Why good UK healthcare businesses stall in the US
The pattern is consistent. A UK provider or healthtech company with genuine traction raises or allocates capital, commissions a market study, confirms the opportunity is large, and commits. Twelve to eighteen months later the pipeline is thinner than forecast, clinical capacity is licensed in the wrong states, and the team is doing operational work nobody costed. Nothing in the strategy was untrue. The plan simply assumed American healthcare behaves like a bigger version of the UK.
Having led operations across a national US behavioural health network — 236 clinics and telehealth services serving patients in all 50 states — my experience is that the difference is almost never conceptual. It is operational and structural, and it shows up in these ten places.
The ten assumptions
- 01
“The US is one market”
It is a federal market with fifty operating environments. Clinician licensure, telehealth practice rules, payer enrolment and credentialling are state-level processes, and each state you add brings its own timeline rather than sharing the last one. Replace the national plan with a state-cluster plan: pick the smallest group of states that gives you a large enough addressable population, and treat further states as a repeatable playbook rather than a growth assumption.
- 02
“Our NHS track record is the proof point”
NHS deployment demonstrates that you can operate inside a complex system, which is worth something. It rarely functions as clinical or economic evidence for a US buyer, who wants outcomes in a comparable US population with US utilisation and US cost of care attached. Plan for a US evidence step — a paid pilot, structured data collection, an economic model in dollars — as part of entry cost, not as an afterthought.
- 03
“The payer is the customer”
Payers pay, but they are frequently not the party experiencing the problem or holding the discretionary budget. Employers, benefits consultants, provider groups, health systems and, in some models, patients themselves may be closer to the decision. Map the buying unit properly: who is measured on the outcome you improve, who signs, who can veto, and how long their procurement cycle really is.
- 04
“Cash-pay is the easy option”
Cash-pay avoids credentialling and claims, which is genuinely faster. It also shifts the entire acquisition burden onto you, in one of the most expensive healthcare marketing markets in the world, with a narrower addressable population. Cash-pay is a legitimate first route, but it should be chosen for speed of validation and pricing freedom, with the acquisition cost modelled honestly rather than assumed.
- 05
“Referrals will arrive the way they do at home”
UK demand often arrives through a small number of institutional routes that, once earned, are relatively stable. US demand is fragmented and competed for continuously, across networks, employers, brokers, digital channels and direct consumer search. Expansion plans that model UK-style referral stability tend to over-forecast retention of volume and under-invest in the front door.
- 06
“Our clinicians can deliver the service”
In most clinical models, care for a US patient is delivered by a clinician licensed in that patient's state. That single fact reshapes hiring, rota design, supervision, pay bands and unit cost — and it means clinical recruitment is on the critical path from the start. Where a model can be delivered non-clinically or asynchronously, establish that early with proper advice, because it changes the entry economics substantially.
- 07
“Headline US pricing means better margins”
US price points genuinely can be higher. They are also carrying billing and coding infrastructure, denials and rework, higher acquisition costs, higher clinical pay, insurance and legal overheads, and non-attendance rates that differ from UK norms. Build the unit economics bottom-up in dollars, with denials and no-shows in the model, before treating price differential as margin.
- 08
“We can run it from the UK for now”
Partly, and briefly. Buyers expect US-hours responsiveness, clinicians expect US-hours supervision, and scheduling across five to eight time zones defeats a UK-based access function quickly. Decide deliberately which functions must be US-based and when — usually clinical delivery, access and scheduling first; finance, product and analytics later — rather than discovering it under pressure.
- 09
“Regulation is a compliance task we handle later”
Regulatory load is not a box to tick at the end; it is the main determinant of sequencing. Licensure and credentialling queues, payer enrolment lead times and state-specific practice requirements decide the order in which markets can be opened and when revenue can start. Take proper legal and regulatory advice, then let those timelines drive the plan rather than sit beside it.
- 10
“If the model works here, it will work there”
The proposition may travel. The operating model usually does not, unchanged. Intake, triage, documentation, scheduling rules, coverage models and escalation paths all need redesign for US expectations and constraints. The most reliable predictor of a successful entry I have seen is a leadership team that expects to rebuild the operating layer and has budgeted the time to do it.
What a more honest entry plan looks like
The strongest US entry plans I have worked on share four features. They name a single buyer and a single route to revenue for the first phase, rather than hedging across three. They treat regulatory and credentialling timelines as the spine of the schedule. They fund a US evidence step deliberately. And they set decision gates: explicit conditions that must be met before the next tranche of spend is released, with a genuine willingness to stop.
They also tend to establish, before committing, how much growth is available at home from converting demand they already have. That is not a delay tactic — a business that has fixed its own access pathway enters a new market with a model worth replicating. More on that in patient access is a growth function, and on the acquire-or-build question in build vs buy.
For how Clarendum works through this in practice, see US healthcare market entry. Legal, tax and regulatory specifics should always be confirmed with qualified US advisers; everything above is commercial and operational judgement, not legal advice.
Frequently asked questions
- What is the single biggest mistake UK healthcare companies make entering the US?
- Treating the US as one market with one buyer. Licensure, credentialling, payer contracting and referral behaviour all vary by state and by plan, so an entry plan built on a national average tends to be right nowhere in particular.
- Should we validate in the US before committing capital?
- Yes, and validation should be commercial rather than exploratory: a signed pilot with a real budget holder, priced, with a defined success measure. Warm interest from clinicians or advisers is not evidence of a route to revenue.
- How much operational infrastructure do we need on day one?
- Less than most plans assume, and in a different shape. What is usually needed early is state-licensed clinical capacity, a functioning access and scheduling pathway, and — for payer routes — billing and denials capability. What is usually needed later is scale management.
Pressure-testing a US entry plan?
A short call is usually enough to identify which of these assumptions your plan is currently resting on.