The American Medical Student Association (AMSA) launched the first PharmFree Scorecard in 2007 with the 2013 Scorecard being its sixth iteration. Since its inception, the AMSA Scorecard team has been committed to objectively evaluating conflict-of-interest policies and curricula at the 158 allopathic and osteopathic medical colleges in the United States and Puerto Rico.
A large body of evidence shows that conflicts of interest between the medical profession and industry can negatively influence medical care. For instance, studies have shown that conflicts of interest threaten the trust at the heart of the doctor-patient relationship. Unregulated marketing influence on medical education can also increase health care costs by increasing the use of treatments that are more expensive but no better than alternatives—allowing profit motives to potentially take precedence over the interests of patients. Medical schools and academic medical centers have been leaders in setting new standards for policies to regulate potential conflicts of interest, as supported by strong guidelines set by the Association of American Medical Colleges (AAMC) in the summer 2008 and the Institute of Medicine in spring 2009. The Scorecard provides an opportunity to highlight many of these accomplishments.
As the Scorecard continues to be revised and expanded, awareness of conflict of interest issues has also steadily risen across the country. Public pressure to disclose conflict of interests is highlighted by the recent finalization of rules governing implementation of the Transparency Reports and Reporting of Physician Ownership or Investment Interests section of the Affordable Care Act (the “Sunshine Act”) by the Centers for Medicare and Medicaid Services (CMS). This legislation requires manufacturers of pharmaceuticals and medical devices to report to CMS their financial ties to physicians and teaching hospitals in categorized domains. For years, the Scorecard team has been awarding higher scores to institutions that are already voluntarily disclosing this information.
The Scorecard is an evolving tool for assessing the policies of academic medical centers and medical schools in terms of interactions between students, faculty, and the pharmaceutical and medical device industries. Using letter grades to assess schools’ performance in eleven potential areas of conflict, the Scorecard offers a comprehensive look at the changing landscape of conflict-of-interest policies across U.S. medical education, as well as in-depth assessments of individual policies that govern industry interaction. The major focus of the Scorecard is to examine the potential for conflicts of interest to impact medical education at the level of the trainee. Of note, the AAMC guidelines discussed above also address institutional and research conflicts of interest that are not evaluated specifically in the AMSA PharmFree Scorecard.
In the coming year, the Scorecard will undergo a major revision in its methodology in an effort to guarantee it remains a relevant and state-of-the art tool for evaluating conflict of interest issues at medical schools and expanding this evaluation to teaching hospitals. Revisions will include a new formula for assessing academic medical centers as well as the framework for grading schools and teaching hospitals. These changes will help to ensure that the Scorecard can continue to push schools to emphasize clinical education and medical care above all other interests, particularly those that could distract from the provision of evidence-based and patient-centered care.
For an archive of the 2008, 2009, 2010, and 2011-and 2011-2012 policy assessments, please go to the bottom of the main Scorecard page at www.amsascorecard.org and click on 2008, 2009, 2010, and 2011-2012 Policy Archive.
As of April 9, 2013, 153 out of 158 medical institutions considered eligible for grading have participated in the Scorecard, a 97% participation rate, improved from 92% in 2009
Of these 158 US medical schools, 40 receive “A”s (25%), 74“B”s (47%), 14 “C”s (9%), and 13 “D”s (8%).
13 schools (8%) receive a grade of F. This includes three schools that submitted policies graded as F, two schools that stated they had no conflict of interest policy in place, and five schools that did not respond to repeated attempts at follow-up in 2008, 2009, 2010, 2011-12 and 2012-2013. Three additional schools received an F as they did not submit new policies or demonstrate a continuing policy development process after remaining In Process for one year.
Assigning a score of F to the three schools which have not submitted policies may slightly overestimate the true prevalence of inadequate policies. Nevertheless, it seems likely that most of the schools that have chosen not to participate do not have strong policies.
Three schools (2%) received a grade of In Process. The schools were granted an In Process grade due to ongoing policy development with completion expected in the next year. This includes schools that matriculated their first students in 2011, and are thus still in the two year grace period for new schools.
In 2012-2013, there is a continued increase in the number of medical schools that now have grades of A or B from over two-thirds in 2011-2012 to over 70% this year. This is yet another tremendous year-to-year increase in schools with "model" policies. In 2011-2, there were 102 A and B schools (67%), 79 A and B schools in 2010 (52%) and over 45 A and B schools (30%) in 2009 compared to 115 today. This demonstrates a new baseline for the management of conflict of interest in medical schools in the United States.
Approximately eight percent of U.S. medical schools improved their conflict-of-interest policies since the 2011-2012 Scorecard was released in March 2012.
There are a number of schools who have made great strides this year.
Three schools deserve particular attention for submitting newly drafted strong policies during their “In Process” grace period changing their grades from Is to As and Bs. These schools are: University of Connecticut School of Medicine, Oakland University William Beaumont School of Medicine, and the Commonwealth Medical College. Both Oakland William Beaumont School of Medicine and Commonwealth Medical College received an A for their policies while the University of Connecticut School Of Medicine received a B.
In addition, ten other schools improved by at least letter grade: University of Arizona College of Medicine, Washington University School of Medicine, University of Colorado Denver School of Medicine, Creighton University School of Medicine, University of South Carolina School of Medicine, Pennsylvania State University School of Medicine, Albany Medical College, Indiana University School of Medicine, Wake Forest University School of Medicine, and University of Central Florida School of Medicine.
In 2013, the number of model policies increased in almost every domain evaluated by the Scorecard. In comparison to years prior, however, it does appear that the number of schools adopting model policies has decreased as there are fewer schools with less than ideal policies. The rate of adoption of model policies has decreased especially compared to last year which may also be attributed to the shorter time period between fifth and sixth iteration (March 2012 – April 2013) of the Scorecard as compared to the time period between the fourth and fifth iteration (December 2010 – March 2012).
Similar to the results of the past, the areas that garnered the greatest number of perfect scores were those addressing industry support of scholarships, off-campus continuing medical education, faculty participation in industry-speaking relationships, purchasing and formulary committees, and gifts. Industry support of scholarships experienced the largest net growth in achieving perfect scores in this domain (15 additional medical schools). New areas being addressed by schools include samples as well as purchasing and formula committees. The growth in ideal policies on speaking arrangements is striking as there are clearly an increasing number of schools banning or severely restricting participation in speakers’ bureaus (44 in 2013 versus 31 in 2011-2).
This year, 18 schools have banned participation by their faculty on speakers’ bureaus. These schools are: Harvard Medical School, New York University School of Medicine, Duke University School of Medicine, Columbia University College of Physicians and Surgeons, University of Arkansas School of Medicine, University of Maryland School of Medicine, Georgia Health Sciences University, University of South Carolina School of Medicine, University of Hawai’i John A Burns School of Medicine, Creighton University School of Medicine, Wake Forest University School of Medicine, University of Massachusetts Medical School, Emory University School of Medicine, Stanford University School of Medicine, Albert Einstein College of Medicine, University of Alabama Birmingham, University of Florida and Jefferson Medical College.
Once again, on-campus continuing medical education and the access of sales representatives remain a challenging area. Only three schools ban sales representatives, University of South Dakota Sanford School of Medicine, Florida State University College of Medicine, and the Commonwealth Medical College. The two former schools, however, state that their policies only apply to a small subset of areas where there students train.
The following is a list of domains and the number of perfect scores in each:
Californian medical schools continued to excel with 7 of their 10 schools receiving an A grade. This is in part due to the strong system-wide University of California (UC) conflict of interest policy, which when graded on its own receives an A grade. However, some of the UC schools go even further by supplementing the system-wide policy with their own regulations. In addition to the UC schools: Stanford maintains an A grade, Loma Linda University Adventist Health Sciences Center keeps its B, and Touro College of Osteopathic Medicine still has a C grade. Western University of Health Sciences, however, did not send updated policies this year and retained their grade from the year prior of an F.
Texan schools continue to show significant improvement. All eight Texan medical schools score at least a B. University of Texas Medical Branch at Galveston, however, remains the lone A in the Lone Star state.
Another major training ground, Massachusetts, continues to show case schools with model policies. This year, University of Massachusetts Medical School and Boston University both received a B grade while Harvard Medical School and Tufts University School of Medicine both received an A grade.
The nine Pennsylvania medical schools have strong policies with University of Pittsburgh Medical Center, Pennsylvania State University College of Medicine, University of Pennsylvania School of Medicine leading the way with A grades. The Commonwealth Medical College in Scranton, PA went from being In Process to also receiving an A grade. The remaining schools received a 3 B's, a D, and an F. In Maryland, all three schools (Johns Hopkins University, University of Maryland, and Uniformed Services of the Health University) received a B grade or higher.
Finally, the state of Florida continues to perform well. University of Miami Miller School of Medicine received the first A grade in the state in 2010, followed by University of Florida in 2011-2012 and is now joined by University of Central Florida School of Medicine. Otherwise, the state has 3 B schools and 1 other school In Process. Of note, Lake Erie College of Medicine, which has received an F, has a branch campus in Bradenton, FL.
The PharmFree Scorecard methodology was developed jointly by AMSA and the Pew Prescription Project, an initiative of the Pew Health Group. Assessed domains are broadly consistent with those identified in recent literature – primarily Brennan et al. Health Industry Practices that Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers. JAMA 2006; 295(4): 429-433. A qualitative decision-tree instrument is used to capture key criteria within each domain.
The Scorecard assesses policies related to: acceptance of gifts and meals from industry; consulting relationships; speaking relationships; disclosure of financial conflicts; pharmaceutical samples; individuals with financial conflicts participating in university purchasing decisions; financial support for educational events (on- and off-campus); industry support for scholarships and trainee funds; access of industry sales personnel to medical school or hospital personnel; and inclusion of education about conflict of interest within the academic curriculum. Additionally, the presence of oversight and sanctions is examined, but not included in grade calculation.
Each year, every school is invited to submit new or updated policies for assessment. Institutions that do not submit policies are assumed to be unchanged from the prior year, and retain an unchanged assessment. Schools that decline to participate after multiple attempts at follow-up receive a grade of F. Any institution submitting a formal notification that its policies are currently under review receives a grade of In Process (I), which may stand for up to one year. Institutions reviewing specific components of polices will retain their most recent grade with a note on current progress and their score evaluated upon implementation of the new policy. After a year of being In Process, if a school does not submit either policies for evaluation or a description of their progress in developing such policies, they receive a grade of F.
Two blinded assessors independently score each set of policies in the eleven areas included in the scorecard. The letter grade is derived using a formula based on cumulative domain scores. An institution may request an explanation or re-assessment of its score if policies change or if it feels it has been scored inappropriately by contacting email@example.com.
The Scorecard serves not only to measure the strength of policies, but also to provide a valuable resource for institutions to develop and refine new policies. The inclusion of full text policies on the website (where permission has been given) will facilitate this goal.
Suggested Citation: AMSA PharmFree Scorecard 2011-12. <<Title of Web Page>> (online), <<URL of Specific Web Page>>, Reston, VA: American Medical Student Association <<Date Accessed>>.