CMSS Code for Interactions with Companies – Too Strict for Some, Not Enough for Others
Last month, the Council of Medical Specialty Societies (CMSS), which represents 32 leading medical professional societies, with a collective membership of more than 650,000 U.S. physicians, released the CMSS Code for Interactions with Companies. Despite providing detailed guidance to medical specialty societies on appropriate interactions with for-profit companies in the health care sector, various sources began to question whether the Code was too stringent or not strict enough, according to the theHeart.org.
Although 12 medical societies signed on to the code, including the American College of Cardiology (ACC), critics are still asking what the new code will do to improve “integrity and transparency,” with some saying the document is a poor fit with cardiology and others saying that it doesn’t go far enough. Some believe the Code falls short of matching a 10-point “zero-dollars” proposal set out by a group of physicians and academics in an editorial published last year in the Journal of the American Medical Association (JAMA).
But ACC CEO Dr. Jack Lewin asserted that the CMSS code is based on a “template” created by the ACC’s board of trustees last August in response to a series of investigations and hearings from Senator Charles Grassley‘s (R-IA) office examining payments to physicians and concerns raised by the Institute of Medicine. Dr. Lewin emphasized that this template was based on meetings with Senator Grassley and Rep. Stupak (D-MI), and discussions with the Office of the Inspector General in the Department of Justice.
Dr. Lewin also emphasized that ACC’s policy is more stringent than the CMSS document, including tougher rules about who can chair and participate in guideline and performance-measure writing groups—50% of the writing committees, plus the chair, can have no relevant ties to industry—and public accessibility of disclosure statements, not only for industry-supported programming, but for all ACC-affiliated programming. Disclosures for committee chairs and for all ACC leaders and members of the board of governors are now published online.
The ACC has also been enforcing its policies by banning presenters from speaking at the annual meeting (for a one-year period) or has asked certain individuals to remove themselves from committees after learning of an undisclosed conflict. Dr. Lewin also recognized that the ACC believes it is possible for ethical physicians and societies to manage relationships with industry to protect against bias.
Still, critics like Dr Steven Nissen (Cleveland Clinic, OH), a coauthor on the 2009 JAMA editorial with lead author Dr, David J Rothman (Columbia University, New York, NY), called the code “weak” and “lacking in courage.” He believed the code was such because it made “no movement whatsoever toward independence,” and it did not “prevent professional societies from accepting large amounts of money from industry for their various educational programs.” Why would any specialty do that? Where would the funding come for research, clinical trials and CME then?
The CMSS is not weak because it has a big emphasis on disclosure of known company support in connection with the presentation or publication of grant-funded research, as well as authors, editors, and reviewers for journal articles. Regardless of this focus, Dr. Nissen still feels disclosure is not enough because it “doesn’t make the conflict go away, it simply tells people that there is a potential conflict.” The code however does deal with industry ties among society leaders, and key society leaders from having direct financial relationships with companies during his or her term of service.
What Dr. Nissen and critics do not realize is that “cardiologists and perhaps even more specifically for interventional cardiologists, need these much-maligned relationships with industry because they are a key driver of progress.” As Dr. Steven R. Bailey (University of Texas Health Sciences Center, San Antonio), current president of the Society for Cardiovascular Angiography and Interventions (SCAI) pointed out, “some of the biggest strides in heart-disease care have been made as a result of research funded by industry, not government, and with breakthrough devices resulting from close collaboration between physician innovators and manufacturers.”
It is also hard to remove these relationships from professional societies because the “leadership process” takes five to eight years and many of the people sought out to lead professional societies are the same individuals tapped simultaneously by industry to provide insight into device development or to lead research trials.
Although there is ‘potential’ for conflict, Dr. Bailey asserted that maintaining these types of relationships “are important for patient care because preserving that ability to help the individuals who initially develop these kinds of tools understand how they would work better, will ensure next iterations are even more effective and safer.”
Conclusion
Although the CMSS code is voluntary, societies are “encouraged to comply with 10 “principles for action,” which individual societies can choose to implement more stringently.” While the principles “state what is expected of societies that sign on to the code [and], the annotations reflect CMSS current interpretation of a given principle.” Critics believe that these annotations are “worded to gently suggest a course of action,” and “are also ambiguous” with regards to industry donations and sponsorships.
Yet as Dr. Robert Harrington of the Duke Clinical Research Institute, noted, the “seemingly permissive language” does not bother him because CMSS represents very different specialty societies. As a result, he felt that “some openness in the language is important, because specific societies may need to handle things differently.” He asserted that the supposed ambiguous language does not leave wiggle room, rather it allows individual societies the ability to mold their own language to fit the needs of their constituency.”
Ultimately, critics have yet to propose a meaningful solution to replacing industry dollars, and most likely never will. Such ideas however, are unnecessary because nothing can replace “relationships with industry, which are a key driver of progress,” and have resulted in “some of the biggest strides in heart-disease care.” Accordingly, doctors need interactions with industry to be current in the best evidence-based care because as history has shown, this collaboration benefit’s patients, and it also means earlier adoption of new therapeutics and devices.