Reductions in Commercial Support for Continuing Medical Education Results in Lower Quality, Harder to Locate and More Expensive CME

In light of the recent report from the American Medical Association (AMA) Council on Ethical and Judicial Affairs (CEJA), as well as continued criticism over the years about potential “conflicts of interest,” there has been increased scrutiny surrounding the use of commercial support in continuing medical education (CME). 

The increased scrutiny has some individuals and groups calling for a complete ban on commercial support in CME.  Others, such as CEJA, have called for significant limits on the use of commercial support and have put forth burdensome rules and guidelines that make the use of commercial support or individuals who work and collaborate with industry extremely difficult.

Such critics have ignored the recent trends and difficulties however, that many CME providers are facing.  For example, since 2007, commercial support of CME has declined $297 million or 31.4%.  In 2010, total commercial support for CME was $856 million, which made up 37% of total CME revenue.  With commercial funding of CME dropping by hundreds of millions of dollars in the past four years, there has been fewer grant dollars available, the number of providers has fallen, and there are fewer hours of instruction being produced.

Moreover, the impact on the decrease of commercial support of CME has affected hospitals, state-accredited CE providers, universities, and even the federal government. 

For instance, the Department of Defense (DOD) announced that its Continuing Education Office (CHE) will be disestablished in FY12.  Similarly, the University of North Carolina School of Medicine, decided to close its CME Office on campus, as a result of state budget reductions. 

Additionally, between 2003 and 2010, the number of CE providers accredited by state medical societies fell by 18.7% to 1,450.  As the AMA’s Council on Medical Education noted, unabated, this trend could “impede the delivery of cost-effective, quality, accessible certified CME” dealing with local health issues.  We have also recently seen a number of cuts from hospital staffs across the country because of the sluggish economy, major state and federal budget cuts, and looming provider payment cuts, which will likely include cuts to CE budgets and resources.

What critics have failed to realize is that the decrease in financial resources, coupled with increased regulatory scrutiny and a difficult economy, have made providing high quality CME extremely difficult to produce.  Consequently, a recent study confirmed these findings and showed that physicians believe there has been a decrease in the quality of CME programs.

Survey Finds Decrease in Access, Quality of CME

Specifically, a survey conducted for Medical Marketing and Media and fielded online by physician portal MDLinx over two days in December, sought to determine the impact on quality, such as speakers and course content.  Out of 515 doctors polled, most—64.1% (330)—said there was no change, while 9.3% (48) said quality has increased.  But 137 (26.6%) reported that they sensed a decline in quality—in other words, about one out of four physicians cited a decrease in the quality of CME programs as commercial support has dissipated.

Among other findings, another  330 (64.1%) said they have had to pay more for the cost of CME for themselves or staff, while 52.2% (268) have had to spend more time and effort locating appropriate CME. 

The access issues came as no surprise to Stephen Smith, chief strategist, MDLinx. “Whenever you’ve put a financial burden on physicians, they adjust their behavior,” he said. “I assumed that the doctors would say it’s harder to find CME now, and we have to pay for it and have to spend more time and effort doing it.”

The survey did not ask whether physicians were engaging in fewer CME activities.  Most physicians have a minimum requirement, mandated by the state they practice in, to maintain licensure and hospital privileges, but many used to take part in programs without claiming credit. “The majority of doctors spend time in CME programs just to learn,” he said, so the regulatory bodies can’t track changes in their attendance.

It is very disturbing that over half of the doctors from the survey are spending more time and effort locating appropriate CME, when their time should be better spent with treating patients, doing research, or reading journal articles—and of course spending time with their families.  Physicians already have very little time between clinical care and other practice/faculty/research responsibilities.  With decreased opportunities for CME, considerations of travel and timing, physicians are now clearly becoming more stressed with locating adequate CME.

If this trend continues, we will see more physicians using online CME or CME journal supplements to complete their state required courses, which could lead to further decreases in patient care.  While online CME and supplements can be adequate, it does not replace the necessary dialogue and interactive exchange that happens at live, smaller, and more intimate CME programs, where discussion and debate produce the most important insights into patient cases and treatments.

What is also troubling about this trend is that it is completely preventable and unnecessary.  If companies could offer more educational grants, physicians would have more options to attend CME all over the country and in all different practice and disease areas.  And such support should be encouraged because the pharmaceutical and medical device industry, as well as the ACCME and individual CME providers have the necessary regulations and firewalls in place to prevent any appearance of bias or undue influence. 

Whether it is the companies who provide the grants and their own internal policies from their educational grant departments—mandated by Corporate Integrity Agreements—or ACCME  Standards for Commercial Support, HHS-OIG/FDA Guidance, PhRMA and AdvaMed Code of Ethics, medical society internal rules, or individual CME provider rules, the abundance of measures in place to ensure the highest level of objectivity and evidence-based CME are already in place. 

Furthermore, several large studies, as we have cited numerous times, show no influence or appearance of bias in commercially supported CME programs.  Yet, the continued pressure from government agencies and a small group of individuals has forced companies to reduce their CME budgets for fear of public scrutiny from organizations with agendas to restrict CME, which has now caused physicians more difficulty finding adequate CME. 

If we continue to allow these groups and individuals to push CME providers around and limit their support and collaboration with industry, we will only be hurting the physicians and professionals that CME providers exist to educate.  This in turn, will only hurt patients and decrease the quality and outcomes of patient care.  

In a rapidly changing healthcare environment, where science is advancing every day, and with monumental and fast changing health care reform initiatives being implemented each day, now is not the time to make it harder for physicians to find the education they need to become better health professionals. 

Discussion

The Obama Administration and almost all of the health care reform initiatives demand from doctors and healthcare professionals increased efficiency, cost effectiveness, and quality out of health care professionals and the system.  But without adequate educational programs and options, and high quality education, none of these goals will be possible.

As a result, the MDLinx survey causes even greater concern considering more than 25% of the doctors are finding the quality of CME to be decreasing.  “That [26.6%] should shock everybody,” said Stephen Smith, chief strategist, MDLinx. “I wouldn’t expect so many to say quality has decreased, because if pharma is not sponsoring [CME], who is? Major medical centers.”

As noted by the article in Medical Marketing & Media, “among those who cited a decline in quality, comments suggest that the lack of authoritative speakers—a hallmark of pharma-backed CME—is what they miss most.”  One theory, according to Smith: academic medical centers are sending clinicians to the podium who are not as connected to the practicing community doctors as was previously the case and thus are not as sharp and insightful.  In addition, Smith noted, these respondents anecdotally complained of a fall-off in the thoroughness of disease state education.  

Smith called the perceptions of lesser quality an unintended consequence of the increase in regulation on pharmaceutical companies’ communications and their resulting pull-out from CME. “We’ve squeezed everything toward mediocrity to prevent abuses.”

What is interesting about this survey, is that while over 25% of doctors found CME quality decreasing, almost 63% of doctors said they had “no concerns about the unbiased nature of CME” they have taken in the past, while only 25% of doctors said they had concerns.  Given that almost two-thirds of the responding doctors are not concerned about the unbiased nature of CME, the decreased quality of CME in light of reduced commercial support is paradoxical. 

On the one hand, we have concerns from certain organizations, government officials, and individuals, that commercially supported CME is biased, and therefore to reduce that bias, we must reduce commercial support, which has now lead to both a decrease in access to CME and a decrease in quality of CME.  However, on the other hand, the overwhelming majority of doctors are not concerned about bias from CME, suggesting—as three large studies have already proven—that concerns about undue influence or bias are misguided and not supported by evidence. 

This means that decreased commercial support and its subsequent effects on CME are merely an overreaction, and this trend should be reversed given the tremendous amount of evidence showing commercially supported CME is unbiased. 

Moreover, this overreaction can be further seen by the fact that almost 44% of doctors from the survey said that commercially supported CME is equally valuable and informative as non-commercially supported CME, while only slightly over 25% found it less valuable and informative.  Once again, these numbers demonstrate greatly that physicians find tremendous value in commercially supported CME, and that the negative impact decreased funding of CME has on physicians clearly outweighs the potential risks for bias or influence, especially considering the significant regulations and firewalls in place to prevent such bias or influence.

Conclusion

Ultimately, we need CE to educate our doctors in practice now, the next generation of our medical students, and the health care system as a whole.  The health problems our country faces today will only continue to grow exponentially with an aging population and a growing epidemic of chronic diseases such as diabetes, obesity, and heart disease.  CE is critical to facilitate the continued integration of new advances in medicine and technology into patient care and curtailing commercial support for CE will only dramatically diminish access to education and negatively affect patient care. 

We must stop focusing on who supports providing CE, because the proper firewalls are in place to ensure quality, integrity and independence.  We must focus on making sure that this country’s physicians have the highest quality continuing education, before it is too late.