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Alternatives to Commercial Support In Continuing Medical Education

Alternatives to Commercial Support In Continuing Medical Education. Stephen E. Willis, MD Associate Dean, CME, Brody School of Medicine At ECU Assistant Vice Chancellor, Health Sciences Continuing Education, East Carolina University Executive Director, Eastern AHEC.

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Alternatives to Commercial Support In Continuing Medical Education

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  1. Alternatives to Commercial Support In Continuing Medical Education Stephen E. Willis, MD Associate Dean, CME, Brody School of Medicine At ECU Assistant Vice Chancellor, Health Sciences Continuing Education, East Carolina University Executive Director, Eastern AHEC

  2. Other Important Points/ Thoughts • No RCTs • No studies with the new ACCME Essentials • Current level of industry support for CME is about $1,200/physician/year • As I understand them, current AHC policies simply reinforce compliance with ACCME SCS

  3. Important Unaddressed Questions • Do attendees view exhibits/ marketing at a CME event as a part of the event? • Is the distinction artificial in a pragmatic sense?

  4. Personal Vision • Commercial support and marketing (exhibits) be eliminated from accredited CME as a long range goal • Physicians (+/- transparently-appropriated public money) should pay the true cost of CME • AMC/SACME should take the lead • As the first step in an incremental change process that CS only be permitted for the “new formats” of CME as they bring CME “closer” to the patient

  5. Why should we look for alternatives to CS? • Concerns with current system • Adverse impact on clinical care? • Ethical concerns

  6. Why look for alternatives? • ? Adverse impact • Wazana in a systematic literature review stated: “Although some positive outcomes were identified (improved ability to identify the treatment for complicated illnesses), most studies found negative outcomes associated with the interaction”. (Wazana, A;JAMA. 2000;283:373-380)

  7. Why look for alternatives? • ? Adverse impact “The industry spends billions of dollars to ‘inform’ physicians. They know it works. Why else would they spend all this money.” Dr. Jordan Cohen (NY Times, 9/18/06)

  8. Why look for alternatives? Ethical Concerns: Personal Disclaimer: • My point of view is as a physician – educator with experience in GME, UME, and now CME. • In the current system, the public contributions to CME are both non-sanctioned and non-transparent.

  9. Why look for alternatives? Ethical Concerns: What is the problem with industry support? • It is really covert public support • Industry support comes at the expense of the health care consumer • Patients do not perceive they have a choice about whether to purchase medication. • Those least able to pay are underwriting the cost of education for those most able to pay. • Persisting concerns about bias and COI • GOLD STANDARD: If asked, would we embrace a public information campaign describing how CME is paid for?

  10. What about other health care disciplines?

  11. Who should pay? • Physicians +/- transparently appropriated public support. Why? • Cost of doing business • Physicians benefit most directly from CME • Professional obligation to enhance/maintain knowledge, skills, and attitudes conducive to clinical competence • There are many theoretical – and demonstrated- advantages in terms of educational quality and clinical care • Why not?

  12. How could this be accomplished? Provider – Specific Considerations: • Seek a diversified portfolio of funding. • At ECU we are funded about 25% School of Medicine, 30% affiliated AHEC, 23% fees/contracts, 15% non-commercial grants and 7% CS and exhibits. • Offer a diversified portfolio of services, particularly ambulatory PI • Partner with medical center and regional hospital QI/PI.

  13. How could this be accomplished? Provider – Specific Considerations: • Raise course fees • Maximize value to MDs by aligning desired outcomes of CME with 3rd party payer initiatives (Goal: NCQA Recognition) • Seek to view CME as a “break even” proposition • “Window” to the AHC • Incremental change

  14. How could this be accomplished? System considerations: • CME-plus: Incentives to providers who offer and registrants who attend programs that are free of commercial support, evidence-based and focused on PI/QI: • Higher fees for more credit. (The real cost of CME for community practitioners is the time away. CME Plus would maximize their ROI)

  15. How could this be accomplished? System considerations: • Continue communication with payers to continue to align both the educational and financial (P4P, etc.) incentives/expectations for MDs. • Create, rather than simply respond to, demand. • Incremental change

  16. Who should take the lead? • Academic CME/SACME • The “house of medicine” must be supportive of industry-wide reform as accredited MECCs and PMOs outnumber School of Medicine by 3.3 to 1. (Acting alone AMCs will simply be outcompeted).

  17. Pie-in-the-sky? • Possibly. • Wouldn’t this be better for all concerned? • And besides, how many of you just love the process of securing CS?

  18. Gold Standard As We Consider Alternatives • Would we embrace a public information campaign to describe to the public how CME is funded?

  19. Background Information • CME is a $2.25 billion industry • Slightly over 50% of revenue is from commercial support. • Additional 11% from advertising and exhibits. • Assuming there are about 1 million licensed physicians in the US, then conservatively $1,100/year/physician to underwrite CME is contributed by industry

  20. Medical Schools • $239.3 million + $13.6 million of $398.2 million from industry (~64%) • Total excess revenue $65.3million • 124 schools = slightly over $500k in excess revenue on average per school

  21. What impacts physician behavior? • Gifts: Compelling reasons to think that even gifts of minimal value influence behavior(Brennan et. al., JAMA. 2006; 295: 429-433) • Detailing • Samples: Expensive (patented) meds, not necessarily more effective • Interactions with pharmaceutical companies and device manufacturers: Research grants, Speakers bureaus, Advisory Committees, Consulting (Wazana, A;JAMA. 2000;283: 373-380; Chren.MM,Landefeld CS; JAMA.1994; 271(9):684-9)

  22. What impacts physician behavior? • Drug Company “sponsorship” of CME: Increased rate of prescription of the sponsor’s drugs, decrease or smaller increase in rate of competitor’s drugs. (Bowman,MA,Pearle, DL;JCEHP 1988, 8(1):13-20) • “Companies acknowledge that they carefully evaluate the market impact of expenditures and support only those demonstrating an increased use of their products” (Brennan, et.al., JAMA. 2006; 295: 429-433 citing PhRMA Congress Conference Spring 2003; June 8-9,2003; Washington, DC)

  23. What does the AMA say about the interactions between physicians and industry? AMA: Opinion E-8.061: clarifying addendum • Guideline 1: “Gifts should primarily entail a benefit to patients and should not be of substantial value …Modest meals…are appropriate if they serve genuine educational function” (AMA Website) WHAT? Isn’t $1,100 substantial? A gift? • Guideline 4: Subsidies to underwrite the costs of CME conferences or professional meetings can contribute to the improvement of patient care and therefore are permissible. EVIDENCE? What exists seems to contradict this ascertion.

  24. What are others doing/saying? • Several medical schools have limited resident, faculty, and student access to commercial entities. • Stanford is perhaps the most recent, enacting a policy on Oct 1. • “It is essential that medical professionals and scientists reclaim the moral high ground and avoid the appearances of conflict of interest” Dr. Philip Pizzo, Dean at the School of Medicine at Stanford (NY Times, 9/18/06) • However, as I understand them, no AMC policy that I have read requires anything other than compliance with ACCME SCS. “The industry spends billions of dollars to ‘inform’ physicians. They know it works. Why else would they spend all this money.”Dr. Jordan Cohen (NY Times, 9/18/06)

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