Does the commercial support system — as it exists today — inevitably compromise CME's independence? That's the question the Accreditation Council for CME will explore over the next year as it conducts its first-ever big-picture review of the funding process. It will examine a range of options, from leaving the system intact, to setting up a centralized grants repository, to limiting — or even prohibiting — pharmaceutical industry funding of CME. Since drug companies funnel about $1 billion annually into CME, accounting for about 50 percent of providers' income, any decisions the ACCME makes as a result of this review could have dramatic consequences for the entire enterprise.

The analysis is one part of the ACCME's action plan undertaken in response to the United States Senate Committee on Finance's report on CME and subsequent letter to the ACCME. The committee is concerned that the ACCME's oversight is not enough to guarantee that CME is independent of drug industry influence.

Many CME professionals believe the real crux of the issue is that the ACCME needs to strengthen enforcement of its existing guidelines, and impose stricter penalties for providers who violate the rules, as we reported in our July/August cover story, “Time to Clean Up.” But some also think there are changes that should be implemented in the funding system to further ensure CME's independence. Regardless of their views, many CME professionals think that the dialogue is healthy.

“Is business being conducted in a way that instills or inspires trust in the whole process by the public?” asks Mike Bigelow, assistant general counsel, Eli Lilly, Indianapolis. “Even if you can say we're doing things in a manner that's wholly legally compliant, I think everybody still has to ask themselves: What can be done to help further make sure that the public is confident in the process and that there isn't bias in the system?”

Central Pool: Sink or Swim?

One idea that has been proposed is to create a central pool or repository for CME funds. Pharmaceutical companies would contribute money into the pool; an independent board would then distribute grants to providers. The concept gets mostly negative reviews from CME professionals.

Damon Marquis, director of education and member services at the Society of Thoracic Surgeons, Chicago, says the idea illuminates an “in-your-face loophole that we all recognize — the assumption that there is such a thing as an unrestricted educational grant. Companies decide based on the content of the session whether they are going to support it or not.” With a central grants repository, the issue for industry would be: What's in it for me? “Will altruism be enough?” he asks.

“It's an excellent idea, but impractical,” agrees George Mejicano, MD, associate dean for continuing professional development, University of Wisconsin School of Medicine and Public Health, speaking as an individual and not in his capacity as an ACCME board member. “The more disconnect there is between pharma and the provider, the less funds are directed for a specific therapeutic area. If you get too far away from the interests of pharma, [CME funding is] going to become a charity,” he says. If that happens, he suspects that funding will drop way off.

Eli Lilly's Bigelow backs up providers' assessments. Pharmaceutical companies wouldn't support a funding pool, he says. “I don't think the company would necessarily feel comfortable without having any say in the final determination of how those monies are spent,” says Bigelow.

More Room for Bias

A further problem with the central pool idea, say providers, is that it creates another level of bureaucracy and raises many operational questions. Who would be in charge? What processes would be put in place for receiving and distributing funds?

In lieu of eliminating commercial support entirely, which he advocates, Daniel Carlat, MD, assistant clinical professor of psychiatry, Tufts University School of Medicine, and editor-in-chief, The Carlat Psychiatry Report, Newburyport, Mass., thinks the central pot idea has merit, but says it would be complicated to execute. Whether ACCME or some other independent body oversaw it, a fair system would need to be devised to distribute the money. Many commercial supporters would need to make commitments to contribute, because if all the funding came from a handful of companies, that might create a situation where only certain therapeutic areas were funded.

Christopher Bolwell, senior director, medical affairs, at Imedex, Alpharetta, Ga., believes the central repository idea would actually create more problems with bias. Instead of teams of experts at pharmaceutical companies making individual grant decisions, a small body or committee — whose members would have their own biases — would be empowered to make all CME funding decisions. “I can't see that as being a viable option,” he says.

Me, Too CME

As Marquis and others point out, one major problem with the current funding system is that pharma companies award grants in the therapeutic areas that support their business goals — which means the bulk of CME activities also focus on those areas. The result, says Carlat, is an explosion of CME that is redundant.

“People might say that pharmaceutical industry funding leads to a lot more medical education,” says Carlat, “but I would say that much of that is not particularly useful education.”

Mejicano concurs that there is a lot of “me too” CME. “Do we really need another conference on GERD [gastroesophageal reflux disease]?” he asks. “There's a bunch of stuff we ought to be dealing with and we're not, and there's a bunch of stuff we're putting tons of resources into that we frankly shouldn't be bothering with.”

To redress the imbalance, Lewis A. Miller, principal, WentzMiller & Associates, Darien, Conn., suggests requiring commercial supporters to contribute a small percentage, say 5 percent or 10 percent, of their CME budgets, to a central repository; those funds would be allocated to underfunded areas. Preventive health for adults and children are two areas, for example, that are critical to improving healthcare but traditionally don't receive much CME funding.

While pharmaceutical companies may argue that it doesn't make sense for them to devote a portion of their budget to areas outside of their business interests, Miller encourages them to see the big picture and consider how underwriting preventive health initiatives would draw public attention to their positive contributions.

“[Pharma companies] would benefit because they are under so many attacks now for all kinds of abuses, real or imagined, that anything they can do to burnish their image would help,” he says.