.

Rae Woods (08:48):
Yeah, generating new revenue is the obvious one for me. Recruitment and retention also makes sense, right? Paul, you came on Radio Advisory at the very beginning of this year talking about a bunch of different international examples for just, how the hell do we get enough staff in the right place with the right level of training, which is a global problem.

(09:05):
But Isis, you're also talking to me about things that aren't so reactive, but are more opportunistic. Like, can we actually accelerate our innovation strategy this way? So it seems to me like it's not just defensive moves.

Isis Monteiro (09:20):
Yeah, absolutely. And the one thing that I will say on the staff recruitment and retention front as well is, so we delivered a webinar on this exact topic to 50-plus health system execs. And we did some live polling in the moment, and we asked them, what opportunities are you seeking when it comes to recruiting and retaining staff?

(09:39):
And a lot of them are still relying on private recruitment agencies for international labor, for instance. But I think there is a missed opportunity for them to leverage their existing partnerships, to create training and development programs for instance, and send their staff abroad, do staff exchanges, things like that.

(09:59):
We also see health systems partnering with universities abroad to create a pipeline of students. Some examples here are like the University of Queensland in Australia partnering with Ochsner Health System here in the US. Where they complete their clinical rotations, and by the end of the program they're licensed to practice both in the US and Australia.

(10:21):
You see New York City hospitals, health and hospitals doing a similar thing and creating scholarship programs with Caribbean universities. This is with the express purpose of increasing the diversity of their workforce.

Rae Woods (11:42):
Isis, is you're already kind of surprising me by listing off more organizations than I thought might be involved in global partnerships. And perhaps I shouldn't be surprised, because you literally just told me that lots and lots of organizations have accelerated their thinking and the opportunities that they're seeking overseas.

(12:01):
But maybe I want to know, who are we actually seeing making these moves, right? We're talking about health systems, but I gather we are not just talking about the Cleveland Clinics and the Johns Hopkins of the world.

Isis Monteiro (12:12):
Absolutely. So one of the most surprising insights that came to me from this research is that, to your point, it's not just these massive private AMCs that are tapping into these opportunities. We also see public health systems and hospitals from all over the world doing this, getting in on this action as well.

(12:32):
So you have national health service hospitals from England going to the Middle East. So one example here is Moorfields Eye Hospital, which is a specialist NHS clinic partnering with an Emirati holding company to open an eye clinic in Abu Dhabi for government workers.

(12:49):
You have public Canadian hospitals like SickKids partnering with the Kui government through consulting arrangements to expand access to cancer services in the region. So it's all kinds of organizations that are looking to do this.

Rae Woods (13:04):
And this is really interesting to me. Because across the different business opportunities that we described, we see lots of different businesses say, let me approach this opportunity. It is not just the biggest, most capital-rich organizations.

(13:19):
It also sounds to me like your research really evolved and shifted over time, right? You even already said, you started off with one research question and then changed it. You got on the phone with a bunch of different health leaders and did some kind of live research in the middle of a webinar, and you're trying to learn more in the moment and change direction.

(13:39):
And you had this moment that surprised you when you found these public institutions also looking into partnerships overseas. I guess my question is, what else has surprised you as you've gone through this work?

Isis Monteiro (13:54):
Yeah, so one of the first polls that we launched, this might've actually been the first poll that we launched in the webinar. It's like, what are you most in interested in? And a lot of people said, innovation. So even though they talk about innovation, they think they're still thinking about it in terms of pursuing traditional clinical research instead of creating something net-new.

(14:14):
So we think there's a lot of opportunity here for health systems to leverage their existing partnerships, or partner with different kinds of organizations like startups, for instance, to co-develop tools or models that they could even potentially monetize.

(14:31):
So the best example that we have of this is Sheba Medical Center in Israel. They have an entire innovation hub or arm that houses all of their global partnerships. So this is with giant life sciences firms, to foreign health systems and governments, to local startups that help them co-develop tools and solutions to very real clinical problems that their clinicians surface.

(14:59):
And then they use this huge global network to get it regulatory clearance so they can scale it across different markets as well.

Rae Woods (15:08):
Oh, what you are describing is a best-in-class example, but in the moment you were surprised that folks weren't even getting there. They were still just focused on innovation in very clinical academic senses.

Isis Monteiro (15:18):
Yes, absolutely. Paul, What surprised you?

Paul Trigonoplos (15:22):
I don't know if this was represented in the polling that we did, but something that came out over the months that we were researching this came from the orgs that you mentioned upfront, those orgs that have been in the international partnership game for decades. So think about UPMC, or Hopkins, or Cleveland Clinic to your point, and a few others like that.

(15:44):
All of them, when we talked to them in interviews, seem to be scaling back the breadth of opportunities that they're pursuing, and focusing in on a smaller number of purposeful, sort of long-term sustainable partnerships.

(16:01):
So we talked to UPMC, they used to be in a dozen countries. Now they picked three. They said, we are going to go all in on these three, and hopefully these three are the ones that we can actually be involved with in a meaningful way, mission and revenue-oriented, in the longterm.

Rae Woods (16:18):
That's really interesting to me, and it is something that I think is really important to communicate to our audience. Because even though we are seeing more of these opportunities, and there is more urgency as the window of opportunity closes, and there are fewer partners out there, we are still seeing folks be selective in terms of the kind of partnership that they're going to pursue, even to the point where they may be unwinding things that have run their course, or perhaps did not work. And saying, we want to actually have a much more scoped approach and go from 12 countries to three.

(16:53):
If that's the case, how should leaders actually approach choosing what partnership they should actually invest in, or what market to focus on? I mean, if we think about global, the opportunity can feel overwhelming.

Isis Monteiro (17:05):
Absolutely. So there's not going to be a one-size-fits-all answer to this. And this is going to look different for every organization depending obviously on what their primary goals are. What are the objectives that you're trying to achieve overseas, and what identity or role they want to play or take on in that market?

(17:25):
So the right answer for some health systems might be to enter a market with a short-term exit strategy, and for others it might be to take the UPMC or Stanford approach, where you are really investing in building up these partnerships with governments. So you can maintain a presence there over years and decades.

(17:46):
But I think that generally your approach should be intentional, and aligned with a broader organizational mission. And this is going to help you decide where and with whom you should partner.

Rae Woods (17:59):
Wait, wait. And you're saying that an intentional strategy can be very short-term with an exit strategy that's kind of quick, or it can be something that you intend to be a decades-long partnership. Is that right?

Isis Monteiro (18:13):
Yes. I think it just depends on what makes the most sense for your organization, and what your overarching mission is as an entity. I don't think your global partnership strategy should be completely divorced from your organizational mission. These two things have to be aligned.

Rae Woods (18:33):
And if I come back to the five opportunities that you described at the beginning, it would make sense to me at least that your strategy around staffing and recruitment and retention is something that's short-term.

Paul Trigonoplos (18:44):
Or revenue, too.

Rae Woods (18:46):
Really?

Paul Trigonoplos (18:46):
Yeah.

Rae Woods (18:47):
I was going to say that one might be more long-term,

Paul Trigonoplos (18:51):
I mean, there are things like remote second opinions. You can stand up pretty quick. But it's just what problem you need.

(18:57):
I also think, I do want to go back to your point in the beginning of this question, which is around the giant grab bag that is the opportunities that exist globally.

(19:09):
And I think one other point I would make here is that, when you look at the organizations that are doing well here and have been doing well here for a long time, there's a difference in how they structure this function internally at the org.

(19:25):
So they all have some sort of centralized function that looks at global opportunities, that manages the partnership portfolio, that reports up to some executives. A lot of the, I think if organizations go into this blind or more of an ad hoc approach, where a researcher in the org goes abroad to do some research abroad and they come back and say, hey, I have a partnership opportunity, and they just chase it. Very ad hoc.

(19:52):
That's where you open up some risk of the partnership not really doing what you want it to in the long term.

Rae Woods (19:59):
Is that something that really sets apart the successful organizations from the pilot programs? I think you all have a running list of almost 200 global partnerships that you're tracking. Is this internal function that is more intentional, more strategic, more business oriented? Something that sets apart the successful ones from the experimenters, from the people that are just saying, oh my gosh, everyone is doing this, I've got to jump on board.

Isis Monteiro (20:25):
Yes, to the point about all of these opportunities being available. Again, I don't think that organizations should pursue international partnerships just for the sake of doing it, and because their competitors are doing it. Because they have this fear of missing out on this action.

(20:42):
But again, these partnerships is a strategy to help them achieve some overarching organizational mission or goal. So this is the point that I want to emphasize about having these two things be aligned, and your global partnership strategy not being completely divorced from this identity that you want to take on.

Rae Woods (21:02):
I'm glad you brought up FOMO. Because it is never a good idea in any strategic business objective to chase a shiny object, whether you're talking about a global partnership, or artificial intelligence, or whatever thing that you see other people doing. FOMO is almost never a good business opportunity for you.

(21:21):
But if I think back to where we started, and the context for why we are seeing more of these global partnerships, I see a lot of similarities everywhere in American healthcare, right? Every health system is struggling financially. Every health system is thinking about what their innovation strategy is. How do they grow into new markets? How can they get some quick revenue? How can they make sure that there is enough staff? How can they continue to deliver on their mission when quality and safety is suffering?

(21:49):
And so if I imagine that every US healthcare system could name one of those objectives as central to what they want to do in 2024, should all of them be thinking about global partnerships?

Isis Monteiro (22:06):
I think that even if a formal partnership is not the right answer for you, you can still stand to learn from your peer organizations abroad. So maybe formalizing an arrangement is not going to be the right answer for you. And this is not to do a shameless self advertisement of API's research, but there's still a lot to learn from your counterparts in other parts of the country.

Rae Woods (22:33):
I don't think it's shameless. It is a lot easier to go on to the links that we'll add to the show notes, or go on to advisory.com and learn about what Advisory Board International is doing than trying to learn for yourself from all of these different countries.

(22:47):
Paul, what do you think? Should everyone be pursuing some kind of global partnership?

Paul Trigonoplos (22:52):
I worry less about the number of organizations doing this, and I worry more about the thought that any one organization would put into going about an international partnership. I think that having a lot of partners, with some Rolodex of partners to call on at any point, whether it's domestically or internationally, is not really a strategy. Is just bloat, if they're not tethered to something that you're trying to achieve.

(23:19):
So whether it's internationally or domestically, figure out what you need help with. But you can look a little bit further than down the road for an option on who to partner with. And I think in that scenario, if the thesis is correct, I don't see why not.

Rae Woods (23:37):
But perhaps your push is think partnership, which may or may not be global.

Paul Trigonoplos (23:42):
Yeah.

Rae Woods (23:42):
Well, Isis, Paul, thank you so much for coming on Radio Advisory.

Isis Monteiro (23:47):
Thank you for having us.

Paul Trigonoplos (23:48):
Thank you.

Rae Woods (23:56):
Look, you might be reflecting on this conversation and thinking, wow, that topic was very specific. I might not want to pursue a partnership with a country overseas, whether that's in Australia, or South America, or Europe, or wherever it might be.

(24:11):
But I actually think we had a conversation about a bigger issue, which is that no matter what strategy you're pursuing, you have to make sure that you are relentlessly focused on the actual business priorities that your organization has for the next year, for the next five years, for the next 10 years.

(24:30):
As Paul said, being relentlessly focused there, whether you're talking about a partnership domestically or overseas, is going to be the thing that helps move your organization forward. And as Isis said, as always, we are here to help.

(24:51):
If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of advisory Board. This episode was produced by me, Rae Woods, as well as Kristin Myers, Atticus Raasch, and Abby Burns.

(25:08):
The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps and Joe Shrum. Additional support was provided by Carson Sisk, Leanne Elston and Erin Collins. Thanks for listening.