Health Systems And Environmental Health: Reducing Harm And Costs
By Gary Cohen and Bill Sadler
Editor’s Note: In our April issue, Health Affairs examined efforts to improve quality in hospitals and other health care settings. Our May issue, which will be published online later this week, looks at the myriad connections between the environment and health. These two themes come together in the blog post below, which examines how hospitals have sought to provide safer and better quality care by incorporating environmental health considerations into their design and operations.
Over the past 15 years, there has been a scientific revolution linking the environment to human health. Many health care systems have shown they can measurably reduce harm to patients and staff, increase the sustainability of their facilities and lower operating costs.
Health Care Without Harm and its membership organization, Practice Greenhealth, have produced specific tools and guides to help all hospitals become safer and more efficient. These strategies have been organized in the new Healthier Hospitals Agenda, a blueprint designed to significantly accelerate improvement nationwide.
In this blog post, we outline the important advances in environmental health that have taken place in the last decade and a half. We discuss the Healthier Hospital Agenda and other strides that the health care industry has made towards improved environmental health and sustainability. Finally, we propose specific federal policies that can reinforce this powerful social movement and help promote environmental health.
A Revolution in Environmental Health Sciences
Over the last fifteen years, there has been a revolution in the science linking toxic chemicals and human health. The extraordinary growth in evidence leads to the following conclusions:
- small doses of chemical exposure matter.
- chemical exposure during critical windows of development in the womb can disrupt hormonal activity and normal gene expression.
- chemicals act in synergistic ways and people are exposed to many chemicals at the same time.
- babies in utero are exposed to more than 100 toxic chemicals, many of them linked to cancer, birth defects, and normal sexual and neurological development.
- the science linking these low dose exposures with a plethora of diseases continues to grow stronger each year.
Similarly, there is also a growing body of evidence linking climate change with a broad array of health effects, including:
- asthma and respiratory disease
- heat-related illnesses
- the spread of infectious diseases through vectors
- water born diseases exacerbated by extreme weather events
In 2010, environmental health science was further validated by the President’s Report on Cancer and the Environment, which claimed that we as a nation have dramatically underestimated the role that environmental factors have played in cancer onset. Also, the Interagency Task Force on Childhood Obesity identified certain endocrine disrupting chemicals coined “obesogens” as important pre-natal chemical exposures that may be contributing to the obesity crisis.
Rising Costs of Preventable Disease Linked to Environmental Sources
The healthcare sector has a strong mission-related interest in understanding this new science linking environmental exposures with patient, employee and community health. The epidemic of obesity, cancer, asthma and diabetes continues to rise, as does the healthcare costs related to treating these diseases.
Recent financial analyses suggest that three diseases alone, all of which have strong environmental health linkages, may be sufficient to bankrupt the healthcare system in the next twenty years. The 2009 America’s Health Ranking report showed that obesity costs in 2008 were $147 billion or almost 10 percent of all healthcare costs. The same report estimated that obesity –related health care costs could reach $344 billion annually by 2020, or 21 percent of all healthcare costs. Diabetes related health costs were $194 billion in 2008. United Healthcare estimated in their 2009 report that 15 percent of all U.S. adults will have diabetes and 37 percent will have pre-diabetes in 2020, compared with 12 percent and 28 percent respectively today. And the National Cancer Institute reported that cancer costs in 2006 were $104 billion. According to the American Cancer Society, one in three American women will get cancer in their lifetime and almost one in two men.
While the 2010 health reform legislation will expand the number of people covered by health insurance and contains a number of important provisions that support prevention, it does not address directly the unnecessary costs from avoidable environmentally caused harm and waste.
The Healthcare Sector’s Enormous Environmental Footprint
The healthcare sector, which represents over 17 percent of the entire economy, has an enormous environmental footprint and itself contributes to environmentally related illness in the general population. Healthcare is one of the largest users of toxic chemicals in the economy, spending more than $100 billion in 2002. Hospitals are also the second most energy intensive commercial building sector. The amount of waste in hospitals is significant – American hospitals generate over 6 tons of waste per day. In the mid 1990s, the EPA identified medical waste incinerators as the largest source of dioxin emissions in the U.S., as well as responsible for 10 percent of all mercury air emissions due to the dumping of mercury-filled thermometers into incinerators.
These activities undermine environmental health in the general population, but also impact healthcare workers and patients. Nurses have one of the highest adult asthma rates of any profession and also suffer from a plethora of environmental exposures. A recent survey conducted by the American Nurses Association showed a positive correlation between a variety of health impacts and the severity and variety of chemical exposures on the job.
Vulnerable patients are also being exposed to dangerous chemicals in healthcare settings. DEHP is a reproductive toxicant (especially toxic to male testes) that is used in a variety of PVC medical devices utilized in neonatal intensive care units. The Food and Drug Administration warned healthcare providers several years ago that hospitals should evaluate safer alternative medical devices that do not contain this chemical. A study conducted by the Harvard School of Public Health found greatly elevated levels of DEHP in infants in the NICU of one Boston hospital that was still using PVC equipment as opposed to another hospital that had switched to alternative plastics for IV bags and tubing. DEHP continues to be used as a softener for PVC in hospitals today.
Other environmental exposures are occurring through cleaning chemicals, emissions from electronics, radiological equipment, anesthetic gases and many other sources.
Promising Progress: Examples Of Improvements
The good news is that health care organizations have begun to recognize that incorporating environmental health and sustainability into healthcare design and operations is good for patient and employee and community health and it saves considerable money.
When the EPA had identified medical waste incinerators as the nation’s largest source of dioxin emissions, there were over 4,200 medical waste incinerators in operation. Now there are less than 80 left. In closing their incinerators, hospitals have saved money on disposal costs and initiated a broad set of programs to reduce their waste volume upstream through repackaging, better waste segregation and recycling.
Additionally, over the last decade, hospitals have largely eliminated mercury thermometer and blood pressure devices. In doing so, they avoided collateral costs associated with training for mercury spills, spill clean up equipment and environmental fines and compliance costs associated with mercury use. All the major pharmacy chains in the country have also eliminated mercury thermometers from their shelves.
Hospitals have begun to utilize their purchasing power in the marketplace to drive safer product innovation and save money in the process. A few years ago, Kaiser Permanente had their purchasing staff identify products that could reduce patient and worker exposure to toxic chemicals, reduce greenhouse gas emissions and achieve other environmental performance characteristics. Two years later, Kaiser has purchased over 25 environmentally superior products and calculated savings of over $25 million annually. (Robert Gotto, Kaiser Permanente Slide Presentation, May 3, 2010)
Beyond the supply chain, healthcare is also learning how to redesign their facilities to reduce energy costs, improve environmental health and contribute to better patient outcomes and fewer medical errors. The Green Guide for Healthcare is a framework for designing and constructing healthier and greener healthcare facilities. Over 275 projects have registered with the Green Guide, representing more than 40 million square feet of healthcare construction. In many of these projects, the initial capital costs for constructing “green” are negligible, while the cost savings over the life of the building through improved environmental health and efficiencies are expected to be significant.
For example, the Shapiro Center in Boston is a new cardiovascular facility built by Partners Healthcare at a cost of $350 million. It followed the GGHC framework and achieved the equivalent of LEED Silver status under the US Green Building Council rating system, yet the sustainable design features only added 0.5 percent of total additional capital costs to the overall building.
Sustainable design has recently become even more embedded into the mainstream healthcare system by the announcement of the first LEED for Healthcare framework being launched in 2011 by the U.S. Green Building Council. The importance of both the GGHC and LEED systems for healthcare is that for the first time they identify occupant health as a critical component of green building and there are specific recommendations for avoiding chemicals of concern for building materials and furnishings.
At the same time, there has been a steady growth in the number of published articles that demonstrate the correlation between the evidence-based design of hospital facilities and improved patient and staff outcomes.
The entire arena of evidence-based design is becoming mainstream in the healthcare sector. This includes designing hospitals with maximum natural light, variable acuity rooms, decentralized nursing stations, single patient rooms and ceiling lifts to avoid worker lift injuries. A recent analysis published in the Hastings Center Report showed that a one-time incremental cost of less than 8 percent to include a series of recommended environmental design innovations would help to produce measurable operating cost savings and a return on investment in less than 3 years. Indeed building designs that help reduce harm are becoming key elements in a hospital’s survival strategy.
The Role of Health Care Without Harm and Practice Greenhealth
Over the last fifteen years, the non- profit Health Care Without Harm and its membership organization Practice Greenhealth, have built up a body of knowledge, tools and case studies with over 1,100 hospitals nationwide and hundreds of others at a global scale to validate the efficacy of environmentally responsible healthcare.
For example, Practice Greenhealth has developed a “Greening the Operating Room Project” that is significantly reducing the volume of waste, re-sterilizing medical devices and savings millions of dollars in the process. Health Trust, which is one of the largest Group Purchasing Organizations, saved $28 million in 2009 while diverting over 300,000 pounds of waste from the nation’s landfills.
The organization has also developed model environmental policies and a check list for evaluating environmental innovations and benchmarking against other systems. HCWH has developed a healthy food program that now has more than 400 hospitals sourcing local and sustainable food, operating farmers markets and eliminating fast food from their premises and vending machines.
In the realms of energy efficiency, waste reduction, safer chemicals, environmental purchasing, healthy food, green building design, water conservation and sustainable operations, hospitals are learning from PGH how to implement environmental health improvements as the next wave of quality improvements in healthcare and also point them in the direction of disease prevention.
The Healthier Hospitals Initiative
With the growing number of individual success stories and the increasing strength of evidence to support good environmental health, the time seems ideal to rapidly accelerate the adoption of proven best practices that reduce harm and save costs. The two highly successful national collaboratives coordinated by the Institute for Healthcare Improvement (the 100,000 Lives Campaign and the Protecting 5 Million Lives from Harm Campaign) point the way to developing a similar initiative with a focus on environmental health.
The Healthier Hospitals Initiative was launched in 2010 and identifies twelve successful environmental strategies. The Agenda is a blueprint developed by leading U.S. hospital systems to accelerate sustainability and environmental health throughout the sector. Similar to the IHI model, specific implementation packages are being developed for six of the strategies (energy reduction, safer chemicals, environmental purchasing, waste reduction, Greening the OR, system culture change) to streamline adoption of best practices and will be available later in 2011. The goal of the HHI Initiative is to encourage health care organizations to enroll in any or all of the strategies, share lessons learned, and embed environmental health into the DNA of their culture.
The emerging experience from hospital systems that have implemented waste reduction strategies, energy efficiencies and environmental purchasing is that they are saving tens of millions of dollars each year. Gunderson Lutheran Hospital in Wisconsin, for example, has already achieved over $1.3 million in annual savings from energy efficiency measures and has plans to become completely reliant on renewable energy sources by 2014. Kaiser Permanente switched to environmentally responsible computers over the last two years and saved 55,185,675 KWh, 10,398 lbs of toxic materials and 169.4 tons of hazardous waste and also saved nearly $5 million in annual costs.
If all hospitals in America were to include sustainability and environmental health strategies into their day to day healthcare operations, the direct savings would be in the billions of dollars annually. Additionally, larger societal savings through prevention-oriented community environmental health programs would begin to bend the cost curve in America’s healthcare system.
Advancing Policies to Support Sustainable Healthcare and Disease Prevention
While individual healthcare organizations can do much to reduce environmental harm and the unnecessary costs incurred, there are specific environmental health policies that would support this larger agenda for healthcare and for the health of the American public:
- Support federal chemical policy overhaul to protect vulnerable Americans from chemical exposure: The Toxics Substances Control Act (TSCA) was passed in 1976 and has not been updated. Over the last thirty five years, despite the fact that there are over 80,000 chemicals in commercial use, only six chemicals have been restricted under TSCA. As the research continues to unfold about the links between toxic chemical exposure and chronic diseases in the general public, updating federal chemical policy to protect vulnerable populations, especially children in the womb, should become a cornerstone of the nation’s healthcare strategy. Bills to reform TSCA were introduced in both the House and Senate in 2010. A recent conservative estimate found that the healthcare costs saved from enacting chemical policy reform would amount to a minimum of $5 billion every year.
- Streamline EPA regulations on carbon sources: Climate change will lead to increased asthma, heat stress-related illness, the spread of infectious diseases and water born diseases. Regulating green house gas emissions from coal and other carbon sources will result in the prevention of asthma and other respiratory diseases as well as reduce avoidable healthcare cost.
- CMS should develop incentives to encourage health care organizations to adopt energy saving, cost saving and harm reducing strategies contained in the Healthier Hospitals Agenda. Opportunities exist through the new Center for Innovation and Pilot Project authority to help stimulate progress in this area.
- Develop a federally supported technical assistance program to widely disseminate the Healthier Hospital Agenda throughout American’s hospitals and clinics and achieve sector-accelerated change.
- Support local and sustainable agriculture for institutional purchasing and food assistance programs in the upcoming Farm Bill re-authorization. Current agricultural subsidies traditionally favor agriculture that relies on pesticides and fertilizers and crops that artificially depress the cost of corn-based food additives, which have been linked to diet related obesity and diabetes issues. In the next round of policy revisions for the Farm Bill, local and sustainable agricultural practices should be given incentives to provide healthier foods to schools and hospitals as well as being identified as preferred providers in federally supported food assistance programs. Federal purchasing power can drive sustainable agriculture as a disease prevention strategy throughout America.
As a nation, we have begun to recognize the growing evidence that supports the enormous harm unintentionally being caused to all Americans, particularly patients and health care workers. We are beginning to recognize the enormous economic costs incurred as well. Fortunately, there are many examples of strategies that have been implemented to reduce the harm of toxic chemicals, reduce energy consumption, and reduce health care operating costs. The time is now for all health care organizations to implement these proven strategies. The tools and techniques now exist – we must find the will to use them. We must also continue to evaluate and test new improvement strategies through research. Several federal policies have been identified that will enhance and support these vitally important efforts to our nation’s health. It is critical that we re-align our health care policies and practices to address these new realities.