HEALTH CARE WITHOUT HARM | JANUARY 2018 1

Safe haven in the storm Protecting lives and margins with climate-smart health care 2 FINANCIAL SAFE HAVEN IN THE STORM: A FISCAL CASE FOR CLIMATE SMART HEALTHCARE HEALTH CARE WITHOUT HARM | JANUARY 2018 1 Extreme weather events are a growing risk to health care margins and an opportunity to differentiate

With the continuing squeeze on In response, a growing number of forward- health care margins, health leaders thinking health leaders are increasing are highly attuned to the potential for even the smallest changes in preparedness so that when the time demographic, economic, regulatory, comes, they can continue full operations or competitive conditions to have a material impact on mission fulfilment and be economic and health anchors for and organizational profitability. their communities. They are also educating Many health systems are already falling short of anticipated earnings policy makers so governments' efforts both due to increased costs and falling support health care resilience, and connect the dots between reimbursement. In this precarious environment, events like heat waves, climate, public health, and the control of health care costs. , or severe storms can There may be no better way to stand out from the crowd. threaten business continuity and wreak fiscal havoc. Hospitals and health systems US billion-dollar weather/climate disasters (1980 – mid 2017)¹ are at the front line of natural disasters, reducing mortality rates, and responding to public Frequency health impacts. As climate change increases the intensity, duration, Economic issues and geographic reach of extreme weather events, development grows in high-risk regions, and communities Mortality struggle with weak infrastructure, more health care organizations are % 0 20 40 60 80 100 asking how these factors might make their margins more vulnerable. ■ rought ■ xtreme winter storms ■ ■ Flooding ■ Severe storms 2 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE

Weather-related risks are rising throughout the US The yearly average for US well-publicized, and expensive events events – including multiple extreme weather events costing are often storms and floods, but all hurricanes and wildfires – over $1 billion has shot up from a regions are at risk, whether through foreshadow increasing harm, historic 5.5 events in 2012 to 10.5 extreme heat, wildfire, , or fatalities, financial damage, events in 2016.² The most damaging, severe winter storms.³ 2017 and displaced populations.

Regional climate trends (2014)4

Wildfire Drought Extreme heat Rising temperatures Warmer temperatures and drought The West is recording more Western states have seen an US temperatures have increased linked to climate change have persistent . In higher increase in severity and 1.3-1.9°F since 1895, the majority increased wildfires in the Northwest emissions scenarios, droughts are frequency. The number of extremely occurring since 1970, with the and Rocky Mountain regions. Hotter, projected to become more common hot days is projected to increase by greatest increases in the North and drier summers are projected to across most of the Central and late century. West. Temperatures are expected cause even more large wildfires. Southern US. to continue to rise with the rate of change dependent on greenhouse gas emission volume.

Extreme winter storms Flooding Severe storms Extreme precipitation Since the 1950s, tracks Increased precipitation and changes The Southeast has seen an Over the past 3-5 decades, the have shifted northward with an in soil moisture have caused severe increased intensity, duration, and US, especially in the Midwest and increased frequency and intensity. flooding in the Mississippi and frequency of hurricanes (including Northeast, has experienced frequent Future trends in severe storms Missouri River Basins. Flood patterns category 4 & 5) since the 1980s. heavy downpours, particularly in (, tornadoes, hail) in this region are expected to worsen Storm impacts are exacerbated the winter and spring. are still uncertain. over time. by population growth and urban development patterns – 10 of the 15 fastest-growing US cities are in the South (including Texas).

HEALTH CARE WITHOUT HARM | JANUARY 2018 3

Collaborate and innovate to weather the storm Major events like hurricanes, including reliable infrastructure gas emissions is critical to floods, and heat waves endanger (e.g., transportation, energy, water), addressing climate change, and lives and shatter economies. secure supply chains, functioning as energy- and resource-intensive Hurricane Katrina, for example, markets, and an agile workforce. enterprises, hospitals and health caused 1,833 fatalities and The health sector must therefore care systems have roles to play. $160 billion in damages. work together with emergency Improvements in procurement, Being resilient to these events planning departments, education resource use, transportation, and requires preparation beyond the service providers, community service other policies and practices can facility level. A health organization’s organizations, and government save money, reduce the carbon ability to survive a major disaster agencies to build stronger, more footprint, and serve as leadership depends on the surrounding resilient communities. examples to others.5 social and economic environment, Furthermore, reducing greenhouse Impact of major events on the US since 20006

160 1,833 Financial impact of extreme weather events in billions Fatalities

■ Severe storms ■ Drought 80 200 ■ looding 70 ■ Tornadoes 60 ■ Wildfire 150 ■ 50 Extreme winter storms

40 100

30

20 50

10

0 0

S S I I I (2005) (2005) (2008) (2003) (2008) (2003) (2012) (2011) (2001) (2008) (2011) (2012) (2011) (2001) (2008) (2011) (2005) (2012) (2005) (2012) S S A A M M C C S S C E E C E C M S M S

The link between changing weather and public health While this paper focuses on the conditions, including asthma. global dengue transmission by 3-6% financial impacts of extreme Increased flooding and changing since 1990, and Scientific American weather, health care leaders cannot temperatures affect the survival, reported increases in Puerto Rico, ignore the serious impacts that distribution, and behavior of water- Florida, New York, and California.7,8 changing weather patterns have on related illnesses transmitted by Finally, any extreme weather event public health. Rising temperatures, pathogens, as well as vector-borne generates significant mental health drought, wildfires, and air pollution diseases transmitted by mosquitoes, impacts, especially for those who increase the prevalence of heat- ticks, and rodents. A recent study lose loved ones, income or jobs, related fatalities and illnesses, and published in The Lancet found that housing, or hard-earned savings. exacerbate respiratory health climate change has increased 4 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE HEALTH CARE WITHOUT HARM | JANUARY 2018 5

H C E 9 T

Traumatic injury & death, mental health Evacuation & consequences from O C D R population displacement, trauma/stress, carbon monoxide poisoning due to loss of property & Suspension or closure Near-term repairs for esearch losses S power outages, post-event essential infrastructure of key operations emergency fix of critical spread of disease & Hazardous materials Cancellations facilities toxic/carcinogenic Patient evacuation clean up postponements of materials Long-term investments elective treatments Damages to critical Compliance costs of infrastructure Loss of market share utility infrastructure upgrades (e.g., power outages, water as patients seek care supplies, sanitation) from other providers

Transportation disruption Population loss Traumatic injury & death (e.g., road closures, Property damage, loss of F (drownings), water-borne & suspension of public essential infrastructure, respiratory diseases, transportation) contaminated drinking mental health water, evacuation, consequences from Government & population displacement trauma/stress management disruption (e.g., law enforcement) S S I L Population displacement Temporary disruption mergency supplies Higher insurance

D Closure or service of critical supplies of food drinks premiums curtailment at hospitals, Change in long-term Medical supplies Less favorale ncreased utilization E medical centers, clinics, I

Heat-related illness, costs or availaility terms with payers R pharmacies, leading to y ununderinsured respiratory impacts, of key supplies treatment delays, patients due to traumatic injury, death mpaired access Poor air & water quality, interruptions, event-related from issues such as Personnel limitations to capital research dangerous road lack of access to injuriesillnesses, direct exposure, funding conditions, property medication leakage from closed low-quality housing, car damage naility to secure accidents, hypothermia, O amulatory facilities, Financial pressures frostbite top talent increased poverty stemming from property andor usiness Greater electricity ecreased personnel destruction, loss of failures savings, business closures gas usage engagement lower retention rates elays reductions Overtime pay for Reduction in tax revenue in reimursements W existing personnel from over-stretched dditional hourly insurers government Smoke inhalation of toxic chemicals, personnel agencies Poor air quality, burns & other traumatic property damage, injuries, asthma population displacement, exacerbations, mental decreased visibility health consequences from trauma/stress D Downward pressure on margin 6 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE

The costs of being ill-prepared Extreme weather events impact a Houston for the 2006–2007 kitchen and food storage, forcing the health system’s margin in a number academic year.¹² Charity Hospital, hospital to put out a call for backup of ways. By disrupting operations the largest safety net facility in the food supplies from local vendors.¹⁴ and utilities, and hindering the region, closed permanently, and it One-third of hospitals in delivery of mission-critical supplies, took ten years for the Louisiana Sandy’s declared disaster area they increase capital, operating, State University system to reported shortages of clinical supply chain, and other costs. re-open a similar suite and nonclinical personnel, Extreme weather can also hurt of services at the as most public revenue through reduced demand new University transportation was and an increased number of patients Medical Center. knocked out and whose lower reimbursement rates The New the majority of gas fall short of costs. York City stations in the health system region closed.¹5 Disruption had a similar Perhaps the most Operating disruption experience disturbing, yet In a best-case scenario, extreme during heroic, aftermath weather events make operating Superstorm Sandy. experience happened conditions more difficult for a health Six hospitals and at Charity Hospital care facility by triggering the use of 26 residential care and Lindy Boggs Medical protective measures like sandbags facilities were shut down, Center in New Orleans during or backup power generators. In a reducing hospital bed capacity by Hurricane Katrina, where personnel worst-case scenario, facilities are 8% in the immediate aftermath, and worked desperately for four days to forced to evacuate patients and 5% four weeks later.¹³ Chronic care keep patients alive as they awaited suspend, or even permanently patients needing dialysis and drug rescue, operating without power, close down, operations. treatment overwhelmed emergency running water, fresh food, blood for departments when ambulatory transfusions, and many centers closed. According to the City key medications.¹6 During Hurricane Katrina, of New York’s Special Initiative on half the hospitals in metro Rebuilding and Resilience, “providers Increased costs who remained open strained to fill New Orleans and all of the Capital costs the health care void – hospitals FEMA estimates that extreme hospitals in the city closed repurposed lobbies as inpatient weather events can cost a hospital rooms, adult care facilities siphoned their doors.¹0 One year after anywhere from $600,000 to $2 billion gas from vehicles to run emergency in infrastructure damages.¹7 These the storm, bed capacity in power generators, and nursing home damages include both emergency staff lived on-site for four or more days Orleans Parish had fallen fixes and longer-term recovery until their replacements arrived.”¹³ efforts such as relocation of critical 79% – from 2,269 beds to just infrastructure and clinical service Supply chain disruption 479 – with only three of the programs above flood elevation, When disaster strikes, the surge hardening of building facades and parish’s original nine acute in demand invariably puts a strain equipment, and installation of on the hospital supply chain as care hospitals even somewhat on-site generator capacity. facilities are forced to rely on their Most facilities will be able to operational.¹¹ existing personnel and in-house secure reimbursement for these inventory. Ben Taub Hospital in capital costs from either a private Tulane Medical School lost Houston ran out of food supplies insurer or a government relief approximately 70% of its teaching after flooding from Hurricane Harvey program, although the process beds and was forced to relocate to contaminated the facility’s basement can be challenging and costly. HEALTH CARE WITHOUT HARM | JANUARY 2018 7

The average amount awarded to a production plants in Puerto Rico.²¹ In addition, due to their role health care organization by FEMA’s Hospitals and health systems as “neighborhood sanctuaries,” Public Assistance program over the also lose valuable inventory during hospitals can be responsible for last ten years was $1.03 million, but major disasters. A 2008 wildfire furnishing food and medical supplies these grants come with a number forced the evacuation of 101-bed to patients, their families, and other of conditions, including: (i) the grant Feather River Hospital in Paradise, community members in times of may be restricted to only restore a CA, and kept the hospital closed for crisis. In the immediate aftermath facility to “pre-disaster” condition, ten days.²² The total cost impact of Superstorm Sandy, one hospital (ii) the grant will only provide support of the event on the hospital was was challenged with feeding the for the most cost-effective option, about $6 million, of which $600,000 community and giving away large and (iii) the grant can cover only was tied to medications that had quantities of supplies purchased 90% of a project’s total cost, with the to be disposed. Additional supply at full retail prices rather than facility responsible for providing the cost impacts included: replacing all wholesale prices.¹6 remaining 10% in matching funds.¹8 air filters, cleaning all air handling systems and hospital surfaces, Other costs Operating costs replacing all food supplies, Research losses are often one of When a disaster knocks out power throwing out diagnostic media the most devastating impacts of and other infrastructure systems, and IVs, testing and recertifying an extreme weather event. After facilities are forced to employ all medical equipment, and replacing Tropical Storm Allison, Texas expensive short-term solutions. or repairing smoke and fire Medical Center lost $2 billion in Backup generators can be costly alarm systems. research, including and troublesome to run; overtime computer wages and benefits add up quickly. data, Massachusetts General Hospital and Brigham and Women’s Hospital incurred $1.3 million and $700,000, respectively, in overtime pay during Boston’s historic winter storms in 2015.¹9 After Hurricane Katrina, Touro Infirmary was paying a 50–100% premium for nurses willing to come to New Orleans.²0

Supply costs Well-organized health systems may be able to secure the supplies they need to weather an extreme event, but they will likely face surcharges on last-minute emergency orders or having to switch sources. Many stories of shortages and higher costs in IV fluids, surgical scalpels, and hernia mesh emerged after Hurricane Maria damaged

8 FINANCIAL SAFE HAVEN IN THE STORM: A FISCAL CASE FOR CLIMATE SMART HEALTHCARE

Lost revenue: Extreme winter storms in 2015 caused reduced admissions and cancelled surgeries at Brigham and Women’s Hospital, resulting in a $10 million loss HEALTH CARE WITHOUT HARM | JANUARY 2018 9 tissue samples, and 30,000 research are forced to triage patients to other Another complication is the animals. It is nearly impossible to locations or even suspend operations chaotic post-disaster environment, recoup this type of loss, as research altogether. which can delay revenue cycle materials are very difficult to value. Achieving pre-disaster revenue activities. Patients whose homes After 10,000 research specimens levels requires not only physical have been destroyed may not be were lost in the basement of NYU repairs to damaged infrastructure, able to provide proof of insurance, Langone's Smilow Research Center but also the restoration of a strong identification, or a usable address. during Superstorm Sandy, the revenue base. This process can take They may seek care as self-pay medical center was reimbursed only months, or even years, as evidenced patients, delay treatment, or move to for their individual book values, not by the fact that twelve years after other institutions of care.²5 Although for the upfront work that had gone Hurricane Katrina, the population of the Health and Human Services into developing the various unique New Orleans is still down by 100,000, secretary often approves short- strains, some estimated by personnel 20% below pre-storm levels. term waivers allowing for expanded to have cost anywhere between Medicaid eligibility and other $20,000 to well over $100,000 to Lower rates of reimbursement measures in the wake of a national develop.²³ In addition, a major loss In addition to driving down total of this nature can jeopardize patient volumes, natural disasters research grants and make it harder also cause major changes to attract top research talent. to the patient mix by Other costs include hard-to- driving up the number measure aspects such as reputation of uninsured or loss, personnel mental health, and underinsured cleanup of hazardous, radioactive, patients. For and other sensitive materials. When example, Mercy Hospital Joplin, MO, was uncompensated seriously damaged by an EF5 care in the in 2011, hospital administrators had Ochsner Clinic to rush to barricade and quarantine Foundation tripled the medical campus while trained after Hurricane professionals shut down MRI Katrina.²0 equipment and removed radioactive There are two likely materials in the cancer center. They drivers for this trend. also had to secure paper medical First, the economic records scattered by the tornado. devastation wrought by a disaster can cause millions to Reduced revenue lose employer-sponsored coverage. Reduced demand Second, low-income populations emergency, delays in government Acute care facilities that stay are more likely to be in harm’s way, reimbursement for services operational during a catastrophic less able to invest in preparations performed during and after an event event often experience a reduction for extreme events, less able to are common.²5 in non-acute and outpatient volumes. relocate to safer areas, and most When asked what the government Brigham and Women’s Hospital in likely to suffer from multiple social had contributed to the efforts of Boston suffered $10 million in lost and environmental health issues the Ochsner Clinic after Hurricane revenue during the extreme winter over decades. Thus, the hardest-hit Katrina, CEO Patrick Quinlan said, storms of 2015 due to cancelled neighborhoods are almost always “Nothing. We have asked and asked elective surgeries and reduced the poorest. In fact, 90 years of [authorities] for fair compensation, general admissions, outpatient FEMA and American Red Cross data and perhaps we will get it eventually, services, and visitors.¹9 Additional indicate that each major catastrophe but we cannot go on indefinitely revenue losses are seen at facilities increases a US county's poverty rate providing uncompensated care.”²0 that, due to severe physical damage, by an average of 1%.²⁴

Photo: FEMA/Andrea Booher 10 SAFE HAVENFINANCIAL IN THE STORM: SAFE HAVEN PROTECTING IN THE STORM: LIVES AND A FISCAL MARGINS CASE WITH FOR CLIMATE-SMART CLIMATE SMART HEALTHHEALTHCARE CARE HEALTH CARE WITHOUT HARM | OCTOBER 2017 11

Case study: NYU Langone’s struggle with Sandy and its aftermath In October 2012, Superstorm Total costs – including reimbursed by a combination of private and public insurers, including Sandy caused 43 deaths and the short-term fixes related to evacuation of 6,500 patients from the National Flood Insurance hospitals and other facilities in cleanup and emergency repairs, Program, HHS Social Services Block Grant Program, and FEMA’s NY and NJ. NYU Langone Medical as well as more permanent Center, which includes a 705-bed Public Assistance Program. hospital, is located on Manhattan's recovery and mitigation projects – Despite these reimbursements, NYU Langone has not received East River, and was one of those exceeded $1.4 billion. affected.²6,²7 The facility’s 12-foot full financial assistance for the flood protection proved inadequate for 18 months.²8 Meanwhile, up to entire loss. NYU was obligated against Sandy’s greater than 14-foot 500 providers were forced to seek to contribute 10% of the $1.13 storm surge. The hospital quickly privileges elsewhere to care for billion grant awarded by FEMA in plunged into darkness as 15 million their patients during the months of 2014. Additionally, certain costs gallons of water knocked out power, rebuilding.²9 Leaders estimate lost were not eligible for government inundated building infrastructure and revenue during this time was at reimbursement, such as lost research research laboratories, and forced the least $400 million.³0 grant opportunities or lost revenue evacuation of all 322 patients.²7 Thanks to NYU’s sophisticated due to business interruption. As a After the event, NYU Langone finance and engineering teams, as result, NYU is still in active litigation had to suspend surgery and inpatient well as effective advocacy by New with its private insurer, even five admissions for two months and York elected officials, the bulk of NYU years later.³¹ close the Emergency Department Langone’s physical damages were

The cost of Superstorm Sandy for NYU Langone

Forced evacuation of all 3 patients

15M gallons of water flooded asements and su-asements in 30 minutes S S T N Y C 10,000 carefully-red rodents lost 1

14 foot storm surge -month suspension of surgery Est. lost 1 of city flooded 18-month closure of the revenue mergency epartment >$400M

500 NYU providers sought privileges elsewhere

Total impact: >8x the 2012 operating margin³² 12 FINANCIAL SAFE HAVEN IN THE STORM: A FISCAL CASE FOR CLIMATE SMART HEALTHCARE HEALTH CARE WITHOUT HARM | JANUARY 2018 13

Case study: “We’d just gone through disaster drills, but in all drills, one assumes the building is Mercy Joplin reels after the still standing.” –Shelly Hunter, Mercy Hospital Joplin CFO deadliest tornado to occur in the US since 1947 On a late afternoon in May of Six people died, five of whom revenue from business interruption 2011, one of the most lethal and were patients. in the first year alone.³6,³7 destructive tornadoes in US history Once the storm had passed, During that time, leadership devastated the city of Joplin, MO. everyone in the building, including had the painful, laborious task of This EF5 tornado – ¾ miles wide, 183 patients, 100 staff, and tallying the total costs and seeking six miles long, with winds in excess uncounted visitors, required reimbursement to fund the rebuild. of 200 miles per hour – caused evacuation for fear the structure Total costs associated with the 161 deaths and destroyed 25% might collapse.³5 While the hospital write-off of the entire 114-acre of the city.³³ did not collapse, it did prove to be campus, and all the supplies within At St. John’s Medical Center (now unsalvageable. it, were estimated at $980M.³8 known as Mercy Hospital Joplin), the Within a week, a 60-bed temporary Climate change impacts on chaos lasted a mere 45 seconds, but field hospital was established in the tornado frequency and intensity the impacts were devastating. Every parking lot of the destroyed facility, are not yet definitive, but Mercy window in the building was blown where limited operations were Joplin provides excellent financial out and the top two floors were maintained until moving to a data on a total loss extreme event. ripped from their structure.³⁴ Interior portable hospital in October and, Financial aspects of the preparation walls and ceilings were torn open ultimately, a 110-bed component for, and impacts of can or destroyed by water from broken hospital in April 2012. The downsize inform risk management of other pipes. Power lines were downed and from a 367-bed facility to a 110-bed extreme events. the main and back up generators caused a 20% drop in market share were torn from their foundations. and an estimated $125 million in lost

The cost of the tornado for Mercy Joplin

114-acre campus 800K square feet damaged eyond use

Forced evacuation of all 183 patients 6 dead E EF : M J 96-hour cache of emergency supplies consumed in less than 4 hours 80M

miles wide, 6 miles long Paper medical records lown across town caused unusual privacy reach Est. lost revenue: 00mph winds Unsecured hazardous waste present in some facility locations $125M

0 reduction in capacity

Total impact: >50x the 2011 operating margin³9 14 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE

Emergency preparedness demonstrates clinical and fiscal smarts Leaders can hope “the big one” US health care facilities can save reimbursement of property and doesn't hit during their watch, or an estimated $15 billion over ten casualty insurance claims, take try to squeeze each dollar hard years.⁴¹ advantage of one-time tax benefits, enough to weather the impacts of The experience at Gundersen and limit adverse revenue cycle increasing incremental losses. But Health Systems, a non-profit impacts. The CHRISTUS Health effective risk management and hospital network serving Wisconsin, Southwest Louisiana system avoided upfront investments in mitigation Minnesota, and Iowa, proves the significant disruption of its back- and climate resiliency enable smart potential size of this opportunity. office functions after Hurricane health systems to come out on top When Gundersen first started Harvey because it had implemented for four reasons. working on these issues in 2008, redundancies while moving many it spent $2 million on energy functions to Irving, TX, during a ROI and risk management conservation, with a 60% return on recent consolidation.4⁴ Relatively small investments investment. All told, its sustainability Facilities that have taken the in hazard management can efforts save the system $3 million time to prepare for disasters are significantly reduce the costs annually.4² also better able to protect their credit incurred during an extreme weather rating and shareholder event. The World Health Organization Fiduciary responsibility value. Following estimates that the price for Preparing for disasters Superstorm retrofitting non-structural items can is an important part Sandy in 2012, cost as little as 1% of the value of of being a good Moody’s put a hospital, while possibly protecting fiduciary. In NYU Langone up to 90% of the hospital’s assets.⁴0 many cities and Medical Case studies here and elsewhere states around Center’s show smart leaders simultaneously the country, A3 credit address sustainability, emissions, resiliency plans rating under and resilience to lower the risks of are now required. review, operational disruption. Separate The Centers for which had efforts can make sense, but better Medicare and the potential returns usually come from mutually Medicaid Services to affect more reinforcing initiatives. Certainly (CMS) have finalized the than $750 million facilities that are designed for Emergency Preparedness in rated debt.⁴5 passive survivability and are efficient Requirements for Medicare and The ratings agency cited with energy, water, and other critical Medicaid participating providers.4³ It concerns about delayed recovery supplies can last longer when outlines risk assessment, procedural, of funds from insurers, FEMA, and sources are limited or interrupted. communications, and training philanthropists, and the potential for Many of these measures have and testing requirements, which decreased patient volume. Moody's fast periods that make providers needed to comply with and ultimately did not lower the rating them no-brainers from a financial implement by November 2017. after affirming that patient volume perspective. The Commonwealth Effective disaster planning and had recovered.⁴6 Fund estimates that reducing waste mitigation also helps hospitals and and cutting energy usage in health systems secure full

Photo: FEMA/Win Henderson HEALTH CARE WITHOUT HARM | JANUARY 2018 15

ROI F E C

nvesting in Resiliency planning Systems that Hospitals in resilient resiliency lowers is required in many respond well communities the total value jurisdictions can in catastrophic have fewer at risk many reduce liaility and conditions oost ununderinsured measures pay improve chances for, the rand, patients and their for themselves and amounts of, differentiate from costs are more (eg, lower reimursement peers, and improve predictale energy costs) staff loyalty and recruitment

M P C

Enhanced reputation personnel engagement, productivity, disaster is generally offset by The way a health system responds and retention. uncertainty in government payouts to or prepares for a crisis situation Boston Medical Center's and insurance reimbursements, can have a major impact on its Senior Vice President of Facilities as well as by the economic loss reputation. Organizations who & Support Services Bob Biggio of displaced people and jobs. put their values on display and said, "Don’t underestimate the Communities that rebound quickly successfully rally communities tangential benefits. Our energy are more likely to retain patients around them benefit from positive and sustainability efforts have with employer-sponsored insurance. media coverage as well as more delivered at least $5 million in gifts. Those that don’t are more likely to formal recognition through channels In recruiting, candidates routinely cite have patients slipping into Medicaid such as “Becker’s 50 Greenest their knowledge of our sustainability or other government programs. Hospitals in America” list or Practice work, and our green bond sold out In addition, when hospitals Greenhealth’s Environmental in a week." invest in resiliency, they also invest Excellence Awards.⁴7,48 This type in the growing green building and of brand boost can help stabilize Coverage stability renewable energy workforces or even grow revenue streams – Making a community more resilient and a clean economy with fewer through increased donations, for helps to create a more stable environmental health risks.49 example. It can also make recruiting coverage environment. Any potential efforts more successful and improve inflow of aid dollars after a natural 16HEALTH CARE WITHOUT HARM | OCTOBER 2017 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE16 HEALTH CARE WITHOUT HARM | JANUARY 2018 17 Scenario analysis helps to show why investing in resiliency protects margins 1 2 Hospital makes no investments in Hospital leadership invests in resiliency When a major hurricane resiliency y hardening and elevating hits, the facility floods, loses power, critical infrastructure When a major and has to shut down key outpatient hurricane hits, the hospital incurs services for 1 weeks only minor damages E A O 1 2 Scenario 1: 10 revenue loss from U N C usiness interruption Net patient service revenue $ 950,000 $ 855,000 $ 950,000 Scenario 2: stays fully operational Provision for bad debts (60,000) (63,000) (60,000) no revenue loss R Net patient service revenue less provision for bad debts 890,000 792,000 890,000 Other revenue 110,000 110,000 110,000 Scenario 1: 5 increase in ununderinsured Total unrestricted revenues 1,000,000 902,000 1,000,000 patients Scenario 2: minimal changes to coverage E environment Salaries & wages 500,000 550,000 550,000 Benefits 100,000 100,000 100,000 Supplies 160,000 163,200 163,200 Scenarios 1 & 2: 5 spike in salary costs Purchased services 90,000 90,000 90,000 due to overtime wages premium for Facilities 40,000 48,000 42,000 emergency supplies Malpractice & general liability insurance 5,000 5,000 5,000 Depreciation & amortization 15,000 15,000 15,000 Interest 60,000 60,000 60,000 Scenario 1: 0 ump due to major Other 5,000 5,000 5,000 emergency repair Total expenses 975,000 1,036,200 1,030,200 Scenario 2: 5 ump due to minor repairs O 25,000 (134,200) (30,200)

Scenarios 1 & 2: 90 reimursement for all N physical damages and overtime staff costs no reimursement for lost revenue Investments 15,000 15,000 15,000 I Disaster reimbursements 0 52,200 46,800 Gifts & other 10,000 10,000 10,000 Total non-operating 25,000 77,200 71,800 Scenario analysis can illuminate potential Excess of revenues over expenses $ 50,000 000 100 financial impacts of severe events, considering likely freuency and RI recovery period. Here, resiliency could provide an almost 100 net N margin improvement, an opportunity twice the 100M sie of the facility's pre-disaster margin. N

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Partners HealthCare plans for a stable, resilient future Case study: Resilience measures that E pay for themselves at Partners HealthCare With 18 million square feet of income, leadership was spurred to HealthCare's efforts are delivering E - S C space, Partners HealthCare is make big changes.50 an 80% reduction in their electricity's E M P Massachusetts’ largest health Since then, Partners HealthCare greenhouse gas emissions. system. The network, which includes has embarked on a strategic plan to Partners HealthCare's increased Massachusetts General Hospital reduce both its energy consumption ability to stay operational during 273 energy conservation hospitals have and Brigham and Women’s Hospital, and environmental footprint while even the most severe weather 20 M 1 in additional projects identified cogeneration provides critical services to patients making its facilities more resilient to events is key. Detailed vulnerability educe energy energy costs due from across the region and operates climate-driven events like flooding assessments are complete for 32 consumption through to fluctuations in conservation on very slim margins. Energy and and sea level rise. “We need to be key sites, and five of the system’s energy prices in climate issues were on Partners a lot more conscious of how we 13 hospitals now have on-site 008009 25% energy reduction HealthCare's support the health care endeavor cogeneration. The new Spaulding 2 goal achieved radar and do it as responsibly and Rehabilitation Hospital in the Convert to on-site economically as possible,” Charlestown Navy Yard sets a leading energy production 20 M in returns said John Messervy, example of resilient, sustainable, New goal to reduce y Partners HealthCare's healing design, with passive ccounted for Corporate Director survivability measures such as a 3 40% of Design and highly insulated building envelope, 12% Move to renewale Construction. operable windows, landscaping that of operating energy sources income in Major capital Partners helps block storm surge, relocation FY009 35% projects improving HealthCare of all critical mechanical and of power from energy efficiency has reduced electrical infrastructure to a rooftop renewales and operating costs electricity penthouse, and installation of a use by cogeneration system.5¹ C 25% and These features and others have lowered helped the new facility become energy enormously successful: between W R S R price fiscal years 2012 and 2016, total M P H volatility occupancy jumped from 77.5% to using power 95.5% and average length of stay purchase went from 22.1 days to 19.8 days. 1 nvestment in resilient agreements for The investments in resiliency have 30% evelop climate and sustainale design more efficient than three-year, fixed paid for themselves. Reflecting back scenarios and hazard features paid off within the typical hospital term, low impact on recent efforts, David Burson, a ising sea levels assessments with hydroelectric power – senior project manager at Partners 18 500K a potential 10-15% HealthCare, said, “close to half of the months annual energy savings after savings from conventional $1.5 million we spent in resilience 2 Hurricane sources even at current low prices. investments were recoverable dentify critical facility Katrina in 2005, but when energy Combined with on- and off-site solar through utility rebates, and, through and clinical operation Storm surge ncreased occupancy price fluctuations in 2008 and 2009 and a 22-megawatt direct delivery our annual energy savings of vulnerailities verage length of stay improves from caused a projected, unbudgeted purchase contract that is catalyzing $500,000, we recouped the $20 million in utilities spend, almost the building of a wind farm in remaining amount within 3 12% of the system’s bottom line New Hampshire, Partners 18 months.” days days Plan for operational enhancements and Localized flooding adaption efforts 77.5% 95.5%

01 016 Photo: Ameresco 20 SAFE HAVENFINANCIAL IN THE STORM: SAFE HAVEN PROTECTING IN THE STORM: LIVES AND A FISCAL MARGINS CASE WITH FOR CLIMATE-SMART CLIMATE SMART HEALTHHEALTHCARE CARE HEALTH CARE WITHOUT HARM | JANUARY 2018 21

Case study:

Successful storm proofing at Texas Medical Center In 2001, Houston, TX, faced a historic Texas Medical Center: Before & after resiliency initiatives Texas Medical Center: Learning from the past thousand-year flood as a result of Tropical Storm Allison. Leaving Tropical Storm Allison - 2001 Hurricane Harvey - 2017 22 dead and causing the county Watertight submarine doors in Basement flood control devices failed almost $5 billion in damages,5² the basement tunnels activated as T : D to activate flooding crippled the Texas Medical planned H A Center (TMC), the largest aggregated medical complex in the US with Catastrophic flooding of most TMC Isolated flooding of a small number 1,000-year historic flood with 23 hospitals covering 1,345 acres. buildings of TMC buildings 3 feet of rain Water damage to TMC’s emergency dead, $5B in damages to generators and electrical switchgear county caused a complete power outage. Widespread patient evacuations Limited patient evacuations T : P Personnel worked by flashlight and Widespread systems failure ventilated patients by hand as more and property damage at TMC than 1,000 patients were evacuated Poor visibility of storm water rise due Monitored Brays Bayou watershed Lost $B in TMC research Housing of vital utility and from hospital rooms and intensive to lack of early warning system through flood alert system (eg, 60K tumor samples, mechanical controls in the care units.5³,5⁴ TMC incurred 30K research animals complexs asements made it extremely vulnerale to $2 billion in research losses alone, flooding including computer data, tissue dependence on Houston’s utility grid said, “We have every institution T : M samples, and research animals.55 during both normal and emergency online. We know the protocols. nsufficient infrastructural In the aftermath of Allison, TMC operations while also reducing costs There’s not a lot of questions. and engineering fortification member institutions united in their and greenhouse gas emissions.5² It’s very well-orchestrated.” against flood damage Hazard Mitigation Plan resolve to learn from the event and Power service was moved to an However, TMC’s success during Lack of flood protocols made invested more than $50 million to elevated utility raceway that also Hurricane Harvey was limited by Flood Management Group it difficult to coordinate an upgrade infrastructure with resilient doubled as a pedestrian walkway. the fact that most patients and Sustainale design measures emergency response and sustainable design features. Since then, TMC institutions’ emergency vehicles were unable to ngagement of stakeholders They engaged a broad range of resiliency investments have been reach the complex due to massive On-site utility plant T : P stakeholders in the rebuild, including put to the test with Hurricane Rita flooding in Houston streets. The H H hydrology experts, Houston city in 2005, Hurricane Ike in 2008, and, revenue losses associated with the Flood alert system officials, FEMA, county flood control most recently, Hurricane Harvey in utilization slowdown – including a Largest amount of rainfall on and subsidence supervisors, and August 2017. Harvey, the largest rain five-day stretch where all elective an uran area in US history utility companies.56 By 2003, TMC event in US history, flooded the entire procedures were cancelled – are ll 3 hospitals and emergency institutions had formed their own Houston area, and yet all hospitals still unknown, but TMC institutions rooms in the complex stayed Hazard Mitigation Plans and Flood and emergency rooms on the TMC had already been working with local operational Management Groups to improve the campus stayed operational. authorities to improve resilience Storm gates protected all campus infrastructure, flood alert “Years ago with (Tropical Storm) within the city and county. By T system, and mitigation planning. All Allison, it was devastating – all the sharing lessons learned from their asements and suterranean critical infrastructure and program hospitals were shut down," said TMC own experience and extending the parking on campus areas were relocated above projected CEO and President Bill McKeon. “And circle of resilience beyond their Mitigating future usiness flood elevations. A new on-site, here we are with even more water facilities' walls, TMC leaders are both continuity risks y sharing 48-megawatt combined heat and and all of them are operational. It’s lowering the odds of similar business lessons learned with local authorities power plant, installed by Thermal really quite a feat of engineering.”57 interruptions and the potential Energy Corporation, eliminated Of TMC’s emergency plans, McKeon resulting fiscal impact. dvocating for improved regional resilience measures like elevating streets and improving flood protection 22 SAFE HAVENFINANCIAL IN THE STORM: SAFE HAVEN PROTECTING IN THE STORM: LIVES AND A FISCAL MARGINS CASE WITH FOR CLIMATE-SMART CLIMATE SMART HEALTHHEALTHCARE CARE HEALTH CARE WITHOUT HARM | OCTOBER 2017 23

Case study:

Wildfire – a growing risk to health care Wildfire is a real and increasing "The fire was raging all around to asthma, chronic obstructive pulmonary disease, and numerous threat to health systems across the the hospital…firefighters were country. The risk is especially high cardiovascular conditions. In in wildland-urban interface areas defending the hospital right up to California’s San Joaquin Valley, which has some of the worst air quality in the Western US, where changing the door.” –Lisa Amador, Director, climate patterns are heightening the in the country, Kaiser Permanente frequency and severity of fire events. North Bay Strategy and Business members have consistently higher rates of hospitalizations and Development at Sutter59 Direct financial impacts emergency room visits for acute Wildfires can start without warning and chronic respiratory conditions and move quickly across great Thanks in large part to heroic on days that have elevated levels distances. The October 2017 fires firefighting efforts, as well as the of fine particulate pollution.60 in northern California were some underground water tanks and wells The health burden caused by of the most destructive in recent that both facilities had in place wildfires is getting worse. Nearly history, forcing the evacuation of beforehand, both facilities survived. 57 million people were affected approximately 130 patients from Total costs, however, are still being by “smoke waves” – two or more Kaiser Permanente’s Santa Rosa tallied. The event caused extensive consecutive days of unhealthy air Medical Center and 80 patients from smoke and heat damage to hospital quality from fires – in the five-year Sutter Health’s Santa Rosa Regional infrastructure and medical supplies. period between 2004 and 2009. This Hospital.58 It also led to major revenue losses: number is likely to rise to 82 million the Sutter hospital, as well as 15 by 2046.6¹ neighboring outpatient and urgent The people most impacted by care clinics, were closed for wildfire pollution are often vulnerable up to eight days. populations with one or more high- cost chronic conditions. Providers The relationship to in fire-prone geographies who care public health for large numbers of uninsured and Wildfires pose a underinsured patients will find their business risk to margins under increasing pressure health systems as wildfire conditions continue to even when drive these populations through they aren’t their doors. threatening to burn down a facility. The fine particulates found in wildfire smoke have proven links

24 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE

Climate change is a critical health care and public health issue Savvy health care leaders chase to most effectively integrate a facilities in areas with lower down every opportunity to strengthen “climate lens” into risk assessments, exposure to flood or other hazards. and protect their operating margins. methodologies, and indicators. Risk reduction strategies can They capture the cascade of benefits Once a health care organization be implemented across design that resiliency provides through four has identified potential risks, the or procurement standards. Risk key strategies. next step is to assess the likelihood transference strategies often and magnitude of each risk’s involve partnering with others or Manage extreme impact to the business. Leaders revisiting insurance policies. The weather risks need to consider more than generic resulting risk plan should include There are three main steps to impacts like a patient surge or policies and procedures to ensure successfully identifying and supply constraints, and think about regular monitoring and updates. managing extreme weather risks. other types of operational and The first is to use forecasts and infrastructural vulnerabilities that Reduce emissions predictive models to consider could result from an extreme weather Extreme weather events will keep how changes to climate, extreme event. It may be helpful to bring in getting worse unless we mobilize our weather, and resulting specialists – including economy to limit the greenhouse gas health impacts enterprise risk emissions contributing to climate play out for the management, tax change. With health care spending organization and and regulatory representing 18% of GDP in 2015, its surrounding advisory, the health sector has an important communities. claims role to play in that effort.6² Large health valuation Organizations that successfully systems and mitigate their climate impacts with multiple actuarial start by measuring baselines, campuses services – setting clear reduction targets, and should to help mobilizing resources from across the conduct both facilitate organization to implement changes individual this process. in energy operations, building design site-level Ultimately, the and operations, transportation, waste assessments aim of assessing management, and supply chain.6³ to understand risk the significance of Leaders take advantage of on-site variations across the each risk is to build a measures like energy efficiency, portfolio, and a network assessment comprehensive and data-driven view renewable energy, battery storage, that considers interdependencies of risk priorities across the portfolio. waste reductions, and sourcing local, across the system. It is critical to The final step is to establish a sustainable food. They also employ meet with government planners response and execution plan that off-site strategies like renewable and your regional health care includes strategies to avoid, reduce, energy power purchase agreements, preparedness coalition to understand and transfer risk. Risk avoidance greening fleet operations, and available resources and explore how strategies might include siting new strengthening public transportation. HEALTH CARE WITHOUT HARM | JANUARY 2018 25

M Risk identification at individual sites and M across portfolio Assessment prioritiation likelihood and magnitude of usiness impact lans eecutions clean energy, on-site generation, hardening, relocation of critical

infrastructure, staff training R H

R L nergy operations conservation, efficiency, renewale energy, caron offsets, revolving funds Built environment green uilding, facility siting, design, construction, facility operations I Transportation fleet emissions, pulic transportation for staff and patients, energy-efficient shipping aste reduction, reuse and recycling, local disposal, supply chain management

I L eighborhood built environment access to Risk cost assessment energy, climate, healthy food, quality of housing, crime and violence transportation and other policies, regulations, prevention, environmental conditions, intermodal standards and codes, oth at individual sites and pulic transportation and across the portfolio Health care access insurance coverage, provider Staff engagement education and activation of coverage, location of facilities, health literacy government relations and communications staff conomic opportunity local hiring and purchasing, so they can engage on climate and energy issues cooperatives, fair wages, training and education, Climate-smart advocacy input and expertise on entrepreneurship city, state, regional, and national policies collaoration with associations and like-minded GOs

W Inside organiation acilities infrastructure inance, risk, tax Community affairs government relations Emergency preparedness medicine

utside organiation Local regional government agencies Emergency management health care preparedness coalitions Mission-critical supply service chains GOs vulnerale community groups Cultural academic institutions Economic development organizations

H Emed in existing capital improvement plans Partner in regional development efforts Pursue resilience grants gifts Self-finance via project-related cost savings, green onds, reatesincentives, green revolving funds, lower insurance premiums 26 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE

US Climate Resilience Toolkit Hospital Preparedness Program The Department of Health and Human Services added The Hospital Preparedness Program is a federally- a health care-specific chapter to the US Climate funded initiative that supports regional health care Resilience Toolkit. This "Sustainable and Climate- system preparedness in order to improve patient Resilient Health Care Facilities Toolkit" includes an outcomes, minimize the need for supplemental state and overview document and a suite of online tools and federal resources during emergencies, and enable rapid resources that highlight emerging best practices for recovery. The program operates through local health care developing sustainable, climate-resilient health care coalitions (HCCs) that bring together diverse and often facilities. The guide provides information about threats competitive health care and emergency management from extreme weather events and how organizations organizations. A list of all HCCs can be found here: around the country are responding. It is available here: https://www.cms.gov/Medicare/Provider-Enrollment- https://toolkit.climate.gov/topics/human-health/ and-Certification/SurveyCertEmergPrep/Downloads/By- building-climate-resilience-health-sector Name-by-State-Healthcare-Coalitions.pdf

Invest in community better education will increase health health and resilience coverage among local populations Best practices for climate- Leaders understand that being and improve baseline health levels. smart policy advocacy climate-smart in only their own Better, multi-modal transportation 1. Track climate-related costs in facilities is insufficient. Their ability systems make it easier for personnel clinical and facility operations, to withstand a disaster is deeply to get to work and patients to reach while actively seeking new intertwined with what happens the help they need. More vibrant, climate, energy, and resilience in surrounding communities. socially connected, equitable funding streams The Robert Wood Johnson communities make it easier for Foundation’s National Health Security neighbors to help neighbors before, 2. Use cost data and health system Preparedness Index measures during, and after a crisis strikes, expertise to collaborate with over 130 indicators of community to heal and regenerate. regional energy NGOs on policy resiliency – including numbers of risks and opportunities paramedics and hospitals, hazard Lead on policy 3. Educate and activate government planning in public schools, wireless It is impossible to overstate the relations staff so they can engage 9-1-1 capabilities, and social extent to which public policy can on climate and energy issues cohesion – to assess health security limit or facilitate a health system's and preparedness of communities climate-smart options. Federal, 4. Add climate, energy, and resilience around the country. Aggregate US regional, state, and municipal actions to hospital association and national health security levels are far largely determine what changes medical society agendas to below optimal, and although scores can be made to institutional and increase leverage and lower are slowly increasing, results are community infrastructure. Public engagement risks and costs widely uneven, with communities utility departments, energy grid 5. Participate in national efforts in the Deep South and Mountain rules, and market structures such as the Health Care Climate West regions lagging the rest of impact energy options. Council and Medical Society the nation.6⁴ As a result, leading health Consortium on Climate and Health True leadership requires care organizations connect the partnering with other local and dots for policy makers between https://noharm-uscanada.org/healthcareclimatecouncil regional players to build community climate-smart policies, public health, https://medsocietiesforclimatehealth.org/ health and resiliency. More jobs and and medical cost containment. HEALTH CARE WITHOUT HARM | JANUARY 2018 27 Massachusetts' health care leaders a collaboration between Cleveland incentive programs, and green have used private meetings, public Clinic, University Hospitals, Case revolving funds. Boston Medical hearings, and op-eds to educate Western, and numerous academic Center’s campus consolidation and governmental decision makers and and cultural institutions in the $15 million cogeneration plant were deliver impressive ROIs: many tens University Circle area has been made possible in part by a green of millions of dollars in technical underway for over ten years. The bond, energy savings, and a $3.7 assistance, utility incentives, grants, collaboration uses a four-pronged million grant from the Massachusetts and awards. In Ohio, health systems strategy backed by millions in Department of Energy Resources’ and the Ohio Hospital Association purchasing and other expenditures – Community Clean Energy Resiliency have helped counter attacks on the to buy local, hire local, live local, and Initiative. Finally, organizations will state's energy efficiency and clean interconnect the community. The find increasing resilience opens energy programs by providing health Greater University Circle Initiative has doors to renegotiating financing or impact and cost data to the Public improved the prospects and income insurance agreements, including Utilities Commission, signing onto of the 60,000 people who live in coverage terms, indemnity periods, support letters, sharing case studies, seven surrounding neighborhoods.66 limitations, and deductibles. and publishing physician-led Op-Eds Similar work is underway in Detroit, Together, these strategies can and Letters to the Editor. where the Henry Ford Hospital help health care organizations keep Often these advocacy efforts partnered with Detroit Medical their patients safe, their property lead to substantive policy change. Center and Wayne State University intact, and their margins stable. Dignity Health has insisted climate to incentivize local procurement. and energy policy are moral and Together these systems have strategic business imperatives for successfully redirected $400,000 over 20 years. Recently, this drove to local businesses.67 them to help secure passage of California Senate Bill 350, the Clean How to fund efforts Energy and Pollution Reduction Act, Resiliency strategies provide with press conferences, Op-Eds, many long-term business testimonies, legislative visits, and benefits, but they can require events in partnership with many upfront investment. Smart businesses and NGOs. executives jump on existing funding sources while also Who to partner with cultivating new ones. One key Achieving true resiliency cannot win is to integrate resilient, happen in a vacuum – it requires sustainable design measures collaboration within and across into existing building retrofits organizations. Intra-organizational or regional development plans. teaming often includes a mix of Another approach is to offset functions, including facilities and with grants and gifts or self-finance infrastructure, finance, risk, tax, through project-related cost savings community affairs, and government projections, green bonds, rebate and relations. The Boston health care Resilience 2.0 report demonstrates how inter-organizational partnerships can be even more diverse and The time to act is now fruitful, with health care partnering If you only do one thing, please direct your emergency with government agencies, medicine and preparedness leaders to include changing utilities, cultural and academic climate risks in both facility and regional emergency institutions, economic development organizations, NGOs, and preparedness planning and implementation. community groups.65 In Cleveland,

Photo: FEMA/Win Henderson 28 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE

SECTION FOUR Endnotes

1 “Billion-Dollar Weather and Climate Disasters: Summary Stats.” NOAA National Centers for Environmental Information (NCEI), 2017.

2 Tafuri, Kyle, and Richard Eidlin. “Climate change puts healthcare in harm’s way.” Becker’s Hospital Review, Jun. 2017.

3 “National Climate Assessment.” U.S. Global Change Research Program, 2014.

4 Balbus, J., A. Crimmins, J.L. Gamble, D.R. Easterling, K.E. Kunkel, S. Saha, and M.C. Sarofim. "2016: Ch. 1: Introduction: Climate Change and Human Health. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment." U.S. Global Change Research Program, Washington, DC, Nov. 2017; 25–42.

5 “Healthy hospitals, healthy planet, healthy people: Addressing climate change in healthcare settings.” World Health Organization and Health Care Without Harm, 2009.

6 “Billion-Dollar Weather and Climate Disasters: Overview.” NOAA National Centers for Environmental Information (NCEI), 2017.

7 Watts et. al. “The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health.” The Lancet, 2017.

8 “Mosquito-borne Diseases on the Uptick – Thanks to Global Warming.” Scientific American,Nov. 2017.

9 “Climate and Health Assessment: Extreme Events Key Findings.” U.S. Global Change Research Program. 2016.

10 King, Ronette. “Hospitals still closed after Katrina.” NOLA, Sept. 2005.

11 Rudowitz, R. et al. “Health Care In New Orleans Before And After Hurricane Katrina.” Health Affairs, Sept. 2006; vol. 25 no.5 pp. 393-406.

12 Taylor, IL. “Hurricane Katrina’s Impact on Tulane’s Teaching Hospitals.” Transaction of the American Clinical and Climatological Association, 2007; 118: 69–78.

13 “A Stronger, More Resilient New York.” PlanNYC and City of New York, Nov. 2017.

14 Khazan, Olga. “The Houston Hospital Running Out of Food.” The Atlantic, Aug. 2017.

15 “Hospital Emergency Preparedness and Response during Superstorm Sandy.” Department of Health and Human Services Office of Inspector General, Sept. 2014.

16 “Hospital Disaster Preparedness: Worker Safety.” The Hartford, Oct. 2014.

17 Thomas, WM. “Code Grey: Protecting Hospitals from Severe Weather.” Earth Zine, Jun. 2011.

18 “FEMA Public Assistance Funded Projects Detail - Open Government Initiative.” FEMA, Nov. 2017.

19 “Attachment A: 2015 Severe Winter Weather Pattern Impacts - Supplemental Information.” Massachusetts Emergency Management Agency, Mar. 2015.

20 Berggren, R. and TJ Curiel. “After the Storm — Health Care Infrastructure in Post-Katrina New Orleans.” New England Journal of Medicine, 2006; 354:1549-1552.

21 Thomas, Katie. “U.S. Hospitals Wrestle With Shortages of Drug Supplies Made in Puerto Rico.” NY Times, Oct. 2007.

22 “The Cost of Inaction.” California Forests, Winter 2009; Vol. 13 No. 1.

23 Sifferlin, Alexandra. “Rebuilding NYU’s Research Labs After Superstorm Sandy.” CNN, Feb. 2013.

24 Platt Boustan, L., et al. “Natural Disasters by Location: Rich Leave and Poor Get Poorer.” Scientific American, Jul. 2017.

25 “Hospitals and health systems feel hurricanes’ effects long after floodwaters recede.” PwC Health Research Institute, Sept. 2017.

26 Adalja, AA., et al. “Absorbing Citywide Patient Surge During Hurricane Sandy: A Case Study in Accommodating Multiple Hospital Evacuations.” Annals of Emergency Medicine, 2014.

27 “NYU Langone 2012 Annual Report.” NYU Langone, Apr. 2013.

28 “Surgery Returns to NYU Langone Medical Center.” New York Times, Dec. 2012.

29 Gold, Jenny. “NYU Langone, Now Reopened, Seeks to Regain Market Share.” WNYC News, Feb 2013.

30 Keller, Maura. “Weathering the Storm.” American Healthcare Leader, 2016.

31 Godoy, Jody. “NYU Sues Insurer For $1.4B In Sandy Damage Coverage.” Law360.com, Nov. 2017.

32 “New York University Consolidated Financial Statements August 31, 2013 and 2012.” NYU.edu, Aug. 2013, 51.

33 “Final Environmental Assessment St. John’s Regional Medical Center Temporary Medical Facilities Joplin, Jasper County Missouri.” FEMA, Jul. 2011. HEALTH CARE WITHOUT HARM | JANUARY 2018 29

34 “Joplin Remember, Rejoice, Rebuild.” The White House, Nov. 2017.

35 “Practicing Good Citizenship in an Emergency.” AAAHC, Jul. 2017.

36 Morse, Susan. “When disaster strikes: CFOs help hospitals recover after Joplin tornado, Hurricane Sandy.” Healthcare Finance News, Sept. 2015.

37 “Mercy Health Years Ended June 30, 2012 and 2011.” EMMA, Sept. 2012.

38 Barr, Paul. “A year later.” Modern Healthcare, May 2012.

39 St. John’s Regional Medical Center. “Cost Report data.” Costreportdata.com, 2017.

40 Guenther, Robin and John Balbus. “Primary Protection: Enhancing Health Care Resilience for a Changing Climate.” US Department of Health and Human Services, Dec. 2014.

41 Kaplan, S., et al. “Can Sustainable Hospitals Help Bend the Health Care Cost Curve?” The Commonwealth Fund, Nov. 2012.

42 Khalamayzer, Anya. “The profitable hospital system with sustainability in its DNA.” GreenBiz, Apr. 2017.

43 “Emergency Preparedness Rule.” CMS, Sept. 2017.

44 Daly, Rich. “Hospitals Expect Financial Impacts From Harvey.” HFMA, Aug. 2017.

45 “Moody’s places NYU Hospitals Center’s (NY) A3 ratings under review for possible downgrade as impact of Hurricane Sandy is assessed.” Moody’s, Nov. 2012.

46 “Moody’s Confirms NYU Langone Medical Center’s A3 Credit Rating.” NYU Langone, Mar. 2013.

47 Punke, Heather. “50 of the greenest hospitals in America | 2016.” Becker’s Hospital Review, Oct. 2016.

48 “The Top 25 Environmental Excellence Award.” Practice Greenhealth, 2016.

49 Winston, Andrew. “Trump’s Climate Rollback Will Hurt the Economy, Not Help It.” Harvard Business Review, Mar. 2017.

50 “Partners HealthCare has a plan for using less energy to improve the lives of our patients, staff and the environment.” Partners HealthCare, Nov. 2017.

51 Quint, Christina. “Partners HealthCare Redefines Resilience and Restoration in Innovative Waterfront Hospital 4/14 Patient rooms.” Healthier Hospitals, May 2014.

52 “After Record-Breaking Rains, a Major Medical Center’s Hazard Mitigation Plan Improves Resilience.” U.S. Climate Resilience Toolkit, Jan. 2017.

53 Goldstein, A., and L. McGinley. “Some hospitals evacuated, but Houston’s medical world mostly withstands Harvey.” The Washington Post, Aug. 2017.

54 “Tropical Storm Allison, June 2001: RMS Event Report.” Risk Management Solutions, 2001.

55 “How Houston hospitals prepared for Hurricane Harvey.” PBS Newshour, Aug. 2017.

56 Cousins, Rick. “Texas Medical Center, hospitals prepare for the worst.” Houston Business Journal, Jun. 2014.

57 Para, Jena. “Updated: Texas Medical Center hospitals remain operational during historic flooding.”Houston Business Journal, Aug. 2017.

58 “Hospitals scramble to evacuate hundreds of patients in Wine Country fire.”Mercury News, 2017.

59 “Bay Area hospitals squeezed after patients evacuated from wildfires.”San Francisco Business Times, 2017.

60 Kaiser Permanente Northern California, “Particulate air pollution and morbidity in the California Central Valley: A high particulate pollution region.” California Air Resources Board, 2002.

61 Liu, Jia Coco et. al. “Particulate air pollution from wildfires in the Western US under climate change.”Climatic Change, 2016.

62 “CMS: US health care spending to reach nearly 20% of GDP by 2025.” Advisory Board, Feb. 2017.

63 “Addressing Climate Change in the Healthcare Setting.” Health Care Without Harm and Practice Greenhealth, Nov. 2017.

64 “The National Health Security Preparedness Index.” Robert Wood Johnson Foundation, Aug. 2017.

65 Resilience 2.0: Healthcare’s Role in Anchoring Community Health and Resilience.” Health Care Without Harm, Jan. 2017.

66 Wright, W., et al. “Cleveland’s Greater University Circle Initiative: An Anchor-Based Strategy for Change.” Democracy Collaborative, Nov. 2017.

67 “Overview: Anchor Institutions.” Community-Wealth.org, Nov. 2017. 30 SAFE HAVEN IN THE STORM: PROTECTING LIVES AND MARGINS WITH CLIMATE-SMART HEALTH CARE Climate-smart health care leaders: Improve facility and community resilience Reduce carbon emissions Invest in community health Weigh in on energy and climate public policy

“The US experiences more extreme, high-impact weather than anywhere else on the planet – and the frequency of major events is increasing. Communities and their health care facilities have proven quite vulnerable, raising the need for a convincing business case and guidance to inform proactive investments in resilience. ‘Safe Haven's’ real-world examples and data meet this need.” -Robin Guenther FAIA, LEED AP, ranked "#1 Most Influential Designer in Healthcare"

"Clinicians and health care leaders have a special opportunity and a big role to play in the face of climate change. Our missions, our communities' respect, and the sector's large carbon footprint give us extra responsibility. Leaders can and should set an example, from organizational climate action, to supporting good government policy on renewable energy, reducing emissions, food waste, and more. 'Safe haven' shows the cost of addressing and preparing for climate change is much lower than the cost of business-as-usual." -Donald M. Berwick, MD, President Emeritus and Senior Fellow, Institute for Healthcare Improvement

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For assistance, contact Health Care Without Harm's: Jessica Wolff Paul Lipke & Bill Ravanesi US Director of Climate and Health Massachusetts Health Care Climate Alliance Co-directors [email protected] [email protected] | [email protected] https://noharm-uscanada.org/healthcareclimatecouncil https://noharm-uscanada.org/boston

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“Safe haven” is made possible thanks in part to support from the Barr Foundation, the Kresge Foundation, the MacArthur Foundation, the Wallace Global Fund, and PricewaterhouseCoopers Advisory Services LLC.

Health Care Without Harm seeks to transform the health sector, without compromising patient safety or care, to be ecologically sustainable, and a leading advocate for environmental health and justice worldwide.