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The next chapter of population health involves specialists. Here’s where to start. (Part 1 of 3)

Introduction to the series

A lot of population health management has focused on primary care, but the industry hasn’t made significant strides in specialty care—even though it drives the bulk of health care spending.

That’s because involving specialists in value-based care is hard. Not only is specialty care a more diverse space, but it's also more tied to traditional fee-for-service reimbursement and episodic care delivery. We’ve previously discussed how engaging specialists in accurate HCC capture is a ‘no-regrets’ opportunity in this hybrid financial incentive state—but what ambitious, yet feasible behavior changes remain for specialists?

In this series, we discuss three near-term strategies to engage specialists in improving population health—even with significant fee-for-service reimbursement. These strategies aim to reduce low-value referrals to specialty care and ensure patients receive the right level of care at the right time.

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This expert insight series is sponsored by Episource. Advisory Board experts wrote the post, conducting the underlying research independently and objectively.

The future of value-based care

Medicare and Medicaid risk is progressing (slowly) — but commercial risk will determine whether the industry tips toward a new cost and quality standard.


The strategy: Evidence-based referral considerations

Not every referral is a good referral. Low-value referrals waste specialist capacity and inflate health care costs. Establishing referral considerations are a low-cost way to prevent low-value referrals.

What we mean: Evidence-based referral considerations aim to inform clinical decision-making, such as a best practice advisory in the EHR or a short list of guiding questions. These help avoid care delays and misuse of specialist time.

What we don’t mean: Note we’re not saying referral protocols here. That’s intentional. Multiple executives told us protocols can be too broad, too specific, not updated, hard to enforce, and doctors just don’t have time. It’s impossible to capture the level of patient diversity and complexity to direct appropriate clinical triage in every situation.


Three imperatives to create considerations that reduce low-value referrals
  • 1. Prioritize common, low-acuity conditions treated in specialties with long wait times
  • 2. Preserve PCP autonomy
  • 3. Create opportunities for PCPs and specialists to collaborate

Next up

Part two of our series examines how specialists should be accessible to PCPs and other referring physicians via e-consult.


About the sponsor

Episource reinvents risk adjustment program management across healthcare organizations with an integrated platform. We empower the most recognizable names in healthcare with end-to-end risk adjustment solutions. From risk adjustment analytics, retrospective chart reviews, in-home assessments, encounter submissions and quality reporting, Episource simplifies healthcare with elegance and innovation.

Learn more about Episource

This expert insight series is sponsored by Episource, an Advisory Board member organization. Representatives of Episource helped select the topics and issues addressed. Advisory Board experts wrote the post, maintained final editorial approval, and conducted the underlying research independently and objectively. Advisory Board does not endorse any company, organization, product or brand mentioned herein.

View Advisory Board's Editorial Guidelines


David G. Li et al, “Evaluation of Point-of-Care Decision Support for Adult Acne Treatment by Primary Care Clinicians,” JAMA dermatology 156, no. 5 (2020): 538-544, doi:10.1001/jamadermatol.2020.0135.

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