Monday, December 21, 2009

OIG-DHHS: Pooled funding for CME

If that alphabet soup is perplexing, folks in the Office of the Inspector General, Department of Health and Human Services, commented on funding for physicians' continuing medical education (see below for cite, subscription required).

Lewis Morris, JD and Julie K. Taitsman, MD, JD include the obligatory Federal disclaimer that they do not speak on behalf of the OIG-DHHS. But they do remind us that their office wields a sizeable stick, having, for example, been involved along with Department of Justice in the recent criminal charges against Pfizer and Warner-Lambert over off-label promotion of Neurontin, which ended in a $430M settlement.

Morris and Taitsman begin by explaining that it is in the public interest to reduce the bias introduced into CME by commercial sponsorship, which now accounts for more than half the total costs of CME in the US. They stress that even if no specific drug is being shilled for at a CME program, commercial sponsorship still skews the content of CME toward drug treatment and the like, and away from equally important topics such as prevention and patient education. They also suggest that current guidelines that supposedly limit commercial interference in the choice of topics and speakers are relatively easy to get around.

They then list several strategies that might be employed to limit undesirable commercial bias in CME programming: avoid commercial funding entirely; insist that companies pay into a common funding pool and then have a neutral third party give CME programs grants from that pool on a competitive basis; accredit specific programs rather than CME providers so that individual programs come under closer scrutiny; and eliminate some types of CME providers who currently receive funding almost solely from commercial sources (medical education and communications companies). The authors' personal choice is for the pooled funding mechanism.

This paper is a good summary of the pitfalls in the current state of CME funding and gives us a hint as to where the Feds are going to be looking for future violations. As we saw in a previous post, others--specifically the IOM--have been less reticent about proposing the full elimination of commercial CME funding as the best option for the future:

Morris L, Taitsman JK. The agenda for continuing medical education--limiting industry's influence. New England Journal of Medicine 361:2478-81, December 17, 2009.


Michael Kirsch, M.D. said...

I read the NEJM piece also. Get ready for OperationOVERKILL. If we strike out every potential conflict, then who will fund medical conferences or publish original research and the review articles we rely upon? Will physicians want to pay $1,500 to attend a CME conference? Will speakers there be permitted to be paid, even if they speak favorably about a drug or medical device? Would such an endorsement, even if sincere, be assumed to be tainted? If scientists and physicians who publish research must be conflict-free, then who will be available to write these papers? At least in my own field of GI, many of our experts have connections with industry. Disclosing these relationships to the public doesn't guarantee that their opinions have not been swayed. Alternatively, drug companies choose physicians whose views are sincere, but happen to coincide with the drug company's interest. We can never entirely sanitize the situation. We should strive for ethical purity, but we can't achieve it. If we go too far, we will stifle innovation and collaboration and may adversely impact physician education.

Howard Brody said...

Dr. Kirsch: Thanks very much for adding your thoughts. In HOOKED, I spend a bit of time addressing the various ways that CME programs could be rendered leaner, so that for only a little more money out of pocket (if any), docs could still get quality education. Many of the costs now subsidized by drug companies are not essential to CME, but reflect the fact that both speakers and attendees have become accustomed to a higher standard of living than what we used to expect a couple of decades ago. One of my favorite quotes in HOOKED was from a highly-placed psychiatrist who said that if his national academy did not take money from drug firms, they'd have to meet "in the basement of the YMCA." Which prompted the response-- so WHY NOT meet in the freakin' basement of the YMCA? Other human beings do-- what makes us so high and mighty?

Michael Kirsch, M.D. said...

Thanks Howard. If CME is made into a 'no frills' experience, then it will be challenging to get speakers to travel and physicians to attend. As you know, CME sites are not randomly selected. They are in posh resorts or cosmopolitan cities to attract attendees. I'm not sure that your basement model will fly. Personally, I rarely attend formal conferences and obtain my CME in other ways. But the conferences do serve a lelgitimate education purpose. Nice blog also.