The top executive at the country’s
pre-eminent health care quality organization is being paid hundreds of
thousands of dollars by two large medical companies that have a stake in the
group’s work.
The payments to Dr. Christine Cassel raise new
conflict-of-interest concerns at the National Quality Forum, which endorses benchmarks that Medicare
uses to compensate hospitals based on performance.
As ProPublica
recently reported, the Quality Forum is reviewing its
conflict-of-interest policies after being stung by allegations that the former
co-chair of one of its endorsement committees had accepted kickbacks to help a
drugmaker win favorable treatment.
Cassel received about $235,000 in compensation
and stock last year as a board member for
Premier Inc., a North Carolina company that says it provides group
purchasing and performance improvement consulting for an alliance of
2,900 hospitals and thousands of nursing facilities and other
providers.
Cassel also was paid $189,000 as a board member
for the Kaiser Foundation Health Plans and Hospitals in 2012, Quality Forum
officials confirmed to ProPublica. Kaiser’s tax forms are not available for
2013, but they show that in 2010 and 2011 Cassel received a total of $357,125.
Quality
Forum officials would not say how much Cassel receives to run the Quality
Forum, but her predecessor was paid about $525,000
in salary and other compensation in 2011, tax documents show.
The group's
chairwoman, Helen Darling, said in an email that the board was “fully aware” of
Cassel’s outside compensation when she was hired in December 2012.
Darling, president of the National
Business Group on Health, initially agreed to an interview but did not
respond to follow-up contacts.
Spokeswoman Ann Greiner said the board got a
legal opinion and discussed it in depth before agreeing that Cassel could recuse herself
“where her outside board service would be construed as an actual or perceived
conflict of interest.” So far that hasn’t happened, Greiner said.
Two ethics experts interviewed by ProPublica said
Cassel’s relationships with Kaiser and Premier present obvious conflicts given
the Quality Forum’s broad involvement in health care.
The Quality Forum maintains a clearinghouse of
more than 700 quality measures — covering everything from tracking hospital
readmissions to setting information technology standards — that are established
by expert committees and widely adopted by U.S. hospitals and other providers.
The ethics experts said they were uncertain how
Cassel could recuse herself to anything related to Kaiser and Premier and still
do her job.
“Would
that mean every time somebody said the word ‘hospital’ she would have to say,
‘I can’t be in this conversation?’” said Eric Campbell,
a Harvard School of Medicine professor who has published extensively on
conflicts of interest.
“Conflict of interest is as much an appearance as
it is an effect,” added Sheldon Krimsky,
a medical ethics expert at Tufts University. He called Cassel’s conflicts
“absolutely egregious.”
Campbell and Krimsky said the cleanest way to
eliminate potential conflicts would be for Cassel to resign from the outside
boards. Campbell also said Cassel
could continue serve but without pay, which would at least remove possible
concerns about the influence of money.
No one has suggested that Cassel has used her
post to benefit Kaiser or Premier. But the disclosure of her outside compensation comes as quality
is increasingly becoming a bottom-line issue for the industry.
Pay-For-Peformance Shift
Not so long ago, hospitals and other medical
providers were paid the same fees by Medicare and other payers based on
services they provided, regardless of whether outcomes were good or bad for
patients. But as medical errors continued to cause harm and
drive up costs, the federal government and others began experimenting
with ways to link payments to performance.
That’s where the Quality Forum’s endorsements
come in.
Established in 1999, the Washington, D.C.,
nonprofit invites hundreds of participants from across the health care spectrum
— insurers, practitioners, researchers, health care systems and consumer groups
— to become members and help
pick the best quality benchmarks for endorsement by consensus.
Kaiser and Premier are among the group’s 375
dues-paying member organizations.
Much of the Quality Forum’s work has been behind
the scenes. But that
changed last month when allegations arose that questioned the group’s
vulnerability to commercial influence.
In settling federal whistleblower lawsuit, the Justice
Department accused a well-known patient safety leader, Dr. Chuck Denham, of accepting
$11.6 million in kickbacks from a drug company while he co-chaired a Quality
Forum committee to endorse patient safety measures.
Denham said he had legitimate contracts with the
drug company, but the
payments were not disclosed to the Quality Forum. ProPublica found
that the group’s final 2010 Safe Practices report endorsed the company’s
surgical antiseptic, a decision that other committee members said was
unintended.
In response to the Denham case, the Quality Forum
launched a review of the committee’s work and the organization’s
conflict-of-interest policies. The review is expected to be complete by Feb.
25.
The Quality Forum’s policy for committee members
defines a “conflict of interest” as any financial or other interest that could
actually, or be perceived to, impede a person’s objectivity or “create an
unfair competitive advantage for you or an organization associated with you.”
Cassel’s outside board positions create
conflicts, according to ethics experts, because Kaiser and Premier could be affected
by Quality Forum endorsements.
Kaiser, an
integrated system that’s been touted as modeling the future of health care, had
hospital revenue of $18 billion and health insurance plan revenue of $37
billion in 2011. The organization
operates in eight states and the District of Columbia at 37
hospitals and hundreds of medical buildings.
In an email, Kaiser spokesman John Nelson said
the health system was “incredibly fortunate” to have Cassel on its board for
the past decade and that “any organization smart enough to engage with her will
receive wise counsel and honorable service."
Premier
reported revenues of $869 million in the fiscal year ending last June. It spent
more than $1 million on lobbying
in 2013, according to OpenSecrets.org. In August and November, the company
urged members of Congress to instruct Medicare to run any quality
measures through the Quality Forum.
The company’s business involves group purchasing
and a consulting arm that uses data analysis to help providers perform better
on various quality metrics. In October, a measure sponsored by Premier to track
hospital care by the average length of stay was up for
renewal by the Quality Forum.
Blair Childs, Premier’s spokesman, said the
company is still evaluating the average length of stay metric and that it could
be submitted for consideration as a Medicare pay-for-performance measure.
Childs said Cassel’s role on the Premier board
doesn’t pose any conflict of interest, and that her relationship with Premier
was vetted carefully by the Quality Forum’s board. Cassel was a good addition
to the Premier board because of her commitment to improved care and lower
costs, he said.
Defining the Strike Zone
Harvard’s Campbell said Cassel’s dual roles aren’t necessarily a
problem if disclosed and carefully managed. But he offered a baseball
analogy to show why they present a risk for the Quality Forum.
Imagine, Campbell said, training umpires to call
balls and strikes — except the person doing the training is also being paid by
the New York Yankees, and the strike zone favors the swing of Derek Jeter.
Campbell said he wasn’t being judgmental about
Cassel’s conflicts of interest. But the Quality Forum is paid taxpayer dollars
by Medicare to perform a
public service in a quasi-regulatory role, he said. When the Quality
Forum’s leader is paid hundreds of thousands of dollars by hospital companies,
Campbell said, it creates a potential incentive to shape the rules in their
favor.
Krimsky, the Tufts ethics expert, was more
critical of the arrangement. He said it’s not enough for Cassel to recuse
herself from decisions or discussions related directly to Kaiser and Premier.
She still could be involved
in choosing who sits at the table to have discussions or make decisions,
he said.
“When there’s a conflict of interest in the
management group, that’s a serious problem,” Krimsky said.
Dr. Peter Pronovost, a well-known patient safety
leader from Johns Hopkins Medicine, said he did not see how Cassel’s outside
board roles would present a direct advantage for Kaiser and Premier. But he
said conflicts of interest in the world of quality improvement are often
indirect, and the industry hasn’t clearly defined how to navigate them.
“That doesn’t mean (the conflicts) are not real,”
Pronovost said. “But they’re less risky. The field does need to articulate the
boundaries for these indirect conflicts.”
Although
Cassel’s relationships were known to the board, it does not appear that they
were widely shared with the Quality Forum’s membership. Cassel’s
biography on the Quality Forum website mentions about a dozen other
affiliations but not Kaiser and Premier.
Some who are active on Quality Forum committees
also said they were unaware.
Leah Binder, president and CEO of The Leapfrog
Group, a coalition of employers that advocates for quality and transparency in
health care, said she respects Cassel but would have liked to have known about
her outside board roles.
“Maybe we need to understand from Chris how she
recuses herself from any kind of decision making that might have an impact on
those two organizations,” Binder said. “I think she would owe us an explanation
of that.”
Lisa McGiffert, director of the Consumers Union
Safe Patient Project, sits on a committee that’s recommending possible
pay-for-performance metrics to Medicare. Recently a debate about a proposed
hospital readmission measure pitted the consumer-minded members, who favored
it, against the providers, who were against it. In the end, the consumer side
didn’t get its way, she said.
“All of this is about relationships, and (Cassel)
has a relationship with that hospital system,” she said. “That relationship
means that Kaiser might weigh in with her on those hospital measures.”
McGiffert said all Quality Forum
conflict-of-interest disclosure forms should be posted online so anyone can
easily see various allegiances.
Rosemary Gibson, an author and senior adviser to
The Hastings Center, a research group dedicated to bioethics in the public
interest, said she wasn’t surprised at Cassel’s outside compensation. So much
money permeates decision-making in Washington, she said, that participants have
become oblivious.
“The
insiders don’t see it,” Gibson said. “It’s like a fish in water.”
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Comment: Joleen Chambers
At the FDA, trained patient
representatives are eliminated because OSHI (Office of Special Health Issues)
must 'vet' the participants in medical device advisory panels. Harmed patients
are often not selected because of their 'bias' (real-life experience!), but
industry insider financial conflicts-of-interest are not an issue that
interferes with their full participation. When the established standard is
engaged patient advocates having access to define and populate panel
discussions at FDA, NQF, IOM, TMIT, PCORI, (etc.) and have equal time at the
microphone on webinars with all compensation (and non-compensation) listed in
the program, the shame of the disparity will highlight the good medical leaders
from the profiteers. For me, a bell weather will be seeing Regina Holliday
properly compensated for her leadership and accomplishments! Google her.
