Payments to CEO raise new conflicts at top health quality group

The National Quality Forum says it approved allowing Dr Christine Cassel collect six-figure compensation to serve on the boards of health care companies affected by the group's work


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.

Cassel, who declined to be interviewed, took over as chief executive officer last summer after a decade as president and CEO of the American Board of Internal Medicine. She also sits on the President’s Council of Advisors on Science and Technology and has been active with the Institute of Medicine.

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.

In 2009, Medicare awarded a $40 million contract to the Quality Forum to recommend measures it could adopt. President Obama’s health care reform law accelerated the move to pay-for-performance. Medicare already has begun penalizing and rewarding hospitals based on readmission rates, mortality and patient satisfaction measures. By 2017, it’s expected that 9 percent of Medicare payments will be based on performance.

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.

Kaiser spent $1.6 million lobbying Congress, the Department of Health & Human Services and other agencies last year, according to the website A Kaiser executive, Jack Cochran, sits on the Quality Forum’s board.

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 In August and November, the company urged members of Congress to instruct Medicare to run any quality measures through the Quality Forum.

Premier featured Cassel’s status as a board member and future top executive of the Quality Forum in documents last May describing its initial public stock offering. In September Cassel acquired 3,704 shares of Premier stock that were then worth about $100,000.

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.”


ProPublica is investigating health care quality and welcomes your input. Medical providers – help us by completing a brief Provider Questionnaire. Patients can complete ProPublica’s Patient Harm Questionnaire.




Domestic savings rate is stabilising in India, says Nomura

According to Nomura, savings rate in India can be improved if fiscal consolidation continues and if inflation moderates, which will pave the way for higher income growth over time

There is stabilisation in the domestic savings rate in India and it is a positive, says Nomura in a research note. Looking ahead, the savings rate can be improved if fiscal consolidation continues and if inflation moderates, paving the way for higher income growth over time. Only then will India be able to finance its investment needs domestically without depending excessively on foreign capital, it added.


According to the national income identity, the current account balance is the gap between domestic savings and domestic investments. The deterioration in India's current account deficit over the last four years can be explained, says Nomura, by the sharper fall in domestic savings (36.8% of GDP in FY08 to 30.1% in FY13) relative to investments (38.1% to 34.8%). This is shown in the chart below:



During FY14, Nomura expects the current account deficit (CAD) to moderate to less than 2% of GDP from 4.7% in FY13. Advanced GDP estimates suggest that investments have continued to moderate, partly explaining the narrower current account deficit, but a stabilisation in the savings rate has also played a role, argues Nomura. The savings rate has stabilised due to ongoing fiscal consolidation (i.e., better public savings), concludes the research note.



‘The same divinity dwells in the entire creation’

Swami Vivekananda spurred the old NRIs into engaging in any kind of business like that of selling Indian goods in the United States rather than cajole the white masters to provide them with menial jobs

Books Reviewed:            

  1. A Monk from Bombay - Swami Vivekananda’s historic voyage from Mumbai to Chicago by Radha Viswanathan & Sudheendra Kulkarni, 62 pages and
  2. Swami Vivekananda in Mumbai and Maharashtra by Sudheendra Kulkarni, 180 pages.

Twin publications of the Observer Research Foundation Mumbai. No price mentioned.


These two slim books are put out to mark the 120th anniversary of Swami Vivekananda’s iconic voyage that commenced from here from Bombay on 31 May 1893 to participate in the Parliament of World Religions that took place in Chicago in September of that year.  Besides the year 2013 also happens to be the Swami’s 150th birth anniversary for he was born on 12 January 1863.


 The present day Mumbaikars and the powers that be need to be awakened to this great man’s presence in Bombay four times in the course of his short lifetime – first and second visits in April and June of 1892, next in the in July 1893 to take the ship to Chicago and last in 1900 after his return.


Mumbai in particular as also Maharashtra have done absolutely nothing either to remember Swami Vivekananda to perpetuate his historic stay not only at this metropolis but in the Maharashtra’s hinterland at Pune, Mahabaleshwar and Kolhapur. The books recount that in Belgaum the small cottage where he stayed for nine days has been preserved as a monument within the main complex of the Ramakrishna Math.  In Goa, where he deepened his understanding of Christianity after intensive interaction with Catholic scholars and priests, the Archaeological Survey of India has undertaken the repair, restoration and conservation of the four hundred year old Catholic Seminary at Raitul/Rachol where he spent three days in its  the various libraries days 15th-17th October, 1892 studying history of Christianity.  Later, in a letter he praised Panjim for its “vibrancy and cleanliness, most Christians here are literate whereas a majority of the Hindus are illiterate.”


The authors very rightly go to point out that we “are proverbially poor in preserving history and historical knowledge. Mumbai itself has forgotten its proud association with the life and legacy of Swami Vivekananda,  one of the greatest spiritual lights and social reformer produced by modern India, a  remarkable Indian who was the first to put Indian  on the world map.”


Swami Vivekananda had reached Bombay in the last week of July 1892 following arduous journeys across the length and breadth of north India mostly on foot.  Because of his deep interest in rock-cut, while in Bombay he visited the hundred plus caves at Kanheri considered to be the largest of the Buddhist caves in western India.  The deep impression that they made on him stirred him deeply, he later spoke at length to his disciples at the Thousand Island Park, USA. He told them that he had great dreams – “One day, we shall have a beautiful place in India with ocean on three sides. There  be small caves to accommodate two each and between each cave will be a pool of water for bathing and pipes carrying drinking water will run up to each one. There will be a great hall with carved pillars for the Assembly Hall and a more elaborate Chaitya Hall for worship. Oh! It will be a luxury.”


 “What can one say about the extreme apathy of the Maharashtra government that it has not deemed it fit to put up even a simple plaque at Kanheri Caves in the famous Borivili National Park which Swami Vivekananda visited in 1893? The beauty of the forests there and the meditative ambience of the ancient Buddhist caves so mesmerised him to express his desire to establish his spiritual monastery there after his return from America.”


 No thought has ever been given to his extremely eloquent and strong views on Shivaji –“It is a pity that in our schools, history of India written by foreigners is taught to our boys. The foreign writers of the Mahratta history can never shake off their bias nor understand the real character and greatness and the inner motives of the actions of Shivaji. There are many Mahratta bhakars or chroniclers who have written about him, but true to their ancient puranic ideal, looked upon him as a God born to relieve his devotees from the oppressions of Mahomedan fanaticism and re-establish Dharma. If our young men with patriot feelings for history of their motherland were to make researches I in finding out and translating these manuscripts, much truer light may be thrown on the greatness of the doings of Shivaji to make valuable addition to our knowledge of the real history of India.”      


Also little has been done to  commemorate the memories of Swamiji’s encounters 1892 and 1901 at Poona with Lokmanya Bal Gangadhar Tilak, then a fiery journalist editor of newspaper Kesari, later to be known as the greatest leader of India’s freedom movement long before the Gandhian era, described by the British as the Father of Indian Unrest for his Swaraj is my birthright and I will have it;  dramatist, novelist, poet and historian Na. Chi Kelkar, Hari Narayan Apte a towering  literary figure, the renowned social reformer, author and one of the founders of the Indian National Congress Justice Mahadev Govind Ranade, author Prof. Mahadev Gole


 The Swami met with Jamshedji Tata a pioneer of India’s swadeshi industrialisation when both boarded the same ship Empress of India at Yokohama in Japan to sail to Vancouver at Canada.  In retrospect is was not just a chance meeting but it carried the force what psychologist Jung terms  ‘synchronicity’ or ‘the experience of two or more causally unrelated events being observed as happening together’.  The great visionary Jamshedji Nussewanji Tata saw in him a spiritual leader that modern India. The Swami blessed him by saying “How wonderful it would be if we combine the scientific and technological achievements of the West with the asceticism and humanism of India!” He shared with the Swami his plans to build steel industry to accelerate India’s industrial development.  The book reproduces the letter to “Dear Swami Vivekananda” that Jamshedji wrote on 2d November 1898.


On June 4 June 1891, he reached Khetri where he spent five months with Raja Ajit Singh who was deeply committed to Indian philosophy and culture This Raja was the first to give him the name “Vivekananda”, before that he had assumed different names during his nation wide travels.  To protect him from the heat of Rajasthan, the Raja gave him his distinctive sartorial look of wearing the turban in Rajasthani style making it a part of his attire thereafter. It was here that Vivekananda learnt a lesson in Advaita philosophy from a dancing girl.  He had initially declined an invitation to a song and dance performance from his host, the Raja, saying that it would be improper and forbidden for a sanyasi to be present at such events.  The girl, who had heard a lot about him, on hearing of this comment expressed her sorrow by rendering melodiously   the famous Surdas song – “O Lord, look not upon my evil qualities! Thy name O Lord is same-sightedness. One piece of iron is in the image in the temple and another is the knife in the hand of the butcher; but when they touch the philosopher’s stone, both alike turn to gold… One drop of water is the sacred Yamuna another is foul in the ditch by the roadside; but when they fall into the Ganga,   both alike become holy. Thy name, O Lord, is same-sightedness.” 


 This completely overwhelmed the Swami to say that the same Divinity   dwells in the high and low, the rich and the poor in the entire creation. After taking a seat in the audience with the Raja, he admitted–“That incident removed the scales from my eyes. Seeing that all are indeed the manifestations of the One, I could no longer condemn anybody.”  The most significant reason that Khetri occupies in his life is that Raja Ajit Singh became the principal sponsor for his visit to Chicago. In a letter of 11 October 1897 to Munshi Jagmohanlal, he wrote “-Between the Raja of Khetri and I, there are closest ties of love. Certain men are born in certain periods to perform certain actions in combination. Ajit Singh and I are two such souls born to help each other in a big work for the good of mankind...We are as supplement and complement.”   Ajit Singh even got the lower berth voyage ticket the Swami had bought for himself for a first class ticket and also arranged to constantly send dollars to the Swami keeping it a secret and not wanting to publicise it in any way.


In August 1892 while at Baroda Swami Vivekananda met with the renowned painter Raja Ravi Verma at his studio.  When he pointed out certain flaws in his paintings, the painter responded that none had detected them until then adding “You must have been an artist at some point in your life.” The response was –“By the grace of God and my Guru, Saraswati (the Goddess of Knowledge) has been generous towards me.” With his deep understanding of the art of painting in the course of discussions on the New Style of Indian Art,   when some one questioned the shortcoming in the paintings of what was then thought of as the greatest living artist, his host during his stay at Bombay    corrected “The Swamiji is not only a spiritual scholar but an expert in music and other arts.” Later   the Swami himself wrote in his book East and West   that Ravi Verma’s paintings had traces of imitation of western art. He urged Indian artists to develop their own indigenous art traditions in the modern context.


He also travelled to Mysore, Cochin and Madras in the five years 1888-1893 before he boarded from the Bombay Port the SS Peninsular at the age of 29 years on his voyage to Chicago.  He journeyed to Europe between 1895 and 1896 which included three visits to England.


The books provide, perhaps for the first time, a wealth of information that is unknown so far coming as it does out of the many of his intimate glimpses and profound thoughts from the pens of those with whom stayed and talked at length on one-on-one terms during   the course of his many travels from Alwar, Jaipur, Ajmer, Khetri, Kathiawar, Ahmedabad, Junagadh, Porbunder, Dwarka, Palitana, Baroda, Bombay, Poona, Kolhapur. They  goon to add in an entirely different perspective to all  that the Ramakrishna Mission and a galaxy of international intellectuals like Romain Rolland, Max Mueller, Paul Deussen, J.J.Goodwin, Nikola Tesla, John D. Rockefellar, Sister Nivedita, Badrinath Chaturvedi, Rev. L.P.Mercer, V.Brodrov, Philip Goldberg and Harriot Monroe have written in the many volumes on his life and works.


In his letters from abroad to his friends and disciples back in India Swamiji spurred them into engaging in any kind of business like that of selling Indian goods in the United states rather than cajole the white masters to provide them with  menial jobs.


 The authors also draw attention to three strange coincidences on 9/11 spanning three centuries:

(a) 1893 Swami Vivekananda’s first address at the World Parliament of Religions at Chicago, 

(b) 1906 Mohandas Gandhi, adopts path of Satyagraha in South Africa,   

(c ) 2001 The terror strikes at the Twin Towers of World Trade Centre, New York.




3 years ago

OMG ! The same divinity dwells in Wendy Doniger too !!!

Narendra Doshi

3 years ago

Dear Nageshji,
Thanks for your write-up. It was refreshing with many unknown information.

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