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A Blueprint for Optimizing In-Network Specialist Referrals

> HEALTH SYSTEM EXECUTIVE PERSPECTIVE

Understanding the Specialist Referral Value Chain 

Health systems have invested significant resources in building their provider networks and aligning around clinical service lines to drive growth and deliver value-based care strategies.
 
Despite these efforts, however, many organizations still face basic logistical challenges in navigating patients through their provider network and achieving the financial outcomes they intended. Patient leakage, referral backlogs, scheduling wait times, and appointment no-shows are all symptoms of a broken process that directly impacts the bottom line.
 
This white paper advocates for a smarter approach to navigating high-priority patients, and lays out the business case for capturing more value from your investment in aligned providers and key service lines.
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> WHAT's INSIDE THE BUSINESS CASE

A Playbook for Increasing the Value of In-Network Referrals

 
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White Paper

Understand the referral value chain and explore strategies to unlock downstream revenue.

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Financial Model

An interactive Excel model that shows the key metrics, calculations and underlying assumptions. Calculate downstream revenue potential for key service lines.

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Infographics

Workflow diagrams showing the sources of specialist referrals and the challenges navigating those patients to in-network appointments. Follow the flow of referrals as they are converted to service line revenue, quality outcomes or network leakage to competitors.

 

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> WHO OWNS THIS PROBLEM
 

"One reason it can be difficult to analyze and improve the referral value chain is that it crosses over multiple health system functions and stakeholders. From the referral capture process in the ED and PCP offices, to the centralized Patient Access team, to the Medical Group specialist offices, to downstream procedures delivered in the hospital, to the strategy team analyzing network leakage – there is no one owner of this problem."

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> THE SOURCES OF VALUE Leakage

Network Leakage and Missed Downstream Revenue

Imagine your integrated health system as a finely-tuned pipeline engineered to maximize the flow of high-quality care and robust revenue. If that pipeline is riddled with leaks - cumbersome referral workflows and inefficient use of specialist schedules – then substantial downstream service revenue flows out of the system.
 

  • Missing referral orders in the ED

  • First-In-First-Out (FIFO) prioritization

  • Self-scheduling yields low-value patients

  • Appointment no-shows waste valuable slots

  • Overburdened office scheduling staff

  • Limited visibility into referral patterns

> A CARDIOLOGY EXAMPLE

Keep High-Value Referrals Attached to Service Line Growth

A patient discharged from the ED with a cardiologist referral has a relatively high rate of downstream utilization for outpatient, inpatient, and surgical services.

This metric can be calculated across a population of ED discharges and represented as an average downstream utilization/margin metric to quantify the average value of each cardiology referral.

Keeping more of these patients in the health system network is an obvious benefit – and reducing network leakage, especially for high-value referrals with a high average downstream utilization rate, can be worth millions to the bottom line of that cardiology service line.

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> cardiology Market Share
 

"Network leakage not only results in lost revenue but also erodes the health system’s market share. Market competition in cardiology is intense, and when specialist referral resources are not optimized to keep high-value patients in network, those patients are more likely to "attach” to competitors for downstream services."