Journal of Sustainable Marketing

Telemedicine and Digital Health

Until the Covid-19 pandemic, healthcare delivery took place primarily in face-to-face settings. In-person delivery is associated with carbon emissions caused by patient transportation, lodging, construction costs for healthcare delivery centers, and so on. The rapid shift to telemedicine caused by infection control measures during the pandemic demonstrates what is possible in remote care. For the most part, services such as follow-up consultations, second opinions, and even initial consultations for non-emergent complaints have been widely delivered via telemedicine (Contreras et al., 2020). A permanent shift away from in-person to remote healthcare delivery would contribute to a reduced healthcare carbon footprint, and, more importantly, expand access to expert care for patients living in geographically dispersed areas of the country. Digital first health systems require less physical space for clinical encounters, which fosters the centralization of highly complicated therapies, while enabling the distribution of routine clinical encounters at the point of need. The sustainability savings of reduced building space, parking, and other infrastructure from routine care is analogous to the efficiencies associated with e-tailing versus bricks and mortar retailing businesses (Schöder, 2016).

Here are multiple opportunities for sustainable marketing researchers to collaborate with clinic and hospital managers/providers to ensure that telemedicine and digital health systems are sufficiently attractive to achieve economies of scale and financially viability.

Data Storage and Services

The US healthcare industry consumes 73 billion kWh of electricity annually (Campion et al., 2015). A large proportion of that energy is expended in documentation and related technologies. While it is estimated that digitalization can reduce document-related emission by 99% (Pu & Lam, 2021), the total environmental costs of electronic medical records, data storage and transfer, and digital- healthcare delivery are yet to be determined. Modern electronic medical records make retrieval and transfer of healthcare information easier and nearly instantaneous. However, there is an energy cost to the transfer, storage, and manipulation of healthcare data, and the sustainability and dollar cost of that energy will vary by the energy sources of the hospital and the data storage facility. Server farms produce large amounts of heat that must be dissipated by actively cooling, which in turn consumes energy. In recent years, there has been an exponential increase in the amount of electronic medical data generated, from genomic data to medical results to operational data. With an increasing use of blockchain technology to improve privacy, more layers of data storage and transfer needs are introduced, adding to the energy cost.

Medicine has been at the forefront of the artificial intelligence revolution driven by deep learning and massive medical image databases. Given the data-intensive nature of deep learning, there have been concerted efforts at various large medical organizations to systemically collect, curate, and store an ever-increasing number of medical images, which are energy intensive enterprises (Howson, 2019; Jiang et al., 2021). To this end, studies have shown that better data center designs have the potential to reduce energy consumption by up to 25% which, in the US, is equivalent to more than 13 billion kWh per year (Shehabi, Masanet, Price, Horvath, & Nazaroff, 2011). Lucivero et al. (2020) recognize the non-explicit costs of massive data storage centers and that these must be weighed against the benefits (Lucivero, 2020). Managing the data costs of healthcare, in terms of energy, environment, and financial costs will require more attention, in addition to the usual sensitivities surrounding privacy and data security typified by HIPAA (Cohen & Mello, 2018) , and the unique data safety considerations in healthcare (Abouelmehdi, Beni-Hessane, & Khaloufi, 2018).

The key to the sustainable implementation of energy-intensive data operations will lie in the widespread adoption of sustainable energy generation. Hence, sustainable marketers specializing in B2B sales research could make important contributions from identifying effective approaches based on theory and validated by real world testing to working with healthcare providers and managers to implement renewable energy systems in their facilities.

Value Based Care

Value based care is a stated goal of most US healthcare organizations. As initially articulated by Porter (Porter et al., 2006), value is equal to quality times the ratio of outcome/cost ( $quality\times \frac{outcome }{cost}$ ). Increasing value in healthcare means reducing waste and improving outcomes, which reduces the environmental impact of healthcare.

Despite widespread interest, there has yet to be generally accepted mechanisms to achieve value-based care (Busse et al., 2013; Steinmann, Delnoij, Bovenkamp, Groote, & Ahaus, 2021) . In a health services research review, Steinmann, Delnoij, Bovenkamp, Groote, & Ahaus (2021 , p. 1) conclude that their research “raises the question whether… [Value Based Health Care]’s widespread international uptake indicates its actual implementation or… an inspiring idea.” Whether hospital systems that say they practice value-based care, in fact do so depends on what they mean by the term. For many, value-based care may simply be another word for cost cutting. In addition, it is simple to control costs by bundling care and fixing a payment value. In the traditional diagnosis-related groups (DRG) payment mechanism, for example, the payer fixes a payment for a given diagnosis that covers all expenses for the healthcare event. This often results in a transfer of value from the healthcare provider to the payer, rather than a true enhancement of value throughout the health ecosystem in which all participants gain (Herwaarden, Wallenburg, Messelink, & Bal, 2020; Woo & Anderson, 2020). Inherently, these payment models reward healthcare systems that predominantly see straightforward versions of a disease state wherein spending may be reined in more effectively. In complex disease states, the DRG model may be insufficient or become inoperably complex to capture all the variables that inform the total cost of care (Woo et al., 2020).

We suggest adding a patient-empowering dimension to the implementation of value-based care by adjusting the systems of financial responsibility for care placed on patients (such as co-pays and deductibles) to encourage patients to choose high value care. For example, small financial incentives could be used to encourage patients to participate in preventive care and health promoting practices, and to discourage unnecessary or low value care. Such a system would require providers and payers to collaborate to specifically identify services that qualify as high value care based on strong evidence spanning efficacy, outcomes, costs, and sustainability. Similarly, specific examples of unnecessary or low value care could be identified, and providers (and patients) could be educated about services that fall into both categories. Over time, this approach may improve the alignment of interests between patients and payers, and could alter the specialization choices of providers as the balance of care services aligns towards sustainable care choices.

New programs using risk sharing methodology link payers and providers incentivizing the parties to reduce unnecessary care and improve patient outcomes, most recently using Direct Contracting Entities (DCE) (Antonanzas, Juárez-Castelló, Lorente, & Rodríguez-Ibeas, 2019). These are private contractors that receive funding from CMS to care for a patient cohort up front and administering care from this pool of funds for the healthcare of the cohort. Like the DRG model, the provider organization profits when the cost of care is less than their contracted pre-arranged payment. Whether these entities achieve their intended goal of achieving value remains to be seen.

Price Signaling and Market Forces

While many parts of the US healthcare system are tightly regulated, there are parts of the system, such as elective cosmetic procedures, that remain largely driven by patient choice. Here, transparent prices that reflect the value of the care are more easily seen, since they are the products of demand and supply. In a sustainable healthcare system, there should be more parts of the healthcare system that are typified by such dynamics. For example, therapies to extend end-of-life care can be very costly in dollar value and societal resources. Yet, we know that most fail to meaningfully extend life or preserve the quality of life. The transparent pricing of care to reflect these difficult realities may help patients and their families make better decisions about the kind of care they choose. If even a larger fraction of patients chose palliative care rather than heroic measures at end of life, the cumulative value of such decisions will allow scarce resources to be directed at health conditions that will benefit from them.

Sustainable marketers who specialize in pricing can play important roles in more effective, transparent, and equitable ways to employ pricing strategy and signaling to reduce waste while ensuring sufficient resources are available to parts of the healthcare system, such as primary and pediatric care, that can truly benefit from proactive investments in quality and safety.

Healthcare Waste

Waste of resources is antithetical to sustainability and across the ideological spectrum there is consensus that waste in healthcare is undesirable (Berwick & Hackbarth, 2012). An OECD report in 2017 estimated that up to 20% of healthcare spending is wasted (Limb, 2017). (Zygourakis et al., 2017) estimated that approximately 968 USD of operating room waste such as unused surgical supplies was generated per case, or 2.9 million dollars per year in the University of California San Francisco neurosurgery department, representing a relatively small division in a large academic medical center. Separately, (Gillerman & Browning, 2000) estimated that roughly 26% of drugs in an anesthesia department that are issued are not used, and so have to be disposed. Part of this problem is primarily the result of inadequately tuned business and operational processes. Sustainable marketers who work in the domain of customer driven business processes can lead the development of standards to reengineer processes to fine-tune them to the needs of the process customers, e.g., designing systems for issuing anesthesia drugs on demand during procedures, rather than pre-packaging for surgery or reducing the size of the pre-op instrument tray and optimizing modular instrument sets to reduce the volume of unused instruments that need to be re-sterilized or discarded post-op.

Healthcare Infrastructure Costs

The US healthcare system is estimated to generate about 10% of the country's greenhouse gases (Chua, Amin, Zhang, Thiel, & Gross, 2021). Healthcare systems are multibillion dollar construction projects that require high quality electricity, air flow, and biosecurity to sequester infectious agents. Maintaining the computers, machines, and personnel in such structures requires substantial resources. For instance, in an assessment of greenhouse gases generated in an interventional radiology suite, (Chua et al., 2021) calculated that 23,500 kg of CO2 is created over the course of 97 patient procedures, the majority of which is related to the energy spent on climate control and disposable surgical supplies (Chua et al., 2021). Buckley and Macmahon (2021) identified digital workstations and data storage equipment as other sources of greenhouse gases. In addition to increasing the share of clean energy in total energy utilized, clinics and hospitals can proactively manage and reduce the energy demands such as designing buildings that generate renewable energy for non-critical systems (Bardineh, Mohamadian, Ahmadi, & Akbarianrad, 2018) and that harvest rainwater (Fulton, 2018) for gray use, contributing to the goal of sustainable healthcare.

Packaging, Drugs, and Devices Redesign

Packing reduces spoilage, conveys product information, preserves sterility, and facilitates efficient transportation of the product. However, packaging also adds costs, increases energy use in transportation and manufacturing, and can introduce waste. This is particularly true with single-use consumables such as surgical swabs, probes, suture packaging, and so on. The use of single-use disposables in healthcare can be costly and wasteful (Karlsson & D, 2005; PGH Waste Management Practice Greenhealth, 2008; Swensen et al., 2011; Tudor, Barr, & Gilg, 2007) with an estimated 5.9 million tons contributed to medical waste annually. Medical waste is produced when packages are incorrectly sized, resulting in unused items (e.g., surgical swabs) being discarded into the waste stream.

The solution to the problem of packaging and single user waste is more nuanced than simply reducing their use. The need for sterility in healthcare devices is the reason for high quality packaging materials for single use disposable devices (King, 2011) and drugs (Pareek & Khunteta, 2014) . While sterilization of reusable devices may seem to be more environmentally friendly, the energy and human resources costs associated with sterilization are not trivial. (Mcgain, Story, Lim, & Mcalister, 2017) estimated that the 30,000 AUD direct savings from sterilizing reusable devices was offset by costs associated with twice the water use and 10% greater CO2 emissions (Mcgain et al., 2017) in their 6-operating theater hospital.

Therefore, designing operating room devices that maintain sterility during use, for example with persistent anti-microbial coatings, can lead to less packaging. Doing so is challenging because of the regulatory and other constraints that come with complex procedures. (Thiel, Woods, & Bilec, 2018) argue that in the case of surgeries, a combination of approaches should be used to reduce environmental emissions, for instance, by minimizing materials, increasing reuse, reducing heat-trapping anesthetic gases, and reducing off-hour energy use in the operating room. In their study, they estimate that this strategy can lead to an 80% decrease in the carbon footprint of laparoscopic hysterectomy procedures (Thiel et al., 2018). (Eckelman, Mosher, Gonzalez, & Sherman, 2012) found that replacing their disposable laryngeal air masks with reusable masks decreased GHG by 25% (Eckelman et al., 2012) . Shockingly, up to 33% of prescription drugs go unused in the United States, with at least 5 billion USD of drugs incinerated or disposed each year (Lenzer, 2014). Strategies to reduce drug waste include take-back programs (Fass, 2011) and more carefully individualizing prescriptions, but these approaches have yet to gain traction.

Once again, multiple opportunities exist for sustainable marketing researchers to play a role in better understanding patient and provider attitudes/behaviors that are critical to identifying packaging and prescription drug consumption communications that can result in a reduction of GHG emissions and post-use pollution. For example, sustainable marketers who work in the domain of product/packaging design and marketing communications can play important roles in understanding the tradeoffs between communication tactics, packaging, and efficient resource use. They can also help develop principles and standards for more sustainable medical product packaging, distribution, inventory handling, and post-use recycling.

Toxicity

Many products used in the provision of healthcare are inherently toxic or radioactive. Gadolinium, a toxic heavy metal used as a contrast reagent for magnetic resonance imaging (MRI), has been found in aquifers near metropolitan centers (Bau, Knappe, & Dulski, 2006; Rabiet, Brissaud, Seidel, Pistre, & Elbaz-Poulichet, 2009), prompting the development of approaches to chelate free gadolinium in the environment so they are less harmful (Ferreira et al., 2020). Research into nontoxic alternatives is ongoing; manganese, for instance, may prove to be a non-toxic alternative to gadolinium for MRI (Erstad et al., 2019; Pan, Schmieder, Wickline, & Lanza, 2011).

Nuclear waste from diagnostic and therapeutic medical procedures requires special handling and disposal (Ring, Osborne, Shapiro, & Johnson, 1993; Sundell-Bergman, Cruz, Avila, & Hasselblad, 2008). The use of these substances adds cost to hospital systems and risk to patients, and while non-radioactive and non-toxic alternatives are available, they are less efficacious. As a result, the economic case for investments to develop non-toxic alternatives can be difficult to make unless marketers can help determine the value proposition for a premium price. Lastly, the production of healthcare products may result in toxicity and pollution that is not obvious to providers, patients, or payers, such as cobalt mining and sourcing that are required to produce many advanced orthopedic implants. For instance, over two-thirds of the global cobalt supply is produced in the Democratic Republic of Congo. The mining of cobalt in that country is fraught with safety, environmental, and social harms because of laxed regulatory standards and enforcement, and governmental corruption (Williams, Vangu, Mabiala, Mangungulu, & Tissingh, 2021). Hence, sustainable healthcare must include matters of supply chain integrity, like the audits that multinational companies are regularly subject to for child labor.

Many sustainable marketers who focus on ethical and social justice issues related to supply chain design and management can make important contributions in researching current practices and testing supply chain models that lead to better design, implementation, and certification of fair-trade practices within global medical device supply chains. Such questions are best investigated by multidisciplinary teams that include experts in marketing, operations management, law, and cross-border trade.