A referral goes out. Two weeks pass. Somewhere between the primary care office and the specialist, the referral falls through the cracks. The patient calls, grows frustrated when there's no clear answer, and books an appointment elsewhere. From inside the practice, the day has felt packed and productive, but from the system’s perspective, another patient has slipped through the cracks.

“$150 billion is what they’re estimating is lost annually to referral leakage," said Michelle Skinner, MBA, BSN, RN, chief clinical executive at Teletracking. She then paired it with another figure that lands just as hard: “38% of those referrals never close the loop.”

That stunning breakdown set the tone for a recent conversation between Skinner and Daniel Williams, senior editor and host of the MGMA Insights Podcast. Skinner has spent years working with health systems on the operational side of care delivery, first as a clinician and later in leadership roles focused on patient flow, capacity, and access. In this podcast episode, she described how ambulatory organizations are trying to manage increasingly complex care networks with fragmented tools, only partial visibility, and a growing amount of manual cleanup.

Ambulatory care grew faster than the operating model

Skinner pointed to the larger shift first. “60% of care is now delivered in ambulatory settings and growing.” Health systems have pushed care far beyond the hospital, but many have not built the same operational visibility on the ambulatory side that they already use in acute care.

“Care is being delivered outside the four walls of the hospital, distributed into post-acute and ambulatory,” she said. Leaders who already use a command-center approach in the hospital notice the gap immediately. “They know what good looks like and how that needs to happen,” Skinner said. What they often cannot see is “where our patients are coming from and where they’re going on the ambulatory side as well.”

Skinner said typical referral leakage sits at “55% to 65%,” so that blind spot reaches beyond mere scheduling inconvenience. Once a patient leaves the network for specialty care, the rest can follow. 

“That could also mean their cath lab care is delivered there, their radiology, their lab,” she added.

Skinner shared an example that may be painfully familiar: A primary care physician sending a patient to cardiology. “Does the cardiologist even know that that referral was received only about 60% of the time?” she asked. Without a clear handoff or follow-up, the referral can simply stall.

“The referral goes out and then it goes into some 'never, never land,' [and] no one really knows where it is,” she said. “The patient can’t see what happens.”

The human becomes the system

The operational burden falls on people who are already stretched thin. Skinner described “that referral coordinator who’s managing 200 referrals in their inbox.” 

“They’re trying to figure out which ones are urgent, which ones are duplicates, which ones have been sitting so long that the patient may have already gone elsewhere,” she added.

The core problem, in her view, is shared visibility. “No one has one view that allows them to do that,” she said. Instead, staff piece together multiple reports, reconcile duplicate records, and manually chase status updates. “They’re always trying to put together three reports [to understand what's happening] or [assigning] four people to do duplicate management for the week.”

Her conclusion was blunt: “Who becomes the coordinator for the system? The human does. It’s not a sustainable problem.”

Full schedules can still hide wasted capacity

Asked about provider capacity, Skinner focused on scheduling structure rather than the clinician shortages often blamed for access problems. “There are actually big holes in the schedule being held for something that we didn’t realize [was there],” she said.

In some practices, new-patient slots are held even when follow-up demand is stronger. “Maybe they are new patient slots, but if I switched those I might be able to take a follow-up slot,” Skinner said. 

The case for changing that schedule has to come from trend data, not from one chaotic week. “There is actually a greater need for follow-up than with new patients,” she said, describing patterns that emerge over months of historical data.

She also pointed out the informal workarounds that shape referral and scheduling decisions every day. “There are mismatches or lots of behind-the-scenes spreadsheets and sticky notes,” she said. In other words, capacity often exists, but it is trapped inside templates, local rules, and incomplete provider data.

Seeing the same data changes the conversation

Skinner often spoke to the disconnect between how the practice feels and what the enterprise sees. “If I can’t see the problem, then I don’t know what the problem is,” she said. That is why her team starts by showing organizations their own data in a different frame.

One example came straight from schedule patterns: “On Mondays, you have a lot of open schedule and on Fridays, you’re full to the brim. What if we spread that across the week?” 

Another came from referral behavior: A primary care physician may prefer one orthopedist, but Skinner said, “If I were to refer to two other people in his practice, I might be able to get my patient in two weeks or one month sooner.”

Better visibility can help clinicians make intentional tradeoffs instead of accidental ones. “I might also decide that 'Dr. Williams' is actually the doctor that the patient needs to see,” she said. The difference is that now the delay is an informed decision, not a hidden consequence.

Case Study: Carilion Clinic found the duplicate problem first

Skinner shared Teletracking’s work with Carilion Clinic in Roanoke, Virginia. Carilion wanted the same network-level visibility in ambulatory care it already had in acute operations. One of the first findings was surprisingly basic and massively expensive in labor.

“They had tons of duplicates in their referral list," Skinner explained. "The number of duplicates was just tremendous.” She said that the staff had been cleaning that up manually. “That can take five to six people, multiple different reports — and they do them a week at a time.”

Teletracking built an AI agent that runs 24/7 to handle much of that cleanup, and Skinner drew an important boundary around the tool. “We don’t expect it to be 100% accurate,” she said. “You clean up the things that are the low-hanging fruit first, and then you maintain the things that the humans need to touch.”

She described the same logic in schedule design. “It’s providing you the most reasonable options, eliminating all the junk and the noise that’s out there,” she said. “This will never occur without human intervention.”

Start where the friction is highest

Skinner’s advice to leaders who feel too overextended to take on more operational work? Start with the points of friction that already consume time every day. 

“That might be around referral losses or referral conversions,” she said. “If they don’t even know those numbers, or they’ve got duplicate management or some of those kind of friction points within their day, certainly those are things that we could have a conversation about.”

She also emphasized that the first step does not require a massive technical lift. “We got their data in a flat file. We don’t need a feed,” she said of the Carilion work. 

The early work focused on outcomes, stakeholders, and process constraints, including one line that should sound familiar to anyone running a medical practice: “We can’t put any more workflow tax on our practice leaders. We can’t put any more workflow tax on our schedulers. And we certainly can’t put that workflow tax on our patients," she said.

That practicality resonated with the people closest to the work. After the design session, practice leaders told Skinner: If I had this, I could shave eight to 10+ hours out of my week.

For Skinner, those reclaimed hours are the opening move, not the end goal. Her teams are now trying to turn that kind of operational relief into something more valuable for organizations and patients alike: “If we did these two tweaks, because we’re seeing this trend, we could be able to bring in this many more patients,” she said, “providing more access to your community.”

Resources

• Connect with Michelle Skinner on LinkedIn
• Teletracking
• MGMA Insights Podcast Network
• "Putting the power of scheduling into patients’ hands" (MGMA Stat Article)
• "Closed-loop referral management: Who owns each step in your practice?" (MGMA Insights Article)
• "Patient access priorities for 2026: Tackling wait times, phones, no-shows and more" (MGMA Stat Article)

Email us at dwilliams@mgma.com if you would like to appear on an episode. If you have a question about your practice that you would like us to answer, send an email to advisor@mgma.com. Don't forget to subscribe to our network wherever you get your podcasts!