REPORT OF THE COUNCIL ON MEDICAL SERVICE
CMS Report 2 - I-98
Subject: Expense of Medical and Biohazardous Waste Removal
Presented by: Kay K. Hanley, MD, Chair
1 At the 1997 Interim Meeting, the House of Delegates adopted the recommendations in Council on
2 Scientific Affairs (CSA) Report 4. The report responded to a referred resolution which asked the
3 AMA to study methods to minimize or eliminate the expense to physicians for the removal of
4 biohazardous waste from physicians’ offices. CSA Report 4 (I-97) summarized the varying
5 definitions of biohazardous waste; described the key generators of such waste; discussed the
6 varying health implications of biohazardous waste; described the components of a biohazardous
7 waste management protocol; and presented available cost estimates and savings. With respect to
8 methods of minimizing or eliminating expenses to physicians, the CSA concluded that “the
9 expense of biohazardous waste management can be reduced by ensuring that only regulated
10 biohazardous waste is processed as such, and by forming alliances with other medical groups or
11 health care facilities to negotiate group disposal rates with vendors.”
13 Testimony before the Reference Committee requested more information about the expense of
14 biohazardous waste removal. As a result, one of the two recommendations added to the report by
15 the Reference Committee asked that the Board of Trustees “refer to the appropriate council the
16 study of mechanisms that might decrease the expense of removal of biohazardous waste from
17 physicians’ offices.” This recommendation, which in essence is identical to the intent of the
18 resolution to which CSA Report 4 (I-97) responded, was assigned to the Council on Medical
19 Service for a report back at the 1998 Interim Meeting.
21 The following report, which is submitted for the information of the House, reviews current
22 estimates of the volume of medical and biohazardous waste generated in the United States, presents
23 available information on the cost of medical and biohazardous waste removal, summarizes relevant
24 AMA policy, and discusses opportunities for potentially decreasing the expense to physicians
25 associated with medical and biohazardous waste removal.
27 VOLUME OF MEDICAL AND BIOHAZARDOUS WASTE
29 Medical waste typically includes human blood and blood products, cultures and stocks of
30 infectious agents, pathological wastes, isolation wastes, laboratory animal wastes and contaminated
31 bedding materials, and used and unused sharps (e.g., needles). Hospitals and laboratories continue
32 to be the largest generators of medical waste. However, as the provision of health care services
33 continues to grow in non-hospital settings, it is likely that the volume of medical waste generated in
34 clinics, ambulatory surgical centers, skilled nursing facilities, physician offices, dental offices,
35 research facilities, and a variety of home health care settings, will increase.
CMS Rep. 2 - I-98 -- page 2
1 The total annual volume of medical waste generated in the United States is currently estimated to
2 be approximately 465,000 tons. Furthermore, the annual rate of growth in the volume of medical
3 waste generated is estimated to be 7-10%. As the CSA previously reported, however, virtually all
4 of the information available on medical waste generation and removal is from a hospital
5 perspective. For example, solid waste generated per person per day in hospital facilities has been
6 estimated to range from 10 to 25 pounds, of which approximately 10-15% is classified as
7 “infectious” under Environmental Protection Agency (EPA) guidelines.
9 As noted in CSA Report 4 (I-97), although there is no standard definition of biohazardous waste,
10 federal agencies such as the EPA, the Centers for Disease Control and Prevention, and the National
11 Institutes of Health have definitions that address the handling of biohazardous waste. The
12 underlying assumption of these definitions is that biohazardous waste is waste contaminated with
13 infectious agents. A review of the literature, however, reveals little information on the volume of
14 biohazardous waste generated specifically by physicians’ offices.
16 COST OF MEDICAL AND BIOHAZARDOUS WASTE REMOVAL
18 It has been estimated that the costs associated with removal of the 465,000 tons of medical waste
19 generated annually in the United States are approximately $1 billion. The most common methods
20 of treating medical waste include incineration, autoclaving, microwave deactivation, chemical
21 disinfection, and electro-thermal deactivation. Medical waste treatment costs vary by method. For
22 example, incineration costs approximately 10 to 15 cents per pound of medical waste. Other
23 techniques, such as electro-thermal deactivation, reportedly are about half the cost of incineration.
25 As the CSA reported, the EPA estimates that the costs for a comprehensive medical waste tracking
26 system are an additional 8 cents per pound—a figure disputed by the American Hospital
27 Association, which estimates such costs at an additional 28 to 58 cents per pound. As was the case
28 with data on the volume of biohazardous waste generated, a review of the literature provides little
29 information on the costs associated with the removal of biohazardous waste from physicians’
30 offices. However, given the diversity in the type and size of physician practices, these costs clearly
33 RELEVANT AMA POLICY
35 Current AMA policy encourages physicians and the medical community to dispose of medical
36 waste in a safe and properly prescribed manner (Policy H-135.973, AMA Policy Compendium),
37 and to develop a biohazardous waste management program that fulfills their county, state, and
38 municipal regulations (Policy H-135.953).
40 AMA policy supports working with Congress and the EPA to modify EPA requirements on
41 medical waste, the goal of which would be to eliminate regulations that cannot be shown
42 scientifically to protect the public health (Policy H-135.958). The AMA also has encouraged
43 the EPA to explore the feasibility of establishing a national definition of biohazardous waste,
44 emphasizing the origins and relative importance of wastes that can plausibly transmit infection
45 compared with wastes that cannot (Policy H-135.953).
CMS Rep. 2 - I-98 -- page 3
1 Finally, the AMA will continue to work with appropriate government agencies and medical
2 societies to educate physicians about the management of biohazardous waste, and to advocate that
3 these groups work collectively to attain cost savings in biohazardous waste management (Policy
8 As indicated throughout this report, a review of the literature does not reveal meaningful
9 information on the volume of biohazardous waste generated by physicians’ offices, nor the specific
10 costs associated with the removal of such waste from physicians’ offices. As the provision of
11 health care services in non-hospital settings continues to grow, it is likely that additional
12 information will become available. At present, however, the majority of the literature addresses
13 only the overall volume and costs of medical waste generated across all health care organizations,
14 and at a more specific level, the volume and costs among hospitals.
16 Council communications with representatives of several medical waste management companies
17 revealed little quantifiable data on the cost to physicians for biohazardous waste removal. In part,
18 this may be due to the current market environment which suggests that skilled nursing facilities,
19 outpatient clinics, and physician offices all generate better gross profit margins for medical waste
20 removal, than do hospitals. Accordingly, such corporate representatives appear hesitant to discuss
21 definitive costs and pricing structures.
23 Consistent with the information previously reported by the CSA, it appears that much of the
24 medical waste removal cost-savings that have been realized by hospitals and outpatient facilities
25 are due to the implementation of comprehensive management plans that include all employees.
26 Such programs typically target non-biohazardous solid waste (e.g., soda cans, newspapers, sterile
27 packing) that was ending up in “red bags” designated for biohazardous waste.
29 The Council believes that a similar approach holds the most potential for decreasing the expense of
30 removal of biohazardous waste from physicians’ offices. The Council also concurs with the
31 conclusion reached by the CSA which advocated that physicians seek to form alliances with other
32 medical groups or health care facilities to lower costs and/or negotiate group disposal rates with
35 As an example of such an approach, the Polk County (IA) Medical Society has encouraged
36 physicians to consider participating with the Iowa Medical Waste Reduction Center (IMWRC)
37 which is owned by a group of Iowa hospitals that joined to build and operate an infectious waste
38 disposal facility. The IMWRC program is focused specifically on assisting small quantity
39 generators of biohazardous waste, and includes supplies of boxes and “red bags”; manifests
40 designed to track the waste from generation site to disposal site; waste pick-up and transportation;
41 and signed documentation that verifies proper disposal of the waste.