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FUNDING CME
Continuing medical education (CME) is one of the three components
of professional development. The other two are formal medical education
and vocational training. While these two are supported and funded, the
funding of CME in Singapore continues to be laissez faire and dependent
on the vested interest of the free market.
A recent editorial of the British Medical Journal (24th January 1998) has highlighted the need for CME to be ‘more effective, accountable and responsive to all stakeholders in health’. Patients and third party payers have as much interest to ensure that doctors practise not only competent but cost-effective medicine.
CME in Singapore has hitherto been dependent on the largesse of pharmaceutical companies. There is a need for a re-look. The Singapore Medical Association (SMA) and the Singapore Association of Pharmaceutical Industry (SAPI) have recognised the need for a better use of the funds provided by pharmaceutical companies for CME. A joint committee of the two Associations formed after the joint conference held last year is now preparing guidelines on how CME should be organised and funded.
These guidelines address the ethical use of market place CME. We hope that this joint SMA-SAPI guideline, which will be published later this year, would result in better use of the funds ear-marked for CME by the industry. There is no running away that as in most countries, the funding of CME activities from the pharmaceutical industry is important.
Healthcare institutions also need to openly set aside funds for effective CME. These institutions have to set aside a portion of their revenue for CME, separate from funds used for marketing their facilities. Funding CME directly from revenues must be seen as part of their national responsibilities to ensure better healthcare for our people. The problem of ‘orphan’ CME activities must also be addressed. These CME activities such as the teaching of basic clinical skills may not attract commercial funding, as they are not products related. This ‘catch-22’ situation means that they are organised only if attendees are willing to pay the full cost for staging these CME activities as there is a lack of direct funding. This explains why there is a paucity of such learning and teaching programmes.
Doctors too must budget the resources to be used for their own CME. Doctors must be prepared not only to pay the course fees but also pay for medical cover of their practices when they are away on course or doing CME activities.
Patients would have to accept their doctors’ absence occasionally. Many GPs may also find this arrangement difficult to adopt. The SMA has received complaints against a GP who declined to register non-urgent patients who appeared after scheduled consultation hours in the afternoon session. This GP had to rush off in between the afternoon and night sessions to attend tutorials for his Master of Medicine (Family Medicine) programme conducted by the University.
The Byzantine tax-exempt policies for CME activities have also to be
looked into. Tax exemption is not allowed for monies spent to attend formal
medical degree or diploma courses. The explanation is that these are capital
expenses-investment that do not qualify for deduction from operational
expenses. What about other CME activities then? Presently, claims are allowed
only if written exemption is granted after bureaucratic shuffling of documents
through professional associations, the Ministry and the Inland Revenue
Authority.
As a result, few doctors bother to apply for such exemptions. The few that do, apply only for ‘big ticket items’ such as conferences held overseas. Ironically, those doctors who have incorporated their practices as private limited companies and probably could well afford it, have less of a problem. There is an urgent need to address this anomaly. Those in authority should work out a system with the tax authorities in which blanket tax exemption could be given for CME activities organised by accredited local medical institutions.
Is there a role that the state can play? In the United Kingdom, general practitioners are paid since 1990 CME allowances equivalent to ‘just under 5% of the GP’s intended net remuneration’ if they attend certain CME activities. If this notion of monetary reimbursement is foreign to us, could funds be channelled directly to the organisers to make CME more affordable?. We have a National Medical Research Committee funded from State coffers to co-ordinate and spearhead medical research. Should we not have a National CME Committee similarly endowed?
This committee can harness the resources of the various stake-holders involved in delivering and monitoring CME. The Singapore Medical Council, the Academy of Medicine, the College of Family Physicians, the University, the various medical institutions and the SMA can be brought together for this national endeavour.
Adequately funded, this committee can develop a system of monitoring and accrediting effective CME. It can also explore ways of delivering CME through media such as the broad band highway now developed by the Medical Faculty through its collaboration with Health-One. SMA has collaborated with the Medical Faculty to put the full-text of articles from the Singapore Medical Journal on the Internet (see N1). This collaboration could with appropriate funding be extended to exploit Internet technology to deliver interacting lectures and courses directly to our doctors’ homes. This new initiative would enhance Singapore as the medical hub for the region. Doctors in neighbouring countries can also similarly benefit from our CME activities delivered through the Internet.
The Ministry has recognised the need for special funding for research, formal medical education and vocational training. We hope that this can be extended now to CME.