Accreditation Council for Continuing Medical Education-accredited CME providers appeared to have had a tough year in 2011, according to the recently released ACCME Annual Report Data 2011 . While a change in the reporting requirements makes it difficult to compare numbers year over year, it appears that the trend for commercial support, which hit its peak of more than $1 billion in 2008  and has been falling since, has now declined to $736 million.
Total income, which had been holding its own due to increases in exhibit fees, advertising, registration, and allocations from parent organizations, also appeared to take a hit in 2011. While advertising and exhibit income crept up 4 percent over 2010  and the “other income” category was up 7 percent, it wasn’t enough to keep total income from hitting $2.2 billion, which is a slide of just 1 percent. Interestingly, the incomes that don’t fall under exhibits, advertising, or commercial support now make up 53 percent of the total income, compared to not quite 42 percent just four years ago. All categories except for nonprofit physician organizations saw increases in this income in 2011.
However, take the total income and commercial support news with a big grain of salt: The 2011 commercial support and total income numbers likely are artificially low because, beginning in 2011, the ACCME now asks providers to report in-kind support such as equipment, supplies, and facilities qualitatively, not quantify and include it in their commercial support reporting as had been the case in the past. It is unknown how big a piece of either pie that in-kind support represents, Because there was no standard way in which organizations tracked and reported the dollar value of in-kind support, the ACCME excluded it to improve the data quality.
Also note that the 2011 data show that 79 percent of CME activities, attended by 80 percent of physician participants and 75 percent of nonphysician participants, were not commercially supported. Murray Kopelow, MD, ACCME chief executive, adds that 20 percent of activities produced by ACCME-accredited-providers are commercially supported and about 60 percent of all accredited providers accept commercial support; the other 40% do not accept support from commercial interests. “Those who say that commercial support drives the curriculum of accredited CME need to get this data so they can recraft their thoughts,” he says. In addition, he says, “It’s not about who funds it—whether it’s doctors or government or companies—it’s about starting with the learner’s professional practice gaps and discovering what causes the gaps. How can anyone say there’s something wrong with CME funded by the companies that make long-acting and extended-release opioids to address data that the government has given us and educational directives the government has given us?
The report, which the ACCME has published since 1998,  provides an annual snapshot of the US. CME enterprise, including CME program revenue, funding, participants, activities, and activity formats. The 2011 report is the second generated using the regulator’s Program and Activity Reporting System, also know as PARS, a centralized Web-based system the ACCME used to collect and manage its accredited providers’ activity and program data. The latest report also is the first to include combined data from ACCME- and state-accredited providers. This is because the state medical society system and the ACCME system have strengthened their alignment during the past decade, in particular during the past 3-5 years, says Kopelow. “All providers follow the same Standards for Commercial Support and accreditation criteria, the state medical society accreditors use the same definitions and quality controls as the ACCME. The accredited CME enterprise is in fact these 2,000-plus organizations. This is now very much a unified system.”
According to Kopelow, the most important takeaways are not about year-over-year comparisons of total revenue or commercial support, which he notes are relatively stable. Though, he does add, “Stability, given what’s going on in the world right now, is remarkable.” More important is the sheer size of the combined ACCME-accredited and state-accredited CME enterprise, including a million hours of instruction and more than 130,000 individual activities, which in addition to CME professionals is run by an estimated 20,000 to 30,000 volunteers. And, he adds, the CME system has to come up with a new curriculum every year, and find the funding to keep going, unlike medical schools and residency training programs funded by tuition.
Slicing the Pie
For ACCME-accredited providers, publishing/medical education companies still lead the pack in commercial support dollars, though they too saw a drop of almost 9 percent over the previous year. The runner-up, the medical school category, was down 13 percent, as were medical associations and societies, which saw an almost 22 percent decline. One would have to assume that the in-kind support for government and military CME providers represents a hefty chunk of the decrease that category saw in commercial support, which dropped from almost $260,000 to $26,650. Then again, less than 1 percent of government and military providers’ total income comes from commercial support, so it’s likely not a big issue for them either way. Hospitals, insurance companies, and other nonprofits also reported decreases in commercial support in 2011.
A category of ACCME-accredited providers called “not classified” seems to be the biggest beneficiary of commercial support, getting the largest percentage of its revenues from commercial support and producing the largest percentage of commercially supported activities. Nonprofit associations are on the other end of the scale, receiving the second-smallest percentage of their revenues from commercial support and putting on the second-fewest commercially supported activities (behind government and military providers). Medical schools, which get about half of their income from commercial support, use it to produce only about 20 percent of their activities.
Not surprisingly, total income also was down for most ACCME-accredited provider types, though publishers/medical education companies and hospitals managed to squeak out slight 2 percent and 3 percent increases, respectively.
Fewer Providers, More Non-Doc Participants
There were seven fewer ACCME-accredited providers in 2011 than in 2010—687, down from 694—continuing a several-year downward slide from the high of 736 in 2007. The industry also lost 58 state-accredited providers, bringing the total to 1,392, or a combined total of 2,079 state- and ACCME-accredited providers last year. While some believe the rising cost of accreditation may be a factor, Kopelow says that external benchmarks say that less than 2 percent of an organization’s expenses should be spent on accreditation, licensing, and other regulatory concerns. If you divide the overall expenses of the CME system with the ACCME’s approximately $5 million budget, it comes out to two-tenths of 1 percent. “The amount the ACCME receives out of the process is very low,” he says.
According to the report, most of those who have voluntarily withdrawn their ACCME accreditation were nonprofit physician membership organizations, publishing/education companies, and hospitals/healthcare delivery systems. Mergers, acquisitions, and other corporate changes were behind most of the reasons they gave to ACCME for leaving. The report also notes that some smaller providers decided to jointly partner with larger accredited organizations rather than remain accredited providers themselves, so there’s no net loss to the physicians and other healthcare professionals looking for opportunities to get accredited CME.
In fact, the number of activities held by ACCME-accredited providers in 2011 has bounced back 8 percent after last year’s 14 percent drop, which capped a trend that began in 2007 when the number of activities offered by accredited providers peaked at 113,000. With more activities come more hours of instruction, not surprisingly: These also were up, though just a scant 1 percent, unlike the number of physician participants, which dropped about 1 percent. While it pales in comparison to the 16 percent increase in nonphysician participants that appeared in the 2010 report, an additional 1 percent of other types of healthcare professionals were attending activities from ACCME-accredited providers.
The most-offered type of activity was courses, followed by online enduring materials, with the bulk of both being provided by publishing/education companies, medical societies, medical schools, and hospitals, though all provider types included these in their 2011 programs. While many believe the future belongs to performance-improvement CME, that future may still be a way off: The number of PI-CME activities did rise, but only from 168 to 252, including both those that were directly and jointly sponsored.
Kopelow points out that the 2011 data also illustrate an ongoing trend toward CME that provides practice-based learning that results in measurable improvements in competence, performance, and patient outcomes, and that it’s being done in the multimodal, multiformat way the literature says is most effective. While courses and regularly scheduled series (live CME activities including lectures) do still dominate, and ACCME does not try to quantify how interactive these courses are,more than half of participants are now engaging in other forms of CME, including live Internet activities and online enduring materials. “People go on a learning journey when they have an issue they want to solve,” says Kopelow. They may begin gathering information by attending large medical congresses and reading journals, but then they move on to the next stage where they interact with colleagues and experts to develop new strategies.
“The accredited provider should reflect on the data that describe the whole enterprise to see if there is a skew toward large-group, synchronous activities that focus on the first stage of learning,” he says, and think about developing more activities in formats that correlate with different stages of change. “As we improve our ability to measure change, I believe we’ll find incremental improvement as learners go through the stages.”
Previous ACCME Data Report Writeups
CME Income Grows Despite Shrinking Commercial Support
Commercial Support Drops Again in 2009
CME Funding Down (2008 Report)
CME Funding Growth Rate Plummets (2007 Data Report) 
CME Funding Growth Slows (2006 Data Report)