Ban Industry-Funded CME--and the ACCME, While You're at It

I'm indebted both to the Prescription Project and to Danny Carlat's blog for accounts of the hearings of Sen. Herb Kohl's (D-WI) select committee on aging, on the issue of industry funded CME and sunshine legislation.

The decks were somewhat stacked with those opposing industry funding. The redoubtable Dr. Thomas Stossel of Harvard and ACRE (see previous posts too numerous to list) was on hand to offer the non sequitur, that because scientific advances in medicine over the past 40 years had helped people, and for the past 40 years we have permitted industry funding of CME, we need to continue the latter or we risk losing the former. Al Franken, making his Senate debut following his long-disputed election in MN, offered the comment that he did not see any logic in Stossel's reasoning. I suppose Franken, as a former comedy writer, is especially qualified to understand the reasonings of Dr. Stossel and colleagues. (Sorry, couldn't resist that.)

All that is bye the bye, as I think the most important exchange by far at the hearings was the indirect exchange between Dr. Steve Nissen of Cleveland Clinic, and Murray Kopelow, head of the Accreditation Council for Continuing Medical Education (ACCME), the outfit that is supposed to monitor all US CME activity. Kopelow offered what to our commentators appeared to be pretty wimpy testimony. Prescription Project summarized it as: "[A]fter mulling a stop to accredited industry-supported programs in 2008, the [ACCME] 'would not be taking any action to end the commercial support of accredited [CME],' and defended its continued efforts to clarify independence criteria and firewalls." The basic message appeared to be: trust us, we're taking care of everything, just leave it to us.

By contrast, Steve Nissen came out swinging. Again, per Prescription Project, Nissen "called the [ACCME] 'uninterested or incapable' of enforcing its own rules, and called for its end. 'Whatever ACCME is doing is ineffective,' said Dr. Nissen. 'We need ACCME to go away and we need to replace it with something else.' He said that third-party companies called medical education communication companies are very much behind the wheel of CME programs that claim support from 'unrestricted educational grants,' and that based on the selected topics and speakers, he can nearly always guess the sponsoring company." To which Danny Carlat added the anecdote that he knows that at least on some occasions, ACCME slaps the wrist of a CME sponsor that allows undue commercial bias, because they issued such a letter after he once complained. Only ACCME took two years to do it, and Danny cannot tell us any details because ACCME also put a gag order on him.

Now, if you go back and look at some of my earlier posts on this blog as well as in HOOKED, I think in hindsight I was overly deferential to ACCME and took them more at their word, that they were working diligently to create firewalls and police commercial bias, than should have been the case. I have certainly heard comments from CME coordinators to the effect that what the CME rules are supposed to be, and how people behave in real life, are often two different things.

Danny Carlat, who blogged the hearings live, also offered later reflections as follows (http://carlatpsychiatry.blogspot.com/2009/07/senate-cme-hearing-impressions-more.html):

Senator Mel Martinez, a republican from Florida, summed up the mood best with his perplexed question (I'm paraphrasing here): "Wouldn't it just be better if doctors paid for their own continuing medical education?" As a lawyer, he said, he always paid for his own CLE (continuing legal education) and he was never paid to give CLE lectures.To those of us who have lived and breathed this issue for years, his question came across as innocent, but in fact it hit the obvious point, and surely summarized the view of most Americans.

Pharma Pulls Support from CME

Again, I can take a rest while my fellow bloggers do the heavy lifting-- see Danny Carlat's blog:

http://carlatpsychiatry.blogspot.com/2009/07/new-accme-report-commercial-cme-support.html

Danny was right on top of the Accreditation Council for Continuing Medical Education's (ACCME's) 2009 annual report, so he picked up the three key facts that it showed:

1. Overall CME spending in the US is down from $2.54B in 2007 to $2.36B in 2008, the first year-to-year drop since ACCME was founded.
2. The reduction is almost completely due to reductions in commercial CME sponsorship, which fell from $1.2B to about $1B.
3. In turn, this reduction was highly selective among CME sponsors. The medical education and communication companies (MECCs) that are almost solely engaged in for-profit work on behalf of commercial sponsors, had their revenues hit by $131M, or a 22% reduction.

What is going on here? I would propose that this represents a working out of forces that started gathering steam as long ago as 2003. In that year the Office of the Inspector General, Dept. of Health and Human Services (as recounted in HOOKED) issued a report that threatened the drug industry with anti-racketeering legal troubles unless it started to disengage from CME sponsorship that was in any way linked to marketing. The response was immediate, and both drug companies and MECCs started to reconfigure themselves administratively to create "firewalls" between the part of the company that does marketing and the part that does (supposedly) education.

As Dr. Carlat then astutely notes, more recent years have seen further changes. The IOM report came out four-square for a serious divestment by Pharma from CME programs: http://brodyhooked.blogspot.com/2009/05/iom-report-on-coi-yes-we-really-mean-it.html The American Psychiatry Association has announced its intention to end all programs sponsored by MECCs at its annual meeting. The AMA's Council on Ethical and Judicial Affairs took a serious swipe at MECC-run CME programs in its draft report on physician conflict of interest. One could say that the handwriting was on the wall that this activity was due for increased regulatory scrutiny and ethical condemnation. The industry may have decided to cut its losses.

Does this mean that the MECCs will go belly-up? Not necessarily. So far as I have been able to learn, an MECC can function in two different ways. It can administer CME courses for which credit is given to physicians in accord with the ACCME rules. Alternatively, it can plan and conduct "educational" programs on behalf of commercial sponsors for which no CME credits are awarded. In the latter case, the rules can be just about as loose as you want, and the meeting can be frankly a marketing session. The new code of conduct from PhRMA suggests that the industry is not about to give up its policy of handing out free meals to docs in exchange for their getting "educated." So it remains to be seen if the drug industry has pulled $200M annually out of physician "education" across the board, or whether it has shifted that money into less regulated, non-CME-credit-granting activities over free dinners. If any readers have any insights into that please comment.