Advisory Board has been tracking site-of-care shifts in the health care industry for many years, but it's important to remember those changes aren't just happening in the United States, but worldwide.

Radio Advisory's Rachel Woods sat down with Advisory Board's Colin Gelbaugh and Paul Trigonoplos to talk about how site-of-care shift trends are changing worldwide and why those shifts are happening.

Infographic: Site-of-care shifts poised to impact providers

Read a lightly edited excerpt from the conversation below, and download the episode for the full interview.

Rachel Woods: I want to ask about an experience that you recently had, Colin, with our members. You convened a group of, I think it's hundreds of provider leaders together to talk about site of care shifts. And you actually asked them what they believe the most threatening shift is for their business. What did they say?

Colin Gelbaugh: We convened over 400 health care leaders recently and overwhelmingly, almost half of them said that surgical care shifts were the most immediate and alarming shift that they're worried about.

Woods: Are they right to be scared about this?

Gelbaugh: Yeah. Surgical shifts are certainly one of the biggest shifts that we recommend providers to be aware of right now.

Woods: What are some of the other shifts that we're tracking? Surgical care is a big one, what else?

Gelbaugh: There'll be emerging shifts to telehealth and to the home—these are in the early stages but have experienced exponential growth. And then there are other shifts that I would call more opportunistic of convenient care sites, urgent care clinics, retail clinics, the expanding access where access is an issue. And then finally, diagnostic services, more groups expanding onsite diagnostics is the last area I'll call out.

Woods: And those are all happening here in the United States, but site-of-care shifts aren't just limited to what we're seeing in America. Paul, how does that compare with what we're seeing in international markets? Are the threats the same?

Paul Trigonoplos: I think all of the shifts that Colin mentioned are happening at least in part in other countries, but there's a little bit more nuance there. Internationally, you can think of health systems in two buckets. There's the systems that want more patients and they want to grow. Those systems are private providers. They are generally worried about the same threats that Colin mentioned, surgical and then anything that could harm inpatient volumes namely, home care ships.

Woods: And what countries are examples of these folks that want to grow?

Trigonoplos: It's usually not full countries. It is usually private systems within each country. Forty percent, give or take, of the population of Australia has private insurance, they can access private hospitals. Denmark, the UK, most of Scandinavia actually, they all have a small private hospital industry that does want to grow, middle east as well.

For the most part, the public systems in these countries are where most of the care is delivered. Those hospitals don't really want to grow. They're trying to deliver as much care as possible as cheaply and safely as possible because they're responsible for the public tax dollar. For them, they are trying to shift as many services as possible into more scalable settings just to meet booming demand.

Woods: And Paul, you're getting to exactly where I want to go next, which is not just what we're seeing, but why it's actually happening? What are the drivers of site-of-care shifts? And my hunch is, they're not going to be the same, certainly not between all countries, but also perhaps not between all sites. Let's start high level. What are all the drivers foresight of care shift that we're tracking?

Gelbaugh: A lot of site-of-care shifts are triggered by regulatory changes. So that's one reason why you might see differences internationally. Reimbursement in the U.S. has been opened up for telehealth and the home setting. Medicare has just approved total knee replacements and coronary interventions for the ASCs, but some is also market level. So you think about the level of payer activism and how much their steering care and also the growth plans of providers in the local market.

Woods: And Paul, you just got at another factor that's maybe not happening in the U.S. that we are seeing play out in some of these public systems.

Trigonoplos: Yeah, that is the backlog. So the deferred care or missed care that happened and it's still happening from the pandemic. A lot of that is taking the form of electives that are now on a backlog that public systems have to go through. Some numbers—the UK as of January had 6.1 million people on their backlog list just Ontario alone as a province had over a million.

Woods: And these are for surgeries?

Trigonoplos: These are elective procedures, some surgeries, some diagnostic. This is generally the stuff that they assume you won't get more sick by delaying the service. But the numbers keep growing.

Woods: Paul, I'm going to ask maybe a silly question. Can those countries just add more beds? There's a backlog that we see in other countries that we don't see here in the US. Is there appetite to hospital build our way out of this?

Trigonoplos: Hospital building and renovation is still happening. Some of these countries have old facilities, they just need to be up kept. But the focus politically now is much more on building and opening up a more diverse set of care sites.

Things like ASC, which historically aren't really very popular outside of the U.S. Poly clinics in the community, these subacute facilities that are basically a multidisciplinary site that you can go to the CGP or a specialist.

Other countries, we're seeing this in Italy and Denmark and the UK and Canada, there's more appetite now to just diversify and expand the number of access points because for most of these places, the hospital is just where you go for everything.

Woods: So there is a need and a recognition that something needs to get built. The question is, it a hospital or is it some of these other things that frankly, we still see being very popular in the U.S. or growing in popularity in the U.S.?

Trigonoplos: Yes, that's exactly right.

Woods: My understanding is that the backlog isn't necessarily a new problem. It might be a problem that is worse now though than it has ever been. And my guess is, that's the same for some of these other forces that we're tracking when it comes to site-of-care shifts. Why are these forces accelerating now?

Gelbaugh: I already mentioned one which is, policy has been changing because of the pandemic to open up reimbursement and the ability of sites to perform different procedures. There's also other factors like unprecedented investment into health care. Growth of these alternate sites, private equity firms, investing, for example, is one factor.

Woods: There's one driver that you didn't mention and I'm a little bit surprised and that's consumer preference. Should that be part of the calculus here?

Gelbaugh: Consumer preference is a factor but it's always been a factor. The acceleration we're seeing today isn't necessarily due to consumers. Physicians, a lot of times are responsive to consumer needs, but they're still the ones driving a lot of these shifts at the end of the day.

That's not the case for all site-of-care shifts, if you look at something like urgent care, where it's the consumer making the decision, they're going to be the most important factor driving that shift.