Dissonance in the Sole Quality Measure for Outpatient Chemotherapy, OP-35

BACKGROUNDCancer is fast-becoming one of the most expensive chronic conditions in the United States, and hospital care accounts for nearly a quarter of this spending. 1Unplanned emergency department (ED) visits and inpatient admissions (ADM) can derail treatment schedules, compromise outcomes, and add substantial out-of-pocket cost.Acknowledging this reality, the Center for Medicare and Medicaid Services (CMS) developed the Outpatient Chemotherapy Quality Measure (OP-35) to measure potentially preventable acute hospital visits for patients receiving chemotherapy. 2This metric was first incorporated into Medicare's Hospital Outpatient Quality Reporting (OQR) Program, is attached to a penalty of up to 2% on Medicare reimbursement, and puts forth an important hypothesis: can performance measurement reshape the role of hospital care in cancer care delivery?Although the measure has been applied since 2018, and its rapid uptake underscores an important clinical need, we notice many problems with the measure specification that hinders its goal of reducing avoidable hospital care.OP-35 is a claims-based measure that aggregates up to three-hundred discharge diagnosis codes representing 10 potentially avoidable conditions (anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, and sepsis).It separately tallies ED visits and ADM for these conditions when they occur within 30 days of outpatient chemotherapy administration. 3It requires a full year of claims to accrue, plus additional time for compilation, so it was first reported in 2020 for performance year 2018.Adapting from OP-35, other similar quality measures have been adopted for Prospective Payment System (PPS)-Exempt Cancer Hospitals (PCH): PCH-30 (for ADM) and PCH-31 (for ED) and into CMS' 2023 value-based payment program, the Enhancing Oncology Model (EOM). 4his experience should serve as a cautionary tale.While OP-35 attempts to risk-adjust based on certain clinical factors, it also does not adjust for social risk factors.OP-35 also contains other cognitively dissonant facets that deserve more attention.