1. CME Market Info Glenn Laudenslager, August 2013

2. Trends – ACCME Data (ACCME-accredited providers only) • Physician participation up 6% 2012 vs. 2011, activities up ~4% • Internet enduring materials account for 27% of activities and 38.5% of physician participations • Average participation vs. registration rates are 30-45% (based on ancedotal conversations) • Online CME activities with commercial support in 2012 • Live: 516 events (↓84%), 14,391 total participants (↓85%), avg = 28 MD participants • Enduring: 5,563 events (↓2%), 1,179,941 (↓3%) total participants, avg = 212 MD participants • Online CME activities without commercial support in 2011 • Live: 1,637 events (↑41%), 37,120 total participants, (↑44%), avg = 23 MD participants • Enduring: 19,135 events (↓2%), 3,460,463 total participants (↑12%), avg = 181 MD participants • 2011 vs. 2012 • Enduring ↓2%, courses ↑9% (↑20% since 2010), regular series ↑2%, PICME ↑15% (↑65% since 2010) • Commercially supported performance improvement activities ↓10% (78 vs. 86)

3. Trends – ACCME Data (State-accredited providers only) • Physician participation flat (down 1%) 2012 vs. 2011, activities down 7% • Internet enduring materials account for small portion of data • ↓20%, only 5% of activities and 3.4% of physician participations • Courses account for 61% of activities and 24% of physician participations • Number of courses ↓4%, total participants ↓3%, avg = 22 MD participants • Shows how difficult it is for state associations to get attendees to their events • Regularly scheduled series are 29% of activities and 70% of physician participations • Number of regularly scheduled series ↓4%, avg= 137 MD participants • Other items of note • Performance improvement activities up 73% (342 vs. 250) • 25,000+ courses offered by state-accredited providers, 2,000+ online enduring materials

4. Trends – Physician Data • Mobile is a driving force • 81% use smartphones (Manhattan Research, 2011) • 47% are digital omnivores – use smartphone, tablet and PC for clinical work (Epocrates, 2013) • 62% use tablets for professional purposes (Manhattan Research, 2012) • 25% use tablets in their practices, 21% more expect to in next year (CompTIA, 2011) • 38% use medical apps on daily basis, and will grow to 50% in next year (CompTIA, 2011) • MedScape Mobile 3 million+ users, Epocrates 1 million+ active members • Increase in usage of social media and number of influencers • 90% use social media professionally or personally (QuantiaMD, Frost & Sullivan, others; 60-90% depending on study) • New guidance released in 2013 from JAMA, ACP • Key channel to reach influencers: physician-bloggers, medical associations, hospitals, advocacy groups • Adjusting to new and evolving requirements • Maintenance of certification (http://www.abms.org/maintenance_of_certification/ABMS_MOC.aspx) • Depending on state, credits are required in risk management, ethics, HIV, end of life, pain management (http://www.medscape.org/public/staterequirements)

5. Trends – Physician Data • Hospitals and health systems are increasing their influence • Higher percentage of graduates choose hospital-owned practice settings (MGMA, 2011) • Higher reimbursements, administrative costs of private practice, Medicare populations, and other reasons • Total number of doctors employed by hospitals ↑75% since 2000 (MGMA, 2011) • Medical practices owned by hospitals ↑90%+ since 2005 to 49.5% of all practices (MGMA, 2011) • Health insurance reform puts more emphasis on risk-based payment approaches, hospitals that own physician groups can shift patients away from higher-cost hospital care into outpatient network and share savings • http://www.healthecareers.com/article/why-hospitals-are-stepping-up-their-physician-hiring/168115 • http://money.cnn.com/2012/07/11/smallbusiness/doctors-employment-survey/index.htm • 4.65MM MD participations in Regularly Scheduled Series in 2012 • 2.34MM non-MD participations in Regularly Scheduled Series • 46,453 total CME activities from accredited hospitals/health systems • 27,059 total CME activities from accredited schools of medicine • 24,583 total CME activities from accredited MD membership organizations

6. Trends – Physician Data • Hospitals and health systems • 26K+ courses, 13K+ regularly scheduled series, 3K+ online enduring activities • 367K+ hours of instruction • 3.2MM MD participations, 1.96 non-MD participations • Schools of medicine • 10K+ courses, 7+K regularly scheduled series, 8K+ online enduring activities • 3.2MM MD participations, 1.62MM non-MD participations • Physician membership organizations • 12K+ courses, 200+ regularly scheduled series, 3K+ online enduring activities • 3.1MM MD participations (2.2 in 2011), 1.3MM (1.06 in 2011)non-MD participations • These three types of providers account for: • 73% of all CME activities • 66% of all MD participations • 48% of all non-MD participations

7. Trends – Physician Data • Physician shortages in key therapeutic areas • Graduating physicians selecting primary care has declined in each year of the past decade (MGMA, 2011) • Oncology, mental health, primary care, dental, and more • Key shortages in primary care and mental health • 5,900 Health Professional Shortage Areas (HSPA) for primary care (HRSA, 2013) • 3,800 HSPAs for mental health (HRSA, 2013) • http://www.hrsa.gov/shortage/ • Growth of PAs and NPs in care delivery system • PAs: 81,000+ in 2012 will grow to 140,000+ by 2020 (AAPA); NPs: 148,000+ NPs in 2012 ↑ 12% from 2008 (AANP) • Growing influence due to physician shortages, healthcare needs in rural areas, new patients due to healthcare reform • From New Nurse Practitioner to Primary Care Provider, 1/19/12, http://www.medscape.com/viewarticle/756444 • “The United States today faces a crisis in access to primary healthcare. Millions of newly insured people will soon seek additional healthcare. They will confront the current and projected shortfall of primary care providers to deliver that care.” • Nurse practitioners look to fill gap with expected spike in demand for health services, 5/13/12, http://www.washingtonpost.com/national/health-science/nurse-practitioners-look-to-raise-profile-fill-gap-from-doctor-shortage/2012/05/12/gIQAHmHYLU_story.html • “A fully enabled nurse practitioner workforce will increase access to quality health care, improve outcomes and make the health-care system more affordable for patients all across America,”

8. Key Takeaways • Clinicians will complete a growing % of education internally • Higher employment and thousands of activity options from hospitals/health systems and schools of medicine • Education on other topics (training, IT, compliance, credentialing) will drive higher utilization of internal processes (online and offline) that also deliver CME, as well as employer-provided mobile devices and content • Financial reward and quality measures increasingly linked to clinical performance • http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande • Physician shortages will drive growth in mobile utilization • Busier schedules and growing clinical applications for tablets facilitate use of these devices for education • http://healthland.time.com/2012/08/16/doctors-using-ipads/ • http://www.informationweek.com/healthcare/mobile-wireless/doctors-tablet-use-almost-doubles-in-201/240000469 • Changing state licensure requirements make membership organizations a default go-to resource • Non-MDs will make up a higher % of education activity participants and drive interest in interprofessional education activities