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One significant driver of the disjointed healthcare often observed in the United States is the traditional fee-for-service payment model which financially incentivizes the volume of care delivered over the quality and coordination of care. This problem is compounded by the wide, often unwarranted variation in healthcare charges that purchasers of health services encounter for substantially similar episodes of care. The last 10 years have seen many stakeholder organizations begin to experiment with novel financial payment models that strive to obviate many of the challenges inherent in customary quantity-based cost paradigms. The Patient Protection and Affordable Care Act has allowed many care delivery systems to partner with Medicare in episode-based payment programs such as the Bundled Payments for Care Improvement (BPCI) initiative, and in patient-based models such as the Medicare Shared Savings Program. Several employer purchasers of healthcare services are experimenting with innovative payment models to include episode-based bundled rate destination centers of excellence programs and the direct purchasing of accountable care organization services. The Geisinger Health System has over 10 years of experience with episode-based payment bundling coupled with the care delivery reengineering which is integral to its ProvenCare® program. Recent experiences at Geisinger have included participation in BPCI and also partnership with employer-purchasers of healthcare through the Pacific Business Group on Health (representing Walmart, Lowe's, and JetBlue Airways). As the shift towards value-focused care delivery and patient experience progresses forward, bundled payment arrangements and direct purchasing of healthcare will be critical financial drivers in effecting change.

Aggregation of huntingtin protein arising from expanded polyglutamine (polyQ) sequences in the exon-1 region of mutant huntingtin plays a central role in the pathogenesis of Huntington's disease. The huntingtin aggregation pathways are of therapeutic and diagnostic interest, but obtaining critical information from the physiologically relevant htt exon-1 (Httex1) protein has been challenging. Using biophysical techniques and an expression and purification protocol that generates clean, monomeric Httex1, we identified and mapped three distinct aggregation pathways: 1) unseeded in solution; 2) seeded in solution; and 3) membrane-mediated. In solution, aggregation proceeded in a highly stepwise manner, in which the individual domains (N terminus containing 17 amino acids (N17), polyQ, and proline-rich domain (PRD)) become ordered at very different rates. The aggregation was initiated by an early oligomer requiring a pathogenic, expanded Gln length and N17 α-helix formation. In the second phase, β-sheet forms in the polyQ. The slowest step is the final structural maturation of the PRD. This stepwise mechanism could be bypassed by seeding, which potently accelerated aggregation and was a prerequisite for prion-like spreading in vivo. Remarkably, membranes could catalyze aggregation even more potently than seeds, in a process that caused significant membrane damage. The N17 governed membrane-mediated aggregation by anchoring Httex1 to the membrane, enhancing local concentration and promoting collision via two-dimensional diffusion. Considering its central roles in solution and in membrane-mediated aggregation, the N17 represents an attractive target for inhibiting multiple pathways. Our approach should help evaluate such inhibitors and identify diagnostic markers for the misfolded forms identified here.

141 Background: Rising costs demand collaborations that lower expenditures and improve patients’ experiences and outcomes. We created a novel employer-provider collaboration to enhance value-based cancer care. Methods: We created an Employers Center of Excellence Network (ECEN) for the Pacific Business Group on Health (PBGH) employee groups. The ECEN provides competitive bundled rates that include travel for in-person patient consultation, advanced assessment and treatment by multidisciplinary case reviews, and ongoing specialized treatment care coordination and follow-up on a routine basis with the local care team.The ECEN development process included: focus groups, expert panel development, and a rigorous selection process. A Request for Proposal was publicized to all west coast NCI-designated comprehensive cancer centers. After interviews, selected sites were invited to submit a full proposal and a few were selected for a site visit.. In addition to overall cancer care excellence, a key criterion for acceptance was the demonstrated willingness and ability of the center to provide long-term support for the patient and home oncologist in the patient’s home market, so that the center’s expertise and support would be ongoing for the duration of the cancer treatment. Results: Of 8 sites that participated in team-assessment interviews, 4 were selected to submit a full proposal, 3 selected for in-person visits, and 1 selected to participate. In January 2019, we plan to implement a 6-month pilot with a PBGH employer group and the provider site to evaluate the ECEN's feasibility and effects on quality, patient-reported outcomes, and costs. Conclusions: Our novel employer-provider collaboration aims to improve cancer care delivery by providing planned and supported NCI-designated cancer care in close collaboration with the home oncologist. We plan to expand the ECEN development process across the US to develop a network of collaborating providers and employers to improve patient-centered, value-based cancer care.

Background Variability exists in the assessment of disease activity in rheumatoid arthritis (RA) patients that may affect quality of care. Objectives To measure the impact on quality of care of a Multi-Biomarker Disease Activity (MBDA) test that quantitatively assesses RA disease activity. Methods Board-certified rheumatologists without prior experience with the MBDA test (N = 81) were randomized into an intervention or control group as part of a longitudinal randomized-control study. All physicians were asked to care for three simulated RA patients, using Clinical Performance and Value (CPV™) vignettes, in a before and after design. CPV™ vignettes have been validated to assess the quality of clinical practice and identify variation in care. The vignettes covered all domains of a regular patient visit; scores were determined as a percentage of explicit predefined criteria completed. Three vignettes, representing typical RA cases, were administered each round. In the first round, no physician received information about the MBDA test. In the second round, only physicians in the intervention group were given educational materials about the test and hypothetical test results for each of the simulated patients. The outcome measures were the overall quality of care, disease assessment and treatment. Results The overall quality scores in the intervention group improved by 3 percent (p = 0.02) post-intervention compared with baseline, versus no change in the control group. The greatest benefit in the intervention group was to the quality of disease activity assessment and treatment decisions, which improved by 12 percent (p

96 Background: Although clinical pathways have the promise to improve the quality of care, they have had limited success changing practice or standardizing care. Moffitt Cancer Center (MCC) has > 40 pathways incorporating interdisciplinary care strategies linked to evidence and decision support tools. Methods: To improve compliance with pathways we used an innovative measure to quantify quality of care, CPV vignettes. CPV vignettes are validated, simulated clinical scenarios constructed so that adherence to pathways is clear-cut. Providers care for identical cases so there is no need for case mix adjustment. After completing each case, providers are given personalized feedback. Twelve breast cancer (ca) vignettes were developed by MCC breast medical oncologists and surgeons and QURE, a healthcare measurement company. The cases were developed using MCC pathways, other evidence and core issues such as diagnostic work-up. The vignettes were randomized at the department level and given to all MCC providers who care for breast ca patients. A total of 18 providers took 34 CPVs: 7 medical oncologists, 6 advanced practitioners and 5 surgeons. QURE-trained physician abstractors blinded to the CPV-taker’s identity scored each vignette and provided confidential feedback. Results: Total scores for providers averaged 55.4%, s.d. 12.5%, a typical score for a CPV baseline study. Adherence to pathways varied by area with the highest concordance for radiation and hormonal therapy and the lowest for management of axillary lymph nodes (see Table). Conclusions: Adherence to pathways varied among providers and by clinical domain. Ongoing efforts will evaluate the impact of serial CPV measurement on pathway adherence. Simulations simplified the task of determining pathway adherence making pathway compliance at the physician level a reasonable expectation and standardization at the group level scientifically rigorous and feasible. [Table: see text]

255 Background: Determining value requires detailed measurement of clinical services and associated costs. In the health reform era value demonstration presents a challenge for both providers and payors: providers, unable to demonstrate value, will be unable to attract payors or patients and expand market share; payors, unable to choose the right providers, will lose opportunities to lower costs and raise quality. Methods: In July 2012, the Moffitt Cancer Center (MCC) launched the mQure (MCC – Quality Understanding Research and Evidence) Initiative to (1) measure and improve clinical performance, (2) increase compliance to evidence-based/cost conscious cancer-care pathways, and (3) demonstrate value. We introduced Clinical Performance and Value (CPV) vignettes, a value measurement tool, to measure pathway adherence, determine diagnostic accuracy and appropriate use of diagnostic tools starting with breast and lung cancer. For selected performance items identified by the CPVs, we audited medical records directly. Results: Measurement revealed high value practices, for example, diagnostic accuracy, appropriate rates of biopsy and more accurate staging compared to other groups. Value determination led to one signed plus two pending payor partnerships to implement a shared savings contract, find ways to reduce utilization and explore creating payor-led networks. The focus on individual responsibility for adherence to evidence-based practices has had an unanticipated and seemingly paradoxical benefit of shifting the group to narrow practice variation thereby shifting providers to a more self-aware culture. An external benefit is that the value signal has led to discussions to form accountable care organization (ACO) networks for cancer care. Since mQure’s inception, MCC has created partnerships with 3 hospitals. Based on the breast cancer initiative alone, financial models indicate an estimated savings of up to $2 million annually that arise from higher quality, fewer unnecessary tests and improved pathway compliance. Conclusions: In just one year, the large scale mQure project has led to expanded provider partnerships, new quality-based arrangements with payors and the formation a specialty-ACO.

Background Assessment of disease activity in patients with RA includes patient and physician reported measures and differs by rheumatologist and practice, resulting in variability in treatment decisions and quality of care. Given multiple and often-expensive therapies with significant potential adverse effects, a more uniform assessment of disease activity may benefit treatment selection and patient care. Objectives The study estimated the impact of a novel Multi-Biomarker Disease Activity (MBDA) test, Vectra™ DA, on the overall quality of RA patient care and on the assessment of disease activity and treatment decisions. Methods This was a randomized controlled study. Eighty-one Board-certified rheumatologists were recruited and then randomized into an intervention and a control group. Quality was measured using Clinical Performance and Value (CPV™) vignettes, on-line simulations of clinical cases. CPV™ vignettes have been validated to assess the quality of clinical practice and identify inherent variation in care. To evaluate the impact of the MBDA test, three types of vignettes, representing typical RA cases, were used. Case type A comprised two RA cases that were insufficiently controlled and required the addition of or change in non-biologic DMARDs; Case type B comprised two cases inadequately controlled that required addition of combination or biologic DMARDs; and Case type C comprised two cases adequately treated with DMARDs but with a worsening co-morbidity. The open-ended responses were scored in five domains: taking a history, performing an examination, ordering laboratory and imaging tests, assessing disease activity and prescribing treatment. Scores were the percentage of physician answers that matched explicit evidence-based criteria and expert opinion. Rheumatologists randomly completed two of each of the three case types, one at baseline and one after the intervention, for a total of six vignettes. Before completing the second round of vignettes, the intervention group was given educational materials about the MBDA test. The intervention group also received simulated MBDA test results as part of their second round cases. The outcome measures were the overall quality of care, the quality of disease assessment and treatment and the secondary outcome measures: appropriate use of biologic and/or combination DMARDs, laboratory and imaging tests, and overall resource use. Results The overall quality scores in the intervention group improved by 3% (p=0.02) post-intervention compared with baseline, versus no change in the control group. The greatest benefit in the intervention group was to the quality of disease activity assessment and treatment, which improved by 12% (p Conclusions In this study, use of the MBDA test in simulated cases improved the overall quality and the assessment of disease activity and subsequent treatment decisions for RA patients. New assessment technologies appear to be an effective means for improving quality of care in RA and should prove useful for rheumatologists in daily practice. Disclosure of Interest J. Peabody Consultant for: Crescendo Bioscience, V. Strand: None Declared, R. Shimkhada: None Declared, D. Chernoff Employee of: Crescendo Bioscience, R. Lee: None Declared