When Memorial Sloan-Kettering Cancer Center in New York City stopped accepting commercial support for its continuing medical education activities last January, many at the institution had their doubts that the program would survive. “Our staff was very worried that this would deep-six the CME program,” says Thomas Fahey Jr., MD, senior vice president, clinical program development at MSKCC, and chairman of the CME committee. He and others were surprised at the decision, particularly because participants had not reported perceiving commercial bias in Sloan-Kettering activities.

One year later, CME at Memorial Sloan-Kettering is alive and well without commercial support, but the program — and the staff — have gone through quite a transition. “It's been a sea change,” says Peter Brodhead, administrator, CME at MSKCC. Here's how they did it.

Squeaky Clean

The decision to ban commercial support for CE/CME throughout the institution was made late in July 2006 by hospital leadership, particularly Robert Wittes, MD, physician in chief.

“Dr. Wittes has a deep belief in education being purely educational,” explains Brodhead. Given the current climate, where pharmaceutical companies are under intense scrutiny for their influence over doctors, Wittes felt it was necessary to cut ties and further remove MSKCC from anything that could compromise physician education.

“We really needed to be squeaky clean and certain that there was no commercial support for our CME activities that could be construed as influencing the program,” says Fahey.

At the recommendation of Wittes and senior management, the board voted unanimously to prohibit commercial support. The ban went into effect in two steps. First, Wittes mandated a six-month trial period, starting in January 2007, banning all commercial support for activities that took place on MSKCC property. “Dr. Wittes was leaving a window open to see if the ban was really was going to cause extensive damage,” says Brodhead.

It didn't, and the ban was made permanent, but the meetings were indeed quite different.

No Free Lunch

Overall, MSKCC runs between 15 and 20 large courses a year for external participants, which attract between 200 and 300 attendees. Plus, it runs dozens of internal sessions for employees. About 25 percent of the center's CME budget came from commercial support before the ban, with the rest coming from registration fees and departmental support.

On the positive side, the CME staff, which remained intact, no longer had to spend their time trying to get commercial support. “Lets face it, soliciting commercial support for any course can be a time-consuming and resource-draining matter,” says Brodhead, citing the stress of wondering if and when you're going to get the support.

But CME staff were busier than ever, helping course directors make the transition. “One of my challenges has been coaxing some course directors who have done commercially supported courses in the past to go ahead with this new policy,” says Brodhead. “The initial reaction from some was, ‘How am I ever going to do it without the money?’”

Brodhead's job was to help them figure it out. “It really involved working closely with course directors to look at budgets in a more strategic light,” he says. Rather than focusing on replacing the money, the staff concentrated on eliminating the excess. They came up with four cost-saving strategies.

The first strategy they implemented was to move three courses that were originally scheduled off-site at hotels to MSKCC's on-site conference center, which seats up to 350, resulting in significant savings. Going forward, all courses will be held on site.

Second, for some courses, CME staff eliminated lunches. Attendees either have to “brown-bag it” or pay for their own meal.

Third, they cut back on journal advertising and direct-mail campaigns to promote CME courses. Instead, they use internal resources, including the public affairs department and the marketing department, which has access to physician networks. They also plan to promote CME activities at meetings where MSKCC exhibits as well as through the alumni affairs department. “Do I think it could put us at a competitive disadvantage, having to limit advertising in journals?” asks Brodhead. “Sure. But it's forced us to look internally for opportunities that were right in front of our eyes that we had never seen before.”

Looking Inward

The fourth strategy was to encourage course directors to use as many internal speakers as possible. “We're taking a hard look at whether we really need to invite as many people from the outside to speak,” says Brodhead. For some courses, they do need to bring outside experts in, but for the most part, they have been able to use internal staff as faculty, saving on travel costs, hotel lodging, and speaker honoraria. (Internal faculty does not receive honoraria for speaking at CME sessions.)

For example, Brodhead is currently planning a CME session on ovarian cancer later this year that had 22 external speakers the last time it ran in 2005. For the 2008 session, they are planning to use just two external speakers.

Does limiting the amount of external speakers compromise the education? Brodhead says no. “We have the advantage of our reputation and a staff here that's extremely accomplished,” he says.

To further close the funding gap, MSKCC raised its registration fees for most external courses from 10 percent to 20 percent. (There are no fees for internal courses.) Course directors are reluctant to increase fees too much for fear that higher rates will deter participation.

So far, courses have paid for themselves with fees and cost-saving measures, but Brodhead knows the day is going to come when additional funds will be necessary. “Dr. Fahey and I have spoken at length about when we will need additional dollars, because we know that time will come.” (See sidebar at left for their solutions).

Checking for Bias

Even though there is no commercial support coming in, some things remain the same. For example, MSKCC still adheres to the Standards for Commercial Support. Also, CME officials still survey participants about whether they detect bias in the courses, just as they did before. Since Brodhead came to MSKCC five years ago, there have never been any complaints in the participants' evaluations of bias in the activities. There wasn't any bias reported last year either — but they still ask. “Just because there's no commercial support in no way makes our activity immune from potential bias,” says Brodhead. “We feel it's still extremely important to ask participants if they felt there was any commercial bias in the delivery of the material.”

Focus on Education

Amenities have been eliminated, fees are higher, and there's less marketing, yet attendance has remained the same and participants have not complained, according to MSKCC evaluations.

Why? Fahey argues that the environment keeps the focus where it should be — on education — and that comes across to participants. “When you really focus on the quality of the program — and stop worrying about the amenities and the place where you can hold it — then you're looking at what the objective of CME is,” he says. “In the long run, this will keep us much more focused on what's important.”

The quality of education is as good if not better than it was with commercial support, he says. “I don't think there's any evidence to show that the extra money made it better.”

A potential negative, or “hidden negative” as Brodhead calls it, are the courses that may not be brought to the CME office because of this policy. “It's very possible that there are course directors who have said, ‘I can’t do this here because there's no commercial support, so I'll go elsewhere,'” explains Brodhead. “That's something we can't quantify. But as far as concrete negatives go, I was anticipating a lot of them, and so far I have experienced none of them — other than some of the strain on us, but that's OK.”

Good Old Days

Sloan-Kettering is among a small percentage of CME providers that don't accept commercial support; however, given the current environment, it's a question that more providers are going to face, says Fahey. In fact, the American Society of Clinical Oncology, where Fahey sits on the CME committee, is currently discussing whether or not to make changes to its commercial-support strategies.

However, Fahey recognizes that shutting off commercial support could be much more difficult for other providers. “It depends on how much money you have coming in from the outside,” he says. Also, while Sloan-Kettering has its own conference center and doesn't need to rent hotel space for meetings, not all providers are so fortunate.

But MSKCC doesn't want to evangelize about the merits of their new model. “This is not an effort by Memorial Sloan-Kettering to differentiate itself or take a lead in any way,” says Brodhead. “This is what's right for us and our population.” And after a year, he's even more convinced of that, despite having his initial doubts. He's not condemning commercial support, but over the last 10 years or so, as it has increased, it has led to a fair amount of fluff, he says.

Operating without commercial support is “like going back to the model of people sitting at a flip-top desk, having a peanut butter and jelly sandwich for lunch, as opposed to what CME in many ways has become over the course of the commercially supported years,” says Brodhead.

Whether the old ways can survive in a new era remains to be seen. “Basically, we want to see if we can do this,” says Brodhead. “The jury's still out. So far we've been OK, but I certainly have a few more grey hairs than I remember.”

Co-sponsor Challenges

One big challenge the commercial support ban creates for Memorial Sloan-Kettering Cancer Center in New York City involves co-sponsored CME. “Our prohibition of commercial support extends into those relationships,” says Peter Brodhead, administrator, continuing medical education at MSKCC. “If we are co-sponsoring, there has to be an understanding that there's no commercial support [for the activity] from either institution. It's just impossible to mix those two recipes.” In one case, they had to withdraw from the partnership and offer the course themselves. In another case, the course will go on as scheduled because the other partner agreed not to accept commercial support for this particular program.

MSKCC will continue to look for partnership opportunities; in fact, they are collaborating with Harvard University on a new pathology course later this year. Harvard won't accept commercial support for this program, but does for others.

The center has even added a few courses since the ban took place, the course with Harvard being one. “There are actually several brand-new courses that have worked well within the new model,” says Brodhead. Among them are some new pathology courses, for example. “The way it used to be, I had to figure out the universe of potential supporters, why they'd want to support this, then build my case and fill out the application,” says Brodhead. With the new model, there are opportunities at just about every area of the hospital for CME courses, many that didn't exist before.

However, there was one course that an MSKCC staff member assembled that ultimately had to be farmed out to another CME provider as a result of the ban. MSKCC staff had contracted with a hotel, but the hotel costs put the program over budget, too high to accommodate without commercial support.

Funding Plan B

While year one without commercial support proved to be a success, CME personnel at Memorial Sloan-Kettering Cancer Center in New York City know that the day will soon come when additional funds will be necessary to run certain CME activities.

In December 2007, Peter Brodhead, administrator, CME, MSKCC, proposed the creation of an internal “start-up” fund. If a course ends up making money, then half of the profits would go into the fund while the course director's department would keep the other half. For instance, MSKCC had a course last year that made $45,000 without commercial support. If that were to happen under the proposed framework, half of that money would go into the start-up fund. If a course were to lose money, the fund would cover half of the shortfall, but the course director's department would be responsible for the rest.

Does this penalize departments that produce a profitable program and reward those that don't? Brodhead doesn't think so, but he will stress to departments that a collaborative effort is necessary to make this work. At press time it had not yet been determined whether this strategy would be approved.

The CME committee has also talked about working with MSKCC's development department to set up a fund for noncommercial donors. There are many people who have been treated at the Center who want to make a donation, says Brodhead. With a donor fund, those patients would have the option to contribute to CME. Foundations and nonprofits could also contribute.

Finally, there has been talk in the CME department about creating a commercial-support pool. Pharmaceutical and medical device companies would not be solicited for a specific course, but they could contribute to a central fund that the CME professionals could access for a variety of CME activities. Obtaining funds in this manner would provide separation, but Brodhead doubts that it would be approved. “I don't think our leadership is going to want any commercial support.”