Power in Numbers

Health care leaders are working together to transform the market, leveraging their collective buying power to accelerate healthy change.

By eric johnson on January 19, 2017

powerinnumbersWhen it comes to operating in a healthy manner, perhaps no industry is under more pressure than health care, whose main mission—to promote health—extends well beyond the examination room.

“There’s a very serious disconnect if you’re purchasing products that might be causing problems,” said Tracey Easthope of the Safer Chemicals Program at Health Care Without Harm (HCWH). “If we’re continuing to degrade the life systems upon which we all depend, that’s going to have an impact on community health and global health.”

Complicating the equation, of course, is the fact that health care is a business with a very definite and demanding bottom line.

A Good Conversation

To help begin a dialogue for change, the three-year Healthier Hospitals Initiative (now Healthier Hospitals) brought health care leaders together to explore ways to leverage their united strengths.

“One of the takeaways was this idea of setting shared goals that the sector was working toward, and then demonstrating strong participation around those goals,” said Lauren Kleinman Koch, outreach and engagement specialist with Practice Greenhealth. “That resulted in a powerful message back to the marketplace.”

From that starting point, HCWH and Practice Greenhealth began a very intentional collaboration with the specific goal of leveraging the aggregate buying power of participating health systems in order to accelerate the transformation of the health care supply chain toward more sustainable products, technologies and services.

Made up of hospitals and health systems from the Practice Greenhealth membership, the effort is currently working on two main engagement initiatives: Less Meat, Better Meat and Safer Chemicals.

For those health systems that had been part of the Healthier Hospitals Initiative, it was a logical evolution.

“Seeing that this was an extension of the Healthier Hospitals Initiative, we already had the leadership and buy-in as a founding member, so there wasn’t a lot of business case to be made,” said Monica Nakielski, senior program manager for sustainability for Partners HealthCare System in Boston. “It was very much inherent to the work that was already being conducted, and it aligned to our philosophy.”

That philosophy—following the built-in motivation health care systems have for making healthy decisions—remains an important driver.

“I came from sustainability in the academic world,” said Sarah O’Keeffe, sustainability manager for Cleveland’s University Hospitals Health System (UH). “When I arrived in health care, I was pleasantly surprised at how much buy-in there can be from leadership. Don’t get me wrong, it’s not always easy to sell—some products are certainly more expensive, for example—but when you have the clinical engagement piece and you’re talking about the health of your patients and your staff, that becomes a really strong decision point.”

And taking that commitment to the marketplace made sense.

“After the groundbreaking consciousness-raising of the Healthier Hospitals Initiative, leveraging purchasing power was the natural next step,” said Mary Larsen, director of sustainability for Advocate Health Care System in Chicago. “This is truly using our purchasing power to leverage our demand for safer products and healthier food, and that’s a dynamic tool for change.”

While HCWH had been working on broad sustainability goals for years, the Healthier Hospitals Initiative focused on getting hospitals to work on a smaller subset of issues to really move the market. If done right, the sector could move the whole material economy by shifting what products get manufactured.

The collaborative effort was very intentional, making it clear to members that they were part of a group working to get safer products for all members. And those hospital systems have become powerful advocates. When organizers of the last market transformation group meeting were having a hard time getting medical mattress and bed manufacturers to attend, one of the big member health systems got on the phone and made a convincing financial case for them to be there.

As they say, there is power in numbers.

Moving Furniture

Purchasing furniture free of harmful chemicals targeted by Healthier Hospitals is important, and not just because it keeps hospital environments free from unhealthy chemicals—those that can become airborne or that can collect in dust after they rub off the product. It also keeps those same chemicals out of the greater environment when the furnishings are cycled out of the hospital.

Identifying chemicals of concern in furnishings was a long process, and the group focused on chemicals that are persistent, bioaccumulative or indoor air contaminants, and chemicals whose life cycles are particularly toxic. The current Version 2.0 priority list includes formaldehyde, perfluorinated compounds, polyvinyl chloride (PVC), antimicrobials and flame retardants.

Another important criteria: The chemicals chosen had to have well-performing, safer alternatives available on the market.

“We don’t want to set a guideline that can’t be met, but rather we want to identify the greenest products out there and drive demand for them,” Easthope said.

All flame retardants and antimicrobials were the newest addition to the Healthy Interiors goal. According to a paper produced by HCWH in 2016, evidence suggests antimicrobials in furnishings have several possible downsides with no real documented upside. And after a change in fire safety standards, it is now possible to meet fire safety standards without the addition of flame retardants for many products.

“When we were interested in tackling flame retardants, we had to develop a business case internally in order to get leadership support,” Nakielski said. “It’s one thing to get these chemicals out of the environment, but we needed evidence-based research that proved that these chemicals were toxic and harmful to human health, and we also had to prove that it was going to be sustainable for our profit.”

She partnered with a vendor to run an analysis. Intuitively, they knew adding flame retardants was more expensive, but they didn’t know how much. What she learned from the analysis was that there was, on average, a 20 to 25 percent upcharge to add flame retardants to a product.

“When we discovered that, we went to leadership and shared with them the opportunities available to us with the amended fire code, and we got the permission to go flame retardant-free where permissible by code,” she said.

Coming up with the list of chemicals of concern was a big step in pushing the manufacturers to move from a lack of awareness to creating a product list that was compliant with the Healthier Interiors criteria.

“That didn’t mean their entire portfolio changed overnight,” Larsen said. “But they slowly had conversations with their suppliers, and once one of the manufacturers did that, we started to see that we could use that peer pressure to reach out to their competitors. We’re leveraging the free market and competition—and, frankly, leveraging our pooled volume.”

Within the last two years, the number of manufacturers providing lists of products that meet the qualifications has risen from three to 33, and the number of products on those lists continues to climb, giving health systems significant opportunities to eliminate those chemicals of concern.

According to Nakielski, 70 percent of all furniture in Partners’ new Assembly Row headquarters, a $22 million spend, meets Healthier Hospitals guidelines, and O’Keeffe reports that 92 percent of UH’s new purchases for the first two quarters of 2016 avoids the list of chemicals outlined by Healthier Hospitals.

Better Meat for People and the Planet

In some ways, the drive to make food standards healthier—particularly offering meat raised without routine antibiotics—seems like an easier case to make, especially with the increasing amount of research indicating the dangers of antibiotic resistance.

“I think on an individual basis, health care really understands how concerning antibiotic resistance is,” said Hillary Bisnett, national procurement director for the Healthy Food in Health Care Program with HCWH. “We just brought a broader lens to that, showing them that animal agriculture is where up to 80 percent of antibiotics are used. Once they hear that, addressing their food purchases is an obvious next step.”

O’Keeffe agrees: “If we are already working on antibiotic stewardship at the clinical level, it only makes sense that we would try to procure food that is also free of antibiotics, because that contributes to our overall goal of decreasing these antibiotic-resistant diseases.”

In UH’s case, that clinical buy-in extends to having a letter of support from the health system’s antibiotic stewardship council.

But however easy it might be to sell as a concept, it’s not necessarily easy to implement an antibiotic-free meat program.

In 2015, HCWH started to provide hospitals with a list of meat and poultry products raised without routine antibiotics to use when talking with their vendors that didn’t carry them. The number of products that meet the qualifications has risen from close to 100 to nearly 500 items, demonstrating a market response to the demand.

Larsen notes that cost continues to be a barrier despite the fact that, according to Bisnett, the price of antibiotic-free chicken is far from the 300 to 400 percent markup seen five years ago. “We are still at the point where demand hasn’t quite caught up with supply, so there is an incremental cost that we’ve had to deal with in health care—a sector burdened with cost containment,” Larsen said.

There are several adjustments health systems are making to help manage the increased cost, however. Some involve engaging suppliers, while others involve adjusting the menu, either by changing the types of meat or the proportions.

While Meatless Mondays may have received bad reviews from the meat-loving segment of the population, the addition of a mushroom burger has stirred up some excitement at Partners.

“It’s a combination of mushrooms as well as antibiotic-free meat, so you keep the texture and taste and the different aspects they typically measure in the food service department, but you have the additional benefit that there’s less meat and the meat being offered is of higher quality and is antibiotic-free,” Nakielski said. “Many of our hospitals are adopting this because of their commitment in the fight against hospital-acquired infections.”

Customer preference isn’t always uniform, however, even within health systems. Charging two dollars more for the grass-fed beef burger may be entirely acceptable—even applauded—in some areas, yet prohibitive in areas where there might be a food desert and a more affordable McDonald’s handy.

“A lot of this is about change management,” Larsen said. “When our associates or people in high-stress situations come to our cafeterias and our comfort food is gone—you can’t make that change overnight.”

Enthusiasm at the health system level for making the healthy choice is growing, however. According to Bisnett, 800 hospitals are participating in the Less Meat, Better Meat initiative, and nine of the participating health systems have set goals for up to 60 percent of their meat and poultry to be antibiotic-free.

Growing the Slice of the Pie

Ultimately, communicating these healthy efforts is important to internal audiences as well as to external audiences, both in terms of overall awareness and expanding their reach.

“We have to educate the people who are making the purchasing decisions,” Larsen said. “We’ve heard from manufacturers that change doesn’t happen within their organizations unless they feel the demand is there. They can’t invest in something unless they know we’re going to buy it.”

That goes for meat raised without routine antibiotics as well as healthy furnishings. But even the aggregated power of the health care sector is only so powerful.

“One of the questions we ask our vendors is, ‘What percentage of revenue is health care?’ and what we’re seeing is we’re on the smaller end,” Nakielski said. “So you’re starting to see a lot more collaboration with the ed/med group. If we can’t tackle it alone with just health care, we know some of these demands are being made by students at the university and college level, and by parents.”

Evidence of the power of combined momentum can be seen especially in furnishings, where institutional furniture manufacturers are getting pressure from the market transformation group as well as the Googles and the Facebooks of the world, and the numbers are advancing at a good pace. Medical furniture manufacturers, on the other hand, are only getting pressure from health care-related concerns, and the needle hasn’t moved there nearly as far.

That power can be seen in the food industry as well, where the market is responding to fast food and retail pressure for meat and poultry raised without antibiotics. By teaming up with other sectors, particularly colleges, universities and K–12 education, the HCWH/Practice Greenhealth network is amplifying its voice for healthier meat in a way that boldly communicates the shared demand.

“The main learning point is that none of these goals lives isolated in our program,” O’Keeffe said. “They have to be connected, and that’s one of the biggest opportunities in these market transformation groups—to help each other connect back to our organizations’ health mission. Health care often gets held up as the moral authority on certain things to do with healthfulness, so it behooves us as health care professionals to really endorse that power, making sure we’re good stewards of it by operating in a healthful way.”