Dr. G’s Hard Medicine

Improvements at the Veteran Health Administration are so dramatic that it is now the basis for a case study taught to health-care professionals at Harvard’s School of Public Policy, and health-care watchdogs use its programs as models for other organizations. “I risk overstatement,” said Donald Berwick, head of the Boston-based, nonprofit Institute for Healthcare Improvements. “But I think the work going on at the VA may be the largest-scale successful effort of its type in the world.”

While at the VA, Garthwaite honed his unflappable approach in a highly charged environment. “You will never frustrate him and you will never see him lose his temper,” said Hershel Gober, who, as acting secretary of the VA, was Garthwaite’s boss. “He is very astute at looking at something and saying, ‘This is stupid. Why are we doing this?’ He looks at the core values and says, ‘This is our mission. This is what we should be doing.’ If anyone can help L.A., Tom Garthwaite can.”

What his work meant at the VA, and what it now means in Los Angeles, Garthwaite said, is shifting the focus from medical accomplishment to patient satisfaction. “In health care, if what’s important to you is how many people get their hearts operated on, that’s not the goal of the patient,” he explained. “Can you live your life better because of the care you received?” He paused. “Hardly ever measured.”

But Garthwaite is making some of the same types of cuts that cost his old boss his job at the VA. When Rancho Los Amigos closes this summer, hundreds of patients who rely on the center for treatment for spinal-cord injuries, respiratory illnesses and a wide range of physical therapies and rehabilitation services will be forced to seek care elsewhere. One such patient, Gary Harris, is a plaintiff in the lawsuit filed by Neighborhood Legal Services of Los Angeles County, the Legal Aid Foundation of Los Angeles and the American Civil Liberties Union of Southern California, which seeks to halt the cutbacks. Harris, a 47-year-old uninsured L.A. resident, was shot in the spine and throat in a random drive-by shooting in December. Another plaintiff, Susan Haggerty, is a 46-year-old uninsured diabetic who had a left toe amputated last year and who has suffered diabetic hemorrhaging in both eyes. In February she was treated at Rancho for a bone infection in her right foot. These patients typify the county’s clients, Legal Services attorney Yolanda Vera said, in that they have no money and limited mobility and are totally ä dependent on the county for their health care. A hearing on the lawsuit, the second such action to challenge the cuts, is scheduled for May 12.

One thing his VA experience did not prepare Garthwaite for was dealing within the county bureaucracy. “At the VA, I had discretion over millions of dollars,” he said. “Here you need a special session with the Board of Supervisors to spend a buck fifty.”

 

Behind Garthwaite’s vision for a new health-care system for L.A. County is one seemingly revolutionary idea: The cash is out there. “I think there’s close to the right amount of money in health care today,” he said, while making his way down the freeway to yet another meeting. “It’s 14 percent of the GDP, and we’re a pretty rich country. I’m not real popular for saying it. Doctors and people don’t like to hear you say that. But there’s a lot of waste, and the incentives are wrong.”

Some potential savings and revenue sources include curbing administrative costs, increasing the number of elderly clients, whose care is paid for by Medicaid, refusing non-emergency care to non-county residents and cutting costly duplicated services. As one example Garthwaite offered, all four remaining county hospitals have their own neonatal centers. Consolidating programs will cut costs, but it will also force residents to travel greater distances for care, no small matter in a county sprawled across 4,000 square miles.

Garthwaite’s contention that there’s plenty of fat to be trimmed has gained support from unlikely quarters. “There’s still a lot of waste in the system,” said Liz Forer, executive director of the Venice Family Clinic, the largest free clinic in the U.S. and a county partner in providing outpatient care. “Now that the financial piece is beginning to stabilize, we get to see him use the skills he was hired for, which is revamping the system. By doing some of the things he has proposed, we will begin to lose some of that waste. The challenge is to do it without losing care.”

William Stringer, director of medicine at Harbor-UCLA and the doc who sported the “Don’t Panic” button at the meeting with Garthwaite in early March, brings a long-term perspective to the current crisis. Back in 1995, Stringer quit rather than continue to work in a system which he felt was being senselessly downsized. After three years in the private sector, he came back. “For all the problems here, this is not a greedy, grubby financially driven system,” he said. “We all agree that we need to treat people regardless of what is in their wallet. If there needs to be some pain along the way to making that happen, it is unfortunate, but unfortunately I think it is probably necessary.”