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NATIONAL HARBOR, Md. -- As the American Medical Association (AMA) House of Delegates was hosting a forum at its interim meeting here on the efforts of the healthcare industry to reduce its carbon footprint, Steve Lee, MD, a delegate from Oakland, California, had a question.

"When I drag someone into the office for intravenous chemotherapy, I get ASP [the average sales price of the infusion drug] plus 6% for the infusion, I get paid for the infusion itself, and I can bill for a modifier 25 if I see them in the office at the same time," said Lee, an oncologist and a delegate for the Association for Clinical Oncology. "Whereas if I give them an equally effective oral medication, I don't see any of it -- it goes to the PBM [pharmacy benefit manager] and the insurance company. From a healthcare efficacy standpoint, what can be done to start a coalition of advocacy to ease these types of disincentives?"

Chris Hanley, director of the Grand Challenge on Climate Change project at the National Academy of Medicine, tried to answer. "I'll speak to half of that ... We do have our policy working group that has started having these conversations," he said. "But again, what we'd be able to put out is likely recommendations" rather than anything stronger. "I wish I had a better answer for you."

Amy Collins, MD, an emergency physician in Boston and the medical director of physician engagement and education at Health Care Without Harm, a group working to reduce healthcare's carbon footprint, said that this example really speaks to the idea that "we need all sectors to take action."

Colin Cave, MD, medical director of external affairs, government relations, and community health at Northwest Permanente, a medical group in Portland, Oregon, that cares for Kaiser Permanente patients, told Lee, "You already know the answer. It's money, and dollars speak." Cave noted that for a few years, he tried to get on a healthcare working group started by Business for Social Responsibility. "I was not able to do so, but there were 15 pharmaceutical companies" on the working group, he said.

"Everything you say makes sense, but we're still trying to get half this country to acknowledge that we have an environmental problem," Cave added. "I hope you ask that question in 6 years, and we might have an answer."

Another audience member asked session moderator David Welsh, MD, a delegate from Batesville, Indiana who is also chair of the AMA's Council on Science and Public Health, whether the association has considered using carbon offsets to make up for the energy involved in convening large meetings twice a year -- the interim meeting in the fall and the annual meeting in June -- at which people fly in from all over the country. "I don't know, but I'll try to find out," Welsh said.

Panelists who worked for health systems discussed what their own employers were doing to reduce greenhouse gas emissions. Cave discussed Kaiser's "Greening of the OR" initiative, in which operating room staff members started reprocessing tissue sealers, tourniquets, and trocars, sending them out for sterilization and cleaning, and then repurchasing them.

"That's about half the reduction of CO₂ in the operating room," he said. "It's also probably one of the biggest savers -- somewhere in the $200,000-to-$1 million range for 620,000 covered lives in our operating rooms." Other savings come from reusing equipment like restraints and getting rid of plastic bins and replacing them with non-plastic options.

The organization also changed its use of anesthetic gases in the operating room. "In 2018, we educated anesthesia colleagues and CRNAs [certified registered nurse anesthetists]" on using less desflurane -- which has a high carbon footprint -- and more sevoflurane, which has a much lower one, Cave said. As a result, "that's 1,000 metric tons of CO₂ equivalents that we are not emitting into our atmosphere every year," and also a savings of $100,000 annually.

Matthew Siegler, senior vice president for managed care and patient growth at NYC Health + Hospitals, which operates 11 acute care facilities and more than 50 community health centers in New York City, said his organization signed the , which calls for participating healthcare systems to reduce organizational emissions by a minimum of 50% by 2030 -- from a baseline no earlier than 2008 -- and achieve net-zero by 2050. Participants also must develop and release a climate resilience plan for continuous operations by the end of 2023 or within 6 months of signing the pledge.

"With the urgency we feel, we are going to [reduce emissions by 50%] by 2028," Siegler said. He noted that "one bright side of having an aged and very challenged infrastructure, is we were starting from an incredibly high baseline and incredibly inefficient energy utilization."

As a result, "we are already down about 30% from our 2008 baseline, and we've done that largely by eliminating fuel oil," he explained. "We powered a lot of our hospitals with old-school heating oil. It's not a tremendously innovative thing to move to natural gas, but we've done it and it has saved tens of thousands of metric tons of CO₂ emissions."

Going forward, achieving more CO₂ reductions will involve "massive investment in energy infrastructure" as well as reducing emissions from outside sources, such as business travel and meat procurement, Siegler said. For example, "our default food option in all hospitals is plant-based meals. They're incredibly popular -- we have very good soy chorizo and all sorts of things."

Although the healthcare sector is not making progress as fast as it should, "there are a lot of things to be hopeful about," Collins said. She added that the Joint Commission announced last spring that it was developing new requirements for environmental sustainability as part of its accreditation program, but instead ended up launching a voluntary sustainability program. "Voluntary efforts aren't going to get us where we need to be; it needs to be mandatory."

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