The $150 Billion Blind Spot in Ambulatory Care That's Hiding in Plain Sight with Michelle Skinner
Download MP3Well, hi, everyone. I'm Daniel Williams, senior editor at MGMA and host of the MGMA Podcast Network. Today, we are addressing one of the issues that MGMA members are dealing with, that ambulatory care and how patients get care and how that patient information and that patient access doesn't get lost in between shared practices. To help us understand this better, we've got Michelle Skinner. Michelle is Chief Clinical Executive at TeleTracking.
Daniel Williams:She spends her time with health systems working on what happens when ambulatory operations outgrow the tools built to run them. Michelle, welcome to the show.
Michelle Skinner:Thank you, Daniel. It's so nice to be here.
Daniel Williams:It is so good to have you here. We were chatting offline. Gonna catch up a lot about Denver and Colorado and the mountains and all those things in a little bit. But first, let's hear a little bit about your background. You were telling us that you had worked in this area where we are in Denver.
Daniel Williams:So share with some of the highlights of your healthcare career.
Michelle Skinner:Yeah. You bet. So I've always been in healthcare. I started as a candy striper at the old Saint Francis Hospital in Colorado Springs, for your knowledge, when it still was run by nuns. And, you know, so I started as a candy striper when I was 14, and I've always done health care.
Michelle Skinner:I worked in the ED as a patient reg clerk at night and then went into the ICU and the ED as a tech while I was in nursing school. I did my nursing degree at Bethel College of Nursing, which is now part of the University of Colorado, and went immediately into ED and ICU care and then into sort of the business side of health care, which is when I decided I needed an MBA, which I also got in Colorado. Yay, Regis. So I think what's important about that, Daniel, is that my framing always comes from the caregiver and the patient's perspective. And so it shapes everything I do and how I think about the work that I do because when the system fails, the tax goes on someone else.
Michelle Skinner:So it goes on the clinician or in the case of ambulatory, often it goes on the patient. So it's interesting that, you know, from that framing, we're always making sure that the technology we build reflects how care works and not just like how we think in a conference room it should work.
Daniel Williams:Okay. Thank you for sharing that. And then you're at an organization named Teletracking. It was a new name for me, maybe to some of our listeners. So bring us up to speed.
Daniel Williams:Tell us about Teletracking. What do you guys do?
Michelle Skinner:Yeah. You bet. So teletracking is the global leader in health care operations platforms, and we serve more than 900 hospitals worldwide. So we work in four countries, United States, Canada, Germany, and The UK. And what's important about that is we see the different problems that people are trying to solve from many different angles.
Michelle Skinner:And what we find is that those are often very similar even if the payer differences are very different. So for over thirty five years, we've been around for thirty five years, privately owned, never taken PE money, never sold to another organization. We've been delivering real time operational solutions that integrate within the EMRs and other solutions within the organization to give leaders that complete visibility and orchestration across their network. So it eliminates efficiencies. It helps to reduce cost.
Michelle Skinner:So thinking about getting the patient in the right place at the right time. And then it drives that measurable ROI, which is so important these days when you're thinking about the slim margins that we're working with.
Daniel Williams:Okay. What would you say is your what does your day to day look like there? And maybe it changes every day, but just give us an idea as let's make sure I get that right. Chief clinical executive, what do you do in that role?
Michelle Skinner:Yeah. I don't sit in this often very this office very often, so that's for sure. So I'm based here in Pittsburgh, which is where we're headquartered, and we have been for the whole thirty five years that we've been in together. I am usually with our either current clients or our prospective clients kind of understanding deeply the problems they're trying to solve. Health care is changing rapidly.
Michelle Skinner:The financial landscape is vastly different than it was even just two years ago. Technology is changing rapidly. And so having our finger on the pulse of what the problems are that we're trying to solve and making sure we're tied to those outcomes is so critical. I'm often talking with people like you, getting the word out there about what we do, and learning about the problems that your clients are trying to solve. You know, speaking at conferences and then always, you know, spending time at the elbow of our clients is so important to me.
Michelle Skinner:I also have a team of subject matter experts that work with me on both the inpatient and ambulatory side. So one of the things that's important about teletracking is we're not just technology. We're people processing technology. We never just drop in technology and leave you alone to kind of figure it out. So we bring those clinicians at the elbow to help you solve those problems or to gather information from other clients.
Michelle Skinner:That's part of being part of our network is that you have access to others who might be able to try might be trying to solve the same problem you are in a different way. We can bring people together to kind of do that together.
Daniel Williams:Okay. So, Medical Group Management Association, MGMA, we've got about 70,000 members currently. The people who are listening right now, they're medical practice leaders. Their titles may be different, but they're people who are making decisions at practices, really supporting the business of healthcare. So, when you hear from somebody who fits that profile, what are they coming to you for?
Daniel Williams:What's going on at their practice where they need teletracking's help, where they are coming coming up against a problem, a challenge, a friction point where they need some help.
Michelle Skinner:Yeah. You know, it's interesting, Daniel. What we're finding is that if you think about it, it's more like, think about that referral coordinator who's managing 200 referrals in their inbox. Right? And 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, and which ones specialist might have availability for this week or next week.
Michelle Skinner:And they're trying to do their best to get those patients in where they are. And those are the days that we're trying to fix for people. That's the information that we're trying to help them with. Those systems where the practice is not giving the the systems that they have isn't giving them the answers that they need on a daily day basis. It's creating more work for them.
Michelle Skinner:And we're seeing that there's this broader pattern that's not a staffing problem. Right? This is about not having the visibility that you need to be able to understand referral status, aging, capacity across your network, and then who becomes the coordinator for the system. The human does, and it's just not a sustainable problem. So what we're finding is, in fact, when we did what what was called an innovation workshop, and we can talk a little bit more about this later, we found that everyone within the problem, so the referring physician, the specialty physician, or coordinators, the the schedulers, everyone is trying to do the right thing, but no one has one view that allows them to do that.
Michelle Skinner:They're always trying to put together three reports to tell them this or four people to do duplicate management for the week. The week they spend clearing up duplicate management when we can run an agent that cleans, you know, 80% of that up over the night when they're sleeping. So that's the kind of problems we're trying to solve is not to be your scheduler and not to be your referral, but to clean up all the information that's between there so that you can see clearly, keep those referrals within your system. That network integrity has gotten so critical at this point that most organizations are really critical about having that that network integrity not get broken across the chain.
Daniel Williams:Okay. One of the things y'all shared with me, you and your team, was that ambulatory care now takes up 60% of care that patients receive. And y'all also shared with me that that's happened pretty fast for ambulatory care to take over the majority of care being delivered. What has that meant to practices? How has that changed things?
Daniel Williams:Just help us gain a perspective on that.
Michelle Skinner:Yeah. You know, it's interesting. I think that we're starting to see organizations, particularly organizations that we've worked with that have thought about acute care in a command center mentality or centralized mentality. They know what that looks like to have the visibility across their system and be able to get patients in the right place at the right time. They're seeing it, I think, the most acutely.
Michelle Skinner:At least that's what we're seeing right now. They know what good looks like and how that needs to happen. But if you think just about the statistics for a while, some of these are your statistics as well, but sixty percent of care now delivered in ambulatory settings and growing. Right? Like, we see, I love SG two.
Michelle Skinner:I'll give them a plug. They put out the impact of care report every year. And you can just see, you know, ten years ago when I used to look at that, I think it's been out for about fifteen, you saw ambulatory acute and post acute. And the hospital sat up here on this hill, and most of the care was delivered there. What we're seeing is that, you know, care is being delivered outside the four walls, what we call the four walls of the hospital distributed into post acute and ambulatory bolts.
Michelle Skinner:And the most expensive care is still being delivered in the hospital there. So that strain, that financial strain on organizations is tremendous. And they also want to provide this access to care in their communities. So thinking about what that ambulatory network looks like, a 150,000,000,000 is what they're estimating is lost annually to referral leakage. So patients who leak outside the system, and I'll give you an example of how that happens, and it's pretty dramatic.
Michelle Skinner:And from your own statistics, MGMA statistics in 2025, thirty eight percent of those referrals never close a loop. So I send out a referral, they to a cardiologist, and 38% of those. 38% don't close the loop. And that's not because that it we just don't want to find them a place to have care. When you think about the typical referral liquid leakage, it's sitting at fifty five to 65%.
Michelle Skinner:So patients who leave the system, how does that happen? So a primary care provider may send a referral to a cardiologist. Does the cardiologist even know that that referral was received only about 60% of the time, so not a 100% of the time. And then the pay the tax always goes on somebody else. In this case, the patient.
Michelle Skinner:So the patient waits two weeks. They call to follow-up. Maybe the cardiologist has an appointment. Maybe they don't. They say, let me give you a callback.
Michelle Skinner:At that point, oftentimes, patients leave the system and take their care somewhere else. So now they've gone to a private physician outside of the system and their care is delivered there. That could also mean their, you know, their cath lab care is delivered there, their radiology, their lab. So you can see where the network integrity begins to break down, and that leakage amount gets grows exponentially in that process. And I'm not able to get the care that was intended for me within that system.
Daniel Williams:Right. So you shared with me that the breakdown show up. You mentioned referrals. What was that number? A $150,000,000,000
Michelle Skinner:Billion lost annually to That referral was out of Health Leaders Media just last year.
Daniel Williams:That's just incredible.
Michelle Skinner:I know.
Daniel Williams:Also, breakdowns are found in scheduling, and as we well know, provider capacity, just that shortage of clinicians that we have right now. Walk us through a case then. Do you have a case study, something where you could show us? Because obviously it is at an epidemic type proportion of this leakage and where things are breaking down in the system. Walk us through how it happens.
Michelle Skinner:Yeah. So, the way that we approach this is we have been working with the Curlean Clinic, which is a health system located in Roanoke, Virginia. They've been a longtime partner of ours. And they came to us and said, Hey, we have always worked with you. They have an amazing command center on their acute side where they have had just fantastic outcomes, where they've really been able to increase access.
Michelle Skinner:Remember that the reason people do this is to be able to provide that care in their community that they've committed to. So access is the name of the game here. There are lots of other outcomes, but that's really the goal is to create that access. They said we wanna make sure we're doing that on the ambulatory side as well. We wanna have that same ability to have a see a seamless view across our system and understand where our patients are coming from and where they're going on the ambulatory side as well.
Michelle Skinner:So does that mean that I need to put another provider two days a week in a clinic that's an outlying clinic? Am I losing my referrals there? Which means, yes, I'm losing referrals, but I'm also not maintaining that access that I've committed to that community. Oftentimes, I've gone there. I've said, hey, here's a part time clinic that's going to be here, and we're going to make sure that you have a cardiologist and primary care orthopedics, all the things that, you know, maybe OB that are able to be in those rural clinics.
Michelle Skinner:But yet patients are not able to get the access that they need. They couldn't see that, though. They were finding that, you know, they thought that, you know, maybe they needed an additional cardiologist. Maybe I only need that cardiologist scheduled to be open on Mondays, and I've worked really hard to open Fridays. So if I can't match my supply with my demand, then it doesn't help.
Michelle Skinner:And this is work that we do in a lot of different areas, particularly in the in the acute space. So we're working with them to be able to provide the same thing. And what we've seen already in looking at their data and showing them is that they have tons of duplicates in their referral list. I mean, the number of duplicates is just tremendous. They told us that that can take five to six people, multiple different reports, and they do them a week at a time.
Michelle Skinner:So just to clean up that duplicates. We created an AI agent that runs twenty four seven, and we don't expect it to be a 100% accurate. You clean up the things that are sort of the low hanging fruit first, and then you maintain the things that the humans need to touch. Right? Those key cases that you think it's just too complicated or this needs a high touch environment, and we allow humans to do that.
Michelle Skinner:The next thing we did is show that provider sort of supply and demand mismatch. And so where do I have open slots that they're not for the right reason? Maybe they are new patient slots. But if I switched those, I might be able to take a follow-up slot. We also have to think about where can the provide where does the provider burnout happen?
Michelle Skinner:If I overload too many of one type of patient, there's definitely this delicate dance between the practice manager and the provider that must happen. And so what we're doing is designing something that will never occur without human intervention. So it's providing you the most reasonable options, eliminating all the junk that and the noise that's out there and saying, hey. Let's talk about these options. If we did these two tweaks because we're seeing this trend, we could be able to bring in this many more patients, providing more access to your community.
Michelle Skinner:So that's the work our teams are doing right now. They're kind of living in Roanoke right now at the elbow of the Corellian team refining this prototype right now.
Daniel Williams:Okay. Let's look at it in a different way, just trying to understand it even better. Do the practices know they have a problem? I mean, you use very specific language, the referral leakage and things of that nature. Does a practice just feel like, Hey, we're not very efficient.
Daniel Williams:We're looking at some KPIs that aren't adding up, and we need some help. What is going on at the practice level when they even come to you in the first place? I'm just trying to frame this where our listeners will understand, Oh boy, I'm fitting what they're saying here. You
Michelle Skinner:know what? That is such a great question, Danielle. One of the things that we're hearing is that the health system is saying this our KPIs look like this,
Daniel Williams:not
Michelle Skinner:so great.
Daniel Williams:Okay.
Michelle Skinner:And the practice is saying, but we feel like we're doing everything right.
Daniel Williams:Right.
Michelle Skinner:Our providers are full. Our panels are full.
Daniel Williams:Right.
Michelle Skinner:We you know, we're doing everything we can. So there's a mismatch between what the KPIs look like and what it feels like in the practice. We feel like we're busy. We're full. We're working as on all cylinders.
Michelle Skinner:And so sometimes if we use data to be able to to share and be able to allow two teams to see the same thing, then we're able to to change behavior because I can see the problem. Right? If I can't see the problem, then I don't know what the problem is. And so that's the first place we started was just taking their actual data and saying, but here's what we see. So on Mondays, you have a lot of open schedule.
Michelle Skinner:And on Fridays, you're full to the brim. What if we spread that across the week? You know? Or on like, you've got one of the things we heard from the teams was, I'm a primary care physician, and I want to refer to doctor Williams who's an orthopedist. And I didn't know that 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.
Michelle Skinner:If I would know that, I would make a different decision. I might make a different decision, but I might also decide that doctor Williams is actually the doctor that the patient needs to see, and I can explain to that patient why the wait will be longer because of that. So there's some self selection that the people just don't know. The other piece is is this loss of of knowledge that happens when the referral happens. And we've seen this across every system.
Michelle Skinner:The referral goes out, and then it goes into some never never land that no one really knows where it is. The patient can't see what happens. So as a patient, I think, gosh. Did doctor Williams tell me I was supposed to follow-up? Are they gonna call me, or am I supposed to call them?
Michelle Skinner:Two weeks goes by. Now I'm frustrated, and doctor Williams didn't call. Well, doctor Williams didn't even get the referral, and so there was a loss in the technology there. So there's no visibility on any of those viewpoints as to where that referral is. So you can see where everyone thinks they're doing the right thing and they think that they're providing the best care.
Michelle Skinner:But without that visibility, we get into this push and pull mismatch that Carillion felt was really important to get everyone on the same page because it allows us to, acknowledge we're trying to solve the same problem, and we just didn't realize that we were coming from a different point of view.
Daniel Williams:Okay. So you presented to me earlier that the breakdown show up with referrals. We've touched on that. Scheduling, you even mentioned that by spreading out the schedule. The third one, help us understand this one, provider capacity.
Daniel Williams:If providers are at capacity, we suddenly figure out a way to correct $150,000,000,000 in leakage, and then suddenly there are a lot more patients to be seen. How are they able to do that? Help us understand that side of it.
Michelle Skinner:Yeah. I think there's the sort of obvious things, and then there's the less obvious things, which is kind of typical of any process kind of solution, which is one, you you do the obvious things first. There's actually big holes in the schedule that were being held for something that we didn't realize. We see this in the OR all the time. I held my block time because I'm afraid if I give it up, then I'm not gonna ever get it back again.
Michelle Skinner:We see the same thing in physician scheduling or provider scheduling is we see you know, there were certain it's usually appointment types that are held for certain reasons, and they're not getting filled. And so can we say with data that we could prove that over historical times that not just this week, not just last week, but for a long time, six months, a year, there is actually a greater need for follow-up than new patients or, you know, or a certain payer type or a certain type of of of patient refer patient type that you have in your clinic. And we don't just say it happened last week or last month, but that we could say that this happens over time and so it's worth actually changing because no provider wants to be changing their schedule routinely. Right? That we just don't want that to happen.
Michelle Skinner:So we wanna use that kind of time that overtime information. The other obvious one we're finding is that there are mismatches or lots of sort of behind the scenes spreadsheets and, like, sticky notes and all of these things that kind of say this, you know, this these providers take this type of patient because what happens in your medical staff office is maybe you're an internist, but you practice as a cardiologist. That does not always flow through the system as well. The other place that doesn't flow is in NPs and PAs where, you know, those get sort of grouped into one big group instead of distributed into those practices. So there are there's an ability to find some space in there.
Michelle Skinner:So we're looking for every little space that might be obvious or not obvious. Then you get you know, you have to start breaking things down, and this is one of the things teletracking does well. You do the big wide swaths of things that we get lots of progress, and then we start having to look at individual process. And we say, okay. In this practice, we're seeing that there are individual processes that just aren't working well.
Michelle Skinner:They're seeing less patients. Then we spend time in there, and we say, why is that happening? Because no organization wants to be providing less care or less access to the clients, patients that they serve. That's where our subject matter experts come in, and we do a deep dive within there to say, you know, within those small cycles, where are there places where we can squeeze a little bit more out? Then lastly, this lets the organization, so as a whole, Carilion as a whole, understand where do they really need more providers and where does that need to happen.
Michelle Skinner:Is it in their rural communities where they're leaking more patients? Is it in, you know, in the city? Do they need more orthopedist? Do they need only a certain type of orthopedist? By having that data down to the granular level, we can make better strategic decisions that we can solve some of these problems with towards the end.
Daniel Williams:Okay. Just a question or two left here. One of them, as you well know, in the healthcare world, people are stretched thin. For our practice leaders who are listening now, who are already stretched to the edges of their capacity, where do they start? Where would you just give them that these are the first steps you need to do?
Daniel Williams:Because they might already feel overwhelmed and just sometimes having your head down and just gritting your teeth and getting through what you have is better, at least in your mind, than starting something new, which might solve a lot of problems, but there is going to be that friction point. Where do they start?
Michelle Skinner:Yeah. So, you know, what we would recommend is if they're feeling those friction points, then that just to start to give, you know, to give us a call and we can talk through what those look like. That might be around referral losses or referral conversions. If they don't even know those numbers or, you know, 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. The other thing that we are really committed to doing is just understanding the problems that people are trying to solve.
Michelle Skinner:As I talked about in the beginning, this all started from an innovation workshop that we did with Corellian, and we're not trying to build bespoke solutions that you have one off. These are problems that we're hearing over and over and over. So these are scalable problems, but we will take your individual intricacies and build that into the system. So what we did was we spent about six to eight weeks prior to the innovation workshop. We got their data in a flat file that we don't need to feed, and we started putting that in the system.
Michelle Skinner:We listened to them about the problems that they're trying to solve. What are the outcomes you're trying to drive? Who are the stakeholders that are part of that? Who are you like, I mean, we heard from them, Daniel, things like, 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.
Michelle Skinner:And so we we you know, they were very clear with us about what their outcomes were. Then we spent two and a half days in a room together. We showed up with a prototype that was probably 60% of what they thought it would be from a technology perspective. We had a room full of people, 40 people. Everyone was represented there.
Michelle Skinner:Every key stakeholder is in that room. We do not speak on their behalf. They speak on their own behalf. We stay very laser focused on those outcomes. And then over two and a half days, our engineers build at their elbow and determine that next stage of what that prototype would look like that would allow us to go into pilot.
Michelle Skinner:At that point is the first time we even talk about pilot. If we can't get through two and a half days and feel like we're gonna build something that's gonna solve the problems you have, we all walk away and say we had a great couple of days and got a few laughs out of it, I'm sure. But, you know, it was just amazing to watch the practice leaders say, if I had this, I could shave eight plus, ten plus hours out of my week that would give me back some time and energy.
Daniel Williams:Okay. Alright. So if our listeners do wanna get in touch, what what's a good contact? Is it a website? Is it an email?
Daniel Williams:How would they reach out to you?
Michelle Skinner:Yep. Teletracking.com is our website, and there's a referral link that's on there that you could listen you could just click. The other piece is Michelle-Skinner@Teladracking.com. My phone number and email address are easy to find out there. You're welcome to use it.
Michelle Skinner:People do it all the time, and that's what I'm here for. And I'll get you to the right person.
Daniel Williams:You're brave, Michelle, to give out that information. I'm just kidding.
Michelle Skinner:Totally okay. Yeah.
Daniel Williams:Before I let you go, we were chatting, right before, and I was thinking, wow. You're from Pittsburgh. I was gonna ask you all these steelers questions, but then I find out
Michelle Skinner:Ask me Broncos questions.
Daniel Williams:I know. I find out, you know, you spent all this time in Colorado. And
Michelle Skinner:That's right.
Daniel Williams:Yeah. So tell us a little bit about that.
Michelle Skinner:Yeah.
Daniel Williams:You were mentioning earlier you really like to get out into nature and walk and hike with two dogs, I believe. Is that your jam?
Michelle Skinner:That's right. I have two wire haired pointing griffons. They're littermates. They're 10, Cookie and Lucius, yes, from the show Empire. Their personalities sort of match: Cookie is a menace, but so she and I grew up East Of Colorado Springs, moved into The Springs, which is where my parents still live.
Michelle Skinner:My son is in Castle Rock. I worked at almost every system there, and I opened Parker Adventist Hospital, which we talked about earlier. So, if anybody wants to tell me how long that's been around, I'll deny it. And, it was such a great time. It is such a great place for outdoor and health care, and Colorado is just a lovely place to be.
Daniel Williams:Alright. Well, you'll have to let me know when you're in town. We'll get a cup of coffee or something. Yeah. So
Michelle Skinner:Love it.
Daniel Williams:Michelle, it has been great chatting with you, everybody. We've been talking with Michelle Skinner, chief clinical executive at Teletracking. We will provide, that information, that contact information in our episode show notes. We'll also put that in an article we'll put together on this interview. Yeah.
Daniel Williams:So until then, thank you everyone for for being MGMA Podcast listeners.
