Future Directions in Industry Funding of Continuing Medical Education or A Rejection of Innovation?
The continuing education and professional development of physicians, nurses and other health care practitioners is crucial to delivering many of the promises contained in the Affordable Care Act (ACA). Improving the quality of treatment patients receive, increasing access to care, employing cost-effective measures, using evidence-based care, and reducing errors and readmissions, all depend on educating our current and future health care workforce.
The 21st century health care system that America envisions will depend on continuing medical education, for both patients and health care practitioners. America as a country cannot begin to implement many of the changes health care reform hopes to achieve without first teaching our doctors and nurses on the front line how to improve patient outcomes and to make patients healthier.
Academic medical centers (AMCs) will have a significant role in opening their doors to training and educating more students. Institutions and health care providers will have to expand the roles of nurses, nurse practitioners, and physician’s assistants to provide primary care services. However, one of the most promising ways we can address the need for more education and training is through continuing medical education (CME).
CME gives health care practitioners the tools, information, training, and data to transform their clinical practices and behaviors all for the purpose of improving patient outcomes. While CME can be offered to health care practitioners in a variety of ways, it is often distinguished by funding: commercial and non-commercial programs. The success of the CME system for both kinds of programs is responsible for much of the continued progress we see in American health care and medicine today.
Patients are being treated earlier and sooner for chronic diseases such as asthma, diabetes, and heart disease. People are surviving longer and recovering from heart attacks, cancer, and HIV/AIDS. Moreover, Americans are living longer, healthier lives. Consequently, many of the changes in practice, diagnosis, guideline following, and clinical behavior, have occurred through CME education and training, often supported by industry.
Despite this success, a small number of critics have been creating obstacles to achieving many of the ideas presented by healthcare reform by criticizing commercial support of CME. According to a recent article in the Archives of Internal Medicine, industry support of CME has “prompted concern that the medical profession has lost control over its own continuing education.”
According to the article, entitled “Future Directions in Industry Funding
of Continuing Medical Education,” this concern is evident by the fact that a few AMCs have stopped accepting support for CME from pharmaceutical and medical device companies. However, only two AMC’s to date have done so (University of Michigan
and Memorial Sloan-Kettering Cancer Center). Not much “evidence” of concern.
In fact, the concern is raised when people suggest eliminating commercial support of CME. As Dr. Murray Kopelow, chief executive of The Accreditation
Council for Continuing Medical Education (ACCME) noted, “many accredited providers and physician learners use this funding for education that could not otherwise be developed, including sophisticated technology applications and availability of experts in geographically isolated and underserved communities.”
Industry Funding of CME
Over the past several years, commercial support of CME has clearly declined. Out of 703 providers listed on the ACCME website in July 2010, only a fifth received no commercial support and a third received no income from advertising and exhibits.
Consequently, what these numbers reflect is that four fifths of CME providers rely in one way or another on commercial support of CME. Without such funding, it is clear that many of these providers would face significant challenges to continue providing the high quality and objective CME programs they currently produce.
However, the concern about commercial funding of CME providers should not be a concern because there are a number of strict standards in place to govern the relations between CME providers and commercial interests, including the ACCME “Standards for Commercial Support.” These standards have frequently been updated and numerous guidance documents have been issued by ACCME and other agencies such as HHS OIG, FDA, PhRMA, and AdvaMed. Moreover, in August 2009, the ACCME began posting on its Web site information about whether a CME provider receives commercial support or advertising and exhibits income.
As the sole accrediting body for CME, the council has time and time again rejected proposals to further restrict or ban commercial support of CME. In March 2009, the ACCME board stated that CME developed in compliance with its standards could be “free of commercial bias” and “not result in an inclination by professionals to direct care that is unwarranted or unnecessary,” even if it “includes commercial support and/or teachers and authors who have financial relationships with ACCME-defined commercial interests.”
ACCME also announced that it would “not be taking any action to end the commercial support” of accredited CME. Rather, it would enhance its monitoring system to assure compliance, such as by direct observation of activities by volunteer monitors, and would scrutinize more closely providers that receive large amounts of commercial support.”
Discussion
In light of all the support ACCME and other organizations have received to continue allowing commercial support of CME, the author believes that the standards “are a floor not a ceiling, and CME providers should consider doing more.” The article recommends that in addition to the numerous standards and strict rules, “CME providers could stop accepting commercial support or limit their commercial support to a small percentage of their total income.” But in doing so, he does not offer any ideas on how these providers would make up for the lost funding. How would programs reach rural areas or larger audiences? How could the same amount of time and effort developing content, ensuring objectivity, and meeting ACCME standards be accomplished with less money? Inevitably, less money and the same pressures and regulations would produce mistakes and poorer CME programs.
The author also recommended that CME providers “stop using faculty who are also paid to speak for companies.” The problem with many of these suggestions is that physicians and health care practitioners want faculty who work with companies because these individuals will have the most insight and experience dealing with the diseases. Often, these individuals are the sponsors or investigators of clinical trials or have spent years conducting research and treating patients in these areas, hence why they also collaborate with industry. As a result, this lends itself to an interactive program where colleagues can exchange ideas and have questions answered.
The author also believes that CME providers should “stop offering programs and courses that are supported by a single company, or stop allowing commercial interests to fund specific activities or educational topics by limiting industry support to contributions to a central repository of funds.” The problem with these recommendations is that the author ignores the fact that 99.9% of the time, CME providers have exclusive control over the content of the program. CME providers create and control every educational aspect of the program, select faculty, conduct conflict of interest screening and follow all ACCME measures to prevent any of the potential problems. Therefore, it is unnecessary to place such restrictions on CME providers because it will only force those providers to spend more time and resources trying to get funding for programs instead of planning them. As to his point about CME providers working with noncommercial partners, many CME providers already do this.
He also recommends that ACCME disclose through a searchable database on its Web site the actual amount of commercial support per year, the percentage of total income, as well as the companies that provided support and the specific amount from each. Companies already publish much of this information on their websites.
Consequently, the author asserts that “physicians or their employers should be prepared to pay more of the true costs of CME, and providers should anticipate lower profit margins.” For the 95% of hospitals, AMCs and institutions that can barely stay afloat now, and with a growing number of patients entering the system, where exactly does the author believe physicians or employers will get this money to provide quality CME?
Conclusion
The author tries to suggest that industry funding of CME is bad by citing a survey which showed that people were concerned that pharmaceutical companies have too much influence on the drugs that doctors prescribe.” This point however is completely unrelated to the topic. There is little influence of manufactures at CME activities supported by industry, as was clearly shown last year by three separate studies (Cleveland Clinic; Medscape, and UCSF).
Contrary to the author’s belief that we should continue “to wean CME from industry funding,” the exact opposite is true. America needs to educate our physicians and health care practitioners so that they are able to provide patients with the best information possible to make informed decisions about their health care. If there is any hope to resolve disparities in access, delivery, and outcomes in our health care system, it will depend on how well trained and prepared our health care providers are. Removing a crucial educational resource that physicians and healthcare providers rely on will not accomplish this goal.
Instead of calling for more restrictions on commercial support of CME or complete bans, all stakeholders in the CME community and the health care system should be working together to discover new ways that commercially support CME can address the issues facing America’s health care system. At this crucial time in our country when 31 million Americans are expected to enter the health care system, we need to focus on what CME providers and commercial support can do to help train and educate physicians that will improve patient outcomes.
The CME system currently in place is more than capable of preventing any potential concerns argued by critics and the overwhelming majority of providers who use commercial support have implemented every safeguard to ensure the absolute integrity and objectiveness of their programs.
Innovation requires resources. If we are serious about improving patient care, delivering Performance Improvement and Quality Improvement CME then we need to accept the fact that we are not going to wake up one day with resources from governments (which is cutting back) and hospitals which are loosing money to support advanced CME methods.
If we continue to criticize the commercial support of CME, it will only push our country further back in medical innovation and progress, and it will create significant disadvantages for health care practitioners if they are prohibited from learning the innovative breakthroughs offered by commercially supported CME.