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07/23/2019

Upcoming Podcast: APHA Executive Director, Dr. Georges Benjamin, Discusses the Climate Crisis (July 24th)

07/21/2019

Dr. Mark Fendrick Discusses Value-Based Insurance Designs (July 19th)

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One way to increase the value of insurance coverage is to eliminate or lower a patient's out of pocket costs (OOP), i.e., their co-pays and/or deductables, for health care services that are of high value, for example, vaccines and/or alternatively increase OOP costs for low value service, for example, certain imaging tests.  The concept is based on the straight forward rationale that, based on clinical evidence, certain health care products or services are proven to be more effective than others.  (This is the rationale for the Choosing Wisely program, at: https://www.choosingwisely.org/.)  OOP costs therefore should not be uniform for all services and medications, particularly when non-adherence rises along with rising health care OOP spending.  This largely explains the problem of medication non-adherence.  Phrased another way, we need need to solve for the increasing problem of under consuming high value care.  This idea was recognized in the 2010 Affordable Care Act, specifically Section 2713 [c] that eliminates patient cost sharing for specific preventive care services.  For example, OOP costs for significantly under-utilized breast and colorectal screenings, for which approximately only 72% and 60% of patients, respectively, are screened.  The value-based idea was furthered by the ACA-created CMS Innovation Center that in 2017 the launch the MA VBID demonstration - that was recently extended to 2024.  (This discussion is related to or can serve as a follow up to my May 11th conversation with Professor Andrew Ryan concerning measuring for value or spending efficiency.)

During this approximately 30 minute conversation, Dr. Fendrick discusses moreover the creation of the University of Michigan's VBID Center, provides his assessment of the current CMS Medicare Advantage VBID demonstration, the U. of MI Center's just announced V-BID X insurance design, VBID efforts at the state level and the Treasury Department's just-announced guidance allowing Health Savings Account/High Deductible Health Plans to practice VBID.   

Dr. A. Mark Fendrick is the Director of the Value-Based Insurance Design Center at the University of Michigan.  He is also Professor of Internal Medicine in the School of Medicine Amfenand a Professor of Health Management and Policy in the School of Public Health at the University of Michigan.  He has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design.  Dr. Fendrick is an elected member of the National Academy of Medicine (formerly the Institute of Medicine or IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the U.S. Senate Committee on Health, Education, Labor and Pensions, the U.S. House of Representatives Ways and Means Subcommittee on Health, and the U.S. Senate Committee on Armed Services Subcommittee on Personnel.  Dr. Fendrick is the co-editor in chief of the American Journal of Managed Care and is an editorial board member for three additional peer-reviewed publications.  He is also a member of the Institute for Healthcare Policy and Innovation at the University of Michigan, where he remains clinically active in the practice of general internal medicine.  Dr. Fendrick received a bachelor’s degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School.  He completed his residency in internal medicine at the University of Pennsylvania where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program.

For information about U. of Michigan's Center for Value-Based Insurance Design to go: https://ihpi.umich.edu/center-value-based-insurance-design-v-bid.

A summary of the V-BID X proposal is at: https://www.healthaffairs.org/do/10.1377/hblog20190714.437267/full/.  The more complete white paper is at: http://vbidcenter.org/wp-content/uploads/2019/07/VBID-X-Final-Report_White-Paper-7.13.19.pdf.  

For information concerning Dr. Fendrick's mention of the just-released US Treasury guidance allowing HSA-HDHP plans the flexibility to cover specified medications and services prior to meeting the plan deductible go to: https://ihpi.umich.edu/center-value-based-insurance-design-v-bid

07/18/2019

Katherine Eban Discusses Her Just-Published Work, "Bottle of Lies, The Inside Story of the Generic Drug Boom" (July 17th)

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Nine in 10 prescriptions are today filled using a generic drug saving Americans tens of billions annually.   A significant amount of generic drugs, along with active ingredients in all drugs, are manufactured overseas.  However, how safely or to what quality standards are these ingredients and generics produced?   Bottle of Lies, published in May, tells the story of appalling practices foreign generic manufacturers use to produce these drugs at the most minimal cost.  The work moreover provides a detailed account of Ranbaxy, the former India-based generic manufacturer that after eight years of investigation was fined a then record amount,$500 million, for significant fraud.  The work questions or brings to serious doubt the FDA's ability to adequately inspect overseas generic manufacturers ensuring these drugs are safe for consumption in the US or around the world.  Listeners may recall I interviewed coauthor Paul Weinberg in September 2017 concerning his related work, Blood On Their Hands, How Greedy Companies, Inept Bureaucracy and Bad Science Killed Thousands of Hemophiliacs and Rosemary Gibson this past December concerning her related, China Rx, Exposing the Risk of America’s Dependence on China for Medicine

During this 37 minute interview. Ms. Eban provides an overview of Ranbaxy's manufacturing practices revealed by former employee and whistleblower, Dinesh Thakur.  She explains the mindset, termed "Jugaad," used in India to produce generics.  She discusses the adequacy of the 2013 US settlement with Ranbaxy , the role the Japanese firm, Daiichi Sankyo, a  major Ranbaxy stakeholder, the FDA's ability to adequately inspect Ranbaxy and other generic manufacturers around the world, e.g., Cipla and Mylan, recent and future related Congressional action, how poor or inadequate manufacturing practices complicate remedying the drug shortage problem and what precautions consumers or patients can take before consuming generic drugs.  

Katherine Eban, an investigative journalist, is a Fortune magazine contributor and Andrew Carnegie fellow. Her articles on pharmaceutical counterfeiting, gun trafficking, and 1811011_HS_114_RTcoercive interrogations by the CIA, have won international attention and numerous awards.  She has also written for Vanity Fair, The New York Times, Self, The Nation, the New York Observer and other publications. Her work has been featured on 60 Minutes, Nightline, NPR, and other national news programs.  She lectures frequently on the topic of pharmaceutical integrity.  Her first book, Dangerous Doses: a True Story of Cops, Counterfeiters and the Contamination of America’s Drug Supply, was named one of the Best Books of 2005 by Kirkus Reviews and was a Barnes&Noble Discover Great New Writers pick.  Her account of reporting on 9/11 was anthologized in At Ground Zero: 25 Stories From Young Reporters Who Were There. Her work has also been awarded grants from the Alfred P. Sloan Foundation, the Fund for Investigative Journalism, the Alicia Patterson Foundation and the McGraw Center for Business Journalism at CUNY’s Craig Newmark Graduate School of Journalism.  Educated at Brown University and Oxford, where she was a Rhodes Scholar.   

Information on Bottle of Lies is at: https://www.harpercollins.com/9780062338785/bottle-of-lies/.  

Ms. Eban's FAQ regarding how to learn about generics or best to consume is at: https://www.katherineeban.com/faqs

07/03/2019

"Can Medicine Be Cured?"

Though I've been asked over the years to recommend readings I've avoided beyond noting those related to podcast interviews.   However, this work and lengthy review may be worth particular notice.  The book is Seamus O'Mahony's Can Medicine Be Cured? The Corruption of a Profession and the June review appearing in the Dublin Review of Books by Paul O'Mahoney is titled, "Made To Measure?"

At: http://headofzeus.com/books/can-medicine-be-cured

At: http://www.drb.ie/essays/made-to-measure-

06/20/2019

Brady President, Kris Brown, Discusses Current Policy Efforts to Curb Gun Violence (June 23rd)

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US gun violence is, in one word, obscene.  It is widely considered an epidemic, even the always cautious AMA termed it a "public health crisis" in 2016.  Through the first five months of this year there were 148 mass shootings that killed or wounded nearly 750 individuals.   It is worth repeating comments I made in April 2018 to introduce Dr. Al-Abga (whom treated victims of the 1999 Columbine High School shooting).  US gun deaths are 96 times higher than in Japan, 55 times higher than in the UK, 32 times higher than in Germany.  Gun violence is particularly common in schools.  Since 2000 there have been over 200 shootings in over 40 states at elementary, middle, high schools and at colleges and universities. Research suggests gun violence is explained largely by one fact: gun prevalence. The US makes up less than 5% of the world's population but owns nearly 45 percent the world's guns, or 300 million that one-third of Americans’ possess.  Ownership is, for example, 150 times higher than in Japan.  This fact largely explains why guns used to commit homicides far exceeds other developed countries.  US gun homicides are 471 times more prevalent than in the UK.  As for whether mental health issues explain US gun violence, the rate of severe mental disorders in the US is no greater than in comparative countries. 

During this 26 minute conversation Ms. Brown discusses Brady United's mission or work activities including its legal efforts relative to the 2nd amendment.  Moreover, she explains current efforts in the Congress to appropriate moneys for federal gun violence research (that has not been conducted for over 20 years) and recently House-passed bills that include regulating gun sales via extending background checks to private fire arm sales.  Ms. Brown also discusses policy plans by Democratic presidential candidates including Sen. Cory Borker to curb gun violence and she discusses the State of Virginia's upcoming special session next month in the wake of the May 31st Virginia Beach shooting that left 12 dead.  

Ms. Kris Brown is the President of Brady.  Ms. Brown began her career working on Capitol Hill for (now former ) Rep. Jim Moran (D-VA), advocating for the bill that would eventually KrisBrown-LipstickLobbyHeadshot_190225_192444become the Brady Act requiring background checks on federally licensed gun sales.  At Brady, she led the lunch of the organization’s safe storage campaign to End Family Fire and formed Brady’s “Team Enough” youth initiative after February 2018 Marjory Stoneman Douglas High School massacre in Florida.  A noted media commentator, Ms. Brown was, for example, featured in the November 2018 TIME magazine cover article titled, “Guns in America.”  Ms. Brown has also served as the Chief Legal Officer to a publicly traded company based in Switzerland and as a lawyer practicing at the law firm Weil, Gotshal & Manges.  She earned her law degree at George Mason University. 

For more on Brady go to: https://www.bradyunited.org/  

For information on the Enhanced Background Checks Act of 2019 go to: https://www.congress.gov/bill/116th-congress/house-bill/1112/text 

The recent debate sparked by FiveThirtyEight regarding the accuracy of CDC's gun injury statistics and titled, "The CDC is Publishing Unreliable Date on Gun Injuries, People Are Using It Anyway," is at: https://fivethirtyeight.com/features/the-cdc-is-publishing-unreliable-data-on-gun-injuries-people-are-using-it-anyway/

06/19/2019

Dr. Renee Salas Discusses Global Warming's Health Effects On Children (June 18th)

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This past June 4th the 9th Circuit Court heard oral arguments concerning Juliana v. the US, a case filed in 2015 by 21 children seeking a jury verdict on whether the US government, by failing to address the climate crisis, is protecting the plaintiff’s rights to life, liberty and the pursuit of happiness.  In its defense the US is arguing these children, now young adults, have “no fundamental constitutional right” to a “climate system capable of sustaining human life.”  In a May 30th essay published in The New England Journal of Medicine Dr. Salas and two colleagues agreed with the plaintiffs concluding , “As the Juliana plaintiffs argue - and we agree - climate change is the greatest public health emergency in our time and is particularly harmful to fetuses, infants, children and adolescent.” (Listeners may be aware this is my 7th climate crisis related interview since October.)

During this 26 minute interview Dr. Salas discusses her related research work, the amicus brief she and her colleagues forwarded in support of Juliana plaintiffs and other related litigation filed world wide.  Moreover, Dr. Salas explains the numerous adverse health effects children are suffering via the climate crisis including various birth defects, heart, lung and neurodevelopment illnesses, vector-borne diseases, harms from high heat and wildfire exposure, cognitive, behavioral and mental health effects, contaminated water, and numerous others.  She discusses what parents need to know or can do to protect their children and the extent the health care industry needs to (better) address its own contribution to greenhouse gas emissions/pollution or global warming. 

Dr. Renee Salas is Affiliated Faculty and a Burke Fellow at the Harvard Global Health Institute.   Her research addresses how climate change is impacting the healthcare system and developing evidence-based adaptation.She is also a practicing physician in the Department of Emergency Medicine at Massachusetts General Hospital and on faculty at Harvard Medical School.  Dr. Salas served as the lead author on the 2018 Lancet Countdown on Health and Climate Change U.S. Salas - HeadshotBrief and will again in 2019.   She lectures on climate and health nationally and internationally, has published in numerous scholarly journals and is the founder and past Chair of the Climate Change and Health Interest Group at the Society of Academic Emergency Medicine.  Dr. Salas received her Doctor of Medicine from the Cleveland Clinic Lerner College of Medicine with a Master of Science in Clinical Research from the Case Western Reserve University School of Medicine.  She also holds a Master of Public Health from the Harvard T.H. Chan School of Public Health with a concentration in environmental health.

Renee Salas, Wendy Jacobs and Frederica Perera's New England Journal of Medicine essay, "The Case of Juliana v US - Children and the Health Burdens of Climate Change," is at: https://www.nejm.org/doi/full/10.1056/NEJMp1905504 

The video of the 9th Circuit Juliana v the US oral argument is at: https://www.ca9.uscourts.gov/media/view_video.php?pk_vid=0000015741&fbclid=IwAR3K3vnHCO4M2KlcMZ1NSQ4ua1ZZhpdyA-hONwyj6N7uS0u1X5ojmuVVkCc

The amicus brief filed in support of the Juliana plaintiffs by 13 medical societies and over 65 medical professionals is at: http://clinics.law.harvard.edu/environment/files/2019/03/Juliana-Public-Health-Experts-Brief-with-Paper-Copy-Certificate.pdf

Again, my related essay, "Can the Climate Crisis Continue to Go Begging?" is at: https://www.3quarksdaily.com/3quarksdaily/2019/06/can-the-climate-crisis-continue-to-go-begging.html.

06/12/2019

175th Interview: University of Michigan's Professor Andrew Ryan Discusses Measuring for Spending Efficiency or Value in Healthcare (June 11th)

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Americans spend over $3.5 trillion or 6% of the GDP annually on health care.  One third, or over $1 trillion, of that spending is considered waste, i.e., health care that does not improve our health status.  Despite substantial efforts to improve health care value or spending efficiency via so called pay for value, performance based and alternative payment models, for example ACOs and bundled payment arrangements, health care providers, Medicare and other payers, do not generally measure for value - defined as outcomes (the numerator) achieved relative to spending (the denominator).   For example, the MACRA MIPS  program, that reimburses Medicare physicians, measures quality and spending separately, not simultaneously.  They are not correlated.  As a solution the government has been over the past few years advocating increasingly health care price transparency, specifically here price transparency.  If prices were transparent patients, less those riding in an ambulance, could shop for value. The problem is even if patients could intelligently shop for value, a big if, they would not get far because prices do not necessarily reflect value.  As I note in my Bloomberg Law essay posted as a run up to this interview, former Princeton economist, Uwe Rinehardt, use to explain this reality, or the fact that the same health care service can dramatically vary in price between/among provides, via the quip, "the finest health care in the world costs twice as much as the finest health care in the world."    

During this 28 minute conversation Prof. Ryan outlines his research interests, provides background on how measuring for quality, cost and spending efficiency has evolved, explains various methods of how spending efficiency is currently being measured (e.g., conditional and unconditional), to what extent pay for value or pay for performance arrangements have proven successful to date, what value-based payment models likely offer the most promise and what the patient can or should know about pay for value arrangements.  

Professor Andrew Ryan is United Healthcare Professor of Healthcare management and Professor or Health Management and Policy at the University of Michigan, Ann Arbor.  AmryanProfessor is also the Director of the Center for Evaluating Health Reform, the co-Director of the Center for Health Outcomes and Policy and the Associate Director of the Institute for Healthcare Policy and Innovation’s Data and Methods Hub.  Prior to coming to Michigan, Professor Ryan was an Associate Professor of Public Health in the Division of Outcomes and Effectiveness Research at Weill Cornell Medical College.  Among other awards he is the recipient of the 2009 AcademyHealth Dissertation Award for "The Design of Value Based Purchasing in Medicare: Theory and Empirical Evidence."  Professor Ryan earned his Ph.D. in social policy with a concentration in health policy from the Heller School of Social Policy and Management at Brandeis University. 

Professor Ryan's publications can be found at: https://sph.umich.edu/faculty-profiles/ryan-andrew.html.

The Bloomberg Law essay is again at: https://news.bloomberglaw.com/health-law-and-business/insight-containing-health-costs-requires-measuring-rewarding-spending-efficiency.

05/28/2019

Essay: "Containing Health Costs Requires Measuring, Rewarding Spending Efficiency" (May 27th)

Today, Bloomberg Law posted this essay in which I argue if Senator Lamar Alexander, Chair, HELP Committee, wants to address cost containment he needs address how we can drive greater spending efficiency or value in health care.  The essay is at: https://news.bloomberglaw.com/health-law-and-business/insight-containing-health-costs-requires-measuring-rewarding-spending-efficiency

Last Thursday, May 23rd, Senator Alexander released a draft list of provisions the HELP Committee is considering to contain costs or reduce spending growth.  The list is at: https://www.help.senate.gov/chair/newsroom/press/senate-health-committee-leaders-release-bipartisan-discussion-draft-legislation-to-reduce-health-care-costs

On June 11th I'll interview U. of Michigan Professor, Andrew Ryan, who has written several articles regarding measuring for value or again spending efficiency.  For example, see: https://journals.sagepub.com/doi/abs/10.1177/1077558716650089?journalCode=mcrd 

05/12/2019

Natural Climate Solutions: The Nature Conservancy's Jennifer Tabola Discusses Its New Initiative to Address Climate Change (May 8th)

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It should go without stating "nature's contribution to people are vital to human existence."  Nevertheless, this was the third line in the May 6th report by the UN Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES).  As the report notes, "70% of drugs used for cancer are natural or are synthetic products inspired by nature, four billion people reply primarily on natural medicines for their health and, among other examples, 70% of global food crops rely on animal pollination.   "Nature underpins," the report states, "all dimension of human health."  Duly noted, noted, the UN report goes on to detail at great length the fact nature is being "significantly altered by multiple human drives" including anthropogenic global warming that among other things is presently threatening approximately 25% of species of assessed animal and plant groups "suggesting that around 1 million species already fact extinction unless action is taken to reduce the intensity of drivers of biodiversity loss."  As of 2016 over 9% of 6,190 domesticated breeds of indigenous mammals used for food and agriculture had become extinct.  (Despite the UN report's devastating findings and/or dire warning), the head of the Democratic Party (the only major party to recognize climate change), House Speaker Nancy Pelosi, did not bother to release a press release commenting on the IPBES report's findings.)  One way to substantially mitigate nature's collapse are via natural climate solutions, largely reforestation.   As it relates to greenhouse gas emissions, forests act as carbon sinks.      

During this approximately 25-minute discussion Ms. Tabola explains how the The Nature Conservancy's (TNC's) Natural Climate Solutions initiative was born or its rationale.  She moreover explains how and why "natural" climate solutions present a substantial opportunity to mitigate the adverse effects of global warming.  I.e., re-greening the planet via net zero deforestation and reforestation, related re-vegetation of coastal habitats (think: mangroves, salt marshes, sea grass beds) and several other changes in land use, e.g., use of cover crops on crop lands, in sum nature-based solutions, are estimated to potentially provide 37% of climate change mitigation until 2030 needed to meet the Paris climate accord goal of keeping warming to no greater than 2 degrees Celsius.  

Ms. Tabola is currently TNC’s Acting Director of its Climate Strategy programming that addresses forest and soil carbon science, forestry, communications, carbon finance and policy, and works to connect global, regional and local climate work across TNC.  Previously, Ms. Tabola served as TNC’s Deputy Managing Director for Global Lands.  Prior to TNC, she was Tabolathe Senior Director for Health and Climate Change at ecoAmerica, leading a national strategy across the health sector to elevate climate solutions as a top health priority.  Ms. Tabola has also been the Senior Director of Education at the National Environmental Education Foundation, leading national strategy, programming and partnerships to advance K-12 climate change and environmental literacy.  Ms. Tabola also worked in the U.S. federal government within the Corporation for National and Community Service as the Education and Training Director for the National Civilian Conservation Corps and as one of the first national AmeriCorps Program Officers.  As a Peace Corps Volunteer in Ecuador, Ms. Tabola collaborated with international and local NGOs to develop the country’s first urban environmental youth service corps.  Ms. Tabola holds a Bachelor Degree in Social Ecology from the University of California, Irvine, and a Masters in Policy from Harvard University.  She is a Board Member of the Green Schools National Network, the Climate for Health Leadership Circle, and is a member of her city’s local Environmental Services Council.

Since Ms. Tabloa is presently serving in an acting role re: TNC's Natural Climate Solutions, her comments are her own. 

TNC's Natural Climate Solutions web page is at: https://global.nature.org/initiatives/natural-climate-solutions

The UN IPBES report's 39-page summary, see particularly "key messages" at pgs. 1-9, is at: https://www.ipbes.net/system/tdf/spm_global_unedited_advance.pdf?file=1&type=node&id=35245  

The October 2017 National Academy of Sciences Proceedings' paper, "Natural Climate Solutions," also mentioned during this discussion, is at: https://www.pnas.org/content/pnas/114/44/11645.full.pdf

05/05/2019

Kaiser's Kathy Gerwig Discusses Her Organization's Effort to Go Carbon Neutral By Next Year Improving the Lives of Millions (May 3rd)

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After the food industry health care is considered this country's second largest emitter of green house gas (GHG) pollution.  With emissions equal to approximately 655m metric tons of CO2 equivalents annually, if the health care industry was its own country it would rank 13th worldwide in GHG emissions.  Yale researchers have estimated the industry's GHG emissions alone are “commensurate with” the 44,000 to 98,000 annual hospital deaths the Institute of Medicine estimated from preventable medical errors nearly 20 years ago.  In addition, more recent research has shown that compared to similarly sized organizations, very few health care organizations make the effort to report their GHG emissions via the Carbon Disclosure Project or by other means.  

During this 29-minute conversation Ms. Gerwig discusses the climate change related adverse health effects Kaiser providers are currently treating.  In California, these result largely from air quality compromised by wildfires.  Moreover, she discusses the specifics concerning Kaiser's recent purchase of 180 MW of clean/renewable energy (wind and solar) along with battery storage, the expected return on this investment, patient and employee reaction to Kaiser's carbon neutral efforts,  related state efforts via the newly-formed CA Health Care Climate Alliance, Kaiser's 2017 issuance of $1 billion in green bonds and additional efforts to reduce KP's carbon footprint via improvements in supply chain management, transportation, water consumption and waste management.   Kaiser anticipates they will be carbon neutral (Katy defines as Scope 1 and 2) by next year. 

Ms. Kathy Gerwig is currently Kaiser Permanente's VP of Employee Safety, Health and Wellness and also serves as KP's Environmental Stewardship Officer.  She is responsible for organizing and 0managing KP's nationwide environmental initiative.  In forwarding this work Kathy has testified twice to Congress on the need for federal chemical policy reform, and she has appeared at numerous hearings on environmental issues.  Ms. Gerwig is also KP's national leader for Employee Safety and Health and Wellness, responsible for eliminating workplace injuries and reducing health risks for the organization.  Prior to joining KP 1993, Ms. Gerwig was an environmental and economic development consultant to businesses and public agencies in the United States and Europe.  Prior still she worked for nonprofit environmental organizations in California.  Ms. Gerwig holds a MBA with honors, from Pepperdine University and a bachelor’s in geography and environmental studies from San Francisco State University.  She is a certified professional health care risk manager, a certified professional environmental auditor, and a certified health care environmental manager.  Her 2014 book published by Oxford and titled, Greening Health Care: How Hospitals Can Heal the Planet, examines the intersections of health care and environmental health both in terms of harmful impacts and the revolution underway to address them.

The Kaiser press release noted is at: https://about.kaiserpermanente.org/community-health/news/kaiser-permanente-finalizes-agreement-to-enable-carbon-neutralit

Information on Greening Health Care is at: https://global.oup.com/academic/product/greening-health-care-9780199385836?cc=us&lang=en&