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Opinion | How health systems can fight climate change by not using desflurane

Physicians, nurses and other front-line providers know firsthand the health impacts of climate change. Air pollution exacerbates asthma and emphysema; extreme heat worsens heart and kidney conditions; and rising temperatures increase the occurrence of a wide range of illnesses, including mosquito-borne infections and depression.

That’s why it’s so shocking to learn that health care itself is a major contributor to climate change.

In the United States, the health sector is responsible for nearly 9 percent of the nation’s greenhouse gases. Researchers estimate that the environmental harm caused by medical care ultimately costs as many lives as preventable medical errors, which are responsible for as many as 98,000 deaths annually. This is in direct conflict with the mission of the healing professions.

Brian Chesebro, an Oregon-based anesthesiologist who serves as medical director of environmental stewardship at Providence, had this “aha” moment in 2016. At the time, he told me, he was going through a period of “eco-grief” about the state of the Earth.

“Instead of spiraling down, I realized that my greatest opportunity to advance environmental stewardship was through my job as a physician,” he said. “I could address it in my own practice, then, as a physician-leader in my hospital, inspire change in my colleagues.”

His work as an anesthesiologist turned out to be the right launchpad. That is because some anesthetic gases commonly used in operating rooms are extremely potent greenhouse gases.

As Emily Mediate from the nonprofit organization Health Care Without Harm told me, the elimination of one specific gas, desflurane, could make a profound impact. “Desflurane has the global warming potential of over 3,700 equivalents of carbon dioxide,” she told me. “It lasts for 14 years in the atmosphere.” Her organization is among those that have been urging health-care systems to move away from desflurane and switch to sevoflurane and isoflurane, anesthetics that are clinically equivalent but have a small fraction of the environmental consequence of desflurane.

Chesebro took on this challenge. He began by educating fellow clinicians. “We weren’t taught to think in terms of environmental impact in residency,” he said, noting that the response from other physicians was primarily “surprise, interest and curiosity.”

He also measured and documented each anesthesiologist’s desflurane use. When Chesebro informed a colleague that his use of desflurane was equivalent to driving a fleet of 12 Hummers, the colleague sputtered in defense, “But I drive a Prius!”

“He was trying so hard to make wise stewardship choices, but he didn’t realize that his environmental impact as an anesthesiologist far outstripped any other facet of his life,” Chesebro said. “He changed his practice that day and has never used desflurane since.”

Over time, Chesebro redesigned systems so that desflurane was less easily accessible than other inhaled gases. “We still keep one or two desflurane vaporizers so someone could use it if they really need it, but it is no longer at arm’s reach in every operating room,” he said. He believes this was more effective than banning the gas. “Instead creating adversaries, we created an army of advocates who are eager to partner with us” on other efforts.

Before this intervention, the Providence system’s eight Oregon hospitals used desflurane 42 percent of the time, according to Chesebro. Now, he says, the rate is 0.07 percent. “We’ve cut emissions related to anesthetic use by 95 percent, and, because desflurane is a more expensive option, we’ve also cut the financial cost by 80 percent.”

Providence is not alone. Mediate shared success stories from around the country. Virginia Mason Medical Center eliminated desflurane use, thanks to the advocacy of an anesthesiologist and an anesthesia tech there. This resulted in an estimated 60 percent decrease annually in its operating room greenhouse emissions and saved the hospital more than $30,000 each year. Advocate Aurora Health, in a nurse-led effort, also cut its use of desflurane. Since 2017, the health system has reduced its anesthetic gas emissions by 75 percent and saved $1.6 million.

There is still a lot more work to be done. While the U.S. health system accounts for about a quarter of all global health sector-related emissions, it is far behind many peer countries in tackling this problem. In fact, many political leaders are actively trying to block sustainability initiatives.

I was heartened to learn that Health Care Without Harm’s Climate Council includes 21 health systems representing more than 600 hospitals across 43 states. In addition to health sector-specific reforms, they are encouraging others to join them in addressing building emissions, switching to renewable energy and limiting single-use plastics, among other efforts to reduce their carbon footprint.

“Health-system leaders understand that the climate crisis is a health crisis,” Mediate said. “Better care is low-carbon care.”

That’s a perspective on medical care that I wasn’t aware of before. Now, I’m convinced that clinicians’ obligation to “first do no harm” should extend to our responsibility to reduce the effects of climate change caused by the health-care sector itself.

Opinions on climate & the environment

Opinion: Promoting high-risk, high-reward medical research

The overall health treatment community’s reaction to COVID-19 has been heroic and transformative. Considering the fact that early 2020, physicians, nurses, personnel customers and scientists have pushed on their own to their limits while corporations have observed new techniques to deliver and streamline care — specifically with the unexpected and wide embrace of telemedicine.

Even as we stand in awe of this grace under stress, this necessary focus on the pandemic has exacted rigid price ranges. Though much attention has been paid out to the vital challenge of burnout, I also believe a creeping cultural shift has happened at educational health-related facilities like the a single I lead at Michigan Medication. Phone it the “lifestyle of no” as in, no we are not able to do this or that for the reason that we ought to muster our restricted useful resource to struggle the disaster. In response, we ought to work to foster a “society of sure,” 1 that evokes our outstanding colleagues to feel the liberty to go after big suggestions that can develop transformative improvements in individual care.

We should cultivate this culture of of course across our business, creating channels so that just about every member of our community knows that their excellent strategies will be read and can flourish. It is in this spirit that I want to spotlight a person of the most remarkable initiatives percolating not just at Michigan Drugs but at educational health-related centers throughout the state: guidance for substantial-hazard, superior-reward study.

As the title implies, these kinds of investigate often will take area on the edges of science. It often consists of a Eureka instant notion for which there is small evidence of its efficacy. These kinds of exterior-the-box pondering poses a problem to the classic funding mechanisms — primarily those used by the most important funder of research, the Nationwide Institutes of Wellness — which really adequately request to direct methods to established thoughts.

But, as a write-up past 12 months released at the web site operated by the Good Science Task noticed, “A typical complaint is that NIH’s peer evaluate method can be overly conservative, mainly because it is so concentrated on preliminary knowledge guaranteeing that a venture will operate. That outcome of peer overview is probably even worse in today’s hypercompetitive natural environment, wherever it isn’t abnormal for only the top rated 10 percent of grant purposes to get funded. In that context, peer reviewers typically search for any cause at all to continue to keep a grant from acquiring funded.”

Large-threat, higher-reward study often receives shunted apart in this funding design. To draw an analogy from Silicon Valley, it is like a startup with a terrific thought that may perhaps or may well not get the job done out. As venture capitalists know, you have to drill a lot of dry holes to find the unicorn good results story like a Facebook or Spotify. But the globe of large-tech also shows us that a tradition that states of course to innovation — one particular that encourages visionaries to consider and aspiration significant — can alter the entire world.

The NIH has regarded this have to have through its Large-Threat Large-Reward Investigation Program, which supports “extremely innovative researchers pursuing really innovative exploration with the probable for broad influence in biomedical, behavioral, or social sciences in just the NIH mission.” In 2022, the NIH gave 103 this sort of awards totaling somewhere around $285 million. That may possibly audio like a great deal, but consider that each and every yr the NIH awards more than $30 billion to 60,000 exploration and instruction grants.

To electrical power innovation, a number of educational clinical centers have developed their possess applications to guidance higher-chance, substantial-reward analysis. Michigan Medicine’s efforts, for case in point, are staying turbocharged by a $20 million grant from the Maxine and Stuart Frankel Foundation. Open to innovators at all phases of a investigate project, the Frankel Innovation Initiative gives financial support and know-how and direction from an advisory committee consisting of entire world-renowned scientists and technology improvement specialists to enable researchers build their strategies.

Recipients involve Dr. Paul S. Cederna, whose pioneering get the job done is revolutionizing the industry of prosthetics. As Cederna explains, while we have extended experienced synthetic limbs, they have been difficult to command. His Eureka moment –—it pretty much came to him in the shower — was that by connecting the current nerves (which have fairly thin pathways) to muscle mass (which have reasonably huge pathways) he could vastly increase the signal sent from the prosthetic to the mind. This provides end users with a vary of fine motor abilities that can vastly strengthen their lives and livelihoods.

One more grant supports the get the job done of a group led by Dr. Molly Stout that seeks to battle the disaster of premature births — which complicates additional than 10 p.c of the country’s just about 4 million yearly births and prices about $26 billion each year. Even with the substantial stress of disorder and significant prices, meaningful progress is hampered by the incapability to forecast, with precision, when labor will come about. Dr. Stout and her workforce are getting supported in their effort to improve the standard transvaginal ultrasound probe now in use to more accurately predict the time of supply and help save the lives of mothers and their toddlers.

This and other groundbreaking do the job would be tough to maintain without a commitment to large-risk, significant-reward study. Transformative suggestions generally start off with an personal, but those people insights are only the commencing. In our intricate planet, even geniuses need nurturing environments to prosper. At root, our programs need to be as inspiring as the folks who perform inside them.

As we glance to the foreseeable future, generating a culture of certainly will promote and really encourage all people in overall health care to discover new approaches to make improvements to affected person treatment. Thomas Edison when claimed, “There is certainly a way to do it better.” The leaders of educational medical facilities need to have to do that, and we are right here to aid you find them.

Dr. Marschall S. Runge is executive vice president for healthcare affairs and dean of the health-related college for the University of Michigan. He serves on the board of directors for Eli Lilly and Co.

Opinion: Don’t blame family doctors for the current health care crisis

Liana Hwang is a family physician working in refugee health and obstetrics in Calgary and Canmore, Alta. Adam Pyle practices emergency medicine in Oshawa, Ont. Both are fellows in journalism at the Dalla Lana School of Public Health at the University of Toronto.

The Ontario government has proclaimed its steadfast support of hospitals, and last month it reaffirmed its commitment to boost their funding by providing an additional $827-million this year.

For family physicians, there have been only stern reprimands.

“We need family physicians to be seeing patients in person,” said Health Minister Sylvia Jones, channelling Elon Musk as she insisted that all parts of the system need to “operate at 100 per cent.”

Then, in late November, her ministry sent the province’s Family Health Teams a memo requesting them to offer services seven days a week, including evenings, seemingly oblivious to the many that already offer extended hours.

There is a pattern of “blaming family physicians based on anecdotes,” according to Tara Kiran, a family physician, whose research team surveyed almost 1,200 Toronto area family physicians and found that even in January, 2021, before most family physicians were vaccinated, 99.7 per cent of practices were open and 95 per cent were seeing patients in person when needed.

If you are fortunate enough to have a family physician now, there is a very real chance that you will soon be joining the five million Canadians who do not. More than half of family physicians report that they are either “exhausted but coping,” or “burned out and thinking of, or have taken, a break from work.” Dr. Kiran’s survey last year revealed almost one in five Toronto family physicians was thinking of closing their practice in the next five years.

Andre Picard: Let’s not forget that our medicare system was also born of war

As two family physicians with a combined 26 years of experience, who both made the difficult decision to close our family practices this year, it is obvious to us that family medicine is in a desperate state of attrition. Burnout existed long before the pandemic, but we are now seeing an unprecedented exodus of physicians from community practices. For example, 10 family physicians closed their practices in Canmore, Alta., in the past 30 months.

We have plenty of family physicians – over the past decade, the number of family physicians has increased by almost a quarter. But working conditions have steadily deteriorated, and like us, many have moved into other areas of practice.

What kept us going in family medicine for so long was our relationships with our patients. Yet far too often, we were forced to choose between spending time with them, or filling out forms and performing other administrative tasks. Each week of family practice requires 11 hours of paperwork, more than any other specialty. Research suggests that more than a third of this burden is unnecessary.

Both of us suffered from the moral distress of caring deeply for our patients and trying to help them navigate a broken system. We tried to make up for the lack of home care, long-term care and mental-health supports. We did our best to help suffering patients trapped in Canada’s waiting-list purgatory for diagnostic procedures, surgeries and appointments with overloaded specialist colleagues.

We’ve heard family medicine described as the foundation of the health care system, but we prefer to think of it as the roots of a giant tree. It’s the source of the tree’s strength, what sustains and nourishes it.

Our roots lie in shallow ground. No amount of individual effort can make up for the lack of systemic support for family medicine over the past decades. In Canada, just 4.7 per cent of current health care expenditure goes toward primary care, defined as general outpatient care. By comparison, Australia spends 11.5 per cent.

Spending on primary care pays for itself many times over. Access to a family physician has been shown to decrease hospitalizations, emergency department use and re-admissions. Patients with continuity of care have better health outcomes, and report better quality of life.

And we’ve long known that we need transformation of primary care systems, not just more money. Team-based models like Alberta’s Primary Care Networks and Ontario’s Family Health Teams must be supported and expanded. Our aging population needs access to long-term care. A national electronic medical record would improve patient care and decrease administrative burden. Streamlined licensing pathways for foreign-trained medical professionals and national licensure for physicians would partially alleviate our work force crisis.

Politicians need to stop crushing the remaining family physicians with unrealistic demands, and start focusing on solutions. It’s time to tend to the roots before the tree topples in the storm.

Opinion | Why American health care is so expensive

David Goldhill’s Dec. 2 op-ed, “In health care, America is the world’s indispensable nation,” was a classic example of using somewhat misleading evidence to tell a story about how innovative our pharmaceutical industry and health-care system are. Yes, it is true that Americans spend far more on pharmaceutical products than people in other highly developed nations. It’s also true that foreign pharmaceutical companies, such as the mentioned Swiss company Novartis, avail themselves of our markets to increase their profits. But Mr. Goldhill didn’t mention that pharmaceutical companies in the United States spend more on sales and marketing (including consumer advertising and direct marketing to physicians and other health providers) than on research. Why, for instance, do we allow advertising of prescription drugs, when its only function is to have ill-informed patients pressuring physicians to prescribe particular drugs? A substantial amount of medical research is performed in our universities and financed by research grants from the National Institutes of Health, i.e., the taxpayers.

Mr. Goldhill asked why competition doesn’t bring U.S. health-care prices down. He blamed the insurance industry for the fact that hospitals and doctors “avoid competing on price.” Instead, he advocated that, except for a separate “safety-net function that insurance provides,” a “consumer economy could drive [price] competition” in the health-care system. Really? As “patient-consumers,” we first ask several providers how much they would charge for some treatment. Never mind that, as patients, we are often under stress or sometimes in an emergency situation. Most of us are also incapable of judging the quality of alternative treatments recommended. Similarly, how would “hospitals compete on price for patients”? None of this is possible without insurance. The almost 10 percent of Americans without health insurance are definitely not being wooed by health-care providers. But here again, our problem is a for-profit insurance industry that is spectacularly complex and inefficient, with more than 1 million people employed, requiring mountains of paperwork from providers as well.

There are, of course, many other flaws in our health-care system (such as the much lower physician-to-population ratio compared with those in other rich countries). This is the result of a classic monopoly strategy by the medical profession to restrict supply through control of medical residency slots. Not surprisingly, this leads to much higher physician incomes in the United States than in other rich countries such as Sweden, Switzerland and France.

Unless we get away from the fantasy that health care is just a consumer product, we will not solve our health-care cost problem. The lack of market regulation has led to this: Our health care is far too expensive, yet it does not even deliver decent care for large segments of U.S. society.

Manfred Stommel, Alexandria

Opinion | Expensive U.S. health care enables low prices in other countries

Comment

David Goldhill is the chief executive of SesameCare.com, a digital marketplace for discounted health services.

The United States spends twice as much per person as other wealthy countries on health care. This fact is well-known, and when it is mentioned, people often point out that the governments of other developed countries leverage purchasing power to drive cheaper, more universal care. So why doesn’t the United States do the same thing?

Because we can’t. In fact, the do-what-everyone-else-does option is uniquely unavailable to us.

The world’s other health-care systems survive only because they receive a massive and ongoing, but hidden, subsidy courtesy of the inefficient U.S. system. Two unique features of our arrangement — the absence of price controls and the profit drive of doctors and hospitals — allow other countries to transfer the risk and cost of medical innovation to Americans.

And unlike in any other industry, once Americans have borne the costs of lifesaving breakthroughs as well as incremental improvements in tools and techniques, these can be used elsewhere at little extra cost. American exorbitance allows other nations to offer price-controlled universal care with none of the decline in quality, technology or productivity that would otherwise result from central planning.

A similar complaint has been made about the country’s defense alliance: U.S. allies ride free on American defense spending. Health care, indeed, is a kind of second NATO.

The United States can’t lower its costs by doing what other countries do, because what others do depends on our unique system remaining as is. Our only hope is to put in place more sensible economic structures that could introduce the competition that’s necessary to bring prices down.

The size of the U.S. health-care system is almost impossible to overstate. With barely four percent of the world’s population, the United States accounts for almost half of the world’s $8 trillion health-care economy. England’s National Health Service is tiny by comparison — barely bigger than U.S. Veterans Affairs health system funding. Canada’s total spending is comparable to the revenue of a single American company, United Health. Free-market star Singapore spends only as much as New Jersey’s Medicaid program.

Opinion | Expensive U.S. health care enables low prices in other countries

The world’s top 10 spenders in pharmaceutical products

In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.

All other top 9

countries combined

Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.

The world’s top 10 spenders in pharmaceutical products

In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.

All other top 9 countries combined

Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.

The world’s top 10 spenders in pharmaceutical products

In 2020, the United States spent more on pharmaceutical products than all other nine spenders in the ranking combined.

All other top 9 countries combined

Notes: Prices are reported at the ex-manufacturer level (price when sold from manufacturer to wholesaler or direct to pharmacies). * Hospital market only. **Pharmacy market only.

This is why all health-care innovators — makers of drugs, devices, diagnostics, medical software — share the same business plan: Make money in the United States and take whatever scraps you can get in the other markets.

The pharmaceutical industry earns almost 50 percent of its worldwide revenue here, as do medical information-technology firms. Device makers earn 40 percent of their money in the United States. And this understates things, because U.S. revenue is generated from higher prices, so margins are greater. If the United States accounts for half of a company’s revenue, it probably contributes at least 75 percent of its profits.

America’s domination might not seem obvious. After all, high-tech health care exists everywhere in the world. Even in emerging economies, brilliant researchers, great universities and advanced companies perform cutting-edge research. Many have close relationships with their countries’ health-care systems, and some innovations are introduced in other nations. But the profit opportunity — the reason to invest — is always generated in the United States.

Consider the well-known miracle drug Gleevec. Before it came along in 2001, less than 30 percent of patients diagnosed with chronic myelogenous leukemia survived at least five years; today, 90 percent do.

Gleevec is also a poster drug for American dysfunction. Novartis steadily raised its price in the United States — even after its patent expired — to eventually reaching more than $123,000 per year in 2020. Yet, in Canada, Gleevec was priced at $38,000. A generic version in India now costs just $400.

Drugmakers and their opponents argue over the “fair” returns on innovation that companies need to maintain their incentive to invest in new medicines. Critics point to the share of pharma’s profits that come from barely legal anticompetitive behavior or from drugs created with heavy public support — such as the U.S. government’s $12 billion investment in coronavirus vaccines.

But enormous returns on a few blockbuster drugs compensate for drugmakers’ many unsuccessful products. That’s the business model, and these big, “unfair” returns are available only in the United States.

If the world’s largest health economy limited drug companies to “fair” returns — as other countries try to — then few new drugs would be created. The United States doesn’t pay $123,000 a year for Gleevec despite Canada paying only $38,000; Canada can pay $38,000 only because the United States pays $140,000.

And while pharmaceuticals might be the most obvious area in which the U.S. economy drives innovation, the $3.5 trillion we spend on care other than drugs makes an even greater contribution to world health-care advances.

In 2000, Intuitive Surgical Systems introduced the first commercially successful robotic surgery system. The company’s da Vinci robots carry $2 million price tags plus costly service contracts. In the first 20 years, 6,000 of the robots were sold worldwide, and American hospitals purchased roughly two-thirds of them.

Why? In the United States, the prices charged by hospitals and doctors are unrestricted. American physicians earn roughly two to three times as much as their counterparts in western Europe. Hospitals charge two to five times as much for their services.

The obvious, if rarely asked, question is: Why doesn’t competition bring U.S. health-care prices down? The answer: America’s stagnant third-party payment system allows hospitals and doctors to avoid competing on price. Instead, they compete on innovation. This is why hospitals advertise advanced, high-tech cancer therapies; surgeons build reputations for cutting-edge procedures; and even your family physician must invest to keep up.

Right now, we’re stuck. We want what every other country has. American reformers believe we’re just one clever policy tweak away from getting it — perhaps by instituting accountable care or “value-based” care.

But the only way to lower U.S. health-care costs is to rethink the system’s top-down policy structures that rely on huge, centralized payers.

What’s needed is a way to separate the safety net function that insurance provides from consumer decision-making. If insurance covered only major and unanticipated health problems, a consumer economy could drive competition in the rest of the system. This would give doctors and hospitals an economic incentive to bundle services, enhance efficiency, reduce waste and offer genuinely “value-driven” care.

In this century, the world has seen the democratization of many services considered “too complicated” for consumers — computers, finance, international travel, furniture construction, you name it. All this happened because people had enough control over their own spending to drive competition among innovators. It’s how industry managed to put supercomputer power in everyone’s pocket, while reducing price by 99 percent.

Until the same kind of competition is introduced in health care, the U.S. system will continue to subsidize the world — and cost us a fortune.