Pharma Support of CME at Lowest Level Ever Recorded!

Pharma Support of CME at Lowest Level Ever Recorded!

According to data maintained by the Accreditation Council for Continuing Medical Information (ACCME), in 2011 the percent of accredited CME revenue attributed to the pharmaceutical/medical device industry (i.e., grants, advertising, and exhibit fees) was 33.2% of total revenue received from all sources.

This is the lowest percentage attributed to commercial sources since ACCME began reporting these data in 1998 when the percent was 34.0%.

Refer to the infographic on left (find a full size view on my Pinterest page here).

These data refer to CME offered primarily to national or international audiences of physicians and other health care professionals by provider directly accredited by ACCME. It does not include data from state-accredited providers.

For the first time, the 2011 ACCME Annual Report Data features separate data sets about the CME delivered by ACCME-accredited providers and by state-accredited providers, offering an overview of the CME system at both the national and state levels.

Whereas the total commercial support for direct ACCME-accredited providers was $1.033 billion ($736 million in grants and $296 million in advertising and exhibit fees) in 2011, state-accredited providers received only $28.5 million from the drug industry ($16 million in grants and $12.6 million in advertising and exhibit fees).

As the last chart in the infographic shows, the trend in the percent of physicians opting for online CME continues to decrease. About the same number of physicians participated in ACCME-accredit CME programs in 2011 as in 2010 (approx. 11.4 million), but a lower percentage (37.8%) participated in online CME (not including live sessions and search learning). That compares to 40.1% in 2010 and a peak of 41.9% in 2009.

Why are fewer physicians participating in online CME activities? There were 25,000 online CME activities offered by ACCME-accredited providers in 2011 vs. 23,300 in 2012. The decline, therefore, cannot be attributed to fewer available activities.

UPDATE: Hat Tip to Mario Nacinovich (@nacinovich), Managing Partner, AXON, for pointing out to me that the CME numbers I quoted above should be bolstered after implementation of the FDA opioid safety plan (see "Drugmakers must pay for opioid continuing medical education programs for physicians").

The FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics (find it attached to above article) calls for "education for prescribers of these medications, which will be provided through accredited continuing education (CE) activities supported by independent educational grants from ER/LA opioid analgesic companies." Unfortunately, the training is voluntary and won't begin until March 2013. The grants may or may not impact the 2012 ACCME data and reverse some of the trends noted above.

Physician Bailout: On Average, Pharma Pays Every US Physician Over $750 Per Year

Physician Bailout: On Average, Pharma Pays Every US Physician Over $750 Per Year

The pharmaceutical industry has been very generous in making payments to physicians. Last year (2010), for example, a mere dozen pharmaceutical companies paid $760 million to physicians and other health care providers for consulting, speaking, research and expenses, according to ProPublica's "Dollars for Docs" project. ProPublica has taken "translucent" -- ie, difficult to analyze -- data reported by pharmaceutical companies and created a single database that makes comparisons simple (see here).

The database contains information about payments made to about 500,000 doctors. That's about half of ALL doctors in the US (including Peurto Rico). That works out to about $1,520 per doctor (or about $760 per EVERY doctor in the US), on average.

Of course, some doctors were paid MUCH more than this -- eg, pain specialist Gerald M. Sacks raked in $270,825 from Pfizer, Johnson & Johnson, Lilly and Cephalon in 2010, up from $225,575 in 2009. And some doctors received only $50 for lunch. At least 20 doctors, however, received "meals worth $2000 or more from Pfizer between July 2009 and March of this year," said ProPublica reporter Charles Ornstein.

According to the ProPublica database, Pfizer paid my doctor -- Catherine Spratt-Turner -- $388 for meals and $1,500 for speaking in 2010. This worries me because she wants me to come in and discuss my high cholesterol. Apparently, generic pravastatin is not doing the job and I suspect she wants to switch me to another anti-cholesterol medication. Will she suggest Pfizer's LIPITOR? I'll let you know when I see her. Previously, she was hot to get me on AstraZeneca's CRESTOR, which I resisted because of its published side effects. BTW, Spratt-Turner did NOT get any money from AZ last year.

This is exactly what worries some physicians who receive payments from pharmaceutical companies. As more and more searchable data becomes easily available to the public, they fear that patients will rebel and resist their advice if it appears that payments are influencing that advice. Oh, well! Welcome to the social media age!

The table above shows physician payments made by some pharma companies compared to sales. Surprisingly, Lilly spent about 2 times as much as did Pfizer despite having only about half Pfizer's sales volume. Perhaps Pfizer is more efficient than Lilly in targeting influential physicians? Nah! Viagra sales don't need much physician goosing to prescribe, whereas Lilly's Cialis needs as much help as money can buy. [I suspect, however, from the fees paid to pain docs like Dr Sacks, that Lilly is more concerned with promoting Cymbalta for pain.]

Overall, it appears that pharma companies tend to spread payments among physicians such that there is a more or less direct correlation between the number of physicians in a state and the amount of payments made to physicians in that state (see chart below).

Of course, $760 (or $1,520) per every physician is not going to improve a physician's lifestyle very much (although I am sure YOU and I would be happy to have an extra thou to spend every year!).

No, this money is central to what I call pharma's "prescribing recovery act" designed to grease the drug prescribing economy.

[This post originally appeared in Pharma Marketing Blog. 

Make sure you are reading the source to get the latest comments.]

ACCME's Dirty Little Commercial Funding "Secret"

ACCME's Dirty Little Commercial Funding "Secret"

Having nothing better to do on a Saturday morning, I posted results of my latest analysis of sources of Continuing Medical Education (CME) funding reported by ACCME (Accreditation Council for Continuing Medical Education) in its 2010 annual report (see "Pharma Support for Accredited CME Continues to Decline"). I was tardy in doing this yearly task -- the report was made public last July. Better late than never.

The real reason why I posted my ACCME analysis over the weekend, however, is because I had in my hands a study of physician attitudes about commercial support of continuing medical education that was going to be published on Monday and the data was relevant to the post I made after the study was published (see "Physicians Are Concerned About Pharma Support of CME, But Are Unwilling to Pay Their Own Way!").

In the meantime, Derek Warnick (@CuratioCME), CME Director at Curatio, an ACCME accredited medical education company (MECC), posted a response to my analysis of the ACCME data (see "Response to CME Post on Pharma Marketing Blog"). Derek takes issues with many points I made in my analysis, but the most interesting comment he made was this:

"I’m going to let you in on a little secret (although, if you work for an accredited CME organization, you probably already know this): those numbers used by the ACCME to report Total Commercial Support? Yeah, they’re not as cut-and-dried as you might think. Sure, you can look at them and say, “Hmmm... looks like MECCs are getting a LOT less commercial support.” But here’s the thing: the Total Commercial Support numbers you see only reflect the amount of commercial support given directly to the accredited provider sponsoring the activity [Derek's emphasis].

"So, if there is an activity that is co-sponsored by two accredited organizations, the organization responsible for certifying the activity is the organization that receives the commercial support. They then re-distribute the money to the other organization for their role in the activity. Typically, the organization that directly receives the commercial support reports the entire amount to the ACCME; the other organization doesn’t report anything. This has been my experience. The ACCME does allow the option of each organization individually reporting their split amount of the grant, but that gets pretty confusing if you have a lot of activities and lots of partners. The ACCME is fine with it either way; [Derek's emphasis] they just don’t want the money 'double-reported'."

This raises a couple of interesting question. First, however, let me say that this may not be as big a secret as Derek thinks.

In July, 2008, Pfizer announced that it would no longer directly fund CME courses provided by for-profit, third-party companies (MECCs) although it would keep paying for courses offered by medical schools, teaching hospitals and medical societies. Shortly after that, I hosted a survey (see "What's the Best Way for Pharma to Support CME?") that asked respondents if they thought all pharmaceutical companies should follow Pfizer’s lead. The following chart shows the results:

An anonymous respondent clued me in on the "little secret" Derek referred to in his post:

"Med schools, teaching hospitals, and medical societies frequently use MECCs to create their CME anyway, and unless CME is funded by pooled grants (ie, from multiple pharma companies), the bias will be no less than it is in the MECCs, or not much less."

Derek claims that because of this kind of "subcontracting," MECCs may not be getting as small a piece of the CME funding pie as I estimated from the ACCME numbers. Fair enough. But I note that only a small fraction of MECC respondents to my survey thought it was a good idea for other pharma companies to follow Pfizer's lead. That's understandable, because MECCs would have new academic bosses to deal with who may nickel and dime them. It's much better to get your slice of the pie direct from the baker than to beg a piece of someone else's slice!

I think Derek agrees with my analogy. He said:

"How often does this happen? Well, I can’t really speak for other companies, but my guess is it hapens (sic) a lot more frequently then it did 5 years ago. As already mentioned, the Pfizer’s and OMJ’s of the world no longer provide commercial support to MECCs. That eliminates a pretty big chunk of money that MECCs used to report to the ACCME. The alternative now is to find another accredited partner, such as a medical school or physician society, to co-sponsor the activity. That medical school or physician society is the accredited provider and they receive the commercial support. So in the past, where a MECC would have directly received a $100,000 grant from Pfizer (and reported it all to the ACCME), now a co-sponsor receives the $100,000 grant, reports it all to the ACCME, and then sends $50,000 to the MECC (or whatever the split is) for their role. That’s a $200,000 swing in how the commercial support is reported to the ACCME, when in reality the actual difference is only half that. Again, the ACCME is OK with this."

So, Derek and I agree that MECCs are losing more than just crumbs from the pie, but we differ on exactly how big the pieces really are. The more important issue, however, concerns bias. Is there any less bias in commercially-supported CME if industry funding in channeled through medical schools and medical societies to for-profit MECCs than if the funding went directly to MECCs?

Further reading:

• "Waning Pharma Support of CME: The Plight of For-Profit MECCs"

Physicians Are Concerned About Pharma Support of CME, But Are Unwilling to Pay Their Own Way!

Physicians Are Concerned About Pharma Support of CME, But Are Unwilling to Pay Their Own Way!

Talk about having your cake and eating it too! Commercial funding of continuing medical education (CME) and the potential for bias appear to concern many physicians, yet only a TINY MINORITY (7%) are willing to pay registration fees to eliminate or offset commercial funding sources, according to a report in the May 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Maybe physicians would like ObamaCME; ie, government subsidy of their education?

No, not quite. But they are willing to give up certain things to reduce costs such as eliminating a printed syllabus. They are not, however, keen to give up the free coffee and snacks!

The authors surveyed attendees at live CME courses delivered by the International AIDS Society–USA (IAS-USA), a nonprofit organization that pools the support it receives from industry so that no one company funds any particular program. In total, 770 attendees (a 57% response rate) completed the 22-item survey, which focused on beliefs about commercial funding and potential for bias, willingness to offset the cost of commercial support, knowledge about the costs of producing CME programs, and demographic information.

Although the study surveyed nurses, nurse practitioners, physician assistants, and persons with Ph.D.s or other academic degrees as well as physicians, I'll just focus on the responses from physicians (N = 378).

Potential for Bias
Although he authors never specifically define what they mean by "bias," I think we all know they are referring to influence over the content of CME courses in such a way as to benefit the commercial supporter.

There are several opportunities for bias to creep into CME, all of which involve money from drug and device companies:

• Faculty members' research may be supported by grants from companies
• Faculty members may be paid members of company speaker bureaus
• Faculty members may be paid directly to speak at CME programs
• The CME program itself is supported to some degree by a grant from a single or multiple companies

Of course, some CME programs are not funded in any way by the drug industry and is paid for entirely  from registration fees paid by physicians (the Institute of Medicine estimates that physicians, on average, spent slightly more than $1400 per year for CME in 2007).

The survey asked physicians how they would rate the bias of CME programs under each of these scenarios. The results are presented in the chart below:

This chart shows the percentage of physician respondents who believe the listed CME funding options have a moderate or large potential for bias.

According to the respondents to this survey, the least potential for bias in CME is when the faculty is completely independent; ie, receives NO funding of any sort from the drug/device industry. However, that is an unlikely scenario given the fact that perhaps 80% of the CME faculty pool receives some form of funding from pharma/medical device companies.

"Speakers will continue to have relationships with industry in various ways, especially for research funding," noted authors of a commentary that was published in the same journal as the report. "Bias will always need to be addressed through speaker disclosures and direct monitoring for bias at CME events."

Given that so many physicians feel that pharma support of CME introduces bias, you would think they would want to eliminate that support. Actually, only 17% of physicians surveyed agreed strongly or somewhat that commercial support of CME should be eliminated entirely (see chart below) and 56% agree that "Pharmaceutical/medical device company support is essential for accredited CME and should not be eliminated" (data not included in following chart).

Physicians were asked what they would be willing to do to "eliminate the need for pharmaceutical/medical device company support" of CME activities they attended. The choices are shown in the list in the above chart.

Only 50% of physicians would give up free food or snacks to eliminate the need for commercial support of CME. BTW, these costs are substantial. Hotels -- where most live CME programs are held -- charge as much as $8.47 for a cup of coffee! "A $9 cup of coffee may not seem to be the most economical use of CME dollars," noted the authors of the study.

It's the Internet Age, Stupid!
Reducing the cost of CME seems to be the best way to eliminate the need for commercial support.

"Barring a substantial reduction in the cost of delivering CME, however, a rapid reduction or elimination of funding might be unacceptably disruptive, and some have postulated that such a change will result in the disappearance of live CME as we know it..." said the authors.

What better way to reduce costs than by delivering CME via the Internet? The survey did NOT ask if physicians would participate ONLY in online CME programs if that meant eliminating the need for commercial support. In fact, more and more physicians are receiving CME credit online (see "Pharma Support for Accredited CME Continues to Decline").

Yes, delivering CME via the Internet would "result in the disappearance of live CME as we know it," but that's a good thing, not a bad thing, given the exobitant costs and biases in the CME as we now know it, IMHO.



Summary of Survey Results

Pharma Support for Accredited CME Continues to Decline

Pharma Support for Accredited CME Continues to Decline

Pharmaceutical industry support - ie,  direct sponsorship PLUS advertising - of physician continuing medical education (CME) declined 13.3% in 2009 compared to 2008. This is based on income data (see here) provided by the Accreditation Council for Continuing Medical Education (ACCME). This marks the second consecutive year of decline as shown in the following chart:

The following chart illustrates the trend in both types of CME income (direct commercial support AND advertising income) that CME providers receive from pharmaceutical companies:

The pharma industry supports CME by funding different types of ACCME-accredited CME providers. These include for-profit Medical Education Communications Companies (MECCs), medical schools, and physician societies. The following chart shows how this funding has changed over the years:

Physician societies and medical schools continue to take pharma CME money away from MECCs as shown in this graph:

Online CME Trends
Meanwhile, the percentage of physicians who receive CME credit online continues to increase, albeit at a slower rate -- at least for the time being -- as shown in the following chart:

The above chart includes physicians who participating in "Enduring" online CME activities, which ACCME defines as: an Internet that is "available when the physician participant chooses to complete it. It is 'enduring,' meaning that there is not just one time on one day to participate in it. Rather, the participant determines when he/she participates. (Examples: online interactive educational module, recorded presentation, podcast)"

The chart does NOT include physicians who participate in "Live" Internet CME; ie, "an online course available at a certain time on a certain date and is only available in real-time, just as if it were a course held in an auditorium. Once the event has taken place, learners may no longer participate in that activity. (Example: webcast)"

In 2009, only about 38,000 physicians participated in live Internet CME courses compared to 4.5 million physicians participating in enduring online CME.

NOTE: These numbers refer to the number of registered attendees of CME events. Some physicians may attend more than one course and thereby be counted more than once.

Internet Searching and Learning
A third type of Online CME defined by ACCME is "Internet Searching and Learning," in which about 116,000 physicians participated in 2009. This is a CME activity "in which a learner accesses the content of the activity directly from the internet. This is differentiated from a 'course' and an 'enduring material' because the provider does not create the content but rather the learner chooses content based on what (s)he feels meets their needs or answers their questions."

Wow! Physicians can get CME credits just by searching for medical information on the Internet. No wonder Wikipedia has become an important source of information for physicians!

For-profit MECCs were responsible for 99.5% of physicians (115,324) who received "Internet Searching and Learning" CME credits.

I suppose MECCs draw up a list of multiple-choice questions that physicians must answer after searching the Internet. Perhaps they are directed to search certain sites such as WebMD or Wikipedia. It's likely that nobody reviews this information to determine if it is "unbiased." It's possible, therefore, for pharma companies to publish non-peer-reviewed content on these sites and thereby "game" the process and not be held responsible for sponsoring "biased" CME content.

P.S. The 2010 ACCME annual report will be available sometime this July at which time I will update these charts.

A Breast Cancer Patient's Painful, Difficult Therapy Choice: Generic vs. Brand?

A Breast Cancer Patient's Painful, Difficult Therapy Choice: Generic vs. Brand?

Since this is national Breast Cancer Month and I am forced to watch NFL linebackers wear pink shoes and mouth guards, I thought it would be appropriate to discuss an issue that just came up in comments to my post about Sanofi-Aventis, Taxotere, and the disgruntled patient (see "Should Sanofi-Aventis Submit an Adverse Event Report Based on 'Disgruntled Patient's' Comments to VOICES FB Page?" and comments).

An anonymous comment to that blog post opened my eyes about issues facing breast cancer patients beyond what I believe many proponents of the "pink" promotional campaign envisioned. Here's the comment:

"It's not just one disgruntled cancer survivor. There are over a hundred of us. Of course, there's no promise that our hair would grow back. GENERALLY grows back. Well for those of us who battled breast cancer but are forced to look at our bald selves in the mirror every day, "generally" isn't good enough. Yes, we're alive. I'm grateful for that. But again, no promise of how long...and with small children, that's another painful reminder of what I've been through. The thing about S-A and Taxotere is this: there's another drug, Taxol, which doesn't cause this permanent alopecia we're dealing with. But we were never told that there was a choice. And what do you think I would have chosen if I'd had a choice? I'm in my early 40s so dealing with permanent alopecial is especially difficult. I have a job in a senior management position. Hard to earn respect when I look like Ben Franklin. We're not mad that Taxotere caused us to experience permanent alopecia...we're mad that we weren't given the choice of the more hair-friendly medication. And why is that? Our oncologists didn't even know. Don't you think they should be made aware of this fact?"

To which I responded:

"While I am not knowledgeable regarding the benefits vs risks of one treatment vs another, shame on your oncologist for not knowing or caring enough to offer you a choice!"

This gave me an idea of how important hair loss can be to breast cancer patients, something that other commenters to my blog post dismissed by saying things like "you should be happy you are alive," etc. Do many pharmaceutical marketers realize this? My friend Rich Meyer thinks not. "Pharma’s priority is still spreadsheets not patients," says Rich (here). "Patients are leaving pharma marketers behind and pharma marketers act like they still matter."

But is Taxol really better than Taxotere with regard to hair loss? To answer this question, I used Google to search on "taxol vs taxotere" and found some interesting online forums and discussions devoted to the issue. Here's a representative post by "billsgirl" that I found on the community.breastcancer.org/ site:

"I have one more A/C tx 2/22, and have done really well with little se to complain about. Now I must decide which Taxane I should go with. I'm leaning toward taxotere because my onc agrees that the bone marrow issues would be easier for my body to tolerate given my positive experience with the A/C, rather than risk neuropathy.

"Also, what about the hair? I've read some who said their hair started growing back after A/C and through T. I've read some scary stories about permanent hair loss. I'd hate that - I mourned my heai more than my breasts (I know that's odd...)

"I'd love your comments. Anything to help me make my decision."

What "help" did "billsgirl" get? There were several somewhat helpful comments and encouraging posts in this forum, but none really answered the question about which drug is best.

On www.medhelp.org -- a Cleveland Clinic "partner" -- I found a similar question by a patient ("Pam") and an "answer" from a physician.

"This forum is just fantastic!! Thank you Cleveland Clinic and Med Help Int'l. for giving people like me a reliable place to ask questions!!!

"My question is: Can you tell me the difference (if any) between Taxol and Taxotere? Does one work better than the other for particular types of breast cancer? My doctor suggested Taxotere, but didn't really give me a good explanation as to why. Your thoughts will be most appreciated."

Doctor's Answer:

"Dear Pam, Thank you for your complimentary comments regarding this Forum.

"Taxol (paclitaxel) and Taxotere (docetaxel) are both from the same family of medications - the taxanes. Both of these show a high level of activity when used as single agents in metastatic breast cancer.

"In reviews of reported studies, when compared with standard therapies Taxotere looks to be the most active single agent in treatment of metastatic breast cancer.

"There are some differences in the treatment schedules of the 2 medications, and there are some differences in the side effects of these 2 medications. I have listed the side effects of both medications.

"Taxotere: decrease of white blood cells, red blood cells and platelets, flu-like symptoms, fluid retention, numbness and/or tingling to fingers and toes, muscle aches or bone pain for a few days after each treatment, mouth sores, hair loss, decreased appetite.

"Uncommon Side Effects: allergic-type reaction, blood pressure and heart rate changes, nausea and vomiting, diarrhea, skin rash usually occurs on hands and feet, nail changes, menstrual cycle may become irregular or stop permanently, menopausal effects including hot flashes and vaginal dryness. Decreased desire for sex during treatment.

"Taxol: decrease of white blood cells, red blood cells and platelets, allergic-like reaction, blood pressure or heart rate changes during the infusion of the medication, mouth ulcers, numbness and/or tingling to fingers and toes, muscle aches or bone pain for a few days after each treatment, mouth sores, hair loss, diarrhea.

"Uncommon Side Effects: nausea and vomiting, nail changes, menstrual cycle may become irregular or stop permanently, menopausal effects including hot flashes and vaginal dryness. Decreased desire for sex during treatment."

Hair loss is mentioned (buried) as one side effect for both drugs.

So, I am still not sure that Anonymous was correct in her assertion that Taxol does not cause hair loss. But it's clear that her oncologist didn't offer her the kind of comparison that was offered to "Pam" online. Could it be that her oncologist had a conflict of interest? I suggested that in my response to Anonymous:

"It's my understanding that oncologists often make a profit 'reselling' these drugs. Obviously, in that case, they have a vested interest in offering patients the drug that gives them the highest profit. I do not know if Taxotere and Taxol differ in this respect."

What I DO know is this: Taxol is a generic medication and Taxotere is a brand medication. And back in 2007, Sanofi-Aventis, which manufactures and markets Taxotere, received a letter from the FDA warning the company not to make superiority claims for Taxotere vs. Taxol (see here).