Has commercial support for CME bottomed out?

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Industry support for continuing medical education (CME) has been waning the last two years, but some say the bottom may be in sight.

“My own guess is that we're near the bottom for commercial support dollars, and that within the next few years we'll be reporting increases, not decreases in the amount of industry funding of certified CME,” said John Kamp, executive director, Coalition for Healthcare Communication.
Support first would have to stabilize. Commercial grants for speakers and courses nationwide came to $856 million last year, 39% of the total expenditure for such courses, according to a 2009 report from the Accreditation Council for CME (ACCME). That's 17% less than in 2008. Grants dipped 14% the year prior from a high of about $1.2 billion in 2007.

Pharmaceutical and device makers have curtailed grants, partly out of fear of liability and regulatory attention, and partly due to the recessionary state of the industry and the limited number of new products in the pipeline. Two Senate committee investigations and the debate over whether medicine should develop a model of CME free of commercial support has put them under a spotlight.

Pfizer, historically one of the industry's largest funders of medical education, has kept its CME budget flat the last three years. “It is my expectation we will hold our own in 2011,” Maureen Doyle-Scharff, senior director, team lead, Pfizer Medical Education Group, told MM&M. “We're not decreasing; [but] it's not increasing and who knows [if] that may happen.”

A meeting in Baltimore starting Wednesday, the American Medical Association's Annual Conference of the National Task Force on CME Provider/Industry Collaboration, will showcase ways companies and CME providers are making strides amidst the criticism.

“CME providers of all types are creating programs that are better than ever, focusing on gaps in treatment, developing innovative programs to fill those gaps, measuring outcomes and continually improving educational programs that support patient care,” said Kamp, who is chair of the two-and-a-half-day meeting. “Certified CME continues to deliver innovative and practical educational solutions.”

The right CME programs could spark a resurgence of industry dollars. Said Doyle-Scharff, “The more we are starting to see some pretty significant outcomes coming in from the grants we are supporting—and I believe senior leadership...is very supportive of my team and the work we do—once we are able to tell some of those powerful stories, there may be in fact an increase in budget to do more of that good work.”

Other reasons to be cautiously optimistic include healthcare reform. Patients and healthcare providers will need CME more than ever, Kamp said, as millions of patients enter the system. “Widespread financial support for CME from all sources—including biopharma and device companies—is absolutely essential if the promise of healthcare reform is going to be delivered to the American patient.”

He also sees a turning point in the debate over medical education's relationship with industry. “The critics of commercial support are running out of gas,” he said. “The vapors that have supported their position of bias are rapidly evaporating and being exposed as a bias of its own.”

For instance, the American Medical Association's Council on Ethical and Judicial Affairs (CEJA) called for an end to almost all commercial support for professional education multiple times, but its bids have been rebuffed each time by AMA members. Two years ago the ACCME had issued a call for comment to do the same before ultimately calling it off.

Several studies looking for bias in commercially supported CME have found no evidence. A study commissioned by the ACCME in 2008 found that, “to date there is no empirical evidence to support or refute the hypothesis that CME activities are biased.”

Nevertheless, substance continues to be built around the movement. In June the University of Michigan Medical School announced a prohibition, through the media, set to begin in January, and Memorial Sloan-Kettering Cancer Center has sworn off commercial support for CME, including in-kind support, since 2006.

This has occurred despite the fact that the ACCME, FDA and other regulators of certified CME have largely agreed on a set of standards for CME provider independence that manage potential bias and improper behavior by grantors, said Kamp. While the argument that ACCME's Standards for Commercial Support can prevent bias is not universally accepted, responsible med-ed policy groups back it.

Dr. Dave Davis, VP for continuing healthcare education and improvement, Association of American Medical Colleges (AAMC), said, “The AAMC policy on commercial support spells out the reservations we have about an overabundance of commercial support and sides with the [ACCME] that says we need to be very, very clear about the bright line of promotional aspects vs. education. Using those standards as a tool is a very useful thing.”

And the CME profession is nearing consensus on the funding issue. A national recommendation is due out in draft form early next year from the Conjoint Committee on CME (CCCME). In addition to its 16 member organizations, another eight were invited to an August meeting. The CCCME, formed in 2009 at the behest of the Institute of Medicine (IOM), is unlikely to declare commercial support problematic, said Dr. Norman Kahn Jr., convener of the group. A March 17 summit is planned for Chicago with the draft report due out this January.

Explaining what the committee found when it delved into the evidence, Kahn said the data are “incontrovertible” that direct financial payments to faculty lead to influence, but a commercially supported CME activity whose faculty have no such ties most likely does not lead to bias. “[W]ithin the context of the firewalls created by the ACCME's Standards for Commercial Support, it's the opinion of the profession that if you follow this framework, you can eliminate influence from commercial support.” Specifics on how to manage conflicts will find their way into the committee's report, he said.

Whether the heyday of criticism over commercial support for CME has passed or not, there is, as yet, no model for industry-free CME. But, said Kamp, “A funding system is in place, grantors have developed elaborate systems to comply, providers have compliance programs in place, ACCME has developed faster and more public enforcement programs, and doctors and other HCPs are attending these programs in increasing numbers."

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