Recent scrutiny has only intensified the debate over how to pay for continuing medical education.
The question of how to fund continuing medical education went from a hot topic to a scorching one since the Institute of Medicine's Conflict of Interest in Medical Research, Education and Practice Committee pronounced last spring that it was time to develop a new model. So it's no surprise that a panel of CME experts took on the perennial problem at the 20th Annual National Task Force on CME Provider/Industry Collaboration in Baltimore in October.
In a session called “Beyond the Tipping Point: Future Options for Commercial Support Funding,” moderator Melinda Steele, MEd, CCMEP, director, office of CME at Texas Tech University Health Sciences Center, Lubbock, put forth four funding options for discussion: 1) the current model, 2) one free of commercial support, 3) directed pooled funding, and 4) nondirected pooled funding. Directed pooled means that funds could be sent to a pool, but directed to a specific need. A nondirected pooled approach would see CME funds sent to a general fund.
Steele, who also chaired the conference, polled the audience at the plenary session to gauge attendees' reactions to the various models. Approximately 58 percent said they'd like to maintain the current model of funding, while 25 percent voted for the directed-pooled approach. Around 12 percent favored the nondirected pooled idea, while just 5 percent wanted to eliminate commercial support. When given just two basic options — maintain commercial support or eliminate it — 83 percent said maintain it. When asked to pick directed-pooled or nondirected pooled, 77 percent voted for the former.
Panelists' Perspectives on Commercial Support
Panelist Norman Kahn, MD, executive vice president and chief executive officer at the Council of Medical Specialty Societies, Chicago, said the current model is fairly effective in fostering independent CME, but the rules need to be better enforced.
Robert Addleton, EdD, CCMEP, executive vice president at the Physicians' Institute for Excellence in Medicine, Atlanta, said that the elimination of commercial support would be “hugely disruptive” and make it difficult for many smaller providers to offer CME. With the need for performance-improvement programs and other new models for delivering CME, providers need the additional resources.
Jack Kues, PhD, assistant dean, CME, at the University of Cincinnati School of Medicine, said it's important to maintain a partnership between industry and providers as long as doctors or other learners are prescribing the drugs and using the devices that industry manufactures. Eliminating commercial support promulgates the idea that a divisive relationship exists between industry and providers, and that's not the case, he said. And, he added, it's a trap to think that if you eliminate commercial support, you eliminate bias; you just would stop looking for it. Kahn added that physicians certainly wouldn't be happy if that money went into marketing instead.
Mike Saxton, MEd, FACME, senior director, team leader, medical education group at Pfizer Inc., New York, says that it is understandable why industry might take a very different view. If commercial support were eliminated, the consequences would not be entirely negative for pharma. It would likely improve the public perception of the pharmaceutical industry and reduce costs — and not just the grants, but also the cost of running a medical education office. Further, he said, the negative public perception of pharma may actually be unintentionally hurting the reputations of providers by association.
Whatever happens, Saxton said, the status quo is unacceptable. It has unnecessary costs and complexities, and the quality of education is uneven, as he would like to see all projects tied to performance improvement, he said, speaking for himself and not Pfizer. “And we're not getting any positive press for what we are doing.”
The Pooled Approaches
Saxton said that industry would not be interested in a nondirected approach. Adopting such a model would essentially lead to the de facto elimination of commercial support. “It increases risk,” said Saxton, because it looks like a gift. “We have to be very clear on why we give money.”
However, Saxton and the other panelists were all intrigued by the directed pooled approach. It's a model that Addleton and PEIM have been using for years. PEIM, which is part of the Medical Association of Georgia, solicits funding from commercial supporters in a specific area — like depression or cardiovascular disease — on behalf of various state medical associations. PEIM then doles out the funding evenly to the participating states. The model not only enables small state associations to get commercial support (which can be difficult), but it also creates a firewall between industry and the state providers. “We are the middle man,” said Addleton. “It eliminates any bias.”
The panelists wondered how that model might work on a national scale. Who would be in charge of receiving and distributing funds? Who would oversee it? Could it be done by provider/organization or by provider type? While questions abound, variations on the model are already being used locally. “We have seen directed pooled funding requests out there,” said Saxton. “I believe new ways of awarding grants like this are the only viable pathway to the future if commercial support is to continue to exist.”
In a separate session, Murray Kopelow, chief executive at the Accreditation Council for Continuing Medical Education, Chicago, floated his own idea, the creation of a “third bucket.” Currently, there are two buckets, one for certified CME and one for promotional education. Maybe there needs to be a third forum where industry and CME can exchange ideas and give physicians the opportunity to interact with industry about new products and drugs, he said. It is just another idea to explore in this period of change and transition.
Consensus Starts With Conversation
This open discussion of ideas by multiple stakeholders was exactly what the Institute of Medicine hoped for when it made its recommendation to develop a new funding model, said panelist Bernard Lo, who chaired of the IOM's Conflict of Interest in Medical Research, Education and Practice Committee. The IOM would like to see all the stakeholders in the CME enterprise come to a consensus on a new system that's free of industry influence, not necessarily industry support. “We want to focus on quality of education, not who pays,” he said. That means producing CME that covers underfunded and overlooked areas, because the goal is improving public health.
The key is to come up with a better way to detect and measure bias in CME without making it expensive and cumbersome, Lo said. “Where there are concerns, we want to say, ‘Here's how to detect it and fix it.’”