CME: Who Will Pay the Tab?

The cost of running a high-quality CME event has gone up, but physicians aren’t willing to cover the tab. That tension has put the squeeze on medical education, bringing into focus the role of industry in the future of CME.

If you spend it, will they come?
Before a single seat can be filled at a CME event, organizers must take on a significant financial risk. The Institute of Medicine has recommended development of a system for funding of CME that is free from commercial influence, while acknowledging that such a system would likely involve higher costs for participants and/or cost-cutting by CME providers.

The cost of running a high-quality CME event has gone up, but physicians aren’t willing to cover the tab. That tension has put the squeeze on medical education, bringing into focus the role of industry in the future of CME.

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As part of an organization that has been putting on CME courses for the last 25 years I can tell you, first hand, that it has become substantially more difficult to obtain the necessary accreditation, and that the cost of producing these conferences has grown substantially. This increase in conference costs, combined with a decreased willingness on the part of physicians to pay more for their own continuing education, has created a training dilemma within emergency medicine.

By way of background, here’s a walk through of the typical steps in putting on a CME course. Organizations that provide CME credit require documentation as to the target audience, the overall objective of the course, what the provider has done to determine that the course fills a “gap in knowledge,” and learning objectives for each lecture.  Then the faculty has to declare, in writing, any potential conflicts of interest. In addition, a fee must be paid to the accreditor before the course is held, and usually after the course, based on the number of attendees.  Finally, accreditors require a post-test asserting that the participants have learned something, and a lecture-by-lecture evaluation of each presentation.

Beyond getting a course accredited, there are multiple other steps.  There is the work of soliciting faculty participation and having them develop their lectures on time. There are honoraria to pay, plane tickets to buy and hotel rooms to reserve. A venue for the course has to be determined, which often requires the guarantee of a minimum number of rooms, even though course organizers can only guess at the attendance. If organizers guess wrong, they’re stuck with the tab. As part of your negotiations, hotels will also want a “food and beverage” guarantee.  It is based on the anticipated number of attendees. Again, if you guess wrong on attendance, you’ll eat the cost.

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Finally, there are marketing costs. To print and mail a brochure to each of the 35,000 emergency physicians in the country it would cost a total of about $14,000.  But it would be suicide to send only one mailing, so typically three brochures would be sent, totaling about $42,000.

Recently, Jeff Tabas and colleagues at San Francisco General published an absolutely fascinating paper that focused on the costs of putting on a CME course and physician perceptions regarding commercial support of these programs.  The findings of the study focus on the conflict between the potential bias of commercially supported programs versus the tuition fees that physicians are willing to pay for courses without commercial support.

CLINICIAN ATTITUDES ABOUT COMMERCIAL SUPPORT OF CONTINUING MEDICAL EDUCATION: RESULTS OF A DETAILED SURVEY
Tabas, J.A., et al, Arch Intern Med 171(9):840, May 9, 2011
BACKGROUND: It has been reported that industry funds up to 60% of costs for accredited continuing medical education (CME). The Institute of Medicine has recommended development of a system for funding of CME that is free from commercial influence, while acknowledging that such a system would likely involve higher costs for participants and/or cost-cutting by CME providers. Average physician spending for CME in 2007 has been estimated to be about $1,400, and elimination of commercial funding could increase these costs to about $3,500.  METHODS: The authors, from UC San Francisco, surveyed 1,347 clinicians attending five single-day CME programs regarding their perceptions about industry funding of CME.  RESULTS: Responses were received from 57%. Most felt that bias is introduced by commercial support of a CME program (80% cited a potential for moderate to large bias if a program has 60% commercial support from a single company), and cited a potential for bias with use of faculty from industry speakers bureaus or those receiving commercial support for research. Most cited registration cost as an important factor in selecting a CME activity (77%), 56% felt commercial support is essential, and fewer than half favored an increase in registration costs as a means of decreasing commercial support. When asked to estimate the costs to CME providers for coffee and lunch, more than 80% of respondents severely underestimated these costs.

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CONCLUSIONS: Despite an assertion of perceived bias with commercial support of CME programs, most clinicians underestimate the costs of presenting such programs, and are unwilling to pay higher registration fees in exchange for elimination of commercial support. 25 references (jeff.tabas@emergency.ucsf.edu – no reprints)  Copyright 2011 by Emergency Medical Abstracts – All Rights Reserved 12/11 – #11

Among the information they turned up in the study were the charges (certainly not costs) of five items associated with an actual one-day course given at multiple locations in the United States. These charges are mind boggling – nearly as bad as charges in the ED. The courses were held in New York, Los Angeles, Atlanta, Chicago, San Francisco and Washington, and their charges were as follows:

• Cup of coffee – $9.28 in New York / $6.53 in LA and Washington
• Bagel – $8.24 in New York / $3.40 in LA
• Lunch – $82.36 in New York / $49.41 in Atlanta
• AV equipment – $2,000 in Chicago / $1,350 in San Francisco
• AV technician – $88/hr in LA / $73.50 in New York

Yes, that’s right – a bagel at $8.24 each and a cup of coffee at $9.28. Participants at these courses rarely have any concept of these costs, and they pack their plates like they haven’t eaten in weeks!   

As can be seen, a CME course without any corporate sponsorship is a very expensive and chancy endeavor, and we haven’t even talked about running a web site and a myriad other incidentals. There are no guarantees that people will attend, and substantial amounts of money are spent or committed before the first person registers. So what’s the point of all of this?  It’s simple – many CME providers want a safety net under them.  They want commercial support – pharmaceutical companies paying for lunches, sponsoring talks and in general, underwriting the conference.

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The trade off is the likelihood for bias to enter the conference. Dr. Tabas’s paper asked important questions in this regard.  Did the 770 respondents (a 57% response rate) believe that commercial support introduced bias?  88% said “yes.”  And the more support provided by commercial sponsors, according the survey, the greater the perceived chance of bias.

But here’s the catch.  Only 15% favored the elimination of commerc
ial support and only 42% said they were willing to pay higher registration fees to eliminate or reduce commercial support.  And, not surprisingly, the study revealed that participants greatly underestimated the costs associated with producing the conferences.  

Enter the world’s least expensive national live CME – Pri-Med. For only $65 you and 8,000 primary care providers can attend over 55 “clinically relevant lectures developed and presented by faculty of Harvard Medical School and the David Geffen School of Medicine at UCLA.”  In addition, you’ll have the opportunity to visit with over 150 exhibitors. But if that weren’t enough, throughout the conference there are other, non-Harvard/UCLA mealtime presentations that you can elect to attend. Some provide CME via pmiCME or other providers and some do not provide CME at all and are presentations regarding products and services by “industry leaders.”

In essence, Pri-Med intermingles three CME programs – the high profile Harvard / UCLA program, the sessions with different CME providers and the corporate “non-CME programs” funded by industry. And it’s a given that the $65 registration fee for the three to four days is unlikely to pay for the coffee or bagels.

So the answer seems plain – despite acknowledging the substantial risk of bias, the majority of doctors want commercially sponsored CME with nice lunches, dinners and breaks. 

Here’s a recent paper that put some numbers on commercial support of CME.  The recent declines reflect an ever-increasing trend to make receiving accreditation more and more difficult to receive and is perhaps being offset by substantially increased spending on direct-to-consumer advertising. 

FUTURE DIRECTIONS IN INDUSTRY FUNDING OF CONTINUING MEDICAL EDUCATION
Steinbrook, R., Arch Intern Med 171(3):257, February 14, 2011
The author, from Yale School of Medicine, comments on concerns about the level of industry funding of continuing medical education (CME) and efforts to return control of the CME process to the medical profession. Commercial support of CME increased from $301 million in 1998 to about $1.2 billion in 2006, after which it decreased by 29.3% in 2008-2009 (when it declined to $856 million). The current “Standards for Commercial Support” of the ACCME specify that, while the organization would not be taking action to end commercial support of CME, accredited programs should be free of commercial bias and should not result in a tendency of professionals to provide unwarranted or unnecessary care. Commercial support accounted for 50.3% of total income for CME providers in 2006 after which it declined to 39.2% of total income in 2009. According to information on the ACCME website, as of July 2010, about one-fifth of CME providers received no commercial support for their programs, and levels of annual support for CME providers ranged from less than $10,000 to more than $10 million (in 2006, 15% of CME providers received at least 90% of their income from commercial support). This author suggests that CME providers should consider extending their efforts to be free of commercial support beyond the standards set by the ACCME, to include declining all commercial support or limiting it to a small percentage of total income and stopping the use of industry faculty in their programs. Although such actions would, in turn, increase the costs of CME for physicians or their employers and decrease the profit margins of CME providers, they would represent a significant step in weaning CME from industry funding. 16 references (rsteinbrook@attglobal.net – no reprints).  Copyright 2011 by Primary Care Medical Abstracts – All Rights Reserved 6/11 – #22

So what are the conclusions to be drawn?  The production of a CME conference, particularly a national one, is a labor intensive and very risky financial undertaking.  Commercial support substantially reduces the financial risks but is perceived by physicians to be associated with biased presentations.  But a persistent dilemma remains – many physicians are unwilling to pay the additional tuitions for CME courses that don’t have commercial support. 

CME as it current is provided is unlikely to change substantially in the near term.  Physicians, as an integral part of their training, need to learn to assess clinical literature in a careful, thorough and skeptical manner so that they can see the pitfalls and limitations of information that is presented to them – whether it be from a colleague, a pharmaceutical representative or at a CME program.

W. Richard Bukata, MD is the Editor of Emergency Medical Abstracts