CME Overview: Class is in Recession
“Many providers are getting 30-40% less financial support from commercial sources than in the past,” reports Marty Cearnal, EVP, chief strategy officer, Jobson Medical Information. Cearnal said it's also harder to get a grant today. “Two years ago…maybe one out of every five grants would get funded. Today that number is one out of every 20-30.”
Commercial support to accredited providers rose just 1% to $1.2 billion in 2007, according to the latest figures from the Accreditation Council for CME (ACCME). Publishing and education companies and hospitals saw their industry dollars fall, while specialist societies and other non-profits, as well as insurance and managed care companies, were the only ones posting gains. The reality may be even more glum than data suggest. Cearnal speculates that the reported rise may be due to providers simply submitting more comprehensive data.
“Present-day economics have challenged all CME stakeholders,” says Pamela Mason, CCMEP, FACME, director, medical education grants office, AstraZeneca US. “Limited and shrinking budgets at academic and healthcare institutions, as well as professional associations, present challenges in the number, type and quality of CME offerings. Pharmaceutical companies are also trying to cope with smaller budgets and, consequently, providing fewer grant awards. The competition for grants is becoming more robust.”
The tight funding climate, along with new regulation, has led to a shakeout in the provider community.
“Many organizations, hospitals and others are not pursuing re-accreditation, not just because of the changes in commercial support levels but because of the difficulty in their minds of reaching compliance with the new accreditation requirements,” notes Marissa Seligman, PharmD, chief, clinical & regulatory affairs and compliance officer, SVP, Pri-Med Institute.
This year marks the first completed accreditation cycle under the 2006 ACCME accreditation criteria. While the majority of providers have been able to meet the new requirements, several aspects of the updated criteria make this more difficult. One is what Seligman terms a “real-time” compliance requirement. According to ACCME, about 50% of the applicants for re-accreditation had one major non-compliance finding that will compel them to write a progress report.
“That's up from previous years, and the cost is real,” Seligman says. Providers have always had to write progress reports. The difference now is that, within a shortened 90-day timeframe, providers must include a description of new practices or corrective actions that will be implemented in order to bring the program into compliance, as well as subsequent evidence of compliance from CME activities that demonstrate the provider's performance in practice.
“You have to change and provide evidence of change to get out of non-compliance,” she explains.
While the ACCME has not released records on the number of providers that have decided not to seek re-accreditation, the number of nationally accredited providers is expected to shrink this year from its current peak of more than 700.
Some say August will be the month when multiple providers will announce their intentions to leave CME. As the phase-in month for ACCME's new definition of a commercial interest (if an organization's corporate structure has not been vetted by ACCME by then, it can't own an accredited provider), August is a natural date for what one provider calls a CME “D-Day” for accredited commercial entities.
So far the list of upcoming casualties includes no less than the longest-running accredited medical education and communications company (MECC), Postgraduate Professional Services (PPS). PPS will cease operating in August.
Jon Bigelow, president and CEO of KnowledgePoint360, parent company of PPS, notes that “CME represented less than 9% of KnowledgePoint360's total business in 2008, and we see our future in the non-CME environment.”
Other MECCs have chosen to stick it out, despite the fact that commercial support to publishing and education companies declined 4.2% in 2007.
“As part of a big organization with considerable resources, maybe we have a little more latitude to make the choice,” says Leo Francis, PhD, who, as president of Publicis Medical Education Group, presides over the accredited provider Discovery Institute of Medical Education (DIME) and several non-accredited education units.
His group is part of Publicis Healthcare Communications Group, the fourth-largest marketing services company in the world.
“We continue to invest in the accredited side of the business, because we truly believe in the health and wellness dialogue,” says Francis, acknowledging that DIME's business has undergone a 10% decline in headcount (he said the non-accredited side is “holding steady”). “Changes in the marketplace may have a negative impact on our business, but we are able to make those investments and wait for such time as the pendulum swings back to a sensible place.”
The more than 1,600 locally accredited community hospitals, whose industry support fell 18% in 2007, may also be at risk of shuttering their CME arms. “I've heard a lot of people say they expect that will be the case, but we have not seen that yet in Texas,” reports Billie Dalrymple, CME director for the Texas Medical Association. Dalrymple says she recently began surveying providers using the updated accreditation criteria. “We are currently in our first cohort of providers, and all of them are seeking re-accreditation.”
If not closing their CME departments, some are reformatting them. Massachusetts is one state where smaller hospitals within close proximity of each other are seeking synergies relative to the physician CME audience and/or patient population they serve, said Caroline Carregal, director of education and certification at the Massachusetts Medical Society, which accredits community hospitals in the state.
As to why smaller institutions are seeking to coordinate, she says, “Tighter operating budgets and an increase in documentation of CME accreditation compliance are also forcing everyone to take a closer look at their CME program.”
Another sign of hard times: IIR's MedEd Congress, the annual spring event bringing together grantors and providers to discuss trends, has been postponed. Academic medical centers are under similar stress. While less dependent on commercial support than MECCs, industry funding is still a large part of their revenue stream. ACCME 2007 figures suggest a 5% decline in commercial support, and that report covers only the first six months of the academic year.
The 2008 AAMC/SACME Harrison survey measures commercial support during the 2006-2007 academic year and shows 76 medical schools received a total of $144 million. The average school conducts 145 courses that received financial support from industry, and almost all (121) would not have been offered had commercial support not been available.
Clearly, change is afoot, and it's not all pleasant. Evolution will leave an indelible mark on funding. Pharmaceutical support probably will never be the same, predicts Mark Schaffer, VP for CME compliance at PPS. With their bottom line under attack due to dry pipelines and a host of other reasons, pharma may feature fewer groups addressing independent med ed in the future. “I'm not sure what will happen with CME provider/industry collaboration, because the perception when dealing with a [biopharma-based] marketing or medical group is that you're still dealing with a pharmaceutical company, and I'm not sure that will survive,” says Schaffer. “I don't think commercial support will go away completely. It will be much less. But even groups like the Josiah Macy Foundation recognized that it cannot be switched off overnight.”
Recommendations from the Macy Foundation, and more recently the Association of American Medical Colleges, have focused on removing potential marketing bias from med ed through pooled funding and other means. The perennial debate as to whether CME providers should reduce or eliminate their industry dependence rages on, fueled by new proposals to clean up perceived conflict of interest.
In April, the Institute of Medicine (IOM) introduced a report on the subject, noting that industry's share of funding for medical education has risen from 34-48% in the last 10 years, raising hackles about industry influence. Even as it recognized that commercial funding is needed, the IOM panel challenged societies to come up with guidelines or recommendations on managing conflicts appropriately and recommended creation of a two-year “consensus process” for a new paradigm for CME and other industry relationships.
Because those recommendations could resurface as Obama administration policy—just as IOM recommendations on FDA in 2006 were largely reflected in the initial drafts of the Food and Drug Amendments Act of 2007—some specialty societies, including the American College of Cardiology (ACC), responded swiftly, arguing that in the absence of public funding, industry grants can be separated from product bias and be firewall-protected to support CME as a means to improve quality of care and outcomes.
“The ACC is very confident that we manage industry funding appropriately, and we are hoping to work with other specialty societies on new codes and guidelines,” said Joseph Green, PhD, SVP of professional development and education and chief learning officer at the ACC.
For their part, all medical schools are either implementing or considering industry relations policies. Usually these cover more than just education and conflict of interest. Boston-based Partners Healthcare, for instance, in April debuted a policy that includes restrictions on gifts, tighter management of faculty financial interests and oversight of outside activities like consulting, as well as a ban on faculty participation in speakers' bureaus and ghostwriting.
A major distraction
The IOM report was just the latest assault on the way societies and other accredited providers handle commercial funds for medical education. An article published in early April by the Journal of the American Medical Association called for medical associations to sever most of that funding, with the exception of journal advertising and exhibit hall fees.
The highly politicized environment, marked by congressional inquiries into industry funding of CME and scrutiny from academic and medical critics, has exacerbated the slowdown and added up to a major distraction for providers. “You're educating on perception and to people who don't know what you [as a CME provider] do,” says Seligman. “How perception drives practice is the opposite of what we are trying to achieve, which is practice based on evidence.”
This spring's decision by the ACCME to nix a proposed ban on industry funding has done little to refocus attention. That's partly because, while it has tabled the proposal for now, the accreditor reserves the right to revisit the topic. Another seminal event with potential economic impact occurred last year when Pfizer, the largest grantor, announced its decision to stop funding CME through MECCs. For now, no other big grantors have followed suit.
AstraZeneca's Mason, who is also 2009 chair of the pharmaceutical section of the Alliance for CME, says the number of grants her company awarded to MECCs represented only about 15% of funding last year and has decreased over the past few years. However, this trend is attributable to “the number of MECCs who are submitting grant applications and overall budget limitations.”
By contrast, in 2008 55% of AstraZeneca grants were awarded to hospitals, medical schools and healthcare systems representing about 25% of available funding.
“AstraZeneca,” she says, “has not changed [its] approach to supporting quality, independent educational activities.”
Opponents of commercially supported CME argue that physicians need to pay their way more often, and other funding sources being explored including third-party payers, large employers, government payers like Medicare and Medicaid and academic institutions.
“It's very clear the funding models, especially in medical schools and hospitals are probably going to have to step up and provide internal support for their CME program. That's one point even our deans need to hear,” says Melinda Steele, MEd, CCMEP, managing director of CME at Texas Tech University Health Sciences Center and immediate past president of SACME.
If the IOMs and Macy's get their way, and pooled funding becomes a reality, that may hinder the movement toward impact performance-improvement oriented CME, which typically costs more to implement.
With less money available for grants, a number of groups also will make the switch to the promotional side because they perceive it as easier to support. Those aligned with the medical community—insurers, foundations and societies—will be able to make that switch most gracefully, says Schaffer.
Brace for another form of downsizing in the CME enterprise: CME, with its traditional emphasis on credit, may one day become extinct. That's what some say may happen with the implementation of Maintenance of Certification (MOC) for physicians by various boards of medicine. That's because boards, which link MOC to a multistage process that includes performance improvement, will ask whether physicians are competent, not whether a physician earned x number of credit hours.
MOC will not dismantle the current credit system, argues Schaffer. Thirty-nine states still require a certain number of credits for individuals to be re-licensed, and state legislatures are not known to move quickly.
To be sure, the emphasis will shift from simple attendance to a portfolio-based approach. Yet, “It will be a long time before you see the credit system, if it ever does, go away,” he says. “The current credit system and MOC will start to work hand in hand. When you look at parts 2 and 4 of MOC [lifelong learning & assessment and practice performance assessment], it's clear that there is a need for formalized med ed. That's where I get excited. I see lots of potential for helping physicians do something they don't know how to do, and that's to learn to look at their entire practice and see what's happening and get better, as opposed to looking at each individual patient, which is currently what they do.”
Evolution, not adaptation
One of the main drivers of change is CME's main regulatory body, the ACCME. Murray Kopelow, MD, ACCME CEO, says he envisions a future in which CME supports physician continuing professional development (CPD).
Drawing an analogy to the law of natural selection, he explains: “In Darwinian terms, this is the time for evolution, not adaptation. The system (enterprise) needs to evolve. System changes will occur, and are occurring, at the people and organizational levels. Some people will move on to other professional pursuits. Some organizations will stop being accredited providers. New people will be drawn to the CME enterprise, and new organizational types will emerge as providers. Data and information about organizational success, driven by the ACCME requirements, will guide this evolution. Emerging CPD systems and the expectation that physicians will improve their practices will drive this evolution.”
The ACCME has been fostering a survival-of-the-fittest mentality via a host of policies and proposals, at the center of which is transparency.
“The provider, the public and those to whom ACCME stands accountable need access to reliable and valid data and information, at the activity level, that describes CME as something that matters to patient care and, in fact, free of bias,” says Kopelow. “The ACCME is going to get that data and information through its monitoring efforts.”
An enhanced monitoring system, slated to be introduced this year, will include an expanded database of CME activities and participation, which Kopelow says will make accessible “information about each and every educational activity occurring in the nation.” The data may help ACCME parry thrusts from legislators and groups that have called the integrity of CME accreditation into question. Answering the call of Sens. Max Baucus (D-MT) and Chuck Grassley (R-IA), who scolded the acceditor in the past for ineffectual enforcement, the group also plans direct observation of CME activities by volunteer monitors and has pledged to publish online more information about the kinds of activities and funds accepted by providers, although it won't release specific dollar amounts.
ACCME, along with SACME, is also co-sponsoring the so-called Mayo Proceedings to drive toward consensus on an agenda for the evolution of research and strategic management of CME that will positively impact the integrity and effectiveness of the whole enterprise.
A matter of degrees
“From ACCME's perspective it is mission critical that CME be about improving quality and safety, be content valid and be developed in a manner that is independent of the influence of commercial interests,” adds Kopelow. “ACCME remains committed to the fulfillment of these elements.”
The profession stands equally committed. Fewer meeting planners are coming into the field, in favor of more people with training in adult education. And an effort is under way to professionalize providers—the National Commission for Certification of CME Professionals CCMEP designator (52 CCMEPs were credentialed last January, bringing to 157 the total number who have earned the credential).
As far as technology, “You will see a lot more in terms of online activities that engage the physician,” Schaffer says, “more just-in-time CME, especially with newly minted medical-school grads entering practice and using their PDAs.”
For now, physicians still need quality education that bridges the gap between clinical quandaries and patient care, and grantors are still willing to fund non-product specific educational initiatives.
Says Schaffer: “I think we'll still go through a lot of pain and suffering and wringing of hands, but in terms of the future of CME, this is a very exciting time to be in this field.”