Since the early 1990s, US CME providers have partnered directly with the pharmaceutical or device industries to obtain financial support.7,8 By 2006 concerns about bias and the promotion of off-label uses of some pharmaceuticals in CME were raised.7–9 In 2009, after an AMA report of these unethical practices, more restrictive policies pertaining to CME content and the nature of partnership with industry were introduced by the ACCME, resulting in a reduction of direct industry funding of CME activities.8,10 Unfortunately, this reduction was not offset by a corresponding increase of funding from other sources.10,12 To fill the funding gap, CME providers in the USA entered into joint provider agreements with MECCs.3,13 MECCs are independent, privately held, education companies, most of which are for-profit entities.14,15 These companies are funded mainly by large US pharmaceutical and device manufacturers,13–15 and MECCs tend to be part of larger public relations organisations for these manufacturers.13,14 MECCs help CME providers design online and live conferences in addition to educational tools and printed material.9,13 But payments by MECCs to accredited CME providers are not subject to transparency laws designed to combat industry influence on physician behaviour, including the 2013 Physician Payment Sunshine Act that mandated public reporting of all financial payments by industry to physicians and teaching hospitals.15–17 Although MECC sponsor names are disclosed during educational activities, their relationship to industry is seldom transparent to audience members. Thus, educational grants from industry are given to MECCs, who, in turn, award it to CME providers in a joint provider activity. This mechanism ensures that industry indirectly stays involved in the educational activity but exempts the industry sponsor from reporting their role and any payments to the CME provider. Since CME providers are financially dependent on MECCs, their obligation towards maintaining the joint provider relationship raises the spectre of a conflict of interest that impugns the integrity of the CME content. Furthermore, even though CME content can influence the prescribing habits of physicians, physicians’ practice groups, as recent as late 2016, were lobbying to increase exemptions to the Sunshine Act.18
The risk of conflicts of interest presented by joint partnerships is not unique to the USA. A 2016 report of pharmaceutical payments to physicians in the UK revealed that up to a third of payments are made for consultancy and service fees, with a large portion going for payments related to educational events, including travel and admission fees to CME events.19 A 25%
increase in payments made to UK physicians in 2016 confirms an ongoing relationship between industry and physicians in the UK.6 Strategies are needed to eliminate ethical concerns related to MECC financial contributions to joint provider activities in the USA and could be a model for the international CME landscape, especially with a burgeoning CME provider sector in Europe.5
In our view, ethical considerations concerning joint provider activities should focus on the undue influence of industry involvement in CME content through joint provider arrangements with CME providers. The solutions proposed (panel) address three ethical concerns. First, joint provider activities are exempt from US transparency mandates and can result in a potential avenue for introducing industry bias in CME activities. Second, payments to CME faculty from MECCs could influence content and prescribing habits. Third, the ACCME has insufficient resources to evaluate the integrity of CME content, and relies mostly on CME providers themselves who are also engaged in joint provider activities. Only by implementing strategies, such as those outlined in the panel, can these ethical problems with CME be confronted.
