Thursday, December 17, 2009

Conflict of interest in continuing medical education

I know I've been on a conflict-of-interest kick lately, and this post will continue in that vein. I have to thank the New England Journal of Medicine for the fodder, which also leads me back to my old assertion: healthcare should NOT be done for profit.

In this week's NEJM, there is a piece from the Office of Inspector General of the US Department of Health and Human Services titled "The Agenda for continuing Medical Education -- Limiting Industry's Influence". In this article Morris and Taitsman lay out the issues and potential solutions. And while the problems are quite apparent, sensible solutions are scarce. The problems may be summarized as the undue influence by the Industry stake holders on the content of physician education. To understand this mouthful, one has to be familiar with the structure of the CME establishment.

The overseeing body for CME accreditation is the Accreditation Council for Continuing Medical Education. ACCME's stated Mission is

...the identification, development, and promotion of standards for quality continuing medical education (CME) utilized by physicians in their maintenance of competence and incorporation of new knowledge to improve quality medical care for patients and their communities.
In their 2008 report the ACCME quantified the total income for the 725 CME providers they accredit to be $2.4 billion. Who are the CME providers? According to the NEJM article, in 2007 they included
...270 physician membership organizations, 150 for-profit medical-education and communication companies, 123 medical schools, 93 hospitals and health care systems, 38 other nonprofit organizations, 15 government entities, 14 insurance and managed-care companies, and 33 providers that were not classified.
It is interesting to note that all of these organizations derive significant revenue from Industry CME funding. While most suspicion of undue influence centers around the for-profit MECCs, it is a fact that MD membership organizations rely heavily on CME funding, in addition to registration fees, to bank-roll their annual congresses. So, the idea is that, since ACCME accredits CME providers and not their programs on the ground, these providers may cater to their Industry clientele by structuring CME programs so as to optimize the chance of being funded. In other words, the relationship between CME providers and Industry is seen as too cozy.

Some solutions are offered by the authors. The one they seem to favor most is a compromise between today's mechanisms of allowing Industry to target specific programs they want to fund and the extreme of removing Industry funding from the CME space altogether: allowing companies to pay dollars into a common pool, which in turn is to be used by a third party to pay for CME programs deemed worthy and without either credit to or input from a company with an interest in the specific area being covered.

So, let's go with this solution. This means that for a private manufacturer the choice now becomes either to play in the common sandbox without any guarantee of a return on their investment (granted, even today the ROI is not supposed to enter into the CME funding calculus), or to get out of the CME funding game and invest elsewhere. If too many manufacturers should choose the latter, the whole CME game will be in trouble, and the physicians will need to pay for their own continuing education. In addition, if you think that meeting registration is expensive now ($400 to $800 in my experience), think what professional societies will have to charge once there is no Industry funding! The whole paradigm as it stands now may tumble.

I personally do not think that this solution is viable. Why not expect the manufacturers to be good corporate citizens and continue to contribute vast sums of money even without direct tangible benefits to them? Well, the answer is surprisingly simple: economic theory. The entire foundation of our capitalist free market theory is the idea of selfish utilities. Simply put, this theory maintains that people will act in their own best interests; this constitutes the rational decision making as promoted by free market economists. The fact that this is a theory that has never been put to a test does not keep our economy, philosophically and pragmatically, from being mired in greed and selfishness. What is the mission of the Boards of Directors of Industry? To generate and maximize profit. Period. Being a good corporate citizen is acceptable only as a by-product of this mission. And this is not a negative judgment of the Industry philosophy; this is the direction backed even by most liberal left-leaning economists in the US today.

OK, then why would we expect Pharma and device manufacturers to "donate" money that will not let them get ahead of their competition? We shouldn't. Having chosen to throw the dice of healthcare on the roulette wheel of free market competition, is it not hypocritical of us to ask that sector to play by different rules? Does it not make more sense to take healthcare out of the for-profit game altogether? I don't know about you, but to me the message is quite clear: by demanding a private industry to give money without an expectation of any ROI is completely at odds with the mission proscribed by free market economic theory. De-profitizing (yes, in fact, it is a neologism; any problem with that?) healthcare is the only solution that I see to remove this dissonance. This is one baby that needs to be thrown out with the bath water.

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