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Public Health
August 3, 2018

How Healthy Is Health Care?

Author Affiliations
  • 1Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
  • 2Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
JAMA Netw Open. 2018;1(4):e181000. doi:10.1001/jamanetworkopen.2018.1000

The health care industry is uniquely charged with tending to human health and wellness and has been called on to help lead the transition to a sustainable world.1,2 Yet, modern health care itself is a leading emitter of environmental pollutants, responsible for 10% of national greenhouse gas emissions and 9% of criteria air pollutants in the United States alone.3 In the United States, health care pollution causes indirect harm to public health, commensurate with the 44 000 to 98 000 deaths from preventable medical errors first reported by the Institute of Medicine (IOM) in To Err Is Human 2 decades ago.3,4 That landmark IOM article sparked a patient safety movement, but the health care industry lags behind in its efforts to reduce harm caused by its own pollution footprint.

Senay and Landrigan5 examine how the health care industry compares with other industries with respect to corporate social responsibility (CSR) reporting. Corporate social responsibility reporting represents a growing commitment to publicly communicate environmental and social performance. International reporting standards exist for environmental performance indicators most notably through the Global Reporting Initiative,6 and also the Carbon Disclosure Project7 with participants representing nearly a fifth of global greenhouse gas emissions. Currently, CSR reporting is voluntary in the United States but published by a majority of the largest publicly traded companies as well as many private and nonprofit companies. Senay and Landrigan5 astutely point out the natural synergy of the mission of health care with environmental and social responsibility—what is good for health and well-being is good for health care. They describe the advantages of sustainability efforts associated with CSR reporting, including reduced operating costs, improved employee well-being, and protection of human health. Yet, they found that the 49 largest US health care organizations (HCOs) included in their study lagged behind other large corporations in CSR reporting during the 2015 to 2016 study period (50% vs 78% of Fortune 500; 33% vs 82% of S&P corporations; 12% of all HCOs including private and charitable organizations). Although the authors went on to extend criteria for HCO reporting beyond the Global Reporting Initiative and the Carbon Disclosure Project, to encompass a web presence for sustainability initiatives, the health care industry still fell short. Senay and Landrigan5 have applied a unique method to uncover an alarming statistic in health care, much like the aforementioned IOM report on medical errors; but, unlike the timing of the IOM report, the sustainability movement may already be under way.

Senay and Landrigan5 defined their inclusion criteria as those HCOs on at least 1 of the following lists: 2016 Fortune 500, S&P 500, Forbes 100 Largest Charities, 2015 Largest Profit and Nonprofit Health Care Systems by number of facilities compiled by Becker’s Hospital Review, and June 2016 Largest Employer in Every State compiled by 24/7 Wall St. Thus, 49 large HCOs were identified, enabling some direct comparisons with CSR reporting by other large corporations. These 49 HCOs represent a small fraction of the more than 5500 hospitals in the United States, and therefore, the majority remains unexamined by the authors. More than 1200 US hospitals enrolled in the Practice Greenhealth Healthier Hospitals Initiative that hosted the following 6 key health care sustainability challenges: engaged leadership, healthier food, leaner energy, less waste, safer chemicals, and environmentally preferable purchasing.8 While only some metrics were publicly reported by the Healthier Hospitals Initiative, this represents a much broader interest in sustainability than the authors were able to measure. Similarly, the American Hospital Association has several health care challenges and provides an option for benchmarking direct energy consumption through the American Society for Healthcare Engineering Energy to Care (Energy Star) program.9 Thus, the health sector seems much more engaged in sustainability initiatives than the authors concluded.

At a recent international Workshop on Environmental Sustainability in Clinical Care hosted by the Yale School of Medicine and New York University School of Medicine, a select group of experts in medicine, sustainability engineering, and health care administration discussed methods for translating environmental assessments into change.10 Clinicians are primary drivers of health care resource use, and their engagement is essential. Demonstrating the return on investment that CSR efforts yield in other industries, such as through facilities-level energy and waste management, may not be enough to change clinician behavior. Sustainability metrics will likely need to be integrated into the Quality Payment Program established by the Medicare Access and Children’s Health Insurance Plan (CHIP) Reauthorization Act of 2015. The Medicare Access and CHIP Reauthorization Act of 2015 is transforming Medicare from a fee-for-service payment system to one that encourages clinician participation and reporting in a merit-based incentive payment system, or advanced alternative payment models. Under a merit-based incentive payment system, physicians are financially rewarded for quality, clinical practice improvement activities, cost containment, and advancing care information technology for patients. Sustainability metrics need to be incorporated into Qualified Clinical Data Registries for application to the merit-based incentive payment system quality component. Cost metrics need to be paired with environmental metrics associated with clinical resource consumption, including greenhouse gas emissions, criteria air and water pollutants, and waste tracking. And, advancing care information technology should include clinician feedback systems and CSR reporting to the public. Quality improvement, cost containment, and information technology also apply to advanced alternative payment models with the potential added benefit of improving population health through pollution prevention.

Senay and Landrigan5 are to be congratulated for developing a measure of the apathy with which large health care organizations in the United States seem to approach sustainability. However, their metric may lead to more pessimism than is necessary. There still remains considerable hope for a more sustainable future as evidenced by the participation of many hospitals in organized sustainability challenges. More important, sustainability metrics and improvement efforts lend themselves well to a reforming health care system that rewards cost containment, quality improvement, and information sharing.

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Article Information

Published: August 3, 2018. doi:10.1001/jamanetworkopen.2018.1000

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Sherman JD et al. JAMA Network Open.

Corresponding Author: Jodi D. Sherman, MD, Department of Anesthesiology, Yale School of Medicine, 333 Cedar St, TMP3, New Haven, CT 06520 (jodi.sherman@yale.edu).

Conflict of Interest Disclosures: None reported.

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Greenhealth Program.  Healthier Hospitals Initiative. http://www.healthierhospitals.org/. Accessed June 4, 2018.
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Yale Climate Change and Health Initiative.  Workshop on environmental sustainability in clinical care. https://publichealth.yale.edu/climate/curricula/hospital_workshop.aspx. Accessed June 4, 2018.