Imaging Services (Outpatient) sector across EMEA

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  • Detailed research report on Imaging Services (Outpatient) services with marketshare and growth rates for 28 countries and information on a further 154 (HBI Intelligence)
  • Database of 154 Imaging Services (Outpatient) service providers, including profile and major external investors (HBI Intelligence)
  • Merger and acquisition (M&A) intelligence showing likelihood of sale (HBI Intelligence)
  • News stories and interviews with Imaging Services (Outpatient) operators (HBI Deals and Insights)
  • Events that cover healthcare services globally including Imaging Services (Outpatient) (HBI 2020)
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Sector Report
Imaging Services (Outpatient) Sector

Updated: June 2020

Executive Summary

Detailed research overview on the imaging sector
 
EXECUTIVE SUMMARY
 
Impact of Covid-19 

We are in the process of analyzing the impact of Covid on the sector and we should have updates for every country’s growth forecasts for 2020 and 2021 by end of May. This is a partially elective sector and there has been a strong short-term impact which we have already reported in news. A serious recession will further hit demand and leave many investors breaking their bank covenants.
 
Introduction
 
Radiologists are the doctors who save lives with the lights off but demand for their services is growing 5-10% globally and the radiologist workforce is increasing by barely a fifth of that. Three big trends are evident.
 
One is the remote reading of images, teleradiology, which has been around since the 90s but is now growing 20-30% annually in Europe’s biggest markets as the scarcity starts to bite.  
 
Artificial intelligence (AI) reading of images can triage and, in the long-term, interpret images instead of humans. It is now demonstrably better than doctors at detecting a small subset of lesion types, but the real benefit in the short-term will be filtering out the “clean” images, the assessment of which can take up over half of a mammogram specialists’ time, for example.
 
Thirdly, tariff and regulatory pressure and an ageing radiology profession are forcing a slow but evident consolidation of the for-profit outpatient radiology sector, in the countries where it exists. Tariff cuts are mitigating growth.
 
Overall growth and utilisation from country to country
 
OECD data shows that, by volumes, demand for positron emission tomography (PET) is growing by an average of 9.2%, computed tomography (CT) by 5.3% and MRIs around 5% each year, from 2014-2017 across 14 of the countries covered in this report. We are told it may underreport private sector activity and that the figures for MRIs and CTs are probably growing faster, especially for MRIs. PET is the newest modality of the three and so is growing the fastest.
 
See the report for full details on countries and country comparison.
 
Market dynamics
 
In some countries, primary care doctors can commission scans routinely.
 
Within NHS models funded out of general taxation (Nordics, UK, Spain and some of Eastern Europe) diagnostic imaging typically happens within a public-sector hospital setting with little outpatient presence. Here, the for-profit market is in hospital outsourcing.
 
In Bismarckian insurance-based systems, (France, Portugal, Switzerland, Germany and Italy) much more happens in outpatient settings, which are often historically owned by doctors.
 
A big West European operator reckons that typically private hospitals commission about half the rate of images as public sector counterparts, albeit at a higher price.
 
See the report for full details on countries and country comparison.
 
Private sector plays  
 
The private sector plays in three main ways: Outpatient consolidator and polyclinics, outsourcing partner, and teleradiology.
 
Outpatient consolidator and polyclinics
 
In the Nordics, Russia, Italy, Portugal, Spain, Switzerland, Germany, Romania and other East European countries, outpatient radiology centres can be easily bought and sold. But the consolidation process in all except Switzerland is still in its infancy.
 
Consolidation of the sector is much less advanced than in clinical laboratories. Only Affidea, Alliance Medical and lab operator Unilabs have pan-European footprints, with Alliance mainly in the UK and Italy. Unilabs gets 20% of its sales from imaging, mainly in Spain, Portugal and the Nordics. In general, mid-sized operators we speak to, or hear about, do not seem that interested in selling, seeing more opportunity in consolidating their home market.

Like in the broader outpatient sector, many consolidation attempts and single-centre acquisitions fail because the new owners cannot keep the leading specialists on board.
 
Groups offering broader outpatient services often tend to be major players in the imaging sector. It is an integral part of the business model in big, for-profit occupational healthcare players such as Terveystalo and Mehilainen in Finland, in Bupa/Luxmed in Poland, Regina Maria and Medlife in Romania and across Eastern Europe for Medicover. Affidea is increasingly moving into broader outpatient services in countries like Ireland, Lithuania and Italy. Alliance has many centres in Italy which offer a mix of labs, imaging and primary care.
 
See the report for further details on private sector plays. See the table of contents for further details on what you can expect in the report.

Artificial Intelligence (AI)
 
AI will most easily be used to filter out the ‘clean’ images leaving radiologists to spend more time looking at potential lesions and abnormalities, or by prioritising images according to the chance of an abnormality.
 
Even if the technology eventually gets better at identifying types of lesions than radiologists, across all types of scans, you then have the arguably more complicated question of where responsibility lies if the machine makes a mistake.
 
It is possible that big imaging groups are reluctant to admit that AI may replace much of what radiologists do, as the radiologists in many cases are their most important customers. 
 
Combining labs and imaging
 
From an operational and cost point of view, there are few synergies between labs and imaging, but they are both capital-intensive. 
 
In some markets, public healthcare sector outsourcing requires providers to offer the whole integrated diagnostic pathway covering clinical laboratories and diagnostic imaging in order to win contracts. In more B2C-focused markets where patients pay cash for diagnostic tests to avoiding public waiting lists, it also makes sense to offer both from one location.

We see the combination of both in most emerging markets, East Europe/Russia, as well as more developed Portugal and Italy. 
 
What are the competitive advantages of for-profit operators?
 
Most public sector systems are inefficient with expensive equipment often used only within a 5-6 hour working day. Many doctors may not be referring the patients they should for the right treatment modality. In many countries, public sector hospital systems do not have the capital to build new centres.
 
For-profit operators advantages are:
 
- Efficient capex allocation and management of capital equipment
- Excellent patient flow systems
- Access to capital, which is effectively providing off-balance sheet finance to the public sector
- Robust IT and management systems
 
For-profit opportunities
 
Meeting explosive demand
 
Particularly in laggard countries, there is an opportunity to meet public sector demand. This is particularly true in the UK where Alliance Medical reckons that CT/MRI scans are growing in value at 8-10% a year, while by volumes we are also told there is double-digit growth in countries like Poland, Hungary and Spain. Even in more mature systems, demand is likely to grow at anywhere from 5-10% and from a higher base. 
 
Much depends on identifying those technologies where help is needed. Alliance Medical, for instance, has moved into cyclotrons and the supply of radiopharmeuticals in Italy and the UK and in 2017 bought Eckert & Ziegler’s cyclotron division in Germany and Austria with revenue of €18m. Voxel, the third-largest imaging group in Poland, is the largest supplier of radiopharmaceuticals in the country.
 
The secret is to identify willing partners, whether they are at the national, regional or hospital level. One source said: "The argument that we can help a public hospital meet demand in a low risk and highly effective way is obvious. The secret is to find the management teams and policymakers who are receptive to working with the private sector."


See the report for full details on opportunities in the for-profit dialysis sector.
 
Threats to imaging service players
 
Tariff drops/budget ceilings
 
Across Europe we are seeing budget ceilings (Poland, Slovakia, France, Germany) as well as tariff pressure (France, Switzerland, Poland, Slovakia, Czech Republic).
 
Despite what some operators say, we are absolutely seeing public payor tariff cuts in imaging across Europe. Cuts of between 3-10% have been seen since 2014 in South Africa, Sweden, Switzerland, Portugal, Turkey and France and virtually all countries have seen some price fall or another.   
 
Germany and Switzerland have joined France in introducing severe limits on the introduction of new imaging scanners to the market, either by limiting public reimbursement or by not allowing their introduction at all except in special circumstances.
 
See the report for full details on threats to imaging services providers.

Cracking down on over-treatment
 
Compared to hospital surgeries, there is not that much hoo-ha about unnecessary imaging scans, even though everyone knows it happens.

Anecdotal evidence suggests overtreatment is rife in Turkey while clearly there are too many scans in Germany too. There seems to be little correlation between scans-per-person and cancer survival rates when looking at the OECD numbers.
 
The Future
 
We think that imaging service groups have a bright future in helping public sectors to meet the demand for new modalities. Much depends upon the vision and salesmanship of top management.
 
Much depends then on the willingness of healthcare systems to involve for-profit players in this process. On this basis, cash-strapped systems in the UK, South and Eastern Europe look like the best options in the short-term. Elsewhere, the sector may be shut out.
 
Sample report pages and data
 
What we offer
 
-       Instant overview of the EMEA imaging services market and players This report gives you visibility of this important, fast-growing market across 26 countries with market data on all as well as detailed profiles of the Top 50 players.
 
-       Ever green!  Updated throughout your subscription As part of our HBI intelligence platform this report is updated throughout the period of your subscription. You will also receive additional news stories and interviews on imaging services throughout the period.
 
-       Insights on business models The report is based on in-depth interviews with many operators. The report also looks at how imaging services players can best build customer loyalty.
 
-       Identify national opportunities We assess opportunities at national level based on the regulatory environment and proposed reforms,
 
-       Size markets This report enables you to swiftly see market sizes and market shares.
 
-       Save time and money This report will save you weeks researching these opaque markets and enable you to swiftly identify investment opportunities, new partners and markets.
 
 
 

Table of Contents

Table of Contents
 
EMEA overview
 
Datasets  
Size of EMEA market 2018
Marketshare of major EMEA players 2018
Comparison of market sizes 2018
Comparison of market growth rates 2016-2020
 
Introduction
 
Acknowledgements
 
Methodology
 
Overall growth and utilisation from country to country
 
Market dynamics
 
Private sector plays
 
                                    - Outpatient consolidator and polyclinics
                                    - Outsourcing partner
                                    - Teleradiology
 
Artificial Intelligence (AI)

Emerging models
 
Combining labs and imaging
 
What are the competitive advantages of for-profit operators?
 
For profit opportunities
 
-       Meeting explosive demand
-       Consolidation
-       Creating major outpatient networks
-       Building private patients
-       Building a wider outpatient service offering
 
Threats to imaging service players
 
-       Political change
-       Tariff drops/budget ceilings
-       Instant death competitive tenders
-       High Capex costs and low usage
 
Changing relationship with equipment suppliers
 
Cracking down on over-treatment
 
The Future
 
Albania
 
Data sets
For-profit /private market size and growth rates 2016-2020
 
Market description and trends.
 
Croatia
 
Data sets
Marketshare of major players 2018
 
Market description and trends.
 
Czech Republic
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Denmark
 
Marketshare of major players 2018
 
Market description and trends.
 
Finland
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
France
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Germany
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Greece
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Hungary
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Ireland         
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Italy
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Netherlands
 
Data sets
Marketshare of major players 2018
 
Market description and trends.
 
Norway
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Poland
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Portugal
 
Data sets
Marketshare of major players 2018
 
Market description and trends.
 
Romania
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Russia
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Saudi Arabia
 
Data sets
For-profit /private market size and growth rates 2016-2020
 
Market description and trends.
 
Serbia
 
Market description and trends.
 
South Africa
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Spain
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Sweden
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Switzerland
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 
Turkey
 
Data sets
Marketshare of major players 2018
 
Market description and trends.
 
Ukraine
 
Data sets
Marketshare of major players 2018
 
Market description and trends.
 
United Kingdom
 
Data sets
For-profit /private market size and growth rates 2016-2020
Marketshare of major players 2018
 
Market description and trends.
 

Imaging Services (Outpatient) News & Interviews

Our indepth stories dig deep and cover profit multiples, revenue, EBITDA and CEO thinking.

415 news stories on Imaging Services (Outpatient).

ICG indirectly acquiring stake in €3bn nuclear medicine group 7d ago

Intermediate Capital Group (ICG) is indirectly acquiring over 25% of the shares of Europe's largest radiopharmaceuticals provider Curium Pharma, HBI can reveal, after owner Capvest earlier pulled a majority sales process because of COVID-19....

Bioiatriki open to sale talks now and international expansion from 2022 2w ago

HBI speaks exclusively to George Spanos, chairman and CEO of Greece's largest primary care and diagnostic chain, about the company's plans for the future and whether rumours the company might be for sale are true....

Interview: Sofia Palmquist, CEO, Aleris 2w ago

Pan-Nordic healthcare group Aleris lost its previous owner Investor AB nearly 1bn SEK (€90m) in its last nine months of ownership before PE group Triton acquired it in late 2019. New CEO Sofia Palmquist, pinched from competitor Capio, has been tasked with th...

Investigation finds 'most' Nigerian labs paying 20% kickbacks 4w ago

An investigation has found that kickbacks are still rife in the Nigerian diagnostics market with some of the market's players artificially hiking prices so as to retain the extra costs....

PWC on M&A drivers in Spanish healthcare sector 1mo ago

The Spanish private healthcare market has been one of Europe's most attractive for institutional investors of late with strong organic and inorganic growth opportunities. PWC Spain's deals leader for Healthcare & Pharma Jose Zarzalejos talks us through the drive...

Multiples drop 10-15% in German outpatient sector 1mo ago

EBITDA multiples paid in the German outpatient sector have fallen 10-15% from pre-COVID levels because of market uncertainty due to the pandemic, an advisor tracking the space tells HBI....

Local PE firm buys Romanian imaging group 2mo ago

A Romanian private equity firm has acquired a majority stake in imaging services operator Medima Health....

Adding value post-COVID - where are the easy wins? 3mo ago

How do you add value to a business in a post COVID world - and are there any easy wins for new acquisitions? On Wednesday last week, an online audience heard HBI365's lively Q&A panel with with Ameos CEO Dr Axel Paeger, McKinsey partner Sebastian Sieler, and L...

Interview: Arjan Toor, CEO, Cigna Europe 3mo ago

Cigna now describes itself as “a global health service company” rather than an insurer and has reorganised its European operations. Toor has recently been promoted to CEO Europe. He says that the insurer, which has 15% (US$840m) of its revenue in Europe, d...

Database of 154 Imaging Services (Outpatient) service providers

HBI has built a unique database of the Top 4,000 operators globally in health care services. As part of this, we have identified the top 154 Imaging Services (Outpatient) operators in Europe and will soon add the major players in Emerging Markets.

Profiles include revenue/sales data as well as EBITDA and other profit margins where known. They also cover private equity ownership with dates and mergers and acquisitions.

Mergers & Acquisition (M&A) Intelligence

Our deal pipeline shows how likely all private equity and some privately companies are to sell based on algorithms and journalistic know-how.

HBI 2020 – the only CEO-level conference to cover healthcare services globally

HBI 2020 – the only CEO-level conference to cover healthcare services globally
 
In 2019 this event brought together 700 delegates from over 40 countries. Over 60% are CEO level and they included 150 specialist investors in health care services. HBI 2020 includes a diagnostics session on opportunities and challenges, with a penal of operator CEOs from the laboratory and imaging sector.
 
Other sessions look at trends in the investment and merger and acquisition, digital health and telehealth.
Contact us in the UK on 0207 183 3779 for more information.