Funding CME -- As Pharma Retreats Who Pays the Price?

Bradley P. Fox, MD; R. Brian Haynes, MD, PhD; Robert W. Morrow, MD; Roy M. Poses, MD

Disclosures

March 18, 2010

Roundtable Question

Continuing medical education (CME) is in flux. We need CME but industry is increasingly reluctant to fund it; if so, where will the money come from?

Bradley P. Fox, MD

Continuing medical education certainly is in flux and a number of factors are influencing the flux. Funding is a challenge. Pharmaceutical companies have cut back on the amount of money they make available for (unbiased) CME and the pathway to get it has become convoluted. Where we once would talk to our local rep to get support for our local CME event, we now need to go through the centralized application process hoping that the funding will be approved and received in time for the conference to be produced.

Those of us who produce CME have been looking to nontraditional sources of funding such as banks and auto dealers. The American Academy of Family Physicians recently announced that they had come to an agreement with the Coca-Cola Company to fund education.

Physicians seem to be less willing to pay for CME -- either provided in traditional or nontraditional forms -- and may be more willing to participate in free CME rather than to seek higher quality CME that has a fee involved. This presents a challenge and will play a part in directing how education will be delivered in the future.

Where will CME be offered in the future? This is a question that has multiple answers. People seem more reluctant to travel now, given the current economy. Attendance at national conferences has dropped as people don't take vacations around CME or don't bring their families with them to conferences. With the amount of CME available in journals, online, and with the regionalization of many conferences, people can stick closer to home. Also a greater percentage of physicians are becoming employed, and, in those situations, education gets budgeted and it becomes almost a salary cap game to decide how to get the most for the limited dollar.

R. Brian Haynes, MD, PhD

As for who will pay, if one considers healthcare a commodity, then continuing education would be a business expense -- a cost of doing business. If healthcare is considered a social good, then continuing education should be negotiated with the funder. In either case, no doubt regulation and enforcement will (need to) come into play.

Roy M. Poses, MD.

It also might be worth discussing the recommendation from the US Institute of Medicine in the 2009 report on conflicts of interest:

"A new system of funding accredited continuing medical education should be developed that is free of industry influence, enhances public trust in the integrity of the system, and provides high-quality education. A consensus development process that includes representatives of the member organizations that created the accrediting body for continuing medical education, members of the public, and representatives of organizations such as certification boards that rely on continuing medical education should be convened to propose within 24 months of the publication of this report a funding system that will meet these goals."

See: http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx

Robert W. Morrow, MD

Has CME come to stand for commercial medical education? Many physicians recognize that the curriculum and content of continuing medical education are largely determined by those who pay for it.

We currently face a rather fierce debate on the question of who should own the CME agenda. Certainly, when a resident goes into practice, the only CME available should not be for "product placement" or understanding disease categories that only serve a market. Nevertheless many CME activities, even those provided by our professional associations, receive industry funding, and must be designed around industry sales agendas.

I live in some fear that pharma will seize good methods to frame the educational process in their model of the sale of drugs, devices, and diseases. An example of this is their clever use of the idea 'clinical inertia.' This framing purports to explain the reluctance of doctors to move patients with diabetes to various proprietary insulin products, at high cost and usually low benefit. Thus the docs who resist this industry standard are sort of stuck in their bad practices due to laziness. This framing seeks to make the docs jump, and is stated without balanced literature, due to funding decisions by industry. Because a good deal of adult education revolves around reframing the learners' perceptions of their professional work, the use of this technique for proprietary sales is disturbing.

Fortunately, there is some pressure coming from the Centers for Medicare & Medicaid Services and other reimbursers of health services to limit industry support. In addition, the Accreditation Council for Continuing Medical Education (ACCME) requires strict firewalls between those who fund CME and those who develop it, which helps protect against undue marketing influences. Nevertheless, those who develop and sell drugs and devices clearly have an interest in motivating physicians to use their proprietary items and to mitigate critical thinking. So, for better or worse, the results of such restrictions are discouraging industry from funding CME activities and are switching their dollars to nonaccredited marketing strategies. So, this leaves the question -- who will now pay for CME?

Hopeful trends reflect government and public health strategies, such as comparative effectiveness research, which offer alternatives to uncontrolled marketing of expensive treatment strategies and favor quality improvement, practice systems enhancement, a patient safety measures. Other positive directions are interprofessional education and lifelong maintenance of certification. In addition, the ACCME now mandates that CME providers measure effectiveness and patient outcomes, which may require attending to and reporting the details of medical practice within the context an educational program.

We have the tools to develop educational programs that will accomplish all of these goals, but they are expensive and capital intensive, and are unlikely to be created without focused external funding and appropriate business models. Measuring more than the most basic administrative data is expensive, complicated, and time-consuming, and ultimately has a real cost.

Another important question is the CME agenda itself. At this time, most topics for CME programs are developed by professionals on the basis of "needs assessment" or "learner-centered education" but this decision-making process has limitations. The learners themselves may not be aware of evolving public health needs or future trends that will change practice. For example, they may not place priority on becoming educated about screening for domestic violence or community efforts in preventing obesity. A good start for a CME agenda is the list of comparative effectiveness research topics, which have been prioritized by the Institute of Medicine. Those who pay for healthcare have an economic interest in better and more efficient patient care, and their agendas should also favor strategies that lead to a new and different set of content areas and teaching methods.

So, given all this, who should pay? First and foremost, any group that finances education -- no matter if the payer is government, pharma, or a nonprofit group -- should employ practice-transforming techniques to improve care. Equity and transparency mandate such funding to support an educational approach to the improvement of patient care systems. (My personal bias is for social learning in group interactive settings, a singularly productive and inexpensive strategy with a good track record in quality improvement projects.) Otherwise, only large institutions could afford practice-improvement CME for medical staff.

Second, doctors should pay some of the cost because they have the greatest stake in their own education, and should have some control over their educational agenda. With the introduction of computer-based education and peer educators, academies and academic medical centers can now develop education at a much lower cost than the traditional massive destination conferences with expensive venues and experts.

Now imagine a National Institute of Continuing Professional Development consisting of a consortium of educators who create curricular priorities, manage research funding for a CME enterprise, and create the conditions for interprofessional outcomes-based education. The capital required to develop such an ethical, academic CME enterprise might be obtained through a tax guaranteed by payers. After all, improved care should lead to lower healthcare costs, fewer mistakes. and a more sophisticated health team that can change as conditions warrant. But commercial entities that contribute financially should have little or no say in the CME agenda. This should remain in the hands of our academies and public health organizations, with the collaboration of the academic medical centers.

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