title: Specializing in accountability: strategies to prepare a subspecialty workforce for care delivery redesign.
abstract: OBJECTIVE
  Accountable care organizations (ACOs) emphasize cost-effectiveness, rewarding health care systems that provide the highest-quality care delivered by the most cost-efficient providers. Transitioning to an ACO model introduces distinct challenges for specialist physicians within academic health centers. As skin diseases constitute a large number of visits to primary care providers and specialists and place a significant financial burden on the health care system, the authors sought to identify specialist-driven strategies for cost-effective, patient-centered care delivery in dermatology.
  
  
  METHODS
  As part of the Massachusetts General Hospital's transition to an ACO, the Department of Dermatology in 2012 employed a team-based strategy to identify measures aimed at curbing the rate of rise in per-patient medical expense. Their approach may represent a methodological framework that translates to other specialist workforces.
  
  
  RESULTS
  The authors identified four action areas: (1) rational, cost-conscious prescribing within therapeutic classes; (2) enhanced management of urgent access and follow-up appointment scheduling; (3) procedure standardization; and (4) interpractitioner variability assessment. They describe the practices implemented in these action areas, which include a mix of changes in both clinical decision making and operational practice and are aimed at improving overall quality and value of care delivery. They also offer recommendations for other specialty departments
  
  
  CONCLUSIONS
  Involving specialist physicians in care delivery redesign efforts provides unique insights to enhance quality, cost-effectiveness, and efficiency of care delivery. With increasing emphasis on ACO models, further specialist-driven strategies for ensuring patient-centered delivery warrant development alongside other delivery reform efforts.
authors.affiliation: Dr. Nambudiri is clinical fellow in medicine, Departments of Internal Medicine and Dermatology, Harvard Medical School, Boston, Massachusetts. Dr. Sober is professor of dermatology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts. Dr. Kimball is professor of dermatology, Harvard Medical School, vice chair, Department of Dermatology, Massachusetts General Hospital, and senior vice president, Practice Improvement, Massachusetts General Physicians Organization, Boston, Massachusetts.
authors.forename: Vinod E
authors.initials: VE
authors.lastname: Nambudiri
authors.forename: Arthur J
authors.initials: AJ
authors.lastname: Sober
authors.forename: Alexa B
authors.initials: AB
authors.lastname: Kimball
mesh_terms: D060866:Accountable Care Organizations / Q000458:organization & administration*; D003362:Cost-Benefit Analysis; D003880:Dermatology / Q000458:organization & administration*; D006769:Hospitals, General / Q000458:organization & administration*; D008404:Massachusetts; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration; D018802:Patient-Centered Care / Q000458:organization & administration; D015397:Program Evaluation; D011787:Quality of Health Care