Building Block Grants

Another effort, already in place, that can help boost pharma's image and bolster CME's independence is a block-grant system developed by Robert Addleton, EdD, executive vice president, Physicians Institute for Excellence in Medicine, which is part of the Medical Association of Georgia in Atlanta. “Initially, I conceived of the plan as a firewall, as a way to ensure that commercial supporters had no influence over the development of continuing education activities,” says Addleton. But he also realized it was an opportunity to move providers towards outcomes-based CME by requiring the state associations to do outcomes measurement as a condition of participating in the block grant.

So far, Addleton has coordinated two block grants, one for depression and one for cardiovascular disease. The first one involved five state medical associations: Massachusetts, Colorado, Georgia, Florida, and Oklahoma. It was funded by Wyeth Pharmaceuticals. The second involved six states — Georgia, Florida, South Carolina, North Carolina, Kentucky, and Oklahoma, with funding provided by Pfizer. Two more are in the works.

The grants, each of which was over a half a million dollars, were split evenly among the participating state associations. These organizations were then responsible for awarding grants to CME providers in their states.

There are several benefits to the block-grant system, says Addleton. There is no contact or connection between the grantor and the recipient. In fact, industry is twice removed since the funds ultimately get doled out by state associations to local CME providers. While grantors do not control which activities are funded, they are allowed access to the outcomes measurements. This data is increasingly important for CME professionals within pharma companies, who are under pressure to demonstrate — both internally and externally — that the education they fund is effective in changing physician behavior and improving patient care. An additional benefit for all involved is that small state-level providers have access to large, national grants, which are usually beyond their reach.

Cutting the Strings

Another aspect of the system that raises red flags is the dependence of some providers on one grantor. Miller supports the idea of establishing a cap on the amount of money that a commercial supporter is allowed to allocate to an individual provider. “Any accredited provider that derives more than 50 percent of its funding from any one company, is at risk of being viewed as an agent of that company,” he says. Caps would be in the best interest of pharmaceutical companies, too, as they would mitigate the perception of undue influence, he adds. Some pharmaceutical companies even ask on grant applications how much the provider gets from them.

Others oppose any limitations on commercial support. “If certified CME is a good idea, which I think it is, why would you want to cap it?” asks John Kamp, PhD, JD, executive director, Coalition for Healthcare Communication, a New York-based organization dedicated to the free exchange of scientific information without undue government interference.

Marissa Seligman, vice president and compliance officer at Pri-Med Institute, Boston, says the idea of less funding for CME is not in anyone's best interest. “It's the provider's job to manage the funds; that's the charge we've been given, that's the expectation we have to meet.”

Instead of setting a cap on how much a company can give to a provider on an annual basis, Mejicano believes it would make more sense to put a limit on how much a company can allocate a provider in any given therapeutic area.

While Lilly's Bigelow doesn't support any funding caps, he does agree with the principle of decreasing provider dependence on individual companies. “Grant recipients need to make sure that the dollars they are receiving come from a wide array of different organizations and that they are not too dependent on any one company” he says.

Providers should also make every effort to solicit multiple grantors for an individual activity, say experts. Mark Schaffer, vice president, CME compliance, Professional Postgraduate Services, Secaucus, N.J., says, “The first thing providers can do is to stop working with a single grantor or at the very least, make a serious attempt to get other grantors for a program.” However, he acknowledges that the goal may be difficult to achieve, as despite providers' best efforts to attain multiple grants, only one company might approve the funding application.

Make Docs Pay

Another avenue to foster CME independence is to alleviate providers' reliance on grants by having participants foot the bill. The enormous amount of money the pharmaceutical industry pours into CME has meant that doctors don't have to pay much to get their credits. And, not surprisingly, they like that setup — at least according to the results of Medical Meetings' physicians CME preferences survey (“Bias? What Bias?” January/February 2006). Most of the respondents were, first of all, not concerned that pharma funding inappropriately influences CME activities, and, second, 78 percent said they would not be willing to pay substantially higher fees for CME to offset the need for industry grants.

But Schaffer and others believe that doctors should be charged a fee to attend CME sessions. “You don't have to charge them [enough to cover the] actual cost of the program because that would be prohibitive, but you can charge them a reasonable amount,” Schaffer says.

To those who say that doctors won't pay fees to attend CME activities, Schaffer bristles. “Not true. Schools have been charging, hospitals sometimes charge. If a physician doesn't want to go to a program because there's a charge, I question one of two things: Is the program really valuable or what's the matter with the physician?” Most other professions, he says, charge participants for continuing education credits. “Doctors have been spoiled, no question about it,” says Schaffer.

Mejicano agrees that doctors should start paying for CME credits. “It would be the professional thing to do.”

But it's not just doctors' attitude of entitlement, but the cost of CME, that is an issue. “Unlike a lot of professions with continuing education programs, the continuing education programs that are developed for physicians often require high-level technology equipment and are very, very expensive to put on,” Marquis says. “It's not realistic to think that we would rely on surgeons or physicians to pay 100 percent of a very expensive education.”

Extreme Measures

Instituting funding caps, encouraging — or requiring — providers to solicit multiple grantors, developing block grants, and charging doctors higher fees, are all tactics that can reduce pharmaceutical influence on CME. But some CME professionals say none of those approaches are enough.

There is a small faction of people within the CME community who advocate prohibiting commercial support altogether. “We have to maintain accredited CME as a safe harbor of trustworthy education, so a doctor can look at a [certified] activity and be completely confident that there is not going to be any commercial or pharmaceutical industry influence over that content,” says Carlat. “The only way to make certain that happens is to not allow pharmaceutical companies to fund CME activities in any way.” Carlat, who published an opinion piece in June in The New York Times about industry influence over CME, funds education via subscription fees for his newsletter.

And Carlat doesn't think the CME world would fall apart without industry grants. “About 50 percent of CME is funded by pharmaceutical companies, so that means 50 percent of CME is not,” he says. “Clearly, we are able to provide an awful lot of CME in this country without commercial support, and if you go back to 1998, about 30 percent of CME was funded by pharma,” he adds. “We've had situations where we were able somehow to educate doctors without much pharma funding.”

Others argue that prohibiting commercial support would not eliminate the potential for bias; there are many other potential sources of influence, such as faculty and institutional relationships with industry. And they say, it's just not realistic. The small group of people who oppose any commercial support are “looking through rose-colored glasses,” Marquis says.

“It's a great myth but I don't believe it,” says Kamp, talking about the prospect of CME thriving without industry funding. “It would severely impact patient care and that's what [Senate Committee on Finance members] and others ought to be focused on,” he says. “The best place for doctors to learn about new drugs and new uses for old drugs is certified CME. If that process were dampened, it would mean that practicing doctors in America would know less about that which they need to know more about. It would be a disaster for patient care.”

Follow the Funding

In 1998 providers received
$302 million in commercial support, representing 34 percent of their total income.

In 2006, providers received $1.2 billion in commercial support, representing 50 percent of their total income.

In 2006, 23 percent of providers (173 out of 729) received 90 percent of all the commercial support, and produced 44 percent of CME activities, accounting for 36 percent of total CME hours.

Source: Accreditation Council for CME

To Be Continued

We will continue this forum in future issues. If you've had success soliciting multiple grantors, creating block grants, establishing a central funding pool in your organization, reducing or eliminating your need for commercial support, or finding alternative funding sources, or you have developed other strategies to ensure CME's independence, we want to hear from you. Contact Editor Tamar Hosansky at (978) 466-6358, thosansky@meetingsnet.com; or Senior Writer Dave Kovaleski at (978)874-0804, dkovaleski@meetingsnet.com.

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