Commercial risk will be a critical catalyst of progress – it’s complicated, but is it possible? We think so.

Blog Post

CMS' chemotherapy measure: What cancer programs need to know

December 3, 2019

    We've been getting a lot of questions about OP-35, the first chemo-specific measure in the Hospital Outpatient Quality Reporting Program (OQR)—questions ranging from how it's calculated, to the impact it will (or will not) have on hospital reimbursement, to how programs can leverage this data. Check out our four key takeaways for every cancer program.

    Dec. 12 webinar: How Medicare reimbursement for cancer services will change in 2020

    OP-35 begins its official inclusion in the OQR Program in calendar year (CY) 2020. OP-35 looks at cancer patient ED visits and inpatient admissions for 10 potentially preventable conditions within 30 days of receiving chemo. Here are our four takeaways for every cancer program:

    1. CMS made changes to initially proposed OP-35 methodology based on 2017 national dry run;

    2. Performance on OP-35 has no direct financial penalty, but it’s not inconsequential;

    3. OP-35 gives hospitals access to a wealth of valuable information; and

    4. Minimal differences identified in rates of inpatient admissions and ED visits for various hospital and patient populations.

    Click each link above to learn more.

    1. CMS made changes to initially proposed OP-35 methodology based on 2017 national dry run

    In 2017, CMS conducted a national dry run of the measure to identify opportunities to refine it before implementation. The agency used one year of performance data—from October 1, 2015 through September 30, 2016—to produce national and facility-specific reports of hospital outpatient department (HOPD) and PPS-exempt cancer hospitals (PCH) participants' performance using the initially proposed parameters. Based on the results and feedback from stakeholders, CMS made the following changes to the measure for the CY 2018 performance period affecting CY 2020 Medicare payment determination:

    • Patient population
      • Excluded patients receiving chemo for autoimmune diseases;

      • Excluded patients with leukemia in remission (in addition to patients with active leukemia initially excluded); and

      • Excluded patients with planned or anticipated hospital visits.
    • Measure code set
      • Removed 17 diagnosis codes (10 for pain, five for sepsis, two for pneumonia) that were too broad or unlikely to affect chemo patients;

      • Added one diagnosis code related to drug-induced diarrhea to list of codes that qualify for measure (numerator of measure/outcome); and

      • Added eight chemo CPT codes to the list of codes that defines episodes qualifying patients to be included in denominator of measure (cohort).
    • Risk-adjustment model
      • Added receipt of concurrent radiation therapy as a risk factor.

    2. Performance on OP-35 has no direct financial penalty, but it's not inconsequential

    Data from CY 2018 will impact CY 2020 payment determination, but there is no direct financial penalty tied to your hospital's performance on OP-35. The Hospital OQR Program is a pay-for-reporting program, meaning your hospital will only be financially penalized (fixed 2% reduction in payment for the next year) if you don't:

    1. Collect and submit the required data for this measure or any of the other measures included in the program; or

    2. Meet other administrative, validation, and publication requirements associated with the OQR Program.

    The good news is that because OP-35 is a claims-based measure, you don't actually need to report any data specifically for this measure.

    However, keep in mind that CMS will publish all participating hospitals' performance on OP-35 on the Hospital Compare website. This means that patients, payers, and referring providers can see your facility's ED and hospital admission rates for cancer patients. As most stakeholders now realize the cost and quality implications of this measure, your performance could influence how they judge your quality and value. CMS will make 2018 performance data public in January 2020 or shortly thereafter.

    3. OP-35 gives hospitals access to a wealth of valuable information

    While quality reporting is no one's favorite pastime, this measure has already produced a great amount of national and facility-specific data from CMS. For example, the data from the 2017 dry run allows you to gauge where your facility stands compared with national rates. All facilities have access to their 2017 facility-specific report, and although the methodology has changed slightly, that data can provide insight into whether certain subgroups of patients have more frequent ED visits or inpatient admissions.

    Additionally, hospitals will have access to two types of performance reports for CY 2018:

    • Claims Detail Reports: These include patient-level data for the chemotherapy measure, but no calculations, and are meant to help facilities catch and correct coding errors and give facilities an opportunity to improve the quality of care provided to chemo patients before final measure calculation and public reporting of measure results; and

    • Facility-Specific Report: This includes performance results, state and national results, detailed patient-level data used to calculate measure results, and a summary of facility case mix.

    Access the data on CMS' QualityNet website.

    4. Minimal differences identified in rates of inpatient admissions and ED visits for various hospital and patient populations

    CMS re-ran the dry run analyses it conducted on the October 1, 2015 through September 30, 2016 data using the updated measure criteria. Here's what the agency found from the national data:

    • HOPDs (n=3,562)
      • National inpatient admission rate: 12.6% (down from 12.9% before measure changes)

      • National ED rate: 5.9% (down from 6.1% before measure changes)
    • PPS-exempt cancer hospitals (n=11)
      • National inpatient admission rate: 14% (down from 14.6% before measure changes)

      • National ED rate: 6.2% (down from 6.5% before measure changes)

    We also ran our own analyses using Medicare SAF inpatient and outpatient data for all hospitals (including PPS-exempt and critical access hospitals) from October 2015-September 2016 to look at differences in overall and per patient inpatient admissions and ED utilization by hospital type and patient characteristics. We found that inpatient admission rates vary slightly by hospital size, but neither inpatient admission nor ED visit rates vary by hospital teaching status, community type, or the percentage of a hospital’s patients who are low income. Our analyses also revealed that overall inpatient admission and ED utilization rates vary by patient tumor site, age, and race, but not by sex. The average numbers of inpatient admissions and ED visits per patient only vary by tumor site and age.

    Reach out to us to see if your hospital has enough cases for us to run a custom analysis of inpatient and ED utilization at your organization, so you can identify and focus your limited resources on supporting cancer patients who are most at risk.


    Have a Question?


    Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory.