Mission Critical

However, the issue of institutional conflict of interest is gaining importance to grantors. While MECCs affiliated with advertising agencies may appear to be more at risk than other providers for blurring the line between education and promotion, commercial supporters are increasingly concerned about conflicts of interest across provider types, says Mike Saxton, Med, FACME, senior director, team leader, Medical Education Group, U.S. Medical, Pfizer Inc., New York. “All conflicts of interest need to be addressed at the organizational level,” he says. “It's no longer enough to resolve conflicts of interest at the individual level. We need to be clear that whether a CME unit is part of a hospital, academic medical center, association, or MECC, if the parent organization's mission is not fundamentally aligned with patient care, there's a potential conflict of interest right at the heart of the relationship.” He agrees with ACCME's proposed position, adding, “Like many, I would say let's not stop there.”

Commercial supporters are increasingly raising questions about various types of financial relationships, he says. “If we have to pay a $50,000 fee — what many call ‘pay or play’ — for a satellite symposium, is that a conflict of interest? What about academic medical centers where clinical departments can bypass their CME office to go directly to the pharmaceutical company for a grant rather than going through their CME department — is that an organizational conflict? How about providers that allow a non-accredited company to secure grants and then they come to the provider for certification? What about a provider that gets 70 percent or 80 percent of funding from one commercial supporter — is that a conflict of interest? What about providers that use business development people — who are paid on a commission basis — to solicit grants? These are questions we need to address with policy changes.”

LOA Tug of War

As for the first, and less controversial proposal — that providers will be found noncompliant if they enter into written agreements with grantors that specify how they plan to fulfill ACCME requirements — again, ACCME did not explain its rationale. However, providers do have some ideas. Steele says pharma companies' letters of agreement have become much more complex and challenging for providers. For instance, she cites a letter that specifically required a provider to use a particular company for outcomes assessment. Agreeing to that requirement would violate the Standards for Commercial Support, as providers are supposed to be in charge of all educational decisions. Steele expressed her concerns to the ACCME, saying that providers “need something with teeth in it so we can legitimately say to commercial supporters, ‘No, we can't do this,’ or ‘We won't sign this letter of agreement.’”

NAAMECC, however, does not support the proposal. “ACCME seems to be trying to stop supporters from inappropriately directing the activity, and of course that's what ACCME should be doing,” says Overstreet. “But as we point out in our response, many supporters are hiring educators now; they're hiring people who are much more knowledgeable and sophisticated regarding CME than in the past. And those people may have something constructive to bring to the table that doesn't influence content or faculty.” The ACCME's proposal might have the unintended result of driving underground productive and compliant discussion between providers and commercial supporters, she says. “I don't think that's good for anybody. The community needs to be more transparent, not less transparent.”

Steele disagrees. “There are a lot of things we shouldn't be talking to commercial supporters about anyway. Some providers who may be a little bit more naive may be talking to industry about things that aren't within their purview. [The proposal] shouldn't limit [appropriate] conversations.”

Saxton also supports the proposal. “Any ACCME policy that ensures that commercial interests are not requiring specific, predetermined solutions for any element of educational design is a good idea,” he says. “There are many ways we can play an appropriate supportive role and champion higher standards regarding outcomes, continuous assessments, various methods. But any time a commercial supporter requires, either explicitly or implicitly, any specific element of that educational process, that crosses the line.”

Rather than restrict dialogue, he thinks the proposed rule will facilitate it. “Any time that we remove the potential that a commercial interest can prescribe a solution, we're opening up dialogue.”

LOA Collaboration

In addition to the example mentioned earlier, where a grantor required a provider to use a certain company for outcomes measurement, there have been other problems with letters of agreement, says Steele. Recently, for example, grantors have been asking providers to attest to the companies' business and compliance practices. Indemnity, arbitration, and refund clauses have also been problems.

To address these issues, Steele, representing SACME's board, is working with NAAMECC board member Mark H. Schaffer, EdM, vice president, CME compliance, Thomson Professional Postgraduate Services, Secaucus, N.J., to put together a position paper about letters of agreement. “You've got MECCs and academic providers working together on the same kinds of issues — that's a pretty strong coalition,” she says.

MECCS Make the Grade

The Accreditation Council for CME has published a list of providers that received one or more exemplary compliance findings during the March, July, and November 2006 accreditation review periods. The numbers show that more MECCS (categorized as publishing/education companies) earned exemplary compliance than any other CME provider type except physician membership organizations.

In terms of percentages, MECCs are ahead. There are 154 MECCs, according to the ACCME 2006 data report. Thirty of them, or 19 percent, received exemplary compliance ratings. Of the 267 physician membership organization providers, 31, or 12 percent, earned exemplary compliance. There are 122 schools of medicine, of which 19, or 16 percent, were awarded exemplary ratings.

Of the 93 providers categorized as hospital/healthcare delivery systems, 12 (13 percent) received exemplary marks. In the smaller categories, three out of the 34 nonprofit (other) providers (9 percent), two out of the 14 insurance company/managed care company providers (14 percent), and two out of the 29 unclassified providers (7 percent) earned exemplary compliance.

• People on the Move

  NANCY DAVIS, PHD, has co-founded the National Institute for Quality Improvement and Education, and serves as its first executive director. The newly founded institute, based in Homestead, Pa., is a not-for-profit organization focusing on the integration of quality improvement and continuing education for healthcare professionals. Davis cofounded the organization with Lloyd Myers, RPh, president of the healthcare technology company CECity, which is providing startup support for NIQIE. Most recently, Davis served as the director of CME at the American Academy of Family Physicians, Leawood, Kan.

• BRUCE BELLANDE, PHD, has joined CME Enterprise, Carmel, Ind., an ACCME-accredited provider, as president. A CME industry leader, Bellande previously served as Alliance for CME executive director for more than a decade, and has more than 30 years experience in the field.

• PAUL D. WEBER has taken the helm as executive director of the Alliance for CME, Birmingham, Ala. A medical association executive with more than 30 years' experience in the healthcare field, Weber joins ACME from the California Medical Association, San Francisco, where he served as chief operating officer for the past two years.